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Association of Vitamin D Metabolites With Arterial Function in the Hemodialysis Fistula Maturation Study.
van Ballegooijen AJ, Zelnick L, Hoofnagle AN, Hamburg NM, Robinson-Cohen C, Roy-Chaudhury P, Cheung AK, Shiu YT, de Boer IH, Himmelfarb J, Beck G, Imrey PB, Kusek JW, Kestenbaum B, Hemodialysis Fistula Maturation (HFM) Study Group
(2017) Am J Kidney Dis 69: 805-814
MeSH Terms: 25-Hydroxyvitamin D 2, Adult, Aged, Anastomosis, Surgical, Arteries, Brachial Artery, Calcifediol, Carotid Arteries, Chromatography, Liquid, Cohort Studies, Cross-Sectional Studies, Ergocalciferols, Female, Femoral Artery, Humans, Kidney Failure, Chronic, Male, Middle Aged, Nitroglycerin, Prospective Studies, Pulse Wave Analysis, Radial Artery, Renal Dialysis, Tandem Mass Spectrometry, Vascular Stiffness, Vasodilation, Vasodilator Agents, Veins, Vitamin D
Show Abstract · Added September 19, 2017
BACKGROUND - Disturbances in vitamin D metabolism are common in patients with end-stage renal disease and may contribute to vascular dysfunction.
STUDY DESIGN - Cross-sectional.
SETTING & PARTICIPANTS - We evaluated 558 of 602 participants at baseline of the Hemodialysis Fistula Maturation (HFM) Study, a 7-center prospective cohort study of a cohort of patients with chronic kidney disease awaiting arteriovenous fistula (AVF) creation surgery.
FACTOR - 4 vitamin D metabolites measured with liquid chromatography-tandem mass spectroscopy from samples obtained within 4 weeks prior to AVF surgery.
OUTCOMES - Vasodilator functions and measurements of arterial stiffness.
MEASUREMENTS - Trained HFM Study personnel measured brachial artery flow-mediated dilation, nitroglycerin-mediated dilation, and carotid-femoral and carotid-radial pulse wave velocities (PWVs) prior to AVF creation. We evaluated associations after basic adjustment for sex, age, and clinical site and more fully adjusted additionally for baseline education, smoking, body mass index, diabetes, dialysis status, and medication use.
RESULTS - Mean participant age was 55±13 (SD) years and 65% were receiving maintenance dialysis. None of the vitamin D metabolites were significantly associated with flow-mediated dilation, carotid-femoral PWV, or carotid-radial PWV in basic or fully adjusted analyses. Higher serum concentrations of bioavailable vitamin D and 1,25-dihydroxyvitamin D were associated with 0.62% and 0.58% greater nitroglycerin-mediated dilation values, respectively, in basic models; however, these associations were no longer statistically significant with full adjustment. There were no significant associations of vitamin D metabolites with carotid-femoral or carotid-radial PWV in fully adjusted analyses.
LIMITATIONS - Cross-sectional ascertainment of vitamin D metabolites and vascular functions late during the course of kidney disease.
CONCLUSIONS - Serum concentrations of vitamin D metabolites are not associated with vasodilator functions or vascular stiffness at baseline in a cohort study of patients with chronic kidney disease awaiting AVF creation surgery. Laboratory measurements of vitamin D metabolites are unlikely to provide useful information regarding vascular functions in this setting.
Copyright © 2017 National Kidney Foundation, Inc. All rights reserved.
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29 MeSH Terms
Tissue sodium accumulation and peripheral insulin sensitivity in maintenance hemodialysis patients.
Deger SM, Wang P, Fissell R, Ellis CD, Booker C, Sha F, Morse JL, Stewart TG, Gore JC, Siew ED, Titze J, Ikizler TA
(2017) J Cachexia Sarcopenia Muscle 8: 500-507
MeSH Terms: Adult, Biomarkers, Blood Glucose, Body Composition, Female, Glucose, Humans, Insulin, Insulin Resistance, Leucine, Magnetic Resonance Imaging, Male, Middle Aged, Muscle, Skeletal, Organ Specificity, Renal Dialysis, Skin, Sodium
Show Abstract · Added April 6, 2017
BACKGROUND - Recent data suggest that sodium (Na ) is stored in the muscle and skin without commensurate water retention in maintenance hemodialysis (MHD) patients. In this study, we hypothesized that excessive Na accumulation would be associated with abnormalities in peripheral insulin action.
METHODS - Eleven MHD patients and eight controls underwent hyperinsulinemic-euglycemic-euaminoacidemic clamp studies to measure glucose (GDR) and leucine disposal rates (LDR), as well as lower left leg Na magnetic resonance imaging to measure Na concentration in the muscle and skin tissue.
RESULTS - The median GDR and LDR levels were lower, and the median muscle Na concentration was higher in MHD patients compared with controls. No significant difference was found regarding skin Na concentration between group comparisons. Linear regression revealed inverse relationships between muscle Na concentration and GDR and LDR in MHD patients, whereas no relationship was observed in controls. There was no association between skin Na content and GDR or LDR in either MHD patients or controls.
CONCLUSIONS - These data suggest that excessive muscle Na content might be a determinant of IR in MHD patients, although the causality and mechanisms remain to be proven.
© 2017 The Authors. Journal of Cachexia, Sarcopenia and Muscle published by John Wiley & Sons Ltd on behalf of the Society on Sarcopenia, Cachexia and Wasting Disorders.
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18 MeSH Terms
Effect of Coenzyme Q on Biomarkers of Oxidative Stress and Cardiac Function in Hemodialysis Patients: The CoQ Biomarker Trial.
Rivara MB, Yeung CK, Robinson-Cohen C, Phillips BR, Ruzinski J, Rock D, Linke L, Shen DD, Ikizler TA, Himmelfarb J
(2017) Am J Kidney Dis 69: 389-399
MeSH Terms: Biomarkers, Double-Blind Method, Female, Heart, Humans, Kidney Failure, Chronic, Male, Middle Aged, Oxidative Stress, Pilot Projects, Renal Dialysis, Ubiquinone
Show Abstract · Added September 19, 2017
BACKGROUND - Oxidative stress is highly prevalent in patients with end-stage renal disease and is linked to excess cardiovascular risk. Identifying therapies that reduce oxidative stress has the potential to improve cardiovascular outcomes in patients undergoing maintenance dialysis.
STUDY DESIGN - Placebo-controlled, 3-arm, double-blind, randomized, clinical trial.
SETTING & PARTICIPANTS - 65 patients undergoing thrice-weekly maintenance hemodialysis.
INTERVENTION - Patients were randomly assigned in a 1:1:1 ratio to receive once-daily coenzyme Q (CoQ; 600 or 1,200mg) or matching placebo for 4 months.
OUTCOMES - The primary outcome was plasma oxidative stress, defined as plasma concentration of F-isoprotanes. Secondary outcomes included levels of plasma isofurans, levels of cardiac biomarkers, predialysis blood pressure, and safety/tolerability.
MEASUREMENTS - F-isoprostanes and isofurans were measured as plasma markers of oxidative stress, and N-terminal pro-brain natriuretic peptide and troponin T were measured as cardiac biomarkers at baseline and 1, 2, and 4 months.
RESULTS - Of 80 randomly assigned patients, 15 were excluded due to not completing at least 1 postbaseline study visit and 65 were included in the primary intention-to-treat analysis. No treatment-related major adverse events occurred. Daily treatment with 1,200mg, but not 600mg, of CoQ significantly reduced plasma F-isoprostanes concentrations at 4 months compared to placebo (adjusted mean changes of -10.7 [95% CI, -7.1 to -14.3] pg/mL [P<0.001] and -8.3 [95% CI, -5.5 to -11.0] pg/mL [P=0.1], respectively). There were no significant effects of CoQ treatment on levels of plasma isofurans, cardiac biomarkers, or predialysis blood pressures.
LIMITATIONS - Study not powered to detect small treatment effects; difference in baseline characteristics among randomized groups.
CONCLUSIONS - In patients undergoing maintenance hemodialysis, daily supplementation with 1,200mg of CoQ is safe and results in a reduction in plasma concentrations of F-isoprostanes, a marker of oxidative stress. Future studies are needed to determine whether CoQ supplementation improves clinical outcomes for patients undergoing maintenance hemodialysis.
Copyright © 2016. Published by Elsevier Inc.
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12 MeSH Terms
Sarcopenic Obesity Definitions by Body Composition and Mortality in the Hemodialysis Patients.
Malhotra R, Deger SM, Salat H, Bian A, Stewart TG, Booker C, Vincz A, Pouliot B, Ikizler TA
(2017) J Ren Nutr 27: 84-90
MeSH Terms: Absorptiometry, Photon, Adiposity, Adult, Body Composition, Body Mass Index, Female, Follow-Up Studies, Humans, Male, Middle Aged, Obesity, Prevalence, Renal Dialysis, Retrospective Studies, Risk Factors, Sarcopenia
Show Abstract · Added December 27, 2016
OBJECTIVE - Sarcopenic obesity (SO), a combination of low muscle mass and high fat mass, is considered as risk factor for mortality in general population. It is unclear if SO affects mortality in maintenance hemodialysis (MHD) patients. In this study, we aimed to determine whether body composition as assessed by currently available SO definitions is related to all-cause mortality in MHD subjects. We also examined the impact of applying different definitions on the prevalence of SO in our MHD database.
DESIGN - Retrospective analysis.
SUBJECTS - Adult patients on MHD for at least 3 months with no acute illness studied in the clinical research center between 2003 and 2011.
INTERVENTION - Assessment of body composition was performed using dual energy x-ray absorptiometry. SO (appendicular skeletal mass: arm lean mass + leg lean mass and fat mass) was defined according to Baumgartner definition, Janssen criteria 1, and Janssen criteria 2.
MAIN OUTCOME MEASURE - All-cause mortality and prevalence of SO. Patient deaths were ascertained from medical records and United States social security death index.
RESULTS - Of 122 participants, 62% were male; mean age was 46 years (interquartile range: 40, 54) in men and 50 years (44, 61) in women. Prevalence of SO ranged from 12% to 62% in men and 2% to 74% in female according to different definitions. SO prevalence was lowest using the Baumgartner criteria (all: 8%, men 12%, women: 2%) and highest according to the Janssen criteria 2 (all: 57%, men 46%, women 74%). There were 45 deaths during a median follow-up period of 44 (20, 76) months. SO by any definition was not statistically significantly associated with mortality during follow-up.
CONCLUSIONS - The current SO definitions are not applicable to predict increased risk of death in MHD patients. We found high degree of variation in the rates of SO when using different definitions. Future studies should focus on establishing MHD population-specific thresholds of muscle mass and adiposity for accurate prognostication.
Published by Elsevier Inc.
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16 MeSH Terms
Biomaterial-Based Approaches to Address Vein Graft and Hemodialysis Access Failures.
Boire TC, Balikov DA, Lee Y, Guth CM, Cheung-Flynn J, Sung HJ
(2016) Macromol Rapid Commun 37: 1860-1880
MeSH Terms: Animals, Biocompatible Materials, Humans, Renal Dialysis, Stents, Treatment Failure, Vascular Grafting, Veins
Show Abstract · Added March 3, 2020
Veins used as grafts in heart bypass or as access points in hemodialysis exhibit high failure rates, thereby causing significant morbidity and mortality for patients. Interventional or revisional surgeries required to correct these failures have been met with limited success and exorbitant costs, particularly for the US Centers for Medicare & Medicaid Services. Vein stenosis or occlusion leading to failure is primarily the result of neointimal hyperplasia. Systemic therapies have achieved little long-term success, indicating the need for more localized, sustained, biomaterial-based solutions. Numerous studies have demonstrated the ability of external stents to reduce neointimal hyperplasia. However, successful results from animal models have failed to translate to the clinic thus far, and no external stent is currently approved for use in the US to prevent vein graft or hemodialysis access failures. This review discusses current progress in the field, design considerations, and future perspectives for biomaterial-based external stents. More comparative studies iteratively modulating biomaterial and biomaterial-drug approaches are critical in addressing mechanistic knowledge gaps associated with external stent application to the arteriovenous environment. Addressing these gaps will ultimately lead to more viable solutions that prevent vein graft and hemodialysis access failures.
© 2016 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.
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MeSH Terms
High Dose Omega-3 Fatty Acid Administration and Skeletal Muscle Protein Turnover in Maintenance Hemodialysis Patients.
Deger SM, Hung AM, Ellis CD, Booker C, Bian A, Chen G, Abumrad NN, Ikizler TA
(2016) Clin J Am Soc Nephrol 11: 1227-35
MeSH Terms: Adult, Aged, Amino Acids, Blood Glucose, C-Reactive Protein, Dietary Supplements, Double-Blind Method, Fatty Acids, Omega-3, Female, Forearm, Humans, Inflammation, Insulin Resistance, Male, Middle Aged, Muscle Proteins, Muscle, Skeletal, Protein Biosynthesis, Renal Dialysis, Renal Insufficiency, Chronic
Show Abstract · Added July 1, 2016
BACKGROUND AND OBJECTIVES - Protein energy wasting and systemic inflammation are prevalent in maintenance hemodialysis (MHD) patients. Omega-3 (ω-3) fatty acids have anti-inflammatory properties and have been shown to improve protein homeostasis. We hypothesized that administration of high-dose (2.9 g/d) ω-3 would be associated with decreased muscle protein breakdown in MHD patients with systemic inflammation.
DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS - This is a substudy from a randomized, placebo-controlled study (NCT00655525). Patients were recruited between September 2008 and June 2011. Primary inclusion criteria included signs of chronic inflammation (average C-reactive protein of ≥5 mg/L over three consecutive measurements), lack of active infectious or inflammatory disease, no hospitalization within 1 month prior to the study, and not receiving steroids (>5 mg/d) and/or immunosuppressive agents. The primary outcomes were forearm muscle and whole body protein breakdown and synthesis before and after the intervention. The patients received ω-3 (n=11) versus placebo (n=9) for 12 weeks. Analysis of covariance was used to compare outcome variables at 12 weeks. Models were adjusted for a propensity score that was derived from age, sex, race, baseline high sensitivity C-reactive protein, diabetes mellitus, and fat mass because the groups were not balanced for several characteristics.
RESULTS - Compared with placebo, ω-3 supplementation was significantly associated with decreased muscle protein breakdown at 12 weeks (-31, [interquartile range, -98--13] versus 26 [interquartile range, 13-87] µg/100 ml per min; P=0.01), which remained significant after multivariate adjustment (-46, [95% confidence interval, -102 to -1] µg/100 ml per min). ω-3 Supplementation resulted in decreased forearm muscle protein synthesis while the rate in the placebo group increased; however, there is no longer a statistically significant difference in skeletal muscle protein synthesis or in net protein balance after multivariate adjustment. There was no statistically significant effect of ω-3 supplementation on whole body protein synthesis or breakdown.
CONCLUSIONS - High-dose ω-3 supplementation over 12 weeks in MHD patients with systemic inflammation was associated with attenuation of forearm muscle protein breakdown but did not influence skeletal muscle protein synthesis, skeletal muscle net protein balance or any component of the whole-body protein balance. These results should be interpreted cautiously given the imbalance in the two groups and the short duration of the intervention.
Copyright © 2016 by the American Society of Nephrology.
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20 MeSH Terms
Pharmacokinetics and Pharmacodynamics of Extended Infusion Versus Short Infusion Piperacillin-Tazobactam in Critically Ill Patients Undergoing CRRT.
Shotwell MS, Nesbitt R, Madonia PN, Gould ER, Connor MJ, Salem C, Aduroja OA, Amde M, Groszek JJ, Wei P, Taylor ME, Tolwani AJ, Fissell WH
(2016) Clin J Am Soc Nephrol 11: 1377-83
MeSH Terms: Acute Kidney Injury, Adult, Aged, Anti-Bacterial Agents, Bacterial Infections, Critical Illness, Dialysis Solutions, Female, Hemodiafiltration, Humans, Infusions, Intravenous, Male, Middle Aged, Penicillanic Acid, Piperacillin, Piperacillin, Tazobactam Drug Combination, Time Factors
Show Abstract · Added June 2, 2016
BACKGROUND AND OBJECTIVES - Infection is the most common cause of death in severe AKI, but many patients receiving continuous RRT do not reach target antibiotic concentrations in plasma. Extended infusion of β-lactams is associated with improved target attainment in critically ill patients; thus, we hypothesized that extended infusion piperacillin-tazobactam would improve piperacillin target attainment compared with short infusion in patients receiving continuous RRT.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS - We conducted an institutional review board-approved observational cohort study of piperacillin-tazobactam pharmacokinetics and pharmacodynamics in critically ill patients receiving continuous venovenous hemodialysis and hemodiafiltration at three tertiary care hospitals between 2007 and 2015. Antibiotic concentrations in blood and/or dialysate samples were measured by liquid chromatography, and one- and two-compartment pharmacokinetic models were fitted to the data using nonlinear mixed effects regression. Target attainment for piperacillin was defined as achieving four times the minimum inhibitory concentration of 16 μg/ml for >50% of the dosing cycle. The probabilities of target attainment for a range of doses, frequencies, and infusion durations were estimated using a Monte Carlo simulation method. Target attainment was also examined as a function of patient weight and continuous RRT effluent rate.
RESULTS - Sixty-eight participants had data for analysis. Regardless of infusion duration, 6 g/d piperacillin was associated with ≤45% target attainment, whereas 12 g/d was associated with ≥95% target attainment. For 8 and 9 g/d, target attainment ranged between 68% and 85%. The probability of target attainment was lower at higher effluent rates and patient weights. For all doses, frequencies, patient weights, and continuous RRT effluent rates, extended infusion was associated with higher probability of target attainment compared with short infusion.
CONCLUSIONS - Extended infusions of piperacillin-tazobactam are associated with greater probability of target attainment in patients receiving continuous RRT.
Copyright © 2016 by the American Society of Nephrology.
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17 MeSH Terms
Glucagon-like peptide 1 receptor activation regulates cocaine actions and dopamine homeostasis in the lateral septum by decreasing arachidonic acid levels.
Reddy IA, Pino JA, Weikop P, Osses N, Sørensen G, Bering T, Valle C, Bluett RJ, Erreger K, Wortwein G, Reyes JG, Graham D, Stanwood GD, Hackett TA, Patel S, Fink-Jensen A, Torres GE, Galli A
(2016) Transl Psychiatry 6: e809
MeSH Terms: Animals, Arachidonic Acid, Arachidonic Acids, Cocaine, Dopamine, Dopamine Plasma Membrane Transport Proteins, Dopamine Uptake Inhibitors, Endocannabinoids, Exenatide, Glucagon-Like Peptide-1 Receptor, Glycerides, Homeostasis, Incretins, Mice, Microdialysis, Peptides, Proto-Oncogene Proteins c-fos, Septal Nuclei, Venoms
Show Abstract · Added April 6, 2017
Agonism of the glucagon-like peptide 1 (GLP-1) receptor (GLP-1R) has been effective at treating aspects of addictive behavior for a number of abused substances, including cocaine. However, the molecular mechanisms and brain circuits underlying the therapeutic effects of GLP-1R signaling on cocaine actions remain elusive. Recent evidence has revealed that endogenous signaling at the GLP-1R within the forebrain lateral septum (LS) acts to reduce cocaine-induced locomotion and cocaine conditioned place preference, both considered dopamine (DA)-associated behaviors. DA terminals project from the ventral tegmental area to the LS and express the DA transporter (DAT). Cocaine acts by altering DA bioavailability by targeting the DAT. Therefore, GLP-1R signaling might exert effects on DAT to account for its regulation of cocaine-induced behaviors. We show that the GLP-1R is highly expressed within the LS. GLP-1, in LS slices, significantly enhances DAT surface expression and DAT function. Exenatide (Ex-4), a long-lasting synthetic analog of GLP-1 abolished cocaine-induced elevation of DA. Interestingly, acute administration of Ex-4 reduces septal expression of the retrograde messenger 2-arachidonylglycerol (2-AG), as well as a product of its presynaptic degradation, arachidonic acid (AA). Notably, AA reduces septal DAT function pointing to AA as a novel regulator of central DA homeostasis. We further show that AA oxidation product γ-ketoaldehyde (γ-KA) forms adducts with the DAT and reduces DAT plasma membrane expression and function. These results support a mechanism in which postsynaptic septal GLP-1R activation regulates 2-AG levels to alter presynaptic DA homeostasis and cocaine actions through AA.
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19 MeSH Terms
Preliminary Diffusive Clearance of Silicon Nanopore Membranes in a Parallel Plate Configuration for Renal Replacement Therapy.
Kim S, Heller J, Iqbal Z, Kant R, Kim EJ, Durack J, Saeed M, Do L, Hetts S, Wilson M, Brakeman P, Fissell WH, Roy S
(2016) ASAIO J 62: 169-75
MeSH Terms: Animals, Equipment Design, Membranes, Artificial, Nanopores, Renal Dialysis, Silicon, Swine
Show Abstract · Added February 22, 2016
Silicon nanopore membranes (SNMs) with compact geometry and uniform pore size distribution have demonstrated a remarkable capacity for hemofiltration. These advantages could potentially be used for hemodialysis. Here, we present an initial evaluation of the SNM's mechanical robustness, diffusive clearance, and hemocompatibility in a parallel plate configuration. Mechanical robustness of the SNM was demonstrated by exposing membranes to high flows (200 ml/min) and pressures (1,448 mm Hg). Diffusive clearance was performed in an albumin solution and whole blood with blood and dialysate flow rates of 25 ml/min. Hemocompatibility was evaluated using scanning electron microscopy and immunohistochemistry after 4 hours in an extracorporeal porcine model. The pressure drop across the flow cell was 4.6 mm Hg at 200 ml/min. Mechanical testing showed that SNM could withstand up to 775.7 mm Hg without fracture. Urea clearance did not show an appreciable decline in blood versus albumin solution. Extracorporeal studies showed blood was successfully driven via the arterial-venous pressure differential without thrombus formation. Bare silicon showed increased cell adhesion with a 4.1-fold increase and 1.8-fold increase over polyethylene glycol (PEG)-coated surfaces for tissue plasminogen factor (t-PA) and platelet adhesion (CD41), respectively. These initial results warrant further design and development of a fully scaled SNM-based parallel plate dialyzer for renal replacement therapy.
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7 MeSH Terms
Coenzyme Q10 dose-escalation study in hemodialysis patients: safety, tolerability, and effect on oxidative stress.
Yeung CK, Billings FT, Claessens AJ, Roshanravan B, Linke L, Sundell MB, Ahmad S, Shao B, Shen DD, Ikizler TA, Himmelfarb J
(2015) BMC Nephrol 16: 183
MeSH Terms: Administration, Oral, Adolescent, Adult, Aged, Aged, 80 and over, Dietary Supplements, Dose-Response Relationship, Drug, Drug Tolerance, Female, Humans, Kidney Failure, Chronic, Male, Maximum Allowable Concentration, Middle Aged, Oxidative Stress, Renal Dialysis, Ubiquinone, United States, Young Adult
Show Abstract · Added November 5, 2015
BACKGROUND - Coenzyme Q10 (CoQ10) supplementation improves mitochondrial coupling of respiration to oxidative phosphorylation, decreases superoxide production in endothelial cells, and may improve functional cardiac capacity in patients with congestive heart failure. There are no studies evaluating the safety, tolerability and efficacy of varying doses of CoQ10 in chronic hemodialysis patients, a population subject to increased oxidative stress.
METHODS - We performed a dose escalation study to test the hypothesis that CoQ10 therapy is safe, well-tolerated, and improves biomarkers of oxidative stress in patients receiving hemodialysis therapy. Plasma concentrations of F2-isoprostanes and isofurans were measured to assess systemic oxidative stress and plasma CoQ10 concentrations were measured to determine dose, concentration and response relationships.
RESULTS - Fifteen of the 20 subjects completed the entire dose escalation sequence. Mean CoQ10 levels increased in a linear fashion from 704 ± 286 ng/mL at baseline to 4033 ± 1637 ng/mL, and plasma isofuran concentrations decreased from 141 ± 67.5 pg/mL at baseline to 72.2 ± 37.5 pg/mL at the completion of the study (P = 0.003 vs. baseline and P < 0.001 for the effect of dose escalation on isofurans). Plasma F2-isoprostane concentrations did not change during the study.
CONCLUSIONS - CoQ10 supplementation at doses as high as 1800 mg per day was safe in all subjects and well-tolerated in most. Short-term daily CoQ10 supplementation decreased plasma isofuran concentrations in a dose dependent manner. CoQ10 supplementation may improve mitochondrial function and decrease oxidative stress in patients receiving hemodialysis.
TRIAL REGISTRATION - This clinical trial was registered on clinicaltrials.gov [NCT00908297] on May 21, 2009.
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19 MeSH Terms