Immunogenicity of a hepatitis B subunit vaccine in hemodialysis and in renal transplant recipients.

A hepatitis B subunit vaccine was given to 59 medical staff members, 106 hemodialysis patients and 28 renal allograft recipients. The vaccine consisted of formalin-inactivated hepatitis Bsurface antigen (HBsAg) and was given in 3 doses (times 0, 1 and 6 months) of 20-40 micrograms. Some of the vaccinees received anti-HBs antibodies together with the first vaccine dose (active/passive vaccination). One month after the last infection, 93% of the medical staff members who had received active/passive immunisation and 97% of those who had received active immunisation had detectable anti-HBs antibodies with mean titers ranging from 1:512 to 1:1024. In the group of hemodialysis patients antibodies were detectable in 63-65% of the individuals who had received active or passive/active immunisation in mean titers between 1:32 and 1:64. Finally, only 32% of the renal allograft patients developed measurable anti-HBs antibodies, the titers of responders being still lower than in the hemodialysis patients. Side effects occurred following 10% of all vaccine injections and were always mild in nature. Within the 12 months observation period period following the first vaccination, 3 HBV events occurred in the 193 individuals: One aclinical case detected by a transient seroconversion against the hepatitis B core antigen, one anicteric and one icteric hepatitis case. The data illustrate the difficulties for active immunisation against hepatitis B of hemodialysis patients or of renal transplant recipients.

Control of epidemic meningococcal meningitis by mass vaccination. I. Further epidemiological evaluation of groups A and C vaccines in northern Nigeria.

Mass vaccination campaigns were mounted by several state governments in the northern Nigerian sector of the African meningitis belt. Bivalent groups A and C polysaccharide vaccines were used. The results of these campaigns in four of the states which are adjacent to each other are presented and assessed. A total of 7535350 persons in the four States, Bauchi, Borno, Gongola and Plateau, were given the vaccine over a period of 4 years (1978-1981). There was a decline in the overall number of cases reported as well as in the number of deaths in the area, where, since 1978, there has not been an epidemic of meningococcal meningitis. Variations were observed among the states which vaccinated over 50% of their populations and had many fewer cases than those which did not. These results show that mass vaccination is an effective means of preventing outbreaks of meningococcal meningitis and may lead to eradication of the disease.

PIP: In mass vaccination campaigns organized by several state governments in northern Nigeria in 1978-81, a total of 7,535,350 people received bivalent groups A and C polysaccharide meningitis vaccines in the states of Bauchi, Borno, Gongola, and Plateau. This figure represents 53% of the population of these 4 states, which are part of the African meningitis belt. Of the total number of reported cases of meningitis from the 4 states in the 1978-81 period, 5565 (80%) occurred in 1978. As more persons were vaccinated over the years, the number of reported cases declined significantly in all states but Gongola, where the percentage vaccinated (19%) was lowest. By 1980 in Bauchi, where 78% of the population had been vaccinated, there were only 12 reported cases of meningitis and no deaths, and there has not been a single reported case of the disease in this state since 1981. These findings confirm the effectiveness of mass vaccination in limiting meningococcal infection. Moreover, mass vaccination has the potential of eradicating the disease, unlike selective vaccination. Epidemiologic research suggests it may be necessary to undertake mass vaccination campaigns only among those 3-15 years of age once every 4-5 years.

Control of plasma aldosterone during chronic hemodialysis.

To investigate the effect of chronic hemodialysis (CH) on adrenal aldosterone release plasma aldosterone (PA), plasma renin activity (PRA), plasma cortisol (PC) and the serum concentrations of potassium (K) and sodium (Na) were measured before and at monthly intervals up to 26 months after initiation of CH in 42 patients with terminal renal failure. Body weight (BW), systolic (BPs) and diastolic (BPd) blood pressure were determined simultaneously. With 2 exceptions PA, PRA and PC as well as BW, BPs and BPd showed no significant changes. Following month 2 K was always significantly higher than the starting value while significantly higher Na values were observed in 12 of 26 different test periods (P less than 0.05--less than 0.001). Correlation analysis between the various parameters determined in this study revealed in 16 of 26 different months a significant relationship between PA and PRA (P less than 0.05--less than 0.001) and as expected in 20 of 26 between BPs and BPd (P less than 0.05--less than 0.001). Only at times were punctual correlations seen between any of the remaining parameters. Our results demonstrate that the prime influence of the renin angiotensin system on PA remains unaltered during CH. We conclude that the observed punctual correlations between the various parameters determined in this study are random and do not reflect a true relationship.

Effect of pindolol and propranolol on plasma renin and aldosterone in patients with renal allograft.

To investigate the effect of propranolol and pindolol on renin and aldosterone secretion, blood samples of 12 nephrectomized kidney transplant recipients were taken after 1 hour in supine position and 30 and 60 minutes after posture change. This procedure was repeated after 4 days under pindolol (3 X 5 mg/day) or propranolol (4 X 40 mg/day). Both pindolol and propranolol suppressed the significant orthostatic rise of plasma renin activity (PRA) seen without medication. Pindolol increased basal PRA markedly, whereas basal PRA under propranolol was the same as without betablockers. Plasma aldosterone (PA) showed significant orthostatic rise under all conditions and thus did not parallel PRA under betablockers. Suppression of PRA response to posture change by betablockers indicates that circulating catecholamines may be involved in orthostatic PRA regulation. The intrinsic sympathetic activity of pindolol results in an increase of basal PRA. In nephrectomized renal transplant recipients, postural PA changes do not seem to be triggered by PRA.

Control of plasma aldosterone in terminal renal failure before and after nephrectomy and after renal transplantation.

In two patients with terminal renal failure the night-day rhythm of plasma aldosterone (PA) renin activity (PRA) and plasma cortisol (PC) were examined before and after bilateral nephrectomy and after renal transplantation. Before nephrectomy changes in abnormally high PA coincided with PC whereas no significant correlation was observed between PA and PRA. In the anephric state secretory episodes of PA occurred independent from those of PC while PRA was undetectable. After renal transplantation a lack of night-day variation in renin secretion was observed in both patients; only one of the two patients showed episodic secretion of PA while PC was suppressed in both patients probably due to the chronic administration of prednisone. Our results indicate, that before nephrectomy under the conditions described in this study plasma aldosterone was predominantly controlled by ACTH. In the anephric state and after renal transplantation other (yet unidentified) factors might have caused episodic secretion of aldosterone. Finally, the lack of night-day variation and secretory episodes in renin secretion after transplantation points to an important role of the sympathetic nervous system in the control of circadian and episodic renal renin release.

Design and testing of the Baxter Integrated Disconnect Systems (IDS).

This paper describes the result of a miltidisciplinary approach to the design and evaluation of a new CAPD disconnect system: the Baxter Integrated Disconnect System (IDS). This system consists of a bag full of fresh Dianeal, an empty bag for the drainage of spent dialysate and tubings connecting the 2 in a Y fashion. With this system, the patient makes only one connection. The system is disposable. The major property that makes this unique is that all components are preassembled, and the whole system is steam-sterilized as 1 unit. In general, similar systems use different sterilization methods for the various components of the system. Those components are then assembled, under clean conditions by the manufacturer, without final sterilization of the unit. Assembly of the components is sometimes left to the patient. The concept of IDS, therefore, is unique and warrants lower rates of contamination. This system has been tested on patients for a total observation period of 765 patient months, and has proven to be simple, safe and effective. It yields a 63% probability of peritonitis-free patients at 24 months.

[Continuous ambulatory peritoneal dialysis in the treatment of end-stage renal insufficiency. Current status in 1991]. / Kontinuální ambulantní peritoneální dialýza pri lécbe terminální renální insuficience. Stav v roce 1991.

CAPD was introduced in the U.S.A in 1978 as a new technique of peritoneal dialysis and as a self-treatment method and new possibility of renal replacement therapy in patients with end-stage renal failure. Up to this time peritoneal dialysis stood in the shade of hemodialysis, so that the new technique brought about a true renaissance of peritoneal dialysis. Owing to its advantages CAPD rapidly expanded worldwide and the number of CAPD patients is still increasing. Patients who could not be taken into consideration for renal replacement treatment because of shortage of facilities, could now be accepted in increasing number; a new era of renal replacement therapy began. The article describes the technique, the advantages, disadvantages and the problems regarding the indications for CAPD as is the status in the year 1991.

[The importance of CAPD in kidney replacement therapy]. / Bedeutung der CAPD für die Nierenersatztherapie.

Continuous ambulatory peritoneal dialysis (CAPD) a method suitable for self-treatment by patients with chronic renal failure, was introduced for clinical use at the end of the seventies. It was rapidly accepted and used worldwide. Based upon a ten-year-old clinical experience at the renal unit of the Stadtspital Waid, Zürich, and on data of a cohort of 113 unselected patients treated by this method, this report aims at the importance of CAPD for renal replacement therapy. Experiences with developments of materials, techniques and measures preventing complications, collected during an observation period, from 1979 to 1989 were analyzed and data from three arbitrarily fixed consecutive periods compared. The Tenckhoff catheter, primarily used for dialysis, has been replaced by the Oreopoulos-Zellermann catheter because of a reduced complication rate. The number of patients treated with CAPD doubled within these ten years. The survival rate for different methods was similar in the three time periods investigated. In accordance with other centers, peritonitis was found to be the most frequent cause for a drop-out and was equally the most frequent complication whose incidence, however, declined over the observation periods. Compared to other centers, incidence of peritonitis was already low before at the renal unit of SWZ. 41% of the patients died, most of them because of cardiovascular problems. Infections of the catheter tunnels were less frequent, but their rate could not be influenced in the course of the ten-year period. Clinical experiences of the first ten years with CAPD at the renal unit of SWZ yielded positive results: 1. CAPD represents a simple and effective method for dialysis therapy of equal value compared to hemodialysis. 2. Success of the CAPD program depends crucially on amelioration of the CAPD materials and techniques as well as on an optimal education of the patient by the nursing staff and the physician. 3. Obviously, the significant decline of the rate of peritonitis in the Stadtspital Waid was due to the introduction of a simple microbiologic method for self-control (so-called dialysate-digest medium tube-method) and to the prophylaxis for fungal peritonitis with Nystatin per os accompanying every antibiotic therapy. 4. A future challenge is seen in increased attention and better prevention of the second most common complication of CAPD, catheter-tunnel infection.

Prophylaxis of peritonitis in continuous ambulatory peritoneal dialysis (CAPD) by a simple microbiological patient self-check.

For prophylaxis of peritonitis a simple microbiological patient self-check method was developed. By regular twice daily cultivation of dialysate drainage in a tube with nutrient medium (= Dialysate-Digest Medium-tube method) a latent peritoneal infection can be detected before the symptoms of peritonitis appear. The outbreak of peritonitis can then be prevented by early antibiotic treatment. After the dialysate digest medium-tube method was introduced in our CAPD programme the incidence of peritonitis was reduced from 5.6 to 0.5 episodes per patient year.

[Surgical experiences with the arteriovenous hemodialysis shunt (1970-1988)]. / Chirurgische Erfahrungen mit arterio-venösen Hämodialyse-Shunts (1970-1988).

Data were collected concerning 307 arteriovenous fistula for hemodialysis created in 186 patients between 1970 and 1988 at the Municipal Hospital Waid of Zurich. The average age of all patients was 52.7 years. The procedure which provides access for 97.2% of all patients is the radiocephalic fistula (Cimino-Brescia), which became dilated within 4 weeks in 82.9%. There was a primary failure rate of 11.2%. The patency rate was 60.2% after 3 years and 36.6% after 5 years. Early complications, especially thrombosis, occurred in 11.2% and were caused usually by technical faults or hypotonia. Late complications were discovered in 42.8% of the patients (22.5% thrombosis, 7% stenosis, 2.1% aneurysm, 2.6% infection, 2.7% steal syndrome and 5.9% skin alterations). During the average period of dialysis (4.6 years), 38% of the patients needed more than one fistula. In that situation too, the same radiocephalic fistula was performed in the contralateral forearm (30%) prior to perform advanced procedures like PTFE-grafts (29%), etc. The patency rate after 3 years was 60.4% for radiocephalic fistula and 69.7% for PTFE transplants. The shuntthrombosis was again the main early (9.9%) and late (24%) postoperative complication. With help of a surgical thrombectomy or more conservative procedures like anticoagulation, local thrombectomy and transluminal angioplasty, 81.2%, respectively 64% of the failed fistula could be restored. Other complications like bleeding, aneurysms and infections occurred especially in arteriovenous grafts (0.5-5.7%).