Ultrasonographic Assessment of Entheseal Sites of Upper and Lower Extremities in Hemodialysis Patients using Madrid Sonography Enthesitis Index

Ultrasonographic Assessment of Entheseal Sites of Upper and Lower Extremities in Hemodialysis Patients using Madrid Sonography Enthesitis Index | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ultrasonographic Assessment of Entheseal Sites of Upper and Lower Extremities in Hemodialysis Patients using Madrid Sonography Enthesitis Index Reham Sabry, Samar Tharwat, Mohammed Kamal Nassar, Ehab E Eltoraby This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1065093/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Musculoskeletal (MSK) complications are one of the most common health concerns that impact individuals on maintenance hemodialysis (HD). However, little is known about the entheseal involvement in HD patients. The aim of this study was to assess the prevalence and distribution of entheseal ultrasonographic (US) alterations in HD patients and to evaluate the association between US findings and both clinical and laboratory data. Methods : This study was conducted on 41 HD and 23 sex- and age- matched controls. All HD patients and healthy controls were evaluated clinically to detect any clinical evidence of enthesopathy. Six entheses sites were scanned bilaterally using grey scale (GS) and power Doppler (PD) ultrasonography (US) and were scored using Madrid Sonography Enthesitis Index (MASEI) scoring system. Results: Clinical examination revealed at least one sign suggestive of enthesopathy in 69 (14.02) of 492 entheses in 41 HD patients. HD patients had statistically significant higher scores of stuctural tendon abnormalities (p<0.001), enthesis thickening (p<0.001), bone erosions (p<0.001) and calcification (p=0.037) than healthy controls. Total MASEI score was higher in HD patients than healthy controls (median ;18 vs 8, p<0.001), also, MASEI-inflammatory (median ;11 vs 3, p<0.001) and damage scores (median ;6 vs 0, p<0.001). There was a statistically significant positive association between total MASEI score and both age (p=0.032) and duration of HD (p=0.037). Duration of HD was predictive for both MASEI-damage component (p=0.004) and total MASEI score (p=0.014). Conclusions: There is a high prevalence of asymptomatic enthesopathy in HD patients. The burden of entheseal US alterations is much higher in HD patients than in healthy subjects. US can be helpful in the early detection of entheseal abnormalities. The duration of HD is the most significant predictor of enthesopathy in HD patients. Orthopedics Orthopedic Surgery Ultrasonography Enthesitis Enthesopathy Hemodialysis MASEI score Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Chronic kidney disease (CKD) affects about 10–15% of adults worldwide [ 1 ]. And therefore, end stage kidney disease (ESKD) represents a global-health and health-care burden that is rapidly increasing [ 2 ]. The high prevalence of diabetes mellitus, hypertension, obesity, and ageing are all contributing to the global rise in this condition [ 3 ]. Dialysis is a form of renal replacement therapy that ensures maintenance of homeostasis in patients with ESRD [ 4 ]. Currently, dialysis is life-saving to nearly 3.4 million people with ESRD around the world [ 5 ]. Hemodialysis (HD), peritoneal dialysis, and hemofiltration are the three main forms of dialysis [ 6 ]. Although HD can reduce morbidity and mortality in renal patients, it can also cause a number of complications during dialysis sessions and/or as a result of long-term HD use [ 7 ]. Amyloidosis, bone disease, endocrine abnormalities, infection and cardiovascular complications are all risks associated with long-term HD [ 7 ]. Musculoskeletal (MSK) complications are one of the most common health concerns that impact individuals on maintenance HD [ 8 ]. Bone cysts, destructive arthropathy, amyloidosis,, carpal tunnel syndrome, and spontaneous tendons rupture are some of these MSK complications [ 9 , 10 ]. In HD patients, spontaneous ruptures of the Achilles and/or quadriceps tendon have been documented on a sporadic basis and are usually viewed as isolated events [ 11 ]. The reasons that predispose to such ruptures are still unknown. Some researchers believe that the tendon is still intact and that the rupture is caused by osteolytic bone resorption at the enthesis [ 12 ]. Enthesis is the area where ligaments, tendons, or joint capsules attach to bone [ 13 ]. Ultrasonography (US) is a widely available, noninvasive, reproducible, low-cost imaging modality that does not expose patients to ionizing radiation and can be used to diagnose, monitor, and stratify enthesopathy. When it comes to diagnosing enthesopathy, US is more sensitive than clinical examination, demonstrating a high frequency of abnormal findings even in asymptomatic patients [ 14 ]. However, little information is known about the entheseal involvement in HD patients; only few studies have been carried out to assess if HD patients have a ‘subclinical' enthesopathy [ 15 , 16 ]. Therefore, the aim of this study was to evaluate the frequency and distribution of entheseal US alterations in HD patients and to evaluate the association between US findings and both clinical characteristics and laboratory data. Materials And Methods Study population This cross-sectional observational study was carried out from October 2017 to March 2020 on 41 patients with ESRD and receiving HD at Mansoura Nephrology and Dialysis Unit, Mansoura University Hospital, Egypt. The sample size was selected as a convenience sample. All patients who met the inclusion criteria were offered to participate in the study unless they qualify for any of the exclusion criteria or refuse to participate. Inclusion criteria included ESRD patients aged more than 18 years and undergoing HD for more than 6 months, three times per week. Patients who had a history of rheumatic or autoimmune diseases, diabetes mellitus, peripheral neuropathy, chronic use of steroids and/ or fluoroquinolone therapy during the previous 6 months, sever trauma or joint surgery were excluded from the study. Twenty-three age- and sex matched healthy controls were also included. The study was performed in accordance with the Declaration of Helsinki. It was approved by the Institutional Research Board of the Faculty of Medicine, Mansoura University (Approval number:MS/17.05.120). The study was explained to all participants, and informed written consent was obtained from all of them before starting the study. Data collection Demographic data including age, sex, occupation, and marital status were recruited. Body weight was measured. Other clinical parameters (e.g., vascular access side and HD duration) were obtained from each HD patient through an interview. Clinical evaluation of different entheseal sites Clinical evaluation was conducted to all HD patients and healthy controls by an expert rheumatologist to detect any clinical signs indicative of enthesopathy. These signs included swelling or tenderness elicited by mobilization, pressure,and contraction against resistance of the corresponding entheses. Madrid Sonographic Enthesis Index (MASEI) Scoring System All US examinations were carried out by a rheumatologist with at least 7 years of experience in the field of musculoskeletal ultrasound (MSUS). At the time of US evaluation, the rheumatologist was blind to the clinical assessment of the entheseal sites. The EDAN U2 ultrasound equipment (Shenzhen, China) with a linear array transducer was employed in the study (8 to 13.4 MHz). The frequency was set to 13 MHz, and the sonographic settings were adjusted to provide the best images of the scanned enthesis. With a constant room temperature of 21 C and a lower wall filter, power Doppler (PD) settings were standardized with a pulse repetition frequency (PRF) of 0.75–1.20 kHz and a PD gain of 50–55 dB. Six entheses were scanned bilaterally in axial and longitudinal planes as specified by de Miguel [ 17 ]. The scanned entheseal sites included the following: proximal plantar aponeurosis, distal Achilles’ tendon, distal and proximal patellar ligament insertion, distal quadriceps tendon and distal triceps tendon. Entheses were scored using the Madrid Sonography Enthesitis Index (MASEI) scoring system [ 17 ].The elementary lesions included thickness, structural tendon abnormalities, enthesis thickening, bone erosions, calcification, PD and bursitis. Additionally, analysis 2 subscores of MASEI were included; the MASEI-inflammatory (structural tendon abnormalities, enthesis thickening, PD and bursitis) and MASEI-damage (calcifications, enthesophytes, and erosions) [ 18 ]. Blood sampling and laboratory tests Just before starting the first HD session of the week, blood samples were taken from the vascular access of HD patients. An automated analyzer was used to perform laboratory tests on the days of blood sampling. Laboratory tests included complete blood count (CBC), total cholesterol, triglycerides, serum calcium, phosphorus, parathyroid hormone level (PTH) and uric acid. Statistical analysis Data were collected and analyzed using IBM SPSS Statistics version 24.0 for Windows (IBM Corp., Armonk, NY, USA) on a personal computer. For all quantitative values, medians (interquartile range [IQR] or 25th percentile – 75th percentile) or means ± standard deviation were used, while numbers of cases and percentages (%) were utilized to illustrate qualitative variables. The Shapiro-Wilk test was used to check for normality in the distribution of continuous variables and the significance of differences between the two groups was assessed by the independent samples t test for normally distributed variables or by the Mann-Whitney test for non-parametric variables. For comparisons between qualitative variables, Chi-square or Fisher exact tests were utilized, as appropriate. Correlation analysis using the Spearman’s test were used to define relevant factors that affected MASEI scores. Subsequently, univariate linear regression analysis was done to assess the predictors of MASEI scores. P value less than 0.05 was considered significant. Results Study population The study included a total of 41 HD patients (mean age 50.7 ± 14.5 years, 25 males and 16 females) and 23 healthy sex- and age-matched controls (mean age 45.3 ± 8.9 years, 14 males and 9 females). We scanned 492 entheses sites in HD patients and 276 in healthy controls. Table 1 shows the clinical characteristics and laboratory data of HD patients and healthy controls. For the HD group, the median duration since onset of HD was 4 years. Majority of patients (80.5%) had vascular access at the right side. Clinical evaluation of different entheseal sites Clinical examination revealed at least one sign suggestive of enthesopathy in 69 (14.02%) of 492 entheses in 41 HD patients. Of which, the most frequently involved entheseal site was proximal patellar ligament (19.5%) followed by quadriceps tendon (18.3%) while the least involved was triceps tendon enthesis (2.4%). No clinical evidence of enthesopathy was detected in healthy controls. Figure 1 shows the distribution of entheseal sites that clinically involved in HD patients. Madrid Sonographic Enthesis Index (MASEI) Scoring System Table 2 illustrates the morphostructural changes of each enthesis according to MASEI scoring system. HD patients had significantly higher thickness and structural tendon abnormalities at almost all scanned entheseal sites when compared to healthy individuals. Table 3 shows the total MASEI scores of each component and each enthesis in HD patients and healthy subjects. There were statistically significant higher scores of structural tendon abnormalities (p<0.001), enthesis thickening (p<0.001), bone erosions (p<0.001) and calcification (p=0.037) in HD patients when compared with healthy subjects. Also, total MASEI score of each enthesis was significantly higher in HD patients in comparison to healthy subjects. HD patients had significantly higher total MASEI score than healthy controls (median ;18 vs 8, p<0.001), also higher MASEI-inflammatory (median ;11 vs 3, p<0.001) and damage scores (median ;6 vs 0, p<0.001). Of a total 492 scanned entheseal sites in 41 HD patients, the highest number of elemental lesions seen was enthesis thickening (272/492 ,55.3%), followed by structural tendon abnormalities (158/492,32.1%), calcification (69/492 ,14%), bone erosions (66/492,13.4%), bursitis (14/492, 2.8%) and power Doppler signal (40/492,8%) as shown in table 4. Correlation between MASEI scores and clinico-laboratory data As shown in table 5, there was a statistically significant positive association between total MASEI score and both age (p=0.032) and duration of HD (p=0.037). However, no statistically significant correlation was found between total MASEI, MASEI-inflammatory, and MASEI-damage sores and the following variables: body weight, total cholesterol, serum calcium, phosphorous and parathyroid hormone levels. Predicting MASEI scores in HD patients Univariate regression analyses revealed the following data: age was predictive for MASEI-inflammatory component (p=0.042) while duration of HD was predictive for both MASEI-damage component (p=0.004) and total MASEI score (p=0.014) as illustrated in table 6. Discussion MSK manifestations are common in patients on long-term HD, with reported frequency up to 70% [ 19 ], most of which are attributable to amyloid deposition [ 19 ]. Amyloid deposits in a variety of tissues, with a higher proclivity for bone and synovial membranes. Additionally, tendons and peripheral nerves can be impacted by this serious condition [ 20 ]. Enthesitis is a common feature of spondylarthritis [ 21 ]. However, the clinical examination and radiology used to evaluate entheses are not reliable nor accurate [ 22 ].High-resolution US is commonly employed as an imaging tool in the diagnosis of enthesopathy [ 23 ].Subclinical entheseal involvement in HD patients has not been deeply investigated [ 15 ]. As a result, this study was carried out to identify entheseal involvement in HD patients using MASEI scoring system. Gutierrez and coworkers conducted a similar study utilizing Glasgow Ultrasound Enthesitis Scoring System (GUESS), although it does not include PD evaluation or upper limb enthesis characteristics [ 15 ]. Our study sheds new light on the topography and prevalence of entheseal involvement in HD patients. To the best of our knowledge, this is the first to use MASEI scoring system in HD patients. Six entheseal sites were scanned using both GS and PDUS. Clinical examination revealed at least one sign suggestive of enthesopathy in 69 (14.02%) of 492 entheses in 41 HD patients. Musculoskeletal US revealed that tendon and ligament thicknesses were significantly higher in HD patients in comparison to healthy controls. Total MASEI score was positively correlated with both age and duration of HD. Age was predictive for MASEI-inflammatory component while duration of HD was predictive for both MASEI-damage component and total MASEI score. MSUS can effectively screen for subclinical enthesopathy [ 24 ]. Chronic subclinical enthesopathy may diminish tendon mechanical resistance, thus representing a potential risk factor for tendon rupture in the future [ 25 ]. In the current study, clinical examination revealed at least one sign suggestive of enthesopathy in 69 (14.02%) of 492 entheses in 41 HD patients, which is much lower than that detected by US (68.9%). A similar pattern of results was obtained in another study ,in which, US signs of enthesopathy were detected in 50% of the scanned entheseal sites in dialysis patients [ 15 ]. A high prevalence of subclinical enthesopathy has also been recognized in Behçet’s disease [ 26 ], Sjögren syndrome [ 27 ], fibromyalgia [ 27 ], psoriasis[ 28 ] and systemic sclerosis [ 29 ]. In this study, there were statistically significant higher scores of structural tendon abnormalities, enthesis thickening, bone erosions and calcification in HD patients when compared with healthy subjects. HD patients had significantly higher total MASEI score than healthy controls, also higher MASEI-inflammatory and damage scores. Overall these findings are in accordance with findings reported by Gutierrez and colleages in a study conducted on 33 dialysis patients and 33 healthy controls adopting Glasgow Ultrasound Enthesitis Scoring System (GUESS) scoring system and demonstrated a higher prevalence of enthesopathy in dialysis patients than in healthy subjects [ 15 ].Tendon abnormalities in the form of calcific deposition, increased thickness and abnormal peritendon tissue have also been documented in another study, in which, quadriceps and Achilles tendons were evaluated in 50 HD patients by MSUS [ 30 ]. Our results demonstrate a statistically significant positive association between total MASEI score and both patients’ age and duration of HD. A similar conclusion was reached by another study [ 15 ]. Age may influence the biological milieu and tendon adaptation to mechanical loading [ 31 ]. Additionally, long-term dialysis has been linked to MSK problems, including bone cysts, amyloidosis, destructive arthropathy, carpal tunnel syndrome, and spontaneous tendon rupture [ 32 ]. Contrary to the findings of Falsetti and colleagues [ 33 ], we did not find a significant association between total MASEI score and body weight. Tendon degeneration is often caused by metabolic disorders (e.g. diabetes, hyperuricemia, or hypercholesterolemia) [ 31 ]. Hypercholesterolemia may be associated with abnormal tendon thickness or structure [ 34 ]. However, no correlation was found between MASEI scores and total cholesterol level in our cohort. Significant osteolytic bone resorption with osteoclasts at the point of tendon insertion has been described in hyperparathyroidism in HD patients [ 35 ]. Secondary hyperparathyroidism may lead to tendon rupture due to changes that occur at the tendo-osseous junction [ 36 ]. Even though, our results suggest no correlation between MASEI scores and PTH level. Using univariate linear regression analysis, age was predictive for MASEI-inflammatory component. This is consistent with what has been found in a recent study [ 37 ], they investigated the contributing factors of US lesions of entheses in healthy subjects and found that age predicted not only inflammation, but also, damage and total US enthesopathy scores. While the ability of the tendons to compensate for stress is preserved in youth, impaired resilience of aged tissues is connected to cellular senescence and changes in extracellular matrix mechanical properties [ 38 ]. One of the strengths of this study is that it represents a comprehensive scanning of entheses at both upper and lower limbs in HD patients. Also, a control group of sex- and age-matched participants was included. However, our study has some limitations: firstly, the relatively small sample size. Secondly, the cross-sectional nature resulting in only a single evaluation of the entheses with absence of long-term follow-up. Finally, only one sonographer was utilized; a second sonographer would aid in determining the reproducibility of findings because US is an operator-dependent examination with possible inter-observer variability. A future study's goal would be to determine inter and intra reader variability. To the best of our knowledge, this is the first study to use the MASEI scoring system to detect enthesopathy in HD patients. Conclusions There is a high prevalence of asymptomatic subclinical enthesopathy in both upper and lower limbs in HD patients. Additionally, the burden of entheseal US alterations is much higher than in healthy subjects. MSUS can be helpful in the early detection of entheseal abnormalities in HD patients. The duration of HD is the significant predictor of enthesopathy in these patients. Finally, entheseal involvement in HD patients do not correlate with PTH or serum calcium level. The current findings need to be replicated in other ethnic groups and with a larger sample size. Abbreviations CKD: chronic kidney disease ESKD: end stage kidney disease GS: grey scale GUESS: Glasgow Ultrasound Enthesitis Scoring System HD: hemodialysis MASEI: Madrid Sonography Enthesitis Index MSK: musculoskeletal MSUS: musculoskeletal ultrasound PD: power Doppler PRF: pulse repetition frequency PTH: parathyroid hormone US: ultrasonographic US: ultrasonography Declarations Ethics approval and consent to participate No parts of the final version of the manuscript contain copied parts and all co-authors take full responsibility for the integrity of the published article. The study was performed in accordance with the Declaration of Helsinki. It was approved by the Institutional Research Board of the Faculty of Medicine, Mansoura University (Approval number: MS/17.05.120). The study was explained to all participants, and informed written consent was obtained from all of them before starting the study. Consent for publication N/A Availability of data and materials All data generated or analyzed during this study are included in this published article or are available from the corresponding author on reasonable request. Competing interests All authors have no conflicts of interest to declare. Funding N/A Authors' contributions Conceptualization: RS, ST, EE Investigation, all authors Data curation, formal analysis: RS, ST, MK, writing–original draft: ST, EE, writing–review & editing: All authors Acknowledgments Not applicable Authors' information (optional) RS, Specialist, https://orcid.org/0000-0002-3940-2168 ST, Associate professor, https://orcid.org/0000-0001-9892-2449 MKN, Associate professor, https://orcid.org/0000-0002-5124-2507 EEE, Professor, https://orcid.org/0000-0003-4183-7475 References Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298(17):2038–47 .https://doi.org/ 10.1001/jama.298.17.2038 . Thurlow JS, Joshi M, Yan G, Norris KC, Agodoa LY, Yuan CM, et al. Global epidemiology of end-stage kidney disease and disparities in kidney replacement therapy. Am J Nephrol.2021;52(2):98–107. https://doi.org/ 10.1159/000514550 . Thomas MC, Cooper ME, Zimmet PJNRN. 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Tables Table 1 Clinical characteristics and laboratory data of HD patients (n=41) and healthy subjects (n=23) Characteristic HD patients (n=41) Healthy subjects (n=23) P Age (years) 50.7 ± 14.5 45.3 ± 8.9 0.068 Sex Males Females 25 (61%) 16 (39%) 14 (60.9%) 9 (39.1%) 0.993 Body weight (Kg) 73 (63 – 78.8) 77 (70 – 80) 0.266 Occupation Not working Working 22 (53.7) 19 (46.3) 18 (78.3) 5 (21.7) 0.051 Marital status Single Married 9 (22) 32 (78) 10 (43.5) 13 (56.5) 0.053 Duration of HD (years ) 4 (2-6) - - Vascular access Right side Left side 8 (19.5) 33 (80.5) - - - Hemoglobin (g/dL) 9.9 (9.2 – 10.9) N/A - Cholesterol (mg/dL) 110 (93 – 130.5) N/A - Triglycerides (mg/dL) 73 (63 – 10.4.5) N/A - Calcium (mg/dL) 8.5 (7 – 9.5) N/A - Phosphorus (mg/dL) 6 (3.6 – 8.5) N/A - PTH (pg/mL) 518 (207 – 1090.5) N/A - Uric acid (mg/dl) 6.4 (5.4 – 7) N/A - Quantitative variables are expressed as mean ± standard deviation for normally distributed data and median (25 th percentile – 75 th percentile) for non-normally distributed data. Qualitative variables are expressed as number (%) PTH: parathyroid hormone Table 2 The morphostructural changes of each entheses according to Madrid Sonographic Enthesis Index (MASEI) Scoring System in HD patients (n=41) and healthy subjects (n=23) Parameter HD patients (n=41) Entheses (82) Healthy controls (n=23) Entheses =46 P Inferior pole of the calcaneus: plantar aponeurosis enthesis Thickness,mm, median (IQR) Stuctural tendon abnormalities ,n (%) Enthesis thickening,n (%) Bone erosions,n (%) Calcification,n (%) Mild Moderate Severe Power Doppler signal,n (%) 4.3 (1.35) 46 (56.1) 36 (43.9) 5 (6.1) 2 (2.4) 14 (17.1) 3 (3.7) 0 3.15 (1.6) 14 (30.4) 7 (15.2) 1 (2.2) 0 3 (6.5) 5 (10.9) 0 0.000* 0.005* 0.001* 0.418 0.104 - Superior pole of the calcaneus: Achilles tendon enthesis Thickness,mm, median (IQR) Stuctural tendon abnormalities ,n (%) Enthesis thickening,n (%) Retrocalcaneal bursitis Bone erosions,n (%) Calcification,n (%) Mild Moderate Severe Power Doppler signal,n (%) 5.2 (1.53) 16 (19.5) 40 (48.8) 10 (12.2) 10 (12.2) 6 (7.3) 8 (9.8) 0 0 4.1 (1.3) 4 (8.7) 6 (13) 3 (6.5) 0 1 (2.2) 2 (4.3) 1 (2.2) 0 0.000* 0.132 0.000 0.375 0..014* 0.208 - Tibial tuberosity: distal patellar ligament enthesis Patellar ligament structure,n (%) Thickness,mm, median (IQR) Stuctural tendon abnormalities ,n (%) Enthesis thickening,n (%) Infrapatellar bursitis ,n (%) Bone erosions,n (%) Calcification,n (%) Mild Moderate Severe Power Doppler signal,n (%) 55 (67.1) 4.45 (1.6) 27 (32.9) 50 (61) 4 (4.9) 7 (8.5) 4 (4.9) 2 (2.4) 1 (1.2) 0 13 (28.3) 3.4 (0.85) 2 (4.3) 10 (21.7) 2 (4.3) 1 (2.2) 0 1 (2.2) 0 0 0.000* 0.000* 0.000* 0.000* 1 0.257 0.401 - Inferior pole of the patella: proximal patellar ligament enthesis Thickness,mm, median (IQR) Stuctural tendon abnormalities ,n (%) Enthesis thickening,n (%) Bone erosions,n (%) Calcification,n (%) Mild Moderate Severe Power Doppler signal,n (%) 4.55 (1.23) 18 (22) 55 (67.1) 4 (4.9) 1 (1.2) 1 (1.2) 0 0 3.5 (1.33) 4 (8.7) 13 (28.3) 1 (2.2) 1 (2.2) 0 0 0 0.000* 0.086 0.000* 0.654 0.693 - Superior pole of the patella: quadriceps tendon enthesis Thickness,mm, median (IQR) Stuctural tendon abnormalities ,n (%) Enthesis thickening,n (%) Bone erosions,n (%) Calcification,n (%) Mild Moderate Severe Power Doppler signal,n (%) 6.4 (1.7) 36 (43.9) 56 (86.3) 28 (34.1) 7 (8.5) 11 (13.4) 1 (1.2) 3 (3.7) 6 (1.53) 9 (19.6) 19 (41.3) 4 (8.7) 2 (4.3) 2 (4.3) 0 0 0.002* 0.006* 0.003* 0.001* 0.218 0.552 Olecranon tuberosity: triceps tendon enthesis Thickness,mm, median (IQR) Stuctural tendon abnormalities ,n (%) Enthesis thickening,n (%) Bone erosions,n (%) Calcification,n (%) Mild Moderate Power Doppler signal,n (%) 4.05 (2.43) 15 (18.3) 35 (42.7) 12 (14.6) 6 (7.3) 2 (2.4) 1 (1.2) 2.7 (1.03) 1 (2.2) 0 1 (2.2) 0 0 0 0.000* 0.010* 0.000* 0.031* .091 1 Table 3 The total MASEI scores of each component and each enthesis in HD patients (n=41) and healthy subjects (n=23) Enthesis HD patients (n=41) Entheses (82) median (IQR) Healthy controls (n=23) Entheses =46 median (IQR) P MASEI components score (maximum score) Stuctural tendon abnormalities (12) Enthesis thickening (12) Bursitis (4) Bone erosions (36) Calcification (36) Power Doppler signal (36) 4 (3) 7 (3) 0 (0) 3 (6) 2 (5) 0 (0) 1 (3) 1 (3) 0 (0) 0 (0) 0 (2) 0 (0) 0.000* 0.000* 0.632 0.000* 0.037* 0.187 Total MASEI score at : Plantar aponeurosis enthesis Achilles tendon enthesis Distal patellar ligament enthesis Proximal patellar ligament enthesis Quadriceps tendon enthesis Triceps tendon enthesis 3 (4) 2 (5) 2 (3) 2 (2) 4 (7) 1 (3) 0 (4) 0 (1) 1 (1) 1 (1) 1 (3) 0 0.015* 0.003* 0.000* 0.001* 0.000* 0.000* Total MASEI score MASEI-inflammatory MASEI-damage 18 (11.5) 11 (7) 6 (9) 4 (8) 3 (5) 0 (2) 0.000* 0.000* 0.000* Table 4 Frequency of involvement of MASEI score components in HD patients (n=41) and healthy subjects (n=23) MASEI score components HD patients (n=41) Entheses =492 n (%) Healthy controls (n=23) Entheses =276 n (%) P Stuctural tendon abnormalities 158 (32.1) 34 (12.3) 0. 000* Enthesis thickening 272 (55.3) 55 (19.9) 0. 000* Bursitis 14 (2.8) 5 (1.8) 0.364 Bone erosions 66 (13.4) 8 (2.9) 0.000* Calcification 69 (14) 18 (6.5) .002* Power Doppler signal 4 (0.8) 0 0.303 Presence of one sign of enthesopathy 339 (68.9) 85 (30.8) 0.000* Table 5 Correlation between MASEI scores and clinico-laboratory data among HD patients (N=41) Variable MASEI-inflammatory MASEI-damage Total MASEI r s P r s P r s P Age (years) 0.297 0.059 0.261 0.099 0.336 0.032* Sex 0.216 0.175 -0.064 0.693 0.055 0.733 Body weight (Kg) 0.128 0.427 -0.057 0.725 0.029 0.855 Duration of HD (years ) 0.171 0.284 0.341 0.029 0.327 0.037* Associated comorbidities -0.052 0.745 0.099 0.539 0.029 0.856 Hemoglobin (g/dL) -0.205 0.199 -0.240 0.130 -0.216 0.176 Cholesterol (mg/dL) -0.275 0.105 0.128 0.424 -0.036 0.822 Triglycerides (mg/dL) -0.106 0.510 -0.112 0.485 -0.134 0.403 Calcium (mg/dL) -0.214 0.180 0.066 0.682 -0.082 0.610 Phosphorus (mg/dL) 0.047 0.770 0.284 0.072 0.139 0.385 PTH (pg/mL) 0.139 0.386 0.076 0.639 0.131 0.414 Uric acid (mg/dl) 0.106 0.511 0.147 0.358 0.138 0.388 *P<0.05,PTH: Parathyroid hormone Table 6 Univariate regression analysis to identify the predictors for MASEI scores among HD patients (n=41) Predictor variable MASEI-inflammatory MASEI-damage Total MASEI B P B P B P Age (years) 0.094 0.042* 0.062 0.357 0.156 0.086 Duration of HD 0.157 0.485 0.875 0.004* 1.032 0.014* Hemoglobin level (g/dl) -0.001 0.998 -0.597 0.278 -0.597 0.43 Serum cholesterol (mg/dl) -0.021 0.164 0.010 0.639 -0.011 0.716 Serum phosphorus (mg/dl) 0.82 0.783 0.391 0.349 0.473 0.409 *P<0.05 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 18 Apr, 2022 Reviews received at journal 04 Apr, 2022 Reviewers agreed at journal 29 Mar, 2022 Reviewers agreed at journal 28 Mar, 2022 Reviewers invited by journal 28 Mar, 2022 Editor assigned by journal 28 Mar, 2022 Editor invited by journal 15 Nov, 2021 Submission checks completed at journal 15 Nov, 2021 First submitted to journal 09 Nov, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1065093","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":63476979,"identity":"ff61aa22-85b4-404b-b052-bb9a744cf855","order_by":0,"name":"Reham Sabry","email":"","orcid":"","institution":"Nephrology unit, Internal Medicine Department, Mansoura New General Hospital, The Egyptian Ministry of Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Reham","middleName":"","lastName":"Sabry","suffix":""},{"id":63476980,"identity":"dcbc3706-abb1-46fd-8543-d81e7b1444cb","order_by":1,"name":"Samar Tharwat","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYPCCAxDqg4EEDz8DAxsROhLAWhgbZ1TYyEk2kKKlmedMmrHBAQJa5NtPJ36u/HFH3nxG8vMHvG2HEzffSH724EMFgzy/2AGsWgzO5G6WPJPwzHDOjTTDBkmglm030swNZ5xhMJw5OwG7FobcDZINCYcZZ0gnGDYYgrUkmEnztjEkGNzGrkW+/+3mn0At9jOk0z82JIIcNiP9G14tDDdyt4FsSZwhnWPYcADkfYkc/LYY3Hi7zbIh7XDyDPk3hTMbgIEsceZNmeSMMxI4/SLfn7v5ZoPNYdsZPMc3fP4Disr29G0SHyps5PmlcTgMEwiAVUoQqxwE+A+QonoUjIJRMApGAAAA5S9qcbf6S3cAAAAASUVORK5CYII=","orcid":"","institution":"Rheumatology \u0026 Immunology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Samar","middleName":"","lastName":"Tharwat","suffix":""},{"id":63476982,"identity":"e60fc62b-cc8e-421d-8ae4-a8f16e8edd5e","order_by":2,"name":"Mohammed Kamal Nassar","email":"","orcid":"","institution":"Mansoura Nephrology \u0026 Dialysis Unit (MNDU), Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Kamal","lastName":"Nassar","suffix":""},{"id":63476984,"identity":"fb4ec198-21f3-443b-840f-e3a689973d30","order_by":3,"name":"Ehab E Eltoraby","email":"","orcid":"","institution":"Rheumatology \u0026 Immunology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ehab","middleName":"E","lastName":"Eltoraby","suffix":""}],"badges":[],"createdAt":"2021-11-09 16:59:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1065093/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1065093/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":15599909,"identity":"9d85446c-4be0-4f15-a863-576010f8a2b7","added_by":"auto","created_at":"2021-11-16 16:10:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":293444,"visible":true,"origin":"","legend":"Clinical evidence of enthesopathy at different entheseal sites in HD patients (n=41)","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1065093/v1/cbdca26457888e643841ffd4.jpg"},{"id":15599907,"identity":"01c053b9-0eee-4090-8068-625baa78839a","added_by":"auto","created_at":"2021-11-16 16:10:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":572878,"visible":true,"origin":"","legend":"A 60-year-old female patient with chronic renal failure on chronic hemodialysis for 5years with calcification at the posterior pole of calcaneus enthesis","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-1065093/v1/39527a50de1de428eb920a4c.png"},{"id":15599908,"identity":"157b24bd-3d71-49c7-92da-b99040b0c7f1","added_by":"auto","created_at":"2021-11-16 16:10:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":306064,"visible":true,"origin":"","legend":"A 42-year-old male patient with chronic renal failure on chronic hemodialysis for 6 years with deep infrapatellar bursitis","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-1065093/v1/cb63489ef69a21592a66b8ac.png"},{"id":15599910,"identity":"05fc1428-9fb0-4754-b072-421e19799129","added_by":"auto","created_at":"2021-11-16 16:10:41","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":415875,"visible":true,"origin":"","legend":"A 45-year-old female patient with chronic renal failure on chronic hemodialysis for 3 years with abnormal structure and hypoechoic pattern of the distal plantar ligament at its insertion at tibial tuberosity","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-1065093/v1/d60637ecc78231853e6f08bd.png"},{"id":15599917,"identity":"c18d3726-5e6e-41d8-9f38-30c1ed9bbf6a","added_by":"auto","created_at":"2021-11-16 16:10:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1440051,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1065093/v1/08b2e46f-6b62-477b-8ca0-c9313881de43.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eUltrasonographic Assessment of Entheseal Sites of Upper and Lower Extremities in Hemodialysis Patients using Madrid Sonography Enthesitis Index\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic kidney disease (CKD) affects about 10\u0026ndash;15% of adults worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. And therefore, end stage kidney disease (ESKD) represents a global-health and health-care burden that is rapidly increasing [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The high prevalence of diabetes mellitus, hypertension, obesity, and ageing are all contributing to the global rise in this condition [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Dialysis is a form of renal replacement therapy that ensures maintenance of homeostasis in patients with ESRD [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Currently, dialysis is life-saving to nearly 3.4 million people with ESRD around the world [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Hemodialysis (HD), peritoneal dialysis, and hemofiltration are the three main forms of dialysis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough HD can reduce morbidity and mortality in renal patients, it can also cause a number of complications during dialysis sessions and/or as a result of long-term HD use [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Amyloidosis, bone disease, endocrine abnormalities, infection and cardiovascular complications are all risks associated with long-term HD [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Musculoskeletal (MSK) complications are one of the most common health concerns that impact individuals on maintenance HD [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Bone cysts, destructive arthropathy, amyloidosis,, carpal tunnel syndrome, and spontaneous tendons rupture are some of these MSK complications [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn HD patients, spontaneous ruptures of the Achilles and/or quadriceps tendon have been documented on a sporadic basis and are usually viewed as isolated events [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The reasons that predispose to such ruptures are still unknown. Some researchers believe that the tendon is still intact and that the rupture is caused by osteolytic bone resorption at the enthesis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Enthesis is the area where ligaments, tendons, or joint capsules attach to bone [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUltrasonography (US) is a widely available, noninvasive, reproducible, low-cost imaging modality that does not expose patients to ionizing radiation and can be used to diagnose, monitor, and stratify enthesopathy. When it comes to diagnosing enthesopathy, US is more sensitive than clinical examination, demonstrating a high frequency of abnormal findings even in asymptomatic patients [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, little information is known about the entheseal involvement in HD patients; only few studies have been carried out to assess if HD patients have a \u0026lsquo;subclinical' enthesopathy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, the aim of this study was to evaluate the frequency and distribution of entheseal US alterations in HD patients and to evaluate the association between US findings and both clinical characteristics and laboratory data.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThis cross-sectional observational study was carried out from October 2017 to March 2020 on 41 patients with ESRD and receiving HD at Mansoura Nephrology and Dialysis Unit, Mansoura University Hospital, Egypt. The sample size was selected as a convenience sample. All patients who met the inclusion criteria were offered to participate in the study unless they qualify for any of the exclusion criteria or refuse to participate. Inclusion criteria included ESRD patients aged more than 18 years and undergoing HD for more than 6 months, three times per week. Patients who had a history of rheumatic or autoimmune diseases, diabetes mellitus, peripheral neuropathy, chronic use of steroids and/ or fluoroquinolone therapy during the previous 6 months, sever trauma or joint surgery were excluded from the study. Twenty-three age- and sex matched healthy controls were also included. The study was performed in accordance with the Declaration of Helsinki. It was approved by the Institutional Research Board of the Faculty of Medicine, Mansoura University (Approval number:MS/17.05.120). The study was explained to all participants, and informed written consent was obtained from all of them before starting the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eDemographic data including age, sex, occupation, and marital status were recruited. Body weight was measured. Other clinical parameters (e.g., vascular access side and HD duration) were obtained from each HD patient through an interview.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eClinical evaluation of different entheseal sites\u003c/h2\u003e \u003cp\u003eClinical evaluation was conducted to all HD patients and healthy controls by an expert rheumatologist to detect any clinical signs indicative of enthesopathy. These signs included swelling or tenderness elicited by mobilization, pressure,and contraction against resistance of the corresponding entheses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMadrid Sonographic Enthesis Index (MASEI) Scoring System\u003c/h2\u003e \u003cp\u003eAll US examinations were carried out by a rheumatologist with at least 7 years of experience in the field of musculoskeletal ultrasound (MSUS). At the time of US evaluation, the rheumatologist was blind to the clinical assessment of the entheseal sites. The EDAN U2 ultrasound equipment (Shenzhen, China) with a linear array transducer was employed in the study (8 to 13.4 MHz). The frequency was set to 13 MHz, and the sonographic settings were adjusted to provide the best images of the scanned enthesis. With a constant room temperature of 21 C and a lower wall filter, power Doppler (PD) settings were standardized with a pulse repetition frequency (PRF) of 0.75\u0026ndash;1.20 kHz and a PD gain of 50\u0026ndash;55 dB.\u003c/p\u003e \u003cp\u003eSix entheses were scanned bilaterally in axial and longitudinal planes as specified by de Miguel [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The scanned entheseal sites included the following: proximal plantar aponeurosis, distal Achilles\u0026rsquo; tendon, distal and proximal patellar ligament insertion, distal quadriceps tendon and distal triceps tendon. Entheses were scored using the Madrid Sonography Enthesitis Index (MASEI) scoring system [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].The elementary lesions included thickness, structural tendon abnormalities, enthesis thickening, bone erosions, calcification, PD and bursitis.\u003c/p\u003e \u003cp\u003eAdditionally, analysis 2 subscores of MASEI were included; the MASEI-inflammatory (structural tendon abnormalities, enthesis thickening, PD and bursitis) and MASEI-damage (calcifications, enthesophytes, and erosions) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eBlood sampling and laboratory tests\u003c/h2\u003e \u003cp\u003eJust before starting the first HD session of the week, blood samples were taken from the vascular access of HD patients. An automated analyzer was used to perform laboratory tests on the days of blood sampling. Laboratory tests included complete blood count (CBC), total cholesterol, triglycerides, serum calcium, phosphorus, parathyroid hormone level (PTH) and uric acid.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were collected and analyzed using IBM SPSS Statistics version 24.0 for Windows (IBM Corp., Armonk, NY, USA) on a personal computer. For all quantitative values, medians (interquartile range [IQR] or 25th percentile \u0026ndash; 75th percentile) or means \u0026plusmn; standard deviation were used, while numbers of cases and percentages (%) were utilized to illustrate qualitative variables. The Shapiro-Wilk test was used to check for normality in the distribution of continuous variables and the significance of differences between the two groups was assessed by the independent samples t test for normally distributed variables or by the Mann-Whitney test for non-parametric variables. For comparisons between qualitative variables, Chi-square or Fisher exact tests were utilized, as appropriate. Correlation analysis using the Spearman\u0026rsquo;s test were used to define relevant factors that affected MASEI scores. Subsequently, univariate linear regression analysis was done to assess the predictors of MASEI scores. P value less than 0.05 was considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003ch2\u003e\u003cu\u003eStudy population\u0026nbsp;\u003c/u\u003e\u003c/h2\u003e\n\u003cp\u003eThe study included a total of 41 HD patients (mean age 50.7 \u0026plusmn; 14.5 years, 25 males and 16 females) and 23 healthy\u0026nbsp;sex- and age-matched\u0026nbsp;controls (mean age 45.3 \u0026plusmn; 8.9 years, 14 males and 9 females). We scanned 492 entheses sites in HD patients and 276 in healthy controls. Table 1 shows the clinical characteristics and laboratory data\u0026nbsp;of HD patients and healthy controls. For the HD group, the median duration since onset of HD was 4 years. Majority of patients (80.5%) had vascular access at the right side.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cu\u003eClinical evaluation of different entheseal sites\u0026nbsp;\u003c/u\u003e\u003c/h2\u003e\n\u003cp\u003eClinical examination revealed at least one sign suggestive of enthesopathy in 69 (14.02%) of 492 entheses in 41 HD patients.\u0026nbsp;Of which, the most frequently involved entheseal site was proximal patellar ligament (19.5%) followed by quadriceps tendon (18.3%) while the least involved was triceps tendon enthesis (2.4%). No clinical evidence of enthesopathy was detected in healthy controls. Figure 1 shows the distribution of entheseal sites that clinically involved in HD patients.\u003c/p\u003e\n\u003ch2\u003e\u003cu\u003eMadrid Sonographic Enthesis Index (MASEI) Scoring System\u003c/u\u003e\u003c/h2\u003e\n\u003cp\u003eTable 2 illustrates the morphostructural changes of each enthesis according to MASEI scoring system. HD patients had significantly higher thickness and structural tendon abnormalities at almost all scanned entheseal sites when compared to healthy individuals.\u003c/p\u003e\n\u003cp\u003eTable 3 shows the total MASEI scores of each component and each enthesis in HD patients and healthy subjects. There were statistically significant higher scores of structural tendon abnormalities (p\u0026lt;0.001), enthesis thickening (p\u0026lt;0.001), bone erosions (p\u0026lt;0.001) and calcification (p=0.037) in HD patients when compared with healthy subjects. Also, total MASEI score of each enthesis was significantly higher in HD patients in comparison to healthy subjects. HD patients had significantly higher total MASEI score than healthy controls (median ;18 vs 8, p\u0026lt;0.001), also higher MASEI-inflammatory (median ;11 vs 3, p\u0026lt;0.001) and damage scores (median ;6 vs 0, p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eOf a total 492 scanned entheseal sites in 41 HD patients, the highest number of elemental lesions seen was enthesis thickening (272/492 ,55.3%), followed by structural tendon abnormalities (158/492,32.1%), calcification (69/492 ,14%), bone erosions (66/492,13.4%), bursitis (14/492, 2.8%) and power Doppler signal (40/492,8%) as shown in table 4.\u003c/p\u003e\n\u003ch2\u003e\u003cu\u003eCorrelation between MASEI scores and clinico-laboratory data\u003c/u\u003e\u003c/h2\u003e\n\u003cp\u003eAs shown in table 5, there was a statistically significant positive association between total MASEI score and both age (p=0.032) and duration of HD (p=0.037). However, no statistically significant correlation was found between total MASEI, MASEI-inflammatory, and MASEI-damage sores and the following variables: body weight, total cholesterol, serum calcium, phosphorous and parathyroid hormone levels.\u003c/p\u003e\n\u003ch2\u003e\u003cu\u003ePredicting MASEI scores in HD patients\u003c/u\u003e\u003c/h2\u003e\n\u003cp\u003eUnivariate regression analyses revealed the following data: age was predictive for MASEI-inflammatory component (p=0.042) while duration of HD was predictive for both MASEI-damage component (p=0.004) and total MASEI score (p=0.014) as illustrated in table 6.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMSK manifestations are common in patients on long-term HD, with reported frequency up to 70% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], most of which are attributable to amyloid deposition [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Amyloid deposits in a variety of tissues, with a higher proclivity for bone and synovial membranes. Additionally, tendons and peripheral nerves can be impacted by this serious condition [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEnthesitis is a common feature of spondylarthritis [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, the clinical examination and radiology used to evaluate entheses are not reliable nor accurate [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].High-resolution US is commonly employed as an imaging tool in the diagnosis of enthesopathy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].Subclinical entheseal involvement in HD patients has not been deeply investigated [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. As a result, this study was carried out to identify entheseal involvement in HD patients using MASEI scoring system. Gutierrez and coworkers conducted a similar study utilizing Glasgow Ultrasound Enthesitis Scoring System (GUESS), although it does not include PD evaluation or upper limb enthesis characteristics [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study sheds new light on the topography and prevalence of entheseal involvement in HD patients. To the best of our knowledge, this is the first to use MASEI scoring system in HD patients. Six entheseal sites were scanned using both GS and PDUS. Clinical examination revealed at least one sign suggestive of enthesopathy in 69 (14.02%) of 492 entheses in 41 HD patients. Musculoskeletal US revealed that tendon and ligament thicknesses were significantly higher in HD patients in comparison to healthy controls. Total MASEI score was positively correlated with both age and duration of HD. Age was predictive for MASEI-inflammatory component while duration of HD was predictive for both MASEI-damage component and total MASEI score.\u003c/p\u003e \u003cp\u003eMSUS can effectively screen for subclinical enthesopathy [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Chronic subclinical enthesopathy may diminish tendon mechanical resistance, thus representing a potential risk factor for tendon rupture in the future [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In the current study, clinical examination revealed at least one sign suggestive of enthesopathy in 69 (14.02%) of 492 entheses in 41 HD patients, which is much lower than that detected by US (68.9%). A similar pattern of results was obtained in another study ,in which, US signs of enthesopathy were detected in 50% of the scanned entheseal sites in dialysis patients [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A high prevalence of subclinical enthesopathy has also been recognized in Beh\u0026ccedil;et\u0026rsquo;s disease [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], Sj\u0026ouml;gren syndrome [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], fibromyalgia [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], psoriasis[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and systemic sclerosis [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, there were statistically significant higher scores of structural tendon abnormalities, enthesis thickening, bone erosions and calcification in HD patients when compared with healthy subjects. HD patients had significantly higher total MASEI score than healthy controls, also higher MASEI-inflammatory and damage scores. Overall these findings are in accordance with findings reported by Gutierrez and colleages in a study conducted on 33 dialysis patients and 33 healthy controls adopting Glasgow Ultrasound Enthesitis Scoring System (GUESS) scoring system and demonstrated a higher prevalence of enthesopathy in dialysis patients than in healthy subjects [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].Tendon abnormalities in the form of calcific deposition, increased thickness and abnormal peritendon tissue have also been documented in another study, in which, quadriceps and Achilles tendons were evaluated in 50 HD patients by MSUS [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur results demonstrate a statistically significant positive association between total MASEI score and both patients\u0026rsquo; age and duration of HD. A similar conclusion was reached by another study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Age may influence the biological milieu and tendon adaptation to mechanical loading [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Additionally, long-term dialysis has been linked to MSK problems, including bone cysts, amyloidosis, destructive arthropathy, carpal tunnel syndrome, and spontaneous tendon rupture [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Contrary to the findings of Falsetti and colleagues [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], we did not find a significant association between total MASEI score and body weight.\u003c/p\u003e \u003cp\u003eTendon degeneration is often caused by metabolic disorders (e.g. diabetes, hyperuricemia, or hypercholesterolemia) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Hypercholesterolemia may be associated with abnormal tendon thickness or structure [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, no correlation was found between MASEI scores and total cholesterol level in our cohort.\u003c/p\u003e \u003cp\u003eSignificant osteolytic bone resorption with osteoclasts at the point of tendon insertion has been described in hyperparathyroidism in HD patients [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Secondary hyperparathyroidism may lead to tendon rupture due to changes that occur at the tendo-osseous junction [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Even though, our results suggest no correlation between MASEI scores and PTH level.\u003c/p\u003e \u003cp\u003eUsing univariate linear regression analysis, age was predictive for MASEI-inflammatory component. This is consistent with what has been found in a recent study [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], they investigated the contributing factors of US lesions of entheses in healthy subjects and found that age predicted not only inflammation, but also, damage and total US enthesopathy scores. While the ability of the tendons to compensate for stress is preserved in youth, impaired resilience of aged tissues is connected to cellular senescence and changes in extracellular matrix mechanical properties [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the strengths of this study is that it represents a comprehensive scanning of entheses at both upper and lower limbs in HD patients. Also, a control group of sex- and age-matched participants was included.\u003c/p\u003e \u003cp\u003eHowever, our study has some limitations: firstly, the relatively small sample size. Secondly, the cross-sectional nature resulting in only a single evaluation of the entheses with absence of long-term follow-up. Finally, only one sonographer was utilized; a second sonographer would aid in determining the reproducibility of findings because US is an operator-dependent examination with possible inter-observer variability. A future study's goal would be to determine inter and intra reader variability.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first study to use the MASEI scoring system to detect enthesopathy in HD patients.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere is a high prevalence of asymptomatic subclinical enthesopathy in both upper and lower limbs in HD patients. Additionally, the burden of entheseal US alterations is much higher than in healthy subjects. MSUS can be helpful in the early detection of entheseal abnormalities in HD patients. The duration of HD is the significant predictor of enthesopathy in these patients. Finally, entheseal involvement in HD patients do not correlate with PTH or serum calcium level. The current findings need to be replicated in other ethnic groups and with a larger sample size.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCKD: chronic kidney disease\u003c/p\u003e\n\u003cp\u003eESKD: end stage kidney disease\u003c/p\u003e\n\u003cp\u003eGS: grey scale\u003c/p\u003e\n\u003cp\u003eGUESS:\u0026nbsp;Glasgow Ultrasound Enthesitis Scoring System\u003c/p\u003e\n\u003cp\u003eHD: hemodialysis\u003c/p\u003e\n\u003cp\u003eMASEI: Madrid Sonography Enthesitis Index\u003c/p\u003e\n\u003cp\u003eMSK: musculoskeletal\u003c/p\u003e\n\u003cp\u003eMSUS: musculoskeletal ultrasound\u003c/p\u003e\n\u003cp\u003ePD: power Doppler\u003c/p\u003e\n\u003cp\u003ePRF: pulse repetition frequency\u003c/p\u003e\n\u003cp\u003ePTH: parathyroid hormone\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUS: ultrasonographic\u003c/p\u003e\n\u003cp\u003eUS: ultrasonography\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eNo parts of the final version of the manuscript contain copied parts and all co-authors take full responsibility for the integrity of the published article.\u0026nbsp;The study was performed in accordance with the Declaration of Helsinki.\u0026nbsp;It was approved by the Institutional Research Board of the Faculty of Medicine, Mansoura University (Approval number: MS/17.05.120). The study was explained to all participants, and informed written consent was obtained from all of them before starting the study.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article or are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eAll authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eConceptualization: RS, ST, EE Investigation, all authors Data curation, formal analysis: RS, ST, MK, writing\u0026ndash;original draft: ST, EE, writing\u0026ndash;review \u0026amp; editing: All authors\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003e\u0026nbsp;Not applicable\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; information (optional)\u003c/h2\u003e\n\u003cp\u003eRS, Specialist, https://orcid.org/0000-0002-3940-2168\u003c/p\u003e\n\u003cp\u003eST, Associate professor,\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0001-9892-2449\"\u003ehttps://orcid.org/0000-0001-9892-2449\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eMKN, Associate professor,\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0002-5124-2507\"\u003ehttps://orcid.org/0000-0002-5124-2507\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eEEE, Professor,\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0003-4183-7475\"\u003ehttps://orcid.org/0000-0003-4183-7475\u003c/a\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCoresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. 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Clin Rheumatol 2011;30(7):907\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1007/s10067-011-1703-8\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin CH, Shiang JC, Tsai MK,Chang CC, Chang DM. Sonographic Evaluation of Lower-limbs Entheses in Subclinical Patients Undergoing Hemodialysis. Formosan Journal of Rheumatology. 2012;26(1\u0026amp;2):41\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Miguel E, Cobo T, Mu\u0026ntilde;oz-Fern\u0026aacute;ndez S, Naredo E, Us\u0026oacute;n J, Acebes JC, et al. Validity of enthesis ultrasound assessment in spondyloarthropathy. 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Rheumatol Int. 2012;32(5):1161\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1007/s00296-010-1756-z\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelly A, Apostle K, Sanders D, Bailey HJCJoS. Musculoskeletal pain in dialysis-related amyloidosis. Can J Surg. 2007;50(4):305.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchett G, Lories RJ, D'Agostino M-A, Elewaut D, Kirkham B, Soriano ER, et al. Enthesitis: from pathophysiology to treatment. Nat Rev Rheumatol. 2017;13(12):731\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1038/nrrheum.2017.188\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD'Agostino M-AJCER. Enthesitis detection by ultrasound: where are we now. Clin Exp Rheumatol.2018;36(Suppl 114):127\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu L, Chen P, Sun X, Zhang S. Musculoskeletal ultrasound for ankylosing spondylitis: A systematic review and meta-analysis. Medicine (Baltimore). 2021;100(18):e25822. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1097/MD.0000000000025822\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVyas K, Jain SK, Mittal A, Kumar R, Saxena S, Malviya S. Sonographic Evaluation of Subclinical Enthesopathy in Patients of Chronic Plaque Psoriasis. Indian Dermatol Online J. 2020;11(4):580\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.4103/idoj.IDOJ_446_18\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Matteo A, Filippucci E, Cipolletta E, Satulu I, Hurnakova J, Lato V, et al. Entheseal involvement in patients with systemic lupus erythematosus: an ultrasound study. Rheumatology (Oxford). AJR Am J Roentgenol. 2018;57(10):1822\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1093/rheumatology/key189\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOzkan F, Cetin GY, Bakan B, Kalender AM, Yuksel M, Ekerbicer HC, et al. Sonographic evaluation of subclinical entheseal involvement in patients with Beh\u0026ccedil;et disease. AJR Am J Roentgenol. 2012;199(6):W723-W9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.2214/AJR.12.8576\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSag S, Sag MS, Tekeoglu I, Kamanlı A, Nas KJJoMU. Presence of enthesopathy in patients with primary Sjogren\u0026rsquo;s syndrome: ultrasonographic study of a local cohort. J Med Ultrason. 2018;45(1):121\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1007/s10396-017-0802-9\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoshrif A, Mosallam AJEjor. Subclinical enthesopathy in patients with psoriasis and its association with other disease parameters: a power Doppler ultrasonographic study. Eur J Rheumatol. 2017;4(1):24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.5152/eurjrheum.2017.16049\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKilic E, Kilic G, Akgul O, Ozgocmen SJMr. Presence of enthesopathy demonstrated with ultrasonography in systemic sclerosis. Mod Rheumatol. 2015;25(5):731\u0026ndash;6.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.3109/14397595.2015.1019962\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussein DA, El-Azizi NO, Meged AHA, Al-Hoseiny SA, Hamada AM, Sabry MHJCMIA, et al. Ultrasonographic tendon alteration in relation to parathyroid dysfunction in chronic hemodialysis patients. Clin Med Insights Arthritis Musculoskelet Disord. 2015;8:CMAMD. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eS20887.https://doi.org/ 10.4137/CMAMD.S20887\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbate M, Schiavone C, Salini V, Andia IJR. Occurrence of tendon pathologies in metabolic disorders. Rheumatology (Oxford). 2013;52(4):599\u0026ndash;608.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1093/rheumatology/kes395\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiota E, Tsuchiya K, Yamaoka K, Kawano OJCO, Research R. Spontaneous major tendon ruptures in patients receiving long-term hemodialysis. Clin Orthop Relat Res. 2002;394:236\u0026ndash;42\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.https://doi.org/ 10.1097/00003086-200201000-00028\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFalsetti P, Conticini E, Baldi C, Bardelli M, Cantarini L, Frediani BJRC. Diffuse Peripheral Enthesitis in Metabolic Syndrome: A Retrospective Clinical and Power Doppler Ultrasound Study. Reumatol Clin (Engl Ed) 2021.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1016/j.reuma.2020.12.005\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbate M, Di Carlo L, Salini V, Schiavone CJCr. Metabolic syndrome associated to non-inflammatory Achilles enthesopathy. Clin Rheumatol. 2014;33(10):1517\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1007/s10067-014-2524-3\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen C-M, Wang S-J, Wu S-S, Chu P, Huang G-SJJotFMA. Spontaneous rupture of the patellar and contralateral quadriceps tendons associated with secondary hyperparathyroidism in a patient receiving long-term dialysis. J Formos Med Assoc. 2006;105(11):941\u0026ndash;5\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.https://doi.org/ 10.1016/S0929-6646(09)60180-7\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsourvakas S, Gouvalas K, Gimtsas C, Tsianas N, Founta P, Ameridis NJAoo, et al. Bilateral and simultaneous rupture of the triceps tendons in chronic renal failure and secondary hyperparathyroidism. Arch Orthop Trauma Surg. 2004;124(4):278\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.1007/s00402-003-0628-3\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBakirci S, Solmaz D, Stephenson W, Eder L, Roth J, Aydin SZJTJor. Entheseal changes in response to age, body mass index, and physical activity: an ultrasound study in healthy people. J Rheumatol. 2020;47(7):968\u0026ndash;72\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.https://doi.org/ 10.3899/jrheum.190540\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasi AT, Andonian B, van der Heijde DJTJoR. Biomechanical factors may be the main contributor to entheseal changes in normal adults. J Rheumatol. 2021;48(4):618\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/ 10.3899/jrheum.201296\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eClinical characteristics and laboratory data of \u0026nbsp;HD patients (n=41) and healthy subjects (n=23)\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003eHD patients (n=41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003eHealthy subjects (n=23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e50.7 \u0026plusmn; 14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003e45.3 \u0026plusmn; 8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003eMales\u003c/p\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25 (61%)\u003c/p\u003e\n \u003cp\u003e16 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (60.9%)\u003c/p\u003e\n \u003cp\u003e9 (39.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.993\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eBody weight (Kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e73 (63 \u0026ndash; 78.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003e77 (70 \u0026ndash; 80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e0.266\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eOccupation\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNot working\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWorking\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (53.7)\u003c/p\u003e\n \u003cp\u003e19 (46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 (78.3)\u003c/p\u003e\n \u003cp\u003e5 (21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eMarital status\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSingle\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (22)\u003c/p\u003e\n \u003cp\u003e32 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (43.5)\u003c/p\u003e\n \u003cp\u003e13 (56.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eDuration of HD (years )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e4 (2-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eVascular access\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRight side\u003c/p\u003e\n \u003cp\u003eLeft side \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (19.5)\u003c/p\u003e\n \u003cp\u003e33 (80.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e9.9 (9.2 \u0026ndash; 10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eCholesterol (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e110 (93 \u0026ndash; 130.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eTriglycerides (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e73 (63 \u0026ndash; 10.4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eCalcium (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e8.5 (7 \u0026ndash; 9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003ePhosphorus (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e6 (3.6 \u0026ndash; 8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003ePTH (pg/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e518 (207 \u0026ndash; 1090.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"28.24074074074074%\"\u003e\n \u003cp\u003eUric acid (mg/dl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.308641975308642%\"\u003e\n \u003cp\u003e6.4 (5.4 \u0026ndash; 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.339506172839506%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.11111111111111%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eQuantitative variables are expressed as mean \u0026plusmn; standard deviation for normally distributed data and median (25\u003csup\u003eth\u003c/sup\u003e percentile \u0026ndash; 75\u003csup\u003eth\u003c/sup\u003e percentile) for non-normally distributed data. Qualitative variables are expressed as number (%)\u003c/p\u003e\n\u003cp\u003ePTH: parathyroid hormone\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u0026nbsp;The morphostructural changes of each entheses according to Madrid Sonographic Enthesis Index (MASEI) Scoring System in HD patients (n=41) and healthy subjects (n=23)\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"51.769911504424776%\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.911504424778762%\"\u003e\n \u003cp\u003eHD patients (n=41)\u003c/p\u003e\n \u003cp\u003eEntheses (82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.353982300884955%\"\u003e\n \u003cp\u003eHealthy controls (n=23)\u003c/p\u003e\n \u003cp\u003eEntheses =46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.964601769911504%\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"51.769911504424776%\"\u003e\n \u003cp\u003eInferior pole of the calcaneus: plantar aponeurosis enthesis\u003c/p\u003e\n \u003cp\u003eThickness,mm, median (IQR)\u003c/p\u003e\n \u003cp\u003eStuctural tendon abnormalities\u0026nbsp;,n (%)\u003c/p\u003e\n \u003cp\u003eEnthesis thickening,n (%)\u003c/p\u003e\n \u003cp\u003eBone erosions,n (%)\u003c/p\u003e\n \u003cp\u003eCalcification,n (%)\u003c/p\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSevere\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePower Doppler signal,n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.911504424778762%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.3 (1.35)\u003c/p\u003e\n \u003cp\u003e46 (56.1)\u003c/p\u003e\n \u003cp\u003e36 (43.9)\u003c/p\u003e\n \u003cp\u003e5 (6.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (2.4)\u003c/p\u003e\n \u003cp\u003e14 (17.1)\u003c/p\u003e\n \u003cp\u003e3 (3.7)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.353982300884955%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.15 (1.6)\u003c/p\u003e\n \u003cp\u003e14 (30.4)\u003c/p\u003e\n \u003cp\u003e7 (15.2)\u003c/p\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e3 (6.5)\u003c/p\u003e\n \u003cp\u003e5 (10.9)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.964601769911504%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.005*\u003c/p\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"51.769911504424776%\"\u003e\n \u003cp\u003eSuperior pole of the calcaneus: Achilles tendon enthesis\u003c/p\u003e\n \u003cp\u003eThickness,mm, median (IQR)\u003c/p\u003e\n \u003cp\u003eStuctural tendon abnormalities ,n (%)\u003c/p\u003e\n \u003cp\u003eEnthesis thickening,n (%)\u003c/p\u003e\n \u003cp\u003eRetrocalcaneal bursitis\u003c/p\u003e\n \u003cp\u003eBone erosions,n (%)\u003c/p\u003e\n \u003cp\u003eCalcification,n (%)\u003c/p\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003cp\u003ePower Doppler signal,n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.911504424778762%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.2 (1.53)\u003c/p\u003e\n \u003cp\u003e16 (19.5)\u003c/p\u003e\n \u003cp\u003e40 (48.8)\u003c/p\u003e\n \u003cp\u003e10 (12.2)\u003c/p\u003e\n \u003cp\u003e10 (12.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (7.3)\u003c/p\u003e\n \u003cp\u003e8 (9.8)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.353982300884955%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.1 (1.3)\u003c/p\u003e\n \u003cp\u003e4 (8.7)\u003c/p\u003e\n \u003cp\u003e6 (13)\u003c/p\u003e\n \u003cp\u003e3 (6.5)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003cp\u003e2 (4.3)\u003c/p\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.964601769911504%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.132\u003c/p\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003cp\u003e0.375\u003c/p\u003e\n \u003cp\u003e0..014*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.208\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"51.769911504424776%\"\u003e\n \u003cp\u003eTibial tuberosity: distal patellar ligament enthesis\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePatellar ligament structure,n (%)\u003c/p\u003e\n \u003cp\u003eThickness,mm, median (IQR)\u003c/p\u003e\n \u003cp\u003eStuctural tendon abnormalities ,n (%)\u003c/p\u003e\n \u003cp\u003eEnthesis thickening,n (%)\u003c/p\u003e\n \u003cp\u003eInfrapatellar bursitis ,n (%)\u003c/p\u003e\n \u003cp\u003eBone erosions,n (%)\u003c/p\u003e\n \u003cp\u003eCalcification,n (%)\u003c/p\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eSevere\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Power Doppler signal,n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.911504424778762%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e55 (67.1)\u003c/p\u003e\n \u003cp\u003e4.45 (1.6)\u003c/p\u003e\n \u003cp\u003e27 (32.9)\u003c/p\u003e\n \u003cp\u003e50 (61)\u003c/p\u003e\n \u003cp\u003e4 (4.9)\u003c/p\u003e\n \u003cp\u003e7 (8.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (4.9)\u003c/p\u003e\n \u003cp\u003e2 (2.4)\u003c/p\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.353982300884955%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (28.3)\u003c/p\u003e\n \u003cp\u003e3.4 (0.85)\u003c/p\u003e\n \u003cp\u003e2 (4.3)\u003c/p\u003e\n \u003cp\u003e10 (21.7)\u003c/p\u003e\n \u003cp\u003e2 (4.3)\u003c/p\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.964601769911504%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.257\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.401\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"51.769911504424776%\"\u003e\n \u003cp\u003eInferior pole of the patella: proximal patellar ligament enthesis\u003c/p\u003e\n \u003cp\u003eThickness,mm, median (IQR)\u003c/p\u003e\n \u003cp\u003eStuctural tendon abnormalities ,n (%)\u003c/p\u003e\n \u003cp\u003eEnthesis thickening,n (%)\u003c/p\u003e\n \u003cp\u003eBone erosions,n (%)\u003c/p\u003e\n \u003cp\u003eCalcification,n (%)\u003c/p\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Power Doppler signal,n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.911504424778762%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.55 (1.23)\u003c/p\u003e\n \u003cp\u003e18 (22)\u003c/p\u003e\n \u003cp\u003e55 (67.1)\u003c/p\u003e\n \u003cp\u003e4 (4.9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.353982300884955%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.5 (1.33)\u003c/p\u003e\n \u003cp\u003e4 (8.7)\u003c/p\u003e\n \u003cp\u003e13 (28.3)\u003c/p\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.964601769911504%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.654\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.693\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"51.769911504424776%\"\u003e\n \u003cp\u003eSuperior pole of the patella: quadriceps tendon enthesis\u003c/p\u003e\n \u003cp\u003eThickness,mm, median (IQR)\u003c/p\u003e\n \u003cp\u003eStuctural tendon abnormalities ,n (%)\u003c/p\u003e\n \u003cp\u003eEnthesis thickening,n (%)\u003c/p\u003e\n \u003cp\u003eBone erosions,n (%)\u003c/p\u003e\n \u003cp\u003eCalcification,n (%)\u003c/p\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSevere\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Power Doppler signal,n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.911504424778762%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.4 (1.7)\u003c/p\u003e\n \u003cp\u003e36 (43.9)\u003c/p\u003e\n \u003cp\u003e56 (86.3)\u003c/p\u003e\n \u003cp\u003e28 (34.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (8.5)\u003c/p\u003e\n \u003cp\u003e11 (13.4)\u003c/p\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003cp\u003e3 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.353982300884955%\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e6 (1.53)\u003c/p\u003e\n \u003cp\u003e9\u0026nbsp;(19.6)\u003c/p\u003e\n \u003cp\u003e19\u0026nbsp;(41.3)\u003c/p\u003e\n \u003cp\u003e4\u0026nbsp;(8.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u0026nbsp;(4.3)\u003c/p\u003e\n \u003cp\u003e2\u0026nbsp;(4.3)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.964601769911504%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003cp\u003e0.006*\u003c/p\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.218\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.552\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"51.769911504424776%\"\u003e\n \u003cp\u003eOlecranon tuberosity: triceps tendon enthesis\u003c/p\u003e\n \u003cp\u003eThickness,mm, median (IQR)\u003c/p\u003e\n \u003cp\u003eStuctural tendon abnormalities ,n (%)\u003c/p\u003e\n \u003cp\u003eEnthesis thickening,n (%)\u003c/p\u003e\n \u003cp\u003eBone erosions,n (%)\u003c/p\u003e\n \u003cp\u003eCalcification,n (%)\u003c/p\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Power Doppler signal,n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.911504424778762%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.05 (2.43)\u003c/p\u003e\n \u003cp\u003e15 (18.3)\u003c/p\u003e\n \u003cp\u003e35 (42.7)\u003c/p\u003e\n \u003cp\u003e12 (14.6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (7.3)\u003c/p\u003e\n \u003cp\u003e2 (2.4)\u003c/p\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.353982300884955%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.7 (1.03)\u003c/p\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.964601769911504%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.010*\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.031*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.091\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eThe total MASEI scores of each component and each enthesis in HD patients (n=41) and healthy subjects (n=23)\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"47.040971168437025%\"\u003e\n \u003cp\u003eEnthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.81638846737481%\"\u003e\n \u003cp\u003eHD patients (n=41)\u003c/p\u003e\n \u003cp\u003eEntheses (82)\u003c/p\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.127465857359635%\"\u003e\n \u003cp\u003eHealthy controls (n=23)\u003c/p\u003e\n \u003cp\u003eEntheses =46\u003c/p\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.015174506828528%\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"47.040971168437025%\"\u003e\n \u003cp\u003eMASEI components score (maximum score)\u003c/p\u003e\n \u003cp\u003eStuctural tendon abnormalities\u0026nbsp;(12)\u003c/p\u003e\n \u003cp\u003eEnthesis thickening\u0026nbsp;(12)\u003c/p\u003e\n \u003cp\u003eBursitis (4)\u003c/p\u003e\n \u003cp\u003eBone erosions\u0026nbsp;(36)\u003c/p\u003e\n \u003cp\u003eCalcification\u0026nbsp;(36)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Power Doppler signal (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.81638846737481%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (3)\u003c/p\u003e\n \u003cp\u003e7 (3)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003cp\u003e3 (6)\u003c/p\u003e\n \u003cp\u003e2 (5)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.127465857359635%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003cp\u003e0 (2)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.015174506828528%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.632\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.037*\u003c/p\u003e\n \u003cp\u003e0.187\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"47.040971168437025%\"\u003e\n \u003cp\u003eTotal MASEI\u0026nbsp;score at :\u003c/p\u003e\n \u003cp\u003ePlantar aponeurosis enthesis\u003c/p\u003e\n \u003cp\u003eAchilles tendon enthesis\u003c/p\u003e\n \u003cp\u003eDistal patellar ligament enthesis\u003c/p\u003e\n \u003cp\u003eProximal patellar ligament enthesis\u003c/p\u003e\n \u003cp\u003eQuadriceps tendon enthesis\u003c/p\u003e\n \u003cp\u003eTriceps tendon enthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.81638846737481%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;3 (4)\u003c/p\u003e\n \u003cp\u003e2 (5)\u003c/p\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003cp\u003e2 (2)\u003c/p\u003e\n \u003cp\u003e4 (7)\u003c/p\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.127465857359635%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (4)\u003c/p\u003e\n \u003cp\u003e0 (1)\u003c/p\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.015174506828528%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.015*\u003c/p\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"47.040971168437025%\"\u003e\n \u003cp\u003eTotal MASEI score\u003c/p\u003e\n \u003cp\u003eMASEI-inflammatory\u003c/p\u003e\n \u003cp\u003eMASEI-damage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.81638846737481%\"\u003e\n \u003cp\u003e18 (11.5)\u003c/p\u003e\n \u003cp\u003e11\u0026nbsp;(7)\u003c/p\u003e\n \u003cp\u003e6 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.127465857359635%\"\u003e\n \u003cp\u003e4 (8)\u003c/p\u003e\n \u003cp\u003e3 (5)\u003c/p\u003e\n \u003cp\u003e0 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.015174506828528%\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u0026nbsp;Frequency of involvement of MASEI score components in HD patients (n=41) and healthy subjects (n=23)\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.334341906202724%\"\u003e\n \u003cp\u003eMASEI score components\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.751891074130107%\"\u003e\n \u003cp\u003eHD patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=41)\u003c/p\u003e\n \u003cp\u003eEntheses =492\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.96217851739788%\"\u003e\n \u003cp\u003eHealthy controls (n=23)\u003c/p\u003e\n \u003cp\u003eEntheses =276\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.951588502269288%\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.334341906202724%\"\u003e\n \u003cp\u003eStuctural tendon abnormalities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.751891074130107%\"\u003e\n \u003cp\u003e158 (32.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.96217851739788%\"\u003e\n \u003cp\u003e34 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.951588502269288%\"\u003e\n \u003cp\u003e0.\u0026nbsp;000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.334341906202724%\"\u003e\n \u003cp\u003eEnthesis thickening\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.751891074130107%\"\u003e\n \u003cp\u003e272 (55.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.96217851739788%\"\u003e\n \u003cp\u003e55 (19.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.951588502269288%\"\u003e\n \u003cp\u003e0.\u0026nbsp;000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.334341906202724%\"\u003e\n \u003cp\u003eBursitis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.751891074130107%\"\u003e\n \u003cp\u003e14 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.96217851739788%\"\u003e\n \u003cp\u003e5 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.951588502269288%\"\u003e\n \u003cp\u003e0.364\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.334341906202724%\"\u003e\n \u003cp\u003eBone erosions\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.751891074130107%\"\u003e\n \u003cp\u003e66 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.96217851739788%\"\u003e\n \u003cp\u003e8 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.951588502269288%\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.334341906202724%\"\u003e\n \u003cp\u003eCalcification\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.751891074130107%\"\u003e\n \u003cp\u003e69 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.96217851739788%\"\u003e\n \u003cp\u003e18 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.951588502269288%\"\u003e\n \u003cp\u003e.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.334341906202724%\"\u003e\n \u003cp\u003e\u0026nbsp;Power Doppler signal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.751891074130107%\"\u003e\n \u003cp\u003e4 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.96217851739788%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.951588502269288%\"\u003e\n \u003cp\u003e0.303\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.334341906202724%\"\u003e\n \u003cp\u003ePresence of one sign of enthesopathy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.751891074130107%\"\u003e\n \u003cp\u003e339 (68.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.96217851739788%\"\u003e\n \u003cp\u003e85 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.951588502269288%\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u0026nbsp;Correlation between MASEI scores and clinico-laboratory data among HD patients (N=41)\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"30.476190476190474%\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"26.984126984126984%\"\u003e\n \u003cp\u003eMASEI-inflammatory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"21.58730158730159%\"\u003e\n \u003cp\u003eMASEI-damage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"20.952380952380953%\"\u003e\n \u003cp\u003eTotal MASEI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.221967963386728%\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003csub\u003es\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.450800915331808%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.789473684210526%\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003csub\u003es\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.331807780320366%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.102974828375286%\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003csub\u003es\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.102974828375286%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e0.261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.336\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.032*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e-0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.693\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.733\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003eBody weight (Kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.427\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e-0.057\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.725\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.855\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003eDuration of HD (years )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e0.171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e0.341\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.327\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.037*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003eAssociated comorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e-0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.745\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.539\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.856\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e-0.205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e-0.240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e-0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.176\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003eCholesterol (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e-0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e-0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.822\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003eTriglycerides (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e-0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.510\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e-0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.485\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e-0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.403\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003eCalcium (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e-0.214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.682\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e-0.082\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.610\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003ePhosphorus (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.770\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.385\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003ePTH (pg/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.386\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.639\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.414\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.524642289348172%\"\u003e\n \u003cp\u003eUric acid (mg/dl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.354531001589825%\"\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.511\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.9697933227345%\"\u003e\n \u003cp\u003e0.147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.651828298887123%\"\u003e\n \u003cp\u003e0.358\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.388\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*P\u0026lt;0.05,PTH:\u0026nbsp;Parathyroid hormone\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 6\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eUnivariate regression analysis to identify the predictors for MASEI scores among HD patients (n=41)\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"102%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"31.31313131313131%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePredictor variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"25.252525252525253%\"\u003e\n \u003cp\u003eMASEI-inflammatory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003eMASEI-damage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"21.21212121212121%\"\u003e\n \u003cp\u003eTotal MASEI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"22.388059701492537%\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.925373134328359%\"\u003e\n \u003cp\u003eP\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.417910447761194%\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.925373134328359%\"\u003e\n \u003cp\u003eP\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.432835820895523%\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.91044776119403%\"\u003e\n \u003cp\u003eP\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"31.632653061224488%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e0.094\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.042*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.357\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.183673469387756%\"\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"31.632653061224488%\"\u003e\n \u003cp\u003eDuration of HD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e0.157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.485\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.004*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.183673469387756%\"\u003e\n \u003cp\u003e1.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.014*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"31.632653061224488%\"\u003e\n \u003cp\u003eHemoglobin level (g/dl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e-0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.224489795918368%\"\u003e\n \u003cp\u003e-0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.183673469387756%\"\u003e\n \u003cp\u003e-0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"31.632653061224488%\"\u003e\n \u003cp\u003eSerum cholesterol (mg/dl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e-0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.639\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.183673469387756%\"\u003e\n \u003cp\u003e-0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.716\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"31.632653061224488%\"\u003e\n \u003cp\u003eSerum phosphorus (mg/dl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.783\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.391\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.349\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.183673469387756%\"\u003e\n \u003cp\u003e0.473\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.409\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;*P\u0026lt;0.05\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ultrasonography, Enthesitis, Enthesopathy, Hemodialysis, MASEI score","lastPublishedDoi":"10.21203/rs.3.rs-1065093/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1065093/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003eBackground \u003c/u\u003e\u003c/p\u003e\u003cp\u003eMusculoskeletal (MSK) complications are one of the most common health concerns that impact individuals on maintenance hemodialysis (HD). However, little is known about the entheseal involvement in HD patients. The aim of this study was to assess the prevalence and distribution of entheseal ultrasonographic (US) alterations in HD patients and to evaluate the association between US findings and both clinical and laboratory data.\u003c/p\u003e\u003cp\u003e\u003cu\u003eMethods\u003c/u\u003e: This study was conducted on 41 HD and 23 sex- and age- matched controls. All HD patients and healthy controls were evaluated clinically to detect any clinical evidence of enthesopathy. Six entheses sites were scanned bilaterally using grey scale (GS) and power Doppler (PD) ultrasonography (US) and were scored using Madrid Sonography Enthesitis Index (MASEI) scoring system. \u003c/p\u003e\u003cp\u003e\u003cu\u003eResults:\u003c/u\u003e\u003c/p\u003e\u003cp\u003eClinical examination revealed at least one sign suggestive of enthesopathy in 69 (14.02) of 492 entheses in 41 HD patients. HD patients had statistically significant higher scores of stuctural tendon abnormalities (p\u0026lt;0.001), enthesis thickening (p\u0026lt;0.001), bone erosions (p\u0026lt;0.001) and calcification (p=0.037) than healthy controls. Total MASEI score was higher in HD patients than healthy controls (median ;18 vs 8, p\u0026lt;0.001), also, MASEI-inflammatory (median ;11 vs 3, p\u0026lt;0.001) and damage scores (median ;6 vs 0, p\u0026lt;0.001). There was a statistically significant positive association between total MASEI score and both age (p=0.032) and duration of HD (p=0.037). Duration of HD was predictive for both MASEI-damage component (p=0.004) and total MASEI score (p=0.014).\u003c/p\u003e\u003cp\u003e\u003cu\u003eConclusions: \u003c/u\u003e\u003c/p\u003e\u003cp\u003eThere is a high prevalence of asymptomatic enthesopathy in HD patients. The burden of entheseal US alterations is much higher in HD patients than in healthy subjects. US can be helpful in the early detection of entheseal abnormalities. The duration of HD is the most significant predictor of enthesopathy in HD patients.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Ultrasonographic Assessment of Entheseal Sites of Upper and Lower Extremities in Hemodialysis Patients using Madrid Sonography Enthesitis Index","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-11-16 16:10:38","doi":"10.21203/rs.3.rs-1065093/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-04-18T08:08:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-04-04T11:31:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26e6e762-c10d-4edc-93ae-5b365b81d7d7","date":"2022-03-29T08:08:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"016e3e17-46cc-443b-a424-799ecc10e09f","date":"2022-03-29T00:40:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-03-28T23:52:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-03-28T23:51:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-11-15T09:26:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-11-15T09:05:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2021-11-09T16:58:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f7d14f5e-cb1e-4930-b93a-4c61d140add4","owner":[],"postedDate":"November 16th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":8552693,"name":"Orthopedics"},{"id":8552694,"name":"Orthopedic Surgery"}],"tags":[],"updatedAt":"2022-06-01T08:29:18+00:00","versionOfRecord":[],"versionCreatedAt":"2021-11-16 16:10:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1065093","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1065093","identity":"rs-1065093","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}