1/9. Ischemic monomelic neuropathy: a complication of vascular access procedure.Ischemic monomelic neuropathy (IMN) is an infrequently recognized type of ischemic neuropathy produced by shunting of blood or due to acute noncompressive occlusion of the major proximal limb artery. Most reports about this complication appear in the neurology literature. IMN predominantly occurs in diabetic patients with evidence of peripheral neuropathy and atherosclerotic peripheral vascular disease. We report a case of ischemic monomelic neuropathy occurring in a patient with end stage diabetic nephropathy following PTFE (polytetrafluoroethylene) graft placement in proximal upper limb for chronic maintenance hemodialysis.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
2/9. hypertension, the endothelial cell, and the vascular complications of diabetes mellitus.hypertension is a major factor that contributes to the development of the vascular complications of diabetes mellitus, which primarily include atherosclerosis, nephropathy, and retinopathy. The mechanism of the pathophysiological effects of hypertension lies at the cellular level in the blood vessel wall, which intimately involves the function and interaction of the endothelial and vascular smooth muscle cells. Both hypertension and diabetes mellitus alter endothelial cell structure and function. In large and medium size vessels and in the kidney, endothelial dysfunction leads to enhanced growth and vasoconstriction of vascular smooth muscle cells and mesangial cells, respectively. These changes in the cells of smooth muscle lineage play a key role in the development of both atherosclerosis and glomerulosclerosis. In diabetic retinopathy, damage and altered growth of retinal capillary endothelial cells is the major pathophysiological insult leading to proliferative lesions of the retina. Thus, the endothelium emerges as a key target organ of damage in diabetes mellitus; this damage is enhanced in the presence of hypertension. An overall approach to the understanding and treatment of diabetes mellitus and its complications will be to elucidate the mechanisms of vascular disease and endothelial cell dysfunction that occur in the setting of hypertension and diabetes.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
3/9. Ischaemic necrosis of the glans penis: a complication of urethral catheterization in a diabetic man.Ischaemic necrosis of the glans penis is rare. Diabetic patients commonly have small vessel disease which may affect the penis. We report the case of a man with extensive diabetic vascular disease, in whom partial penectomy was necessary for ischaemia of the glans penis, following urethral catheterization. The decision to use a urethral catheter in diabetics, particularly those with evidence of vascular disease, must be made with the knowledge that internal compression caused by the catheter may cause irreversible ischaemic changes. In such patients, a suprapubic catheter should be considered as an alternative.- - - - - - - - - - ranking = 2keywords = vascular disease (Clic here for more details about this article) |
4/9. Rapid development of nephrotic syndrome, hypertension, and hemolytic anemia early in pregnancy in patients with IDDM.In recent years, the prognosis for a successful pregnancy has greatly improved for women with insulin-dependent diabetes mellitus (IDDM) who are under good glycemic control and free of complications such as vascular disease and nephropathy. We report the rapid development of severe nephrotic syndrome, malignant hypertension, and microangiopathic hemolytic anemia during the first trimester of pregnancy in a 29-yr-old woman with IDDM of 18 yr duration. Our patient had no pregestational history of retinopathy or hypertension and only minimal proteinuria. Significant improvement in blood glucose levels had been achieved over the 6 mo before conception. kidney biopsy performed before the termination of pregnancy at 10 wk gestation revealed diabetic nephropathy. No other etiology for her renal disease could be found. An arteriole was noted to have entrapped red blood cell fragments and platelet thrombi, revealing the probable source of her hemolytic process. By 8 wk postpartum, her nephrotic syndrome and hemolysis had completely resolved. At 3 mo postgestation, the patient's hypertension was still present but less severe. Her serum creatinine has continued to decrease toward normal. This is the first report of a woman with IDDM in White's classification C who developed a toxemia-like syndrome during the first trimester of pregnancy, attributable to the underlying diabetic state.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
5/9. Identification of risk for renal insufficiency from nonsteroidal anti-inflammatory drugs.Risk for renal insufficiency (RI) resulting from nonsteroidal anti-inflammatory drugs (NSAID) exists in cirrhosis with ascites, nephrotic syndrome, decompensated congestive heart failure, and chronic renal disease. We saw seven cases of NSAID RI that demonstrate important additional clinical risk factors. These include advanced age (mean, 76 years), use of diuretic drugs (6/7 patients), and evidence of renal vascular disease as suggested by long-standing hypertension, diabetes, or atherosclerotic cardiovascular disease (7/7 patients). Analysis of past case reports of NSAID RI also showed these features. Treatment of acute gouty arthritis was the most common precipitating event. Evolving NSAID RI was suggested by rising serum urea nitrogen, serum creatinine, and serum potassium levels, and body weight gain associated with low fractional excretion of sodium. We conclude that since NSAID RI is preventable and reversible, it is important to recognize and monitor the conditions of those patients at risk.- - - - - - - - - - ranking = 2keywords = vascular disease (Clic here for more details about this article) |
6/9. Splenic infarct presenting as sterile peritonitis with peripheral embolic phenomena.Two patients with end-stage renal disease from diabetes mellitus on peritoneal dialysis for 2 or more years developed sterile peritonitis secondary to splenic infarcts with associated peripheral embolic phenomena. The dialysate had WBC counts > 200/microL, of which 70% or more were polymorphonuclear cells, and RBC counts of 60/microL or less, although transient hemoperitoneum occurred in both patients. Extensive atherosclerotic vascular disease as well as hematologic abnormalities were also present in both patients. One patient had polycythemia due to decreased plasma volume. The other patient had evidence of dysfibrinogenemia. The patients responded well to anticoagulation with warfarin. When the warfarin was discontinued, recurrent emboli occurred in both patients. Splenic infarct should be included in the differential diagnosis of diabetic patients with atherosclerotic disease who present with sterile peritonitis that does not respond to antibiotic therapy, especially if hemoperitoneum occurs even transiently. The diagnosis can be confirmed with CT scan of the abdomen. warfarin therapy is effective in preventing recurrent embolic phenomena, but may need to be continued indefinitely.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
7/9. Atypical presentation of stroke in a diabetic hemodialysis patient.Cerebrovascular disease is a major cause of death in patients with end-stage renal disease, particularly in those with diabetes mellitus. Cardiac disease frequently presents itself atypically in diabetic patients. This awareness has led to earlier detection and treatment of cardiac disease in diabetic patients. Whether cerebrovascular disease may also present itself in a highly atypical fashion in the diabetic patient with end-stage renal disease has never been addressed. We report the case of a diabetic hemodialysis patient who had an extremely unusual manifestation of stroke. A 67-year-old diabetic hemodialysis patient had marked distress secondary to the sudden onset of a foreign body sensation in the oropharynx. Results of a laryngoscopy were negative; x-rays of the neck and computerized tomography of the head and neck showed no abnormalities. Neurologic evaluation revealed an inability to detect oropharyngeal stimuli and an absent gag reflex but no other deficits. magnetic resonance imaging of the brain revealed an infarction in the left corona radiata that extended to the thalamocapsular region and external capsule, and a lacunar infarct in the right pons. Cerebrovascular disease in the diabetic patient with end-stage renal disease may present itself atypically, and we suggest that cerebrovascular disease in these patients merits the same level of suspicion as cardiac disease.- - - - - - - - - - ranking = 4keywords = vascular disease (Clic here for more details about this article) |
8/9. Risk of fatal cerebrovascular accident in patients on peritoneal dialysis versus hemodialysis.Several reports have suggested that the incidence of hemorrhagic stroke may be greater on hemodialysis as compared with that among the general population and that patients with intracranial hemorrhage should be treated with peritoneal dialysis rather than hemodialysis. However, whether the risk of fatal stroke is greater on hemodialysis versus peritoneal dialysis has not been systematically examined. In this study, the case of a diabetic patient with extensive peripheral vascular disease who, after 7 years on hemodialysis, was changed to peritoneal dialysis and subsequently suffered two strokes over a 5-month period, is reported. Recent data from the united states Renal Data System, which allow a comparison of death rates from stroke in large numbers of hemodialysis versus peritoneal dialysis patients, are reviewed. These data suggest that the risk of death from stroke may actually be greater for patients on peritoneal dialysis versus hemodialysis in spite of their having a lesser prevalence of preexisting cerebrovascular disease. This risk was greatest for elderly diabetic black patients and women, who experienced a nearly twofold-greater odds favoring death from stroke on peritoneal dialysis versus hemodialysis. Selection of a dialysis modality for a patient beginning renal replacement therapy may require the consideration of such data, particularly in those patients with extensive preexisting vascular disease.- - - - - - - - - - ranking = 3keywords = vascular disease (Clic here for more details about this article) |
9/9. Cryofibrinogenemia: an addition to the differential diagnosis of calciphylaxis in end-stage renal disease.Cryofibrinogenemia is a disorder characterized by cryoprecipitation with variable clinical presentation that was first described by Korst and Kratochvil in 1955. Cryofibrinogen is a cold insoluble complex of fibrin, fibrinogen, and fibrin split products with albumin, cold insoluble globulin, factor viii, and plasma proteins. Cryofibrinogenemia is associated with metastatic malignancies, collagen vascular diseases, and thromboembolic disorders and may be clinically asymptomatic or present with thromboembolic phenomena of skin and viscera. The pathogenesis of cryofibrinogenemia is unknown. It may be caused by the inhibition of fibrinolysis, leading to an accumulation of cryofibrinogen. Treatment of cryofibrinogenemia may include stanozolol, plasmapheresis, and fibrinolytics. Cryofibrinogenemia simulates calciphylaxis clinicopathologically, because both may present with skin necrosis. calciphylaxis has been reported in end-stage renal disease, but we report the first case of cryofibrinogen in a chronic dialysis patient. We suggest that in the appropriate clinical setting, cryofibrinogenemia should be considered in the differential diagnosis of calciphylaxis, and serum cryofibrinogen levels should be measured in end-stage renal disease patients presenting with skin necrosis.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |