Fatigue may predict heart attack for dialysis patients  2/26/2010
For dialysis patients, high scores on a new fatigue rating scale predict an increased risk of heart attack or other cardiovascular events, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society Nephrology.

Fatigue could be an important warning sign of serious cardiovascular events—especially in patients without other obvious risk factors, according to the study led by Hidenori Koyama, MD, PhD, and Yoshiki Nishizawa, MD, PhD (Osaka City University Graduate School of Medicine, Japan).
The researchers evaluated their fatigue questionnaire in a group of 788 dialysis patients. About 16% of the dialysis patients had a high fatigue score. At two years' follow up, patients with high fatigue scores were more than twice as likely to have cardiovascular events such as a heart attack or stroke.      continued.....

Study: Common hyperkalemia treatment has no proven benefit

3/9/2010

For more than half a century, products containing ion exchange resins have been used in patients with dangerously high levels of potassium. However, there is no convincing evidence that these products are actually effective, according to an article appearing in an upcoming issue of the Journal of the American Society Nephrology.
"We suspect that if ion exchange resins were introduced today, they would not be approved," said Richard H. Sterns, MD, of Rochester General Hospital, University of Rochester School of Medicine and Dentistry.
Ion exchange resins, mixed with a cathartic called sorbitol, have long been used to treat hyperkalemia. Millions of doses of this product are prescribed every year in the United States—yet it has never been studied with controlled trials to prove it works. Explains Sterns, "these agents came into widespread use in 1958—four years before drug manufacturers were required to prove the effectiveness of their products before gaining FDA approval. Their approval was essentially 'grandfathered.'"  
Last year, the FDA issued a warning against giving ion exchange resins with sorbitol,  based on reported cases of potentially fatal bowel injury. Yet pre-mixed preparations of  the resin with sorbitol are still marketed and widely used.
"We found no evidence that would meet modern standards for drug approval," Sterns and coauthors concluded. They call for further studies to weigh the harms versus benefits of these products. Meanwhile, they believe that doctors should first try other alternatives to managing high potassium levels, "before turning to these largely unproven and potentially harmful therapies."  
Study co-authors are Maria Rojas, Paul Bernstein, and Sreedevi Chennupati, all of Rochester General Hospital.

An interesting figure in this month's ASN Kidney News details the quarterly earnings for three major dialysis companies in the U.S.: DaVita, Dialysis Corporation of America (DCA), and Fresenius.Also included in the figure (not shown here) is the "revenue per treatment"--that is, how much profit each company obtains from the average patient's dialysis run. For example, Fresenius reported a revenue per treatment of $348 for the 3rd quarter of 2009. I'm not sure how they arrive at these numbers, but you can do a quick calculation to figure out how much a single patient dialyzing on the standard 3x/week schedule is worth to the company on a yearly basis: $348/treatment x 3 treatments/week x 52 weeks/year = $54,288.00/year. Like it or not, dialysis is also a business.

Glomerular Density and Predicting Progression in IgA Nephropathy

IgA nephropathy (IgAN) is an unpredictable beast, and identifying patients who will go on to develop progressive disease can be challenging. The classic predictors of progression, namely heavy proteinuria, CKD, glomerular sclerosis and tubulointerstitial fibrosis, are themselves just markers of advanced disease. There is a real need for better early histopathologic predictors of renal prognosis.

One promising prospect is glomerular density (GD), i.e. the number of nonsclerotic glomeruli per mm2, which was the focus of this recent study from Japan. The investigators performed a retrospective analysis of almost 100 IgAN cases with preserved renal function at the time of biopsy (average GFR 90 ml/min). Interestingly, they found that the GD varied hugely between patients, from 1 to 8 glomeruli per mm2. In multivariate analysis, only GD, and the presence of a cellular/fibrocellular crescent, were found to be significant predictors of progression. Patients with a low GD experienced more rapid decline in renal function, and this enhanced risk for progression was increased if a cellular/fibrocellular crescent was also present. Interestingly, the classic predictors of progression listed above did not predict prognosis, presumably due to the early stage of disease.

Wednesday, March 03, 2010
Recall: Baxter dialysis device over death, serious injury

The Chicago Tribune's Bruce Japsen Tuesday reported that Baxter International Inc. is recalling an in-home dialysis device because it has been linked to serious injury reports and at least one death in the last two years.

"The U.S. Food and Drug Administration has classified the action as a Class I recall, the agency's most serious, for Baxter's HomeChoice and HomeChoice Pro peritoneal dialysis cyclers because the device is causing an 'overfill' of fluid in the patient's stomach," according to Japsen's story.

Japsen's story explained that "a Class I recall means the FDA wants the company to address the problems. 'The action has been classified as a Class I recall because of the risk of serious injury or patient death that could be associated with the use of the device,' the company said in a statement."

Baxter published a press release March 2 including the following information (in italics):
continued.....

By Charles Bankhead, Staff Writer, MedPage Today
Published: February 18, 2010
Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Kidney transplant recipients had similar survival and better renal function with the investigational immunosuppressive agent belatacept compared with cyclosporine, results of two randomized trials showed.

In one trial, two intensity levels of belatacept-based immunosuppression led to one-year patient/graft survival of 95% to 97% compared with 93% with a cyclosporine-based regimen. Significantly fewer belatacept patients met the composite renal-impairment endpoint (P<0.001).

The same two belatacept regimens matched cyclosporine for patient/graft survival with better renal function in a trial involving recipients of extended-criteria donor kidneys.

Belatacept was associated with a higher incidence of post-transplant lymphoproliferative disorder (PTLD) in both studies, published in the March issue of the American Journal of Transplantation.

A selective inhibitor of T-cell activation, belatacept "allows effective immunosuppression, better preservation of renal function, and improved cardiovascular/metabolic risk profile and less toxicity compared with calcineurin inhibitors," Flavio Vincenti, MD, of the University of California San Francisco, and colleagues concluded in reporting the first trial.

Investigators in the extended-criteria study reached similar conclusions and suggested the risk of PTLD might be reduced by avoiding use of belatacept in Epstein-Barr virus (EBV)-naive patients and treating recipients prophylactically against cytomegalovirus (CMV).    continued......

Added to standard treatment, avosentan, a novel endothelin antagonist, reduced albuminuria but heightened the risk of cardiovascular problems in patients with overt diabetic nephropathy, a multicenter, randomized trial showed.

When the planned 42-month trial was prematurely terminated after a median follow-up of just four months, patients who received avosentan were more likely to have fluid overload and congestive heart failure than those who received placebo, according to Giancarlo Viberti, MD, of King's College London School of Medicine, and colleagues.

There was also a nonsignificant trend toward higher mortality in patients taking 25 or 50 mg a day of avosentan (4.6% and 3.6%) than in those taking placebo (2.6%), the researchers reported in the March issue of the Journal of the American Society of Nephrology.

Action Points 

• Explain to interested patients that avosentan, an endothelin antagonist, reduced albuminuria in patients with diabetic nephropathy but increased the risk of fluid overload and congestive heart failure.

• Note that avosentan has not been approved by the FDA for any indication.

"Despite its potent albuminuria-lowering effect, it is clear that avosentan at the doses [used in this study] in a population of patients with type 2 diabetes and 3 to 4 chronic kidney disease stage is not a viable therapeutic option," Viberti and his colleagues wrote.   continued........

Regular exercise reduces patient anxiety by 20%

2/23/2010

http://nephronline.com/news.asp?N_ID=3604

The anxiety that often accompanies a chronic illness can chip away at quality of life and make patients less likely to follow their treatment plan. But regular exercise can significantly reduce symptoms of anxiety, a new University of Georgia study shows.

In a study appearing in the Feb. 22 edition of the Archives of Internal Medicine, researchers analyzed the results of 40 randomized clinical trials involving nearly 3,000 patients with a variety of medical conditions. 
They found that, on average, patients who exercised regularly reported a 20 percent reduction in anxiety symptoms compared to those who did not exercise.

"Our findings add to the growing body of evidence that physical activities such as walking or weight lifting may turn out to be the best medicine that physicians can prescribe to help their patients feel less anxious," said lead author Matthew Herring, a doctoral student in the department of kinesiology, part of the UGA College of Education.   continued......

J Am Soc Nephrol. 2010 Jan;21(1):163-72. Columbia University College of Physicians and Surgeons, Department of Pathology, 

A study published in the Journal of the American Society of Nephrology has suggested a link between kidney disease and long term steroid use. Body builders who utilize steroid for the purposes of increased training performance seem to be the population at risk. The body builders were confirmed to develop a type of kidney disease known as focal and segmental glomerulosclerosis also known as FSGS. Although categorized as scarring of the kidney and known to occur as a final pathway of injury in numerous

Other glomerular diseases FSGS can also be its own unique disease in which case it can be very difficult to treat. Requiring in most cases high doses of …..steroids, although of a different variety than those used in the body builders.

Jody A. Charnow,   February 17, 2010

Tenecteplase, a thrombolytic agent, is a safe and effective treatment for dysfunctional tunneled hemodialysis (HD) catheters, according to researchers.

The finding is based on a study of 149 HD patients with dysfunctional tunneled HD catheters, defined as a blood flow rate (BFR) below 300 mL/min at minus 250 mm Hg pressure in the arterial line. The investigators, led by James Tumlin, MD, of the University of Tennessee College of Medicine in Chattanooga, randomly assigned subjects to receive a one-hour intracatheter dwell with tenecteplase 2 mg/2 mL (74 patients) or placebo (75 patients). The primary end point was the percentage of patients with a BFR of 300 mL/min or above and an increase of 25 mL/min or more above baseline 30 minutes before and at the end of the dialyzing session.