A clinical study of persistent hypotension in patients on chronic hemodialysis

In order to clarify the pathogenesis of hypotension seen in the patients on chronic hemodialysis, we studied the vascular reactivity to exogenous vasoactive substances and the change of plasma ANP level during hemodialysis treatment. The vascular responsiveness to intravenously infused norepinephrine was decreased in hemodialysis patients, particularly in hypotensive group, compared with healthy controls (< 0.05). The blood pressure response to angiotensin II was also diminished significantly in hypotensive patients, compared with normotensive patients (p < 0.05). The plasma ANP concentration before and after each hemodialysis treatment was not different statistically between hypotensive and normotensive patients. Furthermore, the change of plasma ANP concentration was not correlated with the blood pressure change during each hemodialysis procedure. These findings suggest that the decrease of vascular responsiveness may be a factor for causing persistent hypotension in patients on chronic hemodialysis, and that the plasma ANP level is not responsible for the pathogenesis of hypotension.     

N epsilon-(carboxymethyl)lysine in blood from maintenance hemodialysis patients may contribute to dialysis-related amyloidosis

BACKGROUND: Recent studies demonstrated not only that advanced glycation end product could be found in amyloid tissue from patient with dialysis related amyloidosis, but also that amyloid beta2-microglobulin was modified with N(epsilon)-(carboxymethyl)lysine (CML). We wanted to determine if CML could be a biomarker in these patients. METHODS: To raise polyclonal anti-carboxymethyllysine antibody, human serum albumin was carboxymethylated by glyoxylic acid and was immunized to rabbits as antigen. Carboxymethyllysine-hemoglobin (CML-Hb) levels were measured by the dot blotting method using this antibody. RESULTS: The levels of CML-Hb were 6.68 +/- 3.10 nmol CML/mg Hb in nondiabetic hemodialysis patients (N = 70), 6.39 +/- 3.43 nmol CML/mg Hb in diabetic hemodialysis patient (N = 21), and 3.13 +/- 0.88 nmol CML/mg Hb in 47 healthy volunteers. For clinical signs of dialysis-related amyloidosis, 70 nondiabetic hemodialysis patients were scored according Gejyo's criteria. The CML-Hb levels in patients with a high amyloid score as well as a low amyloid score were significantly higher than in patients with negative amyloid score (8.89 +/- 3.53 nmol CMLmg Hb, 7.28 +/- 2.32 nmol CML/mg Hb vs. 5.11 +/- 2.09 nmol CML/mg Hb, P < 0.001, P < 0.05). Furthermore, the CML-Hb levels correlated significantly with serum values of the methylguanidine over creatinine ratio and hyaluronate. CONCLUSIONS: We suggest that CML-Hb is increased in blood from patients on maintenance hemodialysis and is thus a potential biomarker of oxidative damage in these patients. Moreover, CML-modification of protein may play a pathogenic role in the development of dialysis related amyloidosis.     

Pathologic features of spinal disorders in patients treated with long-term hemodialysis

STUDY DESIGN: Pathologic features of hemodialysis-associated spinal disorders were evaluated using preoperative radiographic images and histologic findings of the spinal lesions resected during surgery. OBJECTIVES: To investigate the pathology of hemodialysis-related spinal disorders and to determine the role of amyloidosis in the establishment of severe destruction of the spine. SUMMARY OF BACKGROUND DATA: The pathologic events leading to hemodialysis-associated spinal disorders are poorly understood. The distribution of amyloid deposits in the spine also has not been clarified. METHODS: Twenty patients with hemodialysis-associated spinal disorders were investigated regarding pathologic features of neural compression and spinal destruction. Preoperative radiographic images such as plain radiography, tomography, computed tomography, magnetic resonance imaging, and scintigraphy were assessed for the existence of an intracanal mass, hypertrophy of the ligamentum flavum, and destructive changes of the spinal components. Histologic examination also was conducted by light microscopy and scanning electron microscopy to determine the distribution pattern of amyloid deposits in the spinal components. RESULTS: Six patients with no destructive changes in the spine showed spinal canal stenosis. In the cervical spine, a main factor associated with spinal canal stenosis was the presence of intracanal amyloid deposits in three patients. In the lumbar spine, a main factor associated with spinal canal stenosis was hypertrophied ligamentum flavum in three patients. Destructive changes of the facet joints, intervertebral disc, and vertebral body were seen in the other 14 patients. Amyloid deposits were densely distributed at the enthesis of capsular fibers to the bone and in anular tears in the intervertebral discs. Vertebral end plates were destroyed by penetration of amyloid granulation into the vertebral body. Osteoclast activity in the destroyed vertebral bodies was enhanced, with no evidence of new bone formation. CONCLUSIONS: Amyloid deposits played an important role in the progression of spinal destruction and severe instability.     

Ultrasonographic evaluation of the bursae in patients with dialysis-related amyloidosis

Three enumeration methods for Escherichia coli in foods, the Health Protection Branch most-probable-number (MPN) method MFHPB-19, a hydrophobic grid membrane filter method MFHPB-26 (HGMF-indole), and a hydrophobic grid membrane filter method utilizing 5-bromo-4-chloro-3-indolyl-beta-D-glucuronide in a (modified) mFC agar (HGMF-FC-BCIG) were compared in 80 food samples that included naturally and artificially contaminated raw vegetables, mung bean and alfalfa sprouts, raw meats, and chicken carcass rinses. The number of samples confirmed as positive for E. coli were 44, 36, and 42 for the MPN, HGMF-indole, and HGMF-BCIG methods, respectively. By the MPN method, E. coli was detected in 3 samples at levels below the limits of detection of the HGMFs; but the MPN method was very time-consuming. With the HGMF-indole procedure E. coli was missed in 4 artificially contaminated samples. With the HGMF-FC-BCIG method E. coli was enumerated in 1 sample of bean sprouts missed by both the MPN and HGMF-indole procedures. High levels of indole-positive Klebsiella spp. in bean sprouts interfered with the HGMF-indole method, but the blue colonies of E. coli were easily observed in the HGMF-FC-BCIG method. Specificity of the HGMF-FC-BCIG method is high enough that routine confirmation should be unnecessary; however, confirmation of presumptive E. coli is easier since no lethal indole-staining step is involved. It appears to be a very simple method for quantifying E. coli in foods or carcass rinses.     

Calciphylaxis in patients on hemodialysis: a prevalence study

BACKGROUND: Calciphylaxis is characterized by painful, violaceous, mottled skin lesions (livedo reticularis) that may progress to tissue necrosis, nonhealing ulcers, gangrene, and potentially amputation, sepsis, or death. The prevalence and characteristics of patients who have calciphylaxis need further identification to predict which patients on dialysis may benefit from close monitoring or early surgical intervention. METHODS: All 242 patients undergoing hemodialysis in an outpatient unit were reviewed retrospectively during a 15-month cross-sectional study of the prevalence and characteristics of calciphylaxis. RESULTS: Ten patients (prevalence, 4.1%) had calciphylaxis. Patients with calciphylaxis were significantly younger (49 versus 60 years; p = 0.01), had undergone hemodialysis longer (80 versus 20 months; p < 0.0001), and had higher median serum calcium (9.7 versus 9.2 mg/dl; p = 0.03), phosphate (8.2 versus 5.7 mg/dl; p = 0.001), calcium phosphate product (81.5 versus 52.9; p = 0.0004), parathyroid hormone (1496 versus 138 pg/ml; p < 0.0001), and alkaline phosphatase levels (188 versus 89 IU/L; p = 0.0001). Bone surveys were positive in all 10 patients with calciphylaxis compared with 49 (21%) of the 232 patients without calciphylaxis (p < 0.0001). All patients who underwent parathyroidectomy for calciphylaxis had dramatic healing of the ulcers. CONCLUSIONS: The presence of calciphylaxis is higher among younger patients who had undergone longer periods of hemodialysis. Therefore this group of patients should be monitored aggressively and treated expeditiously for complications of secondary hyperparathyroidism.     

Laparoscopy-assisted radical nephrectomy for renal cell carcinoma in patients on long-term hemodialysis: report of 2 patients

We successfully performed a laparoscopy-assisted radical nephrectomy for renal cell carcinoma in 2 patients on long-term hemodialysis. Both tumors were incidentally discovered on screening by abdominal CT scanning. There were no complications during the operation or in the postoperative period, and both patients resumed normal activities by the fifth postoperative day. A laparoscopic-assisted radical nephrectomy may be useful for the treatment of renal cell carcinoma in hemodialysis patients.     

A clinical study of Thai patients with spondyloarthropathy

Eighty-eight Thai patients (61 males and 27 females) with spondyloarthropathy (SpA) were studied. Their mean age and mean duration of the disease were 25.97 and 3.34 years respectively. In 16 cases the disease first appeared before the age of 16 or had juvenile onset. Eleven cases were ankylosing spondylitis (AS), 9 were juvenile AS (JAS), 20 were Reiter's syndrome (RS), 4 were juvenile RS, 14 were psoriatic arthritis (PsA), 27 were undifferentiated SpA (uSpA), and 3 were juvenile uSpA. Peripheral arthritis, especially oligoarthritis of the lower extremity joints, was the most common form of arthritis in all groups, except for PsA, where polyarthritis was common. Back pain and bilateral sacroiliitis were commonly seen in JAS and AS. Enthesopathy was not uncommon. Extra-articular manifestations were more common in RS patients. Acute inflammatory eye diseases were seen in 45 per cent of AS and 66 per cent of RS cases. In general, the clinical features of Thai patients with SpA were similar to those reported in other countries in Asia and the west.     

A comparative study of the outcome of renal transplantation in peritoneal dialysis and hemodialysis patients

Fifty-four cases of renal transplantation performed in peritoneal dialysis (PD) patients were compared with 48 cases in hemodialysis (HD) patients. Three immunosuppressive treatments were used: prednisolone, azathioprine and cyclosporine. Methylprednisolone was used to treat rejection, and polyclonal Atgem or monoclonal OKT3 antibodies were used if there was no response. There was no difference in sex, age, donor source, immunosuppressive regime, duration of dialysis before transplantation, or duration of follow-up between the two groups. Following transplantation, there was no significant difference in patient mortality and survival or graft survival between the groups. The incidences of infections were also similar in the two groups. PD is commonly used in developing countries as an alternative to hemodialysis for the treatment of chronic renal failure. This study has shown that renal transplantation can be successfully performed in patients treated by this method.     

Prevention of hepatitis B in hemodialysis patients using hepatitis B immunoglobulin. A controlled study

In a controlled study, the protection effect of hepatitis B immune globulin (HBIG) was evaluated in patients hemodialyzed for less than one month in two collaborating units. Fifteen randomly selected patients received HBIG at five to eight week intervals throughout the study, and 13 other control patients received no immunoglobulin. During a follow-up period of 14 to 30 months, none of the HBIG-treated and 12 of the control patients developed evidence of exposure to virus B hepatitis, including 10 with HBs Ag antigenemia (p is less than 0.001): five of these remained persistently antigen positive. Evidence of non-B hepatitis was found in 8 HBIG-treated and in 3 non-treated patients. Only two HBIG-treated patients developed active antibodies against hepatitis B surface antigen. Thus, HBIG seems effective in preventing hepatitis B in hemodialysis patients, provided the interval between two injections is not greater than two months. However, prolonged administration of HBIG may impair passive-active immunization to hepatitis B virus.     

A prospective study of adjustment to hemodialysis

OBJECTIVE: To examine (a) changes in subjects' self-care self-efficacy over time and (b) the relationship of subjects' self-care self-efficacy with adjustment to hemodialysis. DESIGN: A longitudinal design was used to study changes in self-care self-efficacy and associations between self-care self-efficacy and measures of adjustment: health status, mood distress, symptom distress, dialysis stress, and perceived adherence to fluid restriction. SAMPLE/SETTING: Subjects were recruited from 8 settings in the Northeast where outpatient hemodialysis treatment was administered. Sixty-four subjects were recruited to the study. Twenty-eight subjects completed 3 occasions of data collection. METHODS: Data were collected on three occasions: (a) baseline-within 100 days of beginning treatment; (b) 4 months after beginning treatment; and (c) 8 months after beginning treatment. Eta-squared, a measure of practical significance, is reported for four factors of the self-care self-efficacy measure on each of the three occasions. Associations between self-care self-efficacy and measures of adjustment were examined by means of Pearson correlations. RESULTS: Eta-squared estimates showed generally positive changes occurring over time in subjects' self-care self-efficacy, health status, mood distress, symptom distress, dialysis stress, and perceived adherence to fluid restriction. Changes were more positive at 4-months than at 8-months after enrollment. Significant correlations (p < .05) occurred between self-care self-efficacy and mood states, health status, symptom distress, and perceived adherence to fluid restrictions. Correlations occurred more frequently between self-care self-efficacy and mood states than between self-care self-efficacy and other measures of adjustment. CONCLUSIONS: The study provided pilot data suggesting that hemodialysis patients' self-care self-efficacy and measures of adjustment change over time. Patients who had increased confidence in self-care strategies (self-efficacy) were associated with having more positive mood states, health status, and perceived adherence to fluid restrictions and less symptom distress. Interventions designed to increase patients' self-care self-efficacy may yield positive results. Nurses are in an excellent position to give efficacy enhancing feedback that may promote patients' adjustment.     

The study of outcomes for CAPD versus hemodialysis patients

Tacrine [1,2,3,4-tetrahydro-9-acridinamine monohydrochloride monohydrate (THA), Cognex] is a potent acetylcholinesterase inhibitor recently approved for treatment of mild-to-moderate Alzheimer's disease. The potential for THA and/or a metabolite of THA to accumulate in brain tissue was investigated by autoradiographic and metabolic profiling techniques in rats given single and multiple doses of [14C]THA. In addition, the brain-to-plasma distribution time course of orally administered 1-hydroxy-THA (1-OH-THA, 24 mg/kg), a primary rat metabolite with anticholinesterase activity, was also examined. Results from a 16 mg/kg single-dose study showed THA to cross the blood-brain barrier readily and concentrate in brain tissue, approximately 5-fold compared with plasma. The metabolite 1-OH-THA was found in much lower amounts relative to THA and when given separately at a similar dose the levels in brain tissue were comparable with plasma concentrations. After multiple-dose administration, THA concentrations in brain tissue were approximately 3-fold higher than those achieved after a single oral dose. However, concentration of 1-OH-THA metabolite increased only 50%. These data suggest a marked difference between the ability of THA and 1-OH-THA to accumulate in brain tissue and may reflect differences in lipophilicity as estimated by calculated log p values. The relevance of THA accumulation in brain tissue to delays observed in THA clinical management of Alzheimer's disease remains to be established.     

糖尿病肾病血液透析患者的临床特点及护理

目的:探讨糖尿病肾病透析患者的临床特点及护理对策.方法:选择40例糖尿病肾病及同期非糖尿病肾病血液透析患者,分别观察存活率、死亡原因、营养状况和并发症.结果:糖尿病肾病组1年和2年存活率较非糖尿病肾病组低(P<0.05,P<0.01),主要死因为心血管病变和严重感染;糖尿病肾病组Alb和Hb较非糖尿病肾病组低,差别有统计学意义(P<0.01,P<0.01);DN组血液透析中的并发症是低血压35%、低血糖35%和感染30%,与非糖尿病肾病组比较差别有统计学意义(P<0.05,P<0.01,P<0.01).结论:糖尿病肾病血液透析患者是一组高危人群,存活率低,营养状况差,应加强饮食指导;重视透析透析期间护理,降低透析中并发症的发生率,提高存活率和生活质量.     

Intermittent hydronephrosis. A clinical study in 23 pediatric patients

BACKGROUND: It is difficult to diagnose intermittent hydronephrosis and to decide the indication of surgical intervention. We investigated 23 cases of intermittent hydronephrosis. METHODS: From 1978 to 1995, a total of 23 patients were diagnosed as intermittent hydronephrosis in our institution. We inspected their clinical features and treatment which had been performed to them. RESULTS: Our study comprised 21 boys and 2 girls, whose mean age was 6 year old. Their chief complaint was intermittent flank pain (left: 21, right: 1, bilateral: 1) accompanied with gross hematuria (30%) and vomiting (39%). When they were asymptomatic, an excretory urogram revealed only mild pelvic dilatation without calyceal distension and kinking of ureteropelvic junction. Split renal function study by RI showed no difference between the affected side and the normal side except one case. When pelvic or calyceal enlargement was confirmed on ultrasonography while they were symptomatic, surgery was indicated. Surgery was performed in 17 cases (74%) including dismembered pyeloplasty in 14 cases, resection of aberrant vessel in 1, relocation of lower pole renal vessel in 1 and nephrectomy in 1. In surgical and histological view points, intrinsic stenosis was seen in 10 cases, extrinsic obstruction caused by aberrant vessels was seen in 4 and ureteral polyp was seen in 3 (bilateral polyp in 1 case). CONCLUSION: They had no more symptoms after operation. Of 23 among followed up cases without surgery, we experienced 2 cases unexpectedly advancing irreversible hydronephrotic change after the last attack, 1 case of gradually progressing hydronephrotic change and 1 case of severe renal dysfunction after many attacks. Therefore intermittent hydronephrosis should be followed up carefully.     

Symmetric and asymmetric left ventricular hypertrophy in patients with end-stage renal failure on long-term hemodialysis

BACKGROUND: Patients with end-stage renal disease on regular hemodialysis have an increased prevalence of left ventricular (LV) hypertrophy that is associated with morbidity and mortality. Asymmetric septal hypertrophy and impairment of LV outflow can occur in these patients and may contribute to adverse outcomes. More insight into the prevalence, extent, geometry, and promoting factors of LV hypertrophy is important. METHODS: An unselected group of 62 patients (31 women), aged 55 +/- 14 years, on maintenance hemodialysis was investigated by Doppler echocardiography. Eight patients with valvular heart disease were excluded from further analysis. We assessed prevalence of LV hypertrophy and asymmetric septal hypertrophy, as well as parameters of LV geometry and LV filling and outflow dynamics. RESULTS: Prevalence of LV hypertrophy was 65%. Patients were analyzed according to LV mass and geometry. Mean LV mass index was normal (105 +/- 17 g/m2) in Group 1 without LV hypertrophy (n = 19); it was markedly elevated in Group 2 (symmetric hypertrophy, n = 22) and Group 3 (asymmetric hypertrophy with systolic anterior movement of mitral valve, n = 7), and highest (191 +/- 54 g/m2) in Group 4 (asymmetric hypertrophy without systolic anterior movement of mitral valve, n = 6, p < 0.001). Age, body mass index, and duration of hypertension were associated with LV hypertrophy and asymmetric septal hypertrophy (p = 0.01). Group 3 with systolic anterior motion of mitral valve had the smallest end-diastolic LV diameters (p = 0.02); increased heart rates, and increased ejection velocities in the LV outflow tract (p = 0.03, and p = 0.005, respectively, vs. Groups 1, 2, and 4) which pointed to an impairment of LV outflow. CONCLUSIONS: Symmetric LV hypertrophy and asymmetric septal hypertrophy are frequent in patients on maintenance hemodialysis. Predictors for LV hypertrophy were age and body mass index, and, particularly for asymmetric septal hypertrophy, age and hypertension duration. Volume withdrawal during hemodialysis may lead to symptomatic hypotension due to dynamic obstruction in some patients with severe asymmetric septal hypertrophy.     

The impact of long-term hemodialysis on pituitary-adrenocortical function

The activity of the hypothalamic-pituitary-adrenal axis in hemodialyzed (HD) patients has been investigated, with conflicting results. Different results are reported concerning both basal ACTH and cortisol concentration and the responses to different stimulating agents, in chronic hemodialyzed patients. The present study was performed in order to asses whether the length of the hemodialytic treatment may affect the pituitary and adrenocortical response to stimulation with ovine CRH (oCRH) and with exogenous ACTH in a group of patients on chronic HD for more than 10 years. Ten uremic patients (aged 38-71, 6 males and 4 females) on chronic hemodialysis for at least 10 years and 7 healthy subjects matched for age and sex were studied. The patients were tested on the day preceding dialysis session. Each subject received on different non-consecutive days oCRH (100 micrograms i.v. in bolus) and ACTH (Synacthen 0.25 mg i.v. in bolus), and blood samples were obtained at appropriate intervals. Basal ACTH and cortisol levels of HD patients were in the upper limit of normal range (ACTH 39.21 +/- 11.11 pg/mL in HD patients vs. 26.88 +/- 14.12 pg/mL in controls; cortisol 19.96 +/- 5.07 in HD patients vs. 12.66 +/- 4.44 in controls); however, the means were not significantly different compared with controls. Following oCRH administration a net increase of ACTH and cortisol was observed in every patient tested (ACTH peak 83.81 +/- 28.49 in HD vs. 78.73 +/- 22.87 pg/mL in controls; cortisol peak 30.73 +/- 19.31 in HD vs. 20.05 +/- 3.19 micrograms/dL in controls).(ABSTRACT TRUNCATED AT 250 WORDS)     

Augmentation of nutritional intakes in children receiving long-term hemodialysis treatment

One of the major problems confronting children on long-term hemodialysis treatment is an inadequate intake of nutrients. The intake of calories, protein and minerals in children dialyzed for up to 3 years was documented in this study to be low. A simple method of augmenting the nutritional intake that has wide patient acceptibility is presented.