Dimitrie Siriopol

Predictive Value for Galectin 3 and Cardiotrophin 1 in Hemodialysis Patients

Patients with end-stage renal disease (ESRD) have an increased risk of all-cause mortality. The prognostic value of the new cardiac biomarkers, cardiotrophin 1 (CT-1) and galectin 3 (GAL-3), has not yet been defined in hemodialysis (HD) patients. The aim of this study was to determine the use of these novel biomarkers for predicting mortality in HD patients. Plasma GAL-3 and CT-1 concentrations were determined (at baseline) in 88 HD patients followed for 22.2 ± 4.7 months. During the follow-up period, 21 (23.9%) deaths were recorded. According to Cox analysis, the cutoff point for GAL-3 as a predictor of mortality was 23.73 ng/mL, while the cutoff point for CT-1 as a predictor of mortality was 36 pg/mL. In univariate analysis, only GAL-3 >23.73 ng/mL was an independent predictor of mortality (hazard ratio 2.60; 95% confidence interval, 1.09-6.18). In a multivariable Cox proportional hazards model, GAL-3 levels above the cutoff value remained an independent predictor of all-cause mortality. Our data suggest that similar to the general population, GAL-3 is an independent predictor of mortality in HD patients.

Dry weight assessment by combined ultrasound and bioimpedance monitoring in low cardiovascular risk hemodialysis patients: a randomized controlled trial

PurposeFluid overload is associated with adverse outcomes in hemodialysis (HD) patients. The precise assessment of hydration status in HD patients remains a major challenge for nephrologists. Our study aimed to explore whether combining two bedside methods, lung ultrasonography (LUS) and bioimpedance, may provide complementary information to guide treatment in specific HD patients.MethodsIn total, 250 HD patients from two dialysis units were included in this randomized clinical trial. Patients were randomized 1:1 to have a dry weight assessment based on clinical (control) or LUS with bioimpedance in case of clinical hypovolemia (active)-guided protocol. The primary outcome was to assess the difference between the two groups on a composite of all-cause mortality and first cardiovascular event (CVE)—including death, stroke, and myocardial infarction.ResultsDuring a mean follow-up period was 21.3xa0±xa05.6xa0months, there were 54 (21.6%) composite events in the entire population. There was a nonsignificant 9% increase in the risk of this outcome in the active arm (HRxa0=xa01.09, 95% CI 0.64–1.86, pxa0=xa00.75). Similarly, there were no differences between the two groups when analyzing separately the all-cause mortality and CVE outcomes. However, patients in the active arm had a 19% lower relative risk of pre-dialytic dyspnea (rate ratio—0.81, 95% CI 0.68–0.96), but a 26% higher relative risk of intradialytic cramps (rate ratio—1.26, 95% CI 1.16–1.37).ConclusionsThis study shows that a LUS–bioimpedance-guided dry weight adjustment protocol, as compared to clinical evaluation, does not reduce all-cause mortality and/or CVE in HD patients. A fluid management protocol based on bioimpedance with LUS on indication might be a better strategy.

Value of bioimpedance analysis estimated “dry weight” in maintenance dialysis patients: a systematic review and meta-analysis

AbstractBackgroundVolume overload is a common complication in patients with end-stage kidney disease who undergo maintenance dialysis therapy and associated with hypertension, left ventricular hypertrophy and mortality in this population. Although bioimpedance analysis (BIA), an objective method to assess overhydration, is associated with poor outcomes in observational studies, in randomized controlled trials (RCTs) the results were conflicting. We have examined the role of BIA for assessing the “dry weight” and fluid status in order to improve fluid overload in comparison with a control or clinical-based prescription in patients with ESKD receiving haemodialysis or peritoneal dialysis.nMethodsAll RCTs and quasi-RCTs in which BIA was used to improve fluid overload and assess the effect on all-cause mortality, cardiovascular morbidity, systolic blood pressure and volume control and arterial stiffness were included.ResultsSeven RCTs with 1312 patients could be included in this review. In low-to-medium quality of the evidence, the use of BIA did not reduce all-cause mortality (relative risk 0.87, 95% CI 0.54–1.39) and had small to no effect on body change, but it improved systolic blood pressure control (mean difference (MD) −2.73xa0mmHg, 95% CI −5.00 to −0.46xa0mmHg) and reduce overhydration, as measured by BIA, with 0.43xa0L [(MD), 95% CI 0.71–0.15xa0L].ConclusionIn ESKD patients, BIA-based interventions for correction of overhydration have little to no effect on all-cause mortality, whereas BIA improved systolic blood pressure control. Our results should be interpreted with caution as the size and power of the included studies are low. Further studies, larger or with a longer follow-up period, should be performed to better describe the effect of BIA-based strategies on survival.

Real-World Impact of Cardiovascular Disease and Anemia on Quality of Life and Productivity in Patients with Non-Dialysis-Dependent Chronic Kidney Disease

IntroductionPatients with chronic kidney disease (CKD) have an increased risk of comorbid conditions, including cardiovascular disease (CVD). Anemia is prevalent in the CKD population and worsens as kidney function declines, resulting in a diminished quality of life and increased morbidity/mortality. The purpose of this secondary analysis was to determine the real-world prevalence of CVD among patients with non-dialysis-dependent CKD (NDD-CKD), with and without comorbid anemia, and to assess the impact of these conditions on quality of life (QoL) and work productivity.MethodsData were drawn from the Adelphi CKD Disease-Specific Programme, conducted in France, Germany, Italy, Spain, and the UK (2012). Anonymized data were collected via patient record forms and patient-completed questionnaires. Patient data were stratified by anemic status and the presence of CVD comorbidity.ResultsData were collected by physicians for 1993 patients, of whom 867 completed a patient-completed questionnaire. A total of 61.4% of patients had anemia, and the prevalence of anemia increased with CKD stage. Patients with anemia had a higher mean number of cardiovascular comorbidities than non-anemic patients (1.27 vs 0.95, respectively; Pxa0<xa00.001). The presence of cardiovascular conditions was associated with a significantly reduced QoL (EuroQol EQ-5D-3L visual analog scale: coefficient, −5.68 in anemic patients; Pxa0=xa00.028) and work productivity and activity impairment (WPAI activity impairment: coefficient, +8.04 in anemic patients; Pxa0=xa00.032), particularly among anemic patients.ConclusionsThe presence of anemia in this cohort of NDD-CKD patients was high. The presence of concomitant cardiovascular conditions was more common in NDD-CKD patients with comorbid anemia, and was associated with reduced QoL and work productivity outcomes.

B-lines score on lung ultrasound as a direct measure of respiratory dysfunction in ICU patients with acute kidney injury

PurposeFluid overload is frequently found in critically ill patients with acute kidney injury (AKI) and is associated with adverse outcomes. Lung ultrasonography (LUS) and bioimpedance spectroscopy (BIS) are potentially useful tools for the noninvasive volume assessment. We evaluated the utility of these measures, alone or in combination, in estimating the PaO2/FiO2 ratio in critical patients with AKI.MethodsIn a prospective pilot observational study we included 45 patients who presented on admission or developed at any time during intensive care unit stay AKI defined according to KDIGO criteria. Patients were studied at baseline and after 48xa0h with LUS, BIS and arterial blood gas.ResultsIn the univariable analysis, the PaO2/FiO2 ratio was negatively correlated with the B-lines score, and this association was maintained even after adjustments. A cutoff value of 17 for the B-lines score has a sensibility of 76% and a specificity of 65% in identifying patients with PaO2/FiO2xa0<xa0300.ConclusionLUS can be used for functional lung evaluation and identification of patients with increase pulmonary water content and decrease PaO2/FiO2 ratio.

Use of Lung Ultrasound for the Assessment of Volume Status in CKD

Adequate assessment of fluid status is an imperative objective in the management of all types of patients in cardiology, intensive care, and especially nephrology. Fluid overload is one of the most common modifiable risk factors directly associated with hypertension, heart failure, left ventricular hypertrophy, and eventually, higher morbidity and mortality risk in these categories of patients. Different methods are commonly used to determine fluid status (eg, clinical assessment, natriuretic peptide concentrations, echocardiography, inferior vena cava measurements, or bioimpedance analysis). In recent years, lung ultrasonography (LUS), through the assessment of extravascular lung water, has received growing attention in clinical research. This article summarizes available studies that compare LUS with other methods for fluid status assessment in patients with kidney diseases. At the same time, it also presents the association of LUS with different outcomes (physical functioning, mortality, and cardiovascular events) in the same population. It appears that this simple bedside noninvasive technique has significant clinical potential in nephrology.

The Effects of Bariatric Surgery on Renal Outcomes: a Systematic Review and Meta-analysis

Background/ObjectiveAlthough promising, data regarding the renal impact and safety of bariatric surgery (BS) are insufficient. We aimed at investigating the benefits and harms of BS for weight loss on kidney function.MethodsA systematic review and meta-analysis of observational studies reporting data about the impact of BS (any techniques) on serum/plasma creatinine, creatinine clearance, glomerular filtration rate (GFR), proteinuria, nephrolithiasis, and need for renal replacement therapy (RRT)) was performed. Obese adults (non-chronic kidney disease (CKD), CKD or transplanted patients) that underwent BS for weight loss were included. After searching MEDLINE (inception to August 2017), the Cochrane Library (Issue 10–12, October 2017), and the websiteclinicaltrials.gov (August 2017), data were extracted and summarized using a random-effects model.ResultsThe final analysis included 23 cohort studies, comprising 3015 participants. Compared with renal function before treatment, BS significantly decreased serum creatinine level (mean difference (MD), −u20090.08xa0mgxa0dl−1; 95% confidence interval (CI), −u20090.10 to −u20090.06); pu2009<u20090.001) and proteinuria (MD, −u20090.04xa0gxa024xa0h−1; 95% CI, −u20090.06 to −u20090.02; pu2009<u20090.001) in the overall group. GFR significantly improved 6xa0months or more after BS both in the hyperfiltration and CKD subgroups. Renal function also tended to improve in renal transplant patients. Data on nephrolithiasis and the need for RRT were scarce or not reported.ConclusionsBS apparently has positive effects on kidney function and tends to normalize GFR across different categories of renal impairment (hyperfiltration and CKD patients).

Arterial stiffness mediates the effect of salt intake on systolic blood pressure: XXXX

Accumulating evidence indicates that higher levels of salt intake are associated with higher blood pressure levels. The aim of our analysis was to test the hypothesis that the effect of urinary sodium excretion (UNaV) on systolic blood pressure (SBP) is mediated through estimated glomerular filtration rate (eGFR) and arterial stiffness and also to test the direction of the relationship between eGFR and arterial stiffness, in both hypertensive and normotensive patients. We assessed the potential for connection between UNaV and SBP and mediators (eGFR and pulse wave velocity [PWV]) of this relationship using structural equation models of data from 1599 adults ≥18 years of age and without chronic kidney disease who participated in the Third Epidemiologic Study concerning the Prevalence of Arterial Hypertension and Cardiovascular Risk in Romania (SEPHAR III). In hypertensive patients, the indirect effect, mediated through PWV, of UNaV on SBP was 23.9% and 27.7% of the total effect of UNaV on SBP, while in normotensive patients the contribution of PWV to the total effect of UNaV on SBP was slightly lower (15.9% and 18.3% of the total effect of UNaV on SBP). Taken together, our findings support the conclusion that UNaV influences SBP, both directly and indirectly, through the effect on PWV.

Variations of the renal function parameters in rectal cancer patients with a defunctioning loop ileostomy

PurposeThe objective of this study is to investigate the impact of the temporary loop ileostomy on renal function and also to assess the factors associated with the change in renal function observed between the index surgery (the moment of the radical surgical procedure) and the closure of the ileostomy (the moment of the secondary surgical act of suppression of the ileostomy).MethodsA total of 69 rectal cancer patients from a single referral surgical unit who had a loop ileostomy during low anterior resection of the rectum were included in this study. Serum creatinine levels were evaluated, and estimated glomerular filtration rate (eGFR) was calculated prior to index surgery and closure of the ileostomy.ResultsDuring this time interval, there was a significant decrease in eGFR levels (mean difference −u20094.5xa0mL/min/1.73xa0m2, 95% CI −u20097.8 to −u20091.3xa0mL/min/1.73xa0m2), and also a significant increase in the serum creatinine values (mean difference 0.07, 95% CI 0.02–0.12xa0mg/dL). The eGFR decrease was more pronounced in diabetic patients, in those with a baseline Charlson Comorbidity Index scoreu2009≥u20091 or in those that received chemotherapy. In a multivariable regression analysis, the use of neoadjuvant chemotherapy was the only variable significantly associated with the change in eGFR levels between the two surgical interventions.ConclusionRenal function impairment is an important event that the surgeon has to take into consideration when deciding upon opting for a loop ileostomy to temporarily defunction a colorectal anastomosis.

Salt Intake and Immunity

Increased salt intake has been associated with cardiovascular disease,1 and it has been suggested that reductions in dietary salt could substantially reduce cardiovascular events and medical costs and, therefore, should be a public health target.2 The relationship between salt intake and cardiovascular diseases involves the complex interplay of several factors that include age, sex, the renin–angiotensin–aldosterone and kallikrein–kinin systems, sympathetic nervous system activity, endothelial function, and redox balance.3 In addition, it is now recognized that the immune system plays an active role in the development and progression of hypertension, and salt intake not only drives hemodynamic changes but is also associated with changes in the immune responses. Here we review the evidence that indicates that salt intake modulates immune function and salt-driven proinflammatory reactivity induces vascular endothelial dysfunction, immune cell activation, and cytokine secretion, all of which are central characteristics of hypertensive cardiovascular disease.nnEndothelial dysfunction is one of the central characteristics of hypertension and is associated with overexpression of leukocyte adhesion molecules and local inflammation. In spontaneously hypertensive rats, overexpression of ICAM-1 (intercellular adhesion molecule-1), MCP-1 (monocyte chemotactic protein-1), and macrophage adhesion ligand-1 (a cell-surface protein expressed in most leukocytes) has been demonstrated in association with increased monocyte endothelial adhesiveness. These findings play a role in end-organ damage.4–7 Takahashi et al4 studied changes in leukocyte adhesiveness induced by sodium intake in Dahl salt–sensitive rats. They examined adhesion of leukocytes to retinal vessels using acridine orange fluoroscopy and scanning laser ophthalmoscope and followed the expression of adhesion molecules in the kidney. After only 3 days of a diet with 8% NaCl, before hypertension developed, leukocyte adhesion was increased in association with increments in mRNA synthesis of MCP-1 and ICAM-1 in the kidney. Anti-CD18 antibodies inhibited these early effects of high salt intake and …