Long History Of Hemodialysis Research Articles

Living Donor Kidney Transplantation for a Recipient after 41 Years of Hemodialysis

Due to atrophic bladder, patients undergoing long-term dialysis experience vesicoureteral reflux and complicated urinary tract infections after kidney transplantation. A 58-year-old woman underwent living donor kidney transplantation after 41 years of dialysis. She had no contraindications, with good cardiac function and minimal artery calcification despite the long history of hemodialysis. Immunosuppression was initiated with tacrolimus, mycophenolate mofetil, prednisolone, and basiliximab. Ureteroneocystostomy with an antireflux technique was carefully conducted as her bladder volume was 15 mL. The postoperative clinical course was uneventful with immediate graft function. The bladder volume gradually increased to 81 mL at discharge, 3 weeks postoperatively. The patient was initially depressed due to frequent urination early post-transplant but recovered soon after as the bladder volume gradually increased to 400 mL. The patient has not yet reported a urinary tract infection episode. This case highlights living donor kidney transplantation-induced recovery of bladder function with careful ureteroneocystostomy, despite the long dialysis history.

A very high prevalence of hepatitis C virus infection among patients undergoing hemodialysis in Kosovo: a nationwide study

BackgroundPatients on hemodialysis are at high risk for hepatitis C virus (HCV) infection if measures for effective control of HCV infection in the hemodialysis environment are not implemented. Whereas in developed countries isolated small-scale outbreaks of HCV in hemodialysis units are occasionally reported, HCV transmission in the hemodialysis environment still represents a substantial problem in low-resource countries. This study systematically assessed the prevalence of HCV infection among all patients at all hemodialysis centers in Kosovo, determined the HCV genotype distribution, and reviewed the main risk factors associated with HCV infection in this group of patients.MethodsFrom January to March 2013, blood samples from all patients undergoing hemodialysis at all seven hemodialysis centers in Kosovo were collected. The samples were screened for the presence of anti-HCV antibodies, and seropositive samples were also tested for HCV RNA. Genotyping was performed by sequencing the core region of the HCV genome. Subsequently, face-to-face interviews were conducted with consented patients attending hemodialysis in December 2015 and with the management of all hemodialysis centers in Kosovo.ResultsThe overall seroprevalence of HCV infection among hemodialysis patients in Kosovo was 53.0% (354/668), ranging from 22.3 to 91.1% at different centers. HCV RNA was detected in 323/354 (91.2%) seropositive patients. The most frequent HCV genotype was genotype 1a (62.2%), followed by genotypes 4d (33.1%), 1b (4.0%), and 2c (0.7%). The duration of hemodialysis and receiving dialysis at more than one center were identified as independent significant predictors of anti-HCV positivity. Shortage of staff, lack of resources, and inconsistent use of hygienic precautions and/or isolation strategies were observed.ConclusionsThe prevalence of HCV infection among hemodialysis patients in Kosovo is extremely high. The relatively low prevalence of HCV infection in the general population, predominance of two otherwise rare HCV genotypes among hemodialysis patients, and longer history of hemodialysis as a predictor of HCV infection all indicate nosocomial transmission due to inappropriate infection control practices as the main transmission route.

A Longer History of Hemodialysis Can Lead to Sarcopenia in Renal Transplantation Patients

BackgroundSarcopenia is a condition in which the amount of skeletal muscle decreases. Recent studies have suggested that sarcopenia is a risk factor for the incidence of postoperative complications, longer hospitalization, and a poorer prognosis. In this study, we examined the impact of sarcopenia in association with a history of hemodialysis in renal transplantation patients. MethodsA total of 157 patients who underwent renal transplantation at Yokohama City University Medical Center (Yokohama, Japan) from 2005 to 2016 were analyzed in this study. We determined the presence of sarcopenia using the psoas muscle index (PMI). The PMI was calculated based on the left psoas muscle area of L3 (mm2) divided by the square of the body height (m2). ResultsThe mean/median length of time that the patients received hemodialysis was 2059/850 days. The PMI in men was significantly higher than that in women (321.9 ± 10.0 vs 226.6 ± 17.3, P < .001). The group with a longer history of hemodialysis (≥851 days) showed a significantly lower PMI than the short-history group (≤850 days) (355.8 ± 15.1 vs 289.7 ± 11.3, P = .001). The PMI showed a negative correlation according to the dialysis period and a positive correlation according to the sex and triglyceride levels. ConclusionsA longer history of hemodialysis was shown to be associated with a lower PMI in renal transplantation patients. In addition, the higher PMI group showed higher serum triglyceride levels than the lower PMI group.

Single institution outcomes in the first 3 years of pancreas transplantation from brain dead donors.

A total of 26 pancreas transplants from brain dead donors, including 21 simultaneous pancreas and kidney (SPK) transplantation procedures, have been performed at Fujita Health University Hospital since the new pancreas transplant program was initiated in August 2012. The objective of this study is to investigate the outcomes of pancreatic transplantation in our facility in first 3 years of the program. The background characteristics of the donors and the outcomes of 26 pancreas transplant recipients were analyzed. The mean age of the recipients was 44.0 years, and all recipients had a long-term history of diabetes (mean: 30.2 years). In the SPK cases, the patients also had a long history of hemodialysis (mean: 6.3 years). Although the average donor age was 41.0 years and more than half of the donors were marginal donors (defined according to Kapur's criteria and Troppmann's criteria), the patient survival and pancreatic graft survival rates were 100% and 91.7%, respectively. Unfortunately, two recipients experienced graft failure due to graft thrombosis, which resulted in graft loss. The new pancreas transplant program at Fujita Health University has provided excellent outcomes for patients with type 1 diabetes.

Single-Institution Outcomes in the First Year of Pancreas Transplantation From Brain-Dead Donors

BackgroundUnder a revision to the law in 2010, the number of pancreas transplantations from brain-dead donors has been increasing in Japan. We started a new Pancreatic Transplant Program at Fujita Health University Hospital in September 2012. MethodsA total of 11 cases of pancreas transplantation from brain-dead donors performed at Fujita Health University Hospital were analyzed in terms of the background characteristics of the donors and recipients and the outcomes. ResultsThe mean age of the recipients was 45.2 years, and all recipients had a long-term history of diabetes (mean: 32.5 years). In the simultaneous pancreas and kidney transplantation (SPK) cases, the patients also had a long history of hemodialysis (mean: 8.0 years). Although the average donor age was 42.5 years, 90% of the donors were marginal donors, defined according to the following factors: (1) >45 years old, (2) death from cardiovascular disease, (3) episodes of cardiac arrest, (4) use of high doses of catecholamines. The pancreatic graft survival rate was 100%, although 1 patient required a small amount of insulin to maintain euglycemia. In addition, the kidney graft survival rate was also 100% in the SPK cases. ConclusionsThe new Pancreatic Transplant Program at Fujita Health University has provided excellent outcomes for type 1 diabetic patients.

Diabetic Musculoskeletal Complications and Their Imaging Mimics

Diabetes mellitus is increasingly prevalent and results in various clinically important musculoskeletal disorders affecting the limbs, feet, and spine as well as in widely recognized end-organ complications such as neuropathy, nephropathy, and retinopathy. Diabetic muscle ischemia-a self-limited disorder-may be confused with infectious or inflammatory myositis, venous thrombosis, or compartment syndrome. The absence of fever and leukocytosis, combined with the presence of bilaterally distributed lesions in multiple and often noncontiguous muscles in the legs, including the thighs, is suggestive of ischemia; by contrast, the presence of well-defined intramuscular abscesses with rimlike enhancement favors a diagnosis of infectious pyomyositis. In the diabetic foot, an ulcer, sinus tract, or abscess with an adjacent region of abnormal signal intensity in bone marrow favors the diagnosis of pedal osteomyelitis over that of neuropathic arthropathy. Contrast material-enhanced magnetic resonance imaging is important when planning the treatment of foot infections in diabetic patients because it allows the differentiation of viable tissue from necrotic regions that require surgical débridement in addition to antibiotic therapy. Subtraction images are particularly useful for visualizing nonviable tissue. Dialysis-associated spondyloarthropathy characteristically occurs in diabetic patients with a long history of hemodialysis. Intervertebral disk space narrowing without T2 signal hyperintensity, extensive endplate erosions without endplate remodeling, and facet joint involvement are suggestive of spondyloarthropathy instead of infectious diskitis or degenerative disk disease. Although the clinical features of these conditions may overlap, knowledge of the patient's medical history, coupled with recognition of key imaging characteristics, allows the radiologist to make a prompt and correct diagnosis that leads to appropriate management.

Gemcitabine for patients with chronic renal failure on hemodialysis

15189 Background: Numerous studies of gemcitabine (GEM) as an agent for advanced pancreatic carcinoma (APC) have been reported. Although significant and/or unexpected toxicities of GEM have been reported even at low doses in patients (pts) with impaired renal function, no dosing recommendations have been developed for chronic renal failure (CRF). Methods: In this report, we present five APC pts with CRF and discuss the use of GEM for pts on hemodialysis (HD). Results: CASE 1. A-74-year old man with CRF (not on HD) received GEM (800 mg) on days 1 and 8. Grade 3 hematological toxicity (neutropenia and thrombocytopenia) occurred on day 9, which recovered immediately after HD was performed. Ten courses of GEM (800 mg x q2w) with HD initiated 6 h after administration have since been administered without any side effects. CASE 2. A-48-year old man underwent Whipple’s operation and received GEM (1000 mg x3 q4w) as adjuvant chemotherapy. After 10 cycles, he developed hemolytic uremic syndrome (HUS), which recovered immediately after performance of HD. HD was initiated 24 h after GEM (1000 mg), and this sequence was repeated 53 times until recurrence occurred. CASE 3. A-78-year old woman with recurrent pancreatic carcinoma developed HUS after 29 cycles of GEM (800 mg x q2w). After remission of HUS by starting HD, GEM was commenced again (HD was initiated 24 h after GEM at 1000mg x q2w), and has been administered 18 times. Both CASE 4 (a 65-year- old woman) and CASE 5 (a 56-year-old man) are APC pts with a long history of HD. Although HD was initiated within 24 h after GEM (1000mg) administration, Grade 3 hematological toxicity (neutropenia and leukocytopenia) occurred in these pts and we had to give up GEM after several courses. Conclusions: GEM (800–1000 mg) can be administered safely to pts with CRF on HD, especially soon after commencing HD, as long as HD is initiated within 24 h after GEM administration. In pts with a long history of HD, however, GEM should be administered with caution. No significant financial relationships to disclose.

Case Study: Making Room for Alternatives

RS is a ten-year-old Hmong (Southeast Asian) boy with a long history of hemodialysis for end-stage renal disease and hypertension. His parents clearly cared deeply for their son and had been compliant with treatment, but were suspicious about his medical care and his need to continue dialysis. Without notifying their pediatric nephrologist, they took their son off dialysis and traveled to a medical center several hundred miles away. When RS failed to appear for his appointments, a referral was made to Children's Protective Services (CPS). When RS's records were requested by the consulting medical center, CPS was contacted and they intervened by removing RS from his parents' care and placing him in a temporary foster home. RS resumed his dialysis and his parents cooperated with family reunification counseling and agreed to comply with all required medical care. RS was returned to his family several weeks after placement but this incident clearly increased his parents' distrust of the medical team. Several months later, RS was admitted to the hospital after becoming febrile. The line used for his dialysis was infected with Staph. aureus. A routine chest X-ray revealed a complete opacification of his left chest. A chest tap was performed and it revealed that RS had a hemothorax with old, thickened blood surrounding his left lung. A surgical consult suggested that he would require immediate surgery to clear out the blood so that his left lung could possibly return to function. At first, RS's family agreed to this procedure, but they changed their mind after a few hours and rescinded their consent. RS's family, communicating through a translator, stated that they felt that the blood was the result of RS's poor care by his physician and that the hospital wanted to do the surgery to destroy the evidence. They also communicated a strong desire to have RS receive Hmong shaman intervention to treat his lung. An ethics consultation was requested and the options were reviewed. Some members of the treatment team felt that CPS should remove RS from his family and place him in foster care permanently to assure compliance with medical care. Others were less sure that the hemothorax was treatable with surgery--the blood had been present for quite some time and may have permanently affected his left lung. The hospital has a long tradition in working with children of Hmong ancestry and agreed to invite the shaman to come to the hospital to provide alternative treatment. Traditional Hmong health practices are based on the belief that spirits cause illness and that spiritual healing can remove their harmful influence. Healers in the community specialize in treating various specific spiritual illnesses, using a variety of herbs and roots, which are often boiled and made into a tea. The healer may also tie a spirit string around the wrist of the ill person to ward off harmful spirits, or at times perform animal sacrifices to appease the spirits. As some treatments involve the need for heating or igniting different materials, it was suggested that RS's bed could be moved to a interior courtyard of the hospital during these procedures. However, the Hmong shaman told RS'S family that he felt it would be best if RS were discharged home so that he could conduct the ritual healing on a daily basis over a seven to ten-day period. A second ethics consultation session was held and the physician agreed to discharge RS home for shaman treatment. The family agreed to attend a formal ethics meeting three days after discharge so that everyone's concerns could be aired completely. At the meeting, RS's parents reported that the shaman said that if he successfully treated the lung, the cause of the bleeding was spiritual in nature and they should continue to work with RS's doctors. If he was unsuccessful, RS's family was led to believe that the bleeding was then caused by the doctor's poor practice of medicine and they would not want to continue dialysis. …

Vitamin D receptor gene polymorphisms affect secondary hyperparathyroidism in hemodialyzed patients

Adynamic bone disease unrelated to aluminum deposition, with low parathyroid hormone (PTH) levels, has increased in patients with end- stage renal failure. Some patients present with severe secondary hyperparathyroidism despite calcitriol administration and phosphate restriction. Because therapeutic and environmental factors are now similar among hemodialyzed patients, the variable incidence of secondary hyperparathyroidism may be caused by genetic heterogeneity. To examine this possibility, we analyzed restriction fragment length polymorphisms of the vitamin D receptor (VDR) gene in 877 Japanese hemodialysis patients. VDR allelic polymorphism was determined by the method of Morrison et al. Polymerase chain reaction (PCR) amplification and a BsmI endonuclease restriction site at the 5' end of the VDR gene defined BB (absence of restriction site on both alleles), Bb (heterozygous), or bb (restriction site on both alleles). The mean serum PTH level was lower in BB patients (86 +/- 102 pg/mL) than in bb patients (148 +/- 217 pg/mL; P < 0.05). The serum osteocalcin level was also lower in BB than in bb patients (P < 0.05). If results were re- analyzed excluding patients with a history of dialysis exceeding 10 years or those with non-insulin-dependent diabetes mellitus (NIDDM) or who had undergone parathyroidectomy, the differences in serum PTH levels were greater. However, there was no significant difference in serum PTH levels among the VDR genotypes, only for patients with NIDDM. The present study shows that patients with the b allele for the VDR gene have more severe secondary hyperparathyroidism than patients without the b allele. However, NIDDM or a long history of hemodialysis has a stronger power to influence PTH secretion. (Am J Kidney Dis 1998 Sep;32(3):464-9)