Immune responses of patients on maintenance hemodialysis after infection by SARS-CoV-2: a prospective observational cohort study

BACKGROUND

Immune dysregulation in patients with acute COVID-19 under chronic hemodialysis (CHD) is fully not elucidated. The changes of mononuclear counts and mediators before and after HD and associations with final outcome were studied.

METHOD

In this prospective study, hospitalized patients with moderate-to-severe COVID-19 under CHD and matched comparators under HD were analyzed for their absolute counts of lymphoid cells and circulating inflammatory mediators. Blood samples were collected before start and at the end of the first HD session; dialysate samples were also collected.

RESULT

Fifty-nine patients with acute COVID-19 under CHD and 20 uninfected comparators under CHD were enrolled. Circulating concentrations of tumor necrosis factor-alpha (TNFα), interleukin (IL)-10, interferon-γ and platelet-derived growth factor-A were increased in patients. Concentrations of mediators did not differ before and after HD. Significant decreases of CD4-lymphocytes and CD19-lymphocytes were found in patients. The decrease of the expression of HLA-DR on CD14-monocytes was associated with unfavorable outcome (defined as WHO-CPS 6 or more by day 28); increased counts of CD19-lymphocytes were associated with better outcomes.

CONCLUSION

Patients under CHD develop an inflammatory reaction to SARS-CoV-2 characterized by increase of inflammatory mediators, decrease of circulating T-lymphocytes and decrease of the expression of HLA-DR on CD14-monocytes.

Lower serum magnesium is a predictor of left ventricular hypertrophy in patients on dialysis

PURPOSE

Left ventricular hypertrophy (LVH) represents one of the main risk factors for cardiovascular mortality in dialysis patients. Low serum magnesium Mg is related with increased mortality in general and dialysis population. Aim of our study was to evaluate the association of Mg with LVH and cardiac geometry in dialysis patients.

METHODS

Hemodialysis (HD) and peritoneal dialysis (PD) patients from nine nephrology departments were included. Echocardiographic LVH was defined by LV mass index > 95 g/m² in women and > 115 g/m² in men. Four LV geometric patterns were defined: normal, concentric remodeling, eccentric LVH and concentric LVH. Demographic and laboratory data were collected.

RESULTS

133 patients (68 HD, 65 PD) with a median age of 63 years (IQR 52-74) were studied. Mg correlated positively with creatinine, HDL and negatively with CRP levels and BMI. There were no significant differences in Mg between the modality groups. 80 patients presented LVH (43 HD and 37 PD patients). Patients with LVH were older (median age 68 vs 55 years, p < 0.001), with higher BMI (median 26.9 vs 24.7 kg/m², p = 0.009), had a history of PVD or CAD (55% vs 30.2%, p = 0.003), had higher pulse pressure (median 60 vs 50, p = 0.017), MIS score (median 5 vs 4, p = 0.011), lower albumin (median 3.5 vs 3.8 g/dl, p = 0.011) and Mg levels (median 2.1 vs 2.4 mg/dl, p < 0.001). In univariate analysis age, CVD comorbidities, pulse pressure, CRP, BMI, albumin, Mg, MIS and use of b-blockers or calcium blockers were LVH predictors. In multivariate analysis, Mg was an independent predictor of LVH, adjusted for age, MIS and b-blockers. Considering LV geometry, lower Mg levels were mainly correlated with concentric LVH.

CONCLUSION

Low serum magnesium levels seem to be an independent factor for LVH in hemodialysis and peritoneal dialysis patients.

Redefying the therapeutic strategies against cardiorenal morbidity and mortality: Patient phenotypes

Chronic kidney disease (CKD) patients face an unacceptably high morbidity and mortality, mainly from cardiovascular diseases. Diabetes mellitus, arterial hypertension and dyslipidemia are highly prevalent in CKD patients. Established therapeutic protocols for the treatment of diabetes mellitus, arterial hypertension, and dyslipidemia are not as effective in CKD patients as in the general population. The role of non-traditional risk factors (RF) has gained interest in the last decades. These entail the deranged clinical spectrum of secondary hyperparathyroidism involving vascular and valvular calcification, under the term “CKD-mineral and bone disorder” (CKD-MBD), uremia per se, inflammation and oxidative stress. Each one of these non-traditional RF have been addressed in various study designs, but the results do not exhibit any applied clinical benefit for CKD-patients. The “crusade” against cardiorenal morbidity and mortality in CKD-patients is in some instances, derailed. We propose a therapeutic paradigm advancing from isolated treatment targets, as practiced today, to precision medicine involving patient phenotypes with distinct underlying pathophysiology. In this regard we propose two steps, based on current stratification management of corona virus disease-19 and sepsis. First, select patients who are expected to have a high mortality, i.e., a prognostic enrichment. Second, select patients who are likely to respond to a specific therapy, i.e., a predictive enrichment.

Adherence to the Mediterranean Diet Is Associated with a More Favorable Left Ventricular Geometry in Patients with End-Stage Kidney Disease

Introduction. The aim of the study was to examine the impact of adherence to a Mediterranean-style diet (MD) on left ventricular hypertrophy (LVH) and cardiac geometry in chronic kidney disease patients on dialysis (CKD-5D), given the high prevalence of cardiovascular morbidity in this population. Methods. n = 127 (77 men and 50 women) CKD-5D patients (69 on hemodialysis and 58 on peritoneal dialysis) with a mean age of 62 ± 15 years were studied. An MD adherence score (MDS) (range 0−55, 55 representing maximal adherence) was estimated with a validated method. Echocardiographic LVH was defined by LV mass index (LVMI) > 95 g/m2 in women and >115 g/m2 in men. Based on LVMI and relative wall thickness (RWT), four LV geometric patterns were defined: normal (normal LVMI and RWT), concentric remodeling (normal LVMI and increased RWT > 0.42), eccentric LVH (increased LVMI and normal RWT), and concentric LVH (increased LVMI and RWT). Results. Patients with LVH (n = 81) as compared to patients with no LVH (n = 46) were older in age (66 ± 13 vs. 55 ± 16 years; p < 0.001) had lower MDS (24 ± 2.7 vs. 25 ± 4.3; p < 0.05) and higher malnutrition-inflammation score (5.0 ± 2.7 vs. 3.9 ± 1.9; p < 0.05), body mass index (27.5 ± 4.9 vs. 24.1 ± 3.5 kg/m2; p < 0.001), prevalence of diabetes (79% vs. 20%; p < 0.05), coronary artery disease (78% vs. 20%; p < 0.05) and peripheral vascular disease (78% vs. 20%; p < 0.01). In a multivariate logistic regression analysis adjusted for all factors mentioned above, each 1-point greater MDS was associated with 18% lower odds of having LVH (OR = 0.82, 95% CI: 0.69−0.98; p < 0.05). MDS was inversely related to LVMI (r = −0.273; p = 0.02), and in a multiple linear regression model (where LVMI was analyzed as a continuous variable), MDS emerged as a significant (Β = −2.217; p < 0.01) independent predictor of LVH. Considering LV geometry, there was a progressive decrease in MDS from the normal group (25.0 ± 3.7) to concentric remodeling (25.8 ± 3.0), eccentric (24.0 ± 2.8), and then concentric (23.6 ± 2.7) group (p < 0.05 for the trend). Conclusions. The greater adherence to an MD is associated with lesser LVH, an important cardiovascular disease risk factor; MD preserves normal cardiac geometry and may confer protection against future cardiac dysfunction in dialysis patients.

COVID-19 presenting with persistent hiccup and myocardial infarction in a peritoneal dialysis patient: A case report

BACKGROUND

Persistent hiccups, lasting more than 48 h, have been described as an atypical presentation of coronavirus disease 19 (COVID-19) in the general population. To the best of our knowledge, this is the first report of persistent hiccups and non-ST elevation myocardial injury (NSTEMI) as an atypical presentation of COVID-19 in a peritoneal dialysis (PD) patient.

CASE SUMMARY

A 70-year old man, who had been on PD for 3 years with a history of ischemic heart failure and reduced ejection fraction, presented for a scheduled radionuclide myocardial scan. Upon arrival, he complained of anorexia, nausea for 5 d, and unremitting hiccups for the previous 48 h. Clinical and laboratory examinations revealed an NSTEMI plus a positive nasopharyngeal reverse transcriptase polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2. COVID-19 lung involvement was mild and was resolved without specific treatment. Myocardial injury was managed by coronary catheterization and stenting, while hiccups responded only to baclofen per os.

CONCLUSION

Persistent hiccups and NSTEMI can be atypical presentations of COVID-19 in peritoneal dialysis patients, which may be due to involvement of the central nervous system and myocardial injuries.

Clinical presentation and outcomes of chronic dialysis patients with COVID-19: A single center experience from Greece

BACKGROUND

Coronavirus disease 2019 (COVID-19) is still a menacing pandemic, especially in vulnerable patients. Morbidity and mortality from COVID-19 in maintenance hemodialysis (MHD) patients are considered worse than those in the general population, but vary across continents and countries in Europe.

AIM

To describe the clinical course and outcomes of hospitalized MHD patients with COVID-19 in a retrospective observational single center study in Greece.

METHODS

We correlated clinical, laboratory, and radiological data with the clinical outcomes of MHD patients hospitalized with COVID-19 during the pandemic. The diagnosis was confirmed by real-time polymerase chain reaction. Outcome was determined as survivors vs non-survivors and “progressors” (those requiring oxygen supplementation because of COVID-19 pneumonia worsening) vs “non-progressors”.

RESULTS

We studied 32 patients (17 males), with a median age of 75.5 (IQR: 58.5-82) years old. Of those, 12 were diagnosed upon screening and 20 with related symptoms. According to the World Health Organization (WHO) score, the severity on admission was mild disease in 16, moderate in 13, and severe in 3 cases. Chest computed tomography (CT) showed 1-10% infiltrates in 24 patients. Thirteen “progressors” were recorded among included patients. The case fatality rate was 5/32 (15.6%). Three deaths occurred among “progressors” and two in “non-progressors”, irrespective of co-morbidities and gender. Predictors of mortality on admission included frailty index, chest CT findings, WHO severity score, and thereafter the increasing values of serum LDH and D-dimers and decreasing serum albumin. Predictors of becoming a “progressor” included increasing number of neutrophils and neutrophils/lymphocytes ratio.

CONCLUSION

Patients on MHD seem to be at higher risk of COVID-19 mortality, distinct from the general population. Certain laboratory parameters on admission and during follow-up may be helpful in risk stratification and management of patients.

Validation of the International IgA Nephropathy Prediction Tool in the Greek Registry of IgA Nephropathy

Background

Immunoglobulin A nephropathy (IgAN) is among the commonest glomerulonephritides in Greece and an important cause of end-stage kidney disease (ESKD) with an insidious chronic course. Thus, the recently published International IgAN prediction tool could potentially provide valuable risk stratification and guide the appropriate treatment module. This study aimed to externally validate this prediction tool using a patient cohort from the IgAN registry of the Greek Society of Nephrology.

Methods

We validated the predictive performance of the two full models (with or without race) derived from the International IgAN Prediction Tool study in the Greek Society of Nephrology registry of patients with IgAN using external validation of survival prediction models (Royston and Altman). The discrimination and calibration of the models were tested using the C-statistics and stratified analysis, coefficient of determination (RD2) for model fit, and the regression coefficient of the linear predictor (β_PI), respectively.

Results

The study included 264 patients with a median age of 39 (30–51) years where 65.2% are men. All patients were of Caucasian origin. The 5-year risk of the primary outcome (50% reduction in estimated glomerular filtration rate or ESKD) was 8%. The RD2 for the full models with and without race when applied to our cohort was 39 and 35%, respectively, and both were higher than the reported RD2 for the models applied to the original validation cohorts (26.3, 25.3, and 35.3%, respectively). Harrel's C statistic for the full model with race was 0.71, and for the model without race was 0.70. Renal survival curves in the subgroups (<16th, ~16 to <50th, ~50 to <84th, and >84th percentiles of linear predictor) showed adequate separation. However, the calibration proved not to be acceptable for both the models, and the risk probability was overestimated by the model.

Conclusions

The two full models with or without race were shown to accurately distinguish the highest and higher risk patients from patients with low and intermediate risk for disease progression in the Greek registry of IgAN.

Case Report of Cardiorenal Syndrome with Ascites and Listeria monocytogenes Peritonitis: The Role of Large-Volume Paracentesis and Albumin Replacement

Patient: Female, 77-year-old

Final Diagnosis: Cardiorenal syndrome • Listeria monocytogenes infection • spontaneous bacterial peritonitis

Symptoms: Abdominal distension • fever

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases • Nephrology

Siblings with coronavirus disease 2019 infection and opposite outcome—the hemodialysis’s better outcome paradox: Two case reports

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a highly contagious infection caused by the severe acute respiratory syndrome coronavirus 2 virus and has a unique underlying pathogenesis. Hemodialysis (HD) patients experience high risk of contamination with COVID-19 and are considered to have higher mortality rates than the general population by most but not all clinical series. We aim to highlight the peculiarities in the immune state of HD patients, who seem to have both immune-activation and immune-depression affecting their outcome in COVID-19 infection.

CASE SUMMARY

We report the opposite clinical outcomes (nearly asymptomatic course vs death) of two diabetic elderly patients infected simultaneously by COVID-19, one being on chronic HD and the other with normal renal function. They were both admitted in our hospital with COVID-19 symptoms and received the same treatment by protocol. The non-HD sibling deteriorated rapidly and was intubated and transferred to the Intensive Care Unit, where he died despite all supportive care. The HD sibling, although considered more “high-risk” for adverse outcome, followed a benign course and left the hospital alive and well.

CONCLUSION

These cases may shed light on aspects of the immune responses to COVID-19 between HD and non-HD patients and stimulate further research in pathophysiology and treatment of this dreadful disease.

Emperor's syndrome in the COVID-19 era: Time for patient-centered nephrology?

The coronavirus disease-19 (COVID-19) pandemic has been a wake-up call in which has forced us to react worldwide. Health policies and practices have attracted particular attention in terms of human and financial cost. Before COVID-19, chronic kidney disease was already considered a risk multiplier in patients with diabetes and hypertension, the two now being the major risk factors for COVID-19 infection and adverse outcome. In contrast to the urgent need for action, the nephrology field is considered to be in a state of stagnation regarding the management of chronic kidney disease patients who still experience unacceptably high morbidity and mortality. Ironically and paradoxically in a field lacking robust clinical trials, clinical practice is driven by guidelines-based medicine on weak evidence. The Emperor's syndrome, referring to Hans Christian Andersen's fairy tale, has been described in medicine as voluntary blindness to an obvious truth, being a weak evidence-based therapeutic intervention or weak health care. A promising positive example of improving heart and kidney outcomes is the emerging treatment with sodium-glucose cotransporter 2 inhibitors. COVID-19 could boost actions for patient-centered care as a positive shift in nephrology care.

P1168ABDOMINAL AORTIC CALCIFICATION SCORE MODIFIES THE PROGNOSTIC VALUE OF SERUM MAGNESIUM LEVELS ON ALL CAUSE MORTALITY IN PERITONEAL DIALYSIS PATIENTS

Background and Aims

Low serum Mg (s-Mg) concentration has been associated with an increased risk of death in both the general and dialysis populations. In peritoneal dialysis (PD) patients, an inverse correlation between s-Mg and abdominal aortic calcification (AAC), estimated by plain lateral lumbar x-rays, as Leena Kauppila (LK) score (range 0-24), is well documented. LK score of 0-4 has been associated with the best event free survival (CORD study CJASN 2011). Here, we explored the possibility whether AAC could modify the relationship between s-Mg and all-cause mortality in PD patients.

Method

We studied 95 stable PD patients, 51 men 44 women, with a mean age of 63 ±14 years. The degree of AAC was evaluated with on plain lateral abdominal radiographs, as LK score. After completion of baseline assessment, including s-Mg measurements, patients were followed up for all-cause mortality.

Results

The mean of s-Mg and AAC in the whole group were 2.25±0.47 mg/dl and 6.65 ± 5.94 respectively. There was an strong inverse correlation (rho = -0.225; p=0.029) between s-Mg and AAC. During a median follow-up period of 23 months, 16 (17%) deaths occurred. There was a 78% reduction of all-cause mortality for every 1 mg/dl of increase in s-Mg {crude HR: 0.22 (95% CI, 0.06 - 0.78)}. An interacting effect between s-Mg and AAC was significant (p=0.005) after controlling for main effects. Then, the association between s-Mg and all-cause mortality by subgroups of AAC: higher tertile vs all lower, was examined (cut-offs of the tertiles for AAC were 3 and 9). In patients grouped in the lower tertiles, s-Mg was a significant predictor of all-cause mortality, even after adjustment for univariate significant predictors of all-cause mortality: age, cardiovascular disease, PD vintage and malnutrition-inflammation score (MIS) {adjusted HR: 0.14 (95% CI, 0.02-0.0.98)}. On the contrary, patients with AAC in the higher tertile of the baseline distribution, s-Mg levels were not predictive of outcome in either crude or the adjusted models.

Conclusion

The predictive value of s-Mg in all-cause mortality in PD patients appears to be critically dependent on AAC score. Thus, sustaining higher sMg levels, as by using higher Mg dialysate concentration, may have beneficial effects on clinical outcomes only in patients without AAC or at least in those with early lesion development.

Competing Effects of Renin Angiotensin System Blockade and Sodium-Glucose Cotransporter-2 Inhibitors on Erythropoietin Secretion in Diabetes

BACKGROUND

Anaemia is a common finding in diabetes, particularly in those patients with albuminuria or renal dysfunction and is associated with impaired erythropoietin (EPO) secretion. This review focuses on mechanisms involved in the regulation of erythropoiesis in diabetic patients in an effort to elucidate the competing effects of the renin angiotensin system (RAS) blockade and sodium-glucose cotransporter-2 (SGLT2) inhibitors on haemoglobin concentration and hematocrit values.

SUMMARY

The RAS shows significant activation in diabetic subjects. Angiotensin II, its active octapeptide, causes renal tubulointerstitial hypoxia, which stimulates hypoxia-inducible factors (HIF) and increases EPO secretion and erythropoiesis. As expected, drugs that inactivate RAS, such as angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEi/ARB) are associated with a significant hematocrit-lowering effect and/or anaemia in various clinical conditions, including diabetes. Dual blockade by a combination of ACEi and ARB in diabetic patients achieves a better RAS inhibition, but at the same time a worse drop of haemoglobin concentration. Increased glucose reabsorption by SGLTs in diabetic subjects generates a high-glucose environment in renal tubulointerstitium, which may impair HIF-1, damage renal erythropoietin-producing cells (REPs) and decrease EPO secretion and erythropoiesis. SGLT2 inhibitors, which inhibit glucose reabsorption, may attenuate glucotoxicity in renal tubulointerstitium, allowing REPs to resume their function and increase EPO secretion. Indeed, EPO levels increase within a few weeks after initiation of therapy with all known SGLT2 inhibitors, followed by increased reticulocyte count and a gradual elevation of haemoglobin concentration and hematocrit level, which reach zenith values after 2-3 months. Key Messages: The competing effects of RAS blockade and SGLT2 inhibitors on erythropoiesis may have important clinical implications. The rise of hematocrit values by SGLT2 inhibitors given on top of RAS blockade in recent outcome trials may significantly contribute to the cardiorenal protection attained. The relative contribution of each system to erythropoiesis and outcome remains to be revealed in future studies.

Anemia due to coadministration of renin-angiotensin-system inhibitors and PPARγ agonists in uncomplicated diabetic patients

Therapy with either angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARB) or thiazolidinediones (TZD) is associated with dose-dependent decrements in hematocrit and hemoglobin levels. We aimed to investigate the impact of the coadministration of TZD and ACEI/ARB on hematocrit and hemoglobin values in uncomplicated patients with type 2 diabetes mellitus and normal serum creatinine.Data from patients with type 2 diabetes currently followed, were reviewed and patients treated with ACEI/ARB and/or TZD were identified. For the purpose of this study the following 4 groups of 30 stable non-anemic diabetic patients each matched for age, gender, and BMI were formed. Group ACEI/ARB included patients on ACEI/ARB without TZD, group TZD included patients on TZD and antihypertensive agents other than ACEI/ARB, group ACEI/ARB/TZD consisted of patients on combined therapy with ACEI/ARB and TZD and the control group C included patients never exposed to ACEI/ARB or TZD. Clinical and laboratory data were collected prior to initiation of treatment and after 6 months.Neither hematocrit nor hemoglobin showed any significant change from baseline at the end of the study in group C. In both group ACEI/ARB and group TZD a small, but statistically significant reduction in hematocrit (~ 1% point) and hemoglobin levels (~ 0.3 g/dl) was seen. A greater statistically and clinically important reduction in hematocrit (~ 3% points) and hemoglobin (~ 1 g/dl) levels was observed in group ACEI/ARB/TZD. Furthermore, incident anemia at the end reached 7% in group TZD and 23% in group ACEI/ARB/TZD.Coadministration of RAS inhibitors and PPAR-γ agonists should be considered in the differential diagnosis of hematocrit lowering and anemia in uncomplicated type 2 diabetic patients with normal serum creatinine. Further studies are required to clarify the mechanism(s), the cardiovascular consequences and the cost utility of anemia workup in such patients.

Comparative in vitro study of different peritoneal dialysis solutions on cytokine production by peripheral blood mononuclear cells

BACKGROUND/AIMS

Peritoneal dialysis solutions (PDS), new and conventional, do not yet have a clinical biocompatibility profile. We aimed at a comparative laboratory profile based on the effect of PDS on peripheral blood mononuclear cell (PBMC) cytokine release.

METHOD

PBMCs from 19 healthy volunteers were incubated at a concentration of 10(6)/ml in fresh PDS and control medium (RPMI 1640), and stimulated or not with 10 microg/ml Escherichia coli lipopolysaccharide. The tested PDS were glucose/lactate 1.5 and 4.25%, glucose/pyruvate 1.0 and 4.0%, icodextrin and amino acid solutions. The initial incubation in culture flasks for 15 min was followed by 1:1 dilution with RPMI and by additional incubation for 22 h as a 'recovery period'. At the end, the supernatants were tested for cytokines IL-6 and TNFalpha by ELISA.

RESULTS

The hypertonic glucose solutions, irrespective of the buffer, had the most adverse effect on PBMC cytokine release. The icodextrin and amino acid solutions seemed close to the isotonic glucose PDS. The substitution of pyruvate for lactate buffer seemed to offer an advantage only for the hypertonic glucose-based solutions.

CONCLUSIONS

Icodextrin and amino acid solutions seem to offer an advantage only compared to hypertonic glucose PDS.

Combined treatment with low-dose pravastatin and fish oil in post-renal transplantation dislipidemia

BACKGROUND

The most common cause of post-transplant dyslipidemia is the use of corticosteroids and cyclosporin-A (CyA). The HMG-CoA reductase inhibitors have emerged as the agents of first choice in the treatment of post-transplant hyperlipidemia in combination with low fat diet. The objective of this study was to evaluate the efficacy of combined treatment with low-dose pravastatin and fish oil in post-renal transplantation dislipidemia.

PATIENTS AND METHODS

Twenty-four renal transplant patients, 15 men and 9 women aged from 30 to 60 years with stable renal function were included in this study. All patients were transplanted from living related donors and were given a stable triple immunosuppressive therapy, with methylprednisolone, azathioprine and CyA. All patients were also given a standard diet containing 1 g/kg BW protein, reducing the daily fat to less than 30%, and maintaining at least a 1:1 ratio of saturated to polyunsaturated (or monounsaturated) fats. A dosage of 20 mg pravastatin (pravachol) and 1 g of fish oil (prolipid) were added to the diet after dinner, according to our protocol. Blood samples were taken after each study period for total cholesterol, LDL-cholesterol, triglycerides, Apo A(1), Apo B, Lp(a), creatinine, CPK and fibrinogen determination.

RESULTS

At the end of the therapeutic protocol with pravastatin a significant reduction (p < 0.02) of total and LDL-cholesterol was observed, but no significant change in triglycerides, HDL, Lp(a), Apo A(1), Apo B and fibrinogen was shown. At the end of the therapeutic protocol with pravastatin and fish oil supplement significant changes were seen in TC (p < 0.02), TG (p < 0.03), LDL-C (p < 0.03), Apo A(1) (p < 0.04) and Apo B (p < 0.05) concentrations. There were no significant changes in HDL-C and Lp(a) concentrations. Renal function and cyclosporine levels were not changed during and after the study. CPK was increased only in one case.

CONCLUSIONS

It is suggested that if the response to the diet is inadequate, the use of combined treatment with low-dose pravastatin and fish oil is a more effective strategy than the pravastatin treatment alone for changing the lipid profile after renal transplantation.

Hypertension in chronic hemodialysis patients: current view on pathophysiology and treatment

BACKGROUND

Hypertension accounts for 65 - 85% of patients beginning dialysis, and dialysis alone controls hypertension in over 50% of patients.

PATIENT AND METHODS

We have surveyed the status of BP control in 113 hemodialysis patients, 66 men and 47 women, aged 59 +/- 13 years old, with a mean duration on hemodialysis 42 +/- 44 months. The following measurements were recorded: predialysis mean arterial pressure (pre-MAP), post-dialysis MAP (post-MAP), percentage of change in MAP, pre-dialysis weight, post-dialysis weight, fluid removed by ultrafiltration during each dialysis session, interdialytic weight gain and excess weight over the desirable dry weight.

RESULTS

Our results showed a hypertension prevalence of 59% (hypertension defined as pre-MAP +/- 110 mmHg). MAP was not different between men and women, and only 4.5% of patients had isolated systolic hypertension. All hypertensive patients were on treatment with antihypertensives. Reduction in post-MAP by > or = 5% (controlled by ultrafiltration) was found in 68.5% of hypertensive and in 87.5% of normotensive patients. Age, primary renal disease, time on dialysis and adequacy of dialysis were not correlated with pre-MAP. Excess volume and interdialytic weight gain were found to correlate with pre-MAP (p = 0.03). Also, the weekly dosage of EPO had a significant correlation with pre-MAP (p = 0.03). No differences were found among four classes of antihypertensive drugs regarding the BP control. Patients with hypertension requiring one drug achieved a significantly (p < 0.05) lower pre-MAP than the group of patients receiving three or more drugs. In conclusion, hemodialysis population shows high prevalence of hypertension, resistant to antihypertensive treatment.

CONCLUSION

Current methods of hemodialysis are not effective in controlling BP. This implies that more insight into the role of excess volume and vasomotor systems in the pathogenesis of dialysis hypertension is warranted.

The effectiveness of mupirocin preventing Staphylococcus aureus in catheter-related infections in peritoneal dialysis

The objective of this study was to evaluate the effectiveness of mupirocin on Staphylococcus aureus with regard to peritoneal dialysis (PD)-catheter exit-site infections (ESI), tunnel infections (TI), and peritonitis episodes (PE). The study was performed on 42 continuous ambulatory peritoneal dialysis (CAPD) patients (group I) treated from April 1998 to July 1999. These patients were instructed to apply mupirocin daily at the catheter exit site as part of their exit-site care. The control was the same group's historical infection data. Results were also recorded for a second group of 16 patients (group II) with newly implanted PD catheters were also instructed to apply mupirocin at the exit site daily. During the control period (before daily mupirocin application), group I recorded 16 episodes of ESI (0.30 episodes per patient-year), 6 episodes of TI (0.11 episodes per patient-year), 15 episodes of PE (0.28 episodes per patient-year), and one case of catheter removal (0.019 episodes per patient-year) owing to S. aureus exit-site infection coexisting with peritonitis. The rate of S. aureus exit-site infection during this period was 0.11 episodes per patient-year; of S. aureus tunnel infection, 0.057 episodes per patient-year; and of S. aureus peritonitis, 0.076 episodes per patient-year. During the mupirocin period, infections and peritonitis owing to S. aureus dramatically decreased (p < 0.01 and p < 0.001 respectively). The rate of S. aureus exit-site infection was 0.02 episodes per patient-year, with no S. aureus tunnel infections, and no catheter removals owing to S. aureus peritonitis. Similarly, in group II, no episodes were recorded of any ESI, TI, or PE owing to S. aureus, although 4 episodes of ESI (0.37 episodes per patient-year, 2 with other gram-positive bacteria, and 2 with gram-negative bacteria) and 8 PEs (0.75 episodes per patient-year) were seen. We conclude that mupirocin application provides excellent prophylaxis for catheter-related infections owing to S. aureus, and that reduction of these infections may improve the long-term survival of patients on CAPD.