Katarzyna Wyskida

Calcification of coronary arteries and abdominal aorta in relation to traditional and novel risk factors of atherosclerosis in hemodialysis patients

BackgroundProcess of accelerated atherosclerosis specific for uremia increases cardiovascular risk in patients with chronic kidney disease (CKD) and may be influenced by the different structure of arteries. The study assesses the influence of traditional and novel risk factors on calcification of coronary arteries (CAC) and abdominal aorta (AAC) in hemodialysis patients (HD).MethodsCAC and AAC were assessed by CT in 104 prevalent adult HD and 14 apparently healthy subjects with normal kidney function (control group). Mineral metabolism parameters, plasma levels of FGF-23, MGP, osteoprotegerin, osteopontin, fetuin-A, CRP, IL-6 and TNF-α were measured.ResultsCAC and AAC (calcification score ≥ 1) were found in 76 (73.1%) and 83 (79.8%) HD respectively, more frequent than in the control group. In 7 HD with AAC no CAC were detected. The frequency and severity of calcifications increased with age. Both CAC and AAC were more frequently detected in diabetics (OR = 17.37 and 13.00, respectively). CAC score was significantly greater in males. CAC and AAC scores were correlated significantly with pack-years of smoking and plasma osteoprotegrin levels. However the independent contribution of plasma osteoprotegerin levels was not confirmed in multiple regression analysis. Age (OR = 1.13) and hemodialysis vintage (OR = 1.14) were the independent risk factor favoring the occurrence of CAC; while age (OR = 1.20) was the only predictor of AAC occurrence in HD.Conclusions1. AAC precedes the occurrence of CAC in HD patients. 2. The exposition to uremic milieu and systemic chronic microinflammation has more deteriorative effect on the CAC than the AAC.

Daily Magnesium Intake and Hypermagnesemia in Hemodialysis Patients With Chronic Kidney Disease

OBJECTIVE The aim of this study was to evaluate daily magnesium intake and the relation to its serum concentration in hemodialysis (HD) patients with chronic kidney disease (CKD). DESIGN This is a prospective, open-label, cross-sectional clinical study analyzing daily magnesium intake based on nutritional questionnaire. PARTICIPANTS A total of 101 HD patients with CKD were screened for hypermagnesemia. All patients with serum magnesium >1.5 mmol/L were asked to fill in the standard 3-day nutritional questionnaire. The control group consisted of twice as many randomly selected HD patients with serum magnesium concentration <1.5 mmol/L and 20 subjects with normal kidney function on usual diet. RESULTS Mean (±standard deviation) serum magnesium concentration in HD patients was 1.32 ± 0.18 mmol/L. Hypermagnesemia >1.5 mmol/L was found in 17 (16.8%) patients. There was no one case of severe hypermagnesemia (>2.0 mmol/L). The daily intake of magnesium was higher by 31.7% in the group with serum magnesium >1.5 mmol/L. Hypermagnesemia was observed in patients ingesting >281 mg of magnesium daily. In univariate analysis, there was a strong positive correlation between magnesium intake and serum concentration in the whole group (r = 0.870, P < .001). No correlation between Kt/V or residual diuresis and serum magnesium concentration was found. CONCLUSIONS Magnesium consumption is the most important determinant of serum magnesium concentration in HD patients with CKD. Magnesium-containing phosphate binders can be considered in the therapy of hyperphosphatemia in HD patients without hypermagnesemia.

Factors that favor the occurrence of cough in patients treated with ramipril – A pharmacoepidemiological study

Summary Background Dry cough is a common cause for the discontinuation of ramipril treatment. The aim of this pharmacoepidemiological study was to assess the incidence of ramipril-related cough among the Polish population and to characterize patients at risk of experiencing the adverse effect of cough during ramipril treatment. Material/Methods This was a prospective observational study involving 10,380 patients treated with ramipril for a period of no longer than 8 weeks, consisting of 3 visits: baseline, first follow-up (after 4–8 weeks) and second follow-up visit (after 4–8 weeks of cessation of ramipril, conducted only for evaluating coughing patients). Results The incidence of ramipril-related cough was 7.1%. Logistic regression analysis identified female sex (OR=1.35), cigarette smoking (OR=2.50), chronic obstructive pulmonary disease (OR=1.70), asthma (OR=1.60) and previous history of tuberculosis (OR=6.20) to be significantly and independently associated with the onset of ramipril-related cough. Coughing subsided within a period of 2–20 days after ramipril was discontinued. In all patients reporting the appearance of cough within the first 5 days after therapy initiation, the adverse effect subsided after therapy discontinuation. If cough appeared within 6–10 days, it subsided after discontinuation in 81.6% of subjects. Cough persisted in 30.4% of those reporting later onset. Conclusions 1. Female sex, cigarette smoking, COPD, asthma, and previous history of tuberculosis increase the risk of ramipril-related cough. 2. The later the cough occurs during treatment, the less often the drug is the causative agent and the cough and also less likely to disappear after discontinuation of ramipril.

Daily intake and serum concentration of menaquinone-4 (MK-4) in haemodialysis patients with chronic kidney disease.

OBJECTIVES Decreased concentration of menaquinone-4 (MK-4) seems to be an important risk factor of vascular calcification in haemodialysis (HD) patients. Optimal dietary intake, as well as serum MK-4 reference range, in HD has not been determined, yet. The aim of the present study was to assess daily vitamin K1 and MK-4 intakes and their relation to serum MK-4 concentration in HD patients. DESIGN AND METHODS Daily vitamin K1 and MK-4, micro- and macronutrients and energy intakes were assessed using 3-day food diary completed by patients and serum MK-4 concentration was measured by HPLC [limit of quantification (LOQ): 0.055 ng/mL] in 85 HD patients (51 males) and 22 apparently healthy subjects. RESULTS Daily MK-4 intake was significantly lower (by 29%) among HD, while K1 consumption was similar in both groups. Daily MK-4 intake was associated with fat and protein consumption in HD (r=0.43, p<0.001 and r=0.33, p=0.004, respectively). In HD serum MK-4 concentration was more frequently below LOQ (in 41% HD and 5% controls, p<0.001) and in those HD with quantifiable values was lower than in the controls (by 42%). The correlations between MK-4 concentrations and both MK-4 and K1 daily intakes were weaker in HD (r=0.38 and r=0.30 respectively) than in the control group (r=0.47 and r=0.45, respectively). In multiple regression analysis the variability of serum MK-4 concentrations in HD patients was explained by its daily intake. CONCLUSIONS Decreased serum MK-4 concentration in HD patients is caused by lower dietary MK-4 intake, mainly due to diminished meat consumption, and in addition, probably reduced K1 conversion.

N-Terminal Prohormone of Brain Natriuretic Peptide but not C-Terminal Pre-Pro Vasopressin (Copeptin) Level is Associated with the Response to Antihypertensive Therapy in Haemodialysis Patients

Background/Aims: Volume overload, frequently clinically asymptomatic is considered as a causative factor limiting the effectiveness of antihypertensive therapy in haemodialysis (HD) patients. Therefore, the aim of this study was to assess plasma levels of N-terminal fragment of the prohormone brain natriuretic peptide (NT-proBNP) and a C-terminal portion of the precursor of vasopressin (CT-proAVP, copeptin), surrogate markers of volume overload in HD patients in relation to the number of antihypertensive drugs used in the hypertension treatment. Methods: One hundred and fifty adult HD patients (92 males) were enrolled into this study. Clinical data concerning blood pressure (BP) measurements prior haemodialysis session and pharmacotherapy were collected from all patients. In addition to routine laboratory parameters, plasma levels of NT-proBNP and CT-proAVP were measured, and daily sodium and water consumption were estimated with a portion-size food frequency questionnaire. Results: Among 145 (96.7%) hypertensive HD patients, 131 were receiving antihypertensive medication. Despite antihypertensive therapy, 31.0% had inadequate BP control. Plasma concentration of NT-proBNP was associated with systolic (R=0.19; p=0.02) but not diastolic BP values and with the number of received antihypertensive drugs (R=0.21; p=0.01). The highest NT-proBNP values were observed in patients receiving 3 or more antihypertensive drugs. In contrast, no significant correlation was found between plasma CT-proAVP concentrations and BP values as well as and the number of antihypertensive drugs. Receiver operator curve analysis showed that NT-proBNP values over 13,184 pg/mL predicted the use of at least 3 antihypertensive drugs in maximal doses in the therapy of hypertension, similar analyses performed for CT-proAVP showed much less specificity. Conclusions: 1. Increased levels of NT-proBNP seems to be a better biomarker of multidrug antihypertensive therapy requirement than CT-proAVP. 2. Whether estimation of NT-proBNP in these patients will be also better biomarker than copeptin in the prediction of cardiovascular complications related to hypertension needs further investigations.

Pheochromocytoma in pregnancy

Pheochromocytoma occurs with a frequency estimated at 2-7 per 100,000 pregnant women. Unrecognized, and thus untreated pheochromocytoma is associated with very high (40-50%) maternal and fetal mortality. Pheochromocytoma occurs sporadically or as a family trait. Its presence should be suspected in women with paroxysmal or established hypertension, especially before the 20th week of pregnancy, accompanied by headaches and palpitations, and excessive sweating, muscle tremors, vomiting, anxiety, vasomotor disturbances and blurred vision. The variety of clinical presentations and rarity are the cause of not including the disease in differential diagnosis of hypertension in pregnancy. Biochemical tests are essential in the diagnosis of pheochromocytoma, and involving the assessment of methoxycatecholamine urinary excretion. The second step in the diagnostics is magnetic resonance imaging of adrenal glands. Adrenalectomy is the treatment of choice for pheochromocytoma with adrenal location, which depends on the timing of the tumor diagnosis. Conservative treatment for 10-14 days with pharmacological blockade of alpha-adrenergic receptors should precede the surgery. Early diagnosis and properly planned treatment of pheochromocytoma significantly reduces the risk to the mother and fetus.

Novel method of noninvasive ventilation supported therapeutic lavage in pulmonary alveolar proteinosis proves to relieve dyspnea, normalize pulmonary function test results and recover exercise capacity: a short communication

Whole lung lavage (WLL) under general anesthesia with a double-lumen endobronchial intubation has remained standard treatment option for pulmonary alveolar proteinosis (PAP) for over fifty years now. To the best of our knowledge, this is the first description of noninvasive ventilation (NIV) as an innovative alternative, which enables safe and effective treatment. NIV support enabled cost-effective lavage of the most affected segments and resulted in restoration and long-term maintenance of exercise capacity and diffusion, without WLL related hypoxaemia, volume overload, intubation, or mechanical ventilation related complications. The study presents all details of performed procedure, including anesthesia, NIV technique and bronchoscopy, therefore this may be easily implemented into clinical practice at other centers conducting PAP treatment. We assume that presented technique of therapeutic lung lavage (TLL) with NIV support may be considered a novel PAP treatment method, however, target population who will benefit the most from such therapy modification must be assessed in large scale prospective trials.

Hypertension in the course of primary aldosteronism during pregnancy

Hypertension is one of the most common cardiovascular diseases during pregnancy. Primary hyperaldosteronism (PHA) is the most frequent endocrinological, secondary cause of hypertension, rarely diagnosed in pregnant women. In the available literature about 50 cases of PHA in pregnant women have been described. PHA is often a cause of resistant hypertension. PHA can cause life-threatening complications both for the pregnant woman and the fetus. Diagnosis of PHA in pregnancy is difficult due to the antagonistic effect of progesterone on aldosterone, physiological increase of aldosterone release during gestation and frequent normokalaemic clinical course. Typical pharmacological treatment of PHA is limited due to the anti‑androgenic effect of spironolactone, lack of data concerning the safety of eplerenone and limited access to amiloride in Poland. Surgical treatment is a therapeutic option only in early pregnancy. This paper presents the current state of knowledge on diagnostic methods and treatment of PHA in pregnant women and a systematic review of cases described in the literature.