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ABSTRACT: AIM: The Framingham Risk Score (FRS), calculated by considering conventional risk factors of cardiovascular diseases, was developed to predict coronary heart disease in various populations. However, reverse epidemiology has been raised concerning these risk factors in predicting high cardiovascular mortality in hemodialysis patients. Our objectives are to determine whether FRS is associated with overall and cardiovascular mortality and the role of new risk markers when they were added to a FRS model in hemodialysis patients. METHODS: This study enrolled 201 hemodialysis patients aged 20-80 years old. The FRS is used to identify individuals categorized as low (< 6% 10-year risk), intermediate (6-20% risk) or high risk (> 20% risk). Medical records were reviewed to collect clinical information. Data of ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) were obtained by an ABI-form device. RESULTS: The mean follow-up period was 4.4 ± 1.5 years. Intermediate risk predicted overall hazard ratio (HR) (2.157, P = 0.039) and cardiovascular mortality (HR= 5.023; P = 0.004) versus low risk, but "high" risk did not. High risk (versus low risk) predicted cardiovascular events (HR = 2.458, P = 0.05). Besides, addition of ABI < 0.9 (P = 0.021) and baPWV (P = 0.014) to a FRS model significantly improved the predictive value for overall mortality. CONCLUSION: In hemodialysis patients, intermediate risk but not high risk categorization by FRS predicted overall and cardiovascular mortality, and high risk predicted cardiovascular events. ABI < 0.9 and baPWV provided additional predictive values for overall mortality. Future study is needed to develop hemodialysis-specific equations and assess whether risk refinement using ABI < 0.9 and baPWV leads to a meaningful change in clinical outcomes.
Nephrology 05/2013; · 1.31 Impact Factor
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ABSTRACT: Double-lumen central venous catheter (CVC) is a rapid access technique for hemodialysis (HD) when an arteriovenous fistula or graft is not available. A variety of procedure-related complications have been reported, such as infection and pneumothorax, but serious cardiac complications are relatively less mentioned. We report a uremic woman with preexisting left bundle branch block who required emergent HD and received jugular double-lumen CVC insertion, which was complicated by short-duration ventricular tachycardia followed by complete atrio-ventricular block and bradycardia. Pharmacological management did not reverse heart rate and rhythm. External pacing was not applied because she remained hemodynamically stable in the course of HD. Heart rate returned to sinus rhythm with left bundle branch block 4 hours later and did not recur through the whole admission period. We speculate that the transient arrhythmia might have been induced by mechanical contact with the ventricular wall during the procedure with the guided metallic wire. In conclusion, physicians responsible for CVC catheterization should pay more attention to patients with preexisting cardiac arrhythmia to prevent such technical mistakes from transpiring.
Hemodialysis International 03/2013; · 1.54 Impact Factor
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ABSTRACT: BACKGROUND:: Anemia is a common complication in patients with chronic kidney disease (CKD), which may initiate or accelerate left ventricular hypertrophy (LVH). This study is designed to assess whether the coexistence of anemia and LVH is independently associated with the rate of renal function decline and increased cardiovascular events in patients with CKD stages 3 to 5. METHODS:: This longitudinal study enrolled 415 patients, who were classified into 4 groups according to sex-specific median values of hemoglobin and with/without LVH. The change in renal function was measured by estimated glomerular filtration rate slope. Cardiovascular events were defined as cardiovascular death, hospitalization for unstable angina, nonfatal myocardial infarction, sustained ventricular arrhythmia, hospitalization for congestive heart failure, transient ischemia attack, and stroke. The relative risk of cardiovascular events was analyzed by Cox's regression method. RESULTS:: The estimated glomerular filtration rate slope was significantly lower in the group with lower hemoglobin and LVH than in the other groups (P ≤ 0.031). In addition, patients with lower hemoglobin and LVH were independently associated with increased cardiovascular events (hazard ratio, 4.269; 95% confidence interval, 1.402-13.000; P = 0.011). CONCLUSIONS:: Our findings showed that the coexistence of anemia and LVH was independently associated with faster renal function decline and poor cardiovascular outcomes in patients with CKD. Assessments of serum hemoglobin level and LVH by echocardiography may help identify a high-risk group of poor renal and cardiovascular prognosis in patients with CKD stages 3 to 5.
The American Journal of the Medical Sciences 02/2013; · 1.39 Impact Factor
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ABSTRACT: The Framingham Risk Score (FRS) was developed to predict coronary heart disease in various populations, and it tended to under-estimate the risk in chronic kidney disease (CKD) patients. Our objectives were to determine whether FRS was associated with cardiovascular events, and to evaluate the role of new risk markers and echocardiographic parameters when they were added to a FRS model. This study enrolled 439 CKD patients. The FRS is used to identify individuals categorically as "low" (<10% of 10-year risk), "intermediate" (10-20% risk) or "high" risk (≧ 20% risk). A significant improvement in model prediction was based on the -2 log likelihood ratio statistic and c-statistic. "High" risk (v.s. "low" risk) predicts cardiovascular events either without (hazard ratios [HR] 2.090, 95% confidence interval [CI] 1.144 to 3.818) or with adjustment for clinical, biochemical and echocardiographic parameters (HR 1.924, 95% CI 1.008 to 3.673). Besides, the addition of albumin, hemoglobin, estimated glomerular filtration rate, proteinuria, left atrial diameter >4.7 cm, left ventricular hypertrophy or left ventricular ejection fraction<50% to the FRS model significantly improves the predictive values for cardiovascular events. In CKD patients, "high" risk categorized by FRS predicts cardiovascular events. Novel biomarkers and echocardiographic parameters provide additional predictive values for cardiovascular events. Future study is needed to assess whether risk assessment enhanced by using these biomarkers and echocardiographic parameters might contribute to more effective prediction and better care for patients.
PLoS ONE 01/2013; 8(3):e60008. · 4.09 Impact Factor
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ABSTRACT: Background and Aim: Echocardiographic left atrial diameter (LAD) has been documented to be an independent predictor of adverse cardiovascular outcomes in various populations. An enlarged left atrium is frequently noted in chronic kidney disease (CKD). We examined the association between albumin and indexed LAD (indexed to height) and assessed whether the combination of indexed LAD and albumin was independently associated with renal outcomes in patients with CKD stages 3-5. Methods: This longitudinal study enrolled 395 patients, who were classified into four groups according to median values of indexed LAD (LAD/height) and albumin. The change in renal function was measured by estimated glomerular filtration rate (eGFR) slope. Rapid renal progression was defined as eGFR slope less than -3 ml/min/1.73 m(2)/year. The renal end point was defined as commencement of dialysis. Results: Albumin was significantly associated with indexed LAD (β = -0.108, P = 0.024). During follow-up period, seventy-four patients started dialysis. After the multivariate analysis, the group with higher indexed LAD and lower albumin was independently associated with rapid renal progression (odds ratio, 7.979; 95% confidence interval [CI], 3.028 to 21.025) and progression to dialysis (hazard ratio, 2.352; 95% CI, 1.078 to 5.131). Conclusions: Our findings show that albumin is independently associated with indexed LAD and suggest that the combination of increased indexed LAD and hypoalbuminemia is independently associated with rapid renal progression and progression to dialysis in patients with CKD. Assessments of serum albumin and indexed LAD by echocardiography are useful for predicting the risk for adverse renal outcomes.
International journal of medical sciences 01/2013; 10(5):575-84. · 2.24 Impact Factor
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ABSTRACT: : Abnormal ankle-brachial index (ABI) is associated with increased morbidity and mortality in hemodialysis patients. However, whether the decrease in ABI over time carries the prognostic value is unknown. The aim of this study was to assess whether the decrease in ABI over time was a good predictor of poor cardiovascular (CV) prognosis in hemodialysis patients.
: This study enrolled 234 routine hemodialysis patients and 173 patients completed the follow-up. The ABI was measured by an ABI-form device at baseline and at the first year follow-up. The ΔABI was defined as ABI measured at the first year follow-up minus ABI measured at baseline. Progressors of ABI were defined as patients with ΔABI < -0.3. CV events were defined as CV death, hospitalization for unstable angina, nonfatal myocardial infarction, hospitalization for arrhythmia, hospitalization for congestive heart failure and stroke.
: The follow-up period was 37.8 ± 11.1 months. In the multivariate analysis, progressors of ABI (hazard ratio, 2.71; 95% confidence interval, 1.10-6.68, P = 0.03), decreased albumin and increased high-sensitivity C-reactive protein were associated with increased CV events.
: This longitudinal study showed ΔABI < -0.3 was independently associated with an increase in CV events. Hence, a great decrease in ABI over time might be a useful indicator of poor CV prognosis in hemodialysis patients.
The American Journal of the Medical Sciences 12/2012; 344(6):457-61. · 1.39 Impact Factor
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ABSTRACT: BACKGROUND: The inevitable post-inflammatory fibrosis and adhesion often compromises future treatment in peritoneal dialysis patients. Here, we describe a patient who experienced an unusual form of peritoneal adhesion that made her give up peritoneal dialysis. However, its unique pattern also saved her from infection caused by bowel perforation. CASE PRESENTATION: The female patient discontinued peritoneal dialysis due to gradual dialysis inadequacy. Two months after shifting to hemodialysis with generally improved sense of well-being and no sign of abdominal illness, she was admitted to remove the Tenckhoff catheter. The procedure was smooth, but fever and abdominal pain not at the site of operation developed the next day. Abdominal ultrasound showed the presence of ascites and aspiration revealed slimy, green-yellowish pus that gave a negative result on bacterial culture. Abdominal computed tomography (CT) with oral contrast medium was performed, but failed to demonstrate the suspected bowel perforation. The examination, however, did show accumulation of pus inside the abdomen but outside the peritoneal cavity. We drained the pus with two 14-F Pig-tail catheters and the total amount of drainage approached 4000 ml. The second CT was performed with double dose of the contrast medium and found a leak of the contrast from the jejunum. She then received laparotomy and had the perforation site closed. CONCLUSIONS: In summary, this uremic patient suffered from pus accumulation inside her abdomen without obvious systemic toxic effect. The bowel perforation and pus formation might be caused by repeated peritonitis, but the peritoneal adhesion itself might also isolate her peritoneal cavity from the anticipated toxic injuries of bowel perforation.
BMC Nephrology 09/2012; 13(1):113. · 2.18 Impact Factor
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ABSTRACT: A condition involving the growth of the myocardium that exceeds hemodynamic needs has been reported and called as inappropriate left ventricular mass (LVM). The appropriateness of LVM can be estimated by the ratio of observed LVM to predicted LVM. The excessive growth of LVM is frequently noted in patients with chronic kidney disease (CKD). This study is designed to assess whether the ratio of observed to predicted LVM is a useful prognostic indicator of cardiovascular events in patients with moderate to advanced CKD. We consecutively enrolled 485 patients with CKD stages 3-5 from our Outpatient Department of Internal Medicine. Inappropriate LVM was defined as observed LVM more than 28% greater than the predicted value. The relative risk of cardiovascular events was analyzed by Cox-regression methods. There was a significant trend for a stepwise increase in the observed/predicted LVM ratio (P<0.001) and the prevalence of inappropriate LVM (P=0.003) corresponding to advances in CKD stages. In the multivariate analysis, old age, a history of coronary artery disease, congestive heart failure, atrial fibrillation, wide pulse pressure, decreased serum albumin and hemoglobin levels, left atrial diameter >4.7 cm and increased observed/predicted LVM were independently associated with increased cardiovascular events. Our findings show that increased observed/predicted LVM is independently associated with adverse cardiovascular outcomes in patients with CKD stages 3-5.
Hypertension Research 03/2012; 35(8):832-8. · 2.58 Impact Factor
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ABSTRACT: Hypercalcemia has been described in variety of granulomatous diseases and fungal infections. However, hypercalcemia in pulmonary cryptococcosis is rarely disclosed. We report a 57-year-old HIV-uninfected woman with diabetes, who initially presented with altered mental status, severe hypercalcemia with increased serum 1,25-dihydroxyvitamin D [1,25(OH)₂D] concentration and suppressed parathyroid hormone. Pulmonary cryptococcosis was diagnosed as the cause of hypercalcemia. Successful treatment resulted in the resolution of hypercalcemia and decrease of the serum 1,25(OH₂D concentration to within the normal range. In summary, although HIV infection is a major risk factor for cryptococcosis, vitamin D-mediated hypercalcemia could be the initial presentation of pulmonary cryptococcosis in HIV-negative patients.
Internal Medicine 01/2012; 51(13):1793-6. · 0.94 Impact Factor
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ABSTRACT: Patients with chronic kidney disease (CKD) are associated with increased cardiovascular (CV) morbidity and mortality. Echocardiographic measures of heart structure and function have been reported to predict adverse CV outcomes in various pathologic conditions. The aim of this study is to assess whether echocardiographic parameters are independently associated with increased CV events in patients with CKD Stages 3-5.
We consecutively enrolled 505 CKD patients from our outpatient department of internal medicine. CV events were defined as CV death, hospitalization for unstable angina, non-fatal myocardial infarction, sustained ventricular arrhythmia, hospitalization for congestive heart failure, transient ischemia attack and stroke. The relative CV events' risk was analyzed by Cox regression methods.
In the multivariate analysis, old age, the presence of diabetes, coronary artery disease and atrial fibrillation; decreased serum albumin and hematocrit levels; left atrial diameter (LAD) >4.7 cm [hazard ratio (HR), 2.141; 95% confidence interval (CI), 1.155-3.971, P = 0.016]; increased left ventricular mass index (LVMI) (HR, 1.006; 95% CI, 1.002 to 1.010, P = 0.003) and left ventricular ejection fraction (LVEF) <55% (HR, 2.007; 95% CI, 1.007-3.743, P = 0.028) were independently associated with increased CV events.
Our findings show that LAD >4.7 cm, increased LVMI and LVEF <55% are independently associated with adverse CV outcomes in CKD patients. Screening CKD patients by means of echocardiography may help identify a high-risk group of poor CV prognosis.
Nephrology Dialysis Transplantation 08/2011; 27(3):1064-70. · 3.40 Impact Factor
