Removal of large middle molecules via haemodialysis with medium cut-off membranes at lower blood flow rates: an observational prospective study

BACKGROUND: Online haemodiafiltration (OL-HDF) may improve middle molecular clearance in contrast to conventional haemodialysis (HD). However, OL-HDF requires higher convective flows and cannot sufficiently remove large middle molecules. This study evaluated the efficacy of a medium cut-off (MCO) dialyser in removing large middle molecular uraemic toxins and compared it with that of conventional high-flux (HF) dialysers in HD and predilution OL-HDF. METHODS: Six clinically stable HD patients without residual renal function were investigated. Dialyser and treatment efficacies were examined during a single midweek treatment in three consecutive periods: 1) conventional HD using an HF dialyser, 2) OL-HDF using the same HF dialyser, and 3) conventional HD using an MCO dialyser. Treatment efficacy was assessed by calculating the reduction ratio (RR) for β2-microglobulin (β2M), myoglobin, κ and λ free light chains (FLCs), and fibroblast growth factor (FGF)-23 and measuring clearance for FLCs. RESULTS: All three treatments showed comparable RRs for urea, phosphate, creatinine, and uric acid. MCO HD showed greater RRs for myoglobin and λFLC than did HF HD and predilution OL-HDF (myoglobin: 63.1 ± 5.3% vs. 43.5 ± 8.9% and 49.8 ± 7.3%; λFLC: 43.2 ± 5.6% vs. 26.8 ± 4.4% and 33.0 ± 9.2%, respectively; P <  0.001). Conversely, predilution OL-HDF showed the greatest RR for β2M, whereas MCO HD and HF HD showed comparable RRs for β2M (predilution OL-HDF vs. MCO HD: 80.1 ± 4.9% vs. 72.6 ± 3.8%, P = 0.01). There was no significant difference among MCO HD, HF HD, and predilution OL-HDF in the RRs for κFLC (63.2 ± 6.0%, 53.6 ± 15.5%, and 61.5 ± 7.0%, respectively; P = 0.37), and FGF-23 (55.5 ± 20.3%, 34.6 ± 13.1%, and 35.8 ± 23.2%, respectively; P = 0.13). Notably, MCO HD showed improved clearances for FLCs when compared to HF HD or OL-HDF. CONCLUSIONS: MCO HD showed significantly greater RR of large middle molecules and achieved improved clearance for FLCs than conventional HD and OL-HDF, without the need for large convection volumes or high blood flow rates. This would pose as an advantage for elderly HD patients with poor vascular access and HD patients without access to OL-HDF. TRIAL REGISTRATION: Clinical Research Information Service (CRIS): KCT 0003009. The trial was prospectively registered on the 21 Jul 2018.ope

Association between non-alcoholic fatty liver disease and coronary calcification depending on sex and obesity

Non-alcoholic fatty liver disease (NAFLD) is considered a hepatic manifestation of metabolic syndrome and is associated with cardiovascular outcomes. We investigated whether NAFLD was associated with coronary artery calcification (CAC) in participants without a previous history of cardiovascular disease and whether this association differed according to sex and obesity status after adjustment for other atherosclerosis risk factors, alcohol intake, and liver enzyme levels. Among 67,441 participants, data from 8,705 participants who underwent a fatty liver status and CAC assessment during routine health screening were analysed. CAC scores were calculated using computed tomography. NAFLD was diagnosed in patients with evidence of liver steatosis on ultrasonography. Obesity was defined as a body mass index of ≥25 kg/m2. Multivariate analysis showed a significant association between NAFLD and CAC in non-obese participants (odds ratio, 1.24 [95% confidence interval, 1.01-1.53]), whereas NAFLD and CAC were not associated in obese participants. Interaction analysis showed that the association between NAFLD and CAC was influenced by sex and obesity. Subgroup analysis revealed a significant association between NAFLD and CAC in non-obese male participants (odds ratio, 1.36 [1.07-1.75]), but not in female participants. Our study indicates that non-obese men with NAFLD are prone to CAC.ope

Transfusion-free Management for the Severe Anemia Developed after Nephrectomy

A 56-year-old woman with emphysematous pyelonephritis underwent an emergent left nephrectomy due to her religious creed. Postoperative hemoglobin level was decreased to 4.4 g/dL from preoperative value of 13.9 g/dL. The patient completely recovered without transfusion and was discharged on the 40th postoperative day without complication.ope

Incidentally Found Chronic Neutrophilic Leukemia in a Patient with Rectal Cancer

증례는 감염 및 악성종양과 동반되어 백혈병양 반응과의 감별이 어려웠고, 또한 악성종양의 전이와 유사하게 종괴를 형성하여 더욱 감별이 어려웠던 CNL 1예를 경험하였기에 문헌고찰과 함께 보고하는 바이다. Chronic neutrophilic leukemia (CNL) is a rare myeloproliferative neoplasm characterized by sustained neutrophilia, splenomegaly, and hypercellular bone marrow without Philadelphia chromosome. Diagnosis of CNL requires exclusion of identifiable causes of reactive neutrophilia, such as infection and tumors. Our patient presented with general weakness and weight loss. Computed tomography (CT) showed a mass in the distal rectum, which was confirmed to be an adenocarcinoma by colonoscopic biopsy. Positron emission tomography-CT showed multiple liver, bone, and lymph node metastases. Liver and lymph node biopsies revealed neutrophilic infiltration with no evidence of adenocarcinoma. The pathological findings of the bone marrow were compatible with CNL. Cytogenetic analysis revealed a normal karyotype, and molecular analysis was negative for BCR/ABL. Here, we present a 73 year-old man diagnosed with concurrent CNL and rectal cancer.ope

혈액투석 환자에서의 근감소증 유병률 연구: 다양한 근육량 보정 지표 및 마이오카인의 영향

Background: Sarcopenia is a syndrome characterized by decreased skeletal muscle mass with declining muscle strength or function. Although accurate assessment of skeletal muscle mass is essential for the correct diagnosis of sarcopenia, there is currently no global consensus on appropriate adjustment methods and best cutoff values for assessing relative muscle mass of sarcopenia diagnosis. Thus, the aim of this study was to determine which method for normalizing skeletal muscle mass is most useful for defining low muscle mass and to investigate myokines as potential biomarkers for sarcopenia in Korean hemodialysis (HD) patients. Design & Methods: We conducted a cross-sectional observational study in a cohort of 139 Korean HD patients. All patients underwent bioelectrical impedance analysis (BIA) to measure muscle mass 30 minutes after HD session. Handgrip strength, representing muscle strength, was evaluated using a handgrip dynamometer. Muscle function was evaluated by using a gait speed test. Myokine concentration was measured by using a human myostatin and follistatin enzyme-linked immunosorbent assay kit. Results: A total of 139 patients (69 men and 70 women) with a mean age of 63.9±13.1 years were included in this study. Depending on the equation used to standardize appendicular skeletal muscle mass, the prevalence of low muscle mass ranged from 17.3 to 29.5% and the prevalence of sarcopenia ranged from 11.5 to 20.9%. Obese patients (body mass index [BMI] > 25 kg/m2) had a lower prevalence of low muscle mass adjusted for BMI and a higher prevalence of low muscle mass adjusted for body surface area (BSA). Muscle strength and performance were positively correlated with muscle mass normalized by all methods, but the association was less robust in muscle mass indexed to weight. Patients with low muscle mass by all definitions, especially BSA, were more likely to have muscle weakness compared to those with normal muscle mass. Serum myostatin level was proportional to muscle mass and was positively correlated with muscle strength and performance. Conclusions: Muscle mass index adjusted to BSA and BMI (considering both height and body weight) is superior to height or weight alone when assessing relative muscle mass to diagnose sarcopenia among HD patients. Moreover, serum myostatin may act as an adjunct biomarker for predicting sarcopenia in patients undergoing HD. 배경: 근감소증은 근력 또는 기능이 떨어지면서 근육량이 감소하는 경우를 말한다. 근감소증의 정확한 진단을 위해서는 근육량의 정확한 평가가 필수적이지만, 아직까지 근감소증 진단을 위한 적절한 근육량 보정 방법과 기준값이 확립되지 않았다. 따라서 본 연구에서는 국내 혈액투석 환자에서 근육량 감소를 정의하는데 있어 어떠한 근육량 보정 방법이 더 유용한지 확인하고, 근감소증의 잠재적 생체표지자로써 마이오카인을 연구하려고 한다. 방법: 본 연구에서는 139명의 혈액투석 환자를 대상으로 횡단면 관찰 연구를 진행하였다. 환자들은 근육량 측정을 위해 혈액투석 종료 30분 후에 생체 전기저항 분석법으로 근육량을 측정하였다. 근력을 평가하기 위해 악력계를 이용하여 악력을 측정하였다. 근육 기능은 보행 속도 검사를 통하여 평가하였다. 마이오카인 농도는 human myostatin and follistatin enzyme-linked immunosorbent assay kit 를 통해 측정하였다. 결과: 본 연구는 평균 연령이 63.9±13.1세인 139명의 혈액투석 환자를 대상으로 진행하였다. 골격근량을 표준화하는 방법에 따라 근육량 감소의 유병률은 17.3 에서 29.5%, 근감소증의 유병률은 11.5 에서 20.9% 로 나타났다. 비만 환자 (BMI > 25 kg/m2 ) 에서는 BMI 로 근육량을 보정하였을 때 근육량 감소의 유병률이 낮았고, BSA 로 보정하였을 때 근육량 감소의 유병률이 높았다. 근력과 수행능력은 모든 근육량 보정 지표에서 근육량과 양의 상관관계가 있었으나, 체중으로 보정한 지표에서는 그 연관성이 낮았다. 모든 근육량 보정 지표에서 근육량이 적은 환자들이 근력이 약할 위험성이 높았는데, 특히 BSA 로 보정한 지표에서 그 위험성이 높았다. Myostatin 수치는 근육량에 비례하였고, 악력 및 보행속도와 양의 상관관계를 보였다. 결론: 혈액투석 환자에서 근감소증을 진단하기 위해 상대적인 근육량을 평가할 때는 키나 체중만으로 보정하는 것 보다 키와 체중을 모두 고려하는 BSA 와 BMI 로 보정한 근육량 보정 지표를 사용하는 것이 좋겠다. 그리고 혈청 myostatin 은 혈액투석 환자에서 근감소증을 예측하는 보조적인 생체표지자로써 도움이 될 수 있겠다.open석