Use of double-lumen dialysis catheters. Loading with locked heparin.

Improvement in double-lumen catheter usage could provide lasting, user friendly angioaccess for patients on hemodialysis (HD), especially those on home HD. These catheters are routinely locked with concentrated heparin at the end of an HD session, in a volume corresponding to the lumen capacity. At the start of the next HD session, this heparin is aspirated with a small amount of blood and discarded. The cumulative blood loss over a long period becomes significant. The authors aimed to study whether a predetermined loading dose of heparin could be used to lock the catheter, and be administered as such during the next HD session. Thirteen patients were evaluated during four HD sessions (Rx 1 through 4; Rx 4 followed a weekend). Prior to the first study HD (Rx 1), the catheter was locked with 10,000 units heparin per lumen, as per our standard practice. Therefore, Rx 1 was considered the standard for the purpose of the study. On study HD (Rx 1 through 4), the catheter was locked with the patient's loading dose (half per lumen). The heparin loading dose was given as follows: Rx 1 and 2 = fresh heparin; Rx 3 and 4 = locked heparin. Again, activated clotting time (ACT) was measured periodically and heparin was given according to an ACT-based sliding scale. The first ACT and heparin level (drawn after the loading dose) were compared for Rx 1 vs Rx 2, 3, and 4. The mean (+/- SEM) values were as follows: Rx 1--first ACT = 299.2 +/- 16.5 sec, heparin level = 1.25 +/- 0.15 IU/ml; Rx 2--first ACT = 305 +/- 20 sec, heparin level = 1.1 +/- 0.09 IU/ml; Rx 3--first ACT = 293 +/- 18.5 sec, heparin level = 1.1 +/- 0.19 IU/ml; and Rx 4--first ACT = 288 +/- 24.1 sec, heparin level = 1.07 +/- 0.16 IU/ml. The mean of the differences between Rx 1 and Rx 2, 3, and 4, were not significantly different for all of the analyzed parameters. No catheter was lost during the study period. The results suggest that locked heparin can be effectively used as the loading dose. Advantages of this method include decreased blood wastage, heparin cost savings corresponding to the cost of concentrated heparin (approximately $156.00 per patient year for HD three time weekly), and at least one less connection per catheter lumen. The latter would possibly reduce the risk of transluminal catheter related infections.

ATGAM associated coagulopathy in renal transplant patients: a report of two unusual cases.

Polyclonal antibodies, used for both induction and rejection therapy in renal transplant recipients, are associated with such side effects as chills and fever. We describe two patients who developed a coagulopathy during antithymocyte globulin (ATGAM) therapy, a previously unknown complication. The laboratory tests revealed prolonged prothrombin and partial thromboplastin times and thrombocytopenia. Discontinuation of ATGAM therapy resulted in correction of these abnormalities.

Hypocholesterolemia is not associated with neurotoxicity in renal transplant patients.

Cyclosporine-associated neurotoxicity has been reported in recipients of solid organ and bone marrow transplantation. Neurotoxicity during cyclosporine therapy has been suggested to be associated with low levels of serum total cholesterol (TC). We report seven hypocholesterolemic (TC < 150 mg/dl) renal transplant recipients who remained asymptomatic during cyclosporine therapy. Three of these patients were hypocholesterolemic at the time of transplantation and received intravenous cyclosporine as induction therapy. The other four patients became hypocholesterolemic > or = 9 months after renal-transplantation. None of these patients developed neurologic signs or symptoms during cyclosporine therapy. Our short and long-term observations in renal transplant recipients suggest that perhaps factors other than low cholesterol levels may be responsible for cyclosporine-associated neurotoxicity.

Long term effects of ACE inhibitors on the erythrocytosis in renal transplant recipients.

Erythrocytosis is infrequently seen in renal transplant recipients. Both theophylline and angiotensin converting enzyme (ACE) inhibitors have been reported to decrease the elevated hematocrit (Hct) and hemoglobin (Hgb) levels. We studied the efficacy of the ACE inhibitors ramipril (n = 6) and enalapril (n = 1) in seven stable renal transplant recipients. Although the ACE inhibitors significantly reduced the elevated Hct and Hgb levels during the short and long term (Hct 53 +/- 1 vs 48.8 +/- 0.7%; Hgb 17.8 +/- 0.4 vs 16.7 +/- 0.3 vs 16.7 +/- 0.3 gm/dl, at 1 year), the clinical significance of these reductions remains unknown. During therapy there were no significant changes in the blood pressure, serum creatinine and potassium levels and the medications were well tolerated.

Effects of dietary therapy on post renal transplant hyperlipidemia. A prospective study.

Hyperlipidemia often occurs after renal transplantation and may contribute to increased cardiovascular morbidity. The National cholesterol education program guidelines (NCEP) recommend dietary modification as the initial therapeutic intervention. We evaluated the effects of the AHA Step I and Step II diets on the serum total cholesterol (TC) and the triglyceride (TG) levels in nondiabetic renal transplant patients. Both the AHA Step I (TC 296 +/- 7 vs 294 +/- 9 mg/dL, p = ns) and Step II diets (TC 282 +/- 8 vs 292 +/- 16 mg/dL, p = ns) failed to significantly lower the serum total cholesterol and the triglycerides levels. During this dietary intervention, the patients' body weight and serum creatinine level remained stable. Our data suggest that neither the AHA Step 1 nor the Step II diet are effective in significantly lowering elevated serum lipids in nondiabetic renal transplant recipients.

Long-term successful nocturnal intermittent peritoneal dialysis: a ten-year case study.

We report a case of polycystic kidney disease, successfully dialyzed using nocturnal intermittent peritoneal dialysis (NIPD) for ten years. Other forms of renal replacement therapy, which included hemodialysis, continuous ambulatory peritoneal dialysis (CAPD), intermittent peritoneal dialysis (IPD), and renal transplantation, were unsuitable for the patient. A peritoneal equilibration test revealed a 4-h D/P creatinine (Cr) ratio of 0.54. In January 1984, the patient began NIPD for 12 h, using a dialysis solution dose of 14 L/day, and 2 L/exchange. In January 1986, because of clinical under-dialysis, the dialysis solution dose was increased to 20 L/day, with an exchange volume of 1.57 L. The prescribed outflow time was 20 min. Dialysis was still inadequate with a weekly corrected Cr clearance (CoCrCl/w) of 33.6 L. In August 1986, the outflow time was reduced to 14 min and the total dialysis time to 11 h. Despite the latter, the efficiency of dialysis was greater because of longer full contact between dialysate and peritoneum. The last change resulted in marked clinical improvement and CoCrCl/w increased to 39.9 L. Over the years, the patient's peritoneal transport changed to high average (4-h D/P Cr = 0.74) and NIPD provided even better clearances (CoCrCl/w = 59.96 L in 1994). The report emphasizes that NIPD, if properly tailored, can provide clinically adequate long-term dialysis.

Nephrogenic diabetes insipidus presenting after head trauma.

Water diuresis after head trauma is most often due to central diabetes insipidus (DI). We report a patient with a history of a bipolar disorder and past lithium use who was noted to have polyuria and hypernatremia after head trauma. Inappropriate high sodium and volume replacement resulted in an increase in the polyuria. A lack of response to antidiuretic hormone/antidiuretic-hormone-like preparations led to the diagnosis of nephrogenic DI. The case illustrates the importance of calculating electrolyte-free osmolar clearance in the correction of hypernatremia. Persistence of the DI and mild renal impairment probably due to past lithium use are discussed.

Steroidogenic inhibition in testicular tissue of formaldehyde exposed rats.

Three groups of rats (n = 10) were subjected to intraperitoneal treatment of formaldehyde daily at doses of 5, 10 and 15 mg/kg body weight over a period of 30 days. Gradual diminution in body and testicular weight was observed in all treated groups. Leyding cell impairement was conspicuous in those given doses of 10 and 15 mg/kg. Inhibition of 3 beta-delta 5-hydroxy steroid dehydrogenase and accumulation of sudanophillic materials in testicular tissue of formaldehyde treated rats was recorded histochemically. Significant decline of serum testosterone was also observed in the same groups. Structural and functional impairement of Leydig cells after formaldehyde treatment caused steroidogenic inhibition.

Echocardiography and pulmonary artery pressure: correlation in chronic obstructive pulmonary disease.

The aim of this study was to assess whether 2 dimensional echocardiography can provide reliable parameters to quantitatively estimate pulmonary hypertension (PH) in patients with chronic obstructive pulmonary disease. Twenty subjects, 16 males and 4 females, mean age 54.5 year +/- 4.92 were evaluated. Right ventricular dimensions were measured using subcostal 2- dimensional (2D) approach viz. right ventricular maximum short axis (Rv) and tricuspid annulus (TA). Free right ventricular anterior wall (AW) was measured by M-Mode. A 2D Index was calculated RV x TA + Aw and the same correlated with mean pulmonary artery pressure (r = 0.97). This appears to be a useful non-invasive method foe estimating PH in cases of COPD.

Child population and attitudes towards children in an arid village.

PIP: Examines the socioeconomic characteristics of the child population of an arid village. A representative arid village in Jodhpur district was selected; information was collected by means of participant observation and interview. Informal discussions were also conducted with villagers. A total of 10% of the households of different castes were sampled. The 1971 census indicated that children under 15 years of age accounted for 42% of the Indian population, and as much as 45% of the population of the 12 arid districts of Rajasthan. In these villages child marriage is the norm, and there is little or no effort to control the size of families. Moreover, there is a tendency to actively desire a large number of children, particularly boys. This attitude is changing--parents now regard 3 to 5 offspring to be a reasonable amount. Female children are less valued than their male counterparts and subsequently have a higher mortality rate. Feeding practices give priority to boys, even over the head of household, with girls enjoying priority over the adult male, and the adult female being placed last. Children's health is often ar risk from easily preventable and communicable diseases; treatments for these diseases are in many cases traditional remedies. Their poor physical condition notwithstanding, children are treated as important members of the arid zone society, but some of the deep seated feelings concerning children and their welfare constitute part of the problem of development for children in arid regions of India.^ieng