Amyloidosis related carpal tunel syndrome in patients with chronic renal disease: case report

Bolesnici s kroničnim bubrežnim zatajenjem imaju povišene vrijednosti AGE (krajnje produkte glikolizacije). AGE nastaju tijekom procesa glikolizacije i oksidativnim reakcijama, kao dio procesa kronične upale. Amiloidoza je česta komplikacija kod bolesnika s kroničnim bubrežnim zatajenjem, a posljedica je nemogućnosti izlučivanja β2-mikroglobulina. Vremenskim trajanjem hemodijalize povećava se broj bolesnika kod kojih se histološki može utvrditi amiloidoza. Trećina bolesnika koji idu na hemodijalizu manje od 4 godine ima histološke znakove amiloidoze, a redovito se javlja kod 90% bolesnika nakon 5-7 godina hemodijalize. U početnom stadiju prisutni su samo histološki znakovi bolesti, dok se klinički znakovi javljaju kasnije. Jedan od prvih kliničkih znakova amiloidoze je sindrom karpalnog tunela. Javlja se kod trećine bolesnika koji idu 5-10 godina na hemodijalizu, a nakon 20 godina hemodijalize gotovo 100% bolesnika ima sindrom karpalnog tunela. Iako sindrom karpalnog tunela ne dovodi do fatalnog ishoda, njegovim zanemarivanjem dolazi do oštećenja n. medianusa u karpalnom tunelu i atrofije mišića šake s teškim funkcionalnim ispadima. Naš bolesnik je liječen operativno i nakon završene rehabilitacije zaostao je dobar funkcionalni i anatomski rezultat. Zbog toga je pravovremeno dijagnosticiranje i dekompresija n. medianusa preduvjet za uspješno liječenje sindroma karpalnog tunela. Za razliku od „low-flux“ hemodijalizatora, novi „high-flux“ su više biokompatibilni i mogu odstraniti beta-2-mikroglobulin, pa se očekuju rjeđe komplikacije u smislu sindroma karpalnog tunela zbog amiloidoze kod bolesnika s kroničnim bubrežnim zatajenjem.Patients with CRF (chronic renal failure) have elevated AGE (advanced glycation end products). AGE are formed during glycation and oxidative stress, and accumulation of AGE occurs especially in CRF and plays a major pathogenic role. Amyloidosis is a common complication in patients with chronic renal failure. Amyloidosis develops due to impossible β2-microglobulin excretion. The number of patients with histologically demonstrable amyloidosis increases with the length of hemodialysis. Histologic signs of amyloidosis are found in one third and 90% of patients undergoing hemodialysis for up to 4 years and 5-7 years, respectively. Histologic signs alone are present initially, whereas clinical signs develop later. The carpal tunnel syndrome is one of the first clinical signs of amyloidosis. The syndrome develops in one third of patients undergoing hemodialysis for 5-10 years and nearly 100% of those treated by hemodialysis for 20 years. The carpal tunnel syndrome is not a fatal disease; however, if left untreated, it leads to median nerve lesion and atrophy of the hand musculature with severe functional deficits. The patient presented was operatively treated, followed by rehabilitation that resulted in satisfactory functional and anatomical outcome. Accordingly, timely diagnosis and median nerve decompression are the main preconditions for successful management of the carpal tunnel syndrome. In contrast to “low-flux” hemodialyzers, the new ”high-flux” devices offer appropriate biocompatibility and β2-microglobulin removal, thus a lower rate of complications such as carpal tunnel syndrome due to amyloidosis is expected in patients with chronic renal failure