Tarsal tunnel syndrome in hemodialysis patients: a case series.

BACKGROUND: The purpose of our study was to investigate tarsal tunnel syndrome (TTS) arising in patients who have undergone maintenance dialysis at our facility and to evaluate the frequency, pathological characteristics, and diagnosis of TTS. METHODS: We evaluated 1011 patients (mean age 65.1 years) undergoing maintenance dialysis from 2000 to 2006 at our hospital. In patients diagnosed with TTS, we examined clinical symptoms and imaging findings. In addition, we evaluated intraoperative findings in patients who had undergone surgery. A follow-up study was conducted for at least 1 year. RESULTS: Five patients (7 ankles) (mean age 57.8 years) were diagnosed as have TTS, with a mean dialysis duration of 23.4 years (range, 7-30 years). With conservative treatment consisting of rest and a steroid injection, 4 ankles showed improvement. Surgery was performed on 3 ankles. Amyloidoma, nodular tumor fragile deposits in the soft tissue or thecal surface, proliferation of the synovial tendon sheath, and thickened joint capsule were recognized in 3 ankles, and a concomitant ganglion was recognized in 1 ankle. Histologically, the deposition of hyaline material was recognized in all tissues, including the walls of the ganglion or joint capsule, by staining to a pale red color using Congo red stain. An immunohistochemical study indicated positive staining by ß-2 microglobulin staining. The flexor retinaculum was thin in all cases, with retinaculum-like thickness not found in carpal tunnel syndrome. CONCLUSIONS: We believe that the occurrence of TTS in dialysis patients was 0.5%, with a tendency to be more prevalent among patients undergoing maintenance dialysis for 5 or more years. The pathological process of TTS may be different from that of carpal tunnel syndrome. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Survey of the effects of a column for adsorption of ß2-microglobulin in patients with dialysis-related amyloidosis in Japan.

Dialysis-related amyloidosis is a serious complication of long-term hemodialysis. Its pathogenic mechanism involves accumulation of ß2-microglobulin in the blood, which then forms amyloid fibrils and is deposited in tissues, leading to inflammation and activation of osteoclasts. Lixelle, a direct hemoperfusion column for adsorption of ß2-microglobulin, has been available since 1996 to treat dialysis-related amyloidosis in Japan. However, previous studies showing the therapeutic efficacy of Lixelle were conducted in small numbers of patients with specific dialysis methods. Here, we report the results of a nationwide questionnaire survey on the therapeutic effects of Lixelle. Questionnaires to patients and their attending physicians on changes in symptoms of dialysis-related amyloidosis by Lixelle treatment were sent to 928 institutions that had used Lixelle, and fully completed questionnaires were returned from 345 patients at 138 institutions. The patients included 161 males and 184 females 62.9 ± 7.7 years age, who had undergone dialysis for 25.9 ± 6.2 years and Lixelle treatment for 3.5 ± 2.7 years. Based on self-evaluation by patients, worsening of symptoms was inhibited in 84.9-96.5% of patients. Of the patients, 91.3% felt that worsening of their overall symptoms had been inhibited, while attending physicians evaluated the treatment as effective or partially effective for 72.8% of patients. Our survey showed that Lixelle treatment improved symptoms or prevented the progression of dialysis-related amyloidosis in most patients.

Oral nicorandil to reduce cardiac death after coronary revascularization in hemodialysis patients: a randomized trial.

BACKGROUND: Survival after invasive coronary revascularization is worse in patients with chronic kidney disease than in patients without chronic kidney disease. We examined whether oral administration of nicorandil, a hybrid nitrate and adenosine triphosphate-sensitive potassium channel opener, could improve outcome after coronary revascularization in hemodialysis patients. STUDY DESIGN: Open-labeled prospective randomized trial. SETTING & PARTICIPANTS: Maintenance hemodialysis patients who underwent percutaneous coronary artery intervention and had complete coronary revascularization (absence of both restenosis and de novo coronary lesion) at coronary arteriography 6 months later. Enrollment occurred between January 1, 2002, and December 31, 2004. INTERVENTIONS: Treatment with or without oral administration of nicorandil, 15 mg/d. OUTCOMES & MEASUREMENTS: The primary end point was cardiac death (sudden cardiac death or death from acute myocardial infarction or congestive heart failure). The secondary end point was all-cause death. End-point adjudication was performed masked to the intervention. RESULTS: 129 patients (91 men, 38 women) with a mean age of 66 +/- 9 (SD) years. During a 2.7 +/- 1.5-year follow-up, 26 died of cardiac events (acute myocardial infarction, 6; congestive heart failure, 5; sudden cardiac death, 15), and 12 died of noncardiac causes. Cardiac death-free survival rates were greater in the nicorandil group than in the control group (P = 0.009; at 3 years, 86.6% in the nicorandil group and 70.7% in the control group). All-cause death-free survival rates were also greater in the nicorandil group than in the control group (P = 0.01; at 3 years, 79.2% in the nicorandil group versus 60.5% in the control group). Additional percutaneous coronary artery intervention was performed in 6 participants in the nicorandil group and 2 participants in the control group. No serious side effects of nicorandil were reported during the course of the study. LIMITATIONS: Small sample size and open-label design. CONCLUSIONS: Oral administration of nicorandil may reduce cardiac death and improve the survival of hemodialysis patients after coronary revascularization.

Clinical potential of nicorandil to inhibit major cardiac events in hemodialysis patients with suspected myocardial ischemia.

BACKGROUND/AIMS: We examined whether nicorandil, which is a hybrid of an adenosine triphosphate-sensitive potassium channel opener and a nitrate, could inhibit major adverse cardiac events (MACE) in maintenance hemodialysis patients with suspected myocardial ischemia. METHODS: We enrolled 148 asymptomatic patients on maintenance hemodialysis, who had exhibited potential myocardial ischemia as assessed by myocardial fatty acid imaging. The end-point was MACE including cardiac death and non-fatal acute myocardial infarction. A propensity-matched analysis was performed. RESULTS: Over a mean duration of follow-up of 2.8 +/- 1.6 years in the 82 propensity-matched patients (41 in the nicorandil group and 41 in the non-nicorandil group), we observed 17 cardiac deaths and 12 cases of nonfatal myocardial infarction. The incidence of MACE was lower (p = 0.0365) in the nicorandil group (10/41, 24.4%) than in the non-nicorandil group (19/41, 46.3%). On stepwise Cox hazard analysis, MACE was significantly inhibited by administration of nicorandil (hazard risk, 0.387; 95% CI 0.178-0.842; p = 0.0168). Kaplan-Meier survival estimates revealed that MACE-free survival rates at 3 years were 80.5 and 58.5% in patients with and without nicorandil, respectively. CONCLUSIONS: Oral administration of nicorandil may offer new potential for the inhibition of MACE in hemodialysis patients.

Influence of diabetes mellitus on diagnostic potential of iodine-123-BMIPP imaging for coronary artery stenosis in hemodialysis patients.

BACKGROUND: Single-photon emission computed tomography (SPECT) using a fatty acid analogue, iodine-123-beta-methyl iodophenyl-pentadecanoic acid (123I-BMIPP), as a tracer may be effective for detecting coronary artery disease in end-stage renal disease (ESRD) patients. In this study, we investigated whether the presence of diabetes mellitus may affect the diagnostic potential of BMIPP SPECT for detecting coronary stenosis in ESRD patients. METHODS: 123I-BMIPP SPECT was performed in 98 diabetic hemodialysis patients (male to female ratio 66:32; mean age 63.6+/-9.8 years) and 103 nondiabetic hemodialysis patients (68:35; 64.5+/-10.4 years), followed by coronary angiography within 60 days of the SPECT. SPECT imaging was evaluated and graded on a 5-point scale (0=normal, 4=absence of tracer) and assessed as a BMIPP summed score for 17 left ventricular segments. RESULTS: Coronary angiography revealed that 72.4% (71/98) of the diabetic patients and 56.3% (58/103) of the non-diabetic patients had significant coronary stenosis more than 50%; incidences of asymptomatic coronary stenosis were 77.5% in diabetic patients and 72.4% in nondiabetic patients. When a BMIPP summed score of 8 or more was defined as abnormal, sensitivity, specificity and accuracy for detecting coronary stenosis by BMIPP SPECT were 97.2, 63.0 and 87.8% in diabetic patients, and 96.6, 73.3 and 86.4% in nondiabetic patients. In receiver operating characteristic analysis, the areas under the curve of BMIPP SPECT to diagnose coronary stenosis were 0.897 in diabetic and 0.906 in nondiabetic patients. CONCLUSIONS: BMIPP SPECT seems to be able to detect coronary stenosis in diabetic as well as nondiabetic hemodialysis patients.

The high incidence of left atrial appendage thrombosis in patients on maintenance haemodialysis.

BACKGROUND: The incidence of intracardiac thrombosis in haemodialysis patients has not been studied. Here we determined the incidence in end-stage renal disease patients on maintenance haemodialysis. METHODS: Transoesophageal echocardiography was performed in 215 patients (125 males, 90 females; mean age 60 +/- 9 years). Any potential candidate with current or past chronic or intermittent atrial fibrillation or with cardiovascular diseases was excluded from the study. RESULTS: Thrombi were found in the left atrial appendages in 71 out of 215 subjects (33%). Based on multiple logistic regression analyses, the probability of finding a thrombus was found to be increased in patients on chronic antiplatelet therapy (odds ratio 4.268) and in those with diabetes mellitus and a low haematocrit (

Possible involvement of TNF-alpha in left ventricular remodeling in hemodialysis patients.

BACKGROUND: Tumor necrosis factor (TNF)-alpha causes hypertrophic as well as negative inotropic effects on cardiac myocytes. Circulating TNF-alpha levels are reported to be elevated in end-stage renal disease (ESRD) patients undergoing maintenance hemodialysis (HD). We investigated whether increased circulating TNF-alpha is associated with left ventricular remodeling against pressure and/or volume overload in HD patients with or without diabetes mellitus. METHODS: Echocardiography and the measurement of plasma TNF-alpha and B-type natriuretic peptide (BNP) concentrations, one of the parameters indicating left ventricular wall stress, were performed on 176 ESRD patients undergoing maintenance HD (88 non-diabetic and 88 diabetic patients). RESULTS: The mean plasma TNF-alpha concentrations were high, but did not differ between non-diabetic and diabetic patients (9.8 +/- 4.3 pg/mL vs. 9.9 +/- 5.4 pg/mL). In non-diabetic patients, plasma TNF-alpha concentration correlated positively with interventricular septal wall thickness (IVST) and relative left ventricular wall thickness (rLVWT), and inversely with left intraventricular dimensions, but did not correlate with left ventricular mass index (LVMI). In contrast, in diabetic patients, plasma TNF-alpha concentration correlated positively with plasma BNP concentration (r=0.821, p=0.0001) and left intraventricular dimensions, and inversely with rLVWT (r=-0.407, p=0.0001) and left ventricular fractional shortening (r=-0.445, p=0.0001). CONCLUSIONS: Circulating TNF-alpha is possibly involved in concentric left ventricular remodeling in non-diabetic HD patients, whereas it is associated with eccentric left ventricular remodeling against sustained pressure and/or volume overload in diabetic HD patients.