Tandem plasmapheresis and hemodialysis: efficacy and safety.

BACKGROUND: Hemodialysis (HD) and plasmapheresis (PE) are usually performed independently on patients who require renal replacement therapy. We analyzed our experience using a technique that performs both modalities simultaneously. METHODS: Thirty-six patients who were treated with 287 tandem PE and HD (TPH) sessions (mean 7.97 ± 5.6 per patient) were included. PE was connected 30 min after HD started. The mean HD blood flow was 313.7 ± 44 mL/min, the mean PE blood flow was 141 ± 25 mL/min, and the duration of TPH was no longer than 240 min. The heparin dose was similar to that used for a standard HD procedure. RESULTS: In 287 TPH sessions performed, 10.45% experienced minor complications. There were significant changes in mean blood pressure after connection of the PE system. However, these differences were not clinically relevant since patients remained asymptomatic and they did not require saline infusion. At the end of treatment, 38.9% of patients were no longer dependent on dialysis. CONCLUSIONS: Our results suggest that TPH is a safe and effective treatment that decreases exposure to an extracorporeal circuit, reducing the risks that are associated with anticoagulation agents and improving the comfortability of the patient.

Monocytes from dialysis patients exhibit characteristics of senescent cells: does it really mean inflammation?

Hemodialysis treatment induces mononuclear cell activation particularly if cellulosic hemodialysis membrane is used. In normal cells, repeated activation induce a process of accelerate cellular senescence. The aim of the present study was to evaluate whether the mononuclear cell activation associated to hemodialysis with cellulosic membranes favors a process of accelerate senescence in mononuclear cells. Our results show that mononuclear cells from patients dialyzed with cellulosic membranes, exhibit: decrease telomere length, increase percentage of cells CD14dim/CD16bright and increase production of IL-1beta, IL1Ra and IL6 cytokines. After culture in vitro, these cells shown increase susceptibility to undergoing spontaneous apoptosis, that is enhanced by IL-4 and prevented by IL-1beta or LPS. All of these characteristics have been reported associated to senescence of monocytes, and not are observed in cells from controls subjects or patients dialyzed with non-cellulosic membranes, suggesting that hemodialysis with cellulosic membranes induce a process of senescence in mononuclear cells.

The effects of control of thermal balance on vascular stability in hemodialysis patients: results of the European randomized clinical trial.

BACKGROUND: Many reports note that the use of cool dialysate has a protective effect on blood pressure during hemodialysis (HD) treatments. However, formal clinical trials in which dialysate temperature is tailored to the body temperature of appropriately selected hypotension-prone patients are lacking. METHODS: We investigated the effect of thermal control of dialysate on hemodynamic stability in hypotension-prone patients selected from 27 centers in nine European countries. Patients were eligible for the study if they had symptomatic hypotensive episodes in 25% or more of their HD sessions, assessed during a prospective screening phase over 1 month. The study is designed as a randomized crossover trial with two phases and two treatment arms, each phase lasting 4 weeks. We used a device allowing the regulation of thermal balance (Blood Temperature Monitor; Fresenius Medical Care, Bad Homberg, Germany), by which we compared a procedure aimed at preventing any transfer of thermal energy between dialysate and extracorporeal blood (thermoneutral dialysis) with a procedure aimed at keeping body temperature unchanged (isothermic dialysis). RESULTS: One hundred sixteen HD patients were enrolled, and 95 patients completed the study. During thermoneutral dialysis (energy flow rate: DeltaE = -0.22 +/- 0.29 kJ/kg x h), 6 of 12 treatments (median) were complicated by hypotension, whereas during isothermic dialysis (energy flow rate: DeltaE = -0.90 +/- 0.35 kJ/kg x h), the median decreased to 3 of 12 treatments (P < 0.001). Systolic and diastolic blood pressures and heart rate were more stable during the latter procedure. Isothermic dialysis was well tolerated by patients. CONCLUSION: Results show that active control of body temperature can significantly improve intradialytic tolerance in hypotension-prone patients.

Prótesis wallstent en estenosis y oclusiones venosas centrales en pacientes de hemodiálisis / The Wallstent endoprosthesis in hemodialysis patients presenting central venous stenosis or occlusion

Objetivo: Describir la efectividad y complicaciones a medio plazo de la prótesis Wallstent en el tratamiento de estenosis y oclusiones venosas centrales en los pacientes de hemodiálisis.Material y Métodos: Se presentan nueve pacientes en hemodiálisis (cuatro varones y cinco mujeres) con una edad media de 64 años que presentaron estenosis (seis pacientes) o trombosis (tres pacientes) en venas centrales (vena subclavia: cuatro; tronco venoso innominado: cuatro y ambos sectores: uno). Todos los pacientes habían sido antiguos portadores de catéteres yúgulo-subclavios para hemodiálisis en el lado afectado.Las indicaciones para la implantación de la prótesis Wallstent fueron por estenosis elástica postangioplastia inmediata (tres pacientes), reestenosis antes de seis meses postangioplastia (tres pacientes) e indicación primaria de la prótesis por oclusión venosa (tres pacientes).Las prótesis empleadas fueron de 10-16 mm de diámetro y todos los pacientes permanecieron anticoagulados y antiagregados tras la implantación de la misma.Resultados: Un paciente presentó una migración proximal a la vena cava superior a las 48 horas de implantada la prótesis. Otro paciente sufrió un oclusión de la prótesis a las 24 horas que se trató con la implantación coaxial de una nueva.A todos los pacientes se les realizó un seguimiento flebográfico del brazo observándose en cinco de ellos una estenosis dentro de la prótesis y en otros dos una oclusión de la misma tras un tiempo medio de seis meses (2-15 meses) y se trataron mediante angioplastia (cuatro pacientes) o nueva prótesis coaxial (tres pacientes).Tras nueve reintervenciones y un período medio de seguimiento de 16 meses (0-36 meses) hemos obtenido una 'permeabilidad asistida' del 67 por ciento.Conclusión: Aunque la implantación de Wallstents para tratar estenosis y oclusiones venosas centrales es un buen procedimiento que permite prolongar el acceso vascular para la hemodiálisis, no está exento de riesgos y son muy frecuentes las reintervenciones por reestenosis para mantenerla permeable (AU)