Journal of Nephrology & Therapeutics

Aim: Is once daily low dose extended release niacin effective at lowering phosphate?

Background: Serum phosphate levels correlate with mortality in dialysis patients. Current phosphate binders often cause side-effects leading to poor compliance. Niacin has previously been shown to lower serum phosphate in patients with kidney disease. However, at doses previously used (≥ 1 g daily), it is poorly tolerated. Slo-niacin® is a extended release formulation taken once daily.

Methods: The study was a single-centre double-blind placebo-controlled randomised cross-over trial in haemodialysis patients. All patients received both active treatment (500 mg Slo-niacin® daily) and matching placebo for 8 weeks each with intervening 2 week washout phase. All patients continued usual phosphate binders and Cinacalcet/vitamin D analogues, although no dose adjustments were permitted. Patients were recruited if they were >18yo, not pregnant and serum phosphate 4 weeks prior to commencement was ≥ 1.8 mmol/L. All gave informed consent.

Results: 33 patients were recruited. 1 patient died following emergency cardiac surgery during placebo phase & 3 patients withdrew (2 niacin, 1 placebo, p=NS) leaving 29 for analysis. Extended release niacin significantly reduced serum phosphate compared to placebo (p<0.0014, t-test and ANOVA). Mean absolute difference between groups was -0.35 mmol/L (95% CI -0.62 mmol/L to -0.08 mmol/L) in favour of niacin (p ~ 0.01, t-test). Neither treatment altered calcium levels. Extended release niacin was well tolerated apart from early mild flushing which improved with time.

Conclusion: Once daily low dose extended-release niacin is effective at lowering serum phosphate.

Background: Echocardiographic detectable cardiac abnormalities were studied to provide a platform for future longitudinal and interventional studies of children with Chronic Kidney Disease (CKD) in the south- east region of Nigeria.

Methods: A cross-sectional study of echocardiographic screening of children aged between 6 and 17 years with CKD and selected age and sex matched controls that were consecutively enrolled from the Pediatric nephrology clinic of the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria.

Results: Of the 9,419 patients within the age group 6-17 years who were seen at UNTH during the period of the study, 24 had CKD, giving an incidence of approximately 5 new cases per million-child population per year and a prevalence of 18.4 per million children population with a mean age of 12.33 + 4.24 years. Lower mean ejection fraction (EFrac%) values and E/A (transmitral flow velocity ratio) ratio were documented in patients compared to controls (p<0.01). Echocardiographic detectable cardiac abnormalities occurred in 22 (91.7%) of the patients and in 4 (16.7%) of the controls (p<0.01). The most common abnormality was left ventricular hypertrophy in 12 patients (50.0%) with 8 (66.6%) of 12 children having eccentric and 4 (33.3%) having concentric hypertrophy.

Conclusions: This study shows that echocardiographic detectable cardiac abnormalities in children with CKD in the sub-region, is comparable to those of the other parts of the world with eccentric hypertrophy being more prevalent than concentric hypertrophy.

Proton pump inhibitors (PPIs) have emerged as a common cause of drug induced acute interstitial nephritis (AIN) in adults. We present a 15-year-old girl with severe acute kidney injury and biopsy proven AIN attributable to omeprazole. Withdrawal of the drug and steroid therapy affected a recovery of renal function. As the use of PPIs increases in paediatrics, it is important to be aware of this rare but serious side effect.

Febrile urinary tract infection is one of the commonest infections in the childhood. Unrecognized and untreated childhood UTI can lead to scarring of the growing kidneys with subsequent hypertension and renal failure. This study has been done at a tertiary care medical centre to study the clinico - biological and imaging correlation in children with first episode of febrile UTI. Renal function tests, ultrasonogram, DMSA and MCU were done according to ISPN and institutional protocol. Imaging was done on follow up as per need. Majority of the children were found to be in 1 to 5 years age (68%) group and overall there was female preponderance (n=80; 53%). Dysuria was the commonest presentation in febrile UTI and E. coli, the commonest organism isolated. USG was found abnormal in 57.6% of children and DMSA done in acute phase picked up pyelonephritis in 81.5%. MCU revealed VUR in 39% of the study population. The study underlines the importance and efficacy of various investigations apart from the clinical presentation in diagnosing UTI and defining the associated risk factors.

Background: Haemodialysis catheter (HDC) occlusion is a common cause of poor blood flow, inadequate dialysis and HDC loss. From Jan 2009, our unit used infusions of recombinant tissue plasminogen activator (rtPA), Alteplase 0.1-0.2 mg/kg/hour over 1-2 hours for thrombolysis of occluded catheters.

Methods: Retrospective review of outcomes of all patients who were treated with rtPA infusion for HDC occlusion in our unit between Jan 2009 to Dec 2012. Twenty patients underwent 5,407 sessions of catheter-directed haemodialysis in our unit (mean age 7.4 years, range 0.3-15.8 years).

Results: Ten patients accounted for 339 episodes of rtPA infusions (median 12, range 1-115). Thirty-three radiographic contrast studies were performed – 21 (64%) confirmed presence of thrombus. The immediate success rate, defined as return of manual aspiration and infusion capabilities to both ports was 100%. No patients required exclusion from thrombolytic therapy due to contraindications. One patient had rtPA infusion discontinued after 9 infusions due to spontaneous bruising despite normal fibrinogen levels. The remainder of patients tolerated the treatment well. All patients had normal coagulation profile. No HDC were surgically changed due to occlusion by thrombus.

Conclusion: Low dose Alteplase infusion is safe and efficacious in the management of HDC occlusion. It provides a means for improving the long-term survival of HDC catheters in patients with limited available options of vascular access for haemodialysis.

Background: Currently there is a lack of effective treatment options for patients with calciphylaxis. There is anecdotal evidence that non-calcium based phosphorus binders may offer some benefit. The aim of this pilot study is to determine if lanthanum carbonate is effective in inducing remission of calciphylaxis lesions and demonstrate an improved DLQI (Dermatology Life Quality Index). Methods: This is a multi-site exploratory pilot study conducted through the Wisconsin Network for Health Research (WiNHR), a collaboration of health services researchers across the state of Wisconsin. Dialysis patients were recruited from in-center dialysis units, clinics and hospital admissions over a period of 24-months. Results: Due to the low inclusion rate, the trial was terminated after which 4 patients were prospectively analyzed. Dose of lanthanum carbonate was escalated to 3750 mg divided into 3 meals and titrated according to level of serum phosphorus. Gastrointestinal symptoms were the most common adverse effect. All 4 patients achieved complete remission by definition of skin re-epithelialization. Secondary outcome measurements showed a significant improvement in serum albumin (B coeff 0.17, 95% CI 0.002-0.031; p=0.023) and a significant improvement in overall DLQI score (B coeff -0.46, 95% CI -0.85- -0.08; p=0.019). Conclusions: Lanthanum carbonate appears to be efficacious as an adjunctive therapy to improve calciphylaxis lesions and symptom burden. More prospective clinical trials are warranted to determine the feasibility of this novel treatment strategy.

Objectives: To describe the general characteristics and frequency of noninfectious complications in children with end stage renal disease (ESRD) in chronic peritoneal dialysis. Material and methods: A retrospective case series study describing noninfectious complications in the population of children, aged between 1 month and 17 years 11 months, with end stage renal disease from the peritoneal dialysis program at Cayetano Heredia Hospital between 2000 and 2007.

Results: We studied 80 children, 41 male and 39 female; 92 catheters were implanted; the average age of the children was 10.3 years and the largest age group was from 5 to 12 years. The leading cause of end stage renal disease was primary glomerulopathy. The Tenckhoff two-cuff spiral catheter was the most commonly used catheter; continuous ambulatory peritoneal dialysis was the most common mode of dialysis; there were 12 catheter replacements, the most frequent causes being peritonitis and catheter obstruction. The frequency of noninfectious complications was 40.3%; the three most common complications were ultrafiltration failure (low transporter type), umbilical hernia, and catheter obstruction. Conclusions: The frequency of noninfectious complications was 40.3%; the most common complication was ultrafiltration failure.

Objective: Matrix metalloproteinase-3 (MMP-3) has been implicated in experimental and clinical models of human inflammatory conditions. Increased MMPs levels have been shown in serum and body fluids in inflammatory conditions. Familial Mediterranean Fever (FMF) is an inherited, auto inflammatory disease characterized by recurrent self-limited bouts of fever and localized inflammation. We aimed to investigate whether urine MMP-3 level can serve as a biomarker for monitoring attack in FMF patients in daily practice. Methods: We studied 50 patients diagnosed with FMF according to Tel Hashomer criteria and 32 age-matched healthy controls. We determined all subjects both in attack (FMF-AP) and attack free period (FMF-AFP) groups. Serum and urine samples were obtained within the first 6-24 h of the AP, and 10 days later after the attack (AFP). The serum samples were measured on the same day while urine samples were frozen immediately and stored at -80°C. Results: The mean age at onset was 57.26 ± 33.5 months. The most common symptoms seen during the attacks were: fever (80%) abdominal pain (72%), arthritis (40%). In genotype distribution, homozygous M694V mutation was seen mostly (28%). During AP, urine MMP-3 levels of patients were higher as well as during AFP and controls (2.32 ± 0.51, 0.89 ± 2.29 ng/mL and 1.24 ± 0.17 ng/mL, respectively, p=0.00). In AP, urinary MMP levels were higher in patients with arthritis than others (p<0.05). Urinary MMP-3 levels were also significantly higher in males (2.29 ± 0.45 versus 2.24 ± 0.57, p=0, 00). The patients with M694V allele (n=29) had statistically significant high urine MMP-3 levels than others (2.37 ± 0.56 versus 1.99 ± 0.31, p=0.04, respectively). Also, acute phase reactants were higher in patients with M694V allele without statistically significant difference (p=0.89, 0.75, 0.86, 0.85, 0.7, respectively). Conclusion: In this study we focused on presence of MMPs in urine and showed inflammation-specific MMP patterns may provide clinicians valuable information in FMF patients.

We are reporting an infant who was presented to our institution exhibiting a failure to thrive and hyponatremia. An extensive renal evaluation revealed resistive hyponatremia with normal renal glomerular and tubular function. Patient remained hyponatremic even after fluid restriction, salt loading and Fludrocortisone (Florinef) administration. Water deprivation and water loading tests were suggestive of “hyponatremia of reset osmostat”. The infant had no congenital midline defect.

Background: The purpose of this study was to test the hypothesis that decreased dietary intake of Vitamin D contributes to Vitamin D deficiency in end-stage renal disease (ESRD) patients on hemodialysis (HD).

Methods: We performed a cross-sectional study of 58 hemodialysis outpatients from two Mount Sinai Medical Center (MSMC)-affiliated outpatient HD units in New York City and 648 outpatients at MSMC with CKD stages I-IV. Serum 25(OH)D concentrations were measured from August 2010 to July of 2011 in recruited hemodialysis patients (n=58) and linked with results of dietary and lifestyle surveys. The Mount Sinai Data Warehouse (electronic medical record) was used to capture 25(OH) Vitamin D levels for outpatients with CKD stages I-IV who had Vitamin D testing during the same time period.

Results: The prevalence of Vitamin D insufficiency/deficiency in the HD cohort was 96.6%. Mean (SD) and median (IQR) 25(OH)D concentrations were 15.65 (6.82) and 13.55 (10.15) ng/mL, respectively. Dietary surveys showed a median weekly Vitamin D intake of 1044 IU (IQR=808, vs. a recommended weekly allowance of 4200 IU) and specific avoidance of foods containing both Vitamin D and phosphorus. In contrast, mean and median 25(OH)D concentrations in patients with CKD stages I-IV were 25.66 (13.44) and 23.60 (15.48) ng/mL (p<0.001 vs. HD patients).

Conclusions: Vitamin D deficiency is more prevalent in HD patients than in pre-dialysis patients with CKD and is associated with decreased dietary intake of Vitamin D. Dialysis restrictions imposed to reduce dietary phosphorus intake likely contributes to the development of hypovitaminosis D in ESRD patients.

Chronic kidney disease (CKD) is a medical condition characterized by progressive renal dysfunction which leads to permanent renal impairment and premature mortality, which affects patient’s quality of life significantly. Diabetes, hypertension and glomerulo-nephritis are known to be the most common causes of CKD. Recent studies have reported that there is a strong association of oxidative stress, chronic inflammation and psychological stress with CKD. These factors significantly affect the treatment outcome in CKD. Treatment modalities which control these factors can contribute significantly towards CKD management. Yoga is an ancient traditional science which encompasses yogic physical postures (asanas), yogic breathing practices (pranayama), meditations and relaxation techniques. Several scientific studies have shown that yoga reduces blood pressure, heart rate, respiratory rate, oxidative stress, psychological stress and inflammatory conditions. It also improves heart rate variability by bringing balance in autonomic nervous system by reducing sympathetic tone and increasing parasympathetic activity. In several studies, it has been reported that yoga has significant role in the management of non-communicable diseases like diabetes, hypertension, coronary heart diseases etc. Regular yoga practice can help control sugar levels in diabetics, blood pressure in hypertensives and reduce the risk of cardiac complications in patients with heart diseases. Thus, yoga has promising role in the primary and secondary management of CKD as an adjuvant. Here, we compile all these researches and based on this present a yoga module useful in CKD along with necessary precautions to be taken while doing yoga.

Background: To date, the reasons for the higher rates of treated end-stage renal failure in blacks versus whites are poorly understood. Proteinuria is the most important determinant of renal function loss (RFL). Blacks have a higher incidence of proteinuric CKD than whites. The current study evaluates the hypothesis that after adjustment for proteinuria, blacks have faster RFL, more prominent at lower levels of estimated glomerular filtration rates (eGFR). Methods: In a non-referral outpatient CKD population of 1,935 blacks and 6,286 whites, the relationship of zero, <2 plus and ≥ 2 plus dipstick proteinuria to MDRD e GFR change per year (RFL) was analyzed. Next the relationship between race and RFL was examined in patients with higher versus lower eGFR (defined by never or ever having an eGFR <30 ml/min/1.73 m2, respectively during the study using a mixed effects model which includes longitudinal urinalysis (log converted), serum creatinine data points, age and whether a patient died during the study. Results: Versus whites, blacks had higher baseline e GFR (75.3 ml/min/1.73 m2 versus 64.9 ml/min/1.73 m2) higher frequency of e GFR <30 ml/min/1.73 m2 (30.8% versus 21%), higher dipstick proteinuria levels and faster RFL by proteinuria group (range -1.07 to -2.28 ml/min/m2/year in blacks and -0.68 to -1.80 ml/min/1.73 m2/ year, in whites), p< 0.01. In the mixed effects model, blacks had a 0.30 and 0.59 ml/min/1.73 m2/ year, faster loss of renal function in the higher and lower eGFR groups, respectively, p< 0.001. Conclusion: Blacks with CKD appear to lose renal function faster than whites. This effect may be more pronounced at lower e GFR levels.

Barriers to traditional living-donor kidney transplantation include ABO incompatibility and positive cross-match. Paired exchange kidney transplantation (PEKT) is a viable an increasingly popular method to increase live donation. We discuss the pros and cons as well as the various ways to achieve PEKT along with a review of existing literature. To achieve the full potential of PEKT, the transplant community at large needs to work toward a national kidney paired donation program along with a centralized financial intermediary.