Closed Fracture Diagnosed by Bedside Ultrasonography During Hemodialysis: A Report of Seven Cases and Relevant Clinical Characteristics.

BACKGROUND: Patients undergoing dialysis have a high incidence of fracture, and early diagnosis is important. We report seven cases of closed rib or upper-limb fractures diagnosed by bedside ultrasonography during maintenance hemodialysis sessions and describe relevant clinical characteristics. CASE PRESENTATION: We identified seven patients who were injured by falls in their homes. No injuries occurred on the day of dialysis. Five of the 7 patients did not visit the emergency room. All patients complained of persistent unexplained pain during a regular hemodialysis session. Ultrasonography (US) was performed during dialysis sessions, without any reports of pain. Before US evaluation, the sensitivity of radiography for diagnosis of fracture was 25%, while the sensitivity of US was 100%. Compared with other patients in our clinic, these patients were significantly older and had lower serum albumin concentrations and lower hemodialysis efficiency as determined by Kt/V. They also had a higher incidence of diabetes and a greater need for vasopressors during dialysis. These findings were consistent with the results of previous studies of the characteristics of fractures in dialysis patients. However, blood levels of creatinine, corrected calcium, phosphate, intact parathyroid hormone, and hemoglobin, as well as bone density and blood pressure, after the previous dialysis session were not different. CONCLUSIONS: To our knowledge, this is the first report of closed fracture of superficial bone diagnosed by bedside ultrasonography during a hemodialysis session. Ultrasonography is especially useful for diagnosis in these cases because it is noninvasive and highly accurate. Doctors should determine the differential diagnosis for closed fracture in patients undergoing dialysis, especially in those who are older, have diabetes, and are malnourished, and in those with recent contusions and persistent pain.

Dialyzability of Faropenem in Infected Patients on Chronic Hemodialysis.

The aim of this study was to evaluate the profile of dialyzability of an oral penem antibiotic, faropenem (FRPM), in hemodialysis (HD) patients with infections. Eight patients took one tablet of FRPM (200 mg) every 12 h during an inter-dialysis period, and another tablet at 1-5 h before the beginning of the HD session. Blood samples were obtained during the HD session (3-4 h). Plasma FRPM concentrations in the arterial side were 4.8 ± 2.5 and 2.8 ± 1.0 µg/mL before and at the end of HD session, respectively, which are above the 50% minimal inhibitory concentrations of FRPM against the major pathogen (0.015-2 µg/mL). Dialyzer clearance and elimination fraction of FRPM were 14.9 ± 6.8 mL/min per m2 and 20.4 ± 9.9%, respectively. About 2% of FRPM was removed from the body during a single HD session. The infection-related symptoms, the white blood cell count and the level of C-reactive protein were improved by FRPM without any adverse effects. These data suggest that the dialyzability of FRPM is relatively low, and the amount of the drug removed by a single HD session is small. FRPM 200 mg twice daily might provide an effective and safe dosage regimen without additional dosing at the end of the HD session.

Utility of Ultrasonography of the Median Nerve With a High-Frequency Probe for the Diagnosis of Dialysis-Related Carpal Tunnel Syndrome.

This cross-sectional study aimed to determine the utility of ultrasonography with improved resolution using a high-frequency probe for dialysis-related carpal tunnel syndrome (CTS). This study targeted 125 hemodialysis patients at our hospital. A 12 MHz probe was placed on the carpal tunnel area to identify the median nerve. The compression rate of the nerve was calculated by measuring the smallest diameter of the compressed nerve and largest diameter of the unaffected part. To quantify CTS symptoms, we determined the presence of Tinel's sign, measured pinch strength, and used questionnaires to assess numbness and pain. The association of these clinical data with the compression rate was examined. Mean compression rate was 12.1 ± 1.1%. The compression rate cutoff value for those positive with Tinel's sign was 25%, (sensitivity and specificity were 0.80 and 0.91, respectively), and that for those with a history of CTS surgery was 25% (sensitivity and specificity were 0.67 and 0.89, respectively). Multiple regression analysis identified duration of dialysis, ß2-microglobulin(ß2-Mg) concentration, positivity for Tinel's sign, history of CTS surgery, and pinch strength as independent compression rate determinants. Notably, compression rates were significantly higher in patients with a ≥4-year duration of dialysis and a ß2-Mg level of 20 mg/L or more. The compression rate of the median nerve measured by an improved ultrasound device significantly correlated with clinical symptoms, medical history, and serological features associated with dialysis-related CTS. Because ultrasonography is non-invasive, the examination might be a simple method especially for early diagnosis of dialysis-related CTS.

Dialyzability and pharmacokinetics of sitafloxacin following multiple oral dosing in infected hemodialysis patients.

The pharmacokinetics and dialyzability of oral sitafloxacin, a newly available quinolone, in infected intermittent hemodialysis patients have not been reported previously. Seven infected maintenance hemodialysis patients lacking residual renal function were enrolled. Sitafloxacin (50 mg after hemodialysis on the first day, on the next day and 4 h before scheduled hemodialysis session on the 3rd day) was orally administered. On the 3rd day, blood was taken from arterial and venous sides before and 2 and 4 h after session initiation. Another sampling was performed 1 h after the session and on the 5(th) day of the study. Pharmacokinetic parameters and dialyzability of sitafloxacin were evaluated. All patients exhibited improved symptoms without major problems. Drug concentrations in all arterial samples were above the MIC of targeted bacteria. Dialyzer clearance and elimination fraction were 49.9 ± 0.9 mL/min per m(2) and 53.3 ± 2.1%, respectively. Apparent half-life during dialysis session was significantly shorter than that after the session (4.0 ± 0.4 and 46.5 ± 3.6 h, during and after the session, respectively). Dialyzer clearance was positively correlated with urea reduction ratio and negatively correlated with serum albumin concentration. About 23% of the drug in the body was removed by dialysis. Rebound of the drug concentration after the dialysis was not seen. Oral dosing of this drug at 50 mg daily in maintenance hemodialysis patients provides a safe drug concentration compatible with that of healthy subjects orally receiving 100 mg daily. Because a significant amount of the drug was removed, administration might be undertaken after the dialysis session.

Clearance of imidapril, an Angiotensin-converting enzyme inhibitor, during hemodialysis in hypertensive renal failure patients: comparison with quinapril and enalapril.

The dialyzability of imidaprilat, an active metabolite of the angiotensin-converting enzyme (ACE) inhibitor imidapril, was determined and compared with those of enalaprilat and quinaprilat in hypertensive patients on chronic hemodialysis. Imidapril (5 mg/d, n = 6), enalapril (2.5 mg/d, n = 6), or quinapril (2.5 mg/d, n = 6) was given for at least 8 weeks prior to the trial. During dialysis, enalaprilat, but not imidaprilat or quinaprilat, concentrations in both sides decreased significantly. Compared to enalaprilat, the dialyzabilities of imidaprilat and quinaprilat were significantly lower (dialyzer clearance [mL/min/m(2)]: enalaprilat, 41.8 +/- 7.4; imidaprilat, 19.0 +/- 7.8; quinaprilat, 8.9 +/- 1.3). The dialyzabilities of the 3 drugs were negatively correlated with their respective protein-binding rates. During hemodialysis, blood pressure did not change significantly in any group. These results suggest that imidapril provides good blood pressure control without a large fluctuation of drug concentration in hypertensive patients undergoing chronic hemodialysis.

Vitamin E-bonded hemodialyzer improves neutrophil function and oxidative stress in patients with end-stage renal failure.

We evaluated the biocompatibility of a newly developed vitamin E hemodialyzer (CL-EE; Terumo Co Ltd, Tokyo, Japan) by neutrophil function and oxidant stress in patients with end-stage renal failure in a randomized crossover study. Ten patients underwent hemodialysis using either the CL-EE or a control dialyzer membrane identical to the CL-EE except for vitamin E binding for 12 weeks in a crossover fashion after a 1-month washout period with hemophane membranes. White blood cell counts, serum oxidized low-density lipoprotein (Ox-LDL) levels, and malondialdehyde (MDA) levels during hemodialysis sessions were measured at the initiation and end of the CL-EE and control trials. Superoxide anion production by neutrophils just before and 4 hours after starting the session also was measured. Leukocytopenia at 1 hour after starting the session was detected to a similar extent in both membranes. However, the degree of reduction was less in the CL-EE trial after repeated use. Superoxide anion production by neutrophils just before a hemodialysis session was reduced after repeated use of the CL-EE membrane. Serum Ox-LDL levels increased, whereas serum MDA levels decreased during sessions to a similar extent in both trials. However, these parameters were significantly lower in the CL-EE trial after repeated use. Serum LDL concentrations significantly decreased with repeated use of the CL-EE membrane. These data suggest that repeated use of the CL-EE membrane for 3 months improves neutrophil function, oxidant stress, and LDL concentrations in patients with renal failure. This membrane may be useful to reduce the incidence of cardiovascular events in patients with renal failure.