Calcificaciones vasculares y valvulares en pacientes en hemodiálisis crónica / Vascular and valvular calcifications in chronic hemodialysis patients

Introducción: las calcificaciones vasculares y valvulares son un hallazgo común en los pacientes en diálisis y se vinculan con una incrementada morbi-mortalidad. Varios métodos radiológicos (TAC multicorte y con emisión de electrones) han sido utilizados para investigar la presencia de calcificaciones vasculares en esta población, pero solo unos pocos trabajos se han focalizado en la radiología simple. Objetivos: Los objetivos de este estudio son evaluar calcificaciones vasculares mediante índice de Kauppila en pacientes prevalentes en hemodiálisis, identificar factores de riesgo vinculados con las mismas y establecer su asociación con calcificación de válvulas cardiacas. Material y métodos: Se estudiaron 95 pacientes estables en hemodiálisis durante un periodo igual o mayor a 6 meses. A todos se les realizó Rx simple perfil de abdomen para evaluar calcificación de la aorta abdominal mediante índice de Kauppila y ecocardiograma bidimensional para detectar calcificaciones valvulares. Se recolectaron datos sobre sexo, edad, diabetes, HTA, tabaquismo, dislipemia y metabolismo óseo-mineral. Resultados: Se demostraron calcificaciones vasculares en el 64,5 % de los pacientes. El índice de Kauppila promedio fue 6,25 La edad y el tiempo en diálisis correlacionaron con calcificación vascular. En 31,6 % de los individuos se objetivaron calcificaciones valvulares, las cuales presentaron asociación significativa con diabetes e índice de Kauppila. Conclusiones: Las calcificaciones vasculares y valvulares fueron frecuentes en la población estudiada. El índice de Kauppila correlacionó con edad, tiempo en diálisis y calcificaciones valvulares. La calcificación de válvulas cardiacas se asoció con diabetes.

Introduction: vascular and valvular calcifications are a frequent complication in dialyzed patients and are connected to an increased morbi-mortality. Many radiological methods (TAC multiple slices and with electrons emission) have been used to investigate the presence of vascular calcifications in this population, but only few works have been focused on simple radiology. Objectives: The objectives of this work are to evaluate vascular calcifications by means of Kauppila index in hemodialysis prevalent patients, identify linked risk factors and determine their association with heart valves calcification. Methods: 95 stable patients under hemodialysis were surveyed during a period of 6 months longer. Abdominal Rx simple profile were performed on all patients to evaluate calcification of abdominal aorta by Kauppila index and twodimensional echocardiogram to detect valvular calcifications. Data were collected about sex, age, diabetes, Hypertension, tabaquism, dislipemia and bone-mineral metabolism. Results: 64.5% of the patients showed vascular calcifications. Average Kauppila index was 6.25. Age and time on dialysis correlated with vascular calcifications. In 31.6 % of individuals valvular calcifications were found, which presented significant association with diabetes and Kauppila Index. Conclusions: Vascular and valvular calcifications were frequent in the surveyed population. Kauppila index correlated with age, time on dialysis and valvular calcifications. Heart valves calcification was associated with diabetes.

Long-Term Results Following Aortic Valve Replacement for Aortic Valve Stenosis in Patients with Dialysis-Dependent Renal Failure and Risk Factors for Prognosis / 日本心臓血管外科学会雑誌

The objective of this study was to assess the long-term outcomes of aortic valve replacement (AVR) for aortic valve stenosis (AS) in patients undertaking chronic renal hemodialysis at the time of the operation. Seventy five hemodialysis patients who underwent AVR between January 1993 and September 2012 were taken into account in this study. Operations included 40 isolated AVR and 35 concomitant AVR and coronary artery bypass grafting (CABG). Other combined AVR (mitral valve operation and aortic root operation) and emergency operations were excluded. Mean patients' age was 66.7 (±8.5) years and 53 out of 75 (70.6%) were male. The etiology of renal failure consisted of diabetic nephropathy (22 cases, 29.3%) and non-diabetic renal failure (53 cases, 70.7%). The mean duration of hemodialysis was 8.1 years. The operative mortality was 6.6%. The 1-year, 3-year, 5 year, and 10-year survival rates were 74.5, 42.1, 29.9, and 6.8%, respectively. Statistical analysis revealed that aortic valve area of less than 0.9 cm² and serum cholinesterase of less than 200 IU/<i>l </i>lead to significant risk for mortality (<i>p</i><0.05). There was no clear difference between the outcomes of isolated AVR and concomitant AVR and CABG. This study suggests that earlier surgical intervention for AS in hemodialysis patients can improve the long-term outcomes, and serum cholinesterase can be a useful preoperative marker to assess operative results.

Assessment of nutritional status in chronic hemodialysis patients at the galayanivadhana hemodialysis unit.

Malnutrition in patients on maintenance hemodialysis (HD) is an important problem commonly associated with increased risk of morbidity and mortality. The aims of this study are to assess the nutritional status and to determine the cause(s) of malnutrition in stable chronic HD patients treated at the Galayanivadhana hemodialysis Unit, Siriraj Hospital. A total of 145 patients were included in the study and their nutritional status was determined by a questionnaire, a 3-day dietary record, and biochemical and anthropometric assessments including body mass index, ideal and relative body weight, subcutaneous skin fold, % body fat and mid-arm circumference. The prevalence of malnutrition in the studied patients is 52.4% : 27.6% with mild, 16.6% with moderate and 8.3% with severe degrees. Most patients received fewer than 35 Kcal-kg-day. The prevalence of malnutrition is comparable to that reported by Siriraj’s Dialysis Unit (42%) but is less than that of Rajavithee Hospital (81.5%). According to statistical analyses, the factors associated with malnutrition are age, economic factors, patient rights, occupation, plasma cholesterol, Kt/V [two times per week], Hct, Epo treatment and nutritional score. In contrast, there is no association with the presence of a caretaker, education al level, sight viewing, serum C-reactive protein, frequency and sufficiency of HD, number of reused dialyzer, nPCR, Kt/V [three times per week], ideal body weight and height. Our study indicates that assessment of nutritional status in HD patients is crucial in particular for those with economic problems, insufficient dietary nutritional status in HD patients is crucial in particular for those with economic problems, insufficient dietary nutrient intake, low Hct value, and low plasma cholesterol. This is an important and challenging task for HD nurses who are close to patients and their relatives as well as nutritionists who give dietary advice in order to improve the quality of life in chronic HD patients.

Effects of Low-dose Androgen in Combination with Subcutaneous Recombinant Human Erythropoietin (r-HuEPO) on Anemia and Nutritional Parameters in Hemodialysis Patients / 대한신장학회잡지

Recombinant human erythropoietin(r-HuEPO) is the mainstay of anemia therapy in patient with end stage renal disease(ESRD), but the use of r-HuEPO is primarily limited by its high cost. So, it encourages any strategies that potentially enhance the erythropoietic response. However, studies designed to assess whether androgens would enhance the response to r-HuEPO were inconclusive. While androgens may be less expensive and may improve several nutritional parameters, their potential adverse effects discourage usage. We carried out a prospective study to examine the effect of low-dose androgen in combination with subcutaneous r-HuEPO on anemia and nutritional paramenters in hemodialysis patients. Twenty-four hemodialysis patients with hematocrit <24% or hemoglobin <8.0g/dL were randomly assigned into two groups. Group A(n=12) received 2000U r-HuEPO subcutaneously twice a week for six months. Group B(n=12) received the same dose of r-HuEPO plus nandrolone decanoate 100mg intramuscularly biweekly. Anthropometry, albumin, cholesterol, prealbumin, and transferrin were measured as nutritional parameters. The groups showed no differences in baseline levels of the followings : Hemoglobin, hematocrit; transferrin saturation; serum ferritin; intact serum parathyroid hormon, Kt/V; vitamin B12, folate; nutritional parameters. At the completion of the study, both groups showed significant increase in hematocrit compared with baseline levels(group A 20.7+/-2.2% to 26.0+/-3.8%; group B : 21.5+/-3.5% to 30.1+/-2.8%). The mean hematocrit in group B was significantly higher than in group A after 4 month study period(p<0.05). Ten of 12 patients in group B achieved a target hematocrit of 30%, as compared with four of 12 patients in group A. Both groups didn't show significant changes in any nutritional parameters. No significant side effects of androgen were noted during this short-term study. We conclude that low-dose androgen in combination with subcutaneous r-HuEPO is effetive treatment on anemia in hemodialysis patients, but does not improve nutritional status.

A Case of Spontaneous Mediastinal Hemorrhage in Patients on Chronic Hemodialysis / 대한신장학회잡지

Spontaneous hemorrhage in the patients undergoing hemodialysis is the ralatively common problem, but spontaneous mediastinal hemorrhage in such patients reported only few cases. We experienced a case of spontaneous mediastinal hemorrhage in chronic hemodialysis patient who complained of continuous pleuritic chest pain and mild dyspnea. The diagnosis was made dy chest computed tomography,magnetic resonance imaging and percutaneous fine needle aspiration of liquified dark reddish old blood material guided by ultrasonography. Treatment is usually conservative, with blood volume replacement and intensive hemodialysis using regional heparinization. We report on a patient undergoing hemodialysis due to endstage renal disease who developed spontaneous mediastinal hemorrhage.