Mortality due to bleeding, myocardial infarction and stroke in dialysis patients.

Essentials Mortality due to bleeding vs. arterial thrombosis in dialysis patients is unknown. We compared death causes of 201 918 dialysis patients with the general population. Dialysis was associated with increased mortality risks of bleeding and arterial thrombosis. Clinicians should be aware of the increased bleeding and thrombosis risks. SUMMARY: Background Dialysis has been associated with both bleeding and thrombotic events. However, there is limited information on bleeding as a cause of death versus arterial thrombosis as a cause of death. Objectives To investigate the occurrence of bleeding, myocardial infarction and stroke as causes of death in the dialysis population as compared with the general population. Methods We included 201 918 patients from 11 countries providing data to the ERA-EDTA Registry who started dialysis treatment between 1994 and 2011, and followed them for 3 years. Age-standardized and sex-standardized mortality rate ratios for bleeding, myocardial infarction and stroke as causes of death were calculated in dialysis patients as compared with the European general population. Associations between potential risk factors and these causes of death in dialysis patients were investigated by calculating hazard ratios (HRs) with 95% confidence intervals (CIs) by the use of Cox proportional-hazards regression. Results As compared with the general population, the age-standardized and sex-standardized mortality rate ratios in dialysis patients were 12.8 (95% CI 11.9-13.7) for bleeding as a cause of death (6.2 per 1000 person-years among dialysis patients versus 0.3 per 1000 person-years in the general population), 13.4 (95% CI 13.0-13.9) for myocardial infarction (22.5 versus 0.9 per 1000 person-years), and 12.4 (95% CI 11.9-12.9) for stroke (14.3 versus 0.7 per 1000 person-years). Conclusion Dialysis patients have highly increased risks of death caused by bleeding and arterial thrombosis as compared with the general population. Clinicians should be aware of the increased mortality risks caused by these conditions.

Unusual clinical presentation of brown tumor in hemodialysis patients: two case reports.

Brown tumor or osteoclastoma is a lytic bone tumor, which is common in secondary hyperparathyroidism (1.5-13%) in chronic dialysis patients, mainly in those with untreated renal osteodystrophy. Brown tumor appears as a result from excess osteoclast activity and consists of collections of osteoclasts intermixed with fibrous tissue and poorly mineralized woven bone. It can be manifested as a single or multiple bone lesions. Although invasive, it has no malignant potential and should be distinguished from giant cell tumors of the bone. Two unusual cases of brown tumor in dialysis patients are reported. We present a first patient with five subtotal parathyroidectomies between 2002 and 2009 and a tendency toward recurrence of secondary hyperparathyroidism (sHPTH). The double MRI check up could not reveal any ectopic parathyroid gland. Although the patient had permanently high PTH values, serum calcium level was never above the normal range. However, the brown tumor in the cervical spine was destructing the cervical vertebrae and required surgical intervention. Despite the conservative treatment with calcium and non-calcium-based binders and various forms of vitamin D, the patient's clinical and biochemical condition improved only after the use of cinacalcet. The second patient, a 58-years-old female on chronic hemodialysis since 1998, was found with high PTH serum levels in 2009. The development of sHPTH was scintigraphically confirmed and surgically treated. During the late 2008, she started feeling pain, numbness and swelling of the 3rd right hand finger, prior to the full clinical manifestation of the tumor. The CT scan of the right hand showed osteolytic changes and soft tissue destruction of the middle phalanx of the 3rd right hand finger. This formation corresponded to an unusual presentation of brown tumor associated with sHPTH. As expected, after the parathyroidectomy, there was no marked change in the destructed bone of the 3rd right hand finger middle phalanx, but only a gradual improvement in the subjective clinical condition of the patient. Based on these two reports, we would recommend that in cases of severe or recurrent sHPTH either total parathyroidectomy or early administration of calcimimetics should be considered. Furthermore, the implementation of regular checkup and treatment according to the KDIGO guidelines should be advised and clinical appearance of any bone tumor immediately checked for an association with sHPTH, which is a rather common entity in dialysis patients.

[Non invasive evaluation of vascular calcifications in patients on hemodyalisis]. / Evaluacija vaskularnih kalcifikata kod pacijenata na hemodijalizi neinvazivnim dijagnostickim metodama.

INTRODUCTION: Cardiovascular diseases are one of the main causes of morbidity and mortality in dialysis patients. High incidence of cardiovascular diseases in patients with chronic kidney disease (CKD) can not soley be explained by traditional risk factors. Several studies have confirmed association between vascular calcification and increased mortality. MATERIALS AND METHODS: This study included total of 44 patients on chronic hemodialysis program, 18 women and 26 men, with average age of 50.66 +/- 11.62 years and average duration of treatment of 100.25=52.83 months. We analyzed socio-demographic parameters and standard laboratory findings. X-ray of hand and pelvis was obtained from each patient along with echocardiography and carotid ultrasound imaging. To estimate the level of vascular calcifications on the X-rays, we used the simple vascular score (sVC). RESULTS: Using noninvasive methods, we found vascular calcifications in 26 (59%) patients. In 22 (45%) patients, vascular calcifications were found in X-rays. Four (9%) patients with vascular calcifications lacked any abnormality on X-rays but had calcified plaques on carotid arteries or hart valves. In the group of patients that had vascular calcifications, 3 (14%) patients had sVC score of 2,2 (9%) had score of 3,7 (32%) had score of 4,4 (18%) had score of 6, and 6 (27%) had sVC score of 8. Comparing the group of patients with and without vascular calcifications, we found statistically significant age difference (p<0.05) as well as difference in the duration of hemodialysis (p<0.05). There were no other significant differences found between the two groups. There is a statistically significant correlation between sVC score and level of calcium (p<0.09) and iPTH (p<0.05). Using regression model for increase of sVC score, we found significant correlation with duration of hemodialysis (p<0.05). CONCLUSION: Existence of vascular calcifications represents warning sign of increased cardiovascular risk. Simple vascular score is an easy method for assessing that risk. In our study, increased frequency of vascular calcifications was directly correlated with older age and length of hemodialysis. Standard X-rays, echocardiography and ultrasound imaging can be used in screening of vascular calcifications. Among these methods, X-ray has advantage because it is widely available and easy to interpret.

[Changes in lymphocyte receptors and their activation markers during hemodialysis using various membranes]. / Promjene limfocitnih receptora i njihovih aktivirajucih markera tokom hemodijaliznog tretmana na razlicitim membranama.

BACKGROUND: It's known that uremia is accompanying with different alteration of immune system. Also, different type of dialysis membranes can affect the immunological competence cells--lymphocytes and their function during hemodialysis (HD). AIM OF STUDY: To establish the effect of single hemodialysis session with polysulfonic and cellulose--acetat membranes on lymphocyte subpopulations and their activation markers. METHODS: In two groups of seven patients with end stage of renal disease (ESRD) on periodic HD we were investigated flow-cytometrical expression the following markers using monoclonal antibodies (BECTON DICKENSON): CD3 (T-Ly), CD19 (B-Ly), CD4 (T helper/inducer), CD8 (T-suppressor/cytotoxic), CD4/CD8 ratio, CD16 (NK cells), CD3/HLA-DR (late activated T-cells), CD4/CD 25 (IL-2R early activated T4), CD4/HLA-DR (late activated T8), CD8/CD25 (early activated T8), CD8/CD71 (late activated CD8). Blood samples were taken before HD, 30 minutes into HD and at the end of a four-hours HD session. RESULTS: Demostrates statistical increased expression T helper cells on both membranes on minute 30 from beginning of HD procedure, but more on cellulose-acetat membranes and the significant falls to normal value at the end of HD: start 46.7% minute 30: 54.9%, minute 240: 42.7%. Significant changes were in expression of NK cells on cellulose-acetat membranes: start 12.7%; minute 30: 6.0; minute 240: 11.1%. No changes were noted in activations of T Ly, T4 and T8 on the both membranes. CONCLUSION: No significant difference was found in expression of lymphocyte subpopulations and their activations during HD with polysulfone membranes. Significant changes of the expression of NK cells during HD with cellulose acetat, indicated that NK cells can be sensitive marker for biocompatibility of HD membranes.

[The vertigo syndrome, magnetic resonance and magnetic angiography of the head in patients on a chronic hemodialysis program]. / Vertiginozni sindrom, magnetna rezonanca, magnetna angiografija glave kod bolesnika na hronicnom programu hemodijalize.

BACKGROUND: Vertiginous syndrome appears in more then 100 diseases, therefore subject of intensive investigation. Insufficient research has been done on vertiginous syndrome in patients on chronic program of haemodialisis. The aim of this study is to search anatomical and structural changes on blood vessels of the brain by neuroimaging techniques, as well as increased circulatory resistance on TCD, in patients on chronic program of haemodialysis. METHODS: The research has been done on 30 patients with vertiginous syndrome, 22 males and 8 females, average age 45.9 years, average duration of haemodialysis 5.83 +/- 4.5. In all patients relevant diagnostic procedures had been done (EEG, TCD, audio vestibulogram, X-ray of cervical spine), and in 14 patients with increased circulatory resistance TCD we have done MRI and MRA of the brain. Pathological EEG has been found in 10%, 40% of the patients have had normal EEG finding, while 50% had slowing (non-specific disfunction) in EEG record. RESULTS: MRI and MRA had been done in 14 patients of average age 51.21 +/- 10.82. In 13 patients we had a pathological finding of MRI and MRA, while in one patient only we had normal finding of MRA, and another one patient with normal MRI scan. In 64.2% of the sample we have had cortical cerebral atrophy, in 57.1% cortical atrophy of cerebellum, while in 35.8% apart from the mentioned changes atrophy of cerebellar vermis had been found. In 71.4% of all patients cerebrovascular disease (stroke) could be identified. Atherosclerosis changes in blood vessels of anterior or posterior circulatory segment were found in 78.5% of the patients, while spasm of arteries had been registered in 21.4% of the sample. CONCLUSION: MRI and MRA of the brain brought light on aethiological aspect of vertigo in these patients. Results of our research indicate vascular aethiology of vertiginous syndrome in patients on chronic program of haemodialysis.

[A high prevalence of hepatitis C in hemodialysis]. / Visoka prevalenca hepatitisa C na hemodijalizi.

BACKGROUND: Dialysis patients are among groups at risk for development of Hepatitis C infection. Most studies show a significant correlation between anti-HCV seropositivity and the number of blood transfusions and duration of dialysis. Transmission of HCV by transfusions has become rare since the introduction of antibody screening. However nosocomial transmission of HCV within dialysis units increase. The aim of the study was to evaluate the prevalence and the incidence of seroconversion for HCV in our HD unit during the period from January 1997 to 2000. METHODS: We studied 133 pts (59 females) mean age 50.2 + 14 with mean dialysis duration of 35 months, from the beginning of 1997 to January 2000. 71 pts were seronegative and 62 seropositive for anti-HCV antibodies. The seroprevalence of confirmed anti-HCV patients increased from 46.51% (1997 yrs) to 49.06% (1998) and dropped in 1999 (46.62%). RESULTS: The yearly seroconversion rate ranged from 11.52% (1998) to 7.52% (1999). Till the end of 1998 all patients shared same machines, and from 1999 we had 3 separate machines for only negative patients. Our results showed that duration of dialysis is risk factor for development HCV infection (p < 0.01) seropositive 5.215 + 3.9 years, seronegative 2.2 + 1.55, as also multiple blood transfusions > 5 units. CONCLUSIONS: Our results confirmed previous investigations that duration of HD and blood products are risk factor for HCV infection. High incidence seropositivity by our patients suggested nosocomial transmission of HCV, and was needed implementation of universal precautions in HD units.

[Echocardiographic changes in patients with chronic renal insufficiency on hemodialysis]. / Ehokardiografske promjene kod pacijenata sa hronicnom bubreznom insuficijencijom na hemodijalizi.

Cardiovascular diseases cause death in 40% patients on the chronic haemodialysis program. Our aim was to assess the heart changes in these patients by echocardiography. We have tested 40 patients, but 34 of them accomplished criteria for this study. There were 19 (55.88%) females and 15 (44.12%) males. The average age was 44 years and average duration of haemodialysis treatment was 4.72 years. The research was made with ultrasound device TOSHIBA SSH 65 A SONOLAYER and transducers 3.5 and 2.75 MHz. Twenty patients (58.82%) have had pathological echocardiogram. Ten patients (29.42%) have had conditionally normal echocardiogram while four patients (11.76%) have had completely normal echocardiogram. In patients with pathological echocardiogram, some of the left ventricle hypertrophy forms dominated. Echocardiography is a useful method in morphologic and functional cardiac assessment at the last stage renal disease patients on the chronic haemodialysis program. Using the aforementioned method we are able to select the patients who need intensive cardiac care.