Clinical, sociodemographic, and psychological correlates of health-related quality of life in chronic hemodialysis patients.

BACKGROUND: Physical comorbidities and depression are associated with poor health-related quality of life (HRQoL) in patients undergoing chronic hemodialysis, but little is known about the impact of psychological determinants such as coping strategies in this association. This study examined the relation between psychosocial factors, particularly health-related locus of control (HLOC) and quality of life (QoL) in chronic hemodialisys patients. METHODS: Three hundred hemodialysis patients underwent assessment of QoL (SF-36), depression (Beck Depression Inventory score), anxiety (State-Trait Anxiety Inventory), and HLOC profile (Multidimensional Health Locus of Control scale). Comorbidities and sociodemographic factors were assessed. RESULTS: All QoL scores were low. Depression and comorbidities were negatively correlated with physical QoL components and depression, anxiety, and comorbidities were negatively correlated with mental components. However, internal locus of control (LOC) and external LOC (influence of "powerful others") were positively correlated with mental QoL components. Multiple regression analysis showed internal LOC significantly and positively associated with mental QoL components, especially mental health score (P < 0.01). CONCLUSIONS: Altered QoL of patients undergoing chronic hemodialysis is associated with physical and psychiatric comorbidities, in particular depression and anxiety. However, internal and external LOC seem to have differential impact on QoL. Increasing awareness and empowerment of the internal and external components of the LOC could help patients improving QoL.

[Advance directives in hemodialysis patient: A feasibility study]. / Les directives anticipées chez des patients en hémodialyse chronique : étude de faisabilité.

Respect of patient's autonomy is essential. So that patients are able to write their advance directives in case of a situation where they are unable to make decisions for themselves. Currently, few people have written advance directives. We studied the feasibility of a systematic implementation of advance directives in haemodialysis patients. This prospective, single-center study was conducted in an ambulatory hemodialysis center. There were 4 steps: caregivers survey about advance directives; selection of patients and information about advance directives; writing advance directives with the interested patients; and finally, non-participation causes assessment of the other informed patients. Caregivers are not comfortable with advance directives, and have reluctances: the patient's lack of medical knowledge; the anxiety generated by end-of-life talk. Fifty-six patients (51.6%) were included and received the information. Nine of them wanted to write their advance directives on a suitable form. Eight finalised them (7.4% of the initial population). The majority wanted a therapeutic limitation. Twenty-nine patients, who have received the information about advance directives, didn't want to write them, the main reason was that they felt healthy or that they thought that their relatives would take the right decisions. Eighteen patients left the centre during the study. The development of advance directives requires information and training of caregivers and patient support. Few patients went to the end of the process. The limit of the patient's ability to decide for himself is difficult to define. The role of the doctor is central to accompany the patient during this process.

Bilateral adrenal infiltration in Erdheim-Chester disease. Report of seven cases and literature review.

CONTEXT: Erdheim-Chester disease (ECD) is a rare non-Langerhans form of histiocytosis characterized by xanthomatous tissue infiltration with CD68(+) CD1a(-) foamy histiocytes. Endocrine problems, such as diabetes insipidus and hypogonadotropic hypogonadism, frequently occur in ECD, but bilateral adrenal infiltration has rarely been reported in this disease. OBJECTIVE: The aim of the study was to describe adrenal and periadrenal infiltration in ECD. PATIENTS: A total of 22 patients with ECD undergoing systematic computed tomography to search for signs of adrenal enlargement participated in the study. RESULTS: Of the 22 patients with ECD, seven (31.8%) displayed adrenal infiltration on computed tomography. In one case, autopsy confirmed that the adrenal enlargement was due to foamy histiocyte infiltration in the adrenal glands. Possible adrenal insufficiency was assessed in five of the seven patients. One developed signs of adrenal insufficiency, which was confirmed by adrenocorticotropin stimulation tests. Adrenal involvement was reported in only 15 of the 240 ECD cases published up to May 2006. This frequency is significantly lower than that in our series (P = 0.0008; Fisher's exact test). CONCLUSION: Physicians should be aware of ECD as a possible cause of morphological changes in adrenal size and infiltration.

Vancomycin during the Last Hour of the Hemodialysis Session: A Pharmacokinetic Analysis.

BACKGROUND: Vancomycin is usually administered after the dialysis sessions to patients undergoing hemodialysis. Administration of vancomycin during (as opposed to after) sessions would save time, and would be more acceptable to patients and staff, but may lead to vancomycin underexposure. The aim of this study was to propose a new dosing regimen of vancomycin taking into account the dialysis-related losses of vancomycin when administered during dialysis. METHODS: In this monocentric prospective study, vancomycin was infused to dialyzed patients during the last hour of the dialysis session at increased doses. Monitoring of vancomycin was performed using repeated blood samples by pharmacokinetics modeling. Patients were treated according to our protocol and guidelines. RESULTS: Twenty patients were included. Vancomycin protocol was efficient: 17 of 20 (85%) patients were cured, 1 needed additional vancomycin treatment, and 2 died (sepsis n = 1, multiple organ failure n = 1). Median pre-dialysis concentration was adequate (16.2 [10.2-24.4] µg/mL), and there was no emergence of resistant bacteria. Infusion of vancomycin during dialysis therefore decreased the exposure to vancomycin by 25% compared to infusion of vancomycin after dialysis. For a typical patient, the dose of vancomycin to be administered during dialysis would be 1.4 g. CONCLUSION: Administration of vancomycin during the last hour of dialysis session is safe, efficacious with regards to infection control, achieved recommended vancomycin concentrations despite the use of high-flux membranes, and improved patients' quality of life.

[Withdrawal from dialysis: a frequent but sometimes difficult situation]. / L'arrêt de dialyse : une situation fréquente, parfois difficile à accepter.

Withdrawal from dialysis is a frequent cause of death in chronic dialysis patients in a French population, as it is in North America. In both populations dialysis was withdrawn in about 20%, but the characteristics of patients and the decision-making procedure were different. In France, patients in whom dialysis was withdrawn were most often at the end of their life, and the physician essentially made the decision. This decision was often difficult to make and be accepted, particularly when the patient chose himself to stop the dialysis, even if life expectancy would be long on dialysis. A discussion including the patient, his family and the medical staff is crucial. The modification of the French law about the rights of patients at the end of their life will be assistance when such decisions take place, especially in non-conscious patients who are at the end of their life, and in those who want to stop dialysis. Philosophical and ethical reflection with its concepts for autonomy and dignity can be a valuable aid in such situations.

Factors associated with albumin loss in post-dilution hemodiafiltration and nutritional consequences.

INTRODUCTION: Hemodiafiltration is currently one of the most effective techniques of extra-renal purification but results in an increase of albumin loss in dialysate. We aimed to determine the factors associated with albumin loss during post-dilution hemodiafiltration, compare an "automatic" mode of infusate flow control versus a "manual" control, and assess the potential nutritional impact. METHODS: This prospective observational study included all hemodialysis patients in our institution who underwent post-dilution hemodiafiltration 3 times a week on a Fresenius 5008 for at least 2 months. At each session, albumin content was measured in a representative effluent dialysate volume. The automatic mode of the Fresenius 5008 was used for automatic infusate flow control. RESULTS: In all, 18 patients (mean age 60.7 ± 15 years) underwent 85 post-dilution hemodiafiltration sessions. The mean albumin loss was 3134 ± 2450 mg/session. Albumin loss was significantly affected by infusate flow, infusate volume, transmembrane pressure and ultrafiltration volume. The loss was greater with Toraysulfone and FX 1000 membranes rather than FX 80 or FX 100 membranes. With AutoSub rather than manual control, infusate flow was greater (P<.001), transmembrane pressure was higher (P = .004), and the albumin loss was greater (P = .010). However, there was no correlation between albumin loss and nutritional variables. CONCLUSIONS: Albumin loss during post-dilution hemodiafiltration was correlated with increased transmembrane pressure and infusate flow, especially AutoSub flow control, and type of membrane. However, this loss, when moderate, did not seem to affect nutritional aspects and should not limit the use of hemodiafiltration.

An unusual case of central venous catheter-related bacteremia.

Some hemodialysed patients need definitive central venous catheterization. One of the main complications is catheter infection, and each infection must be treated. We report a case of an unusual cause of central venous catheter (CVC) infection: physical examination and catheter opacification demonstrated two pin-holes in the catheter. It was possible to salvage the catheter following a treatment regimen combining systemic antibiotics, antibiotic locks, fibrinolytics, and removal of a catheter segment.

Synthesis of anticoagulantly active heparan sulfate proteoglycans by glomerular epithelial cells involves multiple 3-O-sulfotransferase isoforms and a limiting precursor pool.

Endothelial and other select cell types synthesize a subpopulation of heparan sulfate (HS) proteoglycans (HSPGs), anticoagulant HSPGs (aHSPGs) that bear aHS-HS chains with the cognate 3-O-sulfated pentasaccharide motif that can bind and activate anti-thrombin (AT). Endothelial cells regulate aHSPG production by limiting levels of HS 3-O-sulfotransferase-1 (3-OST-1), which modifies a non-limiting pool of aHS-precursors. By probing kidney cryosections with (125)I-AT and fluorescently tagged AT we found that the glomerular basement membrane contains aHSPGs, with the staining pattern implicating synthesis by glomerular epithelial cells (GECs). Indeed, cultured GECs synthesized aHS with high AT affinity that was comparable with the endothelial product. Disaccharide analyses of human GEC (hGEC) HS in conjunction with transcript analyses revealed that hGECs express predominantly 3-OST-1 and 3-OST-3(A). aHS production has not been previously examined in cells expressing multiple 3-OST isoforms. This unusual situation appears to involve novel mechanisms to regulate aHS production, as HS structural analyses suggest hGECs exhibit excess levels of 3-OST-1 and an extremely limiting pool of aHS-precursor. A limiting aHS-precursor pool may serve to minimize aHS synthesis by non-3-OST-1 isoforms. Indeed, we show that high in vitro levels of 3-OST-3(A) can efficiently generate aHS. Non-3-OST-1 isoforms can generate aHS in vivo, as the probing of kidney sections from 3-OST-1-deficient mice revealed GEC synthesis of aHSPGs. Surprisingly, Hs3st1(-/-) kidney only expresses 3-OST isoforms having a low specificity for aHS synthesis. Thus, our analyses reveal a cell type that expresses multiple 3-OST isoforms and produces minimal amounts of aHS-precursor. In part, this mechanism should prevent aHS overproduction by non-3-OST-1 isoforms. Such a role may be essential, as 3-OST isoforms that have a low specificity for aHS synthesis can generate substantial levels of aHSPGs in vivo.

Death after withdrawal from dialysis: the most common cause of death in a French dialysis population.

BACKGROUND: Discontinuation of dialysis is a common cause of death in end-stage renal disease (ESRD) patients in North America and the UK, but appears to be unusual in the rest of Europe. The aim of this retrospective study was to characterize withdrawal from dialysis in a French population cohort. METHODS: We assessed the cause of death, and the medical and social characteristics of chronic dialysis patients in a French population who died in 2001. We compared patients who died after withdrawal from dialysis and patients continuing dialysis until death. We determined the decision-making process when dialysis was withdrawn. RESULTS: In a population cohort of 1436 dialysis patients, 196 died (13.9%). Of them, 40 patients (20.4%) died following withdrawal from dialysis. This was the most common cause of death, followed by cardio-vascular disease (18.4%). Patients withdrawing from dialysis had a significantly higher rate of dementia (17.5 vs 6.4%, P = 0.02), a poor general condition (55 vs 15.4%, P < 0.001), and were dependent in their life for everyday activities in comparison with patients who died from other causes. They were not different in age, sex, duration of dialysis treatment, dialysis technique, cardio-vascular disease, diabetes, stroke or cancer, but the sample size was small. Treatment was more often removed in patients with severe medical complications and/or cachexia (90%). The decision to stop dialysis was made most often by a physician (77.5%). CONCLUSION: Death after withdrawing from dialysis was the most common cause of death in ESRD patients in our French population cohort. The patients who died after discontinuation of treatment were more often in a poor general condition, near the end of life, and most often the physician decided to stop dialysis treatment.