Upper extremity vascular access for continuous arteriovenous hemofiltration and dialysis after cardiac operations

BACKGROUND: There is increasing interest in the use of continuous arteriovenous hemofiltration/dialysis for treatment of profound renal failure after cardiovascular operations. Vascular access for this is usually accomplished by percutaneous cannulation of the femoral artery and vein, with the inherent risks of vascular trauma, patient immobilization, hemorrhage, or infectious complications. METHODS: Fifteen (0.36%) of 4,166 patients receiving cardiovascular surgical procedures sustained postoperative renal failure requiring treatment with continuous arteriovenous hemofiltration/dialysis. Each patient had creation of acute arteriovenous forearm access using a modified Allen-Brown shunt. Shunts were monitored continuously for hemorrhage, malfunction, infection, and thrombus, and were explanted when no longer required. RESULTS: Sixteen shunts were implanted in 15 patients over the 41-month period. All shunts functioned satisfactorily, with the duration of implantation ranging from 1 to 64 days. There were no infectious or hemorrhagic complications. CONCLUSIONS: The acute creation of a simple forearm shunt for postoperative continuous arteriovenous hemo-filtration/dialysis is preferred over femoral arterial and venous cannulation because it can be constructed rapidly and easily in the operating room or at the bedside, has a low complication rate, is available for immediate use, may be left in place indefinitely, does not interfere with patient mobilization or ambulation, and is easily removed.     

Bradycardia-induced syncope

Vascular surgeons well versed in peritoneal dialysis applications understand the importance of this modality among the limited options afforded to patients in renal failure. Peritoneal and hemodialysis strategies are interdependent and should be considered in concert. Careful assessment often shows that patients with diminishing vascular access have been overlooked as viable peritoneal dialysis candidates. This chapter summarizes peritoneal dialysis in terms of its history, physiological principles, indications, contraindications, catheter placement, types of administration, and the identification and management of complications.     

The use of an indwelling peritoneal catheter in the treatment of chronic renal failure

Thirty-seven patients with end-stage renal failure were treated by dialysis by the peritoneal route, with a Tenckoff catheter. The basic regime was 30 2-litre exchanges twice a week. Two patients died while receiving peritoneal therapy, and 7 patients were transferred to haemodialysis because of catheter failure. Four patients received transplants directly from peritoneal dialysis, 22 were transferred electively to haemodialysis, and 2 are still being treated by peritoneal dialysis. Fourteen (1-2%) of the 1,161 dialyses were complicated by peritoneal infection. This was controlled in 13 instances by the addition of gentamicin to the dialysate, but removal of the catheter was required in one case. The mean duration of peritoneal dialysis was 14-4 weeks; 4 patients underwent this type of therapy for 78, 63, 41 and 40 weeks respectively.     

Treatment of acute renal failure

Acute renal failure is a life threatening illness whose mortality has remained high since the introduction of hemodialysis 25 years ago, despite advances in supportive care. Acute renal failure is an extremely morbid and costly disorder with a significant proportion of patients progressing to end-stage renal disease requiring dialysis. To the nephrologist, acute renal failure remains an extremely frustrating disease, because the pathophysiology is not well understood and the limited therapeutic options force the nephrologist to sit on the sidelines and wait for renal function to return. For example, dialysis remains the only FDA-approved treatment for acute renal failure, but dialysis may also cause renal injury that prolongs renal failure. The purpose of this perspective is to understand the results of the recent, largely negative, clinical trials in view of recent advances in the epidemiology of ARF. This review will also discuss diagnostic tools, strategies for improved design of clinical trials, and other therapeutic interventions that will be needed to properly treat acute renal failure in the 21st century.     

Serious renal disease in Egypt

We studied serious renal disease in Egypt by registering all 155 patients coming to the nephrology service at the University of Cairo during a period of 62 days in 1993. The patients presented with severe uremic symptoms. Admission creatinine and urea levels were high, 804 mumol/l and 64 mmol/l. Fifteen percent of the patients died; 115 underwent dialysis. Sixty patients presented with chronic renal failure; 53 with acute renal failure, but 24 of these were later found to have end-stage renal failure. Of 29 patients with true acute renal failure, 11 (38%) had pre-renal failure and 7 (24%) post-renal failure. Twenty-one patients were followed up after transplantation and chronic dialysis, another 17 had nephrotic syndrome, 3 hypertension, and one had asymptomatic urinary abnormalities. The most common specific etiology for chronic end-stage renal failure was diabetes mellitus type II in the older patients; second most common was Schistosoma in the younger ones. Most diabetic patients came from the city. All but one Schistosoma patient came from rural Egypt. In the 22 patients who underwent renal biopsy the most common diagnosis was mesangio capillary glomerulonephritis. The prevalence of acute renal failure, particularly iatrogenic-toxic, is increasing.     

Continuous renal replacement therapies: an update

Continuous renal replacement modalities have found widespread use and acceptance over the last decade. The various modalities differ in the kind of access (arteriovenous v venovenous); in the application of convective clearance (continuous hemofiltration), diffusive clearance (continuous hemodialysis), or a combination of both (continuous hemodiafiltration); and in the location where the replacement fluid enters the circuit (predilution v postdilution). Continuous therapies incorporate several advantages, such as improved hemodynamic stability, the possibility for unlimited alimentation, optimal fluid balance, and gradual urea removal without fluctuations. However, it has not yet been shown whether these advantages have a significant impact on outcome and prognosis, the ultimate measure of treatment efficiency. Major disadvantages of continuous therapies are the ongoing necessity for continuous anticoagulation, immobilization of the patient, and possible side effects from lactate-containing replacement fluid or dialysate. Continuous renal replacement procedures have certainly made the management of critically ill patients easier. In particular, oligoanuric patients with diuretic resistant volume overload and hemodynamically unstable patients with acute renal failure and concomitant sepsis or multiorgan failure appear to benefit most from continuous treatment. The role of continuous hemofiltration as a method of removing serum cytokines in septic patients without renal failure is still controversial and needs further clinical assessment. Due to slow efficacy, continuous renal replacement is indicated only in rare circumstances for intoxication; this therapy also is of rather limited use in severe hyperkalemia or acidosis. Noncritically ill patients with uncomplicated renal failure (eg, due to the use of dye or antibiotics) should be treated with intermittent hemodialysis or peritoneal dialysis. Furthermore, intermittent hemodialysis is preferable in patients with hemorrhagic diathesis because it can be easily performed without anticoagulants.     

Acute renal failure. Community hospital experience with hemodialysis as intensive care adjunct

A 3-year experience with 50 acute renal failure patients managed by hemodialysis in a 417-bed community hospital is reviewed. The 58% survival rate was better than that reported in other recent series. Possible reasons for our favorable mortality experience include: (1) Hemodialysis was performed within the ICU facility by the ICU staff. Continuity of total care was thereby maintained and hemodialysis problems, such as maintenance of circulating volume, were managed in the context of continued assessment of the patient's cardiopulmonary status. (2) In contrast to previous reports, the presence of sepsis did not influence recovery rates from acute renal failure. Early administration of specific antibiotics, mainly gentamicin, rapid drainage of abdominal abscesses, and early and frequent dialysis were all utilized in spetic patients and may have contributed to their high recovery rate. (3) The use of agressive dialysis may also have lessened other uremic complications, notably gastrointestinal bleeding. Our dialysis organization and procedures are described.     

Acute renal failure following copper sulphate intoxication

Eleven out of a series of twenty-nine patients (37-9%) with acute copper sulphate poisoning developed acute renal failure. Intravascular haemolysis appeared to be the chief factor responsible for renal lesions in these patients. Histological lesions observed in the kidney varied from those of mild shock to well established acute tubular necrosis. In one case, granulomatous lesions were seen in response to tubulorrhexis. Renal failure was the chief indication for dialysis in ten patients, whereas one patient was dialysed primarily for removal of copper. Notwithstanding the adequate control of uraemia by dialysis, only six of the eleven patients recovered. Septicaemia was responsible for death in three, hepatic failure in one and methaemoglobinaemia in another. It is postulated that release of copper from haemolysed red cells during acute haemolytic episodes may initiate, or contribute to, the development of renal damage.     

Revision of dysfunctional Tenckhoff catheters by laparoscopic technique in continuous ambulatory peritoneal dialysis patients

A laparoscopic technique was used to rescue dysfunctional Tenckhoff catheters in five continuous ambulatory peritoneal dialysis (CAPD) patients. This method proved to be effective in recovering the function of the catheters, whose malfunction was found to be due to catheter entrapment or endoluminal tamponing by the omentum. The videoscope-assisted laparoscopic technique provides access and allows identification and eradication of the specific etiology leading to catheter drainage failure. It also provides an alternative for treating patients with a dysfunctional Tenckhoff catheter. This method avoids the need to remove the original catheter or to reimplant a new catheter.     

Perspectives of end stage renal failure therapy in Singapore

Haemodialysis in Singapore started in 1961 when a patient with kidney failure was dialysed using the twin coil artificial kidney. Over the years, we have seen various new techniques like rapid high efficiency dialysis, haemodiafiltration (HDF) and rapid high flux HDF introduced. Dialysers with newer membranes have improved solute transport, biocompatibility and water removal. Mini heparinisation and heparin-free dialysis have circumvented problems of bleeding in high risk patients. Technological advances in haemodialysis will continue with more new modalities introduced. Newer forms of vascular access through the subclavian and internal jugular veins have phased out the use of chronic arterio-venous (AV) shunts. Continuous ambulatory peritoneal dialysis (CAPD) was introduced in 1980. This has been a boon for cardiac and diabetic patients. The initial problems with peritonitis are now manageable with our current rate of 24.1 patient months compared to 13.2 patient months in 1983. This has been achieved through the use of ultraviolet (UV) germicidal exchange device and transfer tube changes by trained nursing personnel as well as better patient training and education. New techniques have included the "O" disconnect set, the use of 2.5 litre dialysate, low calcium dialysate and the introduction of continuous cycling peritoneal dialysis (CCPD). Future focus will be on the problems of nutrition and protein loss. Renal transplantation remains the ideal renal replacement therapy. Cadaveric renal transplantation was initiated in 1970 and living related donor transplant in 1976. From 1970-1985, immunotherapy was azathioprine-based and from 1985, cyclosporin A (CyA) was introduced. CyA has abrogated many immunological risk factors. Preformed cytotoxic antibodies are still important.(ABSTRACT TRUNCATED AT 400 WORDS)     

Ruptured abdominal aortic aneurysms: factors affecting the early postoperative outcome

Long-term experience with 63 polyurethane, pail handle, coiled tip peritoneal dialysis catheters surgically implanted in 57 consecutive patients with renal failure is presented. One hundred percent follow-up of the study group represented 1,248 patient-months of observation. Cumulative catheter survival rates were 80.8% at 12 months, 62.3% at 24 months, and 48.1% through 51 months. Catheter half-life was 32.6 months. Infection was the most frequent catheter related complication. Incidence rate of peritonitis was 0.73, and exit site/tunnel infection was 0.42 episodes per patient-year. Median time to first episode was 11.7 months for peritonitis, and 26.3 months for exit site/tunnel infection. Infection led to removal of 28.6% of implanted devices, mechanical blockage resulted in 6.4% loss, and pericatheter leak and tubing break each accounted for 1.6% of catheter removals. The polyurethane, pail handle, coiled tip peritoneal catheter was found to be a reliable long-term access device compared with reported performances of other catheter types. An adverse outcome was identified in the current clinical series with a model design using a permanently attached catheter adapter that caused large exit site wounds that were predisposed to infection and catheter loss.     

Comparative experience of a simple technique for laparoscopic chronic ambulatory peritoneal dialysis catheter placement

BACKGROUND: Chronic ambulatory peritoneal dialysis (CAPD) is now an established technique for renal dialysis. Patients with renal failure cope poorly with major surgery and it is vital that the dialysis catheter tip is sited accurately in the pelvis if long-term catheter function is to be achieved. Laparoscopic placement of CAPD catheters may have potential advantages for renal patients by avoiding the morbidity of a laparotomy. METHODS: A retrospective audit was performed of all CAPD catheters inserted at the John Hunter Hospital over a 2-year period. Results of laparoscopically inserted catheters and those placed at laparotomy were compared. RESULTS: Sixty catheters were inserted, 30 laparoscopically and 30 at laparotomy. The mean operative time was 41 min in the laparoscopic patients and 57 min in the laparotomy patients (P = 0.0001). The mean total dose of narcotic administered postoperatively was significantly less in the laparoscopic group (5 mg vs 65 mg, P = 0.00002). There were three minor peri-operative complications in the laparoscopic group and seven peri-operative complications in the laparotomy group, three required reoperation and one resulted in the patient's death. There were no significant differences in the incidence of exit-site infection, catheter blockage, peritonitis, and overall catheter survival, although the laparoscopically placed catheters had been followed up for a shorter period (10 vs 16 months). CONCLUSIONS: This laparoscopic technique is safe and effective. Postoperative pain was less than for open placement. Laparoscopically placed catheters had a low incidence of peri-operative complications. Medium-term patency is similar to conventionally placed catheters. This procedure requires no additional equipment to that available for laparoscopic cholecystectomy and takes less time than the open operation.     

Normalization of periodontal tissues in osteopetrotic mib mutant rats, treated with CSF-1

Acute renal failure is a serious complication of pregnancy. Over the past few decades, the overall incidence of acute renal failure in pregnancy has decreased in Western societies. In less developed countries, the incidence of acute renal failure in pregnancy has remained high. This retrospective study examined the incidence, morbidity, fetomaternal mortality, and renal prognosis among pregnant inner-city patients. Serum creatinine levels of all pregnant patients seen at an inner-city hospital from January 1986 to December 1996 were reviewed. Twenty-one consecutive cases of acute renal failure were identified for an incidence of 2 in 10,000 pregnancies. Maternal mortality was high (15.7%) as was morbidity, with a tendency toward a high rate of intrauterine fetal growth retardation. These results suggest that the outlook for acute renal failure in inner-city patients is dismal in sharp contrast to the prognosis for other patient groups with acute renal failure in pregnancy in Western societies. Preventive strategies should be aimed at this subpopulation with a view to improving early prenatal care as well as enhancing overall access to the health-care system.     

Orthognathic surgery effects on maxillary growth in patients with vertical maxillary excess

Patients with acute renal failure in the intensive care unit have high in-hospital mortality. In this setting, decision making with regard to the initiation or discontinuation of dialysis by physicians, patients, and families is challenging because of the desire of all for the patient to recover while sparing unnecessary suffering. Decision making can be facilitated by knowledge of outcomes of the treatment of such patients in the medical literature. This knowledge assists nephrologists to distinguish those patients whose clinical situation indicates a more favorable prognosis from those whose prognosis is uncertain or definitely poor even with dialysis. This information, combined with consideration of relevant ethical guidelines, provides a framework for nephrologists to make decisions that are evidence based and ethically sound. We present and discuss two cases to show the application of evidence-based medicine and ethical considerations to decision making for patients with acute renal failure in the intensive care unit.     

Diagnostic and therapeutic management of ethylene glycol poisoning. Importance of crystalluria. Apropos of a case

During the course of a case of ethylene glycol poisoning with ensuing oliguric renal failure despite early dialysis, we show the importance of early diagnosis of this intoxication in underlined. Characteristics of ethylene glycol poisoning are: metabolic acidosis with anion gap (without lactic acidosis or keto-acidosis) and high plasma osmolarity. Awaiting the result of blood and urinary toxic values, crystalluria, by typical needle monohydrate calcium oxalate crystals finding, evokes the diagnosis and permits to start a specific treatment. This treatment is based on: principles of intensive care, ethanol administration (or 4-methyl-pyrazole now available), also thiamine and pyridoxine administration and finally, dialysis therapy. We can hope, with early and intensive management of this poisoning, to prevent the renal failure, principal complication of ethylene glycol ingestion, which can lead to chronic renal failure. Therefore, crystalluria, an easy and specific diagnosis technic, is of great interest.     

Caring for a rehabilitation patient with chronic renal failure and end-stage renal disease

Patients with chronic renal failure and end-stage renal disease frequently suffer medical setbacks that necessitate a course of rehabilitation. Planning care for these patients requires special consideration if they are to attain a level of function close to what they enjoyed prior to the event that required them to be hospitalized. In this article, the author describes chronic renal failure, end-stage renal disease, types of dialysis and types of access, assessment upon admission to rehabilitation, and nursing care for patients with chronic renal failure and end-stage renal disease in a rehabilitation facility. This information can help nurses learn about what to look for and what questions to ask, common medications and laboratory values, dietary management, and the creation of a successful rehabilitation experience.     

Risk modeling in acute renal failure requiring dialysis: the introduction of a new model

Predicting patient outcome in acute renal failure has become increasingly important as technology advances and ethical questions arise concerning life supporting therapies. We propose a new model which uses mortality as an endpoint and may be applied to the acute renal failure patient in the ICU setting who requires dialysis. This model is based on our ICU acute renal failure registry and has been prospectively validated for our institution. Our registry for the purposes of developing this model consists of data from 512 ICU patients requiring acute dialysis from 1988 until 1992. The model was developed by testing a variety of potential risk factors for mortality in a univariate analysis (Student's t-test and Chi square), and those factors found to be significant (p < 0.05) were subsequently tested in a multivariate fashion. The factors found significant included male gender, respiratory failure requiring intubation, hematologic dysfunction (platelet count < 50,000, leukocyte count < 2,500, or bleeding diathesis), bilirubin < 2.0 mg/dl, the absence of surgery, serum creatinine on the first dialysis treatment day, an increasing number of failed organ systems, and an increased BUN from the time of admission. Weights are assigned to each variable based on the odds ratio, and a score is generated with a range of 0 to 20. The initial data for the registry demonstrates good fit using the Hosmer and Lemeshow goodness-of-fit table. The model is next validated in 88 patients from 1993 through February 1994, then prospectively tested in 35 additional patients using a standard data collection form, and the model continues to demonstrate good fit. Although this model has been prospectively validated at our institution, this model or any such predictive model should be used with caution if not independently validated at any institution which proposes its use.     

Role of intracellular calcium in peroxide-induced potentiation of norepinephrine release from bovine isolated irides

PURPOSE: To assess the safety, efficacy, endothelial changes, and risks of pulmonary embolic events after the use of a new thrombolytic brush catheter in mature thrombosed polytetrafluoroethylene (PTFE) dialysis grafts in an animal model. MATERIALS AND METHODS: Loop configuration PTFE grafts were implanted in the femoral vessels of 12 canines 4 weeks before mechanical thrombosis was performed. The thrombus was allowed to consolidate for 24 hours in 10 animals, 72 hours in one animal, and 7 days in one animal. Standard percutaneous criss-cross catheter access was performed, and a soft, low-speed, brush (6 mm in diameter), aided by 250,000 U of periprocedural urokinase, was utilized for thrombolysis. The native vessels, just distal to the anastomosis, and lungs were evaluated macro- and microscopically. RESULTS: Thrombolysis was complete in all grafts with the exception of a small segment between the crossing of the access vascular sheaths. The total thrombolysis time ranged from 8 to 12 minutes; this included 5 minutes of pulse-spray lacing. No difference in thrombolysis time was found with regard to the age or amount of thrombus. Minimal endothelial changes were noted and no evidence of acute pulmonary embolus was found on necropsy or histologic studies. CONCLUSION: This method offers a simple, safe, and efficient means of recanalization of thrombosed PTFE dialysis grafts in this canine model.     

Current therapy of chronic renal failure

The course of chronic renal failure is generally progressive and mediated by several factors that operate in combination. Several extrarenal events which may cause transient or permanent deterioration of renal function, are important, because their correction may slow the progression of renal disease e.g. volume disorders, infection, nephrotoxic agents. In progression of chronic renal disease leading factors are hypertension, proteinuria and high protein/phosphorus intake. Number of evidence suggests that ameliorating hypertension, reducing proteinuria slow the progression of chronic renal failure. Clinical studies in diabetic nephropathy demonstrated that the renoprotective effect of ACE inhibitors was independent of their effect of systemic blood pressure. In ESRD patients access for renal replacement therapy should be obtained as early as possible. An A-V fistula may take several weeks to mature especially in diabetic or elderly patients. Early dialysis has been advocated in diabetic patients. In general, patients can start ESRD therapy when residual kidney function drops to 5-10% of normal value. High quality of dialysis should be provided to the uremic patient with respect of successful renal transplantation.     

Malnutrition in geriatric patients: a neglected problem?

PURPOSE: The authors report their experience with the translumbar inferior vena cava (IVC) approach for central venous access during a 6-year period at three teaching hospital sites. PATIENTS AND METHODS: Twenty-nine percutaneous IVC central venous access catheters were inserted in 22 patients during a 6-year period in the radiology departments of three teaching hospital sites. All patients had undergone unsuccessful attempts at conventional central venous access. Information was gathered by retrospective radiologic and hospital chart review. RESULTS: All attempted placements were successful. Catheters were in place for a total of 3,510 catheter days. The average length of catheter placement was 121 days (range, 14-536 days). Life-table analysis predicted catheter function rates of 55% and 29% at 6 and 12 months, respectively. Three procedure-related complications occurred. A lower pole branch of the right renal artery was inadvertently entered with a 22-gauge needle during attempted IVC puncture in one patient without clinical sequelae. A second patient developed a small groin hematoma at the femoral venous puncture site, which resolved spontaneously. A third patient developed a moderate retroperitoneal hematoma, which resolved without specific intervention. The sepsis rate was 2.8 infections per 1,000 catheter days with an average time to infection of 127 days (range, 10-536 days). CONCLUSION: In the authors' experience of 29 translumbar central venous catheter insertions, all attempts were successful. Percutaneous central venous access via the IVC is a safe and effective option for patients in whom more conventional access is not possible.