Koji Usui

Frequency of Complications with Prolonged Femoral Vein Catheterization for Hemodialysis Access

Analysis of 120 cases of femoral vein catheterization for > or = 2 days for hemodialysis in 89 hospitalized patients was performed to determine the frequency of catheter-related complications including infection and venous thrombosis. The rate of clinically significant complications was < 3.5% and compared favorably with published complication rates of central vein catheters. We conclude that prolonged femoral vein catheterization for hemodialysis is associated with an acceptably low rate of complications when appropriate techniques for placement and catheter care are followed and should be considered a reasonable option for vascular access in hospitalized patients.

Bone mineral density may be related to atherosclerosis in hemodialysis patients

Biological interactions between the bone and the blood vessels are gradually being clarified. To investigate the relationship between bone mineral density and atherosclerosis in hemodialysis patients, we examined the bone mineral density and the intima-media thickness of the carotid artery in 83 dialysis patients with non-diabetic nephropathy (44 men and 39 women) aged from 23 to 83 years. The duration of hemodialysis ranged from 2 to 344 months. The bone mineral density of the radius was measured by dual-energy X-ray adsorptiometry, and the ratio of this value to the standard value for the same age and gender was calculated (Z-score). As an index of atherosclerosis, the intima-media thickness of the carotid artery was measured by high resolution B-mode ultrasonography. Then the relationship between the Z-score and various factors was examined using Spearmans rank correlation analysis and multiple regression analysis. The Z-score showed a negative correlation with the duration of hemodialysis, the carotid intima-media thickness, and the levels of alkaline phosphatase, intact parathyroid hormone, and low-density lipoprotein cholesterol by Spearmans rank correlation analysis. In addition, the Z-score showed a positive correlation with the lipoprotein (a) level and a negative correlation with the duration of hemodialysis, intima-media thickness, intact parathyroid hormone, and low-density lipoprotein cholesterol by multiple regression analysis. These findings suggest that the decrease of bone mineral density in hemodialysis patients is correlated with secondary hyperparathyroidism and hyperlipidemia, which are factors known to promote atherosclerosis, and thus bone density changes might be related to the progression of atherosclerosis, or vice versa.

Continuous Ambulatory Peritoneal Dialysis Is Superior to Hemodialysis in Chronic Dialysis Patients with Cerebral Hemorrhage

Continuous Ambulatory Peritoneal Dialysis Is Superior to Hemodialysis in Chronic Dialysis Patients with Cerebral Hemorrhage N. Noriaki Yorioka H. Hiroaki Oda T. Takahiko Ogawa Y. Yoshihiko Taniguchi S. Shigeyuki Kushihata A. Atsuo Takemasa K. Koji Usui K. Kenichiro Shigemoto S. Satoru Harada M. Michio Yamakido 2nd Department of Internal Medicine, Hiroshima University School of Medicine, and Ichiyokai Harada Hospital, Hiroshima, Japan

Role of secondary hyperparathyroidism in the development of post-transplant acute tubular necrosis.

Post-transplant cure tubular necrosis (ATN) represents the most frequent cause of delayed graft function in the immediate post-transplant period. Several causes have been associated with the development of post-transplant ATN such as donor and recipient ages, cold-warm ischemia times, HLA mismatches, and postoperative hypotension. In the present study, we retrospectively evaluated the role of secondary hyperparathyroidism and high parathyroid hormone (PTHi) blood levels in the development of post-transplant ATN. One hundred patients submitted to cadaveric renal transplant between January 1992 and March 1993 in our unit were included. Twenty-seven patients (27%) developed post-transplant ATN and seventy-three (73%) did not. Post-transplant ATN was significantly associated with gender (p < 0.01), recipient age (p < 0.01), number of transplantations (p < 0.01), time on hemodialysis (p < 0.001), cold ischemic time (p < 0.05) and PTHi levels (p < 0.001). The bivariate and multivariate statistical analyses demonstrated that the development of post-transplant ATN was significantly more frequent in females; retransplanted patients, patients with a time on dialysis of more than 5 years, recipients over 60 years old, patients with a PTHi blood level higher than 240 pg/ml (4 times normal level) and a cold ischemia time of more than 18 h. Based on these results, we conclude that high PTHi blood levels in the renal transplant recipients represent a relevant factor in the development of post-transplant ATN. The administration of intravenous pulsed of 1,25(OH)2D3 and/or a calcium channel blocker in the perioperative period could be useful to decrease the incidence and severity of post-transplant ATN in these patients.

Plasma thrombomodulin: usefulness as a blood access failure marker in hemodialysis patients.

In 144 patients on hemodialysis (76 males and 68 females, median age 55.7 +/- 14.1 years, mean period on dialysis 44.1 +/- 33.3 months), thrombomodulin was determined by enzyme immunoassay prior to initiation of hemodialysis. The results showed that the mean thrombomodulin value of hemodialysis patients was 13.59 +/- 3.63 ng/ml which was significantly higher than the control value (3.20 +/- 0.90 ng/ml). The thrombomodulin values were significantly higher in patients with blood access failure (15.27 +/- 4.45 ng/ml) than in those without (13.11 +/- 3.31 ng/ml), and the rate of blood access failures was also significantly higher in those with thrombomodulin values of 15.0 ng/ml or higher than in those with values < 15.0 ng/ml. It was evident that there is a higher risk of blood access failure in patients with severe systemic vascular endothelial injury, and thrombomodulin is a useful marker of such an injury.

Effect of rHuEpo Therapy in Dialysis Patients on Endogenous Erythropoietin Synthesis after Renal Transplantation

UNLABELLED We have undertaken a prospective study to examine the effect of recombinant human erythropoietin (rHuEpo) therapy during dialysis on Epo levels after renal transplantation and to evaluate the impact of this therapy on the immediate graft function. Between December 1991 and December 1993, 91 renal transplant recipients were studied. There were 34 females and 57 males and the mean age was 38 years. Forty-two patients were treated during dialysis with rHuEpo due to anemia and 49 patients did not receive it. Endogenous Epo (eEpo), hemoglobin concentration, hematocrit level and serum creatinine were determined on days 0, 2, 4, 8, 15, 30, 60 and 180 after transplantation. Ferritin level was determined pretransplant and on day 60. RESULTS Patients not treated with rHuEpo during dialysis experienced a transient increase in endogenous Epo after renal transplant that was not observed in treated patients (26 +/- 3.3 vs. 9 +/- 1.5 mU/ml, p < 0.001). The eEpo peak was similar in patients with early or delayed graft function (23 +/- 4.3 vs. 32 +/- 5.4 mU/ml, NS). The recovery of the anemia after a successful renal transplant took place in patients treated as well as those not treated with rHuEpo without significant differences. In the treated group, the pretransplant hematocrit level was similar in patients with early or delayed graft function (31 +/- 3.5% vs. 32 +/- 4.8%), but in the untreated group, the hematocrit level was lower in patients with early renal function (28.5 +/- 4% vs. 32 +/- 3%, p < 0.05). However, these patients also had a significantly shorter warm ischemia time (53 +/- 13.8 vs. 64 +/- 14.5 min). Fifty-two percent of the rHuEpo-treated patients and 36% of the untreated patients had delayed graft function. In conclusion, different courses of eEpo levels after renal transplant were observed depending on whether or not patients had been treated with rHuEpo during dialysis. Untreated patients experienced a transient increase which was not observed in the treated group. Immediate or delayed graft function did not modify eEpo levels. No association was found between rHuEpo therapy during dialysis and delayed graft function.

Vitamin K_2 Alters Bone Metabolism Markers in Hemodialysis Patients with a Low Serum Parathyroid Hormone Level

Background: A low level of intact parathyroid hormone (PTH) is an indicator of adynamic bone disease in hemodialysis patients, and is associated with a significant increase of all-cause mortality. Thus, effective treatment for adynamic bone disease is required. We previously investigated the effect of vitamin K2 on adynamic bone disease. In this study, we assessed the efficacy of oral vitamin K2 in a controlled trial. Methods: Forty hemodialysis patients with low intact PTH levels (<100 pg/ml) were randomly divided into two groups, which were a vitamin K2 group receiving oral menatetrenone (45 mg/day) for 1 year and a control group without vitamin K2. Venous blood samples were collected at baseline and during the study for measurement of bone metabolism parameters. Results: Thirty-three patients completed follow-up. There was a significant increase of the serum intact osteocalcin level after 1 month of vitamin K2 administration. Serum levels of intact PTH, bone alkaline phosphatase, and cross-linked N-terminal telopeptide of type I collagen increased significantly after 12 months in the vitamin K2 group. The serum osteoprotegerin level was decreased after 12 months in the vitamin K2 group, but the change was not significant. Conclusion: Vitamin K2 therapy improves bone remodeling in hemodialysis patients with a low intact PTH level.

Hepatocyte growth factor in nephronophthisis-medullary cystic disease complex

Abstract. A 13-year-old Japanese girl presented with severe anemia and renal dysfunction. The nephronophthisis-medullary cystic disease complex was diagnosed from the results of renal biopsy and a family study. Immunohistochemical detection of hepatocyte growth factor in the epithelial cells of dilated renal tubules suggested that it may have a role in the development of the tubular cystic changes which are characteristic of this disease.

A case of renovascular hypertension with marked polyuria after percutaneous transluminal renal angioplasty.

A 43-year-old female patient with hypertension was diagnosed as having one-kidney renovascular hypertension with dysfunction of the contralateral kidney, and percutaneous transluminal renal angioplast

Development of Multiple Myeloma in 2 Patients with Chronic Pyelonephritis and Long-Term Hemodialysis Treatment

Dr. Rumiana Boneva, Medical University, Department of Nephrology, G. Kochev str. 8, Pleven 5800 (Bulgaria) Dear Sir, Different internal (age, sex, race) and external (chronic antigen stimulation, radiation, drugs) factors are discussed in the etiology ofmultiple myeloma [1]. A review of the literature indicates the acceptance that chronic infections could lead to a local plas-mocyte infiltration which may be followed by a malignant transformation [1-5]. To the best of our knowledge there is no published report of a myeloma in patients with chronic pyelonephritis and dialysis treatment. We report 2 cases with chronic pyelonephritis and chronic renal failure (CRF) where myeloma has been diagnosed in the course of maintenance hemodialysis. The first case was a 52-year-old female admitted to the clinic of nephrology in September 1982 with CRF (creatinine 568 μmol/l). Examinations showed latent chronic pyelonephritis. One year later her creatinine climbed to 986 μmol/l and she was placed on chronic hemodialysis. In the following years many complications occurred: chronic pericarditis, viral hepatitis B, stomach resection for a hemorrhagic erosive gastroduodenitis, cirrhosis of the liver. In 1991 the patient’s state worsened – there were frequent gastrointestinal hemorrhages and manifestations of congestive heart failure. Tests performed on hospital admission showed Hb 50 g/l, total protein 80 g/l, para-proteinemia, 80% of the bone marrow substrate in a myelogram, myeloma cells Mar-shalko type, IgG (lambda) from the immu-noelectrophoresis. Polychemotherapy was not instituted because there were contraindications. Two months after diagnosing the myeloma the patient died of congestive heart failure. Pathoanatomically chronic pyelonephritis with nephrosclerosis, heart hypertrophy and dilatation, cirrhosis of the liver, ascites, multiple myeloma with infiltration of bone marrow and spleen were found. The second case was a 66-year-old male with a history of pulmonary tuberculosis in his youth, elimination of a stone from his left kidney in 1972, and frequent urinary infections. In 1986 a nonfunctioning left kidney and CRF (creatinine 275 μmol/l) were noted. In July 1987 the patient underwent right nephrostomy on account of anuria. Histologi-cally, he proved to have active chronic pyelonephritis and no evidence of renal tuberculosis. One month later he began chronic hemodialysis for terminal renal failure. During the following years the patient