Tateki Kitaoka

PSYCHIATRIC DISORDERS AMONG PATIENTS UNDERGOING HEMODIALYSIS THERAPY

We examined the incidence rates of psychiatric disorders in end-stage renal failure patients on hemodialysis (HD) based on 4-year long-term follow-up. Among various psychiatric disorders, the frequency of three psychiatric disorders, dementia, delirium, and major depression, was relatively high. One-year incidence rate of whole psychiatric disorders was 10.6% (7.1% in non-aged and 13.7% in aged). One-year incidence rate of dementia in aged patients was 4.2% (dementia of the Alzheimer’s disease, 0.5%; multi-infarct dementia, 3.7%). One-year incidence rate of multi-infarct dementia in aged HD patients was 7.4 times as large as that in the elderly general populations, suggesting that aged HD patients tend to exhibit multi-infarct dementia. The high incidence rate may be closely related to advanced arteriosclerosis and other medical conditions. Psychiatric management is required for ESRD patients with three major psychiatric disorders, dementia, delirium, and major depression, in particular for aged patients with multi-infarct dementia who has received long-term HD therapy.

Effects of Recombinant Human Erythropoietin and Correction of Anemia on Platelet Function in Hemodialysis Patients

To clarify the effects of correction of anemia with recombinant human erythropoietin (r-HuEPO) on the hemostatic defects in uremia, hemostatic parameters were examined in 18 hemodialysis patients with renal anemia. Anemia improved significantly 12 weeks after r-HuEPO therapy (stage II) compared to pretreatment (stage I) and 6 weeks discontinuation (stage III) periods. Platelet count did not change among the three stages, however, mean platelet volume increased significantly at stage II in comparison with stage I. Ivy bleeding time (BT) significantly shortened at stage II and prolonged again at stage III. Although there were no significant changes in platelet aggregation, plasma TxB2, 6-keto-PGF1 alpha, F.VIII:C and F.VIII:Ag levels throughout the study, platelet adhesion and von Willebrand factor (vWf):Ag significantly increased at stages II and III. Augmentations in these parameters were more remarkable in BT-shortened patients (n = 12) than in the BT-unchanged group. These results indicate that correction of anemia with r-HuEPO brought about improvement in uremic hemostatic defect via the increase in red cell volume and vWf:Ag, and new production of platelets, reflected by the improvement in platelet adhesion.

Facial Paresthesias Resembling Restless Legs Syndrome in a Patient on Hemodialysis

Accessible online at: http://BioMedNet.com/karger Dear Sir, Restless legs syndrome (RLS) is a neurological disorder characterized by unpleasant limb sensations that are precipitated by rest and relieved by activity [1, 2]. RLS symptoms worsen during the evening and may result in insomnia [1, 2]. Most cases are idiopathic, although the condition is sometimes familial and may be associated with a range of medical illnesses, including end-stage renal disease (ESRD) and iron deficiency anemia. RLS is responsive to several medications, including levodopa, dopamine agonists, and benzodiazepines. Despite recent attempts to better characterize RLS, this neurologic disorder remains poorly understood. We have recently encountered a male hemodialysis (HD) patient who exhibited unpleasant facial paresthesias that closely resemble the unpleasant lower extremity sensations seen in RLS. The patient was a 52-year-old man. He had been receiving HD due to ESRD since 48 years of age. He had no history of a neurological and/or psychiatric disorder. No abnormal findings except for the paresthesias were found on neurological examination. His only psychiatric symptoms were irritability secondary to the unpleasant facial sensations that were precipitated by rest and relieved by activity. He described the sensations as ‘water-like fluid flowing into several tubes under my facial skin which sometimes itches’. He stated that he had the symptoms for about 1 year, they were worsened by rest, such as during HD therapy, and also worsened in the evening. Although neither minor tranquilizers, including benzodiazepines, nor major tranquilizers were effective for the unpleasant sensations, levodopa was effective. While the paresthesias in this patient were manifested in the face, the characteristics of these symptoms were strikingly similar to those seen in RLS. We report herein the first case to our knowledge of unpleasant facial sensations which closely resemble the clinical characteristics of RLS in a HD patient. One may speculate that, although the etiology of the unpleasant facial sensations in this patient is unclear, this symptom may be a subtype of the RLS frequently seen in HD patients.

Survey of the Effects of a Column for Adsorption of β2-Microglobulin in Patients With Dialysis-Related Amyloidosis in Japan

Dialysis‐related amyloidosis is a serious complication of long‐term hemodialysis. Its pathogenic mechanism involves accumulation of β2‐microglobulin in the blood, which then forms amyloid fibrils and is deposited in tissues, leading to inflammation and activation of osteoclasts. Lixelle, a direct hemoperfusion column for adsorption of β2‐microglobulin, has been available since 1996 to treat dialysis‐related amyloidosis in Japan. However, previous studies showing the therapeutic efficacy of Lixelle were conducted in small numbers of patients with specific dialysis methods. Here, we report the results of a nationwide questionnaire survey on the therapeutic effects of Lixelle. Questionnaires to patients and their attending physicians on changes in symptoms of dialysis‐related amyloidosis by Lixelle treatment were sent to 928 institutions that had used Lixelle, and fully completed questionnaires were returned from 345 patients at 138 institutions. The patients included 161 males and 184 females 62.9u2003±u20037.7u2003years age, who had undergone dialysis for 25.9u2003±u20036.2u2003years and Lixelle treatment for 3.5u2003±u20032.7u2003years. Based on self‐evaluation by patients, worsening of symptoms was inhibited in 84.9–96.5% of patients. Of the patients, 91.3% felt that worsening of their overall symptoms had been inhibited, while attending physicians evaluated the treatment as effective or partially effective for 72.8% of patients. Our survey showed that Lixelle treatment improved symptoms or prevented the progression of dialysis‐related amyloidosis in most patients.

A Hemodialysis Patient with Trazodone-Induced Parkinsonism

A hemodialysis male patient exhibited depressive symptoms and trazodone was prescribed orally. Although his depressive symptoms disappeared, he gradually presented with parkinsonism. His parkinsonism improved within a week after stopping trazodone. The clinical course strongly suggested that it was induced by trazodone. However, there is no report on antidopaminergic side effects of parkinsonism. This case suggests that antidopaminergic effects leading to parkinsonism need to be considered in patients on hemodialysis that are taking trazodone.

Cardiac Arrest Caused by Maprotiline in an Elderly Hemodialysis Patient

It is commonly known that patients with a depressive disorder often have some medical comorbidity due to antidepressant medication, although tricyclic antidepressants are associated with cardiovascular disease [1]. They are often given to cardiac patients [1–3]. In particular, amitriptyline has been reported to account for approximately 39% of the deaths due to a tricyclic overdose [2]. Several studies have demonstrated that maprotiline, a tetracyclic antidepressant with noradrenaline reuptake inhibition, produces fewer cardiovascular effects than tricyclics [4]. Recent studies, however, have shown that the cardiac effects of maprotiline do not differ either in quality or quantity from those of the tricyclic substances. We report here on an elderly depressed patient on hemodialysis who had a cardiac arrest which may have been caused by maprotiline [1, 2].

The Distribution of 3H-Labeled Endotoxin in the Kidney of Liver Cirrhotic Rats

Although the etiology and pathogenesis of progressive renal failure is largely unknown, endotoxin is supposed to be one of the contributory factors. However, the distribution of endotoxin in liver cirrhosis has not been clarified. Therefore we studied the distribution of 3H-labeled endotoxin in the kidney in rats with CCl4-induced liver injury. Daily inhalations of CCl4 on rats for 6 and 10 weeks produced liver fibrosis (LF group, N = 5) and cirrhosis (LC group, N = 5), respectively. At 6 or 10 weeks, animals were sacrificed 24 hours after an intravenous injection of endotoxin labeled with 3H at the galactose moiety (12,000 cpm/1 g body weight). In the liver, 3H-labeled endotoxin was taken up mainly by Kupffer cells as determined by autoradiography. Compared to control rats, in rats of the LC or LF group the measured amount of 3H-labeled endotoxin per gram kidney or ml blood increased, while that of the liver was significantly decreased. A positive correlation of the amount of 3H-labeled endotoxin per weight or volume respectively was shown between kidney and blood, but not between lung or spleen and blood. These results suggest that overflow of endotoxin due to decreased inactivation in the liver causes endotoxemia in liver injury and that the resulting endotoxemia may directly affect the kidney. The resulting endotoxin-induced vasoconstriction may be a contributory factor for the progressive renal failure frequently observed in liver cirrhosis.

Musical Hallucinations after Childbirth in a Female Patient on Hemodialysis

This article is also accessible online at: http://BioMedNet.com/karger Dear Sir, It is very difficult for patients with endstage renal disease (ESRD) receiving hemodialysis (HD) therapy to undergo childbirth without several somatic risks. ESRD patients may attempt to give birth after receiving kidney transplants. In the United States, the number of ESRD patients who receive a kidney transplant is approximately 1,000/ year; in Japan the number is 600/year. In Japan, therefore, even if patients have a strong desire for pregnancy, they do not usually have a chance for this. ESRD patients on HD therapy have a number of stressful circumstances (e.g., time restrictions due to the HD therapy and control of body weight) [1, 2]. Many patients are prone to unstable mood states [1, 2]. There have been few reports regarding psychiatric symptoms after childbirth in HD patients. We have recently seen a female HD patient who exhibited various psychiatric symptoms including musical hallucinations, panic attacks, and psychogenic pain 18 months after delivery. The patient was a 37-year-old woman receiving HD therapy for 3 years. She had a strong desire for a child. There were several reasons for this. She had already reached middle age. Her relationship with her mother was poor due to her parent’s divorce. She had hoped for a warm home with her own children. Her pregnancy and delivery were successful. For the 1st year, she did her best to take care of her baby, although she was busy going for HD therapy two or three times a week, household matters, etc. She gradually developed fatigue and then suddenly exhibited musical hallucinations, panic attacks, and psychogenic pain. She strongly complained of the musical hallucinations. Although several studies have examined musical hallucinations [3, 4], much still remains unknown. A recent study [4] reported 2 cases of tricyclic-induced musical hallucinations. In our case, however, tricyclic antidepressants were an effective treatment. One may speculate that the musical hallucinations observed in this case may have been caused by psychogenic factors after delivery. We report herein the first case, to our knowledge, of musical hallucinations after childbirth in a HD patient. OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO