It has been suggested that lipid abnormalities may be involved in the development of coronary artery disease (CAD) in patients on hemodialysis (HD). Hypertriglyceridemia commonly accompanies this condition and is associated with decreased HDL-cholesterol levels. Recently, clinical attention has focused on disturbances in lipoprotein (a) [Lp(a)] and apolipoprotein (a) [apo(a)] phenotype, especially low molecular weight (LMW) in relation to CAD. Although high Lp(a) levels and LMW are associated with CAD, such data concerning HD patients appear limited. We therefore investigated whether Lp(a) levels and LMW in HD patients are a risk factor for CAD.
Lp(a) and apo(a) phenotype were measured in 268 HD patients (chronic glomerulonephritis, N=174; diabetic nephropathy, N=94). The onset of CAD in these patients was investigated for up to 5 years. The occurence of CAD in HD patients during the follow-up period was 13.3%. HD patients with CAD were significantly older, and had diabetic nephropathy, higher Lp(a) levels and LMW compared to other HD patients.
Against a background of aging and diabetic nephropathy, Lp(a) levels and LMW can predict the subsequent development of CAD in HD patients.

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Between April 1994 and October 1998, 45 ulnobasilic arteriovenous fistula were constructed using the ulnar artery and basilic vein in the distal forearm for the permanent hemodialysis access. We analyzed the influence of age, gender and hemodiablysis duration on the cumulative primary patency in these patients. Their mean age was 60.2±12.8 years (range: 28-81 years) and median follow-up was 37.7±17.1 months (range: 12-68 months). Sixteen fistulas were patent, twenty-six fistulas were occluded and three fistulas had not matured adequately for hemodialysis access. The cumulative primary patency rate was 51.1% at one year, 35.5% at three years, and 25.4% at five years. The primary patency of ulnobasilic arteriovenous fistula was worse compared with that of the radiocephalic fistula, or graft implantation. The cumulative primary patency rates was slightly lower in female patients, patients 50 or more years old and the patients who had undergone hemodialysis for more than one year. Ten fistulas (35.4%) occluded within the first month and twenty-two fistulas (75.9%) occluded within the first year. It was suggested that in some patients whose fistulas occluded earlier, the basilic vein wasn't adequate for arteriovenous fistula.
In conclusion, although the cumulative patency rate of ulnobasilic arteriovenous fistula was insufficient, we should consider an alternative route in patients with vascular access complications.

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Background: Serum HCV core protein measurement is carried out in a simple fluorescent enzyme immunoassay. Using this assay, one can directly quantify serum HCV with a lower cost than by viral RNA measurement using polymerase chain reaction. In this study, we examined the sensitivity and specificity of HCV core protein assay.
Methods: HCV core protein concentration and serum transaminase levels were quantified in 90 hemodialysis patients with anti HCV antibody and in 49 patients without anti HCV antibody. HCV-RNA was quantified by RT-PCR method only in HCV antibody positive 90 patients.
Results: In 90 patients with anti HCV antibody, HCV-RNA was detected in 73 patients and among them HCV core protein was detected in 54 patients (sensitivity: 54/73, 74%). In 17 patients without HCV-RNA, HCV core protein was not detected (specificity 100%). There was a positive correlation between HCV-RNA titers and HCV core protein concentration (r=0.53, p<0.001), but there was no correlation between HCV-RNA titers and serum transaminase levels.
Conclusion: The sensitivity of HCV core protein assay was comparable in patients with normal renal function (73-79%) and in chronic hemodialysis patients. There was no correlation between HCV-RNA and serum transaminase levels, suggesting that quantification of HCV activity by serum transaminase alone is difficult. However, HCV core protein assay is able to quantify serum HCV titers using a simple low cost method.

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Purpose: Recently, the plasma refilling coefficient (mean Kr) was proposed as a new marker of vascular permeability during hemodialysis (HD). However, there are only a few reports about its utility in clinical examination. Therefore, in this study, we examined the usefulness of mean Kr as a marker of dry weight (DW) in chronic HD patients. Methods: In 41 stable maintenance HD patients, Ht, TP and body weight change were measured before and after HD for 12 months, Mean Kr was calculated from these parameters 446 times. Then, we divided all mean Kr data into four groups according to the absolute value as follows: group I, 0<mean Kr≤1 (n=148); II, 1<mean Kr≤4 (n=218); III, 4<mean Kr (n=45); IV, mean Kr<0 (n=35). Results: 1) There was no correlation between mean Kr and the speed of ultrafiltration during HD, and TP before HD. 2) CTR was 51.3±0.4 in group I, 52.8±0.4 in II, 55.9±0.8 in III and 57.9±1.2% in IV. CTR was significantly smaller in group I than in group III and IV, and in group II than in group IV. 3) The reduction rate of mean arterial pressure (MAP) during HD was larger in group I compared to the other groups. 4) The necessity of saline infusion at HD-related hypotension was higher in group I compared to the other groups. 5) The changes of circulating blood volume during HD (%ΔBV) was -4.2±0.1 in group I, -2.4±0.1 in II, -0.6±0.1 in III and 1.0±0.1% in IV. The difference of %ΔBV was significant in each of the four groups. 6) There was significant positive linear correlation between the ratio of mean Kr (mean Kr/mean Kr) and atrial natriuretic peptide (ANP/ANP) over 5 consecutive months (y=0.73±0.29X, r=0.47, p<0.01, n=36). Conclusions: Mean Kr may be useful to determine the DW in chronic HD patients because it reflected other markers for DW determination. There was the possibility that an adequate value for mean Kr ranged from 1 to 4ml/min/mmHg during HD.

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Six years after double lumen catheter insertion, a 64-year-old man complained of progressive swelling of the left upper arm and left cervical region. The cause was considered to be central venous stenosis and left arteriovenous fistula for dialysis blood access. Our patient was treated by PTA. One week after this procedure, all symptoms disappeared without occlusion of the arteriovenous shunt. We consider PTA the best therapy for a short lesion of central venous stenosis.

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The patient was a 71-year-old female, who had been under hemodialysis since January 1991. On 13 October 1999, she stumbled and fell against the anastomosis site of the autogenous arteriovenous fistula, which became swollen to about 4×3cm on the ulnar side of left forearm. Angiography showed venous pseudoaneurysm measuring 2.1×1.5cm. Since the size of venous pseudoaneurysm was increased to 4.0×3.6cm detected by angiography, she underwent surgery on 5 November. Because the shunt was found to be occluded during operation, the site of venous pseudoaneurysm was excised and a new arteriovenous fistula was remade at a proximal site. Microscopic examination of resected venous pseudoaneurysm showed teared intimal and medial membranes of the shunt vein and the venous pseudoaneurysm consisted of only the outer membrane of the vein. As a cause of venous pseudoaneurysm, tear of the vein should be considered. Under such a condition, surgery is necessary as soon as possible. This case is valuable bacause a rapidly increasing venous pseudoaneurysm caused by a tear in the vein had not been reported previously.

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Recently, in the hemorrhagic tendency and pre- and post- operative status, nafamostat mesilate has often been used as an anticoagulatiant drug during extracorporeal circulation, and reports of anaphylaxis induced by nafamostat mesilate have accumulated. We have observed five cases of anaphylaxis which were induced by the injection of nafamostat mesilate in patients undergoing maintenance of hemodialysis during the past sixteen months. These patients had a history of nafamostat mesilate administration, but had never experienced allergic reactions. Within 30 minutes after initiation of hemodialysis, all 5 cases developed anaphylaxis. Severe hypotension appeared in three cases. The result of a lymphocyte stimulation test (DLST) using nafamostat mesilate was positive in the three of four cases, although antibody of anti-nafamostat mesilate IgE was negative in all cases. There were no other factors present that might have induced dyspnea and hypotension. Therefore, it might be surmised that this event was induced by nafamostat mesilate. It is difficult to anticipate the occurrence of anaphylaxis, but should be considered when the possibility of anaphylaxis nafamostat mesilate is used.

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The patient was a 48-year-old woman. She had a cold and was treated with antibiotics by her home doctor in late December 1999. Since edema of the eyelids developed, she was referred to our hospital on January 19, 2000. On admission, she demonstrated renal failure (BUN 64.2mg/dl, Cr 8.2mg/dl) and microcytic hypochromic anemia (Hb 5.6g/dl, MCV 57.1fl, MCH 17.8pg). Urinalysis showed 1+ protein and 50 to 100 red blood cells per high power field. She did not show hemosputum or hemoptysis, and there was no abnormal shadow on chest X-ray. Acute renal failure due to antibiotics was suspected and hemodialysis was instituted on the second day after admission. On the 12th day after admission, abnormal shadow on chest X-ray was observed and bronchoscopy revealed pulmonary hemorrhage. Anti-glomerular basement membrane antibody (anti-GBM antibody) was high at 300EU/ml, and Goodpasture's syndrome was diagnosed. She was treated with methylprednisolone (500mg/day, for 3 days) and plasma exchange (for 6 days). Although the serum level of anti-GBM antibody decreased and pulmonary hemorrhage was cured, renal function did not improve and chronic hemodialysis therapy was necessary.
Since the prognosis of Goodpasture's syndrome is still poor (mortality about 50%), early diagnosis and the prompt treatment with steroid, immunosuppressive drug, and plasmapheresis are essential. When the patient with acute renal failure shows heavy hematuria and microcytic hypochromic anemia, careful consideration of the possibility of Goodpasture's syndrome is recommended.

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