- レストレス レッグス症候群 ”むずむず足症候群”の診断と治療 JSDT
レストレスレッグ症候群(RLS)は慢性血液透析患者に多くみられ、周期性四肢運動(Periodic Leg Movements:PLM)を伴うことが多い。欧米では本症に対するドーパミン製剤の有効性が示されているが、本邦での報告は極めて少ない。
今回、ホルター心電計を用い、両下肢前脛骨筋でPMLと思われる筋放電を透析治療開始30～60分後に30分間記録し、このPLMが透析患者のRLS診断とドーパミン受容体刺激薬（pergolide mesilate）のRLS症状改善判定に有用か否かに検討を加えた。透析患者230例にRLS症状有無のアンケートを行ってRLS症状を有する症例29例を抽出した。神経内科医によってRLSと診断された症例数は23例、うち4例が服薬を拒否した（拒否群）。残る19例にpergolide mesilate (50～100μg/日)を2週間投与、12例が服薬を継続（継続群）、7例が副作用で服薬を中断した（中止群）。神経内科医によって除外された患者（除外群、n=6）とRLSの症状を欠く透析患者（対照群、n=12）にもPLMの記録を行い、Colemanの定義にほぼ準じた筋放電をPMLとしてカウントした。その結果①服薬前のPLM出現回数は、継続群(n=12)が中止群(n=7)、拒否群(n=4)に比して大であり、除外群と対照群においてPMLの出現は認められなかった。②PMLが検出された継続群(n=10)の服薬前PMLの出現回数は服薬後減少し、PML出現回数減少率と症状改善率に正相関を認めた。③RLS確定例(n=23)と対照例(n=12)の対比から求めたPLMのRLS診断に対する特異度は100%であった。④pergolide mesilate はRLSの自覚症状を約70％改善したが11/19例に副作用（嘔気、眠気）を認め、７例が服薬を中止した。pergolide mesilateは副作用が比較的多いもののRLS症状の優れた改善剤であり、ホルター心電計によるPLMは本症の診断、薬物治療の効果判定に有用であると考えられた。
Holter electrocargiogram recording of periodic limbs movements in uremic restless legs syndrome: Application for diagnosis and evaluation of drug effects
Hidemaro Satou, Hiroyasu Itou*1, Takashi Hattori, Yoshimasa Nagao, Hiromitu Nonomura, Akiharu Furuta, Mihoko Nawa*1, Shiniti Kwachi*1, Mitunobu Tadokoro*1, Hitomi Yokoyama*1, Hajime Araki*1, Shigeki Sawada*1, Akito Kume*2,
Department of Kidney Center, Department of Internal Medicine*1, Sawada Hospital; Kume Clinic*2;
Objective: To investigate the usefulness of Holter electrocardiogram (ECG) recording of periodic limbs movements (PML) in hemodialysis patients with restless legs syndrome (RLS) for diagnosis of RLS and evaluation of the effects of dopaminergic agent pergolide mesylate.
Methods: Two hundred thirty hemodialysis patients were surveyed with questionnaire for RLS and 29 patients were found to have subjective symptoms typical of RLS. Twenty-nine patients were further examined by a eurologist and 23 of those were diagnosed as having RLS. Nineteen of 23 patients were enrolled in the study and 50-100 μg of pergolid before sleep was given for 2 weeks. Efficacy of pergolide was evaluated by a change in subjective symptoms measured by visual analogue scale. Holter ECG recording of PLM was performed under suggested immobilized test at baseline and 2-week endpoint. The sensitivity and specificity of Holter ECG PLM recordings for the diagnosis of RLS were investigated. Correlation between changes in subjective RLS symptoms and PLM frequency was analyzed.
Results: The sensitivity and specificity of positive Holter ECG PML recording for RLS diagnosis were 65% and 100%, respectively. Twelve of 19 patients completed the study and 7 discontinued due to adverse events. Subjective symptoms were improved by approximately 70% by visual analogue scale in all 12 patients and mean PLM frequency significantly decreased from 31.0±7.5/30 to 5.6±3.0/30 min (p<0.05). A significant correlation of between changes in subjective symptoms and PLM frequency ware noted (r＝0.67, p<0.05). Nausea and gastric discomfort as advers event were observed in 10 and somnolence in 1 out of 19 patients.
Conclusions: Holter ECG PML recording is useful in diagnosis of RLS and evaluation of drug effects. Pergolide mesylate is effective against subjective symptoms of RLS in hemodialysis patients, although it may causes gastrointestinal side effects.
日本透析医学会雑誌 2003年3号（36－3） Japanese （P 207）
- An Intradialysis Diagnostic Test for Restless Legs Syndrome:A Pilot Study A J K
An Intradialysis Diagnostic Test for Restless Legs Syndrome:
A Pilot Study
Akito Kume, MD, PhD,1,2 Hidemaro Sato, CE,3 Hiromitsu Nonomura, CE,3 Akiharu Furuta, CE,3 Shigeki Sawada, MD,3 and Shuichi Tsutsui, MD,4
BACKGROUND: Restless legs syndrome (RLS) is common in dialysis patients, but a simple diagnostic test is not available.
STUDY DESIGN: Diagnostic test study.
SETTING & PARTICIPANTS: 32 patients with RLS and 29 patients without RLS in 2 dialysis centers. INDEX TEST: The suggested immobilization test (SIT) was performed during dialysis for at least 30 minutes, and periodic limb movements (PLMs) were assessed by means of electromyography of the anterior tibialis muscles using a Holter monitor as an electromyographic monitoring device. We also assessed changes in number of leg movements on the 30-minute SIT (SIT-PLM) after 4 weeks of treatment with the dopamine agonist pergolide.
REFERENCE TEST OR OUTCOME: Clinical review by a neurologist, International RLS Rating Scale (IRLSRS) score, and changes in IRLSRS score after pergolide treatment.
RESULTS: PLMs on the 30-minute SIT during dialysis were identified in 20 of 32 patients with RLS and 3 of 29 control participants. Sensitivity and specificity of PLMs on the 30-minute SIT during dialysis for RLS diagnosis were 63% and 90%, respectively. SIT-PLM correlated with IRLSRS total score at diagnosis (r = 0.53; P = 0.03), suggesting that SIT-PLM measures the general severity of RLS in uremic patients. Treatment with the dopamine agonist pergolide significantly reduced the IRLSRS total score (from a mean of 24.9 +/- 9.1 [SD] to 9.5 +/- 6.8; P < 0.01) and SIT-PLM (from 41.9 +/- 24.2 to 11.3 +/- 12.3; P < 0.01), but correlation between changes in SIT-PLM and those in IRLSRS score was not significant (r = 0.27; P = 0.3).
LIMITATIONS: Poor correlation may be caused by the small sample size. Time available for the SIT was limited because of the patient's condition during dialysis. Time of day during SIT, mental-alerting activities during SIT, or hemodialysis therapy itself may influence the severity of PLMs.
CONCLUSIONS: A Holter-monitored SIT during dialysis is a valid method for the diagnosis of RLS and to evaluate the effect of treatment with pergolide in uremic patients.
1 Kume Clinic; 2 Nagoya Clinical Neuropharmacology,Laboratory, Nagoya;
3 Sawada Hospital, Gifu;
4 Aoi Central Hospital, Okazaki, Japan.
Am J Kidney Dis 2009 Aug;54(2):318-26. Epub 2009 Jul 2.. © 2009 by the National Kidney Foundation, Inc.