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Andersen M, Bangsgaard KO, Heaf JG, Ottesen JT. Analytical solution of phosphate kinetics for hemodialysis. J Math Biol 2023; 87:11. [PMID: 37332042 DOI: 10.1007/s00285-023-01942-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 05/22/2023] [Accepted: 05/28/2023] [Indexed: 06/20/2023]
Abstract
Chronic kidney diseases imply an ongoing need to remove toxins, with hemodialysis as the preferred treatment modality. We derive analytical expressions for phosphate clearance during dialysis, the single pass (SP) model corresponding to a standard clinical hemodialysis and the multi pass (MP) model, where dialysate is recycled and therefore makes a smaller clinical setting possible such as a transportable dialysis suitcase. For both cases we show that the convective contribution to the dialysate is negligible for the phosphate kinetics and derive simpler expressions. The SP and MP models are calibrated to clinical data of ten patients showing consistency between the models and provide estimates of the kinetic parameters. Immediately after dialysis a rebound effect is observed. We derive a simple formula describing this effect which is valid both posterior to SP or MP dialysis. The analytical formulas provide explanations to observations of previous clinical studies.
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Affiliation(s)
- M Andersen
- IMFUFA, Centre for Mathematical Modeling, Human Health and Disease, Roskilde University, Roskilde, Denmark.
| | - K O Bangsgaard
- DTU Compute, Technical University of Denmark, Kongens Lyngby, Denmark
| | - J G Heaf
- Department of Nephrology, University Hospital of Zealand, Roskilde, Denmark
| | - J T Ottesen
- IMFUFA, Centre for Mathematical Modeling, Human Health and Disease, Roskilde University, Roskilde, Denmark
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Kampmann JD, Heaf JG, Mogensen CB, Mickley H, Wolff DL, Brandt F. Prevalence and incidence of chronic kidney disease stage 3-5 - results from KidDiCo. BMC Nephrol 2023; 24:17. [PMID: 36658506 PMCID: PMC9849831 DOI: 10.1186/s12882-023-03056-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 01/02/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a global challenge. CKD prevalence estimation is central to management strategies and prevention. It is necessary to predict end stage kidney disease (ESKD) and, subsequently, the burden for healthcare systems. In this study we characterize CKD stage 3-5 prevalence and incidence in a cohort covering the majority of the Region of Southern Denmark and investigate individuals' demographic, socioeconomic, and comorbidity status. METHODS We used data from the Kidney Disease Cohort (KidDiCo) combining laboratory data from Southern Denmark with Danish national databases. Chronic kidney disease was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. RESULTS The prevalence varied between 4.83 and 4.98% and incidence rate of CKD was 0.49%/year. The median age was 76.4 years. The proportion of individuals with CKD stage 3-5 in the entire population increased consistently with age. The percentage of women in the CKD 3-5 group was higher than in the background population. Diabetes mellitus, hypertension and cardiovascular disease were more prominent in patients with CKD. CKD stage 5 and ESKD were more frequent as incident CKD stages in the 18-49 year olds when compared to older individuals. CKD patients tended to have a lower socioeconomic status. CONCLUSION Chronic kidney disease stage 3-5 is common, especially in the elderly. Patients with CKD stage 3-5 are predominantly female. The KidDiCo data suggests an association between lower socioeconomic status and prevalence of CKD.
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Affiliation(s)
- Jan Dominik Kampmann
- grid.7143.10000 0004 0512 5013Department of Internal Medicine, University Hospital of Southern Denmark, Sydvang 1, Sonderborg, 6400 Denmark ,grid.10825.3e0000 0001 0728 0170Institute of Regional Health Research, University of Southern Denmark, Campusvej 55, Odense, 5230 Denmark
| | - James Goya Heaf
- grid.476266.7Department of Medicine, Zealand University Hospital, Roskilde, Sygehusvej 10, Roskilde, 4000 Denmark
| | - Christian Backer Mogensen
- grid.10825.3e0000 0001 0728 0170Institute of Regional Health Research, University of Southern Denmark, Campusvej 55, Odense, 5230 Denmark ,grid.7143.10000 0004 0512 5013Department of Emergency Medicine, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, Aabenraa, 6200 Denmark
| | - Hans Mickley
- grid.7143.10000 0004 0512 5013Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, Odense, 5000 Denmark
| | - Donna Lykke Wolff
- grid.7143.10000 0004 0512 5013Department of Internal Medicine, University Hospital of Southern Denmark, Sydvang 1, Sonderborg, 6400 Denmark ,grid.10825.3e0000 0001 0728 0170Institute of Regional Health Research, University of Southern Denmark, Campusvej 55, Odense, 5230 Denmark
| | - Frans Brandt
- grid.7143.10000 0004 0512 5013Department of Internal Medicine, University Hospital of Southern Denmark, Sydvang 1, Sonderborg, 6400 Denmark ,grid.10825.3e0000 0001 0728 0170Institute of Regional Health Research, University of Southern Denmark, Campusvej 55, Odense, 5230 Denmark
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Kampmann JD, Heaf JG, Mogensen CB, Mickley H, Wolff DL, Kristensen FB. Referral rate of chronic kidney disease patients to a nephrologist in the region of Southern Denmark: results from KidDiCo. Clin Kidney J 2022; 15:2116-2123. [DOI: 10.1093/ckj/sfac165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Data on the referral rate of chronic kidney disease (CKD) patients to specialists are sparse. Investigating referral rates and characterising patients with kidney disease not followed by a nephrologist is relevant for future measures in order to optimize public health and guideline implementation.
Methods
Data were extracted from the Kidney Disease Cohort of Southern Denmark (KidDiCo). Referral rates for all incident CKD patients below 60ml/min/1.73m² and referral rates according to the KDIGO guidelines based glomerular filtration rates below 30 ml/min/1.73m² were calculated. Information on contact with one of the nephrologist outpatient clinics in the Region of Southern Denmark was collected from the Danish National Patient Registry. The individual follow up time for nephrology contact was 12 months. Additional data was accessed via the respective national databases. CKD patients on dialysis and kidney transplanted patients were excluded.
Result
Three % of patients with an eGFR < 60 ml/min/1.73m² sixteen % of patients with an eGFR < 30 ml/min/1.73m² and thirty-five % of patients with an eGFR < 15 ml/min/1.73m² were in contact with a nephrologist in the outpatient settings. Younger age, male sex, diabetes, hypertension, higher education and proximity to a nephrology outpatient clinic increased the chance of nephrology follow up.
Conclusion
Only a small fraction of CKD patients are followed by a nephrologist. More studies should be performed in order to find out which patients will profit the most from renal referral and how to optimize the collaboration between nephrologists and general practitioners.
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Affiliation(s)
- Jan Dominik Kampmann
- Department of Internal Medicine, Hospital of Southern Jutland, Sønderborg, Sonderborg , Denmark
- Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - James Goya Heaf
- Department of Medicine, Zealand University Hospital, Roskilde , Roskilde , Denmark
| | - Christian Backer Mogensen
- Department of Emergency Medicine, Hospital of Southern Jutland , Aabenraa , Denmark
- Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - Hans Mickley
- Department of Cardiology, Odense University Hospital , Odense , Denmark
| | - Donna Lykke Wolff
- Department of Internal Medicine, Hospital of Southern Jutland, Sønderborg, Sonderborg , Denmark
- Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - Frans Brandt Kristensen
- Department of Internal Medicine, Hospital of Southern Jutland, Sønderborg, Sonderborg , Denmark
- Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
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Kampmann JD, Goya Heaf J, Mogensen CB, Mickley H, Brandt F. Kidney Disease Cohort (KidDiCo) of Southern Denmark: Design, Coverage, Generalizability and Implications for Use. Clin Epidemiol 2021; 13:971-980. [PMID: 34703319 PMCID: PMC8525414 DOI: 10.2147/clep.s328512] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Background This article provides a description of a large register of a population from the Region of Southern Denmark, the Kidney Disease Cohort (KiDiCo). Coverage and representativeness according to gender and education level are discussed. Methods Data for KiDiCo were obtained using laboratory databases from participating laboratories in the Region of Southern Denmark and were linked to individual personal 10-digit personal identification numbers. The study population includes individuals over 18 years of age living in Denmark, whose serum creatinine was analysed in one of the 27 participating laboratories in the Region of Southern Denmark during the period of 8 years from 1st January 2006 to 31st December 2013. Individually linked data consist of diagnosis codes, date and cause of death, dispensed medicine data, socioeconomic data and demographic data. Results In total, n = 669,929 individuals had their blood tested for creatinine between 2007 and 2013 in a defined geographical area. The estimated geographical coverage was 78%. The median age of the background population was 6 years lower. The cohort had a slightly higher percentage of females (53%) compared to the background population (49%). Differences in educational levels reflect the minor age gap. Conclusion Based on coverage of 78% together with similar characteristics in terms of gender and age, the KiDiCo is a representative cohort of patients in the Region of Southern Denmark. Combining laboratory data with high-quality Danish administrative registers makes diverse research feasible.
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Affiliation(s)
- Jan Dominik Kampmann
- Department of Internal Medicine, Hospital of Southern Jutland, Sonderborg, 6400, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, 5230, Denmark
| | - James Goya Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, 4000, Denmark
| | - Christian Backer Mogensen
- Department of Regional Health Research, University of Southern Denmark, Odense, 5230, Denmark.,Department of Emergency Medicine, Hospital of Southern Jutland, Aabenraa, 6200, Denmark
| | - Hans Mickley
- Department of Cardiology, Odense University Hospital, Odense, 5000, Denmark
| | - Frans Brandt
- Department of Internal Medicine, Hospital of Southern Jutland, Sonderborg, 6400, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, 5230, Denmark
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Lindhard K, Rix M, Heaf JG, Hansen HP, Pedersen BL, Jensen BL, Hansen D. Effect of far infrared therapy on arteriovenous fistula maturation, survival and stenosis in hemodialysis patients, a randomized, controlled clinical trial: the FAITH on fistula trial. BMC Nephrol 2021; 22:283. [PMID: 34419006 PMCID: PMC8379732 DOI: 10.1186/s12882-021-02476-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/12/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND An arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis treatment. After creation many of the AVFs will never mature or if functioning will need an intervention within 1 year due to an AVF stenosis. Studies investigating possible therapies that improves the AVF maturation and survival are scarce. Far infrared therapy (FIR) has shown promising results. In minor single centre and industry supported trials FIR has shown improved AVF maturation and survival. There is a need of a randomized multicentre controlled trial to examine the effect of FIR on the AVF maturation and survival and to explore the possible AVF protective mechanism induced by the FIR treatment. METHODS This investigator initiated, randomized, controlled, open-labeled, multicenter clinical trial will examine the effect of FIR on AVF maturation in patients with a newly created AVF (incident) and AVF patency rate after 1 year of treatment in patients with an existing AVF (prevalent) compared to a control group. The intervention group will receive FIR to the skin above their AVF three times a week for 1 year. The control group will be observed without any treatment. The primary outcome for incident AVFs is the time from surgically creation of the AVF to successful cannulation. The primary outcome for the prevalent AVFs is the difference in number of AVFs without intervention and still functioning in the treatment and control group after 12 months. Furthermore, the acute changes in inflammatory and vasodilating factors during FIR will be explored. Arterial stiffness as a marker of long term AVF patency will also be examined. DISCUSSION FIR is a promising new treatment modality that may potentially lead to improved AVF maturation and survival. This randomized controlled open-labelled trial will investigate the effect of FIR and its possible mechanisms. TRIAL REGISTRATION Clinicaltrialsgov NCT04011072 (7th of July 2019).
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Affiliation(s)
- K Lindhard
- Department of Nephrology, Herlev Hospital, Borgmester Ib Juels Vej 1, DK-2730, Herlev, Denmark.
| | - M Rix
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark
| | - J G Heaf
- Department of Nephrology, University hospital of Zealand, Roskilde, Denmark
| | - H P Hansen
- Department of Nephrology, Herlev Hospital, Borgmester Ib Juels Vej 1, DK-2730, Herlev, Denmark
| | - B L Pedersen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
| | - B L Jensen
- Department of cardiovascular and renal research, University Hospital of Southern Denmark, Odense, Denmark
| | - D Hansen
- Department of Nephrology, Herlev Hospital, Borgmester Ib Juels Vej 1, DK-2730, Herlev, Denmark
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Heaf JG, Hansen A, Laier GH. Hypertensive nephropathy is associated with an increased risk of myeloma, skin, and renal cancer. J Clin Hypertens (Greenwich) 2019; 21:786-791. [PMID: 31127691 DOI: 10.1111/jch.13565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/20/2019] [Accepted: 04/02/2019] [Indexed: 11/29/2022]
Abstract
Previous studies suggest an increased cancer risk in hypertension. Patients with hypertensive nephropathy have not been studied. A national registry study was performed to assess the presence and size of this association. Clinical data and cancer diagnoses for all patients with biopsy-proven hypertensive nephropathy between 1985 and 2015 in Denmark were extracted from four national registries and compared with age- and sex-adjusted national cancer rates. The risk of cancer was twice the background population. It was raised for renal cancer (odds ratio 10.4), myeloma (13.2), skin cancer (7.9), and other/unspecified (1.8). No increase in incidence was seen until 1 year before renal biopsy and then rose rapidly. It was again normal 5 years after biopsy. Hypertensive nephropathy is associated with an increased risk of myeloma, skin, renal, and other cancers. Screening of patients with hypertensive nephropathy, in the presence of reduced renal function or significant proteinuria, may be indicated.
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Affiliation(s)
- James Goya Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Alastair Hansen
- Institute of Clinical Medicine, Herlev Hospital, University of Copenhagen, Herlev, Denmark
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Nelveg-Kristensen KE, Laier GH, Heaf JG. Risk of death after first-time blood stream infection in incident dialysis patients with specific consideration on vascular access and comorbidity. BMC Infect Dis 2018; 18:688. [PMID: 30572826 PMCID: PMC6302499 DOI: 10.1186/s12879-018-3594-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 12/07/2018] [Indexed: 12/14/2022] Open
Abstract
Background The mortality following blood stream infection (BSI) and risk of subsequent BSI in relation to dialysis modality, vascular access, and other potential risk factors has received relatively little attention. Consequently, we assessed these matters in a retrospective cohort study, by use of the Danish nation-wide registries. Methods Patients more than 17 years of age, who initiated dialysis between 1.1.2010 and 1.1.2014, were grouped according to their dialysis modality and vascular access. Survival was modeled in time-dependent Cox proportional hazard analyses. Potential risk factors confined by a modified Charlson comorbidity index (MCCI), were subsequently assessed in stepwise selection models. Results At baseline, 764 patients received peritoneal dialysis (PD), and 434, 479, and 782 hemodialysis (HD) patients were dialyzed by use of arteriovenous fistulas (AVFs), tunneled catheters (TCs), and non-tunneled catheters (NTCs), respectively. We identified 1069 BSIs with an overall incidence rate of 17.7 episodes per 100 person years, and 216 BSIs occurred more than one time in the same patient. HRs of post BSI mortality relative to PD were 3.20 (95% CI 1.86–5.50; p < 0.001) with NTCs; whereas no associations were found for AVF and TC. The risk of subsequent BSIs was higher with NTCs [HR 2.29 (95% CI 1.09–4.82), p = 0.030], and no significant difference was found for AVF and TC, in relation to PD. There was an increased risk of both outcomes with TC relative to AVF [death: 1.57 (95% CI 1.07–2.29, P < 0.021); BSI: 1.78 (95% CI 1.13–2.83, P < 0.014], and risk of death was reduced in patients who changed to AVF after first-time BSI. The MCCI was significantly associated with the risk of subsequent BSI and post BSI death; however, only some of the variables contained in the index were found to be significant risk predictors when analyzed in the fitted model. Conclusions While NTC was the most predominant risk factor for subsequent BSI and post BSI mortality, AVF appeared protective. Electronic supplementary material The online version of this article (10.1186/s12879-018-3594-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - James Goya Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
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Ocak G, Noordzij M, Rookmaaker MB, Cases A, Couchoud C, Heaf JG, Jarraya F, De Meester J, Groothoff JW, Waldum-Grevbo BE, Palsson R, Resic H, Remón C, Finne P, Stendahl M, Verhaar MC, Massy ZA, Dekker FW, Jager KJ. Mortality due to bleeding, myocardial infarction and stroke in dialysis patients. J Thromb Haemost 2018; 16:1953-1963. [PMID: 30063819 DOI: 10.1111/jth.14254] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/21/2018] [Indexed: 01/13/2023]
Abstract
Essentials Mortality due to bleeding vs. arterial thrombosis in dialysis patients is unknown. We compared death causes of 201 918 dialysis patients with the general population. Dialysis was associated with increased mortality risks of bleeding and arterial thrombosis. Clinicians should be aware of the increased bleeding and thrombosis risks. SUMMARY Background Dialysis has been associated with both bleeding and thrombotic events. However, there is limited information on bleeding as a cause of death versus arterial thrombosis as a cause of death. Objectives To investigate the occurrence of bleeding, myocardial infarction and stroke as causes of death in the dialysis population as compared with the general population. Methods We included 201 918 patients from 11 countries providing data to the ERA-EDTA Registry who started dialysis treatment between 1994 and 2011, and followed them for 3 years. Age-standardized and sex-standardized mortality rate ratios for bleeding, myocardial infarction and stroke as causes of death were calculated in dialysis patients as compared with the European general population. Associations between potential risk factors and these causes of death in dialysis patients were investigated by calculating hazard ratios (HRs) with 95% confidence intervals (CIs) by the use of Cox proportional-hazards regression. Results As compared with the general population, the age-standardized and sex-standardized mortality rate ratios in dialysis patients were 12.8 (95% CI 11.9-13.7) for bleeding as a cause of death (6.2 per 1000 person-years among dialysis patients versus 0.3 per 1000 person-years in the general population), 13.4 (95% CI 13.0-13.9) for myocardial infarction (22.5 versus 0.9 per 1000 person-years), and 12.4 (95% CI 11.9-12.9) for stroke (14.3 versus 0.7 per 1000 person-years). Conclusion Dialysis patients have highly increased risks of death caused by bleeding and arterial thrombosis as compared with the general population. Clinicians should be aware of the increased mortality risks caused by these conditions.
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Affiliation(s)
- G Ocak
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M Noordzij
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - M B Rookmaaker
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A Cases
- Registre de Malalts Renals de Catalunya, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - C Couchoud
- REIN Registry, Agence de Biomedecine, Saint Denis La Plaine, France
| | - J G Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - F Jarraya
- Department of Nephrology, Sfax University Hospital and Research Unit, Faculty of Medicine, Sfax University, Sfax, Tunisia
| | - J De Meester
- Department of Nephrology, Dialysis and Hypertension, Dutch-Speaking Belgian Renal Registry, Sint-Niklaas, Belgium
| | - J W Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - B E Waldum-Grevbo
- Department of Nephrology, Oslo University Hospital Ullevål, Oslo, Norway
| | - R Palsson
- Division of Nephrology, Internal Medicine Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - H Resic
- Clinic for Hemodialysis, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - C Remón
- SICATA (The Information System of the Andalusian Transplant Autonomic Coordination Registry), Andalusia, Spain
| | - P Finne
- Finnish Registry for Kidney Diseases, Helsinki, Finland
| | - M Stendahl
- Swedish Renal Registry, Department of Internal Medicine, Ryhov County Hospital, Jönköping, Sweden
| | - M C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Z A Massy
- Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, France
- INSERM Unit 1018, CESP, Team 5, UVSQ, Villejuif, France
| | - F W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - K J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Abstract
Background The association of increased cancer risk with glomerulonephritis (GN) is well known, but controversy exists concerning which types of GN are involved, and the size of the association. A national registry survey was performed to assess the size of this association, and the temporal relationship of cancer diagnosis to GN diagnosis. Methods All patients with biopsy-proven GN between 1985 and 2015 in Denmark were extracted from The Danish Renal Biopsy Registry and the National Pathology Data Bank. Incident cancer diagnoses between 10 years previous and 10 years subsequent to the GN diagnosis were extracted from the Danish Cancer Registry. Residence, birth and death data were obtained from the National Patient Register. Expected cancer incidence, classified according to cohort, age and sex were extracted from the Nordcan database. Results Nine hundred eleven cancers were diagnosed in 5594 patients. Thirty five percent were prevalent at renal biopsy. Prevalence at biopsy was 5.5% (expected 3.1%), but incidence was not increased < 1 year before biopsy. Increased cancer rates were seen for GN forms: minimal change, endocapillary, focal segmental glomerulosclerosis, mesangioproliferative, membranous, focal segmental, membranoproliferative, proliferative, ANCA-associated vasculitis, lupus nephritis and unclassified. Increased cancer rates were seen for lung, prostate, renal, non-Hodgkin lymphoma, myeloma, leukaemia and skin. The increased incidence was mainly limited to − 1 to 1 year after biopsy, but skin cancer showed an increased risk over time. Some diagnoses showed an increase 5–10 years after biopsy. Incidence was raised for patients with uraemia and nephrosis, but less for proteinuria or haematuria. Cancers in patients < 45 years were rare. The risk of developing cancer 0–3 years after biopsy for patients 45–64 years varied from 7.3% (minimal change) to 15.8% (unclassified GN); > 64 years from 11.8 (endocapillary GN) to 20.3% (unclassified). The diagnosis with the highest risk was membranoproliferative GN (8.6 & 19.6%). Conclusions Cancer rates are increased for many cancer and most GN diagnoses. Cancer screening for patients < 45 years and for patients without nephrosis or uraemia may not be necessary. The findings suggest that screening programs for specific GN diagnoses can be extended to other GN forms.
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Affiliation(s)
- James Goya Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark.
| | - Alastair Hansen
- Institute of Clinical Medicine, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
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Popovic V, Zerahn B, Heaf JG. Comparison of Dual Energy X-ray Absorptiometry and Bioimpedance in Assessing Body Composition and Nutrition in Peritoneal Dialysis Patients. J Ren Nutr 2017; 27:355-363. [DOI: 10.1053/j.jrn.2017.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 02/27/2017] [Accepted: 03/22/2017] [Indexed: 11/11/2022] Open
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Abstract
PURPOSE The purpose of this paper was to review the literature concerning the treatment of chronic kidney disease-mineral bone disorder (CKD-MBD) in the elderly peritoneal dialysis (PD) patient. RESULTS Chronic kidney disease-mineral bone disorder is a major problem in the elderly PD patient, with its associated increased fracture risk, vascular calcification, and accelerated mortality fracture risk. Peritoneal dialysis, however, bears a lower risk than hemodialysis (HD). The approach to CKD-MBD prophylaxis and treatment in the elderly PD patient is similar to other CKD patients, with some important differences. Avoidance of hypercalcemia, hyperphosphatemia, and hyperparathyroidism is important, as in other CKD groups, and is generally easier to attain. Calcium-free phosphate binders are recommended for normocalcemic and hypercalcemic patients. Normalization of vitamin D levels to > 75 nmol/L (> 30 pg/L) and low-dose active vitamin D therapy is recommended for all patients. Hyperparathryoidism is to be avoided by using active vitamin D and cinacalcet. Particular attention should be paid to treating protein malnutrition. Fracture prophylaxis (exercise, use of walkers, dwelling modifications) are important. Hypomagnesemia is common in PD and can be treated with magnesium supplements. Vitamin K deficiency is also common and has been identified as a cause of vascular calcification. Accordingly, warfarin treatment for this age group is problematic. CONCLUSION While treatment principles are similar to other dialysis patient groups, physicians should be aware of the special problems of the elderly group.
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Affiliation(s)
- James Goya Heaf
- Department of Medicine, Roskilde Hospital, University of Copenhagen, Copenhagen, Denmark
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Eloot S, Van Biesen W, Axelsen M, Glorieux G, Pedersen RS, Heaf JG. Protein-bound solute removal during extended multipass versus standard hemodialysis. BMC Nephrol 2015; 16:57. [PMID: 25896788 PMCID: PMC4404563 DOI: 10.1186/s12882-015-0056-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/15/2015] [Indexed: 11/10/2022] Open
Abstract
Background Multipass hemodialysis (MPHD) is a recently described dialysis modality, involving the use of small volumes of dialysate which are repetitively recycled. Dialysis regimes of 8 hours for six days a week using this device result in an increased removal of small water soluble solutes and middle molecules compared to standard hemodialysis (SHD). Since protein-bound solutes (PBS) exert important pathophysiological effects, we investigated whether MPHD results in improved removal of PBS as well. Methods A cross-over study (Clinical Trial NCT01267760) was performed in nine stable HD patients. At midweek a single dialysis session was performed with either 4 hours SHD using a dialysate flow of 500 mL/min or 8 hours MPHD with a dialysate volume of 50% of estimated body water volume. Blood and dialysate samples were taken every hour to determine concentrations of p-cresylglucuronide (PCG), hippuric acid (HA), indole acetic acid (IAA), indoxyl sulfate (IS), and p-cresylsulfate (PCS). Dialyser extraction ratio, reduction ratio, and solute removal were calculated for these solutes. Results Already at 60 min after dialysis start, the extraction ratio in the hemodialyser was a factor 1.4-4 lower with MPHD versus SHD, resulting in significantly smaller reduction ratios and lower solute removal within a single session. Even when extrapolating our findings to 3 times 4 h SHD and 6 times 8 h MPHD per week, the latter modality was at best similar in terms of total solute removal for most protein-bound solutes, and worse for the highly protein-bound solutes IS and PCS. When efficiency was calculated as solute removal/litre of dialysate used, MPHD was found superior to SHD. Conclusion When high water consumption is a concern, a treatment regimen of 6 times/week 8 h MPHD might be an alternative for 3 times/week 4 h SHD, but at the expense of a lower total solute removal of highly protein-bound solutes.
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Affiliation(s)
- Sunny Eloot
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Mette Axelsen
- Institute of Public Health, Aarhus University, Nordre Ringgade 1, 8000, Aarhus C, Denmark.
| | - Griet Glorieux
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | | | - James Goya Heaf
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
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Wühl E, van Stralen KJ, Wanner C, Ariceta G, Heaf JG, Bjerre AK, Palsson R, Duneau G, Hoitsma AJ, Ravani P, Schaefer F, Jager KJ. Renal replacement therapy for rare diseases affecting the kidney: an analysis of the ERA-EDTA Registry. Nephrol Dial Transplant 2014; 29 Suppl 4:iv1-8. [PMID: 25165174 DOI: 10.1093/ndt/gfu030] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In recent years, increased efforts have been undertaken to address the needs of patients with rare diseases by international initiatives and consortia devoted to rare disease research and management. However, information on the overall prevalence of rare diseases within the end-stage renal disease (ESRD) population is limited. The aims of this study were (i) to identify those rare diseases within the ERA-EDTA Registry for which renal replacement therapy (RRT) is being provided and (ii) to determine the prevalence and incidence of RRT for ESRD due to rare diseases, both overall and separately for children and adults. METHODS The Orphanet classification of rare disease was searched for rare diseases potentially causing ESRD, and these diagnosis codes were mapped to the corresponding ERA-EDTA primary renal disease codes. Thirty-one diagnoses were defined as rare diseases causing ESRD. RESULTS From 1 January 2007 to 31 December 2011, 7194 patients started RRT for a rare disease (10.6% children). While some diseases were exclusively found in adults (e.g. Fabry disease), primary oxalosis, cystinosis, congenital anomalies of the kidney and urinary tract (CAKUT) and medullary cystic kidney disease affected young patients in up to 46%. On 31 December 2011, 20 595 patients (12.4% of the total RRT population) were on RRT for ESRD caused by a rare disease. The point prevalence was 32.5 per million age-related population in children and 152.0 in adults. Only 5.8% of these patients were younger than 20 years; however, 57.7% of all children on RRT had a rare disease, compared with only 11.9% in adults. CAKUT and focal segmental glomerulosclerosis were the most prevalent rare disease entities among patients on RRT. CONCLUSIONS More than half of all children and one of nine adults on RRT in the ERA-EDTA Registry suffer from kidney failure due to a rare disease, potentially with a large number of additional undiagnosed or miscoded cases. Comprehensive diagnostic assessment and the application of accurate disease classification systems are essential for improving the identification and management of patients with rare kidney diseases.
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Affiliation(s)
- Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Karlijn J van Stralen
- ERA-EDTA Registry and ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Christoph Wanner
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
| | - Gema Ariceta
- Servicio de Nefrología Pediátrica y Hemodiálisis, Hospital Universitario Materno-Infantil Vall d'Hebron, Barcelona, Spain
| | - James Goya Heaf
- Department of Nephrology, Copenhagen University Hospital at Herlev, Herlev, Denmark
| | - Anna K Bjerre
- Department of Pediatrics, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Runolfur Palsson
- Division of Nephrology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Gabrielle Duneau
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Andries J Hoitsma
- Department of Nephrology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Pietro Ravani
- Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Kitty J Jager
- ERA-EDTA Registry and ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
Background Diffuse mesangioproliferative glomerulonephritis (MesP) is the most commonly diagnosed type of glomerulonephritis (GN) in Denmark, with an incidence of 10.8 million per year. In the present study, the 30-year renal survival was estimated. Methods A retrospective cohort investigation of 140 patients with biopsy-proven MesP was performed between the period 1967-2006. Factors influencing renal survival were investigated using Cox regression analysis. Results Renal survival at 5, 10, 20 and 30 years was 87, 78, 59 and 50%, respectively. Female survival after 30 years was significantly better than male survival (70 vs. 40%, p = 0.049). Multivariate analysis, adjusted for age, estimated glomerular filtration rate (GFR) and nephrotic syndrome (NS) was performed for each sex individually. An increase in GFR was associated with a hazard risk (HR) of 0.98 (p = 0.02) in women and 0.99 (p = 0.006) in men. Older age was associated with a HR of 1.04 (p = 0.02) in women and 1.03 (p = 0.004) in men. NS had a poorer prognosis in men (HR 2.53, p = 0.01), but not in women (HR 0.54, p = 0.38). Conclusion Increasing age and decreasing GFR were adversely associated with renal death. Renal prognosis was better for women after 30 years, and NS resulted in a poorer prognosis in men. This suggests that disease course and prognosis are different between men and women.
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Affiliation(s)
- Mette Axelsen
- Institute of Public Health, Aarhus University, Aarhus, Denmark ; Department of Internal Medicine, Ribe County Hospital, Esbjerg, University of Copenhagen, Copenhagen, Denmark ; Diagnostic Center, Regionhospital Silkeborg, Silkeborg, Denmark
| | - Robert Smith Pedersen
- Department of Internal Medicine, Ribe County Hospital, Esbjerg, University of Copenhagen, Copenhagen, Denmark
| | - James Goya Heaf
- Department of Nephrology B, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Torkell Ellingsen
- Institute of Public Health, Aarhus University, Aarhus, Denmark ; Diagnostic Center, Regionhospital Silkeborg, Silkeborg, Denmark
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15
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Redal-Baigorri B, Rasmussen K, Heaf JG. Indexing glomerular filtration rate to body surface area: clinical consequences. J Clin Lab Anal 2013; 28:83-90. [PMID: 24375613 DOI: 10.1002/jcla.21648] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Accepted: 06/03/2013] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Kidney function is mostly expressed in terms of glomerular filtration rate (GFR). A common feature is the expression as ml/min per 1.73 m(2) , which represents the adjustment of the individual kidney function to a standard body surface area (BSA) to allow comparison between individuals. We investigated the impact of indexing GFR to BSA in cancer patients, as this BSA indexation might affect the reported individual kidney function. METHODS Cross-sectional study of 895 adults who had their kidney function measured with (51) chrome ethylene diamine tetraacetic acid. Mean values of BSA-indexed GFR vs. mean absolute GFR were analyzed with a t-test for paired data. Bland-Altman plot was used to analyze agreement between the indexed and absolute GFR values. RESULTS AND CONCLUSION BSA-GFR in patients with a BSA <1.60 m(2) overestimated GFR with a bias of 10.08 ml/min (11.46%) and underestimated GFR in those with a BSA >2 m(2) with a bias up to -20.76 ml/min (-23.59%). BSA is not a good normalization index (NI) in patients with extreme body sizes. Therefore, until a better NI is found, we recommend clinicians to use the absolute GFR to calculate individual drug chemotherapy dosage as well as express individual kidney function.
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Affiliation(s)
- Belén Redal-Baigorri
- Department of Nephrology, Roskilde University Hospital, University of Copenhagen, Roskilde, Denmark
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16
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Redal-Baigorri B, Rasmussen K, Heaf JG. The use of absolute values improves performance of estimation formulae: a retrospective cross sectional study. BMC Nephrol 2013; 14:271. [PMID: 24304464 PMCID: PMC4219448 DOI: 10.1186/1471-2369-14-271] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 11/26/2013] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Estimation of Glomerular Filtration Rate (GFR) by equations such as Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) or Modification of Diet in Renal Disease (MDRD) is usually expressed as a Body Surface Area (BSA) indexed value (ml/min per 1.73 m²). This can have severe clinical consequences in patients with extreme body sizes, resulting in an underestimation in the case of obesity or an overestimation of GFR in the case of underweight patients. The aim of this study was to compare the performance of both estimation formula expressed in ml/min, instead of ml/min per 1.73 m², with a reference method. METHODS Retrospective single centre cross sectional study of 185 patients. GFR was measured with 51Cr-EDTA and estimated with CKD-EPI and MDRD. Bias, precision and accuracy of absolute estimated GFR was calculated. RESULTS Bias of CKD-EPI and MDRD formulae expressed as an absolute value was 0.49 and 0.27 ml/min respectively, which is lower than previously reported. Precision was 12.95 and 16.33 and accuracy expressed as P30 was over 92.43% for CKD-EPI. There were no significant differences in GFR between the reference method and the estimation formulae. CONCLUSIONS The performance of CKD-EPI and MDRD formulae can be significantly improved in the individual patient if the absolute values are used by removing the BSA normalization factor. Absolute estimated GFR by CKD-EPI is comparable to measured GFR, improving the performance of this formula in the assessment of individual kidney function, thus providing clinicians with an alternative to reference methods.
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Affiliation(s)
- Belén Redal-Baigorri
- Department of Nephrology, Roskilde University Hospital, University of Copenhagen, Fjortenskæppevej 23, 4000, Roskilde, Denmark.
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17
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Abstract
Heaf et al. describe the novel multipass system as a most useful application in the setting of daily extended dialysis at home and suggests a number of modifications to our classical dialysis paradigm aimed at reducing water consumption. Their paper shows how continued creative thinking can modify the classical set-up of dialysis to obtain a system which at the same time could be more economical, ecological and simple. Introduction Most home haemodialysis (HD) modalities are limited to home use since they are based on a single-pass (SP) technique, which requires preparation of large amounts of dialysate. We present a new dialysis method, which requires minimal dialysate volumes, continuously recycled during treatment [multipass HD (MPHD)]. Theoretical calculations suggest that MPHD performed six times weekly for 8 h/night, using a dialysate bath containing 50% of the calculated body water, will achieve urea clearances equivalent to conventional HD 4 h thrice weekly, and a substantial clearance of higher middle molecules. Methods Ten stable HD patients were dialyzed for 4 h using standard SPHD (dialysate flow 500 mL/min). Used dialysate was collected. One week later, an 8-h MPHD was performed. The dialysate volume was 50% of the calculated water volume, the dialysate inflow 500 mL/min−0.5 × ultrafiltration/min and the outflow 500 mL/min + 0.5 × ultrafiltration/min. Elimination rates of urea, creatinine, uric acid, phosphate and β2-microglobulin (B2M) and dialysate saturation were determined hourly. Results Three hours of MPHD removed 49, 54, 50, 51 and 57%, respectively, of the amounts of urea, creatinine, uric acid, phosphate and B2M that were removed by 4 h conventional HD. The corresponding figures after 8 h MPHD were 63, 78, 74, 78 and 111%. Conclusions Clearance of small molecules using MPHD 6 × 8 h/week will exceed traditional HD 3 × 4 h/week. Similarly, clearance of large molecules will significantly exceed traditional HD and HD 5 × 2.5 h/week. This modality will increase patients' freedom of movement compared with traditional home HD. The new method can also be used in the intensive care unit and for automated peritoneal dialysis.
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Affiliation(s)
- James Goya Heaf
- Department of Nephrology B, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
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18
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Wühl E, van Stralen KJ, Verrina E, Bjerre A, Wanner C, Heaf JG, Zurriaga O, Hoitsma A, Niaudet P, Palsson R, Ravani P, Jager KJ, Schaefer F. Timing and outcome of renal replacement therapy in patients with congenital malformations of the kidney and urinary tract. Clin J Am Soc Nephrol 2012; 8:67-74. [PMID: 23085722 DOI: 10.2215/cjn.03310412] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Congenital anomalies of the kidney and urinary tract (CAKUT) are the leading cause of ESRD in children, but the proportion of patients with individual CAKUT entities progressing to ESRD during adulthood and their long-term clinical outcomes are unknown. This study assessed the age at onset of renal replacement therapy (RRT) and patient and renal graft survival in patients with CAKUT across the entire age range. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with CAKUT were compared with age-matched patients who were undergoing RRT for other renal disorders on the basis of data from the European Renal Association-European Dialysis and Transplant Association Registry. Competing risk and Cox regression analyses were conducted. RESULTS Of 212,930 patients commencing RRT from 1990 to 2009, 4765 (2.2%) had renal diagnoses consistent with CAKUT. The proportion of incident RRT patients with CAKUT decreased from infancy to childhood and then increased until age 15-19 years, followed by a gradual decline throughout adulthood. Median age at RRT start was 31 years in the CAKUT cohort and 61 years in the non-CAKUT cohort (P<0.001). RRT was started earlier (median, 16 years) in patients with isolated renal dysplasia than in those with renal hypoplasia and associated urinary tract disorders (median, 29.5-39.5 years). Patients with CAKUT survived longer than age- and sex-matched non-CAKUT controls because of lower cardiovascular mortality (10-year survival rate, 76.4% versus 70.7%; P<0.001). CONCLUSIONS CAKUT leads to ESRD more often at adult than pediatric age. Treatment outcomes differ from those of acquired kidney diseases and vary within CAKUT subcategories.
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Affiliation(s)
- Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg,Germany
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19
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Idorn T, Schejbel L, Rydahl C, Heaf JG, Jølvig KR, Bergstrøm M, Garred P, Kamper AL. Anti-glomerular basement membrane glomerulonephritis and thrombotic microangiopathy in first degree relatives: a case report. BMC Nephrol 2012; 13:64. [PMID: 22834933 PMCID: PMC3411442 DOI: 10.1186/1471-2369-13-64] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 07/26/2012] [Indexed: 11/24/2022] Open
Abstract
Background Anti-glomerular basement membrane glomerulonephritis and thrombotic microangiopathy are rare diseases with no known coherence. Case Presentation A daughter and her biological mother were diagnosed with pregnancy-induced thrombotic microangiopathy and anti-glomerular basement membrane glomerulonephritis, respectively. Both developed end-stage renal disease. Exploration of a common aetiology included analyses of HLA genotypes, functional and genetic aspects of the complement system, ADAMTS13 activity and screening for autoantibodies. The daughter was heterozygous carrier of the complement factor I G261D mutation, previously described in patients with membranoproliferative glomerulonephritis and atypical haemolytic uremic syndrome. The mother was non-carrier of this mutation. They shared the disease associated complement factor H silent polymorphism Q672Q (79602A>G). Conclusion An unequivocal functional or molecular association between these two family cases was not found suggesting that the patients probably share another, so far undiagnosed and unknown, predisposing factor. It seems highly unlikely that two infrequent immunologic diseases would occur by unrelated pathophysiological mechanisms within first degree relatives.
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Affiliation(s)
- Thomas Idorn
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark.
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20
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Abstract
Vitamin D receptor agonists (VDRA) are currently recommended for the treatment of secondary hyperparathyroidism in stage 5 CKD. They are considered to be contraindicated in the presence of low or normal (for a dialysis patient) levels of PTH due to the risk of developing adynamic bone disease, with consequent vascular calcification. However, these recommendations are increasingly at odds with the epidemiological evidence, which consistently shows a large survival advantage for patients treated with low-dose VDRAs, regardless of plasma calcium, phosphate, or PTH. A large number of pleiotropic effects of vitamin D have been described, including inhibition of renin activity, anti-inflammation, and suppression of vascular calcification stimulators and stimulation of vascular calcification inhibitors present in the uremic milieu. Laboratory studies suggest that a normal cellular vitamin D level is necessary for normal cardiomyocyte and vascular smooth muscle function. While pharmacological doses of VDRA can be harmful, the present evidence suggests that the level of 1,25-dihydroxycholecalciferol should also be more physiological in stage 5 CKD, and that widespread use of low-dose VDRA would be beneficial. A randomized controlled trial to test this hypothesis is warranted.
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Affiliation(s)
- James Goya Heaf
- Department of Nephrology, University of Copenhagen Herlev Hospital, Herlev, Denmark.
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21
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Koopman JJE, Rozing MP, Kramer A, de Jager DJ, Ansell D, De Meester JMJ, Prütz KG, Finne P, Heaf JG, Palsson R, Kramar R, Jager KJ, Dekker FW, Westendorp RGJ. Senescence rates in patients with end-stage renal disease: a critical appraisal of the Gompertz model. Aging Cell 2011; 10:233-8. [PMID: 21108732 DOI: 10.1111/j.1474-9726.2010.00659.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The most frequently used model to describe the exponential increase in mortality rate over age is the Gompertz equation. Logarithmically transformed, the equation conforms to a straight line, of which the slope has been interpreted as the rate of senescence. Earlier, we proposed the derivative function of the Gompertz equation as a superior descriptor of senescence rate. Here, we tested both measures of the rate of senescence in a population of patients with end-stage renal disease. It is clinical dogma that patients on dialysis experience accelerated senescence, whereas those with a functional kidney transplant have mortality rates comparable to the general population. Therefore, we calculated the age-specific mortality rates for European patients on dialysis (n=274 221; follow-up=594 767 person-years), for European patients with a functioning kidney transplant (n=61 286; follow-up=345 024 person-years), and for the general European population. We found higher mortality rates, but a smaller slope of logarithmic mortality curve for patients on dialysis compared with both patients with a functioning kidney transplant and the general population (P<0.001). A classical interpretation of the Gompertz model would imply that the rate of senescence in patients on dialysis is lower than in patients with a functioning transplant and lower than in the general population. In contrast, the derivative function of the Gompertz equation yielded the highest senescence rates for patients on dialysis, whereas the rate was similar in patients with a functioning transplant and the general population. We conclude that the rate of senescence is better described by the derivative function of the Gompertz equation.
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Affiliation(s)
- J J E Koopman
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
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22
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Heaf JG, Mortensen LS. Uraemia Progression in Chronic Kidney Disease Stages 3–5 Is Not Constant. ACTA ACUST UNITED AC 2011; 118:c367-74. [DOI: 10.1159/000323391] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 11/25/2010] [Indexed: 11/19/2022]
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Heaf JG, Hansen M. Treatment of refractory cancer-associated hypercalcemia with aminohydroxypropylidene diphosphonate. Acta Med Scand 2009; 224:287-8. [PMID: 3239457 DOI: 10.1111/j.0954-6820.1988.tb19375.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The case history is presented of a 45-year-old woman who was receiving chemotherapy for a pulmonary adenocarcinoma and who developed severe symptomatic hypercalcemia. Despite intensive treatment with fluids, loop diuretics, prednisone, calcitonin and repeated doses of mithramycin, she remained hypercalcemic. She was then treated with aminohydroxypropylidene diphosphonate (APD) with consequent rapid normalization of the serum calcium and disappearance of symptoms. We conclude that APD is a valuable supplement to the treatment of malignant hypercalcemia in that it may be effective when traditional therapies have failed.
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Affiliation(s)
- J G Heaf
- Department of Medical Oncology C, Bispebjerg Hospital, Copenhagen, Denmark
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24
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Abstract
BACKGROUND Nephrogenic systemic fibrosis may be caused by gadolinium (Gd)-containing magnetic resonance imaging contrast agents. Most reported cases were associated with one particular agent, gadodiamide. Yet, unidentified cofactors might explain why only a minority of renal failure patients exposed to gadodiamide develop nephrogenic systemic fibrosis. METHODS We conducted a case-control study of 19 histologically verified cases and 19 sex- and age-matched controls. All subjects had chronic renal failure when exposed to gadodiamide. Clinical, biochemical and pharmacological data were retrieved from medical records. RESULTS Cases had been exposed to a mean gadodiamide dose of 0.29 mmol/kg (range 0.18-0.50) shortly before first signs of nephrogenic systemic fibrosis. Controls had been exposed to 0.28 mmol/kg (0.13-0.49). Cumulative gadodiamide exposure while in chronic kidney disease stage 5 was significantly higher among cases compared with controls (0.41 vs 0.31 mmol/kg, P = 0.05) and among severe cases (n = 9) compared with non-severe cases (0.49 vs 0.33 mmol/kg, P = 0.02). Severe cases developed primarily among patients in regular haemodialysis therapy at exposure. Cases had higher serum concentrations of ionized calcium and phosphate than controls and tended to receive higher doses of epoietin-beta than controls at time of exposure. Severe cases were treated with higher doses of epoietin-beta than non-severe cases at exposure (10.8 vs 4.4 10(3) IU/week, P = 0.02). CONCLUSIONS Increasing cumulative gadodiamide exposure, high-dose epoietin-beta treatment, and higher serum concentrations of ionized calcium and phosphate increase the risk of gadodiamide-related nephrogenic systemic fibrosis in renal failure patients. Severe cases seem to develop primarily among patients in regular haemodialysis therapy at exposure.
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Affiliation(s)
- Peter Marckmann
- Department of Nephrology, Herlev Hospital, DK-2730 Herlev, Denmark.
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25
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Abstract
BACKGROUND Acute initiation of dialysis is associated with increased morbidity due to access and uremia complications. It is frequent despite early referral and regular out-patient control. We studied factors associated with end-stage renal disease (ESRD) progression in order to optimize the timing of dialysis access (DA). METHODS In a retrospective longitudinal study (Study 1), the biochemical and clinical course of 255 dialysis and 64 predialysis patients was registered to determine factors associated with dialysis-free survival (DFS). On the basis of these results an algorithm was developed to predict timely DA, defined as >6 weeks and <26 weeks before dialysis initiation, with too late placement weighted twice as harmful as too early. The algorithm was validated in a prospective study (Study 2) of 150 dialysis and 28 predialysis patients. RESULTS Acute dialysis was associated with increased 90-day hospitalization (17.9 vs. 9.0 days) and mortality (14% vs. 6%). P-creatinine and p-urea were poor indicators of DFS. At any level of p-creatinine, DFS was shorter with lower creatinine clearance and vice versa. Patients with systemic renal disease had a significantly shorter DFS than primary renal disease, due to faster GFR loss and earlier dialysis initiation. Short DFS was seen with hypoalbuminemia and cachexia; these patients were recommended early DA. The following algorithm was used to time DA (units: 1iM and ml/min/1.73 m2): P-Creatinine - 50 x GFR + (100 if Systemic Renal Disease) >200. Use of the algorithm was associated with earlier dialysis placement and a fall in acute dialysis requirements from 50% to 23%. The incidence of too early DA was unchanged (7% vs. 9%), and was due to algorithm non-application. The algorithm failed to predict imminent dialysis in 10% of cases, primarily due to acute exacerbation of stable uremia. Dialysis initiation was advanced by approximately one month. CONCLUSIONS A predialysis program based on early dialysis planning and GFR-based DA timing may reduce the requirement for acute dialysis initiation and patient morbidity and mortality, at the cost of slightly earlier dialysis initiation.
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Affiliation(s)
- J G Heaf
- Department of Nephrology, Copenhagen University Hospital, Herlev, Denmark.
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26
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Marckmann P, Skov L, Rossen K, Dupont A, Damholt MB, Heaf JG, Thomsen HS. Nephrogenic systemic fibrosis: suspected causative role of gadodiamide used for contrast-enhanced magnetic resonance imaging. J Am Soc Nephrol 2006; 17:2359-62. [PMID: 16885403 DOI: 10.1681/asn.2006060601] [Citation(s) in RCA: 966] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Nephrogenic systemic fibrosis is a new, rare disease of unknown cause that affects patients with renal failure. Single cases led to the suspicion of a causative role of gadodiamide that is used for magnetic resonance imaging. This study therefore reviewed all of the authors' confirmed cases of nephrogenic systemic fibrosis (n = 13) with respect to clinical characteristics, gadodiamide exposure, and subsequent clinical course. It was found that all had been exposed to gadodiamide before the development of nephrogenic systemic fibrosis. The delay from exposure to first sign of the disease was 2 to 75 d (median 25 d). Odds ratio for acquiring the disease when gadodiamide exposed was 32.5 (95% confidence interval 1.9 to 549.2; P < 0.0001). Seven (54%) patients became severely disabled, and one died 21 mo after exposure. No other exposure/event than gadodiamide that was common to more than a minority of the patients could be identified. These findings indicate that gadodiamide plays a causative role in nephrogenic systemic fibrosis.
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Affiliation(s)
- Peter Marckmann
- Department of Nephrology, Copenhagen University Hospital at Herlev, DK-2730 Herlev, Denmark.
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Heaf JG, Sarac S, Afzal S. A high peritoneal large pore fluid flux causes hypoalbuminaemia and is a risk factor for death in peritoneal dialysis patients. Nephrol Dial Transplant 2005; 20:2194-201. [PMID: 16030031 DOI: 10.1093/ndt/gfi008] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hypoalbuminaemia is common in peritoneal dialysis (PD) patients and has an associated high mortality. An excess morbidity and mortality has previously been found in patients with high peritoneal transport. A high peritoneal large pore fluid flux (Jv(L)) results in increased peritoneal loss of protein that possibly contributes to patient morbidity. Alternatively, hypoalbuminaemia and high transport status could be just a marker of capillary pathology associated with atherosclerotic comorbidity. METHODS Peritoneal dialysis capacity computer modelling of peritoneal transport, based on Rippe's three-pore model, was performed to measure Jv(L) in 155 incident PD patients 2-4 weeks after PD initiation. Patient clinical and biochemical status was determined -6, -3, -1, 1 and 6 months after PD initiation, and every 6 months thereafter. Jv(L) was redetermined in prevalent patients 2 and 4 years after PD initiation. RESULTS Jv(L) was 0.106+/-0.056 ml/min/1.73 m(2) (median 0.094, interquartile range 0.068-0.128). It was correlated to age*** (*P<0.05; **P<0.01; ***P<0.001) (20-30 years 0.079+/-0.04; 70 years 0.121+/-0.071), but not to gender. No correlation to diabetic or preexisting renal replacement therapy was seen, but patients with atherosclerosis had higher Jv(L) (0.123+/-0.06 vs 0.100+/-0.056*) as had patients with other systemic disease (0.121+/-0.68 vs 0.100+/-0.051*). Jv(L) was positively correlated to area parameter (r = 0.41***), and negatively correlated to plasma albumin (-0.36***). Patients were divided into three equal groups: group 1, Jv(L) <0.075 ml/min/1.73 m(2); group 2, 0.075-0.11; group 3: >0.11. There was no difference between the groups in p-albumin prior to PD. Immediately after PD start, differences between the three groups appeared (1 month p-albumin: (micromol/l) group 1, 548+/-83; group 2, 533+/-86; group 3, 497+/-78**), and persisted for up to 6 years. No significant change in Jv(L) was seen at 2 and 4 years. Patients with significant albuminuria also had hypoalbuminaemia (<1 g/day: 546+/-81 mumol/l; >2 g/day: 503+/-54 micromol/l). Intermittent PD ameliorated the effect of Jv(L) on albumin losses and clearance. Mortality was increased significantly with raised Jv(L), independently of age (2 year mortality: group 1, 10%, group 3, 32%*). There was no overall effect on technique survival, but hypoalbuminaemic group 3 patients had a higher failure rate. CONCLUSION Jv(L) is related to hypoalbuminaemia and mortality after PD initiation. A high Jv(L) seems to be a marker of preexisting vascular pathology, and to cause hypoalbuminaemia after PD initiation. It is suggested that peritoneal albumin loss can have an identical pathogenic effect as urinary albumin loss, by causing an iatrogenic "nephrotic" syndrome.
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Affiliation(s)
- J G Heaf
- Department of Nephrology B, Copenhagen University Hospital in Herlev, Herlev, Denmark.
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Abstract
MATERIAL AND METHODS One hundred and forty-four diabetic patients with biopsy-proven diffuse diabetic glomerulosclerosis (DIF), 134 patients with nodular diabetic nephropathy (NOD) and 152 diabetic patients with nondiabetic-related morphology (104 chronic nephropathy, 48 primary GN) were followed for up to 12 years to determine the clinical prognosis. RESULTS Comparing the NOD patients with the DIF patients, there were more females (41% vs 26%, p < 0.05) and they were more often uremic at biopsy (24% vs 12%, p < 0.01), but the age was similar (53.3 years vs 50.1 years, NS). There was no difference in diabetes type I and II incidence. Compared with the general population, the odds ratio (OR) for death was 7.2 (confidence interval 5.5-9.5) for DIF and 10.8 (8.5-13.7) for NOD. The OR for combined renal or patient death was: DIF 15.2 (11.7-19.7); NOD 24.6 (19.4-31.0). After correction for age, sex, and pre-existing uremia, NOD had a 1.70 (p < 0.01) times increased risk of death compared with DIF, and a 2.42 (p < 0.01) times increased risk of renal failure. The life expectancy for NOD was 4.0 years, and average time to dialysis was 2.1 years. NOD prognosis was similar to other chronic nephropathy. The incidence of all atherosclerotic complications except AMI was twice as high in NOD than DIF. Diabetes type had no influence on prognosis. The estimated incidence of diabetic nephropathy was 56/mio/year. CONCLUSION Nodular diabetic nephropathy has a poorer prognosis than diffuse due to a higher rate of atherosclerotic and uremic complications.
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Affiliation(s)
- J G Heaf
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Denmark.
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Abstract
The value of thrice weekly technetium-99m mercaptoacetyltriglycine renography after renal transplantation was investigated in 213 consecutive transplants. A grading system was used: 0 = normal renogram; 1 = normal uptake, reduced excretion; 2 = normal uptake, flat excretion curve; 3 = rising curve; 4 = reduced rate of uptake, rising curve and reduced absolute uptake; 5 = minimal uptake. The initial renogram grade (RG) was primarily a marker of ischaemic damage, being poorer with cadaver donation, long cold ischaemia (>24 h), and high donor and recipient age. High primary RG predicted primary graft non-function, long time to graft function, low discharge Cr EDTA clearance and low 1- and 5-year graft survival. Discharge RG predicted late (>6 months) graft loss. RG was highly correlated (P<0.001) with creatinine and creatinine clearance, and changes in RG were correlated with changes in renal function. A change in RG of 0.5 was non-specific, while a change of 1 or more predicted clinical complications in 95% of cases. The negative predictive value was low (58%). RG change antedated clinical diagnosis in only 38% of cases, and in only 14% of acute rejections did an RG change of 1 or more antedate a rising creatinine. RG did not contribute to the differential diagnosis between acute rejection, acute tubulointerstitial nephropathy and cyclosporine toxicity. In conclusion, an initial renography after transplantation is valuable as it measures ischaemic damage and predicts duration of graft non-function and both short and long-term graft survival. A review of the literature suggests that the indication for serial scintigraphic monitoring for functioning grafts is less certain: the diagnostic specificity is insufficient for it to be the definitive investigation for common diagnostic problems and it does not give sufficient advance warning of impending problems.
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Affiliation(s)
- J G Heaf
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Denmark
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Heaf JG, Honoré K, Valeur D, Randlov A. The effect of oral protein supplements on the nutritional status of malnourished CAPD patients. ARCH ESP UROL 1999; 19:78-81. [PMID: 10201347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- J G Heaf
- Department of Nephrology B, Copenhagen University Hospital in Herlev, Denmark
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Heaf JG, Jensen SB, Jensen K, Ali S, von Jessen F. The cellular clearance theory does not explain the post-dialytic small molecule rebound. Scand J Urol Nephrol 1998; 32:350-5. [PMID: 9825399 DOI: 10.1080/003655998750015322] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
AIM (a) To determine the normalized cellular clearance (Kcn) of urea, creatinine and phosphate in patients undergoing maintenance hemodialysis; (b) To identify the factors, particularly circulatory, which determine Kcn; (c) To evaluate whether intra-dialytic blood sampling can predict the size of the post-dialytic solute concentration rebound. METHODS Kinetic modelling of urea, creatinine and phosphate, using a two-pool variable volume computer simulation, was performed on two occasions on 34 patients undergoing maintenance dialysis. The cellular clearance was determined (a) from the size of the rebound 50 min after the end of dialysis; (b) from a mid-dialytic blood sample. Conventional two-dimensional M-mode echocardiography and Doppler peripheral blood pressure measurement were performed. RESULTS The model produced accurate measurements of rebound Kc for urea in 93% of measurements, creatinine in 49% and phosphate in 13%. The corresponding figures for mid-dialysis Kcn were 76%, 39% and 0%. The rebound Kcn was, for urea, 8.31 +/- 4.31 ml/kg/min, and for creatinine 4.07 +/- 2.98. The mid-dialysis Kcn was, for urea, 8.57 +/- 4.25 ml/kg/min, and for creatinine 5.06 +/- 3.36. High post-dialytic rebounds (and low Kcn values) were associated with erythropoietin use (p < 0.05) and occurrence of end-dialytic hypotension (p < 0.02). Patients treated with calcium antagonists had a significantly (p < 0.001) higher Kcn. There was no correlation between mid-dialysis and rebound Kcn. Circulatory indices had no influence on Kcn. CONCLUSIONS The two-pool cellular clearance model is compatible with urea kinetics, but not creatinine or phosphate. It is therefore unlikely that it is the correct model for small molecule kinetics. The post-dialytic solute rebound may be partly an iatrogenic phenomenon and can be reduced by preventing post-dialytic hypotension and by calcium antagonist treatment, both of which improve regional blood flow. The size of the rebound cannot be predicted by intra-dialytic blood sampling.
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Affiliation(s)
- J G Heaf
- Department of Nephrology, State University Hospital, Copenhagen, Denmark
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Abstract
It has been suggested that poor long-term prognosis of acute rejection is due to hyperfiltration-mediated injury secondary to the initial renal damage, rather than to ongoing immunological mechanisms. A total of 953 renal transplant recipients was reviewed to examine the effect of acute rejection episodes on graft function and survival; 40% had no rejections, 45% one, 12% two and 3% three. Rejection episodes adversely affected short- and long-term prognosis (5-year survival for no rejections, 62%; one, 34%; two, 26%; three, 19%, P < 0.001) and creatinine clearance at one year (cl 1) (none, 56.7 ml/ min; one, 51.1; two, 52.9; three, 35.2, P < 0.01). This was mainly due to increased graft loss, but patient survival was also reduced (5-year survival for no rejections, 77%; one, 76%; two, 63%; three, 53%, P < 0.05). There was no overall effect of rejection number, independently of cl 1. However, subgroup analysis showed a detrimental effect of rejection number on grafts with high residual function, i.e. cl 1 > 60 ml/min (5-year graft survival none and one, 87%; two and three, 71%, P < 0.01). Late initial rejection episodes adversely affected prognosis (5-year survival 1-7 days, 34%; 8-60, 31%; 60-300, 21%, P < 0.05) and residual graft function (cl 1 1-7 days, 56.2 ml/min; 8-60, 48.7; 60-300, 44.6, P < 0.01). In conclusion, the poor long-term prognostic effect of rejection episodes is mainly, but not entirely, related to initial graft destruction. Late (> 2 months after transplantation) initial rejection is an important independent risk factor for graft loss.
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Affiliation(s)
- J G Heaf
- Department of Nephrology P, State University Hospital, Copenhagen OE, Denmark.
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Heaf JG, Løkkegård H. Parathyroid hormone during maintenance dialysis: influence of low calcium dialysate, plasma albumin and age. J Nephrol 1998; 11:203-10. [PMID: 9702872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
UNLABELLED Intact PTH measurements between 1989-96 in a 116-patient (63 HD, 53 PD) dialysis unit were reviewed to evaluate the determinants of PTH. Prophylactic treatment included calcium carbonate and maximal alphacalcidol therapy. A forward stepwise multiple regression analysis showed that duration of dialysis, phosphate, albumin and chronic glomerulonephritis were independently positively correlated with PTH, and that ionized calcium, parathyroidectomy, age, diabetic nephropathy and systemic disease were independently negatively correlated. During the first five years of dialysis PTH rose from 124 ng/L (SD range 33-462) to 160 (63-402)* in HD patients but fell from 119 ng/L (33-423) to 88 (31-251)** in PD patients despite the less intensive treatment. PTH fell with increasing age (40-50 years 173 ng/L (52-575); > 60 years 100 (31-316)**) and hypoalbuminemia (< 400 micromol/L 68 ng/L (22-209); > 550 pmol/1138 (41-457)**). PD patients were generally older and increasingly malnourished; after correcting for these factors, no influence of dialysis modality on PTH could be seen. Low-calcium dialysate (1.25 mmol/L) was introduced for both dialysis groups in 1994. Consequent to this, aluminium consumption was virtually eliminated and consumption of alphacalcidol increased. PTH fell from 161 to 128 ng/L in HD patients but rose from 119 to 135 ng/L in PD patients. The incidence of parathyroidectomy fell from 4.3%/year to 1.5%/year*. CONCLUSION Malnourishment and increasing age reduce PTH secretion and are important determinants of hyperparathyroidism during maintenance dialysis. Adynamic bone disease is common in PD patients and associated with low PTH levels, and may be a consequence of malnourishment and involutional changes. The introduction of low-calcium dialysate reduced the incidence of parathyroidectomy. Control of hyperparathyroidism improved in HD but not PD patients.
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Affiliation(s)
- J G Heaf
- Department of Nephrology, Herlev University Hospital, Copenhagen, Denmark
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34
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Heaf JG, Ladefoged J. Hyperfiltration, creatinine clearance and chronic graft loss. Clin Transplant 1998; 12:11-8. [PMID: 9541417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic graft loss (CGL) may be caused by immunological- or hyperfiltration-mediated tissue destruction. If the hyperfiltration theory is correct, grafts from female donors given to heavy recipients, and having a relatively poor initial function, should suffer an accelerated rate of loss of function. 590 renal transplantations surviving more than 1 yr, including 171 cases of (CGL), were reviewed to identify causes of CGL. No overall influence of recipient or donor sex was found, but female donation resulted in lower acute graft loss and higher CGL. Warm ischemia affected CGL marginally, but cold ischemia < 12 h (excluding living donors) reduced CGL (35 vs. 53% at 10 yr, p < 0.05) and delayed function increased CGL (38% vs. 56% p < 0.001). Patients with a high urea production had high CGL (43% vs. 77%, p < 0.02). No overall effect of recipient weight was found; however 7 patients weighing > 90 kg all had CGL within 10 yr. Creatinine clearance was increasingly correlated to recipient weight (r = 0.23 at 1 yr, 0.38 at 10 yr, p < 0.001). For all years, change in creatinine clearance correlated with change in weight (p < 0.001). The most important factor predicting CGL was creatinine clearance, (> 80 ml/min: 6% at 10 yr; 20-40 ml/min 53%). However, at any level of creatinine clearance, patients with late CGL had a slower loss of renal function. Rate of change of renal function was proportional to creatinine clearance, but only for grafts surviving > 6 yr. Creatinine clearance rose between 3 mths and 2 yr; this rise indicated a good prognosis, was related to recipient weight and weight increase, and was reduced in older donors and cyclosporine treated patients. For patients with low clearance (< 60 ml/min), the increased CGL seen in patients with previous rejection episodes could be explained by their consequent lower clearance, but above this level, rejection episodes had an independent deleterious effect. These findings are compatible with hyperfiltration being the major cause of CGL after 6 yr. Before this immunological factors dominate. Good quality grafts respond to the increased protein load of heavy recipients with an increased GFR. Thus at any time, graft GFR is a function of protein-induced hyperfiltration, immunological graft destruction and hyperfiltration-mediated damage. Hyperfiltration-mediated renal damage is not a problem if the creatinine clearance is greater than 60 ml/min.
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Affiliation(s)
- J G Heaf
- Department of Nephrology P, State University Hospital, Blegdamsvej, Copenhagen, Denmark.
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Wahlberg J, Wilczek HE, Fauchald P, Nordal KP, Heaf JG, Olgaard K, Hansen JM, Lokkegaard H, Mueller EA, Kovarik JM. Consistent absorption of cyclosporine from a microemulsion formulation assessed in stable renal transplant recipients over a one-year study period. Transplantation 1995; 60:648-52. [PMID: 7570970 DOI: 10.1097/00007890-199510150-00005] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
To evaluate the pharmacokinetic properties of the new microemulsion formulation of cyclosporine (Sandimmun Neoral), a double-blind, prospective study in stable renal transplant recipients was performed. The patients were randomized on a 4:1 basis either to receive Sandimmun Neoral (n = 45) or continue on regular Sandimmun (n = 12). Before randomization, a steady-state pharmacokinetic profile study was performed in all patients while they were still on regular Sandimmun. Pharmacokinetic assessments were then performed after 8 and 12 weeks and after 1 year. A milligram-to-milligram dose conversion was shown to be adequate to maintain the patients within a predefined target therapeutic window. Changes in pharmacokinetic parameters after conversion to Sandimmun Neoral were consistent with an increased rate and extent of cyclosporine absorption from the Neoral formulation. This was reflected by a shorter time to reach peak concentration and also by a mean increase in peak concentration by 67%, and an overall mean increase in drug exposure (area under the curve) by 34%. These findings were also confirmed 1 year after conversion. Furthermore, significantly reduced intraindividual variability in pharmacokinetic parameters was found, as well as improvements in the correlation between trough concentrations and area under the curve after conversion to Sandimmun Neoral. In conclusion, our results indicate an improved and consistent absorption of cyclosporine from the Neoral formulation, which should make clinical management easier and safer.
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Affiliation(s)
- J Wahlberg
- Department of Transplantation Surgery, University Hospital, Uppsala, Sweden
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Joffe P, Heaf JG, Jensen LT. Type I procollagen propeptide in patients on CAPD: its relationships with bone histology, osteocalcin, and parathyroid hormone. Nephrol Dial Transplant 1995; 10:1912-7. [PMID: 8592603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Serum procollagen type I carboxyterminal propeptide (PICP) has been shown to be a useful marker of bone formation in patients undergoing haemodialysis. However, PICP levels has not been evaluated in depth in patients maintained on continuous ambulatory peritoneal dialysis (CAPD). Therefore serum and dialysate levels of PICP, its peritoneal clearance (Clp), mass transfer (MTp), and its possible relationship with osteocalcin, parathyroid hormone (PTH), and bone histomorphometry were studied in a group of CAPD patients. Serum PICP was just above the normal range with significant amounts detected in the dialysate but no correlations were found between levels of serum PICP, dialysate PICP, and Clp-PICP. One patient with systemic lupus and osteitis fibrosa had extraordinarily high serum and dialysate levels of PICP. The patient later developed sclerosing peritonitis. No associations were seen between serum PICP and Clp-PICP and any of the 18 bone histomorphometric parameters evaluated. Dialysate level of PICP correlated negatively with mineral appositional rate (r = -0.62, P < 0.01) and mineralization lag time (r = 0.64, P < 0.01). MTp-PICP correlated positively with mineral appositional rate (r = 0.65, P < 0.01). Serum osteocalcin and serum PTH levels did not correlate to serum, dialysate, Clp or MTp measurements of PICP. These results suggest that measurements of PICP in CAPD patients do not give substantial information as an non-invasive marker of bone histology.
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Affiliation(s)
- P Joffe
- Department of Nephrology, Hvidovre Hospital, Denmark
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Abstract
Serum osteocalcin has been found to correlate with bone formation. However, present literature gives only limited data on osteocalcin and bone histomorphometry in patients undergoing peritoneal dialysis. This study assessed serum osteocalcin, dialysate osteocalcin, peritoneal clearance of osteocalcin (Clp-osteocalcin) and mass transfer of osteocalcin (MTp-osteocalcin), and evaluated relationships between these values and bone histomorphometry. Eighteen patients were treated by continuous ambulatory peritoneal dialysis (CAPD). Bone biopsies, serum and dialysate osteocalcin, serum levels of parathyroid hormone, alkaline phosphatase, aluminum, phosphate, Ca2+ and vitamin D3 metabolites were measured at the start and in 10 of the patients a year later. Serum osteocalcin was found to be elevated. Osteocalcin was detected in the dialysate resulting in significant values of Clp-osteocalcin and MTp-osteocalcin. Serum and dialysate levels of osteocalcin correlated significantly (r = 0.66, P < 0.001) and like MTp-osteocalcin with serum levels of alkaline phosphatase and PTH. Histomorphometry showed that osteitis fibrosa was the predominant bone disease detected. Serum concentration of osteocalcin correlated with osteoid thickness, eroded and osteoclast surfaces, aluminum staining, and some of the bone dynamic parameters. Dialysate osteocalcin, MTp-osteocalcin, PTH and alkaline phosphatase correlated with practically the same histomorphometric parameters as serum osteocalcin. No correlations were seen between Clp-osteocalcin and any histomorphometric parameters. Serum osteocalcin was elevated above the normal range, and significant positive correlations between serum osteocalcin and bone formation parameters were found. Serum osteocalcin correlated with almost the same histomorphometric parameters as PTH. Thus, serum levels of PTH and osteocalcin gave additional information to one another as non-invasive parameters in this group of patients.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P Joffe
- Department of Nephrology, Hvidovre Hospital, University of Copenhagen, Denmark
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Heaf JG, Pødenphant J, Gammelgaard B. The reliability and representativity of non-dynamic bone histomorphometry in uremic osteodystrophy. Scand J Urol Nephrol 1993; 27:305-10. [PMID: 8290908 DOI: 10.3109/00365599309180439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In order to evaluate the reliability and representativity of iliac crest bone biopsy in uremic osteodystrophy, non-dynamic bone histomorphometry was performed post-mortem on the right and left iliac crests and the 3rd lumbar vertebra in 20 patients with chronic uremia. High (> 0.8) right-left correlation coefficients were found for bone volume, osteoid volume, osteoid surface, osteoid thickness, eroded surface, osteoclast surface and aluminium labelling intensity; moderate (0.7-0.8) for trabecular thickness, and low (< 0.7) for cortical thickness, porosity and aluminium bone concentration. High iliac crest-vertebra correlations were found for trabecular thickness, osteoid volume, osteoid surface, eroded surface, osteoclast surface and aluminium labelling intensity, and low correlations for bone volume, osteoid thickness and bone aluminium concentration. In conclusion, non-dynamic iliac trabecular bone indices are reliable variables and, with the possible exception of bone mass determination, indicative of systemic bone disease. Bone aluminium concentration and cortical bone indices are unreliable measures of uremic bone disease. These reservations apply to the diagnostic use of biopsy in individuals, but not necessarily its research use in groups of patients.
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Affiliation(s)
- J G Heaf
- Department of Nephrology P, Rigshospitalet, Copenhagen, Denmark
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Heaf JG. [Analysis of phenprocoumon dose regulation based on measurement of coagulation factors II, VII and X]. Ugeskr Laeger 1992; 154:1036-9. [PMID: 1566514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
One hundred anticoagulation treatment records were reviewed retrospectively using stepwise regression analysis to determine the influence of phenprocoumaron on the levels of coagulation factors 2, 7 and 10 (KF) measured relative to normal. The phenprocoumaron dose was expressed relative to the correct maintenance dose determined from the entire record ("overdose", OD measured in mg). Phenprocoumaron treatment influenced the KF over two days, approximately 50% on each day, the total change being -0.03 x OD. Continuous incorrect dosage resulted in KF change, equilibrating at a new level after about four weeks at -0.47 x OD. Similarly, continuous correct dosage in patients with a non-therapeutic FK resulted in equilibration within the therapeutic range after four weeks. For long-term treatment, the dosage was likely to be inaccurate under the following circumstances: 1) if the KF was outside the therapeutic range and moving away from it; 2) if the KF was inside the therapeutic range and the change was greater than 0.05. Algorithms for calculation of phenprocoumaron therapy are presented.
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Affiliation(s)
- J G Heaf
- Medicinsk afdeling B, Centralsygehuset Hillerød
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Joffe P, Hyldstrup L, Heaf JG, Pødenphant J, Henriksen JH. Bisphosphonate kinetics in patients undergoing continuous ambulatory peritoneal dialysis: relations to dynamic bone histomorphometry, osteocalcin and parathyroid hormone. Am J Nephrol 1992; 12:419-24. [PMID: 1292341 DOI: 10.1159/000168492] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In the evaluation of renal osteodystrophy bone biopsy is often performed. However, a reliable noninvasive test could be very useful, and recently the estimation of osseous tracer uptake as an index of bone formation has been introduced-the bone bisphosphonate clearance (BBC). The aim of the present investigation therefore was to compare BBC with parameters of bone histology, serum levels of osteocalcin, alkaline phosphatase, and parathyroid hormone in patients (n = 8) undergoing continuous ambulatory peritoneal dialysis (CAPD). No significant correlations were found between BBC values and the bone histomorphometrical variables measured. A positive correlation was seen between serum osteocalcin and resorption and active resorption surface (p < 0.05), as well as tetracycline-labelled surface, bone formation rate, surfaces, volume and tissue referents, respectively (p < 0.01). Furthermore, levels of alkaline phosphatase showed significant correlations to mineral appositional rate, tetracycline-labelled surface and bone formation rate, volume referent (p < 0.05). Values of parathyroid hormone were significantly correlated to resorption surface (p < 0.02), active resorption surface, mineral appositional rate and mineralization lag time (p < 0.05). In conclusion, BBC was of no use in patients treated with CAPD as a noninvasive test for evaluation of bone histomorphometry. However, osteocalcin correlated best with resorption and bone dynamics indices. Levels of alkaline phosphatase and parathyroid hormone were of a more limited value.
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Affiliation(s)
- P Joffe
- Department of Nephrology, Hvidovre Hospital, University of Copenhagen, Denmark
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Heaf JG. [Hyperlipidemia in nephrotic syndrome]. Ugeskr Laeger 1991; 153:2414-6. [PMID: 1949240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Hyperlipidemia is common in patients with the nephrotic syndrome. The main cause is probably increased hepatic lipogenesis, a non-specific reaction to falling oncotic pressure secondary to hypoalbuminemia. Cardiovascular morbidity and mortality are increased in patients with the nephrotic syndrome, with the exception of patients with minimal change disease. It is not clear whether this is caused by the hypercholesterolemia or secondary to uremia or medical treatment. Experiments suggest that hypercholesterolemia may cause glomerulosclerosis, a common complication of the nephrotic syndrome. The hypercholesterolemia of the nephrotic syndrome can now be treated effectively with HMG coenzyme A reductase inhibitors.
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Affiliation(s)
- J G Heaf
- Nefrologisk afdeling P, Rigshospitalet, København
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Joffe P, Olsen F, Heaf JG, Gammelgaard B, Pödenphant J. Aluminum concentrations in serum, dialysate, urine and bone among patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Clin Nephrol 1989; 32:133-8. [PMID: 2791364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Aluminum (Al) concentration in serum, urine, and dialysate was estimated in 21 patients undergoing continuous ambulatory peritoneal dialysis (CAPD). In 12 of the patients bone Al concentration was measured as well. Mean serum Al level was 32.4 +/- 21.0 micrograms/l. The Al concentrations in the dialysate and urine were 9.1 +/- 4.1 micrograms/l and 52.5 +/- 47.3 micrograms/l, respectively. Bone Al concentration was 21.0 +/- 14.9 ppm and correlated significantly with concentrations of Al in serum (p less than 0.01) and dialysate (p less than 0.01). A mass transfer (MT) from the patients to the dialysate was observed in all patients (-44.0 +/- 28.8 micrograms/24 h). There was a highly significant correlation between peritoneal Al MT and serum Al (p less than 0.001), actual Al consumption (p less than 0.05) and bone Al concentration (p less than 0.005) supporting the existence of an overflow phenomenon. Despite very low Al levels in the dialysate, patients are at risk of elevated Al levels in the serum, dialysate, urine and bone because of consumption of Al-containing phosphate binders.
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Affiliation(s)
- P Joffe
- Department of Nephrology, Hvidovre Hospital, University of Copenhagen, Denmark
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Abstract
45 bone biopsies from patients with chronic uremia were reviewed to define which noninvasive investigations were of value in predicting the histological diagnosis and to quantify the spectrum of uremic bone disease at a center that has consistently used an aluminum-free dialysis bath. 17 biopsies were taken postmortem. 15 patients received conservative treatment, the rest were on maintenance dialysis. 13 patients had symptomatic bone disease. Virtually all patients with a uremia duration greater than 3 years had uremic osteodystrophy. All patients with clinical bone disease, hypercalcemia or raised alkaline phosphatase activity had osteodystrophy, but the specific histology was not indicated. Greatly raised parathyroid levels suggested secondary hyperparathyroidism, but the test was only 100% specific when 20 times normal. Total aluminum consumption was highly indicative of bone aluminum concentration (p less than 0.0001) and aluminum-related osteomalacia (5 cases), suggesting that a considerable proportion of uremic bone disease is iatrogenic. Serum aluminum was of some use in the diagnosis of aluminum-related osteomalacia, but was not wholly reliable. Bone mineral content (BMC) using both forearm measurements and total body bone mineral levels (TBBM) were assessed in 32 patients and were found to be reduced in 12, with a preponderance of secondary hyperparathyroidism. BMC and TBBM were negatively correlated to resorbing surfaces and bone formation rate, suggesting that secondary hyperparathyroidism is the uremic bone disease that represents the greatest threat to bone mass. It is concluded that while noninvasive investigations give considerable information, reliable diagnosis requires the use of histological methods.
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Heaf JG, Pødenphant J, Joffe P, Andersen JR, Fugleberg S, Braendstrup O. The effect of oral aluminium salts on the bone of non-dialysed uremic patients. Scand J Urol Nephrol 1987; 21:229-33. [PMID: 3433024 DOI: 10.3109/00365598709180327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
12 patients with conservatively treated uremia were investigated using bone histomorphometry, bone aluminium concentration determination and total body bone mineral content (TBBM). The bone aluminum was raised in 10 patients and was significantly related to oral aluminium salt consumption (p less than 0.01). Two of four patients who had not received aluminium also had raised levels but the difference was not significant from nonuremic patients. The two patients with the highest levels had a mineralisation defect despite normal levels of 1,25-dihydroxyvitamin D. Three patients had significant bone loss of whom one had osteomalacia (OM) while two had secondary hyperparathyroidism (2HP). It is concluded that 1) aluminium salt consumption results in bone aluminium accumulation, and may contribute to the mineralisation defect; 2) uremic patients not treated ith aluminium salts may have slightly raised levels, but this seems not to be clinically important; 3) secondary hyperparathyroidism causes greater destruction of bone mass than other uremic bone diseases; 4) atomic absorption spectrometry is a more sensitive method for detecting aluminium bone deposition than histochemical methods.
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Affiliation(s)
- J G Heaf
- Department of Nephrology, Hvidovre Hospital
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Heaf JG, Pødenphant J, Andersen JR. Bone aluminum deposition in maintenance dialysis patients treated with aluminium-free dialysate: role of aluminium hydroxide consumption. Nephron Clin Pract 1986; 42:210-6. [PMID: 3945361 DOI: 10.1159/000183669] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Postmortem iliac crest biopsies were performed on 16 uremic patients. 3 had been treated conservatively while 13 had been entered into a maintenance dialysis program. The dialysate was treated by reverse osmosis for more than 10 years, and the aluminium concentration was consistently below the detection limit of 0.15 mol/l. 14 patients had been treated with aluminium hydroxide. Bone histomorphometry, aluminium labelling intensity, osteoid surface aluminium labelling extent (Al/OBI) and bone aluminium concentration were measured. 14 patients had significant bone aluminium deposition, including 2 who were not on dialysis of whom 1 had not received aluminium hydroxide. Bone aluminium concentration and labelling intensity were correlated to total aluminium hydroxide consumption (p less than 0.001, p less than 0.05) and present dose (p less than 0.01, p less than 0.01), while Al/OBI was not. The two patients with the highest aluminium concentrations had symptomatic osteomalacia, but 4 patients with significantly raised concentrations and mineralisation front labelling had secondary hyperparathyroidism. It is concluded that bone aluminium deposition occurs despite the use of aluminium-free dialysate and is associated with total and present aluminium hydroxide consumption; heavy aluminium deposition is associated with severe and symptomatic osteomalacia, but can also be observed in the presence of predominant hyperparathyroidism; aluminium deposition can occur in the absence of treatment with dialysis or aluminium hydroxide; bone aluminium concentration and labelling intensity are a better measure of bone deposition than Al/OBI.
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Pødenphant J, Heaf JG, Joffe P. Metabolic bone disease and aluminium contamination in 38 uremic patients. A bone histomorphometric study. Acta Pathol Microbiol Immunol Scand A 1986; 94:1-6. [PMID: 3962676 DOI: 10.1111/j.1699-0463.1986.tb02956.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Iliac crest biopsies from 38 uremic patients, 26 hemodialysis, and 12 chronic uremics from a nephrology department with verified aluminium free dialysis water were investigated with histomorphometric method and aluminium-specific staining. For both the uremic and the dialysed group the results showed a high incidence of both metabolic bone disease (75%, 69% respectively) and aluminium contamination (25%, 62%).
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Abstract
The amplitude of the QRS wave of the electrocardiogram was correlated with conventional serum electrolyte concentrations in 94 nonhypertensive and 53 hypertensive patients. There was a highly significant correlation of QRS amplitude with serum albumin level in both groups. There was also significant correlation with serum calcium level in the nonhypertensive group, but this significance disappeared after correction for albumin. Changes in the serum albumin level during the hospital admission of the nonhypertensive patients were positively correlated with changes in QRS amplitude. Albumin infusion into 13 healthy persons resulted in significantly increased QRS amplitude, which was related to changes in serum albumin concentration. These results suggest that changes in serum protein concentration cause changes in QRS amplitude, possibly as a result of increased conductivity.
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Nielsen LP, Heaf JG. [Serum aluminum in hemodialysis patients. Relation to osteodystrophy, encephalopathy and aluminum hydroxide consumption]. Ugeskr Laeger 1983; 145:1363-7. [PMID: 6868163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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