Comparison of Intra-articular Knee Injection of Corticosteroid between Hemodialysis and Non-hemodialysis Patients.

Introduction: Hemodialysis patients have various complications, and orthopedic diseases include carpal tunnel syndrome, spinal canal stenosis, spondylosis destruction, fractures, and osteoarthritis. As a treatment for knee osteoarthritis, intra-articular injections of hyaluronic acid and steroids are performed. In general, steroid injections have a strong short-term anti-inflammatory effect, but there is a risk of complications, such as infection. In addition to aging, dialysis patients are prone to weakened immune systems and susceptibility to infection. Therefore, more attention should be paid to the treatment of osteoarthritis in dialysis patients. This study aimed to compare the effects of steroid and complication of infection of dialysis and non-dialysis patients who underwent intra-articular steroid injection. Methods: A total of 20 dialysis patients (23 knees) and 20 non-dialysis patients (24 knees) with knee osteoarthritis who underwent steroid injections were investigated. All patients underwent radiographic diagnosis and were evaluated for the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, visual analog scale (VAS), range of motion (ROM), and side effects before, and at 3, and 6 months after injection. Results: The mean body mass index (BMI) was 21.3 (±standard deviation (SD) 2.8) and 24.9 (±SD 2.6) in dialysis and non-dialysis patients, respectively, showing a significant difference. Both dialysis and non-dialysis patients showed statistically significant improvement in VAS and WOMAC scores after steroid injection. There were no significant differences between dialysis and non-dialysis patients in the gender differences and mean age. There were no infection complications in both groups. Conclusions: This study revealed the analgesic effect of steroids on knee osteoarthritis in dialysis and non-dialysis patients. On the other hand, there were no infection complications in either patient. These findings suggest that intra-articular steroid injection is safe for dialysis patients.

[Adult T-cell leukemia/lymphoma in a patient on hemodialysis-resistance to CHOP, but unexpected effect and remission achieved by sobuzoxane alone].

A 66-year-old man, on thrice-weekly hemodialysis for 7 years, was referred to Chiba Cancer Center Hospital in August 2006 because of a left axillary tumor. Computed tomography revealed several enlarged lymph nodes assembling at the left axilla. The serum soluble IL-2 receptor was 47,500 U/mL, and HTLV-1 antibody was positive. His parents came from Kyushu. The pathological diagnosis was peripheral T-cell lymphoma, CD4(+). He was clinically diagnosed as having an adult T-cell leukemia/lymphoma, lymphoma type, and clinical stage II. Two courses of CHOP therapy were given to the patient, without any response. Because the patient had to undergo hemodialysis consistently, we preferred mild salvage therapy to more intensive treatment. Then, sobuzoxane (SBZ), 1,600 mg/day in two divided doses, was administered orally for 5 days. Soon thereafter, unexpectedly, the axillary tumor rapidly became small, resulting in disappearance four months later. SBZ therapy, 800 mg/day x 3 days, was continued at intervals of 7 to 8 weeks until October 2008. At the time of reporting, May 2009, the patient was well without recurrence of ATLL, and the remission has lasted 26 months or more. The reason why CHOP-resistant ATLL responded dramatically to SBZ alone is not clear, but the plasma concentration of the metabolite of SBZ was possibly very high because of renal failure. Another possibility is that hemodialysis removed the growth factor(s) or anti-apoptotic factor(s) derived from ATLL cells.

Prognostic value of heart rate variability in patients with renal failure on hemodialysis.

BACKGROUND: In patients with renal failure on hemodialysis cardiovascular disease is a major cause of death. It has been reported that diminished heart rate variability (HRV) relates to the unfavorable prognosis in post-infarction and/or heart failure patients. However, the prognostic value of HRV in hemodialysis patients has not been fully established. METHODS AND RESULTS: Time- and frequency-domain analysis of HRV on 24-hour ambulatory electrocardiography recording was assessed prospectively in 383 chronic hemodialysis patients (220 men and 163 women, mean age 57+/-13 years, ejection fraction 65+/-12%). During 2110+/-903 days of follow up, 146 patients died (31 congestive heart failure, 13 fatal myocardial infarction, 13 sudden deaths, 26 stroke, and 63 non-cardiovascular deaths). A Cox univariate analysis identified the following factors as predictors of both all-cause and cardiovascular death: age, gender, ejection fraction, presence of diabetes, and HRV parameters calculated in the time- and frequency-domain. In multivariate analysis, a low standard deviation of all normal RR intervals (SDNN) value was the strongly associated with both all-cause and cardiovascular death (hazard ratios [95% confidence intervals] 0.988 [0.982-0.994] and 0.984 [0.974-0.993], respectively). From Kaplan-Meier survival curves, the incidence of all-cause and cardiovascular death was much greater in patients with a low SDNN (<75 msec), even after adjusting for the presence of diabetes (P<0.0001). CONCLUSIONS: Decreased HRV on 24-hour ambulatory electrocardiography is an independent predictor of mortality in chronic hemodialysis patients.

2005 Japanese Society for Dialysis Therapy guidelines for vascular access construction and repair for chronic hemodialysis.

The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Dr Ohira, has published an original Japanese guideline, 'Guidelines for Vascular Access Construction and Repair for Chronic Hemodialysis'. The guideline was created mainly because of the existence of numerous factors characteristic of Japanese hemodialysis therapy, which are described in this report, and because we recognized the necessity for standardization in vascular access-related surgeries. This guideline consists of 10 chapters, each of which includes guidelines, explanations or comments and references. The first chapter discusses informed consent of vascular access (VA)-related surgeries, which often resulted in trouble between dialysis staff and patients. The second chapter describes the fundamentals of VA construction and timing of the introduction of hemodialysis with emphasis on the avoidance of catheter indwelling if at all possible. In the third chapter, arteriovenous fistula (AVF) construction and management are discussed from the viewpoint of the most preferable type of VA. The fourth chapter deals with arteriovenous grafts (AVG) which has recently increased in clinical applications. The factors which improve the AVG patency rate are discussed and postoperative management methods are emphasized to avoid possible complications. The fifth chapter deals with short and long-term vascular catheters. It is emphasized that these methods are definitely effective but, at the same time, are apt to be associated with several serious complications and might result in vascular damage. In the sixth chapter, superficialization of an artery is explained. This was originally for emergency use or backup but has been used permanently in 2-3% of Japanese hemodialysis patients. In the seventh chapter, methods for the use of VA are described and the buttonhole method is referred to as one of the options for patients who complain of intense pain at every cannulation. In the eighth chapter, the importance of continuous monitoring is stressed for maintaining appropriate function of VA. As a rule, the internal shunt type VA (AVF, AVG) places a burden on cardiac function. Thus, in the ninth chapter, it is stressed that VA construction, maintenance and repair should always be carried out with consideration of cardiac function which is not constant but variable. The 10th chapter forms one of the cores of this guideline and deals with repair and timing of VA. It is shown how to select a surgical or interventional repair method. In the final 11th chapter, VA types and resultant morbidity and mortality of hemodialysis patients are reviewed.

Increase in putrescine, amine oxidase, and acrolein in plasma of renal failure patients.

Since polyamines have been suggested to be one of the uremic "toxins," the levels of each polyamine, its oxidized product, acrolein, and amine oxidase in plasma of patients with renal failure were investigated. The level of putrescine was increased, whereas the level of spermine was decreased in the plasma of patients with renal failure. The patients also had increased serum amine oxidase activity leading to increased degradation of spermine. Both levels of free and protein-conjugated acrolein were also increased in plasma of patients with renal failure. The accumulated acrolein found as protein conjugates was equivalent to 180 microM, which was 6-fold higher than in plasma of normal subjects. It was found that acrolein is mainly produced by polyamine oxidase in plasma. A cell lysate containing polyamine oxidase was cytotoxic in the presence of spermine. Our results indicate that the level of acrolein is well correlated with the degree of seriousness of chronic renal failure.