Long-term cholecalciferol administration in hemodialysis patients: a single-center randomized pilot study

BACKGROUND

Data on the potent pleiotropic extraskeletal effects of vitamin D have renewed interest in its use in selected populations, including patients with chronic kidney disease, but the available data are still insufficient to make recommendations. This study assessed the long-term effect of small cholecalciferol doses on serum vitamin D, parathormone (PTH), and bone mineral density (BMD) in hemodialysis patients.

MATERIAL/METHODS

Nineteen patients with serum 25(OH)D <20 ng/mL were randomized into cholecalciferol (2000 IU 3×/week) and no-treatment groups, then observed for 1 year. Patients with hypercalcemia, hyperphosphatemia, and receiving vitamin D/calcimimetics were excluded. Serum 25(OH)D, 1,25(OH)2D, PTH, and alkaline phosphatase activity were examined every 2 months and BMD was measured before and after the study.

RESULTS

We observed normalization of serum 25(OH)D with an increase in medians from 11.3 to 44.9 ng/mL (P=0.02) in the cholecalciferol group and no change in the controls (P<0.001). Simultaneously, median serum 1,25(OH)2D increased from 18.2 to 43.1 pmol/L (P=0.02) in the cholecalciferol group and from 10.6 to 21.2 pmol/L (P=0.02) in controls (P=0.013). The treatment was associated with a small increase in serum calcium, but serum phosphate, PTH, alkaline phosphatase, and BMD remained unchanged in both groups.

CONCLUSIONS

Oral cholecalciferol at a dose of 2000 IU/3×/week is an effective and safe way to treat vitamin D deficiency in hemodialysis patients, leading to a significant increase in serum 1,25(OH)2D. However, it was insufficient to suppress the activity of parathyroid glands or to significantly change BMD.

[Recommendations for prevention of community-acquired pneumonia with bacteremia as the leading form of invasive pneumococcal infections in the population of people over 50 years of age and risk groups above 19 years of age]

Invasive pneumococcal disease (IPD) is a main cause of mortality associated with pneumococcal infections. Although, IPD is regarding mainly small children and persons in the age > 65 years, the investigations showed that because of IPD exactly sick persons are burdened with the greatest mortality in the older age, rather than of children. The most frequent form of IPD is community acquired pneumonia (CAP) with the bacteremia. The presence of even a single additional risk factor is increasing the probability of the unfavorable descent of pneumococcal infection. The risk factors for IPD and/or pneumonia with bacteremia apart from the age are among others asthma (> 2 x), chronic obstructive pulmonary disease (COPD), sarcoidosis (4 x), idiopathic pulmonary fibrosis (5 x), bronchiectases (2 x), allergic alveolitis (1.9 x) and pneumoconiosis (2 x), type 1 diabetes (4.4 x), type 2 diabetes (1.2 x), autoimmune diseases (e.g. rheumatoid arthritis (4.2 to 14.9 x), kidney failure with the necessity to dialysis (12 x), immunosuppression, cardiovascular disease, alcoholism and cancers. Examinations show that the best method of IPD and CAP preventing are pneumococcal vaccinations. On the market for ages 23-valent polysaccharide vaccine (PPV23) is available covering close the 90% of IPD triggering stereotypes. Her role in preventing CAP is uncertain and the immunological answer after vaccination at older persons and after revaccination is weak. Widely discussed disadvantageous effects of growing old of the immunological system show on the benefit from applying the immunization inducing the immunological memory, i.e. of conjugated vaccines which are activating the T-dependent reply and are ensuring the readiness for the effective secondary response. Examinations so far conducted with conjugated 7-valent and 13-valent (PCV13) vaccines at persons in the age > 50 years are confirming these expectations. Also sick persons can take benefits from PCV13 applying back from so-called IPD risk groups in the age > 19 years. At these work research findings were described above PPV23 and PCV13 at adults and world recommendations of applying both vaccines in risk groups from 19 years up to the advanced years. Also Polish recommendations of optimum applying of these vaccines were presented. They are recommending applying PCV13 at first in them, while PPV23, if to her readings exist should be given to > or = 8 of weeks from PCV13. In persons > or = 19 years which earlier received 1 or should receive more PPV23 doses first PCV13 dose should be given after the year or later than the last PPV23 dose, and then again PPV23 > or = 8 of weeks from PCV13 and the second PPV23 dose not earlier than 5 years from last PPV23. If the PPV23 application seems to be justified, it is irrespective of the more previous state vaccination against pneumococci, PCV13 should be given to as first.

Advanced abdominal arterial calcification sparing kidney allograft--case report

Excess and progressing arterial calcification is a frequent finding in patients with chronic kidney disease and in diabetics. Vascular calcification present in patients on dialysis, usually continues to progress (although possibly with slower rate) in patients after kidney transplantation. These observations are limited mostly to aorta and coronary arteries; virtually no data exist on progression in vascular calcification within the vasculature of transplanted kidney. The case report presents the patient with diabetes and non-functioning renal transplant back on dialysis with extremely severe intra-abdominal artery calcification, sparing renal artery of transplanted kidney. Calcification did not develop within transplanted kidney despite 10 years of exposition to diabetic environment and a few years of chronic kidney disease after transplantation, including CKD-T stage 5 for at least one year after re-starting of dialysis. To the best of our knowledge, this is the second report ever describing sparing of kidney graft from calcification despite disseminated calcification in other vascular beds. It is tempting to speculate that some "intrinsic" factors exist within the transplanted kidney that protects it from calcification despite exposure to procalcifying milieu of diabetes and uremia.

Osteoporosis in mineral and bone disorders of chronic kidney disease

Osteoporosis is one of the epidemics in modern aging societies. Epidemiological studies indicate that many patients with osteoporosis are also characterized by diminished glomerular filtration rate (GFR), which indicates various degrees of chronic kidney disease (CKD). On the other hand, the status of osteoporosis in the classification of mineral and bone disorders in CKD has not been well defined. In the present paper, we review the epidemiology of osteoporosis in the context of kidney failure, discuss tools used to diagnose osteoporosis in patients with CKD, present data on fracture risk in patients with kidney diseases, and describe the relationship between metabolic bone diseases and the development of vascular calcification. We also present current treatments in osteoporosis with special attention to the outcomes of these treatments in patients with low GFR.

Relationship between serum asymmetric dimethylarginine and left ventricular structure and function in patients with end‑stage renal disease treated with hemodialysis

INTRODUCTION

 Asymmetric dimethylarginin (ADMA) is an endogenous inhibitor of endothelial nitric oxide synthase, considered an effector of endothelial dysfunction. Among multiple diseases associated with elevated ADMA, chronic renal disease is often mentioned. ADMA is thought to be related to certain adverse cardiovascular effects of chronic uremia. The association between left ventricular (LV) structure and function and ADMA has been studied in numerous papers, but only few of them addressed this issue in end‑stage renal disease (ESRD).

OBJECTIVES

 The aim of the study was to analyze associations between serum ADMA (sADMA) levels and LV geometry and function in patients with ESRD treated with hemodialysis (HD).

PATIENTS AND METHODS

 The study group included 56 patients (31 women, 25 men) aged 59.0 ±13.1 years, treated with HD for 70 ±67 months. sADMA and biochemical parameters were measured and echocardiography was performed. sADMA levels were also measured in the control group of healthy individuals matched for age. 

RESULTS

 Mean sADMA levels in patients were 2.39 ±1.0 μmol/ and were significantly higher compared with controls (0.55 ±0.12 μmol/l; P <0.01). Based on echocardiography, patients were classified into the following groups: normal LV geometry (17.8%), concentric remodeling (8.9%), concentric hypertrophy (35.7%), excentric hypertrophy (37.5%), impaired systolic function (10.7%), and impaired diastolic function (71.4%) (1 patient could be in 1 or more groups). sADMA correlated with mean (r = 0.78; P <0.05) and relative (r = 0.64; P <0.05) LV wall thickness and with the LV mass index (r = 0.65; P <0.05), but not with the indexes of systolic and diastolic function. sADMA was significantly higher in patients with excentric hypertrophy, concentric remodeling, and concentric hypertrophy compared with patients with normal LV geometry, and the highest was in patients with concentric hypertrophy.

CONCLUSIONS

 Our study demonstrated an association between sADMA and disturbances in LV geometry in patients with ESRD treated with HD.

Renal involvement in multiple myeloma

In this paper, the spectrum of renal involvement in the course of multiple myeloma (MM) is discussed. We describe the most important pathophysiological mechanisms underlying the development of renal complications observed in MM. In particular, we focused on the correlations between morphological changes in the kidneys and clinical signs and symptoms. Physicochemical characteristics of light chains that are synthesized in excess are critically important in the development of different types of renal involvement. It seems that patients with MM should be actively treated regardless of the type of lesions because the current methods allow to reverse renal lesions and reduce the negative effect of renal damage on prognosis in these patients.

Single Dose Pharmacokinetics of α-Dihydroergocryptine in Patients with Moderate to Severe Renal Insufficiency

AIM

This study was carried out to evaluate the pharmacokinetic profile of alpha-dihydroergocryptine (CAS 14271-05-7, DHEC, Almirid) in plasma and urine in patients with moderately to severely impaired renal function (creatinine clearance < 30 ml.min-1.1.73 m-2), following administration of single oral doses.

METHODS

This was an open, nonrandomized trial. Seven patients with chronic renal disease and six healthy subjects received a single dose of 20 mg DHEC. Blood and urine samples were taken at specified intervals up to 72 h after dosing. Concentrations of unchanged DHEC were determined by radio-immunoassay (RIA) and concentrations of unchanged DHEC plus pooled metabolites by enzyme-immunoassay (EIA), respectively.

RESULTS

In patients with impaired renal function, the mean Cmax and AUC(0-infinity) values for unchanged DHEC were 2.1 (95% confidence interval CI: 0.99 to 4.42) and 1.85 (95% CI: 0.72 to 4.77) times larger than in controls. The 24-h urinary excretion was only 0.3 (95% CI: 0.12 to 0.71) times that in healthy subjects. Similar findings were recorded for total DHEC plus metabolites.

CONCLUSIONS

As treatment with DHEC is in general uptitrated starting with doses as low as 5 mg DHEC, which are then increased while accounting for individual effects both in terms of efficacy and tolerability, the observed range of effects of impaired renal function on DHEC's pharmacokinetics does not suggest the need to revise this policy, although lower end-doses are likely to be achieved.

Can we prolong life of patients with advanced chronic kidney disease: what is the clinical evidence?

The risk of death in patients with advanced chronic kidney disease (CKD) is markedly higher than in the population without CKD, even in patients suffering from advanced cardiovascular disease. Among several clinical features of CKD, the following are considered the most important areas of therapeutic intervention: hypertension, lipid abnormalities, mineral and bone disorders of CKD (previously known as renal osteodystrophy), renal anemia, and uremic toxicity. However, numerous treatment strategies, which are applied based on the understanding of underlying pathologies, did not result in significantly improved prognosis. These strategies include lowering of blood pressure, use of statins, control of hyperphosphatemia and hyperparathyroidism, erythropoesis-stimulating agents, use of better and more biocompatible dialysis membranes, and higher dialysis dose. In this critical review, we discuss the most important, large clinical trials, in which the above therapies failed to show desirable results and to reduce mortality in patients with advanced CKD.

Identifying chronic kidney disease in an emergency department: a chance for an early diagnosis

INTRODUCTION

Chronic kidney disease (CKD) has relatively asymptomatic course, but even at its onset, it worsens the prognosis of patients, mainly because of the increased risk of cardiovascular diseases. Several population-based screening programs as well as initiatives focused on certain risk groups were undertaken to better diagnose early stages of CKD. It appears that an emergency department (ED) of a hospital may be the right place to screen for early CKD.

OBJECTIVES

The aim of the study was to assess the accuracy of ED practices in the detection of CKD.

PATIENTS AND METHODS

The study involved 176 subjects who presented at the ED over 1 month and were subsequently admitted to one of the wards at the general hospital. Blood pressure on admission was recorded in 61% of the patients; serum creatinine and estimated glomerular filtration rate (eGFR) were measured in 50% of the subjects, urea in 42.2%, potassium in 87.5%, and glucose in 82%. Patients with previously diagnosed CKD were excluded from the study.

RESULTS

Sixty-three per cent of blood pressure values exceeded 140/90 mmHg, 27.3% of all creatinine samples exceeded the upper limit of 1.2 mg/dl, and 64.8% of eGFR results were below 90 ml/min/1.73 m² (mean 78 ± 36 ml/min/1.73 m²). Abnormal levels of urea (>50 mg/dl) were observed in 32% of the patients. Potassium levels were within the reference range in 81.5% of the patients (3.5-5.0 mmol/l; only 10.4% exceeding 5 mmol/l). Elevated glucose levels (>110 mg/dl) were observed in 60% of the patients.

CONCLUSIONS

ED practices could be used to identify a significant number of patients with undiagnosed CKD. However, these simple, widely available, and cost-effective methods of early CKD detection are underused. Our results show that there is an urgent need for a structural screening program for CKD at the level of ED.