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PURPOSE OF REVIEW: There is an excess of cardiovascular morbidity and mortality in the maintenance haemodialysis population. Targeting traditional risk factors (e.g. hypercholesterolaemia) do not improve cardiovascular outcomes. Repeated myocardial stunning during haemodialysis is an important nontraditional risk, resulting in pathological cardiac remodelling and fibrosis. This review explores dialysate cooling as a management strategy to promote haemodynamic stability, reduce myocardial injury, and improve cardiovascular disease outcomes for individuals receiving maintenance haemodialysis. RECENT FINDINGS: Observational data and small interventional studies demonstrate dialysate cooling has the potential to reduce end-organ damage and provide cardioprotection, renal protection and neuroprotection compared with standard care. These data are limited by the small sample sizes, short follow-up times and lack of long-term patient important outcomes. The MyTEMP study, a multicentre pragmatic randomized controlled trial, demonstrated cooled dialysate (0.5°C below body temperature) vs. standard care did not improve cardiovascular outcomes for prevalent haemodialysis patients. SUMMARY: Dialysate cooling has been widely adopted into routine clinical practice; the MyTEMP study challenges the unit-level approach to implementing dialysate cooling. Due to methodological limitations, the absence of other important patient outcome measures, and lack of granularity of patient-level data, dialysate cooling should not be hastily removed from all dialysis care and warrants further research.
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Purpose of Program: We initiated the Renal Community Photo Initiative to better understand why some hemodialysis users express significant capacities for resilience and hope, demonstrating outward-looking perspectives and enjoying a rich quality of life. Sources of Information: "Photovoice" is a participatory research methodology that encourages individuals to develop positive self-perceptions with photography. Photovoice empowers participants as informants within their communities. Visual arts researchers surveyed existing Photovoice studies to identify gaps in knowledge to be addressed in this study, including challenges related to fostering participant agency and social action. Images and logs were collected and reviewed during organized, participant-led substudy groups. These meetings provided researchers with core study values and direction as to how the images and additional information should be used to raise awareness about living with chronic kidney disease. Methods: To address the complexity of the human condition, the Renal Community Photo Initiative offered participants an array of diverse and accessible image-making techniques. No narrative directives for image-making were provided. This qualitative, interdisciplinary, participant-centric study invited adult chronic hemodialysis patients in 4 dialysis units in London and Stratford, Ontario, to participate. The research team designed a selection of different, accessible photo technologies for participant use. Eligible participants were invited to select photographic technologies and given the additional option to write accompanying logs. Researchers organized substudy meetings for participant-led focus groups to discuss core study values and personal encounters with images and image-making. Participants directed how their generated images should be shared with the public and researchers. Key Findings: A total of 40 participants have been recruited to date, producing more than 1600 images and an archive of handwritten logs. Three participant-led focus groups have established priorities for image sharing and a core set of values for subsequent study phases. A series of public presentations of participant images took place. The research team will pursue further public presentation opportunities and the development of a suitable research database. Limitations: Organizing and categorizing images for access in an interdisciplinary research database remains a challenge. Current health and safety protocols related to COVID-19 require the study to pause recruitment and substudy meetings and reassess immediate outputs for visuals. Implications: A qualitative study of this scope offers a new model for participant agency and collaboration. It requires the onboarding of interdisciplinary researchers to effectively engage with its significant image and log archive. Participants should remain involved in directing future steps for disseminating their images. Following substudy directives, researchers are developing visuals for health care and public settings, and determining opportunities for participants to share their experience in both clinic- and public-based settings.
Objectif du programme: Nous avons lancé la Renal Community Photo Initiative afin de mieux comprendre pourquoi certains utilisateurs de l'hémodialyse font preuve d'importantes capacités de résilience et d'espoir, sont tournés vers le monde extérieur et jouissent d'une riche qualité de vie. Sources: « Photovoice ¼ est une méthodologie de recherche participative qui encourage les individus à développer une perception de soi positive grâce à la photographie. Photovoice permet aux participants de devenir des informateurs au sein de leurs communautés. Les chercheurs en arts visuels ont mené une enquête sur les études existantes de Photovoice afin de révéler les lacunes dans les connaissances qui pourraient être comblées par la présente étude, notamment les défis liés à la promotion de la participation et de l'action sociale des participants. Des images et des registres ont été recueillis et examinés lors de sous-groupes d'étude organisés et dirigés par les participants par les participants. Ces réunions ont permis aux chercheurs de définir les valeurs fondamentales de l'étude et d'indiquer comment utiliser les images et les autres informations pour sensibiliser les gens à la vie avec maladie rénale chronique. Méthodologie: Afin d'aborder la complexité de la condition humaine, la Renal Community Photo Initiative a offert aux participants une gamme diverse et accessible de techniques de création d'images. Aucune directive narrative n'a été fournie pour la création des images. Cette étude qualitative, interdisciplinaire et axée sur les participants a invité des adultes suivant des traitements d'hémodialyse chronique dans quatre unités de dialyse de London et Stratford (Ontario) à participer. L'équipe de recherche a conçu une sélection de technologies photographiques diverses et accessibles à l'usage des participants. Les participants admissibles ont été invités à choisir des technologies photographiques et à tenir un journal s'ils le souhaitaient. Les chercheurs ont organisé des réunions de sous-étude pour des groupes de discussion dirigés par les participants afin de discuter des valeurs fondamentales de l'étude et des expériences personnelles avec les images et la création d'images. Les participants ont établi la façon dont leurs images devraient être partagées avec le public et les chercheurs. Principaux résultats: À ce jour, 40 participants ont été recrutés et plus de 1 600 images ont été produites, de même qu'une archive de journaux manuscrits. Trois groupes de discussion dirigés par les participants ont établi les priorités pour le partage des images ainsi qu'un ensemble de valeurs fondamentales en vue des phases ultérieures de l'étude. Plusieurs présentations publiques des images des participants ont eu lieu. L'équipe de recherche poursuivra les présentations publiques et l'élaboration d'une base de données de recherche. Limites: L'organisation et la catégorisation des images pour y accéder dans une base de données de recherche interdisciplinaire demeurent un défi. Les protocoles actuels de santé et de sécurité liés à la COVID-19 empêchent le recrutement et les réunions de sous-étude pour le moment et imposent de réévaluer les résultats immédiats pour les visuels. Conclusion: Une étude qualitative de cette envergure offre un nouveau modèle pour la participation et collaboration des patients. Elle exige l'intégration de chercheurs interdisciplinaires afin d'exploiter efficacement ses importantes archives d'images et de journaux. Il importe que les participants demeurent impliqués dans la direction des prochaines étapes de diffusion de leurs images. Suivant les directives de la sous-étude, les chercheurs développent des visuels pour les soins de santé et les milieux publics, et recensent les occasions pour les participants de partager leur expérience tant dans les milieux cliniques que publics.
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OBJECTIVES: To determine the associations between comorbidities, health-related quality of life (HRQoL) and functional impairment in people with mild-to-moderate chronic kidney disease (CKD) in primary care. DESIGN: Cross-sectional analysis at 5-year follow-up in a prospective cohort study. SETTING: Thirty-two general practitioner surgeries in England. PARTICIPANTS: 1008 participants with CKD stage 3 (of 1741 people recruited at baseline in the Renal Risk in Derby study) who survived to 5 years and had complete follow-up data for HRQoL and functional status (FS). PRIMARY AND SECONDARY OUTCOME MEASURES: HRQoL assessed using the 5-level EQ-5D version (EQ-5D-5L, with domains of mobility, self-care, usual activities, pain/discomfort and anxiety/depression and index value using utility scores calculated from the English general population), and FS using the Karnofsky Performance Status scale (functional impairment defined as Karnofksy score ≤70). Comorbidity was defined by self-reported or doctor-diagnosed condition, disease-specific medication or blood result. RESULTS: Mean age was 75.8 years. The numbers reporting some problems in EQ-5D-5L domains were: 582 (57.7%) for mobility, 166 (16.5%) for self-care, 466 (46.2%) for usual activities, 712 (70.6%) for pain/discomfort and 319 (31.6%) for anxiety/depression. Only 191 (18.9%) reported no problems in any domain. HRQoL index values showed greater variation among those with lower FS (eg, for those with Karnofsky score of 60, the median (IQR) EQ-5D index value was 0.45 (0.24 to 0.68) compared with 0.94 (0.86 to 1) for those with Karnofsky score of 90). Overall, 234 (23.2%) had functional impairment.In multivariable logistic regression models, functional impairment was independently associated with experiencing problems for all EQ-5D-5L domains (mobility: OR 16.87 (95% CI 8.70 to 32.79, p<0.001, self-care: OR 13.08 (95% CI 8.46 to 20.22), p<0.001, usual activities: OR 8.27 (95% CI 5.43 to 12.58), p<0.001, pain/discomfort: OR 2.94 (95% CI 1.86 to 4.67), p<0.001, anxiety/depression: 3.08 (95% CI 2.23 to 4.27), p<0.001). Higher comorbidity count and obesity were independently associated with problems in mobility, self-care, usual activities and pain/discomfort: for three or more comorbidities versus none: (mobility: OR 2.10 (95% CI 1.08 to 4.10, p for trend 0.002), self-care: OR 2.64 (95% CI 0.72 to 9.67, p for trend 0.05), usual activities: OR 4.20 (95% CI 2.02 to 8.74, p for trend <0.001), pain/discomfort: OR 3.06 (95% CI 1.63 to 5.73, p for trend <0.001)), and for obese (body mass index (BMI) ≥30 kg/m2) versus BMI <25 kg/m2: (mobility: OR 2.44 (95% CI 1.61 to 3.69, p for trend <0.001), self-care: OR 1.98 (95% CI 1.06 to 3.71, p for trend 0.003), usual activities: OR 1.82 (95% CI 1.19 to 2.76, p for trend 0.019), pain/discomfort: OR 2.37 (95% CI 1.58 to 3.55, p for trend <0.001)). Female sex, lower FS and lower educational attainment were independently associated with anxiety/depression (ORs 1.60 (95% CI 1.18 to 2.16, p 0.002), 3.08 (95% CI 2.23 to 4.27, p<0.001) and 1.67 (95% CI 1.10 to 2.52, p 0.009), respectively). Older age, higher comorbidity count, albuminuria (≥30 mg/mmol vs <3 mg/mmol), lower educational attainment (no formal qualifications vs degree level) and obesity were independently associated with functional impairment (ORs 1.07 (95% CI 1.04 to 1.09, p<0.001), 2.18 (95% CI 0.80 to 5.96, p for trend <0.001), 1.74 (95% CI 0.82 to 3.68, p for trend 0.005), 2.08 (95% CI 1.26 to 3.41, p for trend <0.001) and 4.23 (95% CI 2.48 to 7.20), respectively). CONCLUSIONS: The majority of persons with mild-to-moderate CKD reported reductions in at least one HRQoL domain, which were independently associated with comorbidities, obesity and functional impairment. TRIAL REGISTRATION NUMBER: National Institute for Health Research Clinical Research Portfolio Study Number 6632.
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Calidad de Vida , Insuficiencia Renal Crónica , Anciano , Comorbilidad , Estudios Transversales , Inglaterra/epidemiología , Femenino , Estado de Salud , Humanos , Estudios Prospectivos , Insuficiencia Renal Crónica/epidemiología , Encuestas y CuestionariosRESUMEN
The gastro-intestinal tract is being increasingly recognized as the site of key pathophysiological processes in the hemodialysis patient. Intestinal dysbiosis, increased intraluminal toxin production, and increased intestinal permeability are commonly observed processes which contribute to the pathogenesis of cardiovascular disease and thus elevated mortality. The acute circulatory effects of dialysis itself may contribute significantly to the development of gastrointestinal dysfunction as a result of both local and distant effects. Additionally, the liver, a relatively unknown entity in this process, has a substantial role as a functional barrier between the portal and systemic circulation and in the metabolism of pathogenic gut-derived uremic toxins. Here we summarize the evidence for acute gastro-intestinal and hepatic effects of hemodialysis and identify gaps in knowledge to date which require further study.
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Circulación Hepática/fisiología , Estrés Oxidativo , Diálisis Renal , Insuficiencia Renal Crónica/metabolismo , Circulación Esplácnica/fisiología , Toxinas Biológicas/efectos adversos , Humanos , Insuficiencia Renal Crónica/fisiopatología , Insuficiencia Renal Crónica/terapiaRESUMEN
OBJECTIVES: Although many secondary effects of high levels of vanadium (V) and chromium (Cr) overlap with symptoms seen in paediatric patients with chronic kidney disease (CKD), their plasma V and Cr levels are understudied. DESIGN: Ancillary cross-sectional study to a prospective, longitudinal, randomised controlled trial. SETTING: Children's Hospital of Western Ontario, London Health Sciences Centre, London, Ontario, Canada. PARTICIPANTS: 36 children and adolescents 4-18 years of age with CKD. INTERVENTIONS: 1-6 trace element measurements per patient. Cystatin C (CysC) estimated glomerular filtration rate (eGFR) was calculated using the Filler formula. Plasma V and Cr levels were measured using high-resolution sector field inductively coupled mass spectrometry. Anthropomorphic data and blood parameters were collected from our electronic chart programme. Water Cr and V data were obtained from the Ontario Water (Stream) Quality Monitoring Network. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes: plasma Cr and V. SECONDARY OUTCOMES: age, season, CysC, CysC eGFR, and Cr and V levels in environmental water. RESULTS: The median (IQR) eGFR was 51 mL/min/1.73 m2 (35, 75). The median V level was 0.12 µg/L (0.09, 0.18), which was significantly greater than the 97.5th percentile of the reference interval of 0.088 µg/L; 32 patients had at least one set of V levels above the published reference interval. The median Cr level was 0.43 µg/L (0.36, 0.54), which was also significantly greater than the established reference interval; 34 had at least one set of Cr levels above the published reference interval. V and Cr levels were moderately correlated. Only some patients had high environmental exposure. CONCLUSIONS: Our study suggests that paediatric patients with CKD have elevated plasma levels of V and Cr. This may be the result of both environmental exposure and a low eGFR. It may be necessary to monitor V and Cr levels in patients with an eGFR <30 mL/min/1.73 m2. TRIAL REGISTRATION NUMBER: NCT02126293; HC#172241.
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Cromo/sangre , Insuficiencia Renal Crónica/sangre , Vanadio/sangre , Agua/química , Adolescente , Niño , Preescolar , Estudios Transversales , Exposición a Riesgos Ambientales/análisis , Femenino , Tasa de Filtración Glomerular , Humanos , Estudios Longitudinales , Masculino , Ontario , Estudios Prospectivos , Análisis de RegresiónRESUMEN
Hemodynamic stress during hemodialysis (HD) results in recurrent segmental ischemic injury (myocardial stunning) that drives cumulative cardiac damage. We performed a fully comprehensive study of the cardiovascular effect of dialysis sessions using intradialytic cardiac magnetic resonance imaging (MRI) to examine the comparative acute effects of standard HD versus hemodiafiltration (HDF) in stable patients. We randomly allocated 12 patients on HD (ages 32-72 years old) to either HD or HDF. Patients were stabilized on a modality for 2 weeks before undergoing serial cardiac MRI assessment during dialysis. Patients then crossed over to the other modality and were rescanned after 2 weeks. Cardiac MRI measurements included cardiac index, stroke volume index, global and regional contractile function (myocardial strain), coronary artery flow, and myocardial perfusion. Patients had mean±SEM ultrafiltration rates of 3.8±2.9 ml/kg per hour during HD and 4.4±2.5 ml/kg per hour during HDF (P=0.29), and both modalities provided a similar degree of cooling. All measures of systolic contractile function fell during HD and HDF, with partial recovery after dialysis. All patients experienced some degree of segmental left ventricular dysfunction, with severity proportional to ultrafiltration rate and BP reduction. Myocardial perfusion decreased significantly during HD and HDF. Treatment modality did not influence any of the cardiovascular responses to dialysis. In conclusion, in this randomized, crossover study, there was no significant difference in the cardiovascular response to HDF or HD with cooled dialysate as assessed with intradialytic MRI.
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Sistema Cardiovascular/diagnóstico por imagen , Sistema Cardiovascular/fisiopatología , Imagen por Resonancia Magnética , Diálisis Renal , Estudios Cruzados , Femenino , Hemodiafiltración , Humanos , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
INTRODUCTION: Patient reported outcomes (PROs) are a critical metric documenting the impact of disease and treatment from the patient's perspective. A variety of generic and disease specific PRO measures (PROMs) are used in chronic kidney disease (CKD) but studies are primarily cross-sectional. None of the available PROMs are designed for frequent iterative application. METHODS: An online PROM for daily use in dialysis and CKD 4/5 patients was developed. The custom website utilised visual analogue scales to capture 6 PROs (general well being (GWB), pain, sleep, breathing, energy, and appetite). Outcomes of interest were uptake, response rates, intermodality variation, and change in PRO corresponding to predefined events. FINDINGS: Forty-three patients submitted at least once and 34 submitted beyond 30 days. Median follow-up was 247 days, 64% male, age 62 ± 12 years. In individuals submitting for >30 days, dialysis patients had significantly worse median scores compared to CKD for sleep (47[32-80], 97[76-99], P = 0.003), appetite (66[50-96], 97[88-100], P = 0.008), energy (47[40-89], 84[67-96], P = 0.031), and GWB (63[49-94], 93[71-98], P = 0.026). Patients demonstrated a variety of stable bandwidths of response, deviations from this were associated with specific events e.g., acute admission, vascular procedures, disturbed fluid status, and dialysis start. DISCUSSION: We successfully introduced an online, patient acceptable, iterative PROM that discriminates symptom burden, cross-sectionally, and longitudinally. Further work will prospectively examine the predictive power of changes in PRO and more rigorously investigate the potential use of these methods to optimise patient care.
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Medición de Resultados Informados por el Paciente , Diálisis Renal/métodos , Insuficiencia Renal Crónica/terapia , Estudios Transversales , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Calidad de Vida , Resultado del TratamientoRESUMEN
BACKGROUND/AIMS: Some angiotensin converting enzyme (ACE) inhibitors are efficiently removed from circulation by hemodialysis ('high dialyzability'), whereas others are not ('low dialyzability'). In patients receiving hemodialysis, this may influence the effectiveness of ACE inhibitors. METHODS: Using linked healthcare databases we identified older patients receiving chronic hemodialysis who filled new ACE inhibitor prescriptions. The low dialyzability group (n = 3,369) included fosinopril and ramipril. The high dialyzability group (n = 5,974) included enalapril, lisinopril, and perindopril. The primary outcome was all-cause mortality within 180 days of first ACE inhibitor prescription. RESULTS: There were 361 deaths among 5,974 patients (6.0%) prescribed with low dialyzability ACE inhibitors and 179 deaths among 3,369 patients (5.3%) prescribed with high dialyzability ACE inhibitors (relative risk 1.1, 95% CI 0.9-1.3, p = 0.6). CONCLUSION: In this study of older patients receiving hemodialysis, the dialyzability of ACE inhibitors was not associated with mortality or cardiovascular outcomes.
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Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Cardiotónicos/uso terapéutico , Enfermedades Cardiovasculares/sangre , Fallo Renal Crónico/sangre , Diálisis Renal/métodos , Anciano , Anciano de 80 o más Años , Inhibidores de la Enzima Convertidora de Angiotensina/sangre , Inhibidores de la Enzima Convertidora de Angiotensina/farmacocinética , Cardiotónicos/sangre , Cardiotónicos/farmacocinética , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/terapia , Enalapril/sangre , Enalapril/farmacocinética , Enalapril/uso terapéutico , Femenino , Fosinopril/sangre , Fosinopril/farmacocinética , Fosinopril/uso terapéutico , Hemorreología , Humanos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/terapia , Riñones Artificiales , Lisinopril/sangre , Lisinopril/farmacocinética , Lisinopril/uso terapéutico , Masculino , Persona de Mediana Edad , Perindopril/sangre , Perindopril/farmacocinética , Perindopril/uso terapéutico , Ramipril/sangre , Ramipril/farmacocinética , Ramipril/uso terapéutico , Diálisis Renal/instrumentación , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
Cardiovascular disease contributes significantly to the adverse clinical outcomes of peritoneal dialysis (PD) patients. Numerous cardiovascular risk factors play important roles in the development of various cardiovascular complications. Of these, loss of residual renal function is regarded as one of the key cardiovascular risk factors and is associated with an increased mortality and cardiovascular death. It is also recognized that PD solutions may incur significant adverse metabolic effects in PD patients. The International Society for Peritoneal Dialysis (ISPD) commissioned a global workgroup in 2012 to formulate a series of recommendations regarding lifestyle modification, assessment and management of various cardiovascular risk factors, as well as management of the various cardiovascular complications including coronary artery disease, heart failure, arrhythmia (specifically atrial fibrillation), cerebrovascular disease, peripheral arterial disease and sudden cardiac death, to be published in 2 guideline documents. This publication forms the first part of the guideline documents and includes recommendations on assessment and management of various cardiovascular risk factors. The documents are intended to serve as a global clinical practice guideline for clinicians who look after PD patients. The ISPD workgroup also identifies areas where evidence is lacking and further research is needed.
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Enfermedades Cardiovasculares/terapia , Enfermedades Metabólicas/terapia , Diálisis Peritoneal/efectos adversos , Guías de Práctica Clínica como Asunto , Adulto , Enfermedades Cardiovasculares/etiología , Manejo de la Enfermedad , Femenino , Humanos , Masculino , Enfermedades Metabólicas/etiología , Seguridad del Paciente , Diálisis Peritoneal/normas , Medición de Riesgo , Sociedades Médicas , Resultado del TratamientoRESUMEN
Cardiovascular mortality has remained high in patients on peritoneal dialysis (PD) due to the high prevalence of various cardiovascular complications including coronary artery disease, left ventricular hypertrophy and dysfunction, heart failure, arrhythmia (especially atrial fibrillation), cerebrovascular disease, and peripheral arterial disease. In addition, nearly a quarter of PD patients develop sudden cardiac death as the terminal life event. Thus, it is essential to identify effective treatment that may lower cardiovascular mortality and improve survival of PD patients. The International Society for Peritoneal Dialysis (ISPD) commissioned a global workgroup in 2012 to formulate a series of recommendation statements regarding lifestyle modification, assessment and management of various cardiovascular risk factors, and management of the various cardiovascular complications to be published in 2 guideline documents. This publication forms the second part of the guideline documents and includes recommendation statements on the management of various cardiovascular complications in adult chronic PD patients. The documents are intended to serve as a global clinical practice guideline for clinicians who look after PD patients. We also define areas where evidence is clearly deficient and make suggestions for future research in each specific area.
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Enfermedades Cardiovasculares/etiología , Enfermedades Cardiovasculares/terapia , Diálisis Peritoneal/efectos adversos , Fibrilación Atrial/etiología , Fibrilación Atrial/mortalidad , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/patología , Enfermedad de la Arteria Coronaria/etiología , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/mortalidad , Humanos , Hipertrofia Ventricular Izquierda/etiología , Hipertrofia Ventricular Izquierda/mortalidad , Masculino , Diálisis Peritoneal/normas , Guías de Práctica Clínica como Asunto , Pronóstico , Sociedades Médicas , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Análisis de SupervivenciaRESUMEN
A major component of increased mortality risk in people with chronic kidney disease (CKD) is associated with non-traditional cardiovascular risk factors including markers of inflammation. We studied whether a novel marker of systemic inflammation, elevated serum combined polyclonal immunoglobulin free light chains (cFLC), was an independent risk factor for increased all-cause mortality in people with CKD stage 3. In a prospective community based cohort study, 1695 participants with stage 3 CKD and no cases of monoclonal gammopathy had cFLC concentrations measured. cFLC levels were determined using the summation of Freelite kappa and lambda assays. All other bioclinical variables were collected at the time of sample collection. Kaplan-Meier plots and Cox proportional hazards analysis was used to assess the relationship between high cFLC levels (>43.3 mg/L) and mortality. There were 167 deaths (10%) after a median of 1375 days. cFLC levels at recruitment were higher in participants who died compared with those who were alive at the end of the study; median: 46.5 mg/L (IQR: 36.1-65.4 mg/L) and 35.4 mg/L (28.1-46.6 mg/L) respectively, P <0.001. Kaplan-Meier survival analysis demonstrated participants with cFLC >43.3 mg/L levels had an increased risk of mortality compared to people with normal cFLC levels (P <0.001). Elevated cFLC levels were independently associated with worse survival (Hazard ratio: 1.50; 95% confidence interval: 1.04-2.16; P=0.03). Other independent risk factors for worse survival were: older age, male gender, previous cardiovascular event, lower eGFR and higher high sensitivity C-reactive protein (hsCRP). To conclude, high cFLC levels predict increased mortality in people with stage 3 CKD, independent of established risk factors and other markers of inflammation.
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Cadenas kappa de Inmunoglobulina/sangre , Cadenas lambda de Inmunoglobulina/sangre , Insuficiencia Renal Crónica/sangre , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Estudios de Casos y Controles , Femenino , Humanos , MasculinoRESUMEN
Dialysis patients have high mortality rate and the leading cause of death is cardiovascular disease. Uremic cardiomyopathy differs from that due to conventional atherosclerosis, where cardiovascular changes result in ineffective circulation and lead to tissue ischemia. Modern dialysis has significant limitations with fluid management probably the most challenging. Current evidence suggests that both volume overload and aggressive fluid removal can induce circulatory stress and multi-organ injury. Furthermore, we do not have accurate volume assessment tools. As a result, targeting euvolemia might result in more harm than benefit with conventional hemodialysis therapy. Therefore, it might be time to consider a degree of permissive over-hydration until we have better tools to both determine ideal weight and improve current renal replacement therapy so that the process of achieving it is not so fraught with the current dangers.
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Enfermedades Cardiovasculares/etiología , Fallo Renal Crónico/terapia , Diálisis Renal/efectos adversos , Desequilibrio Hidroelectrolítico/prevención & control , Líquidos Corporales , Peso Corporal , Fluidoterapia , Humanos , Desequilibrio Hidroelectrolítico/etiologíaRESUMEN
Endothelial dysfunction is a key initiating event in vascular disease in chronic kidney disease (CKD) patients and haemodialysis (HD) patients exhibit significant vascular abnormalities. To understand this further, we examined how ex vivo intrinsic function in isolated arteries correlates with in vivo assessments of cardiovascular status in HD patients. Abdominal fat biopsies were obtained from 11 HD patients and 26 non-uremic controls. Subcutaneous arteries were dissected and mounted on a wire myograph, and cumulative concentration-response curves to noradrenalin, endothelin-1, a thromboxane A2 agonist (U46619), angiotensin II, vasopressin, bradykinin (BK), acetylcholine (ACh) and sodium nitroprusside (SNP) were constructed. Pulse wave velocity and blood pressure were measured in HD patients. Enhanced (P<0.05-0.0001) maximal contractile responses (Rmax) to all spasmogens (particularly vasopressin) were observed in arteries from HD patients compared to controls, and this effect was more pronounced in arteries with an internal diameter>600 µm. The potency (pEC50) of U46619 (P<0.01) and vasopressin (P<0.001) was also increased in arteries>600 µm of HD patients. The maximal relaxant response to the endothelium-dependent dilators ACh and BK were lower in HD patients (P<0.01-P<0.0001) (worse for ACh than BK); however the endothelium-independent dilator SNP was similar in both groups. PWV was significantly correlated with the vasoconstrictor response to vasopressin (Pâ=â0.042) in HD patients. HD patients are primed for hypertension and end organ demand ischaemia by a highly sensitised pressor response. The failure of arterial relaxation is mediated by endothelial dysfunction. Intrinsic vascular abnormalities may be important in sensitising HD patients to recurrent cumulative ischaemic end organ injury.
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Riñón/fisiopatología , Contracción Muscular/efectos de los fármacos , Relajación Muscular/efectos de los fármacos , Diálisis Renal , Uremia/fisiopatología , Vasoconstrictores/farmacología , Ácido 15-Hidroxi-11 alfa,9 alfa-(epoximetano)prosta-5,13-dienoico/farmacología , Acetilcolina/farmacología , Anciano , Angiotensina II/farmacología , Arterias/fisiopatología , Bradiquinina/farmacología , Endotelina-1/farmacología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Miografía , Nitroprusiato/farmacología , Norepinefrina/farmacología , Análisis de la Onda del Pulso , Vasopresinas/farmacologíaRESUMEN
BACKGROUND: Strain analysis derived from the analysis of speckle tracked imaging echocardiography can be used to examine ventricular contractile functions. In this study, we examined the relationship of hemodialysis (HD)-induced circulatory stress with overall ventricular function assessed according to global longitudinal strain (GLS) and segmental distribution of strain. METHODS: This prospective observational study included 104 conventional HD patients at Royal Derby Hospital. Averaged values of segmental and GLS were determined from the echocardiography of these patients before and at peak dialysis. These values were compared with the reference values of healthy individuals, correlated with their demographic characteristics, and the effect on survival was assessed. RESULTS: The global strain value was -11.5% ± 4.42, and the segmental strain values were significantly greater in HD patients than in healthy individuals by 2.7%-9.8% (P < 0.001). The strain values were not significantly different before dialysis and at peak dialysis (P > 0.05), except within the basal lateral segment (P = 0.01). The adjusted hazard ratio for mortality was 4.3 (95% confidence interval, 1.2-14.9; P = 0.021) when > 80% of the segments exhibited more than the mean of segmental strain values. For the 46 patients who died, there were statistically significant negative correlations between survival time and GLS (r = -0.30; P = 0.04). CONCLUSIONS: Global and segmental strain measured using speckle tracked imaging provides information relating to the effects of HD-induced cardiac injury. The segmental strain abnormalities in the watershed area of the left ventricle suggest a higher degree of vulnerability to HD-induced demand ischemia.
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Ecocardiografía/métodos , Contracción Miocárdica/fisiología , Diálisis Renal , Disfunción Ventricular Izquierda/fisiopatología , Función Ventricular Izquierda/fisiología , Anciano , Estudios Transversales , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Factores de Tiempo , Disfunción Ventricular Izquierda/diagnóstico por imagenRESUMEN
BACKGROUND AND AIMS: Current creatine-based criteria for defining acute kidney injury (AKI) are validated in general hospitalised patients but their application to cirrhotics (who are younger and have reduced muscle mass) is less certain. We aimed to evaluate current definitions of AKI (acute kidney injury network (AKIN) criteria) in a population of cirrhotic patients and correlate this with outcomes. METHODS: We prospectively identified patients with AKI and clinical, radiological or histological evidence of cirrhosis. We compared them with a control group with evidence of cirrhosis and no AKI. RESULTS: 162 cirrhotic patients were studied with a mean age of 56.8±14â years. They were predominantly male (65.4%) with alcoholic liver disease (78.4%). 110 patients had AKI: 44 stage 1, 32 stage 2 and 34 stage 3. They were well matched in age, sex and liver disease severity with 52 cirrhotics without AKI. AKI was associated with increased mortality (31.8% vs 3.8%, p<0.001). Mortality increased with each AKI stage; 3.8% in cirrhotics without AKI, 13.5% stage 1, 37.8% stage 2 and 43.2% stage 3 (p<0.001 for trend). Worsening liver disease (Child-Pugh class) correlated with increased mortality: 3.1% class A, 23.6% class B and 32.8% class C (p=0.006 for trend). AKI was associated with increased length of stay: median 6.0â days (IQR 4.0-8.75) versus 16.0â days (IQR 6.0-27.5), p<0.001. Multivariate analysis identified AKI and Child-Pugh classes B and C as independent factors associated with mortality. CONCLUSIONS: The utility of AKIN criteria is maintained in cirrhotic patients. Decompensated liver disease and AKI appear to be independent variables predicting death in cirrhotics.
RESUMEN
BACKGROUND: GPs in England are required to keep a register of patients with chronic kidney disease (CKD). National Institute for Health and Clinical Excellence (NICE) guidelines recommend regular follow-up, but patients are perceived to be low risk and not requiring active management. AIM: To assess treatment needs of CKD stage 3 patients in primary care, as well as their awareness of CKD. DESIGN AND SETTING: A cross-sectional analysis from a longitudinal prospective study in 32 general practices. METHOD: A total of 1741 participants underwent clinical assessment including urine and blood tests. Participants were asked about awareness of their CKD. Results were reviewed and a letter recommending treatment in line with NICE guidelines was sent to their GP. RESULTS: The mean age of participants was 73 ± 9 years; 60% (n = 1052) were female and diabetes was present in 17%; 67% of participants required further intervention. Most required improved control of hypertension (n = 1576; 33.1% of cohort). Other recommendations included advice to investigate anaemia (n = 1142; 8.2%) or stop nephrotoxic drugs (n = 1120; 7.5%). Less than 6% of participants met NICE criteria for referral to nephrology services and 41% were unaware of their CKD diagnosis. Multivariable analysis identified subjects with formal educational qualifications, age <75 years, estimated glomerular filtration rate (eGFR) 30-44 ml/min/1.73 m(2), and significant albuminuria as more likely to be aware of their diagnosis. CONCLUSION: The study data show that the majority of patients required at least one intervention to improve the management of their CKD. Most interventions could be delivered in primary care and only a minority required nephrology referral. Many patients were unaware of their CKD diagnosis, and efforts should be made to improve this to facilitate involvement in their care.
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Fallo Renal Crónico/terapia , Evaluación de Necesidades , Distribución por Edad , Anciano , Anciano de 80 o más Años , Actitud Frente a la Salud , Concienciación , Estudios Transversales , Inglaterra , Medicina Familiar y Comunitaria , Femenino , Humanos , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/psicología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Derivación y ConsultaAsunto(s)
Hemodinámica , Diálisis Peritoneal , Materiales Biocompatibles/administración & dosificación , Gasto Cardíaco/fisiología , Soluciones para Diálisis/administración & dosificación , Glucosa/administración & dosificación , Corazón/fisiología , Humanos , Infusiones Parenterales , Isquemia Miocárdica/etiología , Resistencia Vascular/fisiologíaRESUMEN
Increases in pediatric overweight and obesity throughout the European Union (EU) generate concern because of the many associated co-morbidities, psychosocial effects, and economic costs. A variety of policy approaches have been implemented, but counteracting weight gain has proven challenging. Do differences in public opinion about policy options to fight the problem exist among EU countries? We obtained data for our study from the Eurobarometer and include representative samples from all EU Member States plus four prospective countries. Our results suggest strong consistency among EU countries in support for two policies: providing information to parents and more physical activity in schools. For improving children's diets, our data show widespread support for providing parents with information, education programs in schools, and restrictions on advertising. For reducing childhood obesity, more physical activity in schools received the most support followed by education and advertising restrictions. There was very little support for imposing taxes on unhealthy food.