Fatal hemothorax caused by a subclavian hemodialysis catheter. Thoughts on prevention.

A 19-year-old woman died when a subclavian catheter that had provided vascular access for plasmapheresis penetrated her right atrium, pericardium, and parietal pleural, causing a hemothorax. Precautions are recommended to minimize the risk of this complication in patients in whom subclavian catheters are used as a vascular access route for hemodialysis or plasmapheresis.

Whole-body protein turnover in adult hemodialysis patients as measured by 13C-leucine.

Muscle wasting may occur in patients with chronic renal failure (CRF). To determine whether this is due to a decrease in the synthesis or an increase in the breakdown of muscle protein, we evaluated postabsorptive whole-body protein breakdown, oxidation, and synthesis rates at steady state during a primed, continuous infusion of 13C-leucine. This was done in seven subjects on chronic maintenance hemodialysis (MHD) and in seven normal control subjects. The protein breakdown rate in MHD was not different from that in controls (103 +/- 19 and 106 +/- 19 mumol leucine.kg-1.h-1, respectively). In MHD, however, the protein oxidation rate was 43% greater than that in controls (20 +/- 6 and 14 +/- 4 mumol leucine.kg-1.h-1, p less than 0.05), whereas net protein synthesis was less (p less than 0.05). Reduced net synthesis and increased oxidation rates of protein in the postabsorptive state may therefore contribute to the muscle-wasting syndrome in patients with CRF.

Skeletal muscle function in chronic renal failure: an index of nutritional status.

To determine whether skeletal muscle function testing (SMF) provides an index of nutritional status in patients with chronic renal failure (CRF), two groups with comparable CRF were studied. In 48 well-nourished (WN) and 17 malnourished (MN) patients with stable CRF, and in 33 WN nonazotemic controls, adductor pollicis function was assessed. The force at 10 Hz was expressed as a % of force at 100 Hz (F10/F100), and maximal relaxation rate (MRR) as % force loss/10 ms. Standard nutritional assessment was also performed. The WN group was not significantly different from controls for either F10/F100 or MRR. The F10/F100 of the MN group was significantly greater than either the WN group or controls (p less than 0.001), while MRR was less (p less than 0.001). Significant malnutrition by conventional parameters was shown in patients with abnormal F10/F100, and also in patients with abnormal MRR. Hence, SMF as described is unaffected by azotemia, and provides a functional measure of nutritional status in CRF.

Relation of immediate post-transplant renal function to long-term function in cadaver kidney recipients.

Renal function studies 12 to 41 months after transplantation have been performed on seven cadaver renal allograft recipients who demonstrated immediate primary function after transplant (group A) and seven similar recipients who had delayed primary function (group B). The groups were matched as closely as possible for major physical characteristics and their postoperative management; in particular, only one patient had a post-transplant renal biopsy. Glomerular filtration rate was determined by 24-hr creatinine clearance, endogenous creatinine clearance, and inulin clearance was usually lower in those patients having delayed primary function and they excreted more glucose per 24 hr and reabsorbed a smaller proportion of the filtered glucose load under infusion conditions. These results are discussed in relation to the effect of immediate and delayed primary function on the long-term prognosis of such patients.

Immunosuppression with polyunsaturated fatty acids in renal transplantation.

A double-blind controlled trial has been undertaken to assess the value of a preparation containing polyunsaturated fatty acids (PUFA) in human cadaveric renal transplantation. Eighty-nine patients were studied and followed for 6 months after transplantation. Forty-four took the PUFA preparation and 45 the placebo (oleic acid). Other immunosuppression was standardised. Functional graft survival was significantly better in the PUFA group than in those taking the placebo during the first 3 to 4 months post-transplant. At 6 months, however, although the difference between the groups persisted, it was no longer statistically significant. Complications were equally distributed between the groups.

Proteins and fibrinolysis in recipients of renal allografts.

Studies of serum proteins, platelets, and fibrinolysis in patients after renal allografting show that a fall in plasma fibrinogen in the postoperative period can be associated with early rejection and that a rise in serum fibrin degradation products when accompanied by a fall in platelets is associated with rejection. Fibrinolysis is depressed in these patients until two months after transplantation and marked depression of fibrinolysis may precede rejection. The late coincidence of fibrinolytic depression with a rise in fibrin degradation products suggests chronic insidious rejection.

Altered reticuloendothelial function in long-term renal allograft recipients.

Using the clearance of microaggregated iodinated human serum albumin reticuloendothialial system (RES) phagocytic function was tested in 48 long-term renal allograft recipients and was found to be defective at the time of testing in 70%. Depression of RES phagocytosis could be related to total steroid dosage in the previous year and to the patients liability to bacterial infections. Evidence from this test does not suggest an immunosuppressive effect of cytomegalovirus. However, three patients are discussed who have developed chronic active hepatitis that is not due to type B virus.

Management of end-stage autosomal dominant polycystic kidney disease with hemodialysis and transplantation.

This is an analysis of the outcome of 35 patients with end-stage autosomal dominant polycystic kidney disease (ADPKD) at Toronto Western Hospital (TWH) during a 10-year period. The primary treatment in each case was hemodialysis. In the 15 patients managed exclusively with hemodialysis the one- and five-year actuarial survival was 93% and 77% respectively. Twenty patients ultimately received a total of 26 cadaveric renal allografts. Graft survival at one year was 76%. One- and five-year patient survival was 92% and 73% respectively. Beyond 5 years a trend towards increased survival in the transplant group was seen, compared with the exclusively hemodialyzed group. Bilateral nephrectomy prior to transplantation was associated with high morbidity and mortality, and did not change either graft or patient survival. In view of the similar survival and because it is accepted that transplantation offers the highest quality of life amongst the modalities of treatment for end-stage renal failure, transplantation should be considered the treatment of choice for end-stage ADPKD. There is no justification for routine bilateral nephrectomy before renal transplantation.

The effect of recurrent early homograft rejection on subsequent patient and renal graft survival.

The effect of recurrent early homograft rejection on subsequent patient and renal graft survival. Two hundred renal transplants performed in Newcastle between 1968 and 1974 and followed up for at least 6 months are reviewed. There was a significant fall ingraft survival at 1 year in those patients who suffered a rejection episode during the first two months post-transplant and this fall became greater with each successive rejection episode. The rise in patient mortality with increasing numbers of rejections showed a similar trend but was less (40-50% at 1 year in those suffering 3 or 4 rejection episodes) and did not reach statistical significance beyond the first episode. We, therefore, conclude that in patients not suitable for home dialysis and in whom, because of uncommon tissue type, a second transplant is not likely to be offered under prevailing conditions of kidney donor shortage, it is justifiable to treat third and fourth rejections occurring during the first two months.

Adverse effect of splenectomy in renal transplantation.

Between January 1968 and June 1974 at Newcastle upon Tyne, 63 patients underwent splenectomy in association with transplantation; 45 of these had splenectomy with bilateral nephrectomy before (20) or at the time of (25) transplantation; 18 had post-transplant splenectomy for leucopenia. Mortality was significantly higher in splenectomized patients than in 136 non-splenectomized controls. Of the 63 splenectomized patients, 25 died within 1 year of transplantation, 12 of severe infection associated with leucopenia. Although splenectomy produced a temporary rise in white cell count, leucopenia during the first year of immunosuppressive therapy was not significantly less frequent in splenectomized patients than in controls. There was no significant difference in graft loss between the splenectomy and control groups. It is concluded that splenectomy is contra-indicated in patients who are to undergo renal transplantation and confers no benefit when carried out because of leucopenia developing after renal transplantation.

Slow continuous hemodialysis for the management of complicated acute renal failure in an intensive care unit.

This paper describes a simple system for the performance of slow continuous hemodialysis (SCHD) as a means of treating difficult and complicated cases of oliguric acute renal failure. The method, which employs access to the circulation via a double-lumen central venous catheter and a BSM 22 blood systems module, can be performed safely in the intensive care unit of a general hospital if closely supervised by a trained nephrologist. The results of treating 16 consecutive cases of complicated acute renal failure in a large general hospital without a hemodialysis unit are described. The method, whose simplicity makes it suitable for intensive care unit nurses without previous hemodialysis training, was not associated with any serious accidents or complications, and was tolerated well by even the most critically ill and hemodynamically unstable patients. The advantages of this approach over more traditional continuous arteriovenous hemofiltration (CAVH) are discussed.

Right atrial ball thrombus as a complication of subclavian catheter insertion for hemodialysis access.

In two patients right atrial ball thrombi developed following prolonged subclavian cannulation for hemodialysis. One patient died, the other had the ball thrombus removed by open heart surgery. It appears that repeated friction of the catheter tip may have damaged the endothelium of the right atrial wall. This hitherto unrecognised complication might be prevented by ensuring that subclavian hemodialysis catheters are never allowed to reach as far as the right atrium.

The use of dual lumen jugular venous catheters as definitive long term access for haemodialysis.

We describe the long term use for haemodialysis of the PermCath (Quinton, Seattle, Washington) dual lumen, jugular venous catheter (DLJVC) in 21 patients who had no apparent alternative means of access. The nineteen patients maintained in this manner for periods of 30 to 600 days (mean 233.2) included 6 patients dialyzed for over 12 months. Blood flows exceeded 250 mls/min and recirculation rates averaged 5.9%. Infection and insufficiency due to thrombosis were the major problems. In 8 patients (38.1%) infection required DLJVC removal; in three the catheter was immediately replaced over a guidewire along the same track under antibiotic cover and infection has not recurred. Insufficiency occurred in 10 patients (47.6%) and was successfully managed with oral anticoagulants, local instillation of urokinase (4 cases), systemic streptokinase (2 cases) or by changing the DLJVC over a guidewire (2 cases). We believe that the DLJVC is the long term access method of choice for patients in whom conventional access cannot be constructed.

Control of oral anticoagulation in patients using long-term internal jugular catheters for haemodialysis access.

Patients using long-term double-lumen silastic jugular catheters for haemodialysis access frequently require oral anticoagulants to maintain patency of the catheter. It may be difficult or impossible to obtain peripheral vein blood samples for PT measurements to regulate the oral anticoagulant dose. Our studies have shown that removal of 3 mls of blood from the catheter limb containing the heparin (to be discarded) followed by 10 mls as a heparin wash-out (to be returned to the patient) allows blood to be taken from the arterial limb of the catheter for PT measurement. The PT measurement obtained from the arterial limb after a 10 ml wash-out is nearly always identical with the PT measurement on blood obtained from a peripheral vein. If the simultaneously measured aPTT is normal the PT is predictably and consistently accurate. If the aPTT is raised due to traces of residual heparin then the PT may be inaccurate and should be repeated. This method is easy and reliable and can be recommended as an aid to regulation of the oral anticoagulant dose.

The WBW jugular catheter as long term vascular access for hemodialysis.

Single-lumen silastic catheters were placed in the jugular veins of 12 patients to provide vascular access for hemodialysis. In all cases construction of arteriovenous fistulas had been difficult or impossible. The catheters have provided adequate dialysis with a single needle system for periods up to 32 months. Only one case of blood stream infection occurred, in a confused patient who damaged his catheter. There has been no evidence of venous thrombosis or other complications. Jugular vein catheters should be considered as long-term alternatives when A-V fistula construction is not possible.