Bunyong Phakdeekitcharoen

Sodium thiosulfate delays the progression of coronary artery calcification in haemodialysis patients

BACKGROUND Coronary artery calcification (CAC) is prevalent among haemodialysis patients and predicts cardiovascular mortality. In addition to modifying traditional cardiovascular risk factors, therapy aimed at lowering serum phosphate and calcium-phosphate product has been advocated. Sodium thiosulfate, through its chelating property, removes calcium from precipitated minerals decreasing calcification burden in calcific uraemic arteriolopathy and soft tissue calcification. The effect of sodium thiosulfate on CAC in haemodialysis patients has never been studied. METHODS Eighty-seven stable chronic haemodialysis patients underwent multi-row spiral computed tomography and bone mineral density (BMD) measurement. Patients with a CAC score >or=300 were included to receive intravenous sodium thiosulfate infusion twice weekly post-haemodialysis for 4 months. CAC and BMD were re-evaluated at the end of the treatment course. RESULTS Progression of CAC occurred in 25% and 63% of the patients in the treatment and control group, respectively (P = 0.03). CAC score was unchanged in the treatment group but increased significantly in the control group. BMD of the total hip declined significantly in the treatment group. In multivariate analysis adjusted for factors that influenced CAC progression, therapy with sodium thiosulfate was an independent protective factor (odds ratio = 0.05, P = 0.04). Major side effects were persistent anorexia and metabolic acidosis. CONCLUSIONS The effect of sodium thiosulfate in delaying the progression of CAC is encouraging and will require a larger study. Determination of the safe therapeutic window is necessary in order to avoid bone demineralization.

Prevalence of the metabolic syndrome in Asian women with polycystic ovary syndrome: Using the International Diabetes Federation criteria

Background. Since insulin resistance and compensatory hyperinsulinemia are the major causes of the metabolic syndrome (MS) and are also the main pathophysiology of polycystic ovary syndrome (PCOS), PCOS women are at risk of MS. The aim of the present cross-sectional study was to determine the prevalence of MS in Asian women with PCOS using the International Diabetes Federation (IDF) criteria and to define the risk factors. Methods. One hundred and seventy women with PCOS were enrolled in the study from September 3, 2002 to June 14, 2005. A 75-g oral glucose tolerance test with plasma glucose and serum insulin levels was performed. Also, blood samples were examined for fasting triglycerides, high-density lipoprotein cholesterol and adiponectin levels. Results. The mean (±standard deviation) age, body mass index (BMI) and waist-to-hip ratio were 28.8±5.9 years, 27.1 ± 7.0 kg/m2 and 0.85±0.06, respectively. The prevalence of MS was 35.3%. Age, BMI, waist circumference and all metabolic parameters were higher in PCOS women with MS than in those without MS. MS prevalence increased with age, BMI and insulin resistance as determined by homeostasis model assessment (HOMA-IR), but not with adiponectin after BMI adjustment. Conclusions. According to the IDF criteria, one-third of the PCOS women had MS. This study also showed that age, BMI and HOMA-IR are important risk factors for MS.

The added-up albumin enhances the diuretic effect of furosemide in patients with hypoalbuminemic chronic kidney disease: a randomized controlled study

BackgroundChronic kidney disease (CKD) with edema is a common clinical problem resulting from defects in water and solute excretion. Furosemide is the drug of choice for treatment. In theory, good perfusion and albumin are required for the furosemide to be secreted at the tubular lumen. Thus, in the situation of low glomerular filtration rate (GFR) and hypoalbuminemia, the efficacy of furosemide alone might be limited. There has been no study to validate the effectiveness of the combination of furosemide and albumin in this condition.MethodsWe conducted a randomized controlled crossover study to compare the efficacy of diuretics between furosemide alone and the combination of furosemide plus albumin in stable hypoalbuminemic CKD patients by measuring urine output and sodium. The baseline urine output/sodium at 6 and 24 hours were recorded. The increment of urine output/sodium after treatment at 6 and 24 hours were calculated by using post-treatment minus baseline urine output/sodium at the corresponding period.ResultsTwenty-four CKD patients (GFR = 31.0 ± 13.8 mL/min) with hypoalbuminemia (2.98 ± 0.30 g/dL) were enrolled. At 6 hours, there were significant differences in the increment of urine volume (0.47 ± 0.40 vs 0.67 ± 0.31 L, P < 0.02) and urine sodium (37.5 ± 29.3 vs 55.0 ± 26.7 mEq, P < 0.01) between treatment with furosemide alone and with furosemide plus albumin. However, at 24 hours, there were no significant differences in the increment of urine volume (0.49 ± 0.47 vs 0.59 ± 0.50 L, P = 0.46) and urine sodium (65.3 ± 47.5 vs 76.1 ± 50.1 mEq, P = 0.32) between the two groups.ConclusionThe combination of furosemide and albumin has a superior short-term efficacy over furosemide alone in enhancing water and sodium diuresis in hypoalbuminemic CKD patients.Trial registrationThe Australian New Zealand Clinical Trials Registration (ANZCTR12611000480987)

Aldosterone increases Na+‐K+‐ATPase activity in skeletal muscle of patients with Conn’s syndrome

Objective  In Conn’s syndrome, hypokalaemia normally results from renal potassium loss because of the effect of excess aldosterone on Na+‐K+‐ATPase in principal cells. Little is known about the effect of aldosterone on cellular potassium redistribution in skeletal muscle. Our study determined the effect of aldosterone on muscle Na+‐K+‐ATPase.

Low Hip Bone Mineral Density Predicts Mortality in Maintenance Hemodialysis Patients: A Five-Year Follow-Up Study

Background: Bone loss is common among hemodialysis patients and contributes to mortality. The association between bone loss and vascular calcification may explain the increased mortality risk. Studies on the association between decreased bone mass and mortality in maintenance hemodialysis patients are limited. Methods: Eighty-three hemodialysis patients underwent bone mineral density (BMD) and coronary artery calcification (CAC) measurements. The relationship between BMD and mortality was analyzed after a 5-year follow-up period. Results: Eighty percent of the patients had reduced hip BMD. In univariate Cox regression analyses, age, cardiovascular disease, dyslipidemia, increased CAC score, increased comorbidity score and decreased hip BMD were associated with mortality. Low hip BMD remained independently associated with mortality after adjustments for cardiovascular risk factors, comorbidity score and CAC score. Patients with BMD in the lowest tertile had the worst survival. Conclusion: Low hip BMD predicted mortality in maintenance hemodialysis patients independent of CAC.

Long-term effectiveness of acetazolamide on permanent weakness in hyperkalemic periodic paralysis.

Acetazolamide is commonly used as an empirical treatment for inherited periodic paralyses although some patients may develop deleterious effects. We report a 65 year-old man with hyperkalemic periodic paralysis and late-onset permanent weakness in association with the common T704M mutation in α-subunit, skeletal muscle voltage-gated sodium channel gene. He rapidly recovered from weakness after acetazolamide treatment. Magnetic resonance imaging of thighs comparing pre- and post-treatment revealed a significant increase in muscle bulk. The patient has been without any type of weakness for over 6 years. This data show the remarkable benefit of acetazolamide on permanent weakness of hyperkalemic periodic paralysis in association with the T704M mutation.

Vascular calcification in long‐term kidney transplantation

Vascular calcification (VC) is common among patients with chronic kidney disease (CKD) due to the strong prevalence of cardiovascular and CKD‐related risk factors such as diabetes mellitus (DM), hypertension and phosphate retention. Kidney transplantation improves kidney function and abnormal mineral metabolism at the same time. It remains unclear whether kidney transplantation favourably impacts VC in the long‐term.

Effects of Therapy on Urine Neutrophil Gelatinase-Associated Lipocalin in Nondiabetic Glomerular Diseases with Proteinuria

Urine neutrophil gelatinase-associated lipocalin (NGAL) is widely used as a biomarker for acute kidney injury. Cross-sectional studies have shown that NGAL may be elevated in glomerular diseases, but there is limited information on the value of NGAL in predicting treatment response or on the changes of NGAL levels after therapy. We prospectively evaluated the effects of therapy on NGAL in nondiabetic glomerular diseases. Urine NGAL was collected at biopsy and follow-up at 12 months. At baseline, NGAL in glomerular disease patients (n = 43) correlated with proteinuria, but not with glomerular filtration rate (GFR). After therapy with renin-angiotensin blockers and/or immune modulating agents, change of NGAL correlated with change of proteinuria, but not with change of GFR. NGAL at baseline was not different between patients in complete remission (CR) at follow-up compared to those not in remission (NR). Compared to baseline, NGAL at follow-up decreased in CR (n = 10), but not in NR. Change of NGAL was greater in CR than NR. In conclusion, the change of urine NGAL correlated with the change of proteinuria. Baseline NGAL was not a predictor of complete remission. Future studies will be necessary to determine the role of NGAL as a predictor of long term outcome in proteinuric glomerular diseases.

Aeromonas hydrophila sepsis with septic embolism and rhabdomyolysis in a chronic iron overload haemodialysis patient treated with deferoxamine

Aeromonas infection in humans is associated with certain underlying diseases, especially chronic liver disease or malignancy. However, Aeromonas infection associated with iron overload is rarely reported. We report a case of a 47-year-old female with end-stage renal disease on haemodialysis and on deferoxamine treatment for iron overload who developed Aeromonas sepsis with septic embolism and rhabdomyolysis. Although the patients with Aeromonas infection and rhabdomyolysis have been correlated with high mortality, this reported case survived. We suggest that a chronic haemodialysis patient on deferoxamine treatment for iron overload is vulnerable to Aeromonas infection. In such cases, the clinician should be alerted to the possibility of rhabdomyolsis, and frequent haemodialysis is necessary.

Early ureteric stent removal reduces urinary tract infection in kidney transplant recipients: A randomized controlled trial

Background: Optimal duration for retaining ureteric stent after kidney transplantation was still controversy. We aimed to determine benefits and risks of early versus routine stent removal in kidney transplantation. Methods: 90 patients who underwent kidney transplantation from April 2010-January 2011 were enrolled in single-center randomized controlled, open label, trial. Patients were randomized to early ureteric stent removal (8 day) or routine ureteric stent removal (15 day) groups. The primary outcome was rate of urinary tract infection (UTI) during postoperative to 1 week after discharge. Results: 74 patients (58% living donor) fulfilled the randomized criteria (early remove n = 37; routine remove n = 37). By intention to treat analysis, incidence of UTI in early stent removal was less than routine stent removal group (15/37, 40.5% VS 27/37, 72.9%; Risk reduction 32.4%; 95%CI 11.1 to 53.7%, P = 0.004). The benefit of early ureteric stent removal is demonstrated mostly in living donor subgroup. Probability of UTI was significantly associated with the duration of stent retention. Incidence of urologic complications was not different in both groups. Conclusions: Shortening duration of ureteric stent in kidney transplant recipients from 15 to 8 days is safe. This approach helps to reduce incidence of UTI particularly in living kidney transplantation (Funded by Thai Transplant Society; Trial registration ACTRN12610000310066). Correspondence to: Vasant Sumethkul MD, Department of Medicine, Ramathibodi Hospital, 270 Rama 6 Road, Bangkok 10400, Thailand, E-mail: vasant.sum@mahidol.ac.th