Nurhan Ozdemir Acar

Long-Term Oral Nutrition Supplementation Improves Outcomes in Malnourished Patients With Chronic Kidney Disease on Hemodialysis

Background: There is no consensus on the type, time of initiation, or duration of use of enteral nutrition in patients with chronic kidney disease (CKD). This study aimed to compare the effects of a renal-specific oral nutrition supplement (RS-ONS) and a standard recommended nutrition regime on biochemical and nutrition markers in malnourished patients with CKD on hemodialysis. Methods: Sixty-two malnourished patients with CKD, divided into experimental (RS-ONS; n = 32; mean [SD] age, 62.0 [11.3] years; 55.2% female) and control (CON; n = 30; mean [SD] age, 57.2 [12.3] years; 31% female) groups, were evaluated for anthropometric, biochemical, and inflammatory parameters. Results: Mean (SD) serum albumin levels were significantly increased in the RS-ONS group from 3.5 (0.3) g/dL at baseline to 3.7 (0.2) g/dL at 6 months (P = .028). Significantly fewer patients had serum albumin levels of <3.5 g/dL after month 6. Dry weight of patients significantly increased in the RS-ONS but decreased in the CON groups (P < .001 for each). Percent change from baseline revealed negative results for bioelectrical impedance analysis (P < .001) in the CON group. Malnutrition inflammation score at 6 months (P = .006) and erythropoietin (EPO) dose requirements were higher in the CON group (P = .012). Conclusions: Our findings indicate that consuming RS-ONS improves serum albumin and anthropometric measures, as well as reduces EPO dose, in patients with CKD.

Differential influence of vitamin D analogs on left ventricular mass index in maintenance hemodialysis patients.

Purpose Secondary hyperparathyroidism (SHPT) is a common feature in maintenance hemodialysis (MHD) patients. Inadequate treatment of SHPT has been associated with cardiovascular complications, and vitamin D therapy might influence the development of cardiovascular diseases. In the present study, we aimed to evaluate the effects of intravenous paricalcitol and calcitriol treatments on left ventricular mass index changes in MHD patients. Methods We conducted an observational study with a 12-month follow-up duration to compare the outcomes of intravenous paricalcitol and calcitriol treatments in MHD patients. Eighty patients with moderate to severe SHPT were enrolled in the study. All the patients had normalized total serum Ca concentration <10.5 mg/dL, serum calcium-phosphorus product (Ca × P) <75, and parathyroid hormone level (PTH) level ≥300 pg/mL at the begining of the follow-up period. Results The patients were divided into a paricalcitol group (n = 40) and a calcitriol group (n = 40). The demographic, clinical, and biochemical characteristics of the patients were similar at baseline. We observed significantly superior control of SHPT; lesser frequency of hypercalcemia and hyperphosphatemia, and Ca × P level elevations; and interruption of vitamin D treatment in the paricalcitol group. Moreover, we found no significant change in left ventricular mass index in the paricalcitol group, but found a significantly increased left ventricular mass index in the calcitriol group during the follow-up period (from 136.6 ± 35.2 g/m2 to 132.9 ± 40.4 g/m2 vs. from 137.2 ± 30.1 g/m2 to 149.4 ± 31.0 g/m2; p<0.044). Conclusion We observed that, compared with calcitriol therapy, paricalcitol therapy reduced the PTH concentrations more effectively without causing hypercalcemia and hyperphosphatemia and might have a substantial beneficial effect on the development of left ventricular hypertrophy.

Association of conicity index and renal progression in pre-dialysis chronic kidney disease.

Abstract Background/objectives: Abdominal fat deposition is represented by means of the conicity index (CI), an anthropometric estimate that models the relative accumulation of abdominal fat. We examined the influence of markers of cardiovascular disease in terms of inflammation and lipid profile and body fat distribution on the progression of renal disease in patients with stable chronic kidney disease (CKD) stages 3–5. Material and methods: We studied 104 pre-dialysis CKD patients (64 males, 62%; age 64.6 ± 14.7 years). Glomerular filtration rate (GFR) was estimated (44.62 ± 14.38 mL/min/1.73 m2) by modification of diet in renal disease formula. GFR values were estimated at baseline and at the end of the 12-month follow-up. Patients were stratified into three groups: group 1 had a loss of GFR ≥20%; group 2 had a loss of GFR 10–20%; and group 3 patients had stable renal functions or GFR change <10% at the end of 12 months. Body mass index (BMI), waist/hip ratio (WHR), and CI were subsequently computed. Renal resistive index (RRI) was measured using Doppler ultrasonography. Results: CI was strongly correlated with total cholesterol (r = 0.37, p < 0.01), low-density lipoprotein (LDL) (r = 0.53, p < 0.01), C-reactive protein (r = 0.21, p < 0.05), and serum potassium (r = 0.216, p < 0.02), whereas BMI and WHR were not associated with these parameters. The values of CI, serum cholesterol, LDL, alkaline phosphatase, alanine aminotransferase, lactate dehydrogenase activity, the degree of proteinuria and microalbuminuria, and RRI were significantly lower in group 3. In linear regression model, LDL (r2 = 0.17, p = 0.02), uric acid (r2 = 0.19, p < 0.01), and RRI (r2 = 0.64, p < 0.01) were independently associated with CI for all groups. Conclusion: CI is an independent predictor of systemic inflammation, cardiovascular risk, and GFR in patients during the pre-dialysis period.

Early Conversion to mTOR Inhibitors Prevents Kidney Function Better Than Late Conversion

Introduction Mammalian target of rapamycin (mTOR) inhibitors are the major alternative immunosuppressive treatment to prevent the adverse effects of calcineurin inhibitor (CNI) based immunosuppressive regimen in kidney transplant (KT) recipients but the timing of conversion to mTOR inhibitors is still a controversial clinical decision. In our study, we aimed to compare the effects of early and late conversion to mTOR inhibitors in our KT recipient population to contribute the data of timing of mTOR inhibitor initiation in patients who were planned to use CNI-free immunosuppressive regimens. Materials and Methods 108 kidney recipients who were converted to mTOR inhibitor based immunosuppressive regimen from CNI-based immunosuppressive regimen were enrolled to our study according to their conversion time. KT recipients who were converted to mTOR inhibitor regimen in the first 12 months after KT were in the early conversion group (Group 1) and KT recipients who were converted to mTOR inhibitor regimen after the first year following KT were in the late conversion group (Group 2). The demographic, clinical and laboratory values of the patients were recorded and patients in both groups were followed-up for 24 months after conversion. Group 1 and Group 2 were compared according to their basic laboratory values, clinical situation and also graft kidney function. Results 32 patients who were converted to mTOR inhibitor based therapy in the first year after KT (Group 1) were compared to 76 patients who were converted to mTOR inhibitor therapy after the first year (Group 2). After 2 years of follow-up of all patients after conversion; serum creatinine levels and 24 hours proteinuria were significantly lower and creatinine clearance and serum high-density lipoprotein levels were significantly higher in the early conversion group compared to late conversion group. Other laboratory values showed no significant difference between two groups. No graft loss was obtained in the 2 years follow-up. Conclusion CNI-based immunosuppressive regimens after KT are still the first choice in the very early period but long-term results are controversial. Until recently, the major adverse effects of CNIs that result with conversion to mTOR inhibitors are malignancy, chronic allograft nephropathy, viral infections and metabolic disturbances. Current studies showed that, early conversion to mTOR inhibitor-based regimens are clearly associated with preserving short and long graft kidney function in the KT recipients. In our study, we determined the early conversion in the first year after KT showed better results compared to late conversion. We suggest that elective conversion to mTOR inhibitors in patients with stable kidney function rather than salvage conversion in patients with worsening kidney function would help maintaining graft kidney and patient survival.

Factors Influencing Hemoglobin Variability and Its Association with Mortality in Hemodialysis Patients

Purpose We aimed to investigate the factors influencing hemoglobin variability with inflammatory and nutritional parameters and its associations with all-cause mortality among hemodialysis patients. Methods One hundred and sixty-nine patients during the entire 12 months were enrolled into the study. Fasting plasma glucose, creatinine, calcium, phosphorus, alkaline phosphatase, parathyroid hormone (PTH), C-reactive protein (CRP), serum iron, serum iron-binding capacity, and transferrin saturation were analyzed. We defined six groups: low, target range, high, low-amplitude fluctuation with low hemoglobin levels, low-amplitude fluctuation with high hemoglobin levels, and high-amplitude fluctuation. Body mass index (BMI), malnutrition-inflammation score (MIS), and Charlson Comorbidity Index were evaluated. Results Hemoglobin variability was significantly correlated with age, platelet count, and number of hospitalization instances and inversely correlated with erythropoietin dose per body surface area. The coefficient of variation of hemoglobin showed a correlation with MIS and ferritin. The absolute level of hemoglobin showed a negative correlation between PTH, CRP, MIS, number of hospitalization instances and a positive correlation with albumin and BMI. High, low, and target-range groups showed survival advantage compared to the other three groups. In regression analysis, age, CRP levels, MIS, and BMI were the predictors of mortality. Conclusion Inflammation and duration of anemia were the major predictors of hemoglobin variability. High-amplitude fluctuation predicts high mortality; on the contrary low-amplitude fluctuations is related to better survival. MIS was independently associated with mortality. This trial is registered with NCT03454906.