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Summary Background and objectives Poorphysical performanceiscommoninpatients with kidneyfailureondialysis (CKD5D). Whether lung congestion, a predictable consequence of cardiomyopathy and fluid overload, may contribute to the low physical performance of CKD-5D patients has not been investigated in hemodialysis patients. Design, setting, participants, & measurements This study investigated the relationship between the physical functioning scale of the Kidney Disease Quality of Life Short Form and a validated ultrasonographic measure of lung water in a multicenter survey of 270 hemodialysis patients studied between 2009 and 2010. ResultsModerate to severe lung congestion by lung ultrasonography was observed in 156 (58%) patients; among these, 60 (38%) were asymptomatic (New York Heart Association [NYHA] class I). On univariate analysis, physical functioning was inversely associated with lung water in the whole group (r=20.22; P,0.001) and in the subgroup of asymptomatic patients (r=20.40; P=0.002). Age (r=20.45; P,0.001) and past cardiovascular events (r=20.22; P=0.002) were also inversely associated with physical functioning, whereas albumin (r=0.23;P,0.001) was directly associated with the same parameter. NYHA class correlated strongly with physical functioning (r=20.52; P,0.001). In a multiple regression analysis, both NYHA class and lung water maintained an independentassociationwithphysical functioning,whereasalbuminandbackgroundcardiovascularevents failed to independently relate with the same outcome. Conclusions Symptomatic and asymptomatic lung congestion is associated with poor physical functioning in hemodialysis patients. This association is independent of NYHA, suggesting that this measurement and NYHA may have complementary value to explain the variability in physical performance in hemodialysis patients. Clin J Am Soc Nephrol 8: 1343–1348, 2013. doi: 10.2215/CJN.11111012

Background. Polymorphisms in the FTO (fat-mass and obesity-associated) gene have been associated with the body mass index, cancer, type 2 diabetes and hypertension. Methods. We investigated the relationship between 17 tag single-nucleotide polymorphisms (SNPs) and all-cause mortality in three cohorts of dialysis patients (CREED-1, North Apulian and CREED-2 cohorts; n=783) and in one cohort of stage 2–5 CKD patients (n= 757). Results. We first explored the association between the 17 tag SNPs and all-cause mortality in the CREED-1 cohort and found that patients with the A allele of the FTO rs708259 polymorphism had an elevated risk of mortality (hazard ratio, HR: 1.52, 95% confidence interval (CI) 1.11–2.08; P = 0.008). Similarly, the A allele was associated with an increased risk of death also in the other two dialysis cohorts (North Apulian cohort, risk: +23%; CREED-2 cohort, risk: +21%). The elevated risk portended by this allele was even higher in the stage 2–5 CKD cohort (+97%). However, the risk of mortality associated with the A allele in the three confirmatory cohorts failed to achieve formal statistical significance. In a meta-analysis including the four cohorts (n= 1540; total deaths, n= 381), individuals with the A allele had a 42% excess risk of death (HR: 1.42, 95% CI 1.14–1.76, P = 0.002). Conclusion. The A allele of the FTO rs708259 polymorphism is an independent predictor of all-cause mortality in patients with CKD of various severity. These data support our hypothesis that the FTO gene may be a relevant genetic risk factor for mortality in this population.

Background. Chest ultrasound (US) is a non-invasive wellvalidated technique for estimating extravascular lung water (LW) in patients with heart diseases and in end-stage renal disease. We systematically applied this technique to the whole peritoneal dialysis (PD) population of five dialysis units. Methods. We studied the cross-sectional association between LW, echocardiographic parameters, clinical [pedal oedema, New York Heart Association (NYHA) class] and bioelectrical impedance analysis (BIA) markers of volume status in 88 PD patients. Results. Moderate to severe lung congestion was evident in 41 (46%) patients. Ejection fraction was the echocardiographic parameter with the strongest independent association with LW (r ¼� 0.40 P ¼ 0.002). Oedema did not associate with LW on univariate and multivariate analysis. NYHA class was slightly associated with LW (r ¼ 0.21 P ¼ 0.05). Among patients with severe lung congestion, only 27% had pedal oedema and the majority (57%) had no dyspnoea (NYHA Class I). Similarly, the prevalence of patients with BIA, evidence of volume excess was small (11%) and not significantly different (P ¼ 0.79) from that observed in patients with mild or no congestion (9%). Conclusions. In PD patients, LW by chest US reveals moderate to severe lung congestion in a significant proportion of asymptomatic patients. Intervention studies are necessary to prove the usefulness of chest US for optimizing the control of fluid excess in PD patients.

Background and methods. The endogenous inhibitor of nitric oxide synthase (NOs) asymmetrical dimethylarginine (ADMA) has been implicated as a possible modulator of inducible NOs during acute inflammation. We examined the evolution in the plasma concentration of ADMA measured at the clinical outset of acute inflammation and after its resolution in a series of 17 patients with acute bacterial infections. Results. During the acute phase of inflammation/ infection, patients displayed very high levels of C-reactive protein (CRP), interleukin-6 (IL-6), procalcitonin and nitrotyrosine. Simultaneous plasma ADMA concentration was similar to that in healthy subjects while symmetric dimethyl-arginine (SDMA) levels were substantially increased and directly related with creatinine. When infection resolved, ADMA rose from 0.62 � 0.23 to 0.80 � 0.18mmol/l (þ29%, P ¼ 0.01) while SDMA remained unmodified. ADMA changes were independent on concomitant risk factor changes and inversely related with baseline systolic and diastolic pressure. Changes in the ADMA/SDMA ratio were compatible with the hypothesis that inflammatory cytokines activate ADMA degradation. Conclusions. Resolution of acute inflammation is characterized by an increase in the plasma concentration of ADMA. The results imply that ADMA suppression may actually serve to stimulate NO synthesis or that in this situation plasma ADMA levels may not reflect the inhibitory potential of this methylarginine at the cellular level.

♦ Background End-stage renal disease (ESRD) is a situation with a cardiovascular (CV) risk profile of almost unique severity. While traditional risk factors dominate the scene in the general population, in chronic kidney disease (CKD), nontraditional risk factors play an increasingly important role, being perhaps dominant in ESRD patients. ♦ Objective We review the role inflammation [C-reactive protein (CRP)], hyperhomocysteinemia, high plasma norepinephrine, and accumulation of the endogenous inhibitor of the nitric oxide synthase asymmetric dimethylarginine (ADMA) in the high all-cause and CV mortality of patients on continuous ambulatory peritoneal dialysis (CAPD). ♦ Results The association between CRP and clinical outcomes in patients on peritoneal dialysis (PD) was examined in six studies totaling 692 subjects. The largest of these studies in Caucasians indicates that the independent risk of CV events in patients in the top CRP quartile is about five times higher than in the bottom quartile. Seven prospective studies, including over 1000 hemodialysis and 176 CAPD patients, reported both positive and negative associations between homocysteine and mortality and/or CV events. Because homocysteine circulates bound to albumin, negative associations — rather than negating the vasculotoxicity of homocysteine — most likely reflect the very deleterious effects of malnutrition. Plasma norepinephrine is higher in CAPD than in hemodialysis patients, and multivariate analyses suggest the difference quantitatively entails a 16% higher risk of incident CV events. Likewise, ADMA is more elevated in CAPD patients and such an elevation corresponds to a 15% increase in risk. ♦ Conclusion Nontraditional risk factors are far more prevalent in ESRD patients than in the general population. ADMA and norepinephrine may play a greater role in CV risk in CAPD than in hemodialysis patients.

BACKGROUND Whether hypertension and left ventricular hypertrophy (LVH) are more prevalent in CAPD than in haemodialysis (HD) patients is still under discussion. METHODS To examine this problem we compared a group of 51 CAPD patients, with a group of 201 HD patients. The evaluation included the measurement of atrial natriuretic peptide (atrial natriuretic factor (ANF)), taken as indicator of volume status, and echocardiographic measurements. RESULTS CAPD patients were older, had been treated for a shorter time, and had lower serum albumin and phosphate than HD patients. Plasma ANF was higher (P

Long-term visit-to-visit blood pressure (BP) variability predicts a high risk for cardiovascular events in patients with essential hypertension. Whether long-term visit-to-visit BP variability holds the same predictive power in predialysis patients with chronic kidney disease (CKD) is unknown. Here we tested the relationship between long-term visit-to-visit office BP variability and a composite end point (death and incident cardiovascular events) in a cohort of 1618 patients with stage 2–5 CKD. Visit-to-visit systolic BP variability was significantly and independently related to baseline office, maximal, and average systolic BPs, age, glucose, estimated glomerular filtration rate, and albumin, and to the number of visits during the follow-up. Both the standard deviation of systolic BP (hazard ratio: 1.11, 95% confidence interval: 1.01–1.20) and the coefficient of variation of systolic BP (hazard ratio: 1.15, 95% confidence interval: 1.02–1.29) were significant predictors of the combined end point independent of peak and average systolic BP, cardiovascular comorbidities, Framingham risk factors, and CKD-related risk factors. Antihypertensive treatment (β-blockers and sympatholytic drugs) significantly abrogated the excess risk associated with high systolic BP variability. Thus, large visit-to-visit systolic BP variability in patients with CKD predicts a higher risk of death and nonfatal cardiovascular events independent of underlying BP levels.

Purpose Decline in physical function is commonly observed in patients with kidney failure on dialysis. Whether lung congestion, a predictable consequence of cardiomyopathy and fluid overload, may contribute to the low physical functioning of these patients has not been investigated. Methods In 51 peritoneal dialysis (PD) patients, we investigated the cross-sectional association between the physical functioning scale of the Kidney Disease Quality of Life Short Form (KDQOL-SF: Rand Corporation, Santa Monica, CA, USA) and an ultrasonographic measure of lung water recently validated in dialysis patients. The relationship between physical functioning and lung water was also analyzed taking into account the severity of dyspnea measured using the New York Heart Association (NYHA) classification currently used to grade the severity of heart failure. Results Evidence of moderate-to-severe lung congestion was evident in 20 patients, and this alteration was asymptomatic (that is, NHYHA class I) in 11 patients (55%). On univariate analysis, physical functioning was inversely associated with lung water ( r = –0.48, p < 0.001), age ( r = –0.44, p = 0.001), previous cardiovascular events ( r = –0.46, p = 0.001), and fibrinogen ( r = –0.34, p = 0.02). Physical functioning was directly associated with blood pressure, the strongest association being with diastolic blood pressure ( r = 0.38, p = 0.006). The NYHA class correlated inversely with physical functioning ( r = –0.51, p < 0.001). In multiple regression analysis, only lung water and fibrinogen remained independent correlates of physical functioning. The NYHA class failed to maintain its independent association. Conclusions This cross-sectional study supports the hypothesis that symptomatic and asymptomatic lung congestion is a relevant factor in the poor physical functioning of patients on PD.

Background Pro-inflammatory cytokines play a key role in bone remodeling. Inflammation is highly prevalent in CKD-5D patients, but the relationship between pro-inflammatory cytokines and fractures in CKD-5D patients is unclear. We studied the relationship between inflammatory cytokines and incident bone fractures in a cohort of CKD-5D patients. Methods In 100 CKD-5D patients (66 on HD, 34 on CAPD; males:63, females:37; mean age: 61 ± 15; median dialysis vintage: 43 months) belonging to a single renal Unit, we measured at enrolment bone metabolic parameters (intact PTH, bone and total alkaline phosphatase, calcium, phosphate) and inflammatory cytokines (TNF-α, IL-6, CRP). Patients were followed-up until the first non traumatic fracture. Results During follow-up (median: 74 months; range 0.5 -84.0) 18 patients experienced fractures. On categorical analysis these patients compared to those without fractures had significantly higher intact PTH (median: 319 pg/ml IQ range: 95–741 vs 135 pg/ml IQ: 53–346; p = 0.04) and TNF-α levels (median: 12 pg/ml IQ: 6.4-13.4 vs 7.8 pg/ml IQ: 4.6-11; p = 0.02). Both TNF-α (HR for 5 pg/ml increase in TNF-α: 1.62 95% CI: 1.05-2.50; p = 0.03) and intact PTH (HR for 100 pg/ml increase in PTH: 1.15 95% CI: 1.04-1.27; p = 0.005) predicted bone fractures on univariate Cox’s regression analysis. In restricted (bivariate) models adjusting for previous fractures, age, sex and other risk factors both PTH and TNF-α maintained an independent association with incident fractures. Conclusions In our bivariate analyses TNF-α was significantly associated with incident fractures. Analyses in larger cohorts and with adequate number of events are needed to firmly establish the TNF α -fracture link emerged in the present study.

The authors report a 29-year-old kidney transplant patient who presented, four episodes of severe hyponatraemia associated with sepsis from 2006 to 2010. He was a long-term user of marijuana. The association between severe recurrent hyponatraemia during sepsis and marijuana addiction might not be casual, since experimental data show that vasopressin release induced by sepsis is modulated by the endocannabinoid system.

An updated review of cases of reactivated visceral leishmaniasis (VL) in transplant patients is presented, with a new report of a kidney transplant patient who had VL caused by reactivation of a dormant infection contracted 21 years previously. Close to the time of disease reactivation, the patient had a primary varicella-zoster infection.

We report the case of a 74-year-old woman with pulmonary edema induced by hydrochlorothiazide. We missed the diagnosis in the first episode, and it was only upon unintentional hydrochlorothiazide rechallenge that we correctly identified the cause of the pulmonary edema.

A number of reports on dialysis and transplantation for diabetic patients in the UK and USA are available. The aim of the present survey was to assess the prevalence, main characteristics and complications of diabetic patients treated by dialysis and transplantation in Italy. On 31 December 1987 in Italy, 1605 diabetic patients were being treated by dialysis or transplantation. The prevalence was 28 per million compared with the UK and the USA where the corresponding figures were 17 and 78 per million respectively. The annual incidence in 1987 was 9 per million (UK: 4 per million; USA: 33 per million). The mean age of the Italian diabetic patients was 59 years whereas that for British diabetic patients similarly evaluated was 48 years. Of the Italian diabetic patients 67% had NIDDM (UK: 22%; USA: 50%). Haemodialysis was used in 81% of the Italian patients, peritoneal dialysis in 14%, and only 5% were transplanted. This is in contrast to the UK where only 18% of the patients were treated by haemodialysis and 39% were transplanted. Amongst Italian patients who started RRT in 1987, 9% died within the year, and of the remainder 38% had severe bilateral visual impairment (UK 35%), 3% had had amputations (UK 6%), 7% had suffered from disabling strokes (UK 6%) and 7% had had a myocardial infarction (UK 17%). Before 31 December 1987 another 2.2% developed severe bilateral visual impairment, 0.6% underwent amputations, 1.0% had a disabling stroke and 0.6% suffered from a myocardial infarction. The proportion of diabetic patients treated by RRT in Italy is twice that of the UK but only half that of the USA.(ABSTRACT TRUNCATED AT 250 WORDS)

Background. Low T3 is a frequent alteration in patients with ESRD. This derangement has been recently linked to inflammation in haemodialysis patients. Whether this association holds true in peritoneal dialysis patients has not been studied. Methods. We investigated the relationship between low-grade inflammation [IL-6, C-reactive protein (CRP) and serum albumin levels] and free triiodothyronine (fT3) in a cohort of 41 CAPD patients (mean age, 66 years; M, 26; F, 15) without heart failure and inter-current illnesses. Results. CAPD patients had lower fT3 levels (2.7 � 0.8 pg/ml) than healthy subjects (3.7 � 1.0 pg/ml, P < 0.001) of similar age. Free T3 levels were directly related to those of serum albumin (r ¼ 0.52, P ¼ 0.001) and inversely to IL-6 (r ¼� 0.30, P ¼ 0.05) and CRP (r ¼� 0.54, P < 0.001). Age (r ¼� 0.61, P < 0.001), haemoglobin levels (r ¼ 0.32, P ¼ 0.05) and diastolic blood pressure (r ¼ 0.50, P ¼ 0.001) were also related to fT3. In multiple regression models adjusting for all variables related to fT3, CRP and albumin were retained as independent correlates of fT3. During the follow-up (2.8 � 1.7 years) 27 patients died. Plasma fT3 levels were lower in patients who died (2.5 � 0.8 pg/ml) compared with survivors (3.3 � 0.5 pg/ml P ¼ 0.001). In Cox analyses, fT3 was a significant predictor of mortality independent of the main traditional as well as non-traditional risk factors. Conclusions. The relationship between fT3, CRP and serum albumin suggests that inflammation– malnutrition might be involved in the low T3 syndrome in CAPD patients. Thyroid dysfunction might be implicated in the pathogenic pathway which links micro-inflammation to survival in PD patients.

Plasma fibrinogen (Fib) and calcium x phosphate product have emerged as cardiovascular (CV) event predictors in hemodialysis (HD) patients, but their role in peritoneal dialysis (PD) is less studied.We investigated whether Fib and calcium x phosphate product predict CV events in a prospective cohort study of 47 continuous ambulatory PD (CAPD) patients (mean follow-up 34.6 months).During the follow-up, 29 patients experienced CV events, which were fatal in 11 of them. Plasma Fib was markedly elevated in the entire population studied (median 612 mg/dL inter-quartile range (IQ): 566-718 mg/dL). On univariate analysis, Fib was higher (p=0.02) in those patients who had fatal or non-fatal CV events (median 654 mg/dL, IQ: 577-801) than in event-free patients (median 579 mg/dL, IQ: 532-629). Patients with incident CV events also tended to have higher calcium x phosphate product (51.6 +/- 12.8 vs. 43.8 +/- 13.9 mg2/dL2, p=0.06). On multivariate Cox's regression analyses, including traditional risk factors and history of previous CV events, Fib (hazard ratio (HR) associated with 100 mg/dL increase in plasma Fib 1.29 95% confidence interval (CI) 1.03-1.63 (p=0.03)) and calcium x phosphate product (HR associated with a 5 mg2/dL2 increase 1.25 95% CI 1.05-1.49 (p=0.01)) emerged as independent CV event predictors.Calcium x phosphate product and Fib are CV event predictors in CAPD patients.

From an evolutionary perspective, Darwinian selection has favored insulin-resistant individuals, ie, those with a trait ensuring brain functioning in situations of extreme fuel deprivation. The ability to mount a powerful inflammatory response to infection was another survival advantage in our ancestors, and we now have solid evidence showing that these 2 traits, insulin resistance and inflammation (as measured by serum C-reactive protein [CRP]), are associated in modern human beings. In an analysis of 192 nondiabetic hemodialysis patients, leptin and adiponectin were related in an opposite fashion with insulin sensitivity in end-stage renal disease (ESRD) and interacted in determining insulin resistance in these patients. The risk of insulin resistance was about 6 times higher in ESRD patients with an unfavorable combination of the 2 adipokines (high leptin and low adiponectin) than in those with a favorable combination (low leptin and high adiponectin). Low adiponectin but not high leptin predicted incident cardiovascular events in this cohort. Neither leptin nor adiponectin were associated with CRP in a cross-sectional analysis, but they were linked in an opposite fashion to CRP in a longitudinal study in 21 patients with acute inflammation secondary to infection. High sympathetic activity predicts adverse cardiovascular outcomes in ESRD. Of note, we found that the risk for cardiovascular events is more than 3 times higher in patients with high sympathetic activity and low adiponectin than in those with high adiponectin and low sympathetic activity. The adipocyte hormones leptin and adiponectin are associated in an opposite fashion to insulin sensitivity and inflammation in ESRD patients. Relatively lower plasma adiponectin levels are associated with a higher rate of incident cardiovascular events. Finally, low adiponectin and high norepinephrine seem to be interacting factors in the dismal cardiovascular outcomes with ESRD.

We report the case of a renal transplant patient on tacrolimus who developed a fully reversible renal failure and a doubling in serum tacrolimus closely associated with initiation of ranolazine (Ranexa) treatment, a new anti-angina drug recently introduced in Europe.

Nocturnal hypoxemia, night-day arterial pressure changes and left ventricular geometry in dialysis patients. It is well established that nocturnal hypoxemia in sleep apnea causes an inversion of the circadian arterial pressure rhythm and triggers nocturnal hypertension. Since sleep apnea is very frequent in dialysis patients, we hypothesized that nocturnal hypoxemia may be a factor that contributes to alter the 24-hour arterial pressure profile in these patients. To test the hypothesis 32 dialysis patients underwent 24-hour blood pressure (BP) monitoring and contin- uous monitoring of arterial O2 saturation during the night-time. Hemo- dialysis patients were studied during the non-dialysis day. All patients underwent an echocardiographic study. Thirteen patients had no episode of nocturnal hypoxemia (group I), 7 had at least one episode overnight but less than 2 episodes/hr (group II) and 12 had $ 2 episodes/hr (group III). The average daytime systolic pressure was similar in the three groups. However, the average nocturnal systolic pressure fell in the first group (22.5 6 4.2%) and rose in the second (12.0 6 3.6%) and in the third (13.9 6 2.2%) group (one way ANOVA, P , 0.005). The relative wall thickness of the left ventricle (RWT) was significantly (P , 0.05) higher in group III than in group I, and in the aggregate (N 5 32) there was an inverse relationship between average nocturnal SaO2 and RWT (r 5 20.43, P 5 0.015). The proportion of patients with concentric remodeling or concentric hypertrophy was higher (P 5 0.05) in the group with a more severe degree of nocturnal hypoxemia (group III, 8 of 12) than in the other two groups (group I, 3 of 13; group II, 2 of 7). Nocturnal hypoxemia is associated with the "non-dipping" arterial pressure profile in dialysis patients. Disturbed respiratory control during the night may represent an important cardiovascular risk factor in dialysis patients. The inability to maintain the circadian profile is an important feature of the altered arterial pressure control in patients with chronic renal failure. Indeed, these patients very frequently fail to show the physiological decrease during night-time ("non-dipping" profile) (1-12). Various hypotheses have been proposed to explain such alteration (2, 4, 5) (see Discussion). We thought that episodes of oxygen desaturation, triggered by sleep apnea, which is very frequent in the dialysis population (13-24; reviewed in 19), could be a contributory factor. Sleep apnea in the general population represents a well established cause of nocturnal hy- pertension (25, 26), and it is frequently associated with primary hypertension (reviewed in 27, 28), as well as with severe cardio- vascular complications (29 -31). Therefore, in this study we sought whether nocturnal hypoxemia is related with altered night-day arterial pressure changes as well as with deranged left ventricular geometry in uremic patients.

Although malnutrition is not uncommon in continuous ambulatory peritoneal dialysis (CAPD) and maintenance hemodialysis (MHD) patients, there has never been a large-scale comparison study of nutritional status with these two dialysis modalities. We therefore assessed protein-calorie nutrition in 224 CAPD patients and 263 MHD patients who were treated in eight centers in Italy. The CAPD patients were slightly older than the MHD patients (60.2 +/- 14.2 years v 56.3 +/- 15.1 years; P < 0.01), had undergone dialysis for less time (2.32 +/- 2.10 years v 3.66 +/- 2.66 years; P < 0.0001), and had higher residual renal function (1.83 +/- 2.29 mL/min v 0.27 +/- 0.91 mL/min; P < 0.0001). Protein nitrogen appearance was 60.5 +/- 16.6 g/d and 61.9 +/- 16.5 g/d in the CAPD and MHD patients, respectively. In CAPD versus MHD patients, serum total protein and albumin tended to be lower; serum transferrin and midarm muscle circumference were similar; and relative body weight, skinfold thickness, and estimated percent body fat tended to be greater. These greater values in CAPD patients were particularly evident in those who were 65 years of age or older. Serum glucose, total cholesterol, and triglycerides also were greater in CAPD patients. The subjective global nutritional assessment indicated a significantly greater proportion of malnourished CAPD patients than MHD patients (42.3% v 30.8%). The greater prevalence of malnutrition in CAPD patients diminished with age. Maintenance hemodialysis patients older than 76 years were more likely to be malnourished than CAPD patients. In patients less than 65 years of age, protein-calorie malnutrition was more likely to be present in CAPD patients than in MHD patients.

An increasing number of elderly patients with uraemia are treated by dialysis therapy. Virtually every published study on nutritional status of patients undergoing maintenance haemodialysis treatment or continuous ambulatory peritoneal dialysis (CAPD) has indicated that a substantial proportion of patients undergoing regular dialysis treatment have protein calorie malnutrition. Problems of undernutrition increase significantly with age; a combination of socioeconomic, psychological, and biochemical problems interfering with acquiring and assimilating a balanced diet are responsible for nutritional deficiencies in older people. We assessed the prevalence of protein calorie malnutrition in 183 regular dialysis patients aged 65 years or older treated with haemodialysis or CAPD. This group of patients was compared to two other groups aged 18-40 years (62 patients) and 41-64 years (239 patients). Presence of malnutrition was assessed by selected serum chemistries, anthropometry and Subjective Global Nutritional Assessment. Adequacy of dialysis, protein nitrogen appearance, as an index of protein intake, and residual renal function were measured. The results indicate that protein calorie malnutrition occurs commonly in regular dialysis patients, with a higher prevalence of malnutrition in the elderly; 51% of patients of the elderly group were classified as malnourished, and no difference was found with the two dialytic modalities.

The authors report the case of a 33-year-old Italian man who had three episodes of hypokalaemia with paralysis linked to hyperthyroidism. Because of its low prevalence in western populations, the diagnosis of thyrotoxic hypokalaemic periodic paralysis can be easily missed in non-Asian countries.

To determine the prevalence of hyperchloraemia (plasma chloride concentration of 107 mmol/l or above) in chronic renal failure (CRF), we retrospectively analysed the acid-base and electrolyte status of 102 Italian and 53 English patients with impaired renal function. Hyperchloraemia was a frequent finding at all stages of CRF with a prevalence ranging from 30 to 50%. It was common both in tubulointerstitial nephropathies (45%) and chronic glomerulonephritis (39%). Hyperchloraemic patients were more acidotic than the normochloraemic.

Effect of blood cooling on cuprophan-induced anaphylatoxin generation. We investigated whether cooling of the extracorporeal blood during hemodialysis could prevent anaphylatoxin generation and leukopenia caused by blood-cuprophan contact. After preliminary in vitro studies confirming the temperature dependence of C5a generation, we carried out hypothermic dialysis on nine patients by manipulating blood and dialysate temperature in such a way that blood temperature within the dialyzer averaged 25°C. In comparison with the control procedure (blood temperature within the dialyzer 35°C) hypothermic dialysis reduced peak C5a generation from 41.7 ± 17 ng/ml to 9.7 ± 3.4 ng/ml (P < 0.01), and white blood cell fall from 72 ± 15 to 25 ± 20% (P < 0.01). Arterial PO2 decreased less in hypothermic dialysis (-19 ± 9% of pre-HD value) than in the control procedure (-30 ± 11%) (P < 0.05). We conclude that blood cooling attenuates cuprophan-induced anaphylatoxin generation and leukopenia.

The authors carried out a retrospective survey assessing the total proportion of diabetic patients and relative proportion of patients with Type I and Type II diabetes among patients receiving renal replacement therapy and those evaluated for chronic renal failure in a southern Italian renal unit during the period 1972–1986. The proportion of diabetics among patients accepted for renal replacement therapy was 10% (34336); of the 34 diabetic patients, only one was clearly affected by Type I diabetes, 26 had Type II diabetes, and the classification was uncertain in four patients. Similar relative proportions of Types I and II diabetes were observed among patients referred during the same period for evaluation of chronic renal failure.

Human X-linked dominant hypophosphatemic rickets (HPDR I) is characterized by hypophosphatemia, hyperphosphaturia, abnormal vitamin D metabolism, and rickets/osteomalacia. Two closely linked hypophosphatemic genes, hypophosphatemia (Hyp) and Gyro (Gy), are known on the mouse X chromosome. The Hyp phenotype is the equivalent of the human X-linked hypophosphatemia, while the human equivalent of the Gyro mouse has not been unambiguously identified. We observed an Italian four-generation pedigree with a new form of X-linked recessive hypophosphatemic rickets (XLRH). We demonstrated that HPDR I and XLRH are two different X-linked genes and that XLRH maps in the Xp11.2 region at 0% recombination fraction from the DXS1039 locus. We discuss this new finding in relation to the identification of the human equivalent of the Gyro mouse and to the recent mapping in Xp11.22 of another X-linked recessive renal disorder named Dent disease.

Malnutrition is a major negative prognostic factor in dialysis patients. Simple and reliable estimations of nutritional status may therefore prove of particular value in the follow-up of these patients. To validate subjective global assessment (SGA) in dialysis patients we compared subjective global assessment with objective measurements (anthropometry, bioelectrical impedance, biochemical measurements) in 59 chronic uraemic patients treated by haemodialysis (n = 36) or CAPD (n = 23). Subjective global assessment was performed by an observer unaware of the results of objective measurements and was related to serum albumin (r = -0.51, P < 0.001) and bioelectric impedance phase angle (r = -0.58, P < 0.001) as well as with MAMC (r = -0.28 P = 0.028), %fat (r = -0.27, P = 0.042) and nPCR (r = -0.29 P = 0.027). Multiple regression analysis showed that the relationship of subjective global assessment (as a dependent variable) with objective measurements (covariates) was stronger (multiple r = 0.77) than the relationship found with univariate analysis. This finding indicates that subjective global assessment gives a well-based and balanced estimation of nutritional status. Our data show that subjective global assessment is a clinically adequate method for assessing nutritional status in dialysis patients. Being an inexpensive method of well-proven reliability, subjective global assessment can be recommended for a more frequent assessment of nutritional status in dialysis patients.

Paraneoplastic syndromes are often associated with renal parenchymal tumours. This report describes a case of renal-cell carcinoma with kappa-chain nephropathy. The patient, a 60-year-old man, had renal tubular dysfunction, shown by low serum concentrations of urate and phosphate. Kappa-chains were found in both serum and urine, but no lambda-chains were found. Investigations showed a clear-cell carcinoma, and the patient underwent a radical nephrectomy. Two years after operation serum phosphate and urate concentrations had returned to normal, and kappa-chains were undetectable in serum or urine. The absence of lambda-chains indicates that the light-chain proteinuria was due to overproduction of the M component, and the disappearance of kappa-chains after the operation suggests a causal relation between the renal tumour and the overproduction of the M component.

In a study of a patient with acute renal failure and uveitis, renal biopsy showed acute interstitial nephritis. Serum calcium and parathyroid hormone concentrations were persistently low during the acute phase and after the resolution of renal failure. Clinical history was negative for intake of drugs capable of inducing acute interstitial nephritis.

A 54-year-old man on regular haemodialysis developed severe amiodarone-induced hypothyroidism after an unusually short latency period. The iodide accumulation and/or the derangement in thyroid function associated with chronic renal failure may predispose uraemic patients to this serious side effect of amiodarone. Although the pharmacokinetics of amiodarone are not altered by renal failure, caution is advised in prescribing this drug to uraemic patients.