Relative hypoparathyroidism and hypoalbuminemia are associated with hip fracture in hemodialysis patients.

AIMS: Patients with end-stage renal disease treated by hemodialysis are at an increased risk of hip fracture. In the general population, hip fractures are associated with increased morbidity and mortality. The objective of this study was to assess the predictors and outcomes of hip fracture in the hemodialysis population, including quality of life post hip fracture. METHODS: A case-control study from 1999 to 2005 included 29 adult hemodialysis patients with hip fracture and 55 controls, matched on age, gender and number of years on hemodialysis. A logistic regression model was used to derive predictors of hip fracture. The association between time to death post hip fracture and parathyroid hormone was analyzed using a Kaplan-Meier curve. The ability to live independently 1 year after hip fracture was used as a measure of quality of life. RESULTS: Variables associated with hip fracture were a reduction in serum parathyroid hormone by 100 pg/ml (OR = 1.65, 95% CI 1.10, 2.46) and a decrease in serum albumin by 1 g/l (OR = 1.18, 95% CI 1.00, 1.39). 40% of the cases died within the first year post hip fracture. Median survival time in patients with hip fracture and a serum PTH value < 100 pg/ml was 17 days (95% CI 0, 37 days) as compared with 280 days (95% CI 103, 471 days) for those with a PTH value > 100 pg/ml (p < 0.02). Among the patients who survived, 53% were subsequently discharged to a long-term care facility. CONCLUSIONS: Relative hypoparathyroidism and hypoalbuminemia are associated with an increased risk of hip fracture in hemodialysis patients. There is also a significant reduction in quality of life in patients sustaining a hip fracture.

Benefit of continuous renal replacement therapy in subgroups of acutely ill patients: a retrospective analysis.

AIMS: Acute renal failure in the intensive care setting is common and impacts on patient's outcome. Continuous hemodialysis or hemofiltration offers theoretical benefit for patients with acute renal failure, but the clinical benefit has not been demonstrated in randomized trials. ICU patients with acute renal failure are a heterogeneous population and we hypothesize that patients with increased illness severity would benefit from continuous renal replacement therapy. METHODS: From a comprehensive ICU database, we identified patients with acute renal failure exposed to continuous or intermittent renal replacement therapy. We a priori identified a subgroup of patients with multiple organ dysfunction syndrome, then used survival analysis to assess the effect of dialysis modality in the overall acute renal failure population and in the subgroup with increased illness severity. RESULTS: We identified 66 patients treated with intermittent and 36 patients treated with continuous renal replacement therapy. Patients with severe illness were preferentially selected for treatment with continuous dialysis (p = 0.01). Overall, there was no significant difference in survival between patients treated with intermittent or continuous dialysis. The relative risk of in-hospital mortality was significantly decreased in patients with multiple organ dysfunction syndrome (relative risk = 0.42+/-0.22, p = 0.027) treated with continuous therapy as compared with intermittent therapy. Among the survivors, continuous dialysis did not appear to hasten the return of renal function. CONCLUSIONS: This retrospective study suggests that continuous dialysis may be beneficial in a subgroup of ICU patients with multiple organ dysfunction syndrome or severe sepsis. Further randomized trials of dialysis modality should, if possible, concentrate on this population.

Liver-kidney transplantation in primary hyperoxaluria type-1: case report and literature review.

Primary hyperoxaluria type-1 (PH1) is a rare inherited autosomal recessive disorder in which a deficiency of the hepatic enzyme alanine-glyoxylate aminotransferase leads to endogenous oxalate overproduction, renal failure, systemic oxalate deposition and death. As hemodialysis provides insufficient oxalate clearance, patients ultimately require both liver and kidney transplantation for correction of the metabolic abnormality and oxalate excretion. Herein, we describe a young adult male with end-stage renal disease and systemic oxalosis causing progressive disabling multi-organ dysfunction while awaiting transplantation. We review the literature regarding liver-kidney transplantation and suggest that for patients with PH1, a standardized assessment of organ dysfunction and functional impairment may improve identification of patients requiring urgent transplantation thereby reducing the morbidity and mortality that can occur with delayed transplantation.