Does leptin contribute to uraemic cachexia?
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Biomarkers↗
Biomedical subjects
Giovanna Luciani
Publications and source records attributed to Giovanna Luciani.
Different profiles of patients who require dialysis after cardiac surgery.
BACKGROUND: This study was aimed at evaluating the determinants of postoperative dialysis-requiring acute renal failure and at identifying eventual correlations between the different etiologic mechanisms and postoperative prognosis. METHODS: We evaluated the preoperative and intraoperative features of the 69 out of 6,542 consecutive cardiac surgery patients who developed postoperative dialysis-requiring acute renal failure at our Institution during a 10-year period. RESULTS: Age, valvular and aortic surgery, hypertension, extracardiac vasculopathy, timing of surgery, cardiopulmonary bypass time, and preoperative creatinine level greater than 2.0 mg/dL were identified as predictors by multivariate analysis. In a second analysis, patients were divided in two groups according to the preoperative creatinine level: group A (preoperative creatinine 2.0 mg/dL or less; 38 cases) and group B (preoperative creatinine 2.1 mg/dL or more; 31 cases). The two groups significantly differed in preoperative and intraoperative characteristics and in postoperative outcome: group A patients were younger, had a lower incidence of cardiac and vascular risk factors and comorbidities, were mainly operated on urgent or emergent basis for valvular or aortic pathologies, had longer cardiopulmonary bypass and cross-clamp time, and worse in-hospital outcome but higher midterm survival. Group B patients were older, had a higher prevalence of comorbidities, required more often in-hospital or after-discharge dialysis, had lower in-hospital mortality, but reduced midterm survival. CONCLUSIONS: Postoperative dialysis-requiring acute renal failure can be the result of two different pathophysiological pathways: complicated perioperative course due to urgent-emergent surgery or main intraoperative technical complications in patients with preoperative normal renal function and uncomplicated perioperative course associated with reduced preoperative kidney function. The two patient groups significantly differ in baseline preoperative features, as well as in in-hospital and in midterm outcome.
Acute Kidney Injury↗
Malnutrition in hemodialysis patients: what therapy?
Malnutrition is common in hemodialysis patients and is a powerful predictor of morbidity and mortality. Although much progress has been made in recent years in identifying the causes and pathogenesis of malnutrition in hemodialysis patients, as well as recognizing the link between malnutrition and morbidity and mortality, no consensus has been reached concerning its management. Along with such conventional interventions as nutritional counseling, oral nutritional supplements, and intradialytic parenteral nutrition, novel preventive and therapeutic strategies have been tested, such as appetite stimulants, growth hormone, androgenic anabolic steroids, and anti-inflammatory drugs, with contradictory and nonconclusive results. Malnutrition still remains a great challenge for nephrologists in the third millennium.
Acidosis↗
Variables associated with reduced dietary intake in hemodialysis patients.
BACKGROUND: Among the causes of malnutrition in hemodialysis (HD) patients, inadequate dietary intake (IDI) seems to be one of the most frequent and important. Although it has been hypothesized that IDI might be secondary to uremia, anorexia, underlying illness, psychosocial conditions, loss of dentures, depression, aging, or chronic inflammation, definite data on the etiology of IDI in HD patients are still lacking. The goal of this study was to measure the actual dietary energy and protein intakes in stable HD patients and to evaluate which demographic, clinical, dialytic, and humoral variables were associated with a dietary intake lower than recommended by international guidelines. METHODS: Thirty-seven patients maintained on regular HD, 3 times per week for 4 hours per session, were included in the study. In addition to epidemiologic data, patients were scrutinized for dry weight, weight change in the last 6 months, height, Body Mass Index, Kt/V, serum leptin, leptin-BMI ratio, presence of anorexia, and dietary energy and protein intake. Anorexia was assessed by means of a questionnaire in which the presence of major symptoms, namely meat aversion, taste and smell alterations, nausea and/or vomiting, and early satiety, was investigated. Dietary intake was recorded for 3 days after questionnaire administration by means of 3-day diet diaries. RESULTS: Overall, the mean (+/- standard deviation) dietary energy and protein intakes were 24.9 +/- 10.1 kcal/kg/day and 0.64 +/- 0.4 g protein/kg/day, respectively. Twenty-six patients (70.2%) had energy and protein intakes lower than recommended, 7 (18.9%) had adequate energy intake but inadequate protein intake, 1 (2.7%) had adequate protein intake and inadequate energy intake, and 3 (8.1%) had both adequate energy and adequate protein intakes. Anorexia was present in 14 of the 26 (53%) patients with low protein and energy intakes, and was absent in the other groups ( P =.003). The age of patients with inadequate energy and protein intakes was significantly higher than the age of patients with adequate energy and protein intakes (62.1 +/- 10.4 versus 37 +/- 20.8, P <.001) and the age of patients with only adequate energy intake (40.5 +/- 10.4, P <.001). Twenty-seven patients (73%) had an energy intake <30 kcal/kg/day, and 10 (27%) had an energy intake > or =30 kcal/kg/day. Compared with patients with energy intakes > or =30 kcal/kg/day, patients with energy intakes <30 kcal/kg/day were significantly older ( P =.0001) and more frequently were anorexic (P <.05). Compared with patients with protein intakes > or =1.2 g/kg/day, patients with protein intakes <1.2 g/kg/day were significantly older (P <.001). Limiting the analysis to the 33 patients with protein intakes <1.2 g/kg/day, we found a significant negative correlation between age and energy intake ( r =-0.612; P <.001) and between age and protein intake ( r =-0.723; P <.001). Correlations between both energy and protein intakes and age, dialytic age, Kt/V, C-reactive protein, parathyroid hormone, and leptin-BMI were not statistically significant. CONCLUSIONS: This study shows that dietary energy and protein intakes are inadequate in the majority of HD patients and are negatively related to the presence of anorexia and age. These data may be potentially useful in the identification of nutritional strategies as well as in improving food intake in HD patients.
Aged↗
Switch from bicarbonate hemodialysis to hemodiafiltration with online regeneration of the ultrafiltrate (HFR): effects on nutritional status, microinflammation, and beta-microglobulin.
BACKGROUND: Hemodiafiltration (HFR) with on-line regeneration of the ultrafiltrate, a technique of hemodiafiltration in which the ultrafiltrate passes through a cartridge containing uncoated charcoal, has been shown to be safe, simple, and well tolerated and has been claimed to improve nutritional status or to prevent its deterioration while decreasing the inflammatory response via a reduced production of proinflammatory cytokines. The purpose of the present prospective study was to ascertain whether HRF improves the nutritional status, reduces microinflammation, and decreases serum beta2-microglobulin levels in patients with end-stage renal disease (ESRD). METHODS: Eight patients, four males and four females, with a mean age of 49.4 +/- 16.8 years, stable on hemodialysis over a period of 8.7 +/- 6.1 years and on standard 4-4.5 h three-times-a-week bicarbonate hemodialysis, were switched to three-times-a-week, 4-h HFR. At baseline and every two months for 12 months at mid-week, serum levels of urea, creatinine, albumin, total cholesterol, C-reactive protein, fibrinogen, complement, ferritin, beta2-microglobulin, intact parathyroid hormone (PTH), hemoglobin concentrations, and hematocrit and the EPO weekly dose were determined. At baseline and at the end of the study, the Malnutrition Inflammatory Score (MIS) was calculated. RESULTS: Nutritional and inflammatory parameters remained constant during the 12-month period of the study. After 12 months of HFR, the MIS trended to be lower, but the difference was not statistically significant. Serum beta2-microglobulin and PTH levels remained constant during all time intervals. Neither hematocrit nor hemoglobin changed over the course of the study as well as the weekly EPO dose. CONCLUSION: The change from bicarbonate hemodialysis to HFR was safe and well tolerated but was not associated with an improvement of nutritional and inflammatory parameters or a reduction of serum beta2-microglobulin levels.
Analysis of Variance↗
Anorexia and serum leptin levels in hemodialysis patients.
BACKGROUND AND AIMS: Hyperleptinemia is a common feature in hemodialysis (HD) patients. However, the role of increased serum leptin levels in the pathogenesis of HD-related anorexia is still controversial. The purpose of the present prospective study was to ascertain whether hyperleptinemia is causally implicated in the pathogenesis of HD-related anorexia. METHODS: We measured the serum leptin levels and the serum leptin/body mass index (BMI) ratio in 24 healthy subjects and in 49 end-stage renal disease patients on maintenance HD. HD patients were subdivided into anorexic (14/49, 28.5%) and non-anorexic (35/49, 71.5%) according to a questionnaire discriminating for the presence of anorexia-related symptoms. RESULTS: Calorie (kcal/kg/day) and protein (g/ kg/day) intakes were significantly lower in anorexic than in non-anorexic patients (20.1 +/- 1.1 vs. 27.9 +/- 1.3, p = 0.004, and 0.82 +/- 0.05 vs. 1.19 +/- 0.05, p = 0.001, respectively). Accordingly, serum albumin, total lymphocyte count, mid-arm muscle circumference, and the protein equivalence of nitrogen appearance (PNA) were significantly lower in anorexic patients. The serum leptin concentration (ng/ml) was significantly higher in HD patients than in controls, in males (15.33 +/- 3.4 vs. 3.7 +/- 0.3, p = 0.003) and in females (42.3 +/- 7.2 vs. 10.5 +/- 1.3, p = 0.03). Similarly, serum leptin/BMI ratio was significantly higher in HD patients than in controls, in males (0.56 +/- 0.1 vs. 0.16 +/- 0.02, p = 0.0028) and in females (1.8 +/- 0.2 vs. 0.4 +/- 0.04, p < 0.0001). However, serum leptin levels were similar in anorexic and in non-anorexic patients, in males (15.3 +/- 5.6 vs. 16.9 +/- 4.2, p = 0.85) and in females (46.6 +/- 12.9 vs. 47.4 +/- 9.4, p = 0.96). No differences were observed between the 2 groups in the serum leptin/BMI ratio, in males (0.59 +/- 0.2 vs. 0.58 +/- 0.14, p = 0.92) and in females (1.5 +/- 0.4 vs. 1.8 +/- 0.3, p = 0.94). Similarly, no statistically significant differences in terms of serum leptin levels and leptin/BMI ratio were observed between patients with dietary energy intake of <30 or > or =30 kcal/kg/day and between those with a dietary protein intake of <1.2 or > or =1.2 g/kg/day. No significant correlations were found between serum leptin levels and PNA, albumin, cholesterol, total lymphocytes number, weight change, C-reactive protein, fibrinogen, ferritin, and complement. CONCLUSION: The present results indicate that mechanisms other than increases in serum leptin levels might be involved in the pathogenesis of HD-related anorexia.
Aged↗
Assessment of parathyroid function in clinical practice: which parathyroid hormone assay is better?
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Adult↗
Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula.
BACKGROUND: In patients in chronic hemodialysis via upper extremity arteriovenous fistula in whom ipsilateral internal thoracic artery graft was used for myocardial revascularization, hemodynamic interference between the fistula and the graft during dialysis can be hypothesized. METHODS AND RESULTS: In 5 patients undergoing chronic hemodialysis via upper extremity arteriovenous fistula, ipsilateral to an internal thoracic to left anterior descending graft mammary flow was studied by means of transthoracic echo-color Doppler at baseline and during hemodialysis. Flow in the contralateral mammary artery was used as control. Transthoracic echocardiography was performed in concomitance with flow evaluation to assess eventual modifications of left ventricular segmental wall motion. Immediately after hemodialysis pump start there was a marked reduction of peak systolic and end-diastolic velocities and time average mean velocity and flow in the ITA ipsilateral to the fistula, whereas no substantial hemodynamic modification was evident in the contralateral artery. Dialysis-induced reduction of ipsilateral ITA flow was accompanied by evidence of hypokinesia of the anterior left ventricular wall. Three cases also experienced clinical angina. CONCLUSIONS: Hemodynamically evident flow steal and consequent myocardial ischemia develop during hemodialysis in patients with upper extremity arteriovenous fistula and ipsilateral internal thoracic artery to coronary graft. These data have major implications for patients' management, both for nephrologists and cardiac surgeons.
Arteriovenous Shunt, Surgical↗
Pregnancy during chronic hemodialysis: a single dialysis-unit experience with five cases.
BACKGROUND: Pregnancy is uncommon in women with end-stage renal disease (ESRD) requiring chronic dialysis. An increasing number of successful pregnancies in women in hemodialytic treatment have been recently reported but few institutions experienced more than one or two cases of pregnancy. METHODS: Between 1988-1998 five pregnancies in patients receiving hemodialysis were observed in our center. Medical records of these patients were reviewed. RESULTS: At the conception the mean age was 27 years. One patient started dialysis after conception. All patients received bicarbonate dialysis. Three patients were dialyzed six times per week, the other two patients three-four times per week. The dry weight was increased progressively; on average of 1.2 +/- 0.5 kg in the first trimester and of 0.5 kg per week since the second trimester. The predialysis BUN was maintained between 50-100 mg/dL (17.85-35,70 mmol/L) during the pregnancy. Four patients were treated with erythropoietin to maintain hematocrit between 30-35%. Erythropoietin related-complications were not observed. Polyhydramnios was observed in all cases. All deliveries occurred before term. The mean gestational age of infants was 28.6 +/- 4 weeks. Four out of five pregnancies resulted in liveborn infants. Two infants had an Apgar score of zero. All neonates were of low birth weight (1,431 +/- 738 g) with percentile of birth weight in the normal range. No one was small for date. CONCLUSION: A successful pregnancy is possible in women on chronic dialysis. Prematurity occurs frequently as well as low weight birth leading to increased perinatal morbidity and mortality.
Adult↗
Parathyroid carcinoma in a chronic hemodialysis patient: case report and review of the literature.
Parathyroid carcinoma is a rare disease in normal population as well as in patients with end-stage renal disease. Approximately 700 cases have been reported and, of these, 20 occurred in patients receiving chronic hemodialysis. We describe a case of parathyroid carcinoma in a 59-year-old female patient with end-stage renal disease secondary to membranous glomerulonephritis treated by hemodialysis since 1995. In September 1998, the calcium level was 12.4 mg/dl and intact parathyroid hormone serum levels were 1366 pg/ml (normal range, 25-65). A routine ultrasonographic examination of the neck revealed enlargement of two parathyroid glands, the left inferior gland being the largest and measuring 2x3x2 cm. In October 1998, resection of two parathyroid glands was performed. On the basis of histology, which documented the presence of proliferating cells arranged in sheets or in a trabecular pattern, numerous mitosis and vascular invasion, a diagnosis of parathyroid carcinoma was made.
Calcium↗
Muscle ubiquitin m-rNA levels in patients with end-stage renal disease on maintenance hemodialysis.
BACKGROUND: Loss of lean body mass is frequently reported in patients with end-stage renal disease (ES-RD). Inadequate nutrient intake, superimposed illnesses, endocrine disorders, uremia and acidosis are some of the potential causes of muscle depletion. Previous reports on experimental models show that lean body mass depletion results from enhancement of muscle tissue protein catabolism, mainly associated with activation of ATP-ubiquitin-dependent proteolysis. Little is known, however, about the affects on this proteolytic system in ESRD patients on maintenance hemodialysis (HD). The present study was designed to investigate the expression of ubiquitin mRNAs in skeletal muscle of patients with ESRD on maintenance HD. METHODS: Biopsies from the rectus abdominis muscle were obtained from eight ESRD patients and from six control subjects undergoing surgery for benign disease. Ubiquitin mRNA levels were measured by Northern blotting analysis. RESULTS: Patients with ESRD had mild metabolic acidosis, as a result of chronic intermittent HD. There were no significant differences between HD patients and controls with regard to the 1.2kb polyubiquitin mRNA species (332.9+/-139 vs 324.2+/-60; ns), but the levels of the 2.4 kb mRNA species were significantly lower in HD patients than in controls (1687+/-542 vs 2529.9+/-325, p=0.01). No correlation was observed between ubiquitin mRNA levels and nutritional parameters and degree of acidosis. CONCLUSIONS: The present study found that the ubiquitin mRNA levels were not increased in the muscle of stable, mildly acidotic hemodialysis patients.
Adult↗
Sustained response with negative serum HCV-mRNA and disappearance of antibodies after interferon-alpha therapy in a kidney transplant recipient with chronic active viral hepatitis C.
BACKGROUND: The use of interferon-alpha (IFN-alpha) to treat viral hepatitis C (HCV) occurring in kidney transplant recipients is controversial. This study reports an HCV patient successfully treated with IFN-alpha therapy achieving sustained response, negative serum HCV-mRNA and the disappearance of HCV antibodies, without impairment of renal function. METHOD: A young kidney transplant recipient developed a proven HCV infection 70 months post-transplantation. The patient received IFN-alpha therapy, and for a 32-month follow-up period was evaluated clinically, serologically and virologically. RESULTS: IFN-alpha therapy resulted in normal transaminase activities within 2 months. Serum HCV-mRNA was negative after 4 weeks of treatment and is still negative. Ten months after IFN-alpha therapy withdrawal, the enzyme immunoassay revealed that HCV antibodies (HCVAb) were absent in the serum. IFN-alpha therapy was safe, well tolerated and renal function was not impaired.
Antiviral Agents↗