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Sarcopenia and sarcopenic obesity (SO) are linked to unfavorable prognosis in maintenance hemodialysis (MHD) populations. We tested whether nonobese sarcopenia and SO, as different stages of extreme protein-energy wasting, have different prognoses.In this prospective observational study, 261 MHD patients were recruited from October 2010 to April 2012 and followed until October 2020. Two definitions were used to diagnose sarcopenia: the European Working Group on Sarcopenia in Older People consensus and the Foundation for the National Institutes of Health (FNIH) Biomarkers Consortium criteria. Obesity was determined as the percentage of total body fat, ≥27% for men and ≥38% for women. Data for all-cause and cardiovascular morbidity and mortality, baseline nutrition markers, inflammation and oxidative stress, adipokines, body composition parameters, handgrip strength, and quality of life (QoL) scores were measured.According to European Working Group on Sarcopenia in Older People, 115 (44.1%) patients were sarcopenic and 120 (46.0%) according to FNIH definitions. Of them, 28.4% and 34.5% were SO, respectively. Higher levels of albumin, creatinine, uric acid, leptin, phase angle, better nutritional scores, and lower adiponectin levels characterized SO patients compared with nonobese sarcopenic patients regardless of indexing method. Better QoL scores were noted in SO compared with nonobese sarcopenic patients using the FNIH sarcopenia criteria. The hazard of all-cause death, cardiovascular death, and first cardiovascular event for patients with SO was lower compared with the nonobese patients after multivariate adjustments. Statistical significance of these associations disappeared after including fat mass in multivariate models.MHD patients with SO have better nutritional status and prognosis for cardiovascular events, all-cause and cardiovascular disease mortality, and possibly better QoL compared with nonobese sarcopenic MHD patients. The better prognosis appears to be entirely due to the excess fat, which is protective in sarcopenic MHD patients similar to that described in the entire MHD population.

Introduction PTSD is common among veteran combatants. PTSD is characterized by brain changes, for which available treatments have shown limited effect. In a short-term study, we showed that hyperbaric oxygen therapy (HBOT) induced neuroplasticity and improved clinical symptoms of veterans with treatment-resistant PTSD. Here, we evaluated the long-term clinical symptoms of the participants of that study. Materials and Methods Veterans from our short-term study were recruited 1 or more years after completing HBOT. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and self-reported questionnaires were administered at a single site visit. Changes in clinical scores between long-term, short-term, and pretreatment evaluations were analyzed. Results Of the 28 participants who received HBOT during or following the short-term study, 22 agreed to participate in the current study. At a mean of 704 ± 230 days after completing the HBOT course, the mean CAPS-5 score (26.6 ± 14.4) was significantly better (lower) than at the pre-HBOT evaluation (47.5 ± 13.1, P Conclusions The beneficial clinical effects of HBOT are persistent and were not attenuated at long-term follow-up of about 2 years after completion of HBOT. Additional long-term effects of the treatment were observed in social function and in decreased medication use.

Introduction Minimally invasive pyeloplasty (MIP), namely, laparoscopic and robot-assisted interventions, has gained popularity in recent years. Double-J ureteral stents are frequently inserted during surgery. Foreign bodies in the urinary tract are considered as risk factor for developing urinary tract infection (UTI). This study aimed to specify the bacteria cultured from urine and stents responsible for UTI in children with indwelling ureteral stents undergoing MIP. Patients and Methods We retrospectively reviewed medical records of 30 children (22 boys and 8 girls) who had undergone MIP between 2014 and 2017. Median age at surgery was 2.7 years (interquartile range [IQR]: 0.5–7.9). Urine cultures were obtained before surgery, before stent removal, 1 month after stent removal, and if UTI was suspected. Stents were removed 4 to 8 weeks after surgery and cultured. Patients' demographics, types of stents, and surgical details were recorded. Results Median stent indwelling time was 5.09 weeks (IQR: 4–6). Postoperative febrile UTI developed in 4/30 (13%) patients. Afebrile UTI occurred in another 4/30 (13%) patients. Stent cultures were positive in 19/30 (63%) patients. Stent and urinary cultures were identical in only one patient. Three of four patients with preoperative asymptomatic bacteriuria developed postoperative UTI. There was no association between UTI, gender, stent diameter, and duration of indwelling catheter. Conclusion After MIP, febrile UTI and afebrile UTI occurred in about one quarter of patients. Pathogens isolated postsurgically from urinary cultures were unrelated to those colonizing the stents. Therefore, routine stent culturing is of low clinical significance. Moreover, small-caliber stents and longer indwelling periods were not risk factors for UTI. Optimizing antibiotic treatment for children with preoperative UTI may potentially prevent morbidity after surgery.

Objective Higher serum alkaline phosphatase (sALP) levels associate with a poor prognosis in maintenance hemodialysis patients. However, little is known about the meaning of lower sALP in this population. We hypothesized that lower sALP concentrations may express nutritional status and survival accordingly. Methods A retrospective, longitudinal cohort study of a clinical database containing the medical records of 554 patients (367 men and 187 women, mean age 67.6 ± 14.2 years) receiving maintenance hemodialysis from November 2007 to July 2018 in a single center was conducted. sALP, nutritional, bone turnover, and inflammatory marker levels were recorded at 0, 6, 12, 18, 24, 30,and 36 months followed by 58 additional months of clinical observations. Results The median sALP level was 90.0 (71.0-125.8) U/L. In a linear mixed effects model adjusted for baseline demographics and clinical parameters, each 1.0 U/L increase above the mean sALP at baseline was associated with 0.7% slower rate of decline in geriatric nutritional risk index per 3 years (P = .02 for sALP × time interaction). sALP remained associated with the rate of change in geriatric nutritional risk index, even after controlling for C-reactive protein and intact parathyroid hormone levels. For each 1.0 U/L increase in sALP over time, the fully adjusted all-cause mortality hazard ratio using Cox models with the time-varying risk effect was 0.996 (95% confidence interval 0.993-1.000, P = .04). Conclusions Increasing longitudinal levels of sALP associate with improved nutritional status and lower mortality rates. sALP can be used as an integrated marker, combining the properties of the nutritional marker, the marker of mineral-bone disease and inflammation, according to its levels.

BackgroundAn elevation in serum chromium levels in individuals treated with renal replacement therapy has been previously described, but chromium levels have not been systematically studied in patients treated with different dialysis modalities. The aim of this study was to compare serum chromium levels in patients treated with chronic peritoneal dialysis (PD) and hemodialysis (HD).MethodsWe studied 169 chronic dialysis patients in a single medical center, of which 148 were treated with HD and 21 with PD. Serum chromium levels were measured by atomic absorption spectrometry. Residual renal function was accessed using a timed urine collection for the measurement of urine output and calculation of glomerular filtration rate (GFR).ResultsThe median (interquartile range) serum chromium level was significantly higher in patients treated with PD than in patients treated with HD: 5.00 (3.24 – 6.15) vs 1.83 (1.29 – 2.45) mcg/L, p < 0.001. In a univariate analysis, serum chromium level was associated with PD modality: Exp (B) 7.46 (95% confidence interval [CI] 2.1 – 26.4), p = 0.002. The association of PD modality with serum chromium level was even more significant using a multivariate logistic regression model: odds ratio (OR) 11.87 (95% CI 2.85 – 49.52), p = 0.001 after adjustment for age, gender, diabetes, smoking, dialysis vintage, use of diuretics, and residual renal function.ConclusionsIn patients treated with chronic dialysis, serum chromium levels are higher in patients treated with PD than in those treated with HD.

Trans rectal ultrasound guided prostate biopsy with periprostatic nerve block (PPNB) is performed following probe insertion and manipulation leaving these initial maneuvers uncovered in terms of pain control. We evaluated whether topical analgesia reduces pain during early stages of the procedure.Seven group prospective, randomized controlled study: groups 1-3: nerve block with 5 ml 1% lidocaine bilaterally plus perianal topical application of 10 ml 5% lidocaine cream. Groups 4-6 as in 1-3 plus digital application of 10 ml 5% lidocaine cream internally on rectal walls. For each approach exposure times were 5 (groups 1 and 4), 10 (groups 2 and 5) and 20 (groups 3 and 6) min, respectively. The control group (7) received PPNB only. Patients filled a 0-10 visual analogue scale (VAS) at five points: after probe insertion, during probe manipulation, following PPNB, after prostate biopsies and a global pain estimation.Two hundred and fifty-two patients were enrolled. Significant differences in VAS between all study groups and controls were observed at the pre-biopsy stages of the procedure. In multivariate analysis adjusted for prostate specific antigen, diabetes mellitus status, spinal disease, abnormal digital rectal examination and non- benign prostate hyperplasia histology, significance remained for probe insertion and intra-rectal manipulation. For each exposure time no significant differences were observed between topical application and topical + intra-rectal application. After PPNB, differences between study and control groups disappeared.Topical anesthesia significantly reduces pain during early stages of prostate biopsy. Perianal application sufficed whereas intra-rectal application of local anesthetics does not add to pain control. Perianal application for 10 min seems to be optimal.

The aims of this study were to describe a novel technique for transvaginal repair of large (> 4 cm) female urethral diverticulum (UD) using bipedicle double-opposing flaps of the periurethral fascia and to evaluate long-term follow-up. The medical records of 29 women who underwent transvaginal excision of UD at our institution were reviewed retrospectively. Seventeen cases with UD > 4 cm were included in the study. Cystourethroscopy was performed at the beginning of the surgery, and in 60% of cases the orifice of the diverticulum was identified. An inverted-U incision was performed at the vaginal anterior wall. The periurethral fascia was incised longitudinal at the midline and parallel to the urethra. The diverticular sac was dissected and resected. The neck of the diverticulum was closed with 4/0 vicryl suture. The periurethral fascia was sutured using bipedicle double-opposing flaps with interrupted 3/0 vircyl suture. The vaginal mucosa was sutured with 2/0 vicryl continuous suture. All 17 women with large UD were operated on using bipedicle double-opposing flaps of the periurethral fascia. Follow-up of 5 ± 2.4 years yielded no recurrence and no other late complications. Using bipedicle double-opposing flaps of the periurethral fascia during transvaginal excision of large UD is safe and effective.

Objective To evaluate whether anesthesia of the meatal orifice reduces pain during cystoscopy in women, known to cause significant pain, discomfort and anxiety in women. Secondary end-point was to compare pain between rigid and flexible cystoscopy. Methods A total of 120 women, median age 66 (interquartile range 57-69), referred for office cystoscopy were prospectively randomized into 2 groups according to meatal orifice exposure: (1) 5-minute meatus exposure with 2% lidocaine gel; (2) 5-minute meatal exposure with water soluble gel. In each group a pad soaked by the gel was externally placed on the meatal orifice. Each group was further divided to flexible or rigid cystoscopy. Exclusion criteria included urethral stricture, urinary tract infection, chronic pain disease (e.g., IC/PBS), neurogenic disorder, allergy to lubricant, and concurrent pain medication. In all patients, a water-based lubricant applied on the cystoscope, was used for lubrication. A 0-10 visual analogue scale was performed at 4 checkpoints: before examination, immediately following urethral penetration, immediately at end of procedure and 15 minutes after completion Results Study groups did not significantly differ in clinical or demographic parameters. Pain level prior to procedure was 0 in all patients. Mean visual analogue scale immediately after urethral penetration was 4.2 ± 2.3 in both groups 1 and 2 (P= 1). No significant differences in other checkpoints was reported. Further subanalysis by cystoscope type did not demonstrate significance. Conclusion Meatal analgesia does not increase tolerance to cystoscopy in females. Pain level is not reduced by the use of flexible cystoscope in the female population.

BACKGROUND: Mortality in patients with end-stage renal disease (ESRD) on maintenance hemodialysis (MHD) remains exceptionally high. While traditional risk factors such as obesity are paradoxically associated with better survival, nontraditional risk factors including cachexia increase the likelihood of poor outcomes. There is accumulating evidence that the endocannabinoid (ECB) system plays a major role in energy preservation and storage, factors which can prevent the deleterious effects of cachexia. Hence, in this study, we evaluated the association of circulating ECB levels with mortality in MHD patients. METHODS: Serum concentrations of anandamide (AEA) and 2-arachidonoyl-sn−glycerol (2-AG), major ECB ligands, were measured in MHD patients. Their correlation with various clinical/laboratory indices and association with 12-month all-cause mortality were examined. RESULTS: Serum 2-AG levels positively correlated with body mass index, serum triglycerides and body anthropometric measures. Meanwhile, serum AEA levels correlated positively with serum interleukin-6, and negatively with serum very low-density lipoprotein levels. While increased serum 2-AG levels were associated with reduced risk of all-cause mortality (hazard ratio [HR] 0.52, 95% CI 0.28–0.98), there was no clear association between serum AEA levels and mortality (HR 0.91, 95% CI 0.48–1.72). CONCLUSIONS: In MHD patients, the circulating levels of ECB ligand, 2-AG, may play an important role in determining body mass and risk of mortality. These observations were unique to 2-AG as similar findings were not obtained with serum AEA. Future studies need to investigate the mechanisms responsible for these associations and examine the modulation of the ECB system as a potential target for therapy in ESRD.

INTRODUCTION:Intradialytic hypotension (IDH) is an important cause of morbidity and mortality among hemodialysis patients. We used an immersion model to evaluate the role of reduced effective circulating volume, and to examine whether facilitated refilling can prevent IDH. METHODS:Ten male hemodialysis patients who had frequent episodes of IDH were randomized to a mid-week "wet" or "dry" hemodialysis session, and subsequently underwent the other session in a crossover manner. The wet sessions were performed while immersed up to the neck in a 34 to 35°C bath, and the dry session was standard hemodialysis. Ultrafiltration goals were determined as the mean ultrafiltration during the 10 sessions preceding the first study session ± 10%. FINDINGS:Mean ultrafiltration was similar for the wet and dry sessions (2.99 ± 0.64 kg vs. 2.96 ± 0.74 kg). Symptomatic hypotension did not develop in any of the patients during the wet session, compared to 4 (40%) during the dry session. Systolic blood pressure adjusted to ultrafiltration was stable during the wet session, 0.22 mmHg/15 min (95% CI -0.27 to 0.70), P = 0.38, and significantly decreased during the dry session, -0.68 mmHg/15 min (95%CI -1.24 to -0.11), P = 0.02. Diastolic blood pressure did not change during the sessions. Mean atrial natriuretic peptide significantly increased in the wet session, by 31.36 pgr/mL (95%CI 8.73-53.99), P = 0.007, and slightly and insignificantly decreased in the dry session, by 21.66 pgr/mL (95% CI -52.59 to 9.25), P = 0.167. Aldosterone blood levels did not change. DISCUSSION:Reduced effective circulating volume is a major cause for IDH, which can be prevented using head-out water immersion facilitated redistribution.

Increased age is strongly associated with anorexia and protein-energy wasting (PEW) in maintenance hemodialysis (MHD) population. We hypothesized that the association of obestatin, a recently discovered anorexigenic gut hormone, with appetite and nutritional status differs by age groups. We performed a cross-sectional study on 261MHD patients. Obestatin, acyl-ghrelin, markers of inflammation (CRP, IL-6, TNF-α) and nutrition (self-reported appetite, dietary intake, biochemical nutritional parameters, and body composition) were measured. Obestatin was associated with appetite in multivariate analyses even after controlling for such confounders as lean body mass (LBM), IL-6 and acyl-ghrelin in patients younger than 71 years. For each ng/ml increase in obestatin levels, the odds for diminished appetite was 0.75 (95% CI: 0.59–0.96). However, these associations were not observed in patients 71 years and older. Multivariable logistic regression models (including appetite) also showed increasing odds for PEW (defined by ESPEN consensus-based criteria for the diagnosis of malnutrition) across increasing serum obestatin levels (OR: 1.51, 95% CI: 1.05–2.18) in patients 71 years and older. However, after lean body mass (LBM) was added to this model, the association between obestatin and malnutrition was abolished (OR: 1.26, 95% CI: 0.83–1.91). The association between serum obestatin, appetite and PEW differs depending on age in MHD patients. A positive link with appetite exists in patients younger than 71 years, whereas this relationship disappears by the age of 71. In older MHD patients, obestatin is associated with PEW through mechanisms related to LBM, but not to appetite.

Background/Aims: Residual kidney function (RKF) is a pivotal predictor of better clinical outcomes in maintenance hemodialysis (MHD) patients. So far there has been no attempt to use bioimpedance analysis (BIA) measurements to calculate residual glomerular filtration rate (GFR) in dialysis population. We hypothesized that performing of multi-frequency BIA at the beginning and end of hemodialysis session can enable us to predict the measured residual GFR in MHD patients. Thus our aim was to develop and validate a new RKF prediction equation using multi-frequency BIA in MHD patients. Methods: It was diagnostic test evaluation study in a prospective cohort. Participants (n=88; mean age, 66.3±13.2 years, 59.1% males) were recruited from a single hemodialysis center. A new equation (eGFRBIA) to predict RKF, utilizing BIA measurements performed pre- and post-dialysis, was generated and cross-validated by the leave-one-out procedure. GFR estimated as the mean of urea and creatinine clearance (mGFR) using urine collections during entire interdialytic period. Results: A prediction equation for mGFR that includes both pre- and post-dialysis BIA measurements provided a better estimate than either pre- or post-dialysis measurements alone. Mean bias between predicted and measured GFR was -0.12 ml/min. Passing and Bablok regression showed no bias and no significant deviation in linearity. Concordance correlation coefficient indicated good agreement between the eGFRBIA and mGFR (0.75, P2 ml/min/1.73 m2 yielded an area under curve of 0.96, sensitivity 85%, and specificity 89% in predicting mGFR. The κ scores for intraobserver reproducibility were consistent with substantial agreement between first and second estimation of RKF according to eGFRBIA (weighted κ was 0.60 [0.37-0.83]). Conclusion: We present a valid and clinically obtainable method to predict RKF in MHD patients. This method, which uses BIA, may prove as accurate, convenient and easily reproducible while it is operator independent.

Background: Recent experimental studies have suggested that obestatin, a proposed anorexigenic gut hormone and a physiological opponent of acyl-ghrelin, has protective cardiovascular effects. We tested the hypothesis that obestatin is independent of inflammatory mediators and/or acyl-ghrelin in predicting outcomes of the maintenance hemodialysis (MHD) population. Methods: It was a 6-year cohort study on 261 MHD patients. Obestatin, acyl-ghrelin, adipokines (leptin and adiponectin), markers of inflammation and nutrition, prospective all-cause and cardiovascular mortality were studied. Results: During the follow-up, 160 patients died in total, with 74 deaths due to cardiovascular causes. For each ng/mL increase in baseline obestatin level in fully adjusted models (including malnutrition-inflammation score, Interleukin-6 [IL-6], adipokines and acyl-ghrelin), the hazard for death from all causes was 0.90 (95% CI 0.81–0.99) and for cardiovascular death 0.85 (95% CI 0.73–0.99). However, these associations were more robust in the subgroup of patients aged above 71 years: 0.85 (95% CI 0.73–0.98) for all-cause death and 0.66 (95% CI 0.52–0.85) for cardiovascular death. An interaction between high IL-6 (above median) and low obestatin (below median) levels for increased risk of all-cause mortality (synergy index [SI] 5.14, p = 0.001) and cardiovascular mortality (SI 4.81, p = 0.02) emerged in the development of multivariable adjusted models. Interactions were also observed between obestatin, Tumor necrosis factor-alpha, adipokines and acyl-ghrelin, which were associated with mortality risk. Conclusion: Serum obestatin behaves as a biomarker for cardiovascular and all-cause mortality in MHD patients. The prognostic ability of obestatin in this regard is independent of inflammation, nutritional status, acyl-ghrelin’s and adipokines’ activity and is modified by age being very prominent in patients older than 71 years.

Introduction The significance of asymptomatic bacteriuria in maintenance hemodialysis (MHD) patients remains controversial. We hypothesized that the presence of asymptomatic bacteriuria as a sole clinical manifestation of urinary tract infection (UTI) in asymptomatic MHD patient may contribute to the chronic inflammatory response. Our aim was to explore the relationship between asymptomatic bacteriuria and elevated levels of inflammatory markers in MHD patients. Methods A randomized open-label single center study of 114 MHD patients was conducted. Forty-six patients presented negative urine culture and 41 subjects were excluded due to different reasons. The remaining 27 patients (mean age of 71.5 ± 12.2 years, 63% men), fulfilling the criteria for having asymptomatic bacteriuria, were randomly assigned to either the treatment group (13 patients) or the observational group (14 subjects). The treatment group received 7 days of antibiotic treatment given according to bacteriogram sensitivity. After 3 months of follow-up all measurements of the study were repeated. The primary end point was change in inflammatory biomarkers from baseline by the end of the study. Findings There were no statistically significant differences in white blood cell changes (P = 0.27), ferritin (P = 0.09), C-reactive protein (P = 0.90), and interleukin-6 (P = 0.14) levels between the groups from baseline to the end of study or at the end of the study. Analyzing cross-sectional data, asymptomatic bacteriuria was found to not be a predictor of higher levels of inflammatory parameters at baseline. Discussion Asymptomatic bacteriuria is not a modifiable risk factor for chronic inflammation in the MHD population.

To assess whether urethral pain during male catheterization can be reduced if the patient is instructed to void during the insertion of the catheter.Ninety-six males (age 66 ± 13) who were referred for multichannel urodynamic study were prospectively randomized to 2 groups according to the catheter insertion technique: (1) patients who were instructed to void during catheterization, and (2) patients who had no guidance prior or during catheterization. Exclusion criteria were the following: use of analgesics within the previous 24 hours, active urinary tract infection, indwelling urethral catheter, pre-existing urethral pain, and known urethral stricture or inability to cooperate with pain assessment due to mental disorders. A 0 to 10 visual analog pain scale was filled in different time points: prior and immediately after instillation of the lubricant gel into the urethra, immediately after the insertion of the catheter, and 15 minutes after the test.Study groups did not differ in terms of demographic, clinical, and urodynamic parameters. The median visual analog pain scale during catheterization was 2 (interquartile range 1-3) and 4 (interquartile range 3-5) in groups 1 and 2, respectively (P .001). There were no differences in the reported scores in the other checkpoints.Pain level during urethral cauterization in males can be significantly reduced when the patient is instructed to void during the insertion of the catheter into the urethra.

The neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios have been proposed as emerging markers of inflammation and prognosis in maintenance hemodialysis (MHD) patients. However, to date, no longitudinal performance of these indices is known. The study’s purpose was to examine the longitudinal relationship between NLR, PLR, inflammatory and nutritional parameters in MHD patients and how their changes over time associate with adverse clinical outcomes. A historical longitudinal cohort study was conducted using a clinical database which included 554 patients (mean age, 67.6 ± 14.2 years; 34% women) from a single center receiving MHD from November 2007 to July 2018. NLR, PLR, C-reactive protein (CRP) and nutritional parameters were recorded at 0, 6, 12, 18, 24, 30 and 36 months, followed by 58 additional months of clinical observations. In a linear mixed-effects model adjusted for baseline demographics and clinical parameters, including white blood cell count, NLR and PLR were both associated with CRP levels at any given time point observation (linear estimates (95% CI): 1.53, (0.11–2.95) and 1.55 (0.15–2.93), respectively). For each 1.0-unit increase in NLR over time, the fully adjusted all-cause mortality hazard ratio using Cox models with the time-varying risk effect was 1.04 (95% CI 1.01–1.07, P = 0.006). However, when CRP was included in this model, the relationship was no longer significant. PLR’s performance did not match the prognostic marker. Longitudinal changes in NLR mimic CRP changes and predict all-cause mortality risk in MHD patients.

Summary Background Obestatin, a physiological opponent of acylated ghrelin, is linked to appetite suppression regulation in mice but its anorexigenic properties in humans are controversial. We aimed to investigate obestatin's potential role in dietary intake regulation by examining response to a meal in maintenance hemodialysis (MHD) patients. Methods In this prospective observational case series study, we investigated the response of obestatin to a fixed calorie meal (500 kcal) in 21 MHD patients (age 69.2 ± 13.1 years, 10 women, with a body mass index 27.2 ± 5.5 kg/m2). Parallel changes in serum obestatin and insulin levels and subjective scores of appetite (visual analogue scales for hunger, satiety, fullness and prospective food consumption) were recorded on fasting and 30, 60 and 120 min after the meal. Results In a linear mixed effects model controlling for baseline demographics and clinical parameters including serum insulin concentrations, postprandial levels of obestatin did not change significantly from baseline in response to the meal. The response was the same in MHD patients treated with high- or low-flux dialyzers. However, postprandial obestatin levels were associated with the rate of change in sensation of fullness (linear estimate: 11.60 (95% confidence interval 0.17 to 23.04, P Conclusions Obestatin levels do not change acutely with food administration in MHD patients, but associate with the changes in sensation of fullness. This supports the possible role of obestatin in the long-term regulation of appetite in MHD patients.

The geriatric nutritional risk index (GNRI) has been reported as a useful predictor of prognosis in maintenance hemodialysis (MHD) patients, demonstrating GNRI less than 90 as a marker of a poorer nutritional status and significantly increased mortality. We tested whether GNRI as a whole associated stronger with clinical and laboratory surrogates of nutrition and inflammation, muscle function, health-related quality of life (QoL), and predicts all-cause and cardiovascular (CV) morbidity and mortality in this population better than its individual components (albumin and body weight to ideal body weight ratio).A prospective observational study with a median follow-up of 30 months (interquartile range - 19-41 months) was performed on 352 MHD outpatients (38.0% women) with a mean age of 67.4 ± 13.2 years. All-cause and cardiovascular hospitalization and mortality, GNRI, handgrip strength (HGS), body composition parameters (anthropometry and bioimpedance) and short form 36 (SF-36) quality-of-life scores were measured. Multivariate linear regression analyses were performed to obtain adjusted correlations. Receiver operating characteristic (ROC) curves were generated and multivariate Cox proportional hazards models were applied to identify the predictive value of GNRI and its components separately.GNRI positively correlated with total score (r = 0.15, P 0.05), the physical health dimension (r = 0.14, P 0.05), the general health (r = 0.18, P 0.01) and some other scales of the SF-36. A significant correlation of GNRI with HGS in male patients didn't stand up to multivariable adjustments. For each one unit increase in baseline GNRI levels, the first hospitalization hazard ratio (HR) after adjustments for confounders was 0.98 (95% confidence interval (CI), 0.97 to 0.99) and the first CV event HR was 0.98 (95% CI, 0.97 to 0.99); all-cause death HR was 0.97 (95% CI, 0.96 to 0.99) and CV death HR was 0.97 (95% CI, 0.95-0.99). Albumin was related to QoL and clinical outcomes with higher strength and magnitude than GNRI.Despite the significant relationship with clinical outcomes and QOL, GNRI is not better and is even slightly worse than albumin's performance. This raises doubts as to the clinical utility of GNRI as a prognostic tool in the MHD population.

We investigated outcomes of patients hospitalized with community-acquired pneumonia (CAP) according to the changes in red cell distribution width (RDW).For 980 adults, clinical characteristics, outcomes during hospitalization for CAP (transfer to the intensive care unit, treatment with mechanical ventilation, prolonged hospital stay, and death), and all-cause mortality following discharge were compared: according to RDW changes versus stable RDW during hospitalization, and according to normal (≤14.7 %) versus high (14.7 %) RDW values on admission/discharge.RDW changes (n = 386) during hospitalization were associated with more severe clinical and laboratory characteristics than stable RDW (n = 594). Changes in RDW strongly predicted poor in-hospital outcomes (p 0.001). The respective 30, 90-day, and total (median follow-up 54 months) mortality rates were significantly higher (9.8, 16.0 and 43.5 %) among patients with RDW changes, compared to 4.0, 7.6 and 30.5 % among those with stable RDW (p 0.001 for all comparisons). RDW changes, as well as high RDW (each 1 % increment) on admission and discharge, were powerful predictors of mortality (the respective relative risks 1.41, 1.13, and 1.15, and 95 % confidence intervals 1.13-1.74, 1.08-1.19, and 1.10-1.21).RDW changes during hospitalization for CAP are common and associated with a severe clinical profile. Time-dependent RDW changes strongly predict poor in-hospital outcomes and increased short- and long-term mortality. Repeated RDW determinations during hospitalization for CAP may provide useful prognostic information.

Hypertension has been shown to be a risk factor for development of dementia. However, medical treatment of hypertension failed to reduce consistently the risk of dementia. Experimental study pointed to the possibility of difference between different calcium channel blockers (CCB) in their neuro-protective effect. The aim of our study was to evaluate the risk of dementia during treatment of hypertension with different CCBs. This is a retrospective cohort study based on electronic database of a large public health care organization. Study period was 11 years and it included patients aged 40-75 years old, having diagnosis of hypertension without diagnosis of dementia at the starting point, treated with either single specific CCB (study group) or with other than CCBs antihypertensive medications (control group) for at least 30 months during the study period. A total of 15,664 patients that satisfied these criteria were identified: 3,884 were treated with amlodipine, 2,062 were treated with nifedipine, 609 were treated with lercanidipine, and 9,109 never received CCBs. Dementia developed in 765 (4.9%) patients. Adjusted hazard ratio (HR) for dementia in patients treated with amlodipine, nifedipine, and lercanidipine was 0.60 (p < 0.001), 0.89 (NS), and 0.90 (NS). Decreased adjusted HR of dementia with amlodipine was demonstrated in the patients aged 60 or more (HR 0.61 [0.49-0.77], p < 0.001), but not in the patients aged less than 60 years old. This study shows that amlodipine therapy may be associated with a decreased dementia risk in hypertensive individuals older than 60 years, compared to those treated without CCBs.

The potential side effects of common phosphate binders are gastrointestinal in practice. We hypothesized that regular use of phosphate binders may be associated with decreased appetite, dietary intake and consequently, poor nutritional status.This was cross-sectional study of 78 patients (mean age 67.5±13.0, 34.6% women) undergoing maintenance hemodialysis (MHD) treatment. Participants were divided into three equal groups - sevelamer (n=25), lanthanum (n=24) and the control group (n=29). Eating motivation was assessed using visual analogue scales (VAS) and by a self-reported appetite assessment which was graded on a 5-point Likert scale. Main outcome measure was differences in VAS scores for appetite, dietary intake and nutritional status (malnutrition-inflammation score [MIS]) in the study groups.Appetite, dietary intake, biochemical nutritional markers, anthropometric measures and MIS were similar in the three groups. A statistically significant difference was observed in sensation of fullness between the groups: multivariable adjusted ORs in the sevelamer carbonate group was 4.90 (95% CI: 1.12 to 21.43), p=0.04 and in the lanthanum carbonate group was 5.18 (95% CI: 1.15 to 23.30), p=0.03 versus the control group. However, no linear association was observed between MIS scores and VAS scores for appetite in any study group.Regular use of these phosphate binders was not associated with anorexia, decreased dietary intake and nutritional status in the study population. Therefore, there is no preference in the choice of phosphate binders in MHD patients with hyperphosphatemia, even those who are at nutritional risk.

The biological basis of abdominal obesity leading to more severe outcomes in patients with normal body mass index (BMI) on maintenance hemodialysis (MHD) is unclear. The aim of this study was to compare the properties of abdominal obesity in different BMI categories of patients on MHD.We performed a cross-sectional study of 188 MHD patients (52.7% women; mean age, 69.4 ± 11.5 y) with abdominal obesity in different BMI groups using criteria from the World Health Organization. Appetite and dietary intake, body composition, handgrip strength, malnutrition inflammation score (MIS), inflammatory biomarkers, adipokines, and health-related quality-of-life (QoL) questionnaires were studied.According to multivariable analyses, abdominally obese patients with normal BMIs consumed less protein per day (P = 0.04); had lower measurements of surrogates of lean (P0.001) and fat mass (P0.001); and had higher total cholesterol, tumor necrosis factor-α (P0.05), and ratios of adiponectin to leptin (P = 0.003) than overweight and obese patients with abdominal obesity. Multivariable analyses showed no differences in handgrip strength among the study groups.The abdominally obese study participants with normal weight had significantly lower scores in role physical (P = 0.003) and pain (P = 0.04) scales after multivariable adjustments.Normal-weight MHD patients with abdominal obesity exhibited a more proatherogenic profile in terms of inflammatory markers and adipokine expression, lower body composition reserves, and lower physical ability than patients with abdominal obesity with overweight and obesity. This at least partially explains the abdominal obesity paradox in the MHD population in which worse clinical outcomes are seen in abdominally obese patients with normal BMIs, as opposed to overweight and obese patients who are also abdominally obese.

Urethral lubrication during catheterization can be performed by instilling the gel directly in the urethra or by pouring the gel on the catheter tip. In this study we compared the pain level associated with each technique during female urethral catheterization in the setup of a multichannel urodynamic study.A total of 94 women with a mean ± SD age of 55 ± 14 years who were referred for a multichannel urodynamic study were prospectively randomized into 2 groups according to lubrication technique, including 1) instillation of 5 ml 2% lidocaine gel in the urethra 5 minutes before catheterization or 2) lubrication of the distal part of the catheter with 5 ml 2% lidocaine gel. A visual analog pain scale of 0 to 10 was completed at different time points, including prior to gel instillation (baseline), during gel instillation (group 1), during catheterization, and 5 and 30 minutes after the procedure ended.The study groups did not differ in demographic, clinical or urodynamic parameters. The mean visual analog scale score during catheterization was 2.3 ± 1.4 and 2.4 ± 1.6 in groups 1 and 2, respectively (p = 0.71). There was no difference in the reported visual analog scale score at the other checkpoints. The mean recorded visual analog scale score during instillation of the lubricant in the urethra in group 1 was 1.9 ± 0.9.The actual act of lubricant instillation in the urethra during catheterization in women causes additional and unnecessary pain. Therefore, it is not recommended. Other than that there is no difference in the urethral pain level between the 2 lubrication techniques.

Aims To find out if information leaflets reduce anxiety levels before urodynamic studies (UDS). Methods One hundred and four patients (age 60 ± 15 years) who were referred for multichannel UDS were prospectively recruited and randomized into 2 groups: (1) received a leaflet containing detailed information regarding the examination; (2) did not receive a leaflet. Patients who were unable to complete the questionnaire due to mental disorders and patients who had previously undergone UDS were excluded. The leaflets were mailed to the patients in group 1 one month before the examination. This leaflet included information on how the examination would be performed, its purpose, recommended preparation, potential complications, and common events that might occur in association with the examination, such as incontinence. Emotional distress was measured by the State Anxiety Inventory (SAI)—a validated questionnaire composed of 20 items measuring anxiety. These measures are divided into two psychological domains: (1) positive well being; (2) psychological distress. Patients filled out the SAI immediately before entering the examination room. Results Demographics and clinical and psychological co-morbidities were similar between the groups. The “psychological distress“ score was significantly lower in group 1 (13.1 ± 2.9 vs. 24.8 ± 5.8, P

Intradialytic hypotension (IDH) is an important cause of morbidity and mortality among hemodialysis patients. We used an immersion model to evaluate the role of reduced effective circulating volume, and to examine whether facilitated refilling can prevent IDH.Ten male hemodialysis patients who had frequent episodes of IDH were randomized to a mid-week "wet" or "dry" hemodialysis session, and subsequently underwent the other session in a crossover manner. The wet sessions were performed while immersed up to the neck in a 34 to 35°C bath, and the dry session was standard hemodialysis. Ultrafiltration goals were determined as the mean ultrafiltration during the 10 sessions preceding the first study session ± 10%.Mean ultrafiltration was similar for the wet and dry sessions (2.99 ± 0.64 kg vs. 2.96 ± 0.74 kg). Symptomatic hypotension did not develop in any of the patients during the wet session, compared to 4 (40%) during the dry session. Systolic blood pressure adjusted to ultrafiltration was stable during the wet session, 0.22 mmHg/15 min (95% CI -0.27 to 0.70), P = 0.38, and significantly decreased during the dry session, -0.68 mmHg/15 min (95%CI -1.24 to -0.11), P = 0.02. Diastolic blood pressure did not change during the sessions. Mean atrial natriuretic peptide significantly increased in the wet session, by 31.36 pgr/mL (95%CI 8.73-53.99), P = 0.007, and slightly and insignificantly decreased in the dry session, by 21.66 pgr/mL (95% CI -52.59 to 9.25), P = 0.167. Aldosterone blood levels did not change.Reduced effective circulating volume is a major cause for IDH, which can be prevented using head-out water immersion facilitated redistribution.

The significance of asymptomatic bacteriuria in maintenance hemodialysis (MHD) patients remains controversial. We hypothesized that the presence of asymptomatic bacteriuria as a sole clinical manifestation of urinary tract infection (UTI) in asymptomatic MHD patient may contribute to the chronic inflammatory response. Our aim was to explore the relationship between asymptomatic bacteriuria and elevated levels of inflammatory markers in MHD patients.A randomized open-label single center study of 114 MHD patients was conducted. Forty-six patients presented negative urine culture and 41 subjects were excluded due to different reasons. The remaining 27 patients (mean age of 71.5 ± 12.2 years, 63% men), fulfilling the criteria for having asymptomatic bacteriuria, were randomly assigned to either the treatment group (13 patients) or the observational group (14 subjects). The treatment group received 7 days of antibiotic treatment given according to bacteriogram sensitivity. After 3 months of follow-up all measurements of the study were repeated. The primary end point was change in inflammatory biomarkers from baseline by the end of the study.There were no statistically significant differences in white blood cell changes (P = 0.27), ferritin (P = 0.09), C-reactive protein (P = 0.90), and interleukin-6 (P = 0.14) levels between the groups from baseline to the end of study or at the end of the study. Analyzing cross-sectional data, asymptomatic bacteriuria was found to not be a predictor of higher levels of inflammatory parameters at baseline.Asymptomatic bacteriuria is not a modifiable risk factor for chronic inflammation in the MHD population.

Aims To compare the pain perception between intraurethral instillation of 2% lidocaine gel and liquid paraffin during Urodynamic study in men. Methods A randomized, single-blind comparison trial was conducted. Forty men scheduled to undergo multichannel Urodynamic study were randomized to receive either 10 ml of 2% lidocaine gel (group 1, n = 20) or 10 ml of liquid paraffin (group 2, n = 20). Patients recorded their pain on a 0–10 visual analog scale prior to lubricant instillation, immediately after lubricant instillation, after the introduction of the Urodynamic catheter, 5 and 30 min after the catheter was taken out. Results pain scores were significantly higher in group 1 compared to group 2 immediately after the instillation of the lubricants (4.2 ± 1.5 vs. 2.6 ± 0.9, P

Objective We hypothesize that longitudinal changes in phase angle (PA) have independent associations with changes in inflammatory parameters over time and consequently with long-term survival in patients on maintenance hemodialysis (MHD). The aim of the present study was to determine the effect of change in nutritional and inflammatory parameters over time on change in PA and on subsequent mortality in patients on MHD. Methods A 2-y prospective longitudinal study was performed on 91 prevalent HD patients (57 men and 34 women), followed by an additional 3 y of clinical observations. Dietary intake, biochemical markers of nutrition, body composition, and interleukin (IL)-6 levels were measured at baseline and at 6, 12, 18, and 24 mo following enrollment. Results In a linear mixed-effect model adjusted for baseline demographic and clinical parameters, each pg/mL increase in IL-6 over time was associated with a decrease in PA levels of 0.001°/2-y ( P = 0.003 for IL-6 × time interaction). PA remained associated with the rate of change in IL-6 even after controlling for extracellular water and fat mass. Changes in PA over time were associated with inverse linear changes in IL-6 (adjusted r = −0.32; P = 0.005) and consequently with mortality risk. For each 1° increase in PA, the crude and adjusted mortality hazard ratios using Cox models with effect of time-varying risk were 0.62 (95% confidence interval [CI], 0.54–0.71) and 0.61 (95% CI, 0.53–0.71), respectively. Additionally, longitudinal changes in PA exhibited significant associations with slopes of changes over time in main nutritional markers. Conclusions Longitudinal changes in PA appear to be reliable in detecting changes in nutritional and inflammatory parameters over time, a combination that may contribute to the understanding of its prognostic utility.

The possibility of developing coronary steal in patients having coronary artery bypass graft (CABG) using internal thoracic artery (ITA) and ipsilateral upper extremity arteriovenous (AV) hemodialysis shunt has been reported. The impact of this phenomenon on clinical outcomes is uncertain. The aim of this study was to investigate an association between the AV dialysis shunt location regarding the side of the ITA CABG and clinical outcomes. This retrospective cohort study included chronic hemodialysis patients having ITA CABG and upper extremity AV shunt. The patients were divided into two groups: those with ipsilateral and those with contralateral location of ITA CABG and AV shunt. The outcomes were: death from any cause, cardiac death and a first cardiac event. In a group of 112 chronic hemodialysis patients having CABG, 32 had an ipsilateral and 25 had a contralateral location of ITA CABG and an upper extremity AV shunt. Significantly more cardiac events occurred in the group with an ipsilateral compared to a contralateral location of ITA CABGs and dialysis AV shunts (hazard ratio, 2.16 [95% CI, 1.11 to 4.19], P = 0.023). There was no difference between the groups in the all cause mortality risk (hazard ratio, 1.005 [95% CI, 0.43 to 2.37], P = 0.990) or the risk of cardiac death (hazard ratio, 2.43 [95% CI, 0.64 to 9.17], P = 0.191). The ipsilateral location of a CABG with the use of ITA and upper extremity AV hemodialysis shunt may be associated with increased risk of cardiac events.

Insulin-like growth factor-1 (IGF-1) and inflammation have both been linked to high cardiovascular risk and mortality in the general population, as well as in hemodialysis (HD) patients. We hypothesized that the association of low IGF-1 with chronic inflammation may increase the mortality risk in HD patients.We investigated the interactions between inflammatory biomarkers (IL-6 and TNF-α) and IGF-1 as predictors of death over a 4 years of follow-up (median--47 months, interquartile range--17.5-75 months) in 96 prevalent HD patients (35% women, mean age of 64.9 ± 11.6 years).A significant interaction effect of low IGF-1 (defined as a level less than median) and high IL-6 (defined as a level higher than median) on all-cause and cardiovascular mortality was found: crude Cox hazard ratios (HR) for the product termed IGF-1 × IL-6 were 4.27, with a 95% confidence interval (CI): 2.10 to 8.68 (P0.001) and 7.49, with a 95% CI: 2.40-24.1 (P=0.001), respectively. Across the four IGF-1-IL-6 categories, the group with low IGF-1 and high IL-6 exhibited the worse outcome in both all-cause and cardiovascular mortality (multivariable adjusted hazard ratios were 4.92, 95% CI 1.86 to 13.03, and 14.34, 95% CI 1.49 to 137.8, respectively). The main clinical characteristics of patients in the low-IGF-1-high IL-6 group didn't differ from other IGF-1-IL-6 categorized groups besides gender that consequently was inserted in all multivariable models together with the other potential confounders.An increase in mortality risk was observed in HD patients with low IGF-1 and high IL-6 levels, especially cardiovascular causes.

Background: The use of an arteriovenous (AV) graft for hemodialysis is associated with a relatively high rate of thrombosis. Unfortunately, the urgent thrombectomy is not always readily available. Our aim was to investigate a possible association between the timing of thrombectomy and the patency rates of AV grafts. Methods: A retrospective single-center study on patients who underwent thrombectomy of clotted AV grafts was conducted. According to the time of thrombectomy, all patients were divided into 4 groups. Results: Primary graft patency at 6 months after thrombectomy was 28.3%, with no significant difference between the study groups ( P = .161). Secondary graft patency at 6 months was significantly worse in the group that underwent thrombectomy between the third and fifth days than in the whole cohort: 15.4% versus 45.6% ( P = .038). Conclusions: Timing of thrombectomy of a clotted AV graft may have a significant impact on the graft survival.

We tested the hypothesis that the basal nitric oxide (NO) levels in prevalent hemodialysis (HD) patients may associate with inflammatory cytokines, predisposing them to increased mortality risk. We performed a prospective cohort study of 76 prevalent HD patients (42 % women), with a mean age of 65.3 ± 11.8 years with a follow-up for almost 4 years (median—47 months, interquartile range −19–75 months). We measured basal NO, proinflammatory cytokines (TNF-α, IL-1, IL-6, and IL-10), dietary intake, biochemical parameters of nutrition, and body composition (anthropometry and bioimpedance analysis). Among various cytokines studied, only IL-6 exhibited a statistically significant linear association (adjusted r = 0.31, p = 0.014) with NO. Statistical interaction analysis showed a departure from multiplicity of effects of high NO (above the median) with high IL-6 (above the median) levels: crude Cox hazard ratios for all-cause and cardiovascular mortality for the product termed IL-6 × NO were 2.73 with a 95 % CI of 1.38–5.40 (p = 0.004) and 5.03 with a 95 % CI of 1.76–14.40 (p = 0.003), respectively. Across the four IL-6 NO categories, the group with high IL-6 and high NO (above their median levels) exhibited worse outcomes in both, all-cause and cardiovascular mortality (multivariable adjusted hazard ratios were 3.06, 95 % CI of 1.24–7.54 and 3.95, 95 % CI of 1.02–15.32, respectively). Chronic inflammation, as measured by higher serum IL-6 levels, in combination with high basal NO is associated with worse clinical outcomes in terms of all-cause and cardiovascular death in clinically stable prevalent HD patients.

This study aimed to compare the longitudinal performance of the malnutrition-inflammation score (MIS) and the geriatric nutritional risk index (GNRI), two nutritional scores for patients on maintenance hemodialysis.Nutritional scores, dietary intake, biochemical markers, and body composition analysis were performed at baseline and at 6, 12, and 18 months after enrollment (which took place from January through December 2006) on 75 prevalent hemodialysis patients (43% women, mean age 64.8 ± 11.9 years). The patients underwent simultaneous MIS and GNRI assessments calculated by two independent examiners from baseline. The study period was 46.8 ± 16.4 months.GNRI had higher interobserver agreement (weighted κ-score 0.98) than MIS (weighted κ-score 0.62). Longitudinally, a 1-unit increase in MIS was associated with a 0.41 kcal/kg per day reduction in daily energy intake (P0.001) and with a 0.014 g/kg per day reduction in nPNA (P=0.02). GNRI did not correlate with the change over time of dietary intake. Longitudinal changes of both scores were associated with appropriate changes over time in levels of nutritional biomarkers, inflammation (IL-6), and body composition parameters. Both scores expressed significant associations with prospective hospitalization, whereas only MIS was associated with mortality in this cohort. The multivariate Cox proportional hazard ratio was 1.15 for death for each 1-unit increase in the MIS (95% confidence interval, 1.03-1.3; P=0.02).Both MIS and GNRI are valid tools for longitudinal assessment of hemodialysis patients' nutritional status. MIS has lower interobserver reproducibility than GNRI; however, MIS is more comprehensive than GNRI.

Background Ghrelin, a gastric orexigenic peptide, and body mass index (BMI) are known as inversely associated to each other and are both linked to cardiovascular (CV) risk and mortality in maintenance hemodialysis (MHD) patients. However, it is unclear whether the interaction between ghrelin and BMI is associated with a risk of all-cause and CV death in this population. Methods A prospective observational study was performed on 261 MHD outpatients (39% women, mean age 68.6 ± 13.6 years) recruited from October 2010 through April 2012, and were followed until November 2014 (median follow-up-28 months, interquartile range-19–34 months). We measured acyl-ghrelin (AG) levels, appetite, nutritional and inflammatory markers, prospective all-cause and cardiovascular (CV) mortality. Results During follow-up, 109 patients died, 51 due to CV causes. A significant interaction effect of high BMI and high AG (defined as levels higher than median) on all-cause mortality was found. Crude Cox HR for the product termed BMI x AG was 0.52, with a 95% confidence interval (CI): 0.29 to 0.95 (P = 0.03). Evaluating the interaction on an additive scale revealed that the combined predictive value of BMI and AG is larger than the sum of their individual predictive values (synergy index was 1.1). Across the four BMI-AG categories, the group with high BMI and high AG exhibited better all-cause and cardiovascular mortality irrespective of appetite and nutritional status (multivariable adjusted hazard ratios were 0.31, 95% CI 0.16 to 0.62, P = 0.001, and 0.35, 95% CI 0.13 to 0.91, P = 0.03, respectively). Data analyses made by dividing patients according to fat mass-AG, but not to lean body mass-AG categories, provided similar results. Conclusions Higher AG levels enhance the favourable association between high BMI and survival in MHD patients irrespective of appetite, nutritional status and inflammation.

Background The possibility of coronary steal through an arteriovenous fistula (AVF) in hemodialysis (HD) patients with coronary artery bypass grafts (CABGs) using an ipsilateral internal thoracic artery (ITA) has been suggested. In order to define the significance of such a possibility, we analyzed cardiac events and mortality risk in patients in relation to AVF flow. Methods A retrospective cohort study was performed on prevalent HD patients from a single center. The outcomes included a first cardiac event, cardiac death and death from any cause. Results The group consisted of 23 chronic HD patients having ITA CABG and upper extremity AV access, 12 patients had an ipsilateral and 11 patients had a contralateral location of ITA CABG and an upper extremity AV access. The mean follow-up period was for 37.0 months. Multivariable Cox proportional-hazards regression analysis of risk of death from any cause in relation to AV access flow showed no increased risk, neither in the group with ipsilateral location of ITA grafts and dialysis accesses (adjusted HR, 3.047 [95% CI, 0.996 to 1.000], p = 0.081), nor in the group with contralateral location of both shunts (adjusted HR, 0.173 [95% CI, 0.997 to 1.002], p = 0.678). There was no significant correlation between AV access blood flow and the risk of first cardiac event as well as cardiac death in either study group. Conclusions In this study on HD patients having ipsilateral ITA CABG and AVF, fistula flow rate was not found to be associated with mortality or cardiac risk.

The prognostic significance of platelet count (PC) changes during hospitalization for community-acquired pneumonia (CAP) has not been investigated. For 976 adults, clinical data during hospitalization for CAP and all-cause mortality following discharge were compared according to ΔPC (PC on discharge minus PC on admission): groups A (declining PC, ΔPC 50 × 109/l), and according to the presence of thrombocytopenia, normal PC, and thrombocytosis on admission/discharge. Groups A, B, and C comprised 7.9%, 46.5%, and 45.6% of patients, respectively. On hospital admission/discharge, thrombocytopenia, normal PC, and thrombocytosis were observed in 12.8%/6.4%, 84.1%/84.4%, and 3.1%/9.2% of patients, respectively. The respective 90-day, 3-year, and total (median follow-up of 54 months) mortality rates were significantly higher: in group A (40.3%, 63.6%, and 72.7%), compared to groups B (12.3%, 31.5%, and 39.0%) and C (4.9%, 17.3%, and 25.4%), p < 0.001; and in patients with thrombocytopenia at discharge (27.4%, 48.4%, and 51.6%), compared to those with normal PC (10.2%, 26.9%, and 35.4%) and thrombocytosis (8.9%, 17.8%, and 24.4%) at discharge (p < 0.001). Mortality rates were comparable among groups with thrombocytopenia, normal PC, and thrombocytosis at admission (p = 0.6). In the entire sample, each 100 × 109/l increment of ΔPC strongly predicted lower mortality (p < 0.001, relative risk 0.73, 95% confidence interval 0.64-0.83). In conclusion, PC changes are common among CAP inpatients. Rising PC throughout hospitalization is a powerful predictor of better survival, while declining PC predicts poor outcome. Evaluation of PC changes during hospitalization for CAP may provide useful prognostic information.

The use of an arteriovenous graft as vascular access for hemodialysis is associated with a high rate of patency loss. The influence of timing of the first cannulation of the graft on graft survival has not been sufficiently studied. The purpose of this study was to investigate an association between the timing of the first cannulation of the polytetrafluoroethylene arteriovenous graft and the incidence of 12-month failure. This is a retrospective study on a cohort of chronic hemodialysis patients treated in a single center. According to the time, in weeks, between graft construction and its first successful cannulation, the grafts were divided into six groups: 2nd, 3rd, 4th, 5th, 6th and 7th or more week after surgery. The primary outcome was primary graft failure at 12 months, defined as the first occurrence of graft thrombosis or any invasive access procedure. The secondary outcome was cumulative graft failure at 12 months, defined as complete loss of the access site for dialysis. Fifty-eight patients with 64 newly-created arteriovenous grafts were included in the study. In the whole cohort, the incidence of primary graft failure at 12 months was 72.2%, and the incidence of cumulative graft failure at 12 months was 40.7%. The incidences of primary graft failure and cumulative graft failure at 12 months did not differ significantly between the study groups. In our study, timing of the first cannulation of a new arteriovenous polytetrafluoroethylene graft had no significant impact on graft survival.

To identify predictors of treatment failure of dimethyl sulfoxide (DMSO) "cocktail" for patients with interstitial cystitis (IC).Fifty-one IC patients received weekly intravesical instillations of "cocktail" composed of 50% DMSO (50 mL), 100 mg of hydrocortisone (5 mL), 10,000 U of heparin sulfate (10 mL), and 0.5% bupivacaine (10 mL) for 12 weeks. A reduction from baseline in the O'Leary-Sant questionnaire score of ≥ 30% was considered as a response. Patients were evaluated every 3 weeks during the treatment course and at 1, 3, 6, 9, and 12 months thereafter. In addition, patients filled in a 3-day bladder diary and a 0-10 visual analogue scale (VAS) for pain. Responders and nonresponders were compared and predictors of treatment failure were identified using univariate analysis and multiple logistic regression.Thirty-one patients (61%) were responders. A significant decrease from baseline in the mean questionnaire's score (27.2 ± 2.8 vs 18.8 ± 2.0, P = .0001) was noted in the responders group. Improvements in the mean daily number of micturitions (16.7 ± 3.6 vs 14.8 ± 2.8, P = .003) and in the mean VAS (7.6 ± 1.6 vs 3.6 ± 1.0, P = .0001) were noted as well. In the nonresponders group, none of these variables improved significantly. Patient age, menopausal state, body mass index, diabetes mellitus, and cystometric and anesthetic capacities were all associated with response. However, only an anesthetic bladder capacity675 mL independently predicted treatment failure (odds ratio 83, 95% CI 9-714, P.0001).Intravesical cocktail for IC patients is associated with a 61% response rate. A small anesthetic bladder capacity predicts treatment failure.

Clinical outcomes in chronic dialysis patients are highly dependent on preservation of residual renal function (RRF). N-acetylcysteine (NAC) may have a positive effect on renal function in the setting of nephrotoxic contrast media administration. In our recent study, we showed that NAC may improve RRF in peritoneal dialysis patients. The aim of the present study was to investigate the effect of NAC on RRF in patients treated with chronic hemodialysis. Prevalent chronic hemodialysis patients with a residual urine output of at least 100 mL/24 hours were included. The patients were administered oral NAC 1200 mg twice daily for 2 weeks. Residual renal function was assessed at baseline and at the end of treatment using a midweek interdialytic urine collection for measurement of urine output and calculation of residual renal Kt/V and glomerular filtration rate (GFR). Residual GFR was measured as the mean of urea and creatinine residual renal clearance. Each patient served as his own control. Twenty patients were prospectively enrolled in the study. Administration of NAC 1200 mg twice daily for 2 weeks resulted in significant improvement in RRF: urine volume increased from 320 ± 199 to 430 ± 232 mL/24 hours (P