The association of systemic lupus erythematosus (SLE) with idiopathic polymyositis or dermatomyositis is reported to occur in the range of 4-16%. Myositis can occur before or after SLE, or sporadically both diseases can be present simultaneously. This case report concerns a 36-year-old female patient suffering from Raynaud's phenomenon, polyarthralgia in the small joints of the hands, and skin changes compatible with Gotron's indications. Symmetric proximal muscle weakness of the extremities, fever of up to 40 degrees C, heliotrope rashes with erythematous changes in the face, upper arms, and posterior shoulders occurred subsequently. Laboratory analyses revealed increased acute phase reactants, hypochromic anaemia, lymphopenia, and increased levels of all muscle enzymes. Immunoserology demonstrated positive ANA, anti-Sm, and anticardiolipin antibodies (aCL), while anti dsDNA, anti Ro, anti La, and anti Jo-1 antibodies proved negative. Hypocomplementaemia and elevated levels of immune complexes were also detected. Pathologic sediment and proteinuria were revealed via urine analyses, while a kidney biopsy confirmed lupus nephritis (type IVa according to the World Health Organisation classification). Biopsy of erythematous changes of the posterior shoulder demonstrated leukocytoclastic vasculitis. Electromyography of the lower extremities established myopathic changes. Inflammation of the muscles was confirmed via magnetic resonance imaging. The patient was categorised as having two separate coexistent diseases--SLE and dermatomyositis. Both the classification criteria of the American College of Rheumatology for SLE and the diagnostic criteria for dermatomyositis, proposed by Bohon and Peter, were fulfilled simultaneously. Treatment commenced with pulses of methylprednisolone and continued with oral therapy, including Resochin. Pulses of intravenous cyclophosphamide were also administered. After six weeks of therapy, biohumoral remission of both diseases was achieved, while complete recovery from muscle weakness was accomplished after four months.
Background and Aims Relative hypervolemia or overhydration (ROH) above 15% of the normally hydrated body extracellular volume (ECV), assessed by bioimpedance spectroscopy (BIS), puts chronic hemodialysis (HD) patients at an increased risk of cardiovascular (CV) incidents and death, as numerous studies have shown. It has also been reported that the reduction of ROH to the value below 15% of ECV can positively affect hypertension and some aspects of the left ventricle (LV) function and morphology. The concept of Active Fluid Management (AFM) has been developed and it hypothesized that maintaining average (weekly) predialysis overhydration (AWOH) below 15% of ECV will preserve heart function and structure and thus lead to fewer CV complications. The purpose of this study was to investigate the effects of AFM concept guided by BIS on cardiac morphology, mechanics and function in chronic HD patients. Methods Randomized prospective single-center study lasted 9 months and included BIS naive HD patients from the Dialysis unit of Zvezdara University Medical Center in Belgrade with HD vintage greater of 3 months. BIS was performed by Body Composition Monitor (BCM). In accordance with the AFM concept, BIS was applied to patients in the Active group every time their average weekly ROH (AWOH) exceeded 15% of their normal ECV and their dry weight (DW) was time-adjusted according to the findings along with clinical assessment. In the Control group, patients were treated in accordance with the standard clinical practice. Cardiac structural and functional characteristics were obtained at the beginning and the end of the study by using 2-dimensional Doppler echocardiography and spackle tracking modality. Cardiac markers (high-sensitivity C-reactive protein, Troponin T and N-terminal pro-brain natriuretic peptide) were measured at the same time. Results The study included 42 patients (25 M) in the Active group and 41 patients (23 M) in the Control group. Patients from both groups were of similar age (56.1 ± 11.5 vs. 57.5 ± 13.2 years, p = 0.6) and HD vintage (79.9 ± 59.2 months vs. 95.3 ± 80.0 months, p = 0.6). 73 patients completed the 9 months study, 38 in the Active group and 35 in Control group. Within the Active group, recommended AWOH lower than 15% ECV has 55% at start and 76% of patients at the end of study (p< 0.01). In parallel, there were improvements in their LV ejection fraction (LVEF), from 41.3 ± 9.3% to 44.0 ± 8.8% (p < 0.01), LV end systolic volume index, from 40.2 ± 12.5 to 35.8 ± 13.5 ml/m2 (p < 0.05), LV mass indexed at height at 2.7 (LVMI2.7) from 62.8 ± 19.7 g / m2.7 to 57.7 ± 16.9 g/m2.7 (p <0.01) and Global radial strain (GRS) - from 18.6 ± 10.2% to 21.8 ± 12.2% (p <0.05). In the Control group, there were signs of LV diastolic function worsening at the end of the study: E/A ratio increased from 1.0 ± 0.3 to 1.2 ± 0.6 (p < 0.01), as well as E/e’ lateral ratio from 10.6 ± 5.0 to 11.1 ±4.1 (p <0.01) and right ventricle systolic pressure (RVSP) from 34.8 ± 10.2 mmHg to 38.8 ± 8.3 mmHg (p <0.05). This worsening of LV diastolic function in the Control group correlated with the increased level of one of the cardiac markers, N-terminal pro-brain natriuretic peptide (NT-proBNP) - from 5810.0 (3339.0-15627.0) pg/ml to 8024.0 (4433.0-17467.0) pg/ml (p <0.04). Conclusion Active Fluid Management leads to the improvement of left ventricle systolic function and prevents worsening of diastolic function in the observed hemodialysis patients. This concept implemented could favourably affect the clinical course of hemodialysis patients in daily clinical practice.
Introduction and Aims: Hypertension in chronic hemodialysis (HD) patients ( pts) is volume dependent on up to 80% of cases. Volume assessment by bioimpedance spectroscopy (BIS) could be more accurate and better target for the treatment then just clinically assessed dry weight (DW). The studies have shown that the relative overhydration (ROH) of HD pts above 15% of their total body extracellular water (ECW), poses increased mortality risk in this population. The concept of the Active Fluid Management (AFM) has been developed and proposed for better control of ECW and less CV complications. This randomized, prospective, blinded, single-center study was aimed to evaluate the impact of active fluid management (AFM) assessed by BIS on hypertension control in HD pts during nine-month period. Methods: Study included 59 BIS naive HD pts. BIS was performed by Body Composition Monitor (BCM). In the 1. (active) group according with AFM concept, this measurement has been done every time when their average weekly overhydration (AWOH) exceeded 15% of their normal extracellular volume (ECW) and their DW was time adjusted according to the finding along with clinical judgment. In the 2. (control) group, BIS has been performed monthly and its results did not influence the clinical assessment of their DW.We registered the average blood pressure of 6 successive dialysis measurements before and after dialysis sessions, as well as the number of antihypertensive (AHT) drugs, their equivalent dose (ED) units and N-terminal brain natriuretic peptide (NTpro-BNP) at the start and after 9 months.
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