Bronchial reactivity in patients undergoing long-term haemodialysis for chronic renal failure.

Trapping of neutrophils within the lung occurs in patients undergoing haemodialysis and is also a possible mechanism in the pathogenesis of bronchial hyper-responsiveness. Falls in peak expiratory flow rate occur in most dialysis patients, and some develop overt asthmatic symptoms. To see whether these changes in airway function are secondary to increases in bronchial reactivity during haemodialysis, we therefore performed histamine challenge testing in 6 non-asthmatic patients before and after haemodialysis. No change in reactivity was observed, suggesting that haemodialysis does not commonly result in bronchial hyper-reactivity in non-asthmatic individuals.     

Impaired high-shear-stress-induced platelet aggregation in patients with chronic renal failure undergoing haemodialysis

We investigated shear-induced platelet aggregation (SIPA) in 30 patients with chronic renal failure (CRF) undergoing haemodialysis. 26 patients showed a significant decrease in SIPA at high shear stress but no change in SIPA at low shear stress. The former reaction reflects the interaction between plasma von Willebrand factor (vWF) and its platelet receptors, glycoprotein (GP) Ib-IX and lIb/ IlIa complex, whereas the latter is assumed to involve the binding of plasma fibrinogen to GP IIb/IIIa complex. These SIPA profiles in CRF patients after haemodialysis showed almost no change compared to those before haemodialysis.
The ratio of ristocetin cofactor/vWF antigen in plasma was slightly lower in CRF patients than in controls (P<0.01). However, the level of GPIb antigen in the platelets of these patients was significantly reduced (42.1±20-3% of normal platelets), with partial destruction of GPIb antigen. The number of vWF receptors on the GPIb molecule was quantitated using the GPIb-binding protein alboaggregin-B (AL-B), purified from the snake venom of Trimeresurus albolabris. AL-B bound to GPIb at a total of 48 760±9944 molecules per normal platelet and a K_d of 85.44±15.70 nM at saturation. In contrast, binding in CRF platelets was 22 980±6395 molecules per platelet and K_d was 50.08±13.83 nM. Taking these results together, we conclude that the impaired SIPA found in CRF patients is due to both abnormalities in plasma vWF and in its platelet GPIb receptor.     

Upper extremity complications in patients with chronic renal failure receiving haemodialysis

Limited data are available about disability associated with upper extremity complications in patients who receive haemodialysis for end-stage renal disease. In this study of 123 patients receiving haemodialysis, the mean Disabilities of the Arm, Shoulder and Hand (DASH) score was 31 ± 22 points, indicating markedly greater disability than in a normal population. Dupuytren's contracture was the most frequent deformity. Brachial, radial and ulnar pulses were present in most upper limbs, but 14 (14%) of 102 patients had poor arterial perfusion pressures. Diabetic patients had residual or complete loss of protective sensation more frequently than nondiabetic patients. Motor testing with the index finger abduction and fifth finger flexion tests showed a significantly greater frequency of weakness in diabetic than nondiabetic patients. In summary, upper extremity disability was noted in haemodialysis patients, including loss of protective sensation and motor strength, both in diabetic and nondiabetic subjects.     

Synovial fluid examination for the diagnosis of synovial amyloidosis in patients with chronic renal failure undergoing haemodialysis.

The diagnosis of synovial amyloidosis is based upon synovial biopsy. Synovial fluid (SF) in seven patients with amyloid arthropathy associated with chronic renal failure undergoing haemodialysis were studied. The SF and synovial samples of 10 consecutive patients with seronegative mono- or oligoarthritis served as controls. Six of the seven patients with amyloid positive synovial biopsy specimens showed amyloid in their SF. No amyloid was found in the synovial tissue or fluid of the 10 patients in the control group, the sensitivity being 87.7%. The finding of amyloid in SF was highly reproducible, showing its presence in the same joint on several occasions. The deposits were Congophilia resistant to potassium permanganate pretreatment, and the immunohistochemical analysis proved that they contained beta 2 microglobulin. The high sensitivity and good reproducibility of the method shows that the finding of amyloid in SF is sufficient for the diagnosis of synovial amyloidosis. It is possible to perform immunohistochemical analysis on the SF sediment. Amyloid arthropathy can therefore be added to the list of conditions in which synovial fluid examination can be clinically helpful.     

Amyloid arthropathy in patients undergoing periodical haemodialysis for chronic renal failure: a new complication.

Seven patients (five male and two female) with chronic renal failure (CRF) treated by periodical haemodialysis presented with swelling and effusion of more than three months' duration in knees (four bilateral), shoulders (two, one of them bilateral), elbow (one), and ankle (one). Four had a carpal tunnel syndrome both clinically and electromyographically (three bilateral). All patients had hyperparathyroidism secondary to their CRF, which was not due to amyloidosis in any of them. The dialysis duration period varied from five to 14 years, with an average of 8.6 years. Amyloid deposits (Congo red positive areas with green birefringence under polarising microscopy) were shown in six of the seven synovial biopsy specimens of the knee, in five of the sediments of the synovial fluids, and in specimens removed during carpal tunnel syndrome surgery. No amyloid was found in the biopsy specimen of abdominal fat of six of the patients. The finding of amyloid only in the synovial membrane and fluid, and carpal tunnel, its absence in abdominal fat, and the lack of other manifestations of generalised amyloidosis (cardiomyopathy, malabsorption syndrome, macroglossia, etc.) and of Bence Jones myeloma (protein immunoelectrophoresis normal) raises the possibility that this is a form of amyloidosis which is peculiar to CRF treated by periodical haemodialysis.     

Serum ghrelin concentrations in patients with chronic renal failure undergoing dialysis

BACKGROUND: Ghrelin is a recently discovered protein hormone mainly synthesized in the gastric endocrine cells. This hormone not only is a potent growth hormone secretagogue but also is involved in the regulation of food ingestion and energy metabolism. Derangements in ghrelin secretion in patients with chronic renal failure (CRF) have not been fully evaluated. OBJECTIVE: Our aim has been to quantify serum concentrations of total ghrelin in a group of patients with CRF on chronic therapy with both haemodialysis (HD) and peritoneal dialysis (PD) in comparison with a group of patients on conservative management (predialysis). PATIENTS AND MEASUREMENTS: We studied 68 CRF patients treated by HD (n = 30, 16 men, age 61.2 +/- 1.8 years) and PD groups (n = 38, 21 men, age 54.4 +/- 1.7 years). A group of 19 uraemic patients on conservative management served as the control. Serum concentrations of ghrelin, leptin, insulin, IGF I and GH were measured in all subjects. RESULTS: Patients undergoing HD showed similar concentrations of ghrelin in comparison with the control group (9491 +/- 787 vs 9280 +/- 918 pg/ml, NS). However, PD patients exhibited baseline ghrelin concentrations significantly lower than those found in patients on conservative management (3230 +/- 216 pg/ml, P < 0.0001). Men and women showed similar serum ghrelin levels in both HD (9845.9 +/- 1071 vs 9085 +/- 1194 pg/ml) and PD patients (3214 +/- 297 vs 3250 +/- 324 pg/ml). Hypertension and diabetes mellitus did not influence ghrelin levels. Serum GH levels were positively correlated with serum ghrelin concentrations in both HD (r = 0.46, P < 0.05) and PD (r = 0.53, P < 0.001) patients; however, no relationships between ghrelin, leptin, insulin and IGF I were found. CONCLUSIONS: These results suggest that PD is accompanied by a striking decrement in baseline ghrelin concentrations in comparison with values found both in HD and control patients. Further studies are necessary to determine mechanisms involved in ghrelin regulation in uraemic patients.     

Long-term low-dose cibenzoline in patients with chronic renal failure undergoing hemodialysis

Because most anti-arrhythmic drugs are eliminated from the kidney, anti-arrhythmic drug therapy is largely restricted in patients undergoing hemodialysis (HD). Cibenzoline is a widely used antiarrhythmic drug excreted mainly from the kidney. The present study evaluated the safety and efficacy of reduced doses of cibenzoline (25 and 50 mg/day chronically) in 8 patients with maintenance HD. Cibenzoline was administered for more than 3 months without any problems in 7 of the 8 patients, although the medication was discontinued in 1 patient due to nausea and anorexia. With cibenzoline administration, the incidence and duration of atrial fibrillation decreased or disappeared in 6 of 7 patients and the frequency of complex ventricular arrhythmias was also reduced in 3 of 4 patients. No adverse side effects were noted. Plasma concentration of cibenzoline ranged from 169 to 220 ng/ml with the 25-mg/day dosage, and from 408 to 500 ng/ml with the 50-mg/day dosage. The concentrations remained stable during the study. In conclusion, low doses of cibenzoline are safe and effective in patients undergoing maintenance HD. However, intermittent monitoring is essential to ensure therapeutic drug concentrations.     

Acute hepatitis C among renal failure patients on chronic haemodialysis

Hepatitis C virus (HCV) infection is common in haemodialysis units, yet little information is available about the clinical feature of acute hepatitis C among renal failure patients. The present study is based on 49 cases of acute hepatitis C seen at a haemodialysis centre where sporadic nosocomial infection was occurring up to June 1993. Liver function tests were done at 4 weekly intervals on all dialysis patients, anti-HCV antibodies were tested by the C-100 and second generation tests and serum HCV-RNA was determined by the branched DNA and Amplicore tests. Diagnosis of acute hepatitis C was made on the basis of an acute rise in alanine aminotransferase (ALT) and seroconversion to positive anti-HCV antibodies. Clinical presentation of acute hepatitis was generally mild with rare overt jaundice and the diagnosis was possible only from increased ALT, which was generally low. Spontaneous resolution of acute hepatitis within 8 months with clearance of viral RNA occurred in only four cases, 91.8% of patients developing chronic hepatitis. Biopsy in 12 cases with high ALT levels showed mild to moderate inflammatory activities. In conclusion, the clinical presentation of acute hepatitis C is generally mild in chronic haemodialysis patients, but spontaneous resolution is infrequent. A longer follow-up period is required for defining the long-term prognosis.     

Effect of haemodialysis on left atrial mechanical function in patients with chronic renal failure

OBJECTIVE: The aim of this study was to investigate the potential effects of haemodialysis on left atrial (LA) mechanical functions in patients with chronic renal failure. METHODS: Thirty-two patients with chronic renal failure (mean age 42.8 +/- 19.6 years) were included in this study. LA volumes were determined echocardiographically at the time of mitral valve opening (maximal,Vmax), at the onset of atrial systole (p wave at the electrocardiography = Vp) and at the mitral valve closure (minimal, Vmin) according to the biplane area-length method in apical 4-chamber and 2-chamber view. All volumes were corrected to the body surface area, and the following left atrial emptying functions were calculated. LA passive emptying volume = Vmax - Vp, LA passive emptying fraction = LA passive emptying volume/Vmax. Conduit volume = LV stroke volume-(Vmax - Vmin), LA active emptying volume = Vp Vmin. LA active emptying fraction = LA active emptying volume/Vp, LA total emptying volume = (Vmax - Vmin), LA total emptying fraction = LA total emptying volume/Vmax. RESULTS: Mean fluid removal was 1,875 +/- 812 milliliter.There was no difference between in the LA passive emptying volume before and after dialysis (10.83 +/- 7.44 vs. 11.47 +/- 7.73 cm3/m2, p > 0.05). Conduit volume (from 15.30 +/- 10.68 to 10.31 +/- 6.83 cm3/m2, p < 0.05), LA active emptying volume (from 12.61 +/- 6.39 to 9.25 +/- 4.40 cm3/m2, p < 0.005), LA total emptying volume (from 23.44 +/- 8.52 to 20.72 +/- 8.58 cm3/m2, p < 0.05), LA maximal volume (from 39.44 +/- 14.07 to 28.89 +/- 11.80 cm3/m2, p < 0.001), LA minimal volume (from 15.99 +/- 9.70 to 8.17 +/- 4.52 cm3/m2, p < 0.001), and the volume at the onset of atrial systole (from 28.61 +/- 10.36 to 17.42 +/- 7.20 cm3/m2, p < 0.001) decreased significantly after the haemodialysis session, whereas LA passive emptying fraction (from 0.27 +/- 0.14 to 0.38 +/- 0.14%, p < 0.001), LA active emptying fraction (from 0.46 +/- 0.18 to 0.53 +/- 0.17%, p < 0.05), LA total emptying fraction (from 0.61 +/- 0.14 to 0.72 +/- 0.09%, p < 0.001) increased significantly after haemodialysis. CONCLUSION: The results of this study suggest that left atrial mechanical functions improve after haemodialysis in patients with chronic renal failure.     

Gastric secretory function in patients with chronic renal failure undergoing maintenance hemodialysis

Gastric secretion was evaluated in 9 male patients with chronic renal failure on maintenance hemodialysis. Five secreted low or normal quantities of acid and 4 exhibited hypersecretion, 2 of whom had associated peptic ulcer disease. Serum gastrin responses to a protein meal were comparable to control subjects. Calcium infusion in two basal hypersecretors depressed acid secretion. The only statistically significant correlation observed was between basal acid output and serum levels of parathormone. These studies suggest that while acid secretory abnormalities vary in patients with chronic renal failure on hemodialysis, there is no apparent sensitivity of the gastrin-secreting cells to protein or calcium ion which might account for acid hypersecretion. Secondary hyperparathyroidism may influence the occurrence of acid secretory abnormalities.     

T-lymphocyte subgroups and tuberculin skin test reactivity in patients with chronic renal failure

As anergy is common in patients with chronic renal failure (CRF), the use of tuberculin skin test (TST) is controversial. Therefore, determination of the factors that affect the TST reactivity would increase the diagnostic value of the test. The aim of the present study was to investigate the factors affecting TST reactivity and evaluate the relationship between T-lymphocyte subsets and TST reactivity. We thus examined 44 patients (mean age 46.6 +/- 15.6 years, 25 males, duration of CRF 5.6 +/- 5.2 years), performed TST (an induration with a diameter of 5 mm or more was considered as positive) and measured Tlymphocyte subsets and biochemical parameters. Twenty-three patients were on hemodialysis, six were on peritoneal dialysis, seven were transplant recipients, and eight were on medical treatment. Eleven patients (25%) had immunosuppressive treatment. Eleven patients (25%) had two, 29 patients (66%) had one, and four patients (9%) had no BCG scars. Five patients (11%) had low body mass index (BMI). T-lymphocyte subsets were as follows: CD4= 40.7 +/- 7.6%, CD8= 32 +/- 8.9%, CD4/CD8= 1.7 +/- 2.5%, CD3= 71.4 +/- 9.4%, CD19= 6.3 +/- 5.1%, NK= 9.7 +/- 5.9. Twenty-two patients had positive TST reactivity. No relation was found between TST reactivity and age, gender, co-morbidity, BCG vaccination, BMI, immunosuppressive therapy, duration and treatment of CRF. Similarly, TST reactivity was not related to the biochemical parameters and Tlymphocyte subsets. These data provide that tuberculin reactivity does not seem to be associated with T-lymphocyte dysfunction and clinical features in patients with chronic renal failure.     

Bronchial hyperresponsiveness in patients with chronic congestive heart failure

To investigate the relationship between pulmonary congestion and bronchial responsiveness, we measured bronchial responsiveness to acetylcholine in 51 patients with left heart disorders. The measurement of bronchial responsiveness was performed by inhaling doses of acetylcholine chloride (0.08 to 20 mg/ml) and calculating the PC20-FEV1. The median value for PC20-FEV1 was above 20 mg/ml in the subjects without history of congestive heart failure (n = 18), was 5.29 mg/ml in the subjects with clinical evidence of congestive heart failure in the past days (n = 18; p less than 0.01), and was 5.74 mg/ml in the subjects with clinical evidence of congestive heart failure at the time of study (n = 15; p less than 0.01). The hemodynamic variables by cardiac catheterization and the clinical symptoms were not correlated with the grade of bronchial responsiveness. These results suggest that the bronchial responsiveness was increased in most of the patients with chronic congestive heart failure. We concluded that continuous pulmonary congestion may contribute to the pathogenesis of bronchial hyperresponsiveness.     

Predictors for silent cerebral infarction in patients with chronic renal failure undergoing hemodialysis

In patients with chronic renal failure undergoing hemodialysis (HD), silent cerebral infarctions (SCIs) are associated with high mortality. Levels of hepatocyte growth factor (HGF) increase with renal dysfunction and may be a novel predictor of cerebrovascular events. We examined if HGF is a predictor of SCI in HD patients. Brain magnetic resonance imaging findings were used to divide 50 patients undergoing HD into 2 groups, a group with SCI (age, 61 +/- 8 years, mean +/- SD; n = 27) and a group without SCI (age, 60 +/- 7 years; n = 23). These patients received 24-hour ambulatory blood pressure monitoring. The number of patients with diabetes or hypertension was not different between the 2 groups. We made the following observations: (1) The percentage of smokers was higher in the group with SCI than in the group without SCI (P < .05). (2) Plasma levels of high-density lipoprotein cholesterol were lower and HGF levels were higher in the group with SCI compared with the group without SCI (P < .05 and P < .005, respectively). (3) Systolic ambulatory blood pressure and mean heart rate at night were higher in the group with SCI than in the group without SCI (P < .05). Multiple logistic regression analysis identified HGF as a significant risk factor for SCI (odds ratio, 1.89; 95% confidence interval, 1.57-3.38; P < .005). Our findings indicate that HGF may be a novel useful predictor of SCI in patients with chronic renal failure undergoing HD.     

The role of melatonin in patients with chronic kidney disease undergoing haemodialysis

Patients with chronic kidney disease including those undergoing haemodialysis have deranged sleep-wake pattern. In large part this is due to an abnormal circadian cycle of melatonin, a hormone secreted by the pineal gland in the evening and induces sleep. Subjects undergoing automated peritoneal dialysis or nocturnal haemodialysis have better sleep profile compared to those on daytime dialysis. Studies have shown that exogenous melatonin improves sleep-wake cycle in daytime haemodialysis patients. However, large randomised controlled trials are needed in order to establish its role in this patient population.     

Effect of haemodialysis on plasma concentrations of atrial natriuretic peptide in adult patients with chronic renal failure

Twenty patients with chronic renal failure were studied before and after haemodialysis. Plasma atrial natriuretic peptide (ANP) concentrations were markedly elevated (P less than 0.01) before dialysis in comparison with healthy control subjects. After haemodialysis the plasma ANP concentration was lower in 19 patients (P less than 0.01) but remained above the normal range in all but three cases. Systolic and diastolic blood pressure and body weight fell during dialysis but none of these changes correlated with the reduction of the plasma ANP concentration. Chromatographic analysis of plasma extracts indicated that alpha-ANP is the predominant circulating molecular form. The increase in concentration of ANP in plasma between dialyses, at a time when many patients are susceptible to sodium and water overload, and its return towards normal after dialysis supports the putative role of ANP as a circulating factor released in response to sodium and water accumulation.     

Selected climatic variables and blood pressure in Central European patients with chronic renal failure on haemodialysis treatment

BACKGROUND/AIMS;Higher blood pressure (BP) in winter has been documented in healthy and hypertensive adults. It may potentially contribute to the observed excess winter cardiovascular mortality in the general population. The aim of the study was to assess whether BP varies similarly among patients with chronic renal failure on haemodialysis treatment, who present an increased risk of cardiovascular death. METHODS: We retrospectively analysed values of pre-dialysis BP and parameters of fluid retention--pre-dialysis body weight and inter-dialytic weight gain measured in 49 patients (23 male, 26 female; aged 46.0+/-13.5 years) from 1995 to 1998. For each patient we calculated deviations of monthly mean values of systolic BP, diastolic BP, pre-dialysis body weight and inter-dialytic weight gain from the lowest monthly means of these parameters in a given year. Monthly means of these deviations for the whole study group (dSBP, dDBP, dBW, dWG, respectively) were subsequently computed. Monthly means of air temperature (T), air relative humidity (H) and atmospheric pressure (AP) were provided by the local Institute of Meteorology. The Wilcoxon paired test was applied to compare mean values of BPs and parameters of fluid retention of every patient in three warmest and three coldest months of each year. Spearman rank correlation analysis was employed to evaluate relationships between dSBP, dDBP and climatic variables, dBW or dWG. RESULTS: Systolic BP was higher in summer than in winter (146.6+/-20.5 vs 143.4+/-18.9 mmHg; p<0.00001). Diastolic BP was also higher in summer than in winter (82.6+/-8.5 vs 79.6+/-7.3 mmHg; p<10(-9)). Pre-dialysis body weight and inter-dialytic weight gain did not differ between summer and winter (66.0+/-13.2 vs 66.0+/-13.2 kg; p=0.98 and 2.27+/-0.6 vs 2.29+/-0.5 kg; p=0.53). There was a positive correlation between dSBP and T (RS=0.424, p<0.003), as well as dDBP and T (RS=0.591, p<0.00001) and an inverse correlation between dSBP and H (RS=-0.372, p<0.01), as well as dDBP and H (RS=-0.408, p<0.004). There were no significant associations between BPs and AP, dBW or dWG. CONCLUSIONS: In haemodialysed patients from southern Poland, BP is higher in summer than in winter. Changes in BP are related to seasonal changes in climatic variables--air temperature and air relative humidity. Seasonal variation in BP is not associated with variation in fluid retention. Possible alteration of cardiovascular reactivity to changes in climatic environment in haemodialysed chronic renal failure patients may be one of the potential explanations of these observations.