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CONTEXT: Diabetic kidney disease (DKD) is the leading cause of end stage kidney disease (ESKD) and is associated with a considerably shortened lifespan. While glucose-lowering therapy targeting glycated hemoglobin (HbA1c)

CKD is steadily increasing along with obesity worldwide. Furthermore, obesity is a proinflammatory risk factor for progression of CKD and cardiovascular disease. We tested the hypothesis that implementation of caloric restriction and aerobic exercise is feasible and can improve the proinflammatory metabolic milieu in patients with moderate to severe CKD through a pilot, randomized, 2×2 factorial design trial. Of 122 participants consented, 111 were randomized to receive caloric restriction and aerobic exercise, caloric restriction alone, aerobic exercise alone, or usual care. Of those randomized, 42% were women, 25% were diabetic, and 91% were hypertensive; 104 started intervention, and 92 completed the 4-month study. Primary outcomes were a change from baseline in absolute fat mass, body weight, plasma F 2 -isoprostane concentrations, and peak oxygen uptake (VO 2 peak ). Compared with usual care, the combined intervention led to statistically significant decreases in body weight and body fat percentage. Caloric restriction alone also led to significant decreases in these measures, but aerobic exercise alone did not. The combined intervention and each independent intervention also led to significant decreases in F 2 -isoprostane and IL-6 concentrations. No intervention produced significant changes in VO 2 peak , kidney function, or urine albumin-to-creatinine ratio. In conclusion, 4-month dietary calorie restriction and aerobic exercise had significant, albeit clinically modest, benefits on body weight, fat mass, and markers of oxidative stress and inflammatory response in patients with moderate to severe CKD. These results suggest healthy lifestyle interventions as a nonpharmacologic strategy to improve markers of metabolic health in these patients.

Chronic kidney disease (CKD) has been shown to be a poor prognostic factor in HIV patients. This study aimed to identify risk factors in HIV-infected patients with early decline in renal function or an estimated glomerular filtration rate (eGFR) less than 90 mL/min/1.73 m2. The study was retrospectively conducted at Panyananthaphikkhu Chonprathan Medical Center, Thailand. The inclusion criteria were HIV-infected adult patients who were treated at the hospital's HIV clinic and whose eGFR levels at the first visit had been evaluated. Eligible patients were categorized according to their eGFR level being lesser or greater than 90 mL/min/1.73 m2. Multivariate logistic analysis was performed to evaluate the association of risk factors with an eGFR of less than 90 mL/min/1.73 m2. There were 301 HIV-infected patients included in the study. Of those, 89 patients (29.57%) had an eGFR of less than 90 mL/min/1.73 m2. Age was the only significant risk factor associated with an eGFR of less than 90 mL/min/1.73 m2 with an adjusted odds ratio of 1.072 (95% confidence interval: 1.015-1.132). Age of over 37 years predicted an eGFR of less than 90 mL/min/1.73 m2 as a risk factor in HIV-infected patients, with a sensitivity of 80.9% and specificity of 34.91%. Age was independently associated with eGFRs of less than 90 mL/min/1.73 m2 in HIV-infected patients. Close monitoring of eGFR should be performed in HIV-infected patients aged over 37 years.

BACKGROUND High glycemic index (GI) and glycemic load (GL) are associated with increased levels of oxidative stress and systemic inflammation in the general population. Maintenance hemodialysis (MHD) patients are known to have excessive oxidative stress burden and inflammation. In this study, we examined the relationship between dietary GI or GL and markers of oxidative stress or inflammation among prevalent MHD patients. METHODS A registered dietitian obtained GI, GL and other dietary data from 58 MHD patients. Two separate 24-h diet recalls (a hemodialysis day and a non-hemodialysis day) were analyzed using the Nutrition Data System for Research (NDS-R) software. Plasma or serum concentrations of F2-isoprostanes, high sensitivity C-reactive protein (hsCRP), leptin and adiponectin (ADPN) were measured in fasting state. Fat mass was measured by dual-energy X-ray absorptiometry (DEXA). Cross-sectional associations between GI, GL and markers of interest were examined by multiple regression analysis with adjustment for potential covariates. RESULTS Mean (±SD) age, body mass index (BMI) and total trunk fat were 47 ± 12 years, 29.5 ± 6.8 kg/m(2) and 16.4 ± 8.8 kg, respectively. Dietary GI was associated with trunk fat (r = -0.182, P = 0.05) but not with F2-isoprostanes and hsCRP. In contrast, GL was significantly associated with F2-isoprostanes (P = 0.002), in unadjusted analysis, which remained in adjusted analyses, adjusting for age and sex (P = 0.005), and after adjusting for BMI, trunk fat and waist/hip ratio (P = 0.004). Addition of leptin or ADPN did not alter the significance of the association. GL also correlated with hsCRP (P = 0.03), but this association was modified by BMI and trunk fat. CONCLUSIONS Dietary GL is significantly associated with markers of oxidative stress and inflammation among prevalent MHD patients, independent of the body composition and adipocytokines. These data indicate the importance of the contents of dietary nutrient intake composition and its potential role in determining the metabolic disturbances in MHD patients.

Adiponectin, an adipose tissue derived hormone, is known to have insulin-sensitizing, anti-inflammatory, and anti-atherogenic properties in the general population. Adiponectin secretion is suppressed by systemic inflammation, a highly prevalent condition in maintenance hemodialysis (MHD) patients. We evaluated whether short-term administration of interleukin 1 receptor antagonist (IL-1ra) improves adiponectin levels and insulin sensitivity in MHD patients. Ad hoc analysis was performed on a pilot randomized placebo-controlled trial of the administration of IL-1ra in chronically inflamed MHD patients. Twenty-two patients were randomly assigned to receive 100 mg of IL-1ra or placebo (1:1) for 4 weeks, and 14 completed the trial. ANCOVA was used to compare percent change from baseline to 4 weeks. The primary outcome was percent change in adiponectin and the secondary outcomes were changes in leptin, homeostatic model assessment of insulin resistance (HOMA-IR) and the leptin-to-adiponectin ratio (LAR). Patients’ mean age was 49 ± 13 years, and 71 % were males. At baseline, the median values for adiponectin, leptin, LAR and HOMA-IR were 11.5 μg/ml [interquartile range (IQR) 9, 28.5], 17.8 ng/ml (3.9, 50.0), 2.20 (0.13, 3.98), and 2.8 (2.0, 3.6), respectively. IL-1ra administration resulted in a mean percent increase in serum adiponectin of 22 % vs. 14 % decrease in the placebo arm (p = 0.003). Leptin, LAR or HOMA-IR levels did not change in either arm. Short-term administration of IL-1ra significantly increased adiponectin levels among prevalent MHD patients. The intervention did not impact insulin sensitivity parameters. Studies of longer duration and larger sample size are needed to further evaluate the potential effect of anti-inflammatory interventions on metabolic markers and insulin sensitivity in MHD patients.

A worldwide vaccination campaign against the 2009 pandemic influenza A (H1N1) virus was launched among high-risk subjects, including hemodialysis patients. The long-term immunogenicity of an influenza vaccine has not been investigated in hemodialysis patients. This study aimed to (1) assess the long-term immunogenicity of a monovalent non-adjuvanted influenza A (H1N1) vaccine in hemodialysis patients and (2) determine the safety of this vaccine. We conducted a prospective cohort study of 44 hemodialysis patients and 149 healthy controls in 2010. All of the participants received a single dose of the monovalent non-adjuvanted 2009 influenza A (H1N1) vaccine. The level of antibodies was measured at baseline and at 4 and 24 weeks post-vaccination using a hemagglutination inhibition assay. The outcomes were the percentages of participants who achieved seroconversion and seroprotection (titer ≥ 1:40) 4 and 24 weeks after vaccination. At 4 weeks post-vaccination, seroconversion was observed in 17 (38.6%) of the hemodialysis patients and 94 (63.1%) of the controls (P=0.056), and protective titers were obtained in 22 (50%) of the hemodialysis patients and 100 (67.1%) of the controls (P=0.426). At 24 weeks post-vaccination, immunogenicity decreased in both the hemodialysis patients and the controls, but there were no significant differences between the hemodialysis patients and the controls in the seroconversion rate (27.3% versus 36.9%, P=0.526) or the seroprotection rate (38.6% versus 48.3%, P=0.996). No differences in adverse events were observed between the hemodialysis patients and the controls. In summary, the 2009 influenza A (H1N1) vaccine elicits a similar immune response in both hemodialysis patients and healthy controls, but immunity declines 24 weeks after vaccination in both groups. Hemodialysis patients should at least be vaccinated annually against the influenza virus.