ISRN nephrology最新文献

Residual Renal function (RRF) has an important role in the overall morbidity and mortality in hemodialysis patients. The role of angiotensin-converting enzyme inhibitor (ACEi) in preserving renal function in chronic proteinuric nephropathies is well documented. We test the hypothesis that enalapril (an ACEi) slows the rate of decline of RRF in patients starting hemodialysis. A prospective, randomized open-label study was carried out. 42 patients were randomized in two groups either in treatment with enalapril or no treatment at all. Our study has proven that enalapril has a significant effect on preserving residual renal function in patients starting dialysis at least during the first 12 months from the initiation of the hemodialysis. Further studies are necessary in order to investigate the potential long-term effect of ACEi on residual renal function and on morbidity and mortality in patients starting hemodialysis.

The Centre de Rein Artificiel in Tassin, France, provides comprehensive care to patients with chronic renal disease similar to the model proposed for Patient Center Medical Homes; patients with end-stage renal disease in the Tassin Hemodialysis Center appear to have better outcomes than patients in the United States. These differences likely reflect this center's approach to patient-centered care, the use of longer dialysis times, and focused vascular access care. Longer dialysis times provide better clearance of small and middle toxic molecules, salt, and water; 85% of patients at the Tassin center have a normal blood pressure without the use of antihypertensive medications. The observed mortality rate in patients at the Tassin Center is approximately 50% of that predicted based on the United States Renal Data system standard mortality tables. Patient outcomes at the Tassin center suggest that longer dialysis times and the use of multidiscipline teams led by nephrologists directing all health care needs probably explain the outcomes in these patients. These approaches can be imported into the U.S healthcare system and form the framework for patient-centered medical practice for ESRD patients.

AN69 membrane is not suited for diffusion, with an suggested limit at 25 mL/min dialysate flow rate. When prescribing continuous hemodialysis this threshold must be surpassed to achieve. We designed a study aimed to check if a higher dose of dialysis could be delivered efficiently with this membrane. Ten ICU patients under continuous hemodiafiltration with 1.4 m(2) AN69 membrane were included and once a day we set the monitor to exclusively 50 mL/min dialysate flow rate and 250 mL/min blood flow rate and after 15 minutes measured dialysate saturation for urea, creatinine, and β 2-microglobulin. We detected that urea saturation of dialysate was nearly complete (1.1 ± 0.09) for at least 40 hours, while creatinine saturation showed a large dispersion (0.86 ± 0.22) and did not detect any relation for these variables with time, blood flow, or anticoagulation regime. Saturation of β 2-microglobulin was low (0.34 ± 0.1) and decreased discretely with time (r (2) = 0.15, P < 0.05) and significantly with TMP increases (r (2) = 0.31, P < 0.01). In our experience AN69 membrane shows a better diffusive capability than previously acknowledged, covering efficiently the range of standard dosage for continuous therapies. Creatinine is not a good marker of the membrane diffusive capability.

Introduction. Acute kidney injury (PRAKI) continues to be common in developing countries. The aim of this paper is to study AKI characteristics in pregnancy and identify the factors related to the unfavorable evolution. Methods. This prospective study was conducted in the University Hospital Hassan II of Fez, Morocco, from February 01, 2011 to January 31, 2012. All patients presenting PRAKI were included. Results. 37 cases of PRAKI were listed. Their ages varied from 20 to 41 years old, with an average of 29.03 ± 6.3 years and an average parity of 1.83. High blood pressure was the most common symptom (55.6%). Thirty-nine percent were oliguric. PRAKI occurred during the 3rd trimester in 66.6% of the cases and 25% of the cases in the postpartum. Hemodialysis was necessary in 16.2% of cases. The main causes were preeclampsia, hemorrhagic shocks, and functional, respectively, in 66.6%, 25%, and 8.3% of the cases. The outcome was favorable, with a complete renal function recovery for 28 patients. Poor prognosis was related to two factors: age over 38 years and advanced stage of AKI according to RIFLE classification. Conclusion. Prevention of PRAKI requires an improvement of the sanitary infrastructures with the implementation of an obligatory prenatal consultation.

The aim of this study was to evaluate the levels of malondialdehyde as an oxidative stress marker in the same hemodialysis patients after changing the quality of dialysate with ultrapure dialysis fluid. Methods. This prospective study concerns hemodialysis patients; all patients were in the first step treated with conventional dialysate, and in the second step (three months later) the same patients were treated with online produced ultrapure dialysis fluid. The malondialdehyde, C-reactive protein, total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein, fibrinogen, and albumin were quantified before the two steps. Results. Thirty-seven patients completed the study. Ultrapure dialysis fluid reduced but not significantly the malondialdehyde concentrations. Both dialysis fluids were associated with improvement in the malondialdehyde level before and after the hemodialysis session. In lipid parameters, there was a significant decrease with conventional dialysis fluid versus ultrapure dialysis fluid of triglycerides, total cholesterol, and high-density lipoprotein in patients' blood. Instead, the level of low-density lipoprotein, fibrinogen, albumin, and C-reactive protein does not change significantly. Conclusion. The lipid parameters were improved for triglycerides and total cholesterol. Malondialdehyde increases following the hemodialysis session, and the conventional dialysate increased malondialdehyde levels more than the ultrapure dialysis but the differences were not statistically significant.

Membrane bioincompatibility was demonstrated by successive white blood cell counts and C3a generation. Pulse wave analysis was obtained by applanation tonometry (SphygmoCor) in a sequential way: basal, after 30 minutes with nul ultrafiltration, and after a complete dialysis with ultrafiltration. At 15 minutes of haemodialysis, significant decrease in leukocyte count occurred: 6801 ± 1186 versus 4412 ± 1333 (P < 0.001), while C3a levels sharply increased from 427 ± 269 to 3501 ± 1638 ng/mL (P < 0.000). No changes were observed in augmentation index without ultrafiltration: 26.1 ± 11.1 versus 26.6 ± 12.4. Only aortic systolic blood pressure was lower at 15 minutes: 120.1 ± 17.7 versus 110.4 ± 25.8 mmHg (P = 0.009), in agreement with a reduction in brachial systolic blood pressure: 135.1 ± 18.1 versus 122.7 ± 27.4 mmHg (P = 0.01), without changes in aortic or brachial diastolic blood pressure. Important changes in pulse wave analysis were observed after a complete haemodialysis session: augmentation index 29.9 ± 10.1 versus 18.6 ± 15.0, aortic systolic blood pressure 139.8 ± 25.5 versus 119.4 ± 28.5 mmHg (P < 0.00), without changes in aortic diastolic blood pressure. In summary, haemodialysis with cellulose diacetate acutely induced a transient state of immunoactivation due to bioincompatibility, this phenomenon was nondetectable by pulse wave analysis. Complete haemodialysis session led to important changes in pulse wave analysis.

Hepatitis C virus infection is still common among dialysis patients, but the natural history of HCV in this group is not completely understood. Recent evidence has been accumulated showing that anti-HCV positive serologic status is significantly associated with lower survival in dialysis population; an increased risk of liver and cardiovascular disease-related mortality compared with anti-HCV negative subjects has been found. According to a novel meta-analysis (fourteen studies including 145,608 unique patients), the adjusted RR for liver disease-related death and cardiovascular mortality was 3.82 (95% CI, 1.92; 7.61) and 1.26 (95% CI, 1.10; 1.45), respectively. It has been suggested that the decision to treat HCV in patients with chronic kidney disease be based on the potential benefits and risks of therapy, including life expectancy, candidacy for kidney transplant, and co-morbidities. According to recent guidelines, the antiviral treatment of choice in HCV-infected patients on dialysis is mono-therapy but fresh data suggest the use of modern antiviral approaches (i.e., pegylated interferon plus ribavirin). The summary estimate for sustained viral response and drop-out rate was 56% (95% CI, 28-84) and 25% (95% CI, 10-40) in a pooled analysis including 151 dialysis patients on combination antiviral therapy (conventional or pegylated interferon plus ribavirin).

Objective. Neutrophil gelatinase-associated lipocalin (NGAL) measured by a research ELISA is described as an early marker of acute kidney injury (AKI). The aim of this study is to define the usefulness of plasma NGAL (pNGAL) and urine NGAL (uNGAL) measured with platform analysers to detect AKI 3 hours after cardiac surgery in fifty adult patients. Methods and Main Results. pNGAL and uNGAL were measured before and 3 hours after cardiac surgery. AKI, defined following the acute kidney injury network definition, was observed in 17 patients. pNGAL was >149 ng/mL in 8 patients with AKI, two of them died in the follow-up. We also observed elevated pNGAL in 8 patients without AKI. Only one uNGAL was >132 ng/mL among the 15 AKI patients. Sensitivity of pNGAL for prediction of AKI is 47% and specificity is 75.7%. The positive likelihood ratio (LR+) is 1.9 and negative likelihood ratio (LR-) is 0.7. uNGAL performance is slightly improved when reported to urinary creatinine. Following this study, a ratio >62 ng/mg assure a sensitivity of 66.6% and a specificity of 78.5%. LR+ is 3 and a LR- is, 0.42. Conclusions. Three hours after cardiac surgery, pNGAL predicts AKI with a low sensitivity and specificity.

Background. Preservation of residual renal function in chronic dialysis patients has proven to be a major predictor of survival. The aim of the present study was to investigate an ability of the combined use of N-acetylcysteine and high-flux biocompatible haemodialysis membranes to improve residual renal function in haemodialysis patients. Patients and Methods. Chronic haemodialysis patients with a residual urine output of at least 100 mL/24 h were administered oral an N-acetylcysteine 1200 mg twice daily for 2 weeks. Treatment group included patients treated with dialysers using high-flux synthetic biocompatible membranes. Control group included patients treated with dialysers using low-flux semisyntetic triacetate haemodialysis membranes. Results. Eighteen patients participated in the study. The residual glomerular filtration rate showed a nonsignificant trend for increase in both groups. The magnitude of GFR improvement after N-acetylcysteine administration was less pronounced in the group treated with high-flux biocompatible membranes: +0.17 ± 0.56 mL/min/1.73 m(2) in treatment group and +0.65 ± 0.53 mL/min/1.73 m(2) in control group (P < 0.05). Conclusion. In this study of favorable effect of N-acetylcysteine on residual renal function in chronic haemodialysis patients may be less pronounced when using high-flux biocompatible, rather than low-flux semisyntetic, HD membranes.

Purpose. To explore factors contributing to chronic kidney disease (CKD) progression and change in estimated glomerular filtration rate over time (ΔeGFR) as a risk factor in predialysis patients under multidisciplinary managements. Methods. Among 113 CKD patients, eGFR, serum creatinine, total protein, albumin, urea nitrogen, uric acid, calcium, inorganic phosphate, total cholesterol, urinary creatinine, urinary protein (UP), hemoglobin A1c, hemoglobin, and hematocrit were analyzed. Results. ΔeGFR analysis in the first six months presented a positive slope (remission group) in 43 patients (38%) and a negative slope (no-remission group) in 70 patients (62%). Three-year dialysis-free rate was 89.4% in the remission group and 39.3% in the no-remission group, with a significant difference (P < 0.0001). To explore factors contributing to dialysis initiation by stepwise Cox regression, baseline eGFR (HR 0.706, P < 0.0001) and ΔeGFR in the first six months of treatment (HR 0.075, P < 0.0001) were identified. To investigate factors affecting remission and no remission by stepwise logistic regression, age (odds ratio 1.06, P = 0.018) and UP excretion (odds ratio 1.223, P = 0.045) were identified. Conclusion. Monitoring of ΔeGFR and UP is not only useful in suppressing CKD 3 progression, but also in deciding strategies to achieve remission in individual patients.