Hospital Hemodialysis Research Articles

Reliability of the Spanish version of the Nottingham health profile in patients with stable end-stage renal disease

Since reproducibility of results is a basic prerequisite of health status measures for its use in prospective and evaluative studies, the reliability of the Spanish version of the Nottingham Health Profile (NHP), a multi-dimensional perceived health status measure, was assessed in a sample of stable end-stage renal disease (ESRD) patients. The NHP was administered on two occasions four weeks apart to a group of hospital hemodialysis program patients who were clinically stable according to their physicians. Correlations of scores and agreement of first and second administrations were assessed together with internal consistency. Afterwards, analyses were repeated taking into account the time (before, during or after the dialysis) and the method of administration (self vs interviewer), and the interviewer. Spearman correlation coefficients (rs) between responses to the first and to the second administration were > 0.6 for all of the six dimensions of the NHP (range = 0.69-0.85) and in every sub-group analyzed (P < 0.01). Agreement percent (AP) between items was > 0.4 (0.48-0.65). Internal consistency was 0.91 for the whole profile and > 0.5 (0.58-0.86) when analyzed by individual dimensions. Reliability did not vary significantly with the time nor the method of administration (self or interviewer). Overall, results suggest that the Spanish version of NHP is sufficiently reliable to be used in ESRD patients. While a higher reliability would have been achieved by a shorter retest period, the study provides a realistic approximation to the reliability of the questionnaire in actual research and clinical applications.

Treatment of resistant peritonitis in continuous ambulatory peritoneal dialysis with intraperitoneal urokinase: a double-blind clinical trial

Resistant peritonitis in continuous ambulatory peritoneal dialysis (CAPD) is an indication for catheter removal, followed by interim haemodialysis and subsequent catheter replacement. This involves two surgical procedures using general anaesthetic and the availability of adequate hospital haemodialysis facilities. Urokinase is an alternative therapy but evidence of its effect is anecdotal and it has not been studied in a double-blind manner. Patients with resistant peritonitis (either no resolution of peritonitis within 4 days of appropriate antibiotic therapy or a third episode of peritonitis within 6 months) were randomized to receive intraperitoneal urokinase or placebo (saline) followed by 14 days of antibiotics in this double-blind prospective study. Treatment success was resolution of peritonitis within 4 days of giving urokinase/placebo (persistent infection) and no recurrence with the same organism for 6 months (recurrent infection). Twelve patients received urokinase and 12 placebo. Treatment was successful in 8/12 in the urokinase group and 1/12 in the placebo group (Fisher's exact test; P = 0.0047). Urokinase was successful in 8/12 patients with resistant peritonitis and significantly better than placebo. Urokinase is an effective and simple treatment that may avoid the need for catheter removal and interim haemodialysis in patients with resistant CAPD peritonitis.

Protein and energy content of diets of patients undergoing haemodialysis for treatment of chronic renal failure–a short report

Estimated food records of 27 patients attending Southmead Hospital haemodialysis unit for regular haemodialysis were analysed for protein and energy and the values compared with the patients' prescribed intake. Fifty two per cent did not meet their prescribed protein intake, 78% did not meet their prescribed energy intake and 52% did not meet their prescribed protein or energy intake. No significant relationship was found between undereating and being underweight.

The effect of treatment with recombinant human erythropoietin on skeletal muscle function in patients with end-stage renal failure treated with regular hospital hemodialysis.

The effect of treatment with recombinant human erythropoietin on skeletal muscle was investigated in 11 anemic transfusion-dependent patients on the hospital hemodialysis program. There were no significant changes in anthropomorphic measurements during the study, but the maximum voluntary contraction increased significantly for each muscle group studied (pre-erythropoietin and post-erythropoietin values, respectively, were as follows: biceps, median 170 N [range, 83 to 220 N] v 189 N [range, 89 to 245 N]; triceps, 88 N [range, 59 to 167 N] v 106 N [range, 95 to 185 N]; deltoid, 168 N [range, 78 to 247 N] v 193 N [range, 93 to 290 N]; and quadriceps, 202 N [range, 165 to 300 N] v 265 N [range, 185 to 335 N]; P < 0.05). There were no significant changes in muscle strength in a control group of regular hemodialysis patients. Programmed electrical stimulation of the quadriceps following erythropoietin treatment resulted in both a greater force generated and a longer duration of contraction. Following cessation of the electrical stimulus the relaxation rate for the type II fibers was quicker following erythropoietin therapy. This suggests that some of the benefit observed in physical well-being following correction of the anemia of chronic renal failure with erythropoietin is due to an improvement in voluntary skeletal muscle function.

An outbreak of Heinz body positive hemolytic anemia in chronic hemodialysis patients.

During the four month period, from December 1988 to March 1989, there was an outbreak of Heinz body positive hemolytic anemia in 34 patients undergoing hemodialysis in a 500-bed hospital, Seoul, Korea. The episodes of hemolysis were not reduced by changing the charcoal column and reverse osmosis system, or by adding ascorbic acid to the dialysate. The concentrations of nitrate, copper, aluminum and zinc in the treated water were all within the standards for hemodialysis. The chloramine concentration of the treated water was over 0.6 mg/L, markedly exceeding the allowable level of 0.1 mg/L. This high level of chloramine was proved to be due to the contamination of the water source by raw sewage. After we changed the source of water supply to another, no more episodes of hemolytic anemia occurred. It is concluded that chloramine is one of the major contaminants causing dialysis-induced hemolytic anemia and regular determinations are necessary, especially during winter and dry seasons.

Renal bone disease in pediatric and young adult patients on hemodialysis in a children's hospital.

Renal bone disease has been well defined in adult patients receiving chronic dialysis and in children on peritoneal dialysis/continuous ambulatory peritoneal dialysis. However, little is known about the histologic features in patients undergoing chronic hemodialysis in a children's hospital center. Twenty one patients, aged 17.5 +/- 1.5 yr, on hemodialysis for 35 +/- 6 months underwent iliac crest bone biopsies and deferoxamine infusion tests. Nineteen of 21 patients were receiving oral calcitriol. The 21 patients were classified by histomorphometry as follows: osteitis fibrosa, 5; mild hyperparathyroidism, 3; normal histology, 3; aplastic, 6; and mixed lesions, 4. Four of 21 patients were surface positive for aluminum, and seven other patients stained positive for iron in bone. Serum parathyroid hormone (PTH) levels correlated directly with the bone formation rate (r = 0.84) and with eroded bone perimeter (r = 0.67). Eight of the nine patients with serum PTH levels above 125 pg/mL had marrow fibrosis. All patients with serum calcium levels < 10.0 mg/dL and serum PTH levels > 125 pg/mL had either osteitis fibrosa or mixed bone lesions--a group of patients that might benefit from aggressive vitamin D therapy. In contrast, an examination of patients with serum calcium levels > 10.0 mg/dL and serum PTH levels < 65 pg/mL correctly identified three out of three patients with aluminum-related bone disease. These findings suggest that measurements of serum intact PTH levels by the immunoradiometric assay method may be valuable in distinguishing high-turnover lesions from normal or low-turnover skeletal lesions in this population.

The effect of treatment with recombinant human erythropoietin on the histological appearance and glycogen content of skeletal muscle in patients with chronic renal failure treated by regular hospital haemodialysis.

The effect of treatment with recombinant human erythropoietin on the histological appearance and glycogen content of the anterior tibialis muscle was studied in 10 patients with chronic renal failure treated by regular haemodialysis. Repeat muscle biopsies taken when the target haemoglobin concentration of 11 g/dl was achieved showed an increase in median glycogen content from 35 mg/g fat-free dry muscle to 51 mg/g (p < 0.05). The histological appearance showed a marked improvement in muscle fibre diameters, in particular for the type I fibres and a reduction in cytoarchitectural abnormalities. These changes would be expected to produce an increase in both muscle strength and performance and are most probably a consequence of an increase in muscle oxygen delivery.

Prevalence of antibodies to hepatitis C in dialysis patients and transplant recipients with possible routes of transmission.

The prevalence of hepatitis C infection and possible predisposing factors was assessed in a renal unit. Of 343 patients at our renal dialysis centre, 37 (10.8%) were anti-HCV positive by a 1st-generation assay (ELISA, Ortho/Chiron) and confirmed positive in 35 (10.2%) with a 2nd-generation test (UBI, New York). Anti-HCV positivity was significantly associated with: duration of renal replacement therapy (P < 0.0001); quantity of blood transfused (P < 0.002); duration of hospital haemodialysis (P = 0.0001); duration with a functional renal transplant (P = 0.039); and aspartate aminotransferase (P < 0.0001). Logistic regression determined the following variables to be independent risk factors: duration of renal replacement therapy with a relative risk of 34.3 for 5-9 years and 87.4 when the duration was in excess of 10 years; renal transplant for less than 1 year (relative risk of 5.0); transfusion in excess of 50 units of blood (relative risk of 11.6). Clinical assessment of anti-HCV-positive patients revealed peripheral signs of chronic liver disease in 40%, hepatomegaly in 34%, and splenomegaly in 9%. This prevalence of hepatitis C infection is similar to other European and North American centres, but contrasts with low prevalence rates reported from dialysis populations in the UK. It adds further support for routine screening of blood and possibly organ donors and implementation of further infection control measures in dialysis centres.

Paediatric dialysis and renal transplantation in the state of Rio Grande do Sul, Brazil.

Renal replacement therapy (RRT) for Brazilian children with uraemia has been utilized since 1970 in the state of Rio Grande do Sul. One hundred and eighty patients receiving this therapy between 1970 and 1988 have been reviewed. The annual acceptance rate of new paediatric patients in this period increased from 0.6 to 6.5 patients per million child population. Glomerulonephritis (36.1%) and pyelonephritis including urological anomalies (31.7%) were the most frequent causes of end-stage renal disease. Outpatient hospital haemodialysis was the primary form of dialytic treatment in patients 5-15 years of age. Continuous ambulatory peritoneal dialysis was more often used in patients less than 5 years of age. The survival after 1 year on dialysis was 79.9% for children aged 5-15 years starting dialysis during the period 1985-1988. Fluid overload with congestive heart failure and infection were the main causes of death in children on dialysis. Eighty-four children received 93 grafts; only 14 (15%) were from cadaveric donors. One-year patient and graft survival of first living-related donor transplants were 92.2% and 78.5% respectively during the period 1985-1988. Infection accounted for 43.5% of deaths after transplantation. We conclude that RRT is becoming increasingly successful for children in our region but that greater emphasis upon patient compliance with all forms of RRT and upon cadaver kidney donation is needed.

Ribosome and free amino acid content in muscle during hemodialysis

Patients (N = 8) with chronic renal failure and uremia treated with hospital hemodialysis were in a pilot study investigated before and after a single hemodialysis session. The extracorporeal dialysis circuit was flushed regularly with saline to avoid clotting and the use of heparin. Percutaneous skeletal muscle biopsies were taken before and after the dialysis to determine the content of free amino acids together with the concentration and size distribution of ribosomes before and after dialysis. After dialysis the alanine concentration in muscle decreased by 20% (P less than 0.05), while all other amino acids were unaffected. The total ribosome concentration per mg of DNA decreased by 31% (P less than 0.01) and the relative proportion of polyribosomes by 7% (P less than 0.05) after the dialysis compared to predialytic values. All individual plasma amino acids decreased during the dialysis procedure except for threonine and arginine, which were unaltered, and leucine and isoleucine, which increased. The decline in ribosome and polyribosome content together with the changes in amino acid levels indicate a low capacity for protein synthesis and increased catabolism in muscle of hemodialyzed patients.

Changes in psychosocial adjustment after renal transplantation.

The psychological aspects of transplantation were studied in 29 children and adolescents with functioning renal transplants. Most parents rated their child's physical health as considerably improved after transplantation. They also noted improvements in the child's behaviour and in the quality of family life. When compared with a sample of children being treated by hospital haemodialysis, children who had received transplants had more favourable parental views of behavioural and emotional adjustment, better parental psychiatric adjustment, and indications of superior child rated mood, self concept, and social functioning. Children who had received transplants did, however, show an increase in minor behavioural symptoms compared with healthy controls, and most parents required continuing psychological and social support as well as attention to physical aspects of the child's condition. Kidney transplantation is associated with improved psychosocial behaviour in children, but there is a continuing need for support for parents in dealing with minor psychological problems after the transplant.

Psychosocial adjustment to end-stage renal failure: comparing haemodialysis, continuous ambulatory peritoneal dialysis and transplantation

Seventy-three children and adolescents in end-stage renal failure (ESRF) undergoing haemodialysis (n = 32), continuous ambulatory peritoneal dialysis (CAPD) (n = 28) or with a functioning transplant (n = 13), were assessed, with their parents, on adjustment to dialysis and psychological functioning. Quantitative assessment techniques were used; the three treatment groups were compared using the Mann-Whitney U test. Findings showed a number of advantages of transplantation over dialysis, and of CAPD over haemodialysis. Children with transplants suffered less functional impairment (P = 0.007), less social impairment (P = 0.001) and fewer practical difficulties associated with treatment (P = 0.000) than children undergoing dialysis. Parents of children with transplants also reported fewer practical difficulties than parents of children on dialysis (P = 0.002). Dialysis and transplant groups did not differ on children's or parents' reports of psychological stress associated with treatment, parents' reports of marital strain, children's and parents' levels of anxiety and depression or children's behavioural disturbance. Compared with children undergoing hospital haemodialysis, those using CAPD suffered less social impairment (P = 0.004), reported better adjustment to dialysis (P = 0.031) and fewer practical problems associated with treatment (P = 0.005), had lower depression scores (P = 0.054), and showed less behavioural disturbance (P = 0.013). Parents of children undergoing either CAPD or hospital haemodialysis reported similar practical difficulties, psychological stress or marital strain associated with treatment, but mean depression and anxiety scores were lower in the parents of children undergoing CAPD (P = 0.042 and P = 0.054).(ABSTRACT TRUNCATED AT 250 WORDS)

“Quality of Life” for Patients with End-Stage Renal Failure

The assessment of health status and quality of life among chronically ill patients is an area of current scientific interest. This paper considers the utility of a short but comprehensive instrument to assess the quality of life for end-stage renal failure patients. the Spitzer QL-Index was completed by 8 nurses for all patients in the Wellington region currently being treated with home hemodialysis (n = 58); hospital hemodialysis (n = 13); and continuous ambulatory peritoneal dialysis (n = 37). Results indicated that home hemodialysis patients achieve the highest quality of life in comparison to the other two treatment modalities. It is concluded that the QL-Index has some discriminative validity for this patient population, and its use may contribute to informed decision making by both patients and doctors.

Comparison of Survival in Continuous Ambulatory Peritoneal Dialysis and Hospital Haemodialysis: A Multicentric Study

We compared the survival of 842 patients on centre haemodialysis to 272 patients on continuous ambulatory peritoneal dialysis (CAPD). All patients selected had begun treatment between 1 January 1984 and 30 June 1988 and were from six centres which participate in a regional renal patients registry. Patients on CAPD were older and had a greater proportion of diabetes and other associated diseases. Age, diabetes, and cardiovascular diseases were associated with a shorter survival on treatment in all the patients studied. Without adjustment for risk factors, patient 3-year survival was higher in centre haemodialysis than in CAPD, 80% versus 64% respectively. However, no significant differences could be shown in the survival rates of the two treatment modalities after accounting for the heterogeneity of the patients in the two groups, either by stratification or by multivariate analysis (Cox). Age was the main predictive factor for CAPD patient survival, while the influence of diabetes and cardiovascular diseases was less clear. Technique survival was much better in centre haemodialysis (94% versus 56% in CAPD, 3-year survival). Older age and diabetes mellitus were associated with a greater risk of switching from centre haemodialysis to CAPD and a trend to retain those patients on CAPD.

Haemodialysis: Effects on White and Red Blood Cell Sodium Content and Transport

A circulating sodium pump inhibitor, released in response to volume expansion, may, by increasing intracellular sodium concentrations, be responsible for some of the features of the uraemic state. Haemodialysis, by correcting volume overload, would be expected to be associated with a decrease in intracellular sodium towards normal. The effects of a haemodialysis session on leukocyte (WBC) sodium content and transport have not been described and there are conflicting reports of the effects of haemodialysis on erythrocyte (RBC) sodium content and transport. We have measured sodium (NaWBC/RBC) and potassium content (KWBC/RBC), net ouabain-sensitive sodium flux rate (FR) and sodium flux rate constant (RC) before and after a standard haemodialysis session in 20 stable hospital haemodialysis patients. In leukocytes (n = 18), sodium (P = 0.078), FR (P = 0.006), and RC (P = 0.071) decreased over dialysis, whereas in erythrocytes sodium increased (P less than 0.001, n = 19) and RC declined (P = 0.002, n = 18). Although in opposite directions in RBC and WBC, the changes in sodium were toward normal in both cell types. Changes in intracellular sodium content and transport did not correlate with changes in measures of ECF volume or biochemical efficiency of dialysis. We conclude that haemodialysis does affect cell sodium content and transport, but in different ways in different cell types. There was no evidence that haemodialysis removed a sodium pump inhibitor. The use of RBC or WBC as 'model' cells to study sodium transport in uraemia is of questionable validity.

Treatment of hyperkalaemia in renal failure with salbutamol inhalation

The aim of this study was to investigate whether beta-2-adrenergic stimulation with inhaled salbutamol is therapeutically useful in hyperkalaemia. Ten patients with renal failure and hyperkalaemia (serum potassium concentration greater than 6 mmol l-1) were given 15 mg salbutamol via a nebulizer over a 30-min period. Serum potassium was measured 30, 60, 180 and 360 min thereafter. All patients had end-stage renal failure on chronic hospital haemodialysis. Serum potassium levels decreased significantly from a pretreatment value of 6.5 +/- 0.6 mmol l-1 to 5.6 +/- 0.6 mmol-1 after 30 min, and this level was maintained for 3 h. Six hours after treatment, the serum potassium concentration was 6 +/- 0.7 mmol l-1. There was a modest increase in heart rate and blood glucose level, but otherwise salbutamol was well tolerated and no serious side-effects occurred. It is concluded that the administration of salbutamol by inhalation is a simple, safe and reasonably effective method for treatment of hyperkalaemia in renal failure.

Psychosocial issues in children on hospital haemodialysis: nurses' views

In a sample of 21 children and adolescents on hospital haemodialysis, nurses identified a substantial percentage of the children (about half) as having marked problems in psychological adjustment. Nearly half of the children were also regarded as showing poor compliance with aspects of treatment other than dialysis. More children were rated as disturbed by nursing than by research psychiatric assessments; there was limited congruence between nurses' and parent/child ratings of problems in physical well-being or in treatment compliance. The reasons for these discrepancies are explored. Our results highlight the importance that psychological aspects in the nursing of children with chronic renal failure on hospital haemodialysis are recognised.

Comparison of Psychosocial Adjustment of Male Nondiabetic Kidney Transplant and Hospital Hemodialysis Patients

Psychosocial adjustment and psychological distress was compared in 31 male nondiabetic successful renal transplant and 31 hospital hemodialysis patients, matched for duration of treatment, age, education, and family status. The only significant difference between the two groups was that the transplant patients were more satisfied with the medical staff. Vocational rehabilitation was similar in both groups. Sexual interrelationships, as reported by the patients, were slightly, but insignificantly, better in the transplanted group. Thus, the psychological adjustment of transplant and hemodialysis patients is similar when demographic differences are accounted for.

Survey of Blood Lead and Plasma Aluminium Concentrations in Patients of a Renal Unit

Blood lead and plasma aluminium concentrations have been measured in patients with end-stage chronic renal failure treated by haemodialysis (HD) or by continuous ambulatory peritoneal dialysis (CAPD) and in a control group of non-dialysed patients with chronic renal failure (CRF). Data on a group of subjects with normal renal function is included for comparison. We have found significantly increased mean blood lead and plasma aluminium concentrations in all patients with chronic renal failure compared to a group with normal renal function. All blood lead concentrations were within the accepted safe exposure range of less than 1.8 mumol/l (380 micrograms/l]. There were significant differences among the patient groups: home HD, 0.60 +/- 0.25 mumol/l (124 +/- 52 micrograms/l); hospital HD, 0.39 +/- 0.31 mumol/l (81 +/- 64 micrograms/l); CAPD, 0.32 +/- 0.17 mumol/l (66 +/- 35 micrograms/l); CRF, 0.38 +/- 0.20 mumol/l (79 +/- 41 micrograms/l); normal, 0.24 +/- 0.11 mumol/l (50 +/- 23 micrograms/l). Correction of the blood lead results for haemoglobin accentuates these differences (i.e. hospital HD, 4.61 +/- 3.25 nmol/g (0.96 +/- 0.67 micrograms/g); CRF, 3.05 +/- 1.46 nmol/g (0.63 +/- 0.30 micrograms/g); normal, 1.65 +/- 0.70 nmol/g (0.34 +/- 0.14 micrograms/g). Plasma aluminium concentrations show a similar pattern: home HD, 1.09 +/- 0.70 mumol/l (29.4 +/- 18.9 micrograms/l); hospital HD, 0.81 +/- 0.58 mumol/l (21.9 +/- 15.7 micrograms/l); CAPD, 0.34 +/- 0.34 mumol/l (9.2 +/- 9.2 micrograms/l); CRF, 0.18 +/- 0.09 mumol/l (4.9 +/- 2.4 micrograms/l); normal, 0.09 +/- 0.07 mumol/l (2.4 +/- 1.9 micrograms/l).(ABSTRACT TRUNCATED AT 250 WORDS)

How parents and families cope with chronic renal failure.

We studied the effects on the family of childhood chronic renal failure by contrasting children with varying degrees of severity of illness with healthy controls. Disruption of family life was most common in families with the more severely ill children (on hospital haemodialysis) and there was a tendency for more mental health problems in the parents in this group. Although more of these parents reported that the child's illness had had an impact on the marriage, marital break up was not related to illness status. There were indications that illness had resulted in an increase of subjective stress but also of support in a number of psychosocial areas for parents, especially those in the more severely affected group. Nevertheless at the time of assessment, fewer mothers in this group were deriving support from their social life and fewer fathers of ill children from their jobs or finances.