Reward (BIS/BAS) mechanisms and fatigue in patients on chronic hemodialysis

Recently, it has been demonstrated that chronic inflammation could have a role on fatigue onset in chronic hemodialysis (HD). Research on neuro-immune interactions highlighted that an alteration of basal ganglia functioning, secondary to chronic inflammation, may translate in a reduced motivation and altered reward processes in chronic diseases. This study investigated a possible correlation between fatigue severity and reward mechanisms, that regulate motivational dispositions, in HD patients. Evaluation scales were administered to ninety-four patients on HD (54 Male, 40 Female; Md_age = 67±26.5; Dialytic Md_age in years = 4±6.3. Fatigue was assessed by using Fatigue Severity Scale (FSS). Behavioural Inhibition System (BIS) and Behavioural Activation System (BAS) Scale was administered to investigate approach/avoidance behaviours. Anxiety and depression were measured by State-Trait Anxiety Inventory (STAI-Y) and Beck Depression Inventory (BDI-II). Results show that the distribution of HD patients for FSS score did not show a normal pattern. FSS score was significantly higher in patients with high BIS Z-score than in patients with low and medium BIS Z-score. BDI score and STAI-Y scores were similar among BIS Z-score groups of patients. Findings suggest that in patients on chronic hemodialysis there is a correlation between fatigue severity symptoms and motivational disposition mechanisms that predispose to action inhibition.

Fatigue is associated with high prevalence and severity of physical and emotional symptoms in patients on chronic hemodialysis

PURPOSE

The symptom burden of fatigued hemodialysis patients is poorly known. We aimed to investigate possible differences in the prevalence and severity of symptoms between fatigued and not fatigued patients on chronic hemodialysis.

METHODS

All prevalent patients on chronic hemodialysis referring to the Hemodialysis Service between January 2016 and June 2017 were considered eligible. The Dialysis Symptom Index (DSI) questionnaire was performed during the dialysis treatment. Patients underwent assessment of fatigue using the Italian version of the vitality scale of the SF-36 (SF-36VS).

RESULTS

We studied 137 patients: 107 (78.1%) were fatigued and 30 (31.9%) were non-fatigued. The median [95% CI] number of symptoms was 15 [14-16] for patients who reported fatigue and 9 [8-19] for the non-fatigued (P < 0.0001). In fatigued patients, with respect to non-fatigued ones, the prevalence of dry skin, itching, muscle soreness, bone or joint pain, restless legs, shortness of breath, feeling sad, feeling anxious, difficulty concentrating, and difficulty becoming sex aroused was significantly higher. Restless legs, feeling sad, difficulty concentrating, and difficulty becoming sex aroused were symptoms independently associated with fatigue. The severity of dry skin, trouble staying asleep, and bone/joint pain was higher in fatigued patients.

CONCLUSION

Fatigued hemodialysis patients report suffering from physical and emotional symptoms more frequently than non-fatigued patients. This finding suggests the need to accurately and routinely define the symptom burden of chronic hemodialysis patients and may help to investigate eventually common underlying pathogenic mechanisms of symptoms in these patients.

Parathyroid Nodular Hyperplasia and Responsiveness to Drug Therapy in Renal Secondary Hyperparathyroidism: An Open Question

The goal of the pharmacological therapy in secondary hyperparathyroidism (SHPT) is to reduce serum levels of parathyroid hormone and phosphorus, to correct those of calcium and vitamin D, to arrest or reverse the parathyroid hyperplasia. However, when nodular hyperplasia or an autonomous adenoma develops, surgery may be indicated. We reviewed the literature with the aim of defining if the echographic criteria predictive of unresponsiveness of SHPT to calcitriol therapy are valid also in the cinacalcet era and if drug therapy may reverse nodular hyperplasia of parathyroid gland (PTG). The responsiveness to therapy and regression of the nodular hyperplasia of PTG remains an open question in the calcimimetic era as well as the cutoff between medical and surgical therapy. Prospective studies are needed in order to clarify if an earlier use of cinacalcet in moderate SHPT might arrest the progression of parathyroid growth and stabilize SHPT.

1-year course of fatigue in patients on chronic hemodialysis

PURPOSE

Fatigue is common in end-stage renal disease patients receiving hemodialysis, reduces significantly their quality of life and is associated with all-cause and cardiac-related mortality. Unfortunately, little is known about the course of fatigue in patients on chronic hemodialysis.

METHODS

The Vitality Subscale of the SF-36 (SF-36 VS), Short-Form Health Survey, was administered to 45 patients in January (T1), June (T2) and November (T3) 2015.

RESULTS

The score of the SF-36 VS did not differ significantly among T1, T2 and T3. Similarly, the 1-year course of the SF-36 Vitality Subscale score did not differ significantly among T1, T2 and T3 after stratification of patients for sex, age, BMI, IADL and Charlson. Between T1 and T2, 21 out of 45 patients (46.6%) changed their fatigue status: 8 fatigued patients became not-fatigued and 13 not-fatigued patients became fatigued. Between T2 and T3, 12 out of 45 (26.6%) patients changed their fatigue status: 5 fatigued patients became not-fatigued and 7 not-fatigued patients became fatigued. Between T1 and T3, 19 out of 45 patients (42.2%) changed their fatigue status: 6 fatigued patients became not-fatigued and 13 not-fatigued became fatigued.

CONCLUSION

The present study is the first to identify variations in fatigue status among patients on chronic hemodialysis during 1-year course. These findings suggest to frequently assess the presence and severity of fatigue in patients on chronic hemodialysis.

Mortality in hospitalized chronic kidney disease patients starting unplanned urgent haemodialysis

AIM

Data on the outcome of chronic kidney disease (CKD) patients who are hospitalized and start unplanned urgent haemodialysis (HD) are lacking. This prospective, longitudinal, observational study aimed to define the hospital mortality rate and associated factors in CKD patients who start unplanned urgent HD.

METHODS

Between January 2003 and December 2009, all patients with CKD who were hospitalized, diagnosed with ESRD and started unplanned urgent haemodialysis at Haemodialysis Service of the Catholic University of Rome, Italy were recruited. Exclusion criteria were: acute renal failure, prior history of dialysis, multiple organ failure, coma, and dementia. Hospital mortality rate was the primary outcome.

RESULTS

Three and hundred sixteen patients were studied: 99 died after 19.5 ± 27.3 days and 217 survived until discharge. Of these, 154 were prescribed chronic HD and 63 restored renal function. Patients who died were significantly older and had a higher Charlson Comorbidity Index score. The mortality rates were 51.1% in patients with 81-90 years, 37.8% with 71-80 years, 34.1% with 61-70 years and 13.9% with age ≤60 years. Logistic regression analysis showed that age only was an independent risk factor for all-cause mortality.

CONCLUSIONS

In CKD patients who need hospitalization and start unplanned urgent haemodialysis the mortality is very high and significantly related to age.

Serum Endotoxin Activity Measured with Endotoxin Activity Assay Is Associated with Serum Interleukin-6 Levels in Patients on Chronic Hemodialysis

BACKGROUND

This study aims to evaluate, in patients on chronic hemodialysis (PHD), the levels of endotoxin through a chemiluminescent bioassay based on the oxidative burst reaction of activated neutrophils to complement coated LPS-IgM immune complexes and define the variables possibly correlated.

METHODS

In 61 PHD, we measured serum endotoxin activity (EA) with the Endotoxin Activity Assay (EAA™) and we defined the possible association with demographic, clinical and laboratory variables.

RESULTS

Mean serum EA was 0.43 ± 0.26 UI. EA was low (<0.40) in 29 patients (47.5%), intermediate (0.40-0.60) in 14 (23%) and high (>0.60) in 18 (29.5%). A significant exponential relationship was detected between EA and serum interleukin-6 (IL-6) levels (r = 0.871). At the multiple regression analysis, intermediate-high EA was directly associated only with serum IL-6 levels. In a second model of multiple regression analysis without the variable serum IL-6 levels, intermediate-high EA was directly associated with constipation and serum troponin levels and inversely associated with serum albumin and the monthly number of sevelamer tablets.

CONCLUSIONS

A high percentage of PHD has intermediate or high EA. Intermediate-high EA is significantly associated with serum IL-6 levels.

Parathyroid Ultrasonography in Renal Secondary Hyperparathyroidism: An Overlooked and Useful Procedure

In secondary hyperparathyroidism (SHPT), ultrasonography (US) can accurately define the size and structure of parathyroid glands as well as differentiate diffuse and nodular hyperplasia. US may be also useful to predict the response of SHPT to vitamin D analogs and cinacalcet and to assess for regression of parathyroid glands hyperplasia by measurement of parathyroid gland volume. There is increasing evidence that US can potentially identify patients who will benefit from prompt surgical intervention. Therefore, US should be part of the diagnostic armamentarium in the treatment of SHPT in the daily clinical practice.

Intra-operative parathyroid hormone monitoring through central laboratory is accurate in renal secondary hyperparathyroidism

OBJECTIVE

The usefulness, the methods and the criteria of intra-operative monitoring of the parathyroid hormone (ioPTH) during parathyroidectomy (PTX) for renal secondary hyperparathyroidism (rSHPT) in patients on chronic hemodialysis remain still matter of debate. The present study aimed to evaluate the ability of a low cost central-laboratory second generation PTH assay to predict an incomplete resection of parathyroid glands (PTG).

METHODS

The ioPTH decay was determined In 42 consecutive patients undergoing PTX (15 subtotal and 27 total without auto-transplant of PTG) for rSHPT. The ioPTH monitoring included five samples: pre-intubation, post-manipulation of PTG and at 10, 20 and 30min post-PTG excision. The patients with PTH exceeding the normal value (65pg/ml) at the first postoperative week, 6 and 12months were classified as persistent rSHPT.

RESULTS

The concentrations of ioPTH declined significantly over time in patients who received total or subtotal PTX; however, no difference was found between the two types of PTX. Irrespective of the type of PTX and the number of PTG removed, combining the absolute and percentage of ioPTH decay at 30min after PTG excision, we found high sensitivity (100%), specificity (92%), negative predictive value (100%) and accuracy (93%) in predicting the persistence of rSHPT.

CONCLUSIONS

The monitoring of the ioPTH decline by a low cost central-laboratory second generation assay is extremely accurate in predicting the persistence of disease in patients on maintenance hemodialysis undergoing surgery for rSHPT.

Dietary intake of trace elements, minerals, and vitamins of patients on chronic hemodialysis

PURPOSE

We aimed to estimate dietary intakes of trace elements, minerals, and vitamins in hemodialysis patients (HDP) of three centers in one metropolitan and two urban areas of Italy.

METHODS

Daily dietary intake was assessed using a 3-day diet diary in 128 HDP.

RESULTS

Mean daily intakes of trace elements were as follows: zinc, 7.6 ± 5.4 mg; copper, 14.3 ± 11.8 mg; selenium, 28.3 ± 18.1 μg; and iron, 7.2 ± 4.1 mg (7.8 ± 2.6 mg in women, 6.9 ± 2.4 mg in men). The distribution of patients by daily intakes of trace elements showed most were under the recommended values, with the exception of copper intake, which was much higher. Mean daily intakes of minerals were as follows: magnesium, 174.4 ± 94.3 mg; phosphorus, 842.6 ± 576.8 mg; calcium, 371.8 ± 363.7 mg; potassium, 1,616.2 ± 897.3 mg; and sodium, 1,350 ± 1,281 mg. Mean daily intakes of vitamins were as follows: vitamin A, 486.1 ± 544.6 μg; vitamin B1, 0.86 ± 0.7 mg; vitamin B2, 1.1 ± 0.7 mg; vitamin B3, 13.3 ± 8.1 mg; vitamin C, 47.8 ± 50.3 mg; and vitamin E, 9.5 ± 3.6 mg. The distribution of patients by daily intakes of vitamins showed most were under the recommended values. Daily intakes of trace elements and vitamins were similar among the three centers and did not differ between dialysis and non-dialysis days.

CONCLUSIONS

Many HDP have daily dietary intakes of trace elements and vitamins below the recommended values, whereas the intake of copper is much higher.

Histology and immunohistochemistry of the parathyroid glands in renal secondary hyperparathyroidism refractory to vitamin D or cinacalcet therapy

BACKGROUND

Cinacalcet is a new effective treatment of secondary hyperparathyroidism (SHPT) in hemodialysis patients (HP), but the alterations of parathyroid gland (PTG) hyperplasia determined by cinacalcet and vitamin D have not been extensively investigated in humans.

METHODS

We performed histological analyses of 94 PTGs removed from 25 HP who underwent parathyroidectomy (PTx) because of SHPT refractory to therapy with vitamin D alone (group A=13 HP and 46 PTGs) or associated with cinacalcet (group B=12 HP and 48 PTGs). The number, weight, the macroscopic cystic/hemorrhagic changes, and type of hyperplasia of PTG (nodular=NH, diffuse=DH) were assessed. In randomly selected HP of group A (4 HP and 14 PTGs) and group B (4 HP and 15 PTGs), the labeling index of cells positive to Ki-67 and TUNEL and the semiquantitative score of immunohistochemistry staining of vitamin D receptor, calcium-sensing receptor, and vascular endothelial growth factor-α (VEGF-α) were measured in the entire PTGs and in the areas with DH or NH.

RESULTS

The number and weight of single and total PTG of each HP were similar in the two groups as well as the number of PTG with macroscopic cystic/hemorrhagic areas. TUNEL, Ki-67, and VEGF-α scores were higher in NH than in DH areas.

CONCLUSION

This observational study of a highly selected population of HP, submitted to PTx because SHPT refractory to therapy, shows that the macroscopic, microscopic, and immunochemistry characteristics of PTG in HP who received or did not receive cinacalcet before PTx did not differ significantly.

P-selectin, E-selectin, and CD40L over time in chronic hemodialysis patients

The aim of this study was to measure P-selectin, E-selectin, and CD-4L levels over time in chronic hemodialysis (HD) patients. Thirty stable patients with end-stage renal failure undergoing chronic HD were included in the study. Blood samples were obtained before HD for measurement of P-selectin, E-selectin, and CD-40L. Measurements were performed at month 0 (T0), 3 (T2), 8 (T3), and 13 (T4). The levels of P-selectin, E-selectin, and CD40L were also analyzed according to the occurrence of cardiovascular disease (CVD) and to CVD-related mortality. The levels of CD40L and P-selectin changed significantly over time, decreasing at month 3 and 6 and returning at the T0 levels at month 13. Conversely, E-selectin levels did not. The levels of CD40L, P-selectin and E-selectin over time did not differ significantly between patients with age ≤ 65 or > 65 years, between patients with or without CVD, or between patients who died or who survived during the follow-up. In end-stage renal failure patients undergoing chronic HD, CD40L and P-selectin, but not E-selectin, showed a transient decrease over time, and the serum levels of these molecules were not associated with CVD or with CVD-related mortality.

Reactive oxygen metabolites (ROMs) are associated with cardiovascular disease in chronic hemodialysis patients

BACKGROUND

The aim of our study was to measure reactive oxygen metabolites (ROMs) in chronic hemodialysis (HD) patients and evaluate the possible association with cardiovascular disease (CVD) and mortality.

METHODS

We measured ROMs in 76 HD patients and correlated with CVD, cardiovascular (CV) events in the follow-up and all-cause and CVD-related mortality.

RESULTS

The levels of ROMs presented a median value of 270 (238.2-303.2) CARR U (interquartile range). We created a ROC curve (ROMs levels vs. CVD) and we identified a cut-off point of 273 CARR U. Patients with ROMs levels ≥273 CARR U were significantly older, had higher C-reactive protein levels and lower creatinine concentrations. The prevalence of CVD was higher in patients with ROMs levels ≥273 (87.1%) than in those with ROMs levels <273 CARR U (17.7%; p<0.0001). ROMs levels were significantly higher in patients with CVD (317±63.8) than in those without (242.7±49.1; p<0.0001). At multiple regression analysis, age, creatinine and C-reactive protein were independent factors associated with ROMs. At multiple logistic regression analysis the association between ROMs and CVD was independent (OR: 1.02, 95% CI: 1.00-1.05; p=0.03). Twenty six patients developed cardiovascular (CV) events during the follow-up. Of these, seven were in the group with ROMs levels <273 CARR U and 19 in the group with ROMs levels ≥273 CARR U. The logistic regression analysis showed that both age (OR: 1.06, 95% CI: 1.01-1.12; p=0.013) and ROMs levels (OR: 1.10, 95% CI: 1.00-1.02; p=0.045) were independently associated with CV events in the follow-up.

CONCLUSIONS

ROMs are independently associated with CVD and predict CV events in chronic HD patients.

Recurrent renal hyperparathyroidism due to parathyromatosis

Parathyromatosis is the most severe type of recurrent secondary hyperparathyroidism (SHPT) after parathyroidectomy (PTX) in haemodialysis patients. It is difficult to completely remove all foci of parathyroid tissue and neck re-explorations are often required. Here, we report for the first time a case of recurrent SHPT due to parathyromatosis treated by radio-guided PTX.

A haemodialysed 48-year-old woman with recurrent SHPT due to parathyromatosis was treated by radio-guided PTX. Preoperatively Ultrasonography, ⁹⁹Tc-SestaMIBI scintigraphy and magnetic resonances of the neck and thorax were performed. The preoperative imaging techniques detected four parathyroid nodules, while intraoperative gamma probe identified six nodules (three in atypical site). No frozen sections were performed during surgery. Post-operative intact parathyroid hormone levels were stabilized in the range 300–500 pg/mL during the 26 month follow-up by means of cinacalcet and paricalcitol therapy. In cases of parathyromatosis, the preoperative imaging techniques are inadequate, while intraoperative gamma probe is useful to detect the parathyroid tissue and allows a more extensive cytoreduction because it ensures the removal of undetectable and ectopic parathyroid foci. The operative time is reduced and frozen sections are unnecessary. However, the radio-guided PTX do not rule out parathyromatosis recurrence and complementary medical treatment is appropriate.

Fatigue in chronic dialysis patients

Fatigue is common in chronic hemodialysis (HD) patients and impacts on daily living, impairs significantly the quality of life, increases the risk of cardiovascular events and negatively influences survival. Although numerous social, demographic, clinical, and laboratory variables have been associated with fatigue, the causes of this symptom are often unclear. In the absence of an underlying, treatable disorder, the results of therapeutic intervention are typically frustrating. So far, none of the drugs tested can be recommended for preventing and treating fatigue in chronic HD patients. There is some evidence that exercise may significantly improve fatigue in dialysis patients; however, this requires confirmation through large, prospective, randomized studies.

[Ultrasound parameter-based response to treatment with new drugs for secondary hyperparathyroidism: a retrospective analysis in a single dialysis center]

In hemodialysis patients with secondary hyperparathyroidism (SHPT) ultrasonography of the parathyroid glands allows to assess the glandular growth and to define the limits of medical treatment. The present retrospective study evaluated the relationship between parathyroid gland hyperplasia and the effectiveness of new drugs. Fifty-three patients with SHPT (iPTH > 400 pg/mL) after treatment with oral calcitriol were included in the study. These patients underwent parathyroid ultrasonography and sequential therapy with intravenous calcitriol (first step), paracalcitol (second step), and paracalcitol + cinacalcet (third step). Patients with median PTH < 300 pg/mL during the period of therapy and follow-up were considered responders. The therapeutic response was correlated with ultrasound parameters (number of parathyroid glands, maximum longitudinal diameter, structural score, and vascular score). Four (10%) of 41 patients treated with IV calcitriol, 7 (27%) of 26 patients treated with paracalcitol, 7 (41%) of 17 patients treated with cinacalcet and paracalcitol, and 1 (20%) of 5 patients treated with cinacalcet alone were responders. ROC curve analysis showed that maximum longitudinal diameter (< 9 mm), number of parathyroid glands (< -1), structural score (< 2), and vascular score (< 2) predicted response to any treatment. New drugs (paracalcitol, cinacalcet) are more effective in SHPT than conventional ones. However, the traditional ultrasonographic cutoff for the efficacy of medical therapy remained unchanged. Thus parathyroid gland ultrasonography predicts the therapeutic response also to the new drugs.

Correlates of symptoms of depression and anxiety in chronic hemodialysis patients

OBJECTIVE

Little is known about the demographic, clinical and laboratory variables which may be correlated with symptoms of depression and anxiety in hemodialysis (HD) patients. The present study aimed at evaluating such correlation in HD patients treated at a single HD center in a Mediterranean country.

METHODS

Eighty HD patients were assessed for depression and anxiety with the Beck Depression Inventory (BDI) and the Hamilton Anxiety Rating Scale (HARS). The scores of BDI and HARS were correlated with demographic, clinical and laboratory variables.

RESULTS

Based on the Beck Depression Inventory, 38 patients had no symptoms of depression and 42 had symptoms of depression. Based on the HARS, three patients had no symptoms of anxiety and 38 had mild symptoms of anxiety, whereas moderate or severe symptoms of anxiety were present in 39 patients. In univariate analysis, BDI score correlated significantly with age, the Charlson Comorbidity Index, SF-36 Vitality Subscale, Mini-Mental Status Examination, creatinine, albumin, plasma 25-hydroxy vitamin D and interleukin-6 (IL-6) levels. HARS score correlated significantly with age, Charlson Comorbidity Index, SF-36 Vitality Subscale and parathyroid hormone (PTH) levels. In the multivariate analysis, a direct and an inverse correlation between BDI and IL-6 [P=.042, OR=1.31 (95% CI=1.01-1.71)] and creatinine [P=.050, OR=0.73 (95% CI=0.54-1.00)] was observed. With regard to HARS, only a direct correlation with Charlson Comorbidity Index [P<.001, OR=1.55 (95% CI=1.22-1.96)] was found.

CONCLUSION

Although numerous demographic, clinical and laboratory variables correlated with BDI and HARS in univariate analysis, the multivariate regression analysis showed only a direct correlation between BDI and IL-6 [P=.042, OR=1.31 (95% CI=1.01-1.71)] and an inverse correlation between BDI and creatinine [P=.050, OR=0.73 (95% CI=0.54-1.00)] and a direct correlation between HARS and the Charlson Comorbidity Index [P<.001, OR=1.55 (95% CI=1.22-1.96)].

Iron, zinc and aluminium ferritin content of hemodialysis hyperferritinemic patients: comparison with other hyperferritinemic clinical conditions and normoferritinemic blood donors

The present study describes the specific content of ferritin iron, zinc and aluminium in four different groups: 1) hemodialysis hyperferritinemic patients; 2) septic patients; 3) iron overloaded patients with hematologic diseases; and 4) blood donors. In all four groups high levels of aluminium and zinc were found in addition to those of iron. However, the sum of the ferritin ions of the control group is significantly higher than that of the other three groups. Furthermore, while ferritin of hemodialysis patients has the same molecular ratio of metal ions as control group (high Al content vs. Fe and Zn), a lower Al/Fe ratio is found both in septic and hematological patients. The results of the present paper might help to explain the high percentage of hyperferritinemia found in hemodialysis patients also in presence of low transferrin saturation and in absence of inflammatory markers. Moreover, the high content of ions other than iron in the ferritin core leads us to believe that ferritin is not only an iron storage protein but rather a regulator of redox active ions.

[Malnutrition in patients on chronic hemodialysis: prevalence, pathogenesis, and treatment]

Malnutrition is common in patients on hemodialysis and is a strong predicor of morbidity and mortality. Much progress has been made in recent years in identifying the causes and pathogenesis of malnutrition in hemodialysis patients as well as in recognizing the link between malnutrition and morbidity and mortality. Nevertheless, there is no consensus concerning its management. Conventional interventions such as nutritional counseling, oral nutritional supplements and intradialytic parenteral nutrition and novel preventive and therapeutic strategies such as appetite stimulants, growth hormone, androgenic anabolic steroids, and antiinflammatory drugs have been tested with contradictory and inconclusive results. Malnutrition still remains an important challenge for the nephrologist in the third millennium.

Body mass index and cardiovascular risk factors and biomarkers in hemodialysis patients

BACKGROUND

Being overweight and obesity are associated with improved survival in hemodialysis (HD) patients, based on mechanisms that are presently uncertain. We compared traditional and uremia-related cardiovascular risk factors in HD patients stratified according to their body mass index (BMI).

METHODS

One hundred sixteen HD patients were stratified into 4 groups according to the BMI: underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9) and obese (> or =30). Blood samples were obtained before the HD session to measure serum albumin, high-sensitivity C-reactive protein, fibrinogen, ferritin, total cholesterol, LDL cholesterol, HDL cholesterol, apolipoprotein A-I and apolipoprotein B-100, apolipoprotein B (apoB) to apolipoprotein A (apoA) ratio and Lp(a) lipoprotein.

RESULTS

There were 3 underweight (excluded from the analysis), 58 normal weight, 35 overweight and 20 obese patients. Their mean age was 62.1 +/- 14.1 years. There were 68 men and 45 women. Mean dialytic age was 5.32 +/- 3.2 years. The mean BMI of the study population was 25.2 +/- 4.1. The prevalence of smoking habit was similar in the 3 groups (17.2%, 8.5% and 25%, respectively; p=0.28). The prevalence of hypertension was higher in overweight (77.1%) and obese (65%) patients than in leaner counterparts (53.4%), although the difference was not significant. Conversely, diabetes prevalence was significantly higher in overweight and obese patients (22.8% and 30%, respectively) than in normal weight patients (6.9%; p=0.02). The serum levels of total cholesterol, HDL cholesterol, LDL cholesterol, Lp(a) lipoprotein, apolipoprotein A-I, apolipoprotein B-100, and apoA/apoB ratio were similar in the 3 BMI groups. Triglycerides levels were significantly higher in obese (221.2 +/- 132.7 mg/dL) and overweight (230.5 +/- 119.3 mg/dL) patients than in those of normal weight (154.6 +/- 78.8 mg/dL; p=0.02). Most of the uremia-related cardiovascular risk factors (anemia, hyperparathyroidism, chronic inflammation) were comparable among BMI categories as well as the levels of C-reactive protein, fibrinogen and ferritin.

CONCLUSION

The present study suggests that almost all traditional and uremia-related cardiovascular risk factors do not differ significantly among different categories of BMI in hemodialysis patients.

Ultrasound patterns of parathyroid glands in chronic hemodialysis patients with secondary hyperparathyroidism

BACKGROUND

The role ofparathyroid glands (PTG) ultrasonography (US) in hemodialysis patients with secondary hyperparathyroidism (SHPT) is still controversial. The present study aimed at evaluating the relationship between US findings and SHPT degree as well as therapeutic outcome.

METHODS

Twenty hemodialysis patients with moderate SHPT and 15 with severe SHPT underwent US to assess the PTG number, maximum longitudinal diameter (MLD), structural (1-hypoechoic, 2-slight heterogeneous, 3-high heterogeneous, 4-nodular) and vascular patterns (1-slight, 2-medium and 3-high).

RESULTS

PTG number, MLD and US patterns were correlated with iPTH levels. MLD of patients with moderate or severe SHPT was 7.2 +/- 2.3 and 15 +/- 5.1 mm (p < 0.001). Most patients with moderate SHPT showed a single PTG with an MLD <9 mm associated with 1-2 structural and vascular pattern, whereas patients with severe SHPT exhibited more than one PTG with MLD >9 mm and 3-4 structural and vascular patterns. Thirteen patients were responders to treatment and 22 nonresponders. In nonresponders, a higher number of PTG was observed as well as higher echostructural and vascular patterns. In 14 patients who underwent parathyroidectomy, no differences were found between PTG US MLD and pathology diameter. All PTG with evidence of 3-4 structural and vascular score at ultrasound showed nodular hyperplasia at pathological examination.

CONCLUSIONS

The adopted classification of US findings is correlated with SHPT degree and therapeutic outcome and might be an adjunctive predictive method useful to assess the SHPT severity and to plan the therapeutic strategy.

Serum albumin, body weight and inflammatory parameters in chronic hemodialysis patients: a three-year longitudinal study

BACKGROUNDS AND AIMS

The present study aimed at making prospective longitudinal measurements of nutritional and inflammatory parameters to determine whether nutritional and inflammatory status decline or increase over time in a cohort of prevalent hemodialysis patients, and to evaluate which factors influence eventual changes.

PATIENTS

64 hemodialysis patients were followed at 0, 3, 6, 9, 12, 15, 18, 21, 24, 27, 30, 33, and 36 months. At each follow-up visit, dry body weight, serum albumin, serum total cholesterol, total white blood cells, total lymphocyte count, serum glucose, C-reactive protein, ferritin, fibrinogen, hemoglobin, and weekly erythropoietin dose were assessed.

MAIN OUTCOME MEASURES

Changes in nutritional and inflammatory parameters over time.

RESULTS

43 patients completed the study at 36 months. Mean serum albumin levels (g/dl) improved significantly between baseline (3.76 +/- 0.24) and 36 months (3.93 +/- 0.27) (F = 4.005; p = 0.0009). Dialytic age was significantly associated with changes of serum albumin (F = 2.797; p = 0.028). The mean dry weight slightly remained stable over time (F = 1.473; p = 1.0) as well as the level of total cholesterol (p = 0.77) and lymphocyte count (F = 1.539; p = 0.186). Over time, the levels of C-reactive protein tended to decrease, although the differences were not statistically significant (F = 1.332; p = 0.19). Over time, the serum level of fibrinogen (F = 0.422; p = 0.17) and ferritin (F = 0.314; p = 0.52) remained stable. The number of white blood cells significantly decreased over time (F = 4.691; p = 0.0079) and dialytic age (F = 3.214; p = 0.015) was the variable significantly associated with such decline. The hemoglobin levels (F = 1.423; p = 0.14) and the weekly erythropoietin dose did not change significantly during the study (F = 1.019; p = 0.61), nor did the serum glucose levels (F = 1.231; p = 0.10).

CONCLUSION

These results support the hypothesis that end-stage renal disease and HD are not necessarily associated with deterioration of the nutritional status over time.

[Extraskeletal retroperitoneal osteosarcoma. A case report and review of the literature]

Extraskeletal osteosarcomas, localized in the retroperitoneal space, are very rare neoplasms (only 200 cases have been described); the case indicated is the second one observed in Literature. The extraskeletal osteosarcomas are very malignant mesenchymal neoplasms reproducing osseous and cartilaginous tissue disconnected from the skeletal system. From a histological point of view, the extraskeletal osteosarcomas are constituted of osseous and cartilaginous tissue with osteo-fibro-chondroblastic cells: the different representation of three types of cells define the variety of extraskeletal osteosarcomas (osteoblastic, chondroblastic, fibroblastic). Histological and ultrastructural study failed to find differences between skeletal and extraskeletal osteosarcomas. In the clinical history of some patients traumas or irradiation has been referred; although extraskeletal osteosarcomas etiology is frequently unknown. Diagnosis is generally delayed because symptoms are often absent of uncertain. Prognosis of these neoplasms is always very poor, and specially in relation to the dimension and to the possibility of its radical removal. All patients died until 2-3 years after surgery.

[Endobronchial lipoma: endoscopic resection or surgical excision? Report of a case and review of the literature]

The Authors report a case of endobronchial lipoma, a rare, benign lung lesion. Literature data show that a correct preoperative diagnosis of nature is possible in less than 50% of all the cases and a thoracotomy is mandatory in 85% of the patients because FNAB or brushing rarely allow a certain cytological diagnosis. When a benign tumor is suspected, an endobronchial resection is the treatment of choice, allowing a correct histological diagnosis and in the same time a definitive therapy with resolution of symptoms. Surgical option is reserved for the not certainly determined benign or malignant lesions.

[The sternotomy and thoracotomy approaches in the treatment of differentiated thyroid cancer in an advanced phase]

The authors report their experience in the treatment of well-differentiated thyroid cancer. The analysis of 5 cases treated with extensive surgery give the opportunity to discuss about the use of sternotomy or thoracotomy to eradicate mediastinal lymph nodes. The importance of preoperative assessment, especially by histological examination is stressed as well as the role of surgery in the multidisciplinary approach for the treatment of the disease.

[Diagnosis and treatment of hepatic echinococcosis with fistulas of the major bile ducts]

The authors report their experience of secondary major biliary fistula (MBF) for hepatic echinococcosis. The analysis of the results of the surgical treatments showed that "conservative" operations have major mortality than "radical" operations. The importance of an exact preoperative diagnosis of presence, side and size of MBF, in order to a correct choice of the most suitable operations, is underlined. Endoscopic retrograde cholangio-pancreatography seems to be a reliable diagnostical technique, also if compared with traditional methods (U.S., C.T.).

Lumbar chemical sympathectomy in end stage of arterial disease: early and late results

Hemodynamic variables were used to evaluate the effectiveness of lumbar chemical sympathectomy in 20 patients with ischemic foot lesions. Early clinical improvement was obtained in 68% of the cases. The two-year cumulative limb salvage rate was 52%. Results indicate that lumbar chemical sympathectomy offers the same benefits as surgical sympathectomy and represents a useful alternative in patients with advanced ischemic disease of the lower limb, decreasing the rate and the level of amputations.

[Radiological diagnosis of constipation and anal incontinence caused by changes in the pelvic floor and anal sphincter. Our experience with 38 patients with constipation with or without incontinence]

Rectal constipation, anal incontinence and constipation combined with incontinence, are often caused by organic or simply functional changes in the pelvic floor and sphincteric apparatus. Therefore morphological as well as manometric and electromyographic studies of these anatomical parts are required. This is possible by combining two techniques: Intestinal Transit Time (ITT) and Defecatory Proctogram with Balloon (DPB). Personal experience of 38 patients with constipation with or without incontinence is reported. The results lead to the following conclusions: 1) ITT is a simple and non-invasive radiological technique that provides us with objective evidence of an impairment, i.e. constipation, whose symptoms are often only subjective; especially it allows us to identify rectal constipation, that can be caused by impairment of the anal sphincteric apparatus. 2) Using an uroprophylactic with a collar that adapts to the size of the anal duct, DPB always permits visualisation of the duct with good representation of the recto-anal angle, whose changes may be the expression of organic or only functional impairments of the anal sphincteric apparatus. Increasing use of the two radiological techniques is therefore recommended in the diagnosis of alterations of the pelvic floor or anal sphincter.

Clinical picture and pelvic floor physiology in the solitary rectal ulcer syndrome

Clinical examination, proctosigmoidoscopy, rectal biopsies, barium enema and pelvic floor physiology studies were performed in four patients with solitary rectal ulcer syndrome. All patients had chronic constipation and rectal bleeding. Resting tone and voluntary contraction were found to be decreased at anal manometry in two patients (maximal squeeze pressures were ten and 35 mm Hg, respectively). Balloon proctogram showed an increased rectoanal angle in these two patients (90 degrees and 93 degrees at rest, unchanged on squeezing) with a poor striated sphincter function at EMG; their deficient anal reflex, slight fecal incontinence and perineal descent seemed consistent with pudendal neuropathy. Fibromuscular obliteration of the lamina propria was found at histology. All subjects had successful conservative treatment, including topical corticosteroids in one patient; normalization of bowel habit was the most effective therapy for the disease. The present study seems to confirm the role of chronic constipation and abnormal pelvic floor physiology in the pathogenesis of the syndrome.

Some parameters of descending inhibition during colonic propulsion

Isolated segments of rabbit distal colon were stimulated by distension of intraluminal balloons, with the aim of investigating the electrophysiological pattern of descending inhibition (DI) during the peristaltic reflex. Incidence, duration, and latency of DI were studied by varying the parameters of stimulation. A linear correlation was found between stimulus duration and DI duration for stimuli up to 10 s long. DI duration increased with the distance of the recording site from the stimulus up to 3 cm. A more complex relation was found between balloon volume and DI duration. Propagation velocity decreased with the distance from the stimulus. The relation between ascending excitation and DI was also studied: ascending excitation could always be suppressed by DI. DI was examined after addition of anticholinergics, ganglionic blocking agents, and tetrodotoxin to the organ bath. The results show that DI parameters are partially related to the stimulus characteristics and that propagation of DI is neurally mediated through nonadrenergic inhibitory nerves.