Role of B-type natriuretic peptide in cardiovascular state monitoring in a hemodialysis patient with primary amyloidosis

BACKGROUND

Cardiac involvement occurs in up to 50% of patients with primary or A amyloidosis (ALA) and is associated with very poor prognosis. B-type natriuretic peptide (BNP) has been proposed as a guide for treatment of heart failure patients and as an index of myocardial dysfunction in patients with ALA. Data about BNP dosage for cardiovascular monitoring of patients with ALA on renal replacement therapy are lacking.

CASE

A 64 year old Caucasian man was admitted because of nephrotic syndrome in July 2003. Renal diagnosis was ALA. Melphalan and prednisolone were given but renal function worsened and in April 2004 standard bicarbonate hemodialysis was started. In March 2004 thalidomide was added to his therapy. During the follow-up ejection fraction was stable and was 65% on the contrary E/A ratio gradually increased and overtook 1. BNP plasma levels were increased and the values recorded during the follow-up were: 2505 pg/mL in October 2003 (normal reference values<100), 1827 in April 2004, 4006 in June 2004, 5000 in September 2004, 3750 in January 2005 and 1920 in April 2005. In September 2005 BNP was 3380 pg/mL. The patient was still alive after a follow-up longer than two years.

CONCLUSION

In ALA patients a powerful prognostic role of BNP has been reported whose expression is increased in ventricular myocytes of patients with cardiac involvement. BNP level monitoring does not appear to be superior to standard echocardiography in evaluating cardiovascular status of uremic patients with ALA.

Exercise training in peripheral vascular arterial disease in hemodialysis patients: a case report and a review

BACKGROUND

Peripheral arterial disease (PAD) is frequently diagnosed in subjects with chronic kidney disease. Hemodialysis (HD) patients with PAD show increased morbidity and mortality and health care costs increase. Management of this complication requires time and skill by nephrologists, although negative results are frequent.

CASE REPORT

A 59-year-old Caucasian man on HD with advanced lower extremities peripheral disease and massive calcification of a plaque in the abdominal aorta has been enrolled in a home-based exercise training program. His compliance was high and claudication improved. Pain threshold speed (PTS) and maximal walking speed rose from 2.8 and 3.3 to 3.6 and 4.6 Km/h respectively. The increasing functional capability improved his quality of life and changed positively his life-style.

CONCLUSIONS

Physical exercise confirms its effectiveness in reducing symptoms due to PAD. A rehabilitation program performed at home at a specific velocity, just below the PTS, and maintained by a metronome appears to be well suited for HD patients because it induces functional improvements and vascular adaptations with low costs.