N-terminal pro-B-type natriuretic peptide(NT-proBNP) is a new biomarker of both the cardiac function and heart failure. The serum concentrations of NT-proBNP increase in hemodialysis(HD) patients. This study examined the usefulness of NT-proBNP measurement in HD patients by examining the relationship between NT-proBNP and electrocardiographic(ECG) findings. This study observed 85 HD patients. The serum concentrations of NT-proBNP were measured by an electrochemiluminescence immunoassay(Elecsys 2010, Roche Diagnosics). RV5+SV1 voltage, RV5 voltage, QRS interval, QTc interval and QRS axis were used as ECG parameters. The serum NT-proBNP concentrations in HD patients(676~127,172 pg/mL) were significantly higher than healthy subjects(9~144 pg/mL). There was a significant positive correlation between NT-proBNP and RV5+SV1 voltage. A receiver-operating characteristic curve demonstrated about 8,000 pg/mL as the cut-off value for NT-proBNP that correlated with cardiac function abnormalities. HD patients were divided into two groups based on their NT-proBNP concentrations(<8,000 pg/mL group and ≥8,000 pg/mL group). The incidence of heart failure in the <8,000 pg/mL group was compared with that in the ≥8,000 pg/mL group. The incidence of heart failure in the ≥8,000 pg/mL group was 31.4%, which was significantly higher than that in the <8,000 pg/mL group;0.0%(p<0.0001). These findings suggest that the NT-proBNP concentrations are a useful marker of cardiac function as well as a predictor of heart failure in HD patients. The NT-proBNP cut-off value in HD patients was thus determined to be 8,000 pg/mL.

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We examined the cause of errors in pulsed Doppler ultrasound blood flow volume measurements, and measurement of vessel diameter.[Experiment 1] We measured the blood flow volume by pulsed Doppler ultrasound at a Doppler angle of 0º after angle correction and at 10º using a polyurethane-tubing circuit with tube diameters of 5 mm and 6 mm. The range of blood flow volume was 250~2,000 mL/min. [Result 1] Blood flow volume measurement at a Doppler angle of 0º showed an error of 8.9±12.9% that was independent of the tube diameter. However, at a Doppler angle of 10º , the error in the measured flow volume was 16.3±9.8%, and the blood flow in the 6 mm tube showed 15% greater underestimation than that in the 5 mm tube. [Experiment 2] We compared angiography and B-Mode ultrasound for the measurement of radial artery diameters in 30 patients on hemodialysis. We measured 2 diameters:one was the distance between the two opposing intimal surfaces on near side and far side of the vascular wall(surface-to-surface method), and the other was the distance between the intima edge of the near side vascular wall and intima surface of far side one(edge-to-surface method) . [Result 2] The measurement of diameters using B-Mode ultrasound showed errors of 0±0.2 mm and -0.3±0.2 mm in the surface-to-surface method and edge-to-surface method, respectively. [Conclusion] Errors in blood flow volume measurements obtained using pulsed Doppler ultrasound can be reduced by controlling the corrected Doppler angle to 0º and by measuring the vessel diameter using the surface-to-surface method.

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We report a 46-year-old female patient on continuous ambulatory peritoneal dialysis(CAPD) who experienced perforation of the ileum incarcerated within the deformed pelvic cavity behind the metal bolt of the implanted head of the right femur. The patient had undergone right hemi-pelvectomy accompanied by total hip arthroplasty for alveolar soft-tissue sarcoma at the age of 41. She was also being treated by CAPD as therapy for end-stage renal disease resulting from hypertensive nephrosclerosis since 2007. In March 2008, she underwent surgery for femur neck fracture and the metal bolt was implanted. She developed abdominal pain in May 2008, which became aggravated and showed turbid CAPD fluid. She was admitted to our hospital because of peritonitis. Six-day administration of antibiotics resulted in no improvement, and her symptoms became further aggravated demonstrating and an increased cell count in cloudy brown-yellow CAPD fluid. Three species of bacilli were detected in the CAPD fluid and imipenem/cilastatin sodium(IPM/CS) was administered. As there was no improvement, we performed abdominal computed tomography and detected a free air space within the abdominal cavity. Emergency surgery demonstrated that the head of the metal bolt was palpable in the pelvic cavity and the small intestine was incarcerated behind it within the deformed pelvic cavity due to partial pelvectomy. Furthermore, there was a perforation at the terminal ileum. Partial ileectomy was performed and the postoperative course was uneventful. Her dialysis therapy was switched to hemodialysis. Perforation of the small intestine incarcerated within the deformed pelvic cavity following hip arthroplasty in a CAPD patient has not been reported previously. A procedure that deforms pelvic cavity may precipitate incarceration leading to complicated peritonitis, which should be differentiated from simple peritonitis.

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A 68-year-old female patient undergoing maintenance hemodialysis presented with chest pain. The patient underwent stable hemodialysis without severe stress, except for mild hypotension during hemodialysis. Electrocardiography showed a reversed T-wave in leads I, II, III, aVF and V2-6 and ST-segment elevation in leads V1-2. Echocardiography demonstrated akinesis in the apical segment of the left ventricle. Because these findings suggested the onset of acute myocardial infarction, the patient was admitted to our cardiovascular medicine unit. However, coronary angiography did not show any pathological lesions, and left ventriculography demonstrated akinesis in the apical segment and hyperkinesis in the basal segment. Based on these findings, we diagnosed the patient as having Takotsubo cardiomyopathy. The patient’s chest pain rapidly disappeared, and akinesis of the left ventricular apex on echocardiography was improved without specific therapy. On the fourth hospital day, the patient was discharged in good condition. After discharge, the patient continued to receive stable hemodialysis without either cardiac symptoms or hypotension, probably due to an increase in the patient’s dry weight. Although the mechanism of this disease has not yet been clarified, catecholamine cardiotoxicity induced by physical or emotional stress is suspected to be a trigger of this syndrome. We hypothesized that sympathetic nerve overactivity in hemodialysis, especially in patients under physical or emotional stress, might therefore be a causative factor for Takotsubo cardiomyopathy. The Takotsubo cardiomyopathy should therefore be considered in the differential diagnosis of hemodialysis patients presenting with cardiac symptoms without any particular signs of stress.

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