Letter to the Editor
Improvement of bilateral lower-limb muscle oxygenation by low-density lipoprotein apheresis in a patient with peripheral artery disease undergoing hemodialysis
Mejora de la oxigenación en los músculos de ambos miembros inferiores mediante aféresis de lipoproteínas de baja densidad en un paciente con arteriopatía periférica sometido a diálisis
Kiyonori Itoa, Susumu Ookawaraa,
, Yuichiro Uedaa, Hideyuki Hayasakab, Masaya Kofujib, Takayuki Uchidab, Harunobu Matsumotoc, Atsushi Yamaguchic, Yoshiyuki Morishitaa
Corresponding author
a Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
b Department of Clinical Engineering, Saitama Medical Center, Jichi Medical University, Saitama, Japan
c Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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"autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Kiyonori Ito, Susumu Ookawara, Yuichiro Ueda, Hideyuki Hayasaka, Masaya Kofuji, Takayuki Uchida, Harunobu Matsumoto, Atsushi Yamaguchi, Yoshiyuki Morishita" "autores" => array:9 [ 0 => array:3 [ "nombre" => "Kiyonori" "apellidos" => "Ito" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Susumu" "apellidos" => "Ookawara" "email" => array:1 [ 0 => "su-ooka@hb.tp1.jp" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Yuichiro" "apellidos" => "Ueda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => 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=> "Mejora de la oxigenación en los músculos de ambos miembros inferiores mediante aféresis de lipoproteínas de baja densidad en un paciente con arteriopatía periférica sometido a diálisis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 994 "Ancho" => 1578 "Tamanyo" => 139539 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The changes in rSO<span class="elsevierStyleInf">2</span> of the forehead and bilateral lower-limb muscle as per the oxygenation values of cerebral and muscle tissues, respectively, under LDL-A with HD. rSO<span class="elsevierStyleInf">2</span> ratio is defined as the ratio of rSO<span class="elsevierStyleInf">2</span> value at <span class="elsevierStyleItalic">t</span> (min) during HD and initial rSO<span class="elsevierStyleInf">2</span> value before HD (rSO<span class="elsevierStyleInf">2</span> at <span class="elsevierStyleItalic">t</span> (min) during HD/initial rSO<span class="elsevierStyleInf">2</span> before HD). The open circle represents the changes in cerebral rSO<span class="elsevierStyleInf">2</span> values, the grey diamond shape represents the changes in right lower-limb muscle rSO<span class="elsevierStyleInf">2</span> values, and the block diamond shape represents the changes in left lower-limb muscle rSO<span class="elsevierStyleInf">2</span> values.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Low-density lipoprotein apheresis (LDL-A), frequently used for peripheral artery disease (PAD) treatment, is expected to induce the improvement of systemic microcirculation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Recently, near-infrared spectroscopy was used to evaluate tissue regional oxygen saturation (rSO<span class="elsevierStyleInf">2</span>) in haemodialysis (HD) patients.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2–5</span></a> However, there is no report regarding the relation between LDL-A and changes in tissue oxygenation. In our HD patient, we confirmed an improvement in lower-limb muscle oxygenation during LDL-A.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 82 year-old woman receiving HD was referred to our hospital for treatment of PAD recurrence. Her past medical history included hypertension and insulin-dependent diabetes. HD was initiated beginning 5-years prior. She was diagnosed with PAD and underwent bypass surgery for the right lower leg 4-years ago. Deteriorations of colour of foot skin and foot ulceration were recently confirmed bilaterally in the lower legs; therefore, LDL-A was performed for preventing PAD progression in our dialysis centre. Blood circuits of each LDL-A and HD were tandemly connected: each therapy was simultaneously performed. LDL-A was performed using Plasmaflo OP (Asahi Kasei Medical, Tokyo, Japan) as a plasma separator, a dextran sulfate cellulose column (Liposorba 15, Kaneka, Osaka, Japan) as a LDL absorber, and 1000<span class="elsevierStyleHsp" style=""></span>U/h of heparin sodium as an anticoagulant. Plasma volume was treated at a rate of 50<span class="elsevierStyleHsp" style=""></span>mL/kg per LDL-A session. The duration of LDL-A with HD was 4-h: totally, she received LDL-A once a week for 10 consecutive weeks. During these 10 weeks of LDL-A with HD, other sessions of HD therapy twice a week was performed at a dialysis clinic that she had been receiving that therapy. To confirm LDL-A's influence on microcirculation impairment, tissue rSO<span class="elsevierStyleInf">2</span> values in brain and lower-limb muscle were monitored from LDL-A with HD initiation to the end. Written informed consent for rSO<span class="elsevierStyleInf">2</span> monitoring during that therapy was obtained. Values of rSO<span class="elsevierStyleInf">2</span> were monitored at forehead and bilateral lower-limbs above the gastrocnemii using INVOS 5100c (Covidien Japan, Tokyo, Japan) during second, sixth and 10th sessions of LDL-A with HD. Fluid was removed by ultrafiltration at the level of 1.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.4<span class="elsevierStyleHsp" style=""></span>L/session, and haemoglobin levels increased from 9.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.4<span class="elsevierStyleHsp" style=""></span>g/dL before LDL-A with HD to 11.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.2<span class="elsevierStyleHsp" style=""></span>g/dL after therapy. The rSO<span class="elsevierStyleInf">2</span> ratios (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation) in bilateral lower-limb muscles rapidly increased from LDL-A with HD initiation to the end, whereas cerebral rSO<span class="elsevierStyleInf">2</span> ratio did not change during that therapy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Notably, changes in the colour of the foot skin and foot ulceration status improved by LDL-A with HD for 10 consecutive weeks.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">LDL-A has been applied in PAD patients in whom efficacy of conventional pharmacological therapy is insufficient and/or those who are unavailable for surgical therapy because LDL-A itself improves peripheral microcirculation via blood rheology amelioration; reduction of blood and plasma viscosity; production of vasodilating nitric oxide, eicosanoids, and bradykinin; improvement of endothelial function through reduction of total LDL and oxidized LDL concentrations; and reduction of circulating inflammatory cytokines and chemokines.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> Improvement of peripheral microcirculation associated with LDL-A would also be expected to improve tissue oxygenation via increased oxygen supply in peripheral tissues. Indeed, oxygen partial pressure (pO<span class="elsevierStyleInf">2</span>) in the anterior tibial muscle rapidly and significantly increased during LDL-A in cardiac allograft vasculopathy patients.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> In the present case, bilateral lower-limb muscle oxygenation rapidly improved from LDL-A with HD initiation to the end; our result is consistent with a previous report.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Ebihara et al. measured systemic blood flow using a laser doppler blood flowmeter during LDL-A, and reported significant increases in tissue blood flow in the head and lower limbs, in which the increase of blood flow was significantly higher in the lower limbs than in the head.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> We did not evaluate the level of tissue blood flow during LDL-A with HD in this case; therefore, we cannot comment on LDL-A-induced blood flow changes in systemic tissues. However, regarding cerebral oxygenation, little changed despite the increase in lower-limb muscle oxygenation; these differences in tissue oxygenation in the brain and lower-limb muscle might be explained by differences in blood flow increase in the head and lower-limb muscle previously reported.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Additionally, our patient simultaneously received LDL-A and HD therapy; therefore, it could not be definitively determined that the improvement in bilateral lower-limb muscle oxygenation was derived only from the application of LDL-A itself. Regarding tissue oxygenation during HD, there were reportedly no significant changes in cerebral and lower-limb muscle rSO<span class="elsevierStyleInf">2</span> values during HD, respectively, although Hb levels after HD increased compared with those before HD.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2,8</span></a> Therefore, the improvement in muscle oxygenation seen in this case might be caused not by HD therapy but by LDL-A itself.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion, LDL-A may have improved lower-limb muscle oxygenation in our patient. Thus, it might have positive effects for lower-limb muscle microcirculation.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest statement</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have declared that no conflict of interest exists.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest statement" ] 1 => array:2 [ "identificador" => "xack395441" "titulo" => "Acknowledgement" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 994 "Ancho" => 1578 "Tamanyo" => 139539 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The changes in rSO<span class="elsevierStyleInf">2</span> of the forehead and bilateral lower-limb muscle as per the oxygenation values of cerebral and muscle tissues, respectively, under LDL-A with HD. rSO<span class="elsevierStyleInf">2</span> ratio is defined as the ratio of rSO<span class="elsevierStyleInf">2</span> value at <span class="elsevierStyleItalic">t</span> (min) during HD and initial rSO<span class="elsevierStyleInf">2</span> value before HD (rSO<span class="elsevierStyleInf">2</span> at <span class="elsevierStyleItalic">t</span> (min) during HD/initial rSO<span class="elsevierStyleInf">2</span> before HD). The open circle represents the changes in cerebral rSO<span class="elsevierStyleInf">2</span> values, the grey diamond shape represents the changes in right lower-limb muscle rSO<span class="elsevierStyleInf">2</span> values, and the block diamond shape represents the changes in left lower-limb muscle rSO<span class="elsevierStyleInf">2</span> values.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blood flow analysis of the head and lower limbs by the laser Doppler blood flowmeter during LDL apheresis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Ebihara" 1 => "T. Sato" 2 => "K. Hirayama" 3 => "M. Seki" 4 => "T. Enami" 5 => "H. 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This work was supported with a grant from the <span class="elsevierStyleGrantSponsor" id="gs1">Japanese Association of Dialysis Physicians</span> (No. 27088) provided to S.O., and a grant from <span class="elsevierStyleGrantSponsor" id="gs2">The Kidney Foundation</span>, Japan (JKFB16-3) provided to S.O.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003900000001/v1_201903030617/S201325141830155X/v1_201903030617/en/main.assets" "Apartado" => array:4 [ "identificador" => "35436" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003900000001/v1_201903030617/S201325141830155X/v1_201903030617/en/main.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S201325141830155X?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 3 | 8 |
| 2024 October | 37 | 35 | 72 |
| 2024 September | 36 | 27 | 63 |
| 2024 August | 51 | 50 | 101 |
| 2024 July | 30 | 24 | 54 |
| 2024 June | 34 | 30 | 64 |
| 2024 May | 36 | 33 | 69 |
| 2024 April | 30 | 28 | 58 |
| 2024 March | 35 | 28 | 63 |
| 2024 February | 22 | 36 | 58 |
| 2024 January | 20 | 33 | 53 |
| 2023 December | 18 | 26 | 44 |
| 2023 November | 27 | 39 | 66 |
| 2023 October | 26 | 33 | 59 |
| 2023 September | 23 | 27 | 50 |
| 2023 August | 27 | 27 | 54 |
| 2023 July | 36 | 26 | 62 |
| 2023 June | 31 | 21 | 52 |
| 2023 May | 48 | 158 | 206 |
| 2023 April | 24 | 23 | 47 |
| 2023 March | 39 | 19 | 58 |
| 2023 February | 36 | 18 | 54 |
| 2023 January | 30 | 26 | 56 |
| 2022 December | 40 | 32 | 72 |
| 2022 November | 52 | 27 | 79 |
| 2022 October | 61 | 34 | 95 |
| 2022 September | 40 | 33 | 73 |
| 2022 August | 30 | 44 | 74 |
| 2022 July | 33 | 45 | 78 |
| 2022 June | 45 | 35 | 80 |
| 2022 May | 38 | 21 | 59 |
| 2022 April | 40 | 50 | 90 |
| 2022 March | 36 | 46 | 82 |
| 2022 February | 36 | 43 | 79 |
| 2022 January | 33 | 37 | 70 |
| 2021 December | 43 | 36 | 79 |
| 2021 November | 42 | 33 | 75 |
| 2021 October | 38 | 38 | 76 |
| 2021 September | 60 | 31 | 91 |
| 2021 August | 40 | 34 | 74 |
| 2021 July | 28 | 38 | 66 |
| 2021 June | 27 | 35 | 62 |
| 2021 May | 35 | 46 | 81 |
| 2021 April | 67 | 68 | 135 |
| 2021 March | 31 | 34 | 65 |
| 2021 February | 23 | 36 | 59 |
| 2021 January | 12 | 15 | 27 |
| 2020 December | 14 | 12 | 26 |
| 2020 November | 15 | 14 | 29 |
| 2020 October | 13 | 16 | 29 |
| 2020 September | 15 | 16 | 31 |
| 2020 August | 19 | 15 | 34 |
| 2020 July | 15 | 16 | 31 |
| 2020 June | 15 | 10 | 25 |
| 2020 May | 10 | 11 | 21 |
| 2020 April | 18 | 19 | 37 |
| 2020 March | 8 | 10 | 18 |
| 2020 February | 14 | 14 | 28 |
| 2020 January | 21 | 19 | 40 |
| 2019 December | 17 | 24 | 41 |
| 2019 November | 15 | 18 | 33 |
| 2019 October | 23 | 24 | 47 |
| 2019 September | 20 | 17 | 37 |
| 2019 August | 28 | 14 | 42 |
| 2019 July | 25 | 26 | 51 |
| 2019 June | 26 | 27 | 53 |
| 2019 May | 28 | 27 | 55 |
| 2019 April | 60 | 49 | 109 |
| 2019 March | 16 | 19 | 35 |
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