Hemodialysis Recipients Research Articles

Secondary hyperparathyroidism associated with multiple brown tumor: a case report

Brown tumour represents a serious complication of hyperparathyroidism. Definitive diagnosis is based on histological examination, clinical, radiological and laboratory data. Here we report a case of multiple brown tumours localised in collarbone, rib and in the distal ulna due to secondary hyperparathyroidism in a 37-year-old women with chronic renal failure. The clinical management of brown tumour aimed primarily to reduce the elevated parathyroid hormone levels by pharmacological treatment. In our experience, clinicians usually consider brown tumor of hyperparathyroidism is caused by giant cell lesions in maintenance hemodialysis recipients, and multiple brown tumours are rarely seen in these patients.

Arterial stiffness and functional properties in chronic kidney disease patients on different dialysis modalities: an exploratory study

Abnormalities of vascular function and accumulation of oxidative stress have been associated with chronic kidney disease (CKD). Dialysis modalities, peritoneal dialysis (PD) and haemodialysis (HD) may differentially impact on vascular function and oxidative stress. Patients undergoing living donor transplantation were studied for vascular stiffness using pulse wave velocity measurements, and inferior epigastric arteries were harvested to examine in vitro stiffness and functional properties and evidence of oxidative stress. Forty-one patients were studied representing PD (n = 12), HD (n = 14) and non-dialysed recipients (n = 15). We demonstrated differences in stiffness from in vivo and in vitro measurements such that non-dialysis < HD < PD groups. The stiffness measurements did not correlate with duration of CKD nor dialysis duration, but did so with phosphate levels (r = 0.356, P = 0.02). From the in vitro isometric force experiments, HD arteries demonstrated decreased contractility and endothelium-dependent relaxation compared with PD and non-dialysis vessels. Level of oxidative stress (as indicated by the 8-isoprostane level) was 30% higher in HD arteries than in PD arteries. Protein expression of inducible nitric oxide synthase, NADPH subunits and xanthine oxidase was upregulated in HD arteries, while superoxide dismutase was downregulated. The compromised vascular function in HD arteries was improved by pharmacological means that eliminated oxidative stress. We report associations between vasomotor function and oxidative stress in the vasculature of patients receiving different dialysis therapies. Oxidative stress, which may be differentially augmented during PD and HD, may play an important role in the vascular dysfunction in dialysis populations.

Monitoring hepatitis C infection in a major Swedish nephrology unit and molecular resolution of a new case of nosocomial transmission

Hepatitis C virus (HCV) infection is a frequent problem in hemodialysis units. The prevalence and incidence of HCV infection over a decade were studied in a nephrology unit affected by previous nosocomial HCV transmission. The HCV non-structural 5B protein gene was sequenced to achieve phylogenetic analysis of a new (incident) case of infection. Proportions of patients who were and were not infected with HCV remained similar over the period, as did the inflow and outflow of patients infected previously. In 1997, 12/157 (8%) of patients at the unit (treatment: hemodialysis, peritoneal dialysis, and renal transplant recipients) were positive in HCV RNA, whereas in 2007 the overall number was 9/239 (4%). One patient acquired an HCV infection, and the NS5B sequence in that case clustered with genotype 2b sequences found in patients from an earlier outbreak. Comparing the HCV from the incident patient with several stored longitudinal samples and cloned PCR products from the most likely source patient revealed close phylogenetic relationship with an HCV quasispecies member from the possible source. The source patient and the incident newly infected patient were not scheduled on the same dialysis shift, although the records showed that simultaneous treatment occurred on two occasions during the months preceding transmission. In conclusion, over the 10-year period, the proportion of HCV-infected patients at the unit was unchanged. Only one new infection occurred, which originated from a fellow patient's quasispecies. This establishes phylogenetic analysis as a valuable tool for tracing patient sources of HCV transmission.

Quantitative and qualitative effects of rosuvastatin on LDL-cholesterol: what is the clinical significance?

Statins have emerged as the global leader in pharmacologic therapy for dyslipidaemia, and rosuvastatin has demonstrated clinical efficacy as well as safety in several clinical trials and postmarketing analyses. The present article reviewed the effects of rosuvastatin on the quantity and the quality of low-density lipoproteins (LDL). We searched for and reviewed all the available evidence in a systematic way. A literature search (by Medline and Scopus) was performed using the following headings: 'LDL-cholesterol', 'LDL size', 'LDL subclasses', 'small dense LDL', 'apolipoprotein B, apo B' and 'rosuvastatin' up to 11 November 2008. The authors also manually reviewed the references of selected articles for any pertinent material. Rosuvastatin reduces LDL-cholesterol levels to a greater extent than other statins and is able to modulate significantly LDL size and subclasses towards less atherogenic particles as well as the LDL particle number, as indirectly measured by the levels of apo B. The recent Justification for the Use of statins in Primary prevention: an Intervention Trial Evaluating Rosuvastatin study provides more evidence about the effectiveness of rosuvastatin therapy in reducing cardiovascular risk, even among persons who would not currently be considered for pharmacotherapy. Further insights on cardiovascular outcomes will be available by the on-going trials included in the GALAXY program that includes subjects with type-2 diabetes, haemodialysis recipients, patients with congestive heart failure and specific ethnic groups, such as African American, Hispanic and South Asian populations.

Candida bloodstream infections in hemodialysis recipients

Candidemia is a major cause of morbidity and mortality in patients undergoing hemodialysis but it has not been well defined in this patient population. We performed a retrospective case-control study to characterize the epidemiology, microbiology, and outcomes of hemodialysis-associated candidemia. All cases of candidemia at our institution were evaluated from 1 January 2000 until 1 September 2004. For each case, two non-candidemic dialysis patients served as controls. Among 350 cases of candidemia, 78 (22%) occurred in adult hemodialysis patients. Cases and controls were similar with respect to age, corticosteroid, antibiotics use, prevalence of diabetes mellitus, liver cirrhosis, surgical procedures, and cancer. Multivariate analysis found total parenteral nutrition (TPN) (19.5% vs. 1.3%; P<0.0001) and dialysis through a vascular catheter (74% vs. 46.8%; P=0.0001) to be independently associated with candidemia. Non-C.albicans Candida spp. particularly C. glabrata and C. krusei were more common in hemodialysis recipients than in candidemic patients not receiving hemodialysis (31% vs. 17% p = 0.009). In-hospital mortality was significantly elevated for candidemic vs. non-candidemic hemodialysis recipients (51.9% vs. 7.8%; P<0.0001). Candidemia in hemodialysis recipients is frequently caused by non-C. albicansCandida species, is associated with TPN and dialysis via a vascular catheter (vs. shunt or fistula) and carries a high mortality rate.

Renal Artery Stent Placement for Restoration of Renal Function in Hemodialysis Recipients with Renal Artery Stenosis

Renal artery stent placement to treat renal artery stenosis (RAS) in patients undergoing hemodialysis is not performed commonly. We present our outcomes of discontinuation of hemodialysis after treating patients with RAS by stent placement on acute (< or =30 days of hemodialysis) and chronic hemodialysis (>30 days). A retrospective study was conducted in 16 patients (nine men) with an average age of 74.6 years +/- 10.6 (range, 49-86 y) who underwent treatment of 22 RAS for acute renal failure (n = 8) or uncontrolled hypertension with chronic hemodialysis (n = 8). The average follow-up was 448 days +/- 450 (median, 363.5 d; range, 6-1,583 d). The primary outcome consisted of discontinuation of hemodialysis, death, and transplantation. Secondary endpoints included restenosis, changes in blood pressure (and use of medications), and estimated glomerular filtration rate (eGFR). After the stent procedure, eight patients were able to discontinue hemodialysis and remained free from dialysis over a mean period of 564 days +/- 533. The predictors of discontinuation of hemodialysis were 24-hour proteinuria, eGFR before renal artery stent placement, and size of the kidney on ultrasound studies (P < .05 for all three). There was no difference in patients who were undergoing acute versus chronic hemodialysis. There were three minor complications, and one patient died 6 days after the procedure because of multiple cardiovascular problems. Renal artery stent placement for the treatment of RAS in patients receiving hemodialysis can result in discontinuation of hemodialysis in patients with low proteinuria level and adequate kidney size and eGFR.

Symptoms and Their Correlates in Chronic Kidney Disease

While there is a significant body of literature documenting the impairments in health-related quality of life (HRQOL) experienced by patients with end-stage renal disease (ESRD), recent work has helped to elucidate the mediators of impaired well-being in this patient group. Physical and emotional symptoms have been shown to be common, frequently severe, and directly linked with impaired HRQOL. The following review explores the process of symptom assessment in patients with chronic kidney disease (CKD), presents an overview of the composite burden and importance of symptoms in patients with ESRD, highlights particularly common and distressing symptoms for which existing treatment strategies may be applicable, and discusses future directions for efforts to address and alleviate symptoms in the growing population of patients who suffer from CKD.

StaphVAX booster worthwhile in haemodialysis recipients

StaphVAX booster worthwhile in haemodialysis recipients

Candesartan cilexetil steady-state concentrations are approximately twice as high in haemodialysis recipients

Candesartan cilexetil steady-state concentrations are approximately twice as high in haemodialysis recipients

Evaluation of MRI-detected White Matter Changes in Relation to Hemodialysis Duration and Renal Transplantation

Compared to the normal population, renal transplant recipients and end-stage renal disease (ESRD) patients on hemodialysis have a higher incidence of white matter changes (WMC) on brain magnetic resonance imaging (MRI). The lesions appear as focal or patchy areas in the periventricular white matter. Both these patient groups are known to be affected by accelerated atherosclerosis, which produces small-vessel disease. This may lead to thromboembolic complications that cause these white matter lesions. This study retrospectively assessed the frequency of MRI-detected WMC in ESRD patients on hemodialysis and kidney recipients, and correlated the rates with hemodialysis duration and post-transplantation interval. Focal and patchy type lesions were distinguished, and the frequencies of these were studied. Also, in the respective groups, comparisons were made among patients with different hemodialysis durations and post-transplantation intervals. The results showed that specifically focal lesions increase in parallel with hemodialysis duration, but there was no statistical relationship between WMC and post-transplantation interval.

Sleep-related breathing disorders impair quality of life in haemodialysis recipients.

It is well known that the quality of life of haemodialysis recipients is often severely compromised. So far, the influence of sleep-related breathing disorders on the quality of life of patients receiving maintenance dialysis has not been evaluated. Quality of life as assessed by the Medical Outcomes Study Short Form-36 (SF-36) and the Nottingham Health Profile Part 1 (NHP1) was determined in 33 patients (20 males, 13 females; median age 66 years (95% CI 22-82)) with end-stage renal disease treated with haemodialysis. Additionally, polygraphy with a validated eight-channel ambulatory recording unit was performed. Twenty-one patients (63.6%) had a clinically significant sleep-related breathing disorder with a median apnoea/hypopnoea index of 13.3 (6.3-78.1)/h and a median oxygen saturation during sleep of 92.5 (88-97)%. In three out of eight subjective measures of the SF-36 (vitality, social functioning and mental health) and in one out of six subjective measures of the NHP1 (emotional reactions), patients without sleep-related breathing disorders had a higher quality of life than patients with this disorder (P<0.05 each). Furthermore, the severity of the sleep-related breathing disorder as indicated by the apnoea/hypopnoea index significantly correlated with the following quality of life measures: physical functioning, social functioning, role limitation due to physical and emotional problems, general health and vitality (SF-36), and also with pain, sleep, social isolation and emotional reactions (NHP1) (P<0.05 each). We conclude that sleep-related breathing disorders independently influence the quality of life of patients receiving maintenance dialysis.

Supportive Relationships Among Hemodialysis Recipients at a Remodeled Kidney Center

ABSTRACT This study investigates the importance of social time spent at a remodeled kidney center among hemodialysis recipients. Twenty hemodialysis treatment recipients were selected to participate in semi-structured interviews to determine how they perceived the time spent at a kidney center. These twenty treatment recipients had received chronic dialysis treatment for at least one year, and were able to articulate an awareness of themselves within a community of other treatment recipients. Although the newly remodeled kidney center prevented unhampered communication with one another while receiving hemodialysis treatment, the recipients were able to generate supportive conversations and relationships in the waiting room and at the kidney center.

Translumbar placement of inferior vena caval catheters: a solution for challenging hemodialysis access.

Access to the central venous circulation for hemodialysis has traditionally been achieved via the subclavian or jugular venous routes. With ongoing improvements in medical management, many hemodialysis recipients develop exhaustion of these routes and require alternative means of central venous access. Inferior vena caval (IVC) catheters have been placed with a percutaneous translumbar approach to allow central venous access for chemotherapy, harvesting of stem cells, and total parenteral nutrition. Translumbar placement of IVC catheters has become accepted by some as a useful and reliable alternative in patients who require long-term hemodialysis but have exhausted traditional access sites. IVC catheters have been placed in patients with IVC filters, and IVC filters have been placed in patients with IVC catheters. Complications include those associated with central venous catheters, for example, sepsis, fibrin sheaths, and thrombosis. A complication specific to placement of IVC hemodialysis catheters is migration of the catheter into the subcutaneous soft tissues, retroperitoneum, or iliac veins. Translumbar placement of IVC catheters is performed only in patients considered to have few or no other medical options and is not intended as a primary means of central venous access.

Distinct prevalence of antibodies to the E2 protein of GB virus C/hepatitis G virus in different parts of the world.

Since the identification of the new human virus, GB virus C (GBV-C)/hepatitis G-virus (HGV), in 1995/1996, reverse transcription polymerase chain reaction remained the sole available diagnostic tool for GBV-C/HGV infection. Recently, a serologic test based on the detection of antibodies to the putative envelope protein 2 (anti-E2) has been introduced. We used this assay for a seroepidemiological survey including 3,314 healthy individuals from different parts of the world, 123 patients from Germany who were suspected to have an increased risk of acquiring GBV-C/HGV infection, 128 multiple organ donors, and 90 GBV-C/HGV RNA positive persons. In European countries, anti-E2 seropositivity ranged from 10.9% (Germany) to 15.3% (Austria). In South Africa (20.3%) and Brazil (19.5%), even higher anti-E2 prevalence rates were recorded. In Asian countries like Bhutan (3.9%), Malaysia (6.3%), and the Philippines (2.7%), anti-E2 positivity was significantly lower. GBV-C/HGV anti-E2 prevalence in potential "risk groups," i.e., patients on hemodialysis and renal transplant recipients, did not vary significantly from anti-E2 seroprevalence in German blood donors. Anti-E2 and GBV-C/HGV RNA were found to be mutually exclusive, confirming the notion that anti-E2 has to be considered as a marker of past infection.

The quality of life of hemodialysis recipients treated with recombinant human erythropoietin. Cooperative Multicenter EPO Clinical Trial Group

Initial clinical trials with recombinant human erythropoietin provided evidence of a quality-of-life benefit for patients with anemic end-stage renal disease who received maintenance hemodialysis. As part of a phase III clinical trial of recombinant human erythropoietin, the quality of life of patients was systematically assessed. More than 300 patients at nine dialysis centers were evaluated. A statistically significant improvement was established between baseline and second follow-up on most objective and subjective quality-of-life parameters, including energy and activity level, functional ability, sleep and eating behavior, disease symptoms, health status, satisfaction with health, sex life, well-being, psychological affect, life satisfaction, and happiness. No change was observed in ability to work or employment status. We conclude that, in addition to substantial improvement in hematologic parameters, recombinant human erythropoietin greatly enhances the quality of life of anemic patients who receive maintenance hemodialysis.

The Quality of Life of Hemodialysis Recipients Treated With Recombinant Human Erythropoietin

Initial clinical trials with recombinant human erythropoietin provided evidence of a quality-of-life benefit for patients with anemic end-stage renal disease who received maintenance hemodialysis. As part of a phase III clinical trial of recombinant human erythropoietin, the quality of life of patients was systematically assessed. More than 300 patients at nine dialysis centers were evaluated. A statistically significant improvement was established between baseline and second follow-up on most objective and subjective quality-of-life parameters, including energy and activity level, functional ability, sleep and eating behavior, disease symptoms, health status, satisfaction with health, sex life, well-being, psychological affect, life satisfaction, and happiness. No change was observed in ability to work or employment status. We conclude that, in addition to substantial improvement in hematologic parameters, recombinant human erythropoietin greatly enhances the quality of life of anemic patients who receive maintenance hemodialysis.

Ethical Implications of Rejecting Patients for Clinical Trials

Once in a blue moon, the request for an editorial to accompany a scientific article creates an opportunity to make an ethical point that is both new and important. Such an opportunity is presented by the article in this issue ofJAMAentitled The Quality of Life of Hemodialysis Recipients Treated With Recombinant Human Erythropoietin.1To quote from the Patients and Methods section, The investigators, in consultation with representatives of the Food and Drug Administration, concluded that a randomized study involving the administration of a placebo was ethically indefensible. Presumably the ethical reasoning was that anyone asked to volunteer for randomization would be sacrificing his or her own health for the good of the study and future patients. That is the standard argument against randomization when there is a reasonable likelihood that the new therapy will be better than the old. It falls down when the expected improvement is entirely

Revaccination of Renal Transplant and Hemodialysis Recipients With Pneumococcal Vaccine

Two years after pneumococcal vaccine was given to patients on a university renal transplant and hemodialysis service, vaccine failures began to occur. Serologic studies showed a threefold decrease in antibody levels during this period, from 913 ng of antibody nitrogen per milliliter to 315 ng/mL. The decrease was greater in patients undergoing hemodialysis than in renal transplant recipients (879 to 215 ng/mL vs 932 to 385 ng/mL). The lowest antibody levels were to types 4, 6A, and 19F. Patients were revaccinated, without serious reactions, and pneumococcal infections decreased as they had after the original vaccination program. After revaccination, there was a twofold increase in antibody levels (315 to 602 ng/mL), but the levels did not reach those seen after primary vaccination. The increase was greater in hemodialysis than in renal transplant recipients (215 to 757 ng/mL vs 385 to 536 ng/mL). This experience indicates that pneumococcal vaccines may be effective in patients undergoing hemodialysis and in asplenic renal transplant recipients, but these groups will require revaccination sooner than normal subjects to maintain immunity.

Revaccination of renal transplant and hemodialysis recipients with pneumococcal vaccine

Revaccination of renal transplant and hemodialysis recipients with pneumococcal vaccine

Studies on the Nature and Causes of Hyperlipidaemia in Uraemia, Maintenance Dialysis and Renal Transplantation

Fasting serum triglyceride and cholesterol measurements, and lipoprotein characterization by ultracentrifugation, were performed in four groups of patients with chronic renal disease (uraemic, short- and long-term haemodialysis and renal transplant recipients) and the results compared with those obtained from age- and sex-matched control subjects. Basal insulin and growth hormone levels, and serum creatinine and albumin concentrations were measured in, and detailed dietary histories taken from patients in each group. The predominant lipid abnormalities were hypertriglyceridaemia and increased very low density lipoproteins (type IV hyperlipoproteinaemia) in both uraemic and haemodialysis patients. Following renal transplantation, a different pattern of hyperlipidaemia was found. Hypercholesterolaemia was more common and hypertriglyceridaemia less common than in the uraemic and haemodialysis group. The lipoprotein abnormalities were increased low density and/or very low density lipoproteins, with types IIa IIb and IV hyperlipoproteinaemia occurring equally frequently. In uraemic and haemodialysis patients, the proportion of carbohydrate in the diet was high, and may have played a role in the genesis of hypertriglyceridaemia. There was a positive correlation between relative body weight and serum triglyceride in the long-term dialysis group. In renal allograft recipients hypertriglyceridaemia could be attributed, at least in part, to obesity, prednisone dosage and the degree of impairment of graft function. The aetiology of hypercholesterolaemia in the transplant recipients was unclear. Neither basal insulin nor growth hormone levels were elevated in any patient group. Uraemic hypertriglyceridaemia is a clearly defined and well documented metabolic abnormality which is not corrected by dialysis. Post-transplantation hyperlipidaemia however, is a condition of variable presentation and multifactorial aetiology.