Functional dependencies among the elderly on hemodialysis.

As the dialysis population ages, their limitations in performing daily activities affect the well-being of the patients as well as increase the burden on caregivers and the use of health services. In this cross-sectional study, we measured the proportion of patients 65 years and older undergoing chronic outpatient hemodialysis who needed help with day-to-day activities and identified the clinical characteristics of this population at most risk. Their dependence in performance of basic self-care tasks and instrumental activities such as driving were measured by the Barthel and Lawton Scales. Associations between disability in four basic activities to age, gender, education, multiple prescription drug needs, diabetes, cognition, depressive symptoms, and physical performance were examined using logistic regression. Of the 162 mostly male participants averaging 75 years old, eight had no disability, 69 had only instrumental dependence, and 85 had combined disability. Multiple prescription drug needs, poor timing in 'up-and-go' mobility performance, and education level were associated with basic dependency. Our study shows that the disability in self-care is common among older patients on hemodialysis. Strategies are needed to routinely identify those older dialysis patients at risk of functional impairment and to limit their disabilities.

Conversion from conventional to nocturnal hemodialysis improves vitamin D levels.

Patients on conventional hemodialysis have low levels of 25-hydroxy-vitamin D probably due to diet and decreased cutaneous synthesis. As 1,25 dihydroxy-vitamin D synthesis is substrate-dependent in end-stage renal disease, this could be a contributing factor to low 1,25 dihydroxy-vitamin D levels in patients undergoing conventional hemodialysis. We converted 35 patients historically on conventional hemodialysis to nocturnal hemodialysis for a minimum of 6 months thereby significantly increasing sessional equilibrated Kt/V from an average of 1.30 to an average of 2.01. Dietary restrictions were also removed. Serum phosphorus significantly fell, whereas the serum calcium, parathyroid hormone, and the mean dose of calcitriol did not change after the conversion. Significant increases in both 25-hydroxy and 1,25-dihydroxy-vitamin D levels were seen after hemodialysis mode conversion. A significant correlation was found between the dialysis dose and the levels of both hydroxylated forms of vitamin D. We suggest that improving uremia by nocturnal hemodialysis in the absence of exogenous supplementation is associated with increased 25 and 1,25-hydroxy-vitamin D levels. Additionally, normalization of serum phosphorus may improve 1alpha-hydroxylation thereby enhancing substrate-dependent generation of 1,25-dihydroxy-vitamin D in chronic dialysis patients.

Improvements in cognition in patients converting from thrice weekly hemodialysis to nocturnal hemodialysis: a longitudinal pilot study.

Cognitive impairment has been documented in uremia with partial improvement after dialysis. Nocturnal daily hemodialysis (NHD) is a novel dialysis modality with multiple benefits. Previous reports have shown marked improvements in quality of life, cardiac function, resolution of peripheral vascular disease, and reversal of central sleep apnea. We hypothesized that patients maintained on NHD would have better cognitive functioning than those receiving conventional therapy. Using a longitudinal study design, patients were tested at baseline and again after >or=6 months NHD. At each of the two time points, a battery of 10 neuropsychological tests were used to evaluate three domains of cognitive functioning--attention and working memory skills, psychomotor efficiency and processing speed, and learning efficiency. Clinical subjective symptoms for cognitive functioning and depression were measured using the Patients Assessment of Own Functioning inventory and the Beck Depression Index. Twelve patients (six males, six females) were recruited. Patients were aged 39.6+/-3.3 years at the time of first testing. Thirty-three percent were diabetic, with a mean Charlson comorbidity score of 3.5+/-2.0. Depression (defined as >16 on the Beck Depression Index score) was not seen in any patient. Over the 6-month period, a 22% reduction in cognitive symptoms (P=0.01), 7% improvement in psychomotor efficiency and processing speed (P=0.02), and 32% improvement in attention and working memory (P=0.04) was seen. Learning efficiency scores were unchanged. NHD may be associated with improved general cognitive efficiency as measured by psychomotor efficiency and attention and working memory.

Geriatric nephrology units: the way of the future.

The emergence of the sub-speciality geriatric nephrology is an exciting development for the future. The main objectives should be to maximise patient independence and minimise deterioration and learn dependent behaviour in this population. To achieve these goals a holistic approach needs to be taken, to the patient, their environment and the efficacy of such units, and this can only be achieved using a multi-disciplinary team approach. In the creation of a geriatric nephrology unit it is important to identify the factors that cause frailty and, if possible, modify or prevent the initial decline using nutritional and other interventions. This requires careful monitoring, not only using the traditional markers of renal disease including urea and creatinine, but also using instruments that measure functional ability. These issues are discussed under the headings prevention, documentation and planning.

Increased mortality of elderly female peritoneal dialysis patients with diabetes--a descriptive analysis.

Three recent studies using registry data from the United States, in comparing the mortality risks between peritoneal dialysis (PD) and hemodialysis (HD), have consistently found that elderly diabetic women on PD have a higher mortality risk as compared with their counterparts on HD. Though the cause for this observation is not clear, the phenomenon may be unique to the United States. Alternatively, a selection bias impossible to decipher may be at work in these studies, as none of them have data on comorbidity, nutrition, or adequacy of dialysis. Finally, the possibility that elderly diabetic women are, for some reason, more vulnerable to the ill effects of peritoneal dialysis should be considered. We report here a retrospective analysis of 47 diabetic women, above 55 years of age, with end-stage renal disease, who were started on PD and who later died on dialysis. The primary outcome of interest was cause of death. Demographic details about the patients, comorbid conditions, dialysis adequacy, and biochemical parameters at the start of PD were noted. Death in these patients was attributed mainly to vascular causes, and there appeared to be a high prevalence of peripheral vascular disease. Infection was the next major cause of death, being the primary cause in 14 patients. Of these, only 5 patients had peritonitis. On a Cox regression analysis, only patient age and duration of diabetes at onset of dialysis were found to be predictive of vascular death. No factor was found to be predictive of death from infection. It appears that elderly diabetic women on PD die mainly of the long-term complications of diabetes.

The effect of small solute clearances on survival of anuric peritoneal dialysis patients.

OBJECTIVE: Primarily, to determine whether peritoneal small solute clearance is related to patient and technique survival among anuric peritoneal dialysis [continuous ambulatory (CAPD) and automated peritoneal dialysis (APD)] patients. A secondary goal was to describe the ability to attain Dialysis Outcomes Quality Initiative (DOQI) targets among anuric patients on peritoneal dialysis. DESIGN: Retrospective cohort study via chart reviews. SETTING: Peritoneal Dialysis Unit of Toronto Hospital (Western Division). PATIENTS: The study included 122 CAPD and APD patients between January 1992 and September 1997, with 24-hour urine volume less than 100 mL, or renal creatinine clearance (CCr) less than 1 mL/minute. Adequacy data were available for 115 patients. OUTCOME MEASURES: Mortality and technique failure (TF). Regression analysis was used to estimate the mortality and TF rate ratios (RR) for peritoneal Kt/V urea (pKt/V) and pCCr, adjusting for age, gender, diabetes, months of follow-up prior to anuria, albumin, transport status, coronary artery disease, cardiovascular disease, and peripheral vascular disease. RESULTS: Fifty seven per cent (51/89) of patients on CAPD and 81% (21/26) on APD had a weekly pKt/V > or = 2 and > or = 2.2, respectively (DOQI targets); whereas only 35% on CAPD (31/89) and 35% (9/26) on APD had a weekly pCCr > or = 60 U1.73 m2 and 66 L/1.73 m2, respectively. Median follow-up times among patients were 16.5 and 19.5 months pre- and postanuria, respectively. Patients with pKt/V > or = 1.85 experienced a strong decrease in patient mortality (RR = 0.54, p= 0.10); the effect was less pronounced for pCCr > or = 50 L/1.73 m2 (RR = 0.63, p = 0.25). No relationship was observed between pKt/V or pCCr and TF. CONCLUSION: Mortality was noticeably less frequent among patients with a pKt/V > or = 1.85 compared with those with a Kt/W < 1.85 (p = 0.10). Given the magnitude of the association, the failure to observe statistical significance relates to the size of the patient cohort. Our results imply that it is, in fact, possible to achieve DOQI targets among anuric patients on peritoneal dialysis.

Venous stenosis and thrombosis associated with the use of internal jugular vein catheters for hemodialysis.

Previous studies have demonstrated venous stenosis and thrombosis in hemodialysis patients who had repeated or prolonged cannulation of the subclavian vein. Early reports, however suggested that patients with catheters placed in the internal jugular vein were not at risk of such complications. We conducted a retrospective case series to determine if this was correct. We report a series of seven patients who were found to have stenosis of the upper neck veins despite having never had subclavian vein cannulation. We suggest that previous reports suggesting a superior safety profile with internal jugular catheters may have been misleading and propose that all measures be taken to encourage wider use of arteriovenous grafts and fistulae.

Resolution of hyperparathyroidism associated with immunosuppressive therapy.

A patient maintained on continuous ambulatory peritoneal dialysis with severe hyperparathyroidism received a cadaver renal transplant. In the weeks following the transplant there was dramatic biochemical resolution of parathyroid hyperfunction associated with intensive immunosuppressive therapy, but without sustained return of function of the transplant kidney. Tertiary hyperparathyroidism often resolves slowly with successful renal transplantation. There are no previous reports of spontaneous resolution of hyperparathyroidism as demonstrated by this patient. Possible mechanisms, including the role of cytolytic antirejection therapy, are discussed.

Clinical practice guidelines: prevention of cytomegalovirus disease after renal transplantation.

OBJECTIVE: To develop a set of comprehensive, standardized, evidence-based guidelines for the use of antiviral therapy to prevent cytomegalovirus disease in adult patients having undergone renal transplantation. OPTIONS: The use of medication, at the time of induction therapy or at the earliest sign of viremia. Treatments were evaluated by patient and donor serologic groups and the induction regimen used. OUTCOMES: The control of symptoms and features of cytomegalovirus disease over the first 6 mo to 1 yr after transplantation. EVIDENCE: Articles, compiled using a MEDLINE search from 1976 to July 1997, were reviewed by representatives of nephrology, microbiology, pharmacy, and epidemiology. Additional information was obtained from recent review articles and conference abstracts, and from experts in the field. VALUES: The evidence-based methods and values of the Canadian Task Force on the Periodic Health Examinations were used. High value was placed on studies with a randomized controlled design and blinded outcome observers. Study quality was classified as poor when cointervention was present (especially with regard to immunosuppressive regimens), when more than 20% of patients were lost to follow-up, and when intention to treat analysis was not performed. Recommendations were made with a graded system (grades A and B: Use of the intervention advised, based on high or fair quality evidence, respectively; grades D and E: Use of the intervention not advised, based on high or fair quality evidence, respectively: grade C: No recommendation made because of insufficient or conflicting evidence). RECOMMENDATIONS: (1) Seropositive recipient; donor seropositive or seronegative; immunosuppression with antilymphocyte products. Prophylaxis with antiviral therapy recommended (grade A recommendation). (2) Seronegative recipient; seropositive donor; immunosuppression with antilymphocyte products. Prophylaxis with antiviral therapy recommended (grade A recommendation) (3) Seronegative recipient; seropositive donor; conventional immunosuppression. Prophylaxis with antiviral therapy recommended (grade B recommendation). (4) Seronegative recipient; seronegative donor; any immunosuppressive regimen. No prophylaxis with antiviral therapy required (grade D/E recommendation). (5) Seropositive recipient: donor seropositive or seronegative; conventional immunosuppression. Prophylaxis left to the discrimination of the physician in charge (grade C recommendation).

Specialized chronic care for dialysis patients--a five-year study.

BACKGROUND: At least 40% of those starting onto renal dialysis at the present time are aged over 65 years old. With old age comes increased comorbidity and decreased functional status. The long term management of older patients is limited by the need for rehabilitation and by placement concerns. We describe a 5-year experience of a pilot program, created in 1991 on the recommendation of the Metropolitan Toronto District Health Council, to rehabilitate and care for elderly and disabled patients on either hemodialysis or peritoneal dialysis. METHODS AND RESULTS: This retrospective, observational study reports on a total of 185 patients admitted over a 5-year period to the Riverdale Chronic Dialysis Unit for chronic care or rehabilitation. The mean age of patients admitted was 67 years (quartiles 61 and 75 years). Eighty-five percent of patients had 2 or more severe comorbidities, while 60% had 3 or more active medical issues. The most commonly used dialysis modality was hemodialysis (80%). Of the 185 patients followed 34% were discharged home, 35% died and 13% were still resident at the time of completion of the study. The most common acute medical problems seen in these patients related to their vascular access and necessitated temporary transfer to an acute nephrology center. A total of 4.7 transfers were recorded for each patient-year of follow up. CONCLUSIONS: This study describes the adaptation of facilities already present in our area, to allow better management and placement of older dialysis patients. Transfer of patients from a high level acute care facility to a chronic care facility makes economic and practical sense and may allow better long term health care planning as well as more stability for the family or care-givers.

Prevalence of central autonomic neuropathy in elderly dialysis patients.

BACKGROUND: Autonomic neuropathy is frequently present in dialysis patients. In addition, deterioration of autonomic function occurs with ageing. This study examines the true prevalence of autonomic neuropathy in elderly dialysis patients and questions whether the combination of age and uraemia further increases the chance of dysautonomia being present. METHODS: We compared the results of five different tests (30:15 ratio; Valsalva ratio; heart rate response to deep breathing and the blood pressure responses to sustained hand grip and standing) of parasympathetic and combined parasympathetic and sympathetic dysfunction in older haemodialysis patients (mean age 70.2 years), younger haemodialysis patients (mean age 48.1 years) and two groups of subjects with normal renal function (mean age 73.0 years and 42.5 years respectively). RESULTS: Parasympathetic dysfunction was most prevalent in older patients on dialysis (65.9% (95% confidence intervals 51.4-80.4%), compared with 33.3% (95% confidence intervals 19.0-47.5% in younger dialysis patients), and 11.8 and 0% in the old and young control groups respectively). Combined parasympathetic and sympathetic dysfunction was seen in 41.5% (95% confidence intervals 26.5-56.5%) and 11.9% (95% confidence intervals 2.1-56.5%) of the old and young dialysis patients respectively but not in any of the control subjects. No interaction was seen between age and subject type. CONCLUSIONS: We conclude that although older dialysis patients have severe impairment of cardiovascular autonomic innervation, the prevalence of dysfunction is not higher than would be expected in an ageing population with uraemia.

Elevation of whole-blood glutathione in peritoneal dialysis patients by L-2-oxothiazolidine-4-carboxylate, a cysteine prodrug (Procysteine).

Glutathione is a major cellular antioxidant that protects protein thiols and inhibits cellular damage due to oxygen free radicals. It has been reported previously that patients undergoing dialysis have low levels of blood glutathione, which may lead to increased susceptibility to oxidant stress. L-2-oxothiazolidine-4-carboxylic acid (OTZ) is a cysteine prodrug that raises cellular glutathione levels by increasing delivery of cysteine, the rate-limiting substrate for glutathione synthesis. This study investigates the effect of OTZ on blood glutathione in a blinded, placebo-controlled study of patients with chronic renal failure treated by peritoneal dialysis. Twenty patients were randomly selected to receive OTZ (0.5 g three times a day orally with meals) or placebo for 14 d. Patients visited the clinic for predose blood collection and safety evaluation at baseline (days 3, 7, and 14 and again at 14 d from the last dose [follow-up]). Glutathione concentrations were determined in whole blood by HPLC. OTZ resulted in a significant rise in whole-blood glutathione at days 7 (594 +/- 129 mumol/L) and 14 (620 +/- 108 mumol/L) compared with baseline (544 +/- 139 mumol/L) (P < 0.01 and P < 0.05, respectively). Glutathione was also significantly increased at days 7 and 14 when normalized by hematocrit (Hct) or hemoglobin to correct for anemic status (e.g., 20.7 +/- 5.7 mumol/L per % Hct [day 7] and 20.9 +/- 4.0 mumol/L per % Hct [day 14] versus 18.0 +/- 4.2 mumol/L per % Hct [baseline]; P < 0.05). Glutathione levels did not change in the placebo group at any patient visit, and levels in the OTZ-treated group returned to baseline at follow-up. There were no serious adverse events attributable to OTZ, and the drug appeared to be well tolerated by patients with renal failure treated by continuous ambulatory peritoneal dialysis. Our results show that OTZ increases blood glutathione levels, which may improve antioxidant status in dialysis patients.

Autonomic function in patients on continuous ambulatory peritoneal dialysis.

OBJECTIVE: To investigate sympathetic function in the peripheries of patients on chronic ambulatory peritoneal dialysis (CAPD) using noninvasive techniques. DESIGN: Comparison of peripheral blood flow responses in sympathetic vasoconstrictor reflexes in CAPD patients and matched control subjects. SETTING: Tertiary care hospital and research institution. PATIENTS: Twenty-three clinically stable CAPD patients and 23 control subjects matched for age, sex, and drug therapy. MAIN OUTCOME MEASURES: Sympathetic activity assessed from the reductions in hand and foot blood flow induced by a deep breath and by body surface cooling. Cardiac autonomic activity measured by the changes in heart rate produced by deep breathing, a Valsalva maneuver, and standing from lying. RESULTS: A deep breath induced mean decreases in hand blood flow of 65.1% in the patients and 82.8% in their matched controls. Corresponding reductions in the foot were 46.0% and 70.0%. Body surface cooling reduced mean hand blood flow by 50.3% in the patients and 71.8% in the control subjects. Corresponding values in the foot were 26.7% and 43.6%. The differences in response between the patients and their matched control subjects were all significant (p < 0.01). Cardiac autonomic function assessed by standard tests of heart rate variability was significantly impaired in the patients compared with the control subjects in two of the three tests used (p < 0.001). CONCLUSIONS: Cardiovascular autonomic impairment can affect the peripheral circulation as well as the heart in patients on dialysis, and this may have implications for cardiovascular homeostasis.

Comparative cost-analysis of two different chronic care facilities for end-stage renal disease patients.

OBJECTIVE: To investigate the cost and quality of life associated with the first specialized chronic care facility for disabled dialysis patients. DESIGN: A case controlled study in dialysis patients admitted to a specialized chronic dialysis unit (RCDU). SETTING: The study compares the cost of care in a specialized chronic care facility with that of a tertiary hospital. PATIENTS: All dialysis patients with severe chronic disability, resident in Greater Toronto, who were unable to be discharged into the community and who were admitted to the RCDU in the first year of the program. INTERVENTIONS: Chronic care and rehabilitation services in a specialized dialysis unit. OUTCOME MEASURES: Costs are expressed as $Cdn per patient year. Quality of life scores were measured using SIP and SF-36 questionnaires. RESULTS: The data show a saving of $37,022 Cdn over the 618 day study period with care in the RCDU compared with that of a tertiary hospital. Quality of life measures show no difference in scores. CONCLUSIONS: We conclude that this preliminary report confirms a cost benefit of a specialized chronic care dialysis unit.