Association of intradialytic blood pressure changes with hospitalization and mortality rates in prevalent ESRD patients

The relationship between blood pressure (BP) and clinical outcomes among hemodialysis patients is complex and incompletely understood. This study sought to assess the relationship between blood pressure changes with hemodialysis and clinical outcomes during a 6-month period. This study is a secondary analysis of the Crit-Line Intradialytic Monitoring Benefit Study, a randomized trial of 443 hemodialysis subjects, designed to determine whether blood volume monitoring reduced hospitalization. Logistic regression was used to estimate the association between BP changes with hemodialysis (Deltasystolic blood pressure=postdialysis-predialysis systoic BP (SBP) and the primary outcome of non-access-related hospitalization and death. Subjects whose systolic blood pressure fell with dialysis were younger, took fewer blood pressure medications, had higher serum creatinine, and higher dry weights. After controlling for baseline characteristics, lab variables, and treatment group, subjects whose SBP remained unchanged with hemodialysis (N=150, DeltaSBP -10 to 10 mm Hg) or whose SBP rose with hemodialysis (N=58, DeltaSBP > or =10 mm Hg) had a higher odds of hospitalization or death compared to subjects whose SBP fell with hemodialysis (N=230, DeltaSBP < or =-10 mm Hg) (odds ratio: 1.85, confidence interval: 1.15-2.98; and odds ratio: 2.17, confidence interval: 1.13-4.15). Subjects whose systolic blood pressure fell with hemodialysis had a significantly decreased risk of hospitalization or death at 6 months, suggesting that hemodynamic responses to dialysis are associated with short-term outcomes among a group of prevalent hemodialysis subjects. Further research should attempt to elucidate the mechanisms behind these findings.

Sorbents in the treatment of renal failure

Standard renal replacement therapy in acute renal failure (ARF) and end-stage renal disease (ESRD) is based on membrane technology. The transition from natural cellulosic membranes to synthetic membranes has not been associated with improvement in mortality rates. Modifications of dialysis with continuous arteriovenous hemofiltration and hemodiafiltration to remove middle molecular weight toxins, low molecular weight proteins and peptides (LMWP) and cytokines involved in inflammation appear to have reached their limits. High flux dialyzers are not efficient at removing LMWP and for this reason sorbents to augment or replace dialysis have been used in clinical trials. Removal of LMWP such as beta2-microglobulin, leptin, complement factor D, angiogenin, and cytokines such as IL-1, IL-6, IL-10, IL-18 and TNFalpha, have been established in animal models of sepsis, and in ESRD patients using sorbents in conjunction with high flux dialysis. Sorbent devices added to hemodialysis, or alone in inflammatory states, are being studied in diseases which possess a common pathway of systemic inflammatory response syndrome; these states are sepsis, ARF, cardio-pulmonary bypass, in brain dead subjects prior to explantation of donor organs and ESRD.

Requirements for urology and renal dialysis PC-based telemedicine applications: comparative analysis

The Imaging Science and Information Systems (ISIS) Center of the Department of Radiology at Georgetown University Medical Center (GUMC) has been developing technical requirements for different telemedicine applications. This paper details the process through which those technical requirements are determined and shows how they may differ substantially, depending on the clinical need. This information is presented in light of two telemedicine applications being undertaken at GUMC: a urology application for the management of patients with surgical stone disease and a nephrology application for monitoring of renal dialysis patients.

Peritoneal dialysis in older individuals

Peritoneal dialysis is a viable alternative to hemodialysis for management of elderly patients requiring renal replacement therapy. Peritoneal dialysis confers several advantages over hemodialysis for the elderly--namely independence, home treatment and perhaps preservation of residual renal function. Although there are a few contraindications, these are minimal and can largely be overcome with attention to special training and the use of healthcare partners to perform the technique of peritoneal dialysis exchanges.

End-stage renal disease and its management in older adults

The older patient with renal disease presents the nephrologist with a formidable problem list: treatment of end-stage renal disease (ESRD) in these patients can be viewed as a continuum in the management of several diseases at one time. The older ESRD patient with complex medical problems is a challenge to the health care team, clearly requiring the cooperation of physician, nurse, dialysis technician, social worker, dietician, physical medicine specialist, and a host of other subspecialists. The outcomes, however, are gratifying, in that a satisfactory and enjoyable autumn of life is attainable for many.

Hemodialysis patient management by telemedicine: design and implementation

The authors describe the design and implementation of a personal computer based telemedicine system for managing patients by telemedicine. With three identical systems connected by high speed T1 lines, the physician (or allied healthcare giver) can interact, by videoconferencing, and by using multimedia files, with patients at two remote hemodialysis sites. The physician is able to visualize specifically the patient's fistula/graft, and auscultate fistula, heart and lung sounds, and incorporate still pictures or audio sounds in the patient's multimedia database folder, which also contains an electronic and paperless medical record. In addition there is the capability of downloading into this database all the machine parameters during dialysis.

Therapeutic uses of aspirin in renal diseases

Inhibition, by aspirin, of platelet aggregation, prostaglandin synthesis, smooth muscle cell proliferation, and thromboxane genesis has potential therapeutic uses in renal diseases. Clinically, some benefit from aspirin has been shown in some forms of glomerulonephritis but not in others, such as renovascular hypertension, pregnancy-induced hypertension, and diabetic nephropathy. Experimentally, aspirin aided in amelioration of cyclosporine toxicity and in preservation of explanted kidneys being prepared for transplantation.

Low-dose subcutaneous erythropoietin in continuous ambulatory peritoneal dialysis

We evaluated changes in hematocrit in patients on continuous ambulatory peritoneal dialysis (CAPD) before and after the administration of erythropoietin (EPO). Thirty-five patients were evaluated at the beginning of treatment with CAPD and after an average of 3.5 years on CAPD; mean hematocrit (Hct) rose from 25.4 +/- 5.4% to 28.1 +/- 6.7% (P less than 0.001). In the period before EPO administration 11 patients required a total of 44 transfusions (one patient needed 23 transfusions). Fifteen patients were started on subcutaneous erythropoietin 3,000 units 3 times a week and were followed for a mean period of 6.3 months. Hct rose from 23.8 +/- 1.8% to 25.2 +/- 2.4% (P less than 0.01) within the first 2 weeks and up to 27.5 +/- 3.7% (P less than 0.01) in the fourth week. By the eighth week the target Hct (30 to 35%) was reached. During the next 5 months the EPO doses were adjusted to each patient's needs ranging between 2,000 U per week to 4,000 U 3 times per week. Mild hypertension was the only side effect seen in some of the patients. In conclusion low dose subcutaneous EPO is effective in managing the anemia of patients on CAPD with only minor side effects.

Ten years' experience with continuous ambulatory peritoneal dialysis

Up to January 1989, 171 patients were trained at our center on continuous ambulatory peritoneal dialysis (CAPD), and 17 on continuous cyclic peritoneal dialysis (CCPD). Over 10 years, we have gained 5,068 patient-months experience. Patient survival was 60% and 31% at 5 and 10 years, respectively. In contrast, diabetics had a survival of 32% at 5 years. Major complications included 499 new episodes of peritonitis, 304 exit-site infections, 22 hernias, five bowel perforations, one hydrothorax, and three episodes of sclerosing encapsulating peritonitis. Our technique survival has been 62% and 40% at 5 and 10 years, respectively. We believe that CAPD is a viable dialysis technique for long-term treatment of chronic renal failure and it should be offered as an option to intermittent hemodialysis.

Chronic dialysis in a patient with cystic fibrosis

To our knowledge this is the first case reported in the literature of a patient with cystic fibrosis and end-stage renal disease, who was on dialysis for 2 years. We discuss here the possible mechanisms responsible for what has been called 'the cystic fibrosis nephropathy' and its consequences.

Sclerosing encapsulating peritonitis in rats induced by long-term intraperitoneal administration of antiseptics

Continuous ambulatory peritoneal dialysis (CAPD) is an effective long-term treatment for renal failure. Sclerosing encapsulating peritonitis (SEP) is a rare but devastating complication of CAPD and may be caused by long-term peritoneal antiseptic exposure. We examined the peritoneal injury resulting from daily inoculations of moderately high concentrations of the following antiseptics: povidone-iodine, Dakin's solution, Amuchina, and Ampercide. After 4, 8, and 12 weeks of daily intraperitoneal injections in rats, a 10% solution of povidone-iodine in dialysis fluid caused a condition that mirrors human SEP. Animals had poor early weight gain, and gross necropsy examination revealed intestinal adhesions and a mesothelium that was sclerotically thickened. From 4 to 8 weeks the 10% povidone-iodine-injected animals showed progressive conditions and the prevalence of multiple encapsulating adhesions increased from 0/6 to 4/4, p = 0.005. Marked visceral mesothelial thickening in the 10% povidone-iodine-injected animals was quantitated after 4, 8, and 12 weeks at 92.0 +/- 11.6, 151.5 +/- 28.8, and 206.0 +/- 36.2 micron, respectively. Rats injected with dialysis fluid (controls) had normal-appearing mesothelial surfaces measured at 1.8 +/- 0.2, 2.4 +/- 0.2, and 2.2 +/- 0.2 micron after 4, 8, and 12 weeks, respectively. The marked thickening of the mesothelium in the 10% povidone-iodine group compared with the controls was highly significant, p less than 10(-8). We conclude that povidone-iodine, the most commonly used antiseptic in CAPD, caused severe tissue injury, whereas other antiseptic solutions, Dakin's, Amuchina, and Ampercide, at the similar dilution did not appear to cause mesothelial injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Bilateral nephrectomy and dialysis as an option for patients with bilateral renal cancer

Six patients who underwent bilateral nephrectomy for renal carcinoma were placed on maintenance dialysis; of these, 1 patient had a renal transplant. A 5-year 44% survival of these patients was observed. We feel that radical nephrectomy followed by chronic dialysis is a reasonable alternative and offers a fair prognosis to patients with bilateral renal cancer in which partial nephrectomy is not possible.

Management of iron overload in dialysis patients

Acquired hemosiderosis resulting from massive iron deposits in various organs, including heart, liver, and pancreas, may lead to architectural and functional disturbances of these organs. Even though iron overload can occur in nonuremic as well as in uremic individuals, the dialysis patient is at particular risk for developing hemosiderosis. Many dialysis patients receive exogenous iron from either oral iron therapy or blood transfusions. In addition, these patients seem to be at high risk for retaining iron. A diagnosis of excess iron deposition should be considered if the patient has unexplained cardiomyopathy, hepatic cirrhosis, proximal myopathy, diabetes mellitus, arthropathy, or immune dysfunction such as listeriosis. Several techniques are available for determining iron overload. Diagnostic tests include measuring serum ferritin levels, staining bone marrow preparations for excess iron, measuring tissue hemosiderin concentrations, magnetic resonance imaging, and the deferoxamine (DFO; Desferal) "challenge test." The simplest treatment for iron overload in nonuremic patients is removal of iron by venesection. However, in patients in whom venesection is not feasible, the chelating agent DFO can effectively remove excess iron. In the dialysis patient, DFO therapy can be combined with either dialysis or hemoperfusion to remove the iron-DFO complex that would otherwise be removed by the kidney. DFO therapy in the nondialyzed individual has proven to be successful, but before treatment, the benefits of the treatment must be weighed against possible adverse side effects such as cataracts, changes in color vision, and anaphylaxis. In the dialysis patient, indications for iron removal are less clearly defined.(ABSTRACT TRUNCATED AT 250 WORDS)

Peritonitis, dialysate infusion and lung function in continuous ambulatory peritoneal dialysis (CAPD)

Pulmonary function tests were done in seven CAPD patients with acute peritonitis on the day of admission to the hospital and after recovery. Subsequently, the effect of dialysate infusion alone on lung function was studied in 19 patients initiated on CAPD and nine of these patients were restudied 7.6 +/- 4.1 months later. Peritonitis was associated with a 30% reduction in vital capacity and a significant fall in arterial oxygen tension (7 to 11 mmHg) (p less than 0.01). Dialysate infusion alone decreased functional residual capacity (FRC) and produced small changes in PaO2 which were more pronounced in the supine position. The decrease in PaO2 observed in changing from sitting prior to dialysate infusion, to supine after dialysate infusion was due to the development of airways closure at resting lung volumes. Follow-up studies in nine patients demonstrated a continued and significant fall in FRC with dialysate infusion, without however, any changes in PaO2. We conclude that peritonitis in CAPD patients is accompanied by significant changes in lung function which are probably due to a decrease in diaphragmatic mobility resulting in atelectasis and underventilation of dependent lung zones. In CAPD patients without peritonitis, dialysate infusion in the supine position produces significant changes in PaO2, but with time, compensatory mechanisms develop to abolish the changes in PaO2.

Captopril-associated cholestatic jaundice

Captopril, the competitive inhibitor of angiotensin-converting enzyme, is of considerable benefit in difficult-to-manage forms of hypertension. Its use has been associated with various untoward effects, but hepatic injury has not been widely reported. We treated a patient with captopril-associated cholestatic jaundice; a review of cases reported to the drug manufacturer and a review of the literature showed 13 additional cases of hepatic injury associated with captopril. In 9 of these the jaundice was categorized as cholestatic, and in 4 of the remaining 5 as mixed cholestatic-hepatocellular. These findings show that jaundice may be an idiosyncratic side effect of captopril, and that captopril-associated jaundice characteristically has strongly cholestatic features.

Haemoperfusion in the management of end-stage renal disease

Haemoperfusion, mainly in the form of activated charcoal haemoperfusion, has been investigated for the treatment of end-stage renal disease. Short-term studies have demonstrated that charcoal haemoperfusion devices in combination with haemodialysis are safe, produce reversal of certain symptoms of uraemia, but do little to define the role of haemoperfusion in the management of end-stage renal disease. Long-term studies, however, have demonstrated that reduction in dialysis time may be achievable with the addition of charcoal haemoperfusion to dialysis or ultrafiltration in the routine management of the dialysis patient. However, since charcoal as an adsorbent fails to remove important uraemic toxins such as water, urea, electrolytes, phosphate and sulphate, haemoperfusion does require the addition of dialysis or ultrafiltration for the removal of such toxins. In future, haemoperfusion will probably consist of sorbents added to an ultrafiltration or dialysis device to form a hybrid artificial organ that will combine sorbents suitable for removal of urea, phosphate, etc., and will be a useful treatment in the routine management of end-stage renal disease.