Perspectives of end stage renal failure therapy in Singapore

Haemodialysis in Singapore started in 1961 when a patient with kidney failure was dialysed using the twin coil artificial kidney. Over the years, we have seen various new techniques like rapid high efficiency dialysis, haemodiafiltration (HDF) and rapid high flux HDF introduced. Dialysers with newer membranes have improved solute transport, biocompatibility and water removal. Mini heparinisation and heparin-free dialysis have circumvented problems of bleeding in high risk patients. Technological advances in haemodialysis will continue with more new modalities introduced. Newer forms of vascular access through the subclavian and internal jugular veins have phased out the use of chronic arterio-venous (AV) shunts. Continuous ambulatory peritoneal dialysis (CAPD) was introduced in 1980. This has been a boon for cardiac and diabetic patients. The initial problems with peritonitis are now manageable with our current rate of 24.1 patient months compared to 13.2 patient months in 1983. This has been achieved through the use of ultraviolet (UV) germicidal exchange device and transfer tube changes by trained nursing personnel as well as better patient training and education. New techniques have included the "O" disconnect set, the use of 2.5 litre dialysate, low calcium dialysate and the introduction of continuous cycling peritoneal dialysis (CCPD). Future focus will be on the problems of nutrition and protein loss. Renal transplantation remains the ideal renal replacement therapy. Cadaveric renal transplantation was initiated in 1970 and living related donor transplant in 1976. From 1970-1985, immunotherapy was azathioprine-based and from 1985, cyclosporin A (CyA) was introduced. CyA has abrogated many immunological risk factors. Preformed cytotoxic antibodies are still important.(ABSTRACT TRUNCATED AT 400 WORDS)

The end-stage renal disease program: trends over the past 18 years

Data from the Michigan Kidney Registry and the US Renal Data System (USRDS) show that the number of patients receiving treatment for end-stage renal disease (ESRD) increased sevenfold following the introduction of Medicare coverage for ESRD in 1973. The number of new patients added per year has also increased dramatically--approximately fourfold. Initial selection criteria for acceptance into the ESRD Program included age less than 65 years and absence of systemic diseases such as diabetes. During the past 18 years, the gradual acceptance of older patients and of diabetic patients has led to an increase in the median age of new patients from 46 to 61 years and a 12-fold increase in the incidence of treatment in patients with ESRD due to diabetes. Given the broad acceptance of sicker and older patients, withdrawal from dialysis has become a consideration when dialysis no longer benefits the patient. Treatment modalities have also changed, and increasing numbers of patients undergo successful renal transplantation or receive continuous ambulatory peritoneal dialysis (CAPD). During the 1980s, hemodialysis treatment times and dialysis staffs decreased; however, several improvements in the care of patients on dialysis occurred during this period.

Development of an extracorporeal liver support system: initial results

A pilot study was undertaken to determine the feasibility of extracorporeal normothermic perfusion of the porcine liver. Seven donor hepatectomies were performed in small 10 kg pigs and the livers were placed in a perfusion cassette of the author's design. Four perfusions were technical failures. Three successful perfusions had several factors in common: hepatic artery inflow roller pump, prompt "pinking up" of the perfused liver, a centrifugal vena cava outflow pump with partial diversion of the outflow into the portal vein with the remaining outflow returned to the anesthetized animal, and production of bile during the perfusion experiment. Successful perfusions lasted 50, 65, and 90 minutes.

Rate of change of end-stage renal disease treatment incidence 1978-1987--has there been selection?

End-stage renal disease (ESRD) treatment rates in the United States have increased steadily since 1973. Decreasing selection against elderly patients with a poor prognostic primary cause of ESRD (i.e., diabetic nephropathy) may partly account for this increase in rates. To test this hypothesis, we calculated log ESRD treatment incidence (ESRDI) rates by four major primary causes of ESRD (diabetic nephropathy (DN), hypertensive nephropathy (HN), glomerulonephritis (GN), and cystic kidney disease (PC); two age groups (old (O), greater than 65 and young (Y), 15 to 44 yr of age) for black and white, male and female, new ESRD patients from 1978 to 1987. As predicted, summary log ESRDI slopes (produced by analysis of covariance) occurred in the following decreasing order, ODN (0.19), OGN = OHN = YDN (0.134). YHN = YPC = YGN (in white patients) = slope not significantly different from 0. Log ESRDI slopes for young black males and females with GN increased significantly between 1978 and 1987, possibly as a result of an increased incidence of GN. In conclusion, decreasing selection may be a factor in the continuing increase in the U.S. ESRD population.

[The future of hemodialysis in the adult]

By the year 2000, the perspectives for hemodialysis performed in adults will be oriented towards facilitation of the practice of hemodialysis as a better control of clinical symptoms observed in end stage renal failure treated by hemodialysis. Blood access is the main problem which remains to be solved. The authors describe the advantages and disadvantages of the methods presently used and give the "state of the art" of "blood access" prosthesis. Almost all symptoms encountered in renal failure patients treated by hemodialysis can be efficiently treated. Hypotensive drugs usually reduce hypertension which resists adequate treatment by hemodialysis. Most of the symptoms of osteodystrophy can be avoided by adequate diet associated with the prescription of vitamin D analogs. Nevertheless, the prolongation of hemodialysis treatment duration over 7 years has led to the apparition of destructive arthropathies which are very painful and handicapping. They are related to amyloid deposit of beta 2-microglobulins. Progress in hemodialysis technics and a better control of uremic symptoms allow application of this treatment at all ages of life. The authors examine specific problems concerning school-aged teenagers and aged persons. They show that results already achieved allow a daily treatment of these patients. This is a first step for the generalisation of this procedure to all patients and its advantages are described. Improvement of hemodialysis technics for the year 2000, as can be expected, mainly depends upon progress in knowledge of biocompatibility parameters between materials used in the artificial kidney and patients tissues, mainly blood vessels.

Medical problems in dialysis patients awaiting renal transplantation

While awaiting renal transplantation, patients with end-stage renal failure frequently have to spend a period of time on dialysis. Although dialysis controls uraemia, the patient undergoing dialysis still faces problems related to the continuing uraemic state such as anaemia, renal bone disease, malnutrition and cardiovascular complications. Apart from the problems related to uraemia, patients on dialysis are also exposed to problems that are peculiar to the mode of dialysis. In haemodialysis, patients face complications related to the use of heparin and dialyser related problems such as air embolism and haemolysis. Patients on continuous ambulatory peritoneal dialysis (CAPD) are exposed to complications such as infection, hernias and hypertriglyceridaemia. The introduction of hormone therapy with erythropoietin and vitamin D and recent advances in dialysate solutions and biocompatibility of membranes in haemodialysis and in control of infection and a better understanding of peritoneal kinetics in CAPD have helped to overcome some of the problems in dialysis patients.

Changing patient characteristics in chronic hemodialysis

Patients accepted to chronic hemodialysis have changed. We analyzed these changes and survival, cause of death and other factors during 23 years at the Karolinska Hospital. Between 1965 and 1987, 274 patients were accepted: 60 are alive on dialysis, 75 died, 113 were transplanted, 25 sent to other units and one recovered renal function. The mean age increased from 44 to 55 years (p=0.001), the creatinine level at acceptance decreased from 1191 to 965 mumol/l (p = 0.001), the hemoglobin level rose from 70 to 85 g/l (p = 0.001) and the diastolic blood pressure decreased from 96 to 90 mmHg (p = 0.007). The number of co-morbid conditions increased from 1.2 to 1.4 (p less than 0.005). The diagnoses changed from over 90% primary renal disease to 20% systemic diseases such as nephrosclerosis and diabetes (p = 0.04). The chance of receiving a renal transplant decreased from 46 to 39% (p = 0.28). The transplanted patients were younger than the dialyzed patients 42 vs 47 years (p = 0.03) before 1980 and 49 vs. 56 years (p = 0.0001) after 1980. The cause of death changed. Withdrawal from dialysis increased from 5% of deaths before to 24% after 1980 (p = 0.047), cardiovascular deaths decreased from 85% to 55% (p = 0.01). Although the patients accepted for dialysis after 1980 had more serious renal disease and other degenerative diseases than those before, the mortality rate was reduced to only 1/4 to that before, in all age groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Principles, uses, and complications of hemodialysis

Hemodialysis replaces missing renal function, and it does so incompletely. Current technology provides for reliable and flexible treatment strategies guided by patient's well-being and careful evaluation of plasma urea concentrations. Hemodialysis is indicated in many medical emergencies, notably fluid overload and hyperkalemia, and all types of renal failure. Hemodialysis requires a sizable effort and a significant commitment of time by both patients and professionals and is not suited for every patient with renal insufficiency. Notable treatment-related side effects include cramps, hypotension, problems with blood access, and reactions to dialyzer membrane materials. Far from treating underlying disease, hemodialysis extends life and permits the expression of much progressive multisystem disease. Cardiovascular disease is the most common comorbid condition and cause of early mortality.

Mortality rates among dialysis patients in Medicare's End-Stage Renal Disease Program

Medicare's End-Stage Renal Disease (ESRD) Program provides funding for life-saving renal replacement therapy for patients with irreversible chronic renal failure. Although more than 100,000 patients are currently alive due to dialysis and transplantation, mortality among ESRD patients is still much higher than in the general population. Gross mortality, calculated from aggregate statistics such as those available from the annual ESRD facility survey, is an extremely imprecise measure of mortality and can lead to misleading conclusions. Standard methods of survival calculation such as actuarial life-table analyses provide more accurate descriptions of variations and trends in mortality. The most important characteristic influencing mortality among ESRD patients on dialysis is the changing age and diagnostic distribution. The average age of dialysis patients has increased by over 5 years during the past decade. Patients whose renal failure is attributed to diabetic nephropathy currently account for 30% of all patients initiating renal replacement therapy each year and constitute the fastest growing group of ESRD patients. From 1982 to 1987, 1-year survival on dialysis was 72.7% for patients whose renal failure was attributed to diabetic nephropathy and 79.8% for all other patients. Survival decreases rapidly with advancing age at time of renal failure, from 95.1% among patients 15 to 24 years to 52.5% for patients over the age of 85 (for non-diabetics). Survival rates for whites are 5% to 6% lower than for other racial categories. There are no obvious trends in mortality among dialysis patients over the past decade. For patients whose renal failure is attributed to diabetic nephropathy, survival rates have remained constant despite overall aging in this group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Dialysis and kidney transplantation]

In the Federal Republic of Germany more than 22,000 patients receive renal replacement therapy. More than 6000 patients live with a functioning graft. Thus the Federal Republic of Germany holds leading position of internationally high standard. Since 1969 the non profit-organisation KfH major contributions to secure dialysis treatment; since 1976 KfH was engaged in the organisation of kidney transplantation. Future goals are the strengthening of reliable and secure dialysis facilities as well as--at least--2400 kidney transplantations per year in the FRG. This figure represents the approximate number of new uremic patients to be treated each year.

[Treatment of chronic kidney failure with dialysis and transplantation. Development, need and organization in Norway]

Treatment of chronic renal failure by dialysis and renal transplantation has been developed over the last 20 years in Norway. 17 local nephrological units with dialysis departments cooperate with one transplantation center in Oslo. The number of new patients starting renal replacement therapy has increased only slightly during the last five years. The mean number of new patients in the period was 52 per million inhabitants per year. The proportion of elderly patients accepted for renal replacement therapy was high (39% above 60 years of age) and approximately 15% of the patients had diabetic nephropathy. Due to an active transplantation policy, the proportion of patients alive on dialysis is low (18%), compared with 82% alive with a functioning graft. The number of patients on dialysis has declined slightly the last four years. The proportion of patients on chronic ambulatory peritoneal dialysis (CAPD) is low (13%), and the number of patients on home hemodialysis has declined in the last five years. Predialytic transplantation has been performed in 18% of the patients starting renal replacement therapy during the last five years. Due to a high transplantation rate and a large number of predialytic transplantations, it has not been necessary to increase the capacity for dialysis in the last five years.

[The development of nephrology and dialysis in the past 40 years]

In the past 40 years the nephrology has been established in the GDR as a subspeciality of internal medicine and pediatrics. In the districts more than 60 nephrological centres were opened and modern diagnostical and therapeutical methods were introduced. More than 2000 patients were treated regularly by artificial kidney. Further detoxification methods including therapeutical plasmapheresis were introduced in the practice in the last years. The number of dialysis increase from 300,000 in 1989 to 500,000 in 1991.