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ABSTRACT: OBJECTIVE: Peripheral artery disease (PAD) is frequently seen in hemodialysis patients, endovascular therapy (EVT) often being performed in such cases. We examined combined prognostic utility of pre-procedural serum albumin and C-reactive protein (CRP) in combination for predicting clinical outcome after EVT in HD patients with PAD. METHODS: A total of 450 hemodialysis patients successfully undergoing EVT for PAD were followed-up for up to 8 years. They were divided according to median serum albumin and CRP levels measured prior to EVT into four groups [those with high albumin and low and high CRP levels, respectively, and low albumin and low and high CRP levels, respectively]. We analyzed the incidence of major adverse events (MAE) as a composite endpoint including target lesion revascularization (TLR), amputation and all-cause death, and major adverse limb events (MALE) as a composite endpoint including TLR and amputation. RESULTS: During the follow-up period (36 ± 31months), 206 MAE (46%) including 67 TLR, 45 amputations and 94 deaths occurred. Event-free survival rates from MAE for 8 years were 41.9%, 21.2%, 29.8%, and 13.2% in groups with high albumin and low CRP levels, with high albumin and high CRP levels, with low albumin and low CRP levels, and with low albumin and high CRP levels, respectively (P = 0.0001). Similar tendency was also seen in incidence of MALE (P < 0.0001). CONCLUSION: Lower albumin and elevated CRP levels could strongly predict MAE and MALE after EVT in hemodialysis patients.
Atherosclerosis 12/2012; · 3.79 Impact Factor
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Hiroshi Takahashi,
Hideki Ishii,
Toru Aoyama,
Daisuke Kamoi,
Hirotake Kasuga,
Yasuhiko Ito,
Kaoru Yasuda,
Miho Tanaka,
Daiji Yoshikawa,
Shoichi Maruyama,
Seiichi Matsuo,
Toyoaki Murohara,
Yukio Yuzawa
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ABSTRACT: BACKGROUND: Cardiac valve calcification is seen frequently in patients undergoing dialysis. Serum C-reactive protein (CRP) level also is reported to predict future cardiovascular events. We investigated the association among valve calcification, CRP level, and mortality in patients with end-stage renal disease who were just beginning hemodialysis (HD) therapy. STUDY DESIGN: Observational cohort. SETTING & PARTICIPANTS: 1,290 consecutive patients who just started HD therapy were enrolled and were followed up to 10 years. PREDICTOR: Patients were divided into 3 groups according to number of calcified valves: those without valve calcification, those with calcification in a single (aortic or mitral) valve, and those with calcification in both valves. They also were divided into tertiles according to CRP level. OUTCOMES: Cardiovascular and all-cause mortality. MEASUREMENTS: Echocardiography and CRP measurement were performed within 1 month after beginning HD therapy. RESULTS: During follow-up (median, 51 months), 335 (25.9%) patients died, including 156 (12.1%) of cardiovascular disease. The adjusted HR for cardiovascular mortality was 2.80 (95% CI, 1.63-4.81) for 2 calcifications versus 0 (P < 0.001). Furthermore, the risk of cardiovascular mortality was 3.66-fold higher in patients with calcifications in both valves (highest tertile of CRP) compared with patients without valve calcification (lowest tertile of CRP; P < 0.001). LIMITATIONS: Precise medical treatments or therapeutic interventions were not evaluated. CONCLUSIONS: Valve calcification and elevated CRP levels were not only related to additively increased risk of mortality, but also improved the prediction of mortality in patients with end-stage renal disease who had just begun HD therapy.
American Journal of Kidney Diseases 11/2012; · 5.43 Impact Factor
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Ryo Takahashi,
Yasuhiko Ito, Hiroshi Takahashi,
Hideki Ishii,
Hirotake Kasuga,
Masashi Mizuno,
Yasuhiro Suzuki,
Yukio Yuzawa,
Shoichi Maruyama,
Toyoaki Murohara,
Enyu Imai,
Seiichi Matsuo
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ABSTRACT: Protein-energy wasting and chronic inflammation are prevalent in patients with end-stage renal disease (ESRD). We investigated the combination of serum albumin, C-reactive protein (CRP) and body mass index (BMI) at initiation of hemodialysis therapy as a predictor of all-cause and cardiovascular disease (CVD) mortality in Japanese ESRD patients.
A total of 1,228 consecutive Japanese ESRD patients on hemodialysis therapy were enrolled and followed for up to 10 years. Patients were divided into quartiles according to levels of albumin, CRP and BMI. Furthermore, to clarify the joint role of these factors, albumin <3.5 g/dl, CRP >4.0 mg/l and BMI <19.6 were defined as risk factors using receiver operating characteristic analysis; thereafter, patients were divided into groups according to the positive number of these factors.
Adjusted hazard ratios (HRs) for lower serum albumin, elevated CRP and lower BMI for 10-year all-cause mortality were 1.97, 3.13 and 2.61, respectively. Regarding the combination of these variables, adjusted HRs for mortality were 2.31, 4.28 and 8.07, respectively, in patients having any one factor, any two factors and all three factors. The C-index for an established risk model with these three positive markers was the most accurate for predicting mortality (0.768), as compared to other models with one or two markers. Similar results were seen for CVD mortality.
Serum albumin, CRP and BMI at the start of hemodialysis therapy were able to individually stratify the risk of long-term mortality in ESRD patients. Furthermore, a combination of these variables could more accurately predict mortality.
American Journal of Nephrology 07/2012; 36(2):136-43. · 2.54 Impact Factor
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ABSTRACT: 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).
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).
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.
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.
Atherosclerosis 12/2011; 219(2):643-7. · 3.79 Impact Factor
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Takashi Sakakibara,
Hideki Ishii,
Takanobu Toriyama,
Toru Aoyama, Hiroshi Takahashi,
Daisuke Kamoi,
Yoshihiro Kawamura,
Kazuhiro Kawashima,
Kohei Yoneda,
Tetsuya Amano,
Miho Tanaka,
Daiji Yoshikawa,
Mutsuharu Hayashi,
Tatsuaki Matsubara,
Toyoaki Murohara
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ABSTRACT: 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.
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).
The use of EES was as safe as that of SES. Moreover, EES significantly prevented restenosis in patients on maintenance HD compared with SES.
Circulation Journal 11/2011; 76(2):351-5. · 3.77 Impact Factor
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Daisuke Kamoi,
Hideki Ishii, Hiroshi Takahashi,
Toru Aoyama,
Takanobu Toriyama,
Miho Tanaka,
Yoshihiro Kawamura,
Kazuhiro Kawashima,
Daiji Yoshikawa,
Tetsuya Amano,
Tadayuki Uetani,
Tatsuaki Matsubara,
Toyoaki Murohara
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ABSTRACT: 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±0.70mm vs. 0.48±0.91mm, 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.
International journal of cardiology 10/2011; · 7.08 Impact Factor
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Mutsuharu Hayashi,
Rei Shibata, Hiroshi Takahashi,
Hideki Ishii,
Toru Aoyama,
Hirotake Kasuga,
Shigeki Yamada,
Koji Ohashi,
Syoichi Maruyama,
Seiichi Matsuo,
Noriyuki Ouchi,
Toyoaki Murohara,
Takanobu Toriyama
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ABSTRACT: 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.
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.
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.
Our data document that adiponectin is associated with increased risk of carotid atherosclerosis in a predialysis CKD population.
American Journal of Nephrology 07/2011; 34(3):249-55. · 2.54 Impact Factor
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Hideki Ishii,
Masami Nishio, Hiroshi Takahashi,
Toru Aoyama,
Miho Tanaka,
Takanobu Toriyama,
Tsuneo Tamaki,
Daiji Yoshikawa,
Mutsuharu Hayashi,
Tetsuya Amano,
Tatsuaki Matsubara,
Toyoaki Murohara
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ABSTRACT: F-18 fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) is a useful tool for the detection of local inflamed atherosclerotic lesions.
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).
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.
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.
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.
Clinical Therapeutics 12/2010; 32(14):2337-47. · 2.32 Impact Factor
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Shigeki Yamada,
Hideki Ishii, Hiroshi Takahashi,
Toru Aoyama,
Yasuhiro Morita,
Hirotake Kasuga,
Keiko Kimura,
Yutaka Ito,
Ryo Takahashi,
Takanobu Toriyama,
Yoshinari Yasuda,
Mutsuharu Hayashi,
Hideki Kamiya,
Yukio Yuzawa,
Shoichi Maruyama,
Seiichi Matsuo,
Tatsuaki Matsubara,
Toyoaki Murohara
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ABSTRACT: Cardiac failure is directly affected by left ventricular (LV) dysfunction, and particularly LV systolic dysfunction is strongly associated with survival in ESRD patients. The aim of this study was to determine the prognostic value of reduced LV ejection fraction (LVEF) measured at the time of initiation of hemodialysis (HD) in incident HD patients.
1254 consecutive ESRD patients who electively started HD therapy were screened by echocardiography within 1 month after its inception. They were divided into five groups according to LVEF levels with a decrease of 0.1 each and were followed up for up to 7 years. Survival was examined with the Kaplan-Meier method and compared using the log-rank test.
Among the 1254 patients, LVEF levels ≥0.6, 0.5 to 0.6, 0.4 to 0.5, 0.3 to 0.4, and <0.3 were seen in 842 (67.1%), 247 (19.7%), 107 (8.5%), 41 (3.3%), and 17 (1.4%) patients, respectively. On Kaplan-Meier analysis, 7-year event-free rates from cardiovascular death were 84.2, 83.7, 73.6, 59.4, and 30.9% in order of groups with decreasing LVEF of 0.1 each, respectively. Seven-year event-free rates from all-cause death were 69.2, 61.7, 57.1, 45.9, and 23.1% in the respective groups. Even after adjustment for other risk factors, decreasing LVEF was a strong independent predictor for cardiovascular death.
Reduced LVEF on starting HD therapy could stratify risk of cardiovascular and all-cause mortality in ESRD patients. Screening by echocardiography at start of HD therapy might be recommended to predict prognosis in patients with ESRD.
Clinical Journal of the American Society of Nephrology 10/2010; 5(10):1793-8. · 5.23 Impact Factor
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ABSTRACT: 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.
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.
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.
Elevated preprocedural serum CRP levels were associated with RAO and any-cause death after EVT in hemodialysis patients with peripheral artery disease.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 10/2010; 52(4):854-9. · 3.52 Impact Factor
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ABSTRACT: 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.
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.
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).
Alexithymia is a strong independent risk factor for all-cause mortality in hemodialysis patients.
Psychotherapy and Psychosomatics 01/2010; 79(5):303-11. · 6.28 Impact Factor
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Hideki Ishii,
Yoshitake Kumada,
Takanobu Toriyama,
Toru Aoyama, Hiroshi Takahashi,
Miho Tanaka,
Daisuke Kamoi,
Yoshihiro Kawamura,
Shigeki Yamada,
Mutsuharu Hayashi,
Yoshinari Yasuda,
Yukio Yuzawa,
Shoichi Maruyama,
Seiichi Matsuo,
Tatsuaki Matsubara,
Toyoaki Murohara
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ABSTRACT: Percutaneous transluminal angioplasty (PTA) for femoropopliteal lesions in peripheral artery disease has been performed in patients undergoing hemodialysis as well as in the general population. Cilostazol, a selective inhibitor of phosphodiesterase 3, has been reported to reduce target lesion revascularization after PTA for femoropopliteal lesions in the general population.
This study investigated the effects of cilostazol use on long-term patency after PTA in patients with femoropopliteal disease undergoing hemodialysis.
In this retrospective study, data from patients undergoing hemodialysis who underwent successful PTA for femoropopliteal disease, defined as a final luminal diameter stenosis <30% without angiographically visual arterial dissection and no in-hospital complications, were included. One study group received long-term treatment with oral cilostazol 100 mg BID after PTA; the control group did not. The duration of follow-up was <or=6 years. The primary outcome of interest was cumulative patency, as measured by the event-free rate 6 years after PTA, with event defined as restenosis of >50% of the vessel diameter in femoropopliteal lesions. Data on baseline characteristics, patency, and covariates (diabetes, hypertension, hyperlipidemia, smoking, coronary artery disease, critical limb ischemia, TransAtlantic Inter-Society Consensus classification, and stenting) were obtained from electronic medical records and telephone interviews with patients. To minimize the effects of selection bias for cilostazol administration, a propensity-matched analysis using Cox univariate and multivariate models including the previously mentioned covariates was conducted. The propensity scores of the 2 groups were matched 1:1 (AUC = 0.69 [receiving operating characteristics analysis]). Data were obtained from electronic medical records and telephone interviews with patients by trained personnel who were blinded to treatment assignment.
A total of 358 consecutive lesions of 174 patients undergoing hemodialysis were included (103 men, 71 women; mean [SD] age, 66 [11] years; cilostazol group, 61 patients, 121 lesions; control group, 113 patients, 237 lesions). The mean duration of follow-up was 37 (27) months. The 6-year event-free rate of restenosis of >50% of the vessel diameter was significantly higher in the cilostazol group than in the control group (72/121 [59.5%] vs 120/237 [50.6%]; P = 0.005 [logrank test]; hazard ratio [HR] = 0.63; 95% CI, 0.45-0.88; P = 0.008 [Cox univariate analysis]). Also, event-free rates of target lesion revascularization and limb amputation were significantly higher in the cilostazol group than in the control group (40/61 [65.6%] vs 57/113 [50.4%]; P = 0.013 [log-rank test] and 54/61 [88.5%] vs 90/113 [79.6%]; P = 0.047 [logrank test], respectively). On propensity score matching (105 lesions), the baseline characteristics were comparable between the 2 groups. The 6-year eventfree rate of restenosis was significantly higher in the cilostazol group than in the control group (66/105 [62.9%] vs 52/105 [49.5%]; HR = 0.58; 95% CI, 0.38-0.88; P = 0.012 [Cox univariate analysis]). On propensity-matched (Cox multivariate) analysis, cilostazol (HR = 0.51; 95% CI, 0.27-0.84; P = 0.008), age (HR = 1.01; 95% CI, 1.01-1.04; P = 0.031), and critical limb ischemia (HR = 2.21; 95% CI, 1.39-3.53; P = 0.001) were independent predictors of restenosis. None of the patients in the cilostazol group discontinued cilostazol treatment during the follow-up period. Four patients (6.6%) experienced mild headache.
This study found that in these patients with femoropopliteal lesions in peripheral artery disease who were undergoing hemodialysis, those treated with cilostazol 100 mg BID after PTA had a higher mean rate of cumulative patency after PTA than those in the control group.
Clinical Therapeutics 01/2010; 32(1):24-33. · 2.32 Impact Factor
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Hideki Ishii,
Takanobu Toriyama,
Toru Aoyama, Hiroshi Takahashi,
Tetsuya Amano,
Mutsuharu Hayashi,
Miho Tanaka,
Yoshihiro Kawamura,
Yoshinari Yasuda,
Yukio Yuzawa,
Shoichi Maruyama,
Seiichi Matsuo,
Tatsuaki Matsubara,
Toyoaki Murohara
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ABSTRACT: Percutaneous coronary intervention (PCI) using drug-eluting stents significantly reduces the risk of restenosis in the general population. However, in patients on hemodialysis, adverse cardiac events are frequently seen even if treated with drug-eluting stents. Recent studies suggest that C-reactive protein (CRP) reflects vascular wall inflammation and can predict adverse cardiac events. We evaluated possible prognostic values of CRP on outcomes in patients on hemodialysis undergoing PCI with drug-eluting stents.
A total of 167 patients undergoing PCI with sirolimus-eluting stents for stable angina (322 lesions) were enrolled. They were divided into tertiles according to serum CRP levels. We analyzed the incidence of major adverse cardiovascular events including cardiovascular death, nonfatal myocardial infarction, and target lesion revascularization after PCI as well as quantitative coronary angiographic data. The mean follow-up was 31 months (SD, 14). Major adverse cardiac events occurred in 11 patients (19.6%) of the lowest tertile, in 22 patients (39.3%) of the middle tertile, and in 28 patients (50.9%) of the highest tertile during follow-up period (P=0.0009). There was a progressive increase in neointimal growth after sirolimus-eluting stent implantation during follow-up because preprocedural CRP levels were higher, despite similar angiographic data just after PCI. Angiographic restenosis at 6 to 8 months after PCI was seen in 10.6% in the lowest tertile, 17.9% in the middle tertile, and 32.0% in the highest tertile (P=0.0007).
Increased preprocedural serum CRP levels would predict higher major adverse cardiac events and restenosis rates after sirolimus-eluting stents implantation in patients on hemodialysis.
Circulation Cardiovascular Interventions 12/2009; 2(6):513-8. · 6.06 Impact Factor
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ABSTRACT: Retrospective analysis of preoperative imaging and clinical data from patients undergoing cervical expansive laminoplasty for cervical myelopathy.
To investigate preoperative parameters that predict the floating status of the spinal cord at the anterior elements of the cervical spine in both intraoperative ultrasonography (US) and postoperative magnetic resonance imaging (MRI), and to evaluate the association between clinical outcome and spinal cord floating.
Intraoperative US has been used to evaluate the status of the spinal cord after cervical laminoplasty for cervical myelopathy. Few studies have evaluated the predictive preoperative parameters for intraoperative US results.
Imaging and clinical outcome data were collected from 101 consecutive patients who underwent cervical expansive laminoplasty for cervical myelopathy at Kaikoukai Nagoya Kyouritsu Hospital, Japan, from April 2004 to April 2008. The preoperative parameters associated with spinal cord floating in intraoperative US and postoperative MR images were investigated. Predictive parameters for the rate of recovery according to the Japanese Orthopedic Association score for cervical myelopathy at each follow-up session were also investigated.
Predictive parameters for spinal cord floating after decompression in intraoperative US were the cervical vertebrae 2 to 7 (C2-C7) sagittal alignment in the standing neutral position on preoperative plain radiograph radiography (cut-off value=3 degrees) and the C5/6 "beak angle" in preoperative MRI (cut-off value=20 degrees). A predictive parameter for spinal cord floating in postoperative MRI was the C5/6 beak angle in preoperative MRI (cut-off value=21 degrees). The preoperative Japanese Orthopedic Association score and spinal cord floating at anterior elements of the cervical spine in intraoperative US were predictive parameters for clinical outcome.
Intraoperative US was more useful than postoperative MRI for predicting the clinical outcome of cervical expansive laminoplasty. Knowledge of the predictive parameters for spinal cord floating after cervical expansive laminoplasty could help evaluate the limitations of posterior decompression.
Spine 11/2009; 34(24):2634-41. · 2.08 Impact Factor
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ABSTRACT: Colonic perforation is a rare but life-threatening complication of colonoscopy. We evaluated the incidence of colonic perforation that resulted from colonoscopy in patients who underwent hemodialysis compared with those who did not have this procedure (controls).
Data from a total of 15,098 consecutive patients who underwent colonoscopy from January 2001 to December 2008 in Nagoya Kyoritsu Hospital were analyzed retrospectively. Patients were divided into 2 groups: 1106 hemodialysis patients and 13,992 controls. The incidence of colonic perforation, patient characteristics, and locations of perforation during colonoscopy were compared between the 2 groups. Furthermore, perforated mucosa samples from colons were examined by pathology analysis.
Colonic perforations occurred in 5 hemodialysis patients and 3 controls. The incidence of colonic perforation was markedly higher in the hemodialysis group than in the control group (0.45% vs 0.02%; odds ratio, 21.17; 95% confidence interval, 5.05-88.73; P < .0001). Even after multivariate analysis of age, sex, and patients who received polypectomies, hemodialysis still was associated independently with the risk of colonic perforation during colonoscopy (odds ratio, 19.91; 95% confidence interval, 4.61-85.93; P < .0001). Pathologic examination of perforated mucosa was performed in 3 hemodialysis patients and 3 control patients. beta2-microglobulin deposition was observed in all 3 hemodialysis patients. In contrast, beta2-microglobulin deposition was not detected in control patients.
There is a higher risk of colonic perforation during colonoscopy among patients who received hemodialysis compared with those who did not. beta2-microglobulin deposition might have a role in perforation in patients who receive hemodialysis.
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 10/2009; 8(1):55-9. · 5.64 Impact Factor
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ABSTRACT: 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.
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.
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.
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.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 09/2009; 50(5):1057-62. · 3.52 Impact Factor
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Hideki Ishii,
Yoshitake Kumada,
Takanobu Toriyama,
Toru Aoyama, Hiroshi Takahashi,
Tetsuya Amano,
Yoshinari Yasuda,
Yukio Yuzawa,
Syoichi Maruyama,
Seiichi Matsuo,
Tatsuaki Matsubara,
Toyoaki Murohara
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ABSTRACT: 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.
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.
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).
AVC provides predictive information regarding DES implantation in patients on maintenance HD.
Nephrology Dialysis Transplantation 12/2008; 24(5):1562-7. · 3.40 Impact Factor
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Shoichi Maruyama,
Akihiko Taguchi,
Shigejiro Iwashima,
Takenori Ozaki,
Kaoru Yasuda,
Akie Kikuchi-Taura,
Toshihiro Soma,
Hideki Ishii,
Toyoaki Murohara, Hiroshi Takahashi,
Hirotake Kasuga,
Yoshitaka Kumada,
Takanobu Toriyama,
Yasuhiko Ito,
Hirohisa Kawahara,
Yukio Yuzawa,
Seiichi Matsuo
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ABSTRACT: 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.
Kidney International 11/2008; 74(12):1603-9. · 6.61 Impact Factor
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Takuya Ishikawa,
Kinichi Takeda,
Masatsugu Itoh,
Tadashi Imaizumi,
Kenji Oguri, Hiroshi Takahashi,
Hirotake Kasuga,
Takanobu Toriyama,
Seiichi Matsuo,
Yoshiki Hirooka,
Akihiro Itoh,
Hiroki Kawashima,
Toshifumi Kasugai,
Eizaburo Ohno,
Ryoji Miyahara,
Masatoshi Ishigami,
Yoshiaki Katano,
Naoki Ohmiya,
Yasumasa Niwa,
Hidemi Goto
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ABSTRACT: Pancreatic cystic (PC) lesions are not necessarily rare, and it is important to diagnose whether PC lesions are neoplastic such as intraductal papillary mucinous neoplasm (IPMN) because of its malignant potential. Reports on PC lesions in hemodialysis (HD) patients are remarkably limited. The aim of this study was to clarify the prevalence and characteristics of PC lesions in HD patients.
We reviewed 1012 consecutive HD patients and 11,100 patients (controls) without renal disease who underwent transabdominal ultrasonography between January 2003 and December 2005. Patients' sex ratio (female-to-male) was less, and the age was older in HD patients. Clinical findings of these patients were examined.
The prevalence both of PC lesions and IPMNs was significantly higher in HD patients than in controls (9.3% vs 1.3% and 2.8% vs 0.2%, P < 0.0001). The incidence of IPMNs in HD patients with PC lesions was higher than that in controls with PC lesions (29.8% vs 17.0%, P = 0.021). Multivariate logistic regression analysis revealed that the odds ratios of PC lesions and IPMNs were 6.38 (95% confidence interval, 4.82-8.45) and 9.39 (95% confidence interval, 5.36-16.49) in HD patients compared with controls.
The prevalence of PC lesions in HD patients is higher, and HD patients with PC lesions have high prevalence of IPMNs.
Pancreas 10/2008; 38(2):175-9. · 2.39 Impact Factor
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Yoshitaka Kumada,
Toru Aoyama,
Hideki Ishii,
Miho Tanaka,
Yoshihiro Kawamura, Hiroshi Takahashi,
Takanobu Toriyama,
Yukio Yuzawa,
Syoichi Maruyama,
Seiichi Matsuo,
Toyoaki Murohara
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ABSTRACT: 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.
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.
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.
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.
Nephrology Dialysis Transplantation 08/2008; 23(12):3996-4001. · 3.40 Impact Factor
