Beta-2-microglobulin-associated amyloidosis in chronic hemodialysis patients with carpal tunnel syndrome

The clinical manifestations of beta-2-microglobulin (beta 2M)-associated amyloidosis in chronic hemodialysis patients with carpal tunnel syndrome from a medical center hospital are presented. The predominant morbidity of beta 2M-amyloid was musculoskeletal, with deposits identified in surgical or biopsy specimens from trigger fingers, carpal tunnels, fractures, and radiolucent bone lesions. Lucent bone lesions were the characteristic radiologic finding of beta 2M-amyloidosis and were most commonly found in carpal bones, humeral heads, and femoral heads. Carpal tunnel syndrome occurred in greater than 20% of our chronic hemodialysis patients. The longer the period of time on chronic hemodialysis the greater the morbidity from beta 2M-amyloid. Although significant amounts of beta 2M-amyloid were detected in the perivascular regions of viscera, clinical compromise of internal organs from this type of amyloid was not documented. In acute studies, beta 2M clearance during hemodialysis was markedly increased using the Fresenius polysulfone dialyzers compared to cuprophane dialyzers. In summary, beta 2M-amyloid is common and causes significant morbidity in chronic hemodialysis patients. Long-term dialysis with highly permeable membranes effects greater beta 2M clearance which may result in less tissue deposition of beta 2M-amyloid, and therefore, fewer clinical complications.     

Synovial amyloid in chronic haemodialysis contains beta 2 microglobulin.

A case of amyloid arthropathy occurring in a patient receiving long term chronic haemodialysis treatment is reported. He was found to have raised serum beta 2 microglobulin (beta 2M). and beta 2M was detected in the synovial amyloid deposits.     

Septicemia in patients undergoing chronic hemodialysis

Between March 1982 and March 1986, 11 out of 72 patients (15%) undergoing chronic hemodialysis in a Tunisian hemodialysis unit developed septicaemia. The causative organism was a staphylococcus aureus in 8 patients, and the main portal of entry was the dialysis catheter (6/8). Septic pulmonary metastasis were observed in 3 cases. REmoval of the dialysis catheter and antibiotic therapy led to recovery in 7 cases. The 4 fatalities were attributed to respiratory failure in 3 cases and septic shock in one case. These results indicate that the prognosis of septicaemia in hemodialysis patients is poor.     

Ischemic cadiopathy in patients undergoing chronic hemodialysis

We report a retrospective study of patients on chronic hemodialysis in whom a diagnosis of ischemic heart disease had been established. We compared the findings on coronary cineangiography and the treatment (medical only, surgical revascularisation [CABG] and percutaneous transluminal coronary angioplasty [PTCA]) with the early and late evolution. From a population of 2,287 patients on chronic hemodialysis treatment during the 5 year period 1994-1999, 83 patients who underwent coronary cineangiography after starting dialysis were selected. Their mean age was 63 +/- 9.4 (39-80) and the mean time on hemodialysis was 6 years (6 months-19 years). RESULTS: 65 patients (78%) had severe coronary lesions, 40% of whom had three vessel disease. 14 patients had medical treatment only (group 1), 23 had CABG (group 2) and 28 PTCA (group 3). Mortality within 30 days of intervention was 13% in group 2 and 21.4% in group 3. Global survival at two years was 82% in group 2 and 69% in group 3. Survival without angina at 6 and 24 months were 69% and 46% in group 2 and 55% and 22% in group 3 respectively. Survival without acute myocardial infarction at 6 and 24 months was 95% and 95% in group 2 and 89% and 64% in group 3. Data analysis using Cox proportional risk model showed that PTCA posed a higher risk of angina and death than CABG. CONCLUSION: Surgery yielded better early and later results than angioplasty even in those patients with severe coronary artery disease.     

Gastric secretory studies in patients undergoing chronic hemodialysis

Summary The composition of gastric secretion in the presence of azotemia has been well defined. The composition of gastric secretion in patients undergoing chronic hemodialysis has not been previously studied. Several reports emanating from dialysis centers in both the United States and England suggest that peptic ulceration may occur more frequently in patients undergoing chronic hemodialysis than in the general population. To better understand the etiology of peptic disease and the possible relationship existing between it and gastric secretion in a chronically hemodialyzed population, gastric secretory studies were performed in a series of 11 patients. The results of these studies indicate basal hyposecretion and hypoacidity to be the most characteristic feature of this group. Following maximal Histalog stimulation, patients were able to secrete a normal amount of gastric juice with a normal pH. Of the patients studied, only one, who manifested basal hyperacidity, had peptic disease. Correlation between volume and acidity of gastric juice and age, duration and type of disease, and biochemical abnormalities could not be demonstrated. It is concluded that factors other than gastric acidity must be implicated in peptic disease occurring in a chronically hemodialyzed population.The authors wish to thank Dr. Robert A. Levine for his advice and criticism.     

Lack of amyloid in abdominal fat aspirates from patients undergoing long-term hemodialysis

Recent reports describe the carpal tunnel syndrome (CTS) due to amyloid infiltration of the beta 2 microglobulin protein as a frequent complication of long-term hemodialysis. Carpal synovial and cystic bone lesion amyloid deposits have been reported; however, the extent of systemic amyloid deposition has not been determined. We examined 30 patients undergoing long-term hemodialysis for CTS and performed abdominal fat tissue aspiration for amyloid staining to evaluate the presence of systemic amyloid disease. In this group, CTS was frequent (37%) and its prevalence correlated with the duration of hemodialysis. In all patients, the abdominal fat tissue, stained with Congo red, was negative for amyloid deposits. These results confirm that CTS is a frequent complication of long-term hemodialysis; however, in this study, no detectable amyloid deposits were found in abdominal subcutaneous fat tissue. Thus, abdominal fat aspiration may not be a reliable screening test for hemodialysis-associated amyloidosis.     

Complications associated with arteriovenous fistulas in patients undergoing chronic hemodialysis

Over a two-year period, 100 venous angiograms were performed on 75 patients because of difficulty with vascular access. Seventy percent of the patients had decreased arterial flow or increased venous resistance. High output failure, sepsis, and aneurysm formation were also found. Venous angiography of the fistula demonstrated significant stenosis in 40% of the cases as well as total occlusion by thrombus in 9%, aneurysm formation in 7%, and abnormal fistula needle placement or anatomic abnormalities in 20% of the cases. Definitive diagnosis with the aid of venous angiography permitted specific surgical intervention in 62% of the cases, and identified new sites for needle placement in 18% of the cases, thus prolonging fistula life and reducing the need for new fistula placement. Our experience with local cellulitis of the fistula site and sepsis is also discussed.     

Anti-N-like antibodies in the sera of patients undergoing chronic hemodialysis

Abstract. Within the last two years, 12 examples of red cell antibody with apparent anti-N specificity have been found in the sera of 416 prospective kidney transplant recipients maintained on chronic hemodialysis. Eight of the 12 patients were N-positive, three of them in the homozygous state. Serial samples from these patients were tested against M, MN and N cells of compatible ABO types, and in 10 of the 12 cases against the patients' own red cells. Anti-N-like antibody was detected only after many months of chronic hemodialysis, and it decreased or disappeared after transplantation. Its appearance was not related to blood transfusion. The ability of the antibody to agglutinate patients' own red cells in the cold explains the loss of several cooled renal allografts.     

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.     

Tuberculosis in patients undergoing hemodialysis

The incidence of tuberculosis is very high in patients treated by hemodialysis particularly in the early stage of hemodialysis. The diagnosis of tuberculosis in dialysis patients was obscured as symptoms were nonspecific and extrapulmonary involvement was seen frequently. We investigated cell mediated immunity in dialysis patients in relation to the period of dialysis. The data indicate that dialysis patients show the following immunological impairments; 1) lymphopenia, 2) decreased B cell, 3) alteration of T cell subset, 4) decreased reaction of PPD skin test, 5) decreased T cell activity, 6) decreased IL-2 production, 7) decreased PHA induced lymphocyte blastogenesis, 8) decreased NK cell. Decreased immunologic host defence mentioned above may contribute to the high incidence of tuberculosis in the early stage as well as in the maintenance phase of dialysis.     

Tuberculosis in patients undergoing hemodialysis

We studied patients who were diagnosed as active tuberculosis while undergoing hemodialysis at Kurume University Hospital. The observation included immunologic and clinical features. Cellular immunity was depressed in our patients undergoing hemodialysis, as evident from the decreased numbers of lymphocytes and anergy to tuberculin skin tests with purified protein derivative (PPD). Further, in a few patients, hemodialysis was shown to eliminate IFN-gamma from the blood. Various antituberculous chemotherapy regimens have been studied in hemodialysis patients. Although the incidence and mortality of tuberculosis have been reported to be higher in hemodialysis patients than in the general population, the clinical outcome of our cases was favorable in this study. One important notice is to recognize promptly peripheral neuropathy while treating tuberculosis associated with hemodialysis, and this could be prevented by the adequate use of pyridoxine.     

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.     

Surgical outcome of abdominal aortic aneurysm repair in patients undergoing chronic hemodialysis

 Abdominal aortic aneurysm repair in patients undergoing chronic hemodialysis presents several surgical difficulties due to tissue fragility, accelerated atherosclerosis, and calcification of the aorta. In addition to these surgical procedure-related problems, anemia, electrolyte abnormalities, bleeding tendency, and susceptibility to infection were also critical issues in perioperative management. The aim of this study was to examine the surgical outcome of abdominal aortic aneurysm repair in patients undergoing chronic hemodialysis. Between January 1988 and August 2001, six patients undergoing chronic hemodialysis underwent repair of an abdominal aortic aneurysm. There were five males and one female, and the mean age was 65 years. Two of the six patients had bilateral common iliac artery aneurysms in addition to the abdominal aortic aneurysm. At the time of abdominal aortic aneurysm repair, the duration of hemodialysis had ranged from 3 to 109 months, with a mean of 34 months. All patients underwent hemodialysis on the day prior to the abdominal aortic aneurysm repair operation. The first postoperative hemodialysis was scheduled to be performed on the day after operation or later. The mean duration of operation was 291 min. Blood transfusion was required in all patients. The first postoperative hemodialysis was performed between the first and third postoperative days. Postoperative complications were: ileus in one, and atrial fibrillation and blue toe syndrome just after operation in one. There was no hospital death. The follow-up period was 56 months. One patient died of lingual cancer at 102 months after operation. Five patients are alive. Abdominal aortic aneurysm repair can be done in patients on chronic hemodialysis with an acceptable early and long-term outcome. Received: March 12, 2002 / Accepted: September 21, 2002 Correspondence to Y. Umeda     

Transmitted murmurs in patients undergoing hemodialysis

Forty patients undergoing hemodialysis were examined for bruits transmitted from the vascular access arm. In patients with forearm access, the bruits were localized to the clavicular and cervical regions on the same side. However, transmission to the sternal edge was noted in 8 of 10 patients with upper arm access. Compression of the fistula is a useful maneuver that allows the clinician to distinguish transmitted murmurs from those arising in cardiac valves.