Dialysis For Chronic Renal Failure Research Articles

Peritoneal dialysis for chronic renal failure in a patient with methylmalonic acidaemia

Chronic renal failure is a common complication of methylmalonic acidaemia (MMA). It is usually managed with haemodialysis and renal transplantation. We report the use of continuous cycling peritoneal dialysis (CCPD) for 20 months in a paediatric patient with chronic renal failure due to MMA. This procedure resulted in the elimination of 950 micromol methylmalonate (MM) per day and a fall in the plasma MM concentration from 3.9 to 0.74 mmol/l. As a result of this treatment, the frequency at which this patient was hospitalised was markedly reduced prior to a successful renal transplantation.

Malnutrition in the Elderly Patient on Dialysis

Approximately one-third of all dialysis patients have mild to moderate malnutrition, while 6–8% have severe malnutrition, which is associated with increased morbidity and mortality rates and numerous pre-existing factors directly correlated with, or existing prior to, replacement hemodialysis. However, moderate to severe malnutrition (present in 10–30% of dialysis patients) is a prevalent cause of death among the elderly. Many of these patients have a particularly unstable cardiovascular and metabolic status that, independent of any underlying uremia and/or dialysis, impacts negatively on both their quality of life and clinical status. Moreover, their condition is often further exacerbated by dialysis itself, with its acute (e.g., hypotension and sensorial alterations) and chronic complications, including an exacerbation of malnutrition and systemic vascular disease. Malnutrition can occur secondary not only to erroneous dietary choices or uremia, but it may also depend on the patient's level of tolerance to dialysis and on the dialysis modality. Despite the improvements made to dialysis techniques, the nutritional condition of elderly patients on dialysis for chronic renal failure remains a cause for concern. In this patient category, it is therefore mandatory to ensure the daily supervision of nutritional status and early control when the first signs of malnutrition appear.

Welches Dialyseverfahren ist das geeignete? – Der ungeplante Dialysebeginn mit der Peritonealdialyse

Insertion of a haemodialysis catheter is one of the most used techniques in Germany to start with the acute or unplanned dialysis in chronic renal failure. Dependent on the peripheral vasculature the catheter rests for a long time. The risk of sepsis due to catheter is high and increases the mortality. First results in 30 patients show that the acute or unplanned start with peritoneal dialysis is a harmless procedure and well accepted by patients if an assisted PD is offered.

Chronic Renal Failure: Another Complication of this Interminable Condition?

Two patients on dialysis for chronic renal failure and hyperparathyroidism were referred for total parathyroidectomy. The first was a 32-year-old man, who had pre-operative methylene blue infusion. Four coloured parathyroid glands were readily identified and excised. Histology confirmed three hyperplastic parathyroids and a thyroid nodule containing a 12-mm diameter incompletely excised papillary carcinoma. This had clearly taken up the methylene blue and masqueraded as a hyperplastic parathyroid. A 20-year-old man with similar renal and endocrine pathophysiology underwent a total parathyroidectomy. Three definite hyperplastic parathyroid glands were encountered and excised and, in lieu of a definite fourth, various small nodules were excised from the environs of his very nodular thyroid. Histology confirmed three parathyroids, reporting all the nodules as thyroid tissue except one, which was a lymph node replaced by papillary thyroid carcinoma. Both patients subsequently had a total thyroidectomy (and completion parathyroidectomy), radio-iodine, and thyroxine replacement/suppression. Both specimens showed multiple foci of papillary thyroid carcinoma. The first patient remains well and cancer-free after 8 years, and the second is well after 4 months. My interest changed from identifying methylene blue as a potential cause of ‘false-positive’ parathyroid localisation, to associating dialysis-dependent chronic renal failure with multifocal thyroid papillary carcinoma. This is difficult to rationalise, as neither of the patients had been transplanted or immunosuppressed. My yearly average return of approximately 50 operative thyroid specimens has yet to comprise any other with occult multifocal papillary carcinoma. However, my interest is piqued: I wonder what the proportion would be in the thyroids of patients with dialysis-dependent chronic renal failure? EDITORIAL COMMENT The hypothesis proposed by these two cases is that patients with chronic renal failure on dialysis have an increased likelihood of developing multifocal papillary carcinoma of the thyroid. Two rare conditions can occur synchronously but is there a true association? Have any of our readers observed a similar relationship?

The Early History of Dialysis for Chronic Renal Failure in the United States: A View From Seattle

Forty-seven years have passed since the first patient started treatment for chronic renal failure by repeated hemodialysis (HD) at the University of Washington Hospital in Seattle in March 1960, and some 34 years have elapsed since the United States Congress passed legislation creating the Medicare End-Stage Renal Disease Program. Many nephrologists practicing today are unfamiliar with the history of the clinical and political developments that occurred during the 13 years between these 2 dates and that led to dialysis as we know it today in this country. This review briefly describes these events. Clinical developments following introduction of the Teflon shunt by Belding Scribner and Wayne Quinton included empirical observations leading to better understanding of HD and patient management, out-of-hospital dialysis by nurses, bioethical discussions of the problems of patient selection, home HD, improved dialysis technology, intermittent peritoneal dialysis, including automated equipment for home use and an effective peritoneal access catheter, the arteriovenous fistula for more reliable blood access, dialyzer reuse, the first for-profit dialysis units, understanding of many of the complications of treatment, the first considerations of dialysis adequacy, early development of other technologies, and more frequent HD. Political developments began less than 3 years after the first Seattle patient began dialysis, but it took another 10 years of intermittent activities before Congress acted on legislation to provide almost universal Medicare entitlement to patients with chronic kidney disease requiring dialysis or kidney transplantation.

Prevention of Limb Amputation in Patients with Limbs Ulcers by Autologous Peripheral Blood Mononuclear Cell Implantation

There are many cases of amputation of ischemic limbs of dialysis patients due to diabetes, despite the availability of medicine therapy and vascular by-pass operations. As there is extensive ruin of the vascular bed due to diabetes, vascular regeneration therapy by stem cell implantation is effective. Thirty patients with ischemic limbs due to diabetes (not including type-I) and on dialysis for chronic renal failure (19 cases), diabetes (5 cases), dialysis patients without diabetes (4 cases), and arteriosclerosis obliterans (ASO, 2 cases) were treated by autologous peripheral blood stem cell (PBSC) implantation where imminent amputation was under consideration. Granulocyte Colony Stimulate Factor (G-CSF: 5 microg/kg/day) was administered subcutaneously for 4 days before PBSC collection, that was carried out using a centrifuge (Spectra and/or CS3000) via the vein. The collected PBSC, containing 4.2 x 10(7) of CD 34 positive cells, was divided into units of 0.5-1.0 mL and implanted, without any purification, to the ischemic area of the limbs in about 65 points. In 21 cases, normalization of limb temperature was observed by thermograph, and symptoms also improved. The result of this first attempt of PBSC implantation is that we were able to save 22 ischemic limbs. This is the first large report of the application of regenerative medicine to peripheral ischemic limbs.

Usefulness of Non‐invasive Tests for Diagnosing Helicobacter pylori Infection in Patients Undergoing Dialysis for Chronic Renal Failure

Helicobacter pylori infection in chronic renal failure patients has been linked to peptic ulcer and gastric neoplasia after kidney transplantation. It may also contribute to the accelerated arteriosclerosis that is usual in this population. Few data are available on the usefulness of noninvasive diagnostic tests for H. pylori infection in dialyzed patients, especially regarding the new fecal antigen detection tests. The objective of this study was to determine the efficacy of a noninvasive test for H. pylori infection in patients with chronic renal failure. Eighty-six patients were included in a cross-sectional study. Urea breath test, serology and three fecal tests--FemtoLab H. pylori (Connex, Germany), Premier Platinum HpSA (Meridian, USA) and Simple H. pylori (Operon SA, Spain) were performed. Helicobacter pylori status was determined by concordance of the tests. Sensitivity, specificity and positive and negative predictive values were calculated for each test. Sensitivity, specificity, positive and negative predictive values were 94%, 96%, 94% and 96% for the urea breath test; 97%, 64%, 66% and 97% for serology; 86%, 100%, 100% and 91%, for FemtoLab H. pylori; 58%, 96%, 91% and 76% for Premier Platinum HpSA and 61%, 78%, 74% and 67% for Simple H. pylori. The urea breath test seems to be the most reliable diagnostic method for H. pylori infection in patients with chronic renal failure. Serology has a low specificity, and the results of the fecal tests vary widely.

Acute Peritoneal Dialysis in Eastern Nepal

B.P. Koirala Institute of Health Sciences is the only dialysis center outside the capital city of Nepal. Although the burden of renal failure in Nepal is high, limited resources and dialysis facilities are the major constraint on management of acute renal failure (ARF) and acute dialysis in chronic renal failure (CRF). In the present study, carried out from January 2000 to June 2002, we looked into the prospect of introducing peritoneal dialysis (PD) to the district hospitals for treatment of ARF and acute dialysis in CRF. We designed a form to evaluate the causes of renal failure and the indications for, complications of, and outcomes of dialysis. During this study, junior doctors in our hospitals completed the forms. Resident doctors were trained to do intermittent peritoneal dialysis (IPD) and were responsible for the carrying out the procedure under supervision, together with a staff nurse. A total of 120 patients underwent IPD during the study period, including 66 men and 54 women. The most common indications for acute dialysis in CRF were metabolic acidosis (56%), uremic encephalopathy (45%), and fluid overload (44%). The most common causes of ARF were acute gastroenteritis (20%), sepsis (20%), and septic abortion (16%). Fifteen patients died of sepsis and multi-organ failure. Lack of dialysis facilities in the geographic periphery means that most patients present late in the course of their disease, as evidenced by severe metabolic acidosis and uremic encephalopathy. Peritoneal dialysis is a simple procedure, easily tolerated by the patient and requiring less expertise than hemodialysis does. Moreover, nursing staff, technicians, and doctors can be easily trained in the technique. Despite certain limitations, PD still has much potential and can be successfully accomplished in district hospitals and less accessible areas.

Early initiation of dialysis fails to prolong survival in patients with end-stage renal failure.

There is a trend to start dialysis earlier in patients with chronic renal failure. Studies that suggest improved survival from earlier initiation of dialysis are flawed in that they have measured survival from start of dialysis rather than from a time point before dialysis, when patients have the same renal function. This flaw is termed lead-time bias. Using the electronic patient record at the renal unit of Glasgow Royal Infirmary, all patients were identified who had received dialysis for chronic renal failure and who had sufficient data to calculate the time point at which they reached an estimated creatinine clearance (eC(Cr)) of 20 ml/min (n = 275). This date was used to time survival. The patients were divided into early and late start groups by the median eC(Cr) for all patients at initiation of dialysis, which was 8.3 ml/min. There was no significant benefit in patient survival from earlier initiation of dialysis. A Cox proportional hazards model demonstrated a significant inverse relationship between eC(Cr) at start of dialysis and survival (hazard ratio, 1.1; P = 0.02), i.e., patients who started dialysis with a lower eC(Cr) tended to survive longer. This relationship retained significance when gender, age, weight, presence of diabetes, mode of first dialysis, initial dialysis access, hemoglobin, serum albumin, blood leukocyte count, Wright/Khan index, and eC(Cr) at the start of dialysis were taken into account. This study fails to support a policy of earlier initiation of dialysis for patients with end-stage renal failure.

Cardiovascular mortality in chronic renal failure: hyperphosphatemia, coronary calcification, and the role of phosphate binders.

Hyperphosphatemia is a strong and unique risk factor for cardiovascular mortality in patients on dialysis for chronic renal failure. Overall treatment of hyperphosphatemia should focus on achieving and maintaining a serumphosphate level less than 5.5 mg/dL. Calcium-containing phosphate binders remain standard therapy, although selected patients may benefit from the addition or substitution of calcium-free phosphate binders. Reducing cardiovascular risk in patients with chronic renal failure should focus on addressing traditional cardiovascular risk factors. The incremental risk-assessment value of coronary artery calcium scoring is limited.

Visual Acuity Disturbances in Chronic Renal Failure

Patients affected by chronic renal failure often complain of blurred vision when submitted to hemodialysis. Refraction, visual acuity and lens transparency have been evaluated in 36 eyes of 18 patients who underwent hemodialysis, before and after the treatment. Student’s t test did not prove any statistically significant difference between the considered parameters. However, a change in refraction was noted in 64% of the eyes, always in hyperopic mean. Corrective glasses had to be changed to ensure the same visual acuity as before the hemodialytic treatment. Particular care must be taken in lens prescription in those patients who could undergo dialysis for chronic renal failure.

Hospital utilization among chronic dialysis patients.

Factors driving inpatient and outpatient utilization were studied among patients who began dialysis for chronic renal failure at the New England Medical Center (NEMC) between 1992 and 1997. Clinical, laboratory, and hospital resource utilization data were obtained from patient records and electronic databases. There were 2.2 hospitalizations and 14.8 hospital days per patient year at risk (PYAR). The number of hospitalizations and hospital days per PYAR were higher in the first 3 mo of initiating dialysis (4.3 and 28.3, respectively) compared to after 3 mo (1.9 and 12.9, respectively). Factors associated with increased risk of hospital days within the first 3 mo included non-health maintenance organization insurance, ischemic heart disease, late referral to the nephrologist, and use of temporary vascular access for the first dialysis. Patients with ischemic heart disease and who received dialysis during the years 1992-1994 compared with 1996-1997 had an increased risk of hospital days after 3 mo of initiating dialysis. There were 16.6 outpatient visits per PYAR, with significant differences in utilization between the first 3 mo and after 3 mo of initiating dialysis. Thus, hospital utilization was significantly higher in the first 3 mo compared to after 3 mo, and factors associated with hospital utilization depended on duration of dialysis. In particular, delayed referral to the nephrologist and lack of permanent vascular access were independently associated with increased risk of hospital utilization in the first 3 mo of dialysis. Greater attention to timely referral to the nephrologist and timely placement of vascular access could result in reduced utilization and cost savings.

What Went Wrong with Home Hemodialysis in the United States and What Can Be Done Now?

In 1973, almost 40% of the more than 10 000 dialysis patients were treated by home hemodialysis. Today, with more than a quarter of a million dialysis patients in the United States, fewer than 2000 are on home hemodialysis. A number of factors have contributed to this change. First, many nephrologists and administrators who were developing new dialysis units had little or no practical experience with dialysis for chronic renal failure. Second, more elderly and diabetic patients were admitted to treatment. Home hemodialysis was more difficult for such patients, and often their helpers were themselves were elderly. Third, hemodialysis machines were difficult to learn and operate. Fourth, following publication of the results of the National Cooperative Dialysis Study, there developed the erroneous concept that a Kt/V equal to 1.0 was "adequate dialysis." As bigger dialyzers became available, there was a widespread shortening of dialysis time. This decrease in time was embraced by for-profit dialysis facilities and inadequately educated patients, and assembly-line dialysis became generally accepted. Finally, continuous ambulatory peritoneal dialysis, with its simplicity and short training time, began to fill the need of many patients for home dialysis and independence, at least temporarily. Fortunately, the trend is now reversing. Two developments clearly have benefits for home hemodialysis. The first is an increasing interest in the use of more frequent dialysis. The second is the development of new equipment designed specifically for use by the patient, and requiring a minimum of effort on the patient's part.

Free thyroxine concentrations in serum measured by equilibrium dialysis in chronic renal failure

The serum concentration of free thyroxine (FT4) is often low in patients with chronic renal failure (CRF) with low serum concentrations of triiodothyronine (T3). We evaluated the serum FT4 concentration by using both an equilibrium dialysis RIA kit (D-FT4) and a labeled-antibody kit (M-FT4) in two different groups of CRF patients, undergoing chronic hemodialysis (HD, n = 145) or not (non-HD, n = 30), and in a group of normal healthy subjects (n = 58). Thyroid peroxidase antibodies and thyroglobulin antibodies were not detected in any patient. Serum FT4 concentrations (mean +/- SD, pmol/L) by the D- and M-FT4 assays were, respectively, 21.5 +/- 4.6 and 16.6 +/- 2.0 in the healthy subjects, 17.8 +/- 4.3 and 13.9 +/- 3.6 in the non-HD patients, and 16.9 +/- 4.9 and 10.7 +/- 1.9 in the HD patients. By the D-FT4 assay, results for both CRF groups were significantly different from those for the healthy group (P <0.01), as were the results for each pair of groups by the M-FT4 assay (P <0.01). FT4 values were reported as being within the healthy reference range by D-FT4 in 73 of 113 HD subjects who had low T3 and low M-FT4 values. Serum FT4 concentrations measured by both assay kits showed a significant inverse correlation with the serum concentration of creatinine (P <0.01), but the serum concentrations of sex-hormone-binding globulin did not differ significantly among the three groups. Our results indicate that the low FT4 concentration measured by D-FT4 in patients with CRF, particularly those on HD, probably reflects the actual, mild nonthyroidal illness of renal failure.

The De Novo Diagnosis of Systemic Lupus Erythematosus in a Hemodialysis Patient

We present the first reported case of a patient who developed de novo systemic lupus erythematosus (SLE) after the initiation of dialysis for chronic renal failure. The etiology of his renal failure was secondary to biopsy-proven idiopathic membranoproliferative glomerulonephritis in conjunction with accelerated hypertension. The physical, biochemical or serologic findings of SLE did not become apparent until 4 years after the initiation of hemodialysis. This deviates from the natural history of SLE; typically, once dialysis is initiated, disease and serologic activity diminish with time to the point where therapy is no longer required. Therefore, this first diagnosis of SLE after years on dialysis represents a novel observation.

Total body nitrogen as a predictor of clinical status in anorexia nervosa.

It has been demonstrated that clinical outcome is positively correlated with depletion of total body nitrogen (TBN) and therefore of body protein in certain serious medical conditions such as cystic fibrosis or patients receiving dialysis for chronic renal failure. Patients with anorexia nervosa are not suffering from medical illness per se yet the illness can be chronic and severely debilitating requiring numerous hospitalizations for refeeding and/or management of medical complications. The prediction of chronicity remains an important and difficult issue that this study seeks to address by examining the correlation between several clinical indices in 18 patients suffering from anorexia nervosa with parameters of body composition, namely TBN and percentage body fat. TBN was measured using the technique of in vivo neutron-activation analysis (IVNAA) and expressed as nitrogen index. Percentage body fat was estimated using skinfold measurements. The highest correlation was between nitrogen index and number of hospitalizations (r = -.80). The data support a relationship between depletion of body nitrogen/protein and chronicity in anorexia nervosa.

Laparoscopy: An Alternative to Surgery in Patients Treated with Continuous Ambulatory Peritoneal Dialysis

Fifteen laparoscopic abdominal operations were performed in 14 patients treated by continuous ambulatory peritoneal dialysis for chronic renal failure. Celioscopic exploration of the abdomen and subsequent operation displayed several advantages specific to the method: identification of the etiology of scrotal dialysate outflow was achieved in 4 cases, peritoneal dialysis catheter salvage during laparoscopic cholecystectomy in 1 case, abdominal exploration during occurrence of peritonitis in 3 cases, and catheter dysfunction or abdominal examination before catheter implantation in 7 cases. The laparoscopic procedure allows early resumption of peritoneal dialysis after surgery, hence avoiding the need for transient hemodialysis. Nevertheless, it seemed unable to offer a salvage capability of infected catheters through extensive abdominal washing. Laparoscopy has been reported to decrease postoperative pain and disorders of ventilation, allowing for rapid recovery of social and professional activities following this minimal invasive surgical technique. Laparoscopy is a novel technique which enables precise diagnosis and surgical operations in patients treated by continuous ambulatory peritoneal dialysis.

Lodine-131 Treatment of Hyperthyroidism in a Patient on Dialysis for Chronic Renal Failure

A 7- to 8-cm diffuse toxic goiter with associated symptoms of hyperthyroidism developed in a 38-year-old black female undergoing regular hemodialysis for renal failure. Our treatment of choice was an ablative dose of radioactive iodine in the form of sodium iodide (Na-131I). To our knowledge, this is only the 4th documented case of hyperthyroidism in a patient with renal failure. Detailed monitoring of 131I radioactivity in the blood, thyroid gland and the dialysate demonstrated that there was no radiation hazard to personnel involved in the patient management.

Radiographic techniques in renal parenchymal disease.

In his or her practice, the nephrologist usually has a substantial number of patients on dialysis for chronic renal failure. The longer a patient remains on either peritoneal dialysis or hemodialysis, the more at risk he or she is of developing acquired cystic disease of the kidney and renal cell carcinoma. Due to recent developments such as lower osmolar intravenous contrast media, sonography, and magnetic resonance imaging, the radiologist has the ability to assess the kidney in chronic renal failure with a growing number of less-invasive modalities. The lower osmolar agents appear to be less toxic to the kidney. Thus, they can be used when the benefit of the information obtained from a necessary procedure, eg, computed tomography or coronary arteriography, surpasses the risk. Duplex Doppler sonography can assess the pressure of flow in the arcuate vessels of the kidney with measurements of the resistive index. The resistive index is a proven tool for assessing rejection of the renal allograft--another newer application is in the diagnosis of obstruction. An elevated resistive index found in a kidney with a dilated collecting system confirms the diagnosis of obstruction. Studies are being made on its application in other renal disease processes as well.

Hepatic iron in dialysed patients given intravenous iron dextran.

Five percutaneous biopsy and 17 necropsy liver specimens were analysed histologically and chemically for iron content in 22 patients receiving dialysis for chronic renal failure, 13 of whom were given intravenous iron-dextran. Brissot scores for assessing histological hepatic iron deposition and chemically measured liver iron concentrations correlated closely. Both variables depended on total cumulative dose of iron, and to a lesser extent, on time since the last dose. Fibrosis (seen in five patients) was minimal and non-specific. Electron microscopic examination showed that there was no generalised damage and confirmed the presence of iron in the hepatocytes in the form of ferritin. High liver iron concentrations, in excess of 1000 micrograms/100 mg dry weight, were seen in two patients. Four others given comparable cumulated amounts (18-23 g iron) did not have such high concentrations. Plasma ferritin concentrations were high in eight patients, some with and some without fibrosis. The risk of temporarily high iron deposition in the liver causing damage seemed to be minimal when weighed against the benefit of increased haemoglobin in most of the patients. Intravenous iron treatment merits further evaluation, particularly with the advent of erythropoietin treatment, which requires continuously available iron.