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Background and objectives Higher fruit and vegetable intake is associated with lower cardiovascular and all-cause mortality in the general population. It is unclear whether this association occurs in patients on hemodialysis, in whom high fruit and vegetable intake is generally discouraged because of a potential risk of hyperkalemia. We aimed to evaluate the association between fruit and vegetable intake and mortality in hemodialysis. Design, setting, participants, & measurements Fruit and vegetable intake was ascertained by the Global Allergy and Asthma European Network food frequency questionnaire within the Dietary Intake, Death and Hospitalization in Adults with ESKD Treated with Hemodialysis study, a multinational cohort study of 9757 adults on hemodialysis, of whom 8078 (83%) had analyzable dietary data. Adjusted Cox regression analyses clustered by country were conducted to evaluate the association between tertiles of fruit and vegetable intake with all-cause, cardiovascular, and noncardiovascular mortality. Estimates were calculated as hazard ratios with 95% confidence intervals (95% CIs). Results During a median follow up of 2.7 years (18,586 person-years), there were 2082 deaths (954 cardiovascular). The median (interquartile range) number of servings of fruit and vegetables was 8 (4–14) per week; only 4% of the study population consumed at least four servings per day as recommended in the general population. Compared with the lowest tertile of servings per week (0–5.5, median 2), the adjusted hazard ratios for the middle (5.6–10, median 8) and highest (>10, median 17) tertiles were 0.90 (95% CI, 0.81 to 1.00) and 0.80 (95% CI, 0.71 to 0.91) for all-cause mortality, 0.88 (95% CI, 0.76 to 1.02) and 0.77 (95% CI, 0.66 to 0.91) for noncardiovascular mortality and 0.95 (95% CI, 0.81 to 1.11) and 0.84 (95% CI, 0.70 to 1.00) for cardiovascular mortality, respectively. Conclusions Fruit and vegetable intake in the hemodialysis population is low and a higher consumption is associated with lower all-cause and noncardiovascular death.

Introduction. Peritonitis is still a serious complication of peritoneal dialysis (PD). Consequences of peritonitis can be severe. The most severe are peritoneal dialysis discontinuation and patient’s death. In majority, peritonitis is bacterial in the origin. Mainly there is a gram-positive infection, less commonly gram-negative one. Some peritonitis are culture-negative, because of former antibiotics use. In minority, fungal, tuberculous or even viral peritonitis are observed. Aim. The aim of the present study is to analyze the number, origin and serious complications of peritoneal-related peritonitis cases found in our PD center. Material and methods. We performed a retrospective five-years evaluation of medical records. The total number of peritonitis episodes was 56 cases, underwent by 30 adult patients on chronic peritoneal dialysis. Peritonitis was diagnosed according to ISPD recommendations. Causes and serious complications of peritoneal-related peritonitis were analyzed in every single year. Etiology of peritonitis was classified on the basis of the result of effluent dialysate culture as: gram-positive, gram-negative and culture negative. Peritoneal dialysis discontinuation or patient’s death were defined as serious complications. Results. Among 56 cases of peritoneal-related peritonitis 44.6% were gram-positive, 26.8% gram-negative and 28.6% culture-negative. No fungal or tuberculosis peritonitis were found. Because of the peritonitis complications in the evaluated period, six patients discontinued peritoneal dialysis and were switched to hemodialysis (20%), two others died (6.7%). Conclusion. The further improvement in peritonitis’ causes identification and treatment is needed in order to reduce number of serious complications in our medical center.

Rationale & Objective Clinical practice guidelines for dietary intake in hemodialysis focus on individual nutrients. Little is known about associations of dietary patterns with survival. We evaluated the associations of dietary patterns with cardiovascular and all-cause mortality among adults treated by hemodialysis. Study Design Prospective cohort study. Setting & Participants 8,110 of 9,757 consecutive adults on hemodialysis (January 2014 to June 2017) treated in a multinational private dialysis network and with analyzable dietary data. Exposures Data-driven dietary patterns based on the GA2LEN food frequency questionnaire. Participants received a score for each identified pattern, with higher scores indicating closer resemblance of their diet to the identified pattern. Quartiles of standardized pattern scores were used as primary exposures. Outcomes Cardiovascular and all-cause mortality. Analytical Approach Principal components analysis with varimax rotation to identify common dietary patterns. Adjusted proportional hazards regression analyses with country as a random effect to estimate the associations between dietary pattern scores and mortality. Associations were expressed as adjusted HRs with 95% CIs, using the lowest quartile score as reference. Results During a median follow-up of 2.7 years (18,666 person-years), there were 2,087 deaths (958 cardiovascular). 2 dietary patterns, “fruit and vegetable” and “Western,” were identified. For the fruit and vegetable dietary pattern score, adjusted HRs, in ascending quartiles, were 0.94 (95% CI, 0.76-1.15), 0.83 (95% CI, 0.66-1.06), and 0.91 (95% CI, 0.69-1.21) for cardiovascular mortality and 0.95 (95% CI, 0.83-1.09), 0.84 (95% CI, 0.71-0.99), and 0.87 (95% CI, 0.72-1.05) for all-cause mortality. For the Western dietary pattern score, the corresponding estimates were 1.10 (95% CI, 0.90-1.35), 1.11 (95% CI, 0.87-1.41), and 1.09 (95% CI, 0.80-1.49) for cardiovascular mortality and 1.01 (95% CI, 0.88-1.16), 1.00 (95% CI, 0.85-1.18), and 1.14 (95% CI, 0.93-1.41) for all-cause mortality. Limitations Self-reported food frequency questionnaire, data-driven approach. Conclusions These findings did not confirm an association between mortality among patients receiving long-term hemodialysis and the extent to which dietary patterns were either high in fruit and vegetables or consistent with a Western diet.

Background Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets associate with lower cardiovascular and all-cause mortality in the general population, but the benefits for patients on hemodialysis are uncertain. Methods Mediterranean and DASH diet scores were derived from the GA(2)LEN Food Frequency Questionnaire within the DIET-HD Study, a multinational cohort study of 9757 adults on hemodialysis. We conducted adjusted Cox regression analyses clustered by country to evaluate the association between diet score tertiles and all-cause and cardiovascular mortality (the lowest tertile was the reference category). Results During the median 2.7-year follow-up, 2087 deaths (829 cardiovascular deaths) occurred. The adjusted hazard ratios (95% confidence intervals) for the middle and highest Mediterranean diet score tertiles were 1.20 (1.01 to 1.41) and 1.14 (0.90 to 1.43), respectively, for cardiovascular mortality and 1.10 (0.99 to 1.22) and 1.01 (0.88 to 1.17), respectively, for all-cause mortality. Corresponding estimates for the same DASH diet score tertiles were 1.01 (0.85 to 1.21) and 1.19 (0.99 to 1.43), respectively, for cardiovascular mortality and 1.03 (0.92 to 1.15) and 1.00 (0.89 to 1.12), respectively, for all-cause mortality. The association between DASH diet score and all-cause death was modified by age (P=0.03); adjusted hazard ratios for the middle and highest DASH diet score tertiles were 1.02 (0.81 to 1.29) and 0.70 (0.53 to 0.94), respectively, for younger patients (≤60 years old) and 1.05 (0.93 to 1.19) and 1.08 (0.95 to 1.23), respectively, for older patients. Conclusions Mediterranean and DASH diets did not associate with cardiovascular or total mortality in hemodialysis.

Introduction The main mediators of the sympathetic nervous system in the effectors part are catecholamines (CA). An increased sympathetic nerve activity observed in chronic kidney disease (CKD), is due to a raised level of CA in plasma. Renalase is a protein secreted by the kidneys, composed of 342 amino acids, which is able to metabolize the circulating CA and possibly play an important role in the regulation of sympathetic tone and blood pressure. Also, oxidative stress, defined as a disruption of the equilibrium between the generation of oxidants, is a crucial factor in the development of the inflammatory syndrome associated with CKD. The advanced oxidation protein products (AOPP) represent exquisite markers of phagocyte-derived oxidative stress. Objective The aim of the study was to investigate the concentration of renalase and explore the associations between AOPP with regards to CA in haemodialysis (HD) patients. Material and methods The study was conducted among 50 residents of the municipality and neighbouring villages in the province of Lublin, central-eastern Poland. Results In the studied patients, it was found that an average concentration of renalase was 44.8 ± 6.5 μg/mL, whereas of AOPP plasma levels - 57.5 ± 21.5 μmol/L. The results demonstrated the correlation between levels of renalase and AOPP in the HD patients. Indeed, elevated levels of renalase and AOPP in HD may be due to the presence of uremic toxins in blood. The concentration of urea affects the plasma concentrations of AOPP and renalase causing a direct relationship between renalase and AOPP. However, there is no clear relationship between renalase and circulating catecholamines in HD patients.

Patients on hemodialysis suffer from high risk of premature death, which is largely attributed to cardiovascular disease, but interventions targeting traditional cardiovascular risk factors have made little or no difference. Long chain n-3 polyunsaturated fatty acids (n-3 PUFA) are putative candidates to reduce cardiovascular disease. Diets rich in n-3 PUFA are recommended in the general population, although their role in the hemodialysis setting is uncertain. We evaluated the association between the dietary intake of n-3 PUFA and mortality for hemodialysis patients.The DIET-HD study is a prospective cohort study (January 2014-June 2017) in 9757 adults treated with hemodialysis in Europe and South America. Dietary n-3 PUFA intake was measured at baseline using the GADuring a median follow up of 2.7 years (18,666 person-years), 2087 deaths were recorded, including 829 attributable to cardiovascular causes. One third of the study participants consumed sufficient (at least 1.75 g/week) n-3 PUFA recommended for primary cardiovascular prevention, and less than 10% recommended for secondary prevention (7-14 g/week). Compared to patients with the lowest tertile of dietary n-3 PUFA intake (0.37 g/week), the adjusted hazard ratios (95% confidence interval) for cardiovascular mortality for patients in the middle (0.37 to1.8 g/week) and highest (≥1.8 g/week) tertiles of n-3 PUFA were 0.82 (0.69-0.98) and 1.03 (0.84-1.26), respectively. Corresponding adjusted hazard ratios for all-cause mortality were 0.96 (0.86-1.08) and 1.00 (0.88-1.13), respectively.Dietary n-3 PUFA intake was not associated with cardiovascular or all-cause mortality in patients on hemodialysis. As dietary n-3 PUFA intake was low, the possibility that n-3 PUFA supplementation might mitigate cardiovascular risk has not been excluded.

Background Periodontitis is associated with cardiovascular mortality in the general population and adults with chronic diseases. However, it is unclear whether periodontitis predicts survival in the setting of kidney failure. Methods ORAL-D was a propensity matched analysis in 3338 dentate adults with end-stage kidney disease treated in a hemodialysis network in Europe and South America designed to examine the association between periodontitis and all-cause and cardiovascular-related mortality in people on long-term hemodialysis. Participants were matched 1:1 on their propensity score for moderate to severe periodontitis assessed using the World Health Organization Community Periodontal Index. A random-effects Cox proportional hazards model was fitted with shared frailty to account for clustering of mortality risk within countries. Results Among the 3338 dentate participants, 1355 (40.6%) had moderate to severe periodontitis at baseline. After using propensity score methods to generate a matched cohort of participants with periodontitis similar to those with none or mild periodontal disease, moderate to severe periodontitis was associated with a lower risk of all-cause (9.1 versus 13.0 per 100 person years, hazard ratio 0.74, 95% confidence interval 0.61 to 0.90) and cardiovascular (4.3 versus 6.9 per 100 person years, hazard ratio 0.67, 0.51 to 0.88) mortality. These associations were not changed substantially when participants were limited to those with 12 or more natural teeth and when accounting for competing causes of cardiovascular death. Conclusion In contrast to the general population, periodontitis does not appear to be associated with an increased risk of early death in adults treated with hemodialysis. Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0574-x) contains supplementary material, which is available to authorized users.

Despite progress in medical care, there is still a problem of high mortality in patients on dialysis. The major cause of death in hemodialysis (HD) patients is cardiovascular disease. It constitutes 53% causes of death [1,7,22,29]. In addition to traditional risk factors for cardiovascular disease like hypertension, diabetes, lipid disorders, volume overload of the circulatory system associated not only with renal failure (RF), but also with the presence of arterio-venous anastomosis and rapid changes in blood volume during HD, chronic systemic inflammation, accumulation of uremic toxins and disorders of calcium and phosphate are responsible. Most patients starting dialysis are hypertensive, suggesting that blood pressure (BP) control is an important target to reduce cardiovascular mortality [23]. Furthermore, the increased sympathetic nerve activity at least in part can explain the raised in plasma catecholamines (CA) observed in chronic kidney diseases. The elevated levels of CA in end-stage renal disease (ESRD) patients are the results of the inhibition of nitric oxide (NO) followed by increased angiotensin II and increases in sympathetic afferent outflow from diseased kidney but also of reduced CA clearance.

Introduction Dialysis patients and patients post-renal transplantation can be predisposed to Legionella infections. The aim of this work was to investigate the prevalence of L. pneumophila serogroups 1–7 (SG 1–7) antibodies in dialysis patients and in patients following renal transplantation, in order to analyse the potential risk factors for infections.

Sexual dysfunction may affect 80% of women in hemodialysis. However the specific patterns and clinical correlates of sexual functioning remain poorly described. The aim of this study was to assess prevalence and correlates of the individual domains of sexual functioning in women treated with hemodialysis. We recruited, into this multinational cross-sectional study, women treated with long-term hemodialysis (Collaborative Working Group on Depression and Sexual dysfunction in Hemodialysis study). Self-reported domains of sexual functioning were assessed by the Female Sexual Function Index, which is routinely administered within the network of dialysis patients followed by the working group. Lower scores represented lower sexual functioning. Socio-demographic and clinical correlates of each domain of sexual functioning were identified by stepwise multivariable linear regression. Sensitivity analyses were restricted to women who reported being sexually active. We found that of 1309 enrolled women, 659 (50.3%) provided complete responses to FSFI survey questions and 232 (35%) reported being sexually active. Overall, most respondents reported either no sexual activity or low sexual functioning in all measured domains (orgasm 75.1%; arousal 64.0%; lubrication 63.3%; pain 60.7%; satisfaction 60.1%; sexual desire 58.0%). Respondents who were waitlisted for a kidney transplant reported scores with higher sexual functioning, while older respondents reported scores with lower functioning. The presence of depression was associated with worse lubrication and pain scores [mean difference for depressed versus non-depressed women (95% CI) -0.42 (-0.73 to -0.11), -0.53 (-0.89 to -0.16), respectively] while women who had experienced a previous cardiovascular event reported higher pain scores [-0.77 (-1.40- to -0.13)]. In conclusion, women in hemodialysis reported scores consistent with marked low sexual functioning across a range of domains; the low functioning appeared to be associated with comorbidity.

Cox proportional hazards of mortality associated with periodontitis in adults with 12 or more teeth; Figure S1. Cumulative incidence of cardiovascular death by periodontitis severity after adjustment for competing causes of death, Appendix. (PDF 197 kb)

Oral disease in adults treated with hemodialysis: prevalence, predictors, and association with mortality and adverse cardiovascular events: the rationale and design of the ORAL Diseases in hemodialysis (ORAL-D) study, a prospective, multinational, longitudinal, observational, cohort study, Study protocol. (PDF 3348 kb)

This study we examined ex vivo potential of the immune response after stimulation of whole blood with L. pneumophila SG 1, SG 2-14 and L. pneumophila standard strain ATCC 33152 in immunocompromised patients, such as: hemodialysis patients and patients after renal transplantation. The levels of TNF-α and IFN-γ in supernatants were measured with the use of commercial ELISA kits. The synthesis of TNF-α and IFN-γ after stimulation with L. pneumophila were analyzed in two aspects: differentiated stimulatory activity in relation to SG 1, SG 2-14 and ATCC 33152 L. pneumophila and differentiated response of the hemodialysis patients and patients after renal transplantation in relation to the control group. The positive and negative results of anti-L. pneumophila antibodies of two groups of our patients were found for the analysis of the stimulatory activity of L.pneumophila as a primary or secondary response. In patients with immunosuppression the response in the secretion of cytokines (TNF-α and IFN-γ) was reduced after stimulation of L. pneumophila SG 1 but in varying degrees after stimulation of L. pneumophila SG 2-14, which indicates that the risk of the infection is varied.

OBJECTIVE The aim of the study was to evaluate the relationship of haemodialysis therapy duration with the function of the cardiac adrenergic system in nondiabetic patients. METHODS Thirty haemodialysed male patients were enrolled in this study; all patients were evaluated by myocardial perfusion imaging at rest and after dynamic stress, with the assessment of left ventricular ejection fraction (LVEF) at rest and after stress and summed stress score (SSS). Single photon emission computed tomography and planar iodine-123 metaiodobenzylguanidine myocardial scintigraphy were also performed in all the patients. Semiquantitative analysis of iodine-123 metaiodobenzylguanidine myocardial uptake was expressed as the routine heart-to-mediastinum ratio (HMR): 15 min [early HMR (eHMR)] and 4 h [delayed HMR (dHMR)] post administration as well as the washout rate. Twenty-four hours of Holter studies were carried out and heart rate variability was evaluated. RESULTS Significant correlations (Spearman's tests) were found between the duration of haemodialysis treatment and the following ratios: eHMR (P=0.03; r=-0.378), dHMR (P=0.04; r=-0.367) and washout rate (P=0.05; r=0.352). Further significant correlations were found between eHMR and LVEFs (P=0.03; r=0.379), SSS (P=0.01; r=-0.429) and between dHMR and LVEFs (P=0.005; r=0.496), LVEFr (P=0.03; r=0.379) and SSS (P=0.02; r=-0.404). CONCLUSION The duration of haemodialysed patients appears to be an important factor influencing the cardiac sympathetic nervous system.

BACKGROUND: Abnormal values of the spatial angle between the directions of ventricular depolarization and repolarization (QRS-T) reflect the action potential inhomogeneities and predict cardiac events and mortality in various patient groups. The study was designed to (i) compare QRS-T in haemodialysis (HD) patients and healthy subjects, (ii) assess the influence of HD on QRS-T and (iii) evaluate the possible associations between QRS-T and echocardiography, haemodynamic as well as biochemical parameters. METHODS: The angular differences between the maximum spatial QRS and T vectors were measured in 73 HD patients and in 57 controls. QRS-T in patients was estimated pre- and post-dialysis together with the evaluation of blood chemistry and haemodynamic parameters. RESULTS: Pre-dialysis QRS-T was higher compared with controls (30.18 ± 9.84 and 13.65 ± 7.23, respectively; P < 0.001). HD induced an increase of QRS-T (41.09 ± 11.74; P < 0.001). Pre-dialysis QRS-T adjusted for left ventricular mass index correlated with troponin T (r = 0.398, P = 0.001) and HDL (r = -0.270, P = 0.043). The differences between pre- and post-dialysis (Δ) QRS-T correlated with Δ potassium (r = 0.453, P < 0.001), Δ calcium (r = -0.309, P = 0.011) and Δ stroke index (SI; r = 0.311, P = 0.017). On multivariate analysis, troponin T was found to be an independent predictor of pre-dialysis QRS-T, whereas independent predictors of the HD-induced increase in QRS-T were potassium and cardiac index changes. CONCLUSIONS: QRS-T is high in HD patients. HD enhances the inhomogeneities of action potential. Pre-dialysis QRS-T is mainly associated with troponin T elevation. HD-induced increase in QRS-T is mainly associated with potassium and SI changes. The possible clinical importance of the higher QRS-T in HD patients remains to be confirmed in further studies.

INTRODUCTION Vitamin D3 has diverse biological effects extending beyond the maintenance of calcium and phosphorus homeostasis and ensuring the proper functioning of the body. OBJECTIVES This study evaluated the levels of vitamin D3 and its association with nutritional status, immunological activity, and selected markers of cardiovascular disease in patients on long-term hemodialysis (HD). PATIENTS AND METHODS We measured 25-hydroxyvitamin D3 (25(OH)D3) levels in a group of 84 patients (mean age, 65 years; average time on dialysis, 32.5 months) and investigated correlations between 25(OH)D3 levels and the following parameters: albumin, body mass index, hemoglobin (Hb), interleukin 6 (IL-6), interleukin 10, C-reactive protein, asymmetric dimethylarginine (ADMA), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and comorbidity score. RESULTS A mean 25(OH)D3 level was 15.4 +/-7.2 ng/ml and only 5% of patients had 25(OH)D3 levels above the normal value of 30 ng/ml. There was no statistically significant difference in 25(OH)D3 levels between women and men (P = 0.06). A negative correlation was observed between 25(OH)D3 and IL-6 (R = -0.31, P = 0.009) and ADMA (R = -0.26, P = 0.03), as well as a positive correlation between 25(OH)D3 and Hb (R= 0.21, P = 0.05). There was no association between 25(OH)D3 levels and nutritional status. CONCLUSIONS A significant vitamin D3 deficiency observed in the majority of patients undergoing long-term HD contributes to the development of chronic inflammation, anemia, and indirectly, to endothelial cell injury.