Gamma knife radiosurgery of brain metastasis from malignant pleural mesothelioma--report of three cases with autopsy study in a case.

The median survival time of malignant pleural mesothelioma (MPM) has been 9 months. Given the short survival, there have been only few cases in which brain metastases have been diagnosed and treated before death. Three cases of brain metastases treated by gamma knife radiosurgery (GKR) are reported. Case I showed a metastatic lesion in the right frontal lobe which was treated by GKR two years after diagnosis of MPM. The lesion markedly reduced and the symptoms were improved, But the patient died of progression of pleural tumor four months after GKR. A year and three months after the diagnosis, asymptomatic bifrontal lesions were treated with GKR. However, Case 2 died of abdominal mass a month after. Case 3 showed headache one and half year after the diagnosis. Three brain lesions were treated by GKR, which disappeared in 4 months. The patient died of new multiple brain metastases and periventricular dissemination seven months after. The autopsy revealed a MPM occupying the left pleural cavity. No neoplastic lesion was found in gamma knife-treated sites. The cause of death was the mass effect by new metastatic lesions. GKR was found effective also for the treatment of brain metastasis of MPM.

Corrigendum to "Detecting MUC1 Variants in Patients Clinicopathologically Diagnosed With Having Autosomal Dominant Tubulointerstitial Kidney Disease"Kidney International Reports, Volume 7, Issue 4, April 2022, Pages 857-866.

[This corrects the article DOI: 10.1016/j.ekir.2021.12.037.].

Percutaneous coronary intervention with bare metal stent vs. drug-eluting stent in hemodialysis patients.

BACKGROUND: Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) is widely performed in patients with coronary artery disease, but the high restenosis rate remains a major clinical problem after implantation of DES in patients on hemodialysis (HD). Until now, there are limited reports regarding the long-term clinical outcome after implantation of DES in this patient population. METHODS AND RESULTS: We compared bare metal stent (BMS) and DES for long-term clinical outcomes, such as target lesion revascularization (TLR), in HD patients undergoing PCI. BMS and DES were implanted in 204 and 301 patients, respectively. Baseline and lesion characteristics were comparable between the 2 groups. By Kaplan-Meier analysis, event rates of major adverse cardiac events for 6 years were significantly lower in the DES group than in the BMS group (42.5% vs. 58.0%, P=0.036). Although there were no significant differences in TLR rates between patients treated with DES and those with BMS at 1 year after PCI (17.8% vs. 21.3%, P=0.32), patients treated with DES had significantly lower rates of TLR compared with those treated with BMS beyond the 1-year follow-up after PCI (16.4% vs. 30.9%, P=0.019). CONCLUSIONS: In patients on HD, implantation of DES might be more effective for preventing TLR in the medium to long follow-up period than BMS, although restenosis after PCI with DES is common in the short term.

Sirolimus-eluting stent vs. everolimus-eluting stent for coronary intervention in patients on chronic hemodialysis.

BACKGROUND: Even in the drug-eluting stent era, adverse cardiac events, including restenosis after percutaneous coronary intervention (PCI), have been more frequently seen in patients on hemodialysis (HD) than in non-HD patients. The objective of this study was to compare the sirolimus-eluting stent (SES) and everolimus-eluting stent (EES) for prevention of adverse cardiac events, including restenosis, in HD patients. METHODS AND RESULTS: A total of 100 consecutive patients on HD who underwent PCI were enrolled and randomly assigned to receive SES or EES. Although there was no difference between the 2 groups in baseline patient and lesion characteristics, the angiographic restenosis rate at 8-month follow-up was 21.2% in the SES group and 8.7% in the EES group (P = 0.041). Significant differences were also seen in % diameter stenosis (%DS), minimal lumen diameter, and late lumen loss at 8-month follow-up (P = 0.0024, P = 0.0040, and P = 0.033, respectively). During the 1-year follow-up, major adverse cardiac events occurred in 11 (22.0%) patients in the SES group and in 5 (10.0%) patients in the EES group (P = 0.10). CONCLUSIONS: The use of EES was as safe as that of SES. Moreover, EES significantly prevented restenosis in patients on maintenance HD compared with SES.

Detecting MUC1 Variants in Patients Clinicopathologically Diagnosed With Having Autosomal Dominant Tubulointerstitial Kidney Disease.

Introduction: Autosomal dominant tubulointerstitial kidney disease (ADTKD)-MUC1 is predominantly caused by frameshift mutations owing to a single-base insertion into the variable number tandem repeat (VNTR) region in MUC1. Because of the complexity of the variant hotspot, identification using short-read sequencers (SRSs) is challenging. Although recent studies have revealed the usefulness of long-read sequencers (LRSs), the prevalence of MUC1 variants in patients with clinically suspected ADTKD remains unknown. We aimed to clarify this prevalence and the genetic characteristics and clinical manifestations of ADTKD-MUC1 in a Japanese population using an SRS and an LRS. Methods: From January 2015 to December 2019, genetic analysis was performed using an SRS in 48 patients with clinically suspected ADTKD. Additional analyses were conducted using an LRS in patients with negative SRS results. Results: Short-read sequencing results revealed MUC1 variants in 1 patient harboring a cytosine insertion in the second repeat unit of the VNTR region; however, deeper VNTR regions could not be read by the SRS. Therefore, we conducted long-read sequencing analysis of 39 cases and detected MUC1 VNTR variants in 8 patients (in total, 9 patients from unrelated families). With the inclusion of family-affected patients (n = 31), the median age at the development of end-stage kidney disease (ESKD) was 45 years (95% CI: 40-40 years). Conclusion: In Japan, the detection rate of MUC1 variants in patients with clinically suspected ADTKD was 18.8%. More than 20% of patients with negative SRS results had MUC1 variants detected by an LRS.

Association of adiponectin with carotid arteriosclerosis in predialysis chronic kidney disease.

BACKGROUND/AIMS: Adiponectin is an adipocyte-derived protein with antiatherogenic properties. Chronic kidney disease (CKD) is one of the risk factors for cardiovascular disease. We investigated the potential association between adiponectin and carotid arteriosclerosis in patients with predialysis CKD. METHODS: We enrolled 95 CKD patients without dialysis and 81 non-CKD patients. Intima-media thickness (IMT) and plaque score (PS) in the common carotid artery were measured using an ultrasound system. Carotid arteriosclerosis was defined as IMT >1.2 mm and/or PS >5.0 mm. RESULTS: The prevalence of CKD was independently associated with carotid arteriosclerosis after adjustment for other risk factors. Higher adiponectin levels were observed in CKD patients compared with non-CKD patients. Adiponectin levels were not independently correlated with the presence of carotid arteriosclerosis in all subjects. To evaluate the association between adiponectin and carotid arteriosclerosis among a CKD population, we divided the CKD patients into 2 groups according to a cutoff level of adiponectin determined by ROC analysis. The prevalence of carotid arteriosclerosis was significantly higher in the low-adiponectin group than in the high-adiponectin group among CKD patients. After adjusting for other risk factors, low levels of adiponectin were independently correlated with carotid arteriosclerosis in CKD patients. CONCLUSION: Our data document that adiponectin is associated with increased risk of carotid atherosclerosis in a predialysis CKD population.

Prognostic values of C-reactive protein levels on clinical outcome after endovascular therapy in hemodialysis patients with peripheral artery disease.

PURPOSE: Endovascular therapy (EVT) has been widely performed for peripheral artery disease. However, the high restenosis rate after EVT remains a major problem in patients on hemodialysis. Recent studies suggest that C-reactive protein (CRP) reflects vascular wall inflammation and can predict adverse events. We evaluated the possible prognostic values of CRP on outcomes in hemodialysis patients undergoing EVT. METHODS: A total of 234 hemodialysis patients undergoing EVT for peripheral artery disease were enrolled and followed-up for up to 5 years. They were divided into tertiles according to serum CRP levels (lowest tertile, < 1.4 mg/L; middle tertile, 1.4-6.0 mg/L; highest tertile, ≥ 6.0 mg/L). We analyzed the incidence of any reintervention or above-ankle amputation of the limb index (RAO) and any-cause death. RESULTS: Kaplan-Meier analysis showed that the event-free rate from the composite end point of RAO and any-cause death for 5 years was 60.2% in the lowest tertile, 50.0% in the middle tertile, and 25.1% in the highest tertile (P < .0001). The survival rate from any-cause death for 5 years was 81.5% in the lowest tertile, 65.2% in the middle tertile, and 59.3% in the highest tertile (P = .0078). Even after adjusting for other risk factors at baseline, preprocedural CRP levels were a significant predictive factor for RAO and any-cause death after EVT in a multivariable Cox analysis. CONCLUSIONS: Elevated preprocedural serum CRP levels were associated with RAO and any-cause death after EVT in hemodialysis patients with peripheral artery disease.

Depression, alexithymia and long-term mortality in chronic hemodialysis patients.

BACKGROUND: Depression increases the risk of mortality in hemodialysis patients. Alexithymia, a disorder of affect regulation, has also been reported to be associated with mortality risk in the general population. We conducted a prospective study to estimate the independent impact of depression and alexithymia on long-term mortality. METHODS: A total of 230 hemodialysis outpatients, with a mean age of 56.3 +/- 9.6 years, completed a batch of self-report measures including the Beck Depression Inventory-II (BDI-II), the 20-item Toronto Alexithymia Scale (TAS-20) and the 36-item Short Form Health Survey (SF-36). Survival status was confirmed every 6 months for up to 5 years. The presence of depression and alexithymia was defined by a BDI-II score of > or =14 and a TAS-20 score of > or =61, respectively. RESULTS: During the follow-up period, 27 deaths were confirmed. Both depression and alexithymia were associated with an increased risk for all-cause mortality; the age- and sex-adjusted hazard ratio for depression was 2.36 (95% CI: 1.08-5.15; p = 0.03) and that for alexithymia was 4.29 (95% CI: 1.95-9.42; p < 0.001). Depression lost its statistical significance after controlling for alexithymia, whereas alexithymia remained significant even after adjusting for the baseline depression, health status (the summary scores of the SF-36), marital status and clinical covariates (multivariate adjusted hazard ratio = 3.62; 95% CI: 1.32-9.93; p = 0.01). CONCLUSIONS: Alexithymia is a strong independent risk factor for all-cause mortality in hemodialysis patients.

Nitinol stenting improves primary patency of the superficial femoral artery after percutaneous transluminal angioplasty in hemodialysis patients: a propensity-matched analysis.

BACKGROUND: Although percutaneous transluminal angioplasty (PTA) has become a common therapeutic standard for peripheral artery disease (PAD), high restenosis rates in the superficial femoral artery (SFA) remain a major problem. Nitinol stent implantation is reported to reduce restenosis in SFA after PTA in the general population; however, little is known about whether the nitinol stent improves primary patency after PTA in hemodialysis patients who are at higher risk of revascularization failure. The aim of this study was to clarify the effects of nitinol stent implantation for primary patency in SFA after PTA in hemodialysis patients with PAD. METHODS: Eighty consecutive hemodialysis patients (167 SFA lesions) who underwent PTA with nitinol stents from January 2006 to January 2008 were compared with 64 hemodialysis patients (128 SFA lesions) who received stainless steel stents in the preceding 2 years. In the follow-up study to 2 years, incidence of restenosis, amputation, and all-cause mortality were analyzed. End points between the groups were examined with the Kaplan-Meier and log-rank methods. Prognostic values for end points were calculated by a Cox univariate analysis and Cox multivariable regression models. To statistically minimize the differences in each stent group, a propensity-matched analysis was also performed using the model including male gender, age, diabetes, hypertension, hyperlipidemia, smoking, incidence of ulcer/gangrene, and TransAtlantic Inter-Society Consensus (TASC) type C+D. RESULTS: The 2-year primary patency rate was 58% in the nitinol group vs 42% in the stainless steel group (hazard ratio [HR], 0.58; 95% confidence interval [CI], 0.39-0.84; P = .0045), despite a higher prevalence of TASC C+D lesion in the nitinol group (68% vs 49%, P = .0014). In 108 lesions matched after propensity score analysis, the primary patency for 2 years was 64% in the nitinol group vs 42% in the stainless steel group (HR, 0.39; 95% CI, 0.24-0.65; P = .0003). Cox multivariate models showed nitinol stent (HR, 0.42; 95% CI, 0.25-0.73; P = .002), age (HR, 1.04; 95% CI, 1.01-1.08; P = .031), and incidence of ulcer/gangrene (HR, 2.35; 95% CI, 1.17-4.75; P = .017) were independent predictors of restenosis. CONCLUSION: These data suggest that nitinol stent implantation improves primary patency in SFA after PTA compared with the stainless steel stent, even in hemodialysis patients with PAD.

Aortic valvular calcification predicts restenosis after implantation of drug-eluting stents in patients on chronic haemodialysis.

BACKGROUND: Even in the drug-eluting stent (DES) era, the restenosis rate of the follow-up period after percutaneous coronary intervention (PCI) is higher in haemodialysis (HD) patients than in non-HD patients. Therefore, higher restenosis remains a clinical limitation in HD patients, and a simple clinical method to predict patients likely to have restenosis after stent implantation is attractive. The present study investigated the potential relationship between aortic valvular calcification (AVC) and angiographical restenosis at follow-up after DES implantation in patients on maintenance HD. METHODS: In the study, 97 patients were enrolled. We prospectively performed echocardiography before elective PCI with DES implantation. Angiographic follow-up was scheduled between 6 and 8 months after PCI. Restenosis at follow-up was defined as a diameter stenosis of > or =50% by measuring quantitative coronary angiography. RESULTS: Of the enrolled patients, 59 patients (60.8%) had AVC. Complete angiographical follow-up was obtained in 86 patients (88.7%). The angiographical restenosis rate during the follow-up period was 24.7% in patients with AVC and 8.9% in patients without AVC [hazard ratio (HR) 3.36; 95% confidence interval (CI) 1.18-9.56, P = 0.023]. Even after multivariate adjustment including covariates related to atherogenecity, AVC remained an independent predictor of restenosis after implanting DES (HR 3.83; 95% CI 1.14-12.9, P = 0.029). Late lumen loss suggesting neointimal growth after DES implantation was 0.28 +/- 0.70 mm in the non-AVC group and 0.64 +/- 0.90 mm in the AVC group (P = 0.013). CONCLUSIONS: AVC provides predictive information regarding DES implantation in patients on maintenance HD.

Low circulating CD34+ cell count is associated with poor prognosis in chronic hemodialysis patients.

Circulating CD34-positive (CD34(+)) cells, a population that includes endothelial progenitor cells, are believed to contribute to vascular homeostasis. Here we determine the prognostic value of CD34(+) cell measurements in 216 chronic hemodialysis patients. A total of 43 cardiovascular events and 13 deaths occurred over an average 23 months follow-up in this cohort. A cutoff number for circulating CD34(+) cells was determined by receiver operating characteristic curve analysis to maximize the power of the CD34(+) cell count in predicting future cardiovascular events. Based on this, 93 patients were categorized as having low and 123 patients as having high numbers of CD34(+) cells, determined by flow cytometry at the time of enrollment. Both cumulative cardiovascular event-free survival and all-cause survival were significantly less in the group of patients with low numbers of CD34(+) cells. By multivariate analyses, a low level of circulating CD34(+) cells was an independent and significant predictor for both cardiovascular events and all-cause mortality. Our study shows that a reduced number of circulating CD34(+) cells is significantly associated with vascular risks and all-cause mortality in patients on chronic hemodialysis. These cells may be a useful biomarker.

Loss of fractal heart rate dynamics in depressive hemodialysis patients.

OBJECTIVE: To assess the relationship between depression, reduced heart rate (HR) variability, and altered HR dynamics among patients with end-stage renal disease who are receiving hemodialysis (HD) therapy. METHODS: We analyzed the 24-hour electrocardiograms of 119 outpatients receiving chronic HD. HR variability was quantified with the standard deviation of normal-to-normal R-R intervals, the triangular index, and the powers of the high- (HF), low- (LF), very-low (VLF), and ultra-low frequency (ULF) components. Nonlinear HR dynamics was assessed with the short-term (alpha(1)) and long-term (alpha(2)) scaling exponents of the detrended fluctuation analysis and approximate entropy. The depression level was assessed using the Beck Depression Inventory, Second Edition (BDI-II). HR variability and dynamics measurements were compared by gender, diabetes, and depression with adjustment for age and serum albumin concentration. RESULTS: Most indices of HR variability and dynamics were negatively correlated with age, serum albumin concentration, depression score, and were lower in women and patients with diabetes. The alpha(2) was inversely associated with these variables. Depressed men had significantly lower HF, LF, VLF, and marginally lower ULF than nondepressed persons after adjustment for diabetes and other covariates; no difference in depression was observed in women. The alpha(2) showed marginally significant difference in depression independent from gender and diabetes. CONCLUSIONS: Among the patients who received HD, depression is associated with reduced HR variability and loss of fractal HR dynamics. However, the influence of depression on HR variability may vary by gender and physiological backgrounds. Further prospective studies are necessary to confirm their association with poor prognosis.

Long-term outcome of percutaneous transluminal angioplasty in chronic haemodialysis patients with peripheral arterial disease.

BACKGROUND: Chronic haemodialysis patients are at an increased risk of peripheral artery disease (PAD). Although percutaneous transluminal angioplasty (PTA) has become a widely used therapeutic intervention for PAD, its outcome in haemodialysis patients remains poorly understood. The aim of this study was to clarify the long-term outcome of PTA as a primary treatment for PAD in haemodialysis patients. METHODS: Consecutive 118 haemodialysis patients with 205 lesions and 108 non-haemodialysis patients with 143 lesions who underwent successful PTA as a first-choice therapeutic option for PAD were enrolled. Outcome measures included primary patency, limb salvage and survival. RESULTS: Incidence of diabetes, history of coronary artery disease and femoropopliteal lesion were significantly more frequent in haemodialysis patients (P = 0.008, 0.005 and 0.0001, respectively), but critical limb ischaemia and TransAtlantic Inter-Society Consensus (TASC) lesion types occurred with comparable frequency in both groups. No patients had in-hospital complications. The 5-year primary patency, limb salvage and survival rates were significantly lower in haemodialysis patients (P = 0.01, 0.029 and 0.0024, respectively). On Cox multivariate analysis, haemodialysis was strongly predictive of amputation and all-cause death, but not of restenosis. In haemodialysis patients, TASC C+D lesion and ulceration/gangrene were independent predictors for restenosis and amputation. CONCLUSIONS: The long-term outcome after PTA may be fully acceptable in haemodialysis patients who are at the highest risk of cardiovascular disease. PTA is a useful therapeutic strategy in haemodialysis patients with PAD, but PTA for TASC C+D lesions remains controversial.

Efficacy of oral nicorandil in patients with end-stage renal disease: a retrospective chart review after coronary angioplasty in Japanese patients receiving hemodialysis.

BACKGROUND: Patients receiving hemodialysis for end-stage renal disease (ESRD) are at high risk for death from ischemic heart disease (IHD). Nicorandil, a hybrid compound of adenosine triphosphate-sensitive potassium channel opener and nitric oxide donor, has been reported to improve the clinical prognosis of patients with IHD. OBJECTIVE: This study sought to investigate the efficacy of oral nicorandil in reducing the risks for cardiovascular events (CVEs) and CVE-related death in patients receiving hemodialysis for ESRD after undergoing percutaneous coronary intervention (PCI) for angina pectoris. METHODS: For this retrospective chart review, we used data from telephone interviews and medical charts from 3 hospitals in Japan. Data from patients aged <80 years who were receiving hemodialysis for ESRD and who had undergone successful PCI for angina between January 1999 and December 2004 were included in the analysis. Patients were stratified based on status of nicorandil treatment before PCI, as follows: patients receiving nicorandil 5 mg PO TID (the recommended dosage in Japan) for >1 month before PCI (nicorandil group) or those who did not receive nicorandil (control group). We investigated 6-year follow-up data on the primary end point, defined as CVEs (ie, unplanned hospital admission for worsening anginal status, or CVE-related death). The secondary end point was CVE-related death. After the data were initially analyzed, we performed a propensity-matched analysis to minimize selection bias. RESULTS: Data from 356 patients were included in the study (235 men, 121 women; mean [SD] age, 69 [9] years; mean [SD] weight, 52.3 [9.1] kg; nicorandil group, 198 patients; control group, 158 patients). According to the estimated propensity scores, 107 patients from each group were matched. There were no differences between the 2 groups in the baseline characteristics. On propensity-matched patient analysis, the estimated rates of patients who were CVE-free at 6 years were 33.5% in the nicorandil group and 21.8% in the control group on Kaplan-Meier analysis (hazard ratio [HR] = 0.53; 95% CI, 0.36-0.78; P < 0.002), and the rates of 6-year survival (ie, patients who did not experience CVE-related death) were 92.7% in the nicorandil group and 85.8% in the control group (HR = 0.27; 95% CI, 0.07-0.89; P = 0.047). Cox multivariate analysis found that nico-randil treatment status was an independent predictor of CVEs (HR = 0.40; 95% CI, 0.18-0.91; P = 0.028) and CVE-related death (HR = 0.38; 95% CI, 0.14-0.78; P = 0.030). CONCLUSION: Results obtained in this retrospective study suggest the potential efficacy of nicorandil treatment in improving clinical outcomes in patients with IHD receiving hemodialysis following PCI.

Independent associations of alexithymia and social support with depression in hemodialysis patients.

OBJECTIVE: The influences of alexithymia and social support on depression among chronically ill patients were examined prospectively. METHODS: The study population was 230 outpatients receiving chronic hemodialysis (HD) therapy. The Beck Depression Inventory-II (BDI-II), the 20-item Toronto Alexithymia Scale (TAS-20), and two subscales of the Social Support Questionnaire were given to the subjects. The BDI-II was readministered after a 6-month interval, and subjects who showed deterioration in their depression score above the level predicted from their baseline score were identified. Multivariate logistic analysis adjusted for age, gender, cause of dialysis, and psychosocial variables were performed. RESULTS: Baseline depression was significantly and independently associated with alexithymia and low satisfaction with available support. Deterioration of depression after 6 months was predicted by alexithymia and poor available support. CONCLUSIONS: Alexithymia and reduced social support might have independent associations with the presence and the prognosis of depression among HD patients.

Comparative studies on effect of risedronate and alfacalcidol against glucocorticoid-induced osteoporosis in rheumatoid arthritic patients.

Osteoporosis is a common adverse reaction induced by glucocorticoid treatment. Bisphosphonate, vitamin D(3) (VD(3)) or vitamin K(2) (VK(2)) is recommended as first or second choice of drug for treatment of glucocorticoid-induced osteoporosis. In the present study, the treatment effect of risedronate against glucocorticoid-induced osteoporosis in rheumatoid arthritic patients was compared with that of alfacalcidol. Twelve patients were randomized to receive either risedronate (2.5 mg) or alfacalcidol (0.5 microg) daily for 48 weeks. Each patient also received 800 mg of calcium supplementation (800 mg/day) daily. Bone mineral density (BMD) and the biochemical markers of bone turnover were measured before (baseline) and 12, 24, and 48 weeks after treatment with risedronate or alfacalcidol, and the percentage changes in these parameters from baseline were compared. The BMD values 12, 24 and 48 weeks after treatment with risedronate increased by 3.9%, 4.1% and 5.2%, respectively, which were significantly higher than those after treatment with alfacalcidol (2.8%, 2.1% and 2.5%, respectively). Urinary excretion of N-telopeptides of type I collagen and deoxypyridinoline after risedronate treatment were more significantly decreased than that after alfacalcidol treatment. The present findings at least suggest that risedronate is more useful for the prevention and treatment of glucocorticoid-induced osteoporosis in patients with rheumatoid arthritis than alfacalcidol, although the number of patients studied was small.

Severe coronary stenosis is an important factor for induction and lengthy persistence of ventricular arrhythmias during and after hemodialysis.

BACKGROUND: Ventricular arrhythmias have been shown to be the major cause of sudden cardiac death in hemodialysis (HD) patients. We investigated whether angiographic coronary stenosis was responsible for the induction of ventricular arrhythmias in HD patients. METHODS: HD patients (n = 150) showing ischemic signs in exercise electrocardiography or echocardiography were divided into 2 groups: the stenotic group (n = 61), with significant coronary stenosis (> or =75% in diameter), and the nonstenotic group (n = 89), without significant coronary stenosis on coronary angiography. Severity of ventricular arrhythmias was evaluated by means of ambulatory 24-hour Holter monitoring in HD patients with and without significant coronary stenosis. RESULTS: The frequency of ventricular premature contractions and prevalence of patients with Lown class 4 ventricular arrhythmias were significantly greater in the stenotic than nonstenotic group during HD and for 12 hours after HD (P < 0.03). In the stenotic group, a significantly greater frequency of ventricular premature contractions and prevalence of patients with complex arrhythmias were observed during HD (1.33% and 31.1%, respectively) compared with before HD (0.50% and 11.5%, respectively), and the high incidence persisted for 6 hours after HD. In the nonstenotic group, a slightly increased incidence was observed only during HD compared with before HD. Multivariate analysis showed only coronary stenosis (odds ratio, 5.69; P = 0.041) as an independent and significant factor for the induction of complex arrhythmias. CONCLUSION: These data clearly indicate that severe coronary stenosis, which may cause myocardial ischemia, is an important factor for the induction and lengthy persistence of ventricular arrhythmias during and after HD.

Sirolimus- vs. paclitaxel-eluting stent to coronary intervention in dialysis patients.

BACKGROUND: Patients on maintenance hemodialysis (HD) are at high risk for restenosis after percutaneous coronary intervention (PCI) even if treated with a sirolimus-eluting stent (SES). The aim of this study was to compare the effects of SES and paclitaxel-eluting stent (PES) in preventing restenosis in HD patients with coronary artery disease. METHODS: A total of 100 consecutive patients on HD who underwent PCI were enrolled into the study. They were randomly assigned to receive either SES or PES. We compared follow-up angiographic outcomes between the SES and PES groups at 8-month follow-up. RESULTS: The angiographical restenosis rate, defined as % diameter stenosis>50% at 8-month follow-up, was 19.7% in the SES group and 20.0% in the PES group (p=0.97). Late loss was also similar between the two groups (0.49±0.70 mm vs. 0.48±0.91 mm, P=0.94). There were no significant differences in the rates of all-cause death, non-fatal myocardial infarction, or TLR due to stent restenosis-induced ischemia between the two groups (2.0% vs. 4.0%, p=0.56, 2.0% vs. 4.0%, p=0.56, and 16.0% vs. 12.0%, p=0.57, respectively). CONCLUSIONS: There was no significant difference in angiographical outcome at 8-month follow-up between HD patients treated with SES and PES. Even if treated with DES including SES and PES, patients on HD are at high risk of restenosis after PCI.

Ankle brachial pressure index but not brachial-ankle pulse wave velocity is a strong predictor of systemic atherosclerotic morbidity and mortality in patients on maintenance hemodialysis.

BACKGROUND: Ankle brachial pressure index (ABPI) and pulse wave velocity (PWV) have been widely recognized as a marker of systemic atherosclerosis. We examined whether ABPI and brachial-ankle PWV (baPWV) predict individual cardiovascular events in patients on maintenance hemodialysis (HD). METHODS: We prospectively followed-up 445 HD patients undergoing both ABPI and baPWV measurements for up to 5 years. They were divided into 2 groups [group with ABPI > 0.9 to ≤ 1.3 (n = 328) and group with ABPI ≤ 0.9 or >1.3 (n = 117)] and were also divided into tertiles according to the baPWV level (T1: <1850 cm/s; T2: 1850-2310 cm/s and T3: ≥ 2310 cm/s). RESULTS: During the follow-up period (mean 43 ± 17 months), 206 cardiovascular events [cardiac event: 125 (28.1%), cerebrovascular events: 39 (8.8%), and peripheral arterial events: 42 (9.4%)] occurred, and 36 (8.1%) and 42 (9.4%) patients experienced cardiovascular and non-cardiovascular deaths, respectively. Cox multivariable analysis showed that presence of ABPI ≤ 0.9 or >1.3 was a significant predictor of cardiac events [hazard ratio (HR) 1.78, 95% confidential interval (CI) 1.27-2.49, p = 0.0008], cerebrovascular event (HR 1.95, 95%CI 1.13-3.36, p = 0.017), peripheral arterial event (HR 3.64, 95%CI 2.10-6.29, p < 0.0001), composite endpoint of cardiovascular events (HR 2.22, 95%CI 1.64-2.99, p < 0.0001), cardiovascular mortality (HR 2.42, 95%CI 1.44-4.06, p = 0.0008) and all-cause mortality (HR 1.52, 95%CI 1.03-2.25, p = 0.037). However, baPWV did not predict cardiovascular events on multivariate analysis. CONCLUSION: ABPI but not baPWV is useful for risk stratification of systemic atherosclerotic morbidity and mortality in HD patients. Furthermore, ABPI could predict not only individual peripheral arterial events but also cardiac and cerebrovascular events.

Comparison of atorvastatin 5 and 20 mg/d for reducing F-18 fluorodeoxyglucose uptake in atherosclerotic plaques on positron emission tomography/computed tomography: a randomized, investigator-blinded, open-label, 6-month study in Japanese adults scheduled for percutaneous coronary intervention.

BACKGROUND: F-18 fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) is a useful tool for the detection of local inflamed atherosclerotic lesions. OBJECTIVE: This study used hybrid PET/computed tomography (CT) to examine the effects of 2 doses of atorvastatin on (18)F-FDG uptake in atherosclerotic plaques in Japanese adults with stable angina pectoris who were scheduled to undergo percutaneous coronary intervention (PCI). METHODS: This was a prospective, randomized, investigator-blinded, open-label study in patients with dyslipidemia (total cholesterol ≥ 220 mg/dL and/or LDL-C ≥ 140 mg/dL) who were scheduled to undergo PCI for stable angina pectoris and had not received any lipid-lowering drugs within 1 year before enrollment. Patients were randomly allocated to receive atorvastatin 5 or 20 mg/d for 6 months. At baseline (the day after PCI), (18)F-FDG uptake in the ascending aorta and femoral artery was determined using PET/CT imaging, and the mean target-to-background ratio (TBR) was calculated in individual plaques. The same regions were assessed by PET/CT after 6 months of treatment. Changes from baseline to follow-up in the lipid profile, serum malondialdehyde-modified LDL-C (MDA-LDL-C), and serum high-sensitivity C-reactive protein (hs-CRP) were also examined. Drug adherence, adverse events, and changes in medications were monitored at monthly outpatient visits. RESULTS: Of 32 patients initially screened, 2 were excluded due to newly diagnosed cancer; thus, 30 patients were randomly assigned to treatment, 15 in each group. Patients were predominantly male (18 [60%]), with a mean (SD) age of 54 (11) years, mean body weight of 65 (12) kg, and mean total cholesterol, HDL-C, and triglyceride concentrations of 240 (29), 48 (14), and 180 (102) mg/dL, respectively. After 6 months, the 20-mg group had significant reductions from baseline in mean (SD) TBR in the ascending aorta (from 1.15 [0.14] to 1.05 [0.12]; percent change, -7.9% [9.4%]; P = 0.007) and the femoral artery (from 1.12 [0.11] to 1.02 [0.11]; percent change, -9.9% [13.8%]; P = 0.012). The corresponding changes from baseline were not statistically significant in the 5-mg group. The differences in percent change in TBR in the 2 locations were not significant between groups. When data from the 2 groups were combined, the overall reduction in TBR from baseline to 6 months was significant in both the ascending aorta (P = 0.003) and the femoral artery (P = 0.021). The decreases in TBR in both arteries were significantly correlated with reductions in LDL-C (ascending aorta: r(2) = 0.230 [P = 0.012]; femoral artery: r(2) = 0.338 [P = 0.003]), MDA-LDL-C (ascending aorta: r(2) = 0.183 [P = 0.028]; femoral artery: r(2) = 0.247 [P = 0.010]), and hs-CRP (ascending aorta: r(2) = 0.132 [P = 0.048]; femoral artery: r(2) = 0.271 [P = 0.007]). One patient in the 5-mg group and 2 patients in the 20-mg group had ∼2-fold increases in serum aminotransferases on a single occasion; however, no specific musculoskeletal or hepatic adverse events were observed, and aminotransferase values decreased to within normal ranges without changes in the atorvastatin dose. CONCLUSION: Six months of treatment with atorvastatin 20 mg, but not 5 mg, was associated with a significant reduction in TBR in the ascending aorta and femoral artery in these Japanese adults with dyslipidemia undergoing PCI for stable angina pectoris. University Hospital Medical Information Network Clinical Trials Registry identifier: C000000371.