Remitting seronegative symmetrical synovitis with pitting edema syndrome in maintenance hemodialysis.

INTRODUCTION: The remitting seronegative symmetrical synovitis with pitting edema syndrome primarily occurs in elderly individuals to represent symptoms of edema, pain, and joint swelling. It could be misdiagnosed in elderly maintenance hemodialysis patients, as hemodialysis patients often present with pain and joint swelling induced by hypervolemia, inflammation, amyloidosis, and/or chronic kidney disease. Here, we describe a maintenance hemodialysis patient with remitting seronegative symmetrical synovitis with pitting edema syndrome. CASE PRESENTATION: A 71-year-old man on maintenance hemodialysis who complained of continuous pain and swelling of joints was diagnosed with remitting seronegative symmetrical synovitis with pitting edema syndrome on his clinical findings that revealed tenosynovitis at the joint without joint erosions and no elevation of anti-cyclic citrullinated peptide antibody and rheumatoid factor. After administration of prednisolone, systemic edema, and pain improved in 2 days. CONCLUSION: Remitting seronegative symmetrical synovitis with pitting edema syndrome should be considered as a differential diagnosis in hemodialysis patients with edema and/or arthralgia.

[Acute headache resulting from intracranial venous reflux due to occlusion of the brachiocephalic vein ipsilateral to a dialysis shunt].

A 72-year-old man on hemodialysis for 7 years with end-stage renal disease was admitted to our institution due to an acute headache. Physical examination revealed normal signs except for noise on the back of his neck. His head CT and brain MRI showed no abnormal findings, while his MRA demonstrated abnormal signals in the left transverse to sigmoid sinus (T-S) suggesting a left dural arteriovenous fistula. After admission, his headache persisted and left orbital numbness also occurred. His digital subtraction angiography performed on the 5th day after admission showed no vascular malformation of either the T-S or cavernous sinus (CS). However, it showed occlusion of the left brachiocephalic vein (BCV) and the origin of the left internal jugular vein (IJV) resulting in intracranial venous reflux. These findings indicated the possibility that his acute headache was caused by intracranial venous reflux and increase of intracranial pressure resulting from the occlusion of the BCV ipsilateral to a dialysis shunt. Percutaneous transluminal angioplasty (PTA) for occlusion of the left BCV was performed on the 9th day and successful dilation of the lesion with a residual stenotic ratio less than 30 percent was obtained. After the angioplasty, venous reflux to the intracranial vein was markedly reduced and his headache and orbital numbness disappeared. One day after the procedure, MRA demonstrated the disappearance of the abnormal signals of the left T-S. Twelve months after discharge, he felt discomfort in the left of his face and the re-occlusion of the left VCV was demonstrated by angiography, therefore he received re-PTA. We recommend that physicians consider occlusion of the BCV ipsilateral to a dialysis shunt and intracranial venous reflux as a cause of acute headache in patients on hemodialysis.

Low parathyroid hormone levels after parathyroidectomy reduce cardiovascular mortality in chronic hemodialysis patients.

BACKGROUND: The aim of the study is to elucidate whether parathyroid hormone (PTH) levels after parathyroidectomy affect the prognosis of patients with secondary hyperparathyroidism. SUBJECTS AND METHODS: Two hundred and ninety-five patients, who underwent PTx without autotransplantation from July 1998 to December 2011, were divided into the low (n = 148) and high (n = 147) PTH groups, using the median value of each mean value of intact PTH after surgery (16.6 pg/mL). After observation for 5.00 years, we evaluated demographic factors, influences of postoperative mineral metabolism, magnitude of uremia, and vitamin D receptor activators on their prognosis, with the multivariate Cox proportional hazard model. RESULTS: While overall survival rates in the high and low PTH groups were 54.9 and 74.2 %, respectively (P = 0.1500), cardiovascular survival rates were 71.6 and 94.4 %, respectively (P = 0.0256). The hazard ratio for cardiovascular mortality in the high PTH group (≥16.6 pg/mL) was 3.132 (P = 0.0470), and those in groups with the median age more than 59 years and with cardiovascular disease were 2.654 (P = 0.0589) and 3.377 (P = 0.0317), respectively. The intact PTH level 6 days after surgery and the mean postoperative intact PTH value showed a strong correlation (Spearman ρ = 0.9007, P < 0.0001, y = 0.4725x + 30.395, R 2 = 0.51798). CONCLUSION: The present study suggests that maintaining low PTH levels after parathyroidectomy reduces cardiovascular mortality and improves the prognosis. Total parathyroidectomy (more than 4 glands) without autotransplantation seems to be one of the treatment options for managing severe secondary hyperparathyroidism.

Fifteen-second skin icing using a frozen gel pack is effective for reducing goserelin injection pain.

OBJECTIVE: The efficacy of skin icing to reduce the pain of goserelin injection has been reported. We investigated the optimal icing time with a frozen gel pack and its effectiveness. METHODS: Abdominal skin temperatures of 49 healthy volunteers were measured after application of the frozen gel pack for 10, 15 and 30 s, and it was decided that a 15-second icing was adequate. For 55 consecutive patients who received goserelin (10.8 mg) injection, pain was evaluated employing a visual analog scale (VAS). The first injection was administered routinely. A second injection was administered after skin icing in 27 of 55 patients who wanted to try icing. At the time of the third injection, all patient decided whether they were to receive icing or the routine method. RESULTS: After icing, VAS scores decreased in 20 of 27 patients. At the third injection, 18 patients requested icing. CONCLUSION: When a patient complains of injection pain, the icing method should be considered for pain reduction.

Mizoribine-induced severe hyperglycemia in a patient with microscopic polyangiitis.

A 77-year-old woman had been receiving prednisolone (PSL) for 5 months as induction therapy for microscopic polyangiitis. Because of repeated elevation of the antineutrophil cytoplasmic autoantibody titer, we added mizoribine (MZR), and, 2 months later, the patient developed severe hyperglycemia with low serum and urinary C-peptide reactivity (CPR). The MZR was, therefore, withdrawn and insulin therapy was started. One month later, the serum and urinary CPR had increased and postprandial hyperglycemia had improved. Previous in vitro studies have shown that MZR can induce hyperglycemia through at least two mechanisms. One is the alteration of insulin secretion from islet cells, and the other is action via the glucocorticoid receptor (GR). MZR reduces insulin secretion through the depletion of intracellular guanosine triphosphate (GTP), which leads to the inhibition of mitogenesis and induction of beta cell apoptosis. MZR affects insulin resistance by activating the GR through interaction with the 14-3-3 protein, leading to postprandial hyperglycemia. Although postprandial hyperglycemia generally appears between 3 and 7 weeks after PSL administration, that in our patient did not become apparent during 5 months of PSL monotherapy, but was manifested 2 months after the introduction of MZR, and improved after MZR had been withdrawn. We conclude from these findings that MZR had been responsible for the hyperglycemia in our patient.

Percutaneous transluminal renal angioplasty remarkably improved severe hypertension and renal function in a patient with renal artery stenosis and postrenal kidney failure.

A 69-year-old man was admitted to our hospital with severe hypertension and rapidly worsening renal function. He presented with a 10-year history of chronic renal failure caused by bilateral ureteral obstruction due to retroperitoneal fibrosis. Magnetic resonance angiography and Doppler ultrasonography suggested severe right renal artery stenosis (RAS). Renal angiography revealed 99% stenosis at the ostium of the right renal artery. We performed percutaneous transluminal renal angioplasty (PTRA) with the support of intravascular ultrasound to decrease the amount of contrast agent needed. In addition, to prevent distal atheroembolism, a distal protection device was used. The procedure was completed without any adverse effects. After PTRA, renal function and blood pressure improved remarkably and remained stable for one year. PTRA for RAS remains controversial, especially in patients with renal insufficiency. Use of new devices should be considered to decrease catheterization-related adverse effects.

Total parathyroidectomy improves survival of hemodialysis patients with secondary hyperparathyroidism.

BACKGROUND AND AIMS: To compare the prognosis of chronic hemodialysis patients with or without parathyroidectomy. METHODS: Among 158 chronic hemodialysis patients who underwent total parathyroidectomy between July 1998 and April 2009, 88 patients were matched with 88 controls for sex, age, underlying disease and prior dialysis history. Then a retrospective evaluation of their prognosis was performed over a median observation period of 4.41 years. RESULTS: The overall survival rate was 90.4% in the parathyroidectomy group and 67.4% in the control group. The cardiovascular death-free survival rate was 94.6% in the parathyroidectomy group and 76.3% in the control group. During observation, intact parathyroid hormone was measured every 6 months, and its average serum level was 37 ± 92 ng/L in the total parathyroidectomy group versus 274 ± 233 ng/L in the control group (p=0.0001). The total parathyroidectomy group had a significantly lower corrected calcium level and higher serum albumin level. Multivariate analysis revealed that parathyroidectomy, atrial fibrillation and serum albumin were significant factors for both total and cardiovascular mortality. CONCLUSION: Total parathyroidectomy was associated with better survival, probably due to decreased cardiovascular mortality.

Endovascular stenting for left subclavian venous stenosis for a hemodialysis patient with a persistent left superior vena cava.

A persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly, and we should be aware of its existence. We encountered a case of significant left arm swelling due to recurrent left subclavian venous stenosis in a hemodialysis patient with a PLSVC. Endovascular stent placement was performed safely and effectively for the stenosis employing the pull-through technique, in which a guidewire was passed from the left internal jugular vein to the access vein. On the following day, left arm swelling had improved. 3 months after stent placement the left arm swelling has not recurred.

[Case of Marfan syndrome with microscopic hematuria].

A 36-year-old man was admitted to our hospital for investigation of microscopic hematuria. He was very tall and presented arachnodactyly of the fingers and toes. Chest computed tomography and cardiac echography revealed annuloaortic ectasia and aortic regurgitation. Based on these findings, we suspected Marfan syndrome and performed gene analysis of the FBN1 gene, which encodes fibrillin-1. Mutational analysis showed the missence mutation, p. Ile 2585 Thr, present in exon 62 of the FBN1 gene. To investigate the genesis of microscopic and dismorphic hematuria, we performed a renal biopsy. Light microscopic analysis revealed the absence of any apparent histological changes in the glomerulus, small artery and arteriole. Electron microscopic analysis revealed the glomerular basement membrane to be irregularly thickened, however, there was neither any electron dense deposition nor fibrillar material. Marfan syndrome is an inherited disorder of connective tissue based on abnormality of the FBN1 gene. Fibfibrllin-1 acts not only as a component of microfibrils, but also as the regulator of transforming growth factor -beta signal transduction. From these points of view, we speculated that irregular formation of the glomerular basement membrane of our patient was induced by an imbalance in production of the extracellular matrix as the consequence of abnormal fibrillin-1--TGF-beta signaling.

Preoperative administration of chlormadinone acetate reduces blood loss associated with transurethral resection of the prostate: a prospective randomized study.

OBJECTIVES: To assess the effects of giving chlormadinone acetate (CMA) before surgery on blood loss associated with transurethral resection of the prostate (TURP), in a prospective randomized controlled study. PATIENTS AND METHODS: Candidates for TURP among patients with benign prostatic hyperplasia were randomized to either treatment with CMA (CMA+) or not (CMA-). In principle, CMA was started at least 28 days before TURP and continued until just before surgery. RESULTS: In all, 33 patients in the CMA+ (median duration of treatment 34.5 days) and 38 in the CMA- group were evaluable. The mean blood loss during TURP was less in the CMA+ (237.3 mL) than in the CMA- group (263.1 mL), but the difference was not significant. There was significantly less blood loss per gram of resected prostate tissue in the CMA+ (9.6 mL/g) than in the CMA- group (13.3 mL/g) (P < 0.05). Haematuria on the day of and the day after TURP was also significantly less severe in the CMA+ than in the CMA- group (P < 0.001 and P < 0.05, respectively). The mean microvessel density of resected prostate tissue was significantly less after CMA treatment (P < 0.001). CONCLUSIONS: CMA given for 1 month before TURP could reduce blood loss to some extent during and after TURP, and this may be related to a decrease in microvessel density.