Recombinant human erythropoietin and phlebotomy in the treatment of iron overload in chronic hemodialysis patients

Five long-term hemodialysis patients with clinical iron overload were treated with 300 U/kg of recombinant human erythropoietin (rHuEPO) intravenously (IV) after each hemodialysis. The patients were phlebotomized after each hemodialysis at any time the predialysis hematocrit was 35% or greater. Over a period of 1 year, the average phlebotomy rate varied from 0.5 to 1.1 U/wk with a mean phlebotomy rate of 45.8 +/- 5.6 U/yr (range, 27 to 57 U). The mean serum ferritin decreased from 8,412 +/- 1,599 micrograms/L (ng/mL) to 3,007 +/- 1,129 micrograms/L (ng/mL), and the mean iron removal over this period was 9.5 g. Liver iron deposition, as measured by density on computed tomographic (CT) scan, improved, while skin color lightened significantly. Patients tolerated phlebotomy with no major symptoms or complications and exhibited no change in the hemogram or serum chemistries. In patients with severe iron overload, changes in serum ferritin with erythropoietin treatment alone may not reflect true change in iron burden. Use of high-dose erythropoietin and phlebotomy is an effective and safe (at least for 1 year) method of reducing iron overload in long-term hemodialysis patients.     

Reduction in liver iron in hemodialysis patients with transfusional iron overload by deferoxamine mesylate

Four hemodialysis patients with transfusional iron overload were treated with three times weekly intravenous (IV) deferoxamine mesylate during the dialysis treatment. Using a gamma ray scattering technique, significant reductions in liver iron content were documented, with a mean follow-up of 20 months. Three of the four patients showed significant improvements in liver enzymes. This decrease in liver iron content could not be predicted by clinical parameters or serum ferritin. Therapy proved to be safe and effective, but follow-up requires monitoring of tissue iron by means other than standard laboratory tests.     

静脉用右旋糖酐氢氧化铁注射液治疗血液透析患者肾性贫血的随机及多中心对照临床研究

目的 评价右旋糖酐氢氧化铁注射液治疗维持性血液透析(血透)患者铁缺乏的有效性与安全性。方法 159例维持性血透患者,肾性贫血程度:血红蛋白(Hb)60～90 g/L,或红细胞压积(Hct)0.18～0.27,随机分为静脉组与口服组,分别采用静脉注射右旋糖酐氢氧化铁及口服琥珀酸亚铁进行补铁治疗,总疗程8周。检测治疗前后血清铁指标、红细胞相关指标及生化指标,并对不良反应进行监测。结果 (1)共136例完成本研究,其中静脉组70例、口服组66例,两组患者年龄、性别、贫血程度、血清铁指标及EPO用量相匹配。(2)治疗8周时,静脉组Hb及Hct显著升高,分别上升(25.5±18.7)％和(28.9±21.1)％,幅度明显高于口服组[(12.0±16.8)％和(16.7±22.5)％],P<0.001。(3)治疗8周后两组血清铁蛋白(SF)与转铁蛋白饱和度(TSAT)均较治疗前显著升高,且静脉组升高幅度[SF(316.0±398.0)％,TSAT(89.7±99.0)％】明显高于口服组[SF(157.0±454.0)％,TSAT(35.2±57.0)％】,P<0.001。(4)治疗8周后静脉组血清白蛋白及血清钾较治疗前升高,白蛋白由(36.9±5.2)g/L升至(39.3±5.9)g/L,血清钾由(4.8±0.8)mmol/L升至(5.1±0.9)mmol/L,P<0.01。两组治疗前后血WBC及其它生化指标均相近。(5)静脉组4例有不良反应,1例出现药物相关皮疹,停药后消失,1例轻微心悸,2     

Efficacy of routine preoperative computed tomography scans in colon cancer

A retrospective review of 180 patients who underwent surgery for primary colon carcinoma from August 1989 to August 1994 was performed to evaluate the necessity of preoperative CT scans in patients with known colon cancer. Sixty-seven patients had preoperative CT scans. Data were collected to evaluate the ability of the scan to detect hepatic metastases, lymph node involvement, and incidental findings that would possibly alter the planned surgical approach. In this study, CT had a sensitivity and specificity of 75 per cent and 88 per cent, respectively, in detecting hepatic metastases. Only 19 per cent of patients with lymph node involvement were correctly staged with CT scans as having lymphadenopathy. Only 3 of 67 patients had incidental findings on CT scans that ultimately changed the surgical approach. It is apparent that because CT scans detect only 75 per cent of hepatic and 19 per cent of hepatic and lymph node involvement and does not seem to alter the planned approach, it is not justified for routine preoperative evaluation of all patients. We, therefore, recommend a more selective approach to patients suspected of having advanced disease if the surgeon suspects that the information may alter the surgical approach.     

Long-term follow-up after liver transplantation in patients with hepatic iron overload.

Patients with hepatic iron overload who undergo orthotopic liver transplantation (OLT) have a worse 1-year survival than those who undergo transplantation for other indications; the long-term outcome in this population is unknown. The purpose of this study is to report long-term follow-up after OLT in a cohort of patients with hepatic iron overload. Five liver transplant centers in the United States reported follow-up data on 37 patients receiving a first liver transplant who had severe hepatic iron overload in their native livers. Kaplan-Meier 5-year survival among these patients was compared with survival data from all age-matched liver transplantations reported to the United Network for Organ Sharing (UNOS) over the same time period (1987 to 1993). The 5-year survival rate after OLT was 40% in the hepatic iron overload group compared with an overall survival rate of 62% for all patient groups from the UNOS registry (P =.0009). Although sepsis was the cause of 53% of all deaths occurring within the first year after OLT, cardiac complications accounted for 50% of the late mortality in patients with hepatic iron overload. In conclusion, long-term survival after OLT is significantly decreased in patients with hepatic iron overload. Infectious and cardiac complications are the most common causes of death in these patients. Further studies are needed to define the relationship between hepatic iron overload and mortality and to examine the effect of iron depletion on outcome after OLT in this patient population.     

Efficacy of multi-slice computed tomography cholangiography before laparoscopic cholecystectomy

BACKGROUND: Bile duct injury is one of the serious surgical complications of laparoscopic cholecystectomy (LC). Clear biliary tract imaging to detect the anomaly of the bile ducts before operation is thought to be useful to prevent this complication. The objective of this study was to investigate the preoperative feasibility of using multi-slice computed tomography scanning after drip infusion cholangiography-computed tomography (DIC-CT) for LC. METHODS: Laparoscopic cholecystectomies were carried out in 33 patients and DIC-CT and magnetic resonance cholangiography (MRC) were also carried out in all of these patients. We evaluated the recognition of the junction of the cystic duct and detection of anomalies of the extrahepatic bile ducts using the latter two methods. RESULTS: In 33 patients, DIC-CT showed the junction of the cystic duct in 31 (94%) and MRC in 25 (76%) patients, respectively. Anomalies of the extrahepatic bile ducts or the cystic duct were detected in four (12%) patients by DIC-CT, but MRC could show only one of these lesions. There were no major adverse reactions in either examination. CONCLUSION: DIC-CT is an efficacious preoperative technique as compared with MRC for the biliary tract imaging. DIC-CT may be of benefit for both patients scheduled to undergo LC and their surgeons.     

Efficacy of spiral computed tomography in diagnosis of thorax injuries due to combined trauma

Spiral computed tomography of the thorax was used in 112 patients with mechanical trauma. High efficacy of this method in diagnosis of fracture of posterior and lateral costal parts (69.6%), pneumo- and hydrothorax (100%), traumatic infiltration and gas-filled cysts of the lung (100%), pulmonary hematoma (90%) was demonstrated. Localization of bone fragments in pleural cavity (100%) had special significance. It is demonstrated that the method has low efficacy in the diagnosis of injuries of anterior costal part and sternum (49.3 and 20%). Indications for this method were formulated. The results of the study recommend spiral computed tomography as a priority diagnostic method in combined trauma of the chest.     

Efficacy of hemopoietic-stimulating factors in patients undergoing chronic hemodialysis

Anemia has been linked to increased mortality and morbidity in renal hemodialysis patients. Other risk factors that contribute to an adverse outcome include the variability of hemoglobin (Hb) levels and the decreased response to erythropoiesis-stimulating factors (ESFs). In this study we evaluated the effectiveness of four different ESFs (epoetin-A, epoetin-B, darbepoetin, and CERA), assessed the variability of Hb levels, and compared ESF dosages which contributed to the achievement of Hb levels in each individual patient with renal failure undergoing chronic hemodialysis maintenance. In conclusion, the four ESFs administered are equally effective in the treatment of anemia in renal hemodialysis patients and they do not influence in a different manner the variability of Hb. The administration of darbepoetin-A and CERA might possibly cause more patients to overshoot the target level of Hb.     

血清脂联素水平与尿毒症患者炎性反应状态的关系

我们采用前瞻、随机对照方法观察蔗糖铁注射液森铁能纠正血液透析患者铁缺乏的疗效，现报告如下。     

Diagnosis and treatment of iron overload in paediatric patients on chronic haemodialysis

In this study the incidence and contributing factors of iron overload in paediatric patients treated with intermittent haemodialysis were evaluated. Particular attention was given to the diagnostic value of serum ferritin in the assessment of body iron stores in patients with hepatocellular damage. The results of treatment of secondary haemosiderosis with desferrioxamine (DFO) are reported. Serum ferritin levels were measured in 18 children and adolescents undergoing long-term haemodialysis; 8 of these had biochemical evidence of hepatocellular damage. In all patients a good correlation was found between serum ferritin levels and the amount of iron stored in the reticuloendothelial system. Six patients developed iron overload. Patients with secondary haemosiderosis were younger at the start of haemodialysis and received significantly more blood. Although not significant, more patients with haemochromatosis-associated alleles and bilateral nephrectomy had iron overload, and the duration of dialysis was obviously longer for overloaded patients (40 months versus 26 months). The patients with iron overload were treated with DFO. The data from all patients showed that DFO was ineffective when administered at a dose of 25 mg/kg during dialysis and that in individual patients changes in serum ferritin correlated with changes in the amount of blood transfusions administered.     

Low dose intravenous ascorbic acid for erythropoietin-hyporesponsive anemia in diabetic hemodialysis patients with iron overload

BACKGROUND: Recent report demonstrates that inadequate iron mobilization and defective iron utilization may cause recombinant erythropoieitin (rEPO) hyporesponsiveness in hemodialysis (HD) patients with iron overload. The effect of intravenous ascorbic acid (IVAA) in HD patients selected on the basis of iron overload and EPO resistance also has been proven. However, it is uncertain whether IVAA still works in diabetic ESRD patients with hyperferritinemia. Therefore, the aim of this study focusing on diabetic ESRD patients was to analyze the potential effect of low dose IVAA on improvement of anemia and erythropoiesis-related parameters when compared with control period. PATIENTS AND METHOD: This study consisted of 22 chronic hemodialysis patients with type II diabetes in a single dialysis unit. In studies of this type, all eligible patients are followed up, but the primary comparison is still between different sequentially treatment including control period and post-IVAA period in same patients. IVAA patients received ascorbic acid, 100 mg each administered intravenously three times per week for eight weeks of treatment and four months of post-treatment follow-up. RESULTS: The demographic characteristics of 22 diabetic uremic patients show that mean age is 63.6 +/- 10.2 years old. The ratio of sex (M/F) = 10/12. Mean duration of HD is 46.7 +/- 33.2 months. As for the urea kinetic study between these two periods including KT/V, nPCR, and URR, there is no significantly different. As for anemia-related parameters, Hb and Hct increased significantly in post-IVAA period after 3 months compared with control period, while MCV did not increase significantly. Serum ferritin significantly decreased at study completion. The same situation is for iron. As for TS, it significantly increased at one month and further markedly increased at subsequent three months. CONCLUSION: This study has demonstrated that short-term low dose IVAA therapy can facilitate iron release from reticuloendothelial system but also increase iron utilization in diabetic hemodialysis patients with iron overload. Therefore, IVAA is a potential adjuvant therapy to treat erythropoeitin-hyporesponsive anemia in iron-overloaded patients.     

Rim enhancement in computed tomography with chronic epidural hematoma.

Three cases of epidural hematoma with delayed clinical course are presented. In each patient, computed tomography (CT) initially failed to show typical biconvex, high density extra-axial lesion. The correct diagnosis was reached only after injection of contrast medium revealed enhancement of the border of the hematoma. Importance of contrast enhancement in selected patients with head injury is stress, and the mechanism of rim enhancement is discussed.     

Risk of iron overload and 'hemochromatosis allele(s)' in patients on maintenance hemodialysis

In the present study, we have evaluated the relationship between serum ferritin (SF) levels, 'hemochromatosis allele(s)', blood transfusions and iron parenteral administration in 69 hemodialysis patients. We demonstrated significantly higher SF levels in patients with hemochromatosis allele(s) (HA+) than in patients without hemochromatosis alleles (HA-). In addition, HA+ patients who had received blood transfusions up to 15 months prior to the study had SF levels even higher than those without blood transfusions. On the other hand, HA- patients had normal levels of SF, independent of blood transfusions. After intravenous administration of 1 g iron saccharate, SF levels were significantly higher only in HA+ transfused patients. In conclusion, our study demonstrated that HA+ patients are at a higher risk of iron overload and therefore the use of transfusional and/or parenteral iron should be strictly limited.