Hemostatic and fibrinolytic response to desmopressin in uremic patients

Recurrent Hemoperitoneum Complicating Continuous Ambulatory Peritoneal Dialysis

♦ Objectives

To study the clinical features, clinical outcomes, and peritoneal transport characteristics of patients with recurrent hemoperitoneum complicating continuous ambulatory peritoneal dialysis (CAPD).

♦ Design

Single-center retrospective case review of patients on CAPD over a 10-year period.

♦ Setting

Renal Unit in Queen Mary Hospital, a tertiary-care referral center in Hong Kong.

♦ Patients

549 patients were available for review. 46 patients (8.4%) had at least one episode of hemoperitoneum during their course of CAPD; 25 patients had only one episode of hemoperitoneum and they were excluded. The remaining 21 patients (3.8%) had two or more episodes of hemoperitoneum and they were included for review.

♦ Main Outcome Measures

Basic demographic factors and the etiology and episodes of hemoperitoneum were recorded. Clinical outcomes included continuation on peritoneal dialysis, conversion to hemodialysis (HD), renal transplantation, and death. The reason for conversion to HD, the causes of death, and serial peritoneal equilibration tests (PET) using dialysate-to-plasma ratio of creatinine (D/P creat) and ratio of dialysate glucose at hours 4 and zero of the dwell (D4/D0) with standard 2-L 2.5% glucose dialysate were assessed.

♦ Results

There were 549 patients with total of 91 episodes of recurrent hemoperitoneum affecting 21 patients (3.8%). Mean age was 50.2 years (range 24 – 76 years) and mean duration of dialysis was 61.6 months (range 2 – 166 months). There were 14 female patients (66.7%) and 7 male patients (33.3%). The average number of hemoperitoneum episodes was 4.3 per patient (range 2 – 12). The mean time interval of the first hemoperitoneum episode from commencement of peritoneal dialysis was 10.5 months (range 1 – 37 months, SD 9.7 months). Most cases were due to retrograde menstruation in females and unknown cause in males. Two patients had intra-abdominal pathology accounting for hemoperitoneum. Thirteen patients (61.9%) continued CAPD, 2 (9.5%) underwent renal transplantation, and 2 (9.5%) were converted to long-term HD. The reason for conversion to HD was related to hemoperitoneum in 1 patient (4.8%) only. Four patients (19.0%) died; the causes of death were unrelated to hemoperitoneum. There was no correlation between recurrent hemoperitoneum and peritonitis episodes ( p = 0.18). There was no significant association between hemoperitoneum episodes and clinical outcomes ( p = 0.91) or survival ( p = 0.52). None of the patients developed ultrafiltration failure on long-term follow-up.

♦ Conclusions

Recurrent hemoperitoneum is a benign complication of CAPD, with no significant long-term effects on patient survival, predisposition to peritonitis, or ultrafiltration failure.

Periprocedural Concerns in the Patient with Renal Disease

Treating patients with kidney disease can be both a difficult and a complex process. Understanding how to care for patients who have kidney disease is essential for lowering perioperative as well as periprocedural morbidity and mortality. The primary aim in renal evaluation and care is to control and mitigate factors that may result in acute kidney injury (AKI) and/or cause further decline in renal function. It is essential for the foot and ankle specialist to recognize patients who are predisposed to developing or already have impairment of renal function.

Surgical Treatment for Non-Small Cell Lung Cancer in Patients on Hemodialysis due to Chronic Kidney Disease: Clinical Outcome and Intermediate-Term Results

Background

Patients on dialysis undergoing surgery belong to a high-risk group. Only a few studies have evaluated the outcome of major thoracic surgical procedures in dialysis patients. We evaluated the outcomes of pulmonary resection for non-small cell lung cancer (NSCLC) in patients on hemodialysis (HD).

Methods

Between 2008 and 2013, seven patients on HD underwent pulmonary resection for NSCLC at our institution. We retrospectively reviewed their surgical outcomes and prognoses.

Results

The median duration of HD before surgery was 55.0 months. Five patients underwent lobectomy and two patients underwent wedge resection. Postoperative morbidity occurred in three patients, including pulmonary edema combined with pneumonia, cerebral infarction, and delirium. There were no instances of in-hospital mortality, although one patient died of intracranial bleeding 15 days after discharge. During follow-up, three patients (one patient with pathologic stage IIB NSCLC and two patients with pathologic stage IIIA NSCLC) experienced recurrence and died as a result of the progression of the cancer, while the remaining three patients (with pathologic stage I NSCLC) are alive with no evidence of disease.

Conclusion

Surgery for NSCLC in HD patients can be performed with acceptable perioperative morbidity. Good medium-term survival in patients with pathologic stage I NSCLC can also be expected. Pulmonary resection seems to be the proper treatment option for dialysis patients with stage I NSCLC.

Pharmacokinetics and antidiuretic effect of high-dose desmopressin in patients with chronic renal failure

High-dose desmopressin shortens the bleeding time in uraemia. The aim of this study was to investigate the pharmacokinetics and the antidiuretic effect of desmopressin when given in a dose normally used for haemostasis to patients with reduced renal function. Ten patients with chronic renal failure of varying aetiology were enrolled in the study. The age was 58 (20-76) years (median and range), serum creatinine 447 (309-691) micromol/l and plasma clearance of iohexol 16 (8-19) ml/min./1.73 m2 body surface. After baseline measurements, desmopressin was infused at a dose of 0.3 microg/kg. The plasma concentration of desmopressin was followed for 26 hr during and after the infusion and the pharmacokinetic parameters were estimated by compartmental analysis. Urine volume and osmolality, as well as body weight, blood pressure, heart rate, haematocrit, serum osmolality, electrolytes and creatinine, were measured repeatedly during the day before and for two days after the infusion. The total clearance of desmopressin was 0.35 (0.21-0.47) ml/min./kg, the volume of distribution at steady state was 0.30 (0.17-0.38) l/kg and the terminal half-life 9.7 (8.4-16) hr. After administration of desmopressin, urine osmolality increased significantly, by approximately 10%, and this increase lasted for 48 hr. Concomitantly, there was a modest but significant decrease in haematocrit. Thus, the clearance of desmopressin was on average decreased to approximately one quarter, and the terminal half-life was prolonged 2-3 times in the patients as compared to previously published values for healthy adults. The single haemostatic dose of desmopressin given to patients with severe renal failure did not cause fluid overload or changes in serum electrolytes.

Renal biopsy in high-risk patients with medical diseases of the kidney

The number of high-risk patients undergoing renal biopsy is likely to increase in the near future because of the increased use of anticoagulants for such conditions as atrial fibrillation, combined liver and kidney disease caused by hepatitis C, and the aging of the population. Nephrologists need to become increasingly familiar with evaluating such patients through both specialized management of percutaneous kidney biopsy and alternate methods of renal biopsy, which primarily consist of open (surgical) biopsy, transjugular (transvenous) biopsy, and laparoscopic biopsy. The indications, complications, and general approach to such patients are discussed. This is a US government work. There are no restrictions on its use.