Hemodialysis.com Author Interview:
Hernán Trimarchi M.D., Ph.D., F.A.C.P.
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Publication:
Author Interview: Hernán Trimarchi M.D., Ph.D., F.A.C.P.
In hemodialysis, adiponectin, and pro-brain natriuretic peptide levels may be subjected to variations in body mass index.
Trimarchi H, Muryan A, Dicugno M, Forrester M, Lombi F, Young P, Pomeranz V, Iriarte R, Barucca N, Campolo-Girard V, Alonso M, Lindholm B.
Hemodial Int. 2011 Aug 12. doi: 10.1111/j.1542-4758.2011.00562.x.
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What are the main findings of the study?
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Cardiovascular disease is the main cause of death in dialysis patients. The physiopathology of vascular disease is aggressive, severe and unique in end-stage renal disease. Finally, the role some molecules play in non-uremic subjects may vary in dialysis patients.
Adiponectin is an adipokine with well-proven antiatherogenic properties; however, it has also been associated with poor cardiovascular outcomes.
Obesity is characterized by hypoadiponectinemia. However, obese patients display a better survival than other groups on dialysis, which is known as the obesity paradox.
We suggest that adiponectin may change its actions depending primarily on the body mass index (BMI), being high in low BMI patients acting as a protective adipokine against a malnourished, hemodynamically unstable and more inflamed milieu. In this population, it would be associated with higher mortality. In high BMI patients, it is low as a result of a better nutritional status despite a worse cardiac condition. In this situation, it would be associated with lower mortality, and unraveling one of the mechanisms that may act in the obesity paradox.
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Were any of the findings unexpected?
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We would have expected a less inflammatory condition in patients with BMIs between 20-25 (normal). In it interesting to note that a simple catheter may silently trigger immunologic cascades that may end-up with a worse nutritional state and may conditionate the hemodynamic response, as the binomium Pro-BNP-adiponectin may play, despite a normal BMI.
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What should clinicians and patients take away from this study?
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In our studied population, in those with low BMI, malnourishment, inflammation, catheters, high Pro-BNP and adiponectin and low myocardial restriction were prevalent.
In the obese, despite higher ultrafiltration rates, Pro-BNP levels remained low, probably causing hypoadiponectinemia, cardiac remodeling and decreased stretching.
For patients: Be aware of any predisposing factor that could eventually lead to a pro-inflammatory state. A good, well-balanced nutritional status plus anti-inflammatory factors (physical exercise, maintain your AV fistula, follow the vaccination schedule, etc) is extremely useful to improve your clinical condition.
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What recommendations do you have for nephrology health care providers as a result of your study?
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Molecules may play different roles depending on the degree of inflammation the subject display at a given time. Therefore, inflammation biomarkers and pro-inflammatory conditions as infections, catheters, non-removed non-functioning grafts or transplants, residual proteinuria, etc may be taken into account when assessing a dialysis patient.
It is probable that normal or low BMI patients may have more complications due to a worse nutritional status.
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Abstract: |
Adiponectin exerts cardiovascular protective actions, although some studies have shown the opposite. In hemodialysis, obese subjects display lower mortality rates despite hypoadiponectinemia, while higher adiponectin concentrations correlate with an elevated cardiovascular risk in nonobese subjects.
The aim of the study is to suggest that adiponectin level variations are associated with differences in the body mass index (BMI).
The interplay between adiponectin and pro-brain natriuretic peptide (Pro-BNP) levels may vary according to body fat mass. Fifty-two chronic hemodialysis patients were divided into three groups. Group A, BMI<25 (n=20); Group B, BMI 25 to 30 (n=21), and Group C, BMI>30 (n=11). Diabetics: Group A 10%; Group B 6 29%; Group C 55%, P=0.027.
Determinations: Adiponectin, Pro-BNP, insulin, insulin resistance (HOMA), troponin T, nutritional status, ultrafiltration rates, C-reactive protein (CRP), vascular accesses, and echocardiography. Group A: adiponectinemia positively and significantly correlated with Pro-BNP, CRP, and troponin T. As BMI increased, adiponectin, Pro-BNP, and malnutrition significantly decreased, while insulin, HOMA, and ultrafiltration rates significantly increased.
Cardiac restriction was significantly higher in obese patients. In all groups, Pro-BNP and troponin T displayed a strong positive correlation. In low-BMI subjects, high Pro-BNP and adiponectin, low myocardial restriction, and worse nutritional status were prevalent. In obesity, hypoadiponectinemia stimulates cardiac remodeling, cardiac hypertrophy, and decreased stretching, rendering Pro-BNP levels low despite high ultrafiltration rates.
Thus, adiponectin correlates inversely with BMI, probably playing different cardiovascular roles as BMI changes.
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Home Dialysis Summit Recommends Policy Changes to Increase Home Dialysis Usage
WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
The Summit's "Report of the Delegates" highlights key findings from a March 29th meeting in Washington, DC where experts probed why, despite widely accepted and well-documented benefits of home dialysis -- improved outcomes, enhanced patient satisfaction, improved quality of life, and lower costs-- fewer than ten percent of the more than 390,000 current U.S. dialysis patients receive treatment at home. Current rates of home dialysis utilization reflect a steep decline from the 1970s, when almost 40% of U.S. dialysis patients were treated in-home.
Specifically, delegates found that policymakers should work with stakeholders in the dialysis community to confront three areas:
Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
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National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
- You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
- You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
- There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
- There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
- You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
- You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
- You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
- You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
- You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
- Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
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