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Unlabelled: In patients older than 75 years with advanced chronic kidney disease (CKD), the decision between treatment with dialysis [intention to treat with dialysis (ITD)] or conservative care (CC) is a challenge. Geriatric assessment can be helpful. The aim was to identify which factors had had an influence on decision-making., Methods: We recruited 56 patients. At baseline we analyzed age, frailty (defined following the criteria of Fried et al. [J Gerontol A Biol Sci Med Sci 2001;56:146-156]), dependence for activities of daily living (ADL), cognitive impairment, depression, comorbidity, cardiovascular disease, and diabetes. After full information about prognosis and treatment options, the preferences of the patients and families were taken into consideration as determinants in the decision-making process. During the follow-up, we evaluated clinical and laboratory parameters, hospitalization, mortality and reevaluated frailty., Results: Twenty patients opted for CC, and 36 patients opted for ITD. On univariate analysis, the predictive factors of the election of CC were age, prefrailty, cognitive impairment, and dependence for ADL. In the multivariate analysis, age and prefrailty remained as predictors for the choice of CC. Hospitalizations were more frequent in CC. Survival was similar in both groups (p = 0.098)., Conclusions: Frailty assessment could be useful for decision-making about the treatment in elderly patients with CKD. CC may be a good treatment option., (© 2014 S. Karger AG, Basel.)

Background/aims: Lower serum sodium levels have been associated with increased mortality among patients with chronic kidney disease (CKD). Our aim was to analyze the independent factors associated with lower sodium levels among nondialysis patients with advanced CKD and to evaluate the evolution of these patients in comparison to those with higher plasma sodium over a 1-year period., Methods: We included 72 patients with CKD stages 4 and 5 without clinically evident cardiopathy or liver disease. Bioelectrical impedance and echocardiography were performed to analyze the possible relation between plasma sodium and volume status and subclinical left ventricular (LV) dysfunction. During follow-up, we compared the evolution of patients with lower baseline plasma sodium (low quartile: <138 mEq/l) with that of patients with higher levels over a 1-year period., Results: At baseline, the independent predictors of lower plasma sodium were C-reactive protein (CRP; OR 0.96; 95% CI 0.91-0.99) and body mass index (OR 0.89; 95% CI 0.78-0.99). An inverse correlation between plasma sodium and CRP was observed (r = -0.32; p = 0.01). Plasma sodium did not correlate with extracellular water and was not different between patients with or without echocardiographic data of LV dysfunction (p = 0.7). During follow-up, patients with lower sodium at baseline showed persistently lower sodium values (p = 0.04), higher CRP (p = 0.05), lower serum albumin (p < 0.01) and higher erythropoietin-stimulating agent resistance index (p = 0.05)., Conclusions: Our results suggest an association between lower plasma sodium and a microinflammatory state among patients with advanced CKD. Inflammation could be an underlying confounding factor explaining the increased mortality in these patients., (© 2014 S. Karger AG, Basel.)

Background: High levels of alkaline phosphatase (ALP) have been associated with increased mortality in patients with advanced chronic kidney disease (CKD). We hypothesize that elevated ALP could be partly explained by subclinical liver congestion related to left ventricular diastolic dysfunction., Methods: Doppler echocardiography was performed in 68 patients with advanced CKD followed up for a median of 2.1 years. Time-averaged levels of ALP and γ-glutamyl transferase (GGT) were compared between patients with and without diastolic dysfunction. We also evaluated the effect of intensifying diuretic treatment on ALP levels in a small group of 16 patients with high ALP and signs of volume overload., Results: ALP correlated significantly (p < 0.001) with GGT but not with parathyroid hormone (p = 0.09). Patients with diastolic dysfunction showed higher ALP (p = 0.01), higher GGT (p = 0.03) and lower albumin (p = 0.04). The highest values of ALP were observed in patients with diastolic dysfunction plus pulmonary hypertension (p = 0.01). Intensifying diuretic therapy in a subgroup of patients with signs of fluid overload induced a significant reduction in body weight, GGT (p < 0.001) and ALP levels (p < 0.001)., Conclusions: Elevated ALP in patients with advanced CKD could be partly explained by subclinical liver congestion related to left ventricular diastolic dysfunction, hypervolemia or both. The worse prognosis of these patients could be explained by their myocardial damage.

Background: Our aim was to analyze the longitudinal changes in cardiac biomarker levels in hemodialysis patients with high comorbidity treated in our special hospital unit. We hypothesize that strict volume control strategy (salt-restricted diet, extended dialysis sessions and dry weight clinical assessment and reassessment in every session) could prevent progression of left-ventricular damage and, therefore, progressive increment in cardiac biomarker levels over time., Methods: This is a longitudinal cohort study including 46 dialysis patients in which a strategy of strict volume control has been adopted. N-terminal pro-B-type natriuretic peptide (NT-proBNP), troponin T and C-reactive protein (CRP) levels were measured at baseline and prospectively at 4, 8 and 12 months. The possible association between volume control and cardiac biomarker levels was analyzed., Results: Dry weight could be reduced (p < 0.01) over time. A reduction in systolic BP (p < 0.05) and in CRP levels (p < 0.05) was observed, whereas NT-proBNP and troponin T values remained stable. However, patients in the high quartile of NT-proBNP at baseline showed a reduction (p = 0.02) in troponin T over time with no significant trend (p = 0.08) to progressive reduction in NT-proBNP values., Conclusions: Strict volume control in dialysis patients may prevent progressive increment in cardiac biomarker levels over time. The impact seems to be higher among patients with higher levels at baseline in whom strict volume control can even reduce cardiac biomarker levels on follow-up.

Background: The prevalence of inflammation is high among patients with chronic renal failure but the reason of inflammation is unclear. We test the hypothesis that inflammation in chronic renal failure could be the consequence of an increased left-ventricular wall tension related to ventricular dysfunction, hypervolemia or both., Methods: For assessing left-ventricular filling pressure, plasma level of N-terminal pro-B-type natriuretic peptide (N-BNP) was used, as B-type natriuretic peptide is secreted from the cardiac ventricles in response to increased wall tension. N-BNP levels and C-reactive protein (CRP) were measured on the same day in 75 pre-dialysis patients. A previous history of cardiomiopathy with systolic dysfunction was present in 27 (36%) of them., Results: The levels of N-BNP were not normally distributed (mean: 2,589 +/- 4,514 pg/ml; median: 789 pg/ml). The distribution of CRP levels was also not normal (mean: 15 +/- 27 mg/l; median: 5 mg/l). Both parameters correlated significantly (r: 0.41; p < 0.005). N-BNP was higher (p < 0.001) in patients with known ventricular dysfunction. Excluding these patients, the correlation between N-BNP and CRP was stronger (r: 0.88; p < 0.001). Univariate analysis in these patients without known cardiomyopathy showed that N-BNP levels also correlated with systolic and diastolic blood pressure (r: 0.54; p < 0.005) and inversely with creatinine clearance (r: -0.43; p < 0.01), serum albumin (r: 0.6; p < 0.001) and hemoglobin levels (r: 0.37; p < 0.05). CRP levels correlated significantly (p < 0.01) with the same parameters as N-BNP in univariate analysis. However, in multiple stepwise regression analysis in which CRP was the dependent variable, only the association with N-BNP remained significant (r: 0.87; p < 0.001)., Conclusions: Our results suggest a link between left-ventricular filling pressure and inflammation in patients with advanced renal insufficiency. The importance of strict volume control in these patients, in order to reduce left-ventricular pressure and therefore inflammation, should be considered., (Copyright 2004 S. Karger AG, Basel)