Blood Pressure of Maintenance Hemodialysis Patients in the Dalmatian Region of Croatia: Differences between Hospital and Out-of-Hospital Dialysis Centers.

AIMS: This study was aimed at comparing the incidence of arterial hypertension and blood pressure (BP) variance in hospital and out-of-hospital hemodialysis (HD) patients during HD sessions. METHODS: A cross-sectional study was conducted for 1 week at all the HD centers in Dalmatia, Croatia. The pre-, intra-, and post-dialysis BP values were collected for 3 consecutive HD sessions per patient. RESULTS: Of the 399 subjects, 73.9% were hypertensives, who showed higher interdialytic weight gain compared to the normotensives (2.58 vs. 2.40). Hospital and out-of-hospital HD patients received identical antihypertensive therapies, except that beta blockers were more frequently administered to out-of-hospital HD patients. Higher pre-, intra-, and post-dialysis BP values were recorded in patients at out-of-hospital HD centers. CONCLUSION: The differences in BP variability and antihypertensive therapies administered to hospital HD patients as compared to out-of-hospital HD patients may reflect differing approaches by the nephrologists at these centers.

Spleen rupture associated with septic emboli and endocarditis in a hemodialysis patient.

We present an uremic patient on chronic hemodialysis with splenic septic emboli associated with active infective endocarditis and anaerobic bacteremia complicated by ruptured spleen. A 62-year-old female patient was admitted because of fever and pain in the left upper abdomen and swelling and hematoma around the left brachiocephalic arteriovenous fistula. Transthoracic echocardiography revealed mobile hyperechoic mass (vegetation) on the anterior mitral valve. Abdominal ultrasound scan showed multiple hypoechoic lesions of the enlarged spleen, described as possible necroses or abscesses, and computed tomography showed low-density inhomogeneous lesions in the enlarged spleen with large perisplenic hematoma, with spleen rupture. Blood culture revealed anaerobic Gram-negative bacilli ( Bacteroides spp.), ampicillin resistant. This is the first report of splenic rupture associated with anaerobic bacteremia and splenic septic emboli in a uremic patient on chronic hemodialysis. Splenic septic emboli with abscess/infarction in hemodialysis patients are a rare disorder but could be a consequence of dialysis access site infection and might predispose to splenic rupture. Ultrasound scan of abdomen is fast, inexpensive and easy to perform. As mortality is high, early surgical intervention on vascular access is mandatory.

Influence of local inflammation of the peritoneal membrane on diuresis and residual renal function in patients treated with peritoneal dialysis.

The aim of this study was to investigate the connection between local inflammation of the peritoneal membrane and diuresis, as well as the residual renal function (RRF) in patients treated with continuous ambulatory peritoneal dialysis (CAPD). Twenty patients treated with CAPD participated in this cross-sectional study. To determine the influence of local inflammation of the peritoneal membrane, effluent interleukin-6 (IL-6) and soluble interleukin-6 receptor (sIL-6R) levels were measured. The level of IL-6, in the group as a whole, was significantly higher in effluent (7.87 pg/mL) than in serum (1.29 pg/mL). There was a significant correlation between effluent and serum IL-6 (r = 0.608; P = 0.002). There was also a significant relationship between effluent and serum IL-6 and duration of CAPD treatment, respectively (r = 0.577; P = 0.004; r = 0.528; P = 0.008). Further, there was a significant negative correlation between effluent IL-6 and daily diuresis (r = -0.533; P = 0.008), but there was no significant correlation between effluent IL-6 and RRF (r = -0.339, P = 0.072). On the other hand, the concentrations of effluent IL-6 were significantly higher in patients with RRF <2 mL/min than in those with RRF ≥2 mL/min (P = 0.039). In conclusion, local inflammation has a significant impact on the amount of diuresis and probably on RRF in patients on CAPD.

[Do we know all effects of heparins in hemodialyzed patients?]. / Znamo li sve o ucincima heparina u bolesnika lijecenih hemodijalizom?

Anticoagulation with heparins during hemodialysis (HD) is aimed at preventing the activation of coagulation in the extracorporeal circuit. As HD patients are exposed to unfractionated and low molecular weight heparins (LMWH) for years, non-hemorrhagic effects (osteoporosis, reduction of elevated blood pressure, with lesser intra- and interdialytic hypotensive episodes, effects on brain microvascular circulation and decreasing vascular dementia and Alzheimer's disease, and chronic and malignant diseases) require new trials with individualized doses of heparins.

Kidney transplantation improves cognitive and psychomotor functions in adult hemodialysis patients.

BACKGROUND: Kidney failure is believed to have a negative impact on cognitive function, and cognitive impairment is common among maintenance hemodialysis (HD) patients. Previous studies have shown a beneficial effect of kidney transplantation in certain cognitive tests but not across all cognitive domains assessed. But, most of these studies performed a cross-sectional analysis, suffered from lack of standardization of adequate dialysis dose, hemoglobin level, and insufficient sensitivity of neuropsychological tests. The aim of this study was to evaluate the effect of successful kidney transplantation on cognitive and psychomotor function in adequately dialyzed HD patients without severe anemia, using sensitive neuropsychological tests. METHODS: Twenty-one medically stable patients (aged 45.1 ± 7.9 years) on maintenance HD (7.6 ± 4.2 years) were investigated before and 20.5 ± 8.5 months after successful kidney transplantation using Complex Reactiometer Drenovac, a battery of computer-generated psychological tests which measure a simple visual discrimination of signal location, short-term memory, simple convergent visual orientation and convergent thinking. RESULTS: Our findings indicated significantly better cognitive and psychomotor performance after transplantation on tests that assess processing speed, attention, short time memory, convergent thinking and executive functioning. Also, significant negative correlation between follow-up time after transplantation and cognitive and psychomotor performance in minimum time of solving test of convergent thinking was found. CONCLUSION: We conclude that cognitive and psychomotor functions are superior after successful kidney transplantation compared with HD, and that early beneficial effects of transplantation are not transient and cognitive and psychomotor performance might be even improved in time following successful transplantation.

Pegylated interferon for treatment of chronic hepatitis C in hemodialysis patients in Croatia.

BACKGROUND AND AIMS: Hepatitis C virus (HCV) infection is a frequent complication among long-term dialysis patients. The aim of the present study was to evaluate the efficacy and side effects of pegylated interferon-α(2a) (PEG-IFN-α(2a)) treatment in hemodialysis patients. METHODS: We retrospectively reviewed charts of 16 HCV-RNA-positive hemodialysis patients. RESULTS: There were 11 male and 5 female patients treated with dialysis for 6-28 years. Twelve patients had HCV genotype 1b, 2 patients had 3a, and 1 patient had genotype 2a. Although only 10 out of 16 patients completed 48 weeks of treatment, early virological response and end-of-treatment virological response were achieved in 9 and 13 patients, respectively. Sustained virological response was recorded in 9 patients. The most common side effect was anemia. A flu-like syndrome was documented in 6, myalgia in 4, and arthralgia in 5 patients. Rectorrhagia, endocarditis and severe cough were recorded in 1 patient each. Nine patients received a renal transplant, and all 6 responders remained HCV-RNA-negative. CONCLUSIONS: PEG-IFN-α(2a) has limited efficacy in dialysis patients. A significant proportion of patients discontinued treatment because of side effects. Additional studies with long-term follow-up are needed to determine the optimal treatment of HCV infection in the dialysis population.

Is there differences in cognitive and motor functioning between hemodialysis and peritoneal dialysis patients?

OBJECTIVE: Change in cognitive function is one of the well-known consequences of the end-stage renal disease (ESRD). The aim of this study was to determine the effect of hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) on cognitive and motor functions. METHODS: In this cross-sectional study, cognitive and motor functions were investigated in a selected population of 42 patients with ESRD (22 patients on chronic HD and 20 patients on CAPD, aged 50.31 ± 11.07 years). Assessment of cognitive and motor functions was performed by Symbol Digit Modalities Test (SDMT) and Complex Reactiometer Drenovac (CRD-series), a battery of computer-generated psychological tests to measure simple visual discrimination of signal location, short-term memory, simple convergent visual orientation, and convergent thinking. RESULTS: The statistically significant difference in cognitive-motor functions between HD and CAPD patients was not found in any of the time-related parameters in all CRD-series tests or SDMT score. Higher serum levels of albumin, creatinine, and calcium were correlated with better cognitive-motor performance among all patients regardless of dialysis modality. The significant correlation between ultrafiltration rate per HD and short-term memory actualization test score (CRD-324 MT) among HD patients was found (r = 0.434, p = 0.025). CONCLUSION: This study has demonstrated that well-nourished and medically stable HD and CAPD patients without clinical signs of dementia or cognitive impairment and without significant difference in age and level of education performed all tests of cognitive-motor abilities without statistically significant difference.

["Sweet" hydrothorax--the early complication of CAPD: case report]. / "Slatki" hidrotoraks rana komplikacija lijecenja CAPD: prikaz bolesnika.

Hydrothorax is a rare or late complication of peritoneal dialysis (PD). As often patients are asymptomatic or with mild shortness of breath, hydrothorax is overlooked in many cases. The patient is 72-years old female who was hospitalized in 2005 with clinical and laboratory signs of end stage renal disease (ESRD). Peritoneal catheter was implanted by laparoscopic technique. First postimplantation washouts didn't provoke any symptoms. Shortness of breath appeared on the second day of CAPD and worsened next five days accompanied with right-sided chest pain. Chest X-ray showed massive right-sided pleural effusion which was complitely evacuated by thoracentesis. The laboratory findings showed simmilar glucose levels in dialysate and pleural fluid and normal glucose in serum. The treatment with CAPD was discontinued and later haemodialysis (HD) was commenced.

Seasonal Variations of Nutritional Status in Maintenance Hemodialysis Patients.

Nutritional status of hemodialysis (HD) patients is influenced by a multitude of factors and it strongly correlates with morbidity and mortality. The aim of this study was to investigate the influence of seasonal changes on nutritional status in maintenance HD patients. A selected population of 84 adult (40 females and 44 males, aged 68.98 ± 13.45 years) HD (5.94 ± 6.44 years) patients were investigated. Clinical, biochemical and nutritional parameters (BMI, creatinine, urea, serum albumin, total cholesterol and Dialysis Malnutrition Score (DMS) were measured in cold (January and December) and mild (June and September) months, altogether in 336 HD sessions. Statistically significant differences between cold and mild months were found in BMI (P = 0.046), creatinine before HD (P = 0.011), urea before HD (P ≤ 0.001), urea after HD (P ≤ 0.001) and glucose (P = 0.001). Differences between male and female patients in DMS, serum albumin and creatinine level in cold and mild months were found; where females altogether had higher DMS score and lower serum albumin and creatinine levels. These results suggest that seasonal variations of clinical and laboratory variables that reflect nutritional status occur commonly among maintenance HD patients and might lead to biases in the interpretation of results in clinical studies in which measurement schedules vary during the year. Also, results suggested that female HD patients may constitute an especially vulnerable population for seasonal oscillations of nutritional status. The reasons for most of these variations are not apparent and require further investigation.

[Effect of gender and body mass on hemodialysis dose]. / Utjecaj spola i tjelesne mase na kolicinu hemodijalize.

INTRODUCTION: Dialysis efficacy affects the outcome of dialysis patient. Increasing the dialysis dose is related with mortality decrease. The measure of hemodialysis dose and single dialysis urea removal is expressed as Kt/V value (K is blood urea clearance, t is dialysis treatment duration, and V is volume of urea distribution). Hemodialysis dose can be prescribed from the urea kinetic model (UKM). Calculation of single dialysis delivered Kt/V is based on predialysis and postdialysis urea concentrations. The aim of the study was to demonstrate the influence of body mass and gender on the delivered and prescribed dialysis dose. PATIENTS AND METHODS: Seventy-five bicarbonate low-flux hemodialysis sessions in 25 anuric subjects (13 males and 12 females) treated with chronic hemodialysis for at least one year were analyzed. For every single hemodialysis session, delivered Kt/V (Daugirdas and Keshaviah) and prescribed Kt/V (according to UKM) were calculated. RESULTS: Hemodialysis sessions in females were more efficient than in male subjects (delivered Kt/V Daugirdas 1.18 +/- 0.24 vs. *1.04 +/- 0.21, p = 0.008 and prescribed Kt/V UKM 1.42 +/- 0.16 vs. 0.92 +/- 0.11, p < 0.001). According to body weight, hemodialysis sessions were more efficient in < 70 kg than in > 70-kg subjects (delivered Kt/V Daugirdas 1.24 +/- 0.24 vs. 1.01 +/- 0.18, p < 0.001 and prescribed Kt/V UKM 1.36 +/- 0.23 vs. 1.00 +/- 0.22, p < 0.001). Body mass of dialyzed subject and delivered/prescribed dialysis dose showed negative correlation (r = -0.45, p < 0.001/r = -0.69, p < 0.001). Male gender and delivered/prescribed dialysis dose also yielded negative correlation (r = -0.31, p = 0.008/r = -0.885, p < 0.001). CONCLUSION: The results of the study demonstrated negligence in prescribing hemodialysis dose in male and heavy subjects. Consequently, in these subjects the single delivered dialysis dose was inadequate. We recommend careful dialysis dose prescribing and frequent measurement of the delivered dialysis dose in heavy males on chronic hemodialysis therapy. In extreme cases, on-line monitors could be a useful tool for real time delivered dialysis dose measurement, so the prescribed dialysis parameters could be revised during the treatment (especially useful would be prolongation of the dialysis session).

[Hepatitis B vaccination in patients on chronic hemodialysis]. / Cijepljenje protiv hepatitisa B na kronicnoj hemodijalizi.

Patients on chronic haemodialysis (PCHD) respond less well to vaccination with recombinant hepatitis B virus superficial antigen (HbsAg) because of immunity disorders in uraemic patients. Today many schemes and vaccination modification for nonresponding PCHD are proposed. The reaction on vaccination with HbsAg is weaker in those PCHD who had diabetes, older age and insufficient nutritive parameters. In those patients some alternative schemes of vaccinating for nonrespondering PCHD must be considered, especially one of the proposed intradermal ways of vaccine inoculation.

[Does efficient haemodialysis improve the response to hepatitis B virus vaccination?]. / Poboljsava li ucinkovitija hemodijaliza odgovor na cijepljenje protiv virusa hepatitisa B?

Patients on chronic haemodialysis (PCHD) elicit a weaker response to vaccination with recombinant hepatitis B virus vaccine. We conducted this study to demonstrate factors which could affect response to HBV vaccination. Subjects were 30 PCHD. All subjects were vaccinated with 4x40 microg recombinant HBV vaccine given i.m. at intervals 0, 1, 2, and 6 months. Subjects were divided into groups according to the level of antibody (HbsAb): nonresponders (<10 i.u./L), weak responders (10-100 i.u./L), and good responders (>100 i.u./L). A statistically significant difference was found between responders and nonresponders in the dialysis efficiency (Kt/V) (p=0.027). A multivariate analysis of variance unveiled a significant difference between the groups of nonresponders, weak and good responders in the Kt/V value (p=0.028), and the subject age (p=0.080). Positive correlation between HBsAb level and Kt/V (r=0.46; p=0.006), and negative correlations between HBsAb and: subject age (r=-0.40; p=0.026), existence of diabetes (r=-0.32; p=0.041), blood leukocyte number (r=-0.31; p=0.050), and body mass index (r=-0.42; p=0.011) were demonstrated. A multiple linear regression analysis demonstrated the most significant positive correlation between HBsAb level and the Kt/V values (p=0.002), and negative correlation between HBsAb level and the subject age (p=0.047). The HBV vaccination response was weaker in PCHD with inefficient dialysis and older age. Efficient haemodialysis most significantly improves the response to vaccination.

[Renal dyslipidemia in patients on chronic hemodialysis]. / Renalna dislipidemija u bolesnika na kronicnoj hemodijalizi.

Disorder of blood lipids plays an important role in atherosclerosis progress in patients ongoing chronic haemodialysis (PCHD). These patients have specific features of blood lipids with increment of triglycerides and decrement of HDL-cholesterol. Phenotype of lipid disorder in PCHD is mostly type IV according to Fredrickson (30%), and IIA and IIB fenotypes are less frequent. About 9% of lipid disorders in PCHD are isolated increase of Lp(a). Main reason of hypertriglyceridemia in PCHD is attenuated metabolism of VLDL-cholesterol because of lipoprotein lipasis inhibition. There are changes in lipoproteins quality, specially changes in LDL particle have atherogenic potential. Renal dyslipidemia treatment must be vigorous in the early stages of renal insufficiency. Treatment can be dietary measures (specially omega-3-fatty acids), statins, gemfibrozil, intravenous L-carnitin and bicarbonate given per os. Haemodialysis modifications such as highflux haemodialysis, low molecular weight heparin, vitamin E coated dialyzers and LDL-apheresis in extreme cases have important role in renal dyslipidemia treatment.

Potential beneficial effects of low molecular weight heparin on cognitive impairment in elderly patients on haemodialysis.

Vascular cognitive impairment or mixed vascular cognitive impairment and Alzheimer's disease (AD) appear to be much more common in elderly patients than AD alone. Furthermore, vascular dementia (VaD) and AD are more prevalent in elderly patients receiving haemodialysis (HD), leading to a loss of independence and a poor quality of life. Hypotensive episodes in patients receiving HD contribute to vascular changes in the brain, with consequent progression of VaD and AD. The use of the lowest individually optimized bolus dose of low molecular weight heparin (LMWH) during HD, with fewer hypotensive episodes during and between HD procedures, may exert a sparing effect on changes in microvascular circulation and decrease the incidence of VaD and AD. We believe that long-term use of LMWH, with its direct effect on amyloid ß protein (Aß) in the blood and on Aß accumulation in the brain and indirect effects on prevention of complement activation, may delay the progression of cognitive impairment in patients receiving HD. There is a need for a robustly designed, prospective trial to evaluate the effects of long-term treatment with LMWH on mild cognitive impairment, VaD and AD in elderly patients receiving maintenance HD.

The influence of decreased low-molecular-weight heparin nadroparin dose on diastolic blood pressure in patients on hemodialysis.

The aim of present study was to assess the impact of decreasing single bolus dose of nadroparin on blood pressure in patients on hemodialysis (HD). Forty HD patients were included in this study. The bolus dose of nadroparin was decreased twice by 25%; this lower dose was maintained for last 4 weeks, during which the dose was adjusted. There were no significant differences between the first and the last predialysis: systolic blood pressure ([pre-SBP]; 131.05 ± 25.58 vs 125.92 ± 25.49 mm Hg; P = .133), diastolic blood pressure ([pre-DBP]; 73.82 ± 11.82 vs 72.89 ± 9.13 mm Hg; P = .653), and pulse pressure ([pre-PP]; 57.24 ± 20.39 vs 53.03 ± 21.20 mm Hg; P = .121). We found correlation between delta nadroparin and pre-DBP in the last HD (rho = 0.310; P = .031) but not between delta nadroparin and pre-SBP and pre-PP values. This is the first report of influence of nadroparin dose lowering on pre-DBP in HD patients.

Cognitive-psychomotor functions and nutritional status in maintenance hemodialysis patients: are they related?

Both cognitive impairment and malnutrition are common in hemodialysis patients and associated with adverse clinical outcome. The aim of the study was to investigate performance on a detailed cognitive and psychomotor battery in maintenance hemodialysis patients in correlation to nutritional status. A selected population of 65 adult (20 females and 45 males, aged 57.84±12.28 years) hemodialysis (4.78±3.62 years) patients were investigated. The total time of test solving was correlated with Dialysis Malnutrition Score (DMS) in tests of simple visual discrimination of signal location (r=0.215, P=0.042), simple convergent visual orientation (r=0.262, P=0.020), and convergent thinking (r=0.244, P=0.034). The minimum time of test solving was also correlated with DMS in the test of simple convergent visual orientation (r=0.227, P=0.038), and in the test of convergent thinking (r=0.223, P=0.048). Total ballast, as a descriptor of stability in reaction time, was correlated with DMS in the test of simple visual discrimination of signal location (r=0.281, P=0.012), and in a test of short term memory actualization (r=0.239, P=0.028). Furthermore, significant correlation was noted between body mass index, serum creatinine, total cholesterol and albumin level with cognitive-psychomotor performance. Hemodialysis patients with a poorer nutritional status performed worse on cognitive and psychomotor tests. Further research is needed to assess the effects of treating malnutrition on cognitive-psychomotor performance in these patients.

The individually optimized bolus dose of nadroparin is safe and effective in diabetic and nondiabetic patients with bleeding risk on hemodialysis.

The risk of bleeding is a well-known complication in patients on hemodialysis (HD). The aim of this prospective study was to determine the lowest single bolus dose of low-molecular-weight heparin nadroparin for safe and effective HD in patients with a bleeding risk. Forty HD patients were divided into 4 subgroups with 10 participants (diabetics with and without a bleeding risk, nondiabetics with and without a bleeding risk). The actual starting bolus dose was decreased by 25% after the initial 4 weeks, further decreased by 25% of the starting dose after 4 weeks, and changed due to extracorporeal circuit clotting in the last 4 weeks. The parameters of coagulation were measured at the beginning, after 2 and 4 h of HD sessions. A significant reduction of nadroparin (first vs. last HD session) was observed in: diabetics with a bleeding risk (49.66 ± 12.33 vs. 28.78 ± 9.60 IU/kg/HD; P<0.001), diabetics without a bleeding risk (50.70 ± 15.23 vs. 33.95 ± 16.97 IU/kg/HD; P<0.001), and nondiabetics with a bleeding risk (61.25 ± 18.68 vs. 32.96 ± 10.06 IU/kg/HD; P<0.001). Altogether, the reduction of the nadroparin dose in these groups was 42.05%; 33.04%, and 46.19%, respectively. Although anti-Xa at hour 4 at the end of the study was <0.4 IU/mL in our diabetic and nondiabetic patients without a risk of bleeding, serious clottings in the extracorporeal circuit and vascular access thromboses were not found. This study demonstrated for the first time that individually optimized doses of nadroparin are sufficient for safe and effective HD in patients with a bleeding risk.