Effect of hypertonic glucose on the muscular cramps of hemodialysis.

The effect of hypertonic (50%) glucose injected for relief of hemodialysis-induced muscular cramps was studied in 15 chronically uremic, nondiabetic patients who experienced a total of 44 cramp episodes. In a double-blind trial either 50 mL (or less) of hypertonic glucose or physiologic (0.9%) saline solution was injected, and the therapeutic response was evaluated. Of a total of 44 episodes of cramps, 26 were treated with hypertonic glucose and 18 with normal saline. Treatment with hypertonic glucose relieved 17 of 26 episodes, in contrast to only five of 18 episodes relieved with 50 mL of normal saline (P less than 0.016). No complications related to hypertonic glucose administration were observed. Hypertonic glucose seems to be safe and effective for the relief of dialysis-induced cramps. It also avoids undesirable loading with sodium and mannitol, which have been suggested for treatment of dialysis-induced cramps.

Death caused by brain herniation during hemodialysis.

Brain edema with brain herniation during or after dialysis has been reported previously. However, coexisting lesions of the central nervous system (CNS) which might play a facilitating role were present in these case reports. Described here is an 18-year-old white man with renal failure who developed clinical signs consistent with brain herniation while receiving his first hemodialysis treatment. He died two days later, after discontinuation of the supportive therapy and after the confirmation of brain death. Autopsy results documented brain edema with uncal and cerebellar tonsillar herniation without other coexisting pathologic lesions. The etiology of brain edema during the initial phase of dialysis is discussed.

Less dialysis-induced morbidity and vascular instability with bicarbonate in dialysate.

We devised three protocols to test the postulate that increased morbidity during high-efficiency dialysis with large-surface-area units (LS) might be due in part to the increased flux of bicarbonate out and acetate into the patient inherent is LS dialysis. The first protocol showed that with LS-acetate dialysis there was a marked fall in plasma bicarbonate and Pco2 during the first 3 to 4 h, followed by a rapid rise in bicarbonate above normal and return to control in Pco2. With LS-bicarbonate dialysis, these oscillations were largely eliminated. A second double-blind protocol showed that central nervous system-type symptoms noted during and after LS-acetate dialysis were reduced significantly by switching to LS-bicarbonate dialysis. The third protocol showed that with LS-carbonate the tolerable rate of ultrafiltration could be increased 67% compared with LS-acetate dialysis.

Spontaneous retroperitoneal bleeding in patients on chronic hemodialysis.

Six patients developed spontaneous retroperitoneal bleeding while on maintenance dialysis (3% of all patients so treated). At the time of the bleeding episode, four patients were receiving Coumadin for prevention of recurrent clotting problems in external shunts. In three patients, including two who had not received Coumadin, bleeding developed while on dialysis. The presenting common symptoms and signs of retroperitoneal bleeding included sudden and progressive abdominal pain with blood pressure drop and subsequent development of an abdominal mass. These symptoms were associated with a falling hematocrit without any documented external blood loss and with suggestive X-ray changes, including absence of psoas shadow with soft tissue density. All six patients recovered. Treatment included blood transfusions, temporary regional heparinization, withdrawal of Coumadin, and bed rest. Surgical exploration was undertaken in two patients, but no obvious bleeding source was found. Anticoagulation therapy and functional platelet abnormalities may be contributory causes.

Clinical use of a totally heparin grafted hemodialysis system in uremic patients.

1. A totally heparin grafted dialysis system shows great promise in the treatment of chronic uremia associated with bleeding risk. 2. Long-term treatment of chronic uremia with this system has to await: a) Further studies of the chronic toxicity of CPC. b) Evaluation of performance which may be achieved by using a more homogeneous heparin with higher bioactivity. 3. Detailed studies of platelet factor 4 release with subsequent heparin neutralization to determine the importance of this variable in its effect on system performance.