Our results showed that Klotho levels are influenced by FGF23, vitamin D and insulin resistance. This suggests that Klotho levels might be affected by renal function as well as having a relevant role on insulin metabolism and ACR homeostasis.
Nowadays, as people age and live longer, they are more likely to develop several comorbid conditions, including chronic kidney disease (CKD) 1,2,3. About 60% of deaths worldwide are related to chronic diseases and this number is expected to rise by 15% by 2020 4. Plus, CKD is the 15 th and 20 th cause of years lived with disability 5 and disability-adjusted life years 6. Khan defined comorbidity in kidney failure patients as a significant concurrent or past disease in addition to CKD, which involved organs other than the kidneys but which may also be responsible for the renal failure 2. Risk factors predicting either increased morbidity or mortality among dialysis patients have been well described by earlier research, but are poorly defined in the pre-dialysis population 7. Population ageing has conditioned a progressive increase of very old, dependent and frail patients on dialysis 8. These patients present multiple comorbidities that worsen prognosis and have a negative impact on their quality of life, since it had been shown that comorbidities tend to worsen after dialysis initiation, as does patients' functional status. Estimated life expectancy for these patients, even with renal replacement therapy (RRT), has been quoted to be as low as 8 months 1,9,10. According to the Portuguese Society of Nephrology Registry, in Portugal, 60.2% of incident dialysis patients in 2018 were over 65 years and the mean age of prevalent patients was 67.2 years 11. Age per se is a strong predictor of mortality and the mortality rate is considerably higher for elderly patients on dialysis than those who are not 10. Additionally, for elderly end stage renal disease (ESRD) patients, prompt RRT is costly and does not necessarily extend survival 12. These older patients who are initiated on dialysis require more medical interventions (including dialysis) and are more commonly hospitalized than those treated conservatively 13. Given the rapid growth of elderly populations, it is necessary to adopt practical and useful tools to make mortality prediction easier. Assessment of the overall comorbidities may be helpful to identify those patients whose condition will probably evolve poorly.
Introduction: Type 1 diabetes mellitus is associated with an increased risk of coronary artery disease, which is frequently asymptomatic. This risk increases significantly in those with nephropathy. In selected patients, simultaneous pancreas-kidney transplantation is the renal and pancreatic replacement therapy of choice, as it increases longevity and stabilizes diabetic complications. Despite essential, universal screening protocols are still controversial for coronary artery disease in this population. Methods: We retrospectively analysed 99 simultaneous pancreas-kidney recipients from our centre from 2011 to 2018 and selected 77 patients who underwent coronary angiography during the pre-transplant evaluation. Our aim was to identify potential risk factors associated with significant lesions on coronary angiography. Results: Almost half of our cohort of 77 candidates submitted to coronary angiography had coronary artery disease. Of these, nearly 30% underwent revascularization, although only one of them reported symptoms of myocardial ischemia. In a univariate analysis, the presence of smoking habits was the only risk factor for coronary artery disease. We also found that 20 or more years of type 1 diabetes mellitus was significantly associated with the presence of coronaropathy. Discussion: Selection of diabetic candidates with acceptable cardiac risk before simultaneous pancreas-kidney transplantation is imperative. Given the impact of a correct diagnosis and a low procedural risk, we defend the routine use of coronary angiography as the initial screening method for coronary artery disease in this population. Particularly care must be taken in evaluating asymptomatic patients with long-term type 1 diabetes mellitus and smokers.
Background and Aims Plasma N-terminal fragment of pro brain natriuretic peptide (NTproBNP) concentration is elevated in cardiovascular diseases such as congestive heart failure, where increased levels of NTproBNP indicate cardiac dysfunction, hypervolemia, and higher risk of hospitalization and death. These associations have also been studied in patients with chronic kidney disease (CKD), where NTproBNP value remains controversial, especially in long-term peritoneal dialysis (PD) patients with respect to its pathophysiologic implications. This study aim was to determine whether NTproBNP was a predictor of hospital admissions and cardiovascular events among patients on automated (APD) and continuous (CAPD) ambulatory peritoneal dialysis. Methods This was a cross-sectional study which included stable patients from two Peritoneal Dialysis Units. Plasma NTproBNP concentration was measured in stable adult peritoneal dialysis patients attending for routine assessments on PD outpatient clinic. In all patients, demographic variables, clinical and other laboratory parameters were recorded and analyzed. Descriptive statistics was performed. Groups were compared using independent t-test for comparison of continuous variables and Chi square test for categorical variables. In order to evaluate relationship between NTproBNP and the other variables multivariate logistic regression and Pearson bivariate analysis were used. Results The study enrolled 70 patients (male/female 44/26; mean age 55.3±14.6 years; APD/CAPD 25/45; PD duration 28±24.2months). One third (31.4%) of the patients was diabetic, 12.9% presented cardiac insufficiency and 20% had cardiovascular disease. Pearson bivariate correlation analysis revealed that patients with higher weekly kt/v (p=0.039), total fluid removal (diuresis and ultrafiltration) (p=0.027) and total weekly creatinine clearance (p=0.007) had lower NTproBNP values. These patients had also significant lower plasmatic creatinine and phosphorus levels. We found no significant association with residual kidney function, peritoneal transport (D/P creatinine), serum albumin levels and c-reactive protein. We also found that patients with higher NTproBNP levels had significantly more cardiovascular events (p=0.010) and a trend for more common hospital admissions (p=0.066). There were no significant differences regarding NTproBNP between the two modalities of peritoneal dialysis (APD and CAPD patients) or in patients who were PD first. As expected, patients with cardiac dysfunction had significant higher NTproBNP values (p=0.004). Diabetic patients had higher NTproBNP levels, althought this difference was not significant. Conclusion Despite the inconsistency in the NTproBNP value among long-term PD patients, results from most studies concur that NTproBNP levels are closely associated with left ventricular dysfunction, morbidity and mortality in these patients. In our study, patients with higher NTproBNP levels had more cardiovascular events and a trend for more common hospital admissions. Regular monitoring of NTproBNP levels among PD patients may be useful for providing care for these patients. Plus, NTproBNP was associated with better PD efficacy, greater fluid removal and higher creatinine clearance, reinforcing clinical relevance of PD optimization. These results require confirmation in a prospective study.
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