RESUMO
BACKGROUND: Among dialysis patients, occlusive mesenteric vascular disease has rarely been reported. OBJECTIVES: To report on the experience of one center with regard to diagnosing and treating this complication. METHODS: The retrospective case-series involved six patients (3 females, 3 males; age 52-88 years; 5/6 were smokers) on chronic hemodialysis at a single center. All patients with symptoms suggestive of occlusive mesenteric disease and a subsequent angiographic intervention were included. Demographic, clinical, and laboratory data were collected from patient charts for the period before and after angioplasty and stenting of the mesenteric vessels. A Wilcoxon signed-rank test was used to compare the relevant data before and after the intervention. RESULTS: All participants had variable co-morbidities and postprandial abdominal pain, food aversion, and weight loss. CT angiography was limited due to heavy vascular calcifications. All underwent angioplasty with stenting of the superior mesenteric artery (4 patients) or the celiac artery (2 patients). All procedures were successful in resolving abdominal pain, malnutrition, and inflammation. Weight loss before was 15 ± 2 kg and weight gain after was 6 ± 2 kg. C-reactive protein decreased from 13.4 ± 5.2 mg/dl to 2.2 ± 0.4 mg/dl (P < 0.05). Serum albumin increased from 3.0 ± 0.2 g/dl to 3.9 ± 0.1 g/dl (P < 0.05). Two patients underwent a repeat procedure (4 years, 5 months, respectively). Follow-up ranged from 0.5-7 years. CONCLUSIONS: Occlusive mesenteric ischemia occurs among dialysis patients. The diagnosis requires a high degree of suspicion, and it is manageable by angiography and stenting of the most involved mesenteric artery.
Assuntos
Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Diálise Renal/efeitos adversos , Stents , Dor Abdominal/etiologia , Idoso , Idoso de 80 Anos ou mais , Angioplastia , Artéria Celíaca/fisiopatologia , Artéria Celíaca/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Artérias Mesentéricas/fisiopatologia , Artérias Mesentéricas/cirurgia , Isquemia Mesentérica/diagnóstico , Isquemia Mesentérica/etiologia , Oclusão Vascular Mesentérica/diagnóstico , Oclusão Vascular Mesentérica/etiologia , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Elderly patients constitute a significant proportion of chronically dialyzed patients. This study evaluated mortality rates and predictors of mortality among very old patients receiving chronic hemodialysis (HDx). METHODS: A single-center retrospective analysis was carried out on patients >84 years of age who started chronic dialysis between 2004 and 2012. Univariate and multivariate analyses determined which parameters predicted survival. RESULTS: Twenty-nine hemodialyzed patients (19 males) were studied. Mean age was 88 ± 3 years. Median survival time was 38 months (range 4-96). One-year and 2-year survival probability was 80 and 65%, respectively. The most common cause of death was complicated peripheral vascular disease. Multivariate analysis revealed the following: for each 1 g/dl decrease in serum albumin level, the hazard ratio for patient death was 2.63 (p = 0.017), and for each weekly HDx treatment time decrease of 1 h, the hazard ratio for patient death was 1.40 (p = 0.006). CONCLUSION: Very elderly patients can be hemodialyzed with cautious optimism.
Assuntos
Doenças Vasculares Periféricas/mortalidade , Diálise Renal/mortalidade , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Análise Multivariada , Doenças Vasculares Periféricas/complicações , Doenças Vasculares Periféricas/etiologia , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Albumina Sérica/análise , Análise de SobrevidaRESUMO
BACKGROUND: The incidence of left ventricular hypertrophy (LVH) in primary aldosteronism (PA) is higher than in essential hypertension. LVH is an independent cardiovascular risk factor. Treatment of PA with mineralocorticoid receptor blockers (MRBs) improves LVH. Previous studies included relatively small groups, low incidence of LVH and used high MRB dose. We tested the hypothesis that long-term regression of LVH in PA/low-renin hypertension may be achieved with low-dose MRB. METHODS: Forty-eight patients (male/female 28/20, age 61.4 years, range 47-84) had PA (low renin, high aldosterone and high aldosterone/renin ratio, n=24) or low-renin hypertension (low renin, normal aldosterone and high aldosterone/renin ratio, n=24). All had either LVH or concentric remodelling. All had an echocardiogram both at baseline and at 1 year after the initiation of spironolactone. A subgroup of 29 patients had an echocardiogram at baseline, 1 year (range 0.5-1.5) and 3 years (range 1.8-7). RESULTS: At baseline, spironolactone was commenced in all patients. The dose was 33.3±13.7 and 29.0±11.7 mg/day at 1 year and 3 years, respectively. A total of 73% of the patients received ≤37.5 mg/day. Introduction of spironolactone enabled the reduction of other antihypertensive medications (from 2.6±1.2 to 1.5±1.0 at 1 year). At 1 year, systolic and diastolic blood pressure decreased (149.3±14.1 to 126.2±12.0 mmHg, P<0.001, and 88.2±9.8 to 78.3±7.1 mmHg, P<0.001, respectively). At baseline, LVH was present in 39 of the 48 (81%) patients, and concentric remodelling, i.e. increased relative wall thickness (RWT) with a normal left ventricular mass index (LVMI), in 36 (75%). At 1 year, LVMI decreased in 44 of the 48 (92%) patients (142.9±25.4 versus 117.7±20.4 g/m2, P<0.001). LVH normalized in 16 of the 39 (41%) patients. RWT normalized in 36% of the patients. The changes in blood pressure and LVMI did not correlate. At 3 years, LVH decreased further and normalized in 57% of the patients. CONCLUSIONS: In patients with PA/low-renin hypertension, long-term regression of LVH may be achieved with low-dose MRB.
Assuntos
Hiperaldosteronismo/complicações , Hipertensão/complicações , Hipertrofia Ventricular Esquerda/tratamento farmacológico , Antagonistas de Receptores de Mineralocorticoides/uso terapêutico , Renina/metabolismo , Espironolactona/uso terapêutico , Idoso , Determinação da Pressão Arterial , Ecocardiografia , Hipertensão Essencial , Feminino , Seguimentos , Humanos , Hiperaldosteronismo/tratamento farmacológico , Hiperaldosteronismo/metabolismo , Hipertensão/tratamento farmacológico , Hipertrofia Ventricular Esquerda/etiologia , Hipertrofia Ventricular Esquerda/metabolismo , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de SobrevidaRESUMO
BACKGROUND: Hemodialysis patients are at high risk for severe COVID-19 disease. Despite a high early seropositivity rate, dialysis patients mount a dampened immune response following two doses of an mRNA vaccine. This study aimed to evaluate the serologic response to a booster dose of BNT162b2 vaccine, 6 months after the second dose, among hemodialysis patients. METHODS: This prospective study included 80 hemodialysis patients and 56 healthcare workers serving as controls. Serologic samples were evaluated before and â¼3 weeks after the third vaccine dose. The primary outcomes were the seropositivity rate and the log-transformed anti-SARS-COV-2 S1 (RBD) IgG as a continuous variable after the third dose. Secondary outcomes were the proportion of participants with "high response," defined as antibody levels >1,000 AU/mL, and "robust response," defined as antibody levels >4,160 AU/mL, according to prespecified cutoff values associated with neutralizing antibodies. Univariate and multivariate analyses were conducted to identify predictors of antibody response. RESULTS: Among 80 hemodialysis patients, seropositivity rates improved from 78% (62/80) before the third dose, up to 96% (77/80) after the booster dose. The S1-RBD log-transformed antibody level increased significantly following the third dose from 2.15 ± 0.75 to 3.99 ± 0.83 compared with 2.65 ± 0.4 to 4.31 ± 0.42 in the control group. Among the hemodialysis patients, 88% (70/80) became "high responders" (>1,000 AU/mL), and of these, 79% (63/80) mounted a "robust response" (>4,160 AU/mL). Baseline antibody level, dialysis therapy, and hypoalbuminemia were independent predictors of impaired antibody response. CONCLUSIONS: A third dose of BNT162b2 COVID-19 vaccine, 6 months after the standard two-dose vaccination regimen, substantially improved humoral response in hemodialysis patients.
Assuntos
Vacina BNT162 , COVID-19 , Humanos , COVID-19/prevenção & controle , Vacinas contra COVID-19 , Estudos Prospectivos , Diálise RenalRESUMO
Glomerular mesangial cells (MCs) proliferate and produce extracellular matrix proteins in many progressive renal diseases. Recently, histone deacetylase inhibitors (HDIs) were shown to have antiproliferative and antifibrogenic effects in some in vitro and in vivo models. Using the [(3)H]-thymidine incorporation test, we have found that the HDI trichostatin A (TSA) effectively inhibits MC growth at nontoxic nanomolar concentrations. Similarly, the HDI valproic acid also inhibited MCs proliferation. Cell-cycle analysis indicated an arrest in G(0)/G(1) phase in response to TSA, which was accompanied by elevation in synthesis of the cyclin-dependent kinase inhibitors (CDKIs) p21/Waf1 and p27/Kip1. TSA treatment suppressed alpha-smooth muscle actin, transforming growth factor-beta1, and collagen protein synthesis by MCs and induced myofibroblast-like appearance of proliferating MCs. In the in vivo model of the anti-Thy1.1-induced glomerulonephritis, TSA and valproic acid treatments significantly suppressed proteinuria. Collectively, these data suggest a therapeutic potential for HDIs in the treatment of mesangial proliferative diseases and glomerulosclerosis.
Assuntos
Inibidores de Histona Desacetilases/farmacologia , Células Mesangiais/efeitos dos fármacos , Actinas/metabolismo , Animais , Ciclo Celular/efeitos dos fármacos , Proliferação de Células/efeitos dos fármacos , Células Cultivadas , Colágeno/biossíntese , Proteínas Inibidoras de Quinase Dependente de Ciclina/metabolismo , Ativação Enzimática/efeitos dos fármacos , Mesângio Glomerular , Glomerulonefrite Membranoproliferativa/complicações , Glomerulonefrite Membranoproliferativa/imunologia , Ácidos Hidroxâmicos/farmacologia , Isoanticorpos/imunologia , Células Mesangiais/citologia , Células Mesangiais/metabolismo , Músculo Liso/metabolismo , Proteinúria/etiologia , Proteinúria/prevenção & controle , Ratos , Ratos Sprague-Dawley , Fator de Crescimento Transformador beta1/biossíntese , Ácido Valproico/farmacologiaRESUMO
BACKGROUND: In patients with euvolemic and hypervolemic hyponatremia, the effect of vasopressin antagonists is yet undefined. STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs). SETTING & POPULATION: In- and outpatients with euvolemic or hypervolemic hyponatremia. SELECTION CRITERIA FOR STUDIES: We included all RCTs regardless of publication status or language. INTERVENTION: Vasopressin antagonists with or without fluid restriction versus placebo or no treatment with or without fluid restriction. OUTCOMES: Response rate defined as normalization of serum sodium level or significant increase in serum sodium level at 3-7 days (primary) and later, change from baseline serum sodium level at 3-7 days and later, adverse events, rate of rapid sodium level correction, and rate of hypernatremia. RESULTS: 15 RCTs were identified. Vasopressin antagonist treatment significantly increased response rate both early (RR, 3.15; 95% CI, 2.27-4.37; 11 trials) and late (RR, 2.27; 95% CI, 1.79-2.89; 4 trials). Response rates were high in trials assessing mostly euvolemic patients and those assessing mostly hypervolemic patients, with greater effect estimate in the former. Change from baseline serum sodium level was significantly increased both early (weighted mean difference, 5.27 mEq/L; 95% CI, 4.27-6.26, 13 trials) and late (weighted mean difference, 3.49 mEq/L; 95% CI, 2.56-4.41, 8 trials). Although there was an increased rate of rapid sodium correction (RR, 2.52; 95% CI, 1.26-5.08, 8 trials) with vasopressin antagonists, hypernatremia rates were not significantly higher (RR, 2.21; 95% CI, 0.61-7.96; 5 trials), adverse events were not increased, and there were no reports of osmotic demyelination syndrome. LIMITATIONS: Significant heterogeneity in the primary outcome. CONCLUSIONS: Vasopressin antagonists are effective for the treatment of hypervolemic and euvolemic hyponatremia.
Assuntos
Antagonistas dos Receptores de Hormônios Antidiuréticos , Azepinas/administração & dosagem , Benzamidas/administração & dosagem , Benzazepinas/administração & dosagem , Hiponatremia/tratamento farmacológico , Morfolinas/administração & dosagem , Compostos de Espiro/administração & dosagem , Humanos , Pirróis , Ensaios Clínicos Controlados Aleatórios como Assunto , Tolvaptan , Resultado do TratamentoRESUMO
OBJECTIVE: The purpose of our study was to determine whether pharmacologic thrombolysis with urokinase in the lyse and wait (L&W) technique compared with mechanical declotting using the Arrow-Trerotola percutaneous thrombectomy device is more efficient, safer, or less expensive in treating thrombosed hemodialysis grafts. MATERIALS AND METHODS: The files of 157 patients who underwent arteriovenous graft declotting from 2000 to 2007 at one tertiary care center were reviewed. The study group included 83 women and 74 men with a mean age of 68 +/- 12 years (range, 27-95 years). A total of 563 procedures were performed: 427 with the L&W technique and 136 with mechanical percutaneous thrombectomy using the percutaneous thrombectomy device. The two types of procedures were compared for success rate, complications, average patency time, and cost. RESULTS: There were no statistically significant differences between the pharmacologic and mechanical procedures in immediate success rate (99% and 98%, respectively) or average patency time (5.44 months and 5.40 months, respectively). The L&W technique was considerably less expensive. CONCLUSION: Given its lower cost and equal efficacy and safety, L&W appears to be preferable to mechanical thrombolysis with a percutaneous thrombectomy device for initial arteriovenous hemodialysis graft declotting.
Assuntos
Derivação Arteriovenosa Cirúrgica , Oclusão de Enxerto Vascular/terapia , Ativadores de Plasminogênio/administração & dosagem , Diálise Renal , Trombectomia/instrumentação , Terapia Trombolítica/métodos , Trombose/terapia , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Oclusão de Enxerto Vascular/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombose/tratamento farmacológico , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
Bezafibrate (BzF) is eliminated by renal excretion and dosage must be reduced in patients with chronic kidney disease (CKD). There is a concern that BzF causes a further deterioration in renal function in patients with CKD. This study assessed whether BzF discontinuation or dose reduction in CKD patients improves renal function. 117 CKD patients treated with BzF between 2009 and 2014 were studied for demographics, comorbid conditions and laboratory variables. Data compared 2 groups: an intervention group of 64 patients where recommendations regarding BzF administration was implemented and a control group of 37 patients. Follow-up was maintained for 12 months. In the intervention group, estimated glomerular filtration rate (eGFR) increased from 38 to 42 mL/min/1.73 m2 (p = 0.01); blood urea levels decreased from 81 to 77 mg/dL (p = 0.04). Serum creatinine decreased by more than 0.2 mg/dL in 45% of the intervention group, as compared to 19% of the control group (p < 0.01). Improvement in eGFR was seen exclusively in patients who stopped BzF completely (eGFR increased from 38 to 44 mL/min/1.73 m2). In the intervention group, TG level increased from 183 to 220 mg/dL (p < 0.001). BzF cessation in approximately 50% of patients with CKD was associated with an increase in eGFR.
Assuntos
Bezafibrato/farmacocinética , Bezafibrato/uso terapêutico , Insuficiência Renal Crônica/tratamento farmacológico , Insuficiência Renal Crônica/metabolismo , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Creatina Quinase/sangue , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular/efeitos dos fármacos , Humanos , Testes de Função Renal , Masculino , Insuficiência Renal Crônica/sangue , Estudos Retrospectivos , Ureia/sangueRESUMO
PURPOSE: To assess the primary and secondary patency rates for juxtaanastomotic stenoses, with or without superimposed thromboses, of arteriovenous hemodialysis fistulas treated with angioplasty and to compare it with National Kidney Foundation Dialysis Outcomes Quality Initiative treatment guidelines for stenosed and occluded arteriovenous fistulas (50% primary patency rate at 12 months). MATERIALS AND METHODS: This study was a retrospective analysis, covering a period of 5(1/2) years. Forty-three hemodialysis patients were referred due to secondary fistula dysfunction, and angiography was diagnostic of a juxtaanastomotic lesion. Interventions consisted of standard angioplasty techniques along with thrombolysis and/or thrombectomy and intravascular stent placement as needed. Follow-up was performed at the attending dialysis center, and repeat angiography was performed as clinically required. RESULTS: Immediate postprocedural angiography demonstrated an angiographic success rate of 98%. Clinical success, with at least one session of normal dialysis, occurred in 95% of interventions. Primary patency rates at 12 months for the stenosed and stenosed/thrombosed fistulas were 56% and 64%, respectively. Secondary patency rates at 12 months were 64% and 63%, respectively. Half of the stenosed fistulas were patent at 1.5 years, 28% were patent at 4 years, and 13% remained patent at 6 years. No major complications were documented. Four minor complications, which did not require therapy, were noted. CONCLUSIONS: The results achieved are comparable to those reported for interventions at nonjuxtaanastomotic sites and exceed those quoted by the National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines. Angioplastic interventions in a juxtaanastomatic area of arteriovenous fistulas are safe, promote prolonged patency, and postpone the need for surgical intervention or creation of a new fistula.
Assuntos
Angioplastia com Balão , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Diálise Renal , Trombose/terapia , Extremidade Superior/irrigação sanguínea , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/instrumentação , Constrição Patológica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Radiografia , Estudos Retrospectivos , Stents , Trombectomia , Terapia Trombolítica , Trombose/diagnóstico por imagem , Trombose/etiologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: Hemodialysis (HD) patients are subjected to increased oxidative stress. Oxidative stress causes DNA damage, which may be repaired by a DNA repair system. 'Spontaneous DNA repair' expresses DNA repair of in vitro unstimulated cells. The aim of the study was to evaluate the effect of one HD session on spontaneous DNA repair in peripheral blood mononuclear cells (PBMC). METHODS: PBMC were separated from blood samples for the determination of spontaneous DNA repair, measured by (3)H-thymidine incorporation, before and immediately after one HD session. Percent double-stranded DNA (ds-DNA) was measured by the fluorometric assay of DNA unwinding (FADU). RESULTS: DNA repair increased significantly following HD. To examine if this increase was caused by newly produced DNA damage, we studied the effect of HD on percent ds-DNA in PBMC. HD significantly reduced percent ds-DNA, indicating increased DNA breakage. By repeating FADU in the presence of formamidopyrimidine-DNA glycosylase (Fpg), which nicks DNA at oxidized purine sites, we could show that the increased DNA damage was caused by oxidation. CONCLUSION: Spontaneous DNA repair increases during HD in response to an increase in DNA damage induced by oxidative stress.
Assuntos
Reparo do DNA , Falência Renal Crônica/genética , Falência Renal Crônica/reabilitação , Leucócitos Mononucleares , Diálise Renal , Adulto , Idoso , Idoso de 80 Anos ou mais , Células Cultivadas , Feminino , Humanos , Falência Renal Crônica/patologia , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Acute phosphate nephropathy (APN) is a clinicopathological entity causing renal failure, after ingestion of oral sodium phosphate solution (OSPS). Approximately 25 cases have been described, but OSPS is still widely used. This study reports a further 5 cases and discusses the ever-growing significance of APN. METHODS: Five cases of APN were included, 3 retrospectively whereas 2 were diagnosed prospectively. In all, use of OSPS was established, and other causes of nephrocalcinosis were excluded. RESULTS: Average age was 67.4 +/- 7.0 years, with a female preponderance (4:1). All patients had hypertension. Baseline serum creatinine: 0.7 to 1.2 mg/dL (creatinine clearance: 52 to 77 mL/min). Time from colonoscopy to presentation was 56 +/- 36 days. Serum creatinine levels at presentation: 1.4 to 3.6 mg/dL. Time from colonoscopy to renal biopsy was 123 +/- 88 days. Urinalysis showed minimal proteinuria, leucocyturia, and hematuria. One patient had renal glucosuria. All patients were anemic (hemoglobin 8.8-11.4 gr/dL). Serum calcium and phosphate were normal. One required hemodialysis. Mean follow-up was 36 +/- 17 months. Serum creatinine levels at end of follow-up were 1.3 to 3.1 mg/dL. Renal function did not recover completely in any patient. Four required long-term erythropoietin treatment. The prominent histopathological findings were calcium-phosphate tubular depositions (100%), interstitial fibrosis (80%), hypertensive changes (80%), and acute tubular degenerative and regenerative changes (60%). CONCLUSIONS: APN is a serious, irreversible renal complication of OSPS. It is probably under-recognized. Risk factors include female gender, older age, hypertension, and renal failure, although it may occur with preexisting normal renal function.
Assuntos
Catárticos/efeitos adversos , Nefrocalcinose/induzido quimicamente , Fosfatos/efeitos adversos , Injúria Renal Aguda/etiologia , Fatores Etários , Idoso , Cálcio/sangue , Colonoscopia/métodos , Creatinina/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nefrocalcinose/sangue , Nefrocalcinose/complicações , Fosfatos/sangue , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Fatores SexuaisAssuntos
Amiloidose/complicações , Febre Familiar do Mediterrâneo/complicações , Bócio/etiologia , Doenças das Paratireoides/etiologia , Adulto , Amiloidose/etiologia , Amiloidose/patologia , Amiloidose/cirurgia , Bócio/patologia , Bócio/cirurgia , Humanos , Achados Incidentais , Falência Renal Crônica/etiologia , Falência Renal Crônica/cirurgia , Transplante de Rim , Masculino , Doenças das Paratireoides/patologia , Doenças das Paratireoides/cirurgia , Glândulas Paratireoides/cirurgia , TireoidectomiaRESUMO
BACKGROUND: Determining the dry weight of chronically hemodialysed patients is a common problem. Patients on intermittent hemodialysis often experience transient hoarseness at the end of dialysis. The vocal folds may be affected by the hydration state. AIM: To test the hypothesis that postdialysis hoarseness may be related to changes in the thickness of the vocal folds. METHODS: Twenty-five stable chronic hemodialysis patients underwent endoscopic nasopharyngeal laryngoscopy before and after dialysis. Pictures of the vocal folds were taken and the folds were measured using computer software. Eighteen vocal folds from 16 patients were technically adequate for analysis. The change in the width/length ratio of the vocal folds (W/L) was used as a measurement of the folds' thickness. RESULTS: W/L decreased from 0.175 +/- 0.011 before dialysis to 0.152 +/- 0.009 after dialysis (p < 0.01, mean reduction 10.9 +/- 3.8%). Patients' weight decreased by 4.7 +/- 0.3% (p < 0.0001), systolic blood pressure decreased by 15.0 +/- 3.1% (p < 0.001), diastolic blood pressure decreased by 13.0 +/- 3.6% (p < 0.01), and mean blood pressure decreased by 14.1 +/- 3.1% (p < 0.001). Sixty percent of the patients had postdialysis hoarseness, and in 72% of the patients a decrease in the vocal folds' thickness was observed. CONCLUSIONS: Chronic hemodialysis patients may experience transient postdialysis hoarseness, and a decrease in the vocal folds' thickness. The latter may result from dehydration.
Assuntos
Desidratação/complicações , Rouquidão/etiologia , Diálise Renal/efeitos adversos , Prega Vocal/patologia , Adulto , Idoso , Pressão Sanguínea , Feminino , Rouquidão/patologia , Humanos , Falência Renal Crônica/terapia , Laringoscopia , Masculino , Pessoa de Meia-Idade , Qualidade da VozRESUMO
Compared to patients with normal renal function, the prevalence of atrial fibrillation (AF) in chronic kidney disease (CKD) is increased, as is consequently the stroke prevalence in these patients. This increased risk of stroke in patients with CKD is caused not only by the increased prevalence of AF, but also by associated co-morbidities, and inherent platelet and vascular dysfunction. Paradoxically, imbalance in the same factors also increases the bleeding risk, imposing a dilemma as to whether anticoagulation should be prescribed or deferred, particularly in patients with end-stage renal disease (ESRD), in whom the bleeding diathesis and thromboembolic predisposition are most recalcitrant. Unfortunately, it is in this vulnerable population, in whom therapeutic options are most limited, that evidence-based studies relating to stroke prophylaxis are scarce, discordant and based only on registry observations. Pending randomized controlled studies on this issue, we will review important epidemiologic data and major recent registry-based studies that the clinician has to weigh when making the best decision on the issue of the prophylactic use of warfarin in patients with CKD with AF, focusing on patients with end-stage renal disease.
Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/complicações , Insuficiência Renal Crônica/complicações , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Relação Dose-Resposta a Droga , Saúde Global , Humanos , Prevalência , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologiaRESUMO
BACKGROUND: Non-occlusive mesenteric ischemia (NOMI) can be a fatal complication in dialysis patients. Intradialytic hypotension is usually the precipitating factor. The occurrence of 16 cases in 5 years (1998-2002), compared with only 4 in previous years, led us to investigate other risk factors contributing to NOMI. A control group of stable hemodialysis patients was used for comparison. RESULTS: 20 patients were studied: 17 diagnosed surgically, and 3 clinically. The mean age was 70.8 +/- 1.8 years, and the male:female ratio 7:13. Nineteen patients were on hemodialysis. Clinically overt atherosclerosis was present in 17 patients. Preceding dialysis-associated hypotension was identified in all patients studied and access thrombosis in 6 patients. In all patients, abdominal pain was the presenting symptom. Initial abdominal examination was unimpressive in 16 patients. The hemoconcentration, leukocytosis and metabolic acidosis were the most prominent laboratory findings. 5/11 abdominal sonograms showed intestinal pathology. 2/3 angiographies were diagnostic. Three patients responded to early fluid challenge and did not require surgery. Pathology was related to the area of the superior mesenteric artery in all 15 patients operated. Twelve (60%) patients died from the event. The 1-year mortality rate was 17/20 patients (85%). Possible contributing factors, other than dialysis-associated hypotension, included: high-dose recombinant human erythropoietin (rhEPO) therapy (179 +/- 35 vs. 116 +/- 10 U/kg/week in the control group, p < 0.05); metastatic calcifications (abdominal aorta 14/14, aortic valve 11/18; medial calcification of mesenteric arteries in 2/11 pathology specimens); digoxin, and hypoalbuminemia. CONCLUSIONS: The increased incidence of NOMI in dialysis patients may be related to overly aggressive rhEPO therapy and the unsuspected presence of mesenteric arterial medial calcifications. Identification of patients at risk, prevention of intradialytic hypotension and a controlled increase in dry weight may help to reduce the incidence of NOMI in chronically dialyzed patients.
Assuntos
Isquemia/etiologia , Mesentério/irrigação sanguínea , Diálise Renal/efeitos adversos , Idoso , Feminino , Humanos , Isquemia/epidemiologia , Masculino , Fatores de RiscoRESUMO
BACKGROUND: The inflammatory marker interleukin-6 (IL-6) increases early in the inflammatory cascade. The aim of this study was to evaluate whether an increase in serum IL-6 levels during a hemodialysis (HD) session is associated with mortality. METHODS: 57 adult patients treated with HD for more than 1 month were prospectively studied over a 3-year follow-up period. Demographic and clinical data were collected and blood samples were drawn before and after a midweek HD session. Events of death and censoring were recorded. RESULTS: During the 3-year follow-up, 50.8% of the patients died. In univariate Cox regression analysis, an increase in IL-6 levels during HD was associated with an increased mortality (HR 1.41 per pg/ml; 95% CI 1.06 to 1.88; P = .017). In multivariate Cox models, the only independent predictors of all-cause mortality were: an increase in IL-6 levels during dialysis (HR 1.46 per pg/ml; 95% CI 1.08 to 1.98; P = .014), higher baseline C-reactive protein (CRP) levels and older age. When predictors of an increase in serum IL-6 levels during HD were introduced into the model, mortality was still significantly associated with IL-6 elevation during dialysis (HR 1.47 per pg/ml, 95% CI 1.01 to 2.14; P = .045). CONCLUSIONS: A rise in serum IL-6 levels during a single HD session is associated with a higher mortality among HD patients, independent of predialysis CRP or IL-6 levels. The results may imply the presence of an intradialytic inflammatory response that affects survival in HD patients.
Assuntos
Interleucina-6/sangue , Falência Renal Crônica/sangue , Diálise Renal/mortalidade , Idoso , Biomarcadores/sangue , Feminino , Humanos , Falência Renal Crônica/mortalidade , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Prognóstico , Taxa de SobrevidaRESUMO
BACKGROUND: The long-term isolated contribution of hemodialysis arteriovenous access (AVA) to cardiac hemodynamics has not been previously investigated in a prospective manner. METHODS: Twelve predialysis patients were studied before and 1 and 3 months after creation of a primary AVA. Evaluation included relevant clinical parameters, echocardiographic studies, and hemodynamic hormones. RESULTS: After creation of an AVA, there was no change in patient weight, blood pressure or hemoglobin level. Cardiac index increased and systemic vascular resistance decreased. Left ventricular mass (LVM) corrected to height increased from 63.8 +/- 5.5 to 68.9 +/- 4.9 g/m(2.7) at 1 month (P = 0.05) and 72.5 +/- 8.9 g/m(2.7) at 3 months (P < 0.05). This increase in LVM was accounted for mostly by an increase in interventricular septal thickness, whereas left ventricular end-diastolic diameter and posterior wall thickness did not change. The incidence of left ventricular hypertrophy (LVH) increased from 67% at baseline to 83% and 90% at 1 and 3 months, respectively. Left atrial area increased from 17.6 +/- 1.0 cm(2) at baseline to 19.7 +/- 1.3 cm(2) at 1 month (P < 0.01) and 20.2 +/- 1.2 cm(2) at 3 months (P < 0.05). Early diastolic transmitral flow increased from 68.0 +/- 4.2 cm/s at baseline to 85.6 +/- 7.3 and 89.2 +/- 6.5 cm/s at 1 and 3 months, respectively (P < 0.01). Inferior vena cava diameter increased at 1 month and did not change at 3 months. Plasma atrial natriuretic polypeptide levels increased from 268 +/- 35 pg/mL (87 +/- 11 pmol/L) at baseline to 461 +/- 63 pg/mL (150 +/- 20 pmol/L) at 1 month (P < 0.01) and 610 +/- 96 pg/mL (198 +/- 31 pmol/L) at 3 months (P < 0.01). Plasma renin activity and serum aldosterone levels decreased. Plasma angiotensin II, angiotensin-converting enzyme, and endothelin levels did not change. CONCLUSION: Creation of a hemodialysis AVA is independently associated with further progression of already existing LVH.
Assuntos
Derivação Arteriovenosa Cirúrgica/métodos , Hipertrofia Ventricular Esquerda/epidemiologia , Diálise Renal/métodos , Adulto , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Débito Cardíaco/fisiologia , Feminino , Hemodinâmica/fisiologia , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Diálise Renal/efeitos adversos , Remodelação Ventricular/fisiologiaRESUMO
Two patients with end-stage renal disease and on long-term hemodialysis presented with hypotension and an acute unilateral loss of vision. A diagnosis of anterior ischemic optic neuropathy (AION) was made quickly, but despite high-dose steroid therapy, significant vision was not recovered. Temporal artery biopsy results showed extensive medial calcification. The possibility that hypotension, when coupled with calcific uremic arteriolopathy in arteries supplying the optic nerve head, will lead to AION in dialyzed patients is discussed. A short review of AION in the dialysis population is given.