Short Duration Of Dialysis Research Articles

Evaluation of acute intradialytic complications, management & outcome in end-stage renal disease patients

Little is known about the challenges of routine renal replacement therapy in Bangladesh. We investigated the fatal and nonfatal acute hemodialysis complications in patients with end stage renal disease (ESRD) in dialysis centers in Mymensingh. 500 consecutive hemodialysis sessions incurred over a 4-month period by 50 patients with ESRD, receiving two weekly hemodialysis sessions of 4 hours each were considered. Personal and clinical profiles before, during, and within 24 hours after hemodialysis sessions were used to diagnose complications. The mean age of the patients was 45.5 ± 16.8 years and the lowest and highest ages were 17 and 82 years respectively. Male was predominant of the patients and male to female ratio was 2:1. Hypotension, muscular cramps, pruritus, nausea and vomiting were the common complications in end-stage renal disease patients. Twenty eight percent of patients presented with hypertensive crisis, 34% fever, 18% bleeding, 44% headache, 32% vomiting, 16% lumber pain, 16% palpitations, 22% disequilibrium syndrome, 36% dyspnea, 28% chest pain, 20% syncope, 32% abdominal problem, 44% neurological problem, 46% electrolyte imbalance, 34% articular & musculoskeletal problems, 48% cramps, 38% convulsions and 20% loss of consciousness. The vascular access was the main bleeding site of the patients (44.5%), followed by 33.3% through nose and 22.2% digestive tract bleeding. Most of patients experienced muscular cramps, hypertensive crisis, pruritus, vomiting, palpitations, disequilibrium syndrome, dyspnea, chest pain, neurologic problem, electrolyte disorders, nausea, vomiting, convulsions and loss of consciousness in shorter duration of dialysis than those in longer duration of dialysis sessions. Bleeding, disequilibrium syndrome and cardiovascular disease were leading cause of death in end-stage renal disease patients. Those complications occurred mostly during understaffed periods. Urgent strategies are needed to quickly solve the human capital crisis in the health care sector. DOI: http://dx.doi.org/10.3329/cbmj.v2i2.16696 Community Based Medical Journal 2013 July: Vol.02 No 02: 35-40

Should We Do Cardiac Stress Tests in Asymptomatic Renal Transplant Candidates?

BackgroundThere is controversy regarding the best method and benefit of cardiac evaluation of asymptomatic renal transplant candidates. The positive predictive value of ischemia on a noninvasive stress test was ∼5%–10% in Kidney Disease Outcomes Quality Initative (KDOQI), American Society of Transplantation (AST), and Lisbon guidelines. We compared prediction of cardiac events with the use of simple transthoracic echocardiography versus a noninvasive stress test in asymptomatic candidates. MethodsWe selected asymptomatic patients with good functional capacity who would be recommended a cardiac stress test by both KDOQI and AST guidelines, we excluding those with a history of cardiovascular disease. Group A (n = 124) underwent only echocardiography, and group B (n = 41) underwent echocardiography and noninvasive stress test. We measured the incidences of cardiac events and cardiac death within 3 years after transplantation. ResultsThe mean age of group A was 39 ± 7 and group B 40 ± 5 years. Diabetic patients among groups A and B were 8.8% (11/124) and 9.7% (4/41), respectively. The mean duration of dialysis was 2.9 ± 5 years. Only 4 group B patients showed a positive result on the noninvasive stress test, but they had no obstructive disease on coronary angiograms. The incidences of ischemic heart disease after transplantation of groups A and B were 4% (5/124) and 4.8% (2/41), respectively (P = .88). There was no death due to cardiac events in either group. ConclusionsIn this study, simple echocardiography showed an ability similar to stress test to predict ischemic heart disease in asymptomatic renal transplant candidates with good functional capacity, relatively younger age, lower prevalence of diabetes, and shorter duration of dialysis.

Association Between Vascular Calcification Scores on Plain Radiographs and Fatty Acid Contents of Erythrocyte Membrane in Hemodialysis Patients

Vascular calcification (VC) scores determined by using simple plain radiographic films are known to be associated with coronary artery disease and mortality in patients undergoing hemodialysis (HD). Omega-3 fatty acid (FA) has been shown to reduce ectopic calcifications in an animal model, and it has also been shown that erythrocyte membrane omega-3 FA content is an independent discriminator of coronary artery disease. The present study was designed to demonstrate relations between VC scores and erythrocyte membrane FA contents in patients undergoing HD. A cross-sectional study was carried out. The study was carried out at an outpatient hemodialysis unit at Dong-A University Hospital, Busan, Republic of Korea. A total of 31 patients undergoing HD were recruited. Patients with significant malnutrition, a short duration of dialysis (<12 months), a history of recent infection, malignancy, or liver disease were excluded. Plain radiographic films of the feet, hands, pelvis, and lateral lumbar spine were examined and VC scores were determined using previously reported methods. Erythrocyte membrane FA contents were analyzed by gas chromatography. The erythrocyte membrane contents of eicosapentaenoic acid and docosahexaenoic acid were not found to be related with VC on simple plain radiographic films. However, erythrocyte membrane contents of oleic acid and total monounsaturated FA (MUFA) were significantly higher in patients with significant VC scores. Furthermore, erythrocyte membrane contents of MUFA and oleic acid were found to be negatively associated with high-density lipoprotein cholesterol level and positively associated with triglyceride level. Erythrocyte membrane contents of MUFA and oleic acid were found to be associated with VC scores determined using plain radiographs and with dyslipidemia in patients undergoing HD.

Comparison of Fatty Acid Contents of Erythrocyte Membrane in Hemodialysis and Peritoneal Dialysis Patients

Membrane fatty acid composition plays an important role in the cellular function. Erythrocyte fatty acid composition mirrors that of myocardium and is influenced by diet. Earlier studies have shown significant alterations of membrane fatty acid composition in ethnically mixed patients with end-stage renal disease. Given the impact of ethnic and dietary factors, we sought to examine membrane fatty acid composition in an ethnically homogeneous end-stage renal disease population residing in a coastal region of Korea with high fish consumption. Cross-sectional study. Outpatient facility at Dong-A University Hospital, Busan, Republic of Korea. We recruited 15 stable hemodialysis patients, 14 peritoneal dialysis patients, and 10 age- and gender-matched normal controls. Patients with significant malnutrition, short duration of dialysis, recent infection, malignancy, or liver disease were excluded. Dietary intake and use of omega-3 fatty acid supplements were determined. Erythrocyte membrane fatty acid contents measured by gas chromatography. Palmitoleic acid and alpha-linolenic acid levels were lower, whereas oleic acid, linoleic acid, and arachidonic acid levels were higher in patients with end-stage renal disease compared with the control group. Total monounsaturated fatty acids (palmitoleic acid and oleic acid) were significantly higher in peritoneal dialysis than in hemodialysis patients. Eicosapentaenoic acid and omega-3 docosapentaenoic acid were significantly higher, but total omega-6 fatty acids, omega-6/omega-3, and arachidonic acid/eicosapentaenoic acid ratios were significantly lower in hemodialysis patients consuming omega-3 supplements compared with those who did not. Patients with end-stage renal disease exhibited significant alterations in erythrocyte membrane fatty acids, which were partially modified by the dialysis modality and omega-3 fatty acid supplementation.

The value of QuantiFERON®TB-Gold in the diagnosis of tuberculosis among dialysis patients

It is difficult to diagnose tuberculosis (TB) in dialysis patients because of the high rate of extrapulmonary TB in these patients compared with the general population. Recently, a new diagnostic test called QuantiFERON (QFT) has been developed and shown promise as a diagnostic tool for active TB diseases and latent TB infection. We examined 162 dialysis patients admitted to a single institute, including 8 patients with active TB, and evaluated the utility of this test in dialysis patients. Among 162 dialysis patients, positive QFT results occurred in 28 (17.3%), negative QFT results occurred in 95 (58.6%) and indeterminate QFT results occurred in 39 (24.1%). All eight active TB patients had positive QFT results, and none of the 95 patients with negative results had active TB. Among 23 patients with a history of active TB, 10 (43.5%) had positive results. Although the indeterminate rate was relatively high, no patient with an indeterminate result had active TB. Factors such as shorter duration of dialysis, lower lymphocyte count and higher white blood cell count were associated with indeterminate results. Among 105 cases after excluding the patients with previous TB or indeterminate results, the sensitivity of the QFT is 100% (8 of 8) and the specificity is 89.7% (87 of 97 cases). Our data suggest that the QFT test is a useful supplementary tool for the diagnosis of active TB even in dialysis patients. Negative and indeterminate results on this test may be used to exclude the presence of active TB.

Effects of Monthly Dose and Regular Dosing of Intravenous Active Vitamin D Use on Mortality Among Patients Undergoing Hemodialysis

To determine if apparent protective mortality benefits of intravenous active vitamin D in patients undergoing hemodialysis extend across all groups defined by dialysis duration; if higher monthly dose and dosing regularity are associated with reduced mortality; and if intravenous active vitamin D use is associated with reduced cardiovascular, infectious, and cancer-related mortality. Retrospective cohort study. Centers for Medicare and Medicaid Services End-Stage Renal Disease database. A total of 193,830 patients undergoing hemodialysis during 1999-2000, of whom 94,208 (48.6%) were taking intravenous active vitamin D in the baseline period. Time-varying Cox proportional hazards models were used to assess the effects of monthly vitamin D dose and dosing regularity over 3-month intervals on risk of all-cause and cause-specific death, by dialysis duration groups (<1 yr, 1 to <3 yrs, 3 to <5 yrs, and >or=5 yrs from dialysis initiation). Models were adjusted for baseline characteristics, time-varying hospital days, monthly epoetin alfa dose, mean hemoglobin level, and urea reduction ratio in the 3-month intervals. Maximum follow-up time was 5.25 years. Adjusted all-cause mortality risk was reduced 7-17% among patients receiving vitamin D each month of the 3-month interval, with the highest reduction among patients with shorter dialysis duration. However, regular vitamin D dosing did not show consistent benefit across dialysis duration groups for cardiovascular, infectious, cancer, or other (all deaths not attributable to cardiovascular disease, infection, or cancer) mortality. Mortality benefits of intravenous vitamin D cannot be easily explained by currently proposed biologic mechanisms. Randomized controlled trials are needed to show definitively whether intravenous vitamin D can reduce all-cause and cause-specific mortality in patients undergoing dialysis compared with placebo.

Active Tuberculosis in Patients Undergoing Hemodialysis for End-stage Renal Disease: A 9-year Retrospective Analysis in a Single Center

Tuberculosis (TB) in patients undergoing hemodialysis (HD) for end-stage renal disease (ESRD) is commonly thought to be associated with a very poor prognosis. Moreover, it is difficult to diagnose. This report was designed to describe this condition and to determine the mortality rate and risk factors associated with mortality. In addition, the study evaluated the usefulness of QuantiFERON TB-2G((R)) (QFT-2G). Retrospective study Patients with confirmed TB admitted between January 2001 and May 2009 were retrospectively identified and enrolled. The clinical, radiological, and bacteriological data at the time of admission were recorded. A multivariate analysis was performed to identify the predictive factors for mortality. A total 19 TB patients (6 females; median age, 73 years) were included. TB occurred in most cases within 1.3 years from the initiation of dialysis. Most patients presented with fever (84.2%) and extrapulmonary TB (57.9%). The mortality rate within 24 weeks of the initiation of TB treatment was 36.8%. The factors associated with mortality were: a short duration of dialysis (HR 8.86, 95% CI 1.03-75.7, p=0.04), and underweight (HR 10.88, 95% CI 1.28-92.6, p=0.02). The sensitivity of QFT-2G, acid-fast smear, and polymerase chain reaction was 50, 80, and 88.2% respectively. These data indicate a high incidence of TB in the early stages of HD and a high mortality rate among these patients. The clinical utility of QFT-2G was found to be limited. Hypoalbuminemia might therefore be related to either indeterminate or negative results of QFT-2G.

Vitamin D Deficiency and Associated Factors in Hemodialysis Patients

Vitamin D deficiency is prevalent in the general elderly population, and is related to an increased risk of osteoporosis, fractures, and cardiovascular calcification. Only limited data and no guidelines are available on vitamin D deficiency in hemodialysis patients. We aimed to assess the frequency of, and factors associated with, 25(OH) vitamin D deficiency in hemodialysis patients in a French dialysis center. In March 2006, we studied all prevalent hemodialysis patients who had not received native vitamin D supplements in the recent past. According to the Kidney Disease Outcomes and Quality Initiative guidelines, patients were assigned to the following 3 groups: group 1, with a sufficient vitamin D serum level (>75 nmol/L); group 2, with an insufficient level (25 to 75 nmol/L); and group 3, with severe deficiency (<25 nmol/L). Patients' characteristics and biochemical findings were compared between patients of groups 1 and 3. Of 253 patients, 11% patients were in group 1; 47% were in group 2; and 42% were in group 3. The proportions of female and diabetes patients were 42% and 34%, respectively. The mean (+/- SD) age of all patients was 66.7 +/- 14 years, and the mean duration of dialysis was 62 +/- 74 months, with a mean schedule of 3 x 6.5 hours and administration of a 1.5 mmol/L calcium dialysate. Concomitant treatment included alfacalcidol (66% of patients) and sevelamer (34% of patients) as a standard phosphate binder. Group 3 patients had a lower dialysis vintage (53 +/- 66 vs. 73 +/- 85 months, P < .05), a higher number of diabetes patients (45% vs. 21%, P < .05), a higher number of female patients (53% vs. 28%, P < .05), and a higher level of intact parathyroid hormone (260 +/- 227 vs. 213 +/- 153 pg/mL, P < .05) than group 1 patients. No relationship was found between vitamin D storage levels and bone markers, serum calcium, phosphorus, albumin, body mass index, normalized protein catabolic rate, radiologic vascular calcification score, and hip bone mineral density. In multivariate logistic regression analyses, no factors were significantly associated with vitamin D deficiency. Calcidiol deficiency was highly prevalent in a French dialysis population. The associated factors mainly included female sex, diabetes, shorter dialysis duration, and higher intact parathyroid hormone level. Although there are no guidelines for the therapy of patients with chronic kidney disease at stage 5, the usefulness of vitamin D supplementation may be assessed by considering its potential direct action, the need for providing fuel for renal and extrarenal calcitriol production in particular, and the numerous potential favorable effects on health.

Cardiac Evaluation before Kidney Transplantation

Evaluation for ischemic heart disease (IHD) is a nonstandardized practice before kidney transplantation. We retrospectively studied pretransplant cardiac evaluation (CE) practices in a national sample of renal allograft recipients. The USRDS data for Medicare beneficiaries transplanted in 1991 to 2004 with Part A&B benefits from dialysis initiation through transplantation were examined. Clinical traits defining "high" expected IHD risk were defined as diabetes, prior IHD, or > or = 2 other coronary risk factors. Pretransplant CE were identified by billing claims for noninvasive stress tests and angiography. Patients were quantified with claims for coronary revascularization procedures between CE and transplant. Post-transplant acute myocardial infarction (AMI) events were abstracted from claims and death records. Among 27,786 eligible patients, 46.3% underwent CE before transplantation. Overall, 9.5% who received CE also received pretransplant revascularization, but only 0.3% of lower-risk patients undergoing CE had revascularization. The adjusted odds of transplant without CE increased sharply with younger age and shorter dialysis duration. Increased likelihood of transplant without CE also correlated with black race, female sex, and certain geographic regions. Among patients transplanted without CE, 3-yr incidence of post-transplant AMI was 3% in lower-risk and 10% in high-risk groups, and varied by individual traits within these groups. Among lower-risk patients transplanted without CE, blacks were higher risk for AMI than whites (adjusted hazards ratio 1.47, 95% CI 1.11-1.93). Observed practices demonstrate infrequent use of pretransplant revascularization after CE but also raise concern for socio-demographic barriers to evaluation access.

Renal Cell Carcinoma Detected by Screening Shows Better Patient Survival Than That Detected Following Symptoms in Dialysis Patients

There is an apparent advantage to early or incidental diagnosis of renal cell carcinoma in the general population. We investigated whether the prognosis of dialysis patients with renal cell carcinoma is better if renal cell carcinoma is detected by screening of patients without symptoms rather than by examination after the appearance of the symptoms. Two groups in which renal cell carcinomas were detected by screening (N = 721) and by symptoms (n = 76) were compared. The model tested consisted of patient age and duration of dialysis in addition to the detection by screening or symptoms. Cox proportional hazard model was used to compare survival rates between the groups. The hazard ratio of death from all causes in patients with renal cell carcinoma detection by screening was 0.653 and the risk of death was reduced by 35%, compared with that in the group with detection due to symptoms. Moreover, the 50% survival rate in the group detected by symptoms was 80 months and the ratio of those detected by screening was 119 months. Therefore, screening provided a survival benefit of 39 months (3.3 years) in death from all causes after adjustment for age and duration of dialysis. The survival rate was best in young patients with a short duration of dialysis and renal cell carcinoma detected by screening. In dialysis patients with renal cell carcinoma, the survival rate in the group detected by screening was better than that in the group detected by symptoms. Especially, there was a large effect of screening for renal cell carcinoma in the young dialysis patients.

An Intron 4 Gene Polymorphism in Endothelial Cell Nitric Oxide Synthase Might Modulate Lipid Metabolism in Nondiabetic Patients on Hemodialysis

We investigated the relationship between endothelial constitutive nitric oxide synthase (ecNOS) gene polymorphism and lipid metabolism in patients with nondiabetic chronic renal failure on hemodialysis. Serum from 181 nondiabetic patients on hemodialysis were examined. A genomic DNA fragment was amplified by polymerase chain reaction (PCR) for determining the ecNOS genotype. The PCR products were designated as a and b alleles by electrophoresis. In hemodialysis patients, the frequency of the ecNOS4 for b/b, b/a and a/a genotype was 76.6, 22.8 and 0.6%, respectively. There was not significant difference in the levels of total cholesterol (TC), triglyceride (TG) and calculated low-density lipoprotein cholesterol (LDL-c) in sera between patients (aa and ba) with the a allele and patients (bb) without the a allele. On the other hand, the levels of serum high-density lipoprotein cholesterol (HDL-c) in patients with the a allele (51.9 ± 3.33 mg/dl) were significantly higher than those in patients without the a allele (43.05 ± 1.40 mg/dl) (p = 0.005). The frequency of patients with the a allele and low levels of serum HDL-c among patients with a long duration of dialysis (≧10 years) was significantly lower than that in patients with short duration of dialysis (<10 years) (p = 0.05). It appears that an intron 4 gene polymorphism in ecNOS may modulate lipid metabolism in nondiabetic patients on hemodialysis and the a allele of ecNOS gene polymorphism may affect the prognosis of hemodialysis patients with low levels of serum HDL-c.

Erosive spondyloarthropathy in peritoneal dialysis patients

Erosive spondyloarthropathy (ESA) is common in long-term hemodialysed patients. However, it has been little recognized in peritoneal dialysis (PD) patients. In a retrospective study, we found severe ESA in 7 of the 87 (8%) patients undergoing PD in our center. Characteristics of our population were advanced age and short duration of dialysis (27±20 months). ESA patients were older than non ESA (74±4 vs 68±11 yrs,p<0.01). Secondary hyperparathyroidism and dialysis amyloid arthropathy were also possible pathogenic factors. Patients were followed for 4 years or until death and remained stable in most ESA cases. We conclude that ESA is age-related, is as frequent in PD as in HD populations and is not related to one single underlying mechanism.

The spectrum of bone disease in end-stage renal failure—An evolving disorder

We have assessed the bone histology in 259 chronic dialysis patients, all of whom were in the same dialysis program. All patients had bone biopsies with quantitative histomorphometry, intact parathyroid hormone (PTH) measurements, basal and deferoxamine stimulated serum aluminum levels. Results demonstrate the increased incidence of the recently described aplastic bone lesion, particularly in patients treated with peritoneal dialysis (PD). Aluminum-related bone disease is much less common than previously described, perhaps in relation to the declining use of aluminum as a phosphate binder. A different pattern of bone lesions is seen in PD as compared with hemodialysis (HD), with low turnover disorders comprising 66% of the lesions seen in PD and high turnover lesions accounting for 62% of the bone histologic findings in HD. The difference in these patterns may relate to alterations in PTH levels, as mean PTH levels in HD patients were 2-1/2 times the levels found in PD patients (P < 0.0005), while older age, higher prevalence of diabetes and a shorter duration of dialysis may also have contributed to the findings in the PD patients. We suggest that PD, perhaps by maintaining calcium at higher levels, may more effectively suppress the parathyroid gland.

Kinetic and Clinical Studies of 2Microglobulin in Continuous Ambulatory Peritoneal Dialysis: Influence of Renal and Enhanced Peritoneal Clearances Using Glucose Polymer

A risk of beta 2-microglobulin (beta 2-M)-associated amyloidosis in long-term CAPD patients has been recognised. We examined the kinetics of beta 2-M and potential clinical manifestations of amyloidosis in patients well-established on CAPD for 1-76 months (mean +/- SEM; 16.4 +/- 14 months). In 57 patients, serum beta 2-M concentration was elevated to 30 +/- 1.8 (mean +/- SEM, mg/l) and correlated positively with the duration on CAPD. In 18 patients studied with variable degrees of residual renal function, serum beta 2-M concentration increased with declining renal function; this was most marked when the creatinine clearance was less than 1 ml/min. Using an isosmolar solution (302 +/- 1.3 mOsm/kg) containing 5% glucose polymer (9.4 mmol/l; MW 16,800), the transperitoneal elimination of beta 2-M was significantly enhanced (1.6 times) compared to conventional 1.36% glucose solution, but without a detectable change in serum concentrations during a 6-h study. No significant difference was found between the estimated minimum volume of distribution of beta 2-M in CAPD and haemodialysis patients. Symptomatic amyloid-associated disease was absent in patients in this study, and may be attributed to the short duration of dialysis.