Hemodialysis Patients In Terms Research Articles

#3043 Epidemiology of infective endocarditis in long term hemodialysis patients in France, from 2014 to 2019

Abstract Background and Aims Infective endocarditis (IE) is a frequent pathology among patients treated with long-term hemodialysis (HD). Its epidemiology and risk factors are scarcely reported in this specific population in France. This study aims to describe the frequency and characteristics of IE in long-term hemodialysis patients in mainland France. Method From the national Programme de médicalisation des systèmes d'information (PMSI) data, we selected patients initiating a renal replacement therapy by long-term hemodialysis from 2014 to 2017, with a follow up from 2017 to 2019. Within this population, we defined hospitalizations due to IE by using the CIM-10 coding system. We analyzed various comorbidities such as sociodemographic factors, cardiovascular diseases, cancer, diabetes and vascular access, identified within the PMSI during a minimum duration of 4 years, looking for IE risk factors. As the IE incidence has a low frequency for this follow up length, it was analyzed with a Poisson distribution model. Results We studied 38 569 patients, with a 36 month follow up. Fig. 1 shows IE incidence during the follow up, in which we identified 2492 cases of EI. The incidence rate was 6.69, or 7 out of 100 000 at first month and 1.97 out of 100 000 at twelve months. In multivariate analysis we found the following risk factors associated with EI: having a central vascular catheter (CVC) as initial vascular access while starting renal replacement therapy, compared to an arteriovenous fistula, OR 2.49 [2.29-2.71], diabetes OR 1.25 [1.14-1.35], cardiovascular conditions OR 1.35 [1.23-1.48] and increasing age was associated with a reduction of an IE diagnosis odds. Conclusion Our study highlights a high IE frequency among long-term hemodialysis patients. Its incidence is particularly high during the first year and decreases afterwards. The main risk factors were: CVC, preexisting cardiovascular conditions and diabetes.

Assessment of drug utilization and potentially inappropriate medications in hemodialysis patients with end-stage renal dysfunction: A study in a tertiary care hospital in Bahrain.

Patients undergoing dialysis pose therapeutic challenges in terms of polypharmacy, administration of potentially inappropriate drugs, and drugs with the potential risk of toxicity. This study evaluated the use of drugs, potentially inappropriate medicines (PIM), drugs with risk of Torsades de Pointes (TdP), and the complexity of the prescribed regimen using the medication regimen complexity index scale in patients undergoing hemodialysis. A retrospective cohort study was carried out amongst patients receiving hemodialysis. Drugs were classified into one of four classes: (i) drugs used in managing renal complications, (ii) cardiovascular drugs, (iii) anti-diabetic drugs, (iv) drugs for symptomatic management, and (v) others. Drugs were considered as PIM according to the Can-SOLVE CKD working group from a network of Canadian nephrology health professionals. The study adhered to the CredibleMeds classification of drugs with known, possible, and conditional risk of TdP and the complexity of prescribed medicines was evaluated based on the pre-validated medication regimen complexity index scale based on form/route, frequency of dosing, and requirement of special instructions. Sixty-three participants were included in the study (49 males and 14 females) with the median (range) age of 45 (21-66) years. Cardiovascular drugs followed by drugs used for managing renal complications were the most common classes administered. Notably, 12 (19.1%) patients received one of the non-steroidal anti-inflammatory drugs, 21 (33.3%) received a proton pump inhibitor, three (4.8%) received pregabalin, two (3.2%) received opioid drugs, and one (1.6%) was administered celecoxib. Atorvastatin, furosemide, omeprazole, and allopurinol were the most common PIM drugs administered to the study participants followed by others. Drugs used for symptomatic management had significantly more PIM compared to other classes (p <0.0001). Six (9.5%) patients received drugs with known TdP risk, one with possible TdP risk, and 61 with conditional risk. Median (range) medical regimen complexity index score was 26.5 (2-62.5). A huge burden of drug therapy was observed in the hemodialysis patients in terms of higher proportions of PIM, complex medical regimen, and prescription of drugs with risk of TdP. Implementation of clinical decision support tools enhancing rational prescription and identification of drugs with TdP risk, introducing antimicrobial stewardship, and stepwise deprescription of the drugs with the least benefit-risk ratio are warranted.

COMPARISON OF LACOSAMIDE VERSUS LEVODOPA IN THE TREATMENT OF RESTLESS LEGS SYNDROME IN HEMODIALYSIS PATIENTS

ABSTRACT&#x0D; Objective: To compare Lacosamide and Levodopa for treating restless-legs-syndrome in hemodialysis patients in terms of mean change of International Restless Leg Syndrome (IRLS) score.&#x0D; Methods: It was a Randomize control trail done at Department of Medicine &amp; Nephrology Department of Mayo hospital, Lahore from April 2019 to March 2020. After taking approval from institutional-Review-board (IRB) of the King Edward Medical University (KEMU), sixty patients coming to hemodialysis unit of Mayo Hospital, Lahore and fulfilling the inclusion criteria were enrolled for study. We used lottery method and randomly divided them in to two groups that is Group-A: Lacosamide (50 mg) given at bedtime. (30 cases) and Group-B: Levodopa (110 mg) given daily 2 hours before bedtime (30 cases). Treatment was continued for 4 weeks. We calculated IRLS score at start of study and four week after treatment and any Change from baseline was calculated for every patient. That difference of –IRLS score documented on the attached Performa along with demographic details about patient.&#x0D; Results: This study showed that after 4 weeks of treatment there was not much difference seen in International Restless Leg Syndrome score in each treatment groups. i.e. [Pre-Treatment (Lacosamide: 20.80±4.78 vs. Levodopa: 22.60±4.66), Post Treatment (Lacosamide: 14.20±2.89 vs. Levodopa: 15.73±3.58), Mean change of score (Lacosamide: 7.10±4.99 vs. Levodopa: 6.86±6.63 . p - Value = 0.878)&#x0D; Conclusion: This trial concludes that Levodpoa and Lacosamide were equally good in treating Restless-Legs-Syndrome among patients who are on Hemodialysis.&#x0D; Key words: Restless legs syndrome, Hemodialysis, Lacosamide, Levodopa.

Self-efficacy among patients with hemodialysis during the COVID-19 pandemic.

Patients with hemodialysis face various problems with self-care behavior. Therefore, these patients need to control and manage adherence to enhance self-care, especially during the COVID-19 pandemic, which has particularly high morbidity in the elderly and co-morbid peoples. Self-efficacy was identified as a number of psychological factors that improve adherence and treatment outcomes among hemodialysis patients. This study aimed to investigate self-efficacy among patients with hemodialysis during the COVID-19 pandemic. A comparative descriptive research design was used to conduct the study. A convenience sample of 95 hemodialysis patients (male and females) was selected from Port-Said city, Egypt, and 115 hemodialysis patients (male and females) were selected from Saudi Arabia. Data collection included a structured interview with three parts assessing socio-demographic characteristics, anthropometric measurements, and self-efficacy. This study revealed a statistically significant difference between Egyptian and Saudi hemodialysis patients, mainly in the main score and levels of self-efficacy (p=0.001). There is a significant relationship between socio-demographic characteristics and chronic disease self-efficiency among Egyptian hemodialysis patients in terms of sex, age, marital status, work, and level of education.

An Observational Cohort Study of the 2-Month Use of Regional Citrate Anticoagulation in Maintenance Hemodialysis Patients with Cerebral Hemorrhage.

BackgroundRegional citrate anticoagulation (RCA) is a recommended anticoagulation alternative for patients at high risk of bleeding while undergoing intermittent hemodialysis. Previous reports implied the risk of citrate application on bone metabolism. It is unclear whether long-term use of RCA is safe for maintenance hemodialysis patients in terms of bone metabolism.Material/MethodsSeven patients with cerebral hemorrhage were included in the study. Blood samples were collected at baseline and 4 and 8 weeks after treatment. Spent dialysate samples were collected during each mid-week dialysis session, using the partial dialysate collection method. All patients were treated with RCA for 4 to 8 weeks, according to their clinical condition. We assessed bone metabolism-associated parameters, bone turnover markers, and magnesium loss at each dialysis session.ResultsSerum magnesium levels were 1.24±0.13 mmol/L at baseline and significantly decreased to 1.16±0.14 mmol/L after 4 weeks of RCA treatment (P=0.025). Most patients had negative magnesium balance during citrate hemodialysis. Serum total calcium levels did not change significantly after treatment. One bone marker, N-terminal propeptide of type I procollagen (PINP), significantly decreased from 146.07±130.12 mmol/L to 92.42±79.01 mmol/L after citrate treatment (P=0.018). No significant changes were detected in other bone turnover markers.ConclusionsRelatively long-term RCA treatment may decrease serum magnesium levels due to negative magnesium balance. Bone formation marker PINP seemed to decrease after treatment, while other bone turnover markers did not change significantly. Further investigation is needed to verify the effect of RCA on bone remodeling.

Reduced erythrocyte lifespan measured by chromium-51 in patients with type 2 diabetes undergoing long-term hemodialysis.

A reduced erythrocyte lifespan potentially explains the low hemoglobin A1c values found in hemodialysis patients. However, data supporting this notion in patients with type 2 diabetes is unclear. We evaluated the erythrocyte lifespan in patients with type 2 diabetes undergoing long-term hemodialysis and investigated potential predictors of erythrocyte lifespan. Long-term hemodialysis patients with type 2 diabetes and type 2 diabetes patients without nephropathy (estimated glomerular filtration rate > 60 mL/min/1.73 m2 ) were included. The erythrocyte lifespan was measured using chromium-51 (51 Cr)-labeled erythrocytes. Blood radiotracer activity was measured six to nine times over a period of 3-5 weeks to determine the erythrocyte lifespan of each patient. Biochemical markers were obtained five times over 16 weeks and associated with the erythrocyte lifespan. Type 2 diabetes patients undergoing hemodialysis (N = 13) had a significantly shorter median erythrocyte lifespan of 49.7 (interquartile range [IQR] = 44.1-58.6) days compared with 64.2 (IQR = 62.6-83.5) days in the control group (N = 10) (P ˂ 0.001) with a difference between medians of 14.5 (95% confidence interval = 8.1-38.8) days. In the hemodialysis group, no association could be detected between the erythrocyte lifespan and markers of hemolysis, level of inflammation, or urea. A reduced erythrocyte lifespan was detected in type 2 diabetes patients undergoing long-term hemodialysis. This may contribute to the reduced hemoglobin A1c values observed in the type 2 diabetic hemodialysis population. An association could not be detected between the erythrocyte lifespan and biochemical markers of hemolysis or inflammation.

Prevalence and Pattern of Cardiovascular Diseases among ESRD Patients Undergoing Short Term and Long Term Hemodialysis

Background: Cardiovascular diseases (CVD) are the major causes of mortality and morbidity among End Stage Renal Disease (ESRD) patient undergoing hemodialysis (HD). The cardiovascular diseases in dialysis patient is related to chronic volume overload, anemia, inflammation, oxidant stress, homocysteine and other aspects of the uremic milieu. The duration of ESRD undergoing dialysis is related to the severity of cardiovascular diseases. The objective is to study the pattern of cardiovascular disease among the ESRD patient undergoing dialysis.&#x0D; Methods: This comparative study was done at Collage of Medical Sciences Bharatpur, Nepal from 1st June 2020 to 30th July 2020. This study included total number of 300 dialysis patients divided into two groups; 150 patients undergoing dialysis for less than one year and rest undergoing dialysis for more than one year. Patients with primary heart disease were excluded from study. Patients were evaluated with demographic data, clinical history, and physical examination with focus on cardiovascular system, lab investigations, electrocardiography (ECG) and echocardiogram variables. The pattern of cardiovascular diseases was compared among patients undergoing short term and long term hemodialysis.&#x0D; Results: The echocardiographic evaluation of the cases under study revealed a diversity of pattern. In this study concentric or eccentric LVH was found in 60 %( n=90) of patients with short-term hemodialysis and 75 %( n=112) of patients with long-term hemodialysis. 30 %( n=45) of patients with short-term hemodialysis had degenerative/atherosclerotic valvular heart disease while the number was 35%(n=52) in patients undergoing long-term hemodialysis. Pericardial effusion was present in 9 %( n=13) of short-term hemodialysis patient and in 5%(n=7) of long-term hemodialysis patient. 18%(n=27) of short-term hemodialysis patient had systolic dysfunction while such change was present in 27%(n=40) of long-term hemodialysis patient. Diastolic dysfunction was present in 35%(n=52) of short-term hemodialysis patient and 49%(n=73) of long-term hemodialysis patient. Pulmonary Artery Hypertension(PAH) was present in 20%(n=30) of short term hemodialysis patient and 32%(n=48) of long term hemodialysis patient. Atrial fibrillation was present in 7 %(n=10) of short-term hemodialysis patient and 5%(n=7) of long term hemodialysis patients. &#x0D; Conclusions: Variety of cardiovascular diseases are common in ESRD patient undergoing hemodialysis. CVD is more prevalent in patient undergoing hemodialysis for long term.

Effect of cerebral microhemorrhages on neurocognitive functions in patients with end-stage renal disease.

Death is the most serious complication of intracerebral hemorrhage. Microbleeding can be a precursor of intracerebral hemorrhage. Susceptibility weighted imaging (SWI) should be included in imaging protocols for some specific groups such diabetic hemodialysis patients in terms of prediction of macrohemorrhages. To investigate intracerebral microbleeding in hemodialysis patients and the correlation between microbleeding and neurocognitive impairment. Forty-nine hemodialysis cases were involved in the study. Locations of microbleeding, correlation between microbleeding and hypertension, diabetes mellitus (DM), age, and duration of dialysis were analyzed. Standardized mini-mental test was performed. The tested cases were divided into two groups: intracerebral microbleeding (group 1, n = 26) and without intracerebral microbleeding (group 2, n = 17). Incidence of microbleeding and macrohemorrhage was noted as 59% and 14%, respectively, in all cases. All macrohemorrhagic cases also have microbleeding. In group 1, neurocognitive impairment was detected in 10 (38.4%) cases: six and four cases with moderate and mild impairment, respectively. In group 2, neurocognitive impairment was detected in 2 (11.7%) cases, both with mild impairment. A significant positive correlation was detected between microbleeding and neurocognitive impairment (P = 0.031). Although there was no correlation between attention disorder and microbleeding, a positive correlation was detected between close memory impairment and microbleeding (P = 0.027). A positive correlation was detected between DM and microbleeding (P = 0.027). In hemodialysis patients, microbleeding can be a cause of neurocognitive impairment which will be important for guide to treatment protocols. SWI should be included in the imaging protocol of diabetic hemodialysis patients with neurocognitive deterioration.

Uremic Pruritus is Associated with Two-Year Cardiovascular Mortality in Long Term Hemodialysis Patients

Background/Aims: Uremic pruritus (UP) is an unpleasant complication in patients undergoing maintenance dialysis. Cardiovascular and infection related deaths are the major causes of mortality in patients undergoing dialysis. Studies on the correlation between cardiovascular or infection related mortality and UP are limited. Methods: We analyze 866 maintenance hemodialysis (MHD) patients in our hemodialysis centers. Clinical parameters and 24-month cardiovascular and infection-related mortality are recorded. Results: The associations between all-cause, cardiovascular and infection related mortality with clinical data including UP are analyzed. Multivariate Cox regression demonstrated that UP is a significantly predictor for 24-month cardiovascular mortality in the MHD patients (Hazard ratio: 3.164; 95% confidence interval, 1.743–5.744; p < 0.001). Conclusion: Uremic pruritus is one of the predictor of 24-month cardiovascular mortality in MHD patients.

Minimally invasive lumbar interbody fusion for long term hemodialysis patients

Minimally invasive lumbar interbody fusion for long term hemodialysis patients

Nutritional Predictors of Mortality in Long Term Hemodialysis Patients.

Serum albumin had been noted to be a predictor of mortality in hemodialysis (HD) patients. Normalized protein catabolic rate (nPCR) less than 0.8 or greater than 1.4 g/kg/d was also associated with greater mortality. There was no previous study to show the effectiveness of combination of serum albumin and nPCR to predict the mortality in chronic HD patients. Eight hundred and sixty-six patients were divided into 4 groups according to their nPCR and serum albumin levels. Biochemical, and hematological parameters were recorded. The associations between groups, variables mentioned above and mortality were analyzed. Multivariate Cox regression analysis showed that age, diabetes mellitus, fistula as blood access, nPCR <1.2 g/kg/day combined with albumin <4 (Group A), nPCR ≧ 1.2 g/kg/day combined with albumin <4 g/dL (Group B) (nPCR ≧ 1.2 g/kg/day combined with Albumin ≧ 4 g/dL as reference group), non-anuria, hemoglobin, creatinine, and log (high sensitivity C reactive protein) were correlated with 36 months mortality. Group A and group B patients had higher 36 months cardiovascular (CV) and infection related mortality rates as compared with group D patients. In conclusion, Group A and Group B patients had significantly higher rate of all-cause, CV and infection related mortality.

A Retrospective Study of Preferable Alternative Route to Right Internal Jugular Vein for Placing Tunneled Dialysis Catheters: Right External Jugular Vein versus Left Internal Jugular Vein.

BackgroundRight internal jugular vein (IJV) is a preferred access route for tunneled (cuffed) dialysis catheters (TDCs), and both right external jugular vein (EJV) and left IJV are alternative routes for patients in case the right IJV isn’t available for TDC placement. This retrospective study aimed to determine if a disparity exists between the two alternative routes in hemodialysis patients in terms of outcomes of TDCs.Methods49 hemodialysis patients who required TDCs through right EJV (n = 21) or left IJV (n = 28) as long-term vascular access were included in this study. The primary end point was cumulative catheter patency. Secondary end points include primary catheter patency, proportion of patients that never required urokinase and incidence of catheter-related bloodstream infections (CRBSI).ResultsA total of 20,870 catheter-days were evaluated and the median was 384 (interquartile range, 262–605) catheter-days. Fewer catheters were removed in the right EJV group than in the left IJV group (P = 0.007). Mean cumulative catheter patency was higher in the right EJV group compared with the left IJV group (P = 0.031). There was no significant difference between the two groups in the incidence of CRBSI, primary catheter patency or proportion of patients that never required urokinase use. Total indwell time of antecedent catheters was identified as an independent risk factor for cumulative catheter patency by Cox regression hazards test with an HR of 2.212 (95% CI, 1.363–3.588; p = 0.001).ConclusionsRight EJV might be superior to left IJV as an alternative insertion route for TDC placement in hemodialysis patients whose right IJVs are unavailable.

Alternative grafts for brachioaxillary hemodialysis access: 1-year comparative results

BACKGROUND: Many chronic renal patients lack autologous veins in the upper limbs suitable for construction of arteriovenous fistulas for hemodialysis. Alternative fistula options for these patients should be evaluated and compared.OBJECTIVE: To compare different types of grafts used for brachioaxillary access in hemodialysis patients in terms of their patency and complication rates.METHOD: Forty-nine patients free from arterial system abnormalities and with no venous options for creation of arteriovenous fistulae in the arm and/or forearm underwent brachioaxillary bypass with implantation of autologous saphenous vein, polytetrafluoroethylene (PTFE), or PROPATEN(r) grafts. Patients were assessed by Doppler ultrasonography at 3, 6, and 12 months after surgery,.RESULTS: The four first saphenous vein grafts had failed by 3 or 6 months after surgery. The autologous saphenous vein group was discontinued at the beginning of the study because of extreme difficulty in achieving puncture and hematoma formation. Failure rates of PTFE and PROPATEN(r) grafts did not differ after 3 (p = 0.559), 6 (p = 0.920), or 12 months (p = 0.514). A log-rank test applied to cumulative survival of grafts at 1 year (0.69 for PTFE, 0.79 for PROPATEN(r)) detected no significant differences (p = 0.938). There were no differences in complications resulting in graft failure between the two types of prosthetic graft.CONCLUSION: Autologous saphenous vein grafts do not appear to be a good option for brachioaxillary hemodialysis access because of difficulties with achieving puncture. Brachioaxillary fistulae constructed using PTFE or PROPATEN(r) grafts exhibited similar patency and complication rates. Further studies with large samples size are warranted to confirm our findings.

Prevalence of Human Herpes Virus 6 (HHV-6) in Patients with Hemodialysis

HHV-6 is the causative agent of exanthema subitum in children. The main modes of transmission of HHV-6 arebody secretions such as infected saliva but it can be transmitted with blood and blood products that are infected with\the virus. Therefore, it is thought that the immunocompromised hemodialysis patients who had multiple bloodtransfusions due to various reasons, and who collectively use devices such as hemodialysis machines are at risk forHHV-6 infection. The present study aimed to determine the incidence of HHV-6 infection in hemodialysis patients. Twenty-five healthy individuals that were matched with 25 hemodialysis patients in terms of gender and age wereincluded in the study. The IgM and IgG sero-prevalence in the patient and control groups wereinvestigated with theindirect fluorescence antibody method and HHV-6 DNA prevalence and the determination of variant types (variant Aand variant B) were investigated with the PCR-RFLP molecular method. HHV-6 IgG and HHV-6 IgM antibodypositivity ratios in the patient and control groups were 76% and 20% respectively. Out of 50 serum samples of hemodialysis patients and healthy individuals, HHV-6 DNA was positive in seven of 25 samples of hemodialysispatients (28%) and it was positive in eight of 25 samples of the control group (32%). Variant analysis was performedwith the PCR-RFLP method in HHV-6 DNA positive hemodialysis patients and control patients. At the end of theanalysis, while variant A was not detected in the patient and control groups, variant B was detected in a total of 15individuals, including seven patients in the hemodialysis patient group and eight patients in the control group. Inconclusion, the researchers believe that there is a need for controlled studies including more samples to determinethe clinical importance of HHV-6 DNA and HHV-6 variants in hemodialysis patients.

Cys327Cys polymorphism of the PAPP-A gene (pregnancy associated plasma protein A) is related to mortality of long term hemodialysis patients

ObjectivesPAPP-A is an independent mortality predictor of long term hemodialysis patients and a prognostic marker of acute coronary syndrome in general population. Cys327Cys PAPP-A polymorphism (SNP) (rs12375498) was found to be of significance in preeclampsia and the C allele of the PAPP-A C/G SNP (rs13290387) was defined as an independent risk factor for acute myocardial infarction. The aim of the study was to test the role of these PAPP-A SNPs in long term hemodialysis patients. Design and methodsThe studied group consisted of 464 subjects — 319 long term hemodialysis patients (183 men, 136 women, 62±14years) and 145 controls (65 men, 80 women, 49±14years). A subgroup of 211 hemodialysis patients (118 men, 93 women, 63±13years) was prospectively followed up for 4.5years. During the follow up, 111 patients died, 51 of them due to cardiovascular events. PAPP-A SNPs were analyzed by DNA sequencing and serum PAPP-A was measured by TRACE. ResultsBoth SNPs were in Hardy–Weinberg equilibrium. Allelic and genotype frequencies did not differ between patients and controls and were not related to serum PAPP-A concentrations. Cys327Cys SNP was significant for patients' survival (HR (95% CI): 1.616 (1.110–2.353), nominal p=0.012, corrected p=0.036) while C/G SNP was not. ConclusionsOur study shows for the first time the significance of Cys327Cys PAPP-A SNP (rs12375498) for overall mortality of long term hemodialysis patients. Although it does not influence the concentration of PAPP-A it still could affect the correct function of this enzyme which has to be clarified in further studies.

Deposits of Amyloid (Beta-2 Microglobulin Type) in the Tongue

To the Editor: A 62-year-old woman was referred to our hospital with a 4-year history of asymptomatic lesion in the tongue, in April 2011 (Fig. 1). Her medical history included chronic renal failure because of renal tuberculosis and long-term hemodyalisis. She has been treated for 20 years using a standard cuprophane and cellulose acetate membrane. Physical examination showed a white-yellow diffuse and firm papular infiltration in the left border of the tongue. The right lateral border also showed a similar lesion. There was no macroglossia or disturbance of tongue mobility. The differential diagnosis was done among granular cell tumor, xanthomatosis and deposit diseases. An excisional biopsy of the lesion was done. Light microscopy study revealed amorphous eosinophilic amyloid deposits distributed from the submucosa to the upper muscular layer of the tongue. The deposits stained with Congo red and displayed an apple-green birefringence with polarized light. Moreover, it showed positivity with Thioflavin T. In the inmunohistochemical studies, it reacted with antibodies to beta-2 microglobulin (β2M) but not with amyloid A component (Fig. 2). The histopathological evidence and history of long-term hemodyalisis confirmed that the tongue lesions were a manifestation of dialysis-related amyloidosis (DRA). The blood test showed an increase of β2M (13929) in plasma. The serum protein electrophoresis was normal. An echocardiography-revealed hyperrefringents infiltrates in the inferior septum that induced a restrictive myocardiopathy. The lesions have been stable during the last year; therefore, we have not treated them. Actually, a high-flux biocompatible membrane is used for the patient's hemodyalisis.FIGURE 1: Lesion in the lateral border of the tongue.FIGURE 2: Histopathologic images. A, Low-power view demonstrates amorphous and eosinophilic deposits distributed from the submucosa to the upper muscular layer of the tongue (hematoxylin–eosin; original magnification, ×20). B, (hematoxylin–eosin; original magnification, ×400). C, Diffuse positive for Thioflavin T (Thioflavin T; ×20) D. Diffuse positive for Congo red (Congo red; ×20).DRA is a complication in long-term hemodyalisis patients caused by amyloid deposition derived from β2M.1 DRA predominantly involves the osteoarticular system, and it is less frequently related to the other extra-articular systems in very long–term hemodialysis patients.2 DRA of the tongue has been rarely reported.3 The tongue lesions are whitish yellow in color and vary in size (3–10 mm) and appear in hemodyalisis patients for more than 20 years. The nodules are firmer in consistency than in intact parts of the tongue. There are 2 locations: type lateral and type diffuse. There is not macroglossia, but it can induce lingual dysfunction.4 The light microscopic study reveals an amorphous eosinophilic material diffuse from the submucosa to the deeper muscle layer, stained with Congo red and its characteristic apple-green birefringence. The study also shows positivity with antibodies to β2M. The treatment is not necessary if the lesions are asymptomatic, and it has been limited to the management of symptoms and the surgical removal of amyloid deposits. Nowadays, new biocompatible high-flux synthetic membranes are used for hemodyalisis patients. This fact delays the DRA development. In conclusion, deposits of β2M in the tongue are a very rare complication in long-term hemodialysis patients. It may indicate that the deposits are widespread.

Does hemodiafiltration reduce vascular stiffness measured by aortic pulse wave velocity compared with high‐flux hemodialysis?

Hemodialfiltration (HDF) has been reported to reduce the frequency of intradialytic hypotension compared with hemodialysis (HD). We wished to determine whether HDF resulted in improvement of arterial stiffness compared with HD. We reviewed peripheral blood pressure and pulse wave velocity measurements in a cross-sectional analysis of stable HDF and HD outpatients. One hundred forty-one HDF patients were matched to 148 HD patients in terms of age, sex, prevalence of diabetes, peripheral blood pressure, and body mass. Pulse wave velocity was not different between the HD and HDF cohorts (median 9.1 [8.0-10.7] m/s vs. 9.7 [8.5-11.6] m/s). Similarly, there were no differences in central aortic pressure (149.2 ± 30.9 mmHg vs. 151.9 ± 35.2 mmHg), or aortic (39 [25.1-51.2]% vs. 38.6 [25.8-51.4]%) and brachial (3.8 [-24.3 to 26.9]% vs. 3 [-22.4 to 27.1]%) augmentation indices, respectively. Pulse wave velocity did not differ between adult patients treated by HD and HDF, and similarly, there were no differences in central aortic pressure, aortic or brachial augmentation indices, and cardiac diastolic perfusion. Our study suggests that HDF does not appear to offer any benefit over HD in terms of vascular stiffness.

Coenzyme Q10 and its Relation with Oxidant and Antioxidant System Markers in Patients with End-Stage Renal Disease

Rationale and objectives: Oxidative stress is increased in chronic kidney disease (CKD) patients and end-stage renal disease (ESRD) patients undergoing dialysis treatment. Coenzyme Q10 (CoQ10) is a ubiquitous and strong antioxidant. Role of CoQ10 is not fully evaluated in renal patients. We aimed to investigate the relationship of CoQ10 with oxidant and antioxidant system markers in patients with renal disease. Material and methods: Forty patients with CKD (stages 3–5) who were managed conservatively without dialysis treatment, 40 hemodialysis, and 60 chronic ambulatory peritoneal dialysis (CAPD) patients were included in the study. Biochemical and whole blood analyses were done using hospital auto-analyzers from stored samples. Serum CoQ10, malondialdehyde (MDA), superoxide dismutase (SOD), and antioxidant activity (AOA) levels were determined. Main findings: There was no difference among the groups in terms of serum CoQ10 levels. However, other components of antioxidant system, namely, SOD and AOA were significantly higher in CAPD patients when compared to CKD patients. MDA levels were not significantly different among the groups. Principal conclusion(s): The results of this study showed no difference among CKD, CAPD, and hemodialysis patients in terms of serum CoQ10 levels.

2004 Japanese Society for Dialysis Therapy Guidelines for Renal Anemia in Chronic Hemodialysis Patients*

The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Professor F. Gejyo of Niigata University, now publishes an original Japanese guideline entitled 'Guidelines for Renal Anemia in Chronic Hemodialysis Patients'. It includes the re-evaluation of the usage of recombinant human erythropoietin (rHuEPO) with the medical and economical arguments regarding the prognosis and the quality of life of Japanese hemodialysis patients. This guideline consists of 7 sections. The first section comprises the general definition and the differential diagnosis of anemia. The hemoglobin (Hb) level of the Japanese population seemed to be low when compared with that of the European and American populations. The second section describes the target Hb level in hemodialysis patients. Multivariate analysis of the data that were collected from dialysis institutions throughout the country showed that an Hb level of 10-11 g/dL (Ht level 30-33%) at the first dialysis session in a week is the ideal range for chronic hemodialysis patients in terms of the 3-5 year survival rate. The supine position at blood sampling and the sampling timing at the first dialysis session in a week might affect the lower setting of target Hb hematocrit (Ht), compared to that of European and American guidelines. However, we particularly recommended that an Hb level of 11-12 g/dL (Ht level from 33 to 36%) at the first dialysis session in a week is desirable in relatively young patients. In the third section, the markers of iron deficiency are discussed. The Transferin saturation test (TSAT) and serum ferritin were emphasized as the standard markers. The routes of administration of rHuEPO and its dosages are written in the fourth section. The subcutaneous route was associated with the occurrence of secondary red cell aplasia due to anti-rHuEPO antibodies; however, secondary red cell aplasia was seldom observed in the venous injection. From this fact we recommend venous injection for chronic hemodialysis patients. We advocate an initial dosage of 1500 U three times per week. The fifth section deals with the factors refractory to treatment with rHuEPO. If the patient shows an inadequate response to the usage of 9000 U per week, this condition defines the inadequate response to rHuEPO in Japan. Blood transfusion must be avoided where possible. The reasons for this and the adverse effects are interpreted in section six. In the final section, the adverse effects of rHuEPO are listed. Among them, hypertension, thrombotic events and secondary red cell aplasia were emphasized as the major complications.

A Community Cancer Center Experience of the Efficacy and Safety of the Use of Intravenous Iron Dextran in Chemotherapy Induced Anemia.

An adequate level of hemoglobin is essential during chemotherapy in order to maintain an acceptable quality of life (QOL) and to prevent cancer related fatigue. The role of hematopoitic growth factors like Erythropoitin or Darbepoitin alfa in chemotherapy induced anemia is now well-accepted with the recommended goal being a hematocrit value of 33% approximately. It is also established that an iron-replete state is essential for proper response to the erythropoitic growth factors and IV iron supplementation has been in routine clinical use in long term hemodialysis patients. Unfortunately many cancer patients are nutritionally depleted and at the same time do not tolerate oral iron replacement. Intravenous iron preparations such as iron dextran or sodium ferric gluconate (Ferrlecit) are good alternatives because of their quick and predictable effect on erythropoisis. However due to heightened concern about infusion related serious side effects their use has not been widespread in community clinical practice. We present our experience of treating 30 patients (7 lung cancer, 6 breast cancer, 3 lymphoma, 6 colorectal, 4 ovarian, 4 others) in our center with documented chemotherapy induced anemia with supplemental intravenous iron. None of the patients had any history of untreated pretreatment iron deficiency anemia. Utilizing a premedication protocol of hydrocortisone 100mg, benadryl 25 mg and ranitidine 50 mg IV prior to iron infusion we could record only 2 cases with grade I/II (mainly nausea and dizziness) and none with grade III/IV acute infusion related toxicity. Only one patient required treatment interruption and no one required hospitalization due to adverse events. There was no death associated with this therapy. The pretreatment average hematocrit was 29.26% (range 26.4–32.3%). The average posttreatment hematocrit was 35.33% (range 33.1–44.6%) within an average of 4 weeks. All patients were treated with Erythropoitin (40,000 unit/wk) or Darbepoitin alfa (200 mg/14 days) during the period of observation. All patients received their respective chemotherapy for the primary cancer without interruption. The effect persisted over the next 10–14 weeks during which the primary therapy was continued. No long term adverse effect was observed during this period of observation.Conclusion- This small observational study indicates that intravenous iron infusion is a safe procedure in the community cancer center setting. It has the potential of significantly augmenting the effect of erythropoitic growth factor therapy for chemotherapy induced anemia. Further studies are required to evaluate the routine use of intravenous iron in chemotherapy induced anemia similar to its use with erythropoitin in patients on chronic hemodialysis.