Tadanobu Goya

Hip arthroplasty in haemodialysis patients

We retrospectively reviewed 17 hip arthroplasties in 15 patients having haemodialysis for chronic renal failure. The duration of haemodialysis before the operation averaged 8.6 years and the average age of the patients was 61 years. All patients were followed for more than two years (mean 4.6 years). Six arthroplasties in four patients had failed due to loosening, and one of these patients died from undiagnosed infection of both hips at 7.6 years after the operation. General skeletal abnormalities caused by maintenance haemodialysis may explain the high incidence of loosening and it is important to be aware of the danger of postoperative infection. The risk-to-benefit ratio of hip arthroplasty is high in patients on haemodialysis.

Destructive spondylo-arthropathy during long-term haemodialysis

We reviewed 29 patients who had developed destructive arthropathy of the spine during long-term haemodialysis. Their mean age when haemodialysis began was 43.8 years; at diagnosis they had been dialysed for an average of 8.6 years. In 26 patients, the lesions were between C4 and C7; in six they were between L4 and S1, three having lesions in both regions. Sixteen patients had had previous surgery for carpal tunnel syndrome. Spinal surgery was performed in nine patients with satisfactory results in only five. We demonstrated beta-2 microglobulin amyloid deposits in the discs and surrounding ligaments in all biopsied cases. The natural history and management of this condition are not yet clear.

Effects of a parathyroidectomy on the immune system and nutritional condition in chronic dialysis patients with secondary hyperparathyroidism

BACKGROUND Parathyroid hormone (PTH) has an adverse effect on the immune system and may cause immunologic disorders in patients with chronic renal failure. The in vivo effects of a parathyroidectomy on the immunologic parameters was examined. METHODS Thirty-four patients under dialysis therapy received a parathyroidectomy (PTx) for secondary hyperparathyroidism (HPT). They were prospectively studied regarding serum immunoglobulins, complements, CD markers, and serum soluble IL-2 receptor (sIL-2R) until 12 months after PTx. RESULTS The serum levels of IgG, IgA and IgM showed significant increase until 12 months after PTx (P<0.001, respectively). C3, C4, and CH50 also indicated significant increase at 12 months after PTx. In cellular immunity, only serum sIL-2R showed significant increase 2 weeks after PTx (P = 0.028). The hematocrit and serum albumin also improved significantly at 12 months. CONCLUSIONS PTx showed beneficial effects on humoral immunological markers. The effects are probably due to the remarkable PTH reduction and partly improved nutritional state after PTx.

Early development of Epstein-Barr virus-associated T-cell lymphoma after a living-related renal transplantation.

We herein report a case of Epstein-Barr virus (EBV)-associated T-cell lymphoma that developed within a month after a kidney transplantation. The recipient was a 37-year-old man who had evidence of a previous EBV infection. Cyclosporine, methylprednisolone, and azathioprine were used for immunosuppression, and acute rejection was treated with high-dose methylprednisolone. The lactate dehydrogenase level started to increase on day 24 and thereafter peaked on day 37 while also demonstrating progressive jaundice and a bleeding tendency. A transplant nephrectomy was done on day 37; however, the patient could not recover and eventually died of respiratory failure as a result of diffuse pulmonary edema. A pathological examination of the resected kidney revealed a diffuse proliferation of large atypical lymphoid cells in the parenchyma. Immunohistochemically, the tumor cells were positive for CD45 and T-cell marker, CD45RO, but negative for B-cell markers. EBV-encoded RNA was demonstrated within the neoplastic cells by in situ hybridization.

Early effects of parathyroidectomy on erythropoietin production in secondary hyperparathyroidism

BACKGROUND Secondary hyperparathyroidism (2-HPT) has an adverse effect on renal anemia and may cause a hyporesponsiveness to recombinant human erythropoietin (rHuEpo) in patients with chronic renal failure. The early effects of parathyroidectomy (PTx) on renal anemia, erythropoietin production, and nutritional state were examined. METHODS Twenty-nine patients under hemodialysis therapy received a PTx for 2-HPT. They were prospectively studied regarding hematological parameters, rHuEpo use, plasma erythropoietin levels, and nutritional condition until 12 months after PTx. RESULTS The hemoglobin level showed a significant increase from 3 months after PTx (10.2% +/- 1.5% to 11.2% +/- 1.3%; P <0.01), associated with a consistent increase of the reticulocyte count. These changes lasted until 12 months after PTx. The plasma erythropoietin level showed a gradual increase of up to about 5 times the level of the preoperative value, until 12 months after PTx (22.6 +/- 10.1 to 106.3 +/- 112.1 mU/mL; P <0.001). The weekly dose of rHuEpo administration decreased after 3 months. The serum levels of albumin and total protein also significantly and gradually improved until 12 months after PTx. CONCLUSIONS PTx caused a significant early improvement in renal anemia in patients with secondary hyperparathyroidism. This effect may be caused by an enhanced erythropoietin production and may also be partially due to the improved nutritional state after PTx.

Superficial repositioning of the artery for chronic hemodialysis: Indications and prognosis

Superficial repositioning of the artery (SRA) is a modality of the blood access operation for chronic hemodialysis that has been previously used in cases of cardiac failure. We performed 42 SRAs from 1986 to 1993; thereafter, we retrospectively investigated the operative indications, postoperative complications, and long-term results. Superficial repositioning of the artery was indicated for the lack of an appropriate vein (17 cases; 40%), frequent and early access failure due to arteriovenous fistula or polytetrafluoroethylene grafts (six cases; 14%), venous hypertension (five cases; 12%), and cardiac failure (two cases; 5%). The patency rates of the SRAs were 87% at 3 years and 58% at 4.5 years. There was some difficulty in finding the returning veins in five of 28 functioning SRAs (18%). The SRA is thus considered to be a secondary-selected blood access operation; however, it also may be used as an efficient blood access for an extended period of time without any serious complications.

ADULT RESPIRATORY DISTRESS SYNDROME ASSOCIATED WITH CRUSH SYNDROME

Gakusen Nishihara, MD, Kidney Center, Saiseikai Yahata Hospital, 5-9-27 Harunomachi, Yahatahigashi-ku, Kitakyushu, Fukuoka 805 (Japan) Dear Sir, Crush syndrome with muscle trauma or compression is a well-known cause of acute renal failure (ARF). Except for ARF, other organ failure is an uncommon complication if other sequelae, such as sepsis and multiple organ failure (MOF), can be prevented. We herein report a case of ARF with adult respiratory distress syndrome (ARDS) associated with crush syndrome. A 33-year-old female without any medical history was referred from another hospital because of anuria for 24 h. Three days previously, she had slipped and fallen on the pavement and had been accidentally trapped for 1 h and 45 min under an open door of the car in which she had been about to ride. Physical examination at the time of admission to our hospital disclosed a conscious woman; temperature 37.4°C, heart rate 94 beats/min, and blood pressure 116/ 70 mm Hg. There were signs of extensive compression with abrasions on the trunk and limbs. A chest X-ray revealed a fracture of the right 9th rib and the left 6th rib but no damage to the bilateral lungs. Abdominal computed tomography scan showed no abnormality of the abdominal organs but indicated edema of the iliopsoas muscle. Laboratory studies showed: hemoglobin 7.5 g/dl, hematocrit 21.7%, white cell count 25,500/ μl, platelets 20.1 × 104/μl, blood urea nitrogen 81 mg/dl, serum creatinine 9.0 mg/dl, Na 138 mEq/1, K 5.0 mEq/1, bicarbonate 18.0mEq/l, creatine phosphokinase (CPK) 39,000 IU/1, myoglobin 22,000 ng/l, aspar-tate aminotransferase 1,689 IU/1, alanine aminotransferase 298 IU/1, lactate dehydro-genase 4,010 IU/1. ARDS v V HD ψψi^ψiψψψψψiCr (mg/dl) ECUM ↓ ↕ CPK (lU/i) 50,000 BW (kg) CTR (%) 56 i–i–i–i–i–i–i–i–i–i–i–γt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 (days)

END-STAGE RENAL DISEASE IN A PATIENT WITH WERNER'S SYNDROME

Gakusen Nishihara, MD, Kidney Center, Saiseikai Yahata Hospital, 5-9-27 Harunomachi, Yahatahigashi-ku, Kitakyushu, Fukuoka 805 (Japan) Dear Sir, Werner’s syndrome is a rare autosomal recessive disorder characterized by premature aging. The clinical feature of this syndrome includes short stature, premature cataracts, skin atrophy, osteoporosis, graying and loss of hair, neoplasia, diabetes mellitus and atherosclerosis [1]. Kidneys with gross impairment are rarely involved and, as far as we know, only 1 case with widespread vascular disease has been reported to die in uremia [2]. We herein present a case of Werner’s syndrome complicated by end-stage renal disease (ESRD) maintained on hemodialysis. A 51-year-old male was referred to our hospital because of chronic renal failure. He had a medical history of bilateral cataract extractions at the age of 37, established pro-teinuria at the age of 44, partial thyroidecto-my due to a thyroid carcinoma at the age of 46, intracranial meningioma removed at the age of 49 and had been on a diet for mild diabetes mellitus for the last 7 years. Consanguineous marriage had allegedly been done for generations in his family and his parents were cousins. His height was 149 cm, weight 39 kg and blood pressure 150/70 mm Hg. He had a squeaky hoarse voice, very sparse and gray hair on his scalp, extremely slender extremities and scleroder-ma-like alterations of the skin. Vascular calcification of the lower extremities was noted radiologically. A diagnosis of Werner’s syndrome was made. Laboratory studies showed: hemoglobin 8.7 g/dl, hematocrit 25.4%, white blood cell count 7,200/μl, platelets 27.6 × 104/μl, blood urea nitrogen 84 mg/dl, serum creatinine 11.9 mg/dl, sodium 140mEq/l, potassium 3.6 mEq/1, calcium 6.4 mg/dl, phosphorus 8.4 mg/dl, total blood proteins 5.5 g/dl, albumin 3.1 g/dl, blood glucose 84 mg/dl, hemoglobin Ale 6.6%, creatinine clearance 6 ml/min. Urina-lysis showed nephrotic proteinuria (7.4 g/ 24 h) and urinary sugar (2.0g/24h) with a normal sediment. An ultrasonographic examination showed contracted kidneys (7.2, 6.5 cm) with decreased visualization of the corticomedullary junction. Ophthalmoscopy showed mild arteriolar changes

VASCULAR ACCESS INFECTION ASSOCIATED WITH METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS NASAL CARRIAGE IN A HEMODIALYSIS PATIENT

Kazuhito Takeda, MD, Kidney Center, Saiseikai Yahata Hospital, 5-9-27 Harunomachi, Yahatahigashi-ku, Kitakyushu, Fukuoka 805 (Japan) Dear Sir, Infection with methicillin-resistant Staphylococcus aureus (MRSA) is one of the major opportunistic hospital infections. MRSA infections cause significant morbidity and mortality in compromised hosts, particularly in the hospital environment. A high incidence of MRSA nasal carriage (MRSA-NC) has been frequently reported in chronic dialysis patients. There is a high risk of bacter-emia in hemodialysis (HD) patients with MRSA-NC as well as a high incidence of exit-site infections or peritonitis in patients treated with continuous ambulatory peritoneal dialysis (CAPD) [1, 2]. Few reports have found severe vascular access infections associated with MRSA-NC in HD patients immediately after the vascular access operation. We herein report a case who suffered from vascular access infection associated with MRSA-NC. A 79-year-old male undergoing maintenance HD was referred from another hospital because ofvascular access complications. The patient had been operated on for a primary standard arteriovenous fistula (AVF) for vascular access in the left forearm, but a few days later the access had failed owing to S. aureus infection, and a similar operation for the vascular access had been performed in the right ellbow area, but the access had failed again because of severe infectious bleeding due to MRSA, and the right bra-chial artery had been partially resected and reconstructed because of the access infection to the artery. The patient had taken sufficient energy and proteins before operations, and had been in good health. Causes of access infections were not clearly elucidated. Physical examination at the time of admission to our hospital revealed: access operation scars in bilateral arms, a body temperature of 36.0°C, a heart rate of 78 beats/min, and blood pressure of 132/72 mm Hg. Laboratory studies showed: hemoglobin 9.4 g/dl, hematocrit 28.8%, white cell count 5,400/μl, platelets 12.8 × 104/μl, blood urea nitrogen 32 mg/dl, serum creatinine 6.5 mg/dl and total protein 6.0 g/dl. Physical examination and laboratory investigation established no inflammation. According to bacteriological examinations, microscopical examinations of sputum, blood, and throat swab were negative for MRSA, and urine cultures were sterile. However, nasal swab culture disclosed

Prosthetic Replacements in Patients on Hemodialysis for Chronic Renal Insufficiency

Twelve prosthetic hip and knee replacements (eight bipolar endoprosthetic replacements, three conventional total hip replacements, and one hemiarthroplasty of the knee) were implanted between 1978 and 1988 in eleven patients who underwent hemodialysis for chronic renal insufficiency. Five replacements (three conventional total hip replacements, one bipolar endoprosthetic replacement, and one hemiarthroplasty of the knee) in four patients had a failure due to the loosening of the component. In these four patients, the median age at operation was 51 years and the average length of follow-up was 6 years. One of these patients died of infection in both loosened total hip replacements seven years and four months after the operation.