Hemodialysis Period Research Articles

Renal Involvement in Wegener’s Granulomatosis

Three patients with rapidly progressive glomerulonephritis due to Wegener's granulomatosis are described. In one patient, acute renal failure was initially the sole manifestation of the disease. Treatment of the two other patients with prednisone and cyclophosphamide resulted in a remarkable recovery of renal function even after a prolonged period of hemodialysis. These cases illustrate that early and sustained treatment with prednisone and cyclophosphamide can restore an adequate renal function in patients with anuria or severe glomerulonephritis due to Wegener's disease.

Prolactin, gonadotropins, testosterone, and estrogens in uremic men undergoing periodic hemodialysis.

Forty-five uremic men, aged 20 to 68 years, undergoing periodic hemodialysis were investigated regarding their plasma testosterone (T) and human prolactin (hPRL); in 25 of those, plasma luteinizing hormone (LH), follicle-stimulating hormone (FSH), estrone (E1) and 17-β estradiol (E2) were also measured by radioimmunoassay (RIA). Means ± standard deviations were: T = 379 ± 157 ng/dl; hPRL = 24 ± 30 ng/ml; LH = 49 ± 48 mlU/ml; FSH = 10 ± 8 mlU/ ml; E1 = 108 ± 35 pg/ml; and E2 = 10 ± 6 pg/ml. Twenty percent had hyperprolactinemia, and 24% had hypotestosteronemia. LH was elevated in 95% of men, while FSH was higher than normal in only three cases (12%). E; was tentatively low in 60%, while E, was elevated in 76% of men. Hyperprolactinemia could be due to hemodilution, reduced renal excretion, stress, or hypothalamic-pituitary disregulation; it cannot be accounted for by E2 induction, since E2 was low in 60% of patients. Low T can be explained by a local toxic effect of uremia on the testis, and high LH would ...

Acute Hemodynamic Effects of Brescia-Cimino Arteriovenous Fistula for Hemodialysis

In ten uremic patients, who were not yet undergoing periodic hemodialysis and in whom we were creating a 1 cm, distal, side-to-side arteriovenous fistula of Brescia-Cimino type for hemodialysis, the acute hemodynamic changes of the systemic and pulmonary circulations were studied immediately after the opening of the fistula. An increase in cardiac output (Q) was observed in one patient, the other patients showing either no change or a slight reduction. In the four patients in whom the Q decreased there was a significant reduction of total blood volume (TBV) and stroke volume (SV) and an increase in systemic vascular resistance (SVR) (p less than 0.05, p less than 0.05, p less than 0.01 respectively). At the level of pulmonary circulation, in these patients a decrease in pulmonary blood volume (PBV) (mean = 20%) and a significant increase in pulmonary vascular resistance (PVR) were also observed. In five patients who had been on chronic hemodialysis and who presented the clinical picture of cardiac failure, the acute hemodynamic changes following temporary closure of the fistula (by a sphygmomanometer) were studied: a significant decrease (p less than 0.05) in Q, TBV and SV was observed. The difference between the two values of Q (i.e. fistula open and closed) was considered to indicate the magnitude of the flow across the fistula.

Minor hemoglobin components in diabetic and uremic patients.

Hemoglobins A1c and A1a+b were measured by an automated chromatographic method in 11 control subjects, 100 diabetics and 30 subjects with renal failure not induced by diabetes. Hb A1c was higher in diabetics than in controls (8.26 +/- 0.31 versus 5.24 +/- 0.28, p less than 0.01) and strongly correlated with blood glucose values for the preceding 4 months. In poorly controlled diabetics, submitted to an intensive therapeutic program, Hb A1c decreased rapidly. Hb A1c was slightly but significantly elevated in the uremic, non-diabetic patients who were not submitted to periodic hemodialysis: 6.42 +/- 0.32, p less than 0.05. It returned, in hemodialyzed patients, to a level not significantly different from the control value. Hb A1a+b was elevated in diabetic subjects (2.43 +/- 0.04 vs. 1.55 +/- 0.01 in controls, p less than 0.001). It was also higher in the uremic patients (2.71 +/- 0.14, p less than 0.001). No decrease occurred in the hemodialyzed patients (3.27 +/- 0.31). Glycosylated hemoglobin values, as routinely estimated and expressed under the name of "Hb A1", should be interpreted with caution in patients with renal failure. Methods discriminating Hb A1a+b have to be used.

Cimetidine-induced PTH variations in uraemic patients evaluated with the aid of antisera against the terminal carboxyl and amino groups of the hormone molecule.

Eight uraemic patients on periodic haemodialysis were given 600 mg of cimetidine every day for 15 days. Parathyroid hormone levels before and at the end of this treatment were evaluated with two different antisera specific against the terminal -COOH and -NH2 groups of the hormone respectively. The results obtained suggest two things: though cimetidine may enhance PTH secretion, at the same time it accelerates peripheral disintegration of some of its metabolically active metabolites. It i therefore necessary to reconsider the possible use of cimetidine in the treatment of hyperparathyroidism associated with uraemia.

Restoration of Renal Function After Bilateral Renal Artery Occlusion

Five patients had anuric renal failure caused by occlusion of the main renal arteries. All had a background of controlled hypertension, but in three patients, hypertension accelerated in the months before anuria. Extensive atherosclerotic disease was clinically evident in the peripheral (3/5), coronary (4/5), and cerebral (1/5) vessels. Identifiable precipitating events preceded the development of anuria in four patients. Although the use of renal ultrasonogram and scintiscan was suggestive, angiography was essential to establish the diagnosis after a brief period of maintenance hemodialysis. Renal artery revascularization performed as long as 38 days after the onset of anuria resulted in restoration of kidney function.

Surgical Management of Patients in a Periodic Hemodialysis Program and Subjected to Cardiopulmonary Bypass

The surgical management of patients who were in a periodic hemodialysis program and were to be subjected to cardiopulmonary bypass is complex and requires special care.1, 2 We have managed 2 patients in the final stages of chronic renal failure who had to undergo surgical correction of cardiac disease. In both cases there had been previous cardiac surgery. The peculiar problems presented by these patients are discussed, as well as the surgical procedure used to prevent potential complications.

Acquired Renal Cysts and Tumors Superimposed on Chronic Primary Kidney Diseases: An Autopsy Study of 24 Patients

Acquired cystic disease of the kidneys was found at autopsy in 24 of 80 patients with chronic renal insufficiency maintained on intermittent hemodialysis for periods ranging up to 7 years. The architecture of the kidney was significantly distorted by the cysts, some of which were multiloculated. These cysts may be regarded as exaggerated "retention" type that have progressed and become widespread as a result of prolongation of life by hemodialysis. Their pathogenesis may be related to obstructive, ischemic and/or toxic factors. Renal tumors, usually multiple, were found in 8 patients. Another patient had metastatic renal adenocarcinoma. No patient died of causes directly attributable to the renal cysts.

Management of Hypertension in Dialysis

Arterial hypertension is a highly frequent symptom in end-stage renal failure. This study was designed to evaluate the importance of total exchangeable sodium (NaE), plasma renin activity (PRA) and the adrenergic nervous system in the pathogenesis of high blood pressure. 86 patients were studied (26 with end-stage kidney disease and under conservative treatment and 60 on maintenance haemodialysis). Under conservative treatment a simple linear regression analysis gave a correlation coefficient of 0.794 for NaE × log. PRA against mean arterial pressure (MAP). This data suggests that before the start of the haemodialytic treatment NaE and PRA are important determinants of hypertension. In patients undergoing chronic heamodialysis the correlation between MAP and the product of NaE × log. PRA was lost. In hypertensive patients we have found indication of an increased adrenergic activity. In fact resting heart rate and two hours walking plasma catecholamines were significantly higher in hypertensive compared with normotensive patients on dialysis. A significant positive correlation was found between basal plasma noradrenaline levels and MAP in 34 patients treated with periodic haemodialysis when hypothyroid patients were excluded. Arterial hypertension is a highly frequent symptom in end-stage renal failure and occurs in over 80% of all case histories (1, 2, 3, 4, 5). This paper is a review of our experience concerned with the pathogenesis and management of hypertension in patients with chronic renal failure.

In vitro characterization of immunological responsiveness of uremic patients.

Uremic patients are thought to have deficient immune reactivity. The mechanisms for immunosuppression are not known. We have studied various in vitro immune response parameters in lymphocytes from uremic patients and from healthy controls. Using polyclonal activating substances, it was found that PHA and LPS responses were reduced in cells from the patient group compared to the control group (p < 0.05). Furthermore, MLC responsiveness using pooled stimulator cells and polyclonal antibody secretion induced by Staphylococcus aureus bacteria in vitro were reduced in the patients (p < 0.05). No differences with regard to proportions of T/B cells in blood were noted between the two groups. No correlation was found between responses of individual cells to different activating substances, with the exception of PHA and ConA. However, low responses to PHA were usually accompanied by a general low responsiveness. Patients were further subdivided into groups according to the type of dialysis treatment, peritoneal dialysis (PD) or hemodialysis (HD), and to the duration of the hemodialysis period (< and > 1 year). Patients treated with PD showed impaired T cell reactivity with loer PHA responses compared to the HD patients (p < 0.05). Between the HD groups there were no significant differences in mitogen or MLC responses. We believe that the differences between PD and HD were due to the facts that the PD patients were older and not in the same nutritional state as the HD patients.

RETROSPECTIVE AND PROSPECTIVE STUDIES ON THE EFFECT OF BLOOD TRANSFUSIONS IN RENAL TRANSPLANTATION IN THE NETHERLANDS

The effect of blood transfusion on cadaveric kidney graft survival was studied retrospectively in 103 Dutch recipients. Seventy-four patients who had never been transfused or pregnant before transplantation had a 1-year graft survival of 32%, whereas 30 patients with only one transfusion had a very superior graft survival of 87% after 1 year (X2 = 22.85 P < 0.00001). Nineteen patients who received prospectively 1 unit of leucocyte-poor blood before transplantation had a 79% graft survival after 240 days. This is not statistically different from the results in the retrospective group with one transfusion. Patients who received prospectively 1 or 3 units leucocyte-free blood before transplantation had a 25% graft survival after 240 days. This does not differ from the graft survival in the never-transfused retrospective group (X2 = 0.31, P = 0.57). HLA matching between kidney donor and recipient could not explain the difference between the two prospectively transfused groups. For both groups the average number of HLA mismatches was equal, namely, 1.7. The average number of HLA mismatches between blood transfusion donors and kidney recipients also did not play a role of importance in both prospectively transfused groups. Even repeated mismatches on the blood transfusion donor as on the kidney donor did not give a worse graft outcome. There was no clear-cut correlation between kidney graft survival and the time of transfusion in the retro- as well as in the prospective groups. The fact that the mean hemodialysis period was longer in the leucocyte-poor prospectively transfused group than in the leucocyte-free transfused group could not explain the better graft survival in the first group, as they received only one transfusion. Finally, there was no beneficial effect seen of peroperative blood transfusions on kidney graft prognosis.

Hemodialysis and Renal Transplantation in Patients With Hypernephroma

Of five patients with hypernephroma who were maintained on hemodialysis after nephrectomy, four died with metastic disease after having been on hemodialysis for an average of 13.7 months (range 8 to 19). The fifth patient had no evidence of malignancy after 21 months of dialysis; he then received a renal allograft from his sister, and did well for 24 months before he developed liver metastasis. We believe hemodialysis is an appropriate mode of treating the renal failure of patients with hypernephroma after therapeutic nephrectomy. These patients may be considered for renal transplantation after a period of hemodialysis, and we suggest the currently recommended 12-month waiting period before transplantation be extended to 18 to 24 months. Use of living related donor renal allograft in these patients is questionable.

BENEFICIAL EFFECT OF BLOOD TRANSFUSION

We analyzed the effect of blood transfusion (BT) on kidney allograft survival in 163 recipients. Transfused recipients (121) had better graft outcome than those never transfused (42), the difference being statistically significant at 3, 6, 12, and 24 months; however, the transfused group had a longer period of hemodialysis (P = 0.01). HLA antigen distribution does not bias the data. The group who had received the last BT within 3 months before grafting had a significantly better graft outcome than the nontransfused group (P less than 0.05 at 3, 6, and 24 months). They also did better (but not significantly) than the group who had been transfused more than 6 months before grafting. The group receiving two to five BTs had the highest rate of graft survival (P less than 0.05, 0.001, and 0.05 at 6, 12, and 24 months) as compared to the nontransfused. Practical suggestions for systematic BTs during hemodialysis are made.

Prevalence of hepatitis B in 27 Michigan hemodialysis centers.

A large epidemiological survey of inhospital chronic hemodialysis patients was conducted in 27 (93%) of the 29 dialysis centers in Michigan. Serum was collected from 699 patients on chronic maintenance hemodialysis for periods from one month to eight years. Hepatitis B surface antigen (HBsAg) was determined in all patients by radioimmunoassay and positive samples were confirmed by specific neutralization. Antibody against HBsAg (anti-HBs) was determined by radioimmunoassay in 110 HBsAg negative patients from six dialysis units with a high prevalence of hepatitis B. HBsAg was detected in 80 (11.4%) patients distributed among 21 (78%) of 27 dialysis units and anti-HBs in 34 (31%) patients from the selected dialysis units. The prevalence of HBsAg was related to duration of dialysis, number of blood transfusions, and to a history of bilateral nephrectomy, but not to age, sex, race, nor the underlying renal disease. Twenty-one (26%) of the 80 HBsAg positive patients had not been previously identified by the clinical laboratories of their institutions. Since preventive measures were not taken in the care of these inapparent carriers of HBsAg, they represent an unrecognized risk.

Release of renal renin in patients under long-term dialysis treatment.

Plasma renin activity (PRA) was studied in 61 patients under long-term dialysis treatment. They were divided into three groups, low (0.1-5.0 ng/ml), normal (5.1-30.0 ng/ml), and high renin groups (more than 30.1 ng/ml) according to the levels of PRA. The difference in clinical features in the three groups and the factors influencing the secretion of renin were investigated. 1) With regard to the pre-dialysis PRA (resting PRA), low renin levels were found in 13.1 per cent of patients, normal in 65.5 per cent, and high in 21.4 per cent. 2) The pre-dialysis PRA (resting PRA) was significantly correlated with the ΔPRA/removed-sodium, but not with the removed sodium or removed water by the preceding dialysis. 3) Severe retinal changes were observed in patients with high resting PRA values. In contrast, fundoscopic findings were mild in patients with low resting PRA values. 4) Eleveted resting PRA values were obtained in younger subjects under 29 years of age, while the PEA levels were very low in patients of advanced ages (over 60 years). The latter showed low levels of ΔPRA/removed-sodium. 5) Though the ratios of ΔPRA/removed-sodium were very low in patients under hemodialysis for over 3 years, the resting PRA levels did not decrease with the duration of dialysis treatment, because renin secretion was stimulated strongly by the excessive removal of sodium and water in these later periods of hemodialysis. 6) With regard to the post-dialysis PRA, low renin levels were found in 6.8 per cent of patients, normal in 55.9 per cent, and high in 37.3 per cent. Post-dialysis PEAS were significantly correlated with the pre-dialysis PRAs and the ΔPRA/removed-sodium. From these results, it may be concluded that high PRA is a risk factor producing the hypertensive complications and ΔPRA/removed-sodium is a most important factor controlling the levels of PRAs (pre-dialysis PRA and post-dialysis PRA). Furthermore, age, removed sodium, removed water and the duration of dialysis also might be concerned with the secretion of renin.

Continuous Blood Glucose Monitoring and Characteristics of Diabetes in Patients on Maintenance Haemodialysis Treatment

The glucose metabolism of diabetes mellitus during maintenance haemodialysis treatment was studied in four patients with endstage renal failure. There was a large day-to-day variation in the predialysis blood glucose levels, which it was difficult to control by adjusting the insulin dose. In spite of very high blood glucose levels, blood lactate and beta-hydroxybutyrate were not elevated. Triglycerides were markedly and constantly elevated, in no apparent association with the predialysis blood glucose level. The patients were shown to release moderate amounts of glucose, beta-hydroxybutyrate and lactate into the dialysate during the dialysis period. A technique of continuous blood glucose monitoring during the haemodialysis period was applied. With this technique blood sugar levels were accurately determined during the whole dialysis period. A rapid drop in the blood glucose level was found in apparent association with an aggravation of symptoms. A very marked tendency to hypoglycaemia was also revealed. It is concluded that the technique is a valuable aid in the proper management of diabetes in these cases.

Plasma amino acid profiles in patients with fulminant hepatic failure treated by repeated polyacrylonitrile membrane hemodialysis

Raised plasma amino acid concentrations have been implicated in the pathogenesis of hepatic encephalopathy. In the present study the effect of repeated 4- to 6-hr polyacrylonitrile membrane hemodialysis on circulating amino acid levels was investigated in 26 patients with fulminant hepatic failure in grade IV coma. Because all patients had grossly abnormal plasma amino acid profiles on admission, the relationship between alterations in plasma amino acid levels and changes in coma grade was also examined. Ten patients fully regained consciousness after two to nine periods of hemodialysis and 9 (34.6%) survived. During comparable periods of hemodialysis, total amino acid removal (range 0.49 to 15.30 mmoles in survivors, 0.45 to 22.85 mmoles in nonsurvivors) and plasma amino acid pool clearances (range 2.54 to 8.47 in survivors, 3.04 to 8.33 in nonsurvivors) in the two groups of patients was similar. Plasma amino acid levels in the nonsurvivors remained elevated throughout their illness despite hemodialysis. In contrast, in the survivors hemodialysis was associated with a gradual reduction in plasma levels of all amino acids, and a trend was observed for plasma tyrosine, phenylalanine, and proline to return to normal levels 24 hr in advance of recovery of consciousness. However, the relationship between coma grade and plasma level was not exact for any individual amino acid. Furthermore, the plasma ratio of branched chain amino acids to aromatic amino acids, also thought to be significant in hepatic encephalopathy, bore no consistent relationship to coma grade. These results, therefore, do not support a unique pathogenic role for plasma amino acids in the encephalopathy of fulminant hepatic failure.

Treatment of encephalopathy during fulminant hepatic failure by haemodialysis with high permeability membrane.

Forty-one patients with fulminant hepatic failure and coma underwent 180 periods of haemodialysis with polyacrylonitrile membrane (AN 69 HD). Hepatic failure was due to viral hepatitis in 40 and drugs in one. Total recovery of consciousness occurred in 17 patients (43.6%), and partial in seven (17.9%)--that is, an overall figure of 61.5%. Regain of consciousness was not related to liver regeneration as assessed by levels of factor V and hepatocyte volume fraction. At the time of the first haemodialysis, neurological status was significantly impaired in the patients who could not be aroused. Mean duration of coma grade IV averaged 6.1 +/- 4.3 days and mean duration of illness until death or decerebration 8.6 +/- 8.3 days. Of the 17 patients who totally regained consciousness, nine recovered and eight died (three from intercurrent complications and five with no liver regeneration).

Impact of Blood Transfusion on Renal Transplantation

The relationship between transfusion of different preparations of blood, sensitization to HLA antigens and survival of subsequent kidney transplants was investigated in 90 consecutive recipients. HLA lymphocytotoxins in transplant candidates precluded or greatly delayed receipt of an allograft (p less than 0.0005). Furthermore, only 17% of such sensitized recipients had functioning grafts one year after transplantation compared to 57% survival for nonsensitized recipients (p less than .02). A small number of nonsensitized patients who were never transfused had surprisingly poor one year graft survival (25%). If frozen blood is used for transfusion rather than whole/packed RBC, the incidence of patient sensitization can be markedly reduced without subsequent compromise in transplant survival (51%). It is concluded that as a consequence of avoiding HLA sensitization by transfusion of frozen blood (processed by agglomeration), the period of hemodialysis required for potential graft recipients will be shortened and an increased proportion of potential recipients will be successfully treated by transplantation.

Deficiency of T and B Lymphocytes in Uremic Subjects and Partial Improvement with Maintenance Hemodialysis

Lymphopenia of a group of uremic patients was associated with normal percentages of T cells but reduced percentages of B cells. Lymphocyte counts improved after a period of maintenance hemodialysis, although not to control levels, and B cell percentages returned towards normal. Uremia is therefore associated with depression of total T and B cell numbers, with a relatively more pronounced effect on B cells. A period of maintenance hemodialysis produces increase in numbers of both cell types and depression becomes nonselective.