Effective interventions with chlorhexidine gluconate (CHG) to decrease hemodialysis (HD) tunneled catheter‐related infections

Purpose:  Identify practices to reduce HD catheter access related bacteremias (ARB). Methods:  Data was collected per the CDC Dialysis Surveillance Network protocol. ARB was defined as a patient with a positive blood culture with no apparent source other than the vascular access catheter. ARB's were calculated in events per 100 patient months with 3 cohorts. Cohort 1 was observed for 12 months, Cohort 2 for the subsequent 10 months, and Cohort 3 for the final 10 months. Cohort 1 had weekly transparent dressing changes, cleansing of the skin and 5 minute soaking of the connection lines with 10% povidone‐iodine (PI) solution, and HCW use of clean gloves and face shield without a mask. Cohort 2 changes consisted of thrice weekly gauze dressing changes, skin cleansing with ChloraPrep, a 2% CHG/70% isopropyl alcohol applicator, masks on the patients, adding a face mask to the shield, and application of 10% PI ointment to the exit site. Cohort 3 changes included weekly application of BioPatch (BioP), an antimicrobial dressing with CHG, sterile glove use, and replacing the PI line soaks with 4% CHG. Results:  The catheter‐associated ARB rate per 100 patient months was 7.9 (17ARB/216 patient months) in Cohort 1 , 8.6 (13/151) in Cohort 2 , and 4.7 (5/107) in Cohort 3 (p = 0.31 compared with Cohorts 1 and 2 combined). During the last 2 months, in Cohort 3 , 9 catheter lumen cracks occurred, with one of the patients having a bacteremia. Conclusions:  Addition of CHG line soaks and BioP reduced tunneled catheter infections, although this is not statistically significant. The increased number of catheter lumen cracks raises concern with the use of CHG line soaks. Further investigation with use of CHG line soaks and the BioP for decreasing ARB is needed.     

Catheter‐related bacteremia in a pediatric hemodialysis unit

Tunneled‐cuffed hemodialysis catheters are frequently used as long‐term vascular access in children due to the technical difficulties in constructing a fistula. Catheter‐related bacteremia (CRB) is still a major complication contributing to patient morbidity and loss of vascular access. Objective:  To investigate the microbiological characteristics of CRB in children on hemodialysis. Methods:  Chart review of 63 children who received hemodialysis with a tunneled‐cuffed catheter between January 1999 and December 2003 was performed. CRB was diagnosed when positive blood cultures were obtained in patients with symptoms of bacteremia, and without an identifiable source. Results:  During the 5 year period, a total of 251 CRB were detected with 313 bacterial and 2 candidal growths in the blood cultures. The distribution of gram positive (Gr+) and gram negative (Gr−) microorganisms and their sensitivity patterns are shown in the table. Coagulase negative Staphylococcus was the most common microorganism, and constituted 62% of all bacterial isolates. All Gr+ microorganisms were sensitive to vancomycin except one isolate of Enterococcus fecalis. Enterobacter cloacae was the most common Gr− microorganism, followed by Klebsiella pneumonia . The sensitivity of Gr− microorganisms to levofloxacin was 100%. The treatment course was complicated by the growth of a second microorganism in subsequent blood cultures in 24% of infections; 54% of these consisted of both Gr+ and Gr− isolates. The etiology of ESRD or the use of immunosuppressive agents had no effect on the occurrence of CRB. The average number of infections were 5.8/1000 catheter days, and the recurrence of CRB was more likely in patients who had two or more CRB in a year.  

     

Ten‐year study of bacteremia in hemodialysis patients in a single center

Background: The incidence of infection in patients on chronic hemodialysis in higher than that of the general population. Infection is known to be a major cause of morbidity and mortality in these patients. The vascular access is important for hemodialysis, but infection through this route is the most common source of bacteremia and can be lethal to the patients. Despite the high morbidity and mortality of bacteremia in patients on chronic hemodialysis, the clinical characteristics of bacteremia in hemodialysis patients is rarely reported yet in Korea. Methods: We included 696 hemodialysis patients from January 1993 to December 2003 at Uijongbu St. Mary's Hospital. We investigated incidence, source, causative organisms, clinical manifestations, complication, and mortality of bacteremia. We compared clinical factors, morbidity, and mortality between arteriovenous fistula and central venous catheter groups. Results: Total 52 cases of bacteremia occurred in 43 patients. The major source of infection was vascular access (48%). Staphylococcus aureus was most common organism isolated. Major complications were septic shock (9.6%), pneumonia (9.6%), infective endocarditis (3.8%), and aortic pseudoaneurysm (1.9%). Nine patients died from septic shock (n = 4), aspiration pneumonia (n = 2), hypoxic brain injury (n = 1), gastrointestinal bleeding (n = 1), and rupture of aortic pseudoaneurysm. The central venous catheter group (n = 22) had higher incidences of vascular access as a source of infection (81.8% vs 23.3%, p < 0.001) and staphylococcus as a causative organism (77.2% vs 50.0%, p = 0.042) than the arteriovenous group. Conclusion: This data shows that bacteremia causes high incidence of fatal complications and mortality. Therefore, careful management of vascular access as well as early detection of bacteremia is an important factor for the prevention of infection and proper antibiotic therapy should be started early.     

Multiple factors affect 3‐year survival of patients on chronic hemodialysis

One of the basic symptoms of a terminal stage chronic renal insufficiency is anemia. From everything, used methods of correction of an anemia, it is considered the most effective application of preparations recombinant human erythropoietin (r‐Hu EPO). Since 1994 in the Scientific Centre of Surgery begins application r‐Hu EPO. Application r‐Hu EPO in patients with a terminal stage chronic renal insufficiency in 90–95% of cases had a positive effect, but 5–10% of patients have intolerance to erythropoietin, that has induced to search of new effective methods of correction of anemia. During research were determined quantity erythrocytes, hemoglobin, reticulocyte in peripheral blood and acid‐alkaline condition of blood. All hematology parameters were defined at the beginning of treatment, over 5 day and for 15 day of stimulation of a bone marrow. For 15 days after stimulation of a bone marrow by the laser there was an authentic increase of quantity erythrocyte, hemoglobin, hematocrit. The initial contents erythrocytes made 2.22 ± 0.1 10 × 12, hemoglobin 67.7 ± 3.2 g/l and hematocrit 18.2 ± 1.2%. During treatment by the laser parameters erythrocytes have increased up to 2.9 ± 0.8 10 × 12, hemoglobin up to 89.6 ± 2.9 g/l and hematocrit up to 28.2 ± 1.3%(P < 0,005). Hematology parameters in blood of control group authentically have not changed.     

Malnutrition‐inflammation‐coronary calcification in pediatric patients receiving chronic hemodialysis

Malnutrition, inflammation, and renal osteodystrophy parameters with resultant coronary calcification (CC) are associated with increased cardiovascular mortality in adults. Previous pediatric studies demonstrated CC in children but none assessed for an association between inflammation, malnutrition, renal osteodystrophy, and CC. To assess CC, ultrafast computerized tomogram was obtained for 16 pediatric patients (6 females; median age 17.2 years; range 9.1–21.2 years) receiving hemodialysis for ≥2 months. Inflammation was assessed by serum IL‐6, IL‐8, and C‐reactive protein levels on the day of the computerized tomogram scan; nutrition parameters included serum albumin, cholesterol, the body mass index standard deviation score, and normalized protein catabolic rate. Renal osteodystrophy parameters included time‐averaged serum calcium, phosphorus, total PTH, and calcitriol/calcium dose. Patients received hemodialysis thrice‐weekly; mean single pool Kt/V 1.48±0.13; and mean normalized protein catabolic rate 1.27±0.17 g/kg/day. Five of 16 patients had CC. Patients with CC were older (19.1±2.1 vs. 15.4±3.1 months; P=0.03), had longer dialysis vintage (49.4±15.3 vs. 17.2±10.5 months, P=0.0002), lower serum cholesterol (122±17.7 vs. 160.4±10.6 mg/dL, P=0.02), and higher phosphorus (9.05±1.2 vs. 6.1±0.96 mg/dL, P=0.0001). Mean serum albumin and normalized protein catabolic rate did not differ for patients with CC. All patients had elevated IL‐6 and IL‐8 levels compared with healthy norms; the mean IL‐6, IL‐8, and C‐reactive protein levels were not different in patients with CC. Coronary calcification was prevalent in older children receiving maintenance hemodialysis with a longer dialysis vintage. Worse renal osteodystrophy control and malnutrition (low cholesterol) may contribute to CC development.     

Role of bicarbonate dialysis in prevention of serious arrhythmias in high‐risk cardiac patients undergoing regular hemodialysis

Background: Cardiac arrhythmias are considered as one of the most important causes of mortality in patients on hemodialysis. Arrhythmias frequently occur in patients with chronic renal failure on regular hemodialysis with reported incidences varying from 30–48% of patients. These abnormalities can span from supraventricular to severe ventricular arrhythmia. There is an increased frequency of occurrence and clustering of arrhythmias around the dialysis time. Aim of the study: To detect the difference between acetate and bicarbonate dialysis as regard to the type and frequency of arrhythmia in those patients. Study design: This study was done on 20 male patients age 51–73, all have history of heart disease. Patients were divided into 2 equal groups using acetate in group 1 and bicarbonate in group 2. All patients were on regular hemodialysis (4 hours, thrice weekly). Careful history and clinical examination were done. Pre‐dialysis investigations included serum creatinine, blood urea nitrogen, serum sodium, potassium, calcium and phosphorus, serum albumin, hemoglobin, and arterial blood gases. Post‐dialysis serum potassium and arterial blood gases were measured. ECG and forty‐eight hours ambulatory monitor (Holter monitor)(before, during, and after hemodialysis, till the end of the dialysis day and throughout the following day) were performed. Results: Group 1 showed significantly less post‐dialysis supraventricular arrhythmias than in dialysis day (210.9 ± 236 and 62.3 ± 14.4), respectively. Significantly less ventricular arrhythmias in post‐dialysis than in dialysis day (30.7 ± 50.4, and 106.2 ± 128.4), respectively. While in Group 2 there were insignificant differences regarding supraventricular arrhythmias (21.9 ± 28.9 and 16.6 ± 36.3) and ventricular arrhythmias (22.9 + 7.8 and 29.6 + 12.8) in dialysis day than in post‐dialysis day. There was significantly higher frequency of supraventricular and ventricular arrhythmias in the dialysis day in acetate hemodialysis in comparison to bicarbonate hemodialysis. Conclusion: Bicarbonate hemodialysis is less arrhythmogenic in comparison to acetate hemodialysis and has better effect on the blood pH and greater degree of base repletion. Continuous ambulatory ECG recording (Holter) is a useful tool in detecting arrhythmias in dialysis patients.     

High‐dose cefazolin on consecutive hemodialysis in anuric patients with Staphylococcal bacteremia

Methicillin‐sensitive Staphylococcus aureus (MSSA) bacteremia is a leading cause of infection in hemodialysis (HD) patients. Cloxacillin, cefazolin, and vancomycin are the mainstay antimicrobials. Cloxacillin administration leads to frequent drug dosing, longer length of stay (LOS), and higher cost, while resistance and poorer outcomes are associated with vancomycin use. Dosing cefazolin during HD allows for prolonged blood therapeutic levels. We assessed the outcomes and safety of a strategy of treating MSSA bacteremia with 2–3 g cefazolin on HD only. All HD patients with MSSA bacteremia admitted in June–December 2009 at our center and receiving this regime were compared with historical controls who received cloxacillin. Demographic characteristics and outcome measures like mortality, LOS, cost, recrudescence, and adverse drug reactions were assessed. Of 27 consecutive episodes reviewed, 14 and 13 patients received cefazolin and cloxacillin, respectively. Baseline demographics were comparable between the 2 treatment groups. More than one‐third of the bacteremia was related to tunneled catheter infection. The 30‐day mortality of cloxacillin‐ and cefazolin‐treated patients was 15% and 7%, respectively (P=0.14). Two of the 11 survivors treated with cloxacillin (18%) had recrudescent bacteremia while none was observed in cefazolin‐treated survivors. Cefazolin was associated with shorter LOS (10 vs. 20 days, P<0.05) and lower cost (US$8262.00 vs. US$15,367.00, P<0.05). Cefazolin use resulted in 3 idiosyncratic adverse drug reactions. Cefazolin dosed on each HD in MSSA bacteremia leads to earlier discharge and less cost. Larger prospective studies are, however, warranted to fully assess its safety and efficacy.     

Quality of life, self‐care and sense of coherence in patients on hemodialysis: A comparative study

The number of patients treated for end-stage renal disease increases in Sweden like the rest of the world. During the last six years more than 1000 persons a year started renal replacement therapy. Today hemodialysis patients have the opportunity to choose different treatment modalities—home hemodialysis, self‐care dialysis, or conventional dialysis. Purpose:  The aim of the study was to investigate differences in patient on home hemodialysis, self‐care dialysis, and conventional dialysis regarding quality of life, self‐care, and sense of coherence. Methods:  Questionnaires were used: Short Form (SF‐36), Appraisal of Self‐Care Agency (ASA‐scale), and Sense of Coherence scale (SOC). 19 patients were included in the study (five patients on home hemodialysis, six self‐care patients, and eight patients on conventional dialysis). Results:  The results showed a tendency of higher scores in quality of life, self‐care, and sense of coherence for the home hemodialysis patients. Conclusion:  Since the number of participants in this study was low, it is necessary to include more patients in a future study in order to verify the results.     

Comparison of alteplase (tissue plasminogen activator) high‐dose vs. low‐dose protocol in restoring hemodialysis catheter function: The ALTE‐DOSE study

Hemodialysis catheter (HDC) dysfunction due to thrombosis is common, and dysfunction incidence can reach up to 50% within 1 year of use. Although administration of intraluminal alteplase (tissue plasminogen activator [tPA]) is the standard of practice to pharmacologically restore HDC function, there are no evidence‐based guidelines concerning the optimal tPA dose. The purpose of this study was to compare the efficacy of 1.0‐mg vs. 2.0‐mg tPA dwell protocols in restoring the HDC function in thrombotic dysfunctional catheters. A retrospective, single‐center study was conducted on two independent cohorts of patients; the first (n = 129) received 2.0 mg tPA/catheter lumen, while the second (n = 108) received 1.0 mg tPA/catheter lumen. Kaplan–Meier and Cox regression analyses were performed to compare the catheter survival time between patients who received 1.0 mg tPA and those who received 2.0 mg tPA. Catheter removal occurred in 25 (19.4%) of those catheters treated with 1.0 mg tPA compared with 11 (10.2%) of catheters treated with 2.0 mg tPA (P = 0.05). The hazard ratio (HR) for catheter removal was 2.75 (95% confidence interval [^95%CI] = 1.25–6.04) for the 1.0‐mg tPA cohort compared with the 2.0‐mg tPA cohort. Correction added on 3 December 2012, after first online publication: The tPA cohort values were changed. Female gender (HR = 2.51; ^95%CI = 1.20–5.27) and age (HR = 0.96; ^95%CI = 0.94–0.98) were also associated with catheter survival. Our findings suggest that treatment of dysfunctional HDC with 2.0‐mg tPA dwells is superior to 1.0‐mg tPA dwells.     

Effect of the decrease in dialysate sodium in pediatric patients on chronic hemodialysis

Optimal dialysate sodium (dNa) is unknown, with both higher and lower values suggested in adult studies to improve outcomes. Similar studies in pediatric hemodialysis (HD) population are missing. This is the first report of the effect of two constant dNa concentrations in pediatric patients on chronic HD. 480 standard HD sessions and interdialytic periods were studied in 5 patients (age 4–17 years, weight 20.8–66 kg) during a period of 6–11 months per patient. dNa was 140 mEq/L during the first half, and 138 mEq/L during the second half of the study period for each patient. Lowering dNa was associated with improved preHD hypertension, decreased interdialytic weight gain, decreased need for ultrafiltration, lower sodium gradient and was well tolerated despite lack of concordance with predialysis sNa, that was variable. Further studies are needed to verify our findings and to investigate if an even lower dNa may be more beneficial in the pediatric HD population.     

Effect of dialysis dose and membrane flux on hemoglobin cycling in hemodialysis patients

Many studies found that hemoglobin (Hb) fluctuation was closely related to the prognosis of the maintenance hemodialysis patients. We investigated the association of factors relating dialysis dose and dialyzer membrane with Hb levels. We undertook a randomized clinical trial in 140 patients undergoing thrice‐weekly dialysis and assigned patients randomly to a standard or high dose of dialysis; Hb level was measured every month for 12 months. In the standard‐dose group, the mean (±SD) urea reduction ratio was 65.1% ± 7.3%, the single‐pool Kt/V was 1.26 ± 0.11, and the equilibrated Kt/V was 1.05 ± 0.09; in the high‐dose group, the values were 73.5% ± 8.7%, 1.68 ± 0.15, and 1.47 ± 0.11, respectively. The standard deviation (SD) and residual SD (liner regression of Hb) values of Hb were significantly higher in the standard‐dose group and low‐flux group. The percentage achievement of target Hb in the high‐dose dialysis group and high‐flux dialyzer group was significantly higher than the standard‐dose group and low‐flux group, respectively. Patients undergoing hemodialysis thrice weekly appear to have benefit from a higher dialysis dose than that recommended by current KDQQI (Kidney Disease Qutcome Quality Initiative) guidelines or from the use of a high‐flux membrane, which is in favor of maintaining stable Hb levels.     

Clinical Experiences High‐flux hemodialysis in the treatment of severe valproic acid overdose: A case report

Introduction:  Hemoperfusion, with or without hemodialysis, has been used to treat patients suffering from severe valproic acid poisoning. We report a patient suffering from severe valproic acid intoxication who was treated effectively with high‐flux hemodialysis alone. Case:  A 20‐year‐old man with a history of bipolar disorder was admitted after having ingested unknown amounts of valproic acid (Depakote®), prednisone, and erythromycin. He was agitated and obtunded but hemodynamically stable initially. Serum valproic acid level was 1,028 μg/mL. Urine toxicology screen as well as serum levels of ethanol, acetaminophen, and acetylsalicylic acid levels were negative. A gastric lavage was followed by activated charcoal instillation. Subsequent myoclonic twitchings that progressed to continuous seizure activity were managed with intravenous lorazepam therapy and endotracheal intubation. Serum valproic acid value measured two hours after admission remained elevated at 1,046 μg/mL. Hemodialysis was performed continuously for 10.5 hours using a high‐flux, polysulfone dialyzer (Polyflux 21S, Fresenius Medical Care, Lexington, MA), a dialyzer blood flow of 200–300 mL/min, and a dialysate flow of 500 mL/min. The therapy brought about a fall in serum valproic acid level to 110 μg/mL and a complete recovery of the patient. Discussion:  Valproic acid (144 Dalton) is 90–95% protein‐bound at therapeutic serum values. However, in the face of an overdose, the unbound fraction rises because of saturation of protein‐binding sites. This unbound fraction is readily dialyzable. We suggest that high‐flux hemodialysis is effective in the treatment of severe valproic acid poisoning.     

Results of improvement in adequacy of intermittent hemodialysis (IHD) in uremic patients

Sodium modeling is a strategy to decrease the incidence of hypotension during hemodialysis. Side effects include increased interdialytic weight gain. By default, all patients at our dialysis center are started on HD with sodium modeling. Purpose: To compare weight gain and blood pressure after discontinuation of sodium modeling. Methods: Ten patients using sodium modeling were changed to a standard sodium bath after a change in attending physician. After IRB approval, we collected and retrospectively reviewed the change in interdialytic weight gains, episodes of hypotension (defined as an episode of hypotension requiring staff intervention), and starting and ending blood pressure. Data from one week prior to Na change (PRE) was compared to one week after Na change (POST) using a paired samples t‐test. Results: Data from 4 men and 6 women with a mean age of 65.2 ± 13.7 years was reviewed. ESRD diagnoses included diabetes (n = 4) and hypertension (n = 6). Interdialytic weight gain significantly decreased after discontinuation of sodium modeling (PRE 3.86 kg, POST 3.11 kg, p = 0.004). No significant change in blood pressure at the start (PRE 154/82 POST 156/83, p = 0.745) or end of HD (PRE 123/69, POST 130/67, p = 0.201) was observed. However, the frequency of symptomatic hypotension increased after change to standard sodium bath (PRE = 6%, POST = 27%, p = 0.031). All episodes of hypotension occurred in 3 of the 10 study patients. No patient required cessation of HD or transfer to the emergency department. The degree of weight gain was not correlated with the likelihood of intradialytic hypotension. Conclusion: A change from sodium modeling to standard sodium dialysate lowers interdialytic weight gain but increases the incidence of mild symptomatic hypotension. Further study is needed to determine whether mild hypotension is preferable to increased interdialytic weight gain and to determine the relationship of increased weight gain to complications of volume overload such as LVH and CHF.     

The effect of small dose of topiroxostat on serum uric acid in patients receiving hemodialysis

Introduction : Topiroxostat, a recently developed xanthine oxidase inhibitor, is expected to have fewer adverse effects than allopurinol because it has different mechanism of action from alloprinol. However, its dosage, usage and safety have not been established in patients with impaired renal function or those undergoing dialysis at the development since no studies was conducted in these patients. Methods : Cross over clinical trial using 3 months of allopurinol and topiroxostat on 27 maintain Japanese HD patients were carried out. The effects on oxidative stress status of both drugs were also evaluated by measuring oxidation reduction potential. Findings : Twenty‐five of twenty‐seven patients completed study. The mean serum uric acid levels in the topiroxostat‐treated arm was significantly lower than it in the allopurinol‐treated arm time‐dependently (P < 0.0001). Corrected oxidative stress ratio defined as biological antioxidant potential/diacron reactive oxygen metabolites was significantly increased in topiroxostat‐arm (*P = 0.0035), but not in allopurinol‐arm (P = 0.1429). No significant difference was seen in diacron reactive oxygen metabolites, biological antioxidant potential, static oxidation‐reduction potential, and capacity oxidation‐reduction potential between pre and post treatment of both drugs. Discussion : It is suggested that a low dose of topiroxostat decreased serum uric acid sufficiently to maintain it below 7.0 mg/dL in patients receiving hemodialysis.     

Weekly high‐dose ergocalciferol to correct vitamin D deficiency/insufficiency in hemodialysis patients: A pilot trial

Controversy exists on which vitamin D (D2 or D3) and which dosage scheme is the best to obtain and maintain adequate 25 OH D levels in dialysis patients safely. We tried to determine whether high‐dose vitamin D2 supplementation could obtain optimal vitamin D status without inducing hypercalcemia. We studied 82 patients on dialysis not taking active vitamin D therapy and supplemented them with oral vitamin D2 72,000 IU/week for 12 weeks followed by 24,000 IU/week as maintenance therapy during 36 weeks. By week 12, serum 25(OH)D increased from 15.2 ± 5.4 to 42.5 ± 13.2 ng/mL (P < 0.01) at week 12 and remained optimal (34.7 ± 12.0); 84.8% of the patients reached values ≥30 ng/mL. iPTH and alkaline phosphatase did not change at 48 weeks compared with baseline, but bone alkaline phosphatase decreased significantly (54.3 ± 46.0 to 44.3 ± 25.0; P = 0.02). Uncorrected serum Ca increased significantly at the end of follow‐up (9.03 ± 0.42 to 9.14 ± 0.62; P = 0.04); hypercalcemia was presented in two patients in the first control visit (week 12), in one patient in the second control (week 30), and in one patient in the third control (week 48). In 222 serum calcium determinations during follow‐up, hypercalcemia was observed in only 1.8% of cases. This vitamin D2 oral regimen with initial high doses was safe and sufficient to obtain and maintain optimal serum 25(OH)D concentrations and prevent vitamin D insufficiency in chronic kidney disease patients on dialysis.     

Hypertension and left ventricular mass index (L.VMI) in patients on regular hemodialysis (RDT)

Background:  Because of high incidence of acquired renal cyst and renal malignancy, it is suggested that spontaneous renal rupture more frequently occurs in patients receiving long‐term hemodialysis than in the general population. This study was performed to evaluate the clinical characteristics of spontaneous renal rupture in hemodialysis patients. Methods:  This retrospective study enrolled 12 hemodialysis patients who developed spontaneous renal rupture. We investigated primary renal disease, duration of dialysis, clinical symptoms and signs, radiologic findings, treatment modalities, and histologic findings. Result:  The mean age of the patients was 54 ± 10 years old and the number of male was 9. Primary renal disease consisted of autosomal dominant polycystic kidney disease (PCKD)(n = 5), chronic glomerulonephritis (n = 2), diabetic nephropathy (n = 1), hypertensive nephropathy (n = 1), unknown cause (n = 3). Presenting symptoms and signs were sudden onset of flank pain in 9 patients and gross hematuria with mild flank pain in 3 patients. Mean duration from initiation of hemodialysis to development of spontaneous renal rupture was 53 ± 36 months. Abdominal computed tomography showed subcapsular or perinephric hematoma in all patients. Of the 7 non‐PCKD patients, 6 patients had multiple acquired renal cysts. Surgical exploration was undertaken in 9 patients. Pathologic examination demonstrated small sized renal cell carcinoma in 2 of 9 patients. Three patients were only treated with conservative management including blood transfusion. All 12 patients recovered without recurrence. Conclusion:  This study demonstrated that genetic or acquired renal cyst was an important cause of spontaneous renal rupture in hemodialysis patients and presenting manifestations were sudden onset of flank pain and gross hematuria.     

Effect of a hydrogen (H2)‐enriched solution on the albumin redox of hemodialysis patients

Elevated oxidative stress (OS) is associated with severe cardiovascular disease and premature death among patients treated with hemodialysis (HD). Oxidative stress is enhanced by contact between blood and dialysis membranes during HD sessions. This study aimed to clarify whether hydrogen (H₂), which is a known antioxidant, is capable of suppressing increased OS induced during HD sessions. Eight patients on regular HD treatment were studied. Two HD sessions were performed in a cross‐over design trial using standard and hydrogen‐enriched solutions (mean of 50 p.p.b. H₂; H₂‐HD). Blood samples were obtained from the inlet and outlet of the dialyzer during HD to determine changes in plasma levels of glutathione, hydrogen peroxide, and albumin redox state as a marker of OS. Comparison of inlet and outlet blood revealed significant decreases in total glutathione and reduced glutathione, as well as significant increases in hydrogen peroxide in both HD treatments. However, the mean proportion of reversibly oxidized albumin in outlet serum was significantly lower than that in inlet serum following the H₂‐HD session, whereas no significant changes were found in the standard solution session, suggesting that “intra‐dialyzer” OS is reduced by H₂‐HD. In conclusion, the application of H₂‐enriched solutions could ameliorate OS during HD.