close

Вход

Забыли?

вход по аккаунту

?

Utility of high-resolution ultrasound for the diagnosis of dialysis-related amyloidosis.

код для вставкиСкачать
926
UTILITY OF HIGH-RESOLUTION ULTRASOUND
FOR THE DIAGNOSIS OF
DIALYSIS-RELATED AMYLOIDOSIS
JONATHAN KAY, CAROL B. BENSON, SUSAN LESTER, JOSEPH M. CORSON,
GERALDINE S. PINKUS, J. MICHAEL LAZARUS, and WILLIAM F. OWEN, JR.
Objective. To evaluate the utility of real-time,
high-resolution ultrasound of the shoulder in the diagnosis of dialysis-related amyloidosis.
Methods. We performed a case series study of 2
groups of patients seen at a referral-based clinic in a
tertiary care hospital. The shoulders of 13 patients with
normal renal function and of 38 patients receiving
long-term hemodialysis were studied by real-time, highresolution ultrasound. All hemodialysis patients were
evaluated clinically for the presence of dialysis-related
amyloidosis. Surgical specimens of joints were available
for all 13 patients with normal renal function and for 17 of
From the Departments of Rheumatology and Immunology,
Radiology, Pathology, and Medicine, Brigham and Women’s Hospital, and the Departments of Medicine, Radiology, and Pathology,
Harvard Medical School, Boston, Massachusetts.
Supported by NIH grants AI-2253 I , AI-23401. AR-35907,
AR-36308, and HL-36110, by a grant from the Peabody Foundation,
and by a Postdoctoral Research grant from the Arthritis Foundation.
Jonathan Kay, MD: Instructor in Medicine, Harvard Medical School, and Department of Rheumatology and Immunology,
Brigham and Women’s Hospital; Carol B. Benson, MD: Associate
Professor of Radiology, Harvard Medical School, and Department
of Radiology, Brigham and Women’s Hospital; Susan Lester, MD,
PhD: Clinical Fellow in Pathology, Harvard Medical School, and
Department of Pathology, Brigham and Women’s Hospital; Joseph
M. Corson, MD: Professor of Pathology, Harvard Medical School,
and Department of Pathology, Brigham and Women’s Hospital;
Geraldine S. Pinkus, MD: Associate Professor of Pathology, Harvard Medical School, and Department of Pathology, Brigham and
Women’s Hospital; J. Michael Lazarus, MD: Associate Professor of
Medicine, Harvard Medical School, and Department of Medicine,
Brigham and Women’s Hospital; William F. Owen, Jr., MD: Assistant Professor of Medicine, Harvard Medical School, and Department of Rheumatology and Immunology, Brigham and Women’s
Hospital.
Address reprint requests to Jonathan Kay, MD, Section of
Rheumatology, Lahey Clinic Medical Center, 41 Mall Road, Burlington. MA 01805.
Submitted for publication October 17, 1991; accepted in
revised form March 2. 1992.
Arthritis and Rheumatism, Vol. 35, No. 8 (August 1992)
the 38 hemdialysis patients. These specimens were evaluated for the presence of &-microglobulin (P2m) amyloid by Congo red and immunohistochemical staining.
Results. Two ultrasonographic findings were selectively observed in the dialysis patients with clinical
and histologic evidence of P2m amyloid in comparison
with patients with normal renal function and no evidence of amyloid: rotator cuffs >8 mm in thickness and
echogenic pads between muscle groups of the rotator
cuff. The presence of at least 1 of these 2 findings
corresponded to the presence of clinically and histologically evident &rn amyloid with a sensitivity of 79% and
a specificity of 100%. When additional patients without
surgical specimens for histologic confirmation of amyloidosis were included, the sensitivity of these 2 sonographic findings was 72% and the specificity was 97%.
Conclusion, Real-time, high-resolution ultrasound is a relatively sensitive and highly specific noninvasive adjunct to the clinical diagnosis of &m amyloidosis in patients receiving long-term hemodialysis.
In patients undergoing long-term dialysis, musculoskeletal complications may develop that manifest
as an arthropathy involving the peripheral joints
and/or spine (1,2). Shoulder pain and dysfunction,
carpal tunnel syndrome, flexor tenosynovitis of the
hands, and pain and soft tissue swelling of other large
joints are often seen in patients who have had more
than 5 years of dialysis (3-7). Congo red staining of
involved areas of synovium and bone demonstrates
amyloid deposits. Based on total amino acid content,
N-terminal amino acid sequence, and immunochemical determinants, &-microglobulin (&m) has been
identified as the predominant component of these
amyloid deposits (8,9). It has been suggested that
HIGH-RESOLUTION ULTRASOUND IN DIALYSIS AMYLOIDOSIS
amyloid composed of &m occurs mostly in the setting
of long-term hemodialysis with cuprophane membranes (10,ll).
The diagnosis of dialysis-related amyloidosis is
based on the presence of characteristic symptoms and
signs in a patient who has had long-term dialysis and is
confirmed by histologic evaluation of involved tissue
(12). Shoulder pain occurs in as many as 95% of
patients with dialysis-related amyloidosis (5) and is
often the initial musculoskeletal symptom in this disease (13). In pursuit of a noninvasive means of establishing the diagnosis of dialysis-related amyloidosis,
we evaluated the utility of real-time, high-resolution
ultrasound in characterizing unique ultrasonographic
abnormalities in the shoulders of patients who have
undergone long-term hemodialysis.
PATIENTS AND METHODS
Patients. The control group (group I) consisted of 13
patients with miscellaneous rheumatologic and orthopedic
disorders but with normal renal function. All 13 had undergone shoulder ultrasonography at the Brigham and Women’s
Hospital, and all had surgical specimens from joints available for histologic examination. Their musculoskeletal diagnoses were as follows: rotator cuff tear (n = 4), osteoarthritis
(n = 31, impingement syndrome of the shoulder (n = 2),
polymyalgia rheumatica (n = l), rheumatoid arthritis (n = l),
avascular necrosis of the humeral head (n = I), and acetabular labrum tear (n = 1).
Shoulders of 38 long-term hemodialysis patients with
shoulder pain, recruited from the hemodialysis centers affiliated with the renal division at the Brigham and Women’s
Hospital, were also studied by ultrasound. All hemodialysis
patients were undergoing routine dialysis with cuprophane
membranes. All hemodialysis patients were evaluated clinically by at least 2 of the authors (JK, JML, WFO) for the
presence of dialysis-related amyloidosis. Criterion for the
clinical diagnosis of dialysis-related amyloidosis was the
presence of at least 2 of the following findings: flexor
tenosynovitis of the hands with diminished extension of the
fingers, signs or symptoms of carpal tunnel syndrome, and
shoulder pain with diminished range of shoulder motion (12).
Eighteen of the dialysis patients had clinical evidence
of dialysis-related amyloidosis (group 11), and the remaining
20 did not (group 111). Biopsy specimens for pathologic
evaluation for the presence of pzm were available from
previous orthopedic surgical procedures in 14 of the 18
patients in group I1 (group IIa) and in 3 of the 20 patients in
group I11 (group IIIa).
Pathologic studies. For histologic characterization of
the pathologic specimens, formalin-fixed, paraffin-embedded
tissue sections were prepared from surgical specimens obtained from the shoulders (n = 5 ) , hip (n = 2), knees (n = 21,
ankles (n = 2), rotator cuff (n = l), and toes (n = 1) of the
patients in group I. In the 17 patients in groups IIa and IIIa,
biopsy specimens for analysis for the presence of a m were
927
from the shoulder (n = 11, hips (n = 6), wrists (n = 7), knees
(n = 2), and rotator cuff (n = 1). Surgical specimens from
joints were not available for study in the remaining 4 patients
with clinical evidence of dialysis-related amyloidosis (group
IIb) or the remaining 17 patients who lacked clinical evidence of amyloidosis (group IIIb).
Tissue sections from patient groups I, IIa, and IIIa
were stained with hematoxylin and eosin and Congo red (14),
and immunohistochemical studies of serial sections were
performed using the peroxidaseantiperoxidase technique
(15). Rabbit anti-human p2m polyclonal antibody (Dako,
Carpinteria, CA) at a final dilution of 1 :200 was utilized as
the primary antiserum, and nonimmune rabbit antiserum
was used as a control. A histologic diagnosis of &m amyloidosis was made if characteristic amyloid deposits, demonstrating apple-green birefringence when Congo redstained sections were visualized under polarized light, were
present and if these deposits were immunoreactive with
polyclonal rabbit anti-human a m .
None of the specimens from the 13 patients in group
I had amyloid demonstrated by Congo red staining, and
immunoperoxidase staining revealed only occasional endothelial staining. In contrast, &m amyloid deposits were
present in the capsular and subsynovial tissues from all 14
patients from group IIa. Amyloid was not demonstrated by
either Congo red or immunoperoxidase staining in any of the
specimens from the 3 patients in group IIIa.
Ultrasonographic studies. Shoulders of all patients
were evaluated, without knowledge of the patient’s clinical
or histologic findings, by real-time, high-resolution ultrasound using a 5-MHz or 7.5-MHz linear transducer (16).
Anterior (region of the pectoralis muscles) to posterior
(region of the teres muscles) scanning of the shoulders was
performed in both transverse and longitudinal planes, and
the results were recorded. On the transverse view, the
thickness of the rotator cuff was measured in the region of
the supraspinatus muscle, which was the point of greatest
thickness. The locations and sizes of areas of altered echogenicity were recorded.
Statistical analysis. For analysis of the sensitivity and
specificity of real-time, high-resolution ultrasound of the
shoulder in the diagnosis of amyloidosis, we first considered
only patients who either had amyloidosis established on the
basis of histologic examination of a surgical specimen (group
IIa) or who had amyloidosis excluded because of the absence of histologic evidence (groups I and IIIa). A positive
finding on ultrasound was defined as the presence of a
rotator cuff >8 mm in thickness and/or an echogenic pad of
material between the muscle layers of the rotator cuff.
Sensitivity was expressed as the proportion of patients with
biopsy evidence of amyloidosis (group IIa) who had a
positive ultrasound result. Specificity was defined as the
proportion of patients who did not have amyloidosis demonstrated by histologic analysis (groups I and IIIa) who had
a negative ultrasound result. Additional analyses of sensitivity and specificity, using clinical criteria for the diagnosis of
amyloidosis, were performed by including patients in groups
IIb and IIIb. Univariate analyses of differences in age and
duration of hemodialysis were performed using Student’s
t-test (17).
KAY ET AL
Table 1. Characteristics of the patients by group
Group*
I
No. of patients
Maleslfemales
Age, mean f SD years
Duration of hemodialysis,
mean f SD years
I1
13
18
6/12
57.8 f 11.2
14.3 2 4.0t
419
62.6 f 18.4
-
~
~
~
~
~
~
~
~
~
~
~
~
~
~~
Ira
Ilb
14
519
57.4 -t 11.8
15.0 f 4.2
4
113
59.3 f 10.2
11.8 f 2.4
~
~
~
~
~
~
~
~
111
IIIa
20
8/12
54.7 f 16.5
8.2 f 5.5t
~
~
~
~
~
~
~
~~~
lIlb
3
17
013
59.3 5 11.2
6.7 5 7.4
819
53.9 f 17.4
10.0 f 5.3
~~~~~~~~~
* Group 1 = patients with normal renal function (control); group I1 = hemodialysis patients with amyloidosis; group IIa = group I1 patients with
clinical and histologic evidence of amyloidosis; group Ilb = group I1 patients with clinical evidence of amyloidosis but with no surgical
specimens available for histologic study; group 111 = hemodialysis patients without amyloidosis; group IlIa = group Ill patients with no clinical
or histologic evidence of amyloidosis; group lllb = group 111 patients with no clinical evidence of amyloidosis but with no surgical specimens
available for histologic study.
t P < 0.001.
RESULTS
Patient characteristics. The clinical and histologic characteristics of the 3 patient groups are
summarized in Table I . The mean ages were 62.6 years
for the patients with normal renal function (group I)
and 57.8 years and 54.7 years, respectively, for the
patients with (group XI) and without (group 111) amyloidosis (P> 0.2 for all pairwise comparisons). However, the patients with amyloidosis had been receiving
dialysis for a significantly longer period of time than
those without amyloidosis (mean k SD 14.3 ? 4.0
years [n = 181 versus 8.2 4 5.5 years [n = 201) (P <
0.001).
Ultrasonographicfindings. Six of the 13 patients
with normal renal function had normal findings on
ultrasound. Several sonographic abnormalities were
noted in the shoulders of the remaining 7 patients in
this group. These consisted of either focal or diffuse
thinning of the rotator cuff to 4 3 mm (normal 4-8 mm),
focal areas of increased echogenicity, and abnormal
fluid collections (Table 2).
In all 14 patients with clinical and histologic
evidence of amyloidosis, abnormalities were exhibited
on shoulder ultrasound. The observed abnormalities
were rotator cuff thickness >8 mm (Figure I), echogenic pads of material between the muscle layers
(Figure 2), focal areas of increased echogenicity within
the rotator cuff, focal or diffuse thinning of the rotator
cuff to 1 3 mm in thickness, irregularity of the humeral
head, and abnormal fluid collections around the joint
(Table 2). All 4 hemodialysis patients with dialysisrelated amyloidosis by clinical diagnosis only also had
abnormal results on shoulder ultrasound, including
rotator cuffs >8 mm in thickness, echogenic pads,
focal areas of increased echogenicity in the rotator
cuff, diffuse thinning of the rotator cuff, irregularity of
the humeral head, and abnormal fluid collections
around the joint (Table 2).
Two of the 3 hemodialysis patients with no
clinical or histologic evidence of amyloidosis had
abnormalities on shoulder ultrasound. The abnormalities were focal areas of increased echogenicity within
the rotator cuff, diffuse thinning of the rotator cuff,
irregularity of the humeral head, and abnormal fluid
collections around the joint. Of the 17 hemodialysis
patients without clinical evidence of dialysis-related
amyloidosis in whom histologic analysis was not performed, sonographic abnormalities were observed in
8. These consisted of focal or diffuse thinning of the
rotator cuff, irregularity of the humeral head, abnor-
Table 2.
Findings on shoulder ultrasonography
Ultrasonographic
finding
Normal
Rotator cuff >8 mm
Echogenic pad
Irregular humeral head
Rotator cuff >8 mm
andor echogenic pad
Increased echogenicit y
in rotator cuff
Focal thinning of
rotator cuff ( 5 3 mm)
Diffuse thinning of
rotator cuff ( 5 3 mm)
Abnormal fluid
collections
Patient group (n)*
I ( 1 3 ) IIa (14) IIb (4) llIa (3) IIIb (17)
6
0
0
0
0
0
10
0
2
4
1
1
11
1
2
2
8
2
4
1
0
0
3
3
1
3
2
I
2
3
I
1
I
* Values are the number of patients.
HIGH-RESOLUTION ULTRASOUND IN DIALYSIS AMYLOIDOSIS
Subcutaneous
929
osis were broadened to include clinical features without histologic confirmation, the sensitivity was 13/18
(72%) and the specificity was 32/33 (97%) (Figure 3).
Humerai head
A
A
B
Figure 1. A, Diagram of tissue layers as imaged on transverse
ultrasound of the normal shoulder. The rotator cuff tendon is a
homogeneous band of tissue overlying the humeral head, deep to the
deltoid muscle and subcutaneous tissue. (Reproduced, with permission, from Bretzke CA, Crass JR, Craig EV, Feinberg SB: Ultrasonography of the rotator cuff: normal and pathologic anatomy.
Znvesrigative Radiology 20:311-315, 1985.) B,Transverse sonogram
showing a thickened rotator cuff tendon in a patient with histologically proven penarticular amyloidosis. The thickness of the rotator
cuff (RC)is 12 mm (calipers). The deltoid muscle (D)is displaced by
the thickened rotator cuff tendon. H = humeral head; SC =
subcutaneous tissue.
ma1 fluid collections around the joint, and nonvisualization of the biceps. In 1 of these 8 patients, an
echogenic pad was seen over the rotator cuff of 1
shoulder.
The diagnostic sensitivity and specificity of a
rotator cuff >8 mm in thickness and/or the presence of
an echogenic pad, in relation to histologically diagnosed amyloidosis, were 11/14 (79%) and 16/16
(100%), respectively. When the criteria for amyloid-
B
Figure 2. Echogenic pads in patients with histologically proven
periarticular amyloidosis. A, Transverse oblique sonogram of the
anterior rotator cuff showing 2 echogenic pads (EP)on either side of
the subscapularis tendon (straight arrows) of the rotator cuffnearits
insertion on the lesser tuberosity of the humeral head (H).B,
Transverse sonogram showing an echogenic pad of 8 x 18 mm
(calipers)between subcutaneous tissue (SC)and the rotator cuff (RC).
KAY ET AL
930
Patients with histologic di.gnos*
BCmlcrogl&ilin
Positive
Negative
Sensitivity
-
amyldd praent
(Croup 11’)
Bpnicmglobulin amyloid absent
(Groups 1. 11P)
79%
Specifidty = 100%
All patients
CIINICAL DIAGNOSIS
UlrruavRo
No amyloidosis
(Gmups I, 1118, I I P )
Sensitivity = 12%
Spesilidiy = 97%
Figure 3. Sensitivity and specificity of high-resolution ultrasound
for the diagnosis of dialysis-related amyloidosis.
DISCUSSION
Shoulder pain is common among hemodialysis
patients, most often arising from tendinitis, bursitis,
rotator cuff tears, and amyloidosis. However, gout,
pseudogout, infections, and hyperparathyroidism
must also be considered in the differential diagnosis
(18-20). Typically, the history, physical examination,
and laboratory data do not permit a clear distinction
among these disorders.
Real-time, high-resolution ultrasound is a sensitive imaging technique for evaluation of select pathologic conditions involving the biceps, rotator cuff
tendons, and subdeltoid bursa of the shoulder (16).
Disorders that can be diagnosed by high-resolution
ultrasound of the shoulder include rupture of the
biceps tendon, excessive fluid in the bursa, and rotator
cuff tendinitis, tears, and atrophy.
High-resolution ultrasonography of the shoulders of hemodialysis patients with and without clinical
and histologic evidence of dialysis-related amyloidosis
revealed numerous abnormalities. In comparison with
patients who had normal renal function (group I), 2
findings were selectively observed in the dialysis patients who had clinical and histologic evidence of
amyloid (group 1Ia): 71% demonstrated greatly increased rotator cuff thickness and 29% exhibited the
presence of an echogenic pad between muscle groups.
At least 1 of these findings was observed in 79% of the
patients in group IIa. Analysis of the diagnostic sensitivity of a thickened rotator cuff and an interposed
echogenic pad was extended to include hemodialysis
patients who had only a clinical diagnosis of dialysisrelated amyloidosis (group IIb). A thickened rotator
cuff was observed in 67% of the patients with histologic and/or clinical evidence of amyloidosis (groups
IIa and IIb combined), and an echogenic pad was
observed in 28% of these patients. At least 1 of these
sonographic findings was seen in 72% of the hemodialysis patients with amyloidosis.
In the remaining group I1 patients with clinical
amyloidosis but without either of the above-described
sonographic findings, rotator cuffs 5 3 mm in thickness, compatible with tears or atrophy, were noted.
Humeral head irregularities, which were observed in
hemodialysis patients with or without amyloidosis,
may represent erosive changes of the humeral head
resulting from inflammatory arthropathy or metabolic
bone disease.
Thus, the sonographic findings of a maximal
rotator cuff thickness >8 mm or the presence of a pad
of echogenic material interposed between muscle layers of the rotator cuff have 72-79% sensitivity in the
diagnosis of amyloidosis. In contrast, these sonographic findings were observed in only 0-3% of the
patients without amyloidosis, indicating a specificity
of 97-100%. These results indicate that high-resolution
ultrasound is a useful, noninvasive technique for diagnosis of dialysis-related amyloidosis.
Dialysis-related amyloidosis typically presents
with a polyarticular distribution (12). Thus, it is not
surprising that sonographic abnormalities in the shoulder are predictive of diagnostic pathologic findings in
other joints. The ultrasonographic findings of increased echogenicity in the rotator cuff, focal or
diffuse thinning of the rotator cuff to 5 3 mm, irregularity of the humeral heads, or abnormal fluid collec-
HIGH-RESOLUTION ULTRASOUND IN DIALYSIS AMYLOIDOSIS
tions were of little use in the diagnosis of amyloidosis
in the patients studied.
The present study has potential limitations. The
ultrasonographic testing was performed at a single
academic medical center, and the population of dialysis patients may not be representative of those at other
institutions. Selection bias was present because dialysis patients were referred for evaluation of shoulder
pain. The number of patients studied was small, and
the estimates of sensitivity and specificity would be
more precise if the sample size were larger. Further
investigations will be needed to generalize our findings. However, the principal results were derived
using patients who did have a definitive histologic
diagnosis of &m amyloidosis.
Although surgical specimens available for
pathologic analysis for the presence of &m were from
joints other than the shoulder or rotator cuff in 12 of
the 14 patients in group IIa, the presence of &m
amyloid in musculoskeletal tissue in a dialysis patient
with shoulder pain suggests involvement of the shoulder. There is, however, a slight possibility that the
changes detected by ultrasonography do not represent
amyloid deposits. Because of its superior imaging
properties and our greater experience with visualizing
pathologic conditions in the shoulder, ultrasonography
was limited to this joint as a representative joint
involved in dialysis-related amyloidosis. Ultrasonographic examination of the shoulder was performed by
an ultrasonographer who was unaware of the patients'
clinical or histologic evaluations. The observations
were extended to those patients whose diagnosis was
based on an ad hoc clinical definition with little change
in either sensitivity or specificity, but we recognize
that this extended observation has not been validated
against a definitive standard.
Previous studies have utilized ultrasonography
of the hips and knees to evaluate synovial thickness in
patients undergoing long-term hemodialysis (21,22).
However, the investigators did not correlate their
findings with synovial histologic analyses, nor did they
define levels of sensitivity or specificity. In an analogous manner to the present investigation, real-time,
high-resolution 2-dimensional echocardiography has
been utilized as a noninvasive tool for diagnosing
myocardial infiltration in patients with primary amyloidosis. Depending on the ultrasonographic criteria
used, the sensitivity of this test is 6047% and the
specificity is 81-100% (23), comparable with the sensitivity and specificity observed using ultrasound of
the shoulder to diagnose dialysis-related amyloidosis.
Results similar to ours were observed in a recent
93 1
investigation using conventional ultrasonography of
the shoulder, but fewer patients were studied and the
presence of &m amyloid deposits was not confirmed
by immunohistochemical studies (24).
Based on these findings, high-resolution ultrasound is a relatively sensitive and highly specific
noninvasive method that can be used as an adjunct to
clinical diagnosis of amyloidosis in patients undergoing long-term hemodialysis. The technique will have to
be studied prospectively in larger numbers of patients
to determine its capacity to detect amyloidosis both in
asymptomatic individuals and individuals with early
disease. It should prove to be a useful tool for assessing the efficacy of therapeutic interventions used to
treat the &m deposition characteristic of this disorder.
ACKNOWLEDGMENTS
The authors thank Dr. Jeffrey N. Katz for his helpful
comments, Sttphanie Bourdelle for excellent manuscript
preparation, and the Massachusetts General Hospital and
the New England Deaconess Hospital for providing paraffin
blocks of some surgical specimens.
REFERENCES
1. Bardin T, Kuntz D, Zingraff J, Voisin M-C, Zelmar A,
Lansaman J: Synovial amyloidosis in patients undergoing long-term hemodialysis. Arthritis Rheum 28: 10521058, 1985
2. Kuntz D, Naveau B, Bardin T, Drueke T, Treves R.
Dry11 A: Destructive spondylarthropathy in hemodialyzed patients: a new syndrome. Arthritis Rheum 27:
369-375, 1984
3. Warren DJ, Otieno LS: Carpal tunnel syndrome in
patients on intermittent haemodialysis. Postgrad Med J
51:450-452, 1975
4. Assenat H, Calemard E, Charra B, Laurent G, Terrat
JC, Vane1 T: Htmodialyse: syndrome du canal carpien
et substance amyloi'de (letter). Nouv Presse Med 9:1715,
1980
5 . Laurent G, Calemard E, Charra B: Dialysis-related
amyloidosis. Kidney Int 33 (Suppl):S-32-S-34, 1988
6. Muhoz-Gbmez J, BergadB-Barado E, G6mez-Perez R,
Llopart-BuisBn E, Subias-Sobrevia E, Rotts-Querol J ,
Solt-Arquts M: Amyloid arthropathy in patients undergoing periodical haemodialysis for chronic renal failure:
a new complication. Ann Rheum Dis 44:729-733, 1985
7. Durroux R, Benouaich L, Bouissou H, Mansat M,
Clanet M: Ttnosynovite du canal carpien et dtp6ts
amyloides chez les insuffisants rknaux chroniques htmodialyses (letter). Nouv Presse Med 10:45, 1981
8. Gejyo F, Yamada T, Odani S, Nakagawa Y, Arakawa
M, Kunitomo T, Kataoka H , Suzuki M, Hirasawa Y,
Shirahama T, Cohen AS, Schmid K: A new form of
932
amyloid protein associated with chronic hemodialysis
was identified a s beta 2-microglobulin. Biochem
Biophys Res Commun 129:701-706, 1985
9. Shirahama T , Skinner M, Cohen AS, Gejyo F, Arakawa
M, Suzuki M, Hirasawa Y: Histochemical and immunohistochemical characterization of amyloid associated
with chronic hemodialysis as beta 2-microglobulin, Lab
Invest 53:705-709, 1985
10. Vandenbroucke JM, Jadoul M, Maldague B, Huaux JP,
Noel H, van Ypersele de Strihou C: Possible role of
dialysis membrane characteristics in amyloid osteoarthropathy (letter). Lancet 1:1210-1211, 1986
11. Chanard J, Lavaud S, Toupance 0, Roujouleh H , Melin
3-P: Carpal tunnel syndrome and type of dialysis membrane used in patients undergoing long-term hemodialysis (letter). Arthritis Rheum 29:1170-1171, 1986
12. Owen WF: Erosive spondyloarthropathy in a long-term
chronic hemodialysis patient. Semin Dial 2:85-88, 1989
13. Chattopadhyay C, Ackrill P, Clague RB: The shoulder
pain syndrome and soft-tissue abnormalities in patients
on long-term haemodialysis. Br J Rheumatol 26: 181187, 1987
14. Puchtler H, Sweat F, Levine M: On the binding of
Congo red by amyloid. J Histochem Cytochem 10:355364,1962
15. Pinkus GS, Said JW: Specific identification of intracelM a r immunoglobulin in paraffin sections of multiple
myeloma and macroglobulinemia using an immunoperoxidase technique. Am J Pathol 87:47-58, 1977
16. Benson CB: Sonography of the musculoskeletal system.
Rheum Clin North Am 17:487-504, 1991
KAY ET AL
17. Colton T: Statistics in Medicine. Boston, Little, Brown
& Co., 1974
18. Llach F, Pederson JS: Acute joint syndrome (AJS) and
maintenance hemodialysis (HD). Proc Clin Dial Transplant Forum 9:17-22, 1979
19. Massry SG, Bluestone R, Klinenberg JR, Coburn JW:
Abnormalities of the musculoskeletal system in hemodialysis patients. Semin Arthritis Rheum 4:321-349,
1975
20. Wright RS, Mehls 0, Ritz E, Coburn JW: Musculoskeletal manifestations of chronic renal failure, dialysis, and
transplantation, The Kidney and Rheumatic Disease.
Edited by PA Bacon, NM Hadler. London, Butterworth, 1982
21. Laurent G , Charra B, Calemard E, Uzan M, Vane1 T,
Terrat JC, Pracros JP: Mesure Bchographique de I’Cpaississement synovial de la hanche: inttret dans I’evaluation de I’arthropathie des dialyses. Presse Med 18:
939, 1989
22. Gielen JL, van Holsbeeck MT, Hauglustaine D, Veerresen L, Verbeken E, Baert AL, Meens L, Vandevoorde P, Michielsen P, Coral A: Growing bone cysts in
long-term hemodialysis. Skeletal Radio1 19:43-49, 1990
23. Falk RH, Plehn JF, Deering T, Schick EC Jr, Boinay P,
Rubinow A, Skinner M, Cohen AS: Sensitivity and
specificity of the echocardiographic features of cardiac
amyloidosis. Am J Cardiol 59:41W22, 1987
24. McMahon LP, Radford J, Dawborn JK: Shoulder ultrasound in dialysis related amyloidosis. Clin Nephrol
35~227-232, 1991
Документ
Категория
Без категории
Просмотров
3
Размер файла
659 Кб
Теги
resolution, dialysis, high, amyloidosis, related, utility, diagnosis, ultrasound
1/--страниц
Пожаловаться на содержимое документа