Masayuki Okazaki

Erythropoietin Resistance Index and the All-Cause Mortality of Chronic Hemodialysis Patients

Background: Evidence suggests hemodialysis (HD) patients with resistance to erythropoiesis-stimulating agents (ESA) have a higher mortality rate. We investigated the association between ESA responsiveness and mortality in our HD population. Methods: A prospective cohort study of chronic HD patients was conducted at Jyoban Hospital in Fukushima, Japan. We collected data on patient demographic factors, comorbidities, dialysis vintage, body weight, ESA dose and hemoglobin concentration, as well as data on known risk factors for ESA hyporesponsiveness. The erythropoietin resistance index (ERI) was calculated by dividing the weekly body-weight-adjusted epoetin dose by the hemoglobin concentration. The association between ESA hyporesponsiveness estimated by the highest tertile of ERI and mortality was investigated by using the Cox proportional hazards model with adjustments for demographic factors, comorbidities, dialysis adequacy and serum biochemical data. Results: A total of 248 patients were included as subjects in the cohort, and their overall 2-year mortality rate was 13.3%. According to the results of the Kaplan-Meier analysis, patients with an ERI in the highest tertile had significantly higher mortality than patients with an ERI in the lower two tertiles (p = 0.0121). The highest ERI tertile was associated with higher all-cause mortality in both the unadjusted hazards model (hazard ratio, HR: 4.429; 95% CI: 1.249-15.704) and the adjusted hazards model (HR: 4.204; 95% CI: 1.173-15.065). Conclusions: A higher degree of resistance to ESA in chronic HD patients is associated with increased mortality.

Aortic arch calcification predicts cardiovascular and all-cause mortality in maintenance hemodialysis patients.

Background/Aim: Vascular calcification is associated with cardiovascular risk in maintenance hemodialysis (MHD) patients. Previous reports have shown that simple assessment of aortic arch calcification (AoAC) using plain radiography is associated with cardiovascular mortality in the general population. We conducted a prospective study to investigate factors associated with the presence at baseline and progression of AoAC in MHD patients and examined its prognostic value in a short-term outcome. Methods: We prospectively evaluated chest X-rays in 301 asymptomatic MHD patients. The extent of AoAC was divided into three Grades (0, 1, 2+3). Demographic data including age, gender, dialysis vintage, co-morbidity and biochemical data were assessed and the patients were then followed for 3 years. Results: AoAC was observed in 126 patients (41.9%) as Grade 0, in 112 patients (37.2%) as Grade 1, and in 63 patients (20.9%) as Grade 2 and 3 at baseline. An increase in the severity of calcification was associated with older male patients who had lower serum albumin levels. During the follow-up period of 3 years, multivariate Cox proportional hazards analysis revealed that high-grade calcification was associated with cardiovascular and all-cause mortality. Patients with AoAC were associated with a worse outcome in survival analysis and the grade of AAC also influenced their survival. Moreover, all-cause death rates were significantly higher in the progression groups than in the non-progression groups. Conclusions: The presence and progression of AoAC assessed by chest X-ray were independently associated with mortality in MHD patients. Regular follow-up by chest X-ray could be a simple and useful method to stratify mortality risk in MHD patients.

Geriatric Nutritional Risk Index Is a Simple Predictor of Mortality in Chronic Hemodialysis Patients

Background: Malnutrition is common in hemodialysis (HD) patients, and it is associated with increasing risk of mortality. The geriatric nutritional risk index (GNRI) has been developed as a tool to assess the nutritional risk. The aim of this study was to examine the reliability of the GNRI as a mortality predictor in a Japanese HD cohort. Methods: We prospectively examined the GNRI of 332 maintenance HD patients aged 65.4 ± 13.2, 213 males, and followed up on them for 36 months. The patients were divided into quartiles (Q) according to GNRI values (Q1: <91.6, Q2: 91.7-97.0, Q3: 97.1-102.2, Q4: >102.3). Predictors for all-cause mortality were examined using Kaplan-Meier and Cox proportional-hazards analyses. Results: The GNRI presented a normal distribution. During the follow-up period of 36 months, 76 patients died. The overall mortality at the end of the 3-year observational period was 22.3%. At the 3-year follow-up period, Kaplan-Meier survival rates for all-cause mortality were 72.3, 79.3, 84.9 and 92.6% in Q1, Q2, Q3, and Q4, respectively (p = 0.0067). Multivariate Cox proportional-hazards analysis demonstrated that the GNRI was a significant predictor of adjusted all-cause mortality (HR 0.958; 95% CI 0.929-0.989, p = 0.0073). Conclusions: The results of the present study demonstrate that the GNRI is a strong predictor of overall mortality in HD patients. However, cardiovascular mortality was not associated with GNRI values, and did not differ among the GNRI quartiles. The GNRI score can be considered a simple and reliable marker of predictor for mortality risk in Japanese HD patients.

Relationship between anaemia management at haemodialysis initiation and patient prognosis.

It has been suggested that anaemia management during a transition period to haemodialysis could influence prognosis. In this paper, we have conducted a retrospective investigation on how Hb levels at haemodialysis initiation in patients with chronic kidney disease (CKD) influence the risk of cerebral infarction and cardiovascular events.

Relationship between anemia management at hemodialysis initiation and patient prognosis

It has been suggested that anaemia management during a transition period to haemodialysis could influence prognosis. In this paper, we have conducted a retrospective investigation on how Hb levels at haemodialysis initiation in patients with chronic kidney disease (CKD) influence the risk of cerebral infarction and cardiovascular events.

Effect of Taurine on Hemodiafiltration in Patients With Chronic Heart Failure

Taurine, an important factor in the living body, is essential for cardiovascular function and development and function of skeletal muscle, retina and central nervous system. In the present study, its effect on cardiovascular function was specifically taken into consideration. In hemodiafiltration (HDF) patients, the effect of taurine on patients with chronic heart failure (CHF), in whom dry weight was difficult to control, was evaluated. All patients who were subjected to regular HDF for 4 h three times per week at Joban hospital were included in this study. Patients with chronic heart failure, in whom dry weight was difficult to control (N = 4), were included in the evaluation of clinical status. X‐ray and echocardiography were determined before and after taurine treatment. Almost all patients were taking nitric acid, warfarin, anti‐platelet agents and vasopressors. Because vital signs were unstable in chronic heart failure, all cases withheld antihypertensive drugs during HDF. For unstable vital signs during HDF, pulmonary congestion was chronically recognized. After taurine was started, vital signs stabilized and lowering of dry weight was possible. In addition, X‐ray and cardiac diastolic failure on echocardiography improved. Taurine was effective for CHF patients on HDF in whom dry weight was difficult to control in spite of various medications.

Association between Increases in Normalized Protein Catabolic Rate and Increases in Creatinine Generation Rate in Dialysis Patients

The older dialysis population is growing, and malnutrition and wasting syndrome are great concerns in this population. The management of these syndromes includes appropriate nutritional intake and physical activity. However, whether management in the form of an increase in protein intake has a beneficial effect on muscle mass has not been demonstrated. In this study, we investigated an association between changes of normalized protein catabolic rate (nPCR), as a proxy for protein intake and percent creatinine generation rate (%CGR), as a proxy for muscle mass in patients receiving hemodialysis. Multiple linear regression models were employed, and we included several sensitivity analyses. The results showed that increases in nPCR were associated with increases in %CGR. The association was stronger in patients with baseline %CGR levels below 100%. This was the first study to demonstrate that an increase in dietary protein intake might increase the muscle mass, but this study had certain limitations. Future interventional studies will be needed to investigate whether increases in protein intake have a beneficial effect on sarcopenia, protein-energy wasting, and frailty.

Association Between Risk Factors Including Bone-Derived Biomarkers and Aortic Arch Calcification in Maintenance Hemodialysis Patients

Background/Aims: Aortic arch calcification (AoAC) is frequently detected in maintenance hemodialysis (MHD) patients and is associated with cardiovascular and all-cause mortality. We investigated the factors associated with AoAC and analyzed the relationship between the factors including bone-derived biomarkers and AoAC. Methods: We enrolled 389 stable MHD patients. AoAC was assessed using chest-X ray examination. Demographic data was collected in addition to serum levels of biochemical and bone-derived biomarkers, including sclerostin and fibroblast growth factor-23 (FGF-23). Results: Two hundred sixteen patients (55.5%) had AoAC. Patients with AoAC score ≥ 4 were older, with a higher percentage being male, and exhibited lower serum levels of albumin and triglyceride. Serum FGF-23 levels were inversely associated with AoAC severity, and FGF-23was directly related to vascular calcification. Age, gender, and dialysis vintage were independent predictors of AoAC. Conclusion: MHD patients have a high prevalence of AoAC. The grade of AoAC was dependent on older age in association with longer dialysis vintage. Levels of circulating FGF-23 but not sclerostin were related to AoAC severity. Serum FGF-23 levels were independently associated with AoAC.

Contents Vol. 39, 2015

Annual Congress of the 230 Chinese Blood Purification Center Administration Committee September 25–28, 2014, Guangzhou Guest Editor: Tao Wei (Beijing) Letter to the Editor 238 The Urokinase Lock-Therapy for Hemodialysis Occluded Central Venous Catheters Li Cavoli, G.; Schillaci, O.; Zagarrigo, C.; Servillo, F.; Li Cavoli, T.V.; Palmeri, M.; Rotolo, U. (Palermo)