Volume 81 (2014), No. 1/2014(January)
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Original
Metabolic syndrome and chronic kidney disease as risk factors of osteoporosis
Jung-ho Shin, Su Hyun Kim, and Suk-Hee Yu
Page No. 1
Abstract
Clinical Nephrology, Vol. 81 – No. 1/2014 (1-8)
Metabolic syndrome and chronic kidney disease as risk factors of osteoporosis
Jung-ho Shin, Su Hyun Kim, and Suk-Hee Yu
Department of Internal Medicine, Chung-Ang University College of Medicine
Aims: Osteoporosis is a significant cause of morbidity and mortality, and is often accompanied by metabolic syndrome (MetS) and chronic kidney disease (CKD). We demonstrated the relationship among MetS, CKD and osteoporosis, and investigated the roles of MetS and CKD in the occurrence of osteoporosis in a healthy Korean population. Methods: The estimated glomerular filtration rate (eGFR) was calculated using the modification of diet in renal disease study equation. The diagnosis of MetS was made according to the updated guidelines from the American Heart Association/ National Heart, Lung, and Blood Institute. Bone mineral density (BMD) values were measured. A decreased BMD level was defined as either osteopenia or osteoporosis. Results: The subjects comprised 38.9% men and 61.1% women; 6.6% had CKD, 19.4% had MetS, and 12.2% had osteoporosis. In females, the prevalence of MetS and CKD was higher in those with decreased BMD (p = 0.034 and p = 0.114, respectively). The risks for decreased BMD increased with fewer MetS components and lower eGFR in a simple logistic analysis. However, the correlation disappeared when adjusted for age. In males, the prevalence of MetS and CKD was lower in decreased BMD (p = 0.034 and p = 0.157, respectively). Both the presence of MetS components and lower eGFR had protective effects on BMD values in simple and multiple logistic analyses. Conclusions: In females, decreased BMD was positively related with both MetS and CKD. But, this relationship was not seen by adjustment for age. In males, lower BMD was negatively related to both MetS and CKD in unadjusted and adjusted models.Correspondence to:
Su Hyun Kim, MD
Department of Internal Medicine
Chung-Ang University Hospital
224-1, Heukseok-Dong,
Dongjak-ku, Seoul, 156-755, Korea
Email: [email protected]
Original
Relationship between heart rate variability and pulse wave velocity and their association with patient outcomes in chronic kidney disease
Preeti Chandra, Robin L. Sands, Brenda W. Gillespie, Nathan W. Levin, Peter Kotanko, Margaret Kiser, Fredric Finkelstein, Alan Hinderliter, Sanjay Rajagopalan, David Sengstock, and Rajiv Saran
Page No. 9
Abstract
Clinical Nephrology, Vol. 81 – No. 1/2014 (9-19)
Relationship between heart rate variability and pulse wave velocity and their association with patient outcomes in chronic kidney disease
Preeti Chandra1, Robin L. Sands2, Brenda W. Gillespie2, Nathan W. Levin3, Peter Kotanko3, Margaret Kiser4, Fredric Finkelstein5, Alan Hinderliter6, Sanjay Rajagopalan7, David Sengstock8, and Rajiv Saran2,9
1Department of Internal Medicine, University of Maryland, Baltimore, MD, 2University of Michigan-Kidney Epidemiology and Cost Center, Ann Arbor, MI, 3Renal Research Institute, New York, NY, 4Department of Internal Medicine, University of North Carolina, Chapel Hill, NC, 5Hospital of St. Raphael Yale University, New Haven, CT, 6Department of Internal Medicine, University of North Carolina, Chapel Hill, NC, 7Department of Cardiovascular Medicine, Ohio State University, Columbus, OH, 8Oakwood Healthcare System, Dearborn, MI, and 9Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
Background: Arterial stiffness and low heart rate variability (HRV) have each been associated with increased cardiovascular risk in a variety of patient populations. We explored the relationship between HRV and pulse wave velocity (PWV measure of arterial stiffness) in patients with chronic kidney disease (CKD prior to ESRD) along with examining their association with the outcomes of cardiovascular disease (CVD), death, and progression to end stage renal disease (ESRD). Methods: The RRI-CKD Study is a 4-center prospective cohort study of CKD stages 3 – 5 (n = 834). A subset underwent both HRV testing by 24-hour Holter and carotid-femoral PWV (n = 240). Multiple linear regression was used to assess predictors of PWV and Cox regression to investigate the association of HRV and PWV with time to first CVD event or death and ESRD. Results: Although several HRV measures were inversely correlated with PWV, this association was attenuated after adjustment for age and/or diabetes and no longer significant after adjustment for C-reactive protein. Low HRV and high PWV were individually associated with increased risk of the composite endpoint of CVD/death in multivariable analysis. The risk of the composite of CVD/death was highest for patients with both low HRV and high PWV. Conclusion: Age, diabetes, and inflammation together explained the inverse association between HRV and PWV. Inflammation may play a role in the pathogenesis of both low HRV and high PWV. The combination of low HRV and high PWV showed the strongest association with a composite CVD outcome. Mechanisms underlying abnormalities in PWV and HRV, and the role of these measures as intermediate outcomes in future trials in CKD patients, merit further study.Correspondence to:
Rajiv Saran, MBBS, MD, MRCP, MS
Professor of Medicine, Division of Nephrology
Department of Internal Medicine, Associate Director
University of Michigan (UM)-Kidney Epidemiology and Cost Center
Henry F. Vaughan School of Public Health I
1415 Washington Heights, Suite 3645A
Ann Arbor, MI 48109-2029, USA
Email: [email protected]
Original
Efficacy and initial dose determination of paricalcitol for treatment of secondary hyperparathyroidism in Chinese subjects
Yucheng Yan, Jiaqi Qian, Nan Chen, Zhaoxing Huang, Gengru Jiang, Xuewang Li, Hongli Lin, Liqiu Liu, Mei Wang, Changying Xing, Xueqing Yu, Li Zuo, Michael Amdahl and Samina Khan
Page No. 20
Abstract
Clinical Nephrology, Vol. 81 – No. 1/2014 (20-29)
Efficacy and initial dose determination of paricalcitol for treatment of secondary hyperparathyroidism in Chinese subjects
Yucheng Yan1, Jiaqi Qian1, Nan Chen2, Zhaoxing Huang3, Gengru Jiang4, Xuewang Li5, Hongli Lin6, Liqiu Liu7, Mei Wang8, Changying Xing9, Xueqing Yu10, Li Zuo11, Michael Amdahl12, and Samina Khan12
1Renji Hospital, 2Ruijin Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 3First Affiliated Hospital of Wenzhou Medical College, Wenzhou, 4Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 5Peking Union Medical College Hospital, Beijing, 6First Affiliated Hospital of Dalian Medical University, Dalian City, 7The Affiliated Hospital of Medical College, Qingdao University, Qingdao, 8Peking University People’s Hospital, Beijing, 9The First Affiliated Hospital of Nanjing Medical University and Jiangsu Province Hospital, Nanjing, 10The First Affiliated Hospital, Sun Yat-sen University, Guangzhou City, 11Peking University First Hospital, Beijing, China, and 12AbbVie Inc., North Chicago, IL, USA
Aim: Prevalence of secondary hyperparathyroidism (SHPT), a renal disease complication, is increasing in China. Available therapies may not optimally control SHPT, particularly in patients with hypercalcemia, hyperphosphatemia, and parathyroid hyperplasia. This study examined efficacy and safety of two dosing regimens of selective vitamin D receptor activator paricalcitol. Materials and methods: Subjects with SHPT (n = 216) undergoing hemodialysis were treated with paricalcitol i.v. for 12 weeks. One group was treated according to the EU paricalcitol package insert (PI) (initial μg dose based on iPTH/80), and the other was treated according to the US PI (initial dose of 0.04 μg/kg). Dose titration was based on iPTH and serum calcium (Ca) and phosphorus (P) levels. Results: The primary endpoint of two consecutive ≥ 30% iPTH decreases was achieved by 88.6% and 55.9% of subjects in the EU and US PI groups, respectively. Noninferiority of the EU PI group vs. the US PI group was demonstrated (lower bound of the 1-sided 97.5% CI = 21.3%). Superiority of the EU PI group was shown (lower limit > 0%) and confirmed by Fisher’s exact test (p < 0.001); both groups showed similar achievement of recommended KDIGO iPTH levels. Ca and P levels were relatively constant. Conclusion: Both EU and US PI paricalcitol dosing strategies effectively reduced iPTH levels in Chinese subjects with SHPT, with minimal impact on Ca and P levels.Correspondence to:
Jiaqi Qian, Dr., MD
Renal Division, Renji Hospital
Shanghai Jiaotong University School of Medicine
No.145 Middle Shandong Rd, Shanghai, 200001, China
Email: [email protected]
Original
Limited health literacy is associated with low glomerular filtration in the Chronic Renal Insufficiency Cohort (CRIC) study
Ana C. Ricardo, Wei Yang, Claudia M. Lora, Elisa J. Gordon, Clarissa J. Diamantidis, Virginia Ford, John W. Kusek, Amada Lopez, Eva Lustigova, Lisa Nessel, Sylvia E. Rosas, Susan Steigerwalt, Jacqueline Theurer, Xiaoming Zhang, Michael J. Fischer, and James P. Lash
Page No. 30
Abstract
Clinical Nephrology, Vol. 81 – No. 1/2014 (30-37)
Limited health literacy is associated with low glomerular filtration in the Chronic Renal Insufficiency Cohort (CRIC) study
Ana C. Ricardo1, Wei Yang2, Claudia M. Lora1, Elisa J. Gordon3, Clarissa J. Diamantidis4, Virginia Ford2, John W. Kusek5, Amada Lopez1, Eva Lustigova6, Lisa Nessel2, Sylvia E. Rosas7, Susan Steigerwalt8, Jacqueline Theurer9, Xiaoming Zhang2, Michael J. Fischer1,10, and James P. Lash1, on behalf of the CRIC Investigators
1Department of Medicine, University of Illinois at Chicago, Chicago, IL, 2Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PN, 3Feinberg School of Medicine, Northwestern University, Chicago, IL, 4University of Maryland School of Medicine, Baltimore, MD, 5National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, 6Tulane University, New Orleans, LA, 7Department of Medicine, University of Pennsylvania/Philadelphia VA Medical Center, Philadelphia, PN, 8St. John’s Health System, Detroit, MI, 9Division of Nephrology, Department of Medicine, MetroHealth Medical Center, Cleveland, OH, and 10Center for Management of Complex Chronic Care, Jesse Brown VA Medical Center, Chicago, IL, USA
Background: Low health literacy in the general population is associated with increased risk of death and hospitalization. The evaluation of health literacy in individuals with predialysis chronic kidney disease (CKD) is limited. Methods: We conducted a cross-sectional study to evaluate the associations of limited health literacy with kidney function and cardiovascular disease (CVD) risk factors in 2,340 non-Hispanic (NH) Whites and Blacks aged 21 – 74 years with mild-to-moderate CKD. Limited health literacy was defined as a Short Test of Functional Health Literacy in Adults (STOFHLA) score ≤ 22. Outcomes evaluated included estimated glomerular filtration rate (eGFR), 24-hour urine protein excretion, and CVD risk factors. Results: The prevalence of limited health literacy was 28% in NH-Blacks and 5% in NH-Whites. Compared with participants with adequate health literacy, those with limited health literacy were more likely to have lower eGFR (34 vs. 42 mL/min/1.73 m2); higher urine protein/24-hours (0.31 vs. 0.15 g); and higher self-reported CVD (61 vs. 37%); and were less likely to have BP < 130/80 mmHg (51 vs. 58%); p ≤ 0.01 for each comparison. After adjustment, limited health literacy was associated with self-reported CVD (OR 1.51, 95% CI 1.13 – 2.03) and lower eGFR (β –2.47, p = 0.03). Conclusion: In this CKD cohort, limited health literacy was highly prevalent, especially among NH-Blacks, and it was associated with lower eGFR and a less favorable CVD risk factor profile. Further studies are needed to better understand these associations and inform the development of health literacy interventions among individuals with CKD.Correspondence to:
Ana C. Ricardo, MD, MPH
Section of Nephrology, University of Illinois at Chicago
820 South Wood Street, Room 470, Chicago, IL 60616, USA
Email: [email protected]
Original
Cost-effectiveness of antiplatelet therapy to prolong primary patency of hemodialysis graft
Robert Nee, Austin L. Parker, Dustin J. Little, Christina M. Yuan, Jonathan Himmelfarb, Stephen R. Lowe and Kevin C. Abbott
Page No. 38
Abstract
Clinical Nephrology, Vol. 81 – No. 1/2014 (38-51)
Cost-effectiveness of antiplatelet therapy to prolong primary patency of hemodialysis graft
Robert Nee1, Austin L. Parker2, Dustin J. Little1, Christina M. Yuan1, Jonathan Himmelfarb4, Stephen R. Lowe3, and Kevin C. Abbott1
1Department of Nephrology, Walter Reed National Military Medical Center, Bethesda, MD, 2Department of Nephrology, Naval Medical Center Portsmouth, Portsmouth, VA, 3Department of Interventional Radiology, Walter Reed National Military Medical Center, Bethesda, MD, and 4Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA, USA
Introduction: The Dialysis Access Consortium (DAC) study group previously reported that treatment with extendedrelease dipyridamole plus aspirin (DASA) resulted in a significant but clinically modest improvement in primary unassisted arteriovenous graft (AVG) patency. Utilizing DAC published data, the objective of this study is to evaluate the cost effectiveness of antiplatelet interventions aimed at preventing loss of primary AVG patency in hemodialysis (HD) patients. Methods: We performed a cost-utility analysis, using a decision analysis tree model with a 12-month time horizon and a third party payer perspective. Interventions included DASA with and without concurrent aspirin, aspirin alone, and no prophylaxis. The modeled population was defined as adult (≥ 18 years of age) end-stage renal disease (ESRD) patients who had undergone placement of a new AVG in the United States. The outcomes were costs, quality-adjusted life-years (QALY), incremental costeffectiveness ratios, and net monetary benefit. Probabilities were based upon published studies performed by the DAC Study Group while costs of medications and procedures were drawn from public sources. Utilities of health states were derived from published reports and the Short Form 6D (SF-6D) instrument. Results: Aspirin alone is the most cost effective strategy for AVG pharmacologic prophylaxis, as compared to no prophylaxis or DASA with or without concurrent aspirin. The results are robust on multiple scenario analyses using both deterministic and Monte Carlo probabilistic sensitivity analyses. Accounting for both costs and QALY, using aspirin alone to prevent AVG thrombosis can potentially reduce healthcare costs by $24,679,412 per year compared to no aspirin use, at a willingness-to-pay of $50,000/ QALY. Conclusions: Aspirin monotherapy compared favorably to other strategies based on cost per QALY. Our findings support the use of aspirin prophylaxis in HD patients with a new AVG who do not have a contraindication to aspirin.Correspondence to:
Robert Nee, MD
Department of Nephrology
Walter Reed National Military Medical Center
8901 Rockville Pike, Bethesda, MD 20889-5600, USA
Email: [email protected]
Nephrology Education
A case of parathyroid adenoma adjacent to the thoracic spine in a hemodialysis patient
Kentaro Nakai, Hideki Fujii, Koichiro Maeno, Kotaro Nishida, Akira Kobayashi, Jeongsoo Shin, Shigeo Hara and Shinichi Nishi
Page No. 52
Abstract
Clinical Nephrology, Vol. 81 – No. 1/2014 (52-57)
A case of parathyroid adenoma adjacent to the thoracic spine in a hemodialysis patient
Kentaro Nakai1, Hideki Fujii1, Koichiro Maeno2, Kotaro Nishida2, Akira Kobayashi3, Jeongsoo Shin4, Shigeo Hara5, and Shinichi Nishi1
1Division of Nephrology and Kidney Center, 2Department of Orthopedic Surgery, Kobe University School of Medicine, 3Kobayashi Clinic, 4Gojin-kai Motomachi HD Clinic, and 5Department of Pathology, Kobe University School of Medicine, Kobe, Japan
Ectopic parathyroid glands are detected occasionally, especially in cases of recurrent hyperparathyroidism after initial parathyroidectomy. Their ectopic locations usually result from faulty migration during embryogenesis. Ectopic parathyroid glands can be found within the thyroid gland, thymus, mediastinum, carotid sheath, or retropharynx, which lie along the path of their normal migration. Here we report a rare case of parathyroid adenoma adjacent to the thoracic spine in a hemodialysis patient who had undergone parathyroidectomy previously. A 67-year-old woman on maintenance hemodialysis since 1993 developed hyperparathyroidism. She underwent total parathyroidectomy with autotransplantation in 2007. Histological examination of the parathyroid glands showed hyperplasia in three glands and adenoma in one. Serum parathyroid hormone levels gradually increased after a year. Ultrasonography of the neck and upper limbs was negative, but technetium-99-sestamibi scanning showed focal uptake in the posterior mediastinum. Computed tomography and magnetic resonance imaging confirmed a tumor adjacent to the left costovertebral junction of the third thoracic vertebra. A tumor resection was performed in 2010, and histopathological examination showed a parathyroid adenoma. Parathyroid adenoma adjacent to the thoracic spine has not been reported previously, and our case suggests that technetium-9-sestamibi scanning is useful for the correct preoperative diagnosis of such rare cases of ectopic parathyroid glands.Correspondence to:
Kentaro Nakai, MD
Division of Nephrology and Kidney Center
Kobe University School of Medicine
7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
Email: [email protected]
Nephrology Education
Watermelon stomach: a rare cause of anemia in patients with end-stage renal disease
Jayakrishnan Kizhakke Pisharam, Arunachalam Ramaswami, Vui Heng Chong and Jackson Tan
Page No. 58
Abstract
Clinical Nephrology, Vol. 81 – No. 1/2014 (58-62)
Watermelon stomach: a rare cause of anemia in patients with end-stage renal disease
Jayakrishnan Kizhakke Pisharam, Arunachalam Ramaswami, Vui Heng Chong and Jackson Tan
RIPAS Hospital, Brunei Darussalam
Watermelon Stomach or gastric antral vascular ectasia (GAVE) is a rare cause of chronic gastrointestinal blood loss. It has been commonly associated with autoimmune connective tissue and chronic liver disease. It is characterized by endoscopic appearances of erythematous patches secondary to dilated vessels that can be diffusely located or in linear stripes. Histology is characterized by dilated mucosa capillaries with fibrin thrombi and fibromuscular hyperplasia. Unless recognized, the endoscopic findings can be misdiagnosed as severe gastritis. GAVE can be treated using various modalities with variable success. We report four cases of GAVE as the cause of chronic gastrointestinal blood loss in patients with end stage renal disease. A literature review of this rare and interesting entity is presented.Correspondence to:
Dr. Jackson Tan
RIPAS Hospital, Brunei Darussalam
Email: [email protected]
Nephrology Education
Sympathomimetic syndrome, choreoathetosis, and acute kidney injury following “bath salts” injection
Grerk Sutamtewagul, Vineeta Sood, and Kenneth Nugent
Page No. 63
Abstract
Clinical Nephrology, Vol. 81 – No. 1/2014 (63-66)
Sympathomimetic syndrome, choreoathetosis, and acute kidney injury following “bath salts” injection
Grerk Sutamtewagul, Vineeta Sood, and Kenneth Nugent
Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
“Bath salts” is a well known street drug which can cause several cardiovascular and neuropsychiatric symptoms. However, only one case of acute kidney injury has been reported in the literature. We present a case with sympathomimetic syndrome, choreoathetosis, gustatory and olfactory hallucinations, and acute kidney injury following the use of bath salts. A 37-year-old man with past medical history of hypertension and depression was brought to the emergency center with body shaking. Three days before admission he injected 3 doses of bath salts intravenously and felt eye pain with blurry vision followed by a metallic taste, strange smells, profuse sweating, and body shaking. At presentation he had a sympathomimetic syndrome including high blood pressure, tachycardia, tachypnea, and hyperhydrosis with choreoathetotic movements. Laboratory testing revealed leukocytosis and acute kidney injury with a BUN of 95 mg/ dL and a creatinine of 15.2 mg/dL. Creatine kinase was 4,457 IU/dL. Urine drug screen is negative for amphetamine, cannabinoids, and cocaine; blood alcohol level was zero. During his ICU stay he became disoriented and agitated. Supportive treatment with 7.2 liters of intravenous fluid over 3 days, haloperidol, and lorazepam gradually improved his symptoms and his renal failure. Bath salts contain 3,4-methylenedioxypyrovalerone, a psychoactive norepinephrine and dopamine reuptake inhibitor. Choreoathetosis in this patient could be explained through dopaminergic effect of bath salts or uremic encephalopathy. The mechanism for acute kidney injury from bath salts may involve direct drug effects though norepinephrine and dopamine-induced vasoconstriction (renal ischemia), rhabdomyolysis, hyperthermia, and/or volume contraction.Correspondence to:
Vineeta Sood, MD
Department of Internal Medicine
Texas Tech University Health Sciences Center
3601 4th Street, Lubbock, TX 79430, USA
Email: [email protected]
Nephrology Education
Measurements of procalcitonin facilitate targeting of endotoxin adsorption treatment in febrile neutropenic patients suffering from shock
Masaki Hara, Ken Tsuchiya, Kosaku Nitta and Minoru Ando
Page No. 67
Abstract
Clinical Nephrology, Vol. 81 – No. 1/2014 (67-70)
Measurements of procalcitonin facilitate targeting of endotoxin adsorption treatment in febrile neutropenic patients suffering from shock
Masaki Hara1,2, Ken Tsuchiya2, Kosaku Nitta2, and Minoru Ando1,2
1Department of Nephrology, Tokyo Metropolitan Komagome Hospital, and 2Department IV, Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
Immediate initiation of hemoperfusion treatment with polymixin B immobilized fiber (PMX-DHP) is a potent strategy to improve hemodynamics in septic patients with critical circulatory failure. However, it is often difficult to accurately and rapidly differentiate between bacterial infections and non-infectious causes of shock in acutely critically-ill patients. Procalcitonin (PCT) measurements may assist in the early identification of bacterial infection/sepsis and determination of severity in such patients. We present two febrile neutropenic (FN) patients who developed severe shock after chemotherapy for hematological malignancies. PCT levels were markedly elevated in both patients (≥ 10 ng/ml), suggesting a high likelihood of bacterial infectious etiology as the cause of their shock, and thus they were promptly treated with PMX-DHP. Measurements of PCT may facilitate targeting of PMX-DHP treatment among FN patients suffering from shock, which may lead to better prognosis. Correspondence to:
Minoru Ando, MD, PhD
Division of Nephrology
Tokyo Metropolitan Komagome Hospital
3-18-22, Honkomagome, Bunkyo-Ku, Tokyo, 1138677, Japan
Email: [email protected]
Letter to the Editor
Circulating levels of interleukin-22 in dialysis patients
Vincenzo Savica, Domenico Santoro, Carmela Giuseppina Condemi, Selene Imbesi, Salvatore Saitta, Valeria Tigano, Mariateresa Cristani, Guido Bellinghieri1 and Sebastiano Gangemi
Page No. 71
Abstract
Clinical Nephrology, Vol. 81 – No. 1/2014 – Letter to the editor
Circulating levels of interleukin-22 in dialysis patients
Vincenzo Savica1, Domenico Santoro1, Carmela Giuseppina Condemi1, Selene Imbesi2, Salvatore Saitta2, Valeria Tigano2, Mariateresa Cristani3, Guido Bellinghieri1 and Sebastiano Gangemi2,4
1Chair of Nephrology and Dialysis, Department of Clinical and Experimental Medicine and Pharmacology, 2School and Division of Allergy and Clinical Immunology, Department of Human Pathology, 3Department Farmaco-Biologico, School of Pharmacy, University of Messina, Messina, and 4Institute of Biomedicine and Molecular Immunology “A. Monroy” (IBIM), Consiglio Nazionale delle Ricerche (CNR), Palermo, Italy
Correspondence to:
Domenico Santoro, MD
Unit of Nephrology and Dialysis
University of Messina
Via Faranda, 2-98123 Messina, Italy
Email: [email protected]
