الفهرس 
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Abstract
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UMMARY
hronic Kidney Disease (CKD) is a functional diagnosis characterized by an irreversible and gradually progressive decline in glomerular filtration rate (GFR). It is further complicated by an increasing inability to maintain normal levels of products of protein metabolism (urea, creatinine), normal blood pressure, hematocrit, sodium, water, calcium phosphate homeostasis, potassium and acid base balance (Li et al., 2024).
Among the myriad complications manifesting in KD (kidney disease), polyneuropathy has been recognized as the most common complication. Uremic neuropathy presents as distal painless, progressive, symmetrical, sensorimotor polyneuropathy. There is segmental demyelination and axonal degeneration in peripheral nerves (Zhu et al., 2022). Early symptoms are paresthesia, paradoxical heat sensation, restless leg syndrome, increased pain sensation, and cramps. Long-term symptoms include weakness, impaired deep tendon reflexes, imbalance, numbness, and atrophy of the lower limbs (Arab et al., 2023).
Despite the high prevalence of peripheral neuropathy in CKD, the pathophysiology remains unclear. Diagnosis of neuropathy is done through a number of procedures such as biochemical tests, CSF examination, electromyography (EMG), nerve muscle biopsy, and electrophysiological studies (EPS).
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Among all the aforementioned investigations, nerve conduction studies have been found to be the most sensitive detector of neuropathy, especially during its asymptomatic phase (Yildoğan et al., 2023).
Recently ultrasound has allowed the clinician to obtain detailed structural images of peripheral nerves by evaluation of the cross-sectional area and its variability along the anatomical course, echogenicity, vascularity and mobility of the peripheral nerves (Kerasnoudis et al., 2015).
The present study is a case control study which was conducted at the Neurosonography unit in Ain Shams University Hospital, on patients of chronic kidney disease visiting outpatient nephrology clinic. We enrolled 30 patients (60 arms and legs) and 25 controls (50 arms and legs) in the study. The aim of our study to assess sensitivity of ultrasound in detection of neuropathic changes in CKD patients and to correlate the extent of nerve damage to renal dysfunction as measured by laboratory investigations.
Scientific and ethical approval were obtained from both ethical committees of neuropsychaitry department and Faculty of Medicine, Ain Shams University, and the cases who accepted to participate signed a written informed consent that was provided within the study.
Cases were selected from patients who were older than 18 years and diagnosed CKD with glomerular filtration rate (GFR) less than 60 with CKD stage 3-5. We excluded from our
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study patients CKD patients on dialysis and post renal transplant patients, pregnant female patients and also patients who gave history or diagnosed of diabetes mellitus or other risk factors for neuropathy. Full history taking as regard sociodemographic and clinical data were collected from each patient by interview. Neuropathy symptoms and signs were assessed by Leeds assessment of neuropathic symptoms and signs (LANSS) scale using its arabic version (Garoushi et al., 2017) and Neuropathy Disability Score (NDS).All patients will undergo nerve ultrasound using ultrasound device Esaote MyLab5 (Italy) with a linear array transducer probe 12 Hz. We conducted our study on 3 particular nerves (median n., ulnar n., tibial n,) on both sides. The CSA was assessed by tracing the margin of the hypoechoic nerve fascicles and the interior of the hyperechoic nerve sheath. All subjects underwent nerve conduction study using Nihon Kohden Neuropack device (Japan) for the same 3 nerves for latency, CMAP amplitude and conduction velocity. All patients underwent serum creatinine, blood urea nitrogen (BUN), serum parathyroid hormone (s.PTH), uric acid, protein / creatinine ratio, sodium (Na), calcium (Ca), phosphorus (Po4), magnesium (Mg),potassium (K), hemoglobin (Hb), lipid profile for total cholesterol, low density lipoprotein (LDL), triglycerides, serum ferritin, C- reactive protein CRP, serum albumin. HbA1c was done to exclude diabetic patients. Data was presented and suitable analysis was done according to the type of data obtained for each parameter.
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There was no significant difference between cases and controls regarding age, sex, BMI. Mean age of patients was 44 years with males constituting 53.3%% of the sample. The present study demonstrated increased cross-sectional area of nerves in uremic neuropathy by ultrasound. The results in our study showed that nerve ultrasound is a useful diagnostic tool for diagnosis of peripheral neuropathy in pre-dialytic chonic kidney disease patients. It was observed that normal CSA by US in the majority of nerves corresponded to normal NCS. Increased CSA was correlated to demylinating neuropathy more than axonal neuropathy. In axonal neuropathy, majority of nerves showed decreased CSA but normal and high CSA was found in nerves with axonal neuropathy.
Sensitivity of ultrasound in median, ulnar and tibial nerves was 91.6%, 80.9% and 96.3% respectively while specificity was 83.3%, 87.2% and 100% respectively. Potassium and hemoglobin levels were positively correlated with degree of neuropathy by NCS.
Results in our study, signify that if the US used as a screening tool in diagnosis of uremic neuropathy instead of NCS which is painful and time consuming procedure. But on the other hand, if neuropathy was detected in the US, NCS should be planned to confirm the findings and differentiate between axonal and demylinating neuropathy. Thus unnecessary NCS can be avoided by using US which is readily available, inexpensive, comfortable for the patient, and reliable.
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To the best of our knowledge, most recent studies that evaluated use of US in uremic neuropathy, focused on dialysis patients and including diabetic patients, most of these studies focused on carpal tunnel syndrome as a common comorbidity in end stage renal disease (ESRD) patients. Few studies evaluated the use of nerve ultrasound in CKD patients pre-dialysis, excluding other risk factors for neuropathy (like diabetes mellitus, autoimmune diseases, etc…) in comparison to nerve conduction studies.
Possible limitations in our study were that most of the patients cause of CKD was hypertensive glomerulosclerosis, other causes for CKD weren’t present in our study. single center-based experience, so further multicenter studies are required for a longer duration on a larger number of patients. The fact that we performed only a 1-time sonographic examination and did not follow-up our patients for development of neuropathy.
We recommend that nerve ultrasound should be a useful tool for diagnosis of neuropathy with high sensitivity and specificity, and a good diagnostic and screening tool for detection of neuropathic changes in CKD patients.Studies with a larger number of patients in multiple centers in Egypt are needed in order to reach conclusive results concerning the Egyptian population