Takatomi Yurugi

Prognostic Significance of Ankle-Brachial Index, Brachial-Ankle Pulse Wave Velocity, Flow-Mediated Dilation, and Nitroglycerin-Mediated Dilation in End-Stage Renal Disease

Background: Identifying patients at high risk of cardiovascular disease is important in managing patients undergoing hemodialysis. Methods: We evaluated a series of prognostic values: flow-mediated dilation (FMD) and nitrogen-mediated dilation (NMD), an index of endothelium-dependent and endothelium-independent function, respectively, ankle-brachial index (ABI), and brachial-ankle pulse wave velocity (baPWV) in patients undergoing chronic hemodialysis. Results: A cohort of 199 patients was studied. At entry, these values were examined and the prognostic significances were investigated. In estimating the significance of baPWV, patients with ABI <0.9 were excluded. During the follow-up period, 24 deaths occurred including 14 cardiovascular and 10 noncardiovascular fatal events. Overall, the survival rates were significantly lower in the low ABI than in the high ABI group, but the survival rates were not significantly different between the high and low FMD, NMD, or baPWV groups. Cardiovascular survival rates were significantly lower in the low ABI than in the high ABI group, and in the high baPWV than in the low baPWV group. The survival rates were not significantly different between the high and low FMD or NMD groups. Conclusions: Screening hemodialysis patients by means of ABI and baPWV but not FMD or NMD provides complementary information in identifying a high-risk population in these patients.

Risk Factors of Normal Ankle–Brachial Index and Low Toe–Brachial Index in Hemodialysis Patients

The prevalence of peripheral arterial occlusive disease is high in patients with terminal renal failure, and it is a major problem in those on dialysis. A low ankle–brachial index (ABI) suggests the presence of arterial stenotic lesions between the aorta and the ankle joint, while a low toe–brachial index (TBI) suggests stenotic lesions between the aorta and the toes. Therefore, a normal ABI (≥0.9) and a low TBI (<0.6) may indicate the presence of stenotic lesions located only on the peripheral side of the ankle joint. In the present study, risk factors of normal ABI/low TBI were investigated. In 115 patients on maintenance dialysis, the ABI and TBI were simultaneously measured, and the background factors and laboratory data of patients with normal ABI/low TBI (L group) and those with normal ABI/normal TBI (≥0.6) (N group) were compared. Low ankle–brachial and toe–brachial indices were detected in 13% and 22% of the patients, respectively. Comparison of the background factors and laboratory data between the N and L groups showed that the ratio of diabetes mellitus, interdialytic body weight gain, and HbA1c values were significantly higher in the L group than in the N group. It was clarified that diabetes and excess body weight gain are involved as risk factors in dialysis patients with normal ABI/low TBI.

Accumulation of visceral fat in maintenance hemodialysis patients

BackgroundIn hemodialysis (HD) patients, obesity has been recognized as a serious risk factor for mortality and morbidity for cardiovascular diseases. In addition, abnormalities of lipid profiles exist in these patients.MethodsIn patients undergoing maintenance HD, incidences of abnormality of lipid profiles and visceral obesity determined by computed tomography scans were compared. In addition, the relationship between visceral fat area (VFA) and brachial-ankle pulse wave velocity (baPWV), an index of arterial stiffness, or carotid intima-media thickness (IMT), an index of atherosis, was examined.ResultsThe incidence of high VFA (27.0%) was significantly greater than that of high body mass index (BMI) (9.7%), high low-density-lipoprotein cholesterol (LDL-C) (4.8%), and high triglyceride (12.7%). In patients with diabetes mellitus (DM), waist circumference and VFA showed a significant positive relationship with baPWV. baPWV was significantly higher in patients with high VFA and DM than in patients with low VFA without DM, those with high VFA without DM, and those with low VFA and DM. Carotid IMT was significantly greater in patients with high VFA and DM than in those with low VFA without DM and those with low VFA and DM.ConclusionsThe incidence of high VFA was much greater than that of high BMI, high LDL-C, or high triglyceride. Visceral fat accumulation may be related to both arterial stiffness and atherosis in diabetic patients on maintenance HD.

Successful Permanent Catheter Implantation After Percutaneous Transluminal Angioplasty to the Right Subclavian and Inominate Vein Stenosis in a Hemodialysis Patient

Difficulties in gaining vascular access have become one of the major problems in long‐term hemodialysis patients. We report a case with an extreme vascular access problem, which was solved by the placement of a permanent central vein catheter after successful angioplasty to the right subclavian and inominate vein stenosis. A 78‐year‐old woman with end‐stage renal disease due to diabetic nephropathy had been on hemodialysis since 1982. She had a history of four procedures that created an arteriovenous fistula during the first four years. In 1986 she was switched to peritoneal dialysis. However, hemodialysis was restarted with a regular arteriovenous fistula in 1991 because of repeated peritonitis, and from 1993 a superficialized brachial artery was used until the artery was exhausted. Since 1997, a permanent central vein catheter was utilized and reinsertion was required four times due to catheter infection during a 6‐year period. In 2004, difficulty was experienced in reinserting a new central venous catheter because of multiple stenotic and occlusive lesions of the central veins. Percutaneous transluminal angioplasty was carried out in the stenotic right subclavian and inominate veins, and after successful angioplasty, a permanent central vein catheter could be placed into the right subclavian vein as a vascular access for hemodialysis. Pretreatment with percutaneous transluminal angioplasty of the stenotic central veins before inserting a permanent catheter may be a useful strategy in patients that experience difficulty in the insertion of a catheter.

Primary hepatic leiomyosarcoma in a patient with autosomal dominant polycystic kidney disease

Primary hepatic leiomyosarcoma is an extremely rare tumor. The diagnosis is difficult, and its etiologic factors have not been clarified. A 63-year-old woman with numerous cysts in her kidneys and liver was diagnosed with autosomal dominant polycystic kidney disease (ADPKD). Several members of her family also had ADPKD. She underwent treatment with tolvaptan to inhibit cyst growth and slow the decline in kidney function. Eight months after the start of the therapy, she was hospitalized with fatigue and fever of unknown origin. Diagnostic imaging showed a very large hepatic tumor, and histologic examination of a fine-needle biopsy specimen revealed the tumor to be malignant. Differentiation between carcinoma and sarcoma was difficult based on the histological findings. The tumor was thought to be excisable; therefore, hepatic resection was attempted. At the time of surgery, as the tumor had grown larger than when imaged, complete resection was impossible. However, a part of the tumor was resected. Histopathological and immunohistological examinations of the surgical specimen confirmed a primary hepatic leiomyosarcoma. Whether the tumor was associated with the presence of ADPKD remains unclear, however, this is the first report of the combination of these two diseases in a patient.

Investigation of small intestinal lesions in dialysis patients using capsule endoscopy: Capsule endoscopy in dialysis patients

Introduction: Although gastrointestinal hemorrhage is an important complication for dialysis patients, the details of many points remain unclear with regard to small intestinal lesions.

Effects of nocturnal oxygen therapy on heart function in SDB patients undergoing dialysis

Abstract There is a close relationship between sleep disordered breathing (SDB) and heart failure. We performed home oxygen therapy (HOT) in patients with SAS undergoing dialysis, and investigated its effects on the heart function. The subjects were 10 SDB patients on dialysis. On retiring at night, oxygen was transnasally administered at 1.0 L/min. The human atrial natriuretic peptide (hANP), brain natriuretic peptide (BNP), total protein, Alb, cholesterol and phosphorus levels were measured before the start of oxygen therapy and after 6 weeks. The mean SpO2 increased from 93.5% [91.5, 97.0] to 96.3% [94.8, 97.4] (median [interquartile range]) (p = 0.015). The hANP (p = 0.0039), BNP (p = 0.0098) and serum Alb (p = 0.015) levels significantly improved. There were no significant changes in the cholesterol, phosphorus or total protein levels. These results suggest that nocturnal oxygen therapy improves indices of heart failure, contributing to the prevention and treatment of heart failure in dialysis patients with SDB.

Increment of cerebral blood flow by LDL-apheresis in dialysis patients with arteriosclerosis obliterans: a pilot study.

OBJECTIVE The prevalence of thrombotic cerebral infarction is higher in dialysis than in general patients. Changes in cerebral blood flow (CBF) during low-density lipoprotein cholesterol-apheresis (LDL-A) in dialysis patients with arteriosclerosis obliterans (ASO) were evaluated employing xenon-CT (Xe-CT) to investigate the possibility of CBF improvement. SUBJECTS AND METHODS Xe-CT was performed before LDL-A in 4 dialysis patients with ASO (3 males and 1 female). LDL-A was then performed once a week 10 times. After the completion of LDL-A treatment, Xe-CT was performed again to observe changes in CBF. RESULTS Before treatment, CBF in the 4 patients was lower than that in the general population in the same age group. After LDL-A treatment, CBF was improved. The improvement was observed in the cerebral cortex rather than the basal ganglia. The grade of improvement and improved cerebral region varied among the patients. CONCLUSION It was suggested that LDL-A may improve not only lower limb blood flow but also CBF. However, further investigation is necessary with regard to the influence of CBF improvement on the brain function and clinical application. The reported results need to be confirmed in larger studies.