Value of Doppler evaluation of physically abnormal fistula: hemodynamic guidelines and access outcomes

BACKGROUND/AIMS: The strategy of access care at out center involves the use of ultrasound (USG) in case of physical examination (PE) abnormality. USG determines the need of angiography. This study investigated the possible association between the need for percutaneous transluminal angioplasty (PTA) and hemodynamic parameters of USG. The study also assessed the effects of this monitoring strategy on outcomes in comparison with a historical control. METHODS: A retrospective study of the medical records of 127 patients (65 PTA, 62 non-PTA) was conducted. Data were analyzed using logistic regression analysis and receiver operating characteristic curve. Fistula outcomes and intervention rates were calculated and compared with 100 historic controls. RESULTS: Logistic regression analysis showed that brachial artery flow volume (FV) 0.63 was independently associated with the need for PTA. This monitoring strategy showed an a reduction in thromboses (0.02 ± 0.11 events/arteriovenous fistula [AVF]-year vs. 0.07 ± 0.23 events/AVF-year, p = 0.046), reduction in central venous catheter placement (0.01 ± 0.05 events/AVF-year vs. 0.06 ± 0.22 events/AVF-year, p = 0.010), reduction in access loss (0.02 ± 0.13 events/AVF-year vs. 0.19 ± 0.34 events/AVF-year, p = 0.015), and increase in access selective repair (0.49 ± 0.66 events/AVF-year vs. 0.21 ± 0.69 events/AVF-year, p = 0.003), compared to historic control. CONCLUSIONS: There was significant stenosis if brachial artery FV was 0.63 for PE abnormality. These parameters should be used as markers for assessing PTA risk in hemodialysis patients. Addition of USG to determine the need of angiography after detection of PE abnormality leads to decreases in access thrombosis, catheter placement, and access loss despite increasing access intervention rates compared to clinical monitoring.

Clinical experience with ultrasound guided angioplasty for vascular access

BACKGROUND: The use of ultrasound guided percutaneous transluminal angioplasty (UG-PTA), which use ultrasound as an imaging modality, is an evolving strategy. But, in Korea, this method is rarely used. We report our experiences with UG-PTA with respect to technical success rates and complication rates compared to conventional PTA (C-PTA), performed between 2010 and 2015 at Samsung Changwon Hospital, Korea. METHODS: In our series, 53 cases of UG-PTA and 90 cases of C-PTA were reviewed, respectively. Cases of central vein stenosis, cephalic arch stenosis, arterial stenosis and thrombosis were excluded. However, cases of juxta-anastomotic stenosis and outflow vein stenosis were included. RESULTS: Technical success was achieved in 96.2% (51 of 53) of cases in the UG-PTA group and in 93.3% (84 of 90) of cases in the C-PTA group, respectively (P = 0.710). Technical failure was experienced in a total 8 cases (UG-PTA group: 2/53, 3.8%; C-PTA group: 6/90, 6.7%). No differences were observed in complications. CONCLUSION: Duplex ultrasound-guided angioplasty for dialysis access in the outpatient setting is feasible, safe, and effective for peripheral venous stenotic lesions. It offers many advantages over conventional angiographic procedures, and, in the future, it has great potential to play a significant role in the management of these challenging patients.

Comparison of Gait Speed and Peripheral Nerve Function Between Chronic Kidney Disease Patients With and Without Diabetes

OBJECTIVE: To compare overall physical function, including gait speed and peripheral nerve function, between diabetic chronic kidney disease (CKD) patients and nondiabetic CKD patients and to investigate the association between gait speed and peripheral nerve function in CKD patients. METHODS: Sixty adult CKD patients (35 with and 25 without diabetes), who received maintenance hemodialysis (HD), were included in this study. Demographic data, past medical history, current medical condition and functional data—usual gait speed, vibration perception threshold for the index finger (VPT-F) and the great toe (VPT-T), activity of daily living (ADL) difficulty, and peripheral neuropathy (PN) along with the degree of its severity—were collected and compared between the two groups. Correlations between the severity of PN and the impairment of other functions were identified. RESULTS: Diabetic CKD patients showed significantly slower gait speed (p=0.029), impaired sensory function (VPT-F, p=0.011; VPT-T, p=0.023), and more frequent and severe PN (number of PN, p<0.001; severity of PN, p<0.001) as compared to those without diabetes. Usual gait speed had a significant negative correlation with the severity of PN (rho=−0.249, p=0.013). By contrast, VPT-F (rho=0.286, p=0.014) and VPT-T (rho=0.332, p=0.035) were positively correlated with the severity of PN. ADL difficulty was comparatively more frequent in the patients with more severe PN (p=0.031). CONCLUSION: In CKD patients with maintenance HD, their gait speed, sensory functions, and peripheral nerve functions were all significantly impaired when they have diabetes, and the severity of PN was negatively correlated with their gait speed, sensory function, and ADL function. Adverse effects of diabetes impacted physical performance of CKD patients. The physical disability of those patients might be attributable to PN and its severity.

Progression of Extramedullary Plasmacytoma in a Multiple Myeloma Patient with No Increment in Serum M Protein Level / 대한내과학회지

A 76 year-old female who was diagnosed with multiple myeloma (IgG, lambda) had received bortezomib, melphalan and prednisolone as first-line treatment. After completing six cycles of chemotherapy, her serum monoclonal protein level decreased from 7.28 g/dL to 0.65 g/dL, indicating a partial response. However, at the next scheduled visit she complained of slowly progressing dyspnea. On chest X-ray, newly developed pleural effusion was found, and rapidly progressing extramedullary plasmacytoma was detected in the anterior mediastinum on chest computerized tomography. However, there was no change in her serum monoclonal protein level. In Korea, extramedullary involvement is encountered in 5% of patients with multiple myeloma. However, evaluation of treatment response using solely the serum monoclonal protein level may not accurately reflect disease status in these patients.

Hypocitraturia-related Ureteral Steinstrasse in a Renal Transplant Recipient / 이화의대지

Urolithiasis is an uncommon complication in renal transplantation. We report a case of hypocitraturia-related ureteral steinstrasse which was spontaneously formed in a renal transplant recipient. The patient who underwent renal transplantation was admitted with acute pyelonephritis. Hydronephrosis in the transplanted kidney and multiple stones (steinstrasse) in the distal ureter were incidentally found on computed tomography scanning. After a failed attempt of ureteroscopic removal of stones, the patient underwent open ureterolithotomy and ureteroureterostomy. On stone analysis, carbonate apatite was confirmed. Urinary citric acid levels were decreased to 127.6 mg/day. Potassium citrate was administered to prevent stone recurrence by increasing urinary citrate excretion. No recurrence of stones was shown six months later. Urolithiasis in renal transplant recipients requires a high index of suspicion. Hypocitraturia can increase the risk for urolithiasis. Rapid recognition by careful surveillance, prompt removal of stones, and precautionary efforts to prevent recurrence are needed.

Two Cases of Treatment with Intrathecal Rituximab for Primary Central Nervous System Lymphoma / 대한내과학회지

Primary central nervous system lymphoma (PCNSL) is an aggressive non-Hodgkin's lymphoma (NHL), usually composed of diffuse large B-cells. Although rituximab is known for its curative effect on B-cell NHL, data on the use of intrathecal rituximab for PCNSL are limited. In this report, we present two patients showing relapsed PCNSL with lymphomatous meningitis. Both patients were refractory to conventional methotrexate-based intrathecal chemotherapy. However, after intrathecal rituximab with or without conventional intrathecal chemotherapy, both patients showed stable disease on magnetic resonance brain imaging and cerebrospinal fluid analysis. There were no serious adverse events during each of 3 and 6 cycles with intrathecal rituximab immunotherapy.

Depression and Life Quality in Chronic Renal Failure Patients with Polyneuropathy on Hemodialysis

OBJECTIVE: To investigate the relationship between severity of peripheral polyneuropathy (PPN) and degree of depression and quality of life in chronic renal failure (CRF) patients on hemodialysis (HD). METHOD: Forty seven chronic renal failure patients on hemodialysis were recruited (22 male, 25 female, mean age of 63.17+/-12.52) and etiology, disease duration, hemodialysis duration, creatinine and hemoglobin were recorded. Motor and sensory nerve conduction studies were carried out on bilateral median, ulnar, tibial and peroneal nerves for diagnosis of polyneuropathy according to our laboratory criteria. The Korean version of Beck depression inventory (BDI) questionnaire translated into Korean for diagnosis of depression, and Korean version of Short Form 36 health survey (SF-36) questionnaire for measurement of general health level were measured in those diagnosed with uremic PPN. RESULTS: Out of 52 patients, 47 were diagnosed with polyneuropathy and mean score for BDI was 18.49+/-9.18. Mean scores for each of Mental Component Summary (MCS) and Physical Component Summary (PCS) of SF-36 were 50.84+/-15.42 and 47.41+/-18.68. The correlation between the scores and polyneuropathy were analyzed by Pearson coefficient. The MCS score was the significant (p<0.05) correlation parameter with depression (R=-0.635) and the PCS score was the only parameter with a significant (p<0.05) correlation with polyneuropathy (R=-0.340). CONCLUSION: Uremic polyneuropathy is commonly observed in chronic renal failure patients on hemodialysis. Depression in CRF with uremic PPN is affected by psychological factors other than the PPN itself.

Characteristics and Survival of Dialysis Patients due to Type 2 Cardiorenal Syndrome / 대한신장학회지

PURPOSE: We evaluated clinical outcomes in patients with type 2 cardiorenal syndrome who were treated with peritoneal dialysis (PD) or hemodialysis (HD). METHODS: A retrospective database of PD or HD patients with type 2 cardiorenal syndrome from January 1, 2002 to December 31, 2010 was established. We evaluated the mean survival on dialysis, days of hospitalizations and NYHA class changes. RESULTS: Thirty-two patients with mean age at the start of dialysis of 68.4+/-10.8 years had mean survival on dialysis of 20.5+/-14.4 months (median survival 17.8 months). Survival after starting dialysis is highly variable, but long term survival was proved possible. The days of hospitalization for cardiovascular causes were reduced (25.1+/-17.7, predialysis vs. 9.5+/-32.8 days/patient/month, postdialysis, p=0.013). All patients showed improvement in NYHA functional class. Kidney function stabilized, while significant improvement in hemoglobin (+16.5%, p<0.001) were achieved. CONCLUSION: After starting dialysis for Type 2 cardiorenal syndrome, the chances of hospitalization for cardiovascular causes were reduced for all patients. Survival on dialysis in these patients was highly variable.

The Effects of Preoperative Practice Patterns on Hemodialysis Vascular Access Outcomes / 대한신장학회지

To evaluate the effects of specialty of the operator and of preoperative ultrasonic mapping at the time of AVF creation on access outcomes, we studied 224 patients who received AVF surgery by nephrologist with preoperative sonographic mapping (Group 1, n=112) or by vascular surgeon with only physical examination (Group 2, n=112) from January 2008 to December 2009. We compared the rate of autogenous fistula formation, primary failure rate (immediate failure, maturation failure) and patency rate between two groups. Group 1 had more autogenous fistula (97.4 vs. 63.0%, p<0.05), more mid-arm fistula (20.7 vs. 0%, p<0.05) compared to group 2. Immediate failure was more common in group 2 (1 vs. 9, p<0.05). Maturation failure was not different between two groups (10 vs. 10, p=ns). Group 1 had higher primary patency rate at 1 year (74.40 vs. 68.27%, p<0.05) and also had higher secondary patency rate at 1 year (87.33 vs. 81.63%, p<0.05) compared to group 2.

Imatinib-Mesylate Induced Interstitial Pneumonitis in Two CML Patients / 결핵및호흡기질환

Imatinib mesylate, a selective inhibitor of BCR-ABL kinase activity, has demonstrated significant clinical efficacy in the treatment of chronic myeloid leukemia (CML) and gastrointestinal stromal tumors (GISTs). It has become the standard of treatment for these diseases. Although the toxicity profile of imatinib is superior to that of interferon or other cytotoxic agents, some adverse events including edema, gastrointestinal toxicities and hematologic toxicities are commonly observed in the patients treated by imatinib. We present two cases of imatinib induced interstitial pneumonitis during the treatment of a chronic phase of CML.

A Single Institution's Experience of Endoscopic Retrograde Cholangiopancreaticography in the Eldery Patients: Outcomes, Safety and Complications / 대한소화기학회지

BACKGROUND/AIMS: As the population ages, endoscopic retrograde cholangiopancreaticography (ERCP) is being used increasingly as a diagnostic and therapeutic tool for elderly patients with pancreatobiliary disease. The aim of this study was to assess the outcomes, safety and complications associated with ERCP performed in the elderly patients. METHODS: We retrospectively reviewed the medical record of 596 patients who were 50 years of age or older and underwent ERCP from January 2005 to September 2010. The patients were classified into two groups according to the age: non-elderly, 50-74 years old and elderly, > or =75 years old. Comparisons were made between two groups. RESULTS: Five hundred and ninety-six patients (132 elderly and 464 non-elderly patients) were enrolled. The success rate of ERCP was 89.4% in the elderly and 91.9% in the non-elderly. The major complications were occurred in 11 patients of the elderly and 16 of the non-elderly, and the complication rate was significantly higher in the elderly compared to the non-elderly (8.3% vs. 3.4%, p=0.011). Pancreatitis occurred in 2 elderly patients and 10 non-elderly patients (1.5% vs. 2.1%, p=1.0). There was a higher rate of bleeding in the elderly patients (4.5% vs. 1.3%, p=0.01). CONCLUSIONS: ERCP is effective and safe even in elderly patients. Outcomes of diagnostic and therapeutic ERCP in the elderly patients were similar to those in non-elderly patients. Elderly patients undergoing ERCP carried similar risk of pancreatitis but a higher risk of bleeding and perforation compared to non-elderly patients.

Clinical Experience of Proximal Radio-Cephalic Fistula / 대한신장학회지

PURPOSE: The first choice of vascular access is a distal radiocephalic fistula (dRCF) at the wrist. In patients with a failed dRCF or with vessels unsuitable for dRCF, the recommendation is to place a brachiocephalic fistula (BC) in the upper arm. Proximal forearm radiocephalic fistulas (pRCF) are created infrequently, but may permit a second forearm fistula before proceeding to the upper arm BC. The goal of the present study was to evaluate the effect of pRCF in hemodialysis patients. METHODS: We included 80 patients who received arteriovenous fistula operation between December, 2008 and July, 2010. The type of arteriovenous fistula (dRCF, pRCF, BC) was determined according to preoperative vascular mapping using doppler ultrasonography. The fistula operation was performed by one surgeon. We compared the non-maturation rates, primary and secondary patency rates among dRCF, pRCF, and BC. RESULTS: The numbers of patients that underwent dRCF, pRCF, and BC operation were 27, 27, and 26, respectively. Only 33.8% of patients needed creation of a dRCF potentially. Non-maturation rates were similar among the patients that underwent dRCF, pRCF and BC (11.1%, 7.4%, and 3.8%, respectively, p>0.05). The primary patency rates of dRCF, pRCF, and BC were 81.5%, 92.6%, 80.8%, respectively (p>0.05). The secondary patency rates of dRCF, pRCF, and BC were 92.3%, 96.3%, and 92.3%, respectively (p>0.05). CONCLUSION: pRCF had non-maturation rate, primary and secondary patency rate, comparable to those of a dRCF and, a BC. pRCF may be an attractive alternative to a BC in patients who do not have vessel suitable for creation of a dRCF.

Sexual Functioning in Male Hemodialysis Patients / 대한신장학회지

PURPOSE: The prevalence of sexual dysfunction among male hemodialysis patients is high. The causes of sexual dysfunction in chronic renal failure are composed of physiological and psychological factors. We assessed the prevalence, severity and factors of sexual dysfunction among male patients undergoing hemodialysis using of International index of erectile function (IIEF). METHODS: A single center cross-sectional study of 57 male hemodialysis patients was conducted to the determinants of sexual dysfunction. All patients were required to complete questionnaires by themselves (IIEF and Beck depression inventory (BDI)) and biochemical and hematological parameters were obtained. RESULTS: Sexual dysfunction prevalence was 86.0% in erectile function, 94.7% in sexual intercourse satisfaction, 86.0% in orgasmic function, 96.5% in sexual desire, 96.5% in overall satisfaction. Age, serum albumin, BDI, Karnofsky index, calcium channel blocker were statistically associated with sexual activity. But a multiple logistic regression analysis demonstrated that BDI is independently associated with sexual activity. A linear multivariable regression analysis demonstrated that age, BDI, serum albumin are independently associated with sexual desire of IIEF. CONCLUSION: Sexual dysfunction among male hemodialysis patients is high. Depression is an independent factor of sexual dysfunction in male hemodialysis patients. Evaluation of depression must be included to properly manage sexual dysfunction.

A Case of Invasive Aspergillosis Limited to Renal Allograft / 대한신장학회지

Though the development of immunosuppressive agents has increased the survival rate of transplanted kidneys, the opportunistic infection has increased in transplant recipients. Aspergillus may cause invasive aspergillosis via sino-pulmonary route in immunocompromized patients. We report a rare case of invasive aspergillosis of a transplanted kidney without having disseminated disease. A 41 year-old female, who underwent cadaveric renal transplantation 10 months ago, presented with diarrhea and anemia. Ultrasound examination and CT scan revealed an abscess lesion in the transplanted kidney. Surgical curettage and percutaneous drainage were performed. Because, microscopic examination demonstrated fungal hyphae consistent with Aspergillus species, antifungal agents were prescribed. Later, partial transplant nephrectomy and embolization of the remnant kidney were performed.

A Case of ANCA-positive RPGN after Propylthiouracil Treatment / 대한신장학회지

Anti neutrophil cytoplasmic antibody (ANCA)-positive vasculitis and crescentic glomerulonephritis has been rarely reported in patients suffering from Graves' disease and treated with Propylthiouracil. We experienced a case of ANCA-positive crescentic glomerulonephritis presenting good prognosis after discontinuing Propylthiouracil. A 40-year-old female visited due to the proteinuria and hematuria in urinalysis. She had been medicated Propylthiouracil for 3 years. Blood pressure was 100/60 mmHg. BUN and serum creatinine were 24.7 mg/dL, and 1.9 mg/dL, respectively. Urinalysis revealed protein 1481 mg/day, many RBC's/HPF (dysmorphic 80%), Serological ANCA was positive, anti-myeloperoxidase (MPO) antibody 1,922 AAU/ mL (normal <150 AAU/mL). The histologic finding showed crescentic glomerulonephritis on light microscopy, but no immuno deposit on immunofluorescence and light microscopy. So we diagnosed ANCA positive pauci-immune glomerulonephritis. Propylthiouracil was discontinued and steroid, cyclophosphamide was medicated within about 1 month, but stopped due to cytopenia. Patient's creatinine level was maintained 1.3 mg/dL and showed stable progress for about over 18 months. We report this case that showed good prognosis after discontinuation of Propylthiouracil.

Depression and Anxiety in Maintenance Hemodialysis Patients: A Single Center Study / 대한신장학회지

PURPOSE: Psychiatric problem such as depression and anxiety is prevalent and is associated with morbidity and mortality in hemodialysis patients. But it is difficult to assess and is undertreated. The aim of this study is investigating the prevalence and the risk factors for depression and anxiety among patients receiving maintenance hemodialysis. METHODS: We used the Hospital Anxiety and Depression scale (HADS. Korean version) as a screening test for 104 hemodialysis patients in a single center. Univariate analysis and mutltivariable logistic regression analysis were used to evaluate the association between the psychiatric problem (depression and anxiety) and other patients' factors (social economic factors and medical conditions). RESULTS: The mean age was 58.2+/-12.1 years and the causes of ESRD were diabetes mellitus (50%), hypertension (27.9%), chronic glomerulonephritis (8.7%), and other or unknown causes (14%). The prevalence of depression was 58.7%, and univariate analysis revealed that comorbidity index, Karnofsky index, serum creatinine, and age were statistically significantly correlated with depression. But Multivariable logistic regression analysis demonstrated that only Karnofsky index was independently associated with depression [odds ratio (OR)=5.834, p=0.007]. The prevalence of anxiety was 27.9% and only karnofsky index was significantly correlated with anxiety on both univariate and multivariable logistic regression analysis. CONCLUSION: Depression and anxiety were prevalent in hemodialysis patients. Poor performance status was highly associated with depression and anxiety.

A Case of Hantavirus Pulmonary Syndrome Mimicking Apalastic Anemia with Invasive Aspergillosis / 대한혈액학회지

Hantavirus is known to a causative agent of hemorrhagic fever with renal syndrome and it can cause hantavirus pulmonary syndrome, a rare disease in Korea. Hantavirus pulmonary syndrome is usually associated with pulmonary hemorrhage and fever. The common hematologic features of this syndrome are elevated hematocrit level, leukocytosis and thrombocytopenia. We report a case of hantavirus pulmonary syndrome with pancytopenia. This patient with severe neutropenia with pulmonary infiltration mimicked aplastic anemia with invasive aspergillosis.

A Case of Primary Renal Amyloidosis with Fulminant Hepatic Failure / 대한신장학회지

We report the case of a patient with primary renal amyloidosis, who was progressed to fulminant hepatic failure. A 68-year-old man visited our hospital for evaluation of anorexia, weight loss and hepatomegaly. Laboratory examination revealed proteinuria and azotemia. He was confirmed to have primary amyloidosis by renal biopsy. His renal function progressed to deteriorate rapidly with marked deterioration of liver function with cholestasis. Peritoneal dialysis and steroid therapy were started for reduction of urine output and rapid progression of azotemia, and aggravation of liver function. Azotemia was improved after peritoneal dialysis but the liver function worsened leading to hepatic failure, causing death. If jaundice has progressed in any patients with primary amyloidosis, liver transplantation and stem cell transplantation should be considered for preparation of hepatic failure.

Allopurinol hypersensitivity syndrome and pure red cell aplasia associated with allopurinol treatment / 대한내과학회지

Allopurinol is widely used to reduce serum uric acid levels and, generally, has mild side effects. Rarely, allopurinol hypersensitivity syndrome occurs and this consists of severe systemic skin lesions, fever, reduced kidney and liver function, and leukocytosis with eosinophilia. Extremely rarely, allopurinol-induced pure red cell aplasia is reported. We report a case of allopurinol hypersensitivity syndrome and pure red cell aplasia following allopurinol therapy for eight weeks and the disease response to steroid therapy in a patient with chronic renal insufficiency.

A Case of Anuric Acute Renal Failure, Acute Hepatitis and Rhabdomyolysis occurred after Carp Bile Ingestion / 대한신장학회지

Gall bladder of a common carp is taken in some areas of Asia as a traditional medicine for improvement of their general health problems like hypertension, poor visual acuity, and impotence. Many cases have been reported on acute hepatitis, acute renal failure, gastrointestinal problems and neurological symptoms following ingestion of raw carp bile juice. We experienced a case of anuric ARF, acute hepatitis, and rhabdomyolysis that developed after indigestion of raw carp bile juice, not yet seen in previous studies. In this case, anuric state of patient was resolved after 4 days with continuous renal replacement therapy. Thus we report this case with review of literature.