Comparative prognostic value of parameters of right ventricular pulsatile afterload in patients with advanced heart failure awaiting heart transplantation

Background

Right ventricular (RV) function demonstrated a strong impact on survival of patients with advanced heart failure with reduced ejection fraction (HFrEF). In particular, increased RV pulsatile afterload (RVPA) was associated with poor prognosis. Several right heart catheterization-derived parameters have been proposed to characterize RVPA, including pulmonary artery compliance (PAC), elastance (PAE) and pulsatile index (PAPi). However, among these indices, the best prognostic indicator is undetermined.

Purpose

To assess the prognostic relevance of RVPA parameters in patients with advanced HFrEF evaluated for heart transplantation.

Methods

149 patients with end-stage HFrEF underwent right heart catheterization during the evaluation for heart transplantation. All patients were clinically followed up until death or any censoring events including heart transplantation, left ventricular assist device (LVAD) and hospitalization for acute heart failure. Cox regression and ROC-curve analysis were used to test the prognostic value of RVPA determinants. Multivariate regression models with C-statistics were used to test the independent predictive value of RVPA indices.

Results

The mean age of the study population was 56.6±10.1 years and 85.2% were male. The most frequent aetiology of HFrEF was ischemic cardiomyopathy (52.3%). Mean LV ejection fraction was 25.7±10.2%.

During a mean follow up time of 17±15 months, 29 (19.5%) patients met the primary endpoint: 9 (6%) patients died, 4 (2.68%) patients underwent an urgent heart transplantation, 11 (7.3%) patients underwent urgent LVAD implantation (as bridge to transplantation therapy) and 5 (3.3%) were hospitalized for HF.

Patients who met the primary endpoint were significantly older patients (61.2±7.8 vs 55.4±10.2, p=0.006) and with worse hemodynamic profile than event-free survivors (PAC [1.8±0.8 vs. 2.7±2.0, p=0.01], mPAP [33.5±11.3 vs. 29.3±11.0, p=0.05], PVR [3.0±1.6 vs. 2.6±2.0, p=0.09] and PAE [1.12±0.5 vs. 0.98±0.6, p=0.04]).

Among the RVPA parameters PAC<1.9 mL/mmHg (HR 4.0, CI 1.3–6.0, p=0.007) and PAE>0.9 mmHg/mL (HR 2.5, 95% CI 1.1–5.2, p=0.02) were associated with the primary endpoint. On the contrary, PAPi was not significantly associated with the outcome.

PAC demonstrated a superior predictive value for the composite adverse outcome compared with pulmonary vascular resistances (PVR) (AUC comparison p=0.019) and PAPi (p=0.03) but similar compared with PAE (p=0.19) and mPAP (p=0.51). In multivariable regression models, PAC, but not PAE showed incremental prognostic value compared with cardiac index (p=0.02).

Conclusions

Hemodynamic indices of RVPA are associated with worse survival in patients with end-stage heart failure. In particular, PAC and PAE demonstrated superior prognostic value compared with PAPi and steady-state PVR. Moreover, PAC showed incremental prognostic value compared with cardiac index in patients awaiting heart transplantation.

Funding Acknowledgement

Type of funding sources: None.

P290 CARDIAC AMYLOIDOSIS, A CHALLENGING DIAGNOSTIC WORK – UP

 

A 79 years–old male presented to our outpatient clinic with symptoms of an initial heart failure. He had an history of atrial fibrillation (AF), anaemia and thrombocytopaenia, which have never been deeply investigated, bilateral carpal tunnel syndrome. Electrocardiogram (EKG) showed AF with normal ventricular rate and low peripherical QRS voltages. Laboratory testing was significant for NT proBNPelevation, pancytopenia and iron overload. An echocardiogram (ECHO) was done showing a hypokinetic and dilated biventricular cardiopathy. The therapy was therefore optimized with clinical benefit. At coronary angiography a severe stenosis of left coronary artery was observed with normal myocardial perfusion imaging. Cardiovascular magnetic resonance (CMR) excluded an iron intramyocardial overload (in contrast to the hepatic and splenic parenchyma) and detected a subendocardial pattern of LGE at lateral and mid–basal septal area. Emochromatosis and Gaucher disease were excluded. As suggested by hematologists, he underwent osteomedullary biopsy (OMB) and a myelodysplastic syndrome (MDS) was diagnosed. He was still symptomatic for dyspnea on mild exertion. The following ECHO revealed normal left ventricular (LV) size with moderate concentric remodeling, mildly impaired LV systolic function and LV filling pattern suggestive of restrictive cardiomyopathy. All these data prompted suspicion for an infiltrative cardiopathy. Nuclear scintigraphy with the use of bone seeking agent was done and showed Perugini grade 2 cardiac uptake. Moreover, amyloid deposits were identified after Congo red–staining from OMB. immunoglobulin light chain (LA) amyloidosis was excluded.

Conclusion

based on the above findings, Cardiac Amyloidosis TTR–related wild type was diagnosed. The diagnosis of MDS and the identification of iron overload were incidental findings. The patient, currently in follow up at our center, is a candidate to Tafamidis.

Type-4 Phosphodiesterase (PDE4) Blockade Reduces NETosis in Cystic Fibrosis

Neutrophilic inflammation is a key determinant of cystic fibrosis (CF) lung disease. Neutrophil-derived free DNA, released in the form of extracellular traps (NETs), significantly correlates with impaired lung function in patients with CF, underlying their pathogenetic role in CF lung disease. Thus, specific approaches to control NETosis of neutrophils migrated into the lungs may be clinically relevant in CF. We investigated the efficacy of phosphodiesterase (PDE) type-4 inhibitors, in vitro, on NET release by neutrophils from healthy volunteers and individuals with CF, and in vivo, on NET accumulation and lung inflammation in mice infected with Pseudomonas aeruginosa. PDE4 blockade curbed endotoxin-induced NET production and preserved cellular integrity and apoptosis in neutrophils, from healthy subjects and patients with CF, challenged with endotoxin, in vitro. The pharmacological effects of PDE4 inhibitors were significantly more evident on CF neutrophils. In a mouse model of Pseudomonas aeruginosa chronic infection, aerosol treatment with roflumilast, a selective PDE4 inhibitor, gave a significant reduction in free DNA in the BALF. This was accompanied by reduced citrullination of histone H3 in neutrophils migrated into the airways. Roflumilast-treated mice showed a significant improvement in weight recovery. Our study provides the first evidence that PDE4 blockade controls NETosis in vitro and in vivo, in CF-relevant models. Since selective PDE4 inhibitors have been recently approved for the treatment of COPD and psoriasis, our present results encourage clinical trials to test the efficacy of this class of drugs in CF.

Improvement in fetal pulmonary hypertension and maturity after reversal of ductal constriction: prospective cohort study

OBJECTIVES

To test the hypotheses that estimated mean pulmonary arterial pressure (MPAP) decreases and pulmonary vascular maturation, assessed by the ratio of pulmonary arterial flow acceleration time to ejection time (AT/ET ratio), increases after reversal of fetal ductus arteriosus constriction by reducing maternal intake of the causal agent (prostaglandin inhibitors, such as polyphenol-rich foods or non-steroidal anti-inflammatory drugs), and that these effects are independent of gestational age, which are inferences not yet demonstrated in the clinical setting.

METHODS

This was a prospective cohort study comparing Doppler echocardiographic ductal flow dynamics, MPAP and pulmonary arterial flow AT/ET ratio in third-trimester fetuses (≥ 28 weeks' gestation) with ductus arteriosus constriction, at the time of diagnosis and after 2 weeks of reduced maternal intake of prostaglandin inhibitors either by suspending the use of pharmacological agents with potential for prostaglandin inhibition or by restricting the consumption of polyphenol-rich foods. MPAP was estimated using the Dabestani equation (MPAP = 90 - (0.62 × AT)), and pulmonary vascular maturity was assessed using the AT/ET ratio, according to reported validation studies. Student's t-test was used for comparison of variables at diagnosis with those after reversal of ductal constriction. Change in MPAP and pulmonary AT/ET ratio between the two assessments was compared with the expected change in the same gestational period in normal fetuses based on reference curves of MPAP and pulmonary AT/ET ratio constructed in normal fetuses from healthy pregnant women at 19-37 weeks' gestation, encompassing the same gestational age range as the study group (28-37 weeks).

RESULTS

Seventy pregnancies with fetal ductus arteriosus constriction were included in the study. After 2 weeks of reduced maternal intake of prostaglandin inhibitors, normalization of mean systolic (change from 1.86 ± 0.34 m/s at diagnosis to 1.38 ± 0.41 m/s; P < 0.001) and diastolic (change from 0.41 ± 0.11 m/s to 0.21 ± 0.065 m/s; P < 0.001) ductal velocities and of mean pulsatility index (change from 1.99 ± 0.20 to 2.55 ± 0.42; P < 0.001) was demonstrated. MPAP decreased between the assessments (change from 66.7 ± 6.90 mmHg at diagnosis to 54.5 ± 6.70 mmHg after 2 weeks; P < 0.001) and mean pulmonary AT/ET ratio increased (change from 0.20 ± 0.06 to 0.33 ± 0.07; P < 0.001). Change in MPAP between diagnosis and after 2 weeks of reduced maternal intake of prostaglandin inhibitors was -12.2 ± 0.30 mmHg, which was 5.3-times higher than that in 305 normal fetuses over 2 weeks during the same gestational period (-2.3 ± 0.19 mmHg) (P < 0.001), and change in pulmonary AT/ET ratio between the two assessments was 0.13 ± 0.08, which was 8.7-times higher than that in normal fetuses in the same gestational period (0.015 ± 0.08) (P < 0.001).

CONCLUSIONS

Resolution of fetal ductal constriction is followed by a fall in MPAP and by an increase in pulmonary vascular maturity, to a significantly greater degree than is observed in normal fetuses in the same gestational-age period. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

P4337Construction and validation of the instrument “nutritional knowledge and feeding practice scale – QCPA” – for children, 7 to 11 years

Introduction

The increase in the prevalence of obesity is one of the major public health problems. There is a weak relationship between nutritional knowledge and feeding practices. Studies have evaluated that the associations between obesity and the level of nutritional knowledge and feeding practices in children are scarce. The evaluation of nutritional knowledge and feeding practices should be carried out using validated instruments. Study showed the need to improve the instruments of habit research and feeding practices in children for better evaluation. Objectives: To develop and validate an instrument about nutritional knowledge and feeding practices for use in children from 7 to 11 years, based on the Food Guide for the Brazilian Population.

Methods

The study filled all the steps expected to validate an instrument: review on the subject, instrument elaboration, Content's Validity (Content Validity Index – CVI) with two groups of judges: 1° – nutritionists and, after adjustments, 2° – multidisciplinary group), FACE Validity, reliability analysis [Intraclass Correlation Coefficient (ICC) and Kappa (K), Internal Consistency Analysis - Cronbach's Alpha] and Validity of Construct (Exploratory Factorial Analysis - EFA) The sample was calculated, considering, at least, 10 subjects for each question of the questionnaire.

Results

Validation occurred in a final sample of 453 children, 46.4% boys and 53.6% girls, mean age 9.45 (SD = 1.44). The validity of the content presented CVI ≥0.80 for relevance in 62.3% of items for nutritionist group and 100% of items for multidisciplinary group), clarity (49.4%, 91.8%), Pertinence (58.8%, 98.4%), respectively. The test-retest had a level of agreement of 84.3% and K=0.740 for the Knowledge Dimension; and the ICC=0.754 for the Practices Dimension. Cronbach's Alpha, for internal consistency analysis, was α=0.589 for the Knowledge Dimension and α=0.618 for the Practices Dimension. The EFA with variance of 47.01% (7.81% at 10.85%), with varimax rotation, it defined five factors for the Practices Dimension: Involvement; Healthy Eating and drinking; Unhealthy eating and drinking; Basic food consumption; Attitudes during the meal.

Conclusion

The instrument QCPA demonstrated validity and reliability to evaluate nutritional knowledge and practices in children aged 7 to 11 years.

Increase of prostaglandin E2 in the reversal of fetal ductal constriction after polyphenol restriction

OBJECTIVE

Anti-inflammatory substances that inhibit the synthesis of prostaglandins, such as non-steroidal anti-inflammatory drugs (NSAIDs) and polyphenol-rich foods, can cause constriction of the fetal ductus arteriosus. This study aimed to test the hypothesis that reversal of fetal ductal constriction after maternal restriction of polyphenol-rich foods, in the third trimester of pregnancy, is accompanied by increased plasma levels of prostaglandin E2 (PGE2).

METHODS

This was a controlled clinical trial of women with singleton pregnancy ≥ 28 weeks undergoing fetal echocardiography. The intervention group included pregnancies with diagnosis of fetal ductal constriction and not exposed to NSAIDs. The control group consisted of third-trimester normal pregnancies. Both groups answered a food frequency questionnaire to assess the amount of total polyphenols in their diet, underwent Doppler echocardiographic examination and had blood samples collected for analysis of plasma levels of PGE2. Intervention group participants received dietary guidance to restrict the intake of polyphenol-rich foods. The assessments were repeated after 2 weeks in both groups.

RESULTS

Forty normal pregnancies were assessed in the control group and 35 with fetal ductal constriction in the intervention group. Mean maternal age (26.6 years) and mean body mass index (30.12 kg/m² ) were similar between the two groups. Intragroup analysis showed that dietary guidance reduced the median consumption of polyphenols (from 1234.82 to 21.03 mg/day, P < 0.001), increasing significantly the plasma concentration of PGE2 (from 1091.80 to 1136.98 pg/mL, P < 0.05) in the intervention group after 2  weeks. In addition, Doppler echocardiography showed reversal of fetal ductal constriction in the intervention group. No significant changes were observed in the control group.

CONCLUSIONS

Dietary intervention for maternal restriction of polyphenol-rich foods in the third trimester of pregnancy is accompanied by increase in plasma levels of PGE2 and reversal of fetal ductal constriction. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Polyphenol supplementation inhibits physiological increase of prostaglandin E2 during reproductive period - A randomized clinical trial

Anti-inflammatory property of polyphenols and their effect on the metabolism of prostaglandins is not established in healthy humans. This study aimed to evaluate the effect of polyphenol supplementation in plasma levels of prostaglandin E₂ and other markers of inflammation and oxidative stress in women using contraceptives. In this randomized double-blind clinical trial, women aged 25-35 years were selected. Participants received capsules containing polyphenols or placebo, to be consumed for fifteen days. From 40 women randomized, 28 completed the study. Control group showed a significant increase in the levels of PGE₂ (p=0.01) while the polyphenols group showed no change in these levels (p=0.79). There was an increase in hs-CRP (p<0.01) and F₂-isoprostane (p=0.04) in the control group. The GSSG to GSH ratio significantly reduced in the polyphenols group (p=0.02). Supplementation with polyphenol capsules inhibited the increase in markers of inflammation and oxidative stress in women of childbearing age using combined hormonal contraceptives.

Pulmonary Vein Flow Impedance: An Early Predictor of Cardiac Dysfunction in Intrauterine Growth Restriction

INTRODUCTION

In intrauterine growth restriction (IUGR), increased uteroplacental vascular impedance contributes to preferential flow to left ventricle (LV), with consequent alteration of its compliance and increased left atrial (LA) pressure. Pulmonary vein pulsatility index (PVPI) reflects the increased impedance to LA filling and could be used as a cardiac monitoring parameter in IUGR.

MATERIAL AND METHODS

A total of 27 IUGR fetuses (group 1), 28 fetuses with appropriate growth for gestational age from hypertensive mothers (group 2), and 28 controls (group 3) were studied. Pulsatility indices (PIs) of pulmonary veins and ductus venosus were calculated by Doppler echocardiography. Obstetric ultrasound was used to assess the PIs of uterine, umbilical, and middle cerebral arteries. Statistical analysis used analysis of variance, post-hoc Tukey, and Pearson's tests.

RESULTS

Mean PVPI was higher in IUGR group (1.27 ± 0.39) when compared to groups 2 (1.02 ± 0.37; p = 0.01) and 3 (0.75 ± 0.12; p < 0.001). In group 2, moderate correlation between PVPI and ductus venosus pulsatility index (DVPI) was found but not between PVPI and cerebroplacental ratio (CPR).

DISCUSSION

Higher PVPI in IUGR reflects decreased LV compliance and altered LA dynamics. As LV dysfunction precedes right ventricle, our results suggest that PVPI could be an early echocardiographic parameter of fetal diastolic function in IUGR.

Thrombin-activated Human Platelets Release two NAP-2 Variants that Stimulate Polymorphonuclear Leukocytes

Thrombin-activated human platelets release substance(s) of a prote-ic nature which induce an increase in the intracellular calcium concentration in polymorphonuclear leukocytes (PMN). Aim of this study was to characterize the platelet released product(s) responsible for PMN stimulation.

PMN-stimulating activity was isolated from platelet supernatant by FPLC and HPLC. The N-terminal sequence analysis revealed that the purified fractions consisted in 90% of a peptide of 73 amino acids and in 10% of a peptide of 74 amino acids; both are truncated forms of the connective tissue-activating peptide III (CTAP-III), a platelet a-granule product, and have 3 and 4 additional amino acids at the N-terminus compared with the neutrophil-activating peptide 2 (NAP-2): Asp-Leu-Tyr and Ser-Asp-Leu-Tyr, respectively. Treatment of platelet supernatant (previously depleted of PMN-activating nucleotides) with Affi-gel heparin resulted in the disappearance of PMN-stimulating effects, suggesting that NAP-2 variants, which are heparin-binding proteins, account for ATP-independent PMN-stimulating activity of the supernatant. Cross-desensitization between rNAP-2 and the platelet supernatant and inhibition by the anti-NAP-2 antibody are in agreement with this conclusion. Although NAP-2 and its variants are reportedly generated from the inactive precursors, CTAP-III and platelet basic protein, through a proteolytic cleavage, NAP-2 variants were not generated in our system by proteases deriving from platelets or contaminating leukocytes. Indeed, treatment of intact platelet suspensions with different protease inhibitors failed to modify the calcium stimulating activity of the resulting supernatants. In conclusion, thrombin-activated platelets release NAP-2 variants which are not generated outside the platelets by proteolytic processing but are released in an active form. This finding enhances our understanding of platelet-PMN interaction in thrombosis and inflammation.

Ductal Adenocarcinoma of the Pancreas: Clinicopathologic Features and Survival

Aims and Background

The prognosis after surgical resection for pancreatic cancer has not been clearly defined because conflicting results have been reported.

Methods

Fifty-five patients who underwent surgical resection for pancreatic carcinoma between 1970 and 1987 were retrospectively reviewed to determine factors influencing long-term survival.

Results

The actuarial 5-year survival rate for all 55 patients was 12.5 %. Type of operation, tumor stage, direct extension into adjacent organs, grading and lymph node involvement were found to significantly influence survival. Age, sex, tumor site, size, invasion into peripancreatic tissue, invasion of lymphatic vessels and small veins, perineural Infiltration, tumor necrosis, round cell infiltrate at the tumor margin, associated chronic pancreatitis, and atypia of pancreatic ductal epithelium demonstrated no predictive capacity. No 5-year survival was observed among the patients who underwent vascular resection. Three of 9 patients who underwent left-sided pancreatectomy for cancer of the tail of the pancreas survived more than 5 years. Multivariate analysis confirmed that lymph node involvement, moderate-poor histologic tumor differentiation, and treatment with total pancreatectomy were signicantly associated with a worse prognosis.

Conclusions

Lymph node status, grading of the tumor and type of operation have a significant impact on prognosis in resected pancreatic cancer.

Serum Deoxyribonuclease and Ribonuclease in Pancreatic Cancer and Chronic Pancreatitis

Serum ribonuclease (RNase) and deoxyribonuclease (DNase) were investigated in 18 control subjects, and in 22 patients with pancreatic cancer, 13 with chronic pancreatitis and 29 with extrapancreatic diseases in order to assess their clinical usefulness in pancreatic cancer diagnosis and to evaluate whether modifications were consensual and/or age-related. Increased DNase and RNase values were found not only in a notable proportion of pancreatic cancer, but also in chronic pancreatitis and extra-pancreatic diseases. Thus the clinical value of both enzymes in pancreatic cancer diagnosis is negligible. DNase does not seem to be strictly age-dependent, whereas serum RNase does. Elevated levels of the two enzymes, when present, were consensual, suggesting that factors involved in such an increase were partially common to both.

Total Body Water Dynamics Estimated with Bioelectrical Impedance Vector Analysis and B-Type Natriuretic Peptide After Exposure to Hypobaric Hypoxia: A Field Study

Strapazzon, Giacomo, Matiram Pun, Tomas Dal Cappello, Emily Procter, Piergiorgio Lochner, Hermann Brugger, and Antonio Piccoli. Total body water dynamics estimated with bioelectrical impedance vector analysis and B-type natriuretic peptide after exposure to hypobaric hypoxia: A field study. High Alt Med Biol. 18:384–391, 2017.—The relationship between total body water (TBW) dynamics and N-terminal pro-B-type natriuretic peptide (NT-proBNP), a stable metabolite of B-type natriuretic peptide, during acute high altitude exposure is not known. To investigate this, we transported 19 healthy lowland subjects to 3830 m with a helicopter after baseline measurements (262 m). The physiological measurements and clinical assessments were taken at 9, 24, 48, and 72 hours and on the eighth day of altitude exposure. A bioelectrical impedance vector analysis (BIVA) from height corrected Resistance–Reactance (R-Xc graph) was used to estimate TBW status. NT-proBNP was measured from venous blood samples. The changes in impedance vector were lengthened at 9 (p = 0.011), 48 (p = 0.033), and 72 hours (p = 0.015) indicating dehydration compared to baseline. However, there was no dehydration at 24 hours (p > 0.05) from the baseline and the subjects trended to get euhydrated from 9 to 24 hours (p = 0.097). The maximum percent changes in vector length from the baseline were within 10%–15%. There was a significant increase of natural logarithm (ln)(NT-proBNP) after ascent with a peak at 24 hours, although similarly to BIVA values, ln(NT-proBNP) returned to baseline after 8 days of altitude exposure. The changes in impedance vector length were not correlated with the changes in ln(NT-proBNP) (r = −0.101, p = 0.656). In conclusion, the dehydration at high altitude as reflected by 10%–15% vector lengthening falls within “appropriate dehydration” in healthy lowland subjects. NT-proBNP does not simply reflect the TBW status during acute high altitude exposure and needs further investigation.

Cigarette Smoking is Associated with Decreased Bone Gla-protein (BGP) Levels in Hemodialysis Patients

BACKGROUND

Bone Gamma-carboxyglutamic acid (Gla)-protein (BGP or osteocalcin) is a vitamin K-dependent protein involved in the regulation of bone mineralization. Smoking is a risk factor for osteoporosis.

METHODS

We carried out a secondary analysis of the Vitamin K Italian (VIKI) study to investigate the association between cigarette smoking and BGP levels in patients with end stage renal disease. Data were collected in 370 haemodialysis patients, 37% (136) smokers (or ex-smokers) and 63% (234) nonsmokers. Vascular calcifications and vertebral fractures (quantitative morphometry) were identified on spine radiographs.

RESULTS

Smokers had significantly lower BGP levels (152 vs. 204 µg/L, p=0.003). Smokers had lower plasma phosphate levels (4.2 vs. 4.7 mg/dl, p<0.01). Lower BGP levels were associated with aortic calcification (p<0.001), iliac calcification (p=0.042) and vertebral fractures (p=0.023). In addition, the regression model showed that smoking is associated with a significant reduction of total BGP levels by about 18% (p=0.01).

CONCLUSION

This is the first clinical study in a haemodialysis population, which identifies cigarette smoking as a potential factor that can lower BGP levels, a protective agent in bone and vascular health.

Mechanisms of endothelial cell dysfunction in cystic fibrosis

Although cystic fibrosis (CF) patients exhibit signs of endothelial perturbation, the functions of the cystic fibrosis conductance regulator (CFTR) in vascular endothelial cells (EC) are poorly defined. We sought to uncover biological activities of endothelial CFTR, relevant for vascular homeostasis and inflammation. We examined cells from human umbilical cords (HUVEC) and pulmonary artery isolated from non-cystic fibrosis (PAEC) and CF human lungs (CF-PAEC), under static conditions or physiological shear. CFTR activity, clearly detected in HUVEC and PAEC, was markedly reduced in CF-PAEC. CFTR blockade increased endothelial permeability to macromolecules and reduced trans‑endothelial electrical resistance (TEER). Consistent with this, CF-PAEC displayed lower TEER compared to PAEC. Under shear, CFTR blockade reduced VE-cadherin and p120 catenin membrane expression and triggered the formation of paxillin- and vinculin-enriched membrane blebs that evolved in shrinking of the cell body and disruption of cell-cell contacts. These changes were accompanied by enhanced release of microvesicles, which displayed reduced capability to stimulate proliferation in recipient EC. CFTR blockade also suppressed insulin-induced NO generation by EC, likely by inhibiting eNOS and AKT phosphorylation, whereas it enhanced IL-8 release. Remarkably, phosphodiesterase inhibitors in combination with a β₂ adrenergic receptor agonist corrected functional and morphological changes triggered by CFTR dysfunction in EC. Our results uncover regulatory functions of CFTR in EC, suggesting a physiological role of CFTR in the maintenance EC homeostasis and its involvement in pathogenetic aspects of CF. Moreover, our findings open avenues for novel pharmacology to control endothelial dysfunction and its consequences in CF.

Usefulness of combining admission brain natriuretic peptide (BNP) plus hospital discharge bioelectrical impedance vector analysis (BIVA) in predicting 90 days cardiovascular mortality in patients with acute heart failure

Heart failure is a disease characterized by high prevalence and mortality, and frequent rehospitalizations. The aim of this study is to investigate the prognostic power of combining brain natriuretic peptide (BNP) and congestion status detected by bioelectrical impedance vector analysis (BIVA) in acute heart failure patients. This is an observational, prospective, and a multicentre study. BNP assessment was measured upon hospital arrival, while BIVA analysis was obtained at the time of discharge. Cardiovascular deaths were evaluated at 90 days by a follow up phone call. 292 patients were enrolled. Compared to survivors, BNP was higher in the non-survivors group (mean value 838 vs 515 pg/ml, p < 0.001). At discharge, BIVA shows a statistically significant difference in hydration status between survivors and non-survivors [respectively, hydration index (HI) 85 vs 74, p < 0.001; reactance (Xc) 26.7 vs 37, p < 0.001; resistance (R) 445 vs 503, p < 0.01)]. Discharge BIVA shows a prognostic value in predicting cardiovascular death [HI: area under the curve (AUC) 0.715, 95% confidence interval (95% CI) 0.65-0.76; p < 0.004; Xc: AUC 0.712, 95% CI 0.655-0.76, p < 0.007; R: AUC 0.65, 95% CI 0.29-0.706, p < 0.0247]. The combination of BIVA with BNP gives a greater prognostic power for cardiovascular mortality [combined receiving operating characteristic (ROC): AUC 0.74; 95% CI 0.68-0.79; p < 0.001]. In acute heart failure patients, higher BNP levels upon hospital admission, and congestion detected by BIVA at discharge have a significant predictive value for 90 days cardiovascular mortality. The combined use of admission BNP and BIVA discharge seems to be a useful tool for increasing prognostic power in these patients.

Body Mass Index and Agreement Between Bioimpedance and Anthropometry Estimates of Body Compartments in Anorexia Nervosa

BACKGROUND

In 74 women with anorexia nervosa (body mass index [BMI] 10-17.5 kg/m(2)), a progressive disagreement between anthropometry and bioelectrical impedance analysis (BIA) estimates of fat (FM) and fat-free mass (FFM) was documented with a BMI <15 kg/m(2). Below this threshold, an abnormal body composition was detected with vector BIA independent on body weight (useful tool at the bedside). Both anthropometry and BIA are used for body composition assessment. We evaluated the agreement between their estimates of FFM and FM in extremely lean subjects with anorexia nervosa.

METHODS

Observational study in 74 women (age 15-45 years; BMI 10.0-17.5 kg/m(2)) with anorexia nervosa. Anthropometry FM and FFM were estimated by skinfold thicknesses. Whole-body impedance vector components, resistance (R) and reactance (X(c)), were measured at the same time (BIA-101 analyzer, 50-kHz frequency; Akern/RJL Systems, Clinton Twp., MI). BIA estimates of FFM and FM were obtained with Sun's equations (BMI 14-39 kg/m(2)). Vector BIA was performed with the RXc graph method. The frequency of disagreement between anthropometry and BIA was evaluated as a function of increasing BMI (receiver operating characteristic curve).

RESULTS

The correlation coefficient between methods was 0.80-0.90. The BMI cutoff value of 15 kg/m(2) predicted disagreement of FM and FFM in patients with a BMI <15 kg/m(2). In the RXc graph, the distribution of vectors from patients with disagreement was significantly shifted out of the right border of the reference tolerance ellipses.

CONCLUSIONS

Anthropometry and BIA equations should not be used in anorexic patients with a BMI <15 kg/m(2). The distribution of vectors from patients with disagreement of methods was shifted out of the right border of the reference tolerance ellipses and was superposed to vectors from patients with a BMI <15 kg/m(2). The identified impedance pattern for anorexia could be useful for feedback in individual patient refeeding (vector back into the 75% reference ellipse).

A recently developed MRI scoring system for hand osteoarthritis: its application in a clinical setting

This study aimed to apply the recently proposed Oslo hand osteoarthritis magnetic resonance imaging (MRI) scoring system to evaluate MRI findings in a cohort of patients affected by long-standing erosive hand osteoarthritis (EHOA). Eleven female EHOA patients (median 59 [interquartile range 62-52] years, disease duration 9.5 [interquartile range 13-3.75] years) underwent MRI (1.5 T) of the dominant hand, and synovitis, bone marrow lesions (BMLs), joint space narrowing, osteophytes, cysts, malalignment, and erosions were scored using the Oslo scoring system. Intra- and inter-reader reliability were assessed. The patients also underwent X-ray examination, and bone features were evaluated using the same scoring system. Pain and tenderness were assessed during a physical examination. Spearman's non-parametric test was used to analyze the correlations between variables. MRI intra- and inter-reader reliability were found between good and moderate for many features. No statistical differences were found between the radiographs and MRI with regard to detection of JSN, malalignment, and bone erosions. Synovitis was detected in 39.8 % of the 80 joints examined (in a mild form in 80 %), erosions were found in 51.1 %, and BMLs were identified in 20.5 and 23.9 % at the distal and the proximal side, respectively. BMLs at both the proximal and distal ends were correlated with tender joints (BML distal p = 0.0013, BML proximal p = 0.012). The presence of synovitis was correlated with tenderness (p = 0.004) and erosions at both the distal and proximal joints (p = 0.004). The presence of erosions correlated with tender joints (p < 0.01) and the mean visual analog scale (VAS) score (distal p = 0.03, proximal p = 0.01). Synovitis and BMLs were correlated with clinical symptoms in our patients affected with long-standing EHOA.

Calcimimetic and vitamin D analog use in hemodialyzed patients is associated with increased levels of vitamin K dependent proteins

Matrix Gla protein (MGP) and bone Gla protein (BGP) are two vitamin K-dependent proteins (VKDPs) involved in the regulation of vascular calcification (VC). We carried out a secondary analysis of the VIKI study to evaluate associations between drug consumption and VKDP levels in 387 hemodialyzed patients. The VIKI study assessed the prevalence of vitamin K deficiency in hemodialysis patients. We evaluated drug consumption, determined BGP and MGP levels, and verified the presence of any vertebral fractures (VF) and VC by spine radiographs. Total BGP levels were twice as high with calcimimetics versus no calcimimetics (290 vs. 158.5 mcg/L, p < 0.0001) and 69 % higher with vitamin D analogs (268 vs. 159 mcg/L, p < 0.0001). Total MGP was 19 % higher with calcimimetics (21.5 vs. 18.1 mcg/L, p = 0.04) and 54 % higher with calcium acetate (27.9 vs. 18.1 mcg/L, p = 0.003); no difference was found with vitamin D analogs (21.1 vs. 18.3 mcg/L, p = 0.43). Median Total BGP level was 29 % lower in patients with ≥1 VF (151 vs. 213 mcg/L, p = 0.0091) and 36 % lower in patients with VC (164 vs. 262.1 mcg/L, p = 0.0003). In non-survivors, median BGP and MGP were lower, but only for MGP this difference reached the statistical significance (152 vs. 191 mcg/L, p = 0.20 and 15.0 vs. 19.7 mcg/L, p = 0.02, respectively). Pending studies on vitamin K supplementation, calcimimetics, and vitamin D analogs may play a role in preserving vitamin K-dependent protein activity, thus contributing to bone and vascular health in CKD patients.

Roflumilast inhibits leukocyte-platelet interactions and prevents the prothrombotic functions of polymorphonuclear leukocytes and monocytes

ESSENTIALS: Thrombosis is a major comorbidity in patients with chronic obstructive pulmonary disease (COPD). Roflumilast is a selective phosphodiesterase type-4 (PDE4) inhibitor approved for treatment of severe COPD. PDE4 blockade by roflumilast inhibits prothrombotic functions of neutrophils and monocytes. PDE4 inhibitors may reduce thrombotic risk in COPD as well as in other vascular diseases.

BACKGROUND

Roflumilast, an oral selective phosphodiesterase type 4 inhibitor, is approved for the treatment of severe chronic obstructive pulmonary disease (COPD). A recent meta-analysis of trials on COPD revealed that treatment with roflumilast was associated with a significant reduction in the rate of major cardiovascular events. The mechanisms of this effect remain unknown.

OBJECTIVES

We tested the hypothesis that roflumilast N-oxide (RNO), the active metabolite of roflumilast, curbs the molecular mechanisms required for leukocyte-platelet (PLT) interactions and prevents the prothrombotic functions of polymorphonuclear leukocytes (PMNs) and monocytes (MNs).

METHODS

Using well-characterized in vitro models, we analysed the effects of RNO on: (i) PMN adhesiveness; (ii) the release of neutrophil extracellular traps (NETs); and (iii) tissue factor expression in MNs. Key biochemical events underlying the inhibitory effects of RNO were defined.

RESULTS AND CONCLUSIONS

In PMNs, RNO prevented phosphoinositide 3-kinase (PI3K)-dependent phosphorylation of Akt on Ser473, and Src family kinase (SFK)-mediated Pyk2 phosphorylation on Tyr579-580, while inducing protein kinase A-mediated phosphorylation of C-terminal Src kinase, the major negative regulator of SFKs. Modulation of these signaling pathways by RNO resulted in a significant impairment of PMN adhesion to activated PLTs or human umbilical vein endothelial cells, mainly mediated by inhibition of the adhesive function of Mac-1. Moreover RNO curbed SFK/PI3K-mediated NET release by PMNs adherent on fibrinogen-coated surfaces. In MNs interacting with activated PLTs, RNO curbed PI3K-mediated expression of tissue factor. The efficacy of RNO was significantly potentiated by formoterol, a long acting β-adrenergic receptor agonist. This study reveals novel antithrombotic activities by which roflumilast may exert protective effects against cardiovascular comorbodities in COPD.

Lengthening the time intervals between doses of biological agents in psoriatic arthritis patients: A single-center retrospective study

Anti-tumor necrosis factor (TNF) alpha therapy has changed the course of psoriatic arthritis (PsA), but clinical experience about lengthening of time intervals between drug administrations is still limited. The aims of the study were to evaluate: (1) the long-term efficacy (over a 4-year period) of etanercept/adalimumab in a subset of PsA patients who did not require switches; and (2) the progressive lengthening of time intervals between treatments in patients who achieved minimal disease activity (MDA). PsA outpatients attending the Rheumatology Clinic-University of Padova who took a single anti-TNF agent (etanercept/adalimumab) for a 4-year period were studied. Therapy efficacy was assessed using clinical, biochemical, and disease activity (DA) indexes. The intervals between treatments were empirically and progressively lengthened after MDA was reached and maintained. One hundred and forty-one patients (mean age, 51.22 ± 12.34 years; mean disease duration, 12.1 ± 8.42 years) treated with etanercept/adalimumab (47.5% and 52.5%, respectively) were studied. DA indexes showed a marked, persistent improvement in all the patients throughout 4 years. The interval between injections could be extended in 46.1% of the patients (35% for adalimumab, 58% for etanercept) without provoking relapses. The mean therapy interval at the end of the study period was 3.12 weeks for adalimumab 40 mg (with respect to 2 weeks) and 2.75 weeks for etanercept 25 mg (with respect to 0.5 weeks). The new therapy timetable also led to cost savings. In conclusion, lengthening the time intervals between injections of anti-TNF agents in PsA patients who reach MDA is safe, effective, cost-effective, and facilitates patient compliance.

Copeptin decrease from admission to discharge has favorable prognostic value for 90-day events in patients admitted with dyspnea

BACKGROUND

With patients referred to emergency departments (EDs) for acute dyspnea, emergency physicians should consider all possible diagnoses and assess patients' risk stratification. Copeptin has been shown to have prognostic power for subsequent events, such as death and rehospitalization in patients admitted for dyspnea. The aim of this study was to investigate prognostic role of copeptin variations during hospitalization in patients admitted for dyspnea.

METHODS

We conducted a prospective, multicentric, observational study in acute dyspneic patients in three ED centers in Italy. Clinical data and copeptin assessments were performed at admission, and at discharge. A 90-day follow-up was performed.

RESULTS

A total of 336 patients were enrolled, and on the basis of final diagnosis distinguished into two groups: acute heart failure and no acute heart failure. Compared to a control group, in all studied population copeptin values at admission resulted in a significantly (p<0.001) higher median (maximum-minimum): 31 (0-905) versus 8 (0-13) pmol/L. Median copeptin value at admission was 42 (0-905) pmol/L in acute heart failure patients and 20 (0-887) pmol/L in no acute heart failure, respectively (p<0.001). In all studied patients and in each group copeptin at admission and discharge showed significant predictive value for 90-day events (p<0.001). Furthermore, in all patients population and in both groups Δ copeptin values from admission to discharge also showed significant predictive value for 90-day events (p<0.001).

CONCLUSIONS

In patients admitted for acute dyspnea, admission, discharge and Δ copeptin variations have significant prognostic value from subsequent 90-day death and rehospitalization.

The relationship between the Spine Deformity Index, biochemical parameters of bone metabolism and vascular calcifications: results from the Epidemiological VERtebral FRACtures iTalian Study (EVERFRACT) in dialysis patients

BACKGROUND

The Spine Deformity Index (SDI) is a measure of vertebral fractures (VFs), providing information on both their number and severity.

METHODS

We evaluated the relationships between SDI and clinical, biochemical and arterial calcification parameters in 387 hemodialysis (HD) patients. VFs, assessed by quantitative vertebral morphometry, and vascular calcifications were identified in the same lateral spinal X-ray. To improve the detection of fracture severity, we created a corrected SDI (c-SDI), by dividing SDI for the number of VFs. We assessed routine biochemistry, bone-Gla-protein (BGP), undercaboxylated BGP (ucBGP), and matrix-Gla-protein (MGP).

RESULTS

VFs prevalence was 55.3%. HD patients with a SDI >1 were more frequently males (p<0.05), and had lower BGP (p<0.01). Patients with a c-SDI >1 had higher LDL-cholesterol (p<0.05) and lower ucBGP (p<0.05) and MGP (p<0.05). Calcifications of the abdominal aorta (AAoC) were more frequent in patients with SDI >1 (p<0.05) and with c-SDI >1 (p<0.05). Multivariate logistic regression showed that male sex (OR 1.86, CI 1.20-2.91), age (OR 1.03, CI 1.01-1.05) and albumin ≥3.5 g/dL (OR 0.54, CI 0.31-0.93) were predictors of a SDI >1. Age (OR 1.05, CI 1.03-1.07), LDL-cholesterol (OR 1.74, CI 1.04-2.92) and ucBGP (OR 0.35, CI 0.18-0.70) were associated with c-SDI >1.

CONCLUSIONS

We conclude that the severity of VFs was associated with age, atherogenic factors and bone metabolism markers.

Phosphodiesterase type 4 blockade prevents platelet-mediated neutrophil recruitment at the site of vascular injury

OBJECTIVE

Platelet-neutrophil interactions play a key role in cardiovascular disease and inflammatory processes. Src family kinases mediate P-selectin glycoprotein ligand-1-Mac-1 cross talk necessary for firm platelet-neutrophil adhesion. Because Src family kinase activity can be regulated by cAMP-dependent pathways, in this work, we evaluated the role of phosphodiesterases in the signaling events that are required to sustain platelet-neutrophil interactions and neutrophil recruitment at the site of vascular injury.

APPROACH AND RESULTS

In neutrophils exposed to P-selectin, selective phosphodiesterase 4 (PDE4) inhibition prevented Src family kinase-mediated phosphorylation of the proline-rich tyrosine kinase 2 on Tyr579/Tyr580. The effects of PDE4 inhibition required protein kinase A, likely through protein kinase A-mediated activation of COOH-terminal Src kinase, a major negative regulator of Src family kinases. PDE4, but not other phosphodiesterase inhibitors, reduced platelet-neutrophil conjugates as well as neutrophil firm adhesion on spread platelets under flow conditions. The effect of PDE4 inhibition on neutrophil adhesion was primarily mediated by downregulation of P-selectin-induced activation of Mac-1. In a murine model of endovascular injury, selective inhibition of PDE4 significantly reduced neutrophil recruitment at the site of vascular damage.

CONCLUSIONS

This study identifies PDE4 as a central node in the signaling network that mediates platelet-neutrophil adhesion and suggests that pharmacological inhibition of PDE4 may represent a novel therapeutic avenue for the treatment of cardiovascular disease.

Combined evaluation of nutrition and hydration in dialysis patients with bioelectrical impedance vector analysis (BIVA)

BACKGROUND & AIMS

Body hydration changes continuously in hemodialysis patients. The Subjective Global Assessment (SGA) is used for the nutritional evaluation but it does not allow a direct evaluation of hydration. Bioelectrical impedance vector analysis (BIVA) is very sensitive to hydration. The potential of the combined evaluation of hydration and nutrition with SGA and BIVA is still lacking.

METHODS

Observational cross-sectional study on 130 (94 Male) uremic patients undergoing chronic hemodialysis three times a week. Nutritional status was evaluated with the SGA. Each subject was classified as SGA-A (normal nutritional status), SGA-B (moderate malnutrition), or SGA-C (severe malnutrition). Body hydration was evaluated with BIVA. The two vector components resistance (R) and reactance (Xc) were normalized by the subject's height and standardized as bivariate Z-score, i.e. Z(R) and Z(Xc).

RESULTS

Undernutrition influenced impedance vector distribution both before and after a dialysis session. In pre-dialysis, the mean vector of SGA A was inside the 50% tolerance ellipse. In SGA B and C, Z(R) was increased and Z(Xc) decreased, indicating a progressive loss of soft tissue mass. Fluid removal with dialysis increased both Z(R) and Z(Xc) in SGA A and B but not in C. With ROC curve analysis on the slope of increase, we found the cutoff value of 27.8° below which undernutrition was present, either moderate or severe. The area under the ROC curve was 77.7° (95% CI 69.5-84.5, P < .0001) with sensitivity 75.9%, specificity 78.6%, positive predicted value 74.6%, and negative predicted value 79%.

CONCLUSIONS

The distribution of impedance vectors is associated with the SGA classification of patients. The change in body hydration in each SGA category can be detected with BIVA.

Prasugrel inhibits platelet-leukocyte interaction and reduces inflammatory markers in a model of endotoxic shock in the mouse

Prasugrel, through its active metabolite, reduces atherothrombosis and its clinical manifestations by inhibiting platelet activation and aggregation. Platelets also contribute to inflammation through interaction with different classes of leukocytes. We investigated whether the inhibitory effect of prasugrel on platelets also counteract inflammatory responses. The effect of prasugrel active metabolite, R-138727, was investigated on platelet P-selectin expression, platelet adhesion to polymorphonuclear leukocytes (PMN) and monocytes (MN) and Mac-1 expression in PMN and MN, in vitro, in human cells. The ex vivo effect of prasugrel administration on P-selectin, thromboxane (TXB)2 formation, platelet-PMN conjugates and Mac-1 expression in PMN triggered by PAR-4 agonist peptide was examined in whole blood from healthy mice as well as from mice in which an acute inflammatory reaction was induced by treatment with endotoxin. The effect of prasugrel on inflammatory markers in endotoxin-treated animals was also tested in vivo. R-138727 inhibited agonist-stimulated expression of platelet P-selectin, platelet-PMN and platelet-MN adhesion and platelet-dependent Mac-1 expression in leukocytes. Addition of aspirin did not modify the inhibitory effect elicited by R-138727. Treatment of mice with prasugrel resulted in a profound inhibition of platelet P-selectin expression, TXB2 production, platelet-PMN adhesion and Mac-1 expression in PMN induced by ex vivo stimulation with PAR-4 agonist peptide of whole blood from healthy or endotoxin-treated mice. Measurement of markers revealed that prasugrel reduced TXB2 and tumour necrosis factor-α synthesis and increased nitric oxide metabolites in endotoxin-treated mice in vivo. In conclusion, prasugrel reduces platelet interactions with PMN and MN. Through these effects prasugrel may curb platelet-mediated inflammatory responses.

Effects of estrogen on endothelial prostanoid production and cyclooxygenase-2 and heme oxygenase-1 expression

We studied the effects of 17β-estradiol (E₂) (10, 40 nM) on 2 vasoprotective pathways, i.e. cyclooxygenase-2 (COX-2)-dependent prostanoids and the antioxidant heme oxygenase-1 (HO-1), in human umbilical vein endothelial cells (HUVEC) exposed for 6h to steady laminar shear stress (LSS, 10 dyn/cm²), characteristic of atherosclerotic lesion-protected areas. COX-2 was induced by LSS versus static condition (SC). E₂ did not significantly affect COX-2 expression in HUVEC cultured in SC or exposed to LSS. Prostacyclin (PGI₂) and prostaglandin (PG)E₂ were induced while PGF(2α) was reduced by LSS. E₂ caused no effect or a small reduction of prostanoid biosynthesis. In HUVEC cultured in SC or exposed to LSS, E₂ 10 nM caused a comparable HO-1 induction (35-45%) while E₂ 40 nM was 5-fold more potent in LSS-exposed HUVEC than in SC (290% and 58%, respectively). PGI₂ receptor antagonist RO3244794 did not affect HO-1 induction by E₂. In conclusion, E₂ may restrain oxidant stress in the endothelium through HO-1 induction by a mechanism independent on PGI₂ signaling.

Dietary phosphate restriction in dialysis patients: a new approach for the treatment of hyperphosphataemia

BACKGROUND AND AIM

Elevated serum phosphate and calcium-phosphate levels play an important role in the pathogenesis of vascular calcifications in uraemic patients and appear to be associated with increased cardiovascular mortality. We aimed to evaluate the effects of a partial replacement of food protein with a low-phosphorus and low-potassium whey protein concentrate on phosphate levels of dialysis patients with hyperphosphataemia.

METHODS AND RESULTS

Twenty-seven patients undergoing chronic haemodialysis were studied for a 3-month period. In the intervention group (n = 15), food protein were replaced by 30 or 40 g of low-phosphorus and low-potassium protein concentrate aimed at limiting the phosphate intake. In the control group (n = 12) no changes were made to their usual diet. Anthropometric measurements, biochemical markers and dietary interviews were registered at baseline and during the follow-up period. From baseline to the end of the study, in the intervention group, serum phosphate and circulating intact parathyroid hormone levels lessened significantly (8.3 ± 1.2 mg/dL vs 5.7 ± 1.4 mg/dL and 488 ± 205 pg/ml vs 177 ± 100 pg/ml respectively; p < 0.05) with decreasing of phosphate and potassium intake. No significant differences were found in the control group. No significant changes were observed in serum albumin, calcium, potassium, Kt/V, body weight and body composition in both the intervention and control groups.

CONCLUSION

Dietary intake of phosphate mainly comes from protein sources, so dietary phosphorus restriction may lead to a protein/energy malnutrition in a dialysis patient. A phosphorus-controlled diet plan including a nutritional substitute resulted in serum phosphate and intact parathyroid hormone decrease without nutritional status modifications in dialysis patients.

Reduction of hyperphosphatemia is related with the reduction of C-reactive protein in dialysis patients. Study in sevelamer-resistant dialysis patients treated with chitosan chewing gum as salivary phosphate binder

BACKGROUND

In end-stage renal disease (ESRD) hyperphosphatemia associates with vascular calcifications and cardiovascular events derived from endothelial dysfunction. In dialysis patients, C-reactive protein (CRP), a marker of inflammation, associates with cardiovascular mortality. Increased PO(4) concentration impairs endothelial integrity via induction of oxidative stress, and sevelamer, a phosphate binder, showed anti-inflammatory effect reducing CRP, which paralleled PO(4) reduction. To give support to a direct proinflammatory role of hyperphosphatemia "per se," we have considered previously studied dialysis patients with sevelamer-"resistant" hyperphosphatemia, who were treated with a chitosan-loaded chewing gum, as salivary phosphate binder, in addition to sevelamer, reduced serum PO(4) to normal, to retrospectively evaluate their CRP and the relationship with hyperphosphatemia and calcium × phosphate (Ca × PO(4)) product.

PATIENTS AND METHODS

High sensitive (hs) CRP of 13 previously studied hemodialysis patients with sevelamer-resistant hyperphosphatemia was evaluated with immunonephelometry.

RESULTS

Chitosan chewing gum use reduced hsCRP (from 1.38 ± 0.61 to 0.39 ± 0.16 mg/L after the gum, p < 0.0002), which returned to baseline after 4 weeks from gum discontinuation (1.25 ± 0.41). hsCRP reduction paralleled serum PO(4) reduction: from 7.60 ± 0.91 mg/dL to 5.18 ± 0.73 (after the gum) (p < 0.00001), returning to baseline (7.55 ± 0.75) after gum discontinuation. hsCRP reduction directly correlated with PO(4) reduction (p = 0.029).

CONCLUSION

The relationship in sevelamer-resistant dialysis patients between the reduction of serum PO(4), induced by the chitosan-loaded chewing gum, and CRP reduction supports also in humans a proinflammatory role of hyperphosphatemia "per se" derived from "in vitro" studies. This further contributes to the high cardiovascular risk of ESRD patients making their serum phosphate in the normal range of vital importance.