Is peritoneal dialysis causing a measurable burden of inflammatory and endothelial injury on top of metabolic syndrome?

PURPOSE: Low-grade chronic inflammation is present in patients on peritoneal dialysis (PD) and in metabolic syndrome (MS). Due to possible greater endothelial changes in dialyzed patients, inflammatory response and oxidative stress are probably stronger in patients on PD. The objective of the study was to investigate possible in between adipokines, inflammatory, endothelial and oxidative stress markers between MS patients and patients on PD. METHODS: Concentrations of adipokines (leptin, resistin), inflammatory markers [interleukin-6 (IL-6), soluble tumor necrosis factor alpha receptor (sTNF-R), myeloperoxidase (MPO), monocyte chemoattractant protein 1 (MCP-1)] and endothelial markers [soluble intracellular adhesion molecule-1 (sICAM-1), soluble CD40 ligand (sCD40L)] were determined in 55 MS patients and 18 patients on PD, with flow cytometry, and visfatin concentration was measured with ELISA. Routine biochemistry parameters were measured on Beckman Coulter AU2700 analyzer. RESULTS: Patients on PD have significantly higher concentration of: CRP [6.5 (3.7-12.1) versus 2.6 (1.3-4.0) mg/L, P < 0.001], IL-6 [13.83 (8.48-31.31) versus 2.05 (0.67-4.11) pg/mL, P < 0.001], MCP-1 [2172.28 (1563.84-2922.77) versus 1353.58 (1166.33-1961.70) pg/mL, P = 0.023], sTNF-R [18.25 (12.81-25.22) versus 1.23 (0.89-1.43) ng/mL, P < 0.001] and sICAM-1 [830.03 (599.21-967.02) versus 463.85 (315.25-751.71) ng/mL, P = 0.006] than subjects with MS. MS patients have higher concentrations of MPO [175.47 (120.15-231.67) versus 101.76 (53.55-186.06) ng/mL, P = 0.016] and visfatin [1.5 (0.9-2.3) versus 0.9 (0.6-1.6) ng/mL, P = 0.013]. CONCLUSION: In patients on PD, inflammatory reaction is higher than in patients with MS. On the contrary, patients with MS have stronger oxidative stress response and adipose tissue activity caused probably by the chronic low level of inflammation and underlying metabolic disorders.

Healing of skin necrosis and regression of anticardiolipin antibodies achieved by parathyroidectomy in a dialyzed woman with calcific uremic arteriolopathy.

AIM: To present the impact of parathyroidectomy on the spontaneous healing of necrotic lesions of the skin of the lower leg and on anticardiolipin antibodies regression in a 68-year-old female dialyzed patient with hyperparathyroidism and calcific-uremic arteriolopathy (CUA). METHODS: After the occurrence of initial lesions of the lower leg skin, the intact parathyroid (iPTH) level, calcium (Ca) and phosphorus (P) product were measured, and on two occasions at 6-week intervals, the titer of anticardiolipin antibodies was determined, followed by a clinical monitoring of the progress of necrotic skin lesions. Two months after the occurrence of the skin lesions, the patient's right leg was amputated below the knee due to gangrene, and a histopathological analysis of the skin tissue sample of the amputated lower leg was made. After parathyroidectomy, iPTH, Ca x P product were measured, and on two occasions at 6 weeks' intervals, anticardiolipin antibodies titer was determined, followed by a clinical monitoring of lesions of the left lower leg skin. RESULTS: Before parathyroidectomy, iPTH level and Ca x P product were increased, as well as IgG anticardiolipin antibody titer measured on two occasions 6 weeks apart. The histopathological analysis of the skin tissue sample of the amputated right lower leg showed mural calcification of artery walls and thrombotic occlusions of small arteries, arterioles, and dermal capillaries, in addition to epidermolysis. A week after parathyroidectomy, iPTH level and Ca x P product were within normal range. Two measurements 6 weeks apart revealed no anticardiolipin antibodies. Eight weeks after parathyroidectomy, spontaneous healing of necrotic skin lesions of the left lower leg was observed. CONCLUSION: Regression of anticardiolipin antibodies, normalization of Ca x P product, and healing of the skin lesions after parathyroidectomy all pointed to the elevated PTH level as a crucial factor in the pathogenesis of CUA.

Hyperexcitability in sensory neurons of rats selected for high versus low neuropathic pain phenotype.

Selection line rats congenitally high or low for autotomy in the neuroma model of neuropathic pain (HA and LA rats) were found to be correspondingly high and low in a second type of neuropathic pain, the Chung model, which employs an alternative phenotypic endpoint, tactile allodynia. It has been proposed that both phenotypes reflect ectopic hyperexcitability in axotomized primary sensory neurons. To test this hypothesis we made in vitro recordings from sensory neurons in the L4 and 5 dorsal root ganglia. Baseline excitability was similar in HA and LA rats, and axotomy caused an increase in both lines. However, in the one neuronal subclass previously linked to neuropathic pain in these models the increase was significantly greater in HA than LA rats, and only at the time when pain scores in the two lines were diverging. Heritable differences in electrical response to axotomy in a specific afferent cell type appear to be a fundamental determinant of neuropathic pain.

Acute acalculous cholecystitis in patients with surgical acute renal failure.

Acute acalculous cholecystitis (AAC) developed in 11 (7.7%) of 143 patients with surgical acute renal failure (ARF) who had no prior biliary tract disease. The cause of this potentially fatal complication is multifactorial and include trauma, previous surgery, sepsis, intermittent positive pressure ventilation, total parenteral nutrition, multiple transfusions, hypotension, and opiate sedation. The diagnosis of AAC was based on clinical suspicion, ultrasound scanning, and laboratory tests (leukocyte count, liver enzymes, bilirubin and C-reactive protein). All our ARF patients with AAC were receiving antibiotics at the time of diagnosis. Five patients were treated conservatively and six underwent cholecystectomy. The mortality rate in our ARF patients with AAC was 45.5%, and was not significantly different from than in ARF patients without AAC. The diagnosis of AAC should be made early, and judicious management (conservative or surgical) decreases its role as a contributory factor to the mortality in ARF patients.

Effects of renal transplantation on hearing and ocular changes in a monozygotic twin with Alport's syndrome: comparison with other twin on hemodialysis.

AIM: To present a unique case of Alport's syndrome in monozygotic twins with two different treatment modalities - renal transplantation and hemodialysis, and to evaluate the effects of therapy on hearing and ophthalmological findings. METHODS: Pure-tone audiogram and ophthalmologic examinations were performed in both twins at the age of 30. At the age of 46, 4 years after renal transplantation in the first twin and after 6 years of hemodialysis in the second twin, both twins underwent control audiometric and ophthalmologic examinations. RESULTS: Control audiometric measurements showed the progression of bilateral sensorineural hearing loss in the high-frequency range (>2,000 Hz) in both twins. The hearing threshold progressed from initial 50 dB in both twins at the time of the diagnosis to 55 dB in the twin on hemodialysis, and 85 dB in the twin with a transplanted kidney. Retinal blurry hyperpigmentations disappeared in the twin with a transplanted kidney. CONCLUSION: In comparison with hemodialysis, renal transplantation in Alport's syndrome may have deleterious effect on hearing, when associated with plasma hyperviscosity and hyperlipidemia, but may lead to regression of retinal hyperpigmentation.

[Acute renal failure, intravascular hemolysis and toxic hepatitis caused by repeated use of rifampicin (case report)]. / Akutno bubrezno zatajenje, intravaskularna hemoliza i toksicni hepatitis uzrokovani opetovanim uzimanjem rifampicina (prikaz bolesnika).

We report the case of a 57-year-old man treated with interrupted rifampicin therapy for urinary tract tuberculosis who experienced acute renal failure, intravascular hemolysis and toxic hepatitis. This combined adverse reactions are rare. Supportive treatment with dialysis and withdrawal of rifampicin result with complete recovery. Interrupted and intermittent therapy with rifampicin should be avoided and noncompliant patients should be given alternative treatment when possible.

Acute carbon monoxide poisoning as the cause of rhabdomyolysis and acute renal failure.

Acute renal failure (ARF) is a severe complication of acute CO poisoning which, combined with other organ lesions, may result in lethal outcome. In all vague cases of ARF with nontraumatic rhabdomyolysis, CO poisoning should be considered as a possible etiologic factor. The diagnosis is made on the basis of several simple laboratory tests: determination of carboxyhemoglobin concentration, demonstration of myoglobin in urine or pigment granulated cylindres in urinary sediment, positive orthotoluidine test, and high CPK values originating from skeletal musculature. Many authors report on excellent prognosis in ARF due to nontraumatic rhabdomyolysis of various causes. Our case report shows that the prognosis of CO poisoned patient greatly depends on timely and appropriate treatment, severity of damage to other organs, and success of the treatment of complications such as hospital infections.

The effect of hollow-fiber dialyzer Plivadial Altra-Flux 140 on beta-2-microglobulin removal.

A thirty-fold or even greater increase in plasma beta-2-microglobulin (beta 2M), which is commonly found in end-stage renal disease (ESRD) patients on long-term hemodialysis (HD), is most likely a consequence of the inability of the dialysis procedure to remove the dally production of beta 2M. In the present study, a newly developed high-flux membrane composed of cellulose diacetate (CDA) (dialyzer Plivadial Altra-Flux 140, Pliva, Zagreb, Croatia) was evaluated with regard to beta 2M removal capacity during HD in 8 stable ESRD patients. Thera was a drop in the plasma beta 2M concentration (-19.8 +/- 8.4) with a clearance of 22.7 +/- 9.2 ml/min (QB = 250 ml/min, QD = 600 ml/min). Accordingly, the sieving coefficient (SC) was found to be 0.37 +/- 0.1 at 60 min after the start of HD. The CDA membrane was able to remove 100.5 +/- 30 mg of beta 2M during a 4-hour HD session. This data demonstrate an increased percentage removal of beta 2M and significantly decreased postdialysis plasma concentrations of beta 2M which is a potential factor in the development of dialysis-related amyloidosis (DRA).

Ascites in a patient undergoing maintenance hemodialysis.

Clinical characteristics and course in a patient with end-stage renal disease and nephrogenic ascites are described. The pathophysiology and current treatment options for this rare condition with poor prognosis are discussed.