Repozitorij Medicinskog fakulteta Sveučilišta u Zagrebu

Važnost ultrazvučnog praćenja promjena na velikim zglobovima u bolesnika s kroničnim bubrežnim zatajivanjem [The role of ultrasonographic monitoring for large joint changes in patients with chronic renal failure]

Matoković, Damir (2011) Važnost ultrazvučnog praćenja promjena na velikim zglobovima u bolesnika s kroničnim bubrežnim zatajivanjem [The role of ultrasonographic monitoring for large joint changes in patients with chronic renal failure]. PhD thesis, Sveučilište u Zagrebu.

[img]
Preview
PDF
Download (1418Kb) | Preview

    Croatian abstract

    Uvod: Bolesnici liječeni hemodijalizom često imaju komplikacije na koštano zglobnom sustavu. One su posljedica bubrežne osteodistrofije i amiloidoze povezane s hemodijalizom. Promjene zahvaćaju meka tkiva zglobova, okolnih struktura i kosti. Morfološke promjene dovode do pojave kliničkih simptoma i funkcionalnih poremećaja. Pretpostavljamo da je UZV i RTG pretragom moguće rano otkriti i pratiti pretkliničke morfološke promjene na velikim zglobovima u bolesnika s kroničnim bubrežnim zatajivanjem i da se na ovaj način može preventivno djelovati u bolesnika koji su liječeni hemodijalizom tako da se smanje i izbjegnu komplikacije. ----- Cilj rada: Ultrazvučnim pregledom utvrditi promjene na tri velika zgloba u bolesnika podvrgnutih hemodijalizi ovisno o vremenskom trajanju hemodijalize, životnoj dobi i koncentraciji β2-mikroglobulina u serumu bolesnika. ----- Ispitanici i metode: Ultrazvukom izmjerena je debljina tetive m. supraspinatusa, m. biceps brachii, zglobne ovojnice kuka, sinovijalne ovojnice koljena i zglobnog izljeva u području kuka i koljena obostrano. Pregledano je 106 bolesnika podvrgnutih hemodijalizi (56 muškaraca i 51 žena prosječne životne dobi 67,9 (28,2-87,4) godina) i 51 zdravi ispitanik kontrolne skupine (25 muškaraca i 26 žena prosječne životne dobi 62,6 (40,0-86,4) godina). Ultrazvukom je pregledano 636 zglobova ispitivane skupine na kojima je učinjeno 2120 ultrazvučnih mjerenja i 306 zglobova ispitanika kontrolne skupine na kojima je učinjeno 1020 ultrazvučnih mjerenja. Uspoređene su izmjerene veličine ispitivane i kontrolne skupine ispitanika. Prema vremenskom trajanju hemodijalize bolesnici su podijeljeni u tri skupine (do 36 mjeseci; 36-72 mjeseca; više od 72 mjeseca) i prema životnoj dobi u tri skupine (18-50 godina, 51-65 godina i više od 65 godina). Prosječno vremensko trajanje hemodijalize u prvoj skupini ispitanika je 16 mjeseci, u drugoj skupini 53 mjeseca, a u trećoj skupini ispitanika 123 mjeseca. Koncentracija β2-mikroglobulina u serumu ispitanika kontrolne skupine određena je u vrijeme ultrazvučnog pregleda, a u ispitanika bolesnika na početku i na kraju hemodijalize. Bolesnicima ispitivane skupine učinjen je rendgenski pregled desnog ramena, kuka i koljena. Na RTG slikama utvrdili smo prisutnost amiloidnih koštanih cista, erozija zglobnih površina, kalcifikata mekih tkiva, aseptične nekroze i patoloških prijeloma. ----- Rezultati: Postoji statistički značajna razlika u debljini tetiva m. supraspinatusa, m. biceps brachii i zglobne ovojnice kuka između sve tri skupine ispitanika koji su vremenski različito dugo podvrgnuti hemodijalizi. Što je duže vremensko trajanje hemodijalize veća je debljina izmjerenih anatomskih struktura. Sve tri skupine ispitanika koji su vremenski različito dugo podvrgnuti hemodijalizi imaju statistički značajno veću debljinu tetive m. supraspinatusa i zglobnog izljeva u području kuka nego ispitanici kontrolne skupine. Tetiva m. biceps brachii i zglobna ovojnica kuka ispitanika koji su podvrgnuti hemodijalizi do 36 mjeseci nije statistički značajno deblja nego ista tetiva u ispitanika kontrolne skupine. U preostale dvije skupine ispitanika tetiva m. supraspinatusa i zglobna ovojnica kuka statistički značajno su deblji. Tetive u području ramena, zglobna ovojnica i zglobni izljev u području kuka deblji su što je duže vremensko trajanje hemodijalize. Nije utvrđena statistički značajna razlika debljine zglobnog izljeva u području koljena između tri skupine ispitanika koji su vremenski različito dugo podvrgnuti hemodijalizi. Sve tri skupine ispitanika koji su vremenski različito dugo podvrgnuti hemodijalizi imaju statistički značajno veću debljinu zglobnog izljeva koljena nego ispitanici kontrolne skupine. Debljina zglobne ovojnice koljena mjerena uzdužno statistički je značajno tanja u skupini ispitanika koji su vremenski podvrgnuti hemodijalizi više od 72 mjeseca nego u ispitanika koji su podvrgnuti hemodijalizi do 36 mjeseci. Nije utvrđena statistički značajna razlika debljine zglobne ovojnice koljena između ispitanika kontrolne i skupine ispitanika koji su vremenski podvrgnuti hemodijalizi do 36 mjeseci, dok je u preostale dvije skupine ispitanika (36-72 mjeseca i više od 72 mjeseca) zglobna ovojnica statistički značajno tanja nego u kontrolnoj skupini. Vremenskim trajanjem hemodijalize zglobna ovojnica koljena je tanja. Nije utvrđena statistički značajna razlika debljine tetive m. supraspinatusa, tetive m. biceps brachii, zglobne ovojnice i izljeva u području kuka, te zglobnog izljeva u području koljena između ispitanika tri životne dobne skupine. Postoji statistički značajna razlika debljine zglobne ovojnice koljena između sve tri skupine ispitanika različite životne dobi. Što su ispitanici stariji debljina zglobne ovojnice koljena je manja. Koncentracija β2-mikroglobulina na početku hemodijalize 18,3 puta veća je nego u ispitanika kontrolne skupine. Koncentracija β2-mikroglobulina na početku hemodijalize statistički je značajno veća što su ispitanici vremenski duže podvrgnuti hemodijalizi. Utvrđeno je da ne postoji statistički značajna razlika u koncentraciji β2-mikroglobulina prije i nakon hemodijalize između tri dobne skupine ispitanika. Životna dob nije utjecala na koncentraciju β2-mikroglobulina prije i nakon hemodijalize. Nije utvrđena statistički značajna povezanost koncentracije β2-mikroglobulina na početku hemodijalize i debljina tetive m. supraspinatusa, debljine zglobnog izljeva u području kuka i koljena. Postoji statistički značajna povezanost između koncentracije β2-mikroglobulina na početku hemodijalize i debljine tetive m. biceps brachii, Tetiva je deblja što je veća koncentracija β2-mikroglobulina na početku hemodijalize. Postoji statistički značajna povezanost debljine zglobne ovojnice kuka s desne strane u ispitanika podvrgnutih hemodijalizi do 36 mjeseci i koncentracije β2-mikroglobulina na početku hemodijalize. U toj skupini ispitanika što je veća koncentracija β2-mikroglobulina na početku hemodijalize zglobna ovojnica je deblja. U ostalim skupinama ispitanika nije utvrđena statistički značajna povezanost koncentracije β2-mikroglobulina na početku hemodijalize i debljine zglobne ovojnice kuka. Koncentracija β2-mikroglobulina na početku hemodijalize i debljina zglobne ovojnice koljena statistički je značajna u skupini ispitanika koji su podvrgnuti hemodijalizi više od 72 mjeseca. U toj skupini debljina zglobne ovojnice veća je što je koncentracija β2-mikroglobulina na početku hemodijalize veća. U svim ostalim skupinama ispitanika s različitim vremenskim trajanjem hemodijalize nije utvrđena statistički značajna povezanost debljine zglobne ovojnice koljena i β2-mikroglobulina na početku hemodijalize. Utvrđena je statistički značajna povezanost između vremenskog trajanja hemodijalize i broja RTG promjena na zglobovima u sve tri skupine ispitanika koji su vremenski različito dugo podvrgnuti hemodijalizi. Što je duže vremensko trajanje hemodijalize statistički značajno više ima RTG promjena na zglobovima ispitanika. Nije utvrđena povezanost između koncentracija β2-mikroglobulina na početku hemodijalize i broja RTG promjena na zglobovima ispitanika. ----- Zaključak: Morfološke promjene koštano zglobnog sustava u bolesnika podvrgnutih hemodijalizi možemo pratiti ultrazvukom. Možemo ih uočiti u ranim stupnjevima bolesti kada još nisu prisutni klinički znakovi. Promjene su vezane uz vremensko trajanje hemodijalize. Životna dob i koncentracije β2-mikroglobulina u serumu ispitanika imaju manji utjecaj na morfološke promjene nego vremensko trajanje hemodijalize. Ovim istraživanjem ukazali smo na važnost i mogućnosti ultrazvučnog otkrivanja i praćenja promjena na velikim zglobovima u bolesnika s kroničnim bubrežnim zatajivanjem i pridonijeli njihovom boljem razumijevanju. Rezultati ove studije mogu poslužiti za daljnja istraživanja.

    English abstract

    Introduction: Patients undergoing hemodialysis frequently develop complications of the osteoarticular system due to renal osteodystrophy and hemodialysis associated amyloidosis. The lesions involve soft tissues of the joints, adjacent structures and bone. Morphological changes lead to clinical symptoms and functional impairments. It is hypothesized that preclinical morphological lesions of large joints in patients with chronic renal failure can be detected and followed up by ultrasonography (US) and x-ray studies, thus enabling preventive measures to be taken in hemodialysis patients to reduce or even avoid these complications. ----- Aim: To assess changes in three large joints of hemodialysis patients by US according to the duration of hemodialysis, age and serum concentration of β2-microglobulin. ----- Subjects and methods: Thickness of the supraspinous muscle and brachial biceps tendons, articular sheath of the hip and knee joints, and articular effusion in the hip and knee areas was measured bilaterally by use of US. The study included 106 hemodialysis patients (56 male and 51 female), mean age 67.9 (range 28.2-87.4) years, and 51 healthy subjects (25 male and 26 female), mean age 62.6 (range 40.0-86.4) years as control group. A total of 2120 US measurements were obtained in 636 patient group joints and 1020 US measurements in 306 control group joints; then the values recorded in the patient and control groups were compared. Study patients were divided into three groups according to the length of hemodialysis treatment (<36 months, 36-72 months, and >72 months) and age (18-50, 51-65 and >65 years). The mean duration of hemodialysis was 16, 53 and 123 months in the first, second and third group, respectively. In control group, serum concentration of β2-microglobulin was determined at the time of US study, and in patient group at the beginning and at the end of hemodialysis session. In study patients, x-rays of the right shoulder, hip and knee revealed the presence of amyloid bone cysts, articular surface erosions, soft tissue calcifications, aseptic necrosis and pathologic fractures. ----- Results: Thickness of the supraspinous muscle and brachial biceps tendons and hip joint sheath differed statistically significantly among the three patient groups with different length of hemodialysis treatment. Thickness of the US measured anatomical structures increased with the duration of hemodialysis. The supraspinous muscle tendon thickness and articular effusion in the hip area was statistically significantly greater in all three groups of hemodialysis patients as compared with control group. There was no statistically significant difference in the thickness of brachial biceps tendon and articular sheath in the hip area between patients undergoing hemodialysis for up to 36 months and control group; however, these values were statistically significantly greater in the other two groups of hemodialysis patients. Thickness of tendons in the shoulder region, articular sheath and articular effusion in the hip area increased with the length of hemodialysis. There was no statistically significant difference in the articular effusion thickness in the knee area among the three patient groups with different length of hemodialysis treatment. Articular effusion thickness in the knee area was statistically significantly greater in all three groups of hemodialysis patients as compared with control group. Longitudinal thickness of the knee joint sheath was significantly smaller in the group of patients undergoing hemodialysis for more than 72 months than in those treated with hemodialysis for up to 36 months. There was no statistically significant difference in the knee joint sheath thickness between patients undergoing hemodialysis for up to 36 months and control group; however, these values were statistically significantly lower in the other two patient groups treated with hemodialysis for 36-72 and more than 72 months. Thickness of the knee joint sheath decreased with the duration of hemodialysis. There was no statistically significant difference in thickness of the supraspinous muscle and brachial biceps tendons, articular sheath and effusion in the hip area among the three patient age groups. A statistically significant difference was found in thickness of the knee joint sheath among the three patient age groups. Thickness of the knee joint sheath decreased with age. At the beginning of hemodialysis session, the mean serum concentration of β2-microglobulin measured in study patients was 18.3-fold that recorded in control subjects. Serum β2-microglobulin concentration at the beginning of hemodialysis session increased statistically significantly with the duration of hemodialysis treatment. There was no statistically significant difference in β2-microglobulin concentration before and after hemodialysis among the three patient age groups. Age had no effect on β2-microglobulin concentration before and after hemodialysis. There was no statistically significant correlation between β2-microglobulin concentration at the beginning of hemodialysis and thickness of the supraspinous muscle tendon and articular effusion in the hip and knee areas. A statistically significant correlation was recorded between β2-microglobulin concentration at the beginning of hemodialysis and brachial biceps tendon thickness. Tendon thickness increased with the rise in β2-microglobulin concentration at the beginning of hemodialysis. A statistically significant correlation was also found between the right-sided hip joint sheath thickness and β2-microglobulin concentration at the beginning of hemodialysis in patients undergoing hemodialysis for up to 36 months. In this group, the joint sheath thickness increased with the rise in β2-microglobulin concentration at the beginning of hemodialysis. No such correlation of β2-microglobulin concentration at the beginning of hemodialysis and hip joint sheath thickness was observed in other patient groups. The mean serum concentration of β2-microglobulin at the beginning of hemodialysis session correlated significantly with the knee joint sheath thickness in patients undergoing hemodialysis for more than 72 months. In this group, the higher the β2-microglobulin concentration at the beginning of hemodialysis, the greater was the knee joint sheath thickness. Other patient groups showed no statistically significant correlation between the knee joint sheath thickness and β2-microglobulin concentration at the beginning of hemodialysis. There was a statistically significant correlation between the length of hemodialysis treatment and number of x-ray joint lesions in all three patient groups divided according to the length of hemodialysis treatment. The number of x-ray joint lesions increased statistically significantly with the length of hemodialysis treatment. β2-microglobulin concentration measured at the beginning of hemodialysis had no effect on the number of x-ray joint lesions. ----- Conclusion: Morphological changes of the osteoarticular system in hemodialysis patients can be followed up by US. The lesions can thus be detected in early stages when clinical signs have not yet manifested. These morphological changes are associated with the duration of hemodialysis, whereas patient age and serum β2-microglobulin concentration have only minor effects on these changes. The present study demonstrated the role and possibilities of US detection and follow up of large joint lesions in patients with chronic renal failure. Results of this study can serve as a basis for additional research in the field.

    Item Type: Thesis (PhD)
    Mentor: Hašpl, Miroslav
    Divisions: Izvan medicinskog fakulteta
    Depositing User: Marijan Šember
    University: Sveučilište u Zagrebu
    Institution: Medicinski fakultet
    Number of Pages: 137
    Status: Unpublished
    Creators:
    CreatorsEmail
    Matoković, Damir
    Date: 22 April 2011
    Date Deposited: 12 May 2011
    Last Modified: 23 Sep 2011 18:11
    Subjects: /
    Related URLs:
      URI: http://medlib.mef.hr/id/eprint/982

      Actions (login required)

      View Item

      Document Downloads

      More statistics for this item...