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Publications (42)75.92 Total impact

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    ABSTRACT: Elevated levels of serum alkaline phosphatase (AlkPhos) have been reported to be associated with increased mortality risk in hemodialysis (HD) patients. We examined the association of serum AlkPhos with all-cause mortality in our PD patients. The study enrolled 90 PD patients beginning in 1995. On enrollment, demographics and clinical and biochemical data were recorded. Patients were followed to September 2011. Mean age of the enrollees was 52 years, with 61% being women, and most (81%) being of African descent. Mean and median AlkPhos were 135 U/L and 113 U/L respectively. Mean and maximum follow-up were 2.61 and 16 years respectively. As expected, AlkPhos correlated directly with serum intact parathyroid hormone (r = 0.36, p = 0.003). In a Cox multivariate regression analysis with adjustment for confounding variables, AlkPhos as a continuous (relative risk: 1.016; p = 0.004) anda categorical variable [> 120 U/L and < or = 120 U/L (relative risk: 6.0; p = 0.03)] remained a significant independent predictor of mortality. For each unit increase in enrollment AlkPhos, there was a 1.6% increase in the relative risk of death. Elevated serum AlkPhos is significantly and independently associated with increased mortality risk in our PD patients followed for up to 16 years. AlkPhos should be evaluated prospectively as a potential therapeutic target in clinical practice.
    Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 01/2013; 29:61-3.
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    ABSTRACT: The relationship between dialysis vintage (length of time on dialysis), body composition, and survival has been reported in hemodialysis patients. In the present study, we examined the association ofdialysis vintage with body composition and survival in peritoneal dialysis (PD) patients. At enrollment, body composition in 65 PD patients was determined by bioelectrical impedance analysis. Patients (mean age at enrollment: 54 years) were followed for up to 11 years maximum. At enrollment, the mean, median, and maximum dialysis vintages were 51, 34, and 261 months respectively. After adjusting for age, race, sex, and diabetes status, dialysis vintage was indirectly correlated (partial correlation coefficients) with body weight (r = -0.40, p = 0.001), body mass index (r = -0.40, p = 0.002), body surface area (r = -0.39, p = 0.002), body cell mass (r = -0.39, p = 0.002), total body fat weight (r = -0.30, p = 0.02), and fat percentage of body weight (r = -0.31, p = 0.018), and directly correlated with extracellular mass to body cell mass ratio (r = 0.27, p = 0.039). The observed cumulative survival was significantly higher (p = 0.007) in patients with a dialysis vintage at enrollment of 35 months or less, than in patients with dialysis vintage at enrollment of more than 35 months. In the multivariate Cox regression analysis, adjusting for age, race, sex, and diabetes, dialysis vintage at enrollment remained an independent predictor of mortality (relative risk: 1.010; p = 0.002). Increase in relative risk of death with increasing dialysis vintage may be partly explained by the association of vintage with unfavorable changes in body composition and the nutrition status of patients over time.
    Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 01/2012; 28:144-7.
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    ABSTRACT: Malnutrition is a strong predictor of mortality in peritoneal dialysis (PD) patients. Extracellular mass (ECM) contains all the metabolically inactive, whereas body cell mass (BCM) contains all the metabolically active, tissues of the body. ECM/BCM ratio is a highly sensitive index of malnutrition. The objective of this study was to explore the relationship between ECM/BCM ratio and survival in PD patients. We enrolled 62 patients from November 2000 to July 2008. On enrollment, demographic, clinical, and biochemical data were recorded. Bioimpedance analysis (BIA) was used to determine ECM and BCM in PD patients. Patients were followed up to November 2008. Mean age was 54+/-16 (s.d.) years; female, 55%; African Americans, 65%; diabetic, 24%. Mean ECM/BCM ratio was 1.206+/-0.197 (range: 0.73-1.62). Diabetics had higher ECM/BCM ratio than nondiabetics (1.29 vs 1.18, P=0.04). ECM/BCM ratio correlated directly with age (r=0.38, P=0.002) and inversely with serum albumin (r=-0.43, P=0.001), creatinine (-0.24, P=0.08), blood urea nitrogen (r=-0.26, P=0.06), and total protein (r=-0.31, P=0.026). Using multivariate Cox regression analysis, adjusting for age, race, gender, diabetes, and human immunodeficiency virus status, enrollment ECM/BCM ratio was a significant independent predictor of mortality (relative risk=1.035, P=0.018). For every 10% increase in the ECM/BCM ratio, the relative risk of death was increased by about 35%. In conclusion, BIA-derived enrollment ECM/BCM ratio, a marker of malnutrition, was an independent predictor of long-term survival in PD patients.
    Kidney international. Supplement 08/2010;
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    ABSTRACT: Magnesium is one of the most abundant cations in the body and is involved in many cell functions. Serum magnesium concentration is maintained within a narrow range by the kidney and digestive tract. It has been reported that a lower serum magnesium level is a significant predictor for mortality in hemodialysis patients. Body composition and inflammation are important predictors of mortality in peritoneal dialysis (PD) patients. The objective of the present study was to examine the relationship of serum magnesium with body composition and inflammation in PD patients. Our study enrolled 62 PD patients treated at the Long Island College Hospital between November 2000 and July 2008. Demographic, clinical, and biochemical data were recorded. Body composition parameters were determined by bioelectrical impedance analysis (BIA). High sensitivity C-reactive protein (hs-CRP), a marker of inflammation was measured by the immunoturbidimetric method. In these patients (mean age: 55 years; 63% African American; 55% women; 25% with diabetes), the mean (+/- standard deviation) serum magnesium and hs-CRP were 1.597 +/- 0.28 mEq/L and 13.70 +/- 21 mg/L respectively. Serum magnesium was directly correlated with serum markers of nutrition: albumin (r = 0.42, p = 0.001), creatinine (r = 0.43, p = 0.0001), and total protein (r = 0.44, p < 0.0001). Serum magnesium was also directly correlated with phase angle, a BIA parameter and marker of cellular health (correlation coefficient: r = 0.35; p = 0.006), and inversely correlated with the extracellular mass/body cell mass ratio (r = -0.34, p = 0.008), a highly sensitive marker of malnutrition. We observed an inverse correlation between serum magnesium and hs-CRP (r = -0.37, p = 0.02) in PD patients. In conclusion, lower serum magnesium is associated with poorer nutrition status, deteriorating cellular health, and increased inflammation, which may contribute to the increased risk of mortality in PD patients.
    Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 01/2010; 26:112-5.
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    ABSTRACT: Fluid overload is a common complication in peritoneal dialysis (PD) patients. The prognostic importance of enrollment fluid status in long-term PD patients remains to be investigated. The objective of the present study was to investigate the prognostic importance of enrollment fluid status in the long-term survival of PD patients. We enrolled 53 PD patients (mean age: 53 years) from November 2000 to February 2006. On enrollment, demographic, clinical, and biochemical data were recorded. Bioelectrical impedance analysis (BIA) was used to determine the fluid status of PD patients, including extracellular water (ECW), intracellular water (ICW), and total body water (TBW). Fluid status was corrected for body surface area (BSA): ECW-BSA, ICW-BSA, and TBW-BSA respectively. Patients were followed to January 2008. The ECW-BSA correlated negatively with albumin, a marker of nutrition (r = -0.53, p < 0.0001). The ICW/ECW ratio (r = 0.36, p = 0.018) correlated directly and the ECW/ TBW ratio (r = -0.36, p = 0.019) correlated negatively with creatinine. Patients who survived during the study period had a significantly lower ECW-BSA (8.29 L/m2 vs. 9.91 L/m2, p = 0.001) than did those who did not survive. Patients with enrollment ECW-BSA below 9 L/m2 had a significantly better 7-year cumulative survival (Kaplan-Meier) than did patients with a ECW-BSA of 9 L/m2 or more (p = 0.019). Using multivariate Cox regression analysis, adjusting for age, race, diabetes, human immunodeficiency virus (HIV) status, and months on dialysis at enrollment, ECW-BSA was a significant independent predictor of mortality (relative risk: 1.50; p = 0.03). In conclusion, ECW-BSA was a significant independent predictor of long-term survival in PD patients.
    Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/2008; 24:79-83.
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    ABSTRACT: The information available in the literature regarding pulmonary hypertension (PH) in peritoneal dialysis (PD) patients is limited. The objective of the present study was to examine the prevalence and characteristics of PH in PD patients. We retrospectively collected the clinical profile, echocardiographic (ECHO) findings, and biochemical data for 36 PD patients for which ECHO findings were available. We compared characteristics between patients with and without PH. We found PH, defined as pulmonary arterial pressure (PAP) > or = 35 mmHg, in 15 patients. The prevalence of PH was 42%. Mean age (+/- standard deviation) of the patients with and without PH was 58 +/- 15 years and 52 +/- 15 years respectively (p = 0.30). Mean PAP of the PH patients was 43.8 +/- 9.0 mmHg (range: 35-65 mmHg). Patients with PH had a lower ejection fraction than did patients without PH (46.3% +/- 19.8% vs. 56.5% +/- 11.8% respectively, p = 0.07). Patients with PH also had a higher prevalence of global hypokinesia (60% vs. 29%, p = 0. 059) and dilated left ventricular chamber (53% vs. 19%, p = 0.03). In PH patients, body mass index (24 +/- 4.5 kg/m2 vs. 28 +/- 5.0 kg/m2, p = 0.024), normalized protein catabolic rate (0. 78 +/- 0.21 g/kg vs. 0.95 +/- 0.27 g/kg daily, p = 0.049), and ferritin (226 +/- 210 ng/mL vs. 873 +/- 965 ng/mL, p = 0.005) were significantly lower and lactate dehydrogenase was higher (264 +/- 99 U/L vs. 206 +/- 79 U/L, p = 0.06) than in patients without PH. We observed no significant differences in race or sex, incidence of hypertension or cardiovascular disease, or vitamin D analog use between the two groups of patients. During the study period, 60% of PH patients and 38% of patients without PH died (p = 0.19). Values of PAP correlated directly with serum levels of phosphorus (r = 0.44, p = 0.02), CaxP product (r = 0.40, p = 0.04), and parathyroid hormone (r = 0.42, p = 0.03). Of continuous ambulatory PD and continuous cycling PD patients, 21% and 55% respectively had PH (p = 0. 049). In PD patients, PH is highly prevalent and may be associated with higher mortality risk.
    Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 01/2007; 23:127-31.
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    ABSTRACT: Inflammation, dialysis adequacy, and peritoneal transport rate (PTR) influence clinical outcomes in peritoneal dialysis (PD) patients. The present study examined the relationship of C-reactive protein (CRP), a marker of inflammation, to PTR and residual renal function (RRF) in PD patients. We recorded the baseline dialysate-to-plasma creatinine (D/P Cr) of 210 PD patients starting in 1986. In a subgroup of 42 patients, we serially measured high-sensitivity CRP levels and.dialysis adequacy, including weekly Kt/V urea and creatinine clearance (CCr), starting in May 2003. The patients were followed to January 2006. Mean age was 53 +/- 16 (standard deviation) years, and 70% of the patients were African American. Enrollment mean and median CRP levels were 13.53 +/- 20.8 (range: 0.2-95.8) and 7.15 mg/L respectively. Mean weekly residual CCr and Kt/V during follow-up were 7.11 +/- 15.47 L/1.73 m2 and 0.14 +/- 0.30 respectively. The mean enrollment D/P Cr was 0.649 +/- 0.12 (range: 0.429-0.954). Patients with CRP > 10 mg/L had significantly lower weekly residual CCr (0.59 L/1.73 m2 vs. 10.1 L/1.73 m2, p = 0.01), residual Kt/V (0.01 vs. 0.20, p = 0.01), total CCr (56 L/1.73 m2 vs. 62 L/1.73 m2, p= 0.047), and total Kt/V (2.09 vs. 2.49, p = 0.001) than did those with CRP < or = 10 mg/L. Levels of CRP correlated negatively with weekly residual CCr (r = -0.42, p = 0.006), residual Kt/V (r = -0.43, p = 0.006), and total Kt/V (r = -0.44, p = 0.004). Enrollment D/P Cr was inversely correlated with serum albumin (r = -0.24, p = 0.001) and directly correlated with peritoneal protein loss (r = 0.34, p = 0.028). Higher enrollment D/P Cr was associated with lower observed cumulative survival (Kaplan-Meier) in PD patients. However D/P Cr was not an independent predictor of long-term survival in PD patients. Using multivariate Cox regression analysis, and including D/P Cr and residual Kt/V in the model, enrollment CRP was an independent predictor of mortality (relative risk = 1.036, p = 0.018). We conclude that elevated CRP is associated with lower RRF As a predictor of mortality, CRP may be better than RRF and D/P Cr.
    Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/2006; 22:2-6.
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    ABSTRACT: Nutritional status is associated with clinical outcomes in dialysis patients. Inflammation may cause malnutrition and increases the risk of poor outcomes. We have investigated the relationship between nutritional markers, an inflammatory marker, and survival in 177 peritoneal dialysis (PD) patients, enrolled from 1991 to 2005. In 53 patients, bioimpedance analysis (BIA) measurements were conducted from November 2000. In a subgroup of 42 patients, we measured high-sensitivity C-reactive protein (CRP) and various nutritional markers including prealbumin serially from May 2003. All the patients were followed to April 2006. Mean enrollment albumin and prealbumin levels were 3.61±0.51 g/dl and 35.8±11.3 mg/dl, respectively. Mean and median enrollment CRPs were 13.53±20.81 (s.d.) and 7.15 mg/l, respectively. Higher enrollment levels of nutritional markers such as albumin (P
    Kidney International 01/2006; · 8.52 Impact Factor
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    ABSTRACT: An elevated level of C-reactive protein (CRP), which is a marker of inflammation, is a risk factor for morbidity and mortality in the general population and in dialysis patients. Recently, the relationship between inflammation and nutrition status has received much attention. Serum prealbumin is a highly sensitive marker of nutrition and survival in dialysis patients. The objective of the present study was to evaluate the prognostic value and clinical correlates of CRP in peritoneal dialysis (PD) patients. Using retrospective chart review, we collected demographic, clinical, and laboratory data on 66 PD patients for the period June 2001 to January 2005. High-sensitivity CRP (hs-CRP) levels were measured in a subgroup of 32 patients starting in May 2003. Over the study period, prealbumin and CRP were assayed serially by the immunoturbidimetric method. Mean age (+/- standard deviation) of the patients was 55 +/- 15 years, and 73% were African American. Mean and median enrollment CRP were 15.2 +/- 24 mg/L (range: 4.2 - 149.5 mg/L) and 6.45 mg/L respectively. Mean and median enrollment hs-CRP were 15.3 +/- 23.5 mg/L (range: 0.2 - 96 mg/L) and 6.55 mg/L respectively. Enrollment CRP was elevated (215 mg/L) in 29% of the patients, and hs-CRP was elevated (> or = mg/L) in 63% of the patients. Enrollment CRP was strongly correlated with hs-CRP (r = 0.7, p < 0.0001). The presence of diabetes (22 mg/L vs. 7.8 mg/L, p = 0.02), infection and inflammatory conditions (44.9 mg/L vs. 11.6 mg/L, p = 0.001), and lower levels of markers of nutrition such as prealbumin (r = -0.47, p < 0.0001) and creatinine (r = 0.35, p = 0.006) were associated with a higher level of CRP. Enrollment hs-CRP was a significant predictor of mortality in PD patients (relative risk = 1.044, p = 0.023). The observed cumulative survival (Kaplan-Meier) of patients with hs-CRP <15 mg/L was significantly better (p = 0.007) than was the survival of patients with a hs-CRP > or =15 mg/L. In a multivariate regression analysis, serum prealbumin was the best and only significant predictor of CRP level (beta = -0.37, p = 0.005). Elevated CRP was associated with infection and inflammation. Therefore, routine testing of hs-CRP in PD patients should be considered.
    Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/2005; 21:154-8.
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    ABSTRACT: Human immunodeficiency virus (HIV)-related renal disease is the third-leading cause of end-stage renal disease (ESRD) among African Americans aged 20-64 years. The number of HIV-infected (HIV+) patients reaching ESRD will increase exponentially over the next decade. Because of significant improvements in therapy and management during the last ten years, survival of HIV+ patients has improved. The survival experience of very long-term HIV+ peritoneal dialysis (PD) patients remains to be investigated. The objective of the present study was to examine the important differences in clinical and laboratory parameters between HIV+ and HIV-negative (HIV-) PD patients. To assess the factors associated with better survival in HIV+ PD patients, we retrospectively reviewed the charts of 488 PD patients, including 53 HIV+ patients, for the period 1987 to September 2004. We collected demographic, clinical, and laboratory data, including CD4 cell counts and history of hospitalizations and peritonitis. Maximum survival of HIV+ PD patients was 12.5 years as compared with 15.87 years in HIV-patients. Not surprisingly, HIV was a strong independent predictor of mortality in PD patients [relative risk (RR) = 3.09, p < 0.0001]. In HIV+ patients, higher CD4 counts at the initiation of dialysis were strongly associated with better survival (RR = 0.10 and p < 0.0001, > or =200 cells/mm3 vs. < or =50 cells/mm3). In univariate analysis, use of highly active antiretroviral therapy (HAART) was associated with significantly improved survival in HIV+ PD patients. Patients treated with I or 2 drugs had a 4.3-times higher mortality risk than those who received HAART therapy (p = 0.012). Independent associations were seen between HIV and younger age, African American race, male sex, and lower serum albumin. The rates of hospitalization (p < 0.0001) and peritonitis (p < 0.01) were significantly higher in HIV+ patients than in HIV-patients. Very long-term survival of HIV+ patients with chronic renal failure is possible on PD therapy. Morbidity and mortality of these patients may be improved with HAART therapy, better nutrition, and treatment of peritonitis.
    Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/2005; 21:159-63.
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    ABSTRACT: Dialysis patients have much higher mortality rates than the general population. Anemia is a common complication of uremia and a major contributor to morbidity and mortality in dialysis patients. The benefits of anemia correction using recombinant human erythropoietin (rHuEPO) are well established. Optimum hemoglobin level for dialysis patients remain controversial. We have investigated the association of enrollment hemoglobin with long-term survival in hemodialysis (HD) and peritoneal dialysis (PD) patients. We enrolled 529 HD and 326 PD patients from 1987 and followed them to April 2003. Demographics, enrollment, and clinical and laboratory data were recorded. The Kaplan-Meier method was used to compute observed survival, and the multivariate Cox regression analysis was used to identify the independent predictors of mortality risk. Mean ages of HD and PD patients were 60 +/- 16 (SD) and 54 +/- 16 (SD) years, respectively. Forty-seven percent of HD patients and 41% of PD patients were diabetic. Mean enrollment hemoglobin levels of HD and PD patients were 9.44 +/- 1.9 and 9.61 +/- 1.77 g/dL respectively. Cumulative 15 year observed survivals of HD (P = 0.05) and PD (P = 0.032) patients with hemoglobin levels greater or equal to 12 g/dL were higher than those with hemoglobin levels less than 12 g/dL. Hemoglobin <12 g/dL was a better predictor of mortality in nondiabetics than diabetics, particularly in HD patients. Both in HD and PD diabetic patients, hemoglobin was not a significant predictor of mortality. By Cox regression analysis, after adjusting for age, race, gender, and months on dialysis at enrollment, the relative risk of mortality of patients with hemoglobin <12 g/dL was 2.13-fold (P = 0.008) higher for HD and 1.85-fold (P = 0.06) higher for PD compared to those with hemoglobin >/=12 g/dL (P = 0.035). A logistic regression analysis revealed a strong inverse relationship between the hemoglobin level and the odds risk of death in HD (OR = 0.83, P = 0.008) and in PD (OR = 0.85, P = 0.02) patients. Enrollment hemoglobin is a predictor of long-term survival in HD and PD patients. Patients with hemoglobin levels that are higher than current treatment recommendations (>12 g/dL) may benefit from long-term survival. Survival of dialysis patients may be improved by better management of malnutrition and anemia.
    Kidney international. Supplement 11/2003;
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    ABSTRACT: Malnutrition is highly prevalent in peritoneal dialysis (PD) patients and is associated with higher mortality in these patients. In this study, we have prospectively examined the relationship of bioimpedance indexes to the nutritional status and survival in PD patients. We enrolled 48 PD patients beginning in November 2000. On enrollment, bioelectrical impedance analysis (BIA) (BIA-101; RJL/Akern, Clinton Township, MI, USA) was performed and monthly blood was analyzed for biochemical markers, including prealbumin. Patients were followed until April 2003. The mean age of PD patients was 51 +/- 15 (SD) years. Fifty-eight percent of the patients were female and 23% of the patients were diabetic. Mean body mass index (BMI) was 25.7 +/- 5.0 kg/m2. Mean resistance, reactance, and phase angle were 521 +/- 104 ohms, 57 +/- 19 ohms, and 6.16 +/- 1.6 degrees, respectively. During the study period, 8 patients (17%) expired. The Kaplan-Meier method was used to compute observed survival. The cumulative observed survival of PD patients with enrollment phase angle greater than or equal to 6 degrees was significantly higher (P = 0.008) than that of patients with phase angle less than 6. Using Cox's multivariate regression analysis, phase angle was an independent predictor (relative risk = 0.39, P = 0.027) of more than two years' survival in PD patients. Serum prealbumin was directly correlated with phase angle (r = 0.54, P < 0.0001), reactance (r = 0.55, P < 0.0001), and resistance (r = 0.29, P = 0.06). BIA indexes reflect nutritional status and may be useful in monitoring nutritional status in PD patients. Phase angle is a strong prognostic index in PD patients. It is useful to incorporate prealbumin and BIA parameters in the regular assessment of PD patients, whose survival may be improved by better management of malnutrition and overall health status.
    Kidney international. Supplement 11/2003;
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    ABSTRACT: Malnutrition, cardiovascular disease, and heightened inflammation are highly prevalent in dialysis patients, and major contributors to morbidity and mortality. We have investigated the inter-relationship between malnutrition and inflammation, and their impact on morbidity and mortality in peritoneal dialysis (PD) patients. We enrolled 63 PD patients beginning in November 2000, and measured C-reactive protein (CRP) and various nutritional markers, including prealbumin. CRP level was elevated in 29% of the PD patients. Diabetics had higher CRP than non-diabetics (24 vs. 9.3 mg/L, P = 0.016). Patients who were hospitalized during the study had higher enrollment CRP (16 vs. 12.5 mg/L, P = 0.05) and lower enrollment albumin (3.5 vs. 3.9 g/dL, P = 0.002), blood urea nitrogen (BUN) (40 vs. 49 mg/dL, P = 0.034), and protein catabolic rate (nPCR) (0.88 vs. 1.0 g/kg/day, P = 0.02) than those who were not hospitalized. Enrollment level of CRP was inversely correlated with nutritional markers prealbumin (r = -0.5, P < 0.0001) and creatinine (r =-0.35, P < 0.01). After adjusting for age, race, gender, diabetes, and CRP level, prealbumin continued to correlate with other nutritional markers. There was a trend toward association of elevated CRP with all-cause mortality in PD patients. It is useful to incorporate prealbumin and CRP in the regular assessment of PD patients, whose survival may be improved by better management of malnutrition and inflammation.
    Kidney international. Supplement 11/2003;
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    ABSTRACT: Malnutrition and inflammation in peritoneal dialysis patients.Background Malnutrition, cardiovascular disease, and heightened inflammation are highly prevalent in dialysis patients, and major contributors to morbidity and mortality. We have investigated the inter-relationship between malnutrition and inflammation, and their impact on morbidity and mortality in peritoneal dialysis (PD) patients.
    Kidney International 10/2003; · 8.52 Impact Factor
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    ABSTRACT: Malnutrition is highly prevalent in peritoneal dialysis (PD) patients and is associated with higher mortality. Lower serum levels of markers of nutrition--such as albumin, creatinine, prealbumin, and total cholesterol--are important risk factors in PD patients. Usefulness of bioimpedance analysis (BIA) in hemodialysis (HD) patients has been reported. In the present study, we prospectively examined the relationship of bioimpedance indexes to the nutrition status and survival of 45 PD patients who were followed for more than 1 year. On patient enrollment, a BIA was performed (Bioelectrical Impedance Analyzer, Model BIA-101: RJL Systems, Clinton Township, MI, U.S.A.). Monthly blood was analyzed for biochemical markers. The mean age of the study group was 50 +/- 15 years. Of the 45 patients, 56% were female and 24% were diabetic. Mean body mass index was 25.7 +/- 5.1. Mean resistance, reactance, capacitance, and phase angle were 524 +/- 106 omega 57 +/- 20 omega, 678 +/- 223 pF, and 6.2 +/- 1.7 degrees respectively. Patients with diabetes had lower capacitance (555 pF vs. 713 pF, p = 0.007) and phase angle (5.35 degrees vs. 6.4 degrees, p = 0.05) than patients without diabetes. During the study period, 4 patients died. Patients who survived had higher capacitance (486 +/- 163 pF vs. 697 +/- 218 pF, p = 0.07) and phase angle (4.65 +/- 0.73 degrees, vs. 6.34 +/- 1.67 degrees, p = 0.008) than those who did not survive. The Kaplan-Meier method was used to compute observed survival. The cumulative observed survival of PD patients with an enrollment phase angle > or = 6 degrees was significantly (p = 0.01) higher than that of patients with an enrollment phase angle < 6 degrees. Reactance was directly correlated with albumin (r = 0.52, p < 0.0001) and total protein (r = 0.44, p < 0.05). Capacitance was directly correlated with body mass index (r = 0.35, p < 0.05), albumin (r = 0.32, p < 0.05), and blood urea nitrogen (BUN) (r = 0.44, p < 0.01), and inversely correlated with body weight (r = -0.51, p < 0.0001). Phase angle was directly correlated with all of the biochemical markers of nutrition, such as albumin (r = 0.54, p < 0.01), total protein (r = 0.38, p < 0.05), creatinine (r = 0.28, p < 0.01), and BUN (r = 0.39, p < 0.05). By stepwise multivariate regression analysis, body weight (beta = -0.60, p < 0.0001) and total protein (beta = 0.32, p = 0.012) were significant determinants of resistance. Body weight (beta = -0.31, p = 0.02) and albumin (beta = 0.59, p < 0.0001) were significant predictors of reactance. Serum albumin (beta = 0.53, p < 0.0001) was the only best predictor of phase angle in PD patients. The BIA indices reflect nutrition status in PD patients, and may be useful in monitoring nutrition interventions.
    Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 01/2002; 18:195-9.
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    ABSTRACT: Excess parathyroid hormone (PTH) has long been considered detrimental to the health of patients with end-stage renal disease. PTH has been implicated as a multisystem uremic toxin, and hyperparathyroidism can be a debilitating complication in dialyzed patients. We have studied prospectively the relationship of enrollment serum intact PTH and various demographic characteristics and other biochemical parameters to all-cause mortality in 345 hemodialysis (HD) and 277 peritoneal dialysis (PD) patients. We monitored the patients for 14 years. Observed survival and survival after adjustment for age, race, gender, months on dialysis at enrollment, diabetic status, and nutritional markers were significantly better for patients with enrollment PTH greater than 200 pg/mL than for patients with PTH 65 to 199 pg/mL and patients with PTH less than 65 pg/mL. Enrollment serum PTH was an independent predictor of survival in HD and PD patients. For HD patients, age and months on HD at enrollment were associated inversely with PTH level, whereas black race, creatinine, and phosphorus were associated directly with PTH. For PD patients, age, diabetes, and months on PD at enrollment were inverse predictors, whereas black race, albumin, creatinine, and phosphorus were associated positively with PTH. Lower than expected levels of PTH in uremic patients is associated with increased mortality. We hypothesize that inadequate protein intake or phosphorus intake or both result in impaired development of the expected secondary hyperparathyroidism and in the excess mortality risk inherent with malnutrition.
    American Journal of Kidney Diseases 01/2002; 38(6):1351-7. · 5.29 Impact Factor
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    ABSTRACT: Protein malnutrition is now well established as an important contributory factor to the high mortality in peritoneal dialysis (PD) patients. Low dietary protein calorie intake is one of the factors leading to protein malnutrition. If PD patients develop difficulty eating, percutaneous endoscopic gastrostomy (PEG) feeding may prove beneficial in providing adequate nutrition. Studies on the effectiveness of PEG feeding in PD patients are limited to pediatric patients. The objective of the present study was to assess the outcome of PEG feeding in adult patients with end-stage renal disease (ESRD) on PD. We retrospectively reviewed charts from May 1992 to February 2000 of 10 consecutive patients in our center who had had feeding tubes inserted. The patients' ages ranged from 37 to 81 years, with mean age of 65. Of the 10 patients, 7 were male, 5 were diabetic, and 1 was infected with the human immunodeficiency virus. Two patients had cerebrovascular accident (CVA) with dysphagia, 3 had multi-infarct dementia, 2 had anoxic encephalopathy, 2 had dementia, and 1 had calciphylaxis with anorexia. Of the 10 patients, 9 failed to eat because of neurologic disorders. Two patients who had functioning PEG feedings before starting PD had no complications. Only 2 of 8 patients already on PD continued with long-term PD after a PEG was inserted. Both patients whose PD was not interrupted at the time of PEG placement immediately developed peritonitis. Of the 6 patients who were maintained on hemodialysis (HD), 2 developed peritonitis within one week of starting PEG feedings. The other 4 had no complications from PEG feedings while being maintained on HD, but 1 developed peritonitis when PD was resumed. Of the 5 patients who developed peritonitis, 3 experienced fungal peritonitis. In PD patients, PEG feeding is associated with frequent complications. However, PEG placement prior to PD initiation appears to be safe. Maintaining patients on HD for at least 6 weeks appears to decrease the incidence of peritonitis, but does not eliminate it. Use of anti-fungal prophylaxis and maintenance of the patient on HD for longer than 6 weeks may produce better results.
    Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/2001; 17:148-52.
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    ABSTRACT: We analyzed the prognostic importance of nutritional markers and mortality data in 537 hemodialysis (HD) and 422 peritoneal dialysis (PD) patients followed for up to 12 years. Patients on HD had a 44% lower risk of mortality than did those treated with PD (P: < 0.0001). The difference in mortality between the modalities was even more striking among diabetics but less striking among younger patients. Over a 12-year period, survival of dialysis patients with lower enrollment levels of albumin, creatinine, and parathyroid hormone (PTH) were significantly lower. In multivariate Cox's proportional hazards models, serum prealbumin and enrollment PTH level of <65 pg/mL were independent predictors of mortality both in HD and PD patients. In conclusion, HD patients had higher cumulative survival than PD patients over a 12-year period. Nutritional markers at enrollment continue to be strong predictors of mortality for up to 12 years.
    American Journal of Kidney Diseases 01/2001; 37(1 Suppl 2):S77-80. · 5.29 Impact Factor
  • American Journal of Kidney Diseases - AMER J KIDNEY DIS. 01/2001; 37(4).
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    ABSTRACT: The relatively high morbidity and mortality during dialytic therapy for end-stage renal disease (ESRD) in the United States is the subject of current inquiry. Identified risk factors for excess mortality include advanced age, diabetes, and malnutrition exemplified by a low serum albumin level. Parathyroid hormone (PTH) has long been thought to contribute to the toxicity of the uremic syndrome. We reviewed the course of patients maintained by hemodialysis (HD) and peritoneal dialysis (PD) to detect any correlation between the level of PTH when beginning dialytic therapy and subsequent morbidity and mortality. Study cohorts consisted of 175 HD and 113 PD patients followed for up to 9 years. Demographic characteristics such as age, race, gender, diabetic status, and prior months on dialysis, as well as biochemical parameters including albumin, creatinine, cholesterol, intact PTH, calcium, and phosphorus levels at enrollment were evaluated for their effect on patient survival. Expected survival was calculated by Cox proportional hazards analysis. Older age and lower enrollment serum creatinine level were associated with increased mortality in both HD and PD patients, whereas low serum albumin and low serum cholesterol levels also predicted high mortality in HD patients. In both HD and PD, patients with enrollment PTH level of < or = 65 pg/mL had more than twice the mortality risk of those with PTH > or = 200 pg/mL. Both observed and expected survival of patients with low PTH were significantly lower than the survival in patients with higher PTH. Five-year HD survivors and four-year PD survivors had significantly higher PTH levels at initiation of dialytic therapy than did those with shorter survival. PTH level correlated with serum creatinine and serum albumin in HD but only with serum creatinine in PD, supporting the inference that patients with high enrollment PTH were better nourished than those with lower PTH.
    American Journal of Kidney Diseases 12/1996; 28(6):924-30. · 5.29 Impact Factor