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Association of Indoxyl Sulfate with Heart Failure among Patients on Hemodialysis

BACKGROUND AND OBJECTIVES Indoxyl sulfate, a protein-bound uremic toxin, may be associated with cardiovascular events and mortality in patients with CKD. This study aimed to investigate the relationship between indoxyl sulfate and heart failure in patients on hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients on hemodialysis for >6 months were enrolled within 6 months. Patients with congestive heart failure, angina pectoris, acute myocardial infarction, cerebral infarction, or cerebral hemorrhage within 3 months before the study or those <18 years old were excluded. The primary end point was first heart failure event during follow-up. RESULTS In total, 258 patients (145 men) with a mean age of 57.0 ± 14.6 years old were enrolled. Median plasma indoxyl sulfate level was used to categorize patients into two groups: the low-indoxyl sulfate group (indoxyl sulfate ≤ 2.35 μg/ml) and the high-indoxyl sulfate group (indoxyl sulfate >32.35 μg/ml). Then, patients were prospectively followed up for a median of 48.0 (interquartile range: 33.5-48.0) months. During follow-up, 68 patients experienced episodes of first heart failure. Kaplan-Meier analysis revealed the incidence of first heart failure event in the high-indoxyl sulfate group was significantly higher than in the low-indoxyl sulfate group (log rank P<0.001). Cox regression analysis showed indoxyl sulfate was significantly associated with first heart failure event (indoxyl sulfate as the continuous variable: hazard ratio, 1.02; 95% confidence interval [95% CI], 1.01 to 1.03; P=0.001; indoxyl sulfate as the dichotomous variable: hazard ratio, 3.49; 95% CI, 1.97 to 6.20; P<0.001). After adjustment for other confounding factors, the results remained significant (indoxyl sulfate as the continuous variable: hazard ratio, 1.04; 95% CI, 1.02 to 1.06; P<0.001; indoxyl sulfate as the dichotomous variable: hazard ratio, 5.31; 95% CI, 2.43 to 11.58; P<0.001). CONCLUSIONS Plasma indoxyl sulfate was associated with first heart failure event in patients on hemodialysis. Whether indoxyl sulfate is only a biomarker or involved in the pathogenesis of heart failure in hemodialysis warrants additional study.

Indoxyl sulfate, a valuable biomarker in chronic kidney disease and dialysis.

Chronic kidney disease (CKD) is an increasingly recognized disease with high global incidence and mortality. Yet, the existing diagnostic tools are not sufficient enough to predict prognosis of CKD and CKD comorbidities. Indoxyl sulfate, a typical uremic toxin, is of great importance in the development of CKD with its nephrotoxicity, cardiovascular toxicity, and bone toxicity. Some reports suggest that indoxyl sulfate directly associate with renal function loss and mortality in CKD patients. This review discusses the diagnostic value of indoxyl sulfate from its biological characteristics, pathophysiological effects, related therapies, and its diagnostic value in clinical studies.

Indoxyl sulfate, a valuable biomaker in chronic kidney disease and dialysis

Chronic kidney disease (CKD) is an increasingly recognized disease with high global incidence and mortality. Yet, the existing diagnostic tools are not sufficient enough to predict prognosis of CKD and CKD comorbidities. Indoxyl sulfate, a typical uremic toxin, is of great importance in the development of CKD with its nephrotoxicity, cardiovascular toxicity, and bone toxicity. Some reports suggest that indoxyl sulfate directly associate with renal function loss and mortality in CKD patients. This review discusses the diagnostic value of indoxyl sulfate from its biological characteristics, pathophysiological effects, related therapies, and its diagnostic value in clinical studies.

24-h residual urine volume at hemodialysis initiation: A possible predictor for acute ischemic stroke incurrence in hemodialyis patients

BACKGROUND Residual renal function (RRF) recently has been confirmed to be a significant predictor of morbidity and mortality in hemodialysis (HD) patients. As RRF is not exactly the same with 24-h residual urine volume, the aim of our study is to evaluate the association of residual urine volume with acute ischemic stroke (AIS) among HD patients. METHODS 282 patients starting chronic HD in our center during January 2005 and December 2008 were enrolled. The clinical data at HD initiation and the occurrence of AIS since starting HD were recorded and obtained from our database. According to the prevalence of AIS, we divided 282 patients into the AIS group (n=69) and non-AIS (n=213) group. RESULTS A total of 69 (24.5%) patients suffered from AIS since HD initiation. Patients with AIS were much older, with more diabetes, had higher levels of hemoglobin, while lower levels of residual urine volume and serum uric acid. In multivariate logistic regression analysis, old age (OR, 1.036; 95% CI, 1.009-1.063; P=0.008), diabetes (OR, 2.385; 95% CI, 1.074-5.294; P=0.033) and 24-h residual urine volume<1290 ml at HD initiation (OR, 2.446; 95% CI, 1.219-4.907; P=0.012) was significant predictors for future AIS occurrence during HD. CONCLUSION This study indicates that residual urine volume levels at HD initiation are inversely associated with AIS risk in future in chronic HD patients. Besides, aging and diabetes should also be noticed for prevention of AIS.

Clinical Factors Associated with Sodium Removal in Peritoneal Dialysis Patients

A cross-sectional study was conducted in 156 clinically-stable peritoneal dialysis patients to identify the factors associated with sodium removal. Serum biochemistry, peritoneal function (modified peritoneal equilibration test [PET]) and the adequacy of dialysis were analysed in relation to sodium removal using multivariate linear regression. Factors significantly affecting peritoneal sodium removal included infusion volume and ultrafiltration volume per 24 h, sodium dip in the first hour of PET and sodium difference between serum and fresh dialysate. Factors significantly affecting total sodium removal included ultrafiltration and urine volume per 24 h, sodium dip in the first hour of PET and sodium difference between serum and fresh dialysate. With traditional dialysate, adequate fluid removal is required to ensure sufficient sodium removal, but a low-sodium dialysate may prevent sodium retention. Sodium removal should be included in evaluation of the adequacy of dialysis.

The Prognostic Value of Red Blood Cell Distribution Width in Patients on Maintenance Hemodialysis.

Aims: To examine the association between red blood cell distribution width (RDW) and mortality in hemodialysis (HD) patients. Methods: Three hundred fifty six patients on HD for >3 months were enrolled and followed for 2 years. Patients were divided into 2 groups according to the median RDW value. Patient survival and risk factors for mortality were investigated. Results: The 2-year survival rate was significantly lower in the high-RDW group (>14.9%; log-rank = 10.00, p = 0.0016). RDW (hazard ratio (HR) 1.34, 95% CI 1.04-1.71, p = 0.021), hemoglobin (HR 0.98, 95% CI 0.96-1.00, p = 0.023) and albumin (HR 0.90, 95% CI 0.82-0.99, p = 0.026) were independent predictors of mortality. Receiver operating characteristic curves of RDW to predict 2-year mortality had an area under the curve of 0.6487 (95% CI 0.5714-0.7260). Conclusions: Abnormal RDW was common in HD patients and significantly related with poor outcomes in these patients.

Clinical status of Sagliker syndrome: a case report and literature review

Abstract In a 53-year-old woman, Sagliker syndrome developed during 22 years of treatment with intermittent hemodialysis as a result of severe secondary hyperparathyroidism (SHPT) complicating end-stage renal disease. She failed medical managements and lost her renal graft just after the kidney transplantation due to acute rejection. Although surgical parathyroidectomy was effective, the parathyroid hormone level became extremely high again due to recurrent hyperparathyroidism. It is possible that such patient could survive long-term with dialysis, but prevention of severe SHPT is the most important.

Value of Abdominal Susceptibility-Weighted Magnetic Resonance Imaging for Quantitative Assessment of Hepatic Iron Deposition in Patients with Chronic Hepatitis B: Comparison with Serum Iron Markers

OBJECTIVE: To assess hepatic iron deposition quantitatively in patients with chronic hepatitis B (HBV) infection, using abdominal susceptibility-weighted magnetic resonance imaging (SWI). METHODS: Patients with HBV infection and healthy controls underwent abdominal SWI and were assessed for serum iron markers. Phase values were measured and five grades of hepatic iron deposition were described by SWI. RESULTS: Patients with HBV infection (n = 327) and healthy controls (n = 50) were prospectively enrolled. In total, 77 (25.4%) patients with HBV infection had hepatic iron deposition as determined by SWI. Phase values were significantly different between patients with hepatic iron deposition compared with patients without hepatic iron deposition or controls, and were significantly different across different grades of hepatic iron deposition. Serum iron, ferritin, transferrin and transferrin saturation were significantly higher in patients with, versus those without, hepatic iron deposition. Only serum ferritin was significantly different across different grades of hepatic iron deposition, and there was a low inverse correlation between serum ferritin and phase values. CONCLUSIONS: Compared with serum iron markers, abdominal SWI may represent a powerful tool to assess hepatic iron deposition quantitatively in patients with chronic HBV infection.

Contents Vol. 42, 2016

121 Selected Abstracts from the 34th Vicenza Course on AKI & CRRT Vicenza, June 7–10, 2016 (available online only)