Eid M El-Shafey

Ultrasound-guided internal jugular vein access: comparison between short axis and long axis techniques.

The use of real-time ultrasound (US) is advantageous in the insertion of central venous catheters (CVCs) in adults, especially in whom difficulties are anticipated for various reasons. The aim of the present study was to compare two different real-time 2-dimensional US-guided techniques [short axis view/out-of-plane approach (SAX OOP approach) versus long axis view/in-plane approach (LAX IP approach)] for internal jugular vein (IJV) cannulation. In this prospective study, 90 critical care and hemodialysis patients were assigned for insertion of CVCs using either the real-time US-guided (SAX OOP approach or LAX IP approach) or landmark technique (control group). Failed catheter placement, risk of complications from placement, failure on first attempt at placement, number of attempts until successful catheterization, time to successful catheterization, incidence of central line-associated blood stream infection (CLA-BSI) and demographics of each patient were recorded. There were no significant differences in patients demographic characteristics, side of cannulation (right or left) or presence of risk factors for difficult venous cannulation between the three groups of patients. Cannulation of the IJV was achieved in all patients by using US (SAX OOP and LAX IP approaches) and in 27 of the patients (90%) by using the landmark technique (P = 0.045). Average access time (skin to vein) and number of attempts were comparable between the SAX OOP and the LAX IP approaches while significantly reduced in both US groups of patients compared with the landmark group (P <0.001). In the landmark group, puncture of the carotid artery occurred in 16.7% of the patients, hematoma in 23.3% of the patients, pneumothorax in 3.3% of the patients and CLA-BSI in 20% of the patients, which were all significantly increased compared with the US group (P <0.05). The findings of this study suggest that the SAX OOP and LAX IP approaches were comparable for cannulation of IJV in critical care and hemodialysis patients. Furthermore, both US-guided techniques were superior to the landmark technique for insertion of CVCs.

HLA-G Expression as a Prognostic Indicator in B-Cell Chronic Lymphocytic Leukemia

Background: The expression of human leukocyte antigen (HLA)-G was studied in certain malignancies and its role in escaping from immunosurveillance in cancers was proposed since HLA-G is a non-conventional HLA class I molecule that protects the fetus from immunorecognition during pregnancy. Some particles involved in the regulation of an immune system might represent prognostic value for B-cell chronic lymphocytic leukemia (B-CLL). The identification of novel prognostic factors in B-CLL may help define patient subgroups that may benefit from early therapeutic intervention. Objective: To evaluate the prognostic significance of HLA-G expression in B-CLL patients and its relationship with other well-established prognostic markers. Methodology: Thirty B-CLL patients diagnosed by clinical, morphological and immunophenotyping criteria were studied for HLA-G expression by flow cytometry. The relationship between HLA-G expression and some known prognostic markers was evaluated. Results: HLA-G was expressed in 36.7% of CLL patients at diagnosis, with a mean expression level of 35.31 ± 12.35%. A significant association between HLA-G expression and common prognostic markers of progressive disease was detected. The group of patients with positive HLA-G expression showed significantly higher absolute lymphocyte counts and serum levels of LDH and β2-microglobulin, lower platelet counts, positive CD38 expression and advanced stages of Binet clinical staging. Conclusion: The present study demonstrated that HLA-G expression correlates with prognostic markers of a poor B-CLL outcome, mainly Binet clinical staging and CD38 expression by B-CLL cells, which indicates that this parameter may play a role as an important prognosticator of disease progression and consequently targeted therapy in B-CLL.

Plasma Adiponectin Levels for Prediction of Cardiovascular Risk Among Hemodialysis Patients

Adiponectin (ADPN) is an endogenous insulin sensitizing and anti‐inflammatory hormone, released by the adipose tissue. We investigated the clinical and biochemical correlates of plasma ADPN levels and the predictive value of ADPN with respect to survival rates and cardiovascular (CV) events was tested prospectively in a cohort of hemodialysis (HD) patients. We measured baseline ADPN in 110 HD patients, in addition to, 34 healthy subjects to serve as reference group. ADPN levels, were related to different clinical and biochemical cardiovascular risk factors such as increased body mass index (BMI), serum triglycerides (TG), duration of HD, smoking, mean arterial blood pressure (MBP), heart rate (HR), high density (HDL) cholesterol, low density (LDL) cholesterol, serum glucose, hemoglobulin and C‐reactive protein (CRP) levels in HD patients. Plasma ADPN levels were higher (P = 0.000) among HD patients (15.06 ± 3.54 μg/mL) than among reference subjects (6.52 ± 1.07 μg/mL), were independent of age, and higher among women (16.13 ± 3.09 μg/mL) than among men (13.94 ± 3.65 μg/mL). Plasma ADPN levels were inversely related to BMI, TG, CRP and glucose levels. Furthermore, plasma ADPN levels were directly related to HDL‐cholesterol and Kt/V. Plasma ADPN levels were lower (P = 0.000) among patients who experienced new CV events (11.13 ± 2.15 μg/mL) than among event‐free patients (16.82 ± 2.45 μg/mL), and seem to predict cardiovascular outcomes. The inverse relationships between ADPN and several cardiovascular risk factors indicate that ADPN may have a protective role in the prevention of CV events.

Is Serum Cystatin C an Accurate Endogenous Marker of Glomerular Filteration Rate for Detection of Early Renal Impairment in Patients with Type 2 Diabetes Mellitus

Background. Researches have recently reported that serum cystatin C is a more sensitive marker of changes in glomerular filtration rate (GFR) than serum creatinine. We conducted this study to evaluate the significance of serum cystatin C as a more sensitive marker of GFR for early detection of renal impairment in special groups of patients with type 2 diabetes mellitus (DM). Methods. The present study included 40 patients with type 2 DM divided into four equal groups based on their urinary albumin excretion and renal function: group 1 was normoalbuminuric, group 2 was microalbuminuric, group 3 was macroalbuminuric, and group 4 was macroalbuminuric with renal dysfunction. All patients underwent a thorough history, full clinical examination, fasting, and renal function tests. Post-prandial blood glucose levels, glycosylated hemoglobin A1c (HbA1c), proteins, albumin in 24 hr urine, and serum cystatin C were collected. Results. Serum cystatin C and creatinine were significantly higher in macrolbuminuric type 2 diabetic patients with renal dysfunction (group 4: 2.26 ± 1.28, 4.21 ± 2.38 mg/dl, respectively; p < 0.001) than macrolbuminuric type 2 diabetic patients with normal renal function (group 3: 1.04 ± 0.24, 0.96 ± 0.20 mg/dl, respectively), the microalbuminuric group (0.87 ± 0.28, 0.71 ± 0.12 mg/dl, respectively), as well as the normoalbuminuric group (0.55 ± 0.41, 0.60 ± 0.18 mg/dl, respectively). ROC plots demonstrated that area under the curve (AUC) of cystatin C (0.74) was greater than that for creatinine clearance (cr.cl) (0.67) and serum creatinine (s‐cr) (0.74); therefore, the sensitivity and diagnostic accuracy of cystatin c was better than cr. cl., and both were better than s-cr. Serum cystatin C showed significant correlation in groups 2–4 with s-cr, cr.cl, and 24 hr urine albumin, but no correlation was found in group 1. Conclusion. Serum cystatin C is a reliable and easily performed marker for GFR to detect renal impairment in patients with type 2 DM.

The level of C-reactive protein in chronic hemodialysis patients: a comparative study between patients with noninfected catheters and arteriovenous fistula in two large Gulf hemodialysis centers.

Hemodialysis (HD) patients have greater morbidity and mortality when they have a central venous catheter (CVC) rather than an arteriovenous fistula (AVF) access. Inflammation associated with dialysis catheter use and resultant higher C‐reactive protein (CRP) levels could have an independent adverse effect on patient outcomes. In this prospective study, we investigated whether HD catheters induce inflammation independent of infection. We compared the mean levels of the inflammatory marker (CRP) in 67 patients on maintenance HD using noninfected catheters with 86 HD patients using AVFs at Prince Salman Center for Kidney Diseases, Saudi Arabia (KSA), and Jahra Hospital, Kuwait, who met our inclusion criteria. C‐reactive protein levels were measured every 2 months over a period of 6 months using immunoturbidimetric assay. One hundred fifty‐three patients on maintenance HD for more than 6 months were included in the study, with mean age of 52.19 ± 16.06 years; 66% were males and 34% were females. Serial levels of mean CRP were statistically and significantly higher in group with noninfected catheters (1.33, 1.24, and 1.10 mg/dL) compared to those with AVFs (0.65, 0.59, and 0.68 mg/dL) with P value of 0.000. In our study, we found no relation between CRP level and age, sex, hemoglobin, albumin, calcium, phosphorus, and iPTH level in both groups. Hemodialysis patients with a catheter have a heightened state of inflammation independent of infection, and thus our study supports the avoidance of catheters and a timely conversion to AVFs with catheter removal.

Intravenous Alfacalcidol Once Weekly Pulse Therapy for Secondary Hyperparathyroidism in Hemodialysis Patients

Background: This study was carried out to assess the efficacy of intravenous administration of alfacalcidol once weekly versus thrice weekly in patients with poorly controlled secondary hyperparathyroidism. Methods: Thirty-six hemodialysis patients with intact parathyroid hormone (i-PTH) > 31.8 pmol/L were divided into two groups. Eighteen patients (Group 1) were given once weekly alfacalcidol for 6 months. The starting dose was 3 µg, which was increased or decreased by 1 µg per week. Eighteen patients (Group 2) were given thrice weekly alfacalcidol for 6 months. The starting dose was 1 µg, which was increased or decreased by 0.5 µg per dose. The dose was increased or decreased according to serum-corrected calcium (CCa), phosphorus (P), and i-PTH. Serum-CCa and P were measured weekly, whereas serum i-PTH and alkaline phosphatase were determined every month. Results: Intact-PTH reduced significantly ( p < 0.001) from 86 ± 33.20 pmol/L to 31.04 ± 7.77 pmol/L and from 83.64 ± 32.12 pmol/L to 33.09 ± 11.37 pmol/L post-treatment in Groups 1 and 2, respectively. Fifty-six percent of the patients had i-PTH ≤ 31.8 pmol/L at the last observation. Serum alkaline phosphatase reduced significantly ( p < 0.001) from 227.94 ± 129.86 IU/L to 163.17 ± 95.29 IU/L and from 285.39 ± 232.36 IU/L to 202.56 ± 165.84 IU/L post-treatment in Groups 1 and 2, respectively. There were no significant differences in serum levels of CCa, P, or their product. Conclusion: Intravenous alfacalcidol thrice or once weekly is safe and effectively reduced the levels of i-PTH in hemodialysis patients.

Reply to letter to the editor: adiponectin levels in hemodialysis patients.

Dear Editor, Classic risk factors only partly explain the high cardiovascular (CV) risk of hemodialysis (HD) patients (1), and it is now recognized that factors peculiar to chronic uremia, such as anemia and hyperphosphatemia, and “emerging” risk factors, including inflammation, hyperhomocysteinemia and the accumulation of endogenous inhibitors of nitric oxide synthase, such as asymmetric dimethylarginine, and/or unknown risk factors play relevant roles among these patients. Adiponectin (ADPN) is a multifunctional adipokine with favorable effects on glucose and lipid metabolism, insulin resistance and inflammation, and has been shown to play a protective role in experimental models of vascular injury (2). Levels are consistently elevated among patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) (3–5). Of interest, however, epidemiological findings on the association between adiponectin and cardiovascular risk are contradictory, with the initial positive findings (3) being currently questioned by recent studies (6–10). We measured adiponectin levels in a cohort of patients undergoing HD, to clarify its role as an independent CV risk factor. Hemodialysis patients who had been receiving regular dialysis treatment (RDT) for at least 6 months and did not exhibit clinical evidence of heart failure, malignancy, major infections or intercurrent illnesses requiring hospitalization for treatment were eligible for our study. Moreover, 26 patients were receiving antihypertensive drugs (20 received single therapy with angiotensin-converting enzyme inhibitors, AT receptor antagonists, calcium channel blockers, or αor β-blockers, and six received double or triple therapy with various combinations of these drugs). None of our patients was receiving medications for weight loss or fibrates, and/or suffered with obstructive sleep apnea and non-alcoholic fatty liver disease. We do not think it is mandatory to enumerate all drugs or diseases that have a relation with plasma adiponectin level. Besides, ADPN levels were studied in our HD patients to clarify its role as an independent CV risk factor. The independent prognostic power of plasma ADPN levels for death or fatal or nonfatal cardiovascular events was analyzed by using the Cox proportional-hazards models. Variables with independent effects on survival rates were identified by constructing hierarchical models, which included traditional risk factors (age, gender, smoking, diabetes mellitus, systolic pressure, serum cholesterol levels and left ventricular hypertrophy [LVH]), and non-traditional risk factors (duration of RDT, serum albumin levels, hemoglobin levels, and serum C-reactive protein [CRP] values). Plasma ADPN levels seem to predict cardiovascular events/mortality in an adjusted analysis (P = 0.04), and the strength of the association is increased after adjustment to traditional and nontraditional risk factors The present study confirms earlier reports that plasma ADPN is elevated among patients with ESRD compared to the general population, and are related to several risk factors, such as serum triglyceride levels, highdensity lipoprotein (HDL) cholesterol levels, serum glucose levels, body mass index (BMI) and CRP in a way consistent with the hypothesis that this protein has a protective effect in patients at high risk of the cardiovascular complications. More interestingly, ADPN seems to be a strong and independent predictor of cardiovascular outcomes among dialysis patients. In multiple studies, ADPN has been shown to be inversely associated with markers of inflammation including CRP (11,12). ADPN has also been shown to exhibit anti-inflammatory activity in atherosclerotic experimental models (13,14). In this study, the directions of the relationships between ADPN and several metabolic risk factors are all in agreement with the hypothesis that ADPN may have a protective role for the cardiovascular system among HD patients. Relatively higher ADPN levels were associated with better cardiovascular outcomes among HD patients. This is supported by the results of recent studies (3,15–19). Other, adequately powered, studies, however, failed to identify adiponectin as an independent cardiovascular risk factor (6–10). Several explanations exist for these conflicting results including population characteristics (diabetes and CKD), case mix, confounding influences of covariates including inflammation and nutritional status, possibly, variants in the gene encoding ADPN (3) and possible differential retention of the high-molecular-weight ADPN isoformin kidney disease (20,21) In conclusion, plasma ADPN concentrations have been found to be more than twofold increased in hemodialysis patients compared with healthy populations. Furthermore, it may be an independent and inverse predictor of CV risk in HD patients. bs_bs_banner

Hemodialysis Adequacy: A Comparative Multicenter Study Between OCM and Calculated Kt/V from Two Centers in the Gulf

Introduction: Adequate delivered dose of solute removal (as assessed by urea reduction and calculation of Kt/V) is an important determinant of clinical outcome in chronic haemodialysis (HD) patients. This requires both prescription of an adequate dose of HD and regular assessment that the delivered treatments are also adequate. On line conductivity monitoring Kt/V OCM online clearance measurement (OCM) (OCM) -using sodium flux as a surrogate for urea- allows the repeated non-invasive measurement of Kt/V on each HD treatment. Methods: We prospectively studied 131 (63 males, 68 females) established chronic HD patients over 8 weeks period (1048 treatments). A pre and post dialyzer measurement of the conductivity is performed by two mutually independent temperature-compensated conductivity cells equipped with Fresenius 4008 S ® dialysis machines. Urea reduction was measured (once a week) by a single pool calculation using immediate post treatment sampling. No changes were made to any of the dialysis prescriptions over the study period. Values of calculated Kt/V (conventional method with Daugirdas’ formula) Kt/V Dau and simultaneously obtained online Kt/V OCM were compared. Results: There was a statistically significant difference between calculated Kt/V DAU and Kt/V OCM over the study period. The mean calculated Kt/V DAU was 1.459 ± 0.31, and mean OCM was 1.139 ± 0.14 (p = 0.000), yet there was moderate correlation between calculated Kt/V DAU and Kt/V OCM (r 2

Upregulation of Monocyte Chemoattractant Protein-1 (MCP-1) in Early Diabetic Nephropathy in Patients with Type-1 Diabetes Mellitus

Background. Monocyte chemoattractant protein-1 (MCP-1) can directly elicit an inflammatory response by inducing cytokine and adhesion molecule expression in the kidney. We investigated the role of MCP-1 in the development of early nephropathy in patients with type-1 diabetes mellitus, in addition to the effect of high-dose vitamin E treatment (8 weeks) on early stages of diabetic nephropathy. Methods. This study was carried out on 30 type-1 diabetic patients subdivided into two equal groups according to their urinary albumin excretion, in addition to 10 healthy matched volunteers included as controls. MCP-1, glycated hemoglobin (HbA1c), and albuminuria—before and after vitamin E treatment—were measured in all studied groups. Results. Serum MCP-1 and HbA1c were significantly elevated in patients with microalbuminuria and poor glycemic control (941.67±47.03 pg/mL; 16.95±2.74%) compared to normoalbuminuric diabetic patients (622.73±103.23 pg/mL; 7.23±0.86%), and controls (366.60±129.01; 3.35±0.66) (P=.001), respectively. There was positive correlation between MCP-1 and HbA1c. Both MCP-1 and albuminuria decreased significantly after using high-dose vitamin E treatment, though there was no change in HbA1c in type-1 diabetic patients with early nephropathy. Conclusion. These observations suggest that MCP-1 may be involved in the pathogenesis of diabetic nephropathy. High-dose vitamin E may provide a novel form of therapy for the prevention of microvascular complications in type-1 diabetic patients.