Complications of vascular access in hemodialysis (HD)--aged vs adult patients.

Reports on the success of permanent vascular access in elderly HD patients vary considerably. We reviewed the records of 149 patients [62F and 87M] aged 20-89 years old (median 59) who were on hemodialysis for 6-242 (49 median) months, and had undergone 202 vascular access procedures (177 Cimmino-Brescia fistulae and 25 PTFE grafts). Patients were divided into two groups according to the age they started HD. Group A: 48 patients, over 60 years old (range 60-83; median 70) on HD for 43.5, (6-140) months. Group B: 101 patients, under 60 years old, range (15-59) median 46, on HD for 54 (6-242) months. There were no differences between the two groups in terms of gender, primary renal disease, (except polycystic kidney disease), Hct and EPO administration. The initial choice of vascular access, the complications and the technique survival were examined in both groups. Cimmino-Brescia fistulae were used as the first choice of vascular access in all patients except one in group B. PTFE-grafts were the second or third choice in 7/48 (group A) and 15/101 (group B) (p: NS). The only reason for technique failure was vascular thrombosis in both groups (11/48 group A and 31/101 group B p: NS). Other complications were: aneurysms (10/48 and 14/101, p: NS), infections (0/48 and 2/101 p: NS) and edema (0/48 and 6/101, p: NS). Five-year technique survival of the first AV fistula in the two groups was 35% and 45% respectively (log-rank test, p: NS). These findings suggest that: a) A.V. fistula is the first choice of vascular access in aged HD patients; b) There is no difference in vascular access complications across age groups; c) Survival of the first A.V. fistula is independent of age.

On the usefulness of glycylglycine in hemodialysis and peritoneal dialysis solutions.

This article reviews current knowledge on the usefulness of glycylglycine in preparing single stable hemodialysis (HD) and peritoneal dialysis (PD) solutions containing bicarbonate. The coexistence of bicarbonate and glycylglycine in a dialysis solution renders it a potent, stable buffer in which the well known reactions between bicarbonate and calcium and magnesium, and the subsequent formation of insoluble neutral calcium and magnesium carbonate salts, are avoided. Single stable bicarbonate-glycylglycine (BiGG) solutions for HD and PD have been successfully prepared and studied, both experimentally and clinically. These studies have demonstrated the advantages of BiGG solutions in terms of simplicity, stability, convenience, tolerance, biocompatibility, protection of the peritoneum, and higher ultrafiltration, compared to standard acetate or lactate solutions, and on-line prepared bicarbonate solutions. Progressive accumulation of glycylglycine or glycine, even after prolonged use, side effects, or signs of toxicity were not observed. In conclusion, BiGG solutions ensure a physiologic dialysis both from the theoretic and practical points of view.

Intrahospital transportation: monitoring and risks.

Patients' intrahospital transport is considered as part of the mediconursing care continuum, since patients frequently need diagnostic or therapeutic procedures not performed at the bedside (Waddell 1975, Rutherford & Fisher 1986). Severe complications, such as airway obstruction, artificial airway or intravenous line removal, arterial blood gas and blood pressure changes, and arrhythmias or cardiac arrest, have been described during this transportation, especially in critically ill patients (Taylor et al 1970). Risks can be diminished if the patients are appropriately selected and carefully monitored during transportation (Venkataraman & Orr 1992).

Sodium thiosulfate in the treatment of tumoral calcifications in a hemodialysis patient without hyperparathyroidism.

Extraskeletal tumoral calcifications (TC) may occur in patients with end-stage renal disease. The TC usually develop in the presence of secondary hyperparathyroidism or a high calcium x phosphate product, while other factors have been also occasionally implicated in their development. At present, no uniformly accepted effective treatment has been described for this condition. We describe a 58-year-old female patient with end-stage renal disease who 7 years after the onset of dialysis presented with pain and movement restriction of various joints. A skeletal X-ray showed huge amounts of periarticular TC. The TC occurred in the absence of hyperparathyroidism or a high calcium x phosphate product as evidenced by hormonal and biochemical examination as well as by a bone biopsy specimen that revealed an adynamic bone disease with significant aluminum staining. Sodium thiosulfate, an inorganic salt that has been claimed to inhibit the formation and to favor the solubility and the mobilization of calcified masses, was administered to the patient, and after a long period of treatment considerable radiological regression of the TC with concurrent clinical recovery was noticed. Aluminum intoxication, along with other factors, was considered to be the cause of TC development. The use of sodium thiosulfate seemed to be a reasonable nonspecific therapeutic approach for the management of TC in this case.

Successful use of recombinant human erythropoietin in a pregnant woman with lupus nephritis.

Recombinant human erythropoietin (r-HuEPO) is broadly accepted as treatment for anemia in dialysis and nondialysis patients with chronic renal failure, but data regarding the safety and efficacy of this drug in pregnancy are limited. Maternal and fetal problems have been reported to be associated with anemia during pregnancy. On the other hand, anemia is a frequent feature of systemic lupus erythematosus. We report the successful use of r-HuEPO in a young woman with lupus nephritis complicated by severe anemia during pregnancy. Additional studies should be encouraged to confirm the safety of r-HuEPO therapy during pregnancy.

Anabolic steroids in the treatment of malnourished CAPD patients: a retrospective study.

OBJECTIVE: To assess the effect of anabolic steroids on malnutrition of continuous ambulatory peritoneal dialysis (CAPD) patients. DESIGN: Retrospective analysis of medical records, charts, and computer-generated laboratory and medication data. SETTING: Peritoneal Dialysis Unit of The Toronto Hospital. PATIENTS: Thirteen patients with moderate to severe malnutrition who had received nandrolone decanoate (ND) intramuscularly (IM) for at least three months. Nine of these patients (group A), with a mean age of 59.4 years, received only ND (100-200 mg IM monthly). Group B consisted of 4 patients (mean age 74.0 years) who, in addition to ND, received intraperitoneal (IP) amino acids. RESULTS: In group A, serum albumin, while declining before ND treatment (34.4 +/- 3.2 to 31.5 +/- 3.35, x +/- SEM, g/L at -2 and 0 months), showed a progressive and significant (p < 0.001) increase during treatment, sustained up to the third month (36.57 +/- 1.51). In group B, serum albumin did not increase significantly (30.25 +/- 2.62, 30.75 +/- 1.9, and 31.5 +/- 4.8, mean +/- SEM, g/L at -2, 0, and +3 months, respectively. In group A, serum creatinine was increased significantly (p < 0.01) from 0 to +3 months (731 +/- 185 to 938 +/- 92.5 mmol/L). Blood urea, bicarbonate, and total protein levels did not change significantly. In group B, serum creatinine fluctuated considerably with an insignificant trend to rise. Blood urea showed a steady trend to increase without reaching statistical significance. In relation to time 0, bicarbonate levels (28.7 +/- 3.3) were decreased significantly (p < 0.05) (27 +/- 0.8, 24.6 +/- 1.5, and 25 +/- 1 mEq/L, at +1, +2, and +3 months, respectively). CONCLUSIONS: Nandrolone decanoate alone, in relatively low doses, exerted a definite anabolic effect in 9 malnourished CAPD patients. The lack of a similar effect in 4 patients, who in addition to ND received amino acids IP, could be explained by the low dose of ND, the concurrent acidosis, the severity of malnutrition, and the older age of this group.

Long-term continuous ambulatory peritoneal dialysis.

Of 174 patients who entered our CAPD program, 58 received transplants, 7 were transferred to another center, one recovered satisfactory kidney function, 22 were transferred to hemodialysis, 24 to IPD, 52 died and 10 remained on CAPD for at least seven years, when this study was completed. These 10 patients (8 women and 2 men) who are described here in detail had a median age of 46 (range of 24 to 63) years at entry. Their primary renal disease was glomerulonephritis (6), polycystic kidney disease (2), nephrosclerosis (1) and Alport's disease (1). They spent 91 to 134 (average 113) months on CAPD. They had a significant (p = 0.025) increase in body weight from 54.5 +/- 2.8 kg to 59.6 +/- 3.0 kg during the first 3 years, and a decrease in ultrafiltration capacity; BUN and serum creatinine remained relatively stable. Mean total protein and serum albumin remained unchanged at 65 and 35 g/l respectively, throughout the study. There were no significant changes in the hemoglobin and lipid values. Renal osteodystrophy progressed slowly. Peritonitis rate in this group was one episode every 18.9 patient months. These 10 patients had a total of 25 catheters implanted during the study period. The average hospitalization rate was 8.76 days per patient year, 5.34 of which were for peritonitis. Of these 10 patients, one was transferred to hemodialysis, 5 died (4 of or during peritonitis, one of myocardial infarction) and 4 remained on CAPD. Our experience with these 10 patients indicates that CAPD can be carried out over long periods.(ABSTRACT TRUNCATED AT 250 WORDS)

Destructive spondyloarthropathy in a patient on continuous ambulatory peritoneal dialysis for 13 years.

Since 1984 there have been reports of a destructive spondyloarthropathy occurring in patients on long-term hemodialysis. The primary abnormality appears to be an accumulation of beta 2-microglobulin, which is not adequately removed by dialysis, and forms amyloid deposits in articular and periarticular tissues. We report a case of this disease in a patient treated only by peritoneal dialysis. While this form of treatment may delay the development of arthropathy, as compared to hemodialysis, it does not prevent it. An increasing incidence of this disorder may be expected, since increasing numbers of patients have been on long-term peritoneal dialysis.

Procollagen type-I in the serum and dialysate of continuous ambulatory peritoneal dialysis patients.

Procollagen-I carboxylterminal extension peptide (PICP) was determined in the serum and dialysate of 26 continuous ambulatory peritoneal dialysis (CAPD) patients and in the serum of 11 healthy controls. PICP serum levels were significantly higher in CAPD patients than in healthy controls (p < 0.001). There was no correlation between serum PICP levels and those of calcium, phosphorus, magnesium, alkaline phosphatase, osteocalcin, and intact parathyroid hormone (iPTH). Serum and dialysate levels of osteocalcin and iPTH showed a significant correlation (p < 0.001). The dialysate-to-serum PICP ratio in 21 patients was lower than 1.0. In the remaining 5 patients, however, the above ratio was higher than 1.0. We conclude that in CAPD patients serum PICP levels do not correlate with biochemical parameters of renal osteodystrophy. A dialysate-to-serum PICP ratio above 1.0 could implicate an increased local peritoneal fibroblastic activity and could be a useful marker of peritoneal fibrosis in CAPD.

Recent developments in peritoneal dialysis.

Significant developments over the past 10 years have established continuous ambulatory peritoneal dialysis as a successful kidney-replacement treatment. Peritonitis rates have fallen, and investigators are attempting to establish objective criteria for adequacy of dialysis. Malnutrition is a serious concern, but short-term experience with intraperitoneal amino acids promises success in the management of this complication. A significant improvement in the well-being of patients with end-stage renal disease was produced by recombinant human erythropoietin, and use of recombinant human growth hormone promises catch-up growth for children receiving long-term peritoneal dialysis treatment. As increasing numbers of patients are maintained on continuous ambulatory peritoneal dialysis over longer periods, we will begin to encounter beta 2-microglobulin-related amyloidosis possibly at the same rate in these patients as in those receiving long-term hemodialysis treatment.

Tumor markers in patients undergoing hemodialysis or kidney transplantation.

The following tumor markers, AFP, CEA, CA 19-9, CA-125 and CA 15-3 were studied in 50 healthy volunteers (group A), in 23 patients on chronic hemodialysis (group B) and in 30 successfully transplanted individuals (group C) who did not present any clinical symptoms or signs of neoplasia. The levels of AFP, CEA and CA 15-3 were significantly higher in group B when compared to groups A and C. The levels of CA 19-9 and CA-125 did not differ significantly among the three groups. Transplanted individuals (group C) presented significantly lower levels of CEA and AFP and higher levels of CA 15-3 when compared to group B patients. The levels of all markers were not influenced by sex or time on dialysis. It is concluded that: (1) CA 19-9 and CA-125 can be considered as reliable tumor markers in patients undergoing hemodialysis or kidney transplantation. (2) The elevation of CEA and AFP levels in hemodialysis and their decline to normal levels found in the group of successfully transplanted individuals, suggest a possible active role of functioning renal tissue in their clearance. (3) The etiology of CA 15.3 elevation following successful kidney transplantation remains obscure and requires further evaluation.

Peritonitis-related deaths in continuous ambulatory peritoneal dialysis (CAPD) patients.

A total of 636 episodes of peritonitis occurred in 440 patients who entered our continuous ambulatory peritoneal dialysis (CAPD) program from September 1977 to February 1988. Sixteen patients (8 male and 8 female, aged 37-77 years) died during an episode of peritonitis (fatality rate 2.5%). They had been on CAPD for 3 to 105 (average 39) months. Six of them were diabetics. The peritonitis rate among these 16 patients were 1 episode per 12 patient months, while the corresponding figure for the whole (440) CAPD population was 14 patient months. Risk factors present in the 16 patients were: cardiovascular disease (12), cerebrovascular accident (2) peripheral artery disease (1) and pulmonary fibrosis (1). Fever and leukocytosis were present on admission in 11 patients, while total serum proteins and albumin were significantly lower (p less than 0.001) than the corresponding values before peritonitis (56 +/- 8 vs. 65 +/- 5). Staph. aureus was isolated in 8 patients (50%), multiple organisms in 6, Pseudomonas and Candida albicans in 1 each. An abdominal abscess was found in 4 (25%) patients. The peritoneal catheter was removed between the 5th and 10th day in 6 and after the 10th day in 7 patients. Peritonitis with sepsis was the cause of death in 13 patients. Contributing factors were cardiovascular accident in 9, uremic coma in 2, extensive GI bleeding in 2, GI perforation in 2, intestinal infarction in 1, and pneumonia in 2 patients. We conclude that the risk of peritonitis-related death in CAPD patients is increased with Staph. aureus or multibacterial peritonitis. Contributing factors are concomitant cardiovascular disease and delayed (greater than 5 days) catheter removal.

Fluorometric study of serum in patients with chronic renal failure.

Sera from 84 uremic patients (53 on conservative treatment and 31 on hemodialysis) were studied spectrofluorometrically in comparison with 20 normal subjects and 11 jaundiced patients. Serum fluorescence in patients with chronic renal failure was significantly higher than in normals and patients with jaundice. Two types of serum fluorescence spectra (A and B) were predominant (93%) and all the patients who were free of any medication for more than two months exhibited the type A spectrum. The intensity of fluorescence was in parallel with the serum creatinine levels. Dialysis experiments of uremic serum in vitro showed that the substance(s) responsible for its fluorescence is dialyzable. Moreover hemodialysis caused a significant decrease in the intensity of serum fluorescence in dialyzed patients. Administration of pyridoxine intravenously caused quite different results in normal subjects and uremic patients. Namely normals presented a transient (for several minutes) increase in serum fluorescence whereas uremics showed a higher and more permanent increase which lasted for several days.

Electron microscopic study of the peritoneal kinetics of iron dextran during peritoneal dialysis in the rabbit.

Iron dextran, an electron-dense tracer, was given intravenously (100 mg of iron/100 g of body weight) to 8 normal rabbits to study its movement from the plasma to the peritoneal cavity during peritoneal dialysis. The dialysate infused at 75 ml/kg contained 1.5 g/dl of glucose in 4 animals and 4.25 g/dl in the remainder. Peritoneal dialysis was discontinued and the peritoneum was fixed in vivo at various times (20-120 min) after the injection of the iron dextran. Large amounts of tracer were detected in the effluent after draining the peritoneal cavity. Electron microscopic examination of the mesentery showed particles of iron dextran in the endothelial cells of small vessels (capillaries and venules) the interstitium and the mesothelial cells adjacent to vessels irrespective of the dialysate concentration or duration of dialysis. Tracer was not clearly demonstrated in the interendothelial or intermesothelial spaces. In the mesothelial cells, the particles were found exclusively in (small, elongated or large) vesicles, while in the endothelial cells they were both in vesicles and free in the cytoplasm. Our findings suggest that during the 20- to 120-min period after intravenous administration, the intracellular transport of iron dextran, depends on either moving vesicles or the presence of pre-existing tunnels in the mesothelial cells of rabbit mesentery.