COVID 19 and myoclonus, do hemodialysis patients have more risk?

We discuss two recent cases from our hospital in which two patients with ESKD receiving periodical hemodialysis (HD) and SarS-Cov-2 infection suffered movement disorders, being the onset related to the HD sessions in both. First case is a 78 year-old woman who is admitted with generalized myoclonic status epilepticus and second case is a 46 year-old male who starts repeatedly suffering myoclonus during his hemodialysis sessions on day +10 after testing positive (asymptomatic infection). There are two main hypotheses when it comes to myoclonus and CNS disorders in COVID19, post-hypoxic origin and inmunomediated postinfectious origin. We wonder if they could both be interacting in patients with kidney disease, and especially in those who receive hemodialysis, maximizing the risk of suffering this type of disorders.

Standardizing health outcomes for chronic kidney disease. Adaptation of the international consortium for health outcomes measurement standard set to the Spanish setting

BACKGROUND AND OBJECTIVES

We aim to adapt the International Consortium for Health Outcomes Measurements standard set for chronic kidney disease (CKD) patients to the Spanish setting and supplement it with those variables agreed upon through initiatives proposed by the Spanish Society of Nephrologists (S.E.N.).

MATERIAL AND METHODS

The working group defined a first standard set of variables based on a literature review. The S.E.N. members then assessed the suitability of each variable for inclusion (Consensus≥75%). A second draft of the standard set was generated and evaluated by the Patient advocacy group Federación Nacional de Asociaciones para la Lucha Contra las Enfermedades del Riñón (ALCER). Lastly, the working group established the final standard set of variables (Consensus≥75%).

RESULTS

The standard set targets patients with very high-risk CKD (G3a/A3 and G3b/A2-G5) in pre-end-stage kidney disease (pre-ESKD), hemodialysis (HD), peritoneal dialysis (PD), kidney transplantation (KT) or conservative care (CC). The essential follow-up variables agreed for all patients (All) were patient survival, hospitalizations, cardiovascular events, smoking status, health-related quality of life, pain, fatigue, physical function, daily activities, depression, renal function and hemoglobin. Additionally, it was agreed to collect PD survival (in PD patients), peritonitis (PD), infection/bacteremia (PD, HD, KT), vascular access type (HD), vascular access survival (HD), acute rejection (KT), post-transplant cancer (KT), albuminuria (KT) and kidney allograft survival (KT). The optional variables agreed were phosphorus (All), potassium (All), diabetes control (All with diabetes), and albuminuria (pre-ESKD).

CONCLUSIONS

This standard set may constitute a highly efficient tool allowing the evaluation of patient outcomes and helping to define strategies to enhance CKD patients' quality of care in the Spanish healthcare system.

[Characterization of hospitalized patients with acute kidney injury associated with COVID-19 in Spain: Renal replacement therapy and mortality. FRA-COVID SEN Registry Data]

Background and objectives

Acute kidney injury (AKI) is common among hospitalized patients with COVID-19 and associated with worse prognosis. The Spanish Society of Nephrology created the AKI-COVID Registry to characterize the population admitted for COVID-19 that developed AKI in Spanish hospitals. The need of renal replacement therapy (RRT) therapeutic modalities, and mortality in these patients were assessed.

Material and method

In a retrospective study, we analyzed data from the AKI-COVID Registry, which included patients hospitalized in 30 Spanish hospitals from May 2020 to November 2021. Clinical and demographic variables, factors related to the severity of COVID-19 and AKI, and survival data were recorded. A multivariate regression analysis was performed to study factors related to RRT and mortality.

Results

Data from 730 patients were recorded. A total of 71.9% were men, with a mean age of 70 years (60-78), 70.1% were hypertensive, 32.9% diabetic, 33.3% with cardiovascular disease and 23.9% had some degree of chronic kidney disease (CKD). Pneumonia was diagnosed in 94.6%, requiring ventilatory support in 54.2% and admission to the ICU in 44.1% of cases.The median time from the onset of COVID-19 symptoms to the appearance of AKI (37.1% KDIGO I, 18.3% KDIGO II, 44.6% KDIGO III) was 6 days (4-10). A total of 235 (33.9%) patients required RRT: 155 patients with continuous renal replacement therapy, 89 alternate-day dialysis, 36 daily dialysis, 24 extended hemodialysis and 17 patients with hemodiafiltration. Smoking habit (OR 3.41), ventilatory support (OR 20.2), maximum creatinine value (OR 2.41) and time to AKI onset (OR 1.13) were predictors of the need for RRT; age was a protective factor (0.95). The group without RRT was characterized by older age, less severe AKI, shorter kidney injury onset and recovery time (p < 0.05). 38.6% of patients died during hospitalization; serious AKI and RRT were more frequent in the death group. In the multivariate analysis, age (OR 1.03), previous chronic kidney disease (OR 2.21), development of pneumonia (OR 2.89), ventilatory support (OR 3.34) and RRT (OR 2.28) were predictors of mortality while chronic treatment with ARBs was identified as a protective factor (OR 0.55).

Conclusions

Patients with AKI during hospitalization for COVID-19 had a high mean age, comorbidities and severe infection. We defined two different clinical patterns: an AKI of early onset, in older patients that resolves in a few days without the need for RRT; and another more severe pattern, with greater need for RRT, and late onset, which was related to greater severity of the infectious disease. The severity of the infection, age and the presence of CKD prior to admission were identified as risk factors for mortality in these patients. In addition chronic treatment with ARBs was identified as a protective factor for mortality.

Humoral response after the fourth dose of the SARS-CoV-2 vaccine in the CKD spectrum: a prespecified analysis of the SENCOVAC study

Background

There is scarce evidence on fourth doses of SARS-CoV-2 vaccines in chronic kidney disease (CKD) patients. We have evaluated the humoral response and effectivity of the fourth dose in the CKD spectrum: non-dialysis CKD (ND-CKD), hemodialysis (HD), peritoneal dialysis (PD) and kidney transplant (KT) recipients.

Methods

This is a prespecified analysis of the prospective, observational, multicentric SENCOVAC study. In patients with CKD who had received a complete initial vaccination and one or two boosters and had anti-Spike antibody determinations 6 and 12 months after the initial vaccination, we analyzed factors associated to persistent negative humoral response and to higher anti-Spike antibody titers as well as the efficacy of vaccination on COVID-19 severity.

Results

Of 2186 patients (18% KT, 8% PD, 69% HD and 5% ND-CKD), 30% had received a fourth dose. The fourth dose increased anti-Spike antibody titers in HD (P = 0.001) and ND-CKD (P = 0.014) patients and seroconverted 72% of previously negative patients. Higher anti-Spike antibody titers at 12 months were independently associated to repeated exposure to antigen (fourth dose, previous breakthrough infections), previous anti-Spike antibody titers and not being a KT. Breakthrough COVID-19 was registered in 137 (6%) patients, of whom 5% required admission. Admitted patients had prior titers below 620 UI/ml and median values were lower (P = 0.020) than in non-admitted patients.

Conclusions

A fourth vaccine dose increased anti-Spike antibody titers or seroconverted many CKD patients, but those with the highest need for a vaccine booster (i.e. those with lower pre-booster antibody titers or KT recipients) derived the least benefit in terms of antibody titers. Admission for breakthrough COVID-19 was associated with low anti-Spike antibody titers.

Real clinical experience after one year of treatment with tolvaptan in patients with autosomal dominant polycystic kidney disease

Background

Tolvaptan (TV) is the first vasopressin-receptor antagonist approved for the treatment of autosomal dominant polycystic kidney disease (ADPKD). No publications report TV experience in real clinical practice during the first year of treatment.

Methods

A prospective study of an initial cohort of 220 rapidly progressing patients treated with TV for 12 months. The tolerability of TV, the evolution of the estimated glomerular filtration rate (eGFR), analytical parameters, and blood pressure were analyzed.

Results

A total of 163 patients (78.2%) received TV for 1 year. The main causes of treatment withdrawal were the aquaretic effects (11%), eGFR deterioration (5%), and hepatic toxicity (2.3%). eGFR decreased significantly after 1 month of treatment without further changes. The decrease in eGFR in the first month was higher in patients with an initially higher eGFR. The eGFR drop during the first year of treatment with TV was lower than that reported by patients in the 2 years prior to TV treatment (–1.7 ± 7.6 vs. –4.4 ± 4.8 mL/min, p = 0.003). Serum sodium and uric acid concentrations increased, and morning urinary osmolality decreased in the first month, with no further changes. Blood pressure decreased significantly without changes in antihypertensive medication.

Conclusion

TV treatment is well tolerated by most patients. Liver toxicity is very rare and self-limited. TV reduces eGFR in the first month without showing further changes during the first year of treatment. Patients with a higher starting eGFR will suffer a greater initial drop, with a longer recovery. We suggest using the eGFR observed after a month of treatment as the reference for future comparisons and calculating the rate of eGFR decline in patients undergoing TV treatment.

Anti-Spike antibodies three months after SARS-CoV-2 mRNA vaccine booster dose in patients on hemodialysis: the prospective SENCOVAC study

Introduction

Patients on hemodialysis are at high-risk for complications derived from coronavirus disease-19 (COVID-19). The present analysis evaluated the impact of a booster vaccine dose and breakthrough severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections on humoral immunity three months after the booster dose.

Methods

This is a multicentric and prospective study assessing IgG anti-Spike antibodies 6 and 9 months after initial SARS-CoV-2 vaccination in patients on hemodialysis that had also received a booster dose before the 6-month assessment (early booster) or between the 6- and 9-month assessments (late booster). The impact of breakthrough infections, type of vaccine, time from the booster and clinical variables were assessed.

Results

A total of 711 patients (67% male, 67 [20-89] years) were included. Of which, 545 (77%) received an early booster and the rest a late booster. At 6 months, 64 (9%) patients had negative anti-Spike antibody titers (3% of early booster and 29% of late booster patients, p = 0.001). At 9 months, 91% of patients with 6-month negative response had seroconverted and there were no differences in residual prevalence of negative humoral response between early and late booster patients (0.9% vs 0.6%, p = 0.693). During follow-up, 35 patients (5%) developed breakthrough SARS-CoV-2 infection. Antibody titers at 9 months were independently associated to mRNA-1273 booster (p = 0.001), lower time from booster (p = 0.043) and past breakthrough SARS-CoV-2 infection (p&lt;0.001).

Conclusions

In hemodialysis patients, higher titers of anti-Spike antibodies at 9 months were associated to mRNA-1273 booster, lower time from booster and past breakthrough SARS-CoV-2 infection.

Management of Kidney Failure in Patients with Diabetes Mellitus: What Are the Best Options?

Diabetic kidney disease (DKD) is the most frequent cause of kidney failure (KF). There are large variations in the incidence rates of kidney replacement therapy (KRT). Late referral to nephrology services has been associated with an increased risk of adverse outcomes. In many countries, when patients reach severely reduced glomerular filtration rate (GFR), they are managed by multidisciplinary teams led by nephrologists. In these clinics, efforts will continue to halt chronic kidney disease (CKD) progression and to prevent cardiovascular mortality and morbidity. In patients with diabetes and severely reduced GFR and KF, treating hyperglycemia is a challenge, since some drugs are contraindicated and most of them require dose adjustments. Even more, a decision-making process will help in deciding whether the patient would prefer comprehensive conservative care or KRT. On many occasions, this decision will be conditioned by diabetes mellitus itself. Effective education should cover the necessary information for the patient and family to answer these questions: 1. Should I go for KRT or not? 2. If the answer is KRT, dialysis and/or transplantation? 3. Dialysis at home or in center? 4. If dialysis at home, peritoneal dialysis or home hemodialysis? 5. If transplantation is desired, discuss the options of whether the donation would be from a living or deceased donor. This review addresses the determinant factors with an impact on DKD, aiming to shed light on the specific needs that arise in the management and recommendations on how to achieve a comprehensive approach to the diabetic patient with chronic kidney disease.

Monographic consultation of onconephrology. Rationale and implementation

The increase in demand for medical care for renal complications associated with neoplastic diseases is a reality in most nephrology departments. In response to this overall situation, the creation of healthcare models such as monographic consultations and develop training programs in Onconephrology could improve the care of these patients. Through an exploratory and descriptive study, we identified current situation of kidney involvement in cancer patients. The objective of the present study is to establish the criteria for specific assistance in the field of Onconephrology. For this, we have reviewed key aspects and analyzed the current situation in our country, through a survey addressed to all nephrologists through the Spanish Society of Nephrology., together with the experience of two Spanish centers. From this information, we have established some requirements and recommendations for the start-up of these consultations.

Monographic consultation of onconephrology. Rationale and implementation

The increase in demand for medical care for renal complications associated with neoplastic diseases is a reality in most nephrology departments. In response to this overall situation, the creation of healthcare models such as monographic consultations and develop training programs in onconephrology could improve the care of these patients. Through an exploratory and descriptive study, we identified current situation of kidney involvement in cancer patients. The objective of the present study is to establish the criteria for specific assistance in the field of onconephrology. For this, we have reviewed key aspects and analyzed the current situation in our country, through a survey addressed to all nephrologists through the Spanish Society of Nephrology, together with the experience of 2 Spanish centers. From this information, we have established some requirements and recommendations for the start-up of these consultations.

Analysis of Patient Flow into Dialysis: Role of Education in Choice of Dialysis Modality

♦ Background

Despite advances in predialysis care, morbidity and mortality remain high.

♦ Objectives

To analyze end-stage renal disease (ESRD) patient demographics and clinical data on education on dialysis treatment options, type of chronic renal replacement therapy (RRT), and effects of planned versus non-planned dialysis start.

♦ Methods

621 patients, from 24 Spanish hospitals, who started RRT in 2002. Peritoneal or vascular access at dialysis initiation was considered “planned.”

♦ Results

304 (49%) patients were non-planned and half of them had prior nephrology follow-up. Of the patients with ≥3 months nephrology follow-up (76% of all), only half were educated on dialysis modalities. Dialysis education was associated with planned start in 73.4% versus 26% in non-educated patients ( p < 0.05), shorter follow-up (55 vs 65 months, p = 0.033), more medical visits in the prior year (6.5 vs 4.4, * p < 0.001), more patients starting peritoneal dialysis (31% vs 8.3%*), and more specific follow-up by ESRD unit versus general nephrology care (63% vs 26%*). Non-planned start was associated with older age (63 vs 60.6 years, p = 0.06), fewer medical visits (4.6 vs 6.4*), less education about modality options, and greater use of hemodialysis (92% vs 75%*). Planned patients had better biochemical parameters at start of dialysis.

♦ Conclusion

Despite nephrology follow-up, half the patients did not have a planned dialysis start. Planned start was associated with better clinical status. More patients chose peritoneal dialysis when educated about dialysis modality options. ESRD-specific units were more likely to provide patient education.

[Cardiovascular risk in women with chronic renal failure: mammographic study of vascular calcifications]

OBJECTIVES

Vascular calcifications are markers of cardiovascular risk in patients with chronic renal failure, and 50% of the deaths in chronic renal failure are due to cardiovascular disease. We analyzed vascular calcifications at mammography in women with chronic renal failure, comparing the vascular calcifications seen at mammography and in skeletal x-ray examinations and analyzing their relation to cardiovascular disease and laboratory parameters.

MATERIALS AND METHODS

We studied the vascular calcifications seen at mammography and in skeletal x-ray examinations in 61 patients (45 dialysis and 16 pre-dialysis) and correlated them with age, time in dialysis, cardiovascular signs and symptoms, glycemia, arterial blood pressure, PTH, phosphorus, calcium, cholesterol (LDL/HDL), atherogenic index, triglycerides, and inflammatory markers. The statistical analysis was performed using SPSS 11.0 .

RESULTS

Vascular calcifications were found in 55.7% of patients at mammography and in a similar percentage in skeletal x-ray examinations; 18% of the women had vascular calcifications at mammography but not in skeletal x-ray examinations, whereas 19.6% had vascular calcifications in skeletal x-ray examinations but not at mammography. Vascular calcifications were found in 60% of the women undergoing dialysis and in 30% of the women who had yet to undergo dialysis. Women with vascular calcifications at mammography were older (p < 0.05), had higher blood glucose (p < 0.05), PTH, phosphorus, and LDL cholesterol. They also had higher ferritin and C-reactive protein levels (p < 0.05) and had more cardiovascular events (myocardial infarction, with p < 0.05). Their HDL and albumin levels (p < 0.05) and blood pressure were lower than in women without vascular calcifications at mammography.

CONCLUSIONS

The presence of vascular calcifications at mammography is associated to increased cardiovascular risk, and this increase is already evident before dialysis. Early diagnosis of cardiovascular risk should help reduce morbidity and mortality in these patients. The study of vascular calcifications at mammography complements skeletal x-ray examinations. Vascular calcifications at mammography are associated to abnormalities in bone metabolism, dyslipemia, and chronic inflammation.

[Comparative study of PTFE grafts in forearm vs cuffed permanent catheters]

INTRODUCTION

As is universally accepted the best form of permanent vascular access for haemodialysis is the native arteriovenous fistula. A second and third options are the politetrafluoroethylene (PTFE) AV grafts and the cuffed, tunneled, internal catheters. The overall performance and complications of catheters is clearly inferior to AV fistula. There are not many studies that compare permanent catheters to grafts in terms of functionality, survival and complications.

METHODS

We analyzed 81 vascular accesses carried out from october 99 to december 03 in 59 patients and during a follow-up period of 35 months. Two groups were considered. Group 1, catheters (n 42) and group 2, grafts (n 39). Clinical aspects, comorbidity index (Wright and Kanh), dialysis dose and complications and survival of the access were registered.

RESULTS

Both groups were similar in age, sex, time on haemodialysis, number of previous accesses and hospitalization days. Cardiovascular morbidity and comorbidity index were significantly higher in patients with catheter. While blood flow during dialysis was higher in grafts both groups showed no significant differences in parameters of efficacy of dialysis (Kt/V, TAC BUN and PCRn). Serum albumin was lower in patients with catheter. The number of accesses that failed was higher in the graft group being thrombosis the main complication followed by infection. Kaplan-Meier curves showed better accumulated survival of permanent catheters versus grafts (61,4% vs 9,8% at 35 months). The most frequent complication of catheter was infection while in the case of grafts it was thrombosis followed by infection.

CONCLUSIONS

Although they were placed in patients with higher comorbidity, cuffed, tunneled catheters showed less number of complications and better survival than PTFE grafts in our patients in haemodialysis. The main cause of failure of both vascular access was thrombosis followed by infection. The dose of dialysis obtained was no different in both groups. Cuffed, tunneled permanent catheters are a very interesting option in a number of patients in haemodialysis and they can be an option to consider in those patients with vascular difficulties and higher comorbidities.

Analysis of patient flow into dialysis: role of education in choice of dialysis modality

BACKGROUND

Despite advances in predialysis care, morbidity and mortality remain high.

OBJECTIVES

To analyze end-stage renal disease (ESRD) patient demographics and clinical data on education on dialysis treatment options, type of chronic renal replacement therapy (RRT), and effects of planned versus non-planned dialysis start.

METHODS

621 patients, from 24 Spanish hospitals, who started RRT in 2002. Peritoneal or vascular access at dialysis initiation was considered "planned."

RESULTS

304 (49%) patients were non-planned and half of them had prior nephrology follow-up. Of the patients with >3 months nephrology follow-up (76% of all), only half were educated on dialysis modalities. Dialysis education was associated with planned start in 73.4% versus 26% in non-educated patients (p < 0.05), shorter follow-up (55 vs 65 months, p = 0.033), more medical visits in the prior year (6.5 vs 4.4, *p < 0.001), more patients starting peritoneal dialysis (31% vs 8.3%*), and more specific follow-up by ESRD unit versus general nephrology care (63% vs 26%*). Non-planned start was associated with older age (63 vs 60.6 years, p = 0.06), fewer medical visits (4.6 vs 6.4*), less education about modality options, and greater use of hemodialysis (92% vs 75%*). Planned patients had better biochemical parameters at start of dialysis.

CONCLUSION

Despite nephrology follow-up, half the patients did not have a planned dialysis start. Planned start was associated with better clinical status. More patients chose peritoneal dialysis when educated about dialysis modality options. ESRD-specific units were more likely to provide patient education.

[Renal hyperparathyroidism's control after subtotal parathyroidectomy]

Parathyroidectomy, in any of its forms, is considered an effective short-term treatment of renal hyperparathyroidism in patients who are not being controlled with drugs. Nevertheless, the outcome in the medium and long term of the various surgical procedures is still unclear and seems a controversial issue. We conducted a prospective study of 15 patients undergoing subtotal parathyroidectomy who were followed up for a period of 48 months after surgery. All patients were included in hemodialysis programmes. Elevated levels of parathyroid hormone which did not decrease with drug therapy recommended parathyroidectomy. The aim of our study is to determine whether subtotal parathyroidectomy is an effective technique in the medium and long term. As regards the results obtained, the levels of parathyroid hormone and calcemia remarkably decreased during the follow-up period, if compared to pre-surgery levels. The level of alkaline phosphatase also showed a reduction and the "hungry bone effect" was observed. The phosphorus and Ca-P product levels only showed a significant reduction immediately after surgery but showed an increment from the first year after surgery onwards. Hemoglobin levels did not show any alteration after parathyroidectomy. In two patients we observed a relapse of hyperparathyroidism. The anatomopathological examination revealed nodular hyperplasia in most of the cases, including the two relapses.

CONCLUSION

Subtotal parathyroidectomy is an effective surgical procedure in the medium-term treatment of renal hyperparathyroidism.

[Cardiac failure and diastolic disfunction in hemodialysis patients: associated factors]

Heart failure (CHF) and diastolic dysfuction (DD) relationship has received poor attention in hemodialysis patients (HD).

OBJECTIVE

To analyse the incidence of CHF in our HD patients, the relationship with DD and impact on mortality.

METHODS

We studied 79 patients: 48 +/- 15 years old, mean time on HD 83 +/- 63 months. Vascular calcification (PVC) was evaluated by radiologic series (55.7%). We analyzed the presence of clinical and analytical cardiovascular factors. All patients underwent M-mode, two-dimensional, Doppler echocardiography. Patients were followed for two years. Clinical information collected: incidence of ischemic heart disease (IHD), CHF, and mortality due to cardiovascular events.

RESULTS

Most frequent finding was Left Ventricular Hypertrophy (LVH) (93%), followed by DD (63.5% had anormal LV relaxation) (ALVR). Incidence of CHF was 38.3%; and was significantly associated with higher: time on HD (130/72 months), Ca x P (74/65), PTH (677/376), bone alkaline phosphatase (27/16), and systolic BP (145 vs 130 mmHg); IHD, PVC, valvular calcification (VC), LVH and ALVR (p < 0.01). Systolic function was normal in both groups (with/without CHF). Logistic regression identified as risk factors for CHF: ALVR (OR: 9.5), IHD (OR: 15) and systolic BP (OR: 2.2). ALVR was associated with greater age (55/37), longer time on HD (76/60), PVC and VC (p < 0.001). Predictor factors identified were age (OR: 2.13) and PVC (OR: 3.9).

CONCLUSIONS

HD patients showed a high incidence of CHF. IHD, systolic BP and DD (ALVR) have behave as risk factors for CHF. Vascular calcifications were intimately related to these findings and, therefore, they contribute to the greater mortality of these patients.

[Early treatment of secondary hyperparathyroidism in moderate renal insufficiency: low-phosphorus diet versus calcium carbonate]

Calcitriol deficiency and phosphorus retention are mechanisms involved in the pathogenesis of renal hyperparathyroidism. The aim of this study was to evaluate the effect of dietary phosphorus restriction versus calcium carbonate treatment for one month on PTH and calcitriol levels in patients with mild renal failure. We studied two groups of patients: Group I: 21 patients (14M/7F); mean age 61 years old; mean glomerular filtration rate 51 ml/min. Their diet contained phosphorus 700 mg/day. Group II: 30 patients (21M/9F); mean age 58; mean glomerular rate 56 ml/min. They were divided in two subgroups: 18 patients treated with calcium carbonate 2.5 g/day and 12 patients with 5 g/day. Serum PTH, calcitriol, 25(OH)D3, calcium, phosphorus and urinary excretion of calcium and phosphorus were measured before and after a 30 day period. The low phosphorus diet (Group I) resulted in a significant decrease in PTH levels (81.3 +/- 35 vs 71 +/- 39 pg/ml, p < 0.05) and significant increase in calcitriol levels (22.4 +/- 4.4 vs 33.4 +/- 7.5 pg/ml, p < 0.05). In our study calcium carbonate treatment (Group II) had no effect on PTH and calcitriol levels.

Vascular calcification in the uremic patient: a cardiovascular risk?

BACKGROUND

Several factors suggest that the presence of vascular calcification (VC) is associated with a high risk of cardiac events in uremic patients. The aim of this study was to analyze the influence of VC on cardiac morbidity and mortality in our hemodialysis (HD) patients.

METHODS

We studied 79 patients on HD: 43 males, mean age 48 +/- 15 years old, mean time on HD 83 +/- 63 months. The presence of VC was evaluated by radiologic series. Other cardiovascular risk factors analyzed were arterial hypertension, diabetes mellitus, obesity, cigarette smoking, anemia, and dyslipidemia. All patients underwent M-mode, two-dimensional, Doppler echocardiography. Patients were followed for two years. During this time, clinical information collected included predialysis blood pressure, incidence of ischemic heart disease, episodes of congestive heart failure, and mortality due to cardiovascular event.

RESULTS

VC was observed in 55.7% of patients. Left ventricular hypertrophy, diastolic dysfunction, and cardiac valve calcification were significantly associated with VC. Ischemic heart disease (71.4% vs. 28.6%) and episodes of cardiac failure (0.41 vs. 0.18 per year; P < 0.05) appeared more frequently in the patient group with VC. VC was present in 80.6% of patients who developed episodes of heart failure. Eight patients died from cardiac disease; each of them had VC.

CONCLUSION

The presence of VC can help to identify those HD patients with a higher cardiovascular risk.

[Prognostic significance of programmed dialysis in patients who initiate renal substitutive treatment. Multicenter study in Spain]

BACKGROUND

The aim of our study was to analyse patient characteristics, mortality and costs, all of them in relation to whether starting dialysis was planned or unplanned.

METHODS

A total of 362 patients (227 male and 135 female) from five hospitals of the National Health System, who were started on chronic renal replacement therapy (RRT) during 1996 and 1997 were included. Patients who were started on RRT after acute renal failure were excluded. We carried out a retrospective analysis of the demographic characteristics, patients' conditions at the time of initiating dialysis and outcome and costs at six and thirty-six months of treatment. Patients were classified as planned (PL-D) or unplanned dialysis (UNPL-D), depending on whether or not the patient had a vascular or peritoneal access ready to use for initiating RRT.

RESULTS

One hundred and eighty-six patients (51.4%) started on dialysis in the PL-D group whereas 176 (48.6%) did it as UNPL-D. In this latter group, 135 (37.3% of the total) had previously been monitored by a nephrologist, and 41 (11.3%) initiated dialysis without previous nephrological follow-up. UNPL-D was associated with older age (p < 0.001), non-nephrological follow-up (p < 0.001), diabetes (34.7% vs 22.6%) (p = 0.011), haemodialysis as a first mode of RRT (94.9 vs 81.7%) (p < 0.001), higher comorbidity risk (p < 0.001), dialysis initiation with uraemic symptoms or fluid overload (p < 0.001), increased blood transfusion requirement (p < 0.001) and lower serum albumin (p < 0.001), creatinine clearance (p < 0.001), haemoglobin concentration (p < 0.001), and weight (p = 0.002). In the PL-D group the main primary renal diseases were glomerular and polycystic disease, whereas interstitial and diabetic nephropathy were higher in UNPL-D group (p = 0.005). Multivariate analysis showed that previous non nephrological follow-up, uraemic symptoms, interstitial nephritis as primary renal disease correlated with UNPL-D initiation, and it was followed by choosing haemodialysis as first RRT. UNPL-D was also associated with increased number of days of hospitalization at the initiation of dialysis, and during the first 6 months (p < 0.001), increase of hospitalization days (p = 0.009), and increased 6-month-mortality (10.2% vs 3.2%) (p = 0.015, log rank test), and three-year mortality (24.2 vs 36.9%) (p = 0.006, log rank test). The costs of UNPL-D were fivefold that of the PL-D group.

CONCLUSION

UNPL-D has been associated with worse overall clinical conditions at the initiation of chronic replacement therapy, choosing haemodialysis as first RRT, increased morbi-mortality and subsequent increase of costs.

[Effects of dietary phosphorus restriction on the production of 1,25(OH)2D3 (calcitriol) in patients with moderated renal failure]

Calcitriol deficiency and phosphate retention are two main factors in the pathogenesis of renal hyperparathyroidism. In spite of normal serum levels, phosphate may have an important role even in moderate RI. The aim of this study was to evaluate the effect of dietary phosphorus restriction on serum levels of calcitriol in patients with moderate RI. We studied 21 patients (7 F/14 M); mean age 61.7 +/- 15 years old; corrected creatinine clearance 51.4 +/- 14 ml/m. Serum PTH, calcitriol 25(OH)D3, calcium, phosphorus and urinary excretion of calcium and phosphorus were measured before and after 30 days on phosphorus restricted diet (700 mg/day).

RESULTS

[table: see text]

CONCLUSIONS

Our patients with moderate RI have elevated serum levels of PTH while calcitriol was in the lower normal range. Dietary phosphorus restriction resulted in a significant decrease in PTH levels and a significant increase in serum calcitriol concentrations. The levels of 25(OH)D3 did not change in this study.

Bone alkaline phosphatase isoenzyme in renal osteodystrophy

Serum total alkaline phosphatase is the most commonly used biochemical marker of bone disease in renal patients, but alkaline phosphatase originates from different organs and sometimes lacks specificity. Bone isoenzyme measurement is considered superior to total alkaline phosphatase for the assessment of bone metabolism. We have studied the value of bone isoenzyme, determined by a new. IRMA (Tandem-R-Ostase), in haemodialysis patients with secondary hyperparathyroidism and renal osteodystrophy. Fifty-six haemodialysis patients were studied. Intact parathyroid hormone (PTH), osteocalcin, total alkaline phosphatase and bone alkaline phosphatase were determined. A transiliac bone biopsy was performed in 20 of the 56 patients after double tetracycline labelling. There was a significant correlation between bone alkaline phosphatase and PTH (r = 0.79, P < 0.001) and between bone and total alkaline phosphatase (r = 0.84, P < 0.001) in all patients. The patients who underwent a bone biopsy showed osteitis fibrosa in 17, mixed lesion in one, adynamic bone disease in one and normal bone in one. Bone alkaline phosphatase showed a significant correlation with static and dynamic histomorphometric indices similar to that obtained with PTH and better than those of total alkaline phosphatase and osteocalcin. It is concluded that bone alkaline phosphatase (ostase) seems to be a useful non-invasive marker of bone metabolism in patients on haemodialysis with high turnover bone disease. More studies are necessary to know its value in low turnover bone disease.