Hemodialysis.com | Kidney Disease | ESRD | Dialysis

Hemodialysis.com
Hemodialysis research, author interviews, dialysis updates and information on chronic
kidney disease and end stage renal failure.

Editor: Marie Benz, MD
info@hemodialysis.com
July 10 2012

Author Interview: Kate Ellingson, PhD,Epidemiologist

Vascular access hemorrhages contribute to deaths among hemodialysis patients
Kidney International , (13 June 2012)

• What are the main findings of the study?
• This study describes fatal instances of vascular access hemorrhage among chronic dialysis patients and is
the first study to examine risk factors for this devastating complication.

• In order to receive life-saving hemodialysis treatment, patients require a catheter, arteriovenous (AV) fistula,
or AV graft. These three types of vascular access are a way to reach the bloodstream in order to remove
toxins from the blood.

• Unfortunately, in rare instances, a problem with the vascular access can cause the site to rupture and bleed
uncontrollably, in some cases, resulting in death. These fatal instances of vascular access hemorrhage
constitute a rare but potentially preventable cause of death in hemodialysis patients.

• The majority of the 88 events reviewed between 2000-2007 in Maryland, District of Columbia and Virginia
involved patients who experienced major hemorrhages at home or in a nursing home, and the majority of
these patients had experienced complications of their vascular access in the six months prior to death.

Read the rest of the interview on Hemodialysis.com

Author Interview:
Hemodialysis.com Author Interview:
Odds of Missed Hemodialysis Sessions Are Increased
During Holiday Periods Among In-Center Hemodialysis Patients

Stephen Crawford ISPOR poster 2012

What are the main findings of the study?
• Hemodialysis.com: What are the main findings of the study?
• The data suggest that there was an increasing trend in the proportion of missed sessions
from 2006 to 2010, particularly during the Thanksgiving and Christmas holiday travel
periods.

• Hemodialysis.com: Were any of the findings unexpected?
• The large increase in the proportion of missed sessions during the 2008 and 2009
Christmas and New Year holidays was not anticipated.
• In contrast, the lower rate during Christmas, 2010 may be due to the shorter period of
observation due to truncation of the data on December 31st, 2010.

• Hemodialysis.com: What should clinicians and patients take away from your report?


Author Interview:

Antibiotic lock solutions allow less systemic antibiotic exposure and less catheter malfunction without
adversely affecting antimicrobial resistance patterns. Hemodialysis International.
A. M. Onder, MD

• We looked at our data by breaking the timeline into three separate periods; no antibiotic lock (ABL)
use, ABL use as needed and ABL use per protocol in the unit.

• By looking at our 10 years retrospective data, we were able to demonstrate that the use of antibiotic locks
(mainly tobramycin-tissue plasminogen activator (TPA) locks) as protocol in our unit, there was a significant
decrease in total systemic antibiotic exposure and the percentage of catheters lost to malfunction.

• This was achieved with similar CRB prevalence between the three ERAs and there was no noted increase
in the infection-related complications.

• Therefore, addendum of ABL to systemic antibiotics for treatment and using them for prevention in the high
risk population offered similar CRB treatment success rates with less exposure to cumulative dose of
systemic antibiotics.


Author Interview:

Pregnancy in CKD: whom should we follow and why?
Barbara Giorgina Piccoli MD


• CKD is a risk factor in pregnancy in all stages. Also stage 1 CKD patients are at increased risk for adverse pregnancy
outcomes, such as Caesarean section, preterm delivery and need for NICU (Neonatal Intensive Care Unit). The risk for adverse
pregnancy related events increases along with the CKD stage.
• Pregnancy is a important occasion for early diagnosis of CKD in stage 1 patients. In our series the prevalence of new diagnosis
was high (over 40%).

• In this study, our analysis was focused on CKD stage 1 patients, both in comparison with a cohort of 267 low-risk pregnancies,
and with 49 patients in later CKD stages.

• At difference with our previous study, in which the results recorded in stage 1 and stage 2 CKD were almost equal, the stepwise
increase along stages is more clear and statistical difference is reached between stage 1 and 2 CKD as for birth weight and
gestational age.

• Therefore, even minor differences in kidney function (stage 2 vs stage 1) increase the risk for adverse pregnancy related
outcomes.


Author Interview:
Comparing the association of GFR estimated by the CKD-EPI and MDRD study equations and
mortality: the third national health and nutrition examination survey (NHANES III) examination
survey (NHANES III).
Tariq Shafi, MBBS, MHS, FACP, FASN, FNKF


• The Chronic Kidney Disease Epidemiology Collaboration equation for estimation of glomerular filtration rate (eGFR-CKDEPI) improves GFR
estimation from serum creatinine compared to the Modification of Diet in Renal Disease Study equation (eGFR-MDRD). We wanted to assess if
this improvement in GFR estimation translates into better prediction of the risk of death among those with reduced eGFR.

• We first categorized the population into five eGFR groups based on the current standard which is eGFR-MDRD. The eGFR groups
were >120, 90-119, 60-89, 30-59 and <30 ml/min/1.73 m2. We then calculated eGFR-CKDEPI and re-categorized the population using the
same cut-offs but basing it on eGFR-CKDEPI instead of eGFR-MDRD.

• We found that by using eGFR-CKDEPI compared with eGFR-MDRD, 26.9% of the US population will be reclassified into higher eGFR
categories and 2.2% will be reclassified to lower eGFR categories. Our next goal was to determine the effect of this reclassification on the risk
of death from any cause and death from cardiovascular disease (CVD).

• When we looked at those with eGFR-MDRD 30-59 ml/min/1.73 m2, we found that 19.4% of this population was reclassified to a higher eGFR-
CKDEPI category and these individuals had a lower risk of death; 47% lower risk of death from any cause and 49% lower risk of death from
CVD. We then looked at those with eGFR-MDRD >60 ml/min/1.73 m2. In this group, 0.5% were reclassified to lower eGFR-CKDEPI and these
individuals had a higher risk of death; 31% higher risk of death from any cause and 42% higher risk of death from CVD.

• So, in summary, we found that categorizing individuals based on eGFR-CKDEPI improves risk prediction compared with categorization based
on eGFR-MDRD.


Author Interview:
Anorexia nervosa and the kidney
Drs. Pierre Delanaye and Antoine Bouquegneau


• AN and eating disorders are frequent and affect a young population.

• Kidney diseases are very frequent and various in these patients: CKD, AKI, lithiasis and electrolytes disturbance.
• However, all these kidney injuries are underestimated.

• When we did the literature review for this paper, we noticed that the prevalence of eating disorders is blurry.

• This is due to the different definitions of these disorders used by the physicians. Also, it is difficult to diagnose CKD in patients
with eating disorders. The frequency and the mechanics of kidney disturbances are neither up to date, nor fully understood.

• Once again, it seems that this type of patients is somewhat neglected.


Author Interview:
A Cause Analysis of Absence of Functional Arterio-Venous (AV)
Access in a Prevalent Hemodialysis Patients Cohort
Drs. Mireille El TersM.D and Marie Hogan M.D. Ph.D


• We found in this study a strong and independent association between PICC use and lack of a functioning AVF and this
association persisted after adjustment for confounders, including upper-extremity vein and artery diameters, sex, and history of
central venous catheter.
• We also found that PICC use is common among our end stage renal disease (ESRD) population evaluated (30% of our studied
hemodialysis patients) with 54% of these placed after dialysis therapy initiation.


• We hypothesized that prior history of PICC is associated with a higher likelihood of lack of functioning arterio-venous fistula (AVF)
by way of venous injury, such as venous thrombosis and stenosis.

• So the finding of a strong and independent association between prior PICC use and a lack of functioning AVF was not
unexpected.

• We were however surprised by the high proportion of ESRD patients receiving a PICC (30%),especially that the majority occurred
after initiation of dialysis (54%).

• It is worthy to note that the most common indication for PICC in our population was antibiotic use,which could arguably be
administered during hemodialysis and thus sparing the patient the need for a PICC line placement.


Author Interview:
Urolithiasis and the Risk of ESRD
CJASN
Ziad M. El-Zoghby, M.D.


• In this large population-based study, we found that symptomatic stone formers are at increased risk of developing end-stage renal
disease (ESRD) compared to matched controls.

• The mechanism of renal failure in stone former appears to be related to their kidney stones and related urological co-morbidities
and procedures, rather than other risk factors known to cause ESRD (hypertension, diabetes, etc.) that are commonly found in
stone formers.


• We previously reported that stone formers have an increased risk of chronic kidney disease (CKD). Hence it is not surprising that
they also have an increased risk of ESRD.
• Furthermore, our new finding that certain urologic conditions which predispose to stone disease (i.e. hydronephrosis, recurrent
urinary tract infection, acquired single kidney, obstruction, neurogenic bladder) associate with ESRD also was not surprising.
• However, the risk of ESRD attributable to stone disease (5.1%) was much higher than expected. In fact, this figure is 20-fold
above previous estimates (0.2%) that were based upon primary cause of ESRD reported to the United States Renal Data
System.


Author Interview:
Quality of Care and Outcomes Among Patients With Acute Myocardial Infarction by Level of Kidney Function at
Admission: Report From the Get With The Guidelines Coronary Artery Disease Program.CJASN
Deepak L. Bhatt, MD


• Among patients presenting with ST-elevation myocardial infarction (STEMI), patients with abnormal kidney function received less
guideline-recommended care and had higher in-hospital mortality.


• Of note, patients with STEMI who had severe renal dysfunction (GFR 15–30 mL/min/1.73 m2) had adjusted in-hospital mortality
rates that were as high as patients on dialysis (in other words, a very high rate of mortality).

• Hemodialysis.com: What should clinicians and patients take away from your report?

• In patients with STEMI and various degrees of renal dysfunction, the treating physicians need to make sure that the patients are
getting appropriate evidence-based care.


Author Interview:
Treatment Intensity at the End of Life in Older Adults Receiving Long-term Dialysis
Susan Wong MD

• In this large retrospective mortality study, we present end-of-life care practices among older Medicare beneficiaries receiving
chronic dialysis.

• We found that older dialysis patients experience very aggressive care at the end-of-life, and hospitalization, intensive care unit
admission, and use of intensive procedures (mechanical ventilation, cardiopulmonary resuscitation, and feeding tube placement)
during the final month of life are common.

• Intensity of care at the end-of-life is more strongly and consistently associated with regional healthcare spending than with
individual patient characteristics in older dialysis patients.

• Rates of hospitalization and use of intensive procedures at the end-of-life in this population also greatly exceed those reported for
other Medicare patients with life-limiting illnesses, such as cancer and heart failure.


Author Interview: Prof. Sergio Stefoni
Thrombosis of Tunneled-Cuffed Hemodialysis Catheters: Treatment With High-Dose Urokinase Lock
Therapy.
Donati G, Colì L, Cianciolo G, La Manna G, Cuna V, Montanari M, Gozzetti F, Stefoni S.
Nephrology Dialysis and Renal Transplantation Unit, S.Orsola University Hospital, Bologna, Italy.
Artif Organs. 2011 Aug 16. doi: 10.1111/j.1525-1594.2011.01290.x.

• High dose urokinase lock therapy allows an optimal TCC patency without
bleeding complications.

• Were any of the findings unexpected?
• The TCC survival with high dose urokinase lock therapy is higher than in the low
dose group reaching 95% at 3 years.

• What should clinicians and patients take away from this study?
• The addition of urokinase lock therapy is useful if an adequate anticoagulation
therapy with warfarin is administered to prevent TCC thrombosis. This is true
especially in patients who did not have alternatives to TCC for vascular access.


Authors Interview' : Drs. Carl-Johan Jakobsen & Dorthe Nielsen
Perioperative aminoglycoside treatment is associated with a higher incidence of
postoperative dialysis in adult cardiac surgery patients.
Nielsen DV, Hjortdal V, Larsson H, Johnsen SP, Jakobsen CJ.
J Thorac Cardiovasc Surg. 2011 Sep;142(3):656-61.

• The major findings were the substantial increased risk of postoperative dialysis in cardiac
surgery patients, if they had received aminoglycosides and that this risk was more or less
independent on dose size and dose numbers.

• In general endocarditis is believed to be associated with a high risk of postoperative dialysis.
This was also demonstrated in our data with a relatively high crude risk ratio which more or
less disappeared when using both adjusted risk ratio and propensity score match.
• Another point of interest is that the general definitions of failing renal function does not fully
apply after cardiac surgery using cardiopulmonary bypass as there is a general
haemodilution effect which indicate that renal failure may be present somewhat later than
expected.


Author Interview: Dr Luca Neri
Joint Association of Hyperuricemia and Reduced GFR on Cardiovascular Morbidity: A Historical Cohort
Study Based on Laboratory and Claims Data From a National Insurance Provider.
Neri L, Rocca Rey LA, Lentine KL, Hinyard LJ, Pinsky B, Xiao H, Dukes J, Schnitzler MA.
Center for Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO; Dipartimento di
Medicina del Lavoro, Clinica del Lavoro "L. Devoto," Milan, Italy.
Am J Kidney Dis. 2011 Sep;58(3):398-408. Epub 2011 Jul 23.

• We performed a historical cohort study evaluating the risk of cardiovascular
events in adult beneficiaries of a national health insurance provider. We
augmented billing claims data with extracts from outpatient laboratory results
and prescription medications. Data were available since January 2003 to
December 2006. We identified 148,217 patients who met the inclusion criteria of
the study (182,730 person-years overall).
• We observed that increased serum uric acid concentration was associated with
excess cardiovascular hospitalization risk independent of established risk factors
and severity of decreased kidney function. In our study cardiovascular risk
increased at uric acid levels lower than the threshold currently defining
hyperuricemia. In addition, we found that the association between serum uric
acid level and cardiovascular risk was stronger in patients with more severe
decreases in kidney function.


Author Interview: Dr. Timm H. Westhoff
Urinary Calprotectin and the Distinction between Prerenal and Intrinsic Acute Kidney Injury
CJASN September 1, 2011 CJN.02490311; published ahead of print September 1, 2011,
doi:10.2215/CJN.02490311

• To date there is no reliable marker for the differentiation of prerenal and intrinsic acute
kidney injury (AKI). Our study indicates that calprotectin, a mediator protein of the innate
immune system, may eventually serve as a diagnostic marker in AKI.

• In our study population patients with prerenal AKI had urinary calprotectin concentrations
similar to healthy control subjects, whereas the mean calprotectin concentration in intrinsic
AKI was increased by a factor of 60.
• In gastroenterology, fecal calprotectin is a well established parameter for the differentiation
between inflammatory bowel disease and irritable bowel syndrome.

• In analogy to irritable bowel syndrome, epithelial structures are completely intact in prerenal
AKI. Therefore, the basic hypothesis of the present study was that urinary calprotectin
concentrations are low in prerenal AKI. The results of our study supported this hypothesis.

• Thus, the findings of our study were rather expected than unexpected.


Author Interview: Michael Heung MD
Fluid overload at initiation of renal replacement therapy is associated with lack of renal recovery
in patients with acute kidney injury
Michael Heung ,Dawn F. Wolfgram ,Mallika Kommareddi, Youna Hu,
Peter X. Song ,Akinlolu O. Ojo
Nephrol. Dial. Transplant. (2011) doi: 10.1093/ndt/gfr470
First published online: August 19, 2011

• We observed that a greater degree of fluid overload at the time of dialysis
initiation in patients with acute renal failure was associated with a lower
likelihood of recovering enough renal function to come off dialysis.
• A strength of this study was that we examined renal recovery up to 1 year out
from the time of dialysis initiation and not just at hospital discharge. Greater
degree of fluid overload was also associated with higher mortality.
• Although we had hypothesized that greater degree of fluid overload would be
associated with lower renal recovery, this had not been previously shown.
Another finding that was surprising was that a longer interval between
nephrology consultation and dialysis initiation was associated with a lower
likelihood of renal recovery.
• We believe this may reflect delays in the initiation of dialysis.


Author Interview: Dr. Csaba Kovesdy MD
Paricalcitol Versus Ergocalciferol for Secondary Hyperparathyroidism in CKD Stages 3 and 4:
A Randomized Controlled Trial
Csaba P. Kovesdy, Jun L. Lu, Sandra M. Malakauskas, Dennis L. Andress,
Kamyar Kalantar-Zadeh, Shahram Ahmadzadeh
American Journal of Kidney Diseases - 01 September 2011 (10.1053/j.ajkd.2011.06.027)

• We designed a randomized controlled trial of oral fixed dose paricalcitol vs. titrated
ergocalciferol (utilizing a regimen similar to one recommended by K-DOQI) for treatment of
secondary hyperparathyroidism in patients with CKD stages 3 and 4. We found that after 4
months of treatment paricalcitol suppressed PTH levels significantly more effectively than
ergocalciferol.
• Both treatments were well tolerated.

• Ergocalciferol had minimal effect on PTH levels, which may be surprising to some. It is
possible, though, that higher doses of ergocalciferol may be more effective, hence we hope
that future studies using different dosing protocols from what K-DOQI recommends will
address this issue.


Author Interview: Dr. Navdeep Tangri
β-Blockers for Prevention of Sudden Cardiac Death in Patients on Hemodialysis:
A Propensity Score Analysis of the HEMO Study
Navdeep Tangri, Shani Shastri, Hocine Tighiouart, Gerald J. Beck,
Alfred K. Cheung, Garabed Eknoyan, Mark J. Sarnak
American Journal of Kidney Diseases - 29 August 2011 (10.1053/j.ajkd.2011.06.024)

• The main findings of the study showed that beta blockers are not associated
with a lower risk of sudden cardiac death in patients on hemodialysis. An
additional finding found a trend towards benefit in patients with pre-existing
ischemic heart disease.
• Our findings on the lack of benefit in patients with pre-existing heart failure were
somewhat unexpected. However, heart failure in patients on hemodialysis can
have a multifactorial etiology, and may include volume overload and diastolic
dysfunction rather than systolic dysfunction, which is predominant in the general
population.
• In addition, the overlap between symptoms of volume overload and cardiac
dysfunction related heart failure, that occurs in dialysis, may lead to
misclassification of the exposure.


Author Interview: Dr Richard Mc Gee
Diagnostic Test Studies in Nephrology: Quantity, Quality, and Scope.
McGee RG, Neuen BL, Mitchell RL, Craig JC, Webster AC.
Centre for Kidney Research and Cochrane Renal Group, The Children's Hospital at Westmead, Westmead,
Australia; Sydney School of Public Health, University of Sydney, Sydney, Australia.
Am J Kidney Dis. 2011 Aug 18.

• The main findings are that diagnostic research in nephrology is published less
frequently than most other medical specialities. The quality of diagnostic test
accuracy studies that are published is variable and leaves room for
improvement.

• A similar study (Stripolli 2004) looking at randomised controlled trials found that
randomised controlled trials were conducted less frequently in nephrology than
other specialities. So we were not too surprised to see that we made a similar
finding in relation to diagnostic tests.


Author Interview: Donald E. Wesson, M.D
Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with
a moderately reduced glomerular filtration rate due to hypertensive nephropathy
Nimrit Goraya, Jan Simoni, Chanhee Jo and Donald E Wesson
Kidney Int advance online publication, August 31, 2011; doi:10.1038/ki.2011.313

• Our study shows that dietary acid reduction with two interventions, addition of
sodium bicarbonate (NaHCO3) or addition of base-inducing fruits, each reduces
urine parameters of kidney injury in subjects with chronic kidney disease (CKD)
due to hypertensive nephropathy.

• These data are consistent with reduced kidney injury in the study subjects who
had kidney injury as reflected by their high levels of these urine indicators of
kidney injury and their reduced kidney function as measured by reduced
glomerular filtration rate (GFR).

• These findings complement multiple published animal studies from our and
other laboratories showing that reduced dietary acid with alkali or with base-
inducing dietary protein reduces kidney injury in animal models of CKD.


Author Interview: Kyoko Kogawa Sato, MD, PhD
Elevated White Blood Cell Count Worsens Proteinuria but Not Estimated Glomerular Filtration Rate:
The Kansai Healthcare Study.
Sato KK, Hayashi T, Harita N, Koh H, Maeda I, Endo G, Nakamura Y, Kambe H, Fukuda K.
Department of Preventive Medicine and Environmental Health,
Osaka City University Graduate School of Medicine, Osaka, Japan.
Am J Nephrol. 2011 Aug 18;34(4):324-329.

• A: We followed 10008 Japanese men aged 40-55 years who had neither proteinuria nor low
eGFR without taking antihypertensive medications to examine the relationships of white
blood cell (WBC) count, as a marker of inflammation, with two outcomes; proteinuria and
low estimated glomerular filtration rate (eGFR) in the prospective study during the 6-year
observation period. Proteinuria was defined as 1+ or higher on urine dipstick. Low eGFR
was defined if eGFR was <60 mL/min/1.73 m2.

• Elevated WBC count was associated with an increased risk of proteinuria, independent of
age, body mass index categories, fasting plasma glucose, systolic blood pressure, diastolic
blood pressure, presence/absence of antidiabetic medications, alcohol consumption
categories, smoking categories, regular leisure-time physical activity, and eGFR categories
at baseline.

• However, no association was found between WBC count and the risk of low eGFR.


Author Interview: Dr Ilia Beberashvili MD
IL-6 Levels, Nutritional Status, and Mortality in Prevalent Hemodialysis Patients.

Beberashvili I, Sinuani I, Azar A, Yasur H, Shapiro G, Feldman L, Averbukh Z, Weissgarten J.
Clin J Am Soc Nephrol. 2011 Aug 18

• In this prospective longitudinal study we evaluated whether nutritional status was associated
with longitudinal changes in IL-6 levels, and, in addition, whether observed changes in
nutritional parameters could be related to survival of our cohort.

• We showed that chronic inflammation, as measured by higher serum IL-6 levels, is
associated with all-cause death without association with changes in clinical and laboratory
markers of nutritional status in clinically stable HD patients.

• Yes - higher IL-6 levels in clinically stable and well nourished prevalent hemodialysis
patients are associated with higher mortality without inducing measurable protein-energy
wasting (PEW) in this population during 2 years of longitudinal observation.


Author Interview: David P. Calfee, MD, MS
Clinical and Molecular Epidemiology of Methicillin-Resistant Staphylococcus aureus
among Patients in an Ambulatory Hemodialysis Center.
Patel G, Jenkins SG, Mediavilla JR, Kreiswirth BN, Radbill B, Salgado CD, Calfee DP.
Department of Medicine, Mount Sinai School of Medicine, New York, New York.
Infect Control Hosp Epidemiol. 2011 Sep;32(9):881-8.

• In this single center study of ambulatory dialysis patients, asymptomatic carriage
of MRSA was relatively common. The baseline prevalence was 12%. Hospital
admission during the previous six months, failed renal transplant, and receipt of
a first generation cephalosporin, cefepime or vancomycin were associated with
MRSA carriage at baseline.

• During the 6 month follow-up period of active surveillance testing, six additional
patients acquired MRSA. Thus, the incidence of MRSA acquisition was 1.2 per
100 patient-months and the overall prevalence was 18%.

• Over the course of the 12-month study period, 4 MRSA carriers (17.6%)
developed invasive MRSA infection (3 primary bloodstream infections and one
skin infection).


Author Interview: Dr Jyoti Baharani FRCP(UK)
Why did I start dialysis? A qualitative study on views and expectations from an elderly cohort of patients
with end-stage renal failure starting haemodialysis in the United Kingdom.
Stringer S, Baharani J.
Department of Renal Medicine, Birmingham Heartlands Hospital, Heart of England Foundation Trust, Bordesley
Green East, Birmingham, B95SS, UK Int Urol Nephrol. 2011 Aug 18.

• This was a prospective interview study of elderly patients commencing haemodialysis in a
centre in the United Kingdom. We were interested in knowing patients views on
haemodialysis treatment at the start and to see if these views changed over a 6 month
period following treatment.
• We interviewed 22 patients within a month of starting treatment. 70% had attended a pre-
dialysis clinic and had received dialysis education before starting haemodialysis.
• Despite this many of the patients expressed views about having had little choice in starting
dialysis and seemed uncertain about what dialysis would involve. Even so, over 90% of
those interviewed were optimistic about dialysis and had high expectations from treatment
and were not keen to discuss advance care planning at first interview.
• We then re-interviewed 16 of the 22 patients at 6 months (4 patients had died within 6
months and 2 had been transferred to other centres).

• At this stage, we found a substantial change in patients‟ attitude, with only 45% still finding
dialysis acceptable and more patients now keen to discuss advance care planning. More
patients also had a higher symptom burden at 6 months than at initiation of dialysis
treatment.


Author Interview: Te-Chao Fang M.D. & Ph.D.
Increased risk of cancer in chronic dialysis patients: a population-based cohort study in Taiwan.
Lin HF, Li YH, Wang CH, Chou CL, Kuo DJ, Fang TC.
1Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan.
Nephrol Dial Transplant. 2011 Aug 22.

• Our study has six major findings. Firstly, the annual incidence of cancer development in
chronic dialysis patients was 1.1%.

• Secondly, there is an increment in the standardized incidence ratio (SIR) of developing
overall cancer in chronic dialysis patients (SIR: 1.4, 95% CI: 1.3–1.4) that is independent of
age, sex and duration of dialysis.

• Thirdly, patients aged <35 years old and patients having a duration of dialysis of <5 years
had a higher risk of cancer.

• Fourthly, the highest SIR of cancers in our study was attributed to genitourinary tract
cancers. Fifthly, the cancers with the highest rates of incidence in our study were
bladder, liver and kidney cancers. Sixthly, our study showed that chronic dialysis patients
had a reduced SIR (SIR: 0.5, 95% CI: 0.5–0.6) of developing lung cancer than the general
population.


Author Interview: Dr. Justyna Golebiewska MD
Influence of megestrol acetate on nutrition, inflammation and quality of life in dialysis patients.
Golebiewska JE, Lichodziejewska-Niemierko M,
Aleksandrowicz-Wrona E, Majkowicz M, Lysiak-Szyd?owska W, Rutkowski B.
Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gda?sk, ul. Debinki 7,
80-952, Gdansk, Poland. Int Urol Nephrol. 2011 Jul 31.

• We have demonstrated that in hypoalbuminemic MHD and CPD patients 160mg
ofan oral suspension of megestrol acetate taken daily for up to 6 month
improved several markers of nutritional state without any influence on
inflammation or quality of life.
• The most impressive was the significant increase in albumin concentration
beginning from the first month, and continuing throughout the whole trial period.
Significant weight gains and increases in BMI were noted in the following
months.
• Weight gain was significantly lower in diabetics, while the rate of increase in
serum albumin concentration remained unaffected. Unlike the presence of
diabetes, the mode of dialysis did not alter the pace of changes in nutritional
status. Side effects were prevalent and significant.


Author Interview: Dr. Carlo Briguori, MD, PhD
Renal Insufficiency After Contrast Media Administration Trial II (REMEDIAL II): RenalGuard System in
High-Risk Patients for Contrast-Induced Acute Kidney Injury.
Briguori C, Visconti G, Focaccio A, Airoldi F, Valgimigli M, Sangiorgi GM, Golia B, Ricciardelli B, Condorelli G;
for the REMEDIAL II Investigator
Laboratory of Interventional Cardiology and Department of Cardiology, Clinica Mediterranea, Naples.
Circulation. 2011 Aug 11

• We observed a significantly lower dialysis rate in the Renalguard group.
Although this was not the primary end-point, this was a pre-specified secondary
endpoint. The occurrence of dialysis is of course the worst scenario that we may
have during CI-AKI. Having a strategy preventing dialysis in this high risk
population represents an important improvement in our clinical practice.

• When dealing with patients with GFR<30 and or high risk score the CIAKI rate is
still high (20%) event with aggressive prophylactic approaches (sodium
bicarbonate solution infusion and high dose of NAC).
Also, in this population we should expect approximately a 4-5% dialysis rate
within 30 days from contrast exposure. The Renalguard system is an effective
and safe strategy significantly reduce the rate of CIAKI in this high risk
population.


Author Interview: Drs. André de Smet MD PhD and Ninos Ayez MD
Secondary interventions in patients with autologous arteriovenous fistulas
strongly improve patency rates.
Ayez N, Fioole B, Aarts RA, Dorpel MA, Akkersdijk GP, Dinkelman MK, de Smet AA.
Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands.
J Vasc Surg. 2011 Aug 11

• The aim of this study was to evaluate the results after secondary interventions in patients
with an upper extremity arteriovenous fistula.
• The 1-year primary patency rates of arteriovenous fistulas (AVF) are poor. To improve these
results several secondary interventions can be performed.
• We found that due to mostly endovascular secondary interventions, 2-year primary assisted
and secondary patency rates of more than 70% can be obtained.

• We didn‟t expect that the arteriovenous fistulas performed so well after secondary
interventions.
• We expected that some patients received more interventions, but that the outcome after
several interventions would be poor.
• Unexpected was the fact that patients received up to eleven interventions, with a still
functioning hemodialysis access.


Author Interview: Dr. Robert L Hanson MD
Albuminuria and Estimated Glomerular Filtration Rate as
Predictors of Diabetic End-Stage Renal Disease and Death.
Berhane AM, Weil EJ, Knowler WC, Nelson RG, Hanson RL.
Phoenix Epidemiology and Clinical Research Branch, NIDDH Phoenix, Arizona.
Clin J Am Soc Nephrol. 2011 Aug 18.

• The main findings of the study are that both albuminuria (which is measured by
the albumin-creatinine ratio from a urine sample) and eGFR (a measure of
kidney function derived from the blood) , separately and together, predicted
which patients developed end stage renal disease (ESRD) and which patients
were likely to experience early mortality. All patients were Pima Indians
participating in a longitudinal study.
• Similar findings have been seen in other studies that included mostly people
who did not have diabetes, but few studies have been done in patients with
diabetes. The present study showed that this is also true in people with
diabetes. This isn‟t entirely unexpected, but since diabetic kidney disease is
characterized by a high level of protein in the urine, the result could not be
predicted beforehand. In fact, in our study the level of albuminuria was a
stronger predictor of who went on to develop ESRD.


Author Interview: Pascal Meier MD FASN
Referral Patterns and Outcomes in Noncritically Ill Patients with Hospital-Acquired Acute Kidney Injury.
Meier P, Meier Bonfils R, Vogt B, Burnand B, Burnier M.
Centre Hospitalier Universitaire Vaudois and University of Lausanne,
Lausanne, Switzerland;


• In this retrospective study, patients with hospital-acquired acute kidney injury (HA-AKI) who
were not referred (nrHA-AKI) or late referred (lrHA-AKI) to the nephrologist represented an
important percentage of the hospitalized population. Furthermore, these conditions were
associated with patients‟ in-hospital mortality, less recovery of renal function, and need for
renal replacement therapy (RRT).

• The potential reasons why 22.3% and 58.3% of the patients hospitalized were either not
referred or referred to the nephrologist late, respectively, are multiple. One explanation may
be the definition of AKI, which is neither uniformly known nor accepted in the non-
nephrologic community. Serum creatinine level alone is a relatively late and imprecise
biomarker of kidney dysfunction, which may also lead to delayed referral. Finally, patients
with AKI had more comorbidities, increasing the complexity of medical care and possibly
increasing the time required to make treatment decisions.


Author Interview: Susan Furth, MD, PhD
Metabolic Abnormalities, Cardiovascular Disease Risk Factors, and GFR Decline
in Children with Chronic Kidney Disease.
Furth SL, Abraham AG, Jerry-Fluker J, Schwartz GJ, Benfield M, Kaskel F, Wong C,
Mak RH, Moxey-Mims M, Warady BA
Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;

• Ours is the first large, North American study of children with moderate Chronic Kidney
Disease. We show that significant growth failure and pubertal delay are common even in
individuals with mild to moderate decrements of kidney function. Additionally, the
constellation of cardiovascular disease risk factors seen in these children with primary
kidney disease is remarkable, and suggests that decreased kidney function is a causal
factor in the excessive cardiovascular disease mortality in individuals with kidney disease.
• Ours is the first to report rates of kidney function decline using a precise measurement of
kidney function, and shows remarkable differences in the rates of GFR decline depending
on the cause of kidney disease in these children.
• Our study shows potential treatment targets that might slow down the worsening of kidney
function over time in children. It is also the first study to report rates of measured GFR
decline in children.
• Our findings suggest a potential explanation for why a high proportion of young people with
kidney disease present for medical care late, when they are close to needing dialysis. Our
findings show much more rapid decline in kidney function in a subgroup of children with
underlying glomerular disease, which predominantly occurs in African Americans.


Author Interview: Susan Furth, MD, PhD
Metabolic Abnormalities, Cardiovascular Disease Risk Factors, and GFR Decline
in Children with Chronic Kidney Disease.
Furth SL, Abraham AG, Jerry-Fluker J, Schwartz GJ, Benfield M, Kaskel F,
Wong C, Mak RH, Moxey-Mims M, Warady BA
Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;

• Ours is the first large, North American study of children with moderate Chronic Kidney
Disease. We show that significant growth failure and pubertal delay are common even in
individuals with mild to moderate decrements of kidney function. Additionally, the
constellation of cardiovascular disease risk factors seen in these children with primary
kidney disease is remarkable, and suggests that decreased kidney function is a causal
factor in the excessive cardiovascular disease mortality in individuals with kidney disease.
• Ours is the first to report rates of kidney function decline using a precise measurement of
kidney function, and shows remarkable differences in the rates of GFR decline depending
on the cause of kidney disease in these children.
• Our study shows potential treatment targets that might slow down the worsening of kidney
function over time in children. It is also the first study to report rates of measured GFR
decline in children.
• Our findings suggest a potential explanation for why a high proportion of young people with
kidney disease present for medical care late, when they are close to needing dialysis. Our
findings show much more rapid decline in kidney function in a subgroup of children with
underlying glomerular disease, which predominantly occurs in African Americans.


An interview with Drs. Miklos Z Molnar and Kamyar Kalantar-Zadeh from Harbor-UCLA
High platelet count as a link between renal cachexia and
cardiovascular mortality in end-stage renal disease patients.
Molnar MZ, Streja E, Kovesdy CP, Budoff MJ, Nissenson AR, Krishnan M, Anker SD,
Norris KC, Fonarow GC, Kalantar-Zadeh K.
Institute at Harbor-University of California Los Angeles Medical Center, Torrance, CA.
Am J Clin Nutr. 2011 Aug 3

• Relatively higher platelet count is associated with surrogates of renal cachexia and
cardiovascular mortality in hemodialysis patients. However, the association of “relative
thrombocytosis” with all-cause and cardiovascular mortality is accounted for by indices of
renal cachexia.

• To our knowledge, this is the first study that indicates that renal cachexia increases mortality
via activating platelet pathway. However, these results need to be confirmed in additional
studies including the potential link between malnutrition or cachexia and thromboembolic or
cardiovascular events, and as usual our findings may not necessarily imply a causal
relationship.
• Discovering the pathophysiological mechanisms underlying the PEW-death link can be a
major step towards improving clinical management of chronic diseases states with wasting
syndrome. To our knowledge, this is the first study that suggests that renal cachexia
increases mortality via platelet link.


American Society of Nephrology Press Release: Metabolic syndrome may cause kidney disease

High blood pressure, high blood sugar, abdominal fat, low good cholesterol may contribute to kidney disease

• Metabolic syndrome comprises a group of medical disorders that increase people's risk of
diabetes, heart disease, stroke, and premature death when they occur together. A patient is
diagnosed with the syndrome when he or she exhibits three or more of the following
characteristics: high blood pressure, high blood sugar, excess body fat in the
waist/abdomen, low good cholesterol, and higher levels of fatty acids (the building blocks of
fat).
• People with metabolic abnormalities are at increased risk of developing kidney disease,
according to a study appearing in an upcoming issue of the Clinical Journal of the American
Society Nephrology (CJASN).
• Sankar Navaneethan, MD (Cleveland Clinic) and his colleagues searched the medical
literature and combined data from 11 studies examining the relationship between metabolic
syndrome and kidney disease. Altogether, they included 30,416 individuals from various
ethnic groups.

• People with metabolic syndrome have a 55% increased risk of developing kidney
problems, especially lower kidney function, indicative of kidney disease.
• Individual components of metabolic syndrome are linked with the development of kidney
disease.
• Kidney disease risk increases as the number of metabolic syndrome components
increases.


Author Interview: Dr. Sankar Navaneethan
Metabolic Syndrome and Kidney Disease: A Systematic Review and Meta-analysis
George Thomas ,Ashwini R. Sehgal , Sangeeta R. Kashyap ,Titte R. Srinivas ,
John P. Kirwan , Sankar D. Navaneethan
CJASN August 2011 CJN.02180311

• The major finding of our study was that patients with metabolic syndrome, which includes a cluster of 3 or
more of the following cardiovascular risk factors - high blood pressure, high fasting blood sugar, a large
waist circumference, low HDL and high triglyceride levels - have a 55% increase in the risk for development
of chronic kidney disease (CKD) as assessed by an eGFR < 60ml/min/1.73 m2.

• The results of our study also show that the risk for CKD increases as the number of components of
metabolic syndrome increase. Each individual risk factor was associated with development of kidney
disease.
• Metabolic syndrome has been associated with cardiovascular disease, stroke, and all-cause mortality in the
general population.

• We hoped to synthesize the results of existing epidemiologic evidence that explored the association of
metabolic syndrome and the risk for development of chronic kidney disease as evidenced by proteinuria
and/or decreased glomerular filtration rate.

• The results of our analysis adds to the growing evidence that metabolic syndrome and its components are
associated with the development of CKD. The risk seems to be consistent across studies conducted in
different countries in different ethnic groups and and that used different definitions of metabolic syndrome.


Author Interview: Dr. Carla Avesani
Annual variation in body fat is associated with systemic inflammation
in chronic kidney disease patients Stages 3 and 4: a longitudinal study.
Carvalho LK, Barreto Silva MI, da Silva Vale B, Bregman R, Martucci RB, Carrero JJ, Avesani CM.
1Clinical and Experimental Physiopathology Program, Rio de Janeiro State University, Rio de Janeiro, Brazil.

• A.We prospectively followed patients with CKD stages 3 and 4 for 12 months and found that
changes in markers of adiposity, such as BMI (body mass index) and WC (waist
circumference), were directly associated with changes in CRP (c-reactive protein), a marker
of systemic inflammation. It is important to highlight that 45% of our patients had BMI ≥ 25
kgm2, none of them showed signs of PEW (protein energy wasting) and all of them were
being regularly followed by a dietitian in a multidisciplinary CKD outpatient clinic.

• These findings were not unexpected as in non-CKD patients, similar findings were observed
in overweight subjects. However, our study is the first one to show these findings in a
population of CKD patients.


Author Interview: Rodney G. Bowden, PhD
Reverse Epidemiology of Lipid-Death Associations in a Cohort of End-Stage
Renal Disease Patients.
Bowden RG, La Bounty P, Shelmadine B, Beaujean AA, Wilson RL, Hebert S.
School of Education, Baylor University, Waco, Tex., USA.
Nephron Clin Pract. 2011 Aug 11;119(3):c214-c219.


• Our study discovered a reverse epidemiological effect (normal values
associated with higher rates of mortality) for LDL, LDL particle number, LDL
size, VLDL, triglycerides, and total cholesterol.

• Additionally regression revealed that LDL and total cholesterol were predictors
of mortality with lower levels being more predictive of death. Additionally, a Cox
multiple regression death hazard ratio revealed LDL particle size as a significant
predictor of mortality with lower levels more predictive of death.

• The results of our study support the findings of the few database studies that
have been published regarding this topic and discovered the existence of a
reverse epidemiological effect regarding cholesterol variables and morality in
ESRD patients.


Author Interview: Dr. Ian De Boer
Serum 25-Hydroxyvitamin D and Change in Estimated Glomerular Filtration Rate.
de Boer IH, Katz R, Chonchol M, Ix JH, Sarnak MJ, Shlipak MG,
Siscovick DS, Kestenbaum B.

• This longitudinal observational study demonstrated that lower serum concentrations of 25-
hydroxyvitamin D (25(OH)D) were associated with increased risk of estimated GFR loss.

• The study was conducted among community-dwelling older adults with predominantly
normal baseline eGFR who participated in the Cardiovascular Health Study. Adjusting for
potential confounding characteristics, each 10 ng/mL lower 25(OH)D concentration was
associated with a 25% greater risk of rapid GFR loss, defined as a loss of at least 12
mL/min/1.73m2 eGFR over the four years of follow-up (95% confidence interval 5%, 49%,
p=0.01).

• Compared with 25(OH)D >= 30 ng/mL, serum 25(OH)D concentration < 15 ng/mL was
associated with a 68% higher risk of rapid GFR loss (95% confidence interval 1%, 177).
Associations of 25(OH)D concentration with GFR loss were observed for participants with
and without diabetes, but tended to be stronger among participants with diabetes.

• Similar findings were observed evaluating a composite endpoint of rapid GFR loss, end
stage renal disease, and death.


Author Interview: Karen Shalansky, Pharm.D.
Iron Indices After Administration of Sodium Ferric Gluconate Complex in Hemodialysis Patients
Karen Shalansky, Jennifer Hanko, Morris Pudek, Guiyun Li, Jacek Jastrzebski
American journal of kidney diseases
16 August 2011 (DOI: 10.1053/j.ajkd.2011.05.021)


• Many hemodialysis units hold IV iron therapy for 2 weeks prior to assessing iron parameters
(TSAT and Ferritin). The main finding in our study was that iron parameters can be
measured 7 days after a dose of sodium ferric gluconate complex (FerrlecitÒ) to determine
whether a change in iron dosage is required.

• The literature currently varies to hold IV iron compounds from 2-14 days prior to assessment
of iron parameters; thus our conclusions are within the realm of the literature
recommendations, and so are not unexpected.

• Patients receiving maintenance IV iron therapy every 1-4 weeks do not need to have their
dosage interrupted as iron indices can be measured 7 days after the last dose has been
administered. From the patient‟s perspective, they are less likely to experience fluctuations
in the management of their anemia.


Author Interview: Valjbona Tiric Preljevic MD
Psychiatric disorders, body mass index and C-reactive protein in dialysis patients.
Preljevic VT, Osthus TB, Sandvik L, Bringager CB, Opjordsmoen S, Nordhus IH, Os I, Dammen T.
Department of Psychiatry, Oslo University Hospital Ullevål, 0407 Oslo, Norway; Faculty of Medicine,
University of Oslo, 0316 Oslo, Norway.
Gen Hosp Psychiatry. 2011 Aug 8.


• A major finding was that dialysis patients with a BMI £ 21 kg/m2 and a CRP level ³ 6 mmol/L had four times
higher odds of having depressive and/or anxiety disorder. As the majority of our patients with psychiatric
comorbidity had such levels of CRP and BMI, this indicate a possible association between psychiatric
comorbidity, inflammation, and malnutrition. Furthermore, we found a significant association between
depressive disorder, high CRP and low BMI levels, which indicates that an association between psychiatric
disorder, high CRP and low BMI was more likely to be explained by depression rather than by anxiety.

• About one third of the dialyis patients in our study had depressive, anxiety, or somatoform disorder.
Depression was the most common psychiatric disorder and was observed in one fifth of the patients.

• We did not find any significant differences between the prevalence of depression or anxiety in patients on
different dialysis modality. However, we observed a tendency toward lower psychiatric comorbidity in
patients using PD.

• Dialysis patients with psychiatric comorbidity had lower HRQoL scores, which indicates that suffering from
anxiety and depression contribute to impaired HRQoL. .


Author Interview Dr. Hitinder S. Gurm
Renal Function-Based Contrast Dosing to Define Safe Limits of Radiographic Contrast Media in Patients Undergoing Percutaneous
Coronary Interventions
Hitinder S. Gurm, MD*,*, Simon R. Dixon, MBChB{dagger}, Dean E. Smith, PhD, MPH*, David Share, MD*, Thomas
LaLonde, MD{ddagger}, Adam Greenbaum, MD§, Mauro Moscucci, MD, MBA|| BMC2
(Blue Cross Blue Shield of Michigan Cardiovascular Consortium) Registry
J Am Coll Cardiol, 2011; 58:907-914, doi:10.1016/j.jacc.2011.05.023


• THE RISK OF CONTRAST INDUCED NEPHROPATHY WAS LOWEST WHEN THE
CONTRAST DOSE/CREATININE CLEARANCE DID NOT EXCEED 2 AND WAS
MARKEDLY ELEVATED WHEN THE RATION EXCEEDED 3.

• THESE FINDINGS ARE NOT UNEXPECTED SINCE IT FOLLOWS FROM BASIC
PHARMACOLOGY PRINCIPLES.
• ALL EFFORTS SHOULD BE MADE TO MINIMISE THE CONTRAST VOLUME USED FOR
PCI. CATHETRIZATION LABORATORIES MAY WANT TO CONSIDER STRATEGIES TO
MONITOR THE CONTRAST VOLUME/CREATININE RATIO TO ENSURE THAT
EXCESSIVE DOSES OF CONTRAST ARE NOT BEING USED


Authors' Interview:
Julie A. Wright Nunes, MD MPH Kerri L. Cavanaugh, MD MHS
Associations among perceived and objective disease knowledge and satisfaction with physician communication
in patients with chronic kidney disease
Julie A Wright Nunes, Kenneth A Wallston, Svetlana K Eden, Ayumi K Shintani,
T Alp Ikizler and Kerri L Cavanaugh
Kidney International , (10 August 2011) | doi:10.1038/ki.2011.240?

• The main finding of this study is that patients‟ perceived knowledge is limited about many
topics important to kidney disease care. In fact, the majority of the 400 patients surveyed
reported knowing little or nothing about medications that help the kidney, medications that
hurt the kidney, foods to avoid if kidney function is low, symptoms of chronic kidney disease,
and functions of the kidney. We found a low-to-moderate correlation between perceived
and objective kidney disease knowledge. Additionally, patients with higher perceived
knowledge had higher odds of being satisfied with their provider‟s communication.
• Our study revealed that although patient perceived and objective disease knowledge are
associated, this association is low-to-moderate (0.32 Spearman correlation). Interestingly,
their respective associations with patient‟s satisfaction of communication are opposite.
Higher perceived knowledge was associated with higher odds of greater satisfaction, but
higher objective knowledge was associated with lower odds of satisfaction. Thus, it appears
that perceived and objective disease knowledge are largely two separate constructs and
may impact patient satisfaction, and possibly other outcomes, in very different ways.


Author Interview: Ditte Hansen MD
No difference between alfacalcidol and paricalcitol in the treatment of secondary hyperparathyroidism in
hemodialysis patients: a randomized crossover trial.
Hansen D, Rasmussen K, Danielsen H, Meyer-Hofmann H, Bacevicius E, Lauridsen TG, Madsen JK, Tougaard
BG, Marckmann P, Thye-Roenn P, Nielsen JE, Kreiner S, Brandi L.
Kidney Int. 2011 Aug 10. doi: 10.1038/ki.2011.226.

• Alfacalcidol has been used for treatment of secondary hyperparathyroidism and
hypocalcemia for many years by the Danish and many European Nephrologists. Paricalcitol
was introduced as a less hypercalcemic and hyperphosphatemic vitamin D analog. This was
based on comparative studies mostly in animals between paricalcitol and another vitamin D
analog; calcitriol. The present study compared alfacalcidol and paricalcitol in the treatment
of secondary hyperparathyroidism in hemodialysis patients.
• We found alfalcalcidol and paricalcitol to equally suppress secondary
hyperparathyroidism, without any difference in the elevation of calcium or phosphate levels.

• As alfacalcidol is hydroxylated by the liver into calcitriol, we might expect similar findings as
in the animal studies mentioned above.This would be a reduced increase in s-calcium and
s-phosphate in the paricalcitol tretaed group. The present study may indicate an intrinsic
effect of alfacalcidol or reflect that the results in animal studies not always can be applied
into human.


Author Interview: Dr. Elif Ari
Accelerated atherosclerosis in haemodialysis patients; correlation of endothelial function
with oxidative DNA damage.
Kaya Y, Ari E, Demir H, Soylemez N, Cebi A, Alp H,
Bakan E, Gecit I, Asicioglu E, Beytur A.

• In this cross-sectional analysis, we found that serum levels of oxidative stress markers and
oxidative DNA damage are correlated with endothelial function in hemodialysis patients. We
suggest that 8-hydroxydeoxyguanosine/deoxyguanosine ratio (8-OHdG/dG ratio) as well as
oxidative enzyme malondialdehyde (MDA) and antioxidant enzymes superoxide dismutase
(SOD) and glutathione peroxidase (GPx) are independent determinants of endothelial
function in maintenance hemodialysis patients without known atherosclerotic disease.

• The association between oxidative DNA damage in terms of 8-OHdG/dG ratio and
endothelial function in maintenance hemodialysis patients is a new finding in the current
literature.


Author Interview: Dr.Paraskevi Theofilou
Quality of Life in Patients Undergoing Hemodialysis or Peritoneal Dialysis Treatment
J Clin Med Res. 2011 May 19; 3(3): 132–138
Paraskevi Theofilou, Department of Psychology, Panteion University, Eratous 12, 14568, Athens, Greece.

• Patients in the HD treatment, compared to PD treatment patients, reported a more compromised QoL in the
domains of environment and social relationships. Accordingly, the HD group indicated experiencing less
support from their community and social relationships.

• Furthermore, HD compared to PD patients, indicated more problems in different aspects of their
environment with a more negative evaluation, including availability/quality of health services, transportation,
finances, recreation and opportunities for acquiring new skills and knowledge.
• Regarding mental health, HD patients were found to evaluate less favourably their overall health status,
reporting more physical and psychological symptoms, such as anxiety, sleeping problems and suicidal
thoughts.

• Concerning internal beliefs about current condition of health, both groups are comparable presenting a
similar pattern, that is scoring higher in the dimension of internal locus, which is followed by the dimensions
of chance, doctors and important others. A difference between the two treatment modalities concerns the
relatively higher values of the HD patients in internal locus, indicating probably the emphasis on their own
behavior for control over their current condition of health, perhaps a counterbalance for feelings of
dependence on the machine.

• On the contrary, PD seemed to give more importance to the function of doctors, probably because they
need to be trained in peritoneal dialysis procedures with the help of medical professionals.


Author Interview: Dr. Ian De Boer
Serum 25-Hydroxyvitamin D and Change in Estimated Glomerular Filtration Rate.
de Boer IH, Katz R, Chonchol M, Ix JH, Sarnak MJ, Shlipak MG,
Siscovick DS, Kestenbaum B.

• This longitudinal observational study demonstrated that lower serum concentrations of 25-
hydroxyvitamin D (25(OH)D) were associated with increased risk of estimated GFR loss.

• The study was conducted among community-dwelling older adults with predominantly
normal baseline eGFR who participated in the Cardiovascular Health Study. Adjusting for
potential confounding characteristics, each 10 ng/mL lower 25(OH)D concentration was
associated with a 25% greater risk of rapid GFR loss, defined as a loss of at least 12
mL/min/1.73m2 eGFR over the four years of follow-up (95% confidence interval
5%, 49%, p=0.01).

• Compared with 25(OH)D >= 30 ng/mL, serum 25(OH)D concentration < 15 ng/mL was
associated with a 68% higher risk of rapid GFR loss (95% confidence interval 1%, 177).
Associations of 25(OH)D concentration with GFR loss were observed for participants with
and without diabetes, but tended to be stronger among participants with diabetes.

• Similar findings were observed evaluating a composite endpoint of rapid GFR loss, end
stage renal disease, and death.


Author Interview: Steven M. Brunelli
A Model of Systolic Blood Pressure During the Course of Dialysis and Clinical Factors Associated With Various
Blood Pressure Behaviors
Kumar Dinesh, Srikanth Kunaparaju, Kathryn Cape, Jennifer E. Flythe, Harold I. Feldman, Steven M. Brunelli
DOI: 10.1053/j.ajkd.2011.05.028

• Despite long-standing and widespread interest in blood pressure in the peri-
dialytic period, we were surprised to realize that no one had characterized the
patterns of blood pressure seen over the course of hemodialysis itself. There
were several findings from this study that bear note. First, blood pressure over
the course of dialysis does not decline in monotonic form. Instead, on average, it
declines rapidly over the first quarter of treatment and much less rapidly over the
remaining three quarters of treatment. Second, we identified several modifiable
clinical practices that associate with different intra-dialytic blood pressure
behaviors including fluid removal goals, ultrafiltration rate and choice among
phosphate binders. Third, we determined that pre-to-post blood pressure rise is
seen in approximately 1/3 of treatments, is associated with a wholly different
intra-dialytic blood pressure pattern, and identified some potential precipitants
thereof.


Author Interview: Akshay S. Desai, MD and Marc A. Pfeffer, MD, PhD
Association Between Cardiac Biomarkers and the Development of ESRD
in Patients With Type 2 Diabetes Mellitus, Anemia, and CKD
Desai AS, Toto R, Jarolim P, Uno H, Eckardt K-U, Kewalramani R, Levey AS, Lewis EF,
McMurray JJV, Parving H-H, Solomon SD, Pfeffer MA.
Cardiovascular Division, Brigham and Women's Hospital, Boston, MA. Am J Kid Dis 2011.

• We studied the association between the cardiac-derived biomarkers troponin T (TnT) and N-
terminal pro-brain natriuretic peptide (NT-pro-BNP) and the development of end-stage renal
disease (ESRD) in the first 1000 subjects with type 2 diabetes, chronic kidney disease, and
anemia enrolled in TREAT (Trial to Reduce Cardiovascular Events with Aranesp Therapy).

• In this ambulatory CKD population, we found that levels of both cardiac biomarkers were
frequently elevated; 45% had TnT levels detectable at greater than the usual reference limit
for myocardial necrosis and 38% had NT-proBNP levels exceeding conservative thresholds
for heart failure diagnosis.

• Levels of both cardiac biomarkers were higher in patients with lower eGFR and also in those
with greater baseline proteinuria. TnT and NT-proBNP levels were associated independently
with the risk of ESRD and the composite of death or ESRD even after adjustment for eGFR,
proteinuria, and other known predictors of CKD progression.


FMC to spend $2.1 billion on U.S. dialysis acquisitions for
Liberty Dialysis and American Access Care

• (Reuters) - Fresenius Medical Care (FMEG.DE) announced two U.S. takeovers with a combined price tag
of $2.09 billion on Tuesday, extending its lead as the largest dialysis company in the United States.

• The Germany-based company said it would buy privately held Liberty Dialysis Holdings for $1.7 billion
including about $1 billion in assumed debt.

• That would add about 19,000 U.S. patients to the 140,000 FMC already has, while its nearest rival, DaVita
(DVA.N), has 128,000 patients.

• The U.S. Medicare system, which provides insurance for about 80 percent of FMC's U.S. patients, no
longer pays clinic operators for individual services and drugs but instead pays a so-called "bundled rate" per
dialysis session.
• The lump-sum reimbursement, which is only paid if patients are being kept in good health, has created
fresh incentives for clinics to cut costs, use drugs sparingly and renegotiate procurement prices, which
tends to be easier for bigger operators.

• Liberty is controlled by buyout firms KRG Capital Partners and Bain Capital and the deal, which is expected
to close in early 2012, will add about $1 billion to FMC's annual sales.


DaVita to Launch Dialyzer Recycling Pilot Project through
Collaboration with Waste Management and BD, Becton, Dickinson and Company

• DENVER (Aug. 2, 2011) – DaVita Inc. (NYSE: DVA), a leading provider of kidney care services for those
diagnosed with end stage renal disease (ESRD) and chronic kidney disease (CKD), today announced the
company is leveraging the expertise of WM Healthcare Solutions, Inc., a subsidiary of Waste Management,
Inc. (NYSE: WM), and BD (Becton, Dickinson and Company) to launch a dialyzer recycling pilot in 106
DaVita® dialysis clinics in Southern California. This recycling pilot project is expected to be the first of its
kind in North America.

• “We have the potential to offset 350,000 pounds of dialyzer waste in this trial alone, which is incredible
because until now, there has not been a „green‟ way to dispose of dialyzers or other medical waste,” said
Kent Thiry, chairman and CEO of DaVita. “This pilot program has the potential to change the landscape of
sustainable health care, particularly in the dialysis industry, and we are excited to be at the forefront of it.”

• This dialyzer recycling pilot builds on business solutions developed by BD and WM through the BD
ecoFinity™ Life Cycle Solution program, which DaVita is also launching in the 106 pilot facilities. With the
BD ecoFinity program, single-use medical sharps devices such as needles and syringes are collected on-
site, then treated and processed by WM to recover reusable materials. BD then uses the recycled plastic to
make new BD container products. The dialyzer recycling pilot follows a similar process: WM will treat and
recover recyclable materials from the dialyzers, and then BD plans to use the recycled plastic to make new
BD products or other applications, creating a closed-loop waste recovery solution of the recyclable
materials.


Author Interview: Eva Schepers
Symmetric Dimethylarginine as a Proinflammatory Agent in Chronic Kidney Disease.
Schepers E, Barreto DV, Liabeuf S, Glorieux G, Eloot S, Barreto FC, Massy Z, Vanholder R.
Department of Internal Medicine, University Hospital Gent, Gent, Belgium;

• In our study we demonstrated both in vitro and in vivo, that SDMA, a uremic retention solute, is associated
to the chronic inflammatory status in CKD patients. In vitro, SDMA activates NF-κB in monocytes resulting
in an increased expression of TNF-α and IL-6 and both these effects were abbrogated by NAC. The pro-
inflammatory character of SDMA was further confirmed in a clinical study in patients at different stages of
CKD in which SDMA, besides being a marker for renal function, was shown to be associated with several
markers of inflammation, like IL-6 and TNF-α.
• ADMA, the structural counterpart of SDMA, was evaluated in parallel, but showed no in vitro effects and its
association with inflammatory parameters in the clinical study was less pronounced.
• SDMA was for a long time considered to be inert while ADMA, an inhibitor of NOS, was generally accepted
to be a marker of endothelial dysfunction and a predictor of cardiovascular disease. Therefore SDMA had
rarely been considered in in vitro or clinical trials until recently.
• In vitro, our group demonstrated that SDMA induced ROS production in monocytes involving Ca2+ influx,
while ADMA did not. Also, in a holistic in vitro approach evaluating ten guanidino compounds SDMA
exerted the highest number of pro-inflammatory and vascular damaging effects. Therefore, it was no
surprise that SDMA induced cytokine production. The fact that ADMA showed no effect at all in vitro, even
at rather high concentrations, was not necessarily expected.
• The fact that SDMA was a better marker for renal function than ADMA might be attributed to their different
removal from the body. While SDMA is completely eliminated by the kidneys in healthy conditions, ADMA is
mainly enzymatically removed. Correlations of both compounds with inflammation described in literature are
rather scarce, but are in correspondence to our in vitro findings.


Author Interview: Shih-Bin Su, M.D., PhD
Risk of Acute Kidney Injury after Exposure to Gadolinium-Based Contrast in Patients with Renal Impairment.
Chien CC, Wang HY, Wang JJ, Kan WC, Chien TW, Lin CY, Su SB.
Department of Nephrology, Chi-Mei Medical Center , Tainan , Taiwan.
Ren Fail. 2011 Jul 22.

• Answer: We found that baseline GFR, coronary artery disease, liver cirrhosis, diabetic
mellitus, and hypertension were not significantly associated with the development of acute
kidney injury (AKI) after Gadolinium-based contrast media (Gd-CM ) administrated at the
usual dose for magnetic resonance imaging or magnetic resonance angiography
examinations.
• However, sepsis was an independent risk factor for AKI after Gd-CM administrated
(adjusted odds ratio: 4.417; 95% confidence interval: 1.671, 11.676, P =.03) in patient with
GFR below 90 ml/min/1.73m2.

• Answer: In our study, we found baseline GFR, diabetic mellitus were not associated with
AKI after Gd-CM administrated; however, it is potential AKI after Gd-CM administrated
under sepsis condition at the dose for MRI and MRA examinations.


Author Interview: Dr. Manish M Sood
The Role of Functional Status in Discharge to Assisted Care Facilities
and In-Hospital Death Among Dialysis Patients.
Sood MM, Rigatto C, Bueti J, Jassal V, Miller L, Verrelli M, Bohm C, Mojica J, Roberts D, Komenda P.University
of Manitoba, Winnipeg, Manitoba, Canada; St Boniface Hospital, Winnipeg, Manitoba, Canada.

• We investigated 1,286 ESRD patients for survival and discharge to an Assisted living facility among
patients admitted to one of 11 are hospitals in Winnipeg, Manitoba, Canada.

• We found a simple 6 domain (bathing, dressing, feeding, transferring, toileting, continence) activities of daily
living measurement within 24 hours of admission combined with age was highly predictive of in-hospital
death or discharge to an assisted care facility.

• We were surprised on how well the simple ADL score predicted patient outcomes!

• The ADL score was performed entirely by Allied Health care (physiotherapists, occupational therapists and
nursing) over a network of eleven hospitals and in situations where assessment of the ADLs was
unattainable due to illness, the measure was estimated.

• Nevertheless the score combined with age differentiated the risk of death from 4.8-46.6% and discharge to
an assisted care facility from 0.6-17.8%, a ten- and thirty-fold increase. Thus this cheap, easy, applicable
on a large scale and sometimes, estimated measure was highly predictive.


Author Interview: Cheng-Chia Lee, MD
Comparable ten-year outcome in hemodialysis patients with
hepatitis C virus and hepatitis B virus coinfection and single hepatitis B virus infection.
Lee CC, Li IJ, Chen YC, Cheng JW, Wu HH, Weng CH, Fang JT, Tian YC.
Department of Nephrology, Lin-Kou Chang Gung Memorial Hospital, Taipei, and Department of Medicine, Chang
Gung University, Taiwan, ROC.
Blood Purif. 2011;32(2):89-95.

• In this prospective observation analysis, we found that HBV and HCV coinfection in
hemodialysis patients did not cause more severe liver disease or increase patient mortality
in comparison with single HBV infection during 10-year follow-up. Moreover, HCV can
suppress HBV replication in hemodialysis patients with HBV and HCV coinfection.

• It has been well documented that HBV and HCV coinfection causes more severeliver
damage when compared with single HBV infection in nonuremic patients. However, this
study demonstrated that HBV and HCV coinfection in hemodialysis patients did not cause
more severe liver outcome with respect to the incidence of acute hepatitis, the development
of liver cirrhosis and HCC during 10-year follow-up.

• The serum HBV DNA level in patients with HBV and HCV coinfection was significantly lower
than that in patients with single HBV infection. Nevertheless, complete eradication of serum
HBV by HCV coinfection determined by both HBsAg and HBeAg seroclearance did not
occur in patients with HBV and HCV coinfection, implying a suppressive but not eradication
effect.


Author Interview: Dr. María José Pérez-Sáez,
Tandem Plasmapheresis and Hemodialysis: Efficacy and Safety.
Pérez-Sáez MJ, Toledo K, Ojeda R, Crespo R, Soriano S,
Alvarez de Lara MA, Martín-Malo A, Aljama P.
Department of Nephrology, Hospital Universitario Reina Sofía , Córdoba , Spain.
Ren Fail. 2011 Jul 20.

• In our study, we analyzed our experience during the last 12 years using a technique that
performs plasmapheresis and hemodialysis simultaneously. These two modalities are
usually carried out independently on patients who require renal replacement therapy. We
observed in 36 patients that tandem plasmapheresis and hemodialyisis significantly reduces
the time of patient exposure to an extracorporeal circuit, decreasing the risks that are
associated with anticoagulation agents and optimizing the human resources. There were not
major complications during the 287 sessions that we analyzed.
• In fact, we expected a higher rate of extracorporeal circuit clotting, as there were two circuits
simultaneously with a similar anticoagulation dose. Instead, we observed that it was not a
frequent problem as it was not higher than we usually observed in our hemodialysis
patients.
• There is a very concise message: patients who need plasmapheresis and hemodialysis are
suitable to undergo both techniques together, what means less time of treatment
and, indirectly, less costs.


Author Interview: Dr. Kurella Tamura
Albuminuria, Kidney Function, and the Incidence of Cognitive Impairment Among Adults in the United States.
Kurella Tamura M, Muntner P, Wadley V, Cushman M, Zakai NA, Bradbury BD,
Kissela B, Unverzagt F, Howard G, Warnock D, McClellan W.
Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA; Geriatric Research and Education
Clinical Center, Palo Alto VA Health Care System, Palo Alto, CA.

• We found that albuminuria and low estimated GFR (glomerular filtration rate) were complementary but not
additive risk factors for cognitive impairment in a large cohort of US adults. That is, when estimated GFR
was preserved, albuminuria independently predicted cognitive impairment. When albuminuria was low or
absent, low estimated GFR independently predicted cognitive impairment.
• Previous studies have shown that albuminuria and low estimated GFR were independent risk factors for
death, cardiovascular events, and ESRD. We expected but did not find a similar relationship for cognitive
impairment, and we speculate that this finding may reflect some distinct aspects about the pathophysiology
of cognitive impairment versus other vascular outcomes.
• One important take-home point is that patients who have a preserved estimated GFR (>60) but albuminuria
were at the highest risk for cognitive impairment in our study.
• What recommendations do you have for nephrology health care providers as a result of your
study?
• Markers of kidney function such as GFR and albuminuria may prove to be useful and simple measures to
assess future risk for dementia and cognitive decline.


Author Interview: Matthew Budoff, MD
Relationship of Estimated GFR and Coronary Artery Calcification in the CRIC
(Chronic Renal Insufficiency Cohort) Study.
Budoff MJ, Rader DJ, Reilly MP, Mohler ER 3rd, Lash J, Yang W, Rosen L, Glenn M, Teal V, Feldman HI;
CRIC Study Investigators.
Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA.

• This large prospective study (Chronic Renal Insufficiency Cohort study) demonstrated that
renal insufficiency was independently associated with coronary atherosclerosis (as
measured by coronary calcium), after controlling for cardiovascular risk factors and other
measures.
• We found that phosphate levels were still strongly related to coronary calcium, even in the
setting of chronic kidney disease (dialysis patients were excluded). This supports
hypotheses that we need to start phosphate control and consider phosphate lowering
therapies pre-dialysis.
• Given the recent results of the SHARP trial, demonstrating that patients with renal
insufficiency benefit from cholesterol lowering, and prior work that Coronary calcium is
associated with adverse events, reinforces the need for clinicians to measure coronary
calcium in patients with chronic kidney disease and treat accordingly (consider phosphate
control if needed, consider statins and other anti-atherosclerotic therapies)


Author Interview: Baris Afsar, M.D
HbA1c Is Related with Uremic Pruritus in Diabetic and Nondiabetic Hemodialysis Patient
Afsar B, Elsurer Afsar R.
Department of Nephrology, Zonguldak Atatürk Government Hospital, Zonguldak, Turkey.
Ren Fail. 2011 Mar 4.

• The main findind of our study was that in both diabetic and non-diabetic subjects uremic
pruritus was associated with hemoglobin A1c (HbA1c).

• The unexpected finding of the study was the presence of association also in non-diabetic
patients. Our findings are novel and preliminary.

• As a take home massage it should be examined in randomized trials whether strict glycemic
control lowers uremic pruritus.


Author Interview: Luca De Nicola, MD-PhD
Prognosis of CKD Patients Receiving Outpatient Nephrology Care in Italy
CJASN August 2011 CJN.01180211
Luca De Nicola Paolo Chiodini Carmine Zoccali Silvio Borrelli
Bruno Cianciaruso Biagio Di Iorio Domenico Santoro
Vincenzo Giancaspro Cataldo Abateruss Ciro Gallo
Giuseppe Conte Roberto Minutolo for the SIN-TABLE CKD Study Group

• For the first time this study addresses the prognosis of CKD patients already seen (from at least one year)
by nephrologist and the main findings in this specific population are
• (1) ESRD is more frequent than death in stage 4 and 5 CKD, but the opposite is true in stage 3;
• (2) among the main modifiable risk factors, proteinuria and high phosphate predict ESRD, whereas
proteinuria, high uric acid, and anemia predict death;
• (3) proteinuria must be considered in conjunction with eGFR to refine risk stratification.

• Absence of any predictive role of BP is somehow unexpected.

• However, a recent paper from our group ( Minutolo R, Agarwal R, Borrelli S, Chiodini P, Bellizzi V, Nappi
F, Cianciaruso B, Zamboli P, Conte G, Gabbai FB, De Nicola L. Prognostic role of ambulatory blood
pressure monitoring in patients with non-dialysis CKD. Arch Int Med 2011; 171:1090-1098) has revealed in
a large cohort of non-dialysis CKD patients that ABPM measures (24h BP) are more effective than office
BP in predicting outcome.


Author Interview: Tara I Chang, MD, MS
Systolic Blood Pressure and Mortality in Patients on Hemodialysis.

Chang TI.
Curr Hypertens Rep. 2011 Jul 30.

• What should clinicians and patients take away from this review?
• This review highlights and updates the reader on recent research and ongoing controversies
regarding systolic blood pressure in patients on hemodialysis. For example, what blood
pressure levels to target, how best to measure blood pressure (pre-dialysis, post-dialysis,
home blood pressure or some other measurement), and how best to treat blood pressure
(both pharmacological and non-pharmacological) remain uncertain.

• What recommendations do you have for nephrology health care providers as a result
of your review?
• This review underscores the fact that although current guidelines provide a framework to
guide nephrologists in managing blood pressure in patients on hemodialysis, many of these
guidelines are based on relatively scant evidence.
• Future research trials focusing on several aspects of blood pressure management in
hemodialysis are still greatly needed.


Author Interview: Dr. Joaquim Abian
Proteomic Analysis of Polypeptides Captured from Blood during
Extracorporeal Albumin Dialysis in Patients with Cholestasis and Resistant Pruritus.
Gay M, Pares A, Carrascal M, Bosch-I-Crespo P, Gorga M, Mas A, Abian J.
CSIC/UAB Proteomics Laboratory, Bellaterra, Spain.


• A: We have identified a number of proteins that are captured from blood during albumin
dialysis in a MARS system. It is accepted that the clinical effects of MARS dialysis are
related to the removal of albumin-bound substances from the patient‟s blood. However,
there is little information on the collection of molecules captured, specially from peptides and
proteins, as well as on the mechanisms involved. Some of the proteins we have detected in
the albumin dialyzates are known to have important biological functions and their removal
could be related either to therapeutic effects or to posible adverse effects associated with
albumin dialysis.

• We have also shown that SLURP1, one of the proteins removed by MARS from patients‟
blood, was overrepresented in serum from patients with cholestasis.


Hemodialysis.com | Kidney Disease | ESRD | Dialysis

Hemodialysis.com | Kidney Disease | ESRD | Dialysis

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Hemodialysis.com | Kidney Disease | ESRD | Dialysis

Similar to Hemodialysis.com | Kidney Disease | ESRD | Dialysis (20)

More from Marie Benz MD FAAD

More from Marie Benz MD FAAD (20)

Recently uploaded

Recently uploaded (20)

Hemodialysis.com | Kidney Disease | ESRD | Dialysis