Personal viewpoint: Limiting maximum ultrafiltration rate as a potential new measure of dialysis adequacy

While the solute clearance marker (Kt/V_urea) is widely used, no effective marker for volume management exists. Two principles apply to acute volume change in hemodialysis: (1) the plasma refill rate, the maximum rate the extracellular fluid can replace a contracting intravascular volume (±5 mL/kg/hour) and (2) the rate of intravascular volume contraction where coronary hypoperfusion, myocardial stun, and vascular risk escalates (observed at ≥10 mL/kg/hour). In extended hour and higher frequency hemodialysis, intravascular contraction rates are usually equilibrated by the plasma refill rate, but in “conventional” in‐center hemodialysis, volume contraction rates commonly exceed the capabilities of the plasma refill rate, resulting in inevitable hypovolemia. To minimize cardiovascular risk, fluid removal rates should ideally be ≤10 mL/kg/hour, acknowledging that this may be challenging in the in‐center setting. Two options exist to limit volume removal to >10 mL/kg/hour: restricting interdialytic weight gain (always conflict‐fraught, often unachievable) or extending sessional duration to allow additional removal time. Just as Kt/V_urea quantifies solute removal, a simple‐to‐apply rate variable should also apply for volume removal. As predialysis and target postdialysis weights are both known, a simple measure—a maximum rate for ultrafiltration (UFR_max)—would advise the sessional duration (T) required to minimize organ stun by removing the required fluid load (V) from any patient of predialysis weight (W). This would ensure a removal rate no greater than 10 mL/kg/hour—T (hours) = V (mL)/10 × W (kg). Used together, Kt/V_urea and UFR_max would form a solute and volume composite, each dialysis treatment continuing until both solute and volume requirements are fulfilled.     

Metastatic pulmonary calcification in a dialysis patient: case report and a review

A 19-year-old male presented with chest pain and dyspnea. He was anephric following nephrectomy for focal segmental glomerulosclerosis, had a subsequent failed transplant, and had been dialysis dependent for 3 years. Workup revealed hyperparathyroidism and an abnormal chest X-ray and computed tomography scan, significant for massive extra-skeletal pulmonary calcification. A markedly abnormal Technitium99 methylene diphosphonate (Tc99m-MDP) bone scan confirmed the clinical suspicion of metastatic pulmonary calcification. Metastatic pulmonary calcification (MPC) is common, occurring in 60% to 80% of dialysis patients on autopsy and bone scan series. It may lead to impaired oxygenation and restrictive lung disease. Typically, the calcium crystal is whitlockite rather than hydroxyapatite, which occurs in vascular calcification. Four major predisposing factors may contribute to MPC in dialysis patients. First, chronic acidosis leaches calcium from bone. Second, intermittent alkalosis favors deposition of calcium salts. Third, hyperparathyroidism tends to cause bone resorption and intracellular hypercalcemia. Finally, low glomerular filtration rate can cause hyperphosphatemia and an elevated calcium-phosphorus product. There may be other factors. Some authors suggest that the incidence of MPC in recent years may be lower due to improved dialysis techniques. The diagnosis is confirmed by biopsy, but can be suspected by typical findings on a Tc99m-MDP bone scan. Therapy is limited to ensuring adequate dialysis, correcting calcium-phosphorus product, and hyperparathyroidism; discontinuing vitamin D analogues may help. Conflicting reports show that transplantation may either improve or worsen the situation. MPC should be considered in dialysis patients who have characteristic abnormal chest radiography and/or pulmonary symptoms.     

Pregnancy in dialysis-dependent women--the importance of frequent dialysis and collaborative care: a case report

An increasing number of successful pregnancies have been reported among women on chronic hemodialysis. Even with reduced fertility and high risk of complications, women of childbearing age receiving hemodialysis, should not be discouraged from pregnancy. Practitioners should be familiar with the effects of renal disease on pregnancy, consult patients about the possibility of pregnancy and its hazards and provide, if necessary, prompt surveillance and treatment. This paper describes the case of an unplanned but successful pregnancy of a woman receiving hemodialysis, emphasizing pregnancy management, mother's response evaluation, and infant growth.     

Effect of timing of dialysis on mortality in critically ill, septic patients with acute renal failure

Acute renal failure with concomitant sepsis in the intensive care unit is associated with significant mortality. The purpose of this study was to determine if the timing of initiation of renal replacement therapy (RRT) in septic patients had an effect on the 28-day mortality. Retrospective data on medical intensive care unit patients with sepsis and acute renal failure requiring RRT were included. Renal replacement therapy started with a blood urea nitrogen (BUN) of <100 mg/dL was defined as early initiation, and initiation with a BUN ≥100 mg/dL was defined as late. Multivariate logistic regression analysis with the primary outcome of death at 14, 28, and 365 days following the initiation of RRT was performed. One hundred thirty patients were studied. The early dialysis (mean BUN 66 mg/dL) group had 85 patients; the late group (mean BUN 137 mg/dL) had 62 patients. The mean acute physiology and chronic health evaluation II score was 24.5 in both groups. The overall 14, 28, and 365-day survival rates were 58.1%, 41.9%, and 23.6%. Survival rates for the early group were 67%, 47.7%, and 30.7% at 14, 28, and 365 days. Survival rates for the late group were 46.7%, 31.7%, and 13.3% at 14, 28, and 365 days. Upon logistic regression analysis, initiating dialysis with a BUN >100 mg/dL predicted death at 14 days (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.7–7.6, P=0.001), 28 days (OR 2.6, 95% CI 1.2–5.7, P=0.01), and 365 days (OR 3.5, 95% CI 1.2–10, P=0.02). Septic patients who started dialysis with a BUN <100 mg/dL had improved mortality rates up to 1 year after initiation of dialysis in this single-center, retrospective analysis.     

Renal involvement in mushroom poisoning: The case of Orellanus syndrome

Although mushroom poisoning is a rare cause of acute renal injury, in some cases it may lead to the development of a severe and irreversible renal failure. Orellanus syndrome is the most important example of organic renal damage related to mushroom consumption. It is caused by the ingestion of orellanine, the main toxin of different types of Cortinarius mushrooms (Cortinarius speciosissimus, C. orellanus, C. orellanoides, etc.), and it is characterized by progressive clinical phases with a predominant kidney involvement, finally requiring renal replacement therapy in about 10% of cases. Renal damage is often late and associated with a histological picture of interstitial nephritis. Diagnosis is essentially clinical and no specific therapy has been shown to be effective in preventing and treating renal damage. Here, we describe the case of a patient with mixed wild mushroom poisoning, presenting the typical clinical signs and course of the Orellanus syndrome. This case offers us the opportunity to review the main clinical features of this severe and little‐known intoxication.     

Reliability estimation of semi-Markov systems: a case study

In this article, we are concerned with the estimation of the reliability and the availability of a turbo-generator rotor using a set of data observed in a real engineering situation provided by Electricité De France (EDF). The rotor is modeled by a semi-Markov process, which is used to estimate the rotor's reliability and availability. To do this, we present a method for estimating the semi-Markov kernel from a censored data.     

Activity-based costing in flexible manufacturing systems with a case study in a forging industry

The objective of this paper is to apply the activity-based costing (ABC) approach together with traditional costing (TC) for parts costing in flexible manufacturing systems (FMS) with the A(2) level of automation. We propose a new model for the implementation of ABC using the product cost tree concept. First, the required resources and activities for each part are recorded, and then their costs are calculated using the appropriate cost formulae. This model was applied in a forging industry. A comparison and analysis between ABC and TC was then carried out based on the computational results obtained from the case study. The results indicate that the ABC outputs are more reliable than the TC outputs, and thus the ABC approach is a more acceptable tool for parts costing in FMS.     

Acute hemolysis with acute renal failure in a patient with valproic acid poisoning treated with charcoal hemoperfusion

Hemoperfusion consists of the passage of anticoagulated blood through a column containing adsorbent particles. It was introduced in 1940 and refined from 1950 to 1970, and then introduced clinically for the treatment of acute intoxications between 1970 and 1980. Life-threatening valproic acid toxicity is an indication for coated charcoal hemoperfusion usually accomplished without complications, but we report a case of acute severe intravascular hemolysis during the time of hemoperfusion with coated charcoal column.     

Indoxyl sulfate,a valuable biomarker in chronic kidney disease and dialysis

Chronic kidney disease (CKD) is an increasingly recognized disease with high global incidence and mortality. Yet, the existing diagnostic tools are not sufficient enough to predict prognosis of CKD and CKD comorbidities. Indoxyl sulfate, a typical uremic toxin, is of great importance in the development of CKD with its nephrotoxicity, cardiovascular toxicity, and bone toxicity. Some reports suggest that indoxyl sulfate directly associate with renal function loss and mortality in CKD patients. This review discusses the diagnostic value of indoxyl sulfate from its biological characteristics, pathophysiological effects, related therapies, and its diagnostic value in clinical studies.     

Freeway management systems and motor vehicle crashes: a case study of Phoenix, Arizona.

This paper measures the impact of a freeway management system (FMS) on the incidence of reported motor vehicle crashes in Phoenix, AZ. Using a fixed effects negative binomial regression model, I find that the FMS reduces the frequency of crashes involving property damage only, possible injury, and minor injury by 25, 30, and 21%, respectively. I find no evidence for an effect on the frequency of major injury crashes or fatal crashes, although such accidents account for less than 5% of the total crashes in Phoenix. Classifying the data by the type of crash rather than by severity, I find that the frequencies of rearend crashes and sideswipe crashes are reduced by 25 and 37%, respectively, and I find no evidence of an effect on single vehicle crashes. The results are robust to many different model specifications, including a variety of functional forms, covariates, and data. A conservative estimate of the annual crash benefits of the FMS in Phoenix ranges from $4.8-13.2 million, depending on various assumptions about the value of pain and suffering and about the extent of crash underreporting. These annual crash benefits far outweigh the $1.6 million in annual operating and maintenance costs of the Phoenix FMS, and they offset considerably the approximately $47 million invested to date in the design and construction of the system.     

Successful treatment of carbamazepine poisoning with hemodialysis: a case report and review of the literature

A 48-year-old man was brought to the emergency room after ingesting an unknown amount of carbamazepine. He was unconscious and not responding to the noxious stimuli. He was intubated and was placed on mechanical ventilation because of respiratory insufficiency. Primary detoxification was performed with a gastric lavage and charcoal instillation. His serum carbamazepine level was 25.6 mcg/mL at the time of admission. His computed tomography of the brain was normal. He was managed conservatively but there was no improvement in his neurological status in the next 24 hours. Serum carbamazepine level was repeated and reported to be 28.3 mcg/mL. As there was no improvement in his sensorium and the serum carbamazepine levels remained persistently high, extracorporeal removal of carbamazepine was attempted. As the facility to carry out hemoperfusion was not available immediately, the decision to initiate hemodialysis was taken. After 3 sessions of hemodialysis, his sensorium improved markedly and the carbamazepine level at this time was within the therapeutic range. He was discharged after psychiatry consultation and counseling. We review the literature regarding extra corporeal techniques for the removal of carbamazepine and discuss them in this article.     

Performance of air sparging systems: a review of case studies

Fluor Daniel GTI (now IT Corporation) has compiled a database of 49 completed in-situ air sparging case studies. Air sparging is a commonly used remediation technology which volatilizes and enhances aerobic biodegradation of contamination in groundwater and saturated zone soil. The air sparging database was compiled to address questions regarding the effectiveness and permanence of air sparging, and to provide predictive indicators of air sparging success to aid in optimization of existing and future air sparging systems. In each case study, groundwater concentrations were compared before sparging was initiated, just before sparging was terminated, and in the months following shutdown of the sparging system. The case studies included both chlorinated solvents and petroleum hydrocarbon contamination, and covered a wide range of soil conditions and sparge system parameters. In many cases, air sparging achieved a substantial and permanent decrease in groundwater concentrations. Successful systems were achieved with both chlorinated and petroleum contamination, both sandy and silty soils, and both continuous and pulsed flow sparging. In other cases, however, a significant rebound of groundwater concentrations was observed after sparging was terminated. Rebound sometimes required 6 to 12 months to develop fully. Rebound was more frequently observed at sites contaminated with petroleum hydrocarbons than with chlorinated solvents. Petroleum-contaminated sites were more likely to rebound when initial groundwater contamination levels were high enough to suggest the presence of LNAPL or a smear zone of residual LNAPL. Rebound at petroleum sites appeared to be minimized by a high density of sparge wells addressing the entire source area and a high sparge air injection rate. In some cases, rebound appeared to be related to a rising water table.     

Reliability assessment of fire safety systems in railway industry: a case study

Within the framework of railroad transportation systems, there are currently system rooms where critical systems such as signalization are available. For the system to achieve an uninterrupted mode of operation, it is crucial to mitigate risks or hazards against the rooms and to ensure an acceptable level of safety. This study handles the protection of a system room, owned by Istanbul Ula??m A.?. Edirnekap? branch, against an incident of fire as a safety-related system practice. Within this scope, the fire safety system has been handled as a safety-related system identified in IEC 61508. The safety integrity level required by the safety lifecycle for the relevant system has also been identified and safety functions that are required to be implemented have been put forth. Taking IEC 61508 as a reference for the functions, the required analyses have been performed through fault tree analysis. It has also been guaranteed that the relevant functions have met the required safety levels.     

Applying RCM in large scale systems: a case study with railway networks

In 2000, the European Union founded a project named ‘RAIL: Reliability centered maintenance approach for the infrastructure and logistics of railway operation’ aimed to study the application of Reliability centered maintenance (RCM) techniques to the railway infrastructure. In this paper, we present the results obtained into the RAIL project, including a RCM methodology adapted to large infrastructure networks and a RCM toolkit to perform the RCM analysis, including cost aspects and maintenance planning guidance. This paper addresses the problem of applying RCM to large scale railway infrastructure networks to achieve an efficient and effective maintenance concept. Railways use nowadays very traditional preventive maintenance (PM) techniques, relying mostly on ‘blind’ periodic inspection and the ‘know-how’ of maintenance staff. RCM was seen as a promising technique from the beginning of the RAIL project because of several factors. First, technical insights obtained were better than the existing, so that several maintenance processes could be revised and adjusted. Second, the interdisciplinary approach used to make the analysis was very enriching and very encouraging for maintenance staff consulted. Third, using the RCM structured approach allowed to achieve well-documented analysis and clear decision diagrams. Our methodology includes some new features to overcome the problems of RCM observed in other projects. As a whole, our methodology and Computerized Maintenance Management Systems have produced two short-term benefits: reduction of time and paperwork because databases and tools are accessible through Internet, and creation of a permanent, accurate, and better collection of information. It will also have some long-term benefits: better PM will increase equipment life and will help to reduce corrective maintenance costs; Production will increase as unscheduled downtime decreases; purchase costs of parts and materials will be reduced; more effective and up-to-date record of inventory/stores reports; and better knowledge of the systems to help the company to chose those systems with the best LCC. The results have been corroborated with the application of our methodology to signal equipment in several railway network sections, as shown in this paper. Because of the successful conclusion of the project, the Spanish railway company (RENFE) and the German railway company (DB A.G.), not only decided to adopt RCM to enhance PM, but they have started a large project to implement Total Preventive Maintenance relying on the implantation of the RCM methodology.     

Kinetics of thermochemical reaction of TBP solutions in HCBD with nitric acid in two-phase systems

The kinetics of thermochemical reaction of 30% TBP in hexachlorobutadiene (HCBD) saturated with HNO₃ (1.35 M HNO₃) in two-phase systems with 12 M HNO₃ at temperatures from 90 to 115°C was studied. The kinetic parameters of thermolysis of organic solutions of TBP in HCBD, contacting with HNO₃ in open and closed vessels, were determined experimentally for the subsequent estimation of the explosion hazard of these systems under conditions of extraction recovery of high-level radioactive materials. It was shown that, in two-phase systems, solutions of TBP in HCBD exhibit increased resistance to thermochemical oxidation with nitric acid in comparison with hydrocarbon solutions of the extractant in the entire temperature range.     

Kinetics of thermochemical reaction of TBP solutions in HCBD with nitric acid in single-phase systems

The reaction of 30% solutions of TBP in hexachlorobutadiene (HCBD) with dissolved HNO₃ at its initial concentration of 1.2 M was studied in the range from 90 to 150°C. The kinetic parameters of HNO₃ consumption, gas release, and accumulation of dibutyl hydrogen phosphate were determined. The boundary temperature conditions for transition of oxidation processes to thermal explosion mode under conditions of extraction reprocessing of high-level radioactive materials were estimated from the kinetic data.