Bilateral nephrectomy for uncontrolled hypertension in hemodialysis patient: a forgotten option?

Resistant arterial hypertension in chronic hemodialysis patients is still a therapeutical challenge despite the development of modern antihypertensive drugs and dialysis procedures. Bilateral nephrectomy seems to be a forgotten option, although it has given good results. We present a case of a 39-year-old female chronic hemodialysis patient, in whom the problem of uncontrolled renal parenchymal hypertension remained despite multiple drug therapy and the ultrafiltration intensification. The problem was solved by bilateral nephrectomy. We discuss the role of bilateral nephrectomy for arterial hypertension control in chronic hemodialysis patients and the surgical and non-surgical options of nephrectomy.

Plasma exchange treatment for acute hyperlipidemic pancreatitis with falsely low levels of serum triglycerides - a case report.

Hypertriglyceridemia is a well-recognized cause of acute pancreatitis. We present a patient with acute hypertriglyceridemic pancreatitis. At presentation serum triglycerides were severely elevated (104 mmol/l) and were decreasing the next day (11 mmol/l). However, based on increasing levels of serum lipase, worsening respiratory failure and evidently lipemic serum, we decided to perform plasma exchange, and patient's condition improved dramatically. Repeated laboratory test of the serum obtained before the first plasma exchange revealed that the actual value of serum triglycerides was 57 mmol/l. A clinically-driven decision is crucial when treating patients with hypertriglyceridemic acute pancreatitis as the serum triglyceride levels can be falsely low.

Comparison of coronary artery calcification and some coronary artery calcification risk factors in patients on haemodialysis and in patients with type 2 diabetes.

Patients on haemodialysis (HD) and patients with type 2 diabetes are at high-risk for coronary artery calcification (CAC). The coronary artery calcium score (CACS), quantified by computed tomography, cannot be completely explained by traditional cardiovascular disease risk factors. CAC was measured in 45 non-diabetic chronic kidney disease patients on HD and in 45 matched type 2 diabetes patients without diabetic nephropathy. Serum calcium, phosphate, 25-hydroxyvitamin D (25[OH]D), alkaline phosphatase, intact parathyroid hormone (iPTH), fetuin-A, high-sensitivity C-reactive protein (hsCRP), albumin, homocysteine, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides and femoral neck bone mineral density were also measured. No differences were observed in patient distribution across the CACS risk categories between the two groups. Significant differences were observed in serum calcium, phosphate, 25(OH)D, alkaline phosphatase, iPTH, fetuin-A, hsCRP, homocysteine and triglycerides between the two patient groups. Further research into the diverse, numerous and often interlinked factors that influence CAC in different groups of patients is warranted.

Lipids, waist circumference and body mass index in haemodialysis patients.

In the general population, dyslipidaemia and abdominal obesity are risk factors for cardiovascular disease, but less is known about their roles in patients on maintenance haemodialysis (HD). This study investigated the association between blood lipids and abdominal obesity, as determined by waist circumference (WAC), and body mass index (BMI) in 72 HD patients (32 women). Blood lipid levels were measured using routine laboratory methods. Abdominal obesity, based on the WAC measurement, was found in 62.5% of HD patients (75.0% of women; 52.5% of men). Triglyceride levels were higher in abdominally obese compared with abdominally non-obese men. According to BMI measurements, 34.7% of HD patients were overweight/obese and 9.7% were underweight. In men, WAC and BMI were positively correlated with triglyceride levels. In women, WAC was negatively correlated with high-density lipoprotein (HDL) cholesterol and apolipoprotein A levels. The results indicated that there was a negative association of abdominal obesity and BMI with HDL cholesterol in HD patients.

Kidney function estimating equations in patients with chronic kidney disease.

BACKGROUND: The current guidelines emphasise the need to assess kidney function using predictive equations rather than just serum creatinine. The present study compares serum cystatin C-based equations and serum creatinine-based equations in patients with chronic kidney disease (CKD). METHODS: Seven hundred and sixty-four adult patients with CKD were enrolled. In each patient serum creatinine and serum cystatin C were determined. Their glomerular filtration rate (GFR) was estimated using three serum creatinine-based equations [Cockcroft-Gault (C&G), modification of diet in renal disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI)] and two serum cystatin C-based equations [our own cystatin C formula (GFR=90.63 × cystatin C(-1.192) ) and simple cystatin C formula (GFR=100/cystatin C)]. The GFR was measured using (51) CrEDTA clearance. RESULTS: Statistically significant correlation between (51) CrEDTA clearance with serum creatinine, serum cystatin C and all observed formulas was found. The receiver operating characteristic curve analysis (cut-off for GFR 60 ml/min/1.73m(2)) showed that serum cystatin C and both cystatin C formulas had a higher diagnostic accuracy than C&G formula. Bland and Altman analysis for the same cut-off value showed that all formulas except simple cystatin C formula underestimated measured GFR. The accuracy within 30% of estimated (51) CrEDTA clearance values differs according to stages of CKD. Analysis of ability to correctly predict patient's GFR below or above 60 ml/min/1.73m(2) showed statistically significant higher ability for both cystatin C formulas compared to MDRD formula. CONCLUSION: Our results indicate that serum cystatin C-based equations are reliable markers of GFR comparable with creatinine-based formulas.

Serum cystatin C-based equation compared to serum creatinine-based equations for estimation of glomerular filtration rate in patients with chronic kidney disease.

Estimation of the glomerular filtration rate (GFR) is essential for the evaluation of patients with chronic kidney disease (CKD). The Cockcroft-Gault (CG) and modification of diet in renal disease (MDRD) formulas are serum creatinine-based equations, and the most widely used tests for renal function. Recently, serum cystatin C-based equations were proposed as markers for estimation of GFR. The present study compares our serum cystatin C-based equation (cystatin C formula) and serum creatinine-based equations for a large group of patients with CKD. In this study, 592 adult patients with CKD were enrolled. In each patient, serum creatinine was determined and creatinine clearance was calculated using the CG and MDRD formulas. The serum cystatin C was determined by an immunonephelometric method and our own cystatin C formula (GFR = 90.63 x cystatin C-1.192) for estimation of GFR was developed. GFR was measured using 51CrEDTA clearance, and the correlation, accuracy, bias and precision were determined. Ability to correctly estimate the patient's GFR with different equations compared to gold standard below and above 60 ml/min/1.73 m2; was analyzed. The mean 51CrEDTA clearance was 47 ml/min/1.73 m2, the mean serum creatinine was 269 micromol/l and the mean serum cystatin C was 2.68 mg/l. Statistically significant correlation between 51CrEDTA clearance with the CG (r = 0.861) and MDRD (r = 0.909) formulas and the cystatin C formula (r = 0.899) was found. The receiver operating characteristic (ROC) curve analysis (cut-off for GFR 60 ml/min/1.73 m2) showed that the cystatin C formula had a significantly higher diagnostic accuracy than the CG formula (p < 0.003). All equations underestimated the measured GFR and lacked precision. Analysis of ability to correctly predict the patient's GFR below or above 60/ml/min/1.73 m2 showed a higher prediction for the cystatin C formula than the MDRD formula (91.6 versus 84.1%, p < 0.0005) and a higher prediction trend than the CG formula (91.6 versus 88.3%, p = 0.078). Our results indicate that serum cystatin C-based equation is a reliable marker of GFR with a very high diagnostic accuracy and ability to predict patients with CKD and GFR under 60/ml/min/1.73 m2.

[Optical coherence tomography findings in hemodialysis patients]. / Optische Kohärenztomografie bei hämodialysierten Patienten.

BACKGROUND: The aim of the present prospective study was to compare retinal thickness between normal healthy subjects and chronic renal failure patients treated with maintenance hemodialysis (HD) as well as to determine whether there was any correlation between age and duration of HD treatment. PATIENTS AND METHODS: A total of 24 eyes of 12 HD patients and 32 eyes of 16 controls underwent optical coherence tomographic scanning (OCT) in the central disc of 6000 mum in diameter. RESULTS: The mean retinal thickness was measured in the inner temporal, superior, nasal and inferior quadrants. There was a highly significant difference in the inner quadrants between controls and HD patients (p < 0.005). The mean retinal thickness was also measured in all outer quadrants. The differences between HD patients and controls were highly significant (p < 0.005). The average reduction in retinal thickness in HD patients compared to the controls in the inner quadrants was 7.9% or 22 microm (279.0 in controls, 257.0 in HD patients) and 7.3% or 17.7 microm in the outer quadrants (244.5 in controls, 226.8 in HD patients). The average reduction in all quadrants was 7.7% or 20.1 microm (262 in controls, 241.9 in HD patients). The differences between HD patients and controls were highly significant in all quadrants (p < 0.001). No differences in foveal thickness between controls and HD patients were found. The reduction of retinal thickness was correlated with the age of HD patients, but not with the duration of HD treatment. CONCLUSION: OCT revealed a significant reduction of retinal thickness in HD patients. The reduction was significant in all quadrants and was correlated to the age of HD patients. No differences in foveal retinal thickness were found.

Ischaemic stroke--impact of renal dysfunction on in-hospital mortality.

Renal dysfunction predicts mortality in patients with myocardial infarction but less is known about the impact of renal dysfunction on in-hospital mortality after ischaemic stroke. All 361 patients (185 men, 176 women; mean age 72.1 years) with ischaemic stroke and glomerular filtration rate (GFR) <90 ml/min/1.73 m2 were followed-up. GFR was calculated according to abbreviated modification of diet in renal disease (MDRD) formula. Stroke severity was determined by National Institutes of Health Stroke Scale (NIHSS). The mean GFR was 61.5 +/- 16.6 ml/min/1.73 m2. There were 49 (13.6%) in-hospital deaths. Patients who died had higher NIHSS (P = 0.0001), were older (P = 0.024), had lower GFR (P = 0.028), higher hs-C-reactive protein (P = 0.001) and lower albumin (P = 0.048). No differences in presence of diabetes and hypertension, cholesterol (total, HDL and LDL), triglycerides and BMI between patients who died or survived were found. With univariate analysis association between in-hospital mortality and NIHSS (P = 0.0001), GFR (P = 0.041), total cholesterol (P = 0.021) and LDL cholesterol (P = 0.034) was found. With Cox multivariable regression analysis of risk factors, NIHSS (P = 0.0001), GFR (P = 0.018), total cholesterol (P = 0.008) and LDL cholesterol (P = 0.011) were only predictors of in-hospital mortality. In patients with ischaemic stroke, decreased GFR was associated with higher in-hospital mortality.

Accelerated atherosclerosis in pre-menopausal female patients with rheumatoid arthritis.

Increased mortality due to cardiovascular disease in rheumatoid arthritis (RA) patients was reported. Using B-mode ultrasonography we compared intima-media thickness (IMT) and plaque occurrence (indicators of asymptomatic atherosclerosis) in the carotid arteries in 70 pre-menopausal, female RA patients and 40 controls. Correlations with different risk factors were evaluated. The IMT values were higher in RA patients (0.59 mm vs. 0.47 mm, P < 0.0001) and they had more plaques (P = 0.023). In RA patients higher levels of sensitive CRP (P < 0.0001), ICAM (P < 0.0001), VCAM (P < 0.0001), IL-2 (P < 0.001), IL-6 (P = 0.009) and TNF-alfa (P < 0.01) were found. A correlation between IMT and triglycerides (P = 0.018) and a negative correlation between IMT and HDL cholesterol (P = 0.037) were found. With multiple regression analysis the association between IMT and sensitive CRP (P = 0.027) and presence of plaques and apolipoprotein B (P = 0.028) was established. The results indicate that even pre-menopausal, female RA patients had accelerated atherosclerosis. Chronic systemic inflammation may play an important role in atherogenesis.

Kidney biopsy and power Doppler imaging.

BACKGROUND: Practically, all complications of kidney biopsy are connected with hemorrhage. In the last years, the use of color Doppler sonography in monitoring kidney biopsies was being described, later the possibility of using power Doppler (PD) in performing kidney biopsies was presented. PD depicts the amplitude, or power, of Doppler signals rather than the frequency shift. This allows detection of a larger range of Doppler shifts and thus better visualization of small vessels, but at the expense of directional and velocity information. PATIENTS AND METHODS: Biopsy of native kidneys was performed in 144 patients. We performed real-time ultrasound-guided biopsy with an automatic biopsy device, 2-4 MHz convex probe and modified 18 G tru-cut needles were used. The vessels in the region of the biopsy were imaged with color Doppler sonography and with PD immediately before, after and the day following biopsy. RESULTS: Adequate tissue for histologic diagnosis was obtained in all patients with average 3.28 attempts at biopsy (range from 2-5). Average 24.15 (range from 7-58) glomeruli were obtained during each session. We observed complications in 6 (4.2%) patients, macrohematuria was presented in 4, and small hematoma with no need for intervention in 2 patients. In 138 (95.8%) patients, no complications were observed, microhematuria was present in 116 (80.6%) patients. CONCLUSIONS: In our study, complication rate of kidney biopsy was low and no complication requiring intervention was observed. Number of glomeruli obtained during each session was high. For better visualization of kidney vessels in biopsy path, PD was used. This additional kidney investigation itself does not essentially prolong the duration of the biopsy.

Serum cystatin C as an endogenous marker of renal function in the elderly.

The glomerular filtration rate (GFR) is the main indicator of kidney function. In clinical practice the GFR is often estimated from serum creatinine. In the elderly, serum creatinine is notoriously unreliable as an estimator of GFR. Recently, serum cystatin C has been proposed as a new endogenous marker of glomerular filtration rate. A total of 144 patients, aged more than 60 years (mean age 70.4 years), who had undergone 51CrEDTA clearance, were enrolled in our study. In each patient serum creatinine and serum cystatin C were determined. The reciprocal of serum creatinine, the reciprocal of serum cystatin C and creatinine clearance (from Cockcroft and Gault formula) were calculated. Serum cystatin C was measured with the particle-enhanced immunonephelometric method. The mean 51CrEDTA clearance was 34.5+/-25.55 ml/min/1.73 m2, the mean serum creatinine was 312+/-210 micromol/l and the mean serum cystatin C 3.15 mg/l+/-1.62 mg/l. We found a significant correlation between 51CrEDTA clearance and serum creatinine, serum cystatin C, the reciprocal of serum creatinine and the reciprocal of serum cystatin C as well as with creatinine clearance. In comparison of the correlation coefficients we found that the correlation between 51CrEDTA clearance and serum cystatin C was significantly better than that with serum creatinine (p < 0.05). The correlation between 51CrEDTA clearance and the reciprocal of serum cystatin C was superior to that with the reciprocal of serum creatinine (p < 0.003) and calculated creatinine clearance (p < 0.003). Our results indicate that serum cystatin C is a more reliable marker of GFR in the elderly than serum creatinine or creatinine clearance.

Bone mineral density in patients beginning hemodialysis treatment.

BACKGROUND: Our study was designed to determine bone mineral density (BMD) in patients beginning hemodialysis (HD) treatment, a possible correlation with the duration of renal failure prior to treatment, a possible correlation with the basic disease and the association with the concentration of intact parathormone (iPTH). METHODS: Our prospective clinical trial included 50 patients beginning HD treatment. Cortical bone mineral density (BMDc) was measured at the left femoral neck and trabecular bone mineral density (BMDt) in the region of the lumbosacral spine. Bone mineral density (BMD) was measured by quantitative digital radiography using a Hologic 2000 plus device belonging to the third generation of densitometers based on dual-energy X-ray absorptiometry. RESULTS: In patients (PTS) beginning HD, the average BMDc was 82 +/- 15% of BMDc in a healthy population of corresponding age and sex. The average BMDt was 91 +/- 16% of BMDt in a healthy population of corresponding age and sex. The difference was statistically significant (p < 0.05). There is a negative correlation between iPTH and BMDc r = -0.34 (p < 0.02). Patients with chronic glomerulonephritis (GN) had a statistically significantly higher BMDc (g/cm(2)) (p < 0.01) than those with analgetic nephropathy (AN). PTS with AN have lower BMDc (g/cm(2), %) (p < 0.02) and BMDt (p < 0.005) than the rest of the PTS, iPTH in PTS with AN is higher than in the rest of the PTS (p < 0.05). CONCLUSIONS: In PTS at the beginning of HD, BMD is lower than in healthy people of corresponding age and sex. This means that BMD already decreases prior to HD. BMDc was statistically significantly lower than BMDt (p < 0.00005). PTS with AN have lower BMD than those with GN and all remaining PTS. A negative correlation between iPTH and BMDc was found.

[Simple renal cysts and hypertension]. / Unkomplizierte Nierenzysten und arterielle Hypertonie.

BACKGROUND: Simple renal cysts are frequent findings in mid-aged people, their frequency increases with age. They are often detected by abdominal ultrasound and/or computed tomography during diagnostic procedures. Hypertension is also a frequent disease and its prevalence increases with age as well. The aim of our study was to evaluate the association between simple renal cysts and hypertension in a group of patients with normal renal function. PATIENTS AND METHODS: Ninety-one patients (58 female and 33 male; mean age 50.5 +/- 16.9 years) were included in the study, all with normal renal function (serum creatinine <100 micromol/l). The patients were examined with a real-time ultrasound device with a 2-4 MHz convex transducer. Kidney size, presence, number and diameter of cysts were examined and the presence of hypertension was determined. The presence of hypertension was defined by the administration of antihypertensive agents, systolic blood pressure greater than 140 mmHg and/or diastolic blood pressure greater than 90 mmHg. RESULTS: Simple renal cysts were found in 19 (20.88%) patients. Only cortical cysts were found in 11 (12.09%) patients, only parapelvinic cysts were found in 4 (4.39%) patients. Four (4.39%) patients had cortical and parapelvinic cysts. Cortical cysts in both kidneys were found in five (5.49%) patients, parapelvinic cysts in both kidneys were found in three (3.29%) patients. Bilateral renal cysts were present in 10 (10.99%) patients, six (60%) of them had hypertension. We found no difference in the presence of simple renal cysts according to sex. Hypertension was detected in 30 (32.97%) patients. Hypertension was significantly more frequent in patients with simple renal cysts (P < 0.041) than in with patients without cysts. Simple renal cysts were also significantly associated with age (P < 0.01). With multiple regression analysis we found a significant association with age only (P < 0.0001), but not with hypertension (P = 0.394). CONCLUSIONS: Simple renal cysts are frequent findings and their incidence increases with age. We found an association between simple renal cysts and hypertension. However, with multiple regression analysis only an association between simple renal cysts and age could be detected.

Carotid intima-media thickness and plaques in hemodialysis patients.

Atherosclerosis is accelerated in hemodialysis patients. Using B-mode ultrasonography, we compared intima-media thickness (IMT) and the prevalence of plaques in the common carotid and internal carotid arteries in 28 randomly selected hemodialysis patients with that in 28 age- and sex-matched normal controls. The IMT values of the common carotid and internal carotid arteries were higher in hemodialysis patients than in controls with more hemodialysis patients having plaques. In hemodialysis patients, there was a relationship between age and IMT in the common carotid arteries, in the area of bifurcation, and in the internal carotid arteries. We found no relationship between IMT and atherosclerotic risk factors or duration of hemodialysis treatment. IMT at all sites correlated with the number of plaques. Age was the only significant determinant for number of plaques. The results indicate that hemodialysis patients showed advanced atherosclerosis in the carotid arteries compared with age- and sex-matched normal subjects.

Hemodialysis vascular access thrombosis and lipoprotein(a).

Background. Vascular access remains the Achilles's heel of successful hemodialysis and thrombosis is the leading cause of vascular access failure. Elevated lipoprotein(a) (Lp(a)) levels in hemodialysis patients were reported, and in some studies were also associated with hemodialysis vascular access thrombosis. Patients and methods. In our study 84 hemodialysis patients with native arteriovenous fistula were included. Two groups of patients were defined: group A including 61 patients with their vascular access either never or only once thrombosed, and group B including 23 patients with two or more thromboses of their vascular access. We determined serum concentrations of Lp(a) in all our patients. Results. Average serum Lp(a) concentration for all the patients included in the study was 0.273 +/- 0.31 g/l. No relationship was found between serum Lp(a) concentrations and age, gender and duration of dialysis treatment. Serum Lp(a) concentrations were higher in group A than in group B patients (0.301 g/l versus 0.198 g/l), but the difference was not statistically significant. There was also no statistically significant difference between group A and group B regarding age, gender and duration of hemodialysis treatment. The use of a cut-off value for Lp(a) of 0.3 g/l and 0.57 g/l also failed to provide a significant difference between group A and B patients. Conclusion. We found no significant differences in Lp(a) concentrations between group A (thrombosis-non-prone) and group B (thrombosis-prone) patients. Our results suggest that Lp(a) is not an independent risk factor for vascular access occlusion in hemodialysis patients.

Rhabdomyolysis and acute renal failure in intensive care unit.

Rhabdomyolysis is common clinical and laboratory syndrome resulting from skeletal muscle injury and acute renal failure is the most important complication. Acute renal failure is common in critically ill medical patients. The aim of our study was to determine the prevalence of rhabdomyolysis induced acute renal failure in these patients and to established the prognosis of critically ill patients with acute renal failure and rhabdomyolysis. In the study were included 1557 patients treated in our medical intensive care unit. Seventy-three patients had criteria for acute renal failure. Twelve of them (16.4%) had rhabdomyolysis, eight were women and four were men (average age was 71 years). Sixty-one patients (83.6%) had acute renal failure without rhabdomyolysis, 33 were women and 28 were men (average age was 69 years). We found no difference in age and sex between patients with acute renal failure with or without rhabdomyolysis. Ten patients (83.3%) with rhabdomyolysis and 39 patients (63.9%) without rhabdomyolysis had multiorgan failure syndrome. In patients with rhabdomyolysis, the number of failing organs were statistically significantly higher (p < 0.027). Nine patients (75%) with rhabdomyolysis and 27 patients (44.3%) without rhabdomyolysis died. Mortality was statistically significantly higher (p < 0.05) in patients with rhabdomyolysis. Rhabdomyolysis with acute renal failure was frequently observed in patients treated in our medical intensive care unit. Multiorgan failure syndrome was common in these patients and mortality was higher compared to patients without rhabdomyolysis.

Intraocular pressure in chronic renal failure patients treated with maintenance hemodialysis.

Ocular complications are frequent in chronic renal failure patients treated with maintenance hemodialysis (HD) and in renal allograft recipients. Headache, nausea and fatigue sometimes develop in combination with a rise in intraocular pressure (IOP). We did not find statistically significant differences in IOP before and after HD. There was no correlation between changes in IOP during HD and the decrease in systolic and diastolic blood pressure or decrease in body weight. No patient had borderline or elevated IOP following HD. Due to improved dialytic techniques a significant rise in IOP during HD rarely occurs anymore.

Rhabdomyolysis and acute renal failure following cardioversion and cardiopulmonary resuscitation.

A 39-year-old male suffered a myocardial infarction at work and cardiopulmonary resuscitation was initiated immediately. After 15 cardioversions, ventricular fibrillation converted to sinus rhythm. Rhabdomyolysis with a 100-fold increase of serum creatine kinase level and myoglobinuria with acute renal failure ensued, requiring hemodialysis treatment. The patient died and autopsy revealed acute posterior myocardial infarction. Prolonged cardiopulmonary resuscitation involving repeated cardioversion may predispose to myoglobinuric renal failure.

Cholecystolithiasis in patients with end-stage renal disease treated with haemodialysis: a study of prevalence.

Gallstones are quite prevalent in western countries (10-20% of adult population), but there are very few data about the prevalence of cholecystolithiasis in haemodialysis (HD) patients. In our study, we found--with real-time ultrasound--a prevalence of gallstones of 16% in patients with end-stage renal disease (ESRD) treated with HD which is similar to the prevalence in a non-uraemic control group matched for age and sex. In most of our HD patients, cholecystolithiasis was asymptomatic. HD patients with cholecystolithiasis were statistically significantly older than patients without gallstones. We found no differences in sex or duration of HD treatment in patients with and without cholecystolithiasis. The prevalence of cholecytolithiasis in patients with ESRD on HD is similar to that of a normal population though some data suggested a higher prevalence in HD patients.