Switching from calcium carbonate to sevelamer hydrochloride has suppressive effects on the progression of aortic calcification in hemodialysis patients: assessment using plain chest X-ray films.

Sevelamer hydrochloride, a non-aluminum- and non-calcium-containing hydrogel, is an effective phosphate binder in dialysis patients. The suppressive effect of the switching from calcium carbonate to sevelamer hydrochloride on the progression of vascular calcification was examined by measuring areas of calcification on routine chest X-rays using image-analyzing software. The data of 69 maintenance hemodialysis patients were analyzed retrospectively. Over a period of 18 months, 19 patients took only sevelamer hydrochloride as a phosphate binder, while the other 50 patients took only calcium carbonate. The area of calcification increased in the calcium carbonate group, but did not change significantly in the sevelamer group. While the usefulness of computed tomography in detecting vascular calcification in hemodialysis patients has been reported previously, the suppressive effects of switching from calcium carbonate to sevelamer hydrochloride on the progression of aortic calcification can be observed without computed tomography by using the plain chest X-ray films that are routinely performed in hemodialysis clinics.

Carpal tunnel syndrome and plasma beta2-microglobulin concentration in hemodialysis patients.

As of the end of June 2005, 27 of 96 dialysis outpatients at our clinic had developed carpal tunnel syndrome (CTS). Of 19 patients who had undergone dialysis for 30 years or longer, 15 had CTS, whereas none of the 38 patients who had received dialysis for less than 10 years had CTS. These data reflect trends in CTS development: from 1983 the incidence of CTS increased for many years, but more recently there has been a decline in new cases of CTS. Comparison of the 27 CTS and 69 non-CTS dialysis patients at our clinic showed that those in the CTS group were older and had a longer duration of dialysis. Patients in the CTS group were found to have had a high plasma beta2-microglobulin (BMG) level in the distant past (15-21 years ago), but conversely had a much lower BMG level in recent years. Simple correlation analysis and multiple logistic regression analysis showed that the presence of CTS was correlated with high BMG levels in the distant past, in addition to age and duration of dialysis. These findings suggest that reduction of the plasma BMG level due to advances in dialysis therapy in recent years has contributed to the decreased incidence of CTS.

Overproduction and secretion of a novel amino-terminal form of parathyroid hormone from a severe type of parathyroid hyperplasia in uremia.

Measurement of bioactive parathyroid hormone (PTH) is essential for optimal management of bone abnormalities in dialysis patients. This can be accomplished by PTH measurements using third-generation PTH assays, which detect more or less of the first six amino acids of the PTH structure. Such assays do not detect non-(1-84) PTH fragments, such as human PTH (7-84), which are recognized by the second-generation PTH assays that use a detection antibody that recognizes an epitope within the 13-34 region of the PTH structure. Therefore, third-generation PTH results are expected to be lower than those that are obtained with second-generation PTH assays. Rare exceptions to this rule have been reported for patients with severe primary hyperparathyroidism or parathyroid cancer. Sera and gland extracts were analyzed from a dialysis patient with high bone turnover disease and with surprising higher PTH levels by a third-generation assay than by a second-generation assay. This finding normalized after the surgical removal of an enlarged gland with a single nodule, an advanced type of nodular hyperplasia. HPLC fractionation of sera and gland extracts revealed the overproduction and secretion of a PTH molecule with an intact amino-terminus structure distinct from (1-84) PTH. This form of PTH was readily detectable by third-generation PTH assays but was poorly reactive in second-generation PTH assays. Therefore, parathyroid glands with advanced uremic nodular hyperplasia may overproduce and secrete a novel, biologically active form of PTH with an intact 1-6 region but a presumably modified 12-18 region required for the detection in second-generation PTH assays.

[2 dialysis cases which came to our clinic for the symptoms caused by hypercalcemia].

We'll report 2 dialysis cases which came to our clinic for the symptoms caused by hypercalcemia. Patients complained of sleeplessness, itching, headache, palpitation, apathy, akinesis, leanness, foot gangrene and so on. Hypercalcemia is one of the complication of vitamin D and calcium carbonate administration in chronic renal failure, though the frequency and risk are not clearly documented. Hypercalcemia aggravates the outcome of patients on dialysis and contributes to vascular calcification in long term. Recently various factors involving cardiovascular calcification are discussed, but first of all we must be very careful for the symptoms of hypercalcemia, and careful monitoring of plasma calcium concentration are recommended.

[A case of sarcoidosis overlapping with rheumatoid arthritis].

We report the case of a 54-year-old woman who presented on May 28, 2001 with sarcoidosis overlapping with rheumatoid arthritis. She had experienced morning stiffness 2 years previously and was diagnosed as having rheumatoid arthritis. She had been treated with bucillamine and loxoprofen for 3 months. In October 2000, she developed proteinurea. The patient discontinued treatment with bucillamine and loxoprofen. Proteinurea persisted, and the patient's renal function declined. On admission, subcutaneous nodules were palpable in the patient's legs. The patient's serum creatinine and calcium levels were 2.49 mg/dl and 11.6 mg/dl, respectively. Intact-PTH was suppressed, and PTHrP was not elevated. Despite the presence of hypercalcemia, the patient's serum 1 alpha 25(OH)2D3 was not suppressed. Serum ACE and lysozyme levels were elevated beyond the normal ranges. A renal biopsy was performed, and non-caseous epithelioid granuloma was found in the renal interstitium. Based on the histological findings, the patient was diagnosed as having sarcoidosis. Following treatment with prednisolone, the patient's serum calcium levels returned to normal and her renal function improved.