Severe asymptomatic coronary obstruction in chronic hemodialysed patient - a case report.

Introduction. Arterial stiffness and vascular calcifications are independent predictors of cardiovascular morbidity and mortality in the chronic kidney disease (CKD) stage 5D population. According to the guidelines, patients on renal replacement therapy represent a very high cardiovascular risk class. Case report. We report the case of a 67-year-old hypertensive male patient, known with CKD stage 5D on hemodialysis (three times per week), secondary bone mineral disease, admitted for progressive right leg pain. The physical examination detected right dorsalis pedis artery pulse absence. Blood biochemistry emphasized hypercalcemia, hyperphosphatemia, increased alkaline phosphatase, metabolic acidosis, hypoalbuminemia, iPTH values above upper limits. The X-ray of right shin highlighted a vascular calcification with a "train track" aspect on the tibial-peroneal artery trunk and the thoracic X-ray (performed with low ray regime) showed calcium deposits in coronary arteries walls. Legs arteriography and coronary angiography were performed revealing multiple lesions on investigated vessels with an 80% narrowing of right coronary artery. The particularity of the case lies in the absence of angina in a chronic hemodialysis patient in whom multiple significant angiographically stenosis of the coronary arteries were found and successful endovascular therapy was performed. Conclusion. The broadening of the indication for coronary angiography should be considered in certain asymptomatic CKD stage 5D patients based on a risk score involving calcium, phosphate, PTH and acid-base imbalances, while considering their major influence on the structure and tone of vascular walls thus on cardiovascular morbidity and mortality rates. Abbreviations. ABI = ankle-brachial index,CAD = coronary artery disease,CKD = chronic kidney disease,CT = computed tomography, EBCT = electron-beam computed tomography,ESRD = end-stage renal disease,GFR = glomerular filtration rate,iPTH = intact parathormon,PCI = percutaneous coronary intervention.

Determining factors of diuresis in chronic kidney disease patients initiating hemodialysis.

BACKGROUND: Patients with stage 5 chronic kidney disease (CKD) begin chronic hemodialysis with variable diuresis levels correlated to a comparable low glomerular filtration rate. Residual diuresis influences long-term evolution of the hemodialyzed patient, modifying the prognosis even if optimal Kt/ V is achieved. AIM OF THE STUDY: The present study emphasizes the main determining factors of diuresis in a cohort of stage 5 CKD subjects at the beginning of hemodialysis. MATERIAL AND METHODS: 216 patients with stage 5 CKD starting chronic hemodialysis were included in the study, and were grouped according to their residual diuresis: group A (urine output ≤ 500 mL/ day); group B (urine output between 500-1200 mL/ day); group C (urine output ≥ 1200 mL/ day). RESULTS: Glomerular etiology, cardiac systolic dysfunction, severe malnutrition, emergency dialysis initiation and lack of permanent vascular access were proved to be associated with significant low diuresis. Age, gender, estimated glomerular filtration rate (GFR) and the presence of systemic hypertension did not influence the amount of daily diuresis. CONCLUSIONS: In CKD stage 5 patients, residual diuresis presents large variations in conditions of comparable low GFR. Factors influencing residual diuresis may be distinct from those that influence residual GFR.

Synergistic approach to patient dialysate.

The stress a patient is subjected to during dialysis treatment can be reduced by using a synergetic approach by the medical team. The integration into therapy of the positive psychical resources such as: active positive coping mechanisms, individual or family mental resilience, improvement of the image and self-esteem, better tolerance to frustration can represent an important part in the improvement of the patient's quality of life, determination of a positive approach of the situations both for him and close friends and relatives.

Thromboangiitis obliterans - case report.

Thromboangiitis obliterans (Buerger'€™s disease) represents an inflammatory disease of limbs'€™ small arteries and veins causing vascular thrombosis, and partial or total obstruction. It affects mostly male gender aged 40 years old. The peculiarity of our case is underlined by presenting a 62 years, chronic tobacco user and not compliant female patient known with thromb oangiitisobliterans for almost 15 years. The arteriographic and clinical features with concomitant and sever affected upper and lower limbs are highly suggestive, emphasizing the possibility of Buerger'€™s disease development even in female patients.

Endomicroscopy with Fluorescent CD105 Antibodies for "In Vivo" Imaging of Colorectal Cancer Angiogenesis.

The aim of this case report was to evaluate the feasibility of in vivo acquisition of microscopic images using fluorescent CD105 antibodies for molecular imaging in human colorectal cancer. After excluding the presence of tissue autofluorescence, the antibody solution was topically administered through a spray-catheter. The targeted area was analyzed by eCLE and images were recorded. The fractal dimension of tumor vessels and the vessel density were determined using ImageJ software. Immunohistochemistry was used as a gold standard. In vivo CLE analysis of CD105 expression enabled the study of tumor vascular network, revealing a chaotic structure.

Calcific uremic arteriolopathy in hemodialyzed patients.

In the present article, we discuss the case of 67-year-old female patient diagnosed with inferior limbs calciphylaxis and hemodialyzed since 2006. The clinical manifestations and pathological lab findings are typical for this rare and extremely severe complication in chronic hemodialyzed individuals. The favorable treatment response to sodium thiosulfate, not often used as elected therapy in international studies, represents the particularity of the case.

Oral treatment of metabolic acidosis in hemodialyzed patients and the implications on the hemodynamic status.

UNLABELLED: Metabolic acidosis slowly develops during renal impairment natural evolution towards ESRD and represents an important contributing factor of CKD progression. Although, several clinical and experimental trials reported the major impact of metabolic acidosis on CKD evolution, the pathophysiology mechanism remains a matter of debate. Furthermore, international guidelines do not impose a specific treatment scheme for metabolic acidosis in CKD patients, and metabolic acidosis is not fully compensated once hemodialysis starts. Therefore, the aim of our study was to determine an adequate follow-up of metabolic acidosis therapy benefits and risks in HD patients. PATIENTS AND METHODS: 164 HD patients were evaluated according to the following protocol: bioumoral laboratory tests, the measure of different important parameters (residual diuresis, UF, BP, LVMI, volemia status). The assessed data were statistic analyzed using non-paired Student's t-test for continuous variables and chi-square (χ²) test for qualitative parameters (p-value <0.05 was considered statistically significant). RESULTS: HD individuals were followed-up depending on their predialysis-alkaline reserve value. After therapy started, predialysis-alkaline reserve mean level increased from 19.4 mEq/L to 22.6 mEq/L (p<0.001). Furthermore, we observed a significant decrease of nitrogenous waste products values (T=10.87<1.66) and intradialytic hypotension events (p<0.001). CONCLUSIONS: Our findings emphasize the beneficial effects of correcting metabolic acidosis using the proposed treatment scheme with direct impact on hemodynamic status improvement.

Functional status of chronic renal replacement therapy in elderly patients--comparison between hemodialysis and peritoneal dialysis.

UNLABELLED: Nowadays, nephrologists are confronted with an increasing number of elderly patients diagnosed with end-stage renal disease (ESRD) in need of dialysis. The benefits of renal replacement therapy are uncertain in this group of patients. Most studies show that the quality of life and survival of elderly dialyzed patients are worse than in younger patients because of multiple comorbidities. Functional status is an important aspect of the quality of life, a strong predictor of survival and a determinant of the health care systems costs. METHOD: In the present research, we compare the change in the functional status--appreciated with the MDS-ADL score--in a cohort of hemodialyzed versus peritoneal dialyzed elderly patients (> 65 years) during a period of 3 years after starting dialysis treatment. RESULTS: At the time of initiating dialysis, the median minimum data set of activities of daily living (MDS-ADL) score in hemodialysis (HD) elderly patients was 4.04 and in continuous ambulatory peritoneal dialysis (CAPD) group was 6.27 (the median MDS-ADL score at the moment of starting dialysis was statistically significant higher in peritoneal group than in hemodialysis elderly group). CONCLUSIONS: The results conclude that elderly treated with peritoneal dialysis have a better evolution of functional status than hemodialyzed elderly patients do.

The role of capsule endoscopy in the detection of small bowel disease.

Videocapsule endoscopy (VCE) can identify lesions in the small bowel which would otherwise be hard to detect. We have selected 53 patients with digestive symptoms in which upper and lower endoscopy had provided no findings. Patients were classified into three groups, based on their main indication for VCE exploration: group one--obscure gastrointestinal bleeding (OGIB); group two--unspecific abdominal symptoms; group 3--monitoring of a prior known pathology. We found that VCE has high predictive values, sensibility and specificity in the diagnosis of OGIB. VCE was also useful in the detection and extent evaluation of lesions in Crohn's and celiac disease. VCE is also able to detect tumors of the small bowel with sufficient accuracy, and can be used to monitor patients with hereditary pre-malignant diseases such as FAP. There were few light adverse effects and no major complications. We conclude that VCE is a safe and effective procedure for the detection of small bowel lesions.

Correlation between albuminemia, natremia and survival rates in patients with hepatorenal syndrome.

A two years prospective study was developed, based on the monitoring of 84 patients with cirrhosis and elevated serum creatinine; 33 patients met the diagnostic criteria for the hepatorenal syndrome. In these 33 patients, survival rate has been studied in correlation with hepatorenal syndrome types, serum albumin and natremia.

New mediators of vascular damage in dialysed patients.

Cardiovascular events are the main causes of mortality in dialysed patients. Traditional risk factors such as hypertension, aging, smoking, diabetes, and abnormal lipid metabolism does not fully explain the high frequency of cardiovascular disease in renal patients, indicating that some other distinct pathogenesis may be involved. Vascular calcification have been associated with high cardiovascular morbidity and mortality in chronic kidney disease (CKD) patients. It is an active process that resembles osteogenesis, regulated by bone proteins and osteoblast-like cells. Elements involved in the pathogenesis are: the risk factors that initiates the process, the promoters released and overexpressed and the dysregulation of the inhibitor factors of extraskeletal calcifications. Although researches in the past decade have greatly improved our knowledge of the multiple factors and mechanisms involved in vascular calcification, many questions remain unanswered.

[Acute-on-chronic renal disease caused by pancreatitis--impact of renal replacement therapy]. / Boala cronica renal acutizata prin pancreatiti--efectele terapiei prin renali supleere renala.

Acute pancreatitis is often complicated by acute renal failure, either isolated or part of multiple organ failure. Preexisting chronic kidney disease worsens the prognosis, especially when the pancreatitis is severe and/or other major comorbidities are present. In case of acute-on-chronic renal failure secondary to acute pancreatitis, an early application of renal replacement therapy has improved the prognosis of patients included in the present clinical study.

Chronic complications in hemodialysis: correlations with primary renal disease.

Although hemodialysis technique has improved in the last decades and the accessibility to this life-sustaining treatment modality increased rapidly, we are still concerned about the morbidity and mortality rates of dialysis patients. While technical advances are increasing the efficacy and safety of renal replacement therapies, latest studies are focused on other outcomes: increasing survival rates and the quality of life by an adequate management of the complications in chronic renal patients. This article reviews the complications of chronic hemodialysed patient with special considerations for the role of the primary renal disease that caused renal failure.

[Management of the chronic renal patient undergoing surgery]. / Managementul medico-chirurgical la bolnavii renali cronici.

Surgery in a chronic renal failure patient carries a substantial higher risk then in normal renal function individuals. This is due to more frequent bleeding and infectious complications, intravascular volume impairments, side effects of anesthesia and others. Development of dialysis technique increased the number of patients receiving treatment for end stage renal disease; their prolonged survival rates, as well as the high percentage of co-morbid conditions will continuously raise the need for surgery in patients with chronic renal failure. The complex and difficult management of these patients requires close cooperation of intensive care specialists and nephrologists, in order to reconcile their frequently opposing views.

Evolution of renal replacement therapy in Central and Eastern Europe 7 years after political and economical liberation. Central and Eastern Europe Advisory Board in Chronic Renal Failure.

PURPOSE OF THE STUDY: The conditions of renal replacement therapy (RRT) were very poor in the countries located in Central and Eastern Europe (CEE) when they were members of the so-called 'socialist bloc'. The aim of the present analysis was to document the impact of the socioeconomic changes on dialysis therapy in the CEE countries. DESIGN: This was a special survey with the participation of 12 CEE countries, with data obtained through national registries (with the exception of Russia). RESULTS: During the period 1990-1996 the number of haemodialysis units increased by 56% and the number of centres performing peritoneal dialysis by 296%. The number of patients increased respectively by 78% (haemodialysis) and 306% (peritoneal dialysis). The percentage of patients with diabetic nephropathy and elderly patients rose dramatically during this period. One of the main reasons of such expansion was the rapid development of peritoneal dialysis programmes in the majority of the CEE countries. The introduction of modern haemodialysis machines and a wider choice of different dialysers and concentrates permitted individualization of dialysis procedures. These points and the wider use of erythropoietin had a positive influence on quality of life and treatment outcome. There was also a notable increase in the number of transplant centres, but less so of the number of transplanted patients. CONCLUSION: Renal replacement therapy experienced a major expansion in the CEE countries. Despite the progress achieved, the level of RRT is not yet completely satisfactory in most CEE countries.

Treatment of end-stage renal disease in central and eastern Europe: overview of current status and future needs.

The situation of end-stage renal disease (ESRD) patients in central and eastern Europe was very poor for many years during the so called socialistic era. Economical and political liberation resulted in the significant growth of renal replacement facilities in this region. The number of hemodialysis units increased significantly (56%) during the period 1990-1996, and the number of patients treated with this modality has risen by 75%. More dramatic progress was achieved in peritoneal dialysis. The number of units performing this method of renal replacement therapy (RRT) increased by 277% and the number of patients by more than 300%. Not only quantitative but also qualitative changes were observed. More modern hemodialysis machines installed in the vast majority of units allow for the performance of bicarbonate dialysis, controlled ultrafiltration, and sodium profile modeling. Also, a wider choice of biocompatible dialyzers has become available during the last few years. The number of centers performing renal transplantation has increased significantly, but the number of renal transplants has not followed this progress. Despite all the progress, further development of all RRT methods is necessary to achieve acceptance rates comparable to those observed in developed countries.