Carpal Tunnel Syndrome and Peripheral Polyneuropathy in Patients with End Stage Kidney Disease

This study was designed to identify the causes of the development of carpal tunnel syndrome (CTS) associated with end stage kidney disease (ESKD). A total of 112 patients with ESKD, 64 on hemodialysis (HD) and 48 on peritoneal dialysis (PD), were enrolled. The duration of ESKD and dialysis, the site of the arteriovenous (A-V) fistula for HD, laboratory data such as blood urea nitrogen, creatinine, and beta-2-microglobulin were determined. Clinical evaluation of CTS and electrophysiological studies for the diagnosis of CTS and peripheral neuropathy were performed. The electrophysiological studies showed that the frequency of CTS was not different in the HD and PD groups (P = 0.823) and the frequency of CTS was not different in the limb with the A-V fistula compared to the contralateral limb (P = 0.816). The frequency of HD and PD were not related to beta-2-microglobulin levels, an indicator of amyloidosis. The frequency of CTS did not increase as the severity of the peripheral neuropathy and the duration of ESKD and dialysis increased (P = 0.307). The results of this study do not support that microglobulin induced amyloidosis or placement of an A-V fistula are associated with an increase in CTS.

Renovascular Hypertension and Nephrotic Range Proteinuria Developed after the Renal Artery Ligation: Successful Treatment by Combination of ACE Inhibitor and Angiotensin II Type 1 Receptor Blocker / 대한신장학회지

A 27-year-old woman presented with severe hypertension and nephrotic range proteinuria. She had a blunt renal trauma 4 weeks ago and was treated by the left main renal artery ligation. The plasma renin activity, angiotension II and aldosterone levels were very high and the abdominal angiography showed the occlusion of the left main renal artery with relatively preserved blood flow in upper pole of the left kidney. In captopril renal scan, relatively preserved perfusion in upper pole of left kidney was further compromised after captopril administration. The massive proteinuria and hypertension were improved after combination of ACE inhibitor and angiotensin II type 1 receptor blocker treatment.

A Case of Splenectomy in a Patient with Refractory Thrombotic Thrombocytopenic Purpura / 대한신장학회지

The introduction of plasma exchange has significantly improved the outcome of thrombotic thrombocytopenic purpura (TTP) and the survival rate was increased from 10 to 80-90%. TTP refractory to plasma exchange therapy, however, is still a therapeutic challenge. We describe here a patient who partially responded to plasma exchange therapy, but remained dependent on plasma infusions. To discontinue plasma therapy, several attempts using agents such as rituximab, vincristine, and cyclosporine A had been tried, but all failed. After splenectomy, serum LDH and blood platelet count were normalized. Plasmapheresis were we able to discontinue after 2 weeks of splenectomy. Steroid and cyclosporine were tapered off after 3 months and 5 months after splenectomy respectively, and the patient has been staying in remission ever since. We suggest that splenectomy is a worthwhile treatment option in patients with refractory TTP.

Intensive Hemodialysis in Patients with ESRD Improves Cardiac Function Through Inflammatory Regulation / 대한신장학회지

PURPOSE: CHF is a life threatening acute complication in ESRD populations. An intensive hemodialysis (HD) has been effective in reducing intravascular volume and in removing uremic toxin with improved systolic function. Although recent progress has identified an inflammation as an important contributor to the pathogenesis of CVD, the effect of intensive HD on inflammatory parameters and left ventricle (LV) systolic dysfunction is not clear. The purpose of this study is to examine the effect of intensive HD on LV systolic function and serum cytokines levels. METHODS: Among ESRD patients who underwent dialysis and developed acute pulmonary edema due to LV systolic dysfunction were enrolled. Intensive HD consisted of daily 4 hours HD for 7 consecutive days. Data were prospectively collected and 2-D echocardiography was done before and after intensive HD. Serum levels of TNF-alpha and IL-10 were compared and lipopolysaccharide (LSP)-stimulated of these cytokines were measured. RESULTS: After intensive HD, weight and mean arterial blood pressure decreased significantly and ejection fraction (EF) increased significantly. Serum IL-10 and TNF-alpha levels decreased significantly after intensive HD. In contrast, LPS stimulated production of these cytokines increased significantly after intensive HD. The difference of CRP between after HD and before HD was negatively correlated with the difference of EF. CONCLUSION: In ESRD patients with acute LV dysfunction, intensive HD significantly improved EF and restored the immune responsiveness. These results suggest that intensive HD has the advantage of improving EF through modulating inflammation and correcting immune dysfunction in ESRD patients with acute LV dysfunction.

Association of Depression with Inflammation and Cardiovascular Risk Factors in End Stage Renal Disease Patients on Hemodialysis / 대한신장학회지

PURPOSE: Depression is associated with increased inflammation and cardiovascular disease. And in patients with end stage renal disease (ESRD), depression is a common problem and cardiovascular disease is the main cause of death. The aim of this study is to investigate the association of depression with various inflammatory markers and with some cardiovascular risk factors in ESRD patients on hemodialysis METHODS: 53 patients with ESRD on maintenance hemodialysis were divided into depressive symptom (BDI> or =11) group and control (BDI < 11) group by the 21-items Becks depression inventory (BDI). We collected patients characteristics and laboratory measurements by medical records. And then, we measured the levels of IL-10 and TNF-alpha a and analyzed the genotype of IL-10 and TNF-alpha a promoter area. RESULTS: The levels of TNF-alpha, CRP and ferritin were significantly higher in depressive symptom group (p=0.001, 0.04, 0.02) and IL-10 concentration tended to be lower in depressive symptom group (p= 0.05). The prevalence of left ventricular hypertrophy was higher in depressive symptom group than in the control group (44% vs 9%, p=0.01). GG genotype known as high IL-10 producer was less common in depressive symptom group than in control group (8% vs 36%, p=0.039). CONCLUSION: Increased inflammation, high left ventricular hypertrophy prevalence and low ejection fraction were observed in depressive hemodialysis patients. Further prospective study is needed to clarify the role of depression in the development of inflammation and cardiovascular disease in ESRD patients.

Effect of Initiating Dialysis on Inflammatory State and Immune Response in Patients with End-stage Renal Disease / 대한신장학회지

PURPOSE: inflammation is a common feature in chronic kidney disease patients, and it could contribute to long-term morbidity and mortality related with malnutrition and atherosclerosis. In this study, we aimed to investigate the effect of initiating dialysis on inflammatory state, nutritional parameter, and immune response in end-stage renal disease (ESRD) patients. METHODS: 57 ESRD patients who initiated hemodialysis (HD, n=31) or continuous ambulatory peritoneal dialysis (CAPD, n=26) were enrolled. Pro-inflammatory cytokine, tumor necrosis factor (TNF)-alpha, and anti-inflammatory cytokines, interleukin (IL)-10 and adiponectin were measured before and 3 months after initiation of dialysis. Inflammatory marker, highly sensitive C-reactive protein (hs-CRP), and nutritional parameter, albumin, were also checked. Lipopolysaccharide (LPS)-stimulated production of TNF-alpha and IL-10 were measured for the evaluation of immune response by external stimuli. RESULTS: As uremia was reduced by initiating dialysis, serum level of TNF-alpha was decreased and adiponectin was increased. These changes were accompanied by the decrease of hs-CRP and the increase of serum albumin. LPS-stimulated cytokines production was increased after initiating dialysis. There differences in these parameters comparing HD and CAPD patients except more increase of serum adiponectin level in CAPD patients. CONCLUSION: Our study demonstrated that initiation of dialysis results in decrease of inflammation, improvement of nutritional status, and restoration of proper immune responsiveness in ESRD patients. These results suggest that correction of uremic milieu through dialysis has beneficial effects. Therefore, initiation of dialysis might have the advantage of improving inflammatory and nutritional status, and correcting immune dysfunction in ESRD patients.

Restless Legs Syndrome and Quality of Life in Hemodialysis Patients / 수면정신생리

OBJECTIVE: Restless legs syndrome (RLS) is known to be associated with chronic renal failure (CRF) patients on hemodialysis, however the prevalence of RLS in CRF patients on hemodialysis is variable due to different diagnostic criteria or dialysis technique. A few reports have indicated the association between RLS symptom and lower life quality in CRF patients on hemodialysis. This study aims to investigate the prevalence of RLS and its association with the quality of life in CRF patients of a single dialysis unit in Korea. METHODS: A total of 83 Korean CRF patients on hemodialysis in the Korea University Hospital were examined. International Restless Legs Syndrome Study Group (IRLSSG) criteria and International Restless Legs Scale (IRLS) were used to determine the diagnosis and severity of RLS. Questionnaires including Athens Insomnia Scale (AIS), Epworth sleepiness scale (ESS), and Medical Outcome Study Form-36 (SF-36) were administered to all the patients for the assessment of sleep and quality of life. Hamilton Depression Rating Scale (HDRS) and Clinical Global Impression (CGI) were also measured for depression and status of mental illness by psychiatrist. RESULTS: Of the 83 patients, 31 (37.3%) patients were found to have RLS and 43 (51.8%) patients met at least one of the RLS diagnostic criteria. The AIS (t=2.40, p=0.019), ESS (t=2.41, p=0.018), HDRS (t=3.85, p<0.001) and CGI (t=3.52, p=0.001) were higher in the subjects with RLS compared to other subjects. The SF-36 scores were significantly lower in the patients with RLS except physical functioning and bodily pain. Total (p=0.005), physical component (p=0.019), and mental component scores (p=0.019) of SF-36 were significantly lower in patients with more severe RLS symptoms. CONCLUSION: There was significant relationship between RLS and poor quality of sleep and life. More severe RLS symptom was proven to be an important factor to make a quality of life worsen.

Restless Legs Syndrome and Quality of Life in Hemodialysis Patients / 수면정신생리

OBJECTIVE: Restless legs syndrome (RLS) is known to be associated with chronic renal failure (CRF) patients on hemodialysis, however the prevalence of RLS in CRF patients on hemodialysis is variable due to different diagnostic criteria or dialysis technique. A few reports have indicated the association between RLS symptom and lower life quality in CRF patients on hemodialysis. This study aims to investigate the prevalence of RLS and its association with the quality of life in CRF patients of a single dialysis unit in Korea. METHODS: A total of 83 Korean CRF patients on hemodialysis in the Korea University Hospital were examined. International Restless Legs Syndrome Study Group (IRLSSG) criteria and International Restless Legs Scale (IRLS) were used to determine the diagnosis and severity of RLS. Questionnaires including Athens Insomnia Scale (AIS), Epworth sleepiness scale (ESS), and Medical Outcome Study Form-36 (SF-36) were administered to all the patients for the assessment of sleep and quality of life. Hamilton Depression Rating Scale (HDRS) and Clinical Global Impression (CGI) were also measured for depression and status of mental illness by psychiatrist. RESULTS: Of the 83 patients, 31 (37.3%) patients were found to have RLS and 43 (51.8%) patients met at least one of the RLS diagnostic criteria. The AIS (t=2.40, p=0.019), ESS (t=2.41, p=0.018), HDRS (t=3.85, p<0.001) and CGI (t=3.52, p=0.001) were higher in the subjects with RLS compared to other subjects. The SF-36 scores were significantly lower in the patients with RLS except physical functioning and bodily pain. Total (p=0.005), physical component (p=0.019), and mental component scores (p=0.019) of SF-36 were significantly lower in patients with more severe RLS symptoms. CONCLUSION: There was significant relationship between RLS and poor quality of sleep and life. More severe RLS symptom was proven to be an important factor to make a quality of life worsen.

A Case of Multiple Organ Failure due to Heat Stoke Following a Warm Bath

Heat stroke is a potentially fatal disorder that's caused by an extreme elevation in body temperature. We report here an unusual case of multiple organ failure that was caused by classical, nonexertional heat stroke due to taking a warm bath at home. A 68 year old diabetic man was hospitalized for loss of consciousness. He was presumed to have been in a warm bath for 3 hrs and his body temperature was 41 degrees C. Despite cooling and supportive care, he developed acute renal failure, disseminated intravascular coagulation (DIC) and fulminant liver failure. Continuous venovenous hemofiltration was started on day 3 because of the progressive oligouria and severe metabolic acidosis. On day 15, septic ascites was developed and Acinetobacter baumanii and Enterococcus faecium were isolated on the blood cultures. In spite of the best supportive care, the hepatic failure and DIC combined with septic peritonitis progressed; the patient succumbed on day 25.

A Case of Acute Renal Failure Resulting from Murine Typhus Infection Induced Acute Tubulointerstitial Nephritis / 대한신장학회잡지

Murine typhus is an infectious disease caused by Rickettsia typhi, an intracellular parasite that lives in the cytoplasm of host cells. Rickettsia typhi infection can induce lymphohistiocytic vasculitis leading to pulmonary, cardiovascular, central nervous system and renal complications. We experienced a case of acute renal failure resulting from acute tubulointerstitial nephritis associated with murine typhus infection. A 67 year old man was transferred from local hospital due to fever, confusion, oliguria with renal failure. Laboratory finding showed elevated liver enzyme with hypoalbuminemia and progressive azotemia. Despite supportive care, his azotemia progressed with anuria and acute hemodialysis was started. Kidney biopsy showed acute tubulointerstitial nephritis with vasculitis and indirect immunofluorecent antibody to murine typhus was 1: 3, 200. Doxycyclin was started and his renal function recovered. We report a case of acute renal failure resulting from murine typhus infection induced acute tubulointerstitial nephritis.

A Case of Idiopathic Erythrocytosis in a CAPD Patient / 대한신장학회잡지

We have experienced a case of idiopathic erythrocytosis developed in a patient with end stage renal disease who had switched to CAPD from hemodialysis. Hemoglobin levels gradually increased from 8 to 19.0 mg/dl, resulting in various symptoms from hyperviscosity during the first 2 months after the initiation of CAPD. There were no other possible causes of secondary erythrocytosis, such as hypoxia, erythropoietin -producing tumor or acquired cyst. Serum level of IGF-1 was above the normal range in contrast with low serum levels in CAPD patients with anemia. Increased IGF-1 levels may possibly influence on the development of erythrocytosis in this case.

Association of IL-10 genotypes with cardiovascular risk factors in patients with hemodialysis / 대한내과학회지

BACKGROUND: Chronic systemic inflammation in ESRD patients due to uremia and hemodialysis procedure itself comes into notice as a main factor for premature mortality secondary to rapid progressing atherosclerosis. Various pro-inflammatory cytokine, known to mediate these reaction of malnutrition, inflammation and atherosclerosis, are regulated by anti-inflammatory cytokine, such as IL-10. Quantitative production of IL-10 shows interindividual variability determined genetically by polymorphisms of promotor gene. The aim of this study was to measure the degree of IL-10 synthesis in ESRD patients treated with hemodialysis and evaluate the association with genotypes and cardiovascular risk factors. METHODS: The IL-10 genotypes for polymorphic bases at position at -1082 was determined in 66 chronic hemodialysis patients and 98 healthy subjects using highly specific PCR and the lipopolysaccharide (LPS)-stimulated IL-10 (sIL-10) release from whole blood were measured by ELISA. RESULTS: The distribution of the IL-10 genotypes in hemodialysis patients were similar to the general population, but the proportion of A allele in hemodialysis group was significantly higher (72.3% vs 59.8%, p=0.05). sIL-10 concentration were lower in hemodialysis patients compared with normal control (21.1 pg/mg vs 36.1 pg/mg, p=0.001) and both groups showed same relationship of sIL-10 with genotypes, that AA type was low producer. In multiple regression analysis, sIL-10 of normal group correlated negatively with age, creatinine, uric acid and existence LVH, and positively with albumin, hemoglobin. On the other hand, lower albumin, lower ejection fraction on echocardiography and existence of left ventricular hypertrophy were associated with higher sIL-10 in hemodialysis group. CONCLUSION: Polymorphisms by IL-10 genotypes were associated with production of IL-10 by endotoxin stimulation, and sIL-10 was lower in hemodialysis patients than in normal control. According to relation of sIL-10 with cardiovascular risk factors such as existence LVH, ejection fraction and malnutrition, it could be suggested that sIL-10 is useful marker in evaluating the risk of cardiovascular events.

A Case of lambda-type Light Chain Deposition Disease Manifested as Acute Renal Failure and Multiple Organ Dysfunction by Embolic Events / 대한신장학회잡지

Light chain deposition disease is caused by systemic paraprotein deposition resulting from monoclonal plasma cell dyscrasia. It is usually characterized rapidly progressive renal failure and multiple organ dysfunctions. Besides deposition of light chain, it can lead to multiple organ dysfunctions due to hyperviscosity syndrome. We experienced a case of 54-year-old man who presented as an acute renal failure, and elevation of liver enzyme. Radiologically, there was no abnormal finding except enlargement of both kidney in abdominal sonogram. Globulinuria was noticed on 24 hrs-urine study. The histologic findings of kidney showed lambda chain deposits in basement membrane of tubules and glomeruli, interstitium, and vessel walls. On 10th day of hospitalization, he developed sudden hypoxia that was not corrected by oxygen supplementation, and focal neurologic signs accompanied with a change of consciousness. We report a case of light chain deposition disease manifested as an acute renal failure and liver enzyme elevation with suspicious multiple organ embolic events later.