Povezanost koncentracije mokraćne kiseline sa tradicionalnim i ne-tradicionalnim faktorima rizika za kardiovaskularne bolesti kod bolesnika na hemodijalizi – retrospektivna analiza

Literature data indicate that increased uric acid (UA) levels are an important risk factor for cardiovascular disease. The aim of this study was to examine the association of UA with cardiovascular risk factors in patients with hemodialysis using retrospective analysis. In 110 patients, we studied the values of basic renal function parameters, bone metabolism and cardiovascular risk factors in the period from 2010 to 2017. The results indicate a significant increase in urea (P=0.004), creatinine (P=0.028) and inorganic phosphate (P=0.001), as well as significant differences in gender (P=0.013), in risk categories defined on the basis of the UA decision limit (cut off <350 μmol/L). After controlling the effects of most parameters, statistically significant correlation coefficients were obtained for UA and urea (r=0.361; P=0.0013), creatinine (r=0.388; P=0.0005) and inorganic phosphate (r=0.366; P=0.0011). Significant regression coefficients were obtained for UA and male gender (β=-0.227, P=0.004), age (β=-0.298, P˂0.001), urea (β=0.271, P=0.005) and inorganic phosphate (β=0.232, P=0.009). The predictive value of independent parameters in relation to UA was confirmed for male gender (OR=3.595; 95% CI: 1.421-9.094; P=0.007) and inorganic phosphate (OR=14.842; 2.518-87.472, P=0.003). By Cox regression analysis of proportional hazard ratio, we obtained the most significant combined effect of the body mass index, dialysis and diastolic pressure on UA concentration in relation to the duration of hemodialysis (P <0.0001). The results of this long-term study suggest that UA can not be considered an independent cardiovascular risk factor, but that HD patients need to strategically control the level of MK in order to reduce the resulting complications, morbidity and mortality.Literaturni podaci ukazuju da povećana koncentracija mokraćne kiseline (MK) predstavlja značajan faktor rizika za kardiovaskularne bolesti. Cilj ove studije bio je da se retrospektivnom analizom ispita povezanost MK sa faktorima rizika za kardiovaskularne bolesti kod bolesnika na hemodijalizi. Za 110 bolesnika analizirane su vrednosti osnovnih parametara funkcije bubrega, metabolizma kostiju i faktora rizika za kardiovaskularne bolesti u periodu od 2010. do 2017. godine. Rezultati ukazuju na značajno povećanje koncentracije uree (P=0,004), kreatinina (P=0,028) i neorganskog fosfata (P˂0,001), kao i značajne razlike u zavisnosti od pola (P=0,013) u kategorijama rizika definisanim na osnovu granične koncentracije MK (cut off <350 μmol/L). Nakon kontrolisanja efekta većine parametara, statistički značajne vrednosti koeficijenata korelacije dobijene su za MK i ureu (r=0,361; P=0,0013), kreatinin (r=0,388; P=0,0005) i neorganski fosfat (r=0,366; P=0,0011). Značajni regresioni koeficijenti su dobijeni za MK i muški pol (β=-0,227, P=0,004), godine starosti (β=-0,298, P˂0,001), ureu (β=0,271, P=0,005) i neorganski fosfat (β=0,232, P=0,009). Prediktivna vrednost nezavisnih parametara u odnosu na MK je potvrđena za muški pol (OR=3,595; 95% CI: 1,421-9,094; P=0,007) i neorganski fosfat (OR=14,842; 95% CI: 2,518-87,472, P=0,003). Cox-ovom regresijom proporcionalnih nepoželjnih ishoda dobijen je najznačajniji udruženi efekat indeksa telesne mase i adekvatnosti dijalize na koncentraciju MK u odnosu na dužinu trajanja hemodijalize (P<0,0001). Rezultati ove dugoročne studije ukazuju da se MK ne može smatrati nezavisnim faktorom rizika za kardiovaskularne bolesti, ali da je kod bolesnika na HD, potrebno strateški kontrolisati nivo MK u cilju smanjenja posledičnih komplikacija, morbiditeta i mortaliteta

Uloga holesterola u malim, gustim LDL česticama u progresiji hronične bubrežne bolesti

Dyslipidemia is a common metabolic disorder in chronic kidney disease (CKD) and is largely responsible for development of cardiovascular complications in these patients. It has been noticed that characteristics of lipid disorders vary according to the degree of renal failure. In this study, we investigated concentrations of cholesterol and apolipoprotein B in small, dense low-density lipoproteins (sdLDL-C and sdLDL-apoB) in pre-dialysis (PD) and hemodialysis (HD) stage of CKD. In addition, we explored independent contribution of sdLDL-C and sdLDL-apoB to progression of CKD. We recruited 38 PD and 41 HD patients in this study. Concentrations of sdLDL-C and sdLDL-apoB were determined by heparin-magnesium precipitation method. Other biochemical parameters were measured by routine laboratory methods. Concentrations of sdLDL-C and sdLDL-apoB were significantly higher in PD than in HD patients (P lt 0,001). SdLDL-C (OR=0,122; P lt 0,001) and sdLDL-apoB (OR=0,109; P lt 0,001) were identified as predictors of progression of CKD towards HD stage. Both of examined parameters were independently associated with the disease progression after adjustment for other lipid and non-lipid risk markers, with an exception for adjustment for urea concentration. Assessment of sdLDL-C and sdLDL-apoB in different stages of CKD could be beneficial in term of prediction of risk for cardiovascular disease development and prediction of progression of CKD itself.Dislipidemija je uobičajen metabolički poremećaj u hroničnoj bubrežnoj bolesti (HBB) i u velikoj meri je odgovorna za nastanak kasnijih kardiovaskularnih komplikacija kod ovih pacijenata. Uočeno je da karakteristike dislipidemije variraju u zavisnosti od stadijuma HBB. U ovom radu ispitivali smo koncentracije holesterola i apolipoproteina B u malim, gustim česticama lipoproteina niske gustine (sdLDL-h i sdLDL-apoB) u predijaliznom (PD) i hemodijaliznom (HD) stadijumu HBB, kao i njihov nezavisni potencijal u predviđanju progresije HBB. U studiji je učestvovalo 38 PD i 41 HD pacijent. Koncentracije sdLDL-h i sdLDL-apoB određene su nakon selektivne precipitacije sa heparinom i Mg-solima, a koncentracije ostalih biohemijskih parametara rutinskim metodama. Koncentracije sdLDL-h i sdLDL-apoB bile su značajno više kod PD u odnosu na HD pacijente (P lt 0,001). SdLDL-h (OR=0,122; P lt 0,001) i sdLDL-apoB (OR=0,109; P lt 0,001) identifikovani su kao značajni prediktori progresije bolesti od PD do HD stadijuma, a nezavisan prediktivni potencijal zadržali su i u prisustvu drugih lipidnih i nelipidnih faktora rizika, osim uree. Određivanje sdLDL-h i sdLDL-apoB kod pacijenata u različitim stadijumima HBB može biti korisno u smislu predviđanja rizika za nastanak aterosklerotskih promena, kao i predviđanja progresije same HBB

Influence of blood pressure control on maintenance of residual function in patients treated by haemodialysis

Introduction. Residual renal function (RRF) in the patients treated by haemodialysis (HD) is associated not only with better volume and blood pressure control but also with better metabolic control. The condition of the cardiovascular system significantly affects RRF. Objective. The aim of the study was to find if there was any association between blood pressure regulation and the achieved HD ultrafiltration in the first year of haemodialysis treatment and the maintenance of RRF. Methods In this retrospective study, 53 patients were analyzed in the period 1994-2002. Residual clearance of urea (RCU) was measured for the first time at the beginning of HD treatment, and for the second time one year later. Laboratory data and values of blood pressure as well as the achieved HD ultrafiltration were taken from the electronic database of the Nephrology Hospital. Results. The value of RCU less than 1ml/min was considered as the loss of RRF and, at the beginning of HD treatment, 14 patients (26.4%) had that result. The rise of mean arterial pressure (MAP) was associated in linear regression analysis with a drop of residual diuresis volume (β=-0.28; p=0.04), but there was no association with RCU. The patients with MAP&gt;105 mm Hg had RKU less than the patients with MAP&lt;105 mm Hg (t=2.23; p=0.03). The rise of the HD ultrafiiltration significantly affected the loss of RRF obtained by the linear regression analysis (β=-0.44; p=0.0001). Conclusion. The greater HD ultrafiltration is related to a drop of RCU values. Only prospective randomised trials with the use of multiple regression analysis could define a more precise association between hypertension and RKU

Serum Amyloid-A Rather Than C-Reactive Protein Is a Better Predictor of Mortality in Hemodialysis Patients

The most frequent cause of death in hemodialysis patients is cardiovascular disease with chronic inflammation being an epidemiologically proved risk factor. Many studies have shown C-reactive protein (CRP) as the strongest predictor of long-term mortality of hemodialysis patients, while other reports have indicated acute phase proteins as potential predictors of the mortality. The present study therefore aimed to evaluate the prevalence of chronic inflammation in hemodialysis patients and the role of acute phase proteins together with lipids and divalent ions for predicting mortality in hemodialysis patients. Chronic inflammation was defined, based on the serum level of high sensitive CRIP > 8.4 mg/L and/or serum amyloid-A (SAA) > 8.9 mg/L. Acute phase proteins are defined as one whose plasma concentration increase (positive) or decreases (negative) by at least 25% during inflammation. High sensitive CRIP and SAA were positive acute phase proteins measured, while albumin and fetuin-A, a calcification inhibitor, were selected as negative acute phase proteins. This prospective 36-month follow-up study included 130 patients (60 males and 70 females, aged 55.1 +/- 12.9 years) maintained by hemodialysis for 107.2 +/- 54.72 months at a Nephrology Clinic in Belgrade. The prevalence of chronic inflammation was 35.4% (46 patients). During the follow-up period, 24 patients (18.5%) died and 2 patients received transplants. In multivariate analysis, potential independent predictors of mortality in hemodialysis patients are hyperphosphatemia, hypoalbuminemia, and high SAA. Considering that assays for SAA are widely used, we propose that SAA is the best predictor for outcomes of end-stage renal disease

Serum Amyloid-A Rather Than C-Reactive Protein Is a Better Predictor of Mortality in Hemodialysis Patients

The most frequent cause of death in hemodialysis patients is cardiovascular disease with chronic inflammation being an epidemiologically proved risk factor. Many studies have shown C-reactive protein (CRP) as the strongest predictor of long-term mortality of hemodialysis patients, while other reports have indicated acute phase proteins as potential predictors of the mortality. The present study therefore aimed to evaluate the prevalence of chronic inflammation in hemodialysis patients and the role of acute phase proteins together with lipids and divalent ions for predicting mortality in hemodialysis patients. Chronic inflammation was defined, based on the serum level of high sensitive CRIP > 8.4 mg/L and/or serum amyloid-A (SAA) > 8.9 mg/L. Acute phase proteins are defined as one whose plasma concentration increase (positive) or decreases (negative) by at least 25% during inflammation. High sensitive CRIP and SAA were positive acute phase proteins measured, while albumin and fetuin-A, a calcification inhibitor, were selected as negative acute phase proteins. This prospective 36-month follow-up study included 130 patients (60 males and 70 females, aged 55.1 +/- 12.9 years) maintained by hemodialysis for 107.2 +/- 54.72 months at a Nephrology Clinic in Belgrade. The prevalence of chronic inflammation was 35.4% (46 patients). During the follow-up period, 24 patients (18.5%) died and 2 patients received transplants. In multivariate analysis, potential independent predictors of mortality in hemodialysis patients are hyperphosphatemia, hypoalbuminemia, and high SAA. Considering that assays for SAA are widely used, we propose that SAA is the best predictor for outcomes of end-stage renal disease

Institutional Care and Social Welfare for People with Disabilities in Serbia

The aim of our study was to analyze institutional care and social welfare for people with disabilities in Serbia. Data collection was performed using a special questionnaire about present institutions, providers and users of social welfare services. Indicators of evaluation were: capacity and structure of accommodation units, accessibility of building, structure of users of services, accessibility of services, the number and types of services and programs for users, transparency, structure of employees and their permanent education. The basic paradigm was that the effects of protection cannot be measured by the number of people treated at certain territory, but the scope and quality of services provided. The study included a total of 18 institutions of social protection (7 residential institutions and 11 day care institutions). Structure of users of social welfare services makes a total of 2 145 people with disabilities (out of which 1 757 (81,91%) in residential institutions and 388 (18,09%) in the daily treatment institutions). Social welfare institutions in Serbia are providing accommodation, food and working-occupational treatment for people with disabilities. They are organized as day care and residential institutions. The level and scope of social protection measures are regulated by a special law, but not by the standards and norms of the profession. Basic features of institutional care and protection of people with disabilities in the Republic of Serbia are: the number and heterogeneity of the group, trying degree of disability service users, systematization inconsistent with the needs and professional standards in this area, a low level of qualification of service providers

Risk Factors Associated with Coronary Artery Calcification Should Be Examined before Kidney Transplantation

The best treatment for end stage renal disease (ESRD) patients is kidney transplantation, but the renal transplant recipients still have a higher incidence of cardiovascular events compared with general population. Cardiovascular risk factors were imposed long before ESRD, as the majority of patients starting dialysis or kidney transplantation already have signs of advanced atherosclerosis. Artery calcification is an organized, regulated process similar to bone formation. Coronary artery calcification (CAC) is found frequently in advanced atherosclerotic lesions and could be a useful marker of them. We evaluated the prevalence of CAC in 49 stable renal transplant recipients and in 48 age- and gender-matched patients with chronic kidney disease (CKD) in stages 2-5 not requiring dialysis to assess risk factors associated with CAC. Computed tomography was used for CAC detection and quantification (CAC score). The prevalence of CAC was 43.8% in transplant recipients and 16.7% in CKD patients (p lt 0.001). Transplant recipients with CAC were significantly older and had longer duration of CKD and/or dialysis than recipients without CAC. In contrast, the serum levels of fetuin A (an inhibitor of vascular calcification) and albumin were significantly lower in CKD patients with CAC than those without CAC. During the observation period (30 months), 30 patients, including 23 CKD patients, began dialysis, and 4 transplant recipients and 2 CKD patients died. Independent predictors of mortality were age, serum amyloid A and the CAC score. In conclusion, the examination and prevention of risk factors associated with atherosclerosis should be started at the beginning of renal failure

Could depression be a new branch of MIA syndrome?

The aims of the present study were to determine the prevalence of depression in our dialysis patients, to detect the most powerful variables associated with depression, and to determine the role of depression in prediction of mortality. The prospective follow-up study of 128 patients (77 HD and 51 CAPD, 65 male, aged 53.8 +/- 13.5 years, dialysis duration 64.7 +/- 64.8 months) was carried out over 3 6 months. Depression by the Beck Depression Inventory-BDI-II score, laboratory parameters (hemoglobin, serum albumin and creatinine concentration), immunological status (cytokines and hsCRP), comorbidity by Index of Physical Impairment (IPI) and adequacy of dialysis by Kt/V were monitored. The overall prevalence of depression in the dialysis patients (BDI score >= 14) was 45.3%, and 28.2%, respectively, for moderate and severe depression (BDI >= 20). The most powerful variable associated with depression was IL-6, but associations with albumin, hemoglobin, creatinine and IPI score were also found. During the follow-up period 36 patients died, 7 patients left the cohort and 2 patients were transplanted. If IPI score was not included in the multivariate Cox analysis, the BDI score remained one of the best predictors of mortality along with albumin. In conclusion, because of the close association of depression with inflammation, malnutrition, and cardiovascular mortality, it could be speculated that depression is one branch of the MIA (malnutrition, inflammation, atherosclerosis) syndrome