Upper gastrointestinal findings in chronic renal failure

Twenty-nine patients with chronic renal failure were examined both during the predialytic stage and after active treatment (dialysis, transplantation) for upper GI diseases. They underwent a gastric dose-response secretion test, gastroduodenoscopy, radiologic upper GI series, and fasting serum gastrin determination. Upper GI diseases increased in the active treatment stage. At the time of examination, patients with these diseases had a positive ulcer history, duodenitis, duodenogastric reflux, and blood group O more often in the predialytic stage. Their stimulation sensitivity to pentagastrin and their acid secretion capacity were greater, and they were less achlorhydric. Their fasting serum gastrin level was also lower. They had less endoscopically discovered gastritis, but microscopically, with regard to gastritis, they did not differ from those who did not develop upper GI complications. In conclusion, in chronic renal failure upper GI findings increase after the active treatment. Secretion tests and endoscopy performed before active treatment give an indication of those who will develop upper GI complications during active treatment.     

Upper gastrointestinal bleeding in patients with chronic renal failure

Endoscopy to evaluate upper gastrointestinal bleeding was done for 482 patients over a 42-month period. Fifty-nine patients (12%) had chronic renal failure and upper gastrointestinal bleeding; the remaining 423 did not have renal failure. Angiodysplasia of the stomach or duodenum was the most frequent source of bleeding in patients with renal failure. Angiodysplasia (p less than 0.001) and erosive esophagitis (p less than 0.01) were significantly commoner causes of bleeding in the renal failure population than in the group without renal failure. Recurrent bleeding was also more frequent in patients with renal failure (25%) than in the other patients (11%). Angiodysplasia was the most frequent source of recurrent bleeding in patients with renal failure (53%) whereas peptic lesions were the most likely sources in those without renal failure (51%). These data show that the differential diagnoses of first and subsequent upper gastrointestinal bleeding sites differ for patients with and without chronic renal failure.     

The analysis of gastrointestinal amyloidosis in 78 patients with chronic renal failure.

Systemic amyloidosis is not a single disease, but the product of a variety of diseases. Amyloid proteins are insoluble fibrils that are deposited extracellularly in many organ tissues. They stain with Congo red and appear apple green under polarized light. Definitive diagnosis and classification ofamyloidosis requires histologic examination of tissue samples. Gastrointestinal tract involvement is common, and all parts of the system can be affected Immunohistochemical studies have shown that amyloid deposited in the gastrointestinal system is most often of the AA, A kappa, or A lambda types. Another type of amyloidprotein, beta-2 microglobulin (beta2M), predominantly affects the musculoskeletal system, and is usually seen in patients who have been on long-term hemodialysis. Mixed systemic amyloidosis (beta2M and AA) is seen only rarely in these patients. In this study, we attempted to answer why this is so, and examined whether or not mixed amyloidosis is related to amyloidogenesis. We studied gastrointestinal tissues from 78 chronic renal failure patients who had systemic amyloidosis with gastrointestinal involvement. A total of 115 endoscopic samples and 1 jejunal resection specimen were analysed immunohistochemically. Immunohistochemical testing using a panel of antisera directed against two major amyloid fibril proteins (AA-Monoclonal, Dako-, and beta2M-Polyclonal, Dako-) showed that all samples contained AA amyloid, but not beta2M type protein. These findings can be explained by the patients' relatively short average duration of hemodialysis and the predominance of endoscopic biopsy samples in our study.     

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.     

The analysis of gastrointestinal amyloidosis in 78 patients with chronic renal failure

Systemic amyloidosis is not a single disease, but the product of a variety of diseases. Amyloid proteins are insoluble fibrils that are deposited extracellularly in many organ tissues. They stain with Congo red and appear apple green under polarized light. Definitive diagnosis and classification of amyloidosis requires histologic examination of tissue samples. Gastrointestinal tract involvement is common, and all parts of the system can be affected. Immuno–histochemical studies have shown that amyloid deposited in the gastrointestinal system is most often of the AA, A kappa, or A lambda types. Another type of amyloid protein, beta–2 microglobulin (β2M), predominantly affects the musculoskeletal system, and is usually seen in patients who have been on long–term hemodialysis. Mixed systemic amyloidosis (β2M and AA) is seen only rarely in these patients. In this study, we attempted to answer why this is so, and examined whether or not mixed amyloidosis is related to amyloidogenesis.

We studied gastrointestinal tissues from 78 chronic renal failure patients who had systemic amyloidosis with gastrointestinal involvement. A total of 115 endoscopic samples and 1 jejunal resection specimen were analysed immunohistochemically. Immunohistochemical testing using a panel of antisera directed against two major amyloid fibril proteins (AA–Monoclonal, Dako–, and β2 MPolyclonal, Dako–) showed that all samples contained AA amyloid, but not β2M type protein. These findings can be explained by the patients' relatively short average duration of hemodialysis and the predominance of endoscopic biopsy samples in our study.     

Endoscopic management of mucosal lesions in the gastrointestinal tract

With the increasing role of endoscopy in patient evaluation, more mucosal lesions, including gastric, duodenal and colonic polyps, are encountered during routine examinations. It is imperative for gastroenterologists to become familiar with the endoscopic management of these various gastrointestinal lesions. In this article, various resection techniques will be discussed, including hot/cold forceps polypectomy, hot/cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection. The article will also discuss the evidence regarding the efficacy and safety of these techniques and the future direction of endoscopic management of mucosal lesions in the gastrointestinal tract.     

Regular hemodialysis reverses gastric mucosal atrophy of patients with chronic renal failure

BACKGROUND/AIMS: Gastric mucosa of patients with chronic renal failure on regular hemodialysis is known to retain fundic glands relatively intact, but no evidence for regeneration of fundic glands by hemodialysis has been provided to date. This study was performed to investigate endoscopically and histopathologically if hemodialysis to treat renal failure would regenerate the background gastric mucosa and to elucidate factors associated with the mucosal regeneration. METHODOLOGY: First, the relationship between duration of hemodialysis and the degree of atrophy of the background gastric mucosa was investigated in patients with chronic renal failure treated and not treated by hemodialysis. Treated patients were further divided into long-term group treated for 4 years or longer and short-term group treated for shorter than 4 years. The degree of atrophy of gastric mucosa was evaluated by hematoxylin-eosin staining, PAS-alucian blue staining and immunohistochemical staining to detect Ki-67 expression using biopsy specimens obtained from gastric mucosa. The labeling index is the proportion of positively labeled cells with respect to the total number of cells. The proliferative index was calculated by multiplying the labeling index and the proliferative zone (length of the area between the uppermost and lowest labeled cells). Serum gastrin, glucagon and cholecystokinin were assayed as well as urine epidermal growth factor to elucidate factors associated with regeneration of gastric mucosa. Helicobacter pylori infection was examined by ELISA. RESULTS: In the long-term group, the degree of atrophy of gastric mucosa was endoscopically evaluated to be C1 type. In both of the two hemodialysis groups, endoscopically identified fundic gland region was histologically confirmed to be fundic glands by both hematoxylin-eosin staining and PAS-alucian blue staining. Epithelial cell proliferative index was significantly higher in long-term and short-term hemodialysis group than non-hemodialysis group (P=0.0001). No significant difference in serum gastrin, glucagon and cholecystokinin as well as urine epidermal growth factor was detectable among the three groups. Most patients of both hemodialysis groups were H. pylori-negative. CONCLUSIONS: A possibility of regeneration of the background gastric mucosa in proportion to the duration of hemodialysis was suggested on the basis of histopathological evidence. The observed regeneration of gastric mucosa was ascribable to elimination of factors associated with atrophy of gastric mucosa including H. pylori by hemodialysis.     

Endocrine abnormalities in chronic renal failure.

Much needs to be achieved in improving survival and quality of life for chronic renal failure patients. Progress in attaining this goal may accrue from attention to underlying pathophysiologic processes early and throughout a person's life. The endocrine perturbations described in this article--alterations in the homeostasis of phosphorus, calcium, vitamin D and parathyroid hormone; erythropoietin deficiency; and sexual dysfunction in uremia--provide good examples for the need to identify early and manage prospectively over time manifestations of chronic renal failure. The complexity of the skeletal and extraskeletal sequelae of dysregulated mineral metabolism and the complications of chronic anemia have been discussed, while stressing possible implications of these endocrine abnormalities for both morbidity and mortality. There is a great need for more randomized clinical trials to evaluate new and old treatment approaches, with the goal of developing better evidence-based practice guidelines.     

Acute pseudogout in chronic renal failure.

Acute pseudogout (calcium pyrophosphate dihydrate deposition disease [CPPD disease]) developed in two patients with chronic renal failure. The disease had atypical features. The calcification of the involved joints was more diffuse than the usual linear stippled calcification. The first patient, age 39, was young to have pseudogout. The second patient had pseudogout and chondrocalcinosis limited to the elbow. Review of wrist roentgenograms of 82 patients (mean age, 49.0 years), undergoing hemodialysis for chronic renal failure revealed three patients (a 3.7% incidence) with chondrocalcinosis. The incidence increased to three of 19 (15.8%) in the patients over the age of 60. Although considered uncommon, pseudogout may cause acute arthritis in chronic renal failure more often than previously suspected. Joint aspiration and identification of CPPD cystals with compensated polarized light microscopy will establish the diagnosis of pseudogout.     

上消化道急性应激性粘膜病变出血的内镜诊断和治疗

目的 探讨上消化道急性应激性粘膜病变出血患者的内镜诊断和治疗。方法 对上消化道急性应激性粘膜病变出血患者在24小时内急查内镜,并进行镜下止血及其他治疗。结果 30例患者中一般性出血20例,大出血10例,其病变内镜下表现为6种类型。单纯内镜下止血7例全部有效,内镜下止血加静脉止血治疗10例亦全部成功,内镜下止血加静脉止血加经胃管止血治疗10例中8例有效、死亡2例,有3例重症患者虽经内、外科综合治疗仍死亡2例。结论 急诊内镜不仅是上消化道急性应激性粘膜病变出血准确可靠的诊断手段,而且也是快速有效的治疗方法。     

Serum somatomedin A in chronic renal failure.

The serum levels of somatomedin A, determined by radioreceptor assay, were significantly higher in 57 adult patients with chronic renal failure (X = 2.57 +/- 0.12 U/ml) than in healthy subjects (n = 131; X = 0.77 +/- 0.02 U/ml). A positive correlation was found between somatomedin A and creatinine levels (r = 0.33), but somatomedin A levels did not decrease after hemodialysis. A reduction was only observed after successful renal allografting. Immunoreactive somatomedin A was also found to be increased in patients with chronic renal failure (X = 2.61 +/- 0.21 U/ml), whereas low levels were obtained by the chick bioassay. However, after separating the inhibitory factors from the stimulatory factors by gel chromatography at neutral pH, uremic serum was shown to contain increased levels of somatomedin activity. Although all somatomedin A, determined by different techniques, was present in high molecular forms, the elution pattern differed from that seen in patients with acromegaly.     

Left ventricular function in chronic renal failure.

Left ventricular function was studied in 14 patients with end-stage chronic renal failure using non-invasive methods (echocardiography and systolic time intervals). Patients were divided into 3 groups. Group 1 consisted of 5 patients who were normotensive at the time of study and group 2 of 7 patients who were hypertensive when studied. Group 3 consisted of 2 patients: one was receiving propranolol and the other, studied 302 days after renal transplantation, was receiving digitalis for recurrent episodes of cardiac failure. All except the patient receiving propranolol had normal left ventricular function in systole with normal measurements of fractional fibre shortening (% delta S, EF) and normal measurements relating to the velocity of ventricular contraction (mean Vcf, mean velocity of posterior wall motion). Stroke volume and cardiac output were normal in some patients but were increased in patients with fluid overload. Early diastolic compliance of the left ventricle seemed to be normal except in the patient with recurrent cardiac failure. The study provided no evidence for the existence of a specific uraemic cardiomyopathy.     

Helicobacter pylori status and esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis

Objectives  

The aim of this study was to elucidate the impact of Helicobacter pylori infection on esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis (HD).     

Serum lipase activity in chronic renal failure.

In a total of 110 patients with chronic renal failure, 46.4% of the cases had a serum lipase activity exceeding 200 IU, the upper limit of the norm. The degree of reduction of renal function is positively correlated to the frequency of hyperlipasaemia as well as to the elevation of the lipase activity in serum. At a glomerular filtration rate (GFR) of less than 20 ml/min, hyperlipasaemia in chronic glomerulonephritis was found in 75%, significantly more frequent than in chronic pyelonephritis (46.8%). The frequency and degree of hyperlipasaemia was not influenced by haemodialysis. Significantly elevated serum lipase activities were also observed in experimentally produced chronic renal failure in the rat.