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Long chain omega-3 (n-3 PUFA) fatty acids may influence clinical outcomes in hemodialysis patients. We therefore performed the largest characterization to date of n-3 PUFA levels in an incident hemodialysis population. Serum n-3 PUFA were measured in samples obtained at baseline in a 400 person subgroup of the ArMORR study, a large representative cohort of U.S. incident hemodialysis patients. n-3 PUFA were measured by gas chromatography, with phospholipid (PL) and triglyceride (TG) fatty acids being separated by solid phase extraction. Signed rank test was used to compare PL and TG fractions. Mean (±SD) age was 66±14 years and body mass index 26±7 kg/m2. 58% were men and 68% white. Cause of ESRD was diabetes and hypertension in 47% and 40% of subjects, respectively. Total serum 20:5n-3 (EPA) (by mean weight %) was 0.09±0.36 (PL vs. TG: 0.09±0.43 vs. 0.07±0.30, p=0.14), and total serum 22:6n-3 (DHA) was 1.46±0.72 (PL vs. TG: 3.03±1.24 vs. 0.21±0.40, p

Objectives: The HIV NNRTI rilpivirine is being evaluated as a possible agent for HIV pre-exposure prophylaxis. We have recently shown that the NNRTI efavirenz may impair endothelial function assessed as flow-mediated dilation (FMD), but whether this impairment is also found with rilpivirine is unknown. We sought to compare cardiovascular risk profiles between efavirenz and rilpivirine in healthy volunteers.Methods: We performed a prospective, randomized, open-label trial in 40 HIV-uninfected healthy volunteers who were randomized 1: 1 to either efavirenz or rilpivirine. Vascular indices, metabolic parameters, inflammatory biomarkers and oxidative stress were measured before and after 4 weeks of treatment. This study is registered at ClinicalTrials.gov (NCT01585038).Results: There were no significant differences in 4 week mean (SD) changes in FMD between efavirenz and rilpivirine [0.089 (3.65)% versus 0.63 (2.42)%; P = 0.77]. There were also no significant differences in 4 week changes in high-sensitivity C-reactive protein, IL-6, soluble vascular cell adhesion molecule-1, HDL-cholesterol, triglycerides or homeostasis model assessment-insulin resistance. However, efavirenz led to significant increases in total cholesterol [19.39 (23.9) versus -5.78 (16.5) mg/dL; P < 0.001], LDL-cholesterol [13.29 (19.5) versus -2.24 (13.4) mg/dL; P = 0.009] and F2-isoprostanes [92.7 (178.6) versus -101.4 (215.7) pg/mL; P = 0.019] compared with rilpivirine. Two participants from each study group discontinued prematurely for adverse events.Conclusions: There were no significant differences in the changes in endothelial function over 1 month between the efavirenz and rilpivirine groups, although efavirenz had worse lipid changes compared with rilpivirine. Longer-term studies are required for confirmation. [ABSTRACT FROM AUTHOR]

Background/Aims: Identifying the best method to estimate the glomerular filtration rate (GFR) in bariatric surgery patients has important implications for the clinical care of obese patients and research into the impact of obesity and weight reduction on kidney health. We therefore performed such an analysis in patients before and after surgical weight loss. Methods: Fasting measured GFR (mGFR) by plasma iohexol clearance before and after bariatric surgery was obtained in 36 severely obese individuals. Estimated GFR was calculated using the Modification of Diet in Renal Disease equation, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation using serum creatinine only, the CKD-EPI equation using serum cystatin C only and a recently derived equation that uses both serum creatinine and cystatin C (CKD-EPIcreat-cystC) and then compared to mGFR. Results: Participants were primarily middle-aged white females with a mean baseline body mass index of 46 ± 9, serum creatinine of 0.81 ± 0.24 mg/dl and mGFR of 117 ± 40 ml/min. mGFR had a stronger linear relationship with inverse cystatin C before (r = 0.28, p = 0.09) and after (r = 0.38, p = 0.02) surgery compared to the inverse of creatinine (before: r = 0.26, p = 0.13; after: r = 0.11, p = 0.51). mGFR fell by 17 ± 35 ml/min (p = 0.007) following surgery. The CKD-EPIcreat-cystC was unquestionably the best overall performing estimating equation before and after surgery, revealing very little bias and a capacity to estimate mGFR within 30% of its true value over 80% of the time. This was true whether or not mGFR was indexed for body surface area. Conclusions: In severely obese bariatric surgery patients with normal kidney function, cystatin C is more strongly associated with mGFR than is serum creatinine. The CKD-EPIcreat-cystC equation best predicted mGFR both before and after surgery. © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Several corrections to articles in previous issues are presented, including "First Evidence of Genetic Association Between AKT2 and Polycystic Ovary Syndrome," by M. O. Goodarzi et al in the 2008 issue, "Value of Urinary Albumin-to-Creatinine Ration as a Predictor of Type 2 Diabetes in Pre-Diabetic Individuals" in the 2008 issue and "American Diabetes Association: Diabetes in Hispanic American Youth: Prevalence, Incidence, Demographics, and Clinical Characteristics: The SEARCH for Diabetes in Youth Study" in the 2009 issue.

Background: Identifying methods to accurately measure the glomerular filtration rate (GFR) in obese individuals without kidney overt kidney disease is necessary to understanding the pathophysiology and natural history of obesity-related kidney disease. Methods: Using a cross-sectional design, iohexol clearance and disposition was measured, an optimal sampling schedule was identified, and the reliability of GFR-estimating methods was described in 29 obese individuals with normal serum creatinine levels. Iohexol disposition was measured using population pharmacokinetics. The agreement with GFR-estimating equations was assessed by intraclass coefficients. Results: Mean age was 44 ± 10 years, body mass index 45 ± 10, creatinine 0.7 ± 0.2 mg/dl (62 ± 18 μmol/l) , and cystatin C 0.83 ± 0.18 mg/dl (8.3 ± 1.8 mg/l). Iohexol disposition fit a two-compartment model and 5 sampling windows were identified over a 4-hour period to optimize model accuracy and minimize blood draws. Precision was not compromised with this sampling design. Neither creatinine nor cystatin C were linearly correlated with the measured GFR though cystatin C was independent of body composition. Agreement was fair to poor between the measured GFR and GFR-estimating equations. Conclusion: This study offers a rigorous method to study obesity-related kidney disease and improve upon suboptimal GFR-estimating methods. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Long-chain polyunsaturated omega-3 fatty acids (n-3 PUFA), which are obtained primarily from dietary sources such as coldwater fish, have diverse and potent mediating effects on the immune, inflammatory, and metabolic pathways, signal transduction, and cell membrane physiology. N-3 PUFA are increasingly being studied for their clinical benefits in a variety of medical conditions, some of which are relevant to individuals with advanced chronic kidney disease (CKD). These include, among others, renoprotection in IgA nephropathy, cardioprotective effects via a variety of mechanisms including blood pressure and triglyceride reduction, maintenance of dialysis access patency, sparing of inflammation-associated muscle loss, and even mortality. However, further confirmatory work needs to be performed before establishing formal intake recommendations and dosing goals for advanced CKD patients. In the meantime, the current American Heart Association n-3 PUFA intake guidelines can be applied to CKD patients, especially given n-3 PUFA’s potential benefits and negligible risk profile. Over time, it will be incumbent upon the nephrology community to more clearly define the utility and optimal dosing of n-3 PUFA in CKD patients with advanced disease via randomized clinical trials. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- The albumin-to-creatinine ratio (ACR) reflects urinary albumin excretion and is increasingly being accepted as an important clinical outcome predictor. Because of the great public health need for a simple and inexpensive test to identify individuals at high risk for developing type 2 diabetes, it has been suggested that the ACR might serve this purpose. We therefore determined whether the ACR could predict incident diabetes in a well-characterized cohort of pre-diabetic Americans. RESEARCH DESIGN AND METHODS -- A total of 3,188 Diabetes Prevention Program (DPP) participants with a mean BMI of 34 kg/m² and elevated fasting glucose, impaired glucose tolerance, and baseline urinary albumin excretion measurements were followed for incident diabetes over a mean of 3.2 years. RESULTS -- Of the participants, 94% manifested ACR levels below the microalbuminuria range and 21% ultimately developed diabetes during follow-up. Quartiles of ACR (median [range] within quartiles: 1, 3.0 [0.7-3.7]; 2, 4.6 [3.7-5.5]; 3, 7.1 [5.5-9.7]; and 4, 16.5 [9.7-1,578]) were positively associated with age, markers of adiposity and insulin secretion and resistance, blood pressure, and use of antihypertensive agents with antiproteinuric effects and inversely related to male sex and serum creatinine. An elevated hazard rate for developing diabetes with doubling of ACR disappeared after adjustment for covariates. Within the DPP intervention groups (placebo, lifestyle, and metformin), we found no consistent trend in incident diabetes by quartile or decile of ACR. CONCLUSIONS -- An ACR at levels below the microalbuminuria range does not independently predict incident diabetes in adults at high risk of developing type 2 diabetes. [ABSTRACT FROM AUTHOR]

There exists in the general population a complex and mostly positive relationship between adiposity and mortality risk. Because the dialysis population has a high prevalence of excess adiposity, in addition to a strikingly elevated mortality rate, the effects of obesity are of potential clinical importance. In contrast to the general population, the preponderance of data in dialysis, particularly hemodialysis patients, suggest that adiposity has a neutral or even protective association with mortality. Although methodological concerns exist with regards to confounding and survival bias, among others, the major limitation of this body of literature is its inability to establish causality. Thus, although obese dialysis patients, with certain exceptions, appear to live longer, there is no evidence to suggest that intentional weight loss adversely affects patient outcomes. In light of these limitations and the substantial body of literature implicating obesity as a pathophysiological state, it is currently premature to advocate for excess adiposity as being beneficial or intentional weight loss as dangerous. Decisions regarding optimal weight should be made by clinicians on an individual basis and with close supervision and follow-up. Efforts should be made to preserve lean mass during weight loss regimens by encouraging exercise and recommending sufficient protein consumption. Future research efforts in this area should focus on interventional trials designed to manipulate weight and measure outcomes, identifying potentially beneficial secretory products of adipose tissue, and documenting obesity's effects on quality of life and resource utilization in the dialysis setting. [ABSTRACT FROM AUTHOR]

The article presents a study which determines the factor structure of staff responses on the WES and to compare the factor structure with that previously reported for patient responses on the WES. The Ward Evaluation Scale is a 69 statement Thurstone equal-appearing intervals scale developed to obtain information and opinions about psychiatric wards from patients. The items in the scale were rationally grouped so that, in addition to a total score, three subscale scores (physical facilities, services, patient management and discipline) can also be computed.

Background. We previously reported that haemodialysis patients have suboptimal blood levels of the cardioprotective omega-3 polyunsaturated fatty acids (n-3 PUFA) eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids. In the present pilot study, we tested the hypothesis that supplementing haemodialysis patients for 12 weeks with the American Heart Association (AHA)-recommended fish oil dose would be well tolerated and efficacious in boosting blood n-3 PUFA levels and improving cardiovascular risk biomarkers. Methods. Twenty-seven subjects were randomized in a 2 : 1 ratio to either 1.3 g of EPA + DHA daily or placebo. Results. At baseline, 83% of subjects consumed inadequate dietary fish and had the following erythrocyte n-3 PUFA levels (mean ± SD,% weight)—EPA: 0.3 ± 0.2, DHA: 2.9 ± 2.0, and ratio of n-6/n-3 PUFA: 4.2 ± 1.3. Supplementation induced large increases in mean blood EPA and DHA levels (% increase, P-value vs placebo group): erythrocyte—EPA: +400%, P = 0.0018, DHA: +205%, P P = 0.0003, DHA: +69%, P = 0.0352. Levels in the placebo group remained relatively unchanged. The omega-3 index, a value correlating with the level of cardioprotection, increased significantly in the fish oil group. A reduction in mean C-reactive protein levels (−3.3 ± 8.1 mg/l, P = 0.0282) and a trend towards lower triglyceride levels (−24 ± 74 mg/dl, P = 0.0783) were also observed in the active vs placebo group. Minimal side effects were noted. Conclusions. Our preliminary observations that the AHA-recommended fish oil dose is well tolerated, efficacious and may improve surrogate markers of cardiovascular disease in haemodialysis patients paves the way for larger clinical trials to confirm a clinical benefit. [ABSTRACT FROM AUTHOR]