Whether a very low-protein diet supplemented with ketoanalogues (sVLPD), compared with a standard low-protein diet (LPD), improves outcomes in patients with chronic kidney disease (CKD) under stable ...nephrology care is undefined.
To compare the effectiveness of sVLPD compared with LPD in patients regularly seen in tertiary nephrology care.
Participants were patients with CKD stages 4–5, followed for at least 6 mo, randomly allocated to receive sVLPD or LPD 0.35 or 0.60 g/kg ideal body weight (IBW)/d, respectively, stratified by center and CKD stage. The primary outcome was time to renal death, defined as the first event between end-stage renal disease (ESRD) and all-cause mortality; secondary outcomes were the single components of the primary outcome, cardiovascular outcome, and nutritional status.
We analyzed 223 patients (sVLPD, n = 107; LPD, n = 116). Mean age was 64 y, 61% were male, and 35% had diabetes. Median protein intake (PI), which was 0.8 g/kg IBW/d at baseline in both groups, was 0.83 and 0.60 g/kg IBW/d in LPD and sVLPD, respectively, during the trial with a large decrease only in sVLPD (P = 0.011). During a median of 74.2 mo, we recorded 180 renal deaths (141 dialysis and 39 deaths before dialysis). Risk of renal death did not differ in sVLPD compared with LPD (HR: 1.17; 95% CI: 0.88, 1.57; P = 0.28). No difference was observed for ESRD (HR: 1.12; 95% CI: 0.81, 1.56; P = 0.51), mortality (HR: 0.95; 95% CI: 0.62, 1.45; P = 0.82), or time to fatal/nonfatal cardiovascular events (P = 0.2, log-rank test). After 36 mo, still active patients were 45 in sVLPD and 56 in LPD. No change of nutritional status emerged during the study in any arm.
This long-term pragmatic trial found that in patients with CKD under stable nephrology care, adherence to protein restriction is low. Prescribing sVLPD compared with standard LPD is safe but does not provide additional advantage to the kidney or patient survival.
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CMK, GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background. The major determinants of pulse wave velocity (PWV) in haemodialysis (HD) patients are not fully known. We studied chronic HD patients to assess the effect of cyclic variations in both ...hydration status and blood pressure on PWV. Methods. Twenty patients were examined along three consecutive HD sessions and interdialysis periods during a week-long period. Twenty healthy subjects and 20 chronic kidney disease (CKD) patients (stage 5) were evaluated as controls. Results. In contrast to controls, HD patients showed cyclic changes in PWV. Specifically, PWV values in HD patients were significantly higher prior to the first HD session of the week compared with values measured prior to the other two HD sessions during the week. In addition, PWV showed significant reductions during each dialysis session (15.6 ± 5.2 to 9.3 ± 2.3, 13.4 ± 4.0 to 8.7 ± 2.4, and 12.4 ± 2.6 to 9.2 ± 2.2 m/sec, before and after the first, second and third weekly dialysis sessions, respectively). Nevertheless, the weighted weekly values of PWV in HD patients (10.8 ± 5.7 m/sec) were similar to those in CKD patients (9.9 ± 4.2 m/sec). The HD ultrafiltration rate (UF) was significantly correlated with intradialysis PWV changes (r = 0.465; P < 0.001) and with after dialysis PWV values (r = −0.654; P < 0.0001). Blood pressure changes during dialysis were weakly correlated with post-dialysis PWV (r = −0.267; P < 0.05), but not with PWV changes during dialysis. Conclusions. In chronic HD patients, single PWV values varied widely during 1 week of HD sessions, whereas the weighted level showed only a slight increase. The major determinant of changes in PWV during HD appears to be the alterations in hydration status; the most representative time point for PWV measurements during HD corresponds to the interdialysis days.
Background. International guidelines have not reached a complete agreement about the optimal amount of dietary proteins in chronic kidney disease(CKD). The aim of this study was to compare, with a ...randomized-controlled design, the metabolic effects of two diets with different protein content (0.55 vs 0.80 g/kg/day) in patients with CKD stages 4–5. Methods. Study design and sample size calculations were based on previously published experience of our group with low protein diet. The primary outcome of the study was the modification of serum urea nitrogen concentration. From 423 patients randomly assigned to the two diets 392 were analysed: 200 for the 0.55-Group and 192 for the 0.8-Group. The follow-up ranged 6–18 months. Results. Mean age was 61±18 years, 44% were women, mean eGFR was 18±7 ml/min/month. Three months after the dietary assignment and throughout the study period the two groups had a significantly different protein intake (0.72 vs 0.92 g/kg/day). The intention-to-treat analysis did not show any difference between the two groups. Compliance to the two test diets was significantly different (P < 0.05): 27% in the 0.55-Group and 53% in the 0.8-Group, with male gender and protein content (0.8 g/kg/day) predicting adherence to the assigned diet. The per protocol analysis, conversely, showed that serum urea nitrogen, similar at the time of randomization, significantly increased in the 0.8-Group vs 0.55-Group by 15% (P < 0.05). Serum phosphate, PTH and bicarbonate resulted similar in the two groups throughout the study. The 24 h urinary urea nitrogen significantly decreased after the first 3 months in 0.55-Group (P < 0.05), as well as the excretion of creatinine, sodium and phosphate (P < 0.05 vs baseline) and were significantly lower than the 0.8-Group. The prescription of phosphate binders, allopurinol, bicarbonate supplements and diuretics resulted significantly less frequent in the 0.55-Group (P < 0.05). Conclusions. This study represents the first evidence that in CKD patients a protein intake of 0.55 g/kg/day, compared with a 0.8 g/kg/day, guarantees a better metabolic control and a reduced need of drugs, without a substantial risk of malnutrition.
Abstract Mentalization, operationalized as reflective functioning (RF), can play a crucial role in the psychological mechanisms underlying personality functioning. This study aimed to: (a) study the ...association between RF, personality disorders (cluster level) and functioning; (b) investigate whether RF and personality functioning are influenced by (secure vs. insecure) attachment; and (c) explore the potential mediating effect of RF on the relationship between attachment and personality functioning. The Shedler-Westen Assessment Procedure (SWAP-200) was used to assess personality disorders and levels of psychological functioning in a clinical sample ( N = 88). Attachment and RF were evaluated with the Adult Attachment Interview (AAI) and Reflective Functioning Scale (RFS). Findings showed that RF had significant negative associations with cluster A and B personality disorders, and a significant positive association with psychological functioning. Moreover, levels of RF and personality functioning were influenced by attachment patterns. Finally, RF completely mediated the relationship between (secure/insecure) attachment and adaptive psychological features, and thus accounted for differences in overall personality functioning. Lack of mentalization seemed strongly associated with vulnerabilities in personality functioning, especially in patients with cluster A and B personality disorders. These findings provide support for the development of therapeutic interventions to improve patients’ RF.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
The Reflective Functioning Scale (Fonagy, Target, Steele, & Steele, 1998) was developed to empirically assess the capacity to mentalize thoughts, intentions, feelings and beliefs of oneself and ...others in the context of attachment relationships (Jurist & Meehan, 2009). To overcome the complexity of the RF scale scoring, the Computerized Text Analysis measure of Reflective Functioning (CRF) was created by Fertuck, Mergenthaler, Target, Levy, and Clarkin (2012). We report the results of a preliminary study applying the CRF to a sample of 540 sessions comprising 27 psychoanalytic treatments. Results show that patients' reflective functioning (RF), as measured at the beginning of treatment, was positively correlated with two global measures of healthy personality functioning-the Global Assessment of Functioning (GAF; American Psychiatric Association, 2000) and the Personality Health Index (PHI; Waldron et al., 2011)-as measured at the end of treatment. Even when the PHI and GAF levels at the beginning of treatment, the length of the treatments, and the average number of sessions per week were controlled for, these correlations remained significant. At the same time, the RF of patients did not increase throughout treatment. The implications of these results and the validity of CRF as an outcome predictor of long-term psychoanalytic treatment are discussed.
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CEKLJ, FFLJ, NUK, ODKLJ, PEFLJ, UPUK
Tumor necrosis factor (TNF) inhibitors are widely used for the treatment of various rheumatic diseases. These agents may lead to development of systemic autoimmune diseases and renal complications. ...We report a patient with psoriatic arthritis and renal failure treated with two TNF inhibitors (Etanercept and then Adalimumab). After this treatment he developed proteinuria with nephrotic syndrome. A renal biopsy was performed highlighting GN with mesangial IgA deposits. Then he developed p-ANCA positivity. Following that, etanercept and adalimumab were stopped and a treatment by corticosteroids was initiated, but renal function decreased. Currently the patient is treated by haemodialysis. In our patient, the pathogenic role for anti-TNF therapy is suggested by the close temporal relationship with development of glomerular disease and by the improvement in proteinuria after drug withdrawal. However, the patient was treated once more with TNF agents, so he developed end stage renal disease.
Sialadenitis (Iodide Mumps) is a rare complication following the administration of iodinated contrast media. It is characterized by the painless bilateral enlargement of the submandibular salivary ...glands. The pathogenesis of this adverse reaction remains unclear. It may be due to an idiosyncratic reaction or related to toxic accumulation of iodide in the ductal systems of the salivary glands. Iodide mumps may occur after administration of any iodinated contrast agent: 98% of injected iodide is eliminated by the kidneys and only 2% is excreted from other organs such as salivary, sweat and lacrimal glands. Normally, the injected dose of contrast medium does not provide a sufficiently high iodide concentration to cause iodide mumps, but impaired renal excretion of contrast medium results in liberation of iodide and enables the salivary glands to concentrate inorganic iodide. This condition is rare and self-limiting. The current management is supportive therapy using analgesics and dialysis. We report two cases of iodide mumps in end-stage renal disease (ESRD) patients treated with haemodialysis after administration of iodinated contrast media. The cases were characterized by rapid onset and resolution of the symptoms in the absence of specific treatment.
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