Akiyasu Tsuchida

Ankle-Brachial Blood Pressure Index Predicts All-Cause and Cardiovascular Mortality in Hemodialysis Patients

A reduction in ankle-brachial BP index (ABPI) is associated with generalized atherosclerotic diseases and predicts cardiovascular mortality and morbidity in several patient populations. However, a large-scale analysis of ABPI is lacking for hemodialysis (HD) patients, and its use in this population is not fully validated. A cohort of 1010 Japanese patients undergoing chronic hemodialysis was studied between November 1999 and May 2002. Mean age at entry was 60.6 +/- 12.5 yr, and duration of follow-up was 22.3 +/- 5.6 mo. Patients were stratified into five groups (< 0.9, > or = 0.9 to < 1.0, > or = 1.0 to < 1.1, > or = 1.1 to < 1.3, and > or = 1.3) by ABPI measured at entry by an oscillometric method. The frequency distribution of ABPI was 16.5% of patients < 0.9, 8.6% of patients > or = 0.9 to < 1.0, 16.9% of patients 1.0 > or = to < 1.1, and 47.0% of patients > or 1.1 to < 1.3, whereas 10.9% of patients had an abnormally high ABPI (> or = 1.3). The relative risk of a history of diabetes mellitus (DM), cardiovascular, and cerebrovascular disease was significantly higher in patients with lower ABPI than those with ABPI > or = 1.1 to <1.3. During the study period, 77 cardiovascular and 41 noncardiovascular fatal events occurred. On the basis of Cox proportional hazards regression analysis, ABPI emerged as a strong independent predictor of all-cause and cardiovascular mortality. After adjustment for confounding variables, the hazard ratio (HR) for ABPI < 0.9 was 4.04 (95% confidence interval, 2.38 to 6.95) for all-cause mortality and 5.90 (2.83 to 12.29) for cardiovascular mortality. Even those with modest reductions in the ABPI (> or = 0.9 to <1.1) appeared to be at increased risk. Patients having abnormally high ABPI (> or = 1.3) also had poor prognosis (HR, 2.33 [1.11 to 4.89] and 3.04 [1.14 to 8.12] for all-cause and cardiovascular mortality, respectively). Thus, the present findings validate ABPI as a powerful and independent predictor for all-cause and cardiovascular mortality among hemodialysis patients.

Evaluation of Blood Coagulation-Fibrinolysis System in Patients Receiving Chronic Hemodialysis

We determined plasma levels of thrombomodulin, thrombin-antithrombin III complex (TAT), protein C, protein S, and plasmin-alpha 2 plasmin inhibitor complex (PIC) before and after hemodialysis in 54 patients receiving chronic hemodialysis, to evaluate the blood-coagulation system and to evaluate the antithrombogenicity of various dialyzer membranes. Predialysis levels of thrombomodulin and TAT were both significantly increased compared with normal control values, but levels of protein C, protein S, and PIC were not changed. In patients dialyzed with ethylene vinyl alcohol (EVAL) and polysulfone membranes, postdialysis levels of thrombomodulin, TAT, protein C, protein S, and PIC were not significantly different from the predialysis levels. However, in patients dialyzed with regenerated cellulose and polymethyl-methacrylate (PMMA) membranes, postdialysis levels of thrombomodulin, TAT, and PIC were significantly higher than predialysis levels. We conclude that patients on maintenance hemodialysis were considered to be in a state of hypercoagulability before hemodialysis, and a single hemodialysis session using regenerated cellulose and PMMA membrane may have caused injury to vascular endothelial cells, hypercoagulability, and enhancement of fibrinolytic activity.

Comparison of the efficacy of an oral calcitriol pulse or intravenous 22-oxacalcitriol therapies in chronic hemodialysis patients.

Background1,25-dihydroxy-22-ovavitamin D3 (22-oxacalcitriol, OCT) was recently introduced commercially as an analogue of 1,25 (OH)2 vitamin D3, but one which has less pronounced calcemic activity.MethodsTo examine the efficacy and tolerability of OCT, 46 hemodialysis patients with secondary hyperparathyroidism were randomly assigned to receive either intravenous OCT or oral calcitriol pulse therapies. The patients were monitored for serum calcium, phosphate, intact parathyroid hormone (PTH), and bone alkaline phosphatase (BAP) for 24 weeks. The efficacy of intravenous OCT was also examined in 24 additional patients who were refractory to oral calcitriol pulse therapy.ResultsIn the randomized trial, intact PTH levels were significantly suppressed within 4 weeks after the initiation of each therapy, and this effect was well maintained thereafter in both treatment groups. While intact PTH was significantly lower at 4 weeks in the calcitriol pulse group than in the OCT group (P = 0.02), no statistical differences were observed during later treatment periods. BAP was reduced equally by each treatment. At 4 weeks (P = 0.02) and thereafter (P = 0.06), serum calcium was higher among calcitriol-treated patients than among those who received OCT treatment. Eight of 24 patients who were refractory to oral calcitriol pulse therapy responded to intravenous OCT. The patients who responded tended to have lower serum intact PTH and phosphorus levels and smaller parathyroid glands at the start of OCT treatment than nonresponders.ConclusionsOCT is as effective as oral calcitriol pulse therapy in suppressing intact PTH and BAP in chronic hemodialysis patients. It was confirmed that OCT exhibits less calcemic activity than calcitriol. Moreover, under certain conditions, switching to OCT may help in the treatment of hyperparathyroidism, which is refractory to conventional oral calcitriol pulse therapy.

A patient who had lost taste acuity during captopril treatment recovered it after zinc supplement

アンギオテンシンI変換酵素阻害剤であるcaptopril治療中の血液透析患者に顕著な味覚障害が出現した.その味覚低下はcaptopril投与中止と硫酸亜鉛投与で改善した.症例は33歳, 男性の血液透析患者, 1日量37.5mgのcaptoprilを投与されていた.投与開始7週後より高度味覚障害が出現した.電気味覚計検査では, 右大錐体神経領域, 舌咽神経領域, 鼓索神経領域, 左大錐体神経領域のすべてに反応は消失し, 左舌咽神経領域の味覚閾値は26dBで左鼓索神経領域では30dBだった. すべての領域で基本の4つの味覚, 酸味, 甘味, 辛味, 苦味が障害されていた.血清亜鉛濃度は65μ9/dlでcaptoprilを中止した. 発中止7日目, 味覚は自覚的および電気味覚計検査で軽度改善した. captopril中止65日目の全血亜鉛濃度は361μg/dlで, 硫酸亜鉛1日量150mg経口投与した. 投与6日目の電気味覚計検査ではさらに改善がみられ, 自覚的改善は顕著だった.亜鉛投与33日目の電気味覚計検査では, 味覚脱失部位はなくなった.この症例においては, captopril治療で惹起された亜鉛欠乏が味覚障害の原因と考えられた.