Volume 69, No. 1/2008(January)
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 Clinical Nephrology
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Review
The transition from childhood to adulthood with ESRD: educational and social challenges
Abstract
P.F. Icard, S.J. Hower, A.R. Kuchenreuther, S.R. Hooper and D.S. Gipson
1UNC Kidney Center, 2School of Education, School Psychology Program,
3Clinical Center for the Study of Development and Learning, and
4Department of Psychiatry, UNC-Chapel Hill, Chapel Hill, NC, USA
Objective: The purpose of this review was to examine potential barriers to adulthood transition for children and adolescents with chronic kidney disease (CKD). Results: The literature was reviewed in regards to medical, neuropsychological, psychiatric and psychosocial barriers that may impede successful transition. Adults with CKD since childhood have been found to be at increased risk for neurocognitive impairment, low educational attainment, unemployment, psychiatric disability, and psychosocial adjustment. Conclusion: Based on the available literature, intervention strategies are discussed in addition to directions for future research.Correspondence to:
D.S. Gipson, MD, MSPH; University of North Carolina School of Medicine, UNC Kidney Center, 7012 Burnett-Womack, CB# 7155, Chapel Hill, NC 27514-7155, U.S.A.
Email: debbie_gipson@med.unc.edu
Viewpoint
Hemoglobin targets: the jury is still out
Abstract
F. Carrera and I.C. Macdougall
1Dialysis Unit, Eurodial, Euromedic, Leiria, Portugal and 2Department of Renal Medicine, King
Correspondence to:
Dr. I.C. Macdougall; Consultant Nephrologist, Renal Unit, King
Email: iain.macdougall@kch.nhs.uk
Originals
Impact of age, body mass index, insulin resistance and proteinuria on the kidney function in obese patients with Type 2 diabetes and renal insufficiency
Abstract
M. Koch, A. Beien, A. Fusshöller, S. Zitta, B. Haastert and R. Trapp
1Center of Nephrology, Mettmann, 2Clinic of Nephrology, Heinrich Heine University, Düsseldorf, 3Department of Medicine, Division of Nephrology, Medical University Graz, Austria and 4Institute of Biometrics and Epidemiology, German Diabetes Center, Leibniz Center at Heinrich Heine University, Düsseldorf, Germany
Aims: To date, several different equations to predict the glomerular filtration rate (GFR) in patients with renal insufficiency have been developed for different patients groups. Our aim was to determine the prognostic factors of GFR in our homogenous patient group of obese, water-loaded patients with Type 2 diabetes and renal insufficiency, since we assumed that the endogenous creatinine clearance (ECC) alone may not be an accurate method to predict GFR. Method: We recruited 46 obese patients (37 men) with Type 2 diabetes and renal insufficiency in our nephrology center in Mettmann (Germany). However, two male patients were excluded from the analysis due to an outlying insulin level or low inulin clearance. The inulin clearance as a measure of renal function performed by the single shot method was compared with the GFR estimated by ECC, Cystatin C, and MDRD formula. Several multiple regression models were built to test the impact of the prognostic factors age, sex, body mass index (BMI), insulin resistance according to the homeostasis model assessment (HOMA), body water (TBW), brain natriuretic peptide (BNP), and proteinuria on the inulin clearance. In the main regression model to predict the inulin clearance by ECC, only the statistically significant prognostic factors of these models were selected, as well as the interaction between GFR predicted by ECC (GFR_ECC) and BMI. Results: The prognostic factors GFR_ECC, age, BMI, HOMA and proteinuria had a statistically significant impact on the inulin clearance (the gold standard of the GFR) in our patient population (p < 0.05). However, the interaction of GFR_ECC and BMI was not significant (p = 0.06) in our model. The model was validated and considered well-fitted with a coefficient of determination (R2) of 0.69. Conclusions: The independent prognostic factors to determine GFR in obese, water-loaded diabetic patients are GFR_ECC, age, BMI, HOMA and proteinuria. However, our model should be revalidated and tested in a larger sample size to probably detect an interaction between GFR_ECC and BMI as an additional prognostic factor.Correspondence to:
M. Koch, MD; Gartenstraße 8, 40822 Mettmann, Germany
Email: Koch@dialyse-mettmann.de
Originals
An investigation of 2,093 renal biopsies performed at Tokai University Hospital between 1976 and 2000
Abstract
M. Honma, M. Toyoda, T. Umezono, M. Kato, K. Kobayashi, M. Miyauchi, N. Yamamoto, M. Kimura, M. Maruyama, M. Nishina, M. Yagame, M. Endoh and D. Suzuki
Department of Internal Medicine, Division of Nephrology and Metabolism,Tokai University School of Medicine, Kanagawa, Japan
We retrospectively investigated 2,093 renal biopsy procedures performed between 1976 and 2000 at Tokai University Hospital. The study period was divided into 5-year intervals, and the frequencies of each renal disease, age and sex of patients were compared across the study period. Clinical diagnosis was based on WHO criteria. A total of 2,093 patients aged 8 months to 84 years underwent renal biopsy during the study period. The percentage of elderly patients who underwent renal biopsy increased from 1.2% in 1976 – 1980 to 9.9% in 1996 – 2000. IgAN was the most common disease in every 5-year period. CresGN showed an increase from 1 patient (0.3%) in 1976 – 1980 to 15 patients (4.0%) in 1996 – 2000. In contrast, the number of patients with PGN or BRH, MPGN significantly decreased during the study period. Although the criteria for renal biopsy and renal diseases detected are expected to change in the future, renal biopsy will remain an essential procedure for making a definite diagnosis, selection of optimum treatment, and prediction of prognosis.Correspondence to:
D. Suzuki, MD; Division of Nephrology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Bohseidai, Isehara-Kanagawa 259-1193, Japan
Email: daisuke@is.icc.u-tokai.ac.jp
Originals
Intravenous N-acetylcysteine during hemodialysis reduces asymmetric dimethylarginine level in end-stage renal disease patients
Abstract
M. Thaha, Widodo, W. Pranawa, M. Yogiantoro and Y. Tomino
1Division of Nephrology-Hypertension, Department of Internal Medicine, Airlangga University School of Medicine, Surabaya, Indonesia and
2Division of Nephrology, Department of Internal Medicine, Juntendo University School of Medicine, Tokyo, Japan
Aim: Cardiovascular disease is the main cause of mortality in chronic kidney disease patients. Moreover, uremic patients are in a pro-oxidant state and show an increase in asymmetric dimethylarginine (ADMA) levels due to inhibition of the enzyme dimethylarginine dimethylaminohydrolase (DDAH). Asymmetric dimethylarginine per se seems responsible for a 52% increase in the risk of death and for a 34% increase in the risk of cardiovascular events in dialysis patients. N-acetylcysteine (NAC) is a thiol molecule that has direct and indirect antioxidant effects which decrease reactive oxidant species and increase the bioavailability of the DDAH enzyme. The aim of the current study was to determine the effect of intravenous NAC on plasma ADMA level when administered during hemodialysis in end-stage renal disease (ESRD) patients. Materials and methods: 40 patients with ESRD were randomized to receive a 4-hour intravenous infusion of NAC or placebo during a 4-hour hemodialysis session. There were 3 diabetic patients (15%) in the treatment group and 6 patients in the control group. Plasma ADMA levels were measured before and immediately after hemodialysis. Hemodynamic parameters, including pulse pressure, were also measured. The paired t-test was used to compare the difference of ADMA levels before and after hemodialysis in each group, while the independent t-test was used to compare the difference of ADMA levels between the groups. Results: Compared with the pre-dialysis condition, there was a decrease of ADMA level in the control group (1.1253 ± 0.1797 µM to 0.8676 ± 0.1449 µM) (p < 0.001), and in the NAC group (1.1522 ± 0.1737 µM to 0.7844 ± 0.1586 µM) (p < 0.001). Compared with hemodialysis alone, NAC had a greater lowering effect on the ADMA level (21.3 vs. 31.9%, p < 0.05). Conclusion: N-acetylcysteine (NAC) administered intravenously during hemodialysis reduced asymmetric dimethylarginine (ADMA) levels more significantly than hemodialysis alone.Correspondence to:
Prof. Y. Tomino, MD Division of Nephrology, Department of Internal Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
Email: yasu@med.juntendo.ac.jp
Originals
Reduction in cardiovascular related hospitalization with nocturnal home hemodialysis
Abstract
A. Bergman, S.S.A. Fenton, R.M.A. Richardson and C.T. Chan
Department of Medicine, Division of Nephrology, The Toronto General Hospital – University Health Network, University of Toronto, Toronto, Ontario, Canada
Cardiovascular disease remains the leading cause of death among patients with end-stage renal disease (ESRD). Nocturnal home hemodialysis (NHD) (5 – 6 sessions per week; 6 – 8 hours per session) is a novel form of home-based renal replacement therapy, which has been shown to improve several cardiovascular risk factors. The impact of NHD on hospitalization rate has remained unclear. We hypothesized that augmentation of small and middle molecular clearance by NHD would result in a reduction of dialysis related or cardiovascular specific hospitalizations. Methods and results: In this controlled cohort study, we studied 32 NHD patients (age: 43 ± 2 [mean ± SEM]) 1 year before and 2 years after conversion to NHD and 42 CHD patients (mean age: 44 ± 2) (matched for age, dialysis vintage and controlled for comorbidities) during the same time period. The primary outcome was the change in a composite of dialysis or cardiovascular related admissions rate before and after conversion to NHD. Secondary outcomes included changes in all cause hospitalization rate, visits to emergency, reasons and duration of hospitalization and dialysis-related biochemical parameters. During the study period, dialysis or cardiovascular-related admission rate was stable for the CHD control cohort (from 0.48 ± 0.14 [baseline] to 0.40 ± 0.12 [end of study] admission per patient year, p = NS). In contrast, conversion to NHD is associated with a decrease in our composite endpoint (from 0.50 ± 0.15 to 0.17 ± 0.06 admission per patient year, p = 0.04). Cardiovascular disease (37%) was the principal cause for hospitalization in the control population. In comparison, vascular access related admission was the primary cause of admission for the NHD cohort (56%), p = 0.001. Of the biochemical parameters, NHD is associated with a decrease in plasma phosphate (from 1.7 ± 0.1 to 1.3 ± 0.1 mM, p = 0.01) and an improved control of anemia (from 114 ± 2 to 122 ± 3 g/l, p = 0.02). Conclusion: Conversion to NHD is associated with a decrease in dialysis and cardiovascular-related hospital admission. The clinical and mechanistic relevance in uremic patients of improved phosphate and anemia management requires further examination.Correspondence to:
Dr. C.T. Chan; 200 Elizabeth Street, 8N room 842, Toronto, ON, M5G 2C4, Canada
Email: christopher.chan@uhn.on.ca
Originals
Sustained low-efficiency daily dialysis with hemofiltration for acute kidney injury in the presence of sepsis
Abstract
B.G. Holt, J.J. White, A. Kuthiala, P. Fall and H.M. Szerlip
Department of Medicine, Medical College of Georgia, Augusta, GA, USA
Aims: Acute kidney injury (AKI) commonly occurs in critically ill patients with sepsis and is associated with poor outcomes. Unfortunately, the ideal mode of renal replacement therapy remains unknown. Because both higher doses of dialysis and hemofiltration have been associated with improved survival, we postulated that adding hemofiltration to the diffusive clearance achieved by sustained low-efficiency daily dialysis (SLEDD-f) would provide a survival advantage over SLEDD. Methods: From December 2003 to October 2005, we retrospectively analyzed all patients with multisystem organ failure, vasopressor-dependent hypotension and oliguric acute kidney failure secondary to nonoperative sepsis who were treated with renal replacement therapy (RRT). After exclusionary criteria were applied, 8 patients received SLEDD-f and 13 patients received SLEDD. All treatments were for 8 – 16 h/day. SLEDD-f was continued until vasopressors were reduced to a minimal dose. Outcomes were mortality and recovery of renal function at 30 days after initiation of RRT. APACHE- II scores were calculated at the time of dialysis initiation to predict mortality. Results: Despite higher APACHE II scores, 30-day survival was 100% in the SLEDD-f group and 38% in the SLEDD group. Furthermore, most of the SLEDD-f patients were able to have vasopressors weaned quickly and all patients in the SLEDD-f group recovered significant renal function to allow discontinuation of RRT. Conclusions: While the optimal treatment remains unknown, this small study raises the possibility that SLEDD-f offers a survival advantage and increases the chance of renal recovery while decreasing the need for vasopressors. A large randomized trial comparing SLEDD-f with other forms of renal replacement therapy is needed.Correspondence to:
H.M. Szerlip, MD; Medical College of Georgia, Room BI 5072, 1120 15th Street, Augusta, GA 30912, USA
Email: hszerlip@mcg.edu
Case Reports
A case of minimal change nephrotic syndrome withA case of minimal change nephrotic syndrome with acute renal failure complicating Hashimoto’s disease
Abstract
Y. Iwazu, J. Nemoto, K. Okuda, E. Nakazawa, A. Hashimoto, Y. Fujio, M. Sakamoto, Y. Ando, S. Muto and E. Kusano
Department of Nephrology, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, Japan
A 63-year-old man was admitted to our hospital for evaluation of generalized edema. Coexistence of severe hypothyroidism and nephrotic syndrome was detected by laboratory examination. High titer of both antimicrosomal antibody and antithyroid peroxidase antibody indicated Hashimoto’s disease. Renal biopsy showed minimal change glomerular abnormality, but no findings of membranous nephropathy. A series of medical treatments, including steroid therapy, thyroid hormone and human albumin replacement therapy, were administered. However, acute renal failure accompanied by hypotension, was not sufficiently prevented. After 9 sessions of plasmapheresis therapy, the severe proteinuria and low serum albumin levels were improved. Even after resting hypotension was normalized, neither renal function nor thyroid function were fully recovered. After discharge, renal function gradually returned to normal, and the blood pressure developed into a hypertensive state concomitant with the normalization of thyroid function. This report is a rare case of autoimmune thyroid disease complicated with minimal change nephrotic syndrome. In most cases of nephritic syndrome, acute renal failure (ARF) has been reported to coexist with hypertension. Although pseudohypothyroidism is well-known in nephrotic pathophysiology, complications of actual hypothyroidism are uncommon. It is suggested that the development of hypotension and ARF could be enhanced not only by hypoproteinemia, but also by severe hypothyroidism.Correspondence to:
Y. Iwazu, MD; Department of Nephrology, Jichi Medical University, Shimotsuke, Tochigi 329-0498, Japan
Email: iwazu@jichi.ac.jp
Case Reports
Vascular access malfunction due to upper extremity embolization in dialysis patients
Abstract
M. Fraer, M.A. Sekkarie, R. Rao and B.P. Sawaya
1Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, 2Bluefield Regional Medical Center, Bluefield, WV, USA
Acute occlusions of arteries such as those of the cerebral and peripheral circulation are usually due to thrombotic or embolic events. Emboli have not been previously reported to cause arteriovenous (AV) dialysis access malfunction. We describe in this report three patients with end-stage renal disease (ESRD) and atrial fibrillation (Afib) who developed acute ischemia of an arteriovenous access-bearing extremity due to embolization. The clinical manifestations mimicked thrombotic events, but the presence of symptoms and signs of limb ischemia distinguished these cases clinically. A timely diagnosis followed by an appropriate intervention can lead to limb and access salvage.Correspondence to:
M.A. Sekkarie, MD; 510 Cherry St., Bluefield Professional Bldg. A, Suite 306, Bluefield, WV, 24701, USA
Email: msekkarie@brmcwv.org
Case Reports
Improvement of peritoneal calcification after parathyroidectomy in a peritoneal dialysis patient
Abstract
H. Inoshita, T. Gohda, H. Io, K. Kaneko, C. Hamada, S. Horikoshi and Y. Tomino
Division of Nephrology, Department of Internal Medicine, Juntendo University School of Medicine, Tokyo, Japan
Peritoneal calcification is one of the complications of peritoneal dialysis (PD). It can become serious, leading to severe abdominal pain and even death. Possible mediators of peritoneal calcification in PD patients are assumed to include acetate buffer, overdosage of vitamin D, repeated peritonitis, hypertonic dialysate, calciphylaxis and secondary hyperparathyroidism (SHPT). However, the mechanism and treatment of peritoneal calcification are controversial. Few reports have appeared on improvement of peritoneal calcification after parathyroidectomy (PTX) for SHPT of long duration. We report herein the case of a 48-year-old man on dialysis for 17 years including PD for 14 years. In 1989, he was admitted to hospital because of end-stage renal disease (ESRD), and started treatment with PD. Abdominal computed tomography (CT) first showed peritoneal calcification in August 2002. Peritoneal calcification did not improve despite conventional treatment including discontinuation of PD, control of calcium phosphate product to less than 55 mg2/dl2, removal of the peritoneal catheter and empirical prednisolone (PSL) usage. The intact parathyroid hormone (i-PTH) level was increased over 1,000 pg/ml and extra-osseous calcification occurred. Total PTX was performed in November 2004. Postoperatively, the i-PTH level decreased immediately and calcium phosphate product was maintained in the reference range. Abdominal CT after PTX showed improvement of peritoneal calcification in September 2005. It appeared that PTX could be used to treat patients with persistent peritoneal calcification not responding to conventional treatment. It was postulated that SHPT might play a crucial role in accelerating peritoneal calcification in PD patients.Correspondence to:
Prof. Y. Tomino, MD; Division of Nephrology Department of Internal Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
Email: yasu@med.juntendo.ac.jp
Letters to the Editor
Diagnostic markers for early detection of diabetic retinopathy and nephropathy
Abstract
N. Futrakul and P. Futrakul
King Chulalongkorn Memorial Hospital, Bangkok, Thailand
Correspondence to:
N. Futrakl, MD, PhD; Department of Physiology King Chulalongkorn Memorial Hospital Rama IV Road, Bangkok 10330, Thailand
Email: fmednft@md.chula.ac.th
Letters to the Editor
Recurrent and progressive nephritis in a patient with acute tubulointerstitial nephritis and uveitis syndrome
Abstract
O. Oymak, A. Unal, M.H. Sipahioglu, M. Akcakaya, B. Tokgoz, T. Patiroglu and C. Utas
Departments of 1Nephrology and 2Pathology Erciyes University Medical School, Kayseri, Turkey
Correspondence to:
O. Oymak, MD; Erciyes
Email: oktayo@erciyes.edu.tr
