Chronic Inflammation and Coronary Atherosclerosis in Patients with End-Stage Renal Disease

The neutrophil percentage-to-albumin ratio is an independent risk factor for poor prognosis in peritoneal dialysis patients

AIM

This study aimed to investigate the predictive ability of the neutrophil percentage-to-albumin Ratio (NPAR) concerning all-cause mortality and cardio-cerebrovascular mortality in patients undergoing peritoneal dialysis (PD).

METHODS

We included a total of 807 PD patients from the Peritoneal Dialysis Center of the Second Affiliated Hospital of Soochow University between January 2009 and December 2019 in this study. Patients were categorized into three groups based on their baseline NPAR. The Kaplan-Meier method, multivariate Cox proportional hazard model, and Fine-Gray competing risk model were employed to examine the relationship between NPAR level and all-cause mortality and cardio-cerebrovascular mortality among PD patients. Furthermore, the ROC curve and calibration plots were utilized to compare the performance between NPAR and other conventional indicators.

RESULTS

The mean follow-up period was 38.2 months. A total of 243 (30.1%) patients passed away, with 128 (52.7%) succumbing to cardio-cerebrovascular diseases. The mortality rates of the Middle and High NPAR groups were significantly greater than that of the Low NPAR group (p < 0.001), and NPAR was independently associated with all-cause mortality and cardio-cerebrovascular mortality. Receiver Operating Characteristic (ROC) analysis indicated that the Area Under the Curve (AUC) of NPAR (0.714) was significantly superior to those of C-reactive protein (CRP) (0.597), neutrophil to lymphocyte ratio (NLR) (0.589), C-reactive protein to albumin ratio (CAR) (0.698) and platelet to lymphocyte ratio (PLR) (0.533).

CONCLUSION

NPAR served as an independent predictive marker for all-cause mortality and cardio-cerebrovascular mortality in PD patients. Moreover, NPAR demonstrated superior predictive potential compared to CRP, CAR, NLR, and PLR.

Refining Treatment Strategies in Patients With Fingertip Wounds and End-Stage Renal Disease

BACKGROUND

Individuals with end-stage renal disease (ESRD) and fingertip wounds are at high risk of poor wound healing, ultimately requiring amputations. Optimal performance of upper extremity amputation (UEA) in patients with ESRD is important to decrease complications and minimize total operative procedures needed. This study evaluated outcomes of UEA in patients with ESRD and described risk factors predisposing patients to complications.

METHODS

A retrospective analysis of patients receiving nontraumatic UEA for fingertip wounds was conducted, stratified by patients with and without ESRD. Demographics, comorbidities, complications, and hospital course were analyzed between groups for differences. Subanalysis of patients with ESRD was conducted to characterize operative course and predictors of complications.

RESULTS

A total of 132 patients were included, 106 controls and 26 with ESRD. Compared with controls, patients with ESRD required more amputations (P < .001) and total operations (P < .001) to achieve wound healing. Patients with ESRD experienced higher rates of postoperative complications (P < .001). Predictors for complications in patients with ESRD were comorbid diabetes (odds ratio [OR]: 45; 95% confidence interval [CI], 1.7-1226.9), vascular disease (OR: 30; 95% CI, 2-441.8), arterial calcification (OR: 18; 95% CI, 1.56-207.5), and presence of a hemodialysis shunt in the affected arm (OR: 18; 95% CI, 1.56-207.5). Within patients with ESRD, initial amputation at, or proximal to, the metacarpophalangeal joint (MCPJ) led to fewer amputations (1.2 vs 2.19, P = .04) and fewer total operative procedures (4.1 vs 6.6, P = .03), compared with initial amputation distal to the MCPJ.

CONCLUSION

In nontraumatic fingertip wounds, patients with ESRD had worse operative outcomes than patients without ESRD. More aggressive management of fingertip wounds using earlier and more proximal initial amputations may expedite wound healing in certain high-risk patients with ESRD.

Baseline and oxidatively damaged DNA in end-stage renal disease patients on varied hemodialysis regimens: a comet assay assessment

Global estimates exhibit that one million people have end-stage renal disease, a disease-state characterized by irreversible loss of kidney structure and function, thus necessitating renal replacement therapy. The disease-state, oxidative stress, inflammatory responses, as well as the treatment procedure can have damaging effects on the genetic material. Therefore, the present study was carried out to investigate DNA damage (basal and oxidative) using the comet assay in peripheral blood leukocytes of patients (n = 200) with stage V Chronic Kidney Disease (on dialysis and those recommended but yet to initiate dialysis) and compare it to that in controls (n = 210). Basal DNA damage was significantly elevated (1.13x, p ≤ 0.001) in patients (46.23 ± 0.58% DNA in tail) compared to controls (40.85 ± 0.61% DNA in tail). Oxidative DNA damage was also significantly (p ≤ 0.001) higher in patients (9.18 ± 0.49 vs. 2.59 ± 0.19% tail DNA) compared to controls. Twice-a-week dialysis regimen patients had significantly elevated % tail DNA and Damage Index compared to the non-dialyzed and to the once-a-week dialysis group implying dialysis- induced mechanical stress and blood-dialyzer membrane interactions as probable contributors to elevated DNA damage. The present study with a statistically significant power implies higher disease-associated as well as maintenance therapy (hemodialysis)-induced basal and oxidatively damaged DNA, which if not repaired has the potential to initiate carcinogenesis. These findings mark the need for improvement and development of interventional therapies for delaying disease progression and associated co-morbidities so as to improve life expectancy of patients with kidney disease.

Thromboinflammatory Biomarkers of Cardiorenal Syndrome in Patients With End-Stage Renal Disease

Cardiovascular disease is a prevalent complication in patients with end-stage renal disease (ESRD) on maintenance hemodialysis. In the ESRD patient population, cardiovascular mortality is 20 times higher compared to the general population. The strong relationship between both illnesses can be explained through cardiorenal syndrome (CRS). CRS encompasses a spectrum of disorders involving both the heart and kidneys in which acute or chronic dysfunction in one organ may induce a similar effect in the other organ. Current literature reveals that inflammation and thrombosis are integral to CRS development. Hence, this study aims to demonstrate whether thromboinflammatory biomarkers and laboratory parameters correlate with ESRD progression and the development of CRS. Ninety-five ESRD patients were recruited at Loyola University Medical Center hemodialysis unit. Epic chart analysis was used to determine patients with CRS. Biomarkers (C-reactive protein, tumor necrosis factor alpha, interleukin-6, Annexin V, L-fatty acid binding protein, monocyte chemoattractant protein 1, nitric oxide, von Willebrand factor, D-dimer, and plasminogen activator inhibitor-1) were profiled using the enzyme-linked immunosorbent assay method in patients with and without CRS in the ESRD cohort. All biomarkers were significantly elevated in ESRD patients compared to normal controls (P < .05) and laboratory parameters, ferritin (521.99 ± 289.33) and PTH (442.91 ± 1.50). Through EPIC chart analysis 47% of ESRD patients have CRS. D-dimer and TNF-α were significantly elevated in patients with CRS compared to patients without CRS. This study suggests that biomarkers, D-dimer, and TNF-α, can be good predictors of CRS in ESRD patients.

Integrated metabolomics and proteomics reveal biomarkers associated with hemodialysis in end-stage kidney disease

Background: We hypothesize that the poor survival outcomes of end-stage kidney disease (ESKD) patients undergoing hemodialysis are associated with a low filtering efficiency and selectivity. The current gold standard criteria using single or several markers show an inability to predict or disclose the treatment effect and disease progression accurately. Methods: We performed an integrated mass spectrometry-based metabolomic and proteomic workflow capable of detecting and quantifying circulating small molecules and proteins in the serum of ESKD patients. Markers linked to cardiovascular disease (CVD) were validated on human induced pluripotent stem cell (iPSC)-derived cardiomyocytes. Results: We identified dozens of elevated molecules in the serum of patients compared with healthy controls. Surprisingly, many metabolites, including lipids, remained at an elevated blood concentration despite dialysis. These molecules and their associated physical interaction networks are correlated with clinical complications in chronic kidney disease. This study confirmed two uremic toxins associated with CVD, a major risk for patients with ESKD. Conclusion: The retained molecules and metabolite-protein interaction network address a knowledge gap of candidate uremic toxins associated with clinical complications in patients undergoing dialysis, providing mechanistic insights and potential drug discovery strategies for ESKD.

Atherosclerosis Specific Features in Chronic Kidney Disease (CKD)

Atherosclerosis is the major cause of cardiovascular disease, leading to a high mortality rate worldwide. Several risk factors are known to favor atherogenesis, among which are high blood pressure, smoking, diabetes mellitus, and others. Chronic kidney disease is another serious health problem associated with significant health care costs, morbidity, and mortality. Chronic kidney disease shares several risk factors with atherosclerosis and cardiovascular diseases, such as hypertension and diabetes mellitus. Additional risk factors for cardiovascular disease development should be considered in patients with chronic kidney disease. Interestingly, patients suffering from chronic kidney disease are more prone to cardiovascular problems than the general population. Moreover, chronic kidney disease is characterized by an increased atherosclerotic burden from the very early stages. The purpose of this review was to summarize data on atherosclerosis in chronic kidney disease, highlighting the specific features of the disease combination.

Radiocephalic Arteriovenous Fistula Patency and Use

We sought to confirm and extend the understanding of clinical outcomes following creation of a common distal autogenous access, the radiocephalic arteriovenous fistula (RCAVF).

Mini-abstract: In this post hoc analysis of randomized clinical trial data including 914 adults with chronic kidney disease, the most robust predictors of radiocephalic arteriovenous fistula patency were larger cephalic vein diameter and access creation prior to a chronic hemodialysis requirement. Successful use occurred at increased rates in men, patients with larger diameter cephalic veins, smaller diameter arteries (albeit ≥2 mm), and when accesses were created using regional anesthesia and at higher volume centers.

RAGE pathway activation and function in chronic kidney disease and COVID-19

The multi-ligand receptor for advanced glycation end-products (RAGE) and its ligands are contributing factors in autoimmunity, cancers, and infectious disease. RAGE activation is increased in chronic kidney disease (CKD) and coronavirus disease 2019 (COVID-19). CKD may increase the risk of COVID-19 severity and may also develop in the form of long COVID. RAGE is expressed in essentially all kidney cell types. Increased production of RAGE isoforms and RAGE ligands during CKD and COVID-19 promotes RAGE activity. The downstream effects include cellular dysfunction, tissue injury, fibrosis, and inflammation, which in turn contribute to a decline in kidney function, hypertension, thrombotic disorders, and cognitive impairment. In this review, we discuss the forms and mechanisms of RAGE and RAGE ligands in the kidney and COVID-19. Because various small molecules antagonize RAGE activity in animal models, targeting RAGE, its co-receptors, or its ligands may offer novel therapeutic approaches to slowing or halting progressive kidney disease, for which current therapies are often inadequate.

The Relationship of Epicardial Adipose Tissue and Cardiovascular Disease in Chronic Kidney Disease and Hemodialysis Patients

Cardiovascular diseases remain the most common cause of morbidity and mortality in chronic kidney disease patients undergoing hemodialysis. Epicardial adipose tissue (EAT), visceral fat depot of the heart, was found to be associated with coronary artery disease in cardiac and non-cardiac patients. Additionally, EAT has been proposed as a novel cardiovascular risk in the general population and in end-stage renal disease patients. It has also been shown that EAT, more than other subcutaneous adipose tissue deposits, acts as a highly active organ producing several bioactive adipokines, and proinflammatory and proatherogenic cytokines. Therefore, increased visceral adiposity is associated with proinflammatory activity, impaired insulin sensitivity, increased risk of atherosclerosis, and high morbidity and mortality in hemodialysis patients. In the present review, we aimed to demonstrate the role of EAT in the pathophysiological mechanisms of increased cardiovascular morbidity and mortality in hemodialysis patients.

Serum myostatin level is a positive predictor of endothelial function measured by digital thermal monitoring of vascular reactivity in kidney transplantation patients

Objectives:

Myostatin is a myokine predominantly expressed and secreted in skeletal muscle in response to stimulations, including oxidative stress or inflammation. We investigated a potential association between myostatin levels and endothelial function among kidney transplantation (KT) patients.

Materials and Methods:

Fasting blood samples were collected from 64 KT patients. The endothelial function that indicated by vascular reactivity index (VRI) was measured by digital thermal monitoring test. Serum myostatin levels were measured using a commercial enzyme-linked immunosorbent assay kit. All patients were categorized into three groups according to their VRI values: poor vascular reactivity was considered if VRI <1.0; 1.0 ≤VRI <2.0 indicated intermediate vascular reactivity, and VRI ≥2.0 was grouped as good vascular reactivity.

Results:

Seven KT patients (10.9%) were categorized as poor vascular reactivity, 24 KT patients (37.5%) were grouped as intermediate vascular reactivity, and 33 KT patients had good vascular reactivity. Advanced age (r = −0.372, P = 0.002) and serum alkaline phosphate (ALP) level (r = −0.341, P = 0.006) were negatively correlated with VRI. However, serum myostatin level (r = 0.430, P < 0.001) was positively correlated with VRI. In multivariable forward stepwise linear regression analysis, high serum level of myostatin (β = 0.441, adjusted R² change = 0.171; P < 0.001), advanced age (β = −0.317, adjusted R² change = 0.138; P = 0.003), and serum ALP level (β = −0.270, adjusted R² change = 0.060; P = 0.011) were significantly associated with VRI in KT patients.

Conclusion:

Our study showed that fasting myostatin level was positively associated with VRI and endothelial function among KT patients.

Self-report of medical diagnosis of chronic kidney disease: prevalence and characteristics in the Brazilian adult population, National Health Survey 2013 and 2019

OBJECTIVE

To estimate the prevalence of chronic kidney disease (CKD) in the adult Brazilian population and to describe its characteristics, according to the National Health Survey (PNS) 2013-2019.

METHODS

Descriptive cross-sectional study, with adults participating in the PNS, based on self-reported medical diagnosis of CKD. Prevalence of CKD and their respective 95% confidence intervals (95%CI) were estimated for Brazil.

RESULTS

In 2013, 60,202 individuals were analyzed, and in 2019, 85,854. The prevalence of self-reported diagnosis of CKD in both editions was 1.4% and increased with increasing age. In 2019, the prevalence of self-reported CKD was 3.3% (95%CI 2.9;3.7) in hypertensive individuals, 4.1% (95%CI 3.4;5.0) among diabetics, and 3.3% (95%CI 2.8;3.9) in those reporting hypercholesterolemia.

CONCLUSION

The prevalence of CKD in Brazil remained stable in the period but reinforces the need for expansion of diagnosis and strengthening of primary care in the Brazilian National Health System (SUS).

Circulating hepassocin level in patients with stable angina is associated with fatty liver and renal function

Background: Chronic kidney disease (CKD) is a major risk factor for coronary artery disease and it is often associated with hepatic steatosis. Hepassocin (also known as hepatocyte-derived fibrinogen related protein or fibrinogen-like 1) is a novel hepatokine that causes hepatic steatosis and induces insulin resistance. However, the role of hepassocin in renal function status remains unclear. Our objective was to investigate the association of plasma hepassocin level with fatty liver and renal function status in patients with stable angina. Methods: Plasma hepassocin levels were determined by enzyme-linked immunosorbent assays in 395 consecutive patients with stable angina. Renal function was defined as an estimated glomerular filtration rate (eGFR). Fatty liver was defined by ultrasonography and fibrosis-4 (FIB-4) index. Results: With increasing hepassocin tertiles, patients had higher prevalence of fatty live, an increased waist-to-hip ratio, and neutrophil count, monocyte count, and FIB-4 index, higher levels of uric acid, blood urine nitrogen and higher sensitivity C-reactive protein. They also had incrementally lower eGFR, serum hemoglobin and albumin levels. In multiple linear stepwise regression analysis, only eGFR was significantly independent negatively associated with plasma hepassocin levels. Conclusion: Our results indicate that circulating hepassocin in patients with stable angina is associated with fatty liver and renal function, which suggests that increased plasma hepassocin may be involved in the pathogenesis of fatty liver and CKD.

Hospital costs and prognosis in end-stage renal disease patients receiving coronary artery bypass grafting

Background

Coronary artery disease is common in patients with end-stage renal disease (ESRD). Patients with ESRD are a high-risk group for cardiac surgery and have increased morbidity and mortality. Most studies comparing ESRD patients receiving coronary artery bypass grafting (CABG) or percutaneous coronary intervention have found that the long-term survival is good in ESRD patients after CABG. The aim of our study was to compare ESRD patients who underwent CABG with the general population who underwent CABG, in terms of prognosis and hospital costs.

Methods

This study analyzed data from the National Health Insurance Research Database in Taiwan for patients who were diagnosed with ESRD and received CABG (ICD-9-CM codes 585 or 586) between January 1, 2004, and December 31, 2009. The ESRD patients included in this study all received catastrophic illness cards with the major illness listed as ESRD from the Ministry of Health and Welfare in Taiwan.

The control subjects were randomly selected patients without ESRD after propensity score matching with ESRD patients according to age, gender, and comorbidities at a 2:1 ratio from the same dataset.

Results

A total of 48 ESRD patients received CABG, and their mean age was 62.04 ± 10.04 years. Of these patients, 29.2% were aged ≥70 years, and 66.7% were male. ESRD patients had marginally higher intensive care unit (ICU) stays (11.06 vs 7.24 days) and significantly higher ICU costs (28,750 vs 17,990 New Taiwan Dollars (NTD)) than non-ESRD patients. Similarly, ESRD patients had significantly higher surgical costs (565,200 vs. 421,890 NTD), a higher perioperative mortality proportion (10.4% vs 2.1%) and a higher postoperative mortality proportion (33.3% vs 11.5%) than non-ESRD patients.

Conclusions

After CABG, ESRD patients had a higher risk of mortality than non-ESRD patients, and ICU and surgery costs were also higher among the ESRD patients than among patients without ESRD.

Relationship Between Epicardial Adipose Tissue and Body Composition as Determined by Multi-Frequency Bioelectrical Impedance Analysis in Patients with Stage 5 Chronic Kidney Disease

Background

The main cause of mortality among chronic kidney disease (CKD) patients is cardiovascular disease (CVD). Epicardial adipose tissue (EAT) is considered to be novel cardiovascular risk factor. We assessed EAT in non-dialyzed stage 5 CKD patients and explored the association of EAT with body composition as determined by multi-frequency BIA.

Material/Methods

The present included 70 stage 5 CKD patients who had not undergone dialysis and 40 healthy control subjects. EAT thickness was assessed by echocardiography. Hydration status and body composition were evaluated by multi-frequency bioelectrical impedance analysis.

Results

Stage 5 CKD patients had significantly higher EAT thickness than healthy subjects (6.56±1.18 vs. 4.05±1.45, p<0.001). Fat tissue mass, systolic blood pressure (SBP), age, fat tissue index, and body mass index were positively correlated with EAT thickness in the CKD patient group (p<0.05). Lean tissue mass, lean tissue index (LTI), and high-density lipoprotein (HDL) were negatively correlated with EAT thickness in the CKD patient group (p<0.05). Stepwise multiple regression analysis showed that age, SBP, and LTI were independently associated with EAT thickness in CKD patients.

Conclusions

We found significantly higher EAT thickness in stage 5 CKD patients who were not on dialysis compared to healthy controls. EAT was significantly associated with age, SBP, and LTI in CKD patients. Interventions to reduce the risk factors associated with EAT thickness might protect against CVD disease in CKD patients.

The role of P2Y6R in cardiovascular diseases and recent development of P2Y6R antagonists

As a member of the P2Y receptor family with a typical 7-transmembrane structure, P2Y₆ purinergic receptor (P2Y₆R) belongs to the G-protein-coupled nucleotide receptor activating the phospholipase-C signaling pathway. P2Y₆R is widely involved in a range of human diseases, including atherosclerosis and other cardiovascular diseases, gradually attracting attention owing to its inappropriate or excessive activation. In addition, it was reported that P2Y₆R might regulate inflammatory responses by governing the maturation and secretion of proinflammatory cytokines. Hence, several P2Y₆R antagonists have been subjected to evaluation as new therapeutic strategies in recent years. This review was aimed at summarizing the role of P2Y₆R in the pathogenesis of cardiovascular diseases, with an insight into the recent progress on discovery of P2Y₆R antagonists.

Intradialytic hypotension is an important risk factor for critical limb ischemia in patients on hemodialysis

BACKGROUND

Critical limb ischemia (CLI) and intradialytic hypotension (IDH) are common complications in patients on hemodialysis (HD). However, limited data are available on whether IDH is related to CLI in these patients. The aim of this retrospective study was to evaluate whether IDH is a risk factor for CLI in HD patients.

METHODS

We examined the frequency of IDH in 147 patients who received HD between January 1 and June 30, 2012. Blood pressure was measured during HD every 30 min and IDH was defined as a ≥ 20 mmHg fall in systolic blood pressure compared to 30 min before and a nadir intradialytic systolic blood pressure < 90 mmHg. The primary study outcome was newly developed CLI requiring revascularization treatment or CLI-related death. We assessed the association of IDH with outcome using a multivariable subdistribution hazard model with adjustment for male, age, smoking and history of cardiovascular disease.

RESULTS

The median follow-up period was 24.5 months. Fifty patients (34%) had episodes of IDH in the study entry period. During follow-up, 14 patients received endovascular treatment and CLI-related death occurred in 1 patient. Factors associated with incident CLI in univariate analysis were age, smoking, diabetes mellitus, peripheral arterial disease, history of cardiovascular disease, and IDH. IDH was significantly associated with the outcome with the subdistribution hazard ratio of 3.13 [95% confidence interval, 1.05-9.37].

CONCLUSIONS

IDH was an independent risk factor for incident CLI in patients on HD.

Dyslipidemia and Intraperitoneal Inflammation Axis in Peritoneal Dialysis Patients: A Cross-Sectional Pilot Study

Background

We have hypothesized that the problem of dyslipidemia in peritoneal dialysis (PD) patients lies beyond certain levels of plasma lipoprotein and involves cardiovascular risk, but can also influence the development of chronic intraperitoneal inflammation.

Objectives

The aim of our work was to define whether the association of dyslipidemia with intraperitoneal inflammation really exists and if it could it be used in a prospective cohort of PD patients.

Patients and Methods

We performed a cross-sectional, single-center, pilot study involving 40 nondiabetic PD patients (27 men and 13 women with an average age of 49.3 ± 12.2 years). The median time on PD was 29 (18.5-37) months. The parameters dialysis adequacy, blood lipid profile, and the concentrations of tumor necrosis factor (TNF)-α, monocyte chemoattractant protein (MCP)-1, and interleukin (IL)-10 in peritoneal dialysate effluent (PDE) were determined. Cohen's d effect size was computed post hoc to determine the differences between groups in the concentrations of pro- and anti-inflammatory mediators.

Results

PD patients with atherogenic dyslipidemia had significantly high levels of MCP-1 compared with dyslipidemia-free patients (Cohen's d = 1.32). A reduced high-density lipoprotein cholesterol level was associated with a high intraperitoneal production of the proinflammatory mediator TNF-α (p < 0.0001) and anti-inflammatory IL-10 (p < 0.0001). Atherogenic index of plasma was directly correlated with MCP-1 (p < 0.0001) and TNF-α (p < 0.0001). In multiple regression analysis, MCP-1 appeared to predict PD inadequacy (R ² = 0.58; F ratio = 9.4; p = 0.006) independently of age and blood C-reactive protein level. Effect size was 1.38 with α = 0.05, n = 40, and 3 predictors.

Conclusions

Our cross-sectional pilot study first demonstrated a close interaction between the atherogenic lipid profile and a high concentration of MCP-1 in PDE; this might be a prognostic marker for PD inadequacy. The potential significance of our finding is that it provides useful preliminary information necessary for further research into this area.

High sensitivity C-reactive protein as a predictive of intima-media thickness in patients with end-stage renal disease on regular hemodialysis

BACKGROUND

Several emerging problems of regular hemodialysis (HD) including cardiovascular complication or atherosclerosis formation caused by chronic inflammation. Intima-media thickness (IMT) of the carotid artery can be applied as a marker of atherosclerosis progression. This study was designed to identify the predictive of IMT progression among end-stage renal disease (ESRD) subject.

METHODS

This cohort study was performed at the Hemodialysis Unit of Dr. Kariadi Hospital and Telogorejo Hospital Semarang between October 2009 and April 2010. The study subjects were the ESRD patients with regular HD.

RESULTS

This study enrolled 78 subjects with regular HD, follow-up 6 months. The subjects which completed the study were divided into two groups that consist of IMT progressive group (n=53) and IMT non-progressive group (n=12). There were no differences between two groups according to age, gender, history of diabetes, blood pressure, duration of HD, urea, creatinine, blood glucose, HbA1C, cholesterol, triglyceride, HDL, uric acid, phosphate, calcium, homocysteine, and albumin. Subject with high-sensitive C-reactive protein (hsCRP) level >0.52 mg/L had an IMT progression. There was a correlation between hsCRP and the thickening of carotid artery wall after 6-month HD (RR=3.6; 95% CI=2.2-22.9). The subject with hsCRP level >9.00 mg/L after 6-month dialysis progress to thickening of carotid artery wall of >0.03 mm. There was a correlation between hsCRP level (cut-off point: 9.0 m/L) and the progression of the carotid artery wall (RR=2.1; 95% CI=1.3-3.37). Statistically, there was no correlation between IL-6-174 G/C gene and eNOS gene polymorphism with IMT progression.

CONCLUSION

hsCRP is a significant predictive of IMT progression at hemodialysis subject. IL -174 G/C gene and eNOS gene polymorphism are not significant predictive of IMT progression at hemodialysis subject.

Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patients: A Meta-Analysis

Introduction

End-stage renal disease requiring renal transplantation comprises a growing patient population at risk for cardiovascular disease (CVD) morbidity and mortality in large part due to accelerated atherosclerosis. Consequently, these patients are at even higher risk of major surgical CVD mortality. A paucity of research has addressed the posttransplantation CVD outcomes related to different treatment strategies in this patient population and therefore, there are no specific preoperative guidelines regarding management of coronary artery disease in this high-risk population undergoing renal transplantation.

Objective

Through meta-analysis we compare coronary revascularization to medical management prior to renal transplantation in patients who are found to have significant obstructive coronary artery disease.

Results

A total of 6 studies were deemed suitable out of 777 articles reviewed. This included 260 patients who received medical management and 338 who received coronary revascularization. There were 36 events in the revascularization and 57 events in the medical management group. One study only reported hazard ratios but no CVD outcomes. Comprehensive Meta-Analysis software was used to calculate pooled odds ratio with 95% confidence intervals (CI) for the fixed effects. The data is presented as forest plots. The pooled odds ratio with 95% CI for the fixed effects was 1.415 (95% CI 0.885–2.263), p = 0.147, indicating that there is no difference in CVD outcomes between pretransplant treatment strategy. This observation suggests that the CVD outcomes posttransplantation are not affected when optimal medical therapy is used instead of coronary revascularization.

Modified creatinine index and risk for cardiovascular events and all-cause mortality in patients undergoing hemodialysis: The Q-Cohort study

BACKGROUND AND AIMS

The modified creatinine (Cr) index, calculated by age, sex, pre-dialysis serum Cr levels, and Kt/V for urea, reflects skeletal muscle mass in patients on hemodialysis. Whether the modified Cr index is associated with cardiovascular events and all-cause mortality remains unknown.

METHODS

A total of 3027 patients registered in the Q-Cohort Study, a multicenter, prospective study of patients on hemodialysis in Japan, were analyzed. The main outcomes were cardiovascular events and all-cause mortality. Associations between sex-specific quartiles of the modified Cr index and outcomes were analyzed by the Cox proportional hazard models and the Fine-Gray proportional subdistribution hazards model.

RESULTS

The modified Cr index was correlated with known nutritional and inflammatory markers. During a 4-year follow-up, 499 patients died of any cause, 372 experienced heart disease, and 194 developed stroke. The risk for all-cause mortality was significantly higher in the lower quartiles (Q1 and Q2) than in the highest quartile (Q4) as the reference group (hazard ratios and 95% confidence intervals: Q1, 2.65 [1.69-4.25], Q2, 1.92 [1.27-2.94], and Q3, 1.31 [0.87-2.02]). The risk of heart disease was significantly higher in Q1 than in Q4 (hazard ratios and 95% confidence intervals: Q1, 1.64 [1.04-2.61], Q2, 1.34 [0.91-2.00], and Q3, 1.04 [0.71-1.52]). The risk of stroke was not associated with the modified Cr index.

CONCLUSIONS

A lower modified Cr index is associated with an increased risk for heart disease and all-cause mortality, but not with the risk for stroke in patients on hemodialysis.

The anti-inflammatory effect of microRNA-383-3p interacting with IL1R2 against homocysteine-induced endothelial injury in rat coronary arteries

MicroRNAs (miRs) are widely reported to be novel biomarkers involved in the process of coronary atherosclerosis (CAS). Hence, this study aims to explore the function of miR-383-3p targeting IL1R2 on inflammatory injury of coronary artery endothelial cells (CAECs) in CAS. The underlying regulatory mechanisms of miR-383-3p were analyzed in concert with the treatment of miR-383-3p mimics, miR-383-3p inhibitors, and the combination of miR-383-3p inhibitors and siRNA against IL1R2 in homocysteine (HCY)-induced CAECs. MTT, Hoechst 33258 staining, and tube formation assay were employed in order to measure cell viability, apoptosis, and tube formation, respectively. The levels of IL-1β, IL-6, IL-10, and IL-18 were determined by ELISA. IL1R2 was verified as the target gene of miR-383-3p by dual-luciferase reporter gene assay. MiR-383-3p was down-regulated in myocardial tissues of AS rats while IL1R2 was the reciprocal. The up-regulation of miR-383-3p decreased the levels of IL1R2, caspase-1, IL-1β, IL-6, and IL-18 expressions, as well as cell apoptosis rate in the HCY-induced CAECs, while IL-10 expression, cell viability, and tube formation ability were increased. These results were contraindicated in the HCY-induced CAECs treated by miR-383-3p inhibitors. In conclusion, miR-383-3p mediating IL1R2 prevents HCY-induced apoptosis and inflammation injury in CAECs through the inhibition of the activation of inflammasome signaling pathway. These findings highly indicate that miR-383-3p may be beneficial in the prevention of CAS and other cardiovascular diseases.

Level of inflammatory factors in chronic hemodialysis patients with and without cardiovascular disease

Background:

Considering the existence of controversies about the predictive value of inflammatory markers for cardiovascular disease (CVD), we aimed to compare the level of high-sensitivity C-reactive protein (hs-CRP) and interlukin-6 (IL-6) level in chronic hemodialysis (HD) patients with and without CVD.

Materials and Methods:

In this historical cohort study, HD patients with and without CVD disease were enrolled. The presence of CVD risk factors, level of inflammatory factors including IL-6 and hs-CRP as well as lipid levels, fasting blood sugar, and other biochemical factors were compared in two studied groups.

Results:

During the study, eighty HD patients with (n = 40) and without (n = 40) CVD were enrolled. Diabetes was more prevalent among HD patients with CVD than those without CVD (P < 0.05). The level of IL-6 and hs-CRP were not different in two studied groups (P > 0.05). Univariate analysis of variance test indicated that there was not any significant relationship between hs-CRP and CVD (P > 0.05).

Conclusion:

The findings indicated that the level of inflammatory factors including hs-CRP and IL-6 are not significantly different in HD patients with and without CVD. However, for obtaining more definite conclusion in this field and evaluation their predicting role in this field, it is recommended to study other novel inflammatory markers as well as the additive effect of the inflammatory factors with traditional ones in larger sample size and longer follow-up.

Frequency of Specific Cardiovascular Disease Risk Factors among Cameroonian Patients on Dialysis: The Cases of Anaemia, Inflammation, Phosphate, and Calcium

Specific cardiovascular risk factors are known to contribute to increasing cardiovascular mortality in patients with chronic renal disease. However, little is known about their distribution in our population. This study aimed at determining the prevalence of anaemia, inflammation, and phosphocalcium disorders in Cameroonian patients on dialysis. Thirty-five participants with stage V chronic kidney disease (defined by glomerular filtration rate, GFR < 15 mL/1.73 m(3)) of age at least 20 years on haemodialysis were randomly recruited. A control group composed of persons without a history of renal or cardiovascular disease was also recruited. Haemoglobin concentration, serum phosphate concentration, serum calcium concentration, and CRP status as a marker of inflammation were determined for all participants. Anaemia, phosphocalcium metabolic disorders, and a positive CRP result among haemodialysed patients were estimated at 94.3%, 61.6%, and 77.1%, respectively. Anaemia was diagnosed in all female patients compared to 92% in males, while a positive CRP result was recorded in 90% of females and 72% of males. No significant differences were observed on the distribution of studied specific cardiovascular risk factors with duration of dialysis. Among the factors studied, anaemia was the most encountered.

Low parathyroid hormone status induced by high dialysate calcium is an independent risk factor for cardiovascular death in hemodialysis patients

Here we studied a possible association between low parathyroid hormone (PTH) status and mortality in incident patients undergoing hemodialysis . A total of 1983 patients were included at baseline and prospectively followed for 24 months. Patients were classified according to their Kidney Disease: Improving Global Outcomes PTH status at baseline and at 12 months, and mortality evaluated at 12 to 24 months using adjusted Cox analysis. Factors potentially involved in PTH status variability between baseline and 12 months were analyzed. A decrease in serum PTH from normal or high to low values between baseline and 12 months was associated with significantly increased cardiovascular mortality at 12 to 24 months (hazard ratio, 2.03; 95% confidence interval, 1.22-3.36). For patients with high or normal baseline PTH levels, the main independent factor at 6 months for a decrease to low PTH levels at 12 months was high dialysate calcium (1.75 mmol/L), whereas prescription of non-calcium-based phosphate binders was associated with a lower risk of PTH decrease. In the high cardiovascular (CV) mortality risk subgroup of patients who acquired a low PTH status at 12 months, the main independent factor at 12 months associated with significant 12- to 24-month CV mortality was high dialysate calcium (odds ratio, 5.44; 95% CI, 2.52-11.75). Thus, patients with a serum PTH decrease to low values after 1 year of hemodialysis treatment are at high risk of short-term CV death. High dialysate calcium was an important contributor to PTH oversuppression, and continued use was associated with increased CV mortality.

A novel anti-inflammatory natural product from Sphaeranthus indicus inhibits expression of VCAM1 and ICAM1, and slows atherosclerosis progression independent of lipid changes

A large body of evidence suggests that atherosclerosis is an inflammatory disease, in which cytokines and growth factors play a major role in disease progression. The methanolic extracts of Sphaeranthus indicus as well as its active ingredient, 7-hydroxy frullanoide (7-HF), are shown to suppress LPS-induced cytokine production from mononuclear cells, and inhibit the expression of VCAM1, ICAM1 and E-selectin by TNF-α- stimulated HUVECs in a concentration-dependent manner. We tested the hypothesis that the inhibition of cytokines and adhesion molecules should attenuate the progression of atherosclerosis, independent of changes in the lipid profile. Studies were carried out in two animal models: a high fat-fed LDLr^-/- mouse and a high fat-fed hyperlipidemic hamster. Methanolic extract of S. indicus was dosed to hyperlipidemic LDLr^-/- at 100 and 300 mg (equivalent to 20 and 60 mg 7-HF)/kg body weight/ day for 8 weeks, and plasma lipids as well as aortic lesion area were quantitated. Hyperlipidemic hamsters were treated with one dose of 200 mg/kg/day. S. indicus extract treatment did not alter the lipid profile in both animal models, but reduced aortic lesion area in LDLr^-/- mice and hyperlipidemic hamsters by 22 % and 45 %, respectively. Fenofibrate, included as a reference agent, decreased aortic lesions by 26 % in LDLr ^-/- mice and 84 % in hyperlipidemic hamsters, respectively, which was driven by massive reductions in proatherogenic lipoproteins. The lipid-independent anti-atherosclerotic activity of S. indicus was associated with the reductions in the circulating levels of MCP-1, TNF-α, and IL-6 via phosphorylation and degradation of IkB-α that prevents translocation of NF-kB in the nucleus to induce proinflammatory cytokines. Our findings demonstrate that anti-inflammatory agents that lower pro-inflammatory proteins inhibit the progression of atherosclerosis. The methanolic extract of S. inducus, currently being used to treat psoriasis, offer promise to benefit individuals who have high circulating pro-inflammatory cytokines, and predisposed to coronary artery disease.

Immunoactivation at the crossroads of human disease

It is becoming increasingly clear that immunoactivation, which evolved as a system of host defense against pathogens, can become dysregulated and promote the pathogenesis of diverse diseases with both known and unknown etiologies (eg, acquired immune deficiency syndrome, age-related macular degeneration, cancer, as well as aging). Immunoactivation seems to be a "common denominator" or general mechanism of pathogenesis and may explain the association and similarities in pathology among otherwise unrelated human diseases. Identification of general mechanisms of immunoactivation may lead to the development of new therapeutic strategies applicable to many diseases even before detailed knowledge of specific etiology and pathogenesis may be available.

Dose equivalence between continuous erythropoietin receptor activator (CERA), Darbepoetin and Epoetin in patients with advanced chronic kidney disease

BACKGROUND

Anemia is a prevalent situation in patients with chronic kidney disease (CKD) and can be well managed with erythropoiesis-stimulating agents (ESAs). Continuous erythropoietin receptor activator (CERA) has a long half-life that allows to be administered once monthly. The lowest recommended dose for patients with non dialysis CKD is 120 μg per month. The objectives were to assess the efficacy of subcutaneous monthly dosing of CERA in CKD stages 4 and 5 not on dialysis, and to determine the equivalent dose to epoetin β and darbepoetin α.

METHODS

This is a cohort study. A 30-patient group that ESAs was changed to CERA (μg/month) was used as treatment group. We used the following clinically-based equivalent dosing: epoetin β (IU/week) and darbepoetin α (μg/week): 3000/15= 50; 4000/20=75; 6000/30=100; 8000/40=150. Another group of 30 patients with similar characteristics was used as control group and received the same epoetin β and darbepoetin α doses.

RESULTS

The mean CERA initial dose and at 6 months was 81.9 ± 35.2 and 82.0 ± 37.82 μg/month (p=0.37). The mean erythropoietin resistance index (ERI) and hemoglobin at baseline and at 6 months in the CERA group and in the control group were not statistically significant.

CONCLUSION

Monthly dosing treatment with CERA is safe and effective. A dose of 75-100 μg/month is enough to maintain stable levels of hemoglobin. Hippokratia 2014; 18 (4): 315-318.

No detection of Helicobacter pylori in atherosclerotic plaques in end stage renal disease patients undergoing kidney transplantation

Chronic infection known to be a predisposing factor for the development of atherosclerosis. Several studies have found a possible role of Helicobacter pylori in the pathogenesis of atherosclerosis. The aim of this study was to investigate the presence of H. pylori in atherosclerotic plaques in iliac arteries in 25 end stage renal disease (ESRD) patients undergoing kidney transplantation. Esophagogastroduodenoscopy was performed in all patients before transplantation. Biopsy specimens obtained from gastric antrum were sent for pathologic evaluation. Gastric H. pylori infection was confirmed by microscopic assessment and rapid urease test. Arterial specimens were obtained from iliac arteries during kidney transplantation. Presence of H. pylori DNA in atherosclerotic plaques and healthy vessel samples was evaluated by the polymerase chain reaction (PCR). The mean age of patients was 44.1 ± 22.6 years. Risk factors in patients with atherosclerosis were hypertension (68%), diabetes mellitus (20%), hyperlipidemia (20%), positive family history (16%). Atherosclerotic plaques were found in 21 (84%) patients. PCR analysis did not detect H. pylori in any case. There was a significant relationship of atherosclerosis with hypertension (P = 0.006) but not with diabetes mellitus and hyperlipidemia (P = 0.5). There was no significant relationship between atherosclerosis and gastric H. pylori infection (P = 0.6). This study revealed no association between the presence of H. pylori as a pathogen of vessel walls and atherosclerosis in ESRD.

Risk factors for atherosclerosis in patients with chronic kidney disease: recognition and management

Heart disease is the most common cause of death in patients with chronic kidney disease (CKD), particularly in those receiving dialysis. Atherosclerosic cardiovascular (CV) disease (CVD) accounts for a large number of these deaths. Atherosclerosis is accelerated in patients with CKD due predominantly to the high prevalence of traditional CVD risk factors in the CKD population. CKD aggravates pre-existent traditional risk factors such as hypertension and dyslipidemia due to secondary renal parenchymal hypertension and secondary dyslipidemia. In addition, a variety of non-traditional risk factors that occur commonly in CKD patients contribute to CV risk. Recent studies suggest that CKD itself may be an independent risk factor for CVD, particularly coronary heart disease (CHD). Many therapies aimed at CV risk factor modification that have been successful in reducing CV risk in the general population are less effective or ineffective in favorably modifying CV risk in CKD.

C-reactive protein and other markers of inflammation in hemodialysis patients

Hemodialysis patients are at greater risk of cardiovascular disease. Higher than expected cardiovascular morbidity and mortality in this population has been attributed to dislipidemia as well as inflammation. The causes of inflammation in hemodialysis patients are multifactorial. Several markers were used for the detection of inflammatory reaction in patients with chronic renal disease. These markers can be used for the prediction of future cardiovascular events. Among the several parameters of inflammatory markers, serum, CRP is well known and its advantages for the detection of inflammation and its predictor ability has been evaluated in several studies. This review addressed the associated factors and markers of inflammation in hemodialysis patients. In addition, their ability in predicting future atherosclerosis and effect of treatment has been reviewed. However, this context particularly in using CRP as a prediction marker of inflammation and morbidity requires further studies.

Effect of cinacalcet on cardiovascular disease in patients undergoing dialysis

BACKGROUND

Disorders of mineral metabolism, including secondary hyperparathyroidism, are thought to contribute to extraskeletal (including vascular) calcification among patients with chronic kidney disease. It has been hypothesized that treatment with the calcimimetic agent cinacalcet might reduce the risk of death or nonfatal cardiovascular events in such patients.

METHODS

In this clinical trial, we randomly assigned 3883 patients with moderate-to-severe secondary hyperparathyroidism (median level of intact parathyroid hormone, 693 pg per milliliter [10th to 90th percentile, 363 to 1694]) who were undergoing hemodialysis to receive either cinacalcet or placebo. All patients were eligible to receive conventional therapy, including phosphate binders, vitamin D sterols, or both. The patients were followed for up to 64 months. The primary composite end point was the time until death, myocardial infarction, hospitalization for unstable angina, heart failure, or a peripheral vascular event. The primary analysis was performed on the basis of the intention-to-treat principle.

RESULTS

The median duration of study-drug exposure was 21.2 months in the cinacalcet group, versus 17.5 months in the placebo group. The primary composite end point was reached in 938 of 1948 patients (48.2%) in the cinacalcet group and 952 of 1935 patients (49.2%) in the placebo group (relative hazard in the cinacalcet group vs. the placebo group, 0.93; 95% confidence interval, 0.85 to 1.02; P=0.11). Hypocalcemia and gastrointestinal adverse events were significantly more frequent in patients receiving cinacalcet.

CONCLUSIONS

In an unadjusted intention-to-treat analysis, cinacalcet did not significantly reduce the risk of death or major cardiovascular events in patients with moderate-to-severe secondary hyperparathyroidism who were undergoing dialysis. (Funded by Amgen; EVOLVE ClinicalTrials.gov number, NCT00345839.).