Barbara G. Delano

Pilot Study of Probiotic Dietary Supplementation for Promoting Healthy Kidney Function in Patients with Chronic Kidney Disease

IntroductionUremic syndrome consists of nitrogenous waste retention, deficiency in kidney-derived hormones, and reduced acid excretion, and, if untreated, may progress to coma and eventual death. Previous experience suggests that oral administration of a probiotic formulation of selected microbial strains may extend renoprotection via intraintestinal extraction of toxic waste solutes in patients with chronic kidney disease (CKD)stages 3 and 4. This report presents preliminary data from a pilot study.MethodsThis was a 6-month prospective, randomized, double-blind, placebo-controlled crossover trial of a probiotic bacterial formulation conducted in four countries, at five institutions, on 46 outpatients with CKD stages 3 an nd 4: USA (n=10), Canada (n=113), Nigeria (n=115), and Argentina (n=8). Outcomes were compared using biochemical parameters:blood urea nitrogen (BUN), serum creatinine, and uric acid. General well-being was assessed as a secondary parameter by a quality of life (QQOL) questionnaire on a subjective scale of 1–10.ResultsOral ingestion of probiotics (90 billion colony forming units [CFUs]/day) was well tolerated and safe during the entire trial period at all sites. BUN levels decreased in 29 patients (63%, P<0.05), creatinine levels decreased in 20 patients (43%, no statistical significance), and uric acid levels decreased in 15 patients (33%, no statistical significance). Almost all subjects expressed a perceived substantial overall improvement in QOL (86%, P<0.05).ConclusionThe main outcomes of this preliminary trial include a significant reduction of BUN, enhanced well-being, and absence of serious adverse effects, thus supporting the use of the chosen probiotic formulation for bowel-based toxic solute extraction. QOL and BUN levels showed statistically significant differences in outcome (P<0.05) between placebo and probiotic treatment periods at all four sites (46 patients). A major limitation of this trial is the small sample size nd elated inconsistencies.

Exercise in Hemodialysis Patients after Treatment with Recombinant Human Erythropoietin

To assess the effect of substantial increases in blood hemoglobin (Hb) caused by treatment with recombinant human erythropoietin (rhEPO) on exercise capacity in maintenance hemodialysis patients, we evaluated 10 patients (7 men and 3 women) at a mean age of 44.3 +/- 8.4 years on maintenance hemodialysis for a mean of 29.7 +/- 30.2 months by treadmill exercise to exhaustion. The patients were tested before administration of rhEPO and after a minimum 1 g/dl rise in Hb. With a change in Hb from 7.1 +/- 1.4 to 9.8 +/- 2.1 g/dl, peak oxygen consumption (VO2 peak) with exercise increased 50.3 +/- 9% (T1 = 15.1 +/- 5.3, T2 = 22.7 +/- 4.6 ml O2/kg/min, p less than 0.05). Respiratory exchange ratio (RER) at a given submaximal exercise level (3 mph, 6% of elevation) decreased significantly (T1 = 1.13 +/- 0.24, T2 = 0.92 +/- 0.08, p less than 0.05). The rhEPO-mediated increase in Hb was associated with an increased VO2 peak--an improvement of the peak exercise capacity and a reduced submaximal RER--reflecting a reduction in anaerobic metabolism at activities of daily living.

Pragmatic Realities in Uremia Therapy

The present status and future prospects of uremia therapy in the United States are reviewed. Approximately 3500 renal transplants were done in 1976 as compared to 3700 in 1975. Functional two-year survival of grafts has not changed recently (40 to 45 per cent for cadaver donors; 70 to 75 per cent for siblings), but patient survival with cadaver grafts continues to improve (now 65 per cent at two years). Patients on hemodialysis in facilities are increasing rapidly. Only 13 per cent are on home dialysis, as compared with nearly 40 per cent five years ago. Home patients do at least as well as those in centers (80 per cent two-year survival) and cost 40 per cent less. Physician bias probably explains the trend to center dialysis, but pending legislation may provide new incentives for home treatment. Prospects for technical advances are good, but a greater federal investment in research and development is needed. Dollars saved on the center dialysis could be used for this purpose.

A multicenter study of noncompliance with continuous ambulatory peritoneal dialysis exchanges in US and Canadian patients

Recent evidence suggested that noncompliance (NC) with continuous ambulatory peritoneal dialysis (CAPD) exchanges may be more common in US than in Canadian dialysis centers. This issue was investigated using a questionnaire-based method in 656 CAPD patients at 14 centers in the United States and Canada. NC was defined as missing more than one exchange per week or more than two exchanges per month. Patients were ensured of the confidentiality of their individual results. Mean patient age was 56 +/- 16 years, 52% were women, and 39% had diabetes. The overall admitted rate of NC was 13%, with a rate of 18% in the United States and 7% in Canada (P < 0.001). NC was more common in younger patients (P < 0.0001), those without diabetes (P < 0.001), and employed patients (P < 0.05). It was also more common in black and Hispanic than in Asian and white patients (P < 0.001). NC was more common in patients prescribed more than four exchanges daily (P < 0.0001) but was not affected by dwell volume. On multiple regression analysis, the independent predictors of NC, in order of importance, were being prescribed more than four exchanges per day, black race, being employed, younger age, and not having diabetes. Being treated in a US unit did not quite achieve significance as a multivariate independent predictor. These findings suggest that NC is not uncommon in CAPD patients and is more frequent in US than in Canadian patients. However, country of residence is less powerful as a predictor of NC than a variety of other demographic and prescription factors.

Deficiency of serum ionized magnesium in patients receiving hemodialysis or peritoneal dialysis

Serum total magnesium (TMg) measurements in dialysis patients are variable, with some groups reporting hypermagnesemia and some hypomagnesemia. It had not been possible to measure the biologically active fraction, ionized magnesium (IMg2+). The authors utilized an ion-selective electrode to measure IMg in 26 hemodialysis patients and 10 peritoneal dialysis (CAPD) patients and compared the results with those from 66 age matched control subjects. Dialysate magnesium was 0.375 mM/L for the hemodialysis and 0.25 mM/L for the CAPD patients. When compared with control subjects, both hemodialysis and CAPD patients had significantly lower IMg2+ (0.55 +/- 0.02 and 0.50 +/- 0.02 vs. 0.60 +/- 0.004 mM/L; p < 0.05) and greater or normal TMg values (0.99 +/- 0.04, different at the p < 0.001 level, and 0.85 +/- 0.04 vs. 0.84 +/- 0.008). Ionized calcium (ICa2+) values were similar for all three groups (1.15 +/- 0.02 and 1.21 +/- 0.04 vs. 1.17 +/- 0.01), resulting in increased mean ICa2+/IMg2+ ratios (2.14 +/- 0.07 and 2.42 +/- 0.06 vs. 1.95 +/- 0.02 for the control subjects; p < 0.05). The percent of total magnesium that was ionized (%IMg2+) was low in both the hemodialysis and CAPD patients (55.6 +/- 0.93 and 59.2 +/- 1.05) compared with that of control subjects (72 +/- 0.61; p < 0.05). IMg2+ values correlated with TMg values in both hemodialysis (r = 0.93; p < 0.0001) and CAPD (r = 0.92; p < 0.0001) patients did not correlate with age, time on dialysis, weight, fasting cholesterol or triglyceride, albumin, blood urea nitrogen (BUN), creatinine, hematocrit, phosphate, or PTH values.(ABSTRACT TRUNCATED AT 250 WORDS)

Gouty Arthritis in End-Stage Renal Disease: Clinical Course and Rarity of New Cases

We studied 201 end-stage renal disease (ESRD) patients sustained on maintenance hemodialysis (MD) (n = 164) and chronic ambulatory peritoneal dialysis (CAPD) (n = 37) to determine (1) the frequency of acute attacks of gouty arthritis (GA) in those ESRD patients who had GA before dialytic therapy, and (2) the incidence of new-onset GA in hyperuricemic long-term (> 12 years) ESRD patients on MD. The 2-month mean of predialysis serum uric acid levels was calculated for each subject and the prevalence of hyperuricemia ascertained. There were 25 patients on MD for more than 12 years, and this group was evaluated and analyzed separately from those patients on dialytic therapy for less than 12 years; the mean of each of their predialysis uric acid values was calculated for each subject for at least 60% of the time they have been on dialysis. Patients who had GA before or after initiation of dialytic therapy were identified, and the frequency of acute attacks of GA determined. The presence of treated hypertension in each subject was noted. Thirteen of 201 patients had clinically active GA before commencing dialytic therapy, and each recalled a minimum of two painful attacks of GA per year before the initiation of ESRD therapy. Mean duration of ESRD for these 13 patients was 25 +/- 3.8 months; painful attacks of GA have not recurred in nine patients (70%), and the frequency of attacks declined by 50% in the remaining four patients (30%), despite persistent hyperuricemia in all 13.(ABSTRACT TRUNCATED AT 250 WORDS)

Psoriasis Developing De Novo During Hemodialysis

Excerpt To the editor: Uncontrolled trials of dialytic therapy in psoriasis (1-3) have recently indicated remarkable improvement in skin lesions and well being. The rationale for beneficial periton...

Perspectives on the Improvement of Quality of Life with Epoetin Alfa Therapy

Epoetin alfa (recombinant human erythropoietin) effectively diminishes the anemia associated with end‐stage renal disease (ESRD). Although many clinical manifestations of ESRD have been attributed to uremic toxins, the ability of epoetin alfa therapy to improve several of these conditions, such as diminished energy levels, appetite, cold tolerance, sexual function, and cognitive abilities, suggests that anemia may be an important factor in uremia‐associated symptoms. Correction of this anemia results in improvements in the patients quality of life. These improvements can be measured by objective criteria such as exercise tolerance tests, or by subjective standards such as patient response to questionnaires. In studies to date, both subjective and objective data show that epoetin alfa therapy significantly improves the quality of life of patients with ESRD.

Predictors of blood pressure control in an urban primary care setting

Despite evidence of decreased cardiovascular disease morbidity and mortality, control of blood pressure is largely suboptimal especially in urban settings. Evaluation of predictors of blood pressure control in these settings is exceedingly important in order to develop strategies for improved outcomes. Methods: We surveyed 259 African–American patients with essential hypertension in an urban primary care setting. Patients were divided into two groups, based on whether blood pressure was controlled, below 140/90 mmHg (n = 181; 70%) or uncontrolled, above 140/90 mmHg (n = 78; 30%). Predictors of blood pressure control were determined using multivariable logistic regression. Results: There were no differences between the two groups in mean age, body mass index or gender. Controlled as compared with uncontrolled patients had a significantly higher percentage of reporting regular exercise (p = 0.01), lower rate of blood pressure medication nonadherence (p = 0.03), were less likely to be prescribed calcium channel blockers (p = 0.01), lower rate of total serum cholesterol (<240 mg/dl; p = 0.03) and lower serum creatinine (p = 0.04). All other factors were similar between the two groups. The odds ratio (OR) of uncontrolled blood pressure was associated with lack of regular exercise (OR: 2.26; 95% confidence interval [CI]: 1.16–4.37; p = 0.02), use of calcium channel blockers (OR 2.30; 95% CI: 1.22–4.32; p = 0.01), total cholesterol greater than 240 mg/dl (OR: 3.10; 95% CI: 1.36–7.00; p = 0.01), and blood pressure medication nonadherence (OR: 1.96; 95% CI: 1.02–3.74; p = 0.01). Conclusion: These data form a basis, and indicate the need for focused interventions to control blood pressure in urban primary care settings.

Part A: Hemodialysis-Clinical Management and Follow Up

World wide, more than 500,000 patients are treated for End Stage Renal Disease. While transplantation and peritoneal dialysis are therapies to be considered, hemodialysis remains the mainstay of treatment. The tremendous and rapid growth of this therapy, which was first reported for the treatment of chronic renal failure in 1960 (1) has made it imperative for all health care providers to become familiar with the care of the dialysis patient. Most of the topics covered in this chapter are dealt with in greater detail in the rest of this book. The following will cover some practical aspects of how to initiate and monitor dialysis in routine and high risk patients