BACKGROUND: The time at which renal replacement therapy (RRT) is initiated in patients with end-stage renal disease (ESRD) has a great influence on the prognosis of the patient; however, there are currently no accurate guidelines for the initiation of RRT. Traditionally, nephrologists usually initiate RRT on the basis of the observation of the uremic symptoms and changes in the laboratory parameters, such as the serum creatinine concentration and/or glomerular filtration rate (GFR). DOQI guidelines suggest a weekly Kt/Vurea < 2.0 or an nPNA < 0.8 g/kg/day as objective indices for the initiation of dialysis. Thus, a KP index was formulated (weekly Kt/Vurea+2.5 X nPNA) X (1/2) using the above two clinically useful and objective indices to determine the adeguate time to initiate RRT in patients with ESRD. METHODS: Of 186 patients admitted to the renal unit of Soonchunhyang Bucheon hospital, those with ESRD and a weekly Kt/Vurea below 3.0 were selected. The patients with a weekly Kt/Vurea index between 1.0 and 2.0 were classified into one of two groups; KP index > 2.0 and KP index < 2.0. The groups were compared and analyzed in relation to their renal function, biochemical indices and the numbers of patients per group starting RRT. Further, the correlations between the KP and other indices were analyzed in all the patients. The patients were then further divided into another two groups according to their weekly Kt/Vurea and KP index: group one; between 1.5 and 2.0 and group 2; between 2.0 and 2.5. The numbers of patients per group starting RRT were compared. RESULTS: The KP index < 2.0 group showed significantly lower indices for weekly Kt/Vurea, nPNA and %LBM (%) than those of the KP index > 2.0 group, while there were no significant differences between the groups in the serum albumin concentration, serum creatinine concentration, FFEFBM and RRF. Also, there was a statistically significant higher rate of incidence of patients starting RRT in the KP index < 2.0 group than in the KP index > 2.0 group. There was a significant correlation between the KP and other indices in all patients. When comparing the number of patients starting RRT, the weekly Kt/Vurea index demonstrated no significant differences between the 1.5 < weekly Kt/Vurea < 2.0 and 2.0 < weekly Kt/Vurea < 2.5 groups, but the number of patients starting RRT in the 1.5 < KP index < 2.0 group was significantly higher than that in the 2.0 < KP index < 2.5 group. CONCLUSION: The KP index is considered a clinically useful index in ESRD patients for determining an appropriate time for the initiation of RRT. Also, the timing of the initiation of RRT should be fixed with regard to the various other indices and clinical features for a desirable prognosis of the patients. In addition, further studies will be required to determine accurate guidelines for an appropriate time for RRT initiation.
Adult ; Aged ; Blood Urea Nitrogen ; Creatinine/blood ; Female ; Glomerular Filtration Rate ; Humans ; Kidney/metabolism ; Kidney Failure, Chronic/epidemiology/*metabolism/physiopathology/*therapy ; Korea/epidemiology ; Male ; Middle Aged ; Nutritional Status ; *Renal Dialysis ; Serum Albumin/metabolism ; Severity of Illness Index ; Urea/blood

PURPOSE: Copeptin has been considered as a useful marker for diagnosis and prediction of prognosis in heart diseases. However, copeptin has not been investigated sufficiently in hemodialysis patients. This study aimed to investigate the general features of copeptin in hemodialysis and to examine the usefulness of copeptin in hemodialysis patients with left ventricular dysfunction (LV dysfunction). MATERIALS AND METHODS: This study included 41 patients on regular hemodialysis. Routine laboratory data and peptides such as the N-terminal of the prohormone brain natriuretic peptide and copeptin were measured on the day of hemodialysis. Body fluid volume was estimated by bioimpedance spectroscopy, and the E/Ea ratio was estimated by echocardiography. RESULTS: Copeptin increased to 171.4 pg/mL before hemodialysis. The copeptin had a positive correlation with pre-dialysis body fluid volume (r=0.314; p=0.04). The copeptin level decreased along with body fluid volume and plasma osmolality during hemodialysis. The copeptin increased in the patients with LV dysfunction more than in those with normal LV function (218.7 pg/mL vs. 77.6 pg/mL; p=0.01). Receiver operating characteristic curve analysis showed that copeptin had a diagnostic value in the hemodialysis patients with LV dysfunction (area under curve 0.737; p=0.02) and that the cut-off value was 125.48 pg/mL (sensitivity 0.7, specificity 0.8, positive predictive value 0.9, negative predictive value 0.6). CONCLUSION: Copeptin increases in hemodialysis patients and is higher in patients with LV dysfunction. We believe that copeptin can be a useful marker for the diagnosis of LV dysfunction in hemodialysis patients.
Adult ; Aged ; Biomarkers/blood ; Echocardiography ; Female ; Glycopeptides/*blood ; Humans ; Kidney Failure, Chronic/*blood/complications/therapy ; Male ; Middle Aged ; Natriuretic Peptide, Brain/blood ; Predictive Value of Tests ; Prognosis ; ROC Curve ; Renal Dialysis/*adverse effects ; Sensitivity and Specificity ; Ventricular Dysfunction, Left/*blood/complications/*physiopathology

This study was designed to examine how such factors as hemodialysis parameters, body mass index, renin and aldosterone concentrations, sympathetic nervous activity, and parathyroid hormone concentrations are associated with the control of hypertension in hemodialysis patients. Hemodialysis patients (n=114) were grouped into four categories. Group 1 had normal BP without antihypertensive medication. Group 2 needed one antihypertensive drug, Group 3 needed combination of two or three categories of antihypertensive drugs without minoxidil. Group 4 needed more than three categories of antihypertensive drugs including minoxidil. Parathyroid hormone, beta2-microglobulin, renin and aldosterone, epinephrine, norepinephrine, and hemodialysis parameters were measured. The fractional clearance of urea as Kt/V urea was significantly lower in Group 3 and Group 4 than in Group 2 (p<0.01). Concentrations of parathyroid hormone were significantly higher in Group 4 than the other groups (p<0.01). Pre-hemodialysis norepinephrine concentrations were significantly higher in Group 4 than the other groups (p<0.05). Traditional factors associated with hypertension did not seem to be relevant to the degree of hypertension in hemodialysis patients in the present study. In conclusion, poor Kt/V urea, elevated parathyroid hormone concentrations, and elevated concentrations of plasma norepinephrine seemed to be the factors that might be associated with control of hypertension in hemodialysis patients.
Adult ; Aged ; Aldosterone/*blood ; Analysis of Variance ; Antihypertensive Agents/therapeutic use ; Blood Pressure/drug effects/*physiology ; Epinephrine/blood ; Female ; Humans ; Hypertension/blood/drug therapy/physiopathology ; Kidney Failure, Chronic/blood/physiopathology/therapy ; Male ; Middle Aged ; Norepinephrine/blood ; Parathyroid Hormone/*blood ; *Renal Dialysis ; Renin/*blood ; Sympathetic Nervous System/*physiology ; Urea/metabolism

Fluid shifts are commonplace in chronic hemodialysis patients during the intra- and interdialytic periods. In this study, we evaluated fluid shifts of body compartments using both bioimpedance spectroscopy and blood volume monitoring from the start to the end of hemodialysis. 24 stable hemodialysis patients were included on the study. Relative change of blood volume was progressively reduced from the start to the end of hemodialysis (1 hr, -7.22+/-3.23%; 2 hr, -9.78+/-4.69%; 3 hr, -12.88+/-5.65%; 4 hr, -15.41+/-6.54%, respectively). Mean % reduction of intracellular fluid was not significantly different to that of extracellular fluid at the end of hemodialysis (delta ICF, -6.58+/-5.34% vs. delta ECF, -7.07+/-5.12%). Mean % fluid reduction of arms, legs and trunk was -11.98+/-6.76%, -6.43+/-4.37% and -7.47+/-4.56%, respectively at the end of hemodialysis. There were 3 characteristic patterns in blood-volume change. Similar amounts of fluid were removed from the extracellular and intracellular compartments during hemodialysis, with the arms showing the greatest loss in terms of body segments. The pattern of blood volume change measured by blood volume monitoring may be useful for more accurate determination of dry-weight and for correcting volume status in hemodialysis patients.
Adult ; Aged ; Aged, 80 & over ; Algorithms ; *Blood Volume ; Body Fluid Compartments/*physiology ; *Electric Impedance ; Female ; Humans ; Kidney Failure, Chronic/blood/physiopathology/therapy ; Male ; Middle Aged ; Monitoring, Physiologic/*methods ; Renal Dialysis ; Reproducibility of Results ; Research Support, Non-U.S. Gov't ; Time Factors

BACKGROUND/AIMS: Aims: Inflammation is an important factor in renal injury. Ferritin, an inflammatory marker, is considered an independent predictor of rapid renal progression in patients with chronic kidney disease. However, the relationship between ferritin and residual renal function (RRF) in patients undergoing peritoneal dialysis (PD) remains unclear. METHODS: We reviewed the medical records of patients who started PD between June 2001 and March 2012 at Soonchunhyang University Bucheon Hospital, Korea. A total of 123 patients were enrolled in the study. At 1 month after the initiation of PD, RRF was determined by a 24-hour urine collection and measured every 6 months thereafter. Clinical and biochemical data at the time of the initial 24-hour urine collection were considered as baseline. RESULTS: The RRF reduction rate was significantly greater in patients with high ferritin (ferritin > or = 250 ng/mL) compared with those with low ferritin (ferritin < 250 ng/mL; -1.71 +/- 1.36 mL/min/yr/1.73 m2 vs. -0.84 +/- 1.63 mL/min/yr/1.73 m2, respectively; p = 0.007). Pearson correlation analysis revealed a significant negative correlation between the baseline serum ferritin level and the RRF reduction rate (r = -0.219, p = 0.015). Using multiple linear regression analysis and adjusting for other risk factors, baseline serum ferritin was an independent factor for the RRF reduction rate (beta = -0.002, p = 0.002). CONCLUSIONS: In this study we showed that a higher ferritin level was significantly associated with a more rapid RRF decline in patients undergoing PD.
Adult ; Aged ; Biological Markers/blood ; Chi-Square Distribution ; Disease Progression ; Female ; Ferritins/*blood ; Hospitals, University ; Humans ; Inflammation Mediators/*blood ; Kaplan-Meier Estimate ; Kidney/*physiopathology ; Kidney Failure, Chronic/blood/diagnosis/physiopathology/*therapy ; Linear Models ; Male ; Middle Aged ; Multivariate Analysis ; Peritoneal Dialysis/*adverse effects ; Predictive Value of Tests ; Proportional Hazards Models ; Republic of Korea ; Risk Factors ; Time Factors ; Treatment Outcome ; Up-Regulation

BACKGROUND: Considering that dialysate calcium concentration is potentially a main determinant of the serum ionized calcium level and vasoconstriction is associated with the blood calcium concentration, we conducted a study to evaluate the interdialytic effects of treatment with a low calcium dialysate (LdCa, 1.25 mmol/L) on the changes in arterial compliance (AC), blood pressure (BP), biochemical parameters and vasoactive substances. METHODS: Eight hemodialysis (HD) patients (mean age: 46.8 +/- 13.7 years, 4 men and 4 women) were included in the study. AC, systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), mean arterial pressure (MAP), serum ionized Ca, intact-PTH, serum nitric oxide and aldosterone were compared after 10 sessions of treatment with LdCa. Right carotid artery diameter was measured 3 times using a real time B-mode ultrasound imager (Hewlett-Packard Sonos 2000 (R) ) and AC was calculated using the Hayoz method. RESULTS: 1) AC was recorded as 0.140 (0.080-0.170) mm2/kPa at the baseline (1.75 mmol/L calcium dialysate), 0.170 (0.050-0.290) mm2/kPa after LdCa treatment (p< 0.05 versus baseline), and 0.140 (0.070-0.250) mm2/kPa following the HdCa treatment (p< 0.05 versus LdCa data). 2) MAP and PP were calculated at 114.12 +/- 10.56 mmHg and 63.50 +/- 10.87 mmHg at the baseline; 98.37 +/- 15.14 mmHg and 56.50 +/- 5.95 mmHg after LdCa treatment (p< 0.05 versus baseline) ; and 115.75 +/- 9.64 mmHg and 62.00 +/- 15.71 mmHg following HdCa treatment (p< 0.05 versus LdCa data). 3) Serum ionized Ca and intact-PTH were measured at 4.66 +/- 0.40 mg/dL and 25.08 +/- 16.44 pg/mL at the baseline; 4.45 +/- 0.28 mg/dL and 90.71 +/- 27.03 pg/mL after LdCa treatment (p< 0.05 versus baseline) ; and 4.65 +/- 0.43 mg/dL and 24.08 +/- 15.44 pg/mL following HdCa treatment (p< 0.05 versus LdCa data). 4) Serum aldosterone concentration was 300.8 (65.5-836.1) pg/mL at the baseline, and 220.2 (42.8-527.9) pg/mL after LdCa treatment (p< 0.05). CONCLUSION: There were favorable changes in AC, BP, biochemical parameters after treatment with LdCa. These changes may be associated with the reduction in serum ionized calcium and decreased serum aldosterone concentration.
Adult ; Arteries/drug effects ; Blood Pressure/*drug effects ; Calcium/*pharmacology ; Compliance/drug effects ; Cross-Over Studies ; Dialysis Solutions/*pharmacology ; Female ; Human ; Kidney Failure, Chronic/*physiopathology/therapy ; Male ; Middle Aged ; *Renal Dialysis ; Support, Non-U.S. Gov't

BACKGROUND: It is absolutely necessary to evaluate cardiac function on starting and during hemodialysis in patients with end stage renal disease. In this study, we tried to determinate the changes of cardiac function associated with hemodialysis. METHODS: Twenty patients with end stage renal disease, who had been in a hemodialysis program from February, 1997 to August, 1999 in Pusan National University Hospital, were enrolled. They were examined with echocardiography and gated blood pool scintigraphy on starting hemodialysis and after follow-up. The data were analyzed by paired t-test. RESULTS: The patients were 46.2 +/- 16.8 years old and male to female ratio was 8 : 12. The underlying diseases were diabetes mellitus (n=10), hypertension1), glomerulonephritis2) and others1). The duration of symptoms associated with end stage renal disease and underlying diseases was 3.4 2.6 years and the duration of hemodialysis was 13.8 7.0 months. The LVEDID, LVESID and RVC decreased significantly (-6.10, -7.80 and -20.00%, respectively, p < 0.05) with no significant changes for LAD, IVS, PWT and EF (p > 0.05). In ten cases associated with diabetes, LVEDID decreased (-7.90%, p < 0.05). In twelve cases associated with cardiac diseases, LVEDID and LVESID decreased (-8.60 and -10.50%, respectively, p < 0.05). In four cases associated with diabetes without cardiac diseases, LAD decreased (-5.10%, p 0.05) and in four cases associated with cardiac diseases without diabetes there were no significant changes in cardiac dimensions and EF. In seven cases associated with diabetes and cardiac diseases, LVEDID decreased (-10.50%, p < 0.05). The EF on gated blood pool scintigraphy decreased (-0.9%, p < 0.05) as a whole while it increased (5.90%, p < 0.05) in the cases associated with diabetes and cardiac diseases. CONCLUSION: During the early hemodialysis stage of end stage renal disease, we found a change of concentric left ventricular hypertrophy and relatively preserved left ventricular function. Furthermore, we can expect that adequate hemodialysis - with dry weight as low as possible - may prevent progression to eccentric left ventricular hypertrophy and dilated cardiomyopathy.
Adult ; Aged ; Cardiomyopathy, Congestive/prevention & control ; Diabetic Nephropathies/pathology/physiopathology/therapy ; Echocardiography ; Female ; Gated Blood-Pool Imaging ; Heart/*physiopathology ; Human ; Hypertrophy, Left Ventricular/prevention & control ; Kidney Failure, Chronic/pathology/*physiopathology/*therapy ; Male ; Middle Age ; Myocardium/pathology ; *Renal Dialysis ; Ventricular Function, Left

BACKGROUND/AIMS: Chronic inflammatory status is a possible risk factor for vascular access dysfunction in hemodialysis (HD) patients, but susceptibility differences appear among individuals. Interleukin (IL)-6 is a well-known inflammatory cytokine with various polymorphisms. We examined whether IL-6 polymorphisms are associated with vascular access dysfunction in HD patients. METHODS: A total of 80 HD patients (including 42 diabetic patients) were enrolled. Polymorphisms in the IL-6 gene promoter (-634 C/G and -174 G/C) were studied using restriction length polymorphism polymerase chain reaction analysis. Vascular access patency was compared between the patient groups with respect to IL-6 polymorphisms. An additional 89 healthy individuals were enrolled in the control group. Plasma IL-6 levels were de termined by enzyme-linked immunosorbent assay. RESULTS: The GG genotype and G allele at position -634 in the IL-6 promoter were more frequently observed in HD patients than in controls. Furthermore, the distribution of the -634 polymorphism differed according to vascular access patency in non-diabetic HD patients. However, the G allele was not a significant risk factor for early access failure. No significant association appeared between the IL-6 -634 C/G polymorphism and plasma IL-6 levels. The C allele of the IL-6 -174 G/C polymorphism was not detected in our study population. CONCLUSIONS: The IL-6 -634 G allele appears with greater frequently in patients with end-stage renal disease and may be associated with vascular access dysfunction in non-diabetic HD patients.
Adult ; Aged ; Arteriovenous Shunt, Surgical/*adverse effects ; Asian Continental Ancestry Group/*genetics ; Case-Control Studies ; Chi-Square Distribution ; Enzyme-Linked Immunosorbent Assay ; Female ; Gene Frequency ; Genotype ; Graft Occlusion, Vascular/blood/ethnology/*genetics/physiopathology ; Humans ; Interleukin-6/blood/*genetics ; Kidney Failure, Chronic/blood/ethnology/genetics/immunology/*therapy ; Logistic Models ; Male ; Middle Aged ; Odds Ratio ; Phenotype ; Polymerase Chain Reaction ; *Polymorphism, Genetic ; Promoter Regions, Genetic ; *Renal Dialysis ; Republic of Korea ; Time Factors ; Treatment Outcome ; Vascular Patency/*genetics