Patients surviving 10 years of hemodialysis

Hyperparathyroidism presented as multiple pulmonary nodules in hemodialysis patient status post parathyroidectomy: A case report

BACKGROUND

Primary hyperparathyroidism is typically caused by a single parathyroid adenoma. Ectopic parathyroid adenomas occur as well, with cases involving various sites, including the mediastinum, presenting in varying frequencies. Secondary hyperparathyroidism develops in the context of chronic kidney disease, primarily due to vitamin D deficiency, hypocalcemia, and hyperphosphatemia. It is frequently diagnosed in patients undergoing dialysis. This article presents a rare case of hyperparathyroidism involving multiple hyperplastic parathyroid glands with pulmonary seeding in a 50-year-old female patient undergoing hemodialysis (HD).

CASE SUMMARY

The patient had a history of parathyroidectomy 10 years prior but developed recurrent hyperparathyroidism with symptoms of pruritus and cough with sputum during a period of routine dialysis. Radiographic imaging revealed multiple nodules in both lungs, with the largest measuring approximately 1.35 cm. Surgical histopathology confirmed the presence of hyperplastic parathyroid glands within the pulmonary tissue. After tumor resection surgery via video-assisted thoracic surgery with wedge resection, the patient was discharged in stable condition and in follow-up her symptoms showed improvement.

CONCLUSION

This article describes hyperparathyroidism presenting as pulmonary nodules in a patient undergoing post-parathyroidectomy HD, highlighting diagnostic challenges and a positive outcome from tumor resection surgery.

Biochemical Changes following Parathyroidectomy

Biochemical changes that had appeared after subtotal parathyroidectomy (PTx) in 26 patients with end-stage renal failure were observed. The volume of excised parathyroid glands was also measured. Serum calcium and inorganic phosphorus levels fell after PTx; only to rise in due course. Serum alkaline phosphatase levels rose after PTx, reaching a peak by the 14th postoperative day. These elevated levels returned to normal range at about three months after PTx. Strong correlation was noted among the degree of postoperative hypocalcemia, and increase in serum alkaline phosphatase, but not between absolute pre or postoperative alkaline phosphatase levels and changes in serum calcium or phosphorus concentrations. Nevertheless, significant correlation was seen between pre-PTx levels of alkaline phosphatase and its short-lived postoperative rise, indicating hastened osteoblastic activity.

Diabetic Kidney Disease: A Syndrome Rather Than a Single Disease

The term "diabetic kidney" has recently been proposed to encompass the various lesions, involving all kidney structures that characterize protean kidney damage in patients with diabetes. While glomerular diseases may follow the stepwise progression that was described several decades ago, the tenet that proteinuria identifies diabetic nephropathy is disputed today and should be limited to glomerular lesions. Improvements in glycemic control may have contributed to a decrease in the prevalence of glomerular lesions, initially described as hallmarks of diabetic nephropathy, and revealed other types of renal damage, mainly related to vasculature and interstitium, and these types usually present with little or no proteinuria. Whilst glomerular damage is the hallmark of microvascular lesions, ischemic nephropathies, renal infarction, and cholesterol emboli syndrome are the result of macrovascular involvement, and the presence of underlying renal damage sets the stage for acute infections and drug-induced kidney injuries. Impairment of the phagocytic response can cause severe and unusual forms of acute and chronic pyelonephritis. It is thus concluded that screening for albuminuria, which is useful for detecting "glomerular diabetic nephropathy", does not identify all potential nephropathies in diabetes patients. As diabetes is a risk factor for all forms of kidney disease, diagnosis in diabetic patients should include the same combination of biochemical, clinical, and imaging tests as employed in non-diabetic subjects, but with the specific consideration that chronic kidney disease (CKD) may develop more rapidly and severely in diabetic patients.

Current understanding of optimal blood pressure goals in dialysis patients

The hemodialysis population is associated with a very low survival rate, with myocardial infarctions and strokes accounting for most of the increased mortality. Recent observational studies demonstrate a paradoxical relationship between increasing blood pressure and increasing mortality. Hypertension treated with antihypertensive medications unequivocally reduces cerebrovascular risk, but demonstration of a survival benefit for cardiovascular mortality has proven more difficult to demonstrate. Increased pulse pressure is caused by inadequate dialysis treatment that increases arterial wall stiffness and afterload, and decreases coronary perfusion. The disproportionate representation of diastolic dysfunction and coronary artery atherosclerosis may explain why increased pulse pressure is associated with higher cardiovascular risk for the dialysis population. Optimum blood pressure control has not been established, due to a lack of prospective studies targeting blood pressure reduction. Opinion-based recommendations are offered, but goals should be individualized based on a complete assessment of prevailing comorbidities and should target normalization of the pulse pressure.

Influence of Hypertension on Cardiovascular Outcomes in Hemodialysis Patients

Cardiovascular disease is a leading cause of morbidity and mortality in chronic hemodialysis patients. Most patients with chronic kidney disease have hypertension and its prevalence remains high following renal replacement therapy. Early studies suggested that hypertension was a risk factor for total and cardiovascular mortality in chronic hemodialysis patients, but the results of more recent studies have caused experts to question these assertions. Systolic hypertension, widened pulse pressure, and nondipping may be better predictors of mortality compared to diastolic hypertension or increased mean arterial pressure. Hypertension in hemodialysis patients is a risk factor for left ventricular hypertrophy (LVH), diastolic dysfunction, and congestive heart failure; good blood pressure control may promote its regression. Atherosclerosis and ventricular arrhythmias may also be linked to hypertension. Thus blood pressure control with a focus on systolic pressure appears to be a prudent strategy to improve cardiovascular outcomes in hemodialysis patients.

Secondary hyperparathyroidism in chronic hemodialysis patients: prevalence and race

Secondary hyperparathyroidism is a common complication of renal failure. The exact prevalence in chronic hemodialysis patients in not known. We evaluated 122 patients who were receiving maintenance hemodialysis for at least 12 months in 2 dialysis centers in mid Michigan. Seventy-eight percent of the patients had iPTH above 200 pg/mL (mean 481 pg/mL), 19% had iPTH within the accepted normal range (mean 155 pg/mL), while 3% had level below 100 (mean 53 pg/mL). Phosphate, calcium, calcium phosphate product, age and time on dialysis are the important factors correlating with elevated iPTH. There was no significant difference in iPTH between diabetic and nondiabetic patients with mean iPTH of 403 pg/mL and 407 pg/mL respectively. Black patients had a statistically significant elevated iPTH compared with white patients with a mean iPTH of 438 pg/mL and 283 pg/mL respectively (p < or = 0.004). Factors that predict the response to vitamin D therapy need to be evaluated to help reduce the high prevalence of secondary hyperparathyroidism. The patterns of bone disease in black patients need to be evaluated to further define the accepted normal iPTH range for this population.

Effect of hypertension before beginning dialysis on survival of hemodialysis patients

BACKGROUND

The role of hypertension as a predictor of mortality in hemodialysis patients is controversial. The purpose of this study is to investigate the effect of hypertension before starting hemodialysis therapy on survival of patients without diabetes during renal replacement therapy.

METHODS

We reviewed 184 patients starting hemodialysis therapy. Variables studied were age, sex, renal disease, hypertension, comorbidity, vascular calcifications, left ventricular hypertrophy, body mass index, and albumin, cholesterol, and alkaline phosphatase levels. Regarding blood pressure control, three groups were considered: normotensive (NH), controlled hypertensive (c-HT), and uncontrolled hypertensive (uc-HT).

RESULTS

The Cox model was performed considering all-cause and cardiovascular mortality. The model was adjusted for age, sex, serum albumin level, vascular calcifications, history of hypertension, and comorbidity. Comorbidity included cardiovascular comorbidity. For all-cause mortality, comorbidity and history of uncontrolled hypertension were independent risk factors (comorbidity relative risk, 1.95; 95% confidence interval, 1.26 to 3.1; P = 0.003; uncontrolled hypertension relative risk, 1.79; 95% confidence interval, 1.15 to 2.8; P = 0.01). For cardiovascular mortality, uncontrolled hypertension was the main risk factor (relative risk, 2.93; 95% confidence interval, 1.68 to 5.12; P = 0.000). Mortality rates were 7.9/100 patient-years for NH, 8.7/100 patient-years for c-HT, and 14.1/100 patient-years for uc-HT patients.

CONCLUSION

This study suggests that uncontrolled hypertension in renal patients before starting dialysis therapy is a major risk factor for cardiovascular mortality during hemodialysis. Because hypertension usually starts in the initial stages of renal disease, we emphasize the importance of prompt and adequate control of blood pressure in this population.

Interdialytic weight gain, compliance with dialysis regimen, and age are independent predictors of blood pressure in hemodialysis patients

Hypertension is a common problem in patients undergoing chronic hemodialysis. The purpose of this study is to identify the clinical and demographic factors independently associated with blood pressure in this population. Data collected for the Dialysis Morbidity and Mortality Study Wave 1 by the US Renal Data System were analyzed. The mean predialysis blood pressure for this cohort of 5,369 patients was 149/79 mm Hg. Sixty-three percent of the patients were hypertensive; 27%, 25%, and 11% had stages 1, 2, and 3 hypertension, respectively. Young age, black race, male sex, diabetes as cause of end-stage renal disease, erythropoietin therapy, and smoking were associated with higher blood pressure in the univariate analysis. Patients skipping or shortening one or more dialysis treatments had higher blood pressure. The presence of congestive heart failure and coronary heart disease was associated with lower blood pressure. On multivariate analysis, high interdialytic weight gain, noncompliance with dialysis regimen, and younger age were independent predictors of higher blood pressure. In summary, hypertension is common and poorly controlled in patients undergoing chronic hemodialysis. Greater interdialytic weight gain and noncompliance with dialysis regimen are independently associated with higher blood pressure, and advancing age is associated with lower blood pressure levels in this population. Therapeutic regimens emphasizing reduction of interdialytic weight gain and improved compliance with the dialysis regimen need to be evaluated for improving the management of hypertension. The effect of age and other comorbid conditions, particularly cardiovascular disease, must be considered while studying the relationship between blood pressure and mortality in patients undergoing chronic hemodialysis.

Factors associated with inadequate blood pressure control in hypertensive hemodialysis patients

Hypertension is common in hemodialysis patients and increases cardiovascular morbidity and mortality. We determined the prevalence of inadequate control of hypertension in 489 patients receiving hemodialysis and identified factors associated with uncontrolled hypertension. We interviewed the patients and abstracted demographic and clinical information from a computerized database. The prevalence of uncontrolled hypertension (average predialysis blood pressure, > or =160/90 mm Hg) was 62%. Ninety-one percent of patients with uncontrolled hypertension were receiving submaximal antihypertensive drug therapy, and 59% withheld their medications before dialysis. Uncontrolled hypertensives had a greater interdialytic weight gain (3.8% v 3.5%, P = 0.07) and a greater excess weight gain (3.1 +/- 1.6 kg v 2.5 +/- 1.4 kg; P < 0.05) compared with controlled hypertensives. Patients with uncontrolled hypertension showed higher interdialytic weight gain (2.7 +/- 0.06 kg v 2.2 +/- 0.13 kg; P < 0.05), were more likely to be black (94% v 81%; P < 0.05), were more likely to have hypertension as the cause of their end-stage renal disease (ESRD) (42% v 24%; P < 0.05), and had been receiving hemodialysis for a shorter time (4.3 +/- 2 yr v 6.1 +/- 0.9 yr; P < 0.05) compared with normotensive patients. There was significant correlation between diastolic blood pressure and both interdialytic weight gain (r = 0.31, P < 0.05) and percent weight gain (r = 0.34, P < 0.05) in the hypertensive but not in the normotensive patients (r = -0.21). Interdialytic weight gain and hypertension as a cause of ESRD were independent predictors of predialysis systolic blood pressure. We conclude that hypertension is uncontrolled in most patients undergoing hemodialysis. Submaximal antihypertensive therapy, excessive interdialytic weight gain, and withholding antihypertensive medication before dialysis are correctable factors potentially contributing to uncontrolled hypertension.

"U" curve association of blood pressure and mortality in hemodialysis patients. Medical Directors of Dialysis Clinic, Inc

BACKGROUND

Hypertension may play an important role in the pathogenesis of the excess cardiovascular and cerebrovascular (CV) morbidity observed in hemodialysis patients (HD). However, the optimal blood pressure (BP) range for HD patients has not been defined. We postulated that there is a "U" curve relationship between BP and CV mortality. To explore this hypothesis we studied 5,433 HD patients in Dialysis Clinic Inc., a large not-for-profit chain, over a five year period.

METHODS

Cox regression, with fixed and time-varying covariates, was used to assess the effect of systolic blood pressure (SBP) and diastolic blood pressure (DBP), pre- and post-dialysis, on CV mortality, while adjusting for age, gender, ethnicity, primary cause of end-stage renal disease, Kt/V, serum albumin, and antihypertensive medications.

RESULTS

The overall impact of BP on CV mortality was modest. Pre-dialysis, neither systolic nor diastolic hypertension were associated with an increase in CV mortality. Post-dialysis, SBP > or = 180 mm Hg (RR = 1.96, P < 0.015) and DBP > or = 90 mm Hg (RR = 1.73, P < 0.05) were associated with increased CV mortality. Low SBP (SBP < 110 mm Hg) was associated with increased CV mortality, pre- and post-dialysis.

CONCLUSIONS

The results suggest the presence of a "U" curve relationship between SBP post-dialysis and CV mortality in HD patients.

Cardiac disease in chronic uremia: clinical outcome and risk factors

Cardiac disease is common and is the major killer in end-stage renal disease (ESRD). Cardiac failure is a highly malignant condition in ESRD patients. Cardiac failure mediates most of the adverse prognostic impact of ischemic heart disease. Left ventricular (LV) abnormalities are already present at initiation of dialysis therapy in approximately 80% of patients. These abnormalities (ie, systolic dysfunction in approximately 15%, LV dilatation with preserved systolic function in 30%, concentric LV hypertrophy [LVH] in 40%) independently predict ischemic heart disease and cardiac failure, and are the largest baseline predictor of mortality after 2 years on dialysis therapy. The associations between classical risk factors (eg, hyperlipidemia, smoking, hypertension) and cardiac outcomes in ESRD are inconsistent. "Uremic" risk factors represent a nascent, but potentially important field. In our prospective 10-year study of 433 patients starting renal replacement therapy, we identified the following as major independent risk factors for cardiac disease: (1) hypertension (concentric LVH, LV dilatation, ischemic heart disease, cardiac failure, inverse relationship with mortality); (2) anemia (LV dilatation, cardiac failure, death); and (3) hypoalbuminemia (ischemic heart disease, cardiac failure, death). Transplantation dramatically improved LV abnormalities, suggesting that a uremic environment is cardiotoxic. Multiple risk factors act in concert to produce cardiac disease in ESRD; many of these are avoidable, suggesting that the enormous burden of disease can be reduced considerably.

Nandrolone decanoate reduces serum lipoprotein(a) concentrations in hemodialysis patients

We have studied the changes in the lipid profile of 14 chronic hemodialysis patients receiving a 6-month cycle of nandrolone decanoate as treatment for anemia. Nandrolone decanoate was administered in a weekly intramuscular dose of 200 mg and resulted in an increase in the hemoglobin concentration (baseline, 7.9 +/- 0.9 g/dL; month 6, 10.8 +/- 1.7 g/dL; P < 0.001, ANOVA) and also produced relevant modifications in the lipid concentrations. The most significant finding was a decrease in the concentration of lipoprotein(a) [Lp(a)]: baseline, 19.8 mg/dL (median), month 2, 10.6 mg/dL; month 4, 8.7 mg/dL; and month 6, 7.1 mg/dL (P < 0.001, Friedman). Other lipid changes induced by nandrolone decanoate were an increase in the concentrations of apolipoprotein B (P < 0.02, ANOVA) and triglyceride (P = NS, ANOVA) and a decrease of high-density lipoprotein (HDL) cholesterol (P < 0.001, ANOVA) and apolipoprotein A-I (P = NS, ANOVA). The decrease in HDL cholesterol was at the expense of the HDL2 cholesterol subfraction, whereas HDL3 remained unchanged. These lipid modifications were reversible; 4 months after nandrolone decanoate withdrawal, the lipid concentrations were similar to the basal values. The changes in Lp(a) levels did not correlate with those of hemoglobin or the other lipid parameters, suggesting that the underlying mechanisms are unrelated. Our findings could be clinically relevant if confirmed by further studies.

Hypertension in the hemodialysis population: any relation to one-year survival?

Few studies have quantified the effect of hypertension on survival in the hemodialysis population. We report the effect of hypertension on 1-year survival in 649 hemodialysis patients (89% black). In univariate analysis, hypertension was associated with improved 1-year survival (relative risk [RR], 0.48; P = 0.002 compared with normotensive patients). This effect of hypertension was mostly caused by the associated antihypertensive treatment because untreated hypertensive patients had survival rates equal to normotensive patients (RR, 0.87; P = 0.70). On the other hand, treated hypertensive patients fared better than normotensive patients (RR, 0.41; P = 0.0006). This was also true in multivariate analysis, in which antihypertensive treatment was associated with reduced RR (RR, 0.55; P = 0.02) whereas the level of blood pressure per se was insignificant (RR, 0.99; P = 0.63 per 1 mm Hg increase in predialysis mean arterial pressure). Other factors of significance in multivariate analysis included age (RR, 1.03/y; P = 0.0004), serum albumin (RR, 0.38/g; P = 0.002), and diabetes mellitus (RR, 1.58; P = 0.06). Our study suggests that antihypertensive treatment has a favorable effect on survival in the hemodialysis population irrespective of the level of blood pressure control.

Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease

A cohort of 432 ESRD (261 hemodialysis and 171 peritoneal dialysis) patients was followed prospectively for an average of 41 months. Baseline and annual demographic, clinical and echocardiographic assessments were performed, as well as serial clinical and laboratory tests measured monthly while on dialysis therapy. The average mean arterial blood pressure level during dialysis therapy was 101 +/- 11 mm Hg. After adjusting for age, diabetes and ischemic heart disease, as well as hemoglobin and serum albumin levels measured serially, each 10 mm Hg rise in mean arterial blood pressure was independently associated with: the presence of concentric LV hypertrophy (OR 1.48, P = 0.02), the change in LV mass index (beta = 5.4 g/m2, P = 0.027) and cavity volume (beta = 4.3 ml/m2, P = 0.048) on follow-up echocardiography, the development of de novo cardiac failure (RR 1.44, P = 0.007), and the development of de novo ischemic heart disease (RR 1.39, P = 0.05). The association with LV dilation was of borderline statistical significance (OR 1.48, P = 0.06). Mean arterial blood pressures greater than 106 mm Hg were associated with both echocardiographic and clinical endpoints. Paradoxically, low mean arterial blood pressure (RR 1.36 per 10 mm Hg fall, P = 0.009) was independently associated with mortality. The association of low blood pressure with mortality was a marker for having had cardiac failure prior to death. We conclude that even moderate hypertension worsens the echocardiographic and clinical outcome in ESRD patients, especially in those without previous clinical cardiac disease.

Role of systolic blood pressure in determining prognosis of hemodialyzed patients

The role of blood pressure in determining the prognosis of hemodialyzed patients was examined in 195 patients who were introduced to hemodialysis. The relationship between blood pressure and survival or death was analyzed. In 46 patients who died within 3 years after the introduction of hemodialysis (nonsurvivors), the age was higher (61 +/- 2 years v 50 +/- 1 years), the occurrence of diabetic nephropathy was higher, and the systolic pressure was higher in both the introduction (178 +/- 4 mm Hg v 167 +/- 2 mm Hg) and maintenance (165 +/- 4 mm Hg v 147 +/- 2 mm Hg) phases than in 132 patients who survived more than 3 years (survivors). On the other hand, there were no significant differences in diastolic pressure during either phase between the two groups of patients. When diabetic nephropathy was excluded, only systolic pressure during the maintenance phase was higher in the nonsurvivors than in the survivors. Therefore, based on systolic pressure during the maintenance phase, patients were divided into two groups, the HT group (> or = 160 mm Hg) and the NT group (< 160 mm Hg), and cumulative survival rates were compared. Whether all patients, only those patients with diabetic nephropathy, or only those patients without diabetic nephropathy were examined, the survival rate was higher in the NT group than in the HT group.(ABSTRACT TRUNCATED AT 250 WORDS)

Morbidity and mortality due to hypertension in patients with renal failure

The incidence of, and the mortality from, cardiac disease is strikingly increased in dialysis patients. Coronary disease existing prior to the onset of dialysis is an important determinant of ischemic heart disease (IHD) on dialysis. Death from IHD on dialysis is higher by factor 5-20 than in the general population. In several studies either a marginal or no relation between blood pressure on admission to renal replacement therapy, or average predialysis blood pressure and cardiac death has been noted. In other studies blood pressure was, however, predictive of IHD. Such discrepancies may be explained by a low-risk threshold, a nonlinear relationship, and the necessity to examine large patient cohorts to document the effect. Of great importance may be the potentially increased susceptibility of the heart to hypertensive injury and ischemia. This may be related to factors like left ventricular hypertrophy, cardiac fibrosis and altered cardiac mechanical properties, diminished coronary reserve, and reduced ischemia tolerance, particularly during intradialytic hypotensive episodes due to compromised microcirculation and disturbed insulin-induced glucose uptake and abnormalities of autonomous neural innervation of the heart.

Lipoprotein heterogeneity in end-stage renal disease

Fifteen patients on chronic maintenance hemodialysis without any additional known cause for dyslipidemia were arbitrarily divided into two groups based on fasting plasma triglyceride levels. The hypertriglyceridemic patients (plasma triglyceride levels above 170 mg/dl, N = 7) also had decreased high density lipoprotein (HDL) cholesterol levels and decreased post-heparin plasma lipoprotein lipase activity compared to the normotriglyceridemic patients (N = 8). All lipoprotein fractions collected by density gradient ultracentrifugation were triglyceride-enriched in the hypertriglyceridemic patients. Both groups of patients had elevated intermediate density lipoprotein levels, heterogeneity in the distribution of low density lipoproteins (LDL) and apoprotein-specific HDL subpopulations, and abnormalities in the size and composition of both LDL and HDL. The described alterations tended to be more marked in hypertriglyceridemic patients and are not detected by the usual laboratory evaluation of lipoproteins. These lipoprotein abnormalities have been shown to be atherogenic in patients without renal disease and are likely to contribute to the high prevalence of premature atherosclerosis in end-stage renal disease.

Survival differences among older dialysis patients in the southeast

Older end-stage renal disease (ESRD) patients treated by chronic dialysis have higher mortality in the United States than in many other countries. While increasing age, white race, male sex, and/or diabetes are considered risk factors for survival, few studies of older dialysis patients have simultaneously considered multiple predictor variables and their interactions. Using information contained in the 1982 to 1986 ESRD Network 20 database for Georgia and South Carolina, we studied hospitalizations and survival of 1,354 blacks and 965 whites who were age 60 years or older when they began dialysis therapy. Survival time was modeled using the Cox life-table regression method. Older blacks' median age at dialysis initiation was 67.4, compared with 68.7 for older whites (P = 0.001). Blacks were more likely than whites (P < 0.001) to have hypertension-related or diabetes-related ESRD. White patients experienced approximately 25% more hospitalization when adjustment was made for patient-days at risk. Separate multivariate survival models were required for patients with diabetes-related versus non-diabetes-related ESRD. Among diabetics, mortality was higher among whites and among patients who were older when they began dialysis. Among patients with non-diabetes-related ESRD, mortality was higher among patients who were older when they began dialysis, but the age effect was much stronger for white males. Our hospitalization and mortality data support the view that unmeasured severity (or frailty) differences characterize white as compared with black dialysis patients. Among non-diabetes-related ESRD patients, the age effect on survival was more severe in white males than in blacks or in white females. The high mortality we observed among older dialysis patients in Georgia and South Carolina warrants further study; the data may in part reflect patients' lower socioeconomic status compared with age, race, and sex-matched controls.

Simultaneous analysis of morbidity and mortality factors in chronic hemodialysis patients

The Cox stepwise logistic regression model was applied to analyze 22 factors potentially affecting morbidity and mortality (MM) in a cohort of 104 patients on chronic hemodialysis (CHD). Two groups of predictor variables were considered: patients' characteristics at the start of the study, and treatment-related factors recorded throughout the observation period. End points were either failure (death or admission to a hospital) or success. Patients were followed for 24 months. Thirty-nine patients were hospitalized and seven died in the interval. The two leading causes of failure were cardiovascular and infectious complications. Variables significantly associated with the result were: cardiac status (score greater than 2, beta = 1.16), mean predialysis blood pressure (greater than 115 mm Hg, beta = 0.94), total dialysis dose (greater than 0.90, beta = -0.59) and age (greater than 55 years, beta = 0.51). The probability of failure was 0.13 for patients who presented the four variables in the lowest risk class. This increased to a maximum of 0.60 with one risk factor, to 0.91 with two risk factors, and to 0.99 with three or more risk factors. We conclude that, given the conditions for this study, two treatment-related variables of CHD (mean predialysis blood pressure and total dialysis dose) are MM factors even when simultaneously analyzed with other well-established predictors (cardiac status and age). Mean arterial pressure (MAP) is the most important CHD treatment-related MM predictor.

Canadian Hemodialysis Morbidity Study

The objective of this study was to determine the probabilities of specific morbid events or death among patients with end-stage renal disease (ESRD) treated by hemodialysis. A prospective cohort study was performed between March 1988 and September 1989 in 18 hemodialysis centers in 13 Canadian cities, representing about one third of the hemodialysis population in Canada. The inception cohort consisted of 496 patients entering hemodialysis who had survived 1 month. The few new hemodialysis patients who received erythropoietin (EPO) in the last 3 months of the study were excluded. Survival curves were compared using the Cox proportional hazards regression model. Older age and history of cardiovascular disease were independently associated with a greater probability of death. Age and history of cardiovascular disease were also associated with a greater probability of nonfatal circulatory events (myocardial infarction, angina requiring hospitalization, or stroke), while a serum albumin level less than or equal to 30 g/L (3.0 g dL) was associated with an increased probability of pulmonary edema. The probability of surviving 12 months without receiving a blood transfusion was 47.2% for males and 27.5% for females. The incidence of non-A, non-B hepatitis, as estimated by unexplained elevations in serum aspartate aminotransferase (AST) values, was not different between patients receiving and not receiving blood transfusions. The probability of hospitalization for any cause was greater for patients with grafts for vascular access than for those with fistulae, for those with a history of cardiovascular disease, for those with a serum albumin level less than or equal to 30 g/L, and for those with renal disease due to diabetes or vascular disease. Hospitalization due to circulatory disease was more likely among those with a history of cardiovascular disease and among those with a lower serum albumin level. Hospitalization for infectious disease was more likely among those with a lower serum albumin level and less likely among those with a fistula for vascular access. Among all patients receiving hemodialysis treatment for more than 6 months, there were 14.8 hospital days per year.(ABSTRACT TRUNCATED AT 400 WORDS)

Efficacy of mupirocin nasal ointment in eradicating Staphylococcus aureus nasal carriage in chronic haemodialysis patients

Topical 2% mupirocin ointment eradicated chronic Staphylococcus aureus nasal carriage immediately post-therapy in 17 (77%) of 22 haemodialysis patients. Mean time to recurrence was 3.8 weeks. Similar pre-therapy and post-therapy phage types occurred in 12 (71%) of 17 patients. Staphylococcus aureus infections developed in none of 17 successfully treated patients, two of five treatment failures (P = 0.05), and 10 of 46 untreated patients studied concurrently (P = 0.03).

Time-related increase in hematocrit on chronic hemodialysis: uncertain role of renal cysts

We studied the long-term changes in hematocrit in 283 center hemodialysis patients. Mean duration of dialysis (+/- SD) was 53.8 +/- 43.4 months, with a range of 6 to 176 months. The correlations of hematocrit with clinical factors, laboratory values, and renal cystic changes were investigated. Time on dialysis was the strongest single predictor of hematocrit for the whole group (r = 0.351, P less than 0.001) and for men and women analyzed separately. Longitudinal 5-year (n = 83) and 10-year (n = 21) data showed a continuous increase in hematocrit levels over time (r = 0.414, P less than 0.001 over 10 years). Patients at the dialyzer reuse center (n = 224) had higher hematocrit levels than those at the center that did not reuse (n = 59). Although time on dialysis was strongly correlated with increasing extent of renal cystic change (r = 0.387, P less than 0.001), the correlations of cyst extent and time on dialysis with hematocrit were not independent by multiple regression analysis. We conclude that hematocrit increases progressively over time in patients on chronic hemodialysis. The mechanisms responsible for this do not seem to involve cystic transformation of the kidneys and remain unclear.

Biopsychosocial aspects of long-term survival on end-stage renal failure therapy

At ten-years follow-up of 64 haemodialysis patients, 43 had died and 21 were alive, twelve with cadaver renal transplants and nine on haemodialysis. Examination of the influence of psychological, demographic, physical and biochemical factors revealed the Beck Depression Inventory and age as the two most important predictors of survival. The behaviour of the patient was directly responsible for five (11.6%) of the deaths, by suicide in three cases and dietary non-compliance in two cases. Hypothetical mechanisms linking depression with reduced survival have been reviewed. As the impact of depression on survival was maximal in the first few years of dialysis, monitoring for depression should be incorporated into routine care from the start of dialysis together with evaluative interventions that might enhance survival.

Heparin and Prostacyclin

Hemodialysis performed with prostacyclin (5 ng/kg/min) as a sub stitute for heparin was studied in 10 patients. The subjects were studied during heparin perfusion alone and during heparin perfusion together with prostacyclin. The authors inves tigated the effect of two heparin regi mens (regimen I: 2,000 U/hr and reg imen II: 500 U/hr) upon plasma anti thrombin level (IU/mL) and activated thromboplastin time (sec).

Our findings show: (1) prostacy clin can substitute for heparin anti coagulaton in hemodialysis; (2) the concomitant administration of pro stacyclin enhances the anticoagulant effect of heparin, based on the mea surement of the activated partial thromboplastin time; (3) the anti thrombin activity is increased by both treatments but more so with prostacyclin; and (4) platelet activa tion plays a role in limiting heparin anticoagulation, a conclusion partly supported by the finding that acti vated partial thromboplastin time is somewhat more prolonged by hepa rin when measured in platelet-poor rather than in platelet-rich plasma in the presence of prostacyclin. Physio pathologic implications of these pre liminary findings are discussed.

Quality of life in chronic dialysis patients. Factors unrelated to dialysis modality

The quality of life (medical, psychological, and social adaptation) of 66 chronic dialysis patients was studied cross-sectionally. The participants had similar levels of medical, psychological, and social adaptation to those found in previous studies of chronic dialysis patients. Medical, psychological, and social adaptation are independent dimensions that are only weakly intercorrelated. When categorized by specific individual or treatment characteristics, men and those over age 51 had poorer medical and psychological adaptation than did women and younger dialysis patients. Duration of dialysis was not related to quality of life. Vocationally active as compared to vocationally inactive subjects had generally superior medical, psychological, and social adaptation. Male sex, age over 51, and vocational inactivity are all associated with poorer dialysis patient adaptation. The development of profiles of groups of dialysis patients at increased risk for poor adaptation may help in targetting scarce psychosocial intervention resources. Studies of the psychosocial efficacy of differing treatment modalities need to consider non--treatment-related factors that may affect patient psychosocial outcomes.

Renal osteodystrophy

Over the past decade important advances in our understanding of the pathophysiology and treatment of renal osteodystrophy have been made. In particular, the role of calcitriol deficiency in the genesis of hyperparathyroidism in early renal failure is now better understood. So too are the effects of aluminium on bone, and whereas the more florid aluminium related disease is now unusual the more subtle effects of aluminium are now being appreciated. There is still a major problem in the long-term treatment of hyperparathyroid bone disease. The reasons why parathyroid gland proliferation continues to occur on dialysis therapy require a better understanding of cellular events regulating hormone production and parathyroid cell replication. The case for early intervention with vitamin D is now strong but whether such an approach materially influences the long-term outcome is not yet established. Changes in the approach to treatment and in the modalities used for renal replacement therapy will continue to modify the nature of the bone disease.

The donor's decision in renal transplantation: a cost-benefit analysis

We previously suggested that a fully informed competent potential donor be allowed to donate his/her kidney as long as society will not suffer from the proposed transplant, even if there is added risk for the donor. To help make this sometimes difficult determination, we have constructed a benefit equation that calculates the benefit to society (either positive or negative) of any proposed living-related transplant. We believe that as long as the benefit calculated is positive, the prospective donor should generally be allowed to donate his kidney, since society will not be injured. It is emphasized that the benefit equation should be viewed as a guide to be used in difficult situations where the donor may be at added risk of renal death, and is not meant to supplant the entire complex decision-making process regarding living-related kidney donation.

Neutrophil and monocyte alterations in chronic dialysis patients

Chronic renal failure patients maintained on dialysis have an increased risk for infection. This article summarizes research that has been done on the function of neutrophils (PMNs) and monocytes from chronic hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) patients. The studies involving the HD patients showed that there is a decreased PMN in vitro chemotactic response, decreased C5a receptors on both PMNs and monocytes, and decreased oxidative metabolic responses of PMNs and monocytes to the chemotactic stimuli C5a and formyl-met-leu-phe (fMLP), but not to nonchemotactic factors. The results of studies involving phagocytosis have been conflicting and are discussed in this paper. Due to the basic principles of peritoneal dialysis, this treatment approach depletes the peritoneum of phagocytic cells, adversely affects the function of peritoneal WBCs, dilutes the existing opsonins, and alters the physiologic environment of the peritoneal cavity. Studies of peripheral PMN and monocyte function in CAPD patients have shown that, similar to HD patients, they also have decreased C5a receptors and decreased oxidative metabolic responses to the chemotactic factors C5a and fMLP. Although the factors contributing to the risk of infection in chronic dialysis patients are multifaceted, there are definitely alterations in PMN and monocyte function.

Long-term survival in haemodialysis patients

Survival rates and causes of death were analysed for 177 patients who started dialysis between 1970 and 1975. 99 patients survived 5 years of treatment, and at this stage 74 had functioning transplants; thereafter, only 4 changed between treatment by dialysis and transplantation. For patients surviving for 5 years those treated by dialysis and those treated by transplantation had a similar probability (+/- standard error) of surviving to 10 years (0.84 +/- 0.07 v 0.82 +/- 0.04), but the probability of surviving to 15 years was lower for dialysis patients than for transplant patients (0.31 +/- 0.14 v 0.63 +/- 0.08; p less than 0.05). Infection, particularly with Staphylococcus aureus, was an important cause of late mortality in dialysis patients.

Reducing the hemorrhagic complications of hemodialysis: a controlled comparison of low-dose heparin and citrate anticoagulation

We report a randomized prospective study comparing the results of anticoagulation using hypertonic trisodium citrate and low-dose controlled heparin during 45 hemodialysis treatments performed on patients determined to be at high or very high risk for bleeding. Dialysis-associated bleeding was more frequent following low-dose controlled heparin anticoagulation than during hypertonic citrate therapy (P less than .05). Dialysis effectiveness measured by postdialysis chemistries and weight loss was equivalent in the two groups.

Acquired cystic disease of the end-stage kidney

The development of multiple cysts in the previously noncystic chronically diseased kidneys of patients undergoing long-term dialysis appears to be associated with spontaneous renal bleeding and benign and malignant renal tumors. Two cases of acquired cystic disease with renal hemorrhage and adenocarcinoma are presented; metastases occurred in one patient and the other had bilateral carcinoma requiring bilateral nephrectomy. Combined data from 13 studies indicate acquired cystic disease occurs in one third of patients undergoing maintenance hemodialysis and is associated with adenocarcinoma in 4 percent of cases. Four cases of metastases and five deaths linked to acquired cystic disease have been reported. Eight of 24 patients with acquired cystic disease and clinical manifestations of renal bleeding had renal adenocarcinoma. Autopsy series indicate tumors associated with acquired cystic disease are usually benign but commonly bilateral and multiple. Cystic transformation of the end-stage kidney is more frequent after several years of hemodialysis. It is suggested that patients receiving dialysis treatments for more than three years have a baseline radiologic examination of the kidneys so that subsequent problems can be more easily identified and evaluated.

Endurance exercise training. An effective therapeutic modality for hemodialysis patients

These results demonstrate that some of the metabolic complications of chronic uremia treated with maintenance hemodialysis are related to the deterioration in physical fitness and strength that accompanies this chronic disease. Exercise training increased the physical work capacity, improved the lipid profile, normalized insulin sensitivity and glucose metabolism, and lowered the dose of antihypertensive medications required by some of the patients. These changes occurred in the absence of significant changes in diet or body weight. Furthermore, during an equivalent period of follow-up there was a significant deterioration in the lipid profiles of sedentary controls. Thus, exercise training has the potential to reduce the prevalence of many of the medical conditions thought to promote atherogenesis in hemodialysis patients. In addition, there was a significant improvement in the degree of anemia of the exercising patients. None of these metabolic and physiological changes could be attributed to factors related to changes in dialysis scheduling or technology, medications, or diets. Exercise training was associated with an improvement in the mood, level of depression, and psychosocial functioning of these patients; the sedentary controls either became more depressed or reduced their participation in pleasant, socially oriented activities. This raises the possibility that exercise training may have the potential to return some dialysis patients to a more normal social lifestyle, perhaps improving their socioeconomic status and reducing their dependency. These are extremely optimistic possibilities that could have far-reaching implications for the hemodialysis population. The dramatic improvements in lipid and glucose metabolism, hematologic function, blood pressure and work capacity in the exercising patients indicates that aerobic physical training is an effective therapeutic modality with a wide spectrum of effects on many pathologic processes previously thought to be a consequence of chronic uremia. Not only were there major biochemical changes as a result of exercise training, but the psychosocial functioning of these dialysis patients improved. Some of the physiologic changes, such as the increase in work capacity, greater strength and energy, and the rise in hematocrit, contributed to the psychological improvements, but in some patients accomplishing the goal itself (for most a 1-mile jog was the ultimate) seemed sufficient. There are a multitude of potential long-term benefits of exercise training programs for hemodialysis patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Cystic kidneys: an enigma evolves

Substantial contributions to the field of RCD have been made over the past 15 years. Most intriguing is a growing awareness of acquired RCD and its complications. Data have been published and are reviewed here in support of a possibility that APKD and RCD acquired during hemodialysis are premalignant lesions. More data are needed before the possibility can be confirmed or denied. The collection of these data is an immediate need in the field of RCD.

Effects of prazosin and propranolol on blood pressure and plasma lipids in patients undergoing chronic hemodialysis

Twenty patients receiving hemodialysis who had mild to moderate hypertension were treated with prazosin or propranolol to control predialysis hypertension. Effective blood pressure control was achieved with prazosin (mean dose 8.3 +/- 2.2 mg [+/- standard error of the mean], n = 10) and propranolol (mean dose 123 +/- 39 mg, n = 10). Therapy with prazosin did not significantly affect total plasma triglyceride or total cholesterol levels. The level of high-density lipoprotein (HDL) cholesterol tended to increase, but not significantly. However, the HDL3 subfraction did increase significantly, from 16.3 +/- 1.5 to 20.6 +/- 1.5 mg/dl (p = 0.05). Propranolol therapy increased plasma triglyceride levels, primarily of the very low density lipoprotein class. HDL cholesterol levels decreased from 44.2 +/- 6.7 to 34.7 +/- 4.2 mg/dl (p less than 0.03). The reduction in the HDL cholesterol levels was attributable to a decrease in HDL2 cholesterol levels (from 21.3 +/- 3.8 to 16.3 +/-3.0 mg/dl, p less than 0.04) and HDL3 cholesterol levels (from 23.0 +/- 3.1 to 19.5 +/- 2.1 mg/dl, difference not significant). Thus, both prazosin and propranolol are effective in controlling hypertension in patients undergoing hemodialysis. HDL3 cholesterol levels increased in patients treated with prazosin, but no other significant changes in the plasma lipids occurred. Patients treated with propranolol had a significant decrease in plasma HDL2 and HDL3 cholesterol levels.