Yoshihiko Imamura

Calcaneal Osteopenia Is a New Marker for Arterial Stiffness in Chronic Hemodialysis Patients

Background: A high frequency of simultaneous low estimated bone mineral density (BMD) and atherosclerotic vascular disease is found in chronic dialysis patients. The degree of BMD may be closely related to the severity of atherosclerosis in dialysis patients. The purpose of this study was to determine the association of estimated BMD with severity of atherosclerosis using popular economical non-invasive strategies in chronic dialysis patients. Methods: This cross-sectional design study included 58 subjects receiving maintenance hemodialysis (HD) therapy. The mean age was 68 ± 12 years (range 39–93), 22 subjects were female, and 26 subjects (45%) had diabetic nephropathy. The brachial-ankle pulse wave velocity (baPWV) and estimated BMD, using calcaneal quantitative ultrasound measurements of the osteo-sono index (OSI) were measured in all of the subjects. Results: The mean levels of OSI and baPWV were 2.3 ± 0.3 and 21 ± 5 m/s, respectively. Based on single variable regression analysis, the C-reactive protein concentration correlated with baPWV (r = 0.272, p = 0.039), and the serum albumin concentration was inversely correlated with baPWV (r = –0.318, p = 0.015). In addition, OSI had a strong negative correlation with baPWV (r = –0.470, p = 0.0002). To identify the independent factors correlating with baPWV, multivariate regression analysis was performed using confounding variables which had significant association in univariate analysis. OSI and diabetic nephropathy were found to be significant independent parameters. Conclusion: Calcaneal OSI, a surrogate marker for estimated BMD, has a strong ability to predict the severity of arterial stiffness independent of classical risk factors and markers of inflammation and malnutrition.

Angiographical severity of coronary atherosclerosis predicts death in the first year of hemodialysis

Background: Cardiac deaths andevents tend to cluster within the early-phaseafter starting dialysis. Our goal is toclarify the influence of severity of coronaryatherosclerosis on early-phase death afterstarting hemodialysis (HD) therapy. Patients and Methods: Eighty-threeconsecutive patients [mean age 62 years;male/female 64/19; diabetic nephropathy in 50(54%)] with end-stage renal disease whoadmitted to our hospital to initiate regular HDtreatment, and then received coronaryangiography within 3 months after firstdialysis therapy, were eligible for this study. Angiographical severity of coronaryatherosclerosis was scored by numerically usingGensini scoring system. The patients who diedwithin one year from starting HD were comparedwith those who survived as control by means oflogistic regression analysis.Results: Of 83 patients, 12 (14%) died lessthan one year after starting dialysis therapy. Of these 12 patients, nine died for cardiaccauses. Confirmed predictors of death fromcardiac cause were older age (>70 years),lower mean blood pressure (<100 mmHg),presence of ischemic heart disease (IHD),myocardial infarction (MI), angina pectoris(AP), chronic heart failure (CHF), poor cardiacfunction, abnormal wall motion of leftventricule (LV) and angiographical severity ofcoronary atherosclerosis by univariate model. Adjusting for confounding variables bymultivariate model, only severity of coronaryatherosclerosis (Gensini score >40 points)had a powerful influence, increasing risk forcardiac cause of early-phase death by about 17times. Conclusions: Severity ofcoronary atherosclerosis predicts death in thefirst year of HD. These findings suggest thatthe strategy for prevention of coronaryatherosclerosis should be instituted during theearly phase of chronic renal failure.

Independent Risk Factors for Progression of Coronary Atherosclerosis in Hemodialysis Patients

Abstract:  Not uncommonly, hemodialysis patients with normal results in myocardial perfusion tests can still have a cardiac event within 2 years of evaluation. We examined possible risk factors for progression of coronary atherosclerosis in hemodialysis patients. We prospectively evaluated ability of myocardial perfusion imaging carried out under pharmacologic stress to predict 2‐year outcomes in 77 hemodialysis patients, specifically thallium‐201 single‐photon emission computed tomography (SPECT) using high‐dose adenosine triphosphate as the stressor. The primary end‐point was a cardiac event (cardiac death, non‐fatal acute coronary syndrome, or hospitalization for acute ischemic heart failure). Factors independently influencing duration until a cardiac event in hemodialysis patients were identified using stepwise multiple regression analysis. Myocardial perfusion defects were shown in 36 patients. Patients with a perfusion defect were more likely to have cardiac events than those with normal perfusion (78% vs. 15%, P < 0.001). Time until occurrence of a cardiac event in hemodialysis patients showed a significant, independent association with known coronary artery disease [regression coefficient (RC) = −3.391, P = 0.046], elevated C‐reactive protein (RC = −5.813, P = 0.005), and a reversible myocardial perfusion defect (RC = −7.386, P < 0.001). An analysis based on the ‘best cut‐off’ of CRP as identified on the basis of the ROC curve augmented the positive and negative predict value of CRP for the prediction of coronary events to 65 and 74%, respectively. Myocardial perfusion SPECT and measuring the plasma concentration of CRP might be useful for the prediction of hemodialysis patients with progression of coronary atherosclerosis.

A rare case of laryngeal myxoma

We report a rare case of laryngeal myxoma in a 57-year-old Japanese man. Except for a five-year history of gradually progressive hoarseness, he had been in good health. Video-stroboscopic examination revealed a solid mass in the anterior third of the right vocal fold. Phonosurgery performed with a microscope showed that the mass was encapsulated and located between the epithelium and vocal fold ligaments of the right vocal fold. This hard, elastic mass which measured 7 mm in diameter, was diagnosed as a myxoma. Only three cases of myxoma of the larynx have been reported in the English literature, with only one other case involving the vocal fold.

Combined Assessment of Cardiac Systolic Dysfunction and Coronary Atherosclerosis Used to Predict Future Cardiac Deaths after Starting Hemodialysis

Background/Aims: Identification of end-stage renal disease (ESRD) patients at high risk for cardiac events is important for clinical dialysis management. The present study determined whether the combination of cardiac function and coronary atherosclerosis could predict future cardiac events after starting renal replacement therapy (RRT). Methods: We prospectively assessed left ventricle ejection fraction (EF) and Gensini score (GS) using angiographic severity of coronary atherosclerosis in 88 consecutive ESRD patients [mean age 62 years; 69 males (78%); 55 patients (64%) with diabetic nephropathy] at the initiation of RRT. EF was analyzed by echocardiogram, and GS was scored by coronary angiography within 3 months after starting RRT. The study end point was cardiac death. For analysis of the association between cardiac death and EF and GS measures, the univariate and multivariate Cox proportional hazards model was used. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value, and accuracy of event-free prediction were evaluated. Results: Twenty-four patients (27%) had low cardiac function (EF <50%; low EF) and 44 patients (50%) had severe coronary atherosclerosis (GS >15; high GS). During a follow-up period of 3 years, cardiac death occurred in 21 patients (24%). The PPV of low EF and high GS was 42 and 39%, respectively; the highest PPV (53%) was obtained when low EF and high GS were combined. The cumulative survival rate at 5 years in patients with both low EF and high GS was significantly lower than those with high EF and low GS (91 vs. 22%, p < 0.0005). Conclusion: The combined assessment of cardiac function and coronary atherosclerosis at the initiation of RRT strongly predicts future cardiac events.

Declining Prevalence of Coronary Artery Disease in Incident Dialysis Patients Over the Past Two Decades

AIM The medical management of patients with chronic kidney disease(CKD) has changed within the past 20 years. We speculate that this change has resulted in a decrease in the prevalence of atherosclerotic cardiovascular disease in patients with CKD. The aim of the present study was to analyze changes in the prevalence of coronary artery disease(CAD) in patients newly started on hemodialysis, as well as trends in clinical factors and medications over the past two decades. METHODS This single-center cross-sectional study examined data for 315 consecutive patients starting hemodialysis(age, 64±12 years; men, 73%; diabetic nephropathy, 57%) between January 1993 and December 2010. All patients were routinely screened for CAD within three months of starting hemodialysis, regardless of whether ischemic heart disease was suspected. The patients were categorized into six groups based on the date of the initial dialysis session in order to compare the historical prevalence of unidentified CAD(uCAD) in association with the clinical factors. In addition, we performed a subgroup analysis among 222 patients without known cardiac disease. RESULTS The prevalence of uCAD gradually declined from 69% to 25% over 18 years(p＜0.001 for trend). The mean high-density lipoprotein cholesterol(HDL-C) concentration increased(p＜0.001 for trend), while the median C-reactive protein(CRP) level decreased over time. In parallel with these trends, the proportion of statin users significantly increased over time(p＜0.001 for trend). The use of erythropoiesis-stimulating agents(ESAs) and renin angiotensin aldosterone system inhibitors(RAS-Is) also increased during the same period(both p＜0.001 for trend). A univariate logistic regression analysis identified a significant association between the prevalence of uCAD and the use of ESAs(OR: 0.565, p=0.016) or RAS-Is(OR: 0.501, p=0.004). In addition, a lower BMI, lower HDL-Clevel and higher CRP level were found to be closely associated with uCAD, independent of confounding variables. The findings for the new dialysis patients without cardiac disease were similar. CONCLUSIONS The prevalence of uCAD in patients with end-stage kidney disease has remarkably decreased over the past two decades. Major improvements in the medical management of CKD may modify the prevalence of coronary atherosclerosis.

Efficacy of N-terminal pro-brain natriuretic peptide digit number for screening of cardiac disease in new haemodialysis patients

The usefulness of the absolute N‐terminal pro‐brain natriuretic peptide (NT‐ProBNP) concentration and its digit number for screening for cardiac disease was explored in new haemodialysis patients.

Usefulness of an Upright T-Wave in Lead aVR for Predicting the Short-Term Prognosis of Incident Hemodialysis Patients: A Potential Tool for Screening High-Risk Hemodialysis Patients

Background/Aims: An upright T-wave in lead aVR (aVRT) has recently been reported to be associated with cardiovascular death and mortality among the general population and patients with prior cardiovascular disease (CVD). However, evidence for the predictive ability of aVRT in patients with chronic kidney disease is lacking. Therefore, a hospital-based, prospective, cohort study was conducted to evaluate the predictive ability of an upright aVRT for the short-term prognosis in incident hemodialysis patients. Methods: Among 208 patients who started maintenance hemodialysis, 79 with preexisting CVD (CVD cohort) and 129 with no history of CVD (non-CVD cohort), were studied. An upright and non-upright aVRT were defined as a wave with a positive deflection in amplitude of ≥0 mV and a negative deflection in amplitude of <0 mV, respectively. The endpoint was all-cause death. Results: Overall, the prevalence of an upright aVRT was 22.6% at baseline. During the mean follow-up period of 2.1 ± 1.0 years, 33 deaths occurred. Cumulative survival rates at 3 years after starting dialysis in patients with an upright and non-upright aVRT were 50.0 and 80.7%, respectively, in the CVD cohort and 92.0 and 91.3%, respectively, in the non-CVD cohort. In the CVD cohort, multivariate Cox regression analysis showed that an upright aVRT was an independent predictor of death after adjusting for confounding variables. Conclusion: Among Japanese hemodialysis patients at high risk for CVD, an upright aVRT seems to be useful for predicting death.

Increment of monthly mean predialysis heart rate reflects early cardiac overload in hemodialysis patients with normal cardiac function.

BACKGROUND The aim of our study was to examine the association of heart rate (HR) with the onset of congestive heart failure (CHF), and to compare the predictive value of HR with that of the serum level of human atrial natriuretic peptide (hANP) and the cardiothoracic ratio (CTR). METHODS Thirty-eight patients on chronic hemodialysis (HD) aged 68 ± 11 years (61% men, 41% with diabetes) who had normal cardiac function were enrolled in this study. Among them, 6 patients had suffered CHF. Baseline characteristics and HR, hANP and CTR were compared between the 2 groups. RESULTS At baseline, the monthly mean pre-HR (before HD), CTR and hANP values were higher in CHF patients compared with non-CHF patients. In the CHF group, the monthly mean pre-HR increased progressively beginning 10 months before the onset of CHF, which was earlier than the increments of hANP and CTR. A significant difference between the CHF and non-CHF groups was observed earlier for monthly mean pre-HR (4 months before CHF) and ANP (4 months before CHF) than for CTR (2 months before CHF). CONCLUSIONS The increment of monthly mean pre-HR may reflect the early phase of cardiac overload, and is of equal significance to hANP. Further large-scale prospective studies are required to confirm these results.

Contents Vol. 5, 2015

S. Brietzke, Columbia, Mo. M. Bursztyn, Jerusalem K.C. Dellsperger, Augusta, Ga. V. DeMarco, Columbia, Mo. J.P. Dwyer, Nashville, Tenn. K.C. Ferdinand, New Orleans, La. J.M. Flack, Springfield, Ill. E.P. Gomez-Sanchez, Jackson, Miss. M.R. Hayden, Camdenton, Mo. E.J. Henriksen, Tucson, Ariz. K. Kalantar-Zadeh, Orange, Calif. W. Lockette, Columbia, Mo. J.M. Luther, Nashville, Tenn. F. Murad, Washington, D.C. C. Ronco, Vicenza N. Stern, Tel Aviv C.S. Stump, Tucson, Ariz. A.T. Whaley-Connell, Columbia, Mo. Editorial Board