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Abstract

T. Takahashi, A. Kato, N. Ikegaya, T. Takita, Y. Maruyama, A. Hishida and M. Takahashi

¹Maruyama Hospital, ²First Department of Medicine and ³Orthopedics Surgery, Hamamatsu University School of Medicine and ⁴Shizuoka University, Hamamatsu, Shizuoka, Japan
Background: Carpal tunnel syndrome
(CTS) is one of the major problems of long-term hemodialysis (HD), but sometimes difficult
to distinguish from uremic or diabetic neuropathy by clinical symptoms. Patients and
methods: To evaluate the diagnosis of CTS more precisely, we examined the
ultrasonographic alterations of the carpal tunnel and tendons of 90 wrists from 45
patients undergoing HD for more than 5 years. We measured the thickness of the palmar
radiocarpal ligament (PRL), corresponding to the posterior wall of the carpal tunnel (CT),
and the width of the CT, and compared those values with sensory (SCV), motor conduction
velocity (MCV) of the median nerve and clinical symptoms. In addition, we longitudinally
measured CT and PRL in the same patients for 5 years, and compared ultrasonographic
changes and clinical parameters. Results: A linear positive relationship was found
between HD duration and PRL thickness (r = 0.43, p < 0.01) or CT width (r = 0.53, p
< 0.01). CT diameter was negatively correlated with MCV (r = –0.30, p < 0.01)
and SCV (r = –0.33, p < 0.04). PRL thickness was also inversely correlated with
MCV (r = –0.44, p < 0.01) and SCV (r = –0.46, p < 0.01) of the median
nerve, respectively. The wrists with clinical CTS and/or previous CTS surgery had
significantly greater CT and PRL values compared to patients without CTS (CT: 6.1 ± 0.2
vs. 8.0 ± 0.3 mm, p < 0.01; PRL: 1.9 ± 0.1 vs. 3.6 ± 0.2 mm, p < 0.01). There was
a significant increase in CT width from 6.2 ± 0.2 to 7.1 ± 0.2 mm (p < 0.01) and PRL
thickness from 2.4 ± 0.2 to 2.8 ± 0.2 mm (p < 0.01) during the 5-year observation,
respectively. PRL thickness was constantly increased at the rate of 0.4 mm during the
study. However, no significant association was found between the 5-year increases in CT
and PRL distance and age, gender, the prevalence of diabetes, or laboratory parameters
such as blood b₂-microglobulin,
pentosidine and Kt/Vurea. Conclusion: Our data suggest that echographic evaluation
of the wrist tissue thickness was useful to assess the progression of CTS. Serial
measurements of the wrist by echography may be helpful to clarify the advance of
subclinical CTS in patients receiving long-term HD.

Abstract

A. Kato, H. Yasuda, A. Togawa, T. Yamamoto, K. Yonemura, T. Maruyama, Y. Maruyama and A. Hishida

First Department of ¹Medicine and ²Dialysis Unit, Hamamatsu University School of Medicine, ³Maruyama Hospital, Hamamatsu and ⁴Shizuoka Cancer Center Hospital, Nagaizumi-cho, Shizuoka, Japan
Background: The prevalence of anti-hepatitis virus C (HCV) antibody is much higher in hemodialysis (HD) patients than in the normal population. Recently, blood des-g-carboxy prothrombin (PIVKA-II) has been demonstrated as a sensitive marker for the early detection of hepatocellular carcinoma (HCC). In this study, we measured blood PIVKA-II in HD patients positive for anti-HCV antibody or hepatitis B virus surface (HBs) antigen to examine if HD therapy may affect the measurement of PIVKA-II. Patients and methods: Ninety-four stable HD patients who had anti-HCV antibodies (n = 86) or HBs antigen (n = 8) without any evidence of HCC were enrolled in the study (age: 60 ± 11 years, duration of HD: 17 ± 10 years, male/female = 63/31). Five patients had liver cirrhosis and another 5 patients received warfarin treatment. We simultaneously measured serum PIVKA-II and a-fetoprotein (AFP), and compared the association between these markers and HCV RNA titer and laboratory parameters. Results: Serum PIVKA-II became positive (³ 40 mAU/ml) in only 5.6% (5/89) of patients without warfarin administration, ranging from 47 to 71 mAU/ml. Seventy out of 89 patients (78.7%) were below 20 mAU/ml. Serum PIVKA-II did not correlate with biochemical parameters including HCV RNA, while serum AFP was significantly correlated with serum AST (r = 0.21, p < 0.05), g-GTP (r = 0.21, p < 0.01) and platelet counts (r = –0.29, p < 0.01), respectively. In contrast, 5 patients receiving warfarin had an extremely high PIVKA-II value ranging from 1,930 to 19,900 mAU/ml. PIVKA-II was significantly and inversely correlated with the thrombotest value (r = –0.72, p = 0.01). Conclusion: The positivity of blood PIVKA-II in HD patients with hepatitis viremia was identical to that in patients without renal failure. Warfarin treatment dramatically increased serum PIVKA-II more than 1,000 mAU/ml. These findings suggested that HD treatment itself did not affect the measurement of PIVKA-II, but vitamin K deficiency can readily influence the PIVKA-II level in dialysis patients.

Abstract

H. Fukasawa, A. Kato, T. Fujimoto, H. Suzuki, Y. Fujigaki, T. Yamamoto, A. Endoh, K. Yonemura and A. Hishida

¹First Department of Medicine, ²Department of Pediatrics and ³Hemodialysis Unit, Hamamatsu University School of Medicine, Hamamatsu, Japan
Panhypopituitarism manifests various symptoms including growth failure, hypothyroidism, adrenal insufficiency and hypogonadism. Dwarfism is an important problem in children with this condition, and long-term treatment with recombinant human growth hormone (GH) is usually required. We report a 24-year-old man with panhypopituitarism complicated by focal segmental glomerulosclerosis (FSGS). The patient had been treated with GH for hypopituitary dwarfism from 3 years of age. Proteinuria was initially noticed at 15 years of age and persisted despite cessation of GH supplementation at 18 years of age. A renal biopsy specimen showed glomerular hypertrophy and limited glomerulosclerosis, compatible with FSGS. To our knowledge, this is the first reported case of panhypopituitarism complicated by FSGS. Our case suggests that GH treatment for dwarfism may induce irreversible glomerular disease.

Abstract

H. Fukasawa, R. Furuya, A. Kato, K. Yonemura, Y. Fujigaki, T. Yamamoto and A. Hishida

¹First Department of Medicine and ³Hemodialysis Unit, Hamamatsu University School of Medicine, Hamamatsu, and ²Department of Internal Medicine, Iwata City Hospital, Iwata, Japan
Pseudohyperkalemia is defined as a serum potassium concentration 0.4 mEq/l greater than the plasma concentration. The basis of this phenomenon is the release of intracellular potassium from platelets, leukocytes, or erythrocytes, commonly in the setting of extreme leukocytosis (> 10 × 104/ml) or thrombocytosis (> 60 × 104/ml). We report a case of pseudohyperkalemia in a patient with chronic renal failure and polycythemia vera without the finding of severe leukocytosis or thrombocytosis (white blood cell count 1.88 × 104/ml and platelet count 37.9 × 104/ml, respectively). The serum potassium concentration was 8.2 mEq/l, while the plasma potassium level was 6.4 mEq/l in a sample obtained simultaneously. The concentrations of platelet factor IV and b-thromboglobulin, known to be markers of platelet activation, were greater than 100 ng/ml and 200 ng/ml, respectively, indicating that platelet activation may have been related to the development of pseudohyperkalemia in this patient. These findings suggest that pseudohyperkalemia should be considered when hyperkalemia is seen in a patient with chronic renal failure and myeloproliferative disorders.

Abstract

A. Kato, M. Odamaki and A. Hishida

¹Shizuoka Cancer Center Hospital, ²First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, and ³Department of Clinical Nutrition, School of Food and Nutritional Science, University of Shizuoka, Shizuoka, Japan
Background: Indoxyl sulfate (IS) is a protein-bound solute, which is progressively retained in blood according to the decline of renal function. However, clinical relevance of excess IS in hemodialysis (HD) patients remains unknown. Patients and methods: We measured serum IS and clinical parameters including pentosidine, carboxymethyllysine (CML) and homocysteine levels in 55 HD patients (age: 67 ± 2 years, time on HD: 67 ± 11 months, male/female = 30/25), and examined the relationship between IS and these data. Results: Serum IS was markedly increased in HD patients (80.49 ± 6.17 mg/ml) compared to normal range (< 1.9 mg/ml). IS was significantly and positively correlated with time on HD (p < 0.01), blood urea nitrogen (p < 0.01), b2-microglobulin (p < 0.03), and protein catabolic rate (PCR) (p < 0.01). The patients with increased IS needed a higher erythropoietin dosage. Blood IS was positively correlated with pentosidine (r = 0.505, p < 0.01) and CML (r = 0.275, p < 0.05). In contrast, blood IS was not associated with nutritional and inflammatory parameters. A stepwise multiple regression analysis revealed that time on HD, PCR and pentosidine were significant determinants of IS. Conclusions: Serum IS was related to time on HD and dietary protein intake. Accumulated IS may be associated with enhanced carbonyl stress in chronic HD patients.

Abstract

N. Ohashi, K. Yonemura, T. Goto, H. Suzuki, Y. Fujigaki, T. Yamamoto and A. Hishida

¹First Department of Medicine, and ²Hemodialysis Unit, Hamamatsu University School of Medicine, Hamamatsu, Japan
A 57-year-old woman was admitted because of severe bradycardia and hypotension caused by an anti-arrhythmic agent and b-blocker. For 19 months before admission, she had been undergoing hemodialysis with an F8-HPS polysulfone membrane hemodialyzer without any complications. In 2 dialysis sessions after admission, when a BS polysulfone membrane was used, she experienced anaphylactoid shock with severe hypotension leading to syncope, dyspnea and vomiting, just after the start of hemodialysis. After the anaphylactoid shock, her dialyzer membrane was changed to a cellulose triacetate membrane and she did not suffer from such attacks. This case indicates that severe anaphylactoid shock may be caused by a biocompatible dialyzer membrane and that the reactions of patients to each polysulfone membrane may differ among polysulfone membranes made by different manufacturers.

Abstract

K. Yonemura, T. Ohtake, H. Matsushima, Y. Fujigaki, and A. Hishida

¹Hemodialysis Unit and ⁴First Department of Medicine, Hamamatsu University School of Medicine, ²Department of Nephrology, Shonan Kamakura General Hospital, Kamakura, and ³Department of Nephrology, Seirei Mikatagahara General Hospital, Hamamatsu, Japan
Aim: Diagnosis of tuberculosis is sometimes difficult because of the low specificity of diagnostic procedures especially in patients on end-stage renal disease (ESRD). As abnormal vitamin D metabolism has been reported in tuberculosis, the aim of the present study was to determine whether serum concentration of 1,25-dihydroxyvitamin D₃ (1,25-(OH)₂D₃) may be a useful diagnostic indicator of tuberculosis in patients with ESRD. Patients and methods: Serum concentrations of 1,25-(OH)₂D₃, parathyroid hormone (PTH), and calcium were compared in 6 patients with ESRD and active tuberculosis (ESRD-TB group) and 110 patients with ESRD and no tuberculosis (ESRD group). These parameters were compared before and after treatment for tuberculosis in patients of ESRD-TB group. Results: Hypercalcemia was observed in all 6 patients in the ESRD-TB group. Both higher serum concentration of 1,25-(OH)₂D₃ and lower serum concentration of PTH were observed in the ESRD-TB group relative to the ESRD group, suggesting enhanced extrarenal production of 1,25-(OH)₂D₃ and suppressed secretion of PTH by hypercalcemia in the ESRD-TB group. However, these parameters could not be used to distinguish the ESRD-TB group from the ESRD group. The ratio of 1,25-(OH)₂D₃ to PTH in serum was above 0.9 in the ESRD-TB group and below 0.9 in the ESRD group. Antituberculous treatment reduced this ratio to the range observed in the ESRD group. Conclusion: High ratio of 1,25-(OH)₂D₃ to PTH in serum is noted in active tuberculous patients with ESRD because of enhanced extrarenal production of 1,25-(OH)₂D₃.Correspondence to:
Dr. K. Yonemura Hemodialysis Unit Hamamatsu University School of Medicine 1-20-1 Handayama Hamamatsu, 431-3192, Japan
Email: [email protected]

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