Outcomes of case-matched injection sclerotherapy with a new agent for hemorrhoids in patients treated with or without blood thinners

Purpose

In Japan, a new type of sclerotherapy termed ALTA (aluminum potassium sulfate and tannic acid) injection therapy has recently been introduced. The objectives of this study were to determine whether the presence or absence of antithrombotic treatment (AT) affected the efficacy rate or the occurrence of complications associated with ALTA injection sclerotherapy.

Methods

This study was a case-matched study of 37 patients who underwent ALTA therapy to treat hemorrhoids between 2007 and 2009. Each AT patient was matched for age and degree of hemorrhoids with a control non-AT patient. In each of the subgroups, the therapeutic efficacy of ALTA therapy was evaluated by comparing an assessment completed before therapy with an assessment completed 6 months after therapy.

Results

The efficacy in patients with bleeding did not differ between the two groups (P = 0.074). The efficacy in patients with prolapse was significantly lower in the AT group than in the non-AT group (P = 0.013). The two groups did not differ significantly in the occurrence of complications (P = 0.450).

Conclusions

Among patients with hemorrhoids receiving AT, ALTA injection sclerotherapy is recommended for those in whom it is difficult to discontinue AT.     

Aluminum Overload Hampers Symptom Improvement Following Parathyroidectomy for Secondary Hyperparathyroidism

Background

Aluminum overload and accumulation in tissues may lead to skeletal, hematological, and neurological toxicity. The aim of this study was to assess the effects of serum aluminum levels on presentations, postoperative recovery, and symptom improvement in patients undergoing parathyroidectomy for secondary hyperparathyroidism.

Methods

From 2008 to 2013, all patients with end-stage renal disease undergoing initial parathyroidectomy were included in the study. Serum aluminum level was measured preoperatively and/or within 1 week after surgery. Preoperative and postoperative biochemical profile and symptoms were compared between the low and high aluminum groups.

Results

A total of 176 patients were included in the study. Of these, 38 (22 %) patients had serum aluminum levels higher than 20 μg/L. A higher percentage of patients in the high aluminum group were on peritoneal dialysis than in the low aluminum group (24 vs. 4 %, p = 0.001). Both groups had similar bone mineral density and changes in biochemical profiles. The preoperative parathyroidectomy assessment of symptoms (PAS) score was not associated with serum aluminum levels (p = 0.349), whereas the postoperative PAS score showed positive association (p = 0.005). There was a negative association between serum aluminum levels and the improvement of total PAS scores (p = 0.001). The high aluminum group had more residual symptoms in three aspects: bone pain (p = 0.038), difficulty getting out of a chair or car (p = 0.045), and pruritus (p = 0.041).

Conclusions

A high serum aluminum level was associated with reduced symptom improvement in patients undergoing parathyroidectomy for secondary hyperparathyroidism.     

A prospective study comparing the new sclerotherapy and hemorrhoidectomy in terms of therapeutic outcomes at 4 years after the treatment

Purpose

Recently, sclerotherapy using a new sclerosing agent (aluminum potassium sulfate and tannic acid) has become widespread in Japan as a treatment for hemorrhoids. In the present study, we investigated whether sclerotherapy or surgical therapy (hemorrhoidectomy) is superior in terms of the therapeutic outcomes at 4 years.

Methods

We sent a questionnaire on symptoms and the degree of satisfaction to patients who underwent sclerotherapy or hemorrhoidectomy for grade 3 or 4 hemorrhoids in 2007, and compared the two therapies based on the responses, with respect to superiority of the therapeutic outcomes at 4 years. To identify the factors affecting the symptom-free and satisfaction rates, the univariate and multivariate analyses were performed for the following seven parameters: age, sex, degree of hemorrhoids, presence of external hemorrhoids, past history of treatment for hemorrhoids, number of hemorrhoids treated and the type of treatment.

Results

Overall, 75 % of the patients (195/260) responded to the questionnaire. In this study, the symptom-free rates were 53 % (30/57 patients) in the sclerotherapy group and 80 % (111/138 patients) in the hemorrhoidectomy group, and the satisfaction rates were 70 % (40/57 patients) in the sclerotherapy group and 88 % (121/138 patients) in the hemorrhoidectomy group. The results revealed that the type of treatment was the only factor affecting these two outcomes.

Conclusions

Our results indicate that hemorrhoidectomy is superior to sclerotherapy. These findings may be useful in the treatment of hemorrhoid patients.     

Visualization of diffusion of the drug solution during aluminum potassium tannic acid injection therapy: a pilot study

Sclerotherapy with aluminum potassium tannic acid (ALTA), which was approved in Japan for the treatment of internal hemorrhoids in July 2004 (Takano et al., Int J Colorectal Dis 21:44–51, 2006), has been widely accepted because of its effectiveness and low invasiveness. More than 200,000 patients have received ALTA injection therapy. ALTA is injected directly into 4 points of an internal hemorrhoid (4-step injection) to induce sclerosis and remission of the hemorrhoids, and consequently, resolution of symptoms such as prolapse and bleeding. The precision of the 4-step injection is considered to be a crucial determinant of the success of this therapy and the risk of complications. However, sufficient evidence has not yet been obtained concerning the diffusion and distribution of the injected drug. A pilot study visualized the real-time diffusion/distribution of the drug solution following the 4-step injection, using the ICG (indocyanine green) fluorescence technique, and an infrared camera (Photodynamic EYE; PDE, Hamamatsu Photonics K.K.).     

Aluminum transfer during dialysis: a systematic review

Purpose

Dialysis-dependent patients are particularly susceptible to the toxic effects of aluminum (Al) because of their impaired ability to eliminate it. Al contamination of dialysis fluid remains a threat in this population. The mechanism for Al diffusion across dialysis membranes is not well established. Our objective is to verify, in AL-exposed patients, the postulate that the direction of Al transfer is predicted by the concentration gradient between free diffusible plasma Al and dialysate Al.

Methods

A systematic review of the literature was performed. Only papers which included Al plasma concentration ([Al]p), Al dialysate concentration ([Al]d) and direction of Al transfer (positive = from dialysate to plasma, negative = from plasma to dialysate) were selected. We also included four patients from our own cohort. Assuming that [Al]p has an ultrafiltrable fraction between 17 and 23 %, cases were considered in keeping with our hypothesis if any of the following scenarios was present: negative Al transfer when [Al]d < [Al]p*23 % and positive Al transfer when [Al]d > [Al]p*17 %.

Results

The search yielded 409 articles, of which 12 were selected for review. When reviewing individual patients for analysis, 108 out of 115 (94 %) patients followed our hypothesis. By further excluding cases in which Al transfer could not be determined, only three out of 111 patients were contrary to out hypothesis.

Conclusion

Comparing ultrafiltrable Al to dialysate Al permits to accurately predict the direction of Al transfer. The optimal [Al]d should be <20 % of the maximally acceptable [Al]p. In order to follow K/DOQI guidelines ([Al]p < 20 μg/L), the [Al]d should therefore not exceed 4 μg/L. At the level presently supported by K/DOQI ([Al]d < 10 μg/L), [Al]p could realistically reach 50 μg/L and potentially cause toxicity.     

Nutritional predictors of early mortality in incident hemodialysis patients

Purpose

Low serum albumin concentration and low dietary protein intake are associated with protein-energy wasting (PEW) and higher mortality in maintenance hemodialysis patients. The role of these nutritional markers is less clear in clinical outcomes of the first several months of dialysis therapy, where mortality is exceptionally high.

Methods

In a cohort of 17,445 incident hemodialysis patients, we examined variation in serum albumin and the normalized protein catabolic rate (nPCR), a surrogate of dietary intake, and quarterly mortality in the first 2 years of dialysis therapy. Cox proportional hazard models were fitted to estimate the association between mortality and combined albumin/nPCR categories for eight quarters. We investigated the associations between mortality and baseline and subsequent serum albumin levels per cohort quarter as well as changes in albumin and nPCR over time.

Results

Patients were 64 ± 15 years old (mean ± SD) and included 45 % women, 24 % African Americans and 58 % diabetics. Correlations between quarterly serum albumin and nPCR varied from 0.18 to 0.25. Serum albumin <3.5 g/dL was consistently associated with high mortality as was nPCR <1 g/kg/day (except for qtr1). Low serum albumin and nPCR greater than 0.2 g/dLg/dL or g/kg/day, respectively, were associated with increased risk of death. Quarterly rise in nPCR (>+0.2 g/kg/day) showed reverse effect on mortality from the 2nd to the last quarter.

Conclusions

Low serum albumin and nPCR are associated with mortality. A rapid rise in nPCR by the end of the second year may indicate pre-existing PEW.     

S100B,intraoperative neuromonitoring findings and their relation to clinical outcome in surgically treated intradural spinal lesions

Background

Neurophysiological monitoring (IOM) consisting of somatosensory (SEPs), muscle (MEPs) and spinal motor evoked (D-wave; spinal MEPs) potentials is used to indicate injury related to surgical treatment of intradural and intramedullary lesions. Combining spinal and muscle MEPs reliably predicts long-term motor deficit. If spinal MEPs recording is not possible, additional markers—e.g. S100B, a serum marker for glial injury—may be a helpful adjunct. Thus, serial serum S100B measurements were related to both the intraoperative IOM recordings and the long-term neurological outcome in patients surgically treated for cervical and thoracic intradural lesions.

Methods

In 33 patients (9 men, 24 women, 54?±?17 years) during intramedullary (8) or intradural (25) cervical or thoracic spinal surgeries significant intraoperative SEP-amplitude decrement >50 % or MEP loss and serial S100B serum concentration (perioperative days 0, 1-3, 5) were related to outcome (>1 year after discharge, grouped into improved and unchanged/altered neurological symptoms).

Results

Differences in S100B levels between patients with improved and unchanged/altered neurological outcome were significantly on postoperative days 2 (0.085?±?0.08 μg/l vs 0.206?±?0.07 μg/l, p?=?0.005) and 3 (0.076?±?0.03 μg/l vs 0.12?±?0.05 μg/l, p?=?0.007). All patients with permanent altered neurological symptoms developed S100B levels >0.08 μg/l (0.09–0.35 μg/l). Eighty-one percent of patients with improved neurological symptoms presented with S100B levels ≤0.08 μg/l (0.02–0.08 μg/l). Nine out of ten patients (90 %) without changes in EP and S100B had an improved long-term outcome, whereas 9/13 patients (69 %) with changes in EP and S100B had altered neurological symptoms in long-term outcome.

Conclusion

Intraoperative stable EPs and S100B?≤0.08 μg/l may be used as a marker to predict long-term neurological improvement, whereas EP-changes and elevated S100B levels on the 3rd postoperative day may be useful as a marker to predict long-term neurological alteration. In summary, the combined use of S100B and EPs might be helpful in the prediction of the severity of adverse spinal cord affection following surgery and guidance of patients.     

Contact Patch to Rim Distance Predicts Metal Ion Levels in Hip Resurfacing

Background

Component design, size, acetabular orientation, patient gender, and activity level have been suggested as factors leading to elevated metal ion concentrations after-on-metal hip resurfacing arthroplasty (MMHRA). The calculation of the contact patch to rim (CPR) distance integrates component size, design, and acetabular orientation and may be a good predictor of elevated metal ion levels.

Questions/purposes

We evaluated the effects and the predictive value of the CPR distance on serum cobalt (CoS) and chromium (CrS) ion levels.

Methods

We retrospectively studied 182 patients with Conserve Plus MMHRAs at a minimum of 12 months after surgery (median, 57 months; range, 12–165 months). CoS and CrS levels were analyzed using inductively-coupled plasma mass spectrometry. Multiple logistic regression was performed to determine which if any of the factors related to serum ion levels.

Results

Patients with CPR distances of 10 mm or less had a 37-fold increased risk of having elevated CoS of 7 μg/L or higher. Similarly, these patients had an 11-fold increased risk of having elevated CrS of 7 μg/L or higher. Sex and University of California Los Angeles activity scores did not influence the postoperative CoS and CrS levels. The negative predictive value for CPR distance less than 10 mm was 99.3% for CoS greater than 7 μg/L and 98.0% for CrS greater than 7 μg/L.

Conclusions

Our observations suggest the CPR distance would be a useful indicator to determine which patients are at risk for elevated ion levels. Patients with CPR distances greater than 10 mm need not be monitored unless they become symptomatic.     

Dialysis adequacy in Chinese anuric peritoneal dialysis patients

Purpose

We aimed in this study to explore how lower-protein diet would affect dialysis adequacy in anuric peritoneal dialysis (PD) patients.

Methods

Patients’ demographic features were collected, namely age, gender, weight, height, underlying renal disease, and time on PD. Urea kinetic model was used to assess solute clearance. A consecutive 3-day dietary record was collected to evaluate dietary protein intake (DPI), and normalized protein nitrogen appearance (nPNA) was also calculated to reflect protein intake. Blood samples were collected to measure hemoglobin and biochemistry. Patient’s nutritional status was assessed by biochemistry, handgrip strength, and subjective global assessment (SGA). Body fluid distribution was measured by body composition monitor.

Results

Patients were 60.8 ± 14.92 years old, and the time on PD was 40.15 ± 22.90 months. Daily prescribed dialysis dose was 7,178 ± 1,326 mL. Kt/V was 1.6 ± 0.32. DPI was 0.8 ± 0.25 g/kg/day. nPNA was 0.9 ± 0.21 g/kg/day. Serum albumin was 39.42 ± 4.83 g/L. Prevalence of malnutrition (assessed by SGA) was 20.2 %. Serum phosphate and serum bicarbonate were 1.68 ± 0.47 and 27.16 ± 3.49 mmol/L, respectively. Systolic blood pressure and diastolic blood pressure were 123.4 ± 20.0 and 74.2 ± 12.6 mmHg, respectively. Patients with nPNA less than 0.6 had significantly lower serum albumin concentrations than the average, and patients with nPNA more than 1.2 g/kg/day had significantly higher levels of serum phosphate and serum urea than the average.

Conclusions

Our study suggested that anuric PD patients could achieve adequate dialysis even under lower solute clearance. And lower-protein diet contributed largely to adequate dialysis in these patients.     

Non-cirrhotic portal-systemic encephalopathy caused by enlargement of a splenorenal shunt after pancreaticoduodenectomy for locally advanced duodenal cancer: report of a case

We report a case of portal-systemic encephalopathy occurring secondary to a splenorenal shunt, 2 years after a pancreaticoduodenectomy for locally advanced duodenal carcinoma. A 55-year-old woman was brought to our hospital with a decreased level of consciousness. Laboratory testing revealed an elevated serum ammonia level (221 μg/dl) and normal liver function. Retrospective review of a series of contrast-enhanced computed tomography scans of the abdomen identified a splenorenal shunt, which had gradually enlarged over the past 2 years (Fig. 1). The decreased level of consciousness was thought to be due to portal-systemic encephalopathy secondary to the splenorenal shunt. We performed balloon-occluded retrograde transvenous obliteration to occlude the splenorenal shunt, following which her serum ammonia level returned to normal (28 μg/dl) and an alert level of consciousness was maintained.

Zoledronic acid in combination with alfacalcidol has additive effects on trabecular microarchitecture and mechanical properties in osteopenic ovariectomized rats

Background

We conducted the present study to investigate the therapeutic effects of the antiresorptive agent zoledronic acid (ZOL), alone and in combination with alfacalcidol (ALF), in a rat model of postmenopausal osteoporosis.

Methods

Female Wistar rats were ovariectomized (OVX) or sham-operated at 3 months of age. Twelve weeks post surgery, rats were randomized into six groups: (1) sham + vehicle, (2) OVX + vehicle, (3) OVX + ZOL (100 μg/kg, i.v. single dose), (4) OVX + ZOL (50 μg/kg, i.v. single dose), (5) OVX + ALF (0.5 μg/kg, oral gauge daily) and (6) OVX + ZOL (50 μg/kg, i.v. single dose) + ALF (0.5 μg/kg, oral gauge daily) for 12 weeks. After treatment, we evaluated the mechanical properties of the lumbar vertebra and femoral mid-shaft. Femurs were also tested for bone density, porosity and trabecular micro-architecture. Biochemical markers in serum and urine were also determined.

Results

With respect to improvement in the mechanical strength of the lumbar spine and the femoral mid-shaft, the combination treatment of ZOL and ALF was more effective than each administered as a monotherapy. Moreover, combination therapy using ZOL and ALF preserved the trabecular micro-architecture and cortical bone porosity. Furthermore, the combination treatment of ZOL and ALF corrected the decrease in serum calcium and increase in serum alkaline phosphatase and the tartarate-resistant acid phosphatase level better than single-drug therapy using ZOL or ALF in OVX rats. In addition, the combination treatment of ZOL and ALF corrected the increase in urine calcium, phosphorous and creatinine levels better than single-drug therapy using ZOL or ALF in OVX rats.

Conclusions

These data suggest that the combination treatment of ZOL and ALF has a therapeutic advantage over each monotherapy for the treatment of osteoporosis.     

Immunogenicity of low-dose MF59-adjuvanted 2009 influenza A/H1N1 vaccine in dialysis patients

Background

In response to the pandemic 2009 A/H1N1 virus, monovalent MF59-adjuvanted vaccines were prepared. Recently, single 3.75-μg doses of MF59-adjuvanted vaccines have shown good immunogenicity in young adults. However, the immunogenicity of these vaccines has not been evaluated in dialysis patients.

Methods

Dialysis patients received a single 3.75-μg dose of MF59-adjuvanted vaccine by intramuscular injection. For immunogenicity assays, serum samples were obtained before vaccination and 28 days after vaccination. All sera were tested by hemagglutination inhibition assays.

Results

Overall, 48 hemodialysis (HD) patients and 34 peritoneal dialysis (PD) patients were included in immunogenicity analysis. In HD patients, geometric mean titers (GMTs) were significantly increased compared with baseline GMTs in both young (aged 18–60 years) and elderly (aged ≥60 years) patients (51.2 ± 51.4 vs. 14.1 ± 20.7 in young patients, P = 0.012; 37.9 ± 73.9 vs. 6.8 ± 8.0 in elderly patients, P = 0.018, respectively). The rates of seroprotection and seroconversion were 27.6 and 17.2 % in young patients and 31.6 and 26.3 % in elderly patients, respectively. Among PD patients, GMTs were increased only in young patients (39.8 ± 51.4 vs. 6.8 ± 5.0, P = 0.001). The rates of seroprotection and seroconversion were 36.0 and 36.0 % in young patients and 11.1 and 0.0 % in elderly patients, respectively.

Conclusion

A single 3.75-μg dose of MF59-adjuvanted vaccine was suboptimal to elicit protective antibody response in dialysis patients. Antibody responses against vaccine were compromised especially in elderly PD patients. Trials of different vaccination protocols such as a two-dose schedule or a higher hemagglutinin antigen dose of MF59-adjuvanted vaccine are necessary for improving antibody response in dialysis patients.     

Endothelial dysfunction, inflammation and malnutrition markers as predictors of mortality in dialysis patients: multimarker approach

Backgrounds

Cardiovascular disease is reported to be major cause of mortality in dialysis patients. Multimarker approach is new approach in risk stratification. Creating a common predictive value, many different pathophysiological components are covered. The aim of this study was to examine the combined predictive value of markers of endothelial dysfunction (ADMA), inflammation (CRP, SAA) and malnutrition (albumin) in dialysis patients.

Methods

In this prospective 3-year follow-up study, 153 prevalent patients (105 males and 48 females) on hemodialysis were included. ADMA were measured by HPLC; CRP and SAA were measured using immunonephelometric assays. Albumins were measured by the use of standard methods on the automated analyzer. The patients were stratified into five groups based on the presence of 1, 2, and 3 or more risk markers, respectively, namely high ADMA (≥0.49 μmol/L), high CRP (≥6.0 mg/L), high SAA (≥7.6 mg/L) and low albumin (<30.3 g/L).

Results

The patients with 1, 2, 3 or more risk markers had an adjusted hazard ratio (HR) of 2.419 (0.728–8.034), 6.720 (2.100–21.503), 10.455 (3.193–24.227), respectively, for mortality, compared to those without risk markers. The patients with 1, 2, 3 or more risk markers had an adjusted HR of 1.838 (0.307–11.006), 9.924 (2.052–28.003), 14.823 (0.2.962–34.189), respectively, for cardiovascular mortality than those without risk markers.

Conclusions

The results of this study demonstrate that the common predictive value of several markers is higher than individual predictive value of examined risk factors. Patients with multiple risk factors had higher mortality. Multimarker approach provides an opportunity for better risk stratification in dialysis patients.     

An algorithm using the early changes in PINP to predict the future BMD response for patients treated with daily teriparatide

Summary

About two thirds of patients with a procollagen type I N-terminal propeptide (PINP) increase of >80 μg/l at 1 month after starting teriparatide therapy showed a ≥10 % increase in lumbar spine (LS) bone mineral density (BMD) from baseline at 12 months. We recommend this algorithm as an aid in the clinical management of patients treated with daily teriparatide.

Introduction

An algorithm using PINP is provided in osteoporotic patients with teriparatide treatment. The correlations between the early changes in PINP and the subsequent BMD changes after daily teriparatide therapy were studied to develop an algorithm to monitor patients.

Methods

We evaluated whether early changes in PINP correlated with the changes in BMD at 12 months and developed an algorithm using the early changes in PINP to predict the upcoming BMD increases.

Results

The highest correlation coefficient for the relationship between PINP and LS BMD response was determined for the absolute change in PINP at 1 month and the percent change in LS BMD at 12 months (r?=?0.36, p <0.01). Using a receiver operator curve analysis, we determined that an 80 μg/l increase in PINP was the most convenient predictor of a 10 % increase in LS BMD from baseline (area under curve?=?0.72). Using a cut-off value of 80 μg/l, the positive predictive value for predicting a 10 % increase in LS BMD from baseline to 12 months was 65 %.

Conclusion

Greater short-term changes in PINP with teriparatide therapy are associated with greater 12-month increases in LS BMD. About two thirds of patients with a PINP increase of >80 μg/l at 1 month after starting treatment showed a ≥10 % increase in LS BMD from baseline at 12 months. We recommend this algorithm as an aid in the clinical management of patients treated with teriparatide.     

High uric acid and low superoxide dismutase as possible predictors of all-cause and cardiovascular mortality in hemodialysis patients

Purpose

We investigated the role of serum uric acid (sUA) and superoxide dismutase (SOD) as predictive factors for mortality in hemodialysis (HD) patients.

Methods

SOD, butyrylcholinesterase, and malondialdehyde were estimated spectrophotometrically and the other parameters by standard procedures. High-sensitive C-reactive protein was assayed by a sandwich ELISA method.

Results

sUA among survivors (112.1 ± 13.82 μmol/L) was significantly lower than in deceased (160.8 ± 16.81 μmol/L, p < 0.001), while SOD was higher in survivors (31.8 ± 6.61 kU/L) than among deceased (20.2 ± 3.03, p < 0.05). Kaplan–Meier survival curves showed the greatest mortality risk in the highest tertile of basal sUA concentration (≥127.11 μmol/L, p < 0.001), and for SOD in the lowest tertile (≤23.83 kU/L, p < 0.05).

Conclusion

Our results suggest that high sUA and low SOD may predict all-cause and cardiovascular mortality in HD patients.     

Efficacy and safety of darbepoetin alfa for anemia in children with chronic kidney disease: a multicenter prospective study in Japan

Background

We evaluated the safety and efficacy of darbepoetin alfa (DA), an attractive alternative to recombinant human erythropoietin (rHuEPO) in managing renal anemia, in Japanese children with chronic kidney disease (CKD) on peritoneal dialysis (PD) and hemodialysis (HD), and not on dialysis (ND).

Methods

A total of 31 pediatric CKD patients (13 PD, 2 HD, and 16 ND) were enrolled. DA was administered bi-weekly intravenously (IV) or subcutaneously (SC) for PD or ND patients, and weekly IV for HD patients for 24 weeks. The target Hb was defined as 11.0 to ≤13.0 g/dl. In patients receiving rHuEPO, the initial DA dose was calculated at 1 μg DA for 200 IU rHuEPO. The initial DA dose for naïve patients was determined by body weight, and intended not to exceed 0.5 μg/kg per administration. For some PD or ND patients, the dosing frequency was subsequently changed to once every 4 weeks.

Results

Mean Hb values increased from 10.5 ± 1.1 to 11.1 ± 1.1 g/dl after 4 weeks of DA treatment. The target Hb was achieved in all patients, 64.5 % of whom maintained the value at completion of the study. Hb responses were similar between IV and SC. The dosing frequency was extended to once every 4 weeks in 37.9 % of PD or ND patients. Eighty-seven adverse events were noted in 27 (87.1 %) of 31 patients, none of which were associated with DA.

Conclusion

These results suggest that IV or SC administration of DA is an effective and safe treatment for renal anemia in Japanese children with CKD.     

Acidosis and coma in adult diabetic maintenance dialysis patients with extreme hyperglycemia

Background

Extreme hyperglycemia (serum glucose ≥ 800 mg/dL or 44.4 mmol/L) is infrequently associated with impaired consciousness in patients on maintenance dialysis. The purpose of this study was to determine features of extreme hyperglycemia that bring about coma in dialysis patients who do not have any of the potential conditions, other than hyperglycemia, that can affect the sensorium.

Methods

We analyzed 24 episodes of extreme dialysis-associated hyperglycemia in men who did not have neurological disease or sepsis. We compared serum parameters related to hyperglycemia between a group of 12 patients (8 on peritoneal dialysis, 4 on hemodialysis) who were alert and oriented (group A) and another group of 12 patients (5 on peritoneal dialysis, 7 on hemodialysis) who displayed varying degrees of impairment of sensorium, ranging from drowsiness to coma (group B).

Results

Group B had, in the serum, lower total carbon dioxide (TCO₂, 8 ± 4 vs. 20 ± 3 mmol/L, P < 0.01) and higher anion gap (AG, 32 ± 8 vs. 15 ± 4 mEq/L, P < 0.01) and potassium (6.3 ± 1.5 vs. 4.6 ± 1.0 mEq/L, P < 0.05) than group A. Serum levels of glucose, chloride, urea nitrogen, calculated osmolarity and tonicity did not differ between the two groups. The test for serum ketone bodies was positive only in group B (all patients). Stepwise multiple linear regression identified serum TCO₂ and AG as the only predictors of impaired sensorium (r ² = 0.74. P < 0.01).

Conclusion

There is a strong statistical association between the severity of diabetic ketoacidosis (DKA) and the level of impairment of consciousness in patients on dialysis with extreme hyperglycemia and no neurological or infectious disease. This association suggests that the presence or absence of DKA is usually the primary etiologic factor in the development of impaired sensorium in these patients.