DOI: 10.7860/JCDR/2016/15279.

7172
Original Article

Comparison of Long-term Complications

Internal Medicine

in Patients on Haemodialysis and

Section

Peritoneal Dialysis Longer than 10 Years

Arzu OZDEMIR KAYALAR1, Taner BASTURK2, Yener KOC3, Figen YILMAZ4, Feyza BAYRAKTAR CAGLAYAN5,
Tamer SAKACI6, Elbis AHBAP7, Abdulkadir ÜNSAL8

ABSTRACT and congestive heart failure (n=1) were investigated.

Introduction: Depending on developments in dialysis techni­ Uraemic peripheral neuropathy was observed in 14 of the
ques and new treatment strategies for comorbid diseases, life patients (8 HD, 6 PD patients). Eight patients had mixed type
expectancy has increased. As a result, dialysis related long term sensory motor neuropathy and 3 patients had mixed type
complications could be seen more frequently. We investigated sensorial neuropathy, 2 patients had demyelinating PNP,
and compared long term complications of the Haemodialysis 1 patient had axonal PNP and 3 of them had CTS related to
(HD) and Peritoneal Dialysis (PD) in patients with history if either peripheral neuropathy.
mode at least 10years. Parathyroid adenoma was detected in 4 patients (2 HD, 2 PD)
Materials and Methods: A 13HD & 16PD patients were included and 3 patients (1 HD, 2 PD) had history of parathyroidectomy.
to the study. Basic demographic parameters and prevalence of Serum phosphate and iPTH levels were higher in HD patients
cardiovascular diseases (CVD), uraemic peripheral neuropathy (p=0.003, p=0.04, respectively).
(PNP), parathyroid adenoma, parathyroidectomy and acquired ACD was detected in 14 patients (7 HD, 7 PD). There was no
cystic disease (ACD) were assessed. difference between PD and HD patients (p=0.75).
Results: HD patients were older than PD patients (p=0.035) and Conclusion: HD patients were older than PD patients and
duration of dialysis was longer in HD patients (p=0.001). had longer duration of dialysis. The prevalence of long term
CVD was present in 18 patients (9 HD, 9 PD). There was no complications was similar in HD and PD modalities. CVD
difference in presence of CVD between HD and PD patients especially valvular diseases were common complication in both
(p=0.455). Valvular diseases (n=15), diastolic dysfunction (n=8), modalities
left ventricular hypertrophy (n=5), ischemic heart disease (n=3)

Keywords: Amyloidosis, Acquired cystic disease, Cardiovascular disease, Renal osteodystrophy

Introduction From clinical records, we retrieved information about complications

Developments in dialysis techniques involving peritoneal dialysis related to cardiovascular diseases (CVD), parathyroid (PT)
(PD) and haemodialysis (HD) expended the life span of the patients adenoma, parathyroidectomy and acquired cystic disease (ACD).
with end stage renal failure (ESRD) attributable to various causes, Prospective analysis were performed about long term complicatios
though this is not without complication [1]. The most frequent including CVD, uraemic peripheral neuropathy (PNP), PT adenoma,
long-term dialysis complications relate to cardiovascular disease, PT hyperplasia and ACD.
peripheral neuropathy, parathyroid adenoma, parathroidectomy Symptoms related to CVD such as dyspnea, chest
and acquired cystic disease of the kidney [1,2]. pain and oedema were questioned and history of CVD was
Few data are available regarding the prevalence of long-term recorded; cardiovascular medications were documented. A
complications, particularly comparison of the prevalence of 12-lead electrocardiogram was reviewed for signs of coronary
complications between long-term survivors of different modes of artery disease and left ventricular (LV) hypertrophy. M-mode
dialysis. We performed a retrospective analysis of patients in a echocardiography was performed to reveal systolic and diastolic
single center who dialysed for at least 10 years and still on dialysis dysfunction, LV hypertrophy and dilatation, valvular disease. LV
and assessed prevalence of complication of long term dialysis. systolic dysfunction was defined as the ejection fracture less than
40% by echocardiography. Blood pressure was calculated as
average of 3 seated measurements taken after a 5-minute rest.
MATERIALS AND METHODS
It was measured before dialysis on a short (2-day) break in all HD
We included all patients who have been commenced dialysis
patients and at the time of clinic visit in PD patients.
before 2004 with total dialysis history of more than 10 years. All
included patients are still on dialysis and attending to the out- Signs and symtoms related to uraemic PNP were assessed and
patient clinics regularly. The censoring date was 30 June 2014. electrophysiological studies for diagnosis of PNP and carpal tunnel
syndrome (CTS) were performed by the same doctor and device.
Patients who have been switched dialysis therapies, followed up
Detailed history was elicited pertaining to patients' neurological
in different centers and died after 10 years of commencement
symptom such as tingling and prickling sensation in the legs,
of dialysis, and with policystic kidney disease were excluded
paresthesias, hyperalgesia, weakness, numbness of lateral four
from the study. We retrieved demographic, clinical, dialysis, and
fingers for compressive neuropathies, pain and stiffness of the
biochemical data from the most recent follow-up. The dialysis data hands. Muscle atrophy, loss of deep tendon reflexes, abnormal
included dialysis mode (HD, Ambulatory Peritoneal Dialysis (APD), or absent reflexes (particularly ankle jerk), and impaired sensation
Continous Ambulatory Peritoneal Dialysis (CAPD)) and vascular (vibratory, light touch pressure, and pain) were assessed
access for HD patients (location and site of arteriovenous fistula). objectively.
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 Arzu Ozdemir Kayalar et al., Long-term Dialysis Complications www.jcdr.net

Nerve conduction studies were performed using Nihon Kohden Overall HD patients PD patients p
equipment in the room temperature. Bilateral median, ulnar, (n= 29) (n= 13) (n= 16)
peroneal, and tibial motor nerves and median, ulnar, superficial Age (years) 45.04±12.88 51±14.6 (32-74) 40.2±11.5 (22-59) 0.035
peroneal, sural sensory nerves were evaluated using standard Sex M 13 (44.8%) 6 (46.1%) 7 (43.7%)
conduction techniques. Distal latency, amplitude and nerve
F 16 (55.1%) 7 (53.8%) 9 (56.2%) 0.214
conduction velocity (NCV) of motor and sensory nerves and
Age at initiation 34.0±13.1 38.9±13.0 (21-57) 28.6±11.4 (12-49) 0.057
f wave’s minimal latency of all motor nerves were measured. of dialysis
PNP was diagnosed when slowing of nerve conduction velocity
Duration of 12.5±3.2 13.9±3.6 (10-19) 10.4±0.7 (10-22) 0.001
and/or decrease of amplitude of muscle action potential and/ dialysis
or lenghtening of distal latencies were present in two or more [Table/Fig-1]: Baseline characteristic of the patients.
nerves and longer f wave response was present in one or more
nerves. CTS were diagnosed if slowing of NCV and/or decrease of ischemic heart disease was noted in 3 patients that did not require
amplitude of muscle action potential and/or lenghtening of distal angioplasty or bypass surgery after angiographic examination. LV
latency of either sensory or motor median nerve were present. systolic dysfunction was present only in one patient. The most
Nerve conduction study was performed only in one upper extremity frequent valvular diseases were mitral regurgitation (n=10) and
if the patients did not accept stimulation of median and ulnar nerve aortic regurgitation (n=7). Valvular calcifications were present in 8
on the limb with fistula. (27.5%) patients, 4 with mitral valve calcifications and 4 with aortic
valve calcifications. There was no difference in prevalence of CVD
Presence of PT adenoma and history of parathyroidectomy were
between HD and PD patients (p=0.455).
obtained from clinical records. Ultrasonographic examination of PT
gland was performed if the patient had elevated level of iPTH. PT In the patient cohort, 8 of the (3 HD, 5 PD) patients had complain
hyperplasia was recognized by enlarged PT glands (larger than 0.5 of weakness and tingling and prickling sensations in the legs.
cm3) and the presence of round or oval masses, hypoechogenic, None of them had loss of deep tendon reflexes, abnormal or
homogenous, with or without blood flow, located in the rear section absent reflexes and impaired sensation on physical examination.
of the thyroid gland. If sonographic characteristics of PT glands Electodiagnostic finding reveal that 48.2% of patients (8 HD, 6
included homogeneous hypoechogenicity and an extrathyroidal PD) had PNP, 8 with mixed type sensory motor neuropathy, 3 with
feeding vessel with peripheral vascularity seen on colour-doppler mixed type sensorial neuropathy, 2 with demyelinating motor and
imaging, PT adenoma was diagnosed and then sestamibi nuclear sensory PNP, 1 with axonal sensory PNP. Statistically significant
scan was performed to measure the activity of the adenoma. relationship was not found between uraemic PNP and age, sex,
mode of dialysis, the duration of dialysis, iPTH level, presence of
ACD was confirmed by ultrasonography. Loin pain and (if residual
diabetes mellitus and history of parathyroidectomy.
renal function was present) hematuria were questioned. As ACD
can be detected prior to ESRD, older ultrasonographic findings CTS related to PNP was noted in 3 patients (2 PD, 1 HD). Only
were examined and new enhacement of four or more cysts per one PD patient had numbness of lateral four fingers, pain and
kidney was accepted as ACD. stiffness of the hands and tenar atrophy. In 3 HD patients, one
with documented CTS, nerve conduction study were performed in
Statistical analysis only one upper extremity because these patients did not accept
Statistical analysis was done by Scientific Package for Social stimulation of median and ulnar nerve on the limb with fistula. There
Science (version 17.0; SPSS Inc., Chicago, IL, USA). All continuous was no significant difference in frequency of CTS between the
data were expressed as mean±SD and were analysed by unpaired two groups (p=0.60). Our results revealed that PT adenoma was
t-test. Categorical data were expressed as number (percentage) present in 4 patients (2 HD, 2 PD). PT hyperplasia was found in
and were analysed by χ² test. Correlation analysis were tested by one HD patient. Three patients (1 HD, 2 PD) had history of subtotal
pearson’s correlation statistics for analysing parametric parameters parathyroidectomy. Fracture of femur head has occured in 3 HD
and Spearman’s rho test was used for analysing non parametric patients. Lower serum phoshate and iPTH level were observed in
parameters. Differences were considered statistically significant if PD patients (p= 0.003, p= 0.04, respectively) [Table/Fig-2].
p-value was less than 0.05. A 60.8% of the patients (7 HD, 7 PD) have had documented
ACD of which 9 patients (6 HD, 3 PD) have had loin pain. Two PD
RESULTS patients with residual renal function did not have hematuria and 2
The records of 524 HD and 367 PD patients starting dialysis before PD patients had cystic disease before initiation of dialysis. One of
2004 were evaluated retrospectively. Totally 29 patients were HD patient had history of cystectomy and none of participiants had
included into the study [Table/Fig-1]. Participiants predominantly
were female (55.17%) with a mean age of 45.04±12.88 years and Overall HD patients PD patients p
(n= 29) (n= 13) (n= 16)
mean follow-up of 12.5±3.2 years. Glomerulonephritis (27.58%)
and diabetic nephropathy (17.24%) were the leading causes of Urea (mg/dl) 114.5±37.8 127.8±±26.7 100.0±43.8 0.078
(71-163) (53-206)
ESRD.
Creatinin (mg/dl) 8.7±1.7 8.4±1.7 (6.1-10.9) 9.1±1.8 (6-12,7) 0.290
Baseline characteristics of the patients are detailed in [Table/
Ca (mg/dl) 8.9±1.1 9.0±1.1 (6.4-10.4) 8.9±1.3 (7.4-10.8) 0.935
Fig-1]. HD patients were older than PD patients (p =0.035) and
had longer duration of dialysis (p= 0.001). Twenty three percent of P (mg/dl) 4.9±1.3 5.5±1.1 (4.1-7) 4.2±1.1 (2.8-5.8) 0.003

patients in HD group had left sided fistula in cubital area, 61.5% Ca*P 43.1±13.0 47.4±11.3 (29-65) 38.5±13.6 (20-62) 0.099
of them had left sided radial fistula and 15.3% of them had right iPTH (pg/ml) 925.0±1069.6 1153.4±1323.9 675.8±676.8 0.04
sided radial fistula. Seven PD patients (43.7%) were treated with (230-4160) (73-2523)
APD, 9 of them (56.3%) were treated with CAPD. Albumin(g/l) 3.8±0.5 3.9±0.2 (3.5-4.4) 3.6±0.6 (2.3-4.6) 0.075

CVD was present in 18 (62.1%) patients (9 HD, 9 PD). Haemoglobin 10.6±2.2 11.4±1.7 (9.4-15) 9.8±2.3 (6.6-14.9) 0.066
(g/dl)
Hypertension was found in 11 (5 HD/ 6PD) of the 29 long-term
patients, with similar prevalence in the PD and HD groups ALP (U/L) 207.0±175.5 212.1±198.3 201.5±156.3 0.878
(17-700) (46-505)
(p=0.537). With regard to cardiovascular complications, valvular
diseases have found in 15 patients, diastolic dysfunction in 8 CRP (mg/L) 18.2±26.4 12.0±13.3 (3-47) 25.1±35.4 (22-59) 0.306

patients, left ventricular hypertrophy (LVH) in 5 patients. History of [Table/Fig-2]: Biochemical parameters of patients.

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www.jcdr.net Arzu Ozdemir Kayalar et al., Long-term Dialysis Complications

Overall HD patients PD patients p other studies emphasizing that the most frequent cardiovasculer
(n= 29) (n= 13) (n= 16) problem in ESRD was LVH. One of the possible explanations is the
Cardiovascular disease 18(62.1%) 9(69.2%) 9(56.2%) 0.455 death of the patient as a result of CAD and heart failure in the early
Uraemic polyneuropathy 14 (48.2%) 6 (46.1%) 8 (50.0%) 0.600 years of dialysis. There was no difference in prevalence of CVD
between HD and PD patients. Limited number of the patients may
Parathyroid adenoma 4 (13.7%) 2 (15.3%) 2 (12.5%) 0.750
be another possible reason for this difference.
Parathyroidectomy 3 (10.3%) 1 (7.6%) 2 (12.5%) 0.560
Polyneuropathy due to uraemic toxins is a distal, motor and
Acquired cystic disease of 14 (48.2%) 7 (53.8%) 7 (43.7%) 0.750
kidney sensory polyneuropathy in which there is segmental demyelination,
axonal degeneration, and segmental remyelination. The condition
[Table/Fig-3]: Prevalance of long term complications.
is of insidious onset and has been estimated to be present in 60 to
100% of patients on dialysis [11]. In the EPINEURIM study, carried
malignant change. There was no difference between PD and HD
out in Colombia in 2003, PNP was affected 30% more women
patients (p= 0.75). Prevalance of long term complications among
than men, predominantly in those over 40, and mononeuropathy
the patients are given in [Table/Fig-3].
was predominant in 65.8% of case [12]. Adriana Ondina et al.,
investigated 27 out of 78 patients on HD treatment for six to sixty
DISCUSSION months and observed PNP in 92.6% of patients [13]. Our results
HD patients were older and had longer duration of dialysis
showed that uraemic PNP were present in 48.2% of the patients.
in comparison to the PD patients. HD patients had higher
CTS is the most common complication of dialysis-related
serum phosphate and iPTH levels. The prevalence of long
amyloidosis (DRA) and can ocur due to acumulation of Beta-2
term complications was similar in both HD and PD modalities.
Microglobulin in carpal tunnel. Duration of dialysis treatment is
Cardiovascular-related problems especially valvular heart diseases
significant risk factor for the development of CTS. Investigations
were the most common complications in both modalities.
found that one-third of chronic haemodialysis patients suffered
Although the life expectancy of patients with ESRD has improved CTS/DRA after less than 4 years of dialysis and reached nearly
in recent years, it is still far below that of the general population. 100% after 20 years [14-16]. PD is associated with similar risk as
Over the last two decades, based on 2014 USRDS Annual Report, HD, a finding that would be expected since there is limited removal
adjusted death rates fell by 9 percent from 1993 to 2002, and by of Beta-2 Microglobulin by PD. Three of our patients had CTS
26 percent from 2003 to 2012. Moreover, 54% of HD patients related to peripheral neuropathy. Symptoms related to CTS were
and 65 % of PD patients were alive three years after ESRD [3]. In present only in one patient. There was no significant difference
Turkey, according to Society of Turkish Nephrology 2013 Report, between groups (p=0, 60).
survival rate at the end of the 5 years is similar in HD (66,35 %) Secondary hyperparathyroidism (SHPT) is one of the major causes
and PD 70.2% [4]. Since we have excluded the patients who of serious morbidity in long-¬term dialysis patients. Although
commenced dialysis in our centre and then transferred to other the majority of patients are successfully managed medically, in
dialysis units in subsequent years, we did not estimate survival a considerable number of patients with refractory symptoms,
rate of our patient groups. palliative surgical treatment is necessary. Approximately 10% of
According to 2009 USRDS Annual Report, new ESRD patients patients with ESRD undergo parathyroidectomy for SHPT [17].
who choose PD as their initial treatment modality tend to be The prevalence of parathyroidectomy in almost 14,180 patients
who received RRT between 1983 and 1996 was 9.2% after 10 to
younger than those starting HD [5]. Similar to literature, we found
15 years, and increased with the duration of RRT to 20.8% after
that mean age of the PD patients were 10.8 years younger than
16 to 20 years [18]. We showed that PT adenoma was present in
that of the HD patients
13.8% of patients. Parathyroidectomy was performed in 10.34%
Compared with the general population, patients undergoing of patients (1 HD, 2 PD).
maintenance dialysis have a significantly increased incidence of
Chronic kidney disease (particularly in patients on maintenance
CVD including LVH, accelerated valvular damage, atherosclerosis, HD or PD) is frequently associated with the development of
coronary heart disease. This is due to both an increased multiple and bilateral renal cysts, which are usually less than 0.5
prevalence of traditional risk factors for CVD and nontraditional cm in diameter, but can be as large as 2 to 3 cm. The incidence
risk factors related to uremia [6,7]. Approximately 80% of 1846 of ACD increases progressively with duration of dialysis. Fifty
patients enrolled in HAEMO study had some form of heart disease, to 80 percent of patients are affected after 10 years on dialysis
prevalance of LVH was 75%, of coronary heart disease was 40%, [19,20]. In a study evaluating 130 patients with advanced renal
of congestive heart failue was 40% and of valvular heart disease disease or ESRD, the incidence of multiple cysts was noted to
was nearly 50% [8]. The available evidence from a few studies, be 7 percent in those with chronic renal failure and 22 percent in
although limited due to bias, suggests that similar cardiovascular those on maintenance dialysis [21]. Most patients with ACD are
outcomes between HD and PD [9]. Kai-Chung Tse et al., showed asymptomatic. In one review, only 14 percent of patients developed
that CVD was present 83.3% of the patients treated with HD or symptoms, with hematuria being most common, followed by
PD for more than 12 years, the most common types being LVH lumbar pain and urinary tract infection. Park JH et al., examined
and ischemic heart disease. The prevalence of cardiovascular 49 HD and 49 CAPD patients who had received dialysis therapy
involvement was found similar in the PD and HD groups in this for at least 12 months and found that the prevalence of ACKD
study [1]. is not different according to the mode of dialysis, and the major
determinant of acquired cyst formation is duration of dialysis [22].
Suskic SH et al., has evaluated 30 dialysis patients with the average
The development of renal cell neoplasms ranging from adenoma
length of dialysis 5.8 years. Morphological and functional changes
to metastatic carcinoma is the most serious complication of
in the valves were present in 90% of the patients, suggesting ACD. A comprehensive review of the pertinent literature shows
that valvular disease is extremely present in patients on chronic that there is up to 50-fold increased risk of renal cell carcinoma in
haemodialysis. They also reported frequency of LVH 66.6% and ACD compared to the general population [23]. In our study, ACD
coronary heart disease 16.6% [10]. We have observed that CVD was detected in 60.8% patients and renal neoplasm has been
was present in 62.1% patients and the most frequent subgroup demonstrated in none of them as a complication. There was no
was valvular diseases. Our results differed from most of the difference between PD and HD patients.

Journal of Clinical and Diagnostic Research. 2016 Feb, Vol-10(2): OC05-OC08 7

 Arzu Ozdemir Kayalar et al., Long-term Dialysis Complications www.jcdr.net

CONCLUSION [10] Suskic SHi, Suskic A. Cardiovascular diseases in chronic dialysis treatment.
Diagnostic and Therapeutic Study. 2013;2(Issue 4):93-97.
HD patients were older than PD patients and had longer duration of [11] Krishnan AV, Kiernan MC. Uraemic neuropathy: clinical features and new
dialysis. HD patients at their 10th and subsequent years of follow- pathophysiological insights. Muscle Nerve. 2007;35(3):273-90.
up had higher serum phosphate and iPTH levels than PD patients. [12] Ramírez BG, Gómez PAB. Uraemic neuropathy: A review. International Journal of
Genetics and Molecular Biology. 2012;3(11):155-160.
The prevalence of long term complications such as CVD, uremic [13] Santos, Adriana Ondina Pestana. Peripheral neuropathy in patients in
PNP, PT adenoma, parathyroidectomy and CAD was similar in HD haemodialysis treatment. http://hdl.handle.net/10400.6/1104
and PD modalities. CVD especially valvular disease was the most [14] Charra B, Calemard E, Laurent G. Chronic renal failuretreatment duration and
common complication in both modalities. mode: their relevance to the latedialysis periarticular syndrome. Blood Purif.
1988;6:117-24.
[15] Jadoul M. Dialysis-related amyloidosis: importance of biocompatibilityand age.
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PARTICULARS OF CONTRIBUTORS:
1. Fellow in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital, Istanbul-Turkey.
2. Associate Professor in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital, Istanbul-Turkey.
3. Associate Professor in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital, Istanbul-Turkey.
4. Associate Professor in Physical treatment and rehabilitation, Department of Physical Treatment and Rehabilitation,
Sisli Etfal Research and Education Hospital, Istanbul-Turkey.
5. Fellow in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital, Istanbul-Turkey.
6. Specialist in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital, Istanbul-Turkey.
7. Specialist in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital, Istanbul-Turkey.
8. Professor in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital, Istanbul-Turkey.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Taner Basturk,
Clinic of Nephrology, Sisli Etfal Research and Education Hospital Istanbul-Turkey. Date of Submission: Jun 19, 2015
E-mail: tanerbast@yahoo.com Date of Peer Review: Sep 04, 2015
Date of Acceptance: Nov 22, 2015
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Feb 01, 2016

8 Journal of Clinical and Diagnostic Research. 2016 Feb, Vol-10(2): OC05-OC08