Personal viewpoint: hemodialysis--water, power, and waste disposal: rethinking our environmental responsibilities

While medical health professionals are trained to detect, treat, and comfort, they are not trained to consider the environmental impact of the services they provide. Dialysis practitioners seem particularly careless in the use of natural resources—especially water and power—and seem broadly ignorant of the profound medical waste issues created by single use dialysis equipment. If the data we have collected is an indication, then extrapolation of this data to a dialysis population currently estimated at ~2 million patients worldwide, a “world dialysis service” would use ~156 billion liters of water and discard ~2/3 of that during reverse osmosis. This waste occurs, despite the discarded water being high-grade “gray water” of potable standard. The same world dialysis service would consume 1.62 billion kWh of power—mostly generated from coal and other environmentally damaging sources. Our world dialysis service, based on ~2 kg of waste from each dialysis treatment, would generate ~625,000 tonnes of plastic waste—waste that would be potentially reusable if simple sterilizing techniques were applied to it at the point of generation. Dialysis services must begin to explore eco-dialysis potentials. The continued plundering of resources without considering reuse or recycling, exploration of renewable energy options, or the reduction of the carbon footprint of the dialysis process . . . is unsustainable. Sustainable dialysis practices should be a global goal in the coming decade.     

Polycythemia due to obstructive sleep apnea in a patient on hemodialysis

Both anemia and sleep disordered breathing are common in patients with dialysis‐dependent stage 5 chronic kidney disease. Erythrocytosis resulting from obstructive sleep apnea (OSA) is rare in the general population and has never been described in the hemodialysis population. We present a case of asymptomatic isolated erythrocytosis and elevated serum erythropoietin level in an otherwise well and previously erythropoietin‐dependent chronic hemodialysis patient with chronic kidney disease secondary to ischemic nephropathy. There was no history or symptoms of cardio‐pulmonary or hepatic diseases nor any relevant family history. Screening work‐up for malignancies was negative. The clinical history was highly suggestive of OSA and severe OSA (respiratory disturbance index of 59) was confirmed by polysomnographic studies. Successful treatment of the OSA with continuous positive airway pressure resulted in permanent stabilization of the hemoglobin to levels below 13 g/dL without the need for repeated phlebotomies and in dramatic lowering of serum erythropoietin levels. To our knowledge, this is the first case of OSA mediated erythrocytosis in a dialysis patient documented in the literature.     

Biocompatibility of heparin-grafted hemodialysis membranes: impact on monocyte chemoattractant protein-1 circulating level and oxidative status

This prospective observational study aimed at evaluating efficacy and biocompatibility performances of the new heparin-coated Evodial dialyzers with/without systemic heparin reduction. After a 4-week wash-out period with reference polysulfone F70S dialyzers, 6 hemodialysis patients were sequentially dialyzed with Evodial, F70S, and Evodial dialyzers using 30% heparin reduction, each period of treatment was 4 weeks. Removal rates (RR) (urea, creatinine, and β2-microglobulin), dialysis dose, and instantaneous clearances (urea and creatinine) were measured as well as inflammatory (C-reactive protein, fibrinogen, interleukin 6, tumor necrosis factor α, and monocyte chemoattractant protein-1) and oxidative stress (OS) (superoxide anion, homocysteine, and isoprostanes) parameters at the end of each study period. Patients treated with Evodial or F70S dialyzers for 4 weeks presented comparable dialysis efficacy parameters including urea and creatinine RR, dialysis dose and instantaneous clearances. By contrast, a significantly lower but reasonably good β2-microglobulin RR was achieved with Evodial dialyzers. Regarding biocompatibility, no significant difference was observed with inflammation and OS except for postdialysis monocyte chemoattractant protein-1 which significantly decreased with Evodial dialyzers. Thirty percent heparinization reduction with Evodial dialyzers did not induce any change in inflammation but led to an improvement in OS as demonstrated by a decrease in postdialysis superoxide production and predialysis homocysteine and isoprostane. This bioactive dialyzer together with heparin dose reduction represents a good trade-off between efficacy and biocompatibility performance (improvement in OS with a weak decrease in efficacy) and its use is encouraging for hemodialysis patients not only in reducing OS but also in improving patient comorbid conditions due to lesser heparin side effects.     

Changes in circulating biomarkers during a single hemodialysis session

The hemodialysis (HD) procedure induces an inflammatory response potentially contributing to cardiovascular disease. Here we investigated the acute impact of HD on circulating biomarkers. Circulating biomarkers (small solutes, middle molecular‐sized peptides, and proteins) related to inflammation, oxidative stress, and vascular calcification (VC) were measured before and after a single session of HD in 45 clinically stable patients. Concentrations were corrected for ultrafiltration‐induced hemoconcentration. Among vascular calcification‐related biomarkers, osteoprotegerin and fetuin‐A remained unchanged while fibroblast growth factor‐23 (FGF23) decreased by ?19%. Changes of FGF23 and changes of phosphate correlated (ρ = 0.61, P < 0.001). While C‐reactive protein did not change, interleukin‐6 (IL‐6) increased by 14% and pentraxin 3 (PTX3) increased by 45%. IL‐6 and PTX3 appear to be valid biomarkers of the intradialytic inflammatory response. VC‐related markers were in general not affected by the single HD session; however, the observed correlation between acute changes of FGF‐23 and phosphate during HD warrants further studies.     

糖尿病患者血液透析的护理干预

目的探索对糖尿病血透患者的护理干预会对病患的治疗产生哪些影响。方法对2006年1月至2010年1月60例病患实施进行了血液透析针对性的护理。结果护理干预明显影响了患者的血糖指标和心理评价指标。结论护理干预可以明显地调整糖尿病血透患者的心理,对辅助治疗有明显的效果。     

Survival pattern of hemodialysis patients in Kumasi, Ghana: A summary of forty patients initiated on hemodialysis at a new hemodialysis unit

To evaluate the survival pattern of hemodialysis patients at a dialysis unit in Kumasi, Ghana, through a retrospective (observational) study. Patients who were placed on hemodialysis at the dialysis unit at Komfo Anokye teaching hospital from October 25, 2006 to December 2007. The patients were followed from initiation of dialysis until December 31, 2007. The overall mortality was 14 (35.9%) on the incident population for the period and that for the first 90 days was 12 (32.4%) patients. Chronic glomerulonephritis was the underlying kidney disease in 35.9%. This was followed by hypertension (19.1%) and diabetes mellitus (15.4%), respectively. Cardiovascular diseases accounted for 42% of mortality. This was followed by septicemia (25%) from the access site and anemia (25%). Fifty percent of the patients were able to afford 20 sessions of hemodialysis before stopping. The most powerful predictors of survival were the duration of hemodialysis (P=0.05) and the number of hemodialysis sessions (P=0.02). Age at initiation of hemodialysis was not significant. First 90-day mortality of patients on hemodialysis is high in poor African countries. This is due partially to the late referral of patients and also the cost of the dialysis treatment. Efforts will have to be made to reduce the cost of the dialysis treatment. Reuse technology (of dialyzer, etc.) should be introduced to cut down the cost of hemodialysis. Peritoneal dialysis should also be introduced for highly motivated patients. Efforts should also be made to reduce the increasing incidence of kidney disease, and finally third-world countries should consider establishing kidney transplantation, that is cost effective.     

Residual renal function and arterial stiffness mediated the blood pressure change during interdialytic weight gain in hemodialysis patients

Volume overload is thought to be the main cause of hypertension in dialysis patients. However, the effect of interdialytic weight gain (IDWG) in hemodialysis (HD) patients, which was considered as an increase in extracellular water (ECW), on blood pressure (BP) change, was controversial. Our aim was to examine the changes in hemodynamics and arterial stiffness during IDWG in HD patients and attempt to explore the possible mechanism of diverse BP change. Thirty prevalent patients on HD were enrolled. The height, weight, BP, blood chemistry, volume status assessed by bioelectrical impedance analysis, hemodynamic parameters obtained by echocardiography, and pulse wave velocity (PWV) were collected within 1 hour postdialysis and again just before the next dialysis session. Meanwhile, blood samples were drawn to analyze vasoactive hormones, including renin, angiotensin II, catecholamine, and endothelin. The patients' weights and ECWs during the next predialysis were significantly higher than those during the postdialysis. The BP showed no difference between postdialysis and the next predialysis. There was an obvious increase in cardiac output and decrease in total peripheral resistance as a whole during the next predialysis than that during postdialysis. When patients were divided into the BP increase group (BPI group, 13 patients) and BP decrease group (BPD group, 11 patients) according to the change in systolic BP higher than 10 mmHg, both groups displayed a significant increase in weight, ECW, cardiac output, and a decrease in total peripheral resistance. As compared with the BPI group, patients in the BPD group had significantly lower IDWG, shorter time on dialysis treatment, and higher residual renal function. A decrease in catecholamine and endothelin in the next predialysis was obvious in the BPD group. There was a significant decrease in PWV at the next predialysis in the BPD group while the PWV did not change significantly in the BPI group. Our results showed that the diverse BP change during IDWG was significantly affected by residual renal function, PWV, and vasoactive substances.     

利用~(125)I标记的抗人活化血小板单抗检测血液透析中血小板活化程度

利用~(125)I标记的抗人活化血小板α颗粒膜蛋白(GMP-140)特异性单抗SZ-51,来检测12例维持血液透析病人血透过程中体内血小板的活化程度。血透过程中体内血小板数呈显著性下降,以血透2小时为最低;血小板膜表面GMP-140分子数血透30分钟开始升高,血透2～3小时达高峰,血透结束时基本恢复到血透前水平;而血浆内GMP-140分子数血透3小时才开始升高,血透结束时达高峰,血透结束后24小时接近血透前水平;血浆β-TG浓度血透早期降低,血透晚期又增高;血浆TXB_2浓度血透30分钟明显增高,血透2小时达高峰,血透结束时仍较血透前为高。结果提示血透过程中体内血小板存在一过性的活化过程。     

Successful management of severe hyponatremia in CKD‐VD: In a cost limited setting

Patients with end stage renal disease (ESRD) and severe hyponatremia always pose a challenge to manage. It is necessary to correct biochemical parameters, advanced azotemia, and fluid overload with conventional haemodialysis (HD) but it may correct serum sodium (Na) rapidly resulting in neurological complications like seizures and osmotic demyelination syndrome. Continuous renal replacement therapy (CRRT) is an ideal modality to manage such patients. However, most of the centers in the developing or underdeveloped nations do not have CRRT facility. We present two cases of ESRD, who had advanced azotemia requiring dialysis, also had persistent vomiting and severe hyponatremia (one with Na 107, another with Na 109 mEq/L), both cases were managed with conventional HD using dialysate Na concentration of 128 mEq/L (lowest permissible level of Na in a traditional HD machine) and keeping the blood flow of 50 mL/min. The serum Na increased by 1 mEq/L/h during first HD session, during the next session blood flow increased to 100 mL/min, and serum Na increased by two mEq/L/h. At the end of 48 hours, we were able to successfully correct serum Na by 18 mEq/L, with complete resolution of uremic manifestations and no neurological deficits. The current reports highlight management of hyponatremia in newly diagnosed ESRD in a cost limited setting.