Routine Hemodialysis Treatment Research Articles

Effectiveness of Resistance Exercise Therapy on Patients' Physiological Status during Hemodialysis: A Randomized Controlled Trial

Background: Management disorder of vital signs remains a critical issue worldwide, particularly regarding hypertension in chronic renal disease (CRD), both of which are associated with a higher risk of cardiovascular (CV) and renal events. Physical inactivity resulting in poor exercise capacity is a common consequence of chronic kidney disease and is associated with increased mortality in the general population. Nursing management for patients undergoing hemodialysis requires an experienced nurse who understands the types of complications. Objective: The present study aimed to evaluate the effectiveness of resistance exercise therapy on patients’ physiological status by utilizing a checklist of physiological parameters and comparing it with a control group. Patients and Methods: The study was designed as a randomized controlled trial (RCT), using a double-blind technique, and it was conducted on patients divided into two groups (study and control groups). A total of 63 patients were included as follows: 32 patients for the study group and 31 patients in the control group. The patients were diagnosed with chronic kidney disease and were undergoing hemodialysis. The patients were randomly assigned to receive exercise therapy under the supervision of trained therapists during the second hour of the three routine hemodialysis treatments per week and under the supervision of the researcher. The study took place in Al-Najaf Al-Ashraf City/Al-Sadder Medical City and Al-Hakeem Hemodialysis Center. Results: The study results indicated an improvement in the physiological status of the study group compared to the control group. Conclusions: Exercise therapy effectively improves the physiological status of patients with chronic kidney disease undergoing hemodialysis.

Application of Wearables to Facilitate Virtually Supervised Intradialytic Exercise for Reducing Depression Symptoms.

Regular exercise can reduce depression. However, the uptake of exercise is limited in patients with end-stage renal disease undergoing hemodialysis. To address the gap, we designed a gamified non-weight-bearing intradialytic exercise program (exergame). The intradialytic exergame is virtually supervised based on its interactive feedback via wearable sensors attached on lower extremities. We examined the effectiveness of this program to reduce depression symptoms compared to nurse-supervised intradialytic exercise in 73 hemodialysis patients (age = 64.5 ± 8.7years, BMI = 31.6 ± 7.6kg/m2). Participants were randomized into an exergame group (EG) or a supervised exercise group (SG). Both groups received similar exercise tasks for 4 weeks, with three 30 min sessions per week, during hemodialysis treatment. Depression symptoms were assessed at baseline and the fourth week using the Center for Epidemiologic Studies Depression Scale. Both groups showed a significant reduction in depression score (37%, p < 0.001, Cohen’s effect size d = 0.69 in EG vs. 41%, p < 0.001, d = 0.65 in SG) with no between-group difference for the observed effect (p > 0.050). The EG expressed a positive intradialytic exercise experience including fun, safety, and helpfulness of sensor feedback. Together, results suggested that the virtually supervised low-intensity intradialytic exergame is feasible during routine hemodialysis treatment. It also appears to be as effective as nurse-supervised intradialytic exercise to reduce depression symptoms, while reducing the burden of administrating exercise on dialysis clinics.

Associations between dialysate sodium concentration and plasma sodium concentration of dogs receiving intermittent hemodialysis treatments.

OBJECTIVE To compare dialysate sodium concentration and patient plasma sodium concentration of dogs during intermittent hemodialysis treatments. SAMPLE 211 intermittent hemodialysis treatments performed on 40 client-owned dogs for the management of dialysis-dependent uremia. PROCEDURES Medical records were reviewed to determine the plasma sodium concentration of each dog before and after routine hemodialysis treatments. Associations between detected changes in plasma sodium concentration and dialysate sodium concentration were evaluated by use of Spearman rank correlations and linear regression analysis. RESULTS Significant linear correlations were found between the dialysate sodium concentration and patient sodium concentration. The starting dialysate-to-patient sodium gradient was associated with the strongest correlation to the change in patient sodium concentration at the end of the dialysis session. Modest correlations existed between the dialysate sodium concentration and postdialysis patient sodium concentration as well as between the predialysis dialysate-to-patient sodium gradient and postdialysis dialysate-to-patient sodium gradient. CONCLUSIONS AND CLINICAL RELEVANCE The dialysate sodium concentration was correlated with the patient sodium concentration in dogs, and the dialysate-to-patient sodium gradient could be used to further refine this association to predict the postdialysis patient sodium concentration and potentially manage dysnatremia during hemodialysis. Prospective studies should be performed to determine how these associations can be used to correct aberrations as well as to avoid unwanted alterations in patient sodium concentrations.

The effects of acupressure on depression, anxiety and stress in patients with hemodialysis: A randomized controlled trial

BackgroundPatients with end stage renal disease on hemodialysis are affected by physiological and psychological stressors, which contribute to poor quality of life and negative clinical outcomes. Depression, anxiety, and stress are highly prevalent in this population. Effective interventional strategies are required to manage these psychological symptoms. Acupressure has been believed to be one of the complementary therapies that could promote psychological wellbeing. ObjectiveThe aim of this study was to evaluate the effects of acupressure on depression, anxiety, stress, and general psychological distress in patients with hemodialysis. DesignOpen-label randomized controlled trial. SettingThree hemodialysis centers. ParticipantsA total of 108 patients with hemodialysis were randomly recruited into the acupressure group (n=54) and the control group (n=54). MethodThe intervention was carried out from January to March 2014. The acupressure group received routine hemodialysis treatment plus 15min acupressure applied three times a week for four weeks. The control group received only usual care with routine hemodialysis treatment. The outcome measurements were the Depression, Anxiety Stress Scales (DASS-21), and general psychological distress using the General Health Questionnaire (GHQ-28). Statistical analysis was performed using Wilcoxon signed-rank test to compare DASS scales and GHQ-28 scores before and after acupressure intervention. ResultsThe acupressure group had significantly lower DASS scores and GHQ scores compared to the control group, signifying improvements in depression, anxiety, stress and general psychological distress. The sub-score of the GHQ-28 for social dysfunction, however, were similar in both groups. ConclusionFindings from this study indicates that acupressure therapy delivered three times a week for four weeks was able to significantly reduce depression, anxiety, stress, and general psychological distress in patients with hemodialysis. This positive finding suggests that acupressure may have a role in promoting psychological wellbeing of patients. Promoting psychological wellness will improve patients’ quality of life, and reduce negative outcomes associated with psychological illnesses and distress experienced by patients with hemodialysis.

Vitamin D and UV exposure in chronic kidney disease

With loss of renal function and decreasing glomerula filtration rate the serum levels of 25-hydroxyvitamin D [25(OH)D] as well as 1,25-dihydroxyvitamin D [1,25 (OH)2 D] often decrease simultaneously. In representative groups of German patients on renal replacement therapy (hemodialysis, peritoneal dialysis, kidney transplantation) our group retrospectively analyzed the vitamin D status over a period of 12 y (1995‒2006). Only 11% of patients had a serum level of 25(OH)D that was > 30 ng/ml, more than 70% had a level of 25(OH)D < 20 ng/ml. In clinical trials we used sun-simulating artificial lamps to produce vitamin D3 in the skin. Partial-body irradiation (15% of body surface) was used during the routine hemodialysis treatment. Whole-body UV exposure was done in a standing position three times a week before the hemodialysis treatment. With both procedures we observed an increase of the serum level of 25(OH)2D3 by approx. 35–50% over a period of 2‒3 mo, maintenance of trabecular bone mineral density and a normalization of systolic and diastolic blood pressure. Heart rate variability improved during the whole-body radiation intervention period by 20‒25%. Patients who continued the whole-body irradiation regularly two or three times before starting the routine hemodialysis session had maintained normal levels of circulating 25(OH)D3 and of 1,25(OH)2D3. Therefore, from our data it can be recommended that intermittent suberythemal UVB exposure with a sun-simulation spectrum is effective to treat and/or protect against vitamin D deficiency in chronic and end-stage kidney disease patients.

DIFFERENCES BETWEEN AUSTRALIAN INDIGENOUS AND NON-INDIGENOUS MAINTENANCE HEMODIALYSIS PATIENTS

Indigenous Australians have an increased incidence of kidney disease and decreased survival on hemodialysis. The aim of this study was to investigate whether differences in nutritional status exist between indigenous and non-indigenous patients undergoing maintenance hemodialysis in South Australia. Seventy-two (22 Australian indigenous, 50 non-indigenous) stable hemodialysis patients were enrolled in a three month cross-sectional study. During the study patients underwent routine hemodialysis treatment and biochemical tests. Weight and biochemical measurements were collected pre and post dialysis on the first Tuesday or Wednesday of each month. A patient generated subjective global assessment (PG-SGA) was conducted in the third month of the study. Pre-dialysis albumin was 32.8+/4.1g/L in Australian indigenous patients and 36.2+/-4.5g/L in non-indigenous patients (p= 0.003). The difference between pre-dialysis and post-dialysis albumin was -4.0+/-2.8g/L in indigenous patients and -1.0+/-1.9g/L in non-indigenous patients (p=0.000). Intra-dialytic weight gain was 3.0+/-2.6kg in indigenous patients and 2.0+/-0.8kg in non-indigenous patients (p=0.010). Serum sodium and bicarbonate were 136.2+/-2.7mmol/L and 22.3+/-1.7mmol/L in indigenous patients and 138.5+/-2.3mmol/L and 25.2+/-5.8mmol/L in non-indigenous patients (p=0.010,0.003). Glucose, HbA1c and triglyceride were 9.7+/-4.6mmol/L, 7.0+/-1.7% and 2.2+/-1.3mmol/L in indigenous patients and 7.0+/-2.8mmol/L, 6.2+/-1.0% and 1.4+/-0.7mmol/L in non-indigenous patients (p= 0.005, 0.047, 0.016). No differences were observed in dry weight, PG-SGA, post-dialysis albumin, serum potassium, urea, creatinine, parathyroid hormone, phosphate, calcium, C-reactive protein or hemoglobin. This study indicates that differences exist between Australian indigenous and non-indigenous maintenance hemodialysis patients, with indigenous patients less likely to be meeting recommendations.

Anxiety and Depression in Maintenance Dialysis Patients: Preliminary Data of a Cross-sectional Study and Brief Literature Review

Anxiety and depression affect the quality of life of maintenance dialysis (MD) patients. There is little information concerning the extent to which the experience of individual hemodialysis treatments engenders anxiety in this patient population. This preliminary study examined the prevalence and severity of anxiety and depression in MD patients and the incidence of anxiety related to dialysis treatment. One hundred seventy patients, 155 undergoing maintenance hemodialysis and 15 undergoing chronic peritoneal dialysis, were examined. Inclusion criteria included dialysis vintage of at least 6 months. Patients completed the Beck Anxiety Inventory and Beck Depression Inventory and questionnaires that examined their feelings of anxiety related to individual hemodialysis sessions. Patients' mean age was 56 ± standard deviation of 16 years; dialysis vintage, 55 ± 48 months; 46% were female. The data confirmed a high prevalence of anxiety and depression in MD patients. Many MD patients become anxious, often severely, by merely going for routine hemodialysis treatment and also owing to such common events as being connected to the hemodialyzer by a new person or on hearing their hemodialyzer alarm sound. Anxiety and depression are common in MD patients. Many patients who are well established on MD experience anxiety during individual maintenance hemodialysis treatments.

An Experimental, Simplified Method for Intradialytic Cardiac Output Measurement

Hypotension during hemodialysis (HD) is a frequent and troublesome treatment complication. A decrease in the cardiac output (CO) due to an imbalance in the rates of fluid ultrafiltration vs. tissue reabsorption is a major cause of such episodes; thus, routine repeated measurements of CO during HD sessions could be of use in preventing its occurrence. We tested an experimental method (EXP) for measuring CO during HD using hardware already supplied with current Gambro dialysis machines. In 12 HD patients, CO was measured twice during dialysis by injecting a small (2 mL) bolus of highly concentrated saline into the patient's bloodstream and measuring the subsequent increase in dialysate conductivity using the Diascan technology. CO was calculated with the Stewart-Hamilton method using the area under the conductivity curve, measured dialysate flow rate, and dialyzer clearance. Compared with ultrasound hemodilution measurements, the EXP showed no bias and limits of agreement of ±34.6%. The intradialytic trend correlated well between the two methods (r(2) = 0.63, concordance rate 100%). We propose that with further development and refining, reliable measurements of CO could be performed easily during routine HD treatment using this new methodology.

C054 Sound localisation in binaural cochlear implanted patients with single device

Patients with end stage renal disease on hemodialysis are affected by physiological and psychological stressors, which contribute to poor quality of life and negative clinical outcomes. Depression, anxiety, and stress are highly prevalent in this population. Effective interventional strategies are required to manage these psychological symptoms. Acupressure has been believed to be one of the complementary therapies that could promote psychological wellbeing.The aim of this study was to evaluate the effects of acupressure on depression, anxiety, stress, and general psychological distress in patients with hemodialysis.Open-label randomized controlled trial.Three hemodialysis centers.A total of 108 patients with hemodialysis were randomly recruited into the acupressure group (n = 54) and the control group (n = 54).The intervention was carried out from January to March 2014. The acupressure group received routine hemodialysis treatment plus 15 min acupressure applied three times a week for four weeks. The control group received only usual care with routine hemodialysis treatment. The outcome measurements were the Depression, Anxiety Stress Scales (DASS-21), and general psychological distress using the General Health Questionnaire (GHQ-28). Statistical analysis was performed using Wilcoxon signed-rank test to compare DASS scales and GHQ-28 scores before and after acupressure intervention.The acupressure group had significantly lower DASS scores and GHQ scores compared to the control group, signifying improvements in depression, anxiety, stress and general psychological distress. The sub-score of the GHQ-28 for social dysfunction, however, were similar in both groups.Findings from this study indicates that acupressure therapy delivered three times a week for four weeks was able to significantly reduce depression, anxiety, stress, and general psychological distress in patients with hemodialysis. This positive finding suggests that acupressure may have a role in promoting psychological wellbeing of patients. Promoting psychological wellness will improve patients’ quality of life, and reduce negative outcomes associated with psychological illnesses and distress experienced by patients with hemodialysis.

Clinical study on effects of different blood purification treatment to cardiovascular stability

Objective To compare different blood purification techniques on cardiovascular stability in patients with chronic renal failure (CRF) and its inherent possible mechanism. Methods 90patients with CRF were randomly divided into 3 groups. Group A (HD Group) was applied 3 times per week hemodialysis (HD) treatment; Group B (HDF group) 2 times a week routine standard hemodialysis (HD)treatment and 1 time a week hemodiafiltration (HDF) treatment; Group C (HP group) 2 times a week routine standard blood dialysis (HD) treatment and 1 time a week hemoperfusion (HP) combined with hemodialysis (HD) treatment. The treatment time in every group is 10 weeks, after that there was an interval of 2 weeks with a Fresenius F6 or F8 routine HD treatment , the total time was 6 months. The incidence of cardiovascular complications in the three groups during dialysis, and parathyroid hormone (iPTH), plasma renin (RA),angiotensin Ⅱ (Ang Ⅱ ) changes after 6 months of treatment were compared. Results During dialysis,patients of groups B and C compared with group A significantly reduced cardiovascular complications( group B is 11.3%, group C is 10.9%, but group A is 20.4% ), after treatment plasma iPTH, renin (RA),angiotensin Ⅱ (Ang Ⅱ ) were also decreased significantly compared with group A, but the groups B and C had no significant difference. Conclusion Patients with Hemodialysis or hemoperfusion treatment have better cardiovascular stability, This may be associated with the effective removal of plasma RA, Ang Ⅱ , parathyroid hormone (iPTH) and other middle molecule toxins, both treatments have an equal effect due to simple operation and low equipment requirements, hemoperfusion is much easier to be carried out universally. Key words: Cardiovascular complications; Hemodiafiltration HDF; Hemoperfusion; Parathyroid hormone; Renin; Angiotensin Ⅱ (Ang Ⅱ )

Negative Dialysate to Sodium Gradient Does not Lead to Intracellular Volume Expansion Post Hemodialysis

Intradialytic hypotension remains the most common complication of routine outpatient hemodialysis treatments. There is debate as to the optimum dialysate sodium concentration, with hypotonic dialysates potentially causing intracellular swelling and hypertonic ones intracellular dehydration. Multi-frequency bioimpedance was used to assess extracellular and intracellular fluid volumes in 53 adult hemodialysis patients. Dialysate sodium was checked by ion electrophoresis. The mean decrease in extracellular volume and intracellular volumes were 1.01 ±0.09 and 0.88 ±0.18 kg, respectively. The median dialysate to sodium gradient was -3 mmol/L (-1 to -6), with a median dialysate sodium of 136 mmol/L (136-138). There was no association between changes in body fluid composition and sodium concentrations, or gradients. The mean difference between dialysate sodium prescribed and delivered was 2.4 ±0.8 mmol/L. In this study we were unable to demonstrate a relationship between predialysis serum sodium and the dialysate sodium prescribed and changes in extracellular or intracellular fluid volumes. However this study showed that using a negative sodium gradient, patients can be successfully ultrafiltrated without setting up intracompartmental fluid gradients. The caveat is that the prescribed dialysate to serum sodium gradient may differ from the actual gradient.

White Thrombus Formation in Blood Tubing Lines in a Chronic Hemodialysis Unit

Previous reports have described white particulate matter in banked blood components, but no prior public reports describe such matter in blood tubing during the course of routine in-center hemodialysis. This report describes the events, investigations, and preliminary conclusions associated with the spontaneous formation of adherent white thrombus in the venous and arterial blood lines during routine in-center hemodialysis treatments. Design setting, participants, & measurements: This investigation occurred at the Portland Veterans Administration Medical Center (PVAMC) Hemodialysis Unit from October 2006 through April 2007. Sixty-eight variables regarding demographics, medical history and dialysis treatments were collected on our 34 chronic hemodialysis outpatients. Over a 5-wk interval, 62% (21 of 34) of the chronic hemodialysis patients unexpectedly developed a white precipitate adhering to the lumenal surface of their dialysis blood tubing, with 73 of 580 chronic dialysis treatments exhibiting the phenomenon. Microscopic and biochemical analyses were consistent with white thrombus, formed by an aggregation of platelets and fibrin. An alert was issued and other in-center hemodialysis units noted similar findings. This was remedied by the removal of specific tubing. Both patient-specific and tubing-specific factors may have been operative. Although patient safety was not adversely affected, assessment of clinical and manufacturing variables potentially affecting platelet activation is warranted.

Randomized Controlled Trial of Intradialytic Resistance Training to Target Muscle Wasting in ESRD: The Progressive Exercise for Anabolism in Kidney Disease (PEAK) Study

To determine whether prolonged (24 weeks) intradialytic progressive resistance training (PRT) could counteract muscle wasting more effectively than short-duration training (12 weeks) in patients with end-stage renal disease. Randomized controlled trial. 49 patients (age, 62.6 +/- 14.2 years; 0.3 to 16.7 years on hemodialysis therapy) were randomly assigned to PRT plus usual care for 24 weeks (24WK group) or a crossover control group that received usual care for the first 12 weeks, then PRT plus usual care for the latter 12 weeks (12WK group). Two sets of 10 free-weight PRT exercises were performed at a high intensity during routine thrice-weekly hemodialysis treatment under direct supervision. Primary outcomes include thigh muscle cross-sectional area by means of computed tomography and intramuscular lipid content estimated through attenuation. Secondary outcomes include muscular strength, exercise capacity, and C-reactive protein level. The 24WK group increased muscle cross-sectional area (+1.82 +/- 3.25 cm(2)) compared with losses in the 12WK group (-1.37 +/- 6.87 cm(2); relative effect size, 0.59; 95% confidence interval [CI], -0.27 to 6.65; P = 0.04). However, this outcome did not achieve the level of statistical significance required (P = 0.025) after Bonferroni correction for multiple primary outcomes. There was no significant change in intramuscular lipid content between groups (+0.19 +/- 1.32 versus +0.16 +/- 1.69 Hounsfield units in the 24WK and 12WK groups, respectively; P = 0.31). Log C-reactive protein level tended to decrease in the 24WK group compared with the 12WK group (relative effect size, -0.63; 95% CI, -0.27 [-0.54 to 0.00]; P = 0.05). The 24WK group improved muscular strength measures and exercise capacity throughout the trial. Single geographic site used; no control group without exercise exposure; unblinded assessment of some secondary outcome measures. Prolonged intradialytic PRT did not significantly improve muscle cross-sectional area or intramuscular lipid content compared with a shorter duration of exercise. Future trials are required to more thoroughly investigate the clinical importance and magnitude of myogenic adaptations to PRT in this cohort.

Progressive Exercise for Anabolism in Kidney Disease (PEAK)

Skeletal muscle wasting is common and insidious in patients who receive maintenance hemodialysis treatment for the management of ESRD. The objective of this study was to determine whether 12 wk of high-intensity, progressive resistance training (PRT) administered during routine hemodialysis treatment could improve skeletal muscle quantity and quality versus usual care. Forty-nine patients (62.6 +/- 14.2 yr; 0.3 to 16.7 yr on dialysis) were recruited from the outpatient hemodialysis unit of the St. George Public Hospital (Sydney, Australia). Patients were randomized to PRT + usual care (n = 24) or usual care control only (n = 25). The PRT group performed two sets of 10 exercises at a high intensity (15 to 17/20 on the Borg Scale) using free weights, three times per week for 12 wk during routine hemodialysis treatment. Primary outcomes included thigh muscle quantity (cross-sectional area [CSA]) and quality (intramuscular lipid content via attenuation) evaluated by computed tomography scan. Secondary outcomes included muscle strength, exercise capacity, body circumference measures, proinflammatory cytokine C-reactive protein, and quality of life. There was no statistically significant difference in muscle CSA change between groups. However, there were statistically significant improvements in muscle attenuation, muscle strength, mid-thigh and mid-arm circumference, body weight, and C-reactive protein in the PRT group relative to the nonexercising control group. These findings suggest that patients with ESRD can improve skeletal muscle quality and derive other health-related adaptations solely by engaging in a 12-wk high-intensity PRT regimen during routine hemodialysis treatment sessions. Longer training durations or more sensitive analysis techniques may be required to document alterations in muscle CSA.

Acute effects of hemodialysis on cytokine transcription profiles: Evidence for C-reactive protein-dependency of mediator induction

Chronic microinflammation increases cardiovascular morbidity in chronic hemodialysis (HD) patients. Previously published studies are controversial with respect to acute effects of HD treatment on up- or downregulation of cytokine protein levels. Twenty-nine chronic HD patients were hemodialysed for 4 h with a 4008 dialyser using high-flux membranes. Patients were separated into a low (up to 1 mg/dl) and a high (1.1 to 5.5 mg/dl) C-reactive protein (CRP) group. Blood was drawn before HD and 240 min after initiation of HD. Acute changes of transcript levels encoding pro- and anti-inflammatory mediators were analyzed in RNA stabilized immediately from blood leukocytes using microarray analysis (n=1) and quantitative real-time polymerase chain reaction (PCR) (Light Cycler) (n=29). In both patient groups, HD treatment significantly increased the transcript levels of several pro-inflammatory cytokines, such as tumor necrosis factor alpha and interleukin-8 (IL-8), and chemokine receptors such as C-X-C chemokine receptor type 4, C-C chemokine receptor type 7, and the fractakine receptor CX3C chemokine receptor 1. In the low CRP group, the increase of transcript levels for anti-inflammatory IL-1-receptor antagonist and of the receptor for the anti-inflammatory cytokines IL-10 and interferon gamma was significantly more pronounced than in the high CRP group. Subgroup analysis revealed no difference between diabetic vs non-diabetic patients. These observations point towards a marked influence of a routine hemodialysis treatment on transcription in leukocytes of pro- and anti-inflammatory cytokines and receptors relevant for microinflammation. Diminished upregulation of receptors for anti-inflammatory factors in HD patients with high CRP levels could contribute to enhanced microinflammation in those patients.

Acute and chronic inflammation in pediatric patients receiving hemodialysis

ObjectivesTo assess chronic and acute inflammation in children receiving maintenance hemodialysis. Study designTo assess markers of acute inflammation, serum levels (ELISA) of the cytokines tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-10, and IL-6, 3 to 5 mL of serum was obtained from 13 pediatric patients (mean patient weight, 37.0±15.2 kg; mean age, 14.6±4.6 years) before and 30 minutes and 24 hours after a routine midweek hemodialysis treatment session. Chronic inflammation was assessed by serum C-reactive protein (CRP) levels. ResultsEarly-response cytokines TNF-α at 30 minutes (5.84±0.94 to 9.67±0.92 pg/mL; P=.002) and 24 hours (5.84±0.94 to 9.54±1.05 pg/mL; P=.008) and IL-1β at 30 minutes (17.19±2.00 to 26.17±1.12 pg/mL; P=.001) and 24 hours (17.19±2.00 to 23.01±1.13 pg/mL; P=.02) increased significantly after hemodialysis. Later-response cytokines IL-10 and IL-6 activation was not significant. CRP levels were elevated in 10 of 13 patients (mean, 14.7±9.5mg/L; range, 7.2-38.8 mg/L) and correlated with dialysis vintage. Baseline IL-6 and IL-10 levels correlated with dialysis vintage and correlated negatively with eqKt/V. ConclusionsWe observed a chronic inflammatory state in pediatric hemodialysis patients not related to the hemodialysis treatment but rather dialysis vintage and hemodialysis adequacy. We suggest that either more frequent dialysis or enhanced cytokine clearance may ameliorate the chronic inflammatory state observed in pediatric patients receiving hemodialysis.

Human Fatalities from Cyanobacteria: Chemical and Biological Evidence for Cyanotoxins

An outbreak of acute liver failure occurred at a dialysis center in Caruaru, Brazil (8 degrees 17' S, 35 degrees 58' W), 134 km from Recife, the state capital of Pernambuco. At the clinic, 116 (89%) of 131 patients experienced visual disturbances, nausea, and vomiting after routine hemodialysis treatment on 13-20 February 1996. Subsequently, 100 patients developed acute liver failure, and of these 76 died. As of December 1996, 52 of the deaths could be attributed to a common syndrome now called Caruaru syndrome. Examination of phytoplankton from the dialysis clinic's water source, analyses of the clinic's water treatment system, plus serum and liver tissue of clinic patients led to the identification of two groups of cyanobacterial toxins, the hepatotoxic cyclic peptide microcystins and the hepatotoxic alkaloid cylindrospermopsin. Comparison of victims' symptoms and pathology using animal studies of these two cyanotoxins leads us to conclude that the major contributing factor to death of the dialyses patients was intravenous exposure to microcystins, specifically microcystin-YR, -LR, and -AR. From liver concentrations and exposure volumes, it was estimated that 19.5 microg/L microcystin was in the water used for dialysis treatments. This is 19.5 times the level set as a guideline for safe drinking water supplies by the World Health Organization.

Human fatalities from cyanobacteria: chemical and biological evidence for cyanotoxins.

An outbreak of acute liver failure occurred at a dialysis center in Caruaru, Brazil (8 degrees 17' S, 35 degrees 58' W), 134 km from Recife, the state capital of Pernambuco. At the clinic, 116 (89%) of 131 patients experienced visual disturbances, nausea, and vomiting after routine hemodialysis treatment on 13-20 February 1996. Subsequently, 100 patients developed acute liver failure, and of these 76 died. As of December 1996, 52 of the deaths could be attributed to a common syndrome now called Caruaru syndrome. Examination of phytoplankton from the dialysis clinic's water source, analyses of the clinic's water treatment system, plus serum and liver tissue of clinic patients led to the identification of two groups of cyanobacterial toxins, the hepatotoxic cyclic peptide microcystins and the hepatotoxic alkaloid cylindrospermopsin. Comparison of victims' symptoms and pathology using animal studies of these two cyanotoxins leads us to conclude that the major contributing factor to death of the dialyses patients was intravenous exposure to microcystins, specifically microcystin-YR, -LR, and -AR. From liver concentrations and exposure volumes, it was estimated that 19.5 microg/L microcystin was in the water used for dialysis treatments. This is 19.5 times the level set as a guideline for safe drinking water supplies by the World Health Organization.

Biochemical and hematological changes in low-level aluminum intoxication.

The aim of this study was to investigate the biochemical and hematological changes in patients on routine hemodialysis treatment when they were accidentally exposed to moderately high serum aluminum concentrations during a period of time of less than four months. We studied the changes in biochemical and hematological measurements in 33 patients on dialysis in our hospital before and during the exposure to about 0.85 pmol/l of aluminum in dialysis water due to a malfunction of the reverse osmosis system of water purification. Patients showed a decrease in the hemoglobin concentration from 115+/-12.4 g/l to 108+/-12.2 g/l (p=0.026) and in the mean corpuscular hemoglobin concentration from 5.15+/-0.22 to 5.02+/-0.30 mmol/l (p=0.014). Ferritin was decreased from 243+/-192 microg/l to 196+/-163 microg/l (p=0.047) and transferrin saturation from 0.20+/-0.06 to 0.15+/-0.07 (p=0.004). Biochemical measurements related to calcium-phosphate metabolism did not change. Otherwise, all patients showed an increase in serum aluminum from 0.56+/-0.44 to 1.63+/-0.52 micromol/l (p<0.001). No differences were detected in serum aluminum between patients receiving and not receiving oral aluminum salts. Even moderately high aluminum concentrations maintained during a short period of time could produce significant hematological alterations and a depletion of body iron stores before clinical manifestations were evident.

Failure of advance care planning to elicit patients' preferences for withdrawal from dialysis.

Although withdrawal from dialysis is relatively common among dialysis patients, little is known about the patients' consideration of withdrawal during advance care planning. We studied a stratified random sample of 400 hemodialysis patients in two geographic areas (all six dialysis units within 75 miles of Morgantown, WV, and all nine dialysis units in Rochester, NY) by reviewing responses to a questionnaire addressing issues of advance care planning. Interviews were performed by trained interviewers during a routine hemodialysis treatment. Fifty-one percent of the patients had completed an advance directive (29% had a living will and a health care proxy, 22% had a living will or proxy). Patients who had completed advance directives were more likely to have notified their decision makers of their roles (91% with a living will and health care proxy, 81% with a living will or proxy v 55% who had no advance directive; P < 0.01). Most patients had not discussed their wishes for specific interventions in the event of permanent coma: 41% had discussed mechanical ventilation; 35%, tube feedings; 25%, cardiopulmonary resuscitation; and only 18% had discussed stopping dialysis. Patients who had completed a living will and proxy were most likely to have discussed end-of-life care, but stopping dialysis was the least often discussed intervention, even in this patient subset. Sixty-nine percent had discussed mechanical ventilation; 55%, tube feedings; 43%, cardiopulmonary resuscitation; and only 31% had discussed stopping dialysis (all P < 0.001). Although withdrawal from dialysis is relatively common, it is rarely discussed in advance care planning by dialysis patients. Dialysis unit staff and nephrologists should address issues involving withdrawal from dialysis with their chronic dialysis patients.