Clinical value of ultrasound in adult Wilms' tumor patient with uremia: A case report and literature review.

RATIONALE: Wilms' tumor (WT) is the most common pediatric kidney malignancy and is rarely found in adults. Nonspecific clinical symptoms and imaging features often lead to delayed diagnosis or misdiagnosis of adult WT, resulting in poor clinical outcomes. Ultrasound (US), as an efficient and noninvasive examination method, has been widely used in clinical diagnosis and treatment. Therefore, various US evidence is meaningful to improve understanding of adult WT characteristics in ultrasound. PATIENT CONCERNS: A 45-year-old female patient with uremia (regular hemodialysis for 13 years) with painless gross hematuria was diagnosed with a right kidney tumor penetrating to the lung. Preoperatively, B-mode ultrasonography showed an ill-defined hyperechoic mass in the right kidney, which revealed an unclear border, uneven internal echoes, and calcification. Besides, the internal blood flow signal of the tumor was detected. Contrast-enhanced ultrasound (CEUS) showed an uneven hyper-enhancement in the tumor ("fast in and slow out"). Contrast-enhanced computed tomography of the kidney indicated a similar result as the CEUS. Moreover, the chest CT identified multiple pulmonary metastatic nodules. DIAGNOSES: An ultrasound-guided percutaneous core needle biopsy of the tumor proceeded to make a definite diagnosis of adult WT (epithelial type). INTERVENTIONS: The patient was treated with tislelizumab. OUTCOMES: No progress was found to date. LESSONS: We report the first case in which CEUS was performed in an adult WT patient with uremia and multiple pulmonary metastases. The features obtained by the US can help in the diagnosis of adult WT and direct further diagnostic procedures.

The Value of CT Angiography Based on Intelligent Segmentation Algorithm for Survival of Hemodialysis Patients.

This study was to explore the application value for central venous stenosis and occlusion in hemodialysis patients under the CT angiography based on intelligent segmentation algorithm, so that patients can survive better. Spiral CT was used to examine upper limb swelling in 62 uremic hemodialysis patients at a speed of 3.8 mL/s. Nonionic iodine contrast agent was injected around the contralateral limb. The total dosage of 90-102 mL, it was scanned by intelligent trigger technology. The trigger scanning threshold was set. The monitoring point was located in the superior vena cava. CT with convolutional neural network intelligent segmentation algorithm was used to process image data. Finally, the quality of life and related biochemical levels of patients before and after hemodialysis were detected. Under the CT angiography of intelligent segmentation algorithm, 77 stenoses were found in 62 uremic patients, including 48 stenoses of the brachial vein and 17 stenoses of the superior vena cava. The correlation coefficient between CT angiography and digital subtraction angiography (DSA) imaging results of intelligent segmentation algorithm was 0.411. Segmentation effect of the algorithm in this study: automatic segmentation accuracy was greater than 79%. After hemodialysis treatment, the scores of physical fitness, pain, social function, and energy status of patients were significantly increased compared with those before treatment, and the levels of albumin, serum phosphorus, and parathyroid hormone were significantly decreased (P < 0.05). In summary, CT angiography with intelligent segmentation algorithm can obtain clear, intuitive, and complete vascular walking images, and better display subclavian vein, brachiocephalic vein, and superior vena cava. It can provide more valuable support for surgical intervention and has certain application value for better survival of hemodialysis patients.

Lentiform fork sign: Uremia alone or multifactorial causation?

Neurological complications are common in patients with acute or chronic renal failure, especially when there is marked reduction in the glomerular filtration rate (GFR). One such clinical syndrome, uremic encephalopathy (UE), occurs due to widespread dysfunction of central nervous system (CNS). It manifests with myriad clinical features and usually is suggested by bedside elicitation of asterixis (flapping tremor). Symptomatic involvement of the basal ganglia manifesting as choreoathetosis and clinical and radiological resolution with hemodialysis has been reported in the medical literature, but only rarely. The present report details such a case.

Point-of-care ultrasound in Management for Dyspneic Uremic Patients: a case report.

BACKGROUND: Point-of-Care Ultrasound (PoCUS) is considered as an extension of clinicians' patient care and can be integrated into daily clinical practice. Dyspnea is a common presentation in uremic patients. With the aids of PoCUS and integrated assessments of lung, heart and inferior vena cava (IVC), the etiology of dyspnea in uremic patients can be determined earlier. CASE PRESENTATION: A 67-year-old woman presented with progressive shortness of breath and bilateral legs edema for 3 weeks. The laboratory data revealed marked elevated level of serum creatinine and blood urea. A large amount of pericardial effusion was timely detected by PoCUS. Uremic pericarditis was suspected. Emergent hemodialysis was initiated and her symptoms improved. CONCLUSIONS: PoCUS is a noninvasive and cost-effective imaging modality and it has been popular in the emergency department (ED). In uremic patients presenting with dyspnea, the integration of PoCUS into traditional physical examinations help emergency physicians narrow down the differential diagnoses.

Assessment of the left ventricular function in patients with uremia using layer-specific 2-dimensional speckle tracking echocardiography.

The aim of this research is to evaluate the longitudinal and circumferential systolic function of the left ventricle with different configurations from endocardium, midmyocardium, and epicardium, respectively, in patients with uremia using layer-specific 2-dimensional speckle tracking echocardiography (2D-STE).According to the different left ventricular (LV) configurations, 119 patients with uremia were divided into 2 groups: LV normal group (LVN group, n = 63) and LV hypertrophy group (LVH group, n = 56). In all, 66 healthy volunteers were selected as controls. High-frame rate 2-dimensional images were recorded from the apical 4-chamber view, apical 2-chamber view, parasternal LV long-axis view, and mitral annulus, papillary muscle, and apical levels of the parasternal LV short-axis view during 3 consecutive cardiac cycles. The peak systolic longitudinal strain (LS) and circumferential strain (CS) were measured in the endocardium, midmyocardium, and epicardium.In the 3 groups, the endocardium had the highest LS and CS, whereas the epicardium had the lowest LS and CS; the LS and CS of each group gradually decreased from the endocardium to the epicardium in all the 3 sections; the LS and CS of the myocardial layers were kept gradient features, namely, endocardium > midmyocardium > epicardium. The LS of the endocardium in the LVN and LVH groups was significantly lower than that in the control group (P < .05). The LS of the midmyocardium and epicardium in the LVH group were significantly lower than those in the control group (P < .05). The LS of the endocardium significantly decreased in the LVH group compared with that in the LVN group (P < .05). The CS of the endocardium and midmyocardium in the LVH group significantly decreased compared with those in the control and LVN groups (P < .05). There were no significant differences in the CS between the LVN and control groups (P > .05).In patients with uremia, the longitudinal and circumferential systolic function in 3 myocardial layers of the LVH group, and the longitudinal systolic function in endocardium of the LVN group were found significantly impaired by layer-specific 2D-STE.

Ultrasonic image analysis of longitudinal strain in uremic patients with preserved left ventricular ejection fraction.

BACKGROUND: Patients with uremia have high cardiovascular disease morbidity and mortality despite having normal left ventricular ejection fraction (LVEF). Longitudinal strain (LS) can be associated with subtle changes in LV systolic function. The aim of this study was to use two-dimensional speckle-tracking echocardiography (2DSTE) to assess subclinical LV myocardial dysfunction and to explore strain-changing regularities in uremic patients with LVEF ≥ 55%. METHODS: The study population included 40 uremic patients and 40 healthy volunteers. 2DSTE was performed on all participants to assess peak LS in the basal, mid and apical LV (BLS, MLS and ALS) and the respective time to peak LS (T-BLS, T-MLS, T-ALS). RESULTS: BLS, MLS, and ALS were significantly decreased in the uremic group relative to healthy controls and LS increased going in a basal to apical direction in both groups. T-BLS, T-MLS and T-ALS was significantly increased in the uremic group compared with the control group. In uremic patients, T-BLS, but not T-MLS or T-ALS, was significantly delayed relative to the control group. Bivariate analysis of creatinine (Cr) or urea nitrogen and strain parameters revealed a correlation only between ALS and Cr. CONCLUSION: 2DSTE can identify LV myocardial abnormalities in uremic patients with preserved LVEF at early stage, as well as some changing regularities of LS and T-LS in the left ventricle.

Evaluation of carotid artery elasticity in patients with uremia by echo tracking.

PURPOSE: The purpose of this study was to compare the carotid artery wall elasticity between patients with uremia and controls using echo tracking (ET). METHODS: Ninety-three patients with uremia and 35 control subjects (Group A) were enrolled in this study. In the ET mode, the carotid artery elasticity parameters including stiffness index (ß), pressure-strain elasticity modulus (EP), arterial compliance (AC), and one-point pulse wave velocity (PWVß) were measured, and carotid intima-media thickness (IMT) was measured with B-mode ultrasonography. The patients were classified into three groups: Group B (normal IMT), Group C (thickened IMT), and Group D (one single atheroma plaque). RESULTS: ß, EP, and PWVß were significantly higher in Group B, C, and D (especially in group D) than those of the control group (P < 0.05), and there were significant differences between Group A and Group B, while AC was lower than in controls, but there were no statistically significant differences among the four groups. CONCLUSIONS: ET is a noninvasive method that can demonstrate a loss in carotid artery elasticity in uremia patients with normal IMT.

Uremic pleuritis: A case report and review of recurrent exudative pleural effusions in children.

Despite similar mechanisms driving pleural fluid accumulation, the causes of pleural effusions in children differ significantly from that of adults. When a pleural effusion re-occurs in an adult, literature recommends early thoracentesis, and consideration for pleuroscopy with biopsy to guide the diagnostic evaluation. In children, there is a paucity of literature for guiding management of recurrent exudative pleural effusion. We present an unusual pediatric case of uremic pleuritis with recurrent pericardial and exudative pleural effusions.

Uremic tumoral calcinosis in the cervical spine: case report.

Tumoral calcinosis is an uncommon condition characterized by the calcification of periarticular soft tissue. In uremic patients the disease is secondary to metabolic disturbances in predisposed patients. The authors report the case of a 73-year-old woman who presented with a new painful cervical mass while undergoing continuous ambulatory peritoneal dialysis for long-standing end-stage renal disease (ESRD). A CT scan of the neck showed a lobulated, calcified mass in the left paraspinal soft tissue at C2-3. This mass affected the facet joint and also extended into the neural foramen but did not cause any neurological compromise. Due to the patient's significant medical comorbidities, resection was deferred and the patient was followed in the clinic. Subsequent repeat imaging has shown a significant decrease in the size of the mass. In the context of ESRD, a diagnosis of uremic tumoral calcinosis (UTC) was made. The authors conducted a search of the PubMed and EMBASE databases and identified 7 previously reported cases of UTC of the cervical spine. They present a summary of these cases and discuss the etiology, diagnosis, and management of the condition. Although the metabolic disturbances seen in patients undergoing dialysis can lead to tumoral calcinosis, most reported cases involve large joints such as the shoulder or the hip; however, the spine can also be affected and should be considered in the differential diagnosis of patients with uremia as it can mimic aggressive bone-forming neoplasms.

Echocardiographic evaluation of epicardial adipose tissue in non-diabetic, non-hypertensive hemodialysis patients.

PURPOSE: It has been found out that the epicardial adipose tissue (EAT) measured by echocardiography is related with various metabolic parameters. Being accepted as the new cardiovascular risk indicator, there have been few studies on EAT in relation to the patients with end-stage renal failure. In our study, we aim to evaluate EAT and carotid intima media thickness (CIMT) in non-diabetic, non-hypertensive hemodialysis (HD) patients. METHODS: Our study recruited 47 non-diabetic, non-hypertensive HD patients (22 males, 25 females, median age 54 (44.3-60.8) years) and an age-gender matched control group consisting 41 healthy subjects (17 males, 24 females, median age 52 (48-56) years). In all patients, EAT was measured by echocardiography and CIMT by ultrasonography; and routine laboratory parameters were studied. RESULTS: In our study, we obtained laboratory findings matching with the profiles of uremic patients among HD patients and CIMT values of HD patients are significantly higher than that of the control group [0.79 (0.64-0.93) vs. 0.6 (0.53-0.68) p < 0.001], and EAT values are similar [0.5 (0.33-0.6) vs. 0.4 (0.4-0.53) p > 0.05]. CONCLUSIONS: EAT is not a cardiovascular risk indicator in HD patients without diabetes mellitus and hypertension. Besides, echocardiographic measurement of EAT is easy, non-invasive, cheap and credible method.

Occurrence of new bone-like tissue formation in uremic tumoral calcinosis.

A 55-year-old woman who had been on hemodialysis for 5years was admitted for evaluation of a hard mass in the right hip region. Her serum calcium (Ca)-phosphate (P) product was elevated. Radiographs showed periarticular calcified masses in the soft tissues around both hips and shoulders, which were characteristic of uremic tumoral calcinosis (UTC). Biopsy specimens were obtained from both right hip mass and the right iliac crest. Histological examination of hip mass revealed bone-like tissue with marrow, as well as calcified material. The bone-like tissue was categorized as heterotopic ossification (HO), because it had been formed inside soft tissue where bone-like tissue does not normally exist. Histological analysis of HO showed the formation of cancellous bone-like tissue. Woven mineralized bone-like tissue was predominant over lamellar bone-like tissue. High bone turnover combined with osteitis fibrosa-like lesion was diagnosed because of an increase of the fibrous volume, as well as clear double tetracycline labeling. Near a site of HO, numerous ALP- and Runx2-positive cuboidal osteoblast-like cells and TRAP- and cathepsin K-positive multinucleated osteoclast-like cells were noted. Histomorphometric analysis of the right iliac crest revealed osteitis fibrosa. This is the first report of HO in a patient with UTC. After parathyroidectomy, the patient's Ca-P imbalance was corrected and UTC subsided. Although the mechanism by which new bone-like tissue formation arises in the soft tissues has not yet been determined, secondary hyperparathyroidism may have contributed to the progression of UTC in this patient.

Preliminary study of sural nerve morphological changes in uremic hemodialysis patients using 22-MHz high-frequency ultrasound.

INTRODUCTION: The aim of this study was to evaluate the ultrasound (US) morphological changes of sural nerves (SNs) of uremic patients on hemodialysis. METHODS: Sixty-six SNs in 33 uremic patients were examined by 22-MHZ high-frequency US and routine nerve conduction studies (NCS), and 76 SNs in 38 controls were also examined. Cross-sectional area (CSA) and maximal fascicular thickness (MFT) of the SNs were measured. RESULTS: The inner parts of the SN were clearly identified in all participants. There were significant increases in CSA and MFT in the patient group (1.86 ± 0.53 mm(2) and 0.37 ± 0.08 mm, respectively) compared with the control group (1.38 ± 0.25 mm(2) and 0.32 ± 0.03 mm, respectively) (P < 0.001). Fifty-seven SNs (86.36%) had abnormal CSAs, and 51 SNs (77.27%) had abnormal MFTs in the patient group, which was higher than NCS abnormalities (66.67%). CONCLUSIONS: A 22-MHZ US can show morphological changes in the SNs of uremic patients and may be a valuable tool.

Advanced left ventricular diastolic dysfunction in uremic patients with type 2 diabetes on maintenance hemodialysis.

BACKGROUND: Diabetic nephropathy is the leading cause of end-stage renal disease (ESRD). Myocardial dysfunction may occur in patients with diabetes mellitus (DM) in the absence of coronary artery disease or left ventricular (LV) hypertrophy. Although tissue Doppler imaging (TDI) is a highly effective means of quantifying myocardial diastolic function, its differences in ESRD patients with diabetes and without diabetes remain unclear. METHODS AND RESULTS: A total of 101 ESRD patients on maintenance hemodialysis with normal LV systolic function were studied: 37 with type 2 DM and 64 without DM. Conventional echocardiography and TDI were performed to evaluate LV systolic and diastolic functions. The conventional LV systolic and diastolic echocardiographic parameters did not differ according to presence of DM, except for the left atrial size and volume index (P<0.001). The ESRD patients with DM, however, had significantly decreased mitral annular early diastolic peak velocity (e') and ratio of early to late diastolic mitral annular velocity (e'/a'; both P<0.02). Additionally, the group with DM had markedly higher estimated LV end-diastolic filling pressure (E/e'; P=0.011). CONCLUSIONS: ESRD patients with DM had advanced LV diastolic dysfunction on TDI. In ESRD patients with DM, diabetic cardiomyopathy associated with advanced LV diastolic dysfunction is observed. (Circ J 2012; 76: 2380-2385).

Assessment of left ventricular hemodynamics and function of patients with uremia by vortex formation using vector flow mapping.

A novel echocardiographic method, vector flow mapping (VFM), acquires velocity vector from color Doppler velocity data. The purpose of this study was to evaluate whether VFM could provide useful information on intracardiac flow and helpful to evaluate left ventricular (LV) function. Thirty-eight patients with uremia undergoing hemodialysis and 30 healthy volunteers were enrolled. The maximum vector velocity, maximum diameter and duration of the intracardiac vortex were measured using VFM software during systole and diastole. The maximum vector velocity of the vortex and the peak velocities at the basal septum and lateral mitral annulus measured by tissue Doppler imaging (TDI) were correlated. The maximum diameter and duration of vortex formation were significantly higher in uremic patients compared with the control group during the ejection phase (40.6 ± 7.9 cm/sec vs. 28.1 ± 3.9 cm/sec; 297.1 ± 22.1 msec vs. 145.4 ± 19.3 msec, all P < 0.001). The maximal diameters of the vortex were higher in uremic patients compared with the control group during diastole (25.6 ± 3.4 mm vs. 16.4 ± 2.1 mm; 34.3 ± 3.1 mm vs. 26.8 ± 3.9 mm; 37.5 ± 2.4 mm vs. 20.9 ± 2.1 mm; all P < 0.001). The maximum vector velocities were lower in mid-diastole and late diastole (23.6 ± 2.3 cm/sec vs. 45.2 ± 3.7 cm/sec; 31.9 ± 2.9 cm/sec vs. 54.7 ± 3.2 cm/sec, all P < 0.001). There was a correlation between the maximum vector velocity of the vortex in mid-diastole and E'/A' at the septum and lateral mitral annulus (r = 0.70, r = 0.76, P < 0.001). Vortex can be utilized to provide intracardiac dynamic information using VFM and it may be a good supplement for evaluating LV function.

Role of the parathyroid gland vascularization index in predicting percutaneous ethanol injection efficacy in refractory uremic hyperparathyroidism.

AIMS: To evaluate the role of the quantitative vascularization index (VI) as a measure of the completeness of percutaneous ethanol injection therapy (PEIT). METHODS: A total of 37 dialysis patients with secondary hyperparathyroidism refractory to medical therapy received PEIT. We analyzed the role of a quantitative marker of parathyroid adenoma activity, i.e. VI, flow index and vascular flow index as measured by 3-dimensional Doppler ultrasound with a 3-dimensional histogram software, for all patients before treatment and at 1 month and 6 months after PEIT. RESULTS: Serum intact parathyroid hormone (i-PTH) level showed a strong positive correlation with the VI both before (p < 0.001) and after (p < 0.001) PEIT. There was no correlation between i-PTH level and the volume of the gland either before (p = 0.697) or after (p = 0.564) PEIT. One month after PEIT, 20 patients (group 1) reached the target of i-PTH ≤ 300 pg/ml and 17 patients (group 2) did not. Group 2 patients had significantly greater VI and i-PTH prior to PEIT than group 1 patients (42.23 ± 8.38 vs. 14.95 ± 8.07, p <0.001 and 1,447 ± 243 vs. 859 ± 231, p < 0.001 respectively). CONCLUSION: A higher VI indicates a higher i-PTH, and the VI may be a reliable predictor of the completeness of PEIT.

Sex differences in kidney size and clinical features of patients with uremia.

BACKGROUND: Ultrasonographic evaluation of the kidney size is a useful method for assessment of the progression and, in some cases, the type of nephropathy. Ultrasonography (USG) also plays an important role in the evaluation of both acute and chronic renal failure. OBJECTIVE: To investigate the ultrasonographic appearance of the kidneys in patients with uremia, underlying renal diseases and clinical characteristics, including biological sex, were studied. METHODS: This was a retrospective study of data from consecutive adult patients with uremia starting a dialysis program between January 2005 and December 2006 at the nephrology department of a university hospital in Taiwan. Kidney size was determined by USG; demographic and clinical data were obtained prior to initiation of dialysis. RESULTS: Of the patients (167 men, 151 women) included in the analysis, diabetes mellitus (DM) was the leading cause of uremia (127/318; 39.9%). The distribution of DM was similar between male and female patients. In addition to levels of blood urea nitrogen and hemoglobin, body mass index was similar between male and female patients (mean [SD], 22.9 [3.1] vs 22.1 [3.4] kg/m(2), respectively). Female patients had significantly lower serum creatinine levels (P < 0.05) and higher estimated glomerular filtration rates (P < 0.01) than did male patients when they initiated chronic dialysis therapy. Among those with DM, male patients were younger and had larger kidney size on initiation of dialysis therapy than did female patients (age, 59.9 [9.4] vs 64.6 [11.9] years; right renal length, 10.3 [1.4] vs 9.5 [1.5] cm; left renal length, 10.4 [1.5] vs 9.5 [1.4] cm; all, P < 0.05). These sex differences in age and kidney size at the start of dialysis were not observed in patients who did not have DM. Patients with DM had significantly larger kidney size than those without DM (P < 0.05). CONCLUSIONS: The kidney size of these uremic patients varied considerably, depending on sex and the underlying disease. Male patients with DM at the terminal stage of renal failure had larger kidney size and were younger at the start of dialysis therapy than female patients with DM. In uremic patients without DM, no such discrepancy was observed, and both male and female patients started dialysis therapy at a comparable age and kidney size.