Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal failure

White blood cells as a novel mortality predictor in haemodialysis patients

BACKGROUND

Many conventional cardiovascular risk factors in the general population are not as predictive in end-stage renal disease (ESRD). As absolute neutrophil count and total white blood cell (WBC) count are associated with adverse cardiovascular outcomes and all-cause mortality, this analysis was undertaken to explore the associations of WBC variables with mortality risk in ESRD.

METHODS

Of a total study population of 44 114 ESRD patients receiving haemodialysis during 1998 at facilities operated by Fresenius Medical Care, North America, 25 661 patients who underwent differential white cell count and had complete follow-up were included. Information on case mix (age, gender, race), clinical (diabetes, body mass index), and laboratory variables (haematocrit, albumin, creatinine, potassium, calcium, phosphorus, bicarbonate, ferritin, transferrin saturation and differential WBC count) was obtained. Associations between lymphocyte count, neutrophil count and demographic and clinical variables were examined using linear regression. Associations between WBC variables and survival were estimated using Cox proportional hazard regression.

RESULTS

A higher lymphocyte count was associated with higher serum albumin and creatinine, lower age and black race. High neutrophil count was associated with lower serum albumin and creatinine, younger age and white race (all Ps <0.0001). Cox proportional hazard regression showed an increased lymphocyte count was associated with reduced mortality risk [HR 0.86 (0.83-0.89) per 500/ml increase in lymphocyte count] and an increased neutrophil count was associated with increased mortality risk [HR 1.08 (1.06-1.09) per 1000/ml increase in neutrophil count].

CONCLUSIONS

An increased neutrophil count is strongly associated with, and reduced lymphocyte count associated less strongly with, many surrogates of both malnutrition and inflammation. An increased neutrophil count and reduced lymphocyte count are independent predictors of increased mortality risk in haemodialysis patients.

Predictors of serum creatinine in haemodialysis patients: a cross-sectional analysis

BACKGROUND

C-reactive protein (CRP) levels, an acute phase response index, predict cardiovascular outcome and are inversely related to visceral proteins, including albuminaemia in haemodialysis patients. Less definite is the relationship between inflammation and markers of somatic proteins such as serum creatinine in such patients. To explore these questions, a cross-sectional analysis of potential predictors of serum creatinine was performed.

METHODS

One hundred and seventy-nine prevalent haemodialysis patients as of June 2001 were included in the cohort. Midweek pre-dialysis blood samples were collected during the months of June, September through to December 2001 inclusive, and determinations of serum urea (urease method), creatinine (alkaline picrate method) and CRP levels by means of a high sensitivity immunonephelometric method were performed. Furthermore, pre- and post-dialysis body weights were recorded and 2 min post-dialysis serum urea levels were determined three times. They were utilized for the calculation of single pool Kt/V and of normalized protein catabolic rate (nPCR). Each of the data represents the mean of three determinations made every 3 months in the study period.

RESULTS

The analysis of multivariate linear regression was able to validate our model characterized by a dependent variable, serum creatinine and four independent variables (age, CRP, Kt/V and nPCR) (R(2)=0.60; F=24.10; P<0.00001; SE=1.94). Age (-0.08 mg/dl decrease in serum creatinine per 1-year increase in age), Kt/V (-0.25 mg/dl decrease in serum creatinine per 0.1 increase in Kt/V) and nPCR (0.10 mg/dl increase in serum creatinine per 0.1 g protein/kg/day increase in nPCR) were independently predictive of serum creatinine (P<0.00001). CRP and dialysis vintage did not predict serum creatinine. Stratifying the patients for the effects of CRP, only CRP values </=4 mg/l were directly predictive of serum creatinine (P<0.00001), whereas CRP values >4 mg/l were not. A further insight was given by the stratification of the patients for the effects of the interquartile ranges of CRP: it showed a progressive and statistically significant reduction of beta-coefficient inversely related to the increasing CRP values (P=0.003). Thus, the nature of the correlation between CRP and serum creatinine changes with increasing CRP values: from being a direct one, it shows a trend towards a transformation into an indirect one with beta=0 at a CRP value of approximately 9 mg/l. However, this indirect relationship does not reach statistical significance.

CONCLUSIONS

The present cross-sectional study suggests that the activation of acute phase response does not influence creatinine metabolism in haemodialysis patients; in contrast, age, Kt/V and nPCR predict serum creatinine levels. Larger prospective trials are needed to achieve a definitive answer about the relationship between somatic proteins, acute phase response activation and nutrition in dialysis patients.

Uraemic medium accelerates proliferation but does not induce apoptosis of endothelial cells in culture

BACKGROUND

Chronic renal failure patients exhibit accelerated atherosclerosis, which is associated with a high incidence of cardiovascular death. We investigated the potential effect of uraemic medium on cell proliferation and apoptosis of endothelial cells in culture (ECs), two key processes in the development of atherosclerosis. Phosphorylation kinetics of the mitogen-activated protein kinase (MAPK) p42/44 and p38 were also evaluated.

METHODS

ECs were cultured with growth media supplemented with pooled sera from healthy donors. Semiconfluent ECs were incubated for 24 h with media supplemented with pools of control or uraemic sera. Cell proliferation was assessed through morphometric analysis and by flow cytometry evaluation of cell cycle. To investigate if uraemic medium induces apoptosis in ECs, we used a combination of terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling (TUNEL) assay and activation of caspase-3 using flow cytometry. Changes in the phosphorylation levels of MAPK were evaluated in cell lysates by western blotting.

RESULTS

Exposure to uraemic media caused an alteration in the morphology of ECs, showing irregular shape and size. The number of ECs at S+G(2)M phase in the cell cycle was found to be increased when exposed to uraemic media for 24 h (28.4+/-2.9 vs 20.2+/-2.6% in control ECs). There was a transient increase in levels of phosphorylation of MAPK in both cells, although these levels were significantly higher in ECs exposed to uraemic media, especially after 5 min. In contrast, no signs of apoptosis were observed in ECs incubated with uraemic medium at the conditions applied.

CONCLUSIONS

Under our experimental conditions, uraemic medium accelerates proliferation of ECs, but it does not seem to induce apoptosis. The increased proliferation observed could be related to a higher MAPK activity in these cells. Although the enhanced atherosclerosis cannot be explained on the basis of an apoptotic process, the proliferative status could contribute to intimal proliferation, which is considered to be an earlier step in the development of atherosclerosis.

Associations between circulating inflammatory markers and residual renal function in CRF patients

BACKGROUND

Circulating levels of cytokines and other inflammation markers are markedly elevated in patients with chronic renal failure. This could be caused by increased generation, decreased removal, or both. However, it is not well established to what extent renal function per se contributes to the uremic proinflammatory milieu. The aim of the present study is to analyze the relationship between inflammation and glomerular filtration rate (GFR) in 176 patients (age, 52 +/- 1 years; GFR, 6.5 +/- 0.1 mL/min) close to the initiation of renal replacement therapy.

METHODS

Circulating levels of high-sensitivity C-reactive protein (hsCRP), tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), hyaluronan, and neopterin were measured after an overnight fast. Patients subsequently were subdivided into two groups according to median GFR (6.5 mL/min).

RESULTS

Despite the narrow range of GFR (1.8 to 16.5 mL/min), hsCRP, hyaluronan, and neopterin levels were significantly greater in the subgroup with lower GFRs, and significant negative correlations were noted between GFR and IL-6 (rho = -0.18; P < 0.05), hyaluronan (rho = -0.25; P < 0.001), and neopterin (rho = -0.32; P < 0.0005). In multivariate analysis, although age and GFR were associated with inflammation, cardiovascular disease and diabetes mellitus were not.

CONCLUSION

These results show that a low GFR per se is associated with an inflammatory state, suggesting impaired renal elimination of proinflammatory cytokines, increased generation of cytokines in uremia, or an adverse effect of inflammation on renal function.

Are advanced oxidation protein products potential uremic toxins?

Oxidative stress, defined as a disruption of the equilibrium between the generation of oxidants and the activity of anti-oxidant systems, plays a significant role in the development of the inflammatory syndrome associated with chronic renal failure and hemodialysis. In our recent work, the aim of which was to better characterize oxidative stress in dialysis patients, we described the presence of oxidized protein products, which we have termed advanced oxidation protein products (AOPP), in the plasma of dialysis patients and we proposed AOPP as new markers of oxidative stress and potential inflammatory mediators. AOPP represent an exquisite marker of phagocyte-derived oxidative stress, and their role in the pathophysiology of chronic renal failure and dialysis-related complications might be of great importance. Regarding the mechanisms of generation of AOPP, we pointed out the importance of myeloperoxidase and the subsequent generation of chlorinated oxidants, previously considered solely as microbicidal agents, in the formation of AOPP. Indeed, AOPP appear to act as true inflammatory mediators since they are able to trigger the oxidative burst and the synthesis of inflammatory cytokines in neutrophils, as well as in monocytes. Thus, it could be hypothesized that the AOPP, which arise from the reaction between chlorinated oxidants and plasma proteins, constitute new uremic toxins with pro-inflammatory effects.

Endothelium-dependent vasodilation and oxidative stress in chronic renal failure: impact on cardiovascular disease

Despite significant progress in renal replacement therapy, the mortality from cardiovascular disease (CVD) in patients with chronic renal failure (CRF) is many times higher than in the general population. The traditional risk factors are frequently present in CRF patients. However, based upon conventional risk factor analysis, these factors do not fully explain the extraordinary increase in morbidity and mortality in CVD among patients with CRF. Accumulating evidence suggests that CRF is associated with impaired endothelial cell function. In recent years, the role of endothelial dysfunction (ED) and excessive oxidative stress (OS) in the development of CVD has been highlighted. ED is an early feature of vascular disease in different diseases such diabetes, hypertension, hypercholesterolemia, and coronary heart disease. The precise mechanism which induces ED is not clear. Several factors however, including OS-related accumulation of uremic toxins, hypertension and shear stress, dyslipidemia with cytotoxic lipoprotein species such as small, dense low-density lipoprotein (LDL) particles, competitive inhibition of endothelial nitric oxide (NO) by increased production by asymmetrical dimethylarginine (ADMA) are pathogenic. In addition, it is known that excessive OS causes ED. An overproduction of reactive oxygen species (ROS) may injure the endothelial cell membrane, inactivate NO, and cause oxidation of an essential cofactor of nitric oxide synthase (NOS). Recent studies have demonstrated that an impaired endothelium-dependent vasodilation and OS are closely related to each other in patients with CRF.

Hyperhomocysteinemia and end-stage renal disease: determinants and association with cardiovascular disease in Tunisian patients

The study reports on plasma total homocysteine (tHcy) levels in Tunisian patients with chronic renal failure (CRF) and those treated with hemodialysis (HD) and renal transplant (RT). The aims of the study were to identify the determinants of tHcy concentration and to test the association between hyperhomocysteinemia and atherothrombotic disease in end-stage renal disease (ESRD). A total of 35 CRF patients on conservative treatment, 50 HD patients, and 30 RT recipients, and 31 age- and sex-matched healthy subjects were included. Plasma tHcy was assessed by a fluorescent-polarizing immunoassay method. Multivariate analysis was applied to identify the main determinants of tHcy concentration and to assess the relationship between hyperhomocysteinemia and cardiovascular disease. Plasma mean tHcy concentration was significantly increased (p < 0.001) in CRF patients (mean +/- SD) (28.9 +/- 9.8 micromol/l), in HD patients (29.4 +/- 11.1 micromol/l), and in RT (19.3 +/- 6.3 micromol/l) patients compared to controls (11.9 +/- 4.1 micromol/l). Multivariate analysis using GLM ANOVA modeling demonstrated that tHcy was significantly higher in males (p = 0.02), and was related to age (p = 0.008), albumin (p = 0.005), vitamin B12 (p = 0.002), folate (p = 0.00001), and creatinine clearance (p = 0.0008). However, tHcy was not associated with C-reactive protein and did not significantly differ between CRF, HD, or RT patients. The upper quartile of tHcy concentration was significantly associated with atherothrombotic cardiovascular disease (unadjusted odds ratio (OR) = 3.09; 95% CI, 1.11-8.61; p = 0.01). This association remained significant after adjusting for sex, age, hypertension, and smoking (multi-adjusted OR = 4.78; 95% CI, 1.92-11.9; p = 0.0008). The mean tHcy concentration was 2 to 3 times higher in ESRD patients than in subjects with normal renal function. This increase could be related to glomerular filtration rate reduction and functional B vitamins deficiency, but was not associated with inflammation. The upper quartile of tHcy concentrations confers 4.78-fold increased independent risk for atherothrombotic events in ESRD patients.

Uremic malnutrition: new insights into an old problem

Uremic malnutrition is highly prevalent and is associated with poor clinical outcomes in end-stage renal disease (ESRD) patients. Inadequate diet and a state of persistent catabolism play major roles in predisposing these patients to uremic malnutrition and appear to have an additive effect on overall outcome. Recent studies highlight the existence of a complex syndrome involving chronic inflammation, metabolic abnormalities, and hormonal derangements contributing to the increased morbidity and mortality observed in ESRD patients. Novel strategies such as appetite stimulants, anti-inflammatory drugs, and anabolic hormones along with conventional nutritional supplementation may provide potential interventions to improve clinical outcome in ESRD patients.

Vitamin E-bonded hemodialyzer improves atherosclerosis associated with a rheological improvement of circulating red blood cells

BACKGROUND

Vitamin E-bonded hemodialyzer is known to improve oxidative stress in patients with hemodialysis. However, there is little information available as to whether or not this membrane clinically improves atherosclerosis. Furthermore, it remains unknown whether there is any effect of the membrane on rheology of circulating red blood cells.

METHOD

We conducted a randomized, open-labeled, prospective control study (N = 34) for 1 year to investigate the effect of vitamin E-bonded cellulose membrane dialyzer (EE) (N = 17) on carotid atherosclerotic changes [intima-media thickness (IMT) of carotid arteries] and the viscosity, percentage of dysmorphism (%DMR) of red blood cells (RBCs) and their distribution width-standard deviation (RDW-SD), in comparison with cellulose membrane (SU) (N = 17) identical to EE without vitamin E-bonded membrane. Erythropoietin (EPO) dose used for the treatment of uremic anemia was also calculated.

RESULTS

The IMT significantly decreased in the EE group, while in the SU group the IMT significantly increased. The viscosity of RBCs in hemodialysis patients (4.70 +/- 0.45 cP) was greater than that in healthy individuals (3.73 +/- 0.15 cP). EE significantly improved the viscosity (from 4.84 +/- 0.41 cP to 4.51 +/- 0.54 cP, P < 0.01), %DMR (from 2.29 +/- 2.17% to 1.90 +/- 1.49%, P < 0.01), and RDW-SD (from 54.4 +/- 7.6 fL to 49.3 +/- 5.9 fL, P < 0.01). On the contrary, these parameters all worsened in the SU group. EPO dose needed for the treatment of anemia was significantly (P < 0.05) reduced from 5383 +/- 2655 U/week to 4235 +/- 3103 U/week in the EE group. During these period, mean blood pressure, Kt/V urea, and serum beta2-microglobulin were not changed between the two groups.

CONCLUSION

These findings suggest that vitamin E-bonded hemodialyzer is very useful for improving atherosclerosis from a clinical point of view. As one of the underlying mechanisms, as well as antioxidant effects, we want to address an important role of the improvement of rheology of circulating RBCs, which may also help to reduce the requirement of EPO dose in the treatment of anemia of ESRD patients.

Genetic approaches in the clinical investigation of complex disorders: malnutrition, inflammation, and atherosclerosis (MIA) as a prototype

Despite major research efforts and improvements in dialysis technology, patients with end-stage renal disease (ESRD) experience an extremely high mortality, which seems to be increasingly related to cardiovascular disease. Cardiovascular disease has been linked to the presence of systemic inflammation and malnutrition (MIA syndrome), in addition to the high prevalence of traditional risk factors observed in ESRD patients. Since the mechanisms underlying the development of these complications of ESRD are largely unknown, new strategies for identification of risk factors, pathophysiologic pathways, and targets for intervention are warranted. Although the combined impact of MIA complications seems to determine the extremely poor clinical outcome in the ESRD patients, there are significant unexplained individual differences in the development of the MIA syndrome, implying that genetic differences might play a role. The vast information generated by the advances in molecular genetics offers a great opportunity to analyze the causes of differences not only in our susceptibility to (or protection from) various diseases, but also in the age of onset, severity of illness, and in the way our bodies respond to treatment. In this review, we summarize an integrated approach in the investigation of complex disorders, requiring the interactive collaboration between laboratory, clinical, and epidemiologic resources using the MIA syndrome as a prototype. We focus on the application of common genetic variations (single nucleotide polymorphisms [SNPs]) in association with studies to generate potential risk profiling using data from multiple vulnerability genes. The appropriate application of this approach may be essential in the early identification of high-risk individuals and groups of patients for whom specific therapeutic interventions are indicated, thus creating a tailor-made clinical management for the future.

Factors affecting progression of renal failure in patients with type 2 diabetes

OBJECTIVE

Hyperglycemia and hypertension are known to be risk factors for the development of proteinuria in patients with diabetes. Little is known, however, about predictors of progression of renal failure in diabetic patients.

RESEARCH DESIGN AND METHODS

We investigated factors affecting progression of renal failure by measuring the doubling of serum creatinine (s-Cr) as an end point in a cohort of 85 type 2 diabetic patients with chronic renal insufficiency/failure (s-Cr >1.5 and <3.7 mg/dl, 61 +/- 11 years old, 51 men and 34 women, mean s-Cr 2.3 +/- 0.6 mg/dl).

RESULTS

The survey period (mean +/- SD) was 14.2 +/- 10.8 months. The cumulative incidence of the end point in patients with insulin therapy (n = 41) was significantly lower than that in patients without it (n = 44) (P = 0.0022, P values by log-rank test). Multivariate Cox analysis revealed insulin therapy (hazard ratio [HR] 0.435, 95% CI 0.252-0.750, P = 0.0027), serum albumin (0.484, 284-0.823, P = 0.0074), mean blood pressure (1.023, 1.004-1.043, P = 0.017), and hemoglobin (0.841, 0.728-0.972, P = 0.0194) to be independent and significant predictors of progression to renal failure, whereas HbA(1c) or serum cholesterol were not.

CONCLUSION

In type 2 diabetic patients with renal failure, hypoalbuminemia, anemia, higher mean blood pressure, and lack of use of insulin predict rapid progression of renal failure, but HbA(1c) does not, and insulin therapy may be possibly an indicator of the delay in progression of renal failure.

Why do we need a statin trial in hemodialysis patients?

BACKGROUND

The risk of cardiovascular complications is markedly increased in patients on dialysis treatment. This includes cardiac disease, stroke, and peripheral vascular disease. The mortality in dialysis patients is markedly higher compared to a nonuremic population. There are several cardiovascular (CV) risk factors that are unique to this population, one of which is dyslipidemia. Uremic patients do not usually develop hypercholesterolemia, but rather are characterized by high levels of very low density lipoprotein (VLDL) triglycerides, low high density lipoprotein (HDL) cholesterol, and elevated levels of modified low density lipoprotein (LDL) particles, which are particularly harmful to the vascular wall. HMG-CoA reductase inhibitors (statins) have been proven to be very efficient in reducing CV events in a nonrenal population. There are several landmark trials that have demonstrated that statins reduce the mortality in cardiovascular disease (CVD) in populations with normal, or close to normal, renal function. There are some observational registry data indicating that this may also be true in hemodialysis (HD) patients, but no prospective controlled trial has been performed to date.

METHODS

We present the rationale for, and a brief outline of, a randomized placebo-controlled trial using a novel drug, rosuvastatin, in HD patients, to target cardiovascular events (the AURORA study). This study will include close to 3000 male and female HD patients, aged 50-80 years. The study is event driven and it has been estimated that it will run for a follow-up time close to four years.

CONCLUSION

There is a sound rationale for making a randomized placebo-controlled statin trial in HD patients, with the objective to demonstrate an effect on CV mortality and morbidity.

[Atherosclerosis and uremia: signifance of non-traditional risk factors]

Arteriosclerosis, atherosclerosis and vascular calcification are causally related to the high morbidity and mortality of patients with chronic renal failure. Oxidative stress and carbonyl stress of uremia, dialysis procedure and/or intravenous iron therapy result in AGE (advanced glycation end-product), ALE (advanced lipoxidation end-product) and AOPP (advanced oxidation protein product) formation, favouring together with elevated CRP (C-reactive protein) levels the development of cardiovascular and cerebrovascular complications. Enhanced plasma levels of homocysteine and ADMA (asymmetric dimethylarginine) contribute to this process. In addition, in chronic renal insufficiency hyperphosphatemia and an enhanced calcium x phosphorus ion product are associated with the morbidity and mortality of the patients, particularly in the presence of fetuin deficiency. Phosphorus, AGEs and AOPPs, beside other factors, catalyze the conversion of vascular smooth muscle cells to osteoblast--like cells (particularly in the presence of monocytes/macrophages), resulting in bone matrix protein formation. Other risk factors, such as age, male sex, smoking, hypertension, diabetes, chronic inflammation, insulin resistance or dyslipidemia (enhanced non-HDL-cholesterol) also contribute to the atherosclerotic risk profile of the patient with chronic renal insufficiency. While there is growing understanding of the mechanisms involved in arteriosclerosis, atherosclerosis and vascular calcification in uremia, we are still missing effective therapeutic maneuvers for reduction of excess mortality in uremic patients.

Inflammation in ESRD: causes and potential consequences

Malnutrition in end-stage renal disease (ESRD) is characterized by hypoalbuminemia, decreased serum creatinine and prealbumin, and decreased subjective global assessment (SGA) scores. Markers of malnutrition predict mortality and correlate closely with inflammatory markers, including serum cytokines and acute phase proteins. After multiple regression analysis, markers of inflammation become stronger predictors of mortality than nutritional markers, suggesting that malnutrition is a result of inflammation. The etiology of inflammation is variable and includes vascular access infection, bioincompatible dialyzers, back filtration of nonsterile dialysate, periodontal disease, urinary tract infections, and other pyogenic infections. Renal failure also may serve to promote inflammation through protein carbonylation. Differences in care patterns of ESRD patients and genetics may contribute to inflammation as evidenced by lower levels of C-reactive protein (CRP) in Asian populations. Inflammation results in loss of muscle mass and hypoalbuminemia as a consequence of its decreased synthesis and increased catabolism. Vascular disease occurs partly because of changes in lipoprotein structure and function, including oxidation of low-density lipoprotein (LDL) and modification of high-density lipoprotein (HDL) by serum amyloid A (SAA) and loss of apolipoprotein A-I. Leukocyte adhesion is promoted by changes in endothelial structure and function, whereas plasma proteins associated with cardiovascular disease (fibrinogen, lipoprotein[a]; SAA) are increased. Consequences of inflammation in ESRD patients include muscle wasting, erythropoetin resistance, and vascular disease. Whereas improvements in nutrition can increase serum albumin and creatinine levels, identification and removal of the underlying cause of inflammation should be one treatment goal.

Diagnosis and therapy of coronary artery disease in renal failure, end-stage renal disease, and renal transplant populations

Even though cardiovascular disease is the leading cause of death in patients with CRF and end-stage renal disease (ESRD), ill-conceived notions have led to therapeutic nihilism as the predominant strategy in the management of cardiovascular disease in these populations. The recent data clearly support the application of proven interventions in the general population, such as angiotensin-converting enzyme inhibitors and statins to patients with CRF and ESRD. The advances in coronary stents and intracoronary irradiation have decreased the restenosis rates in renal failure patients. Coronary artery bypass with internal mammary graft might be the procedure of choice for coronary revascularization in these patients. The role of screening for asymptomatic coronary disease is established as a pretransplant procedure, but it is unclear whether this will be applicable to all patients with ESRD. Future studies need to focus on unraveling the mechanisms by which uremia leads to increased cardiovascular events to design optimal therapies targeted toward these mechanisms and improve cardiovascular outcomes.

Risk factors for coronary artery disease in patients with renal failure

Cardiovascular mortality is markedly increased in patients with end-stage renal disease (ESRD), particularly those receiving dialysis. Coronary artery disease is the most important cause of death in these patients. As in the general population, older age, male gender, and the postmenopausal state in women are cardiovascular risk factors in patients with ESRD. However, hypertension, diabetes mellitus, and dyslipidemia, known to promote cardiovascular disease in the general population, are particularly likely to do so in patients with ESRD because of their high prevalence in this population. In addition, nontraditional cardiovascular risk factors, such as hyperhomocystinemia, inflammation, elevated calcium x phosphate product, endothelial dysfunction, and oxidant stress, occur frequently in patients with ESRD. Vigorous treatment of modifiable cardiovascular risk factors has reduced cardiovascular risk in patients without ESRD. The extent to which such risk factor modification would alter cardiovascular risk in ESRD remains uncertain.

Nutrition in hemodialysis patients previously on a supplemented very low protein diet

BACKGROUND

Nutritional safety of protein-restricted diets in patients with chronic renal failure is controversial. In the present study, we have assessed the evolution of nutritional status after initiation of hemodialysis in patients previously treated by a supplemented very low protein diet (SVLPD).

METHODS

Nutritional data were prospectively collected during the first year of hemodialysis from 15 consecutive patients treated with a SVLPD (0.3 g protein/kg/day supplemented with essential amino acids, calcium, iron, and vitamins) and compared to 15 age- and gender-matched end-stage renal disease (ESRD) patients previously on a less-restricted diet (0.90 +/- 0.21 g protein/kg/day) who started hemodialysis during the same period. Dual-energy x-ray absorptiometry (DEXA) was used to assess body composition at 0, 6, and 12 months. Hemodialysis prescriptions, biologic data and 3-day food records were collected every 3 months.

RESULTS

Protein intake was higher than 1.2 g/kg/day in both groups as soon as 3 months after the start of hemodialysis. Albumin and prealbumin increased significantly during the first 6 months in all patients. Body mass index (BMI) increased in all patients (+0.97 +/- 1.31 kg/m2; P < 0.001) reflecting a gain in fat mass in the overall population (+2.36 +/- 2.94 kg/m2; P < 0.001) while lean body mass remained stable overall.

CONCLUSION

Once on hemodialysis, SVLPD patients rapidly increased protein intake. Nutritional status improved in all patients, with a gain in fat mass in all, and a gain in lean body mass in SVLPD men only. These data indicate that treatment with a SVLPD prior to hemodialysis initiation is nutritionally safe.

The risk of developing end-stage renal disease in patients with type 2 diabetes and nephropathy: the RENAAL study

BACKGROUND

Diabetic nephropathy has become the single most important cause of end-stage renal disease (ESRD) worldwide. Strategies to slow the rate of loss of renal function in these patients have been developed. We examined the risk factors that predict loss of kidney function (doubling of serum creatinine) or ESRD (dialysis or transplantation) in patients with type 2 diabetes in whom blood pressure was controlled.

METHODS

We evaluated risk factors for doubling of serum creatinine or the development of ESRD in the Reduction of End Points in NIDDM with the Angiotensin II Receptor Antagonist Losartan (RENAAL) study, which included 1513 patients with type 2 diabetes and nephropathy.

RESULTS

Univariate analyses demonstrated a group of 23 risk factors that significantly predicted doubling of serum creatinine or ESRD. From these univariate analyses, a multivariate model was developed that demonstrated four independent risk factors: proteinuria, serum creatinine, serum albumin, and hemoglobin level. Proteinuria was the strongest and most consistent risk factor. The multivariate risk model was derived from only the placebo group and was similar to that derived for the total population, suggesting that the risk predictors for progression of kidney disease were independent of therapy.

CONCLUSION

After control of blood pressure in type 2 diabetic patients with nephropathy, proteinuria, degree of renal failure, serum albumin, and hemoglobin level are independent risk factors that predict renal outcomes. The level of proteinuria proved to be the most important risk for progressive kidney injury in these diabetic patients.

Why is coronary heart disease of uraemic patients so frequent and so devastating?

On September 6, 2001, Professor Fernando Valderrabano (Hospital Gregorio Marañon, Madrid) died at the age of 59 years. He was a leading figure in Spanish nephrology, a full professor of Medicine/Nephrology at the University Complutense of Madrid, and an outstanding scientist who published more than 300 articles in medical journals. He was a very intelligent and cultured person, and a man of great style who enjoyed a wide range of hobbies and interests in addition to his medical work. All his colleagues and friends mourn his passing.

Effects of ramipril in nondiabetic nephropathy: improved parameters of oxidatives stress and potential modulation of advanced glycation end products

Enhanced oxidative stress is involved in the progression of renal disease. Since angiotensin converting enzyme inhibitors (ACEI) have been shown to improve the antioxidative defence, we investigated, in patients with nondiabetic nephropathy, the short-term effect of the ACEI ramipril on parameters of oxidative stress, such as advanced glycation end products (AGEs), advanced oxidation protein products (AOPPs), homocysteine (Hcy), and lipid peroxidation products. Ramipril (2.5-5.0 mg/day) was administered to 12 newly diagnosed patients for 2 months and data compared with a patient group under conventional therapy (diuretic/beta-blockers) and with age- and sex-matched healthy subjects (CTRL). Patients had mild to moderate renal insufficiency and showed, in the plasma, higher fluorescent AGE and carboxymethyllysine (CML) levels, as well as elevated concentrations of AOPPs, lipofuscin and Hcy when compared with CTRL. Basal data of the patients on conventional therapy did not differ significantly from the ramipril group, except for higher Hcy levels in the latter. Administration of ramipril resulted in a drop in blood pressure and proteinuria, while creatinine clearance remained the same. The fluorescent AGEs exhibited a mild but significant decline, yet CML concentration was unchanged. The AOPP and malondialdehyde concentrations decreased, while a small rise in neopterin levels was evident after treatment. The mentioned parameters were not affected significantly in the conventionally treated patients. Evidence that ramipril administration results in a mild decline of fluorescent AGEs is herein presented for the first time. The underlying mechanism may be decreased oxidative stress, as indicated by a decline in AOPPs and malondialdehyde.

Fluid status in CAPD patients is related to peritoneal transport and residual renal function: evidence from a longitudinal study

BACKGROUND

Both peritoneal transport characteristics as well as residual renal function are related to outcome in patients treated with continuous ambulatory peritoneal dialysis (CAPD). It has been suggested that part of this relationship might be explained by an effect of both parameters on the fluid state in CAPD patients or by the relationship between inflammation and peritoneal transport.

METHODS

In the present study, the relationship between fluid state [extracellular water (ECW) (sodium bromide); total body water (TBW) (deuterium oxide)] with peritoneal transport characteristics (2.27% glucose dialysate/plasma creatinine [D/P (creat)] ratio), residual renal function (residual glomerular filtration rate [rGFR] by urine collection) and C-reactive protein (CRP) was assessed in 37 CAPD patients in a cross-sectional and longitudinal design, with 25 patients completing the study.

RESULTS

In the cross-sectional part ECW, corrected for height (ECW:height), was inversely related to rGFR (r=-0.40, P=0.016), whereas during the longitudinal part, D/P[creat] was related to the change in ECW (r=0.40, P=0.05). Neither D/P[creat] nor rGFR were related to CRP, whereas a significant relationship was observed between ECW:height and CRP (r=0.58, P=0.0001). Patients were dichotomized according to rGFR (<2 or >2 ml/min). Despite a higher daily peritoneal glucose prescription (216.3+/-60.0 vs 156.5+/-53.0 g/24 h; P=0.004) and peritoneal ultrafiltration volume (1856+/-644 vs 658+/-781 ml/24 h, respectively; P=0.0001), the patients with a rGFR <2 ml/min showed a higher ECW:height compared with the group with rGFR >2 ml/min (12.5+/-3.8 vs 9.2+/-2.2 l/m, respectively; P=0.003). Results for TBW were comparable.

CONCLUSION

Fluid state was significantly related to peritoneal transport characteristics and rGFR. The larger ECW:height in CAPD patients with a negligible rGFR existed despite a higher peritoneal ultrafiltration volume and higher peritoneal glucose prescription. These findings raise doubts as to whether fluid state in CAPD patients with a diminished rGFR can be adequately controlled on standard glucose solutions without an additional sodium and fluid restriction. The preliminary finding of a relationship between CRP and fluid state might suggest a relationship between overhydration and inflammation.

Influence of concurrent renal dysfunction on outcomes of patients with acute coronary syndromes and implications of the use of glycoprotein IIb/IIIa inhibitors

OBJECTIVES

The purpose of this study was to examine the in-hospital outcome and influence of glycoprotein (GP) IIb/IIIa antagonists on patients with acute coronary syndromes (ACS) across a range of renal function.

BACKGROUND

Recent studies demonstrate increasing cardiovascular risk with progressive renal dysfunction. Previous studies investigating GP IIb/IIIa antagonist use have excluded patients with renal dysfunction.

METHODS

Patients presenting with ACS between January 1999 and May 2000 were identified, and data on demographics, in-hospital management, and clinical events were collected using standardized definitions. Patients were stratified according to renal function assessed by calculated creatinine clearance (CrCl) at presentation. Primary outcome measures included in-hospital mortality and major bleeding events.

RESULTS

Renal insufficiency was present in 312 of 889 patients. There were 40 in-hospital deaths. In non-dialysis-dependent patients, as CrCl worsened, there was a decline in utilization of routine diagnostics and therapeutics, an increase in in-hospital mortality (p = 0.002), and an increase in major bleeding (p = 0.03). Although the use of GP IIb/IIIa antagonists was associated with an increase in major bleeding (p < 0.001), there was a protective effect on in-hospital mortality (p = 0.04) after controlling for CrCl.

CONCLUSIONS

Renal dysfunction is present in a substantial proportion of patients with ACS and is associated with increased in-hospital death. Although GP IIb/IIIa antagonist use in patients with ACS and renal insufficiency resulted in increased bleeding events, its administration was associated with a decreased risk of in-hospital mortality. These preliminary findings need to be confirmed in future randomized clinical trials.

Oxidant stress in hemodialysis patients: what are the determining factors?

Oxidant stress contributes to morbidity in hemodialysis patients. Three possible causes of oxidant stress have been suggested: the uremic state, the dialyzer membrane, and bacterial contaminants from the dialysate. Oxidant stress occurs in uremia before dialysis therapy is initiated, as evidenced by increased production of reactive oxygen species, increased levels of oxidized plasma proteins and lipids, and decreased antioxidant defenses. It has been proposed that increased production of reactive oxygen species during hemodialysis is also an important contributor to oxidant stress. Hemodialysis is associated with a transient increase in production of reactive oxygen species, particularly with cellulose membranes. In addition, surveys have shown widespread contamination of dialysate by endotoxin, which may cross membranes and prime production of reactive oxygen species by phagocytic cells. Recent studies, however, show a decrease in protein oxidation from pre- to post-dialysis and a normalization of neutrophil reactive oxygen species production. Taken together, these data suggest that uremia, per se, is the most important cause of oxidant stress in hemodialysis patients. Dialysate quality may also contribute to oxidant stress, but evidence that the dialyzer membrane plays a role is weak.

Recent advances in management of type 2 diabetes and nephropathy: lessons from the RENAAL study

BACKGROUND

Diabetic nephropathy has become the single most important cause of end-stage renal disease (ESRD) worldwide. Strategies to slow the rate of loss of renal function in these patients recently have been developed. The renin-angiotensin-aldosterone system has proven to be an important target for intervention.

METHODS

The Reduction of Endpoints in NIDDM with the Angiotensin II Receptor Antagonist Losartan (RENAAL) study was a randomized, double-blind, multinational, clinical trial that studied 1,513 patients with type 2 diabetes and nephropathy for a mean of 3.4 years. Patients were administered either losartan or placebo, each in addition to conventional antihypertensive therapy, with dosage adjustments as necessary to achieve a target blood pressure of less than 140/less than 90 mm Hg.

RESULTS

The study showed a significant benefit of losartan, beyond the effects of lowering blood pressure, on the primary composite end point of doubling serum creatinine level, ESRD, or death (-16%; P = 0.02). Losartan reduced the incidence of serum creatinine level doubling (-25%; P = 0.006) and ESRD (-28%; P = 0.002), but had no effect on rate of death. The composite end point of cardiovascular morbidity and mortality was similar in the two groups. The rate of first hospitalization for heart failure was reduced in the losartan group (-32%; P = 0.005), as was proteinuria (-35%; P < 0.001). The RENAAL study also provided the opportunity to evaluate risk factors that predict ESRD in patients with type 2 diabetes in whom blood pressure was aggressively treated. In our multivariate model, four independent risk factors, proteinuria (most important), serum creatinine level, hypoalbuminemia, and anemia, were identified that predicted the development of ESRD.

CONCLUSION

Proteinuria is the single most powerful predictor of ESRD in patients with type 2 diabetes and nephropathy. Thus, it is imperative that it be assessed in all patients with type 2 diabetes to identify those at risk for progressive renal disease. The routine availability of the urinary albumin-creatinine ratio as a diagnostic test provides an important opportunity to further improve the prognosis of individuals with type 2 diabetes and nephropathy.

Hyperhomocysteinemia and its relationship to cardiovascular disease in ESRD: influence of hypoalbuminemia, malnutrition, inflammation, and diabetes mellitus

BACKGROUND

In the general population, a mildly elevated plasma total homocysteine (tHcy) level is an independent and graded risk factor for cardiovascular disease (CVD). In patients with end-stage renal disease (ESRD), CVD is highly prevalent and a major cause of premature mortality, and plasma tHcy levels are as much as three to four times greater than in the general population. Several other risk factors, such as diabetes mellitus (DM), inflammation, and malnutrition, also are prevalent and contribute to CVD in patients with ESRD, and there are strong associations between inflammation, malnutrition, and hypoalbuminemia in these patients. Several investigations in patients with ESRD have shown the important role of vitamin status for plasma tHcy, but little attention has been given to the influence of nutritional status. However, it is obvious that hypoalbuminemia is of interest because a substantial fraction of tHcy (>70%) is protein bound, mainly to albumin.

RESULTS

In studies of patients with ESRD in whom the prevalence of hyperhomocysteinemia was very high (>90%), tHcy level was strongly related to serum albumin level, and patients with malnutrition had lower levels of both tHcy and serum albumin than those with normal nutritional status. Furthermore, inflammation, DM, and CVD are associated with hypoalbuminemia and therefore a lower degree of hyperhomocysteinemia. In our studies, in different groups of patients with ESRD, we showed that greater tHcy levels were associated with lower CVD mortality. However, this apparently paradoxical association between lower CVD mortality and lower plasma tHcy levels (although still abnormally high) does not refute the concept that hyperhomocysteinemia is a risk factor for CVD because almost all patients may have had long-standing elevated plasma tHcy levels within a range that makes them prone to develop atherosclerosis. Instead, a potentially detrimental effect of hyperhomocysteinemia on CVD in patients with ESRD may be obscured by the influence of hypoalbuminemia, whatever the cause, because hypoalbuminemia and its causes are strong predictors of mortality.

CONCLUSION

Our findings imply that nutritional status and serum albumin level, as well as the presence of inflammation and DM, should be taken into consideration when evaluating tHcy as a risk factor for CVD in patients with ESRD.

Uremia-related metabolic cardiac risk factors in chronic kidney disease

Growing evidence has been gathered over the last 15 years regarding the role of nontraditional or uremia-related risk factors in the pathogenesis of atherosclerosis in subjects with renal failure. Among those factors, dyslipidemia, inflammation, hyperhomocysteinemia, and oxidant stress have been extensively studied. However, the clinical significance of many of these factors remains controversial in light of reported studies. In this article, the existing evidence regarding the role of uremia-related risk factors in the pathogenesis of atherosclerosis is reviewed, with special emphasis on prevalence, cardiac risk, and management in patients with chronic kidney disease (CKD). Consensus treatment recommendations are provided for risk factors for which there is evidence to support preventive or therapeutic interventions.

Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients

Conventional risk factors of cardiovascular disease and mortality in the general population such as body mass, serum cholesterol, and blood pressure are also found to relate to outcome in maintenance dialysis patients, but often in an opposite direction. Obesity, hypercholesterolemia, and hypertension appear to be protective features that are associated with a greater survival among dialysis patients. A similar protective role has been described for high serum creatinine and possibly homocysteine levels in end-stage renal disease (ESRD) patients. These findings are in contrast to the well-known association between over-nutrition and poor outcome in the general population. The association between under-nutrition and adverse cardiovascular outcome in dialysis patients, which stands in contrast to that seen in non-ESRD individuals, has been referred to as "reverse epidemiology." Publication bias may have handicapped or delayed additional reports with such paradoxical findings in ESRD patients. The etiology of this inverse association between conventional risk factors and clinical outcome in dialysis patients is not clear. Several possible causes are hypothesized. First, survival bias may play a role since only a small number of patients with chronic kidney disease (CKD) survive long enough to reach ESRD. Hence, the dialysis patients are probably a distinctively selected population out of CKD patients and may not represent the risk factor constellations of their CKD predecessors. Second, the time discrepancy between competitive risk factors may play a role. For example, the survival disadvantages of under-nutrition, which is frequently present in dialysis patients, may have a major impact on mortality in a shorter period of time, and this overwhelms the long-term negative effects of over-nutrition on survival. Third, the presence of the "malnutrition-inflammation complex syndrome" (MICS) in dialysis patients may also explain the existence of reverse epidemiology in dialysis patients. Both protein-energy malnutrition and inflammation or the combination of the two are much more common in dialysis patients than in the general population and many elements of MICS, such as low weight-for-height, hypocholesterolemia, or hypocreatininemia, are known risk factors of poor outcome in dialysis patients. The existence of reverse epidemiology may have a bearing on the management of dialysis patients. It is possible that new standards or goals for such traditional risk factors as body mass, serum cholesterol, and blood pressure should be considered for these individuals.

Survival of hemodialysis patients and uremic toxin removal

Uremic toxin removal based on diffusion and/or convection allows eliminating solutes with negative metabolic impact. Uremic solutes can be classified as small and water-soluble compounds, larger "middle" molecules, or protein bound solutes. The question arises whether more removal of each of these solute classes affects patient survival. Kt/V of urea is currently used as a surrogate for small water-soluble solute removal. There is ample evidence that Kt/V and survival are correlated, but the threshold Kt/V remains a matter of debate. Probably, the actually proposed threshold of 1.2 is too low. This impact of Kt/V is in contradiction with the low toxicity of urea and points to a role for other water-soluble solutes, e.g., potassium. More removal of middle molecules results in a lower morbidity and also in a lower mortality. In addition, a relationship has been demonstrated between the use of membranes with large pore size and a decrease of inflammatory status, by itself an important factor related to mortality. One of the problems is that large pore membranes are at the same time more biocompatible and reflect more dialysate impurities, compared to many small pore membranes, whereas they also reflect more dialysate impurities. It remains uncertain which one of these factors, if any, has a predominant effect. Recent studies point to a separate effect of pore size but await confirmation. Protein bound toxins inhibit several biochemical functions. Their removal pattern is totally different from that of classical markers such as urea. In analogy with drugs, it is essentially the free unbound fraction that exerts biological action; this free fraction is inversely related to serum albumin, another inflammatory marker related to survival. In a final section of this presentation, attention will be drawn to the relationship in uremic patients between inflammation, malnutrition, cardiovascular disease, and mortality, and some of the potential culprits are discussed. Virtually all of these molecules have a high molecular weight or are protein bound. It is concluded that both small and middle molecule removal have an impact on survival, so that more than urea removal alone should be pursued.

Elevated cardiac troponin T in predialysis patients is associated with inflammation and predicts mortality

OBJECTIVES

Cardiac troponin T (cTnT) is a highly sensitive and specific marker of myocardial damage. It has been shown that elevated serum concentrations of cTnT in haemodialysis (HD) patients are associated with poor prognostic outcome. The aim of the present study was to investigate the predictive value of cTnT in samples from predialysis patients and to investigate associations between cTnT and inflammatory markers, such as C-reactive protein (CRP) and interleukin-6 (IL-6).

DESIGN

Cohort, follow-up study.

SETTING

Huddinge University Hospital, Sweden.

SUBJECTS

A total of 115 (62% males, 28% diabetic patients) end-stage renal disease (ESRD) patients (52 +/- 1 years), of which 29% had cardiovascular disease (CVD), were studied shortly before the onset of dialysis therapy. Sixty-four patients started peritoneal dialysis (PD) as renal replacement therapy, whilst 49 started HD during the follow-up.

MAIN OUTCOME MEASURES

The cTnT was analysed with the third generation TnT assay on Elecsys 2010. The prognostic value was calculated for cTnT, IL-6, age, CVD, malnutrition, diabetes mellitus (DM) and gender. Survival analyses were made with Kaplan-Meier and Cox regression analyses, with all-cause mortality as the clinical end point (mean follow-up period 2.7 +/- 0.1 years).

RESULTS

Significant correlations were found between cTnT and CKMB (rho = 0.52, P < 0.0001), IL-6 (rho = 0.23, P < 0.05), CRP (rho = 0.30, P < 0.05), and serum albumin (rho = -0.31, P < 0.001), respectively. Diabetic patients had higher median serum cTnT level (0.09 microg L-1; range <0.01-0.51 vs. 0.04 microg L-1; range <0.01-0.67 microg L-1; P < 0.005) compared with nondiabetic patients. Likewise, patients with CVD had a significantly higher median level (0.08 microg L-1; range <0.01-0.67 microg L-1 vs. 0.04 microg L-1; range <0.01-0.61 microg L-1; P < 0.01) of cTnT compared with patients without CVD. Patients with cTnT > or =0.10 microg L-1 had a higher cumulative mortality rate than patients with cTnT < 0.10 microg L-1 (chi2 = 7.04; P < 0.01). Whilst age, CVD, malnutrition, DM, IL-6, cTnT and male gender were associated with poor outcome in the univariate analysis, only DM (P < 0.05) and cTnT (P < 0.05) were independently associated with mortality in a multivariate analysis.

CONCLUSIONS

The present study demonstrates that serum concentrations of cTnT > or =0.10 microg L-1 is a significant predictor of mortality in patients starting dialysis. Moreover, the positive correlations between cTnT and IL-6, and CRP, respectively, suggest an association between inflammation and cTnT levels. Finally, the results of the present study suggest that cTnT is an independent predictor of mortality in ESRD patients starting dialysis.

Elevations of inflammatory and procoagulant biomarkers in elderly persons with renal insufficiency

BACKGROUND

Renal insufficiency has been associated with cardiovascular disease events and mortality in several prospective studies, but the mechanisms for the elevated risk are not clear. Little is known about the association of renal insufficiency with inflammatory and procoagulant markers, which are potential mediators for the cardiovascular risk of kidney disease.

METHODS AND RESULTS

The cross-sectional association of renal insufficiency with 8 inflammatory and procoagulant factors was evaluated using baseline data from the Cardiovascular Health Study, a population-based cohort study of 5888 subjects aged > or =65 years. C-reactive protein, fibrinogen, factor VIIc, and factor VIIIc levels were measured in nearly all participants; interleukin-6, intercellular adhesion molecule-1, plasmin-antiplasmin complex, and D-dimer levels were measured in nearly half of participants. Renal insufficiency was defined as a serum creatinine level > or =1.3 mg/dL in women and > or =1.5 mg/dL in men. Multivariate linear regression was used to compare adjusted mean levels of each biomarker in persons with and without renal insufficiency after adjustment for other baseline characteristics. Renal insufficiency was present in 647 (11%) of Cardiovascular Health Study participants. After adjustment for baseline differences, levels of C-reactive protein, fibrinogen, interleukin-6, factor VIIc, factor VIIIc, plasmin-antiplasmin complex, and D-dimer were significantly greater among persons with renal insufficiency (P<0.001). In participants with clinical, subclinical, and no cardiovascular disease at baseline, the positive associations of renal insufficiency with these inflammatory and procoagulant markers were similar.

CONCLUSION

Renal insufficiency was independently associated with elevations in inflammatory and procoagulant biomarkers. These pathways may be important mediators leading to the increased cardiovascular risk of persons with kidney disease.

Relation between serum albumin and carotid atherosclerosis: the NHLBI Family Heart Study

BACKGROUND AND PURPOSE

Lower concentrations of albumin have been positively related to coronary disease. The aim of this project was to assess the association between serum albumin and carotid atherosclerosis.

METHODS

B-mode ultrasound was used to assess carotid plaques and intima-media thickness (IMT) among white subjects from 592 randomly ascertained families in the National Heart, Lung, and Blood Institute Family Heart Study. Logistic regression was used to estimate prevalence odds ratios of any carotid plaques.

RESULTS

Of the 2072 persons studied, 47% were men. Higher serum albumin was associated with younger age, lower body mass index, and lower prevalence of hypertension and coronary disease. Lower serum albumin levels were not associated with an increased odds of carotid plaques. From the lowest to the highest quartile of albumin, multivariate adjusted odds ratios for the prevalence of any carotid plaques were 1.05 (95% CI, 0.59 to 1.86), 1.34 (95% CI, 0.78 to 2.32), 1.03 (95% CI, 0.52 to 1.86), and 1.0 (reference), respectively, in men and 0.71 (95% CI, 0.40 to 1.26), 0.76 (95% CI, 0.42 to 1.36), 0.79 (95% CI, 0.46 to 1.36), and 1.0, respectively, in women. Similarly, in a linear regression model adjusted for demographic, lifestyle, and metabolic factors, serum albumin was not associated with carotid IMT. When the first 3 were compared with the highest quartile of serum albumin, regression coefficients for internal carotid IMT were 0.06458 (SE, 0.06408), 0.07205 (SE, 0.05469), and 0.000773 (SE, 0.05687), respectively, for men and -0.01795 (SE, 0.05085), -0.08501 (SE, 0.04800), and 0.009528 (SE, 0.04622), respectively, for women.

CONCLUSIONS

Our data suggest that lower serum albumin levels are not associated with an increased odds of prevalent carotid atherosclerosis in either men or women.

Ultrasound evaluation of intima media thickness of carotid arteries in dialysis patients and correlation with proposed risk factors

Atherosclerosis is significant risk factor for cardiovascular morbidity and mortality in dialysis patients. Aim of the study was ultrasound evaluation of intima media thickness on carotid arteries (as a marker of atherosclerosis), in dialysis patients and its correlation with proposed risk factors. Intima media thickness was measured in 45 dialysis patients with no signs of cardiovascular diseases (15 on peritoneal dialysis, group I,30 on hemodialysis, group II) and 20 healthy controls. The mean carotid artery intima media thickness was significantly higher in dialysis patients than in control group. According to intima media thickness, dialysis patients were divided in group A (patient with intima media thickness less or equal 0,720 mm) and group B (intima media thickness higher then 0,720mm). Intima media thickness in bout group was correlated with proposed risk factors. In group A there was not significant correlation of intima media thickness with risk factors. In group B significant correlation have been found between intima media thickness and LDL, VLDL cholesterol, body mass index and systolic, diastolic and mean blood pressure. Although atherosclerosis was not the only cause for cardiovascular morbidity and mortality, it has a dominant role in dialysis patients. Augmented intima media thickness could be early marker of atherosclerosis. The risk factors of great influence on intima media thickness are lipid disturbances, obesity and hypertension.

[Dialysis as a risk factor for development of atherosclerosis]

INTRODUCTION

Atherosclerosis is a major risk factor for increased cardiovascular morbidity and mortality in dialysis patients. First clinical symptoms are usually associated with initial atherosclerotic changes of blood vessels. The aim of this study was ultrasound evaluation of intima media thickness (IMT) of carotid arteries in dialysis patients and its correlation with certain risk factors.

PATIENTS AND METHODS

IMT was measured in 45 dialysis patients with no signs of cardiovascular diseases: 15 continuous ambulatory peritoneal dialysis (CAPD) patients, 30 hemodialysis (HD) patients and in 20 healthy controls. IMT was correlated with certain risk factors for atherosclerosis (general parameters--age, gender, duration of dialysis, cause of renal diseases, parameters of nutrition, parameters of calcium and phosphorus metabolism, lipid parameters, blood pressure and smoking).

RESULTS

The mean carotid artery IMT was significantly higher in dialysis patients than in the control group (p < 0.05). In addition, the mean IMT was statistically significantly higher in PD than in HD patients (p < 0.05). In CAPD patients there was a significant correlation between IMT and total and LDL cholesterol. In the second group (HD patients) IMT significantly correlated with diastolic blood pressure, BMI and smoking.

CONCLUSION

Although atherosclerotic cardiovascular disease may not manifest in dialysis patients, IMT of carotid arteries significantly increases. Major risk factors affecting IMT are lipid disturbances in patients on peritoneal dialysis and hypertension, obesity and smoking in HD patients.

Normalized protein nitrogen appearance is correlated with hospitalization and mortality in hemodialysis patients with Kt/V greater than 1.20

OBJECTIVES

Normalized protein nitrogen appearance (nPNA), also known as protein catabolic rate (nPCR), reflects the daily protein intake in maintenance hemodialysis (MHD) patients. Several studies indicate that nPNA and Kt/V correlate with clinical outcome and also with each other. Thus, the relationship between low nPNA and poor outcome could be due to uremia, low Kt/V or due to reported mathematical coupling between nPNA and Kt/V. We therefore investigated whether nPNA is associated with outcome in patients who have adequate or high Kt/V.

DESIGN

Prospective cohort.

SETTINGS

Outpatient dialysis unit affiliated with a tertiary-care community medical center.

PATIENTS

From a pool of 135 MHD outpatients in one dialysis unit, 122 patients with a delivered, Kt/V(sp)>1.20, independent of their residual renal function, were evaluated. Patients (61 women, 61 men), aged from 23 to 89 years (53.4+/-14.0 years)(+/-SD), had been undergoing MHD for one month to 17 years.

INTERVENTION

Review of laboratory values and clinical outcome.

MAIN OUTCOME MEASURES

Twelve-month mortality and hospitalization.

RESULTS

Delivered Kt/V(sp) ranged from 1.23 to 2.71 (1.77+/-0.34), nPNA from 0.5 to 2.15 (1.13+/-0.29 g/kg/day), and serum albumin, from 1.9 to 4.6 (3.76+/-0.37 g/dL). During the 12-month follow-up, 55 patients were hospitalized overnight at least once; 12 patients died; 5 patients underwent renal transplantation, and 6 patients left the study. The nPNA and Kt/V(sp) did not correlate significantly (r=.09) except when analysis was limited to Kt/V values < 1.5 (r=.54). Serum nPNA and albumin were the only variables with statistically significant correlations with both mortality and 3 measures of hospitalization (H): total days of H (H(D)), total number of H (H(F)), and time to first H (H(T)). The case-mix adjusted correlations for serum albumin and nPNA versus total days (r(HD)) and frequency of H (r(HF)) were significant, and Cox analysis based on H(T) and time to death resulted in significant odds ratios for each standard deviation decrement for both serum albumin and nPNA. Serum total iron binding capacity (TIBC) and creatinine concentrations also correlated with some but not all outcome measures: lower serum concentrations of these values were each significantly associated with poor clinical outcomes.

CONCLUSIONS

Both nPNA and serum albumin predict prospective hospitalization and mortality in MHD patients with Kt/V > 1.20. Serum TIBC and creatinine concentrations appear to have association with some outcome measures as well. These data are consistent with the possibility that protein intake affects the clinical course even in the setting of an adequate to high hemodialysis dose. Studies based on randomized assignments to different protein intakes would be helpful to confirm these conclusions.

Down-regulation of hepatic cytochrome p450 in chronic renal failure: role of uremic mediators

1. Chronic renal failure (CRF) is associated with a decrease in liver cytochrome p450 (p450). The mechanism remains poorly understood. The present study aimed to investigate the effects of the serum of rats with CRF on liver p450. 2. Normal rat hepatocytes were incubated for 24 h with serum (concentration of 10%) from rats with CRF and from control animals in order to measure (1). total p450 level, (2). protein expression and mRNA levels of major p450 isoforms, and (3). some of their specific metabolic activities (N-demethylation of erythromycin). Time-course experiments (incubation time from 12 to 48 h) and dose-response curves (concentration of serum ranging from 1 to 30%) have been conducted. 3. In normal hepatocytes incubated for 24 h with serum (concentration of 10%) from rats with CRF, total p450 level, protein expression and mRNA levels of several p450 isoforms (CYP2C6, 2C11, 3A1 and 3A2) were decreased by more than 35% (P<0.001) compared to serum from control animals. The protein expression as well as the mRNA levels of CYP2D were similar in hepatocytes incubated with serum from either control or CRF rats. The N-demethylation of erythromycin was decreased by more than 35% (P<0.001) in hepatocytes incubated with serum from rats with CRF. The inhibitory effect of serum from rats with CRF tended to peak at 48 h of incubation and was maximum at a concentration of 20%. 4. In conclusion, uremic serum contains mediator(s) that down-regulate the cytochrome p450 of normal hepatocytes secondary to reduced gene expression.

Increased C-reactive protein following hemodialysis predicts cardiac hypertrophy in chronic hemodialysis patients

BACKGROUND

Chronic inflammation characterized by increased C-reactive protein (CRP) levels strongly predicts cardiovascular death in both nonrenal and renal patients. We investigated the role of hemodialysis-induced elevated CRP levels on cardiac hypertrophy in hemodialysis patients.

METHODS

We grouped 118 stable patients as responders and nonresponders according to the response of CRP (>4 mg/L) after a single hemodialysis session.

RESULTS

Predialysis CRP and interleukin-6 (IL-6) concentrations were significantly greater in responders compared with nonresponders (6.4 versus 2.0 mg/L and 8.7 versus 4.8 ng/L, respectively; P < 0.01). Postdialysis CRP concentrations in responders (8.8 mg/L; P < 0.05) and IL-6 concentrations in responders and nonresponders (10.0 versus 5.4 ng/L; P < 0.05) further increased. Intact parathyroid hormone, fibrinogen, total cholesterol, low-density lipoprotein cholesterol, and lipoprotein(a) [Lp(a)] levels (P < 0.05), as well as interventricular septal thickness (IVST; P < 0.005), left ventricular posterior wall thickness (LVPWT; P < 0.05), and left ventricular mass index (LVMi; P < 0.05) were significantly greater in responders compared with nonresponders. Predialysis and postdialysis CRP levels correlated positively with Lp(a) (P < 0.01, P < 0,05, respectively), fibrinogen, and predialysis and postdialysis IL-6 levels (P < 0.001) and negatively with albumin level (P < 0.05, P < 0.01, respectively). LVMi, as well as IVST and LVPWT, correlated not only with predialysis and postdialysis CRP levels, but also IL-6 levels (P < 0.05). The interval changes in postdialysis to predialysis CRP levels correlated significantly with IVST, PWT (r = 0.500; r = 0.458; P < 0.001, respectively), and LVMi (r = 0.252; P < 0.05). On multivariate analysis, the responder was the only predictor of IVST, LVPWT, and LVMi (P < 0.001, P < 0.001, and P < 0.01, respectively).

CONCLUSION

Elevated CRP concentrations associated with hemodialysis may be useful for the prediction of proatherogenic reactivity and cardiac hypertrophy.

Inflammation and outcome in end-stage renal failure: does female gender constitute a survival advantage?

BACKGROUND

Elevated C-reactive protein (CRP) is a strong predictor of cardiovascular events and all-cause mortality in end-stage renal disease (ESRD) patients. However, although sex hormones may influence serum levels of inflammatory proteins, gender has not been taken into consideration in previous studies of inflammation and outcome in ESRD patients.

METHODS

We included 663 (374 males) ESRD patients (59 +/- 1 year) from three European renal centers (Sweden, Germany and Italy) in which CRP levels and outcome data (follow-up 33 +/- 1 months) were available. The relation between outcome and serum levels of the soluble intercellular adhesion molecule (sICAM-1) was evaluated in 312 of the patients.

RESULTS

The present study shows that elevated CRP is a strong predictor of outcome, but whereas no difference in all-cause mortality was observed between non-inflamed (CRP <or=3.4 mg/L) males and females, inflamed males had a significantly (log rank 6.1; P = 0.01) higher mortality rate than inflamed females. A strong positive correlation between CRP and sICAM-1 was found in the combined patient material (rho = 0.37; P < 0.0001) as well as in the male (rho = 0.25; P < 0.01) and female (rho = 0.52; P < 0.0001) subgroups. The Cox proportional hazard model showed that whereas both elevated sICAM-1 and log CRP predicted outcome in males, neither predicted outcome significantly in females.

CONCLUSIONS

As inflamed female patients have a better outcome that inflamed males the present observation suggests that sex hormones may have important cardioprotective effects that limit the effect of inflammation on vascular injury in female ESRD patients.

The elephant in uremia: oxidant stress as a unifying concept of cardiovascular disease in uremia

Cardiovascular disease is the leading cause of mortality in uremic patients. In large cross-sectional studies of dialysis patients, traditional cardiovascular risk factors such as hypertension and hypercholesterolemia have been found to have low predictive power, while markers of inflammation and malnutrition are highly correlated with cardiovascular mortality. However, the pathophysiology of the disease process that links uremia, inflammation, and malnutrition with increased cardiovascular complications is not well understood. We hereby propose the hypothesis that increased oxidative stress and its sequalae is a major contributor to increased atherosclerosis and cardiovascular morbidity and mortality found in uremia. This hypothesis is based on studies that conclusively demonstrate an increased oxidative burden in uremic patients, before and particularly after renal replacement therapies, as evidenced by higher concentrations of multiple biomarkers of oxidative stress. This hypothesis also provides a framework to explain the link that activated phagocytes provide between oxidative stress and inflammation (from infectious and non-infections causes) and the synergistic role that malnutrition (as reflected by low concentrations of albumin and/or antioxidants) contributes to the increased burden of cardiovascular disease in uremia. We further propose that retained uremic solutes such as beta-2 microglobulin, advanced glycosylated end products (AGE), cysteine, and homocysteine, which are substrates for oxidative injury, further contribute to the pro-atherogenic milieu of uremia. Dialytic therapy, which acts to reduce the concentration of oxidized substrates, improves the redox balance. However, processes related to dialytic therapy, such as the prolonged use of catheters for vascular access and the use of bioincompatible dialysis membranes, can contribute to a pro-inflammatory and pro-oxidative state and thus to a pro-atherogenic state. Anti-oxidative therapeutic strategies for patients with uremia are in their very early stages; nonetheless, early studies demonstrate the potential for significant efficacy in reducing cardiovascular complications.

Cardiovascular disease in patients with chronic kidney disease

Cardiovascular disease (CVD) is the major cause of morbidity and mortality in patients with renal failure. Patients with chronic kidney disease have significant CVD, and carry a high cardiovascular burden by the time they commence renal replacement therapy (RRT). The severity of CVD that has been observed in dialysis patients lead to a growing body of research examining the pathogenesis and progression of CVD during the progression of chronic kidney disease (CKD) to end-stage renal disease (ESRD) (ie, predialysis phase). Multiple factors are involved in the development of CVD in CKD. More importantly, critical and key factors seem to develop early in the course of CKD, and result in preventable worsening of CVD in this patient population. Anemia is common in patients with CKD, and has been shown to have an independent role in the genesis of left ventricular hypertrophy (LVH) and subsequent CVD. Unfortunately, it is underdiagnosed and undertreated in patients with CKD. Early intervention, and better correction of anemia, seems to gain a great momentum in the prevention and management of CVD in CKD. Hypertension is another risk factor that has been targeted by the National Kidney Foundation Task Force on CVD in chronic kidney disease. This article reviews the different factors involved in the pathogenesis of CVD in CKD and the evidence supporting early and aggressive intervention.

Soluble leptin receptors and serum leptin in end-stage renal disease: relationship with inflammation and body composition

BACKGROUND

Elevated serum leptin (S-leptin) levels have been reported in patients with end-stage renal disease (ESRD). Apart from the decreased glomerular filtration rate (GFR), body composition and inflammation may affect leptin levels in ESRD. Leptin circulates both free of and bound to soluble leptin receptors (sOB-R), which are the main determinants of leptin activity and have not been described in ESRD until now.

DESIGN

To analyze the association between S-leptin, sOB-R, and inflammation and body composition, we studied 149 (62% males) normal weight (BMI 24.7 +/- 0.4 kg m(-2)) ESRD patients (51 +/- 1 years old) shortly before the start of dialysis (GFR 7.0 +/- 0.2 mL min(-1)). sOB-R and plasma interleukin-6 (IL-6; n= 113) levels were evaluated using ELISA, S-leptin using RIA, and body composition was assessed by X-ray absorptiometry (n = 139). Forty-one healthy subjects age (51 +/- 1 years), BMI (23.6 +/- 0.5 kg m(-2)) and gender-matched (59% males) were used as controls.

RESULTS

Median S-leptin was higher in the ESRD patients (10.0 ng mL(-1)) compared with the controls (3.9 ng mL(-1)) (P < 0.001). The median sOB-R did not differ significantly between the ESRD patients (44 U mL-1) and the controls (37 U mL-1). Thus, the sOB-R/S-leptin ratio was lower in the ESRD patients (9.5 +/- 1.2 vs. 12.3 +/- 1.8; P < 0.01) than the controls. A negative correlation was observed between S-leptin and sOB-R (Rho = -0.42; P < 0.0001) in the ESRD patients, a positive correlation was observed between lean body mass and the sOB-R/S-leptin ratio (Rho = 0.33, P = 0.0001) whereas fat mass was negatively correlated to both sOB-R (Rho = -0.26, P = 0.002), and the sOB-R/S-leptin ratio (Rho = -0.62, P < 0.0001). Positive correlations were observed between IL-6 and S-leptin (Rho = 0.19; P < 0.05) and weak but significant body fat mass (Rho = 0.20; P < 0.05), respectively.

CONCLUSIONS

This study demonstrates that despite markedly elevated S-leptin levels in the ESRD patients, sOB-R did not differ from the controls. In view of the anorexigenic and pro-atherogenic effects of leptin, further elucidation of the consequences of free bioactive leptin in the development of complications such as malnutrition and cardiovascular disease in ESRD patients is required.

Comorbidity and cardiovascular risk factors in patients with chronic kidney disease

The mortality rate among dialysis patients is high. Although guidelines have been in place to improve outcomes in dialysis patients, new emphasis is being placed on better management of patients who are pre-end-stage renal disease (pre-ESRD)-patients with chronic kidney disease (CKD). Spearheaded by the National Kidney Foundation, the National Institute of Health, and the nephrology community at large, an effort is underway to improve the care of patients with kidney disease. We hope that improvement in health and outcomes of patients with kidney disease will be optimized through attention to care before the development of advanced renal disease. Cardiovascular disease (CVD) is an important comorbidity of chronic kidney disease, and reducing cardiovascular events in this population is an important goal for the people who care for chronic kidney disease patients. In this article, we review the available literature regarding certain risk factors for cardiovascular disease: proteinuria, hyperglycemia, hypertension, homocysteine, hyperlipidemia, and inflammation. When possible, recommendations for treatment are provided based on the information reviewed.

Impact of renal failure on the risk of myocardial infarction and death

BACKGROUND

It is unclear whether pre-existing cardiovascular disease or predisposition of the uremic state leads to the high cardiovascular morbidity and mortality associated with renal failure. We examined whether renal failure independently increases the risk of myocardial infarction and death.

METHODS

A total of 8600 patients with variable glomerular filtration rate (GFR) at the time of coronary angiography participated in the Intermountain Heart Study. Coronary disease was defined as >or=70% stenosis. Modification of Diet in Renal Disease formula was used to calculate glomerular filtration rate (GFR). Cox regression models were used to compare outcomes.

RESULTS

The mean GFR was 71 +/- 24 mL/min. There were 1320 (15%) deaths, 657 (9%) myocardial infarctions and 1776 (21%) death or myocardial infarctions over 3.2 +/- 1.9 years. Compared to the highest GFR quartile, the lowest GFR quartile (mean GFR 41 +/- 14 mL/min) was associated with higher risk for myocardial infarction (RR 1.43, 95% CI 1.15 to 1.78), death (RR 2.77, 95% CI 2.32 to 3.30) and death/myocardial infarction (RR 2.13, 95% CI 1.85 to 2.45) in multivariable models adjusted for age, sex, hypertension, hyperlipidemia, smoking, family history of coronary disease and diabetes. Even after further adjustment for coronary angiographic data and the choice of initial therapy, lowest GFR quartile was associated with increased risk of myocardial infarction (RR 1.51, 95% CI 1.21 to 1.88), death (RR 2.60, 95% CI 2.18 to 3.10) and death/myocardial infarction (RR 2.08, 95% CI 1.80 to 2.39).

CONCLUSIONS

Even moderate renal failure increases the risk of myocardial infarction and death independent of clinical variables, baseline angiographic evidence of coronary disease and therapy.

Association of serum albumin and atherosclerosis in chronic hemodialysis patients

BACKGROUND

Because cardiovascular disease is the leading cause of death and hypoalbuminemia predicts mortality, hypoalbuminemia may be associated with atherosclerosis.

METHODS

In 1,411 patients enrolled in the HEMO study, associations of albumin with the presence of coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral vascular disease (PVD), and any one of the three conditions at baseline were examined using multivariable logistic regression models.

RESULTS

In the two-slope model, when albumin level was 3.6 g/dL (36 g/L) or greater, with each 1-g/dL (10-g/L) increase in albumin level the odds for CAD (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.17 to 0.59), PVD (OR, 0.39; 95% CI, 0.18 to 0.80), CVD (OR, 0.33; 95% CI, 0.15 to 0.73), and any one of the three conditions (OR, 0.23; 95% CI, 0.12 to 0.44) decreased. When albumin level was less than 3.6 g/dL (36 g/L), none of the conditions was statistically significantly associated with each 1-g/dL (10-g/L) increase in albumin level. When normal- and low-albumin groups were compared with each other, patients with albumin levels less than 3.6 g/dL (36 g/L) had a higher association with CAD (OR, 1.32; 95% CI, 1.03 to 1.70) and for any one of the three conditions (OR, 1.38; 95% CI, 1.07 to 1.78).

CONCLUSION

The odds for atherosclerosis linearly decreased as albumin level increased in the normal-albumin group, and a plateau was seen in the low-albumin group; however, the low-albumin group had significantly greater CAD. The nonlinearity of association of albumin level with prevalence of atherosclerosis might be due to the cross-sectional nature of the study of higher mortality with hypoalbuminemia.

A new approach to classifying malnutrition in the hemodialysis patient

BACKGROUND

Novel classification nomenclature defining the type of malnutrition by the root cause of the hypoalbuminenia has been developing in the literature since 1999. As the classification of malnutrition became more definite in the literature, the need to assess the type of malnutrition, thereby the root cause(s) and initiate appropriate intervention(s), has become apparent.

METHODS

In September 1999, San Diego Dialysis began a continuous quality improvement (CQI) project to assess the root causes of hypoalbuminemia for patients with serum albumin level <3.5 g/dL. An extensive review of the literature was conducted on the subject of malnutrition, inflammation, and the acute-phase reaction.

FINDINGS

Two major groups of patients emerged: those consuming adequate protein and calories, yet presenting with hypoalbuminemia, and those suffering from a protein calorie deficit. Observation of the second group showed that although the monthly percentage of patients with hypoalbuminemia remained fairly constant, the names on the list changed from month to month.

CONCLUSIONS

The CQI team developed a protocol and a unique nomenclature to classify the types of malnutrition, type I, type IIa, type IIb, or mixed, by adapting the definitions in the literature through clinical practice. Interventions were developed to address each classification of malnutrition.

Blood histamine is associated with coronary artery disease, cardiac events and severity of inflammation and atherosclerosis

BACKGROUND

Mast cells are prevalent in the shoulder of unstable atheromas; cardiac mast cells secrete proteases capable of activating matrix metalloproteinases. Histamine is essential in the inflammatory cascade of the unstable plaque. Ascorbate depletion has been correlated with histaminemia which has been shown to impair endothelial-dependent vasodilation. This study evaluates whether oxidative stress as measured by isoprostanes (PGF(2alpha)) coupled with an inflammatory state characterized by histaminemia predisposes patients to acute coronary syndrome (ACS).

METHODS

Whole blood histamine, serum vitamin C, and serum PGF(2alpha) levels were drawn on 50 patients with ACS as determined by standard diagnostic criteria, 50 patients with stable coronary artery disease (SCAD), and 50 age and sex matched normal controls (C).

RESULTS

Data were analyzed by stepwise discriminant and Spearman's rank correlation coefficient. A significant relationship exists between histamine and PGF(2alpha). As PGF(2alpha) rises above 60 pg/mL, an increase in histamine occurs in both the ACS and SCAD groups. A significant inverse relationship exists between ascorbate and histamine in the ACS versus C groups (P < 0.01) and the SCAD versus C groups (P < 0.01).

CONCLUSION

Histamine and isoprostane levels increase in SCAD and ACS patients. Mast cell activation and lipid oxidation generated during atherosclerosis manifest this inflammatory response. Accelerated isoprostane formation and depleted ascorbate paired with histaminemia is active in CAD and predispose patients to acute coronary syndrome. Blood histamine alone may be a better risk factor for coronary events, and a better prognostic indicator than CRP even when combined with lipid indexes.

Tissue factor and thrombomodulin in hemodialysis patients: associations with endothelial injury, liver disease, and erythropoietin therapy

Patients receiving maintenance hemodialysis (HD) present with hemostatic abnormalities, which may be aggravated by comorbid conditions, especially liver disease. The factors that influence plasma levels of thrombomodulin (TM), an initiator of the anticoagulant protein C pathway, and those of tissue factor (TF), which triggers the extrinsic coagulation pathway, were assessed. In 63 HD patients, TM and TF levels were higher than those in healthy controls. In bivariate analysis, TF positively correlated with TM, and both were directly associated with the presence of viral hepatitis B or C marker, serum liver enzymes, use of erythropoietin therapy, hemoglobin levels, and duration of HD therapy, and inversely correlated with body mass index. TF was also positively associated with plasma von Willebrand factor (vWF) antigen, and inversely associated with activated partial thromboplastin time. In multivariate analysis, increased vWF, alanine aminotransferase, and use of erythropoietin independently predicted both TF and TM levels. HD patients with vWF and ALT levels lower than middle, and not treated with erythropoietin had normal TF but increased TM concentrations compared with levels in healthy controls. Increased plasma levels of TM and TF in patients on maintenance HD are surrogates of vascular endothelial injury. Liver disease and use of erythropoietin treatment are also important determinants of these markers, and should be considered in further studies.