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Answer from UpToDate

• accumulation and tissue deposition of amyloid fibrils consisting of beta2-microglobulin (beta2-m) in the bone, periarticular structures, and viscera of patients with chronic kidney disease (CKD
• prevalence of DRA has...
Answer from UpToDate

• accumulation and tissue deposition of amyloid fibrils consisting of beta2-microglobulin (beta2-m) in the bone, periarticular structures, and viscera of patients with chronic kidney disease (CKD
• prevalence of DRA has decreased with the use of high-flux biocompatible membranes, which provide better clearance of beta2-m and are less likely to induce reactive inflammation
• Amyloid deposition results in the following common presentations:

●Carpal tunnel syndrome (CTS)

●Scapulohumeral periarthritis

●Flexor tenosynovitis

●Destructive spondyloarthropathy

●Bone cysts

●Visceral involvement, particularly gastrointestinal

• lesions in which beta2-m amyloid is deposited are associated with a marked influx of activated macrophages expressing cytokines, such as interleukin-1, tumor necrosis factor-alpha, and transforming growth factor-beta
• Beta2-m may cause bone destruction by directly stimulating formation of osteoclasts

• A prospective postmortem study found joint amyloid deposition in 21 percent of patients receiving hemodialysis for <2 years, 50 percent at 4 to 7 years, 90 percent at 7 to 13 years, and 100 percent at >13 years
• Risk factors for DRA include the following
○ ●Increasing age and dialysis vintage
○ ●Use of low-flux dialysis membranes
○ ●Use of bioincompatible dialysis membrane
○ ●Lack of residual renal function

• Physical exam - Guitar string hand - fixed flexion deformity of the hand. Amyloid hand - decreased prominence of thenar eminence.
• renal transplantation since it provides the most effective reduction of beta2-m levels

• Rx
○ hemodialysis patients with DRA, we use a highly biocompatible, high-flux membrane
○ increase the dialysis duration and/or frequency. Increasing the weekly treatment time decreases beta2-m concentrations
○ consider switching to either nocturnal or short daily hemodialysis since both modalities may be better than conventional thrice weekly dialysis for reducing beta2-m

○ Significant removal of beta2-m occurs with hemofiltration and hemodiafiltration

○ use of a beta2-m column that is available for clinical use in Japan in patients with DRA is associated with increased beta2-m removal and better improvement in symptoms versus dialysis alone
○ PD - May or may not have lower incidence - confounded by RRF

○ Surgery and analgesia helpful - in surgical treatments removal of the beta2 m infiltrated synovium is advisable.
  1.   Nikhil Shah
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Resolved Locked Unanswered
1. Maximize the osmotic gradient
a) Higher tonicity dwells
b) Shorter duration dwells
c) Higher dwell volumes
2. Osmotic agent with higher reflection coefficient eg Icodextrin (reflec Coeff = 1.0, glucose reflection coeff = 0.03)
3....
1. Maximize the osmotic gradient
a) Higher tonicity dwells
b) Shorter duration dwells
c) Higher dwell volumes
2. Osmotic agent with higher reflection coefficient eg Icodextrin (reflec Coeff = 1.0, glucose reflection coeff = 0.03)
3. Increasing urine output (eg Diuretics)

ref - Daugirdas Handbook.
  1.   Nikhil Shah
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1. Concentration gradient for the osmotic agent eg Glucose.
2. Effective Peritoneal surface area.
3. Hydraulic conductance of the peritoneal membrane
4. Reflection coefficient of the osmotic agent - glucose
5. Hydrostatic pressure gradient.
6...
1. Concentration gradient for the osmotic agent eg Glucose.
2. Effective Peritoneal surface area.
3. Hydraulic conductance of the peritoneal membrane
4. Reflection coefficient of the osmotic agent - glucose
5. Hydrostatic pressure gradient.
6. Osmotic pressure gradient
7. Sieving
8. Alternative osmotic agents - eg Icodextrin.

Ref Daugirdas, Handbook of Dialysis.
  1.   Nikhil Shah
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the approximate incidence of the different bleeding complications was as follows:
●Transient macroscopic hematuria (3.5 percent)
●Requirement for erythrocyte transfusion (0.9 percent)
●Requirement for angiographic intervention to control...
the approximate incidence of the different bleeding complications was as follows:
●Transient macroscopic hematuria (3.5 percent)
●Requirement for erythrocyte transfusion (0.9 percent)
●Requirement for angiographic intervention to control bleeding (0.6 percent)
●Requirement for nephrectomy to control bleeding (0.01 percent)
●Death (0.02 percent)

The rate of requiring erythrocyte transfusion, which was 0.9 percent overall, was on average significantly higher in patients with the following characteristics
●Systolic blood pressure greater than or equal to 130 mmHg (1.4 versus 0.1 percent)
●Serum creatinine greater than or equal to 2 mg/dL (177 micromol/L) (2.1 versus 0.4 percent)
●Hemoglobin concentration less than 12 g/dL (2.6 versus 0.5 percent)
●Age over 40 years (1 versus 0.2 percent)

Ref:
Bleeding complications of native kidney biopsy: a systematic review and meta-analysis. Corapi KM, Chen JL, Balk EM, Gordon CE
Am J Kidney Dis. 2012 Jul;60(1):62-73. Epub 2012 Apr 24.
and UpToDate
  1.   Nikhil Shah
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Contraindications - (Absolute in italics) -

Small hyperechoic kidneys (less than 9 cm), which are generally indicative of chronic irreversible disease
Solitary native kidney
Multiple, bilateral cysts or a renal tumor
Uncorrectable bleeding...
Contraindications - (Absolute in italics) -

Small hyperechoic kidneys (less than 9 cm), which are generally indicative of chronic irreversible disease
Solitary native kidney
Multiple, bilateral cysts or a renal tumor
Uncorrectable bleeding diathesis
Severe hypertension, which cannot be controlled with antihypertensive medications
Hydronephrosis
Active renal or perirenal infection
Anatomic abnormalities of the kidney which may increase risk (see above)
Skin infection over the biopsy site
An uncooperative patient

Ref - Clinical competence in percutaneous renal biopsy. Health and Public Policy Committee. American College of Physicians. PMID 3341661
and UpToDate.
  1.   Nikhil Shah
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