Volume 74, No. 3/2010(September)
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 Clinical Nephrology
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Review
Nocturnal home hemodialysis and its impact on erythropoietin responsiveness
J.-P. Rioux and C.T. Chan
Abstract
Clinical Nephrology, Vol. 74 – No. 3/2010 (167-172)
Nocturnal home hemodialysis and its impact on erythropoietin responsiveness
J.-P. Rioux and C.T. Chan
Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
Anemia secondary to end-stage renal disease (ESRD) is an important but complex syndrome which directly contributes to significant morbidity and mortality in this patient population. The interactions between uremia, bone marrow biology and erythropoietin (EPO) responsiveness are of significant interest to improve our basic understanding of anemia management in ESRD. Nocturnal home hemodialysis is an intensive mode of renal replacement therapy, which has been associated with an improvement in EPO responsiveness. The aims of the present review are (1) to update the recent advances in uremia associated perturbations in bone marrow-derived hematopoietic stem cells and (2) to discuss the potential mechanistic explanations by which augmented uremia clearance may directly affect EPO responsiveness.Correspondence to:
Dr. C.T. Chan
Toronto General Hospital
200 Elizabeth Street, 8N Room 842
Toronto, Ontario, M5G 2C4, Canada
Email: christopher.chan@uhn.on.ca
Lead Article
Recurrent focal segmental glomerulosclerosis in the renal allograft: single center experience in the era of modern immunosuppression
M.E. Schachter, M. Monahan, J. Radhakrishnan, J. Crew, M. Pollak, L. Ratner, A.M. Valeri, M.B. Stokes and G.B. Appel
Abstract
Clinical Nephrology, Vol. 74 – No. 3/2010 (173-181)
Recurrent focal segmental glomerulosclerosis in the renal allograft: single center experience in the era of modern immunosuppression
M.E. Schachter1, M. Monahan2, J. Radhakrishnan2, J. Crew2, M. Pollak4, L. Ratner5, A.M. Valeri2, M.B. Stokes3 and G.B. Appel2
1Dept of Medicine, Division of Nephrology, St. Paul’s Hospital, Division of Nephrology, Vancouver, Canada, 2Department of Medicine, 3Department of Pathology, Columbia University, New York, NY, 4Department of Medicine, Harvard University, Boston, MA, and 5Department of Surgery, Columbia University, New York, NY, USA
FSGS is an important cause of ESRD and tends to recur in allografts (rFSGS). Older series suggest recurrence rates of 30 – 60%. In the modern era of transplant immunosuppression, recurrence rates are unknown. There are also few data regarding prevalence of known genetic mutations in adult FSGS patients who undergo transplantation. Recently, FSGS has been subdivided into histological variants, which may predict renal outcomes; there is little information on patterns of recurrence and outcomes in these variants. Finally, treatment for rFSGS relies upon up-titrating calcineurin inhibitors and plasmapheresis. Insufficient information exists on the use of these regimens for rFSGS in the era of modern immunosuppression. We conducted a retrospective chart review involving all renal transplant recipients at Columbia University Medical Center from December 1999 to March 2007. Those with biopsy confirmed primary FSGS were included and information regarding baseline characteristics, histologic variants, genetics, treatment, and clinical outcomes were collected. FSGS recurred in 23% of patients. Those with collapsing histology on native kidney biopsy, tended to recur with the same histology. No known genetic mutations were identified among those with recurrence. Plasmapheresis resulted in complete or partial remission in 75% of those with recurrence. Recurrent FSGS resulted in a trend toward the combined outcome of ESRD or death compared to those without recurrence (27% vs. 12%). Modern immunosuppression does not reduce the rate of rFSGS, known genetic mutations are uncommon in such adult patients, collapsing FSGS tends to recur with the same histology, and plasmapheresis may be helpful in the treatment of recurrence.Correspondence to:
M.E. Schachter, MSc, MD
Department of Medicine, Division of Nephrology
St. Paul’s Hospital, Division of Nephrology
1081 Burrard Street, Providence Wing RM 6010A
Vancouver, BC, V6Z 1Y8, Canada
Email: mschac1@gmail.com
Original
Clinical relevance of dietary salt intake on aldosterone and the aldosterone-to-renin ratio as screening parameters for primary aldosteronism
M. Koch, S. Aker, B. Haastert and L.C. Rump
Abstract
Clinical Nephrology, Vol. 74 – No. 3/2010 (182-189)
Clinical relevance of dietary salt intake on aldosterone and the aldosterone-to-renin ratio as screening parameters for primary aldosteronism
M. Koch1, S. Aker1, B. Haastert2 and L.C. Rump3
1Center of Nephrology, Mettmann, 2mediStatistica, Neuenrade, and 3Clinic of Nephrology, Heinrich Heine University Düsseldorf, Germany
Aims: The recommendations for screening for primary aldosteronism (PA) are determination and interpretation of both plasma aldosterone and the aldosterone-renin ratio (ARR). Although it is known that oral sodium chloride intake has an important impact on plasma aldosterone and ARR, more detailed data of this impact are sparse. We evaluated the relevance of natriuresis as a parameter of oral sodium intake, as well as patient age and antihypertensive medication on the PA screening parameters in our hypertensive patient population. Method: Our cross-sectional, single-center study investigated the impact of natriuresis, patient age, body mass index, Ca-antagonists, beta-blockers, ACE inhibitors and/or AT1 blockers on aldosterone and ARR in 777 hypertensive patients (393 men, 384 women) with a mean age (± SD) of 49.5 ± 15.7 years and an endogenous creatinine clearance of at least 80 ml/min. A total of 401 patients (51.6%) were on antihypertensive therapy. The mean natriuresis of the total population was 206.7 ± 97.0 mmol/day. The potential impact factors on plasma aldosterone and ARR were analyzed in two separate univariate, bivariate, and multiple regression analyses, respectively, with natriuresis as the main impact factor. Results: Natriuresis as well as patient age had a significant impact on both plasma aldosterone and ARR. In addition, beta-blockers, ACE inhibitors and/or AT1 blockers had a significant impact on ARR (p < 0.05). Conclusions: In addition to antihypertensive medication, natriuresis as well as patient age seem to need further consideration in the process of PA screening and interpretation of its results. Additional experimental studies are warranted to confirm and generalize our results.Correspondence to:
M. Koch, MD
Gartenstraße 8
40822 Mettmann, Germany
Email: Koch@dialyse-mettmann.de
Original
Longitudinal changes of left ventricular filling pressure and N-terminal pro-brain natriuretic peptide on chronic hemodialysis
Y.K. Kim, S.J. Shin, S.-H. Ihm, C.S. Park, H.-Y. Kim, T.Y. Hong, H.C. Song, C.W. Yang, Y.-S. Kim and E.J. Choi
Abstract
Clinical Nephrology, Vol. 74 – No. 3/2010 (190-197)
Longitudinal changes of left ventricular filling pressure and N-terminal pro-brain natriuretic peptide on chronic hemodialysis
Y.K. Kim1, S.J. Shin1, S.-H. Ihm1, C.S. Park1, H.-Y. Kim1, T.Y. Hong2, H.C. Song1, C.W. Yang1, Y.-S. Kim1 and E.J. Choi1
1Department of Internal Medicine and 2Department of Emergency Medicine, The Catholic University of Korea, Seoul, Korea
Background: Left ventricular filling pressure (LVFP) is related to the long-term prognosis in end-stage renal disease. The aims of this study were to evaluate the time course of the changes in LVFP, the predictors for the changes of LVFP, and the plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) levels as indicators for the changes of LVFP in chronic hemodialysis (HD). Methods: This study was designed prospectively. Doppler echocardiographic examinations and measurement of plasma NT-proBNP levels were performed in 37 consecutive patients on chronic HD and repeated at median of 43 months later. A ratio of peak early transmitral flow velocity to peak early diastolic mitral annular velocity (E/Em), an estimate of LVFP, was calculated. Results: E/Em ratios were significantly increased during the follow-up period. In multivariate analysis, age and changes of LVMI were independently associated with the changes of E/Em ratios. The plasma NT-proBNP levels were independently associated with E/Em at baseline and at the end of follow-up. The changes of plasma NT-proBNP levels were independently associated with changes of E/Em ratios (b-coefficient 0.453, p = 0.003). Conclusions: Our data suggest that the deterioration of LVFP parallels with the progression of LV hypertrophy. Monitoring the plasma NT-proBNP levels might be useful for the detection of the LVFP changes in chronic HD.Correspondence to:
H.C. Song, MD
Department of Internal Medicine
Holy Family Hospital
Sosa-dong, Wonmi-gu
Bucheon-si, Geoynggi-do, 420-717 Korea
Email: drsong@catholic.ac.kr
Original
“Real-World” use of cinacalcet for managing SHPT in different European countries: analysis of data from the ECHO observational study
M. Vervloet, V. Bencova, F. Malberti, N. Ashman, I. Os, H. Saha, P. Ureña, E. Zitt, M. Rix, M. Ryba, D. Fouque, B. Dehmel, F. Petavy and S.H. Jacobson
Abstract
Clinical Nephrology, Vol. 74 – No. 3/2010 (198-208)
“Real-World” use of cinacalcet for managing SHPT in different European countries: analysis of data from the ECHO observational study
M. Vervloet1, V. Bencova2, F. Malberti3, N. Ashman4, I. Os5, H. Saha6, P. Ureña7, E. Zitt8, M. Rix9, M. Ryba10, D. Fouque11, B. Dehmel12, F. Petavy12 and S.H. Jacobson13
1VU Medisch Centrum, Amsterdam, The Netherlands, 2DIA_NE sro, Nitra, Slovakia, 3AO Istituti Ospitalieri di Cremona, Cremona, Italy, 4The Royal London Hospital, London, UK, 5Oslo University Hospital, Ullevål, Oslo, Norway, 6Tampere University Hospital, Tampere, Finland, 7Clinique du Landy, Saint-Ouen, France, 8Academic Teaching Hospital, Feldkirch, Austria, 9Rigshospitalet, University of Copenhagen, Denmark, 10Krajska Nemocnice Liberec, Liberec, Czech Republic, 11Hôpital Edouard Herriot, University Lyon 1, France, 12Amgen Europe GmbH, Zug, Switzerland and Uxbridge, UK and 13Danderyd Hospital and Karolinska Institute, Stockholm, Sweden
Aims: The pan-European ECHO observational study evaluated cinacalcet in adult dialysis patients with secondary hyperparathyroidism (SHPT) in “real-world” clinical practice. A sub-analysis compared data for 7 European countries/country clusters: Austria, CEE (Czech Republic and Slovakia), France, Italy, Netherlands, Nordics (Denmark, Finland, Norway, and Sweden), and the UK/Ireland. Methods: Data on serum intact parathyroid hormone (iPTH), phosphorous, calcium, as well as the usage of cinacalcet, active vitamin D analogues and phosphate binders were compared. Results: 1,865 patients (mean age 58 years) were enrolled: median baseline iPTH levels ranged from 605 pg/ml in Austria to 954 pg/ml in the UK/Ireland. After ~1 year of cinacalcet, median iPTH reductions from baseline ranged from 38% in the UK/Ireland to 58% in the Netherlands. The proportion of patients achieving NKF/K-DOQITM iPTH targets (150 – 300 pg/ml) at Month 12 ranged from 14% in the UK/Ireland to 40% in CEE. In general, use of sevelamer decreased, while use of calcium-based phosphate binders increased, during cinacalcet treatment. Vitamin D changes were more variable. Conclusion: The iPTH level at which cinacalcet is initiated in clinical practice differs considerably among different countries: where cinacalcet was started at a lower iPTH level this resulted in better achievement of serum iPTH targets.Correspondence to:
M. Vervloet, MD
VU Medisch Centrum
De Boelelaan 1117
1081 HV Amsterdam, The Netherlands
Email: M.Vervloet@vumc.nl
Clinical impact of a combined therapy of peritoneal dialysis and hemodialysis
N. Matsuo, K. Yokoyama, Y. Maruyama, Y. Ueda, H. Yoshida, Y. Tanno, R. Yamamoto, H. Terawaki, M. Ikeda, K. Hanaoka, H. Yamamoto, M. Ogura, S. Watanabe, Y. Kimura and T. Hosoya
Abstract
Clinical Nephrology, Vol. 74 – No. 3/2010 (209-216)
Clinical impact of a combined therapy of peritoneal dialysis and hemodialysis
N. Matsuo1, K. Yokoyama1, Y. Maruyama1, Y. Ueda1, H. Yoshida1, Y. Tanno1, R. Yamamoto1, H. Terawaki1, M. Ikeda1, K. Hanaoka1, H. Yamamoto1, M. Ogura1, S. Watanabe2, Y. Kimura1 and T. Hosoya1
1Division of Kidney and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, and 2Department of Internal Medicine, Kobari General Hospital, Chiba, Japan
Aims: Although peritoneal dialysis (PD) is recommended as the first-line treatment for end-stage renal disease, limitations exist to achieving good clinical status when the residual renal function (RRF) has declined. Combined therapy with PD and hemodialysis (HD) is the treatment of choice for patients who cannot control body fluid status and/or cannot obtain adequate solute removal by PD alone. The aim of this study was to evaluate the clinical efficacy of this combined therapy. Methods: In this retrospective study, 53 patients on PD and diagnosed with underdialysis and/or overhydration with declining RRF were recruited. Parameters of volume control, uremic solute removal, anemia, and predictors for encapsulating peritoneal sclerosis (EPS) were compared before and 1 year after combined therapy. Results: The patients’ hydration status improved significantly with reductions in atrial natriuretic peptide and blood pressure. Serum creatinine and beta2 microglobulin also decreased significantly. The hemoglobin level increased remarkably from 8.2 ± 1.6 to 10.7 ± 1.2 g/dl (p < 0.01) and the reticulocyte count also increased significantly, even though at the same time the dose of recombinant human erythropoietin decreased significantly. The dialysate to plasma creatinine ratio obtained from the fast peritoneal equilibration test (PET) decreased significantly from 0.65 ± 0.11 to 0.59 ± 0.13, and the level of interleukin 6 in PET drainage also significantly decreased. Furthermore, serum C-reactive protein and fibrinogen decreased significantly. Conclusions: Combined therapy with PD and HD is an effective way to control fluid status and to correct inadequate solute removal, leading to improvement in inflammation, peritoneal function and anemia.Correspondence to:
Dr. N. Matsuo
Division of Kidney and Hypertension
Department of Internal Medicine
The Jikei University School of Medicine
3-25-8 Nishi-shimbashi Minato-ku
Tokyo 105-8461, Japan
Email: nana77m@jikei.ac.jp
Original
Incidence and clinical course of lercanidipine-associated cloudy effluent in continuous ambulatory peritoneal dialysis
P.-J. Hsiao, H.-W. Lin, C.-C. Sung, C.-W. Wang, P. Chu and S.-H. Lin
Abstract
Clinical Nephrology, Vol. 74 – No. 3/2010 (217-222)
Incidence and clinical course of lercanidipine-associated cloudy effluent in continuous ambulatory peritoneal dialysis
P.-J. Hsiao1, H.-W. Lin1, C.-C. Sung1, C.-W. Wang2, P. Chu1 and S.-H. Lin1
1Division of Nephrology, Department of Medicine, and 2Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Background: Lercanidipine, a novel dihydropyridine calcium channel antagonist, has been reported to cause sterile cloudy effluent in patients on continuous ambulatory peritoneal dialysis (CAPD). The purpose of the study was to evaluate the incidence and clinical course of cloudy effluent associated with lercanidipine in uremic patients on CAPD. Methods: We designed a consecutive observation study in 40 non-diabetic uremic patients on CAPD treated with lercanidipine 5 mg daily. Lercanidipine-induced cloudy effluent was defined as acellular and culture-negative effluent associated with the use of this drug and exclusion of other causative factors. Time to develop cloudy effluent, dwell effluent amount and the associated symptoms were recorded. Baseline peritoneal membrane characteristics, net ultrafiltration per session and routine biochemistry in serum and dialysate were compared between patients with and without the development of cloudy effluent. Results: 9 patients (22.5%) developed cloudy effluent within 2 days of lercanidipine initiation. The triglyceride concentration in cloudy effluent was greater than 10 mg/dl (19.3 ± 6.3 mg/dl). There was a significant increase in dwell effluent amount (93.3 ± 64 ml/exchange, p < 0.05). Clinical symptoms as abdominal cramping or fullness were observed in 3 patients. All cloudy effluent disappeared after ceasing lercanidipine but recurred after resumption of lercanidipine. Baseline dialysate to plasma (D/P) creatinine ratio (0.7 ± 0.1 vs. 0.51 ± 0.1; p = 0.07) tended to be higher and dialysate total protein (93.4 ± 33 vs. 61.5 ± 24 mg/dl; p < 0.05) were significantly higher in patients with than without the development of cloudy effluent. Conclusion: The incidence of lercanidipine-associated cloudy effluent is relatively higher with transient benign clinical symptoms. Patients with lercanidipine associated cloudy effluent tend to have a higher membrane transport with an increased effluent amount.Correspondence to:
S.-H. Lin, MD
Division of Nephrology
Department of Medicine
Tri-Service General Hospital
Number 325, Section 2, Cheng-Kung Road
Neihu 114, Taipei, Taiwan
Email: l521116@ndmctsgh.edu.tw
Original
Intra-abdominal hypertension can be monitored with femoral vein catheters during CRRT and may cause access recirculation
P. Sood, B. Dass, C. Bakuzonis and E.A. Ross
Abstract
Clinical Nephrology, Vol. 74 – No. 3/2010 (223-228)
Intra-abdominal hypertension can be monitored with femoral vein catheters during CRRT and may cause access recirculation
P. Sood1, B. Dass1, C. Bakuzonis2 and E.A. Ross1
1Division of Nephrology, Hypertension and Transplantation, University of Florida, and 2Shands at the University of Florida, Gainesville, FL, USA
Objectives: Intra-abdominal hypertension (IAH) is an increasingly recognized disorder, and its diagnosis depends on accurate pressure monitoring. Bladder-based protocols are favored, but are not always clinically feasible. Abdominal venous (i.e. vena cava) pressure measurements are an alternative but are logistically challenging. We hypothesized that for patients suffering acute kidney injury, transducers built into renal replacement therapy (RRT) machines offer a simple opportunity to monitor pressures using catheters inserted via femoral veins. Design: We performed in vitro testing of the accuracy of pressure transducers incorporated into continuous RRT devices, using highly calibrated instrumentation in the IAH-relevant range of 0 to +50 mmHg. We developed a protocol for using this modality in vivo, by stopping all pumps so as to allow equilibration of pressures: clinical application in a patient with femoral vein catheters and IAH was then described. Results: In vitro analyses showed accuracy of the extracorporeal pressure transducers with an r2 of 0.998, p < 0.001. In the patient case, the pressure transduced at the RRT device was identical to those obtained from bladder catheters. IAH also led to access recirculation and ineffective therapy. Conclusions: Pressure sensors incorporated into continuous RRT machines can be accurate in the IAH physiologic range, and thus may be used to easily measure intra-abdominal pressure via appropriate-length femoral vein-inserted access catheters. If not relieved, IAH can be an under-appreciated cause of access recirculation and ineffective clearance for any RRT modality (continuous or intermittent) using femoral catheters.Correspondence to:
E.A. Ross, MD Director
End-Stage Renal Disease Program
Division of Nephrology, Hypertension and Transplantation
University of Florida
Box 100224, Gainesville, FL 32610-0224, USA
Email: rossea@medicine.ufl.edu
Case Report
Spontaneous retroperitoneal hemorrhage in dialysis: a presentation of 5 cases and review of the literature
T. Malek-Marín, D. Arenas, T. Gil, A. Moledous, M. Okubo, J.J. Arenas, A. Morales and E. Cotilla
Abstract
Clinical Nephrology, Vol. 74 – No. 3/2010 (229-244)
Spontaneous retroperitoneal hemorrhage in dialysis: a presentation of 5 cases and review of the literature
T. Malek-Marín1, D. Arenas1, T. Gil1, A. Moledous1, M. Okubo2, J.J. Arenas3, A. Morales1 and E. Cotilla1
1Department of Nephrology, Hospital Perpetuo Socorro, 3Department of Radiology, Hospital General of Alicante, Spain, and 2Department of Medicine, Kitasato University School of Medicine, Sagamihara, Japan
Background: Spontaneous retroperitoneal hemorrhage (SRH) is a rare but potentially fatal entity. Despite published case reports of SRH in dialysis, little systematic information is available. Methods: Report of 5 cases and review of MEDLINE database from 1971 until 2008. Results: Incidence of SRH in our unit was 0.86 cases per 100 patients; annual incidence rate 8/10,000 patients. We identified 34 publications, comprising 55 cases. The existing cases and the 5 reported were analyzed: 74.5 % male, average age 53.3 years (range 27 – 78), average time on dialysis 7.1 years (range 3 weeks – 27.5 years), 95% on hemodialysis and 5% on peritoneal dialysis. There was significant heterogeneity in clinical presentation. The kidney was the most commonly reported origin (87.8%), and acquired cystic kidney disease (ACKD) was the most frequent underlying cause. 91.8% received some kind of anticoagulation. Treatment was conservative, included angioembolization or surgery in 33.3%, 17.6% and 49% of the cases respectively. Mortality rate was 18.3%. Conclusions: More than 85% of SRH in dialysis had a renal cause, ACKD being predominant. The complication occurs mainly in the HD modality, possibly in relation to anticoagulation. There is no evidence that screening of ACKD is of benefit predicting SRH. Therefore, awareness of ACKD as a manifestation of ESRD patients and its risk of bleeding is necessary. Because of the summation of risk factors that appears in the population on dialysis, SRH should be considered in the differential diagnosis of unexplained pain before drop in blood pressure or hematocrit occurs.Correspondence to:
T. Malek-Marín
Nephrology Department
Hospital Perpetuo Socorro
Plaza Dr. Gómez Ulla, 15+
Apartado de Correos n 240
03013 Alicante, Spain
Email: tamaramalek@gmail.com
