Peter M. Jehle

Serum levels of insulin-like growth factor (IGF)-I and IGF binding protein (IGFBP)-1 to -6 and their relationship to bone metabolism in osteoporosis patients.

BACKGROUND: Insulin-like growth factor (IGF) system components are important regulators of bone formation. Alterations of individual IGF system components have been described in osteoporosis (OP) patients; however, no study has addressed changes in free IGF-I and in all six IGF binding proteins (IGFBPs). METHODS: A cross-sectional study was performed in 45 OP patients and 100 healthy matched controls. Serum levels of free and total insulin-like growth factor I (IGF-I), IGFBP-1 through -6, intact parathyroid hormone (PTH), 25-OH-vitamin D(3) (25OHD(3)), 1,25-(OH)(2)-vitamin D(3) (1,25-(OH)(2)D(3)), osteocalcin (OSC), bone alkaline phosphatase (B-ALP), and carboxyterminal propeptide of type-I procollagen (PICP) were measured with specific assays. Bone mineral density (BMD) of the lumbar spine was determined by dual-energy X-ray absorptiometry (DEXA). RESULTS: Compared with age- and sex-matched control subjects, OP patients showed a 73% decrease in free IGF-I, a 29% decrease in total IGF-I, a 10% decrease in IGFBP-3, and a 52% decrease in IGFBP-5 levels; they had higher levels of IGFBP-1 (4.1-fold), IGFBP-2 (1.8-fold), IGFBP-4 (1.3-fold), and IGFBP-6 (2.1-fold). Alterations in IGF system components were most evident in 13 OP patients with vertebral fractures in the past 4 years compared to patients without fractures. In OP patients with fractures, the ratio between IGFBP-4 and IGFBP-5 was increased whereas levels of OSC were decreased. CONCLUSIONS: Our data provide strong indirect evidence for a functional connection between circulating IGF system components and bone metabolism and the susceptibility to fractures in OP patients.

Clinical nutrition scores are superior for the prognosis of haemodialysis patients compared to lab markers and bioelectrical impedance

BACKGROUND Malnutrition is closely related to inflammation and atherosclerosis in uraemic patients. There is still debate on how to quantify nutritional status in order to achieve the best prediction of mortality and hospitalization. METHODS Different methods to detect malnutrition were prospectively investigated for their prognostic impact on mortality and hospitalization of haemodialysis (HD) patients. We compared clinical nutrition scores (body mass index, BMI; subjective global assessment, SGA; malnutrition inflammation score, MIS; and nutritional risk screening, NRS) to lab parameters of protein and lipid metabolism, or bioelectrical impedance analysis (BIA) in 90 HD patients. Over a 3-year follow-up, all-cause mortality and hospitalization were evaluated using a Cox regression model. RESULTS The scores SGA, NRS, MIS, serum albumin, prealbumin, transferrin and BIA were predictive of both mortality and hospitalization. Elevated CRP predicted only a significantly higher mortality. After adjustment for age, gender, dialysis vintage and diabetes status, the best prognostic parameters for mortality were the clinical nutrition scores, MIS-Index > or = 10 [HR 6.25 (2.82-13.87), P < 0.001], NRS [HR 4.24 (1.92-9.38), P < 0.001] and SGA B/C [HR 2.70 (1.14-6.41), P < 0.05]. CONCLUSIONS In HD patients, serum markers of protein metabolism and BIA can be used for evaluation of the nutritional status. However, with regard to mortality and hospitalization risk, the individual clinical nutrition scores are superior compared to lab markers and BIA. To confirm malnutrition, we propose using clinical nutrition score generally or at least in the case of two malnutrition-positive parameters (lab, BIA, BMI).

Effects of reduced dialysate calcium on calcium-phosphorus product and bone metabolism in hemodialysis patients.

Background: The safety of using reduced calcium dialysate (RDC) in hemodialysis (HD) patients is controversial due to related changes in bone metabolism. In the present study we investigated whether an 18-month treatment period with RDC may induce significant changes in calcium-phosphorus product (CaxP), bone metabolism, and components of the insulin-like growth factor (IGF) system in HD patients. Study Design: In this prospective study, 13 HD patients with biochemical signs of diminished or low-normal bone turnover and high CaxP due to high serum calcium level were treated by lowering dialysate calcium from 3.5 to 2.5 mEq/l for 18 months. By specific immunometric assays, serum levels of intact parathyroid hormone (PTH), bone alkaline phosphatase (B-ALP), pyridinoline (PYR), desoxypyridinoline (D-PYR), 25-OH-vitamin D3 (25-vit D3), 1,25-(OH)2-vitamin D3 (1,25-vit D3), free IGF-I, IGF-II, and IGF-binding protein (IGFBP)-1 to -6 were measured. Results: CaxP decreased significantly from 5.62 (baseline) to 3.95 mmol2/l2 (at 18 months), whereas PTH increased from 81 ± 57 pg/ml at baseline to 236 ± 188 at 12 months (p < 0.01), remaining in this range thereafter. Parameters of bone resorption (PYR) as well as formation (B-ALP) significantly increased during RDC, with peak levels after 12 months. Despite increasing doses of oral alfacalcidol, levels of 25-vit D3 and 1,25-vit D3 subsequently declined during RDC. In parallel with the changes in bone markers, free IGF-I levels decreased (baseline: 1.9 ± 0.9 ng/ml, after 18 months: 1.1 ± 0.7; p < 0.01). The decline of free IGF-I correlated with decreasing levels of IGFBP-3 and increasing levels of IGFBP-1/-4. Conclusion: The treatment with RDC effectively lowered CaxP and stimulated bone formation and resorption. The different changes in bone markers and IGF system components mirror the complex effects on bone metabolism.

Prevalence of Elevated Liver Enzymes in Adults with Type 1 Diabetes: a Multicenter Analysis of the German/Austrian DPV Database

To assess the prevalence of elevated liver enzymes in adults with type 1 diabetes mellitus (T1DM) in routine clinical care and the association with cardiovascular risk profile in the Diabetes‐Prospective‐Documentation (DPV) network in Germany and Austria.

Ernährung bei Niereninsuffizienz

ZusammenfassungBei Patienten mit chronischer Niereninsuffizienz (CNI) kann die richtige Ernährung nicht nur die Lebensqualität, sondern auch die Prognose entscheidend verbessern. Während die diätetischen Empfehlungen in der Frühphase der chronischen Niereninsuffizienz vor allem auf eine Progressionshemmung abzielen, sollte in fortgeschrittenem Stadium der Niereninsuffizienz in erster Linie auf eine kalorisch ausreichende Ernährung geachtet werden. Die Malnutrition ist eine tückische Komplikation, da sie meist erst im fortgeschrittenen Stadium diagnostiziert wird, aber bereits bei milder Ausprägung die Überlebensrate signifikant verschlechtert. CNI-Patienten haben einen erhöhten Energiebedarf, führen aber in der Regel zu wenig Energie zu. Dies begünstigt eine Protein-Energie-Malnutrition, die bei Prädialyse-Patienten bereits in 20–50% und bei Dialysepatienten in bis zu 70% der Fälle vorliegen kann. Das gleichzeitige Auftreten von Malnutrition, Inflammation und Atherosklerose (MIA-Syndrom) wird bei bis zu 70% der Dialysepatienten beschrieben und ist mit einer besonders hohen Mortalität behaftet.AbstractFor patients with chronic renal failure (CRF), correct nutrition can not only improve the quality of life but also the prognosis. Whereas the diet recommendations in the early phases of chronic renal insufficiency aim to inhibit progression of the disease, in advanced stages of renal failure the main concern is a sufficient caloric nutrition. Malnutrition is an insidious complication, because it is mostly initally diagnosed in advanced stages of CRF but even when mildly present can significantly affect survival. CRF patients have an increased energy requirement but normally supply too little energy. This favors a protein energy malnutrition, which can already be present in 20-25% of predialysis patients and up to 70% of dialysis patients. The simultaneous presence of malnutrition, inflammation and atherosclerosis (MIA syndrome) has been recorded in up to 70% of dialysis patients and is correlated to a particularly high mortality rate.