Usefulness of PET/CT with Carbon-11-Labeled Methionine in the Diagnosis of Tertiary Hyperparathyroidism.

Introduction: Tertiary hyperparathyroidism (tHP) may develop in patients treated with hemodialysis or peritoneal dialysis. Parathyroidectomy may result in a significant reduction in the severity of symptoms. For the effective surgical treatment of hyperparathyroidism, proper localization of the parathyroid glands prior to surgery is essential. The sensitivity of scintigraphy in the diagnosis of tHP is lower than in the diagnosis of primary hyperparathyroidism. In recent years, positron emission tomography (PET/CT) has been gaining importance, usually as a complementary technique. Aim: The aim of this study was to determine the usefulness of PET/CT with [11C]MET in the preoperative localization diagnosis of patients with tertiary hyperparathyroidism caused by chronic kidney disease, in whom first-line diagnostic methods did not allow the localization of pathologically parathyroid glands. Material and methods: The study was conducted in a group of 19 adult patients with severe tHP who were resistant or intolerant to non-invasive treatment, with negative results of scintigraphy and ultrasonography of the neck. The study protocol included measurement of the concentration of calcium, phosphorus, and PTH in the blood serum and performing PET/CT with [11C]MET. Results: A positive result of PET/CT was obtained in 89.5% of the patients (17/19). Parathyroidectomy was performed in 52.9% of the patients (9/17) with positive results of PET/CT with [11C]MET, which were fully consistent with the results of the histopathological examinations of the removed parathyroid glands. On this basis, the sensitivity of PET/CT with [11C]MET in the preoperative localization diagnosis of patients with tHP was found to be 100%. Multiple lesions were visualized in 57.9% of the patients (11/19). Ectopic lesions were visualized in 21.1% of the patients (4/19). Conclusions: PET/CT with [11C]MET is a sensitive technique for the second-line preoperative imaging of parathyroid glands in patients with tertiary hyperparathyroidism in whom first-line examinations, such as ultrasound and scintigraphy, has failed.

Renal vascular response to angiotensin II inhibition in intensive antihypertensive treatment of essential hypertension.

INTRODUCTION: High blood pressure (BP) leads to target organ damage. It is suggested that regression of early organ lesions is possible on condition of BP normalization. The study objective was to assess whether permanent reduction of BP to the recommended values modifies renal vascular response to acute angiotensin II inhibition in the Doppler captopril test (DCT) in patients with essential hypertension (EH). MATERIAL AND METHODS: Twenty-nine persons (58 kidneys) were found eligible for the study: 18 patients with EH and 11 healthy volunteers constituting the control group. Glomerular filtration rate estimation (eGFR), 24-h ambulatory BP monitoring (ABPM) and DCT with evaluation of renal resistive index change (ΔRI) were performed before and after a 6-month period of intensive antihypertensive therapy (IAT). Additional ABPM was performed at the end of IAT. RESULTS: The mean IAT period was 8.5 ±2.4 months. The mean 24-h values of systolic and diastolic BP in the EH group were significantly lower in the IAT period than at the beginning and at the end of the study. Significantly lower systolic and diastolic BP (p < 0.05) and improvement of renal function (eGFR 121 ±38 vs. 139 ±40 ml/min, p < 0.001) were found after IAT as compared to initial values. Before IAT, ΔRI was significantly lower in the EH group as compared to the controls, but no such differences were found after IAT. CONCLUSIONS: In EH patients, intensive BP lowering to the recommended values was associated with improvement of renal function and normalisation of renal vascular response to acute angiotensin II inhibition.

Renal autoregulation in medical therapy of renovascular hypertension.

INTRODUCTION: Renovascular hypertension (RVH) is caused by renal ischaemia associated with haemodynamically significant renal artery stenosis (RAS). The choice of optimal treatment of atherosclerotic RAS is still controversial. Increase in the renal resistive index (RI) value after captopril administration is considered to indicate preserved renal autoregulation. The objective of the study was to assess the effect of medical therapy of RVH on renal autoregulation efficiency in patients with atherosclerotic RAS. MATERIAL AND METHODS: 19 persons (38 kidneys) in 2 groups: 1) study: with RVH and stenosis of 1 renal artery - 8 patients; 2) control: - 11 healthy volunteers. Doppler captopril test with RI measurements and estimation of creatinine clearance (CCr) were performed in both groups at baseline, and after a period of controlled medical therapy (CMT) only in the study group. ABPM was evaluated in controls at baseline, and in the study group at the end of CMT. RESULTS: In the study group the mean period of CMT was 8.3 ±2.7 months, the number of antihypertensive drugs was 4.1 ±1.0, and mean 24-hour blood pressure was 138/74 mmHg. Mean CCr was stable during the study. Significant increase of RI after captopril was found only in controls. At baseline, in the group of kidneys with a non-stenotic renal artery, significant lowering of RI was observed, and ΔRI differed significantly from controls. After CMT, ΔRI increased in non-stenotic kidneys in comparison to the baseline, and did not differ from controls. CONCLUSIONS: Adequate medical therapy of RVH preserved renal function and improved renal autoregulation efficiency in non-stenotic kidneys.

Peritoneal dialysis as a therapeutic approach in congestive heart failure resistant to pharmacological treatment.

Given an increasing number of patients with congestive heart failure (CHF) refractory to diuretics, new and more effective therapeutic modalities are sought. Peritoneal dialysis (PD), which provides continuous, slow ultrafiltration, may be an alternative to hemodialysis in this population. The current paper, based on a comprehensive literature review, addresses the role of PD in improving the quality of life of patients with CHF.

Atypical clinical presentation of Churg-Strauss syndrome with rapidly progressive glomerulonephritis: case report.

The case of a 48-year-old man presented in this paper illustrates an atypical clinical course of Churg-Strauss syndrome with rapidly progressive glomerulonephritis with no signs of bronchial asthma.

Peritoneal dialysis as a therapeutic approach in congestive heart failure resistant to pharmacological treatment: case report.

This report describes the use of continuous peritoneal dialysis (PD) as an alternative to hemodialysis (HD) in a patient with type 2 cardiorenal syndrome in the course of congestive heart failure resistant to standard pharmacological treatment. A 39-year-old man presented with a 24-year history of progressive heart failure. Ineligibility for heart transplant and previous inefficient treatment with different modifications of HD reduced his treatment options to PD. After 7 months of continuous PD (1 overnight exchange with icodextrin and 2 daily standard continuous ambulatory PD exchanges) his overall condition significantly improved compared with his status while on HD. An increase from NYHA class IV to class II, increase in left ventricular ejection fraction from 50% to 55%, decrease in right ventricular systolic pressure from 73 to 53 mmHg, and improvement in the quality of life enabled him to resume his daily activities.

The kinetics of water transperitoneal transport during long-term peritoneal dialysis performed using icodextrin dialysis fluid.

INTRODUCTION: Dialysis fluid containing icodextrin is used in patients on peritoneal dialysis (PD) because of its significant ultrafiltration properties. The use of the fluid in treating patients with congestive heart failure resistant to diuretics has also been reported. OBJECTIVES: The aim of the study was to evaluate water peritoneal transport during a 16-hour dialysis exchange performed using icodextrin-containing dialysis fluid. PATIENTS AND METHODS: Eleven clinically stable patients were enrolled in the study (5 women and 6 men; mean age, 50.4 +/- 18.3 years), treated with PD for 26.9 +/- 22.4 months. Water transperitoneal transport was evaluated using a modified version of Babb-Randerson-Farrell thermodynamic model of membrane transport with human albumin marked with iodine as the marker of intraperitoneal volume. Based on blood and dialysate samples collected during the 16-hour dialysis exchange, the intraperitoneal volume of dialysate and dialysate reverse absorption were calculated. RESULTS: There were no clinical complications associated with the use of icodextrin fluid during the study. A significant increase in intraperitoneal volume of dialysate (950 ml on average) compared to the initial value was observed in the whole group at the 16th hour of the exchange. CONCLUSIONS: The study demonstrated that dialysis fluid with icodextrin ensured effective ultrafiltration during a 16-hour dialysis exchange. This indicates its potential usefulness in the treatment of patients with severe congestive heart failure with or without coexisting end-stage renal disease.

[Influence of controlled hypotensive therapy on renal autoregulation efficiency in the doppler captopril test in patients with chronic glomerulonephritis]. / Wplyw kontrolowanej terapii hipotensyjnej na sprawnosc autoregulacji nerkowej w dopplerowskim tescie kaptoprylowym u chorych na przewlekle klebuszkowe zapalenie nerek.

UNLABELLED: Regulation of renal vascular resistance is one of main mechanisms of the renal autoregulation. Renal vascular resistance is expressed in the Doppler sonography as a resistance index (RI). AIM OF THE STUDY: Estimation of renal resistance index variability in the Doppler Captopril Test in patients with chronic glomerulonephritis and hypertension in the course of controlled hypotensive therapy. MATERIAL AND METHODS: 21 patients (13 men + 8 female, age 40 +/- 14.5 years) with chronic glomerulonephritis and hypertension were enrolled to the study. Twice, in about 6 months period of intensive hypotensive treatment, the Doppler Captopril Test was performed and variability of RI (deltaRI) was estimated. RESULTS: Significant rise of deltaRI 0.11 (-11.86:2.83) vs 1.15 (-3.86:7.11); p < 0.05 was found, after 5.8 +/- 2.4 months of hypotensive therapy, and by preserved renal function. CONCLUSIONS: Controlled hypotensive therapy significantly improves efficiency of renal vascular autoregulation expressed as the variability of renal resistance index in the Doppler Captopril Test.

[Treatment of renal anemia with intravenous erythropoietin in patients in the program of continuous ambulatory peritoneal dialysis]. / Leczenie niedokrwistosci nerkopochodnej erytropoetyna podawana dozylnie u chorych w programie ciaglej ambulatoryjnej dializy otrzewnowej.

AIM OF THE STUDY: In the face of non fully correctable renal anemia in patients on continuous ambulatory peritoneal dialysis (CAPD) injecting erythropoetin subcutaneously by themselves, we compared the effectiveness of renal anemia compensation as well as potentially positive influence on the clinical course of CAPD erythropoietin alpha (EPOalpha) given intravenously 1 or 2 times weekly, by PD-nurse at patients home with the same protocol of erythropoietin beta (EPObeta) given subcutaneously by patient himself or by family helper. MATERIAL AND METHODS: There were 2 groups of CAPD patients qualified in years 2003-2005 to the 6 months study. Group 1 consisted of 12 patients who were receiving EPOalpha intravenously (7 women and 5 men; aged 57.8 +/- 14.0 years) and group 2 consisted of 12 patients who were given EPObeta subcutaneously by themselves (7 women and 5 men; age 58.0 +/- 12.5 years). In the course of home visits the nurses supervised the correctness of CAPD program performed by patient or family helper. RESULTS: The results were as follows: we observed significant increase of the Hgb level in the group 1 between 3-rd and 6-th month of the study without significant increase of EPO dose. With respect to the course of CAPD program we found significantly higher frequency of peritonitis (1/11 vs 1/68 patient months; p < 0.05) and longer mean time of hospitalization (2.33 +/- 1.97 vs 1.17 +/- 1.03 days/pt; p < 0.05) in the group 2 in comparison with group 1. Mean peritonitis-free survival time was significantly longer in the group 1 in comparison with the group 2 (22.14 +/- 6.41 vs 16.51 +/- 9.70 weeks; p < 0.05). CONCLUSIONS: We conclude that EPOalpha given intravenously by PD-nurse in patient home enabled maintenance of recommended Hgb level. The additional benefit from nurse assisted PD was reduction of peritonitis rate as well as duration of hospitalization from various reasons.

[Translumbar cannulation of vena cava inferior as an alternative method of vascular access for hemodialysis]. / Przezledzwiowa kaniulacja zyly glównej dolnej jako alternatywny dostep naczyniowy do hemodializ.

The aim of our report is description of the first in Poland translumbar cannulation of vena cava inferior used as an alternative vascular access for hemodialysis in 62 years old patient without further access for hemodialysis and no access for peritoneal dialysis.

[Schönlein-Henoch purpura--case report]. / Plamica Schönleina-Henocha--opis przypadku.

Schönlein-Henoch purpura is a systemic vasculitis characterised by purpura, joints and gastrointestinal involvement and glomerulonephritis. Organs injuries are associated with the deposition of immune complexes containing IgA in the wall of small vessels. This disease rarely affects adults. On the basis of the case of 50 years old man clinical presentation, prognosis and treatment are presented.

[Advances in diagnosis and treatment of AL amyloidosis]. / Postepy diagnostyki i leczenia AL amyloidozy.

AL amyloidosis is a systemic disease characterized by extracellular amyloid deposition in tissues, causing progressive dysfunction of affected organs. The main clinical syndroms include nephrotic-range proteinuria with or without renal dysfunction, congestive heart failure, hepatomegaly and peripheral or autonomic neuropathy. The aim of therapy is the reduction of monoclonal light chains, by suppressing the underlying plasma cell dyscrasia. Recent therapeutic strategies involve intermediate-dose chemotherapy or high-dose melphalan supported by peripheral blood stem cell transplantation. Alternative therapeutic approaches include thalidomide, lenalidomide, iododoxorubicin, etanercept and rituximab. This paper reviews the pathogenesis, diagnosis and therapy of the AL amyloidosis, focusing on clinico-morphological symptoms of renal involvement, monitoring of treatment response and supportive therapy.

[Causes and clinical implications of hypervolemia in peritoneal dialysis]. / Przyczyny i implikacje kliniczne przewodnienia w dializie otrzewnowej.

In our paper we present actual data from world literature as well as own experiences with respect to chronic hypervolemia as a very important clinical problem in peritoneal dialysis. We discussed the causes and clinical picture of hypervolemia as well as differential diagnosis of ultrafiltration failure as a potential cause of hypervolemia in peritoneal dialysis patients. Special attention was paid to the kinetic modelling of sodium and water removal in peritoneal dialysis.

[Effectiveness of subcutaneous and intravenous epoetin alpha in haemodialysed patients]. / Ocena skutecznosci podskórnego i dozylnego podawania erytropoetyny alpha u chorych hemodializowanych.

UNLABELLED: According to recommendations of exclusively intravenous administration of erythropoietin alpha (EPOalpha) produced in Europe (Eprex-Janssen-Cilag), we compared the effectiveness of EPOalpha during 6 months of the therapy after conversion from s.c. to i.v. route in 21 hemodialysed patients. MATERIAL AND METHODS: The inclusion criteria were as follows: stable blood morphology over the 3 months before conversion; haemoglobin concentration > 10.0 g/dl; transferrin saturation > 20% and serum ferritin > 200 microg/l. Dose of EPOalpha was verified every month in the course of the study, depending on actual haemoglobin concentration. RESULTS: There were no significant differences in haemoglobin concentration and EPOalpha dose in all monitored time intervals. We didn't find any differences in transferrin saturation, serum albumin concentration and haemodialysis adequacy between starting values and results after 6 months of the therapy. Only values of CRP, serum ferritin concentration and iPTH were significantly higher after 6 months of i.v. EPOalpha therapy comparing to the initial data. CONCLUSION: in hemodialysed patients with adequate iron stores and stable values of haemoglobin change of the route of EPOalpha administration from s.c. to i.v. is not connected with the increase of the dose of EPOalpha to maintain the haemoglobin values in the target range.

[Influence of parathormone level on the doses of human recombinant erythropoietin in haemodialysed patients]. / Wplyw stezenia parathormonu na dawke ludzkiej rekombinowanej erytropoetyny u chorych przewlekle hemodializowanych.

UNLABELLED: The purpose of the study was to determine the doses of rHuEPO, which are necessary to obtain the same correction of renal anaemia in chronically haemodialysed patients with different levels of iPTH. 25 haemodialysed patients with stable values of iPTH for at least 6 months (mean age 58 +/- 15.6 years; 6 females and 19 males on haemodialysis from 1 to 126 months) were divided into 3 groups: group 1 (7 patients) with iPTH < 100 pg/ml, group 2 (12 patients) with iPTH 100-300 pg/ml and group 3 (6 patients) with iPTH > 300 pg/ml. In all groups adequacy of haemodialysis (HD) measured by Kt/V was similar. Every month the following data were determined: Ca, P, CaxP product, HCT, HGB, Fe, transferrin saturation (TSAT) and weekly dose of rHuEPO. Patients with chronic infections, neoplastic diseases or those after blood transfusions were excluded from the study. Significantly higher weekly dose of rHuEPO was needed in patients with iPTH > 300 pg/ml to obtain similar correction of renal anaemia in comparison with patients with iPTH from 100 to 300 pg/ml. There were no statistically significant differences between the groups with respect to other data except significantly higher values of Cas in the group with iPTH > 300 pg/ml. CONCLUSION: Higher doses of rHuEPO to obtain the same correction of renal anaemia are necessary only in patients with iPTH > 300 pg/ml.

[Sterile peritonitis associated with the use of icodextrin solution. Case report]. / Jalowe zapalenie otrzewnej podczas stosowania wymian dializacyjnych plynem zawierajacym ikodekstryne. Opis przypadku.

Sterile peritonitis after dialysis with the use of icodextrin-containing solution is a rare complication of peritoneal dialysis programme. On the basis of the case of hypersensitivity to icodextrin accompanied by peritonitis, the diagnostic problems were described and a review of literature on this complication is presented.

[Diverticulosis as a background of "abdominal catastrophe" in the course of peritoneal dialysis. Care Report]. / Uchylkowatosc jelita grubego jako tlo "katastrofy brzusznej" w przebiegu dializoterapii otrzewnowej. Opis przypadku.

Peritonitis complicating peritoneal dialysis (PD) may represent a difficult diagnostic and therapeutic problem if it coexists with surgical pathology of intra-abdominal organs defined as "abdominal catastrophe". The illustration of this problem is the case of 70-year-old patient treated with automated PD, in whom recurrent episodes of peritonitis (Escherichia coli) were typical of "abdominal catastrophe" and were probably caused by microperforations of the colon in the course of diverticulosis.

[Enoxaparin in haemodialysis]. / Enoksaparyna w hemodializie.

Using of low-molecular-weight heparins (LMWH) in haemodialysis therapy significantly reduced the incidence of haemorrhagic complications with the same clinical efficacy in comparison to standard unfractionated heparins. Taking enoxaparin as example, we present the mechanisms of action of LMWH paying special attention to efficacy in haemodialysis and adverse effects.

[Report from the XXVIII Congress of ERA-EDTA, Vienna, June, 2001]. / Sprawozdanie z XXXVIII Kongresu ERA-EDTA, Wieden, czerwiec 2001 r.

This paper refers to selected reports on nephrology and renal dialysis therapy presented on the XXXVIII Congress of European Renal Association--European Dialysis and Transplant Association (ERA-EDTA), held in 2001 in Vienna. Special attention was paid to diagnosis and therapy of renal anaemia, calcium-phosphate metabolism, Fabry's disease and vascular access in hemodialysed patients.