[Sleep disorders in patients treated with continuous ambulatory peritoneal dialysis]. / Poruchy spánku u pacientu lécených kontinuální ambulantní peritoneální dialýzou (CAPD).

BACKGROUND: A lot of patients with end stage renal disease with the necessity of renal replacement therapy have some sleep problems. The aim of this study was to get basic information about the sleep of patients treated with continuous ambulatory peritoneal dialysis (CAPD), mainly their subjective view on their sleep, including comparison with hemodialyzed patients (HD). METHODS: All patients treated with continuous ambulatory peritoneal dialysis in two dialysis centres were given a simple questionnary containing 20 questions concerning sleep. It was filled in by all these patients--25 patients (mean age 58.1 years)--12 men and 13 women. Data obtained from 103 hemodialyzed patients from the same two-dialysis centres were used for comparison (mean age 60.4 years)--61 men and 42 women (the same questionnary). RESULTS: 40% of CAPD patients regard their sleep as bad. Thirty six percent of patients have problems with falling asleep, 32% awake three times or more during the night and 28% snore or have some breath problems. CAPD patients feel more frequently tired after the night (32% vs. 18.4% HD), more patients sleep during the day (64% vs. 5.15% HD) and fewer patients feel restlessness of legs (36% vs. 45.6% HD). These differences are not statistically significant. CONCLUSION: Occurrence of sleep disorders and their characteristics in patients on CAPD is similar to that in hemodialyzed patients.

Vascular access monitoring evaluated from automated recirculation measurement.

Vascular access quality monitoring by means of vascular access blood flow (QVA) evaluated from automated thermodilutional measurement of recirculation with reverse needle position is described. This method provides significant advantages over conventional methods based on simple monitoring of pressures in the extracorporeal circuit and/or measurement of recirculation with normal needle position. AQVA evaluation protocol was developed and introduced into the system of primary nursing. The QVA values were found independent of the extracorporeal blood flow used during the recirculation measurement. QVA values from below 200 ml/min to over 2 l/min were seen. In general, lower values were found in diabetics compared to non-diabetics and in females compared to males. While blood flow below 600 ml/min is considered risky for synthetic vascular grafts, native AV-fistulae seem to remain stable and patent at a flow of 400 ml/min or even below. The method is able to detect erroneous needle placement in looped grafts, stenosis between needles, and is also well suited for effective evaluation of success/failure of interventions on access.

[Evaluation of vascular access for hemodialysis using combined measurement of recirculation in normal and inverted needle placement and determination of blood flow through the access]. / Hodnocení stavu cévního prístupu pro hemodialýzu kombinovaným merením recirkulace pri normálním a invertovaném zapojení jehel a stanovení prutoku krve prístupem.

The article describes novel method of vascular access quality assessment by means of combined measurement of recirculation with normal and inverse needles placement and calculation of vascular access blood flow from the recirculation data. Blood flow values seen in a large group of patients ranged from as low as 200 ml/min up to as high as 2 l/min. Females and diabetics exhibited lower values as compared to males and non-diabetics. The method enables to detect a number of anomalous sates which cannot be detected by conventional means based on monitoring of pressures or recirculation measurement at normal needles placement only (stenosis between both needles, uintentionally erroneous placement of needles in accesses with a loop). Assessment of access blood flow is suitable also for evaluation of interventions on the access, such as percutaneous transluminal angioplasty or surgical narrowing of anastomosis in case of too high blood flow.

Serum leptin levels in diabetic patients on hemodialysis: the relationship to parameters of diabetes metabolic control.

Leptin is a protein hormone produced predominantly by adipocytes that affects food intake and energy expenditure. Its serum levels are significantly higher in patients with chronic renal failure compared to healthy subjects. The aim of this study was to compare serum leptin levels in hemodialyzed patients with type II diabetes mellitus (n=26) with body content-matched hemodialyzed patients without diabetes (n=26) and to explore the relationship between parameters of the long term diabetes metabolic control and serum leptin levels. Serum leptin levels in diabetic patients did not significantly differ from those of non-diabetic patients (25.3+/-8.8 vs 25.7+/-8.7 ng/ml). Serum leptin levels in diabetic patients positively correlated with body fat content, body mass index and predialysis serum insulin levels. No significant relationship were observed between serum leptin levels and blood glucose, glycated hemoglobin, glycated protein, serum urea, creatinine, leukocyte count and total hemoglobin respectively. The multiple stepwise regression analysis revealed that body fat content together with body mass index accounted for 77.8% of variations in predialysis serum leptin levels, while insulin levels and the parameters of diabetes metabolic control had only slight prediction value for leptin concentrations. We conclude that serum leptin levels in hemodialysed patients with type III diabetes mellitus do not significantly differ from those of hemodialysed non-diabetic patients. The body fat content and body mass index are the strongest predictors of serum leptin levels, while parameters of long term diabetes metabolic control play probably only minor direct role in its regulation.

[Mushroom poisoning by Cortinarius orellanus]. / Intoxikace houbou Pavucinec plysový (Cortinarius orellanus).

The authors present the case-records of three patients who became intoxicated with the mushroom Cortinarius orellanus. This mushroom is very rare in this country and is not well known. The toxin orellanin is solely nephrotoxic and renal affection can lead to acute renal failure. A specific feature of this intoxication is the symptom-free period from 2 to 21 days, gastrointestinal complaints associated with back pain. The diagnosis can be established from a mycological analysis or by estimation of toxin in serum or tissue obtained by renal biopsy. The basis of treatment is disposal of the toxin by extracorporeal elimination methods: haemodialysis and haemoperfusion. As with the length of the interval between intoxication and onset of treatment the probability of irreversible renal affection increases, the medical community should take into consideration possible intoxication with this mushroom in the differential diagnosis of acute renal failure.

[The effect of erythropoietin on fibrinolysis in hemodialyzed patients]. / Vliv erytropoetinu na fibrinolýzu u hemodialyzovaných nemocných.

BACKGROUND: According to some data treatment with human recombinant erythropoietin (EPO) in dialyzed patients leads to a more frequent occurrence of thromboses. One of the possible causes could be reduced fibrinolysis. The objective of the present study was to assess the effect of EPO in dialyzed patients on two key enzymes of fibrinolysis, i.e. the tissue activator of plasminogen (t-PA) and the inhibitor of the plasminogen activator (PAI-1). METHODS AND RESULTS: In eight patients dialyzed for prolonged periods examined under otherwise equal conditions before EPO treatment (haematocrit 22.9%--median value) and after 9.5 weeks of EPO treatment (Recormon, s.c.) when a haematocrit of 30% was achieved, activities (chromogenic substrates) and antigens (ELISA of t-PA and PAI) were assessed. All examinations were made before and after venous occlusion. Between examinations made before treatment and during EPO treatment no significant difference was found in the t-Pa activities assessed before venous occlusion (before EPO 0.9 IU/ml--during EPO 0.6, not significant Wilcoxon's paired test) nor after venous occlusion (3.2-3.8, n.s.). PAI activities before venous occlusion (10.9 U/ml-18.3, n.s.) and after venous occlusion (9.7-11.5, n.s.) did not differ significantly either, when comparing values before and in the course of EPO treatment. Similarly as in the case of activities in antigens t-PA and PAI no difference was found before and during EPO. CONCLUSIONS: No effect of EPO on the investigated indicators of fibrinolysis was found. The results of the presented investigation are at variance with the idea that EPO reduces fibrinolysis in dialyzed patients and thus contributes to the development of thrombotic complications.

[Determination of peritoneal permeability in chronic peritoneal dialysis using the peritoneal equilibration test]. / Stanovení propustnosti peritonea pri chronické peritoneální dialýze peritoneálním ekvilibracním testem.

BACKGROUND: The success of chronic peritoneal dialysis depends among others on the extent of its function as a semipermeable membrane. This so-called functional characteristic can be assessed by several procedures, e.g. by using the so-called peritoneal equilibration test. The objective of the author's investigation was to assemble experience with the method, and based on the results, elaborate an individual therapeutic plan. METHODS AND RESULTS: In 17 patients (8 men, 9 women, mean age when chronic peritoneal dialysis was started 58.4 +/- 11.8 years) the functional capacity of the peritoneum was evaluated using the peritoneal equilibration test (PET). The principle of the test is assessment of the D/P ratio for creatinine and D/Do for glucose (D = concentration of the substance in the dialysate, p = blood concentration of the substance, Do = glucose concentration in the dialysis solution at the time of onset of the test) during four-hour dialysis with 2000 ml solution with a glucose concentration of 2.27% (127 mmol/l). The standardized procedure of the peritoneal equilibration test (12) was modified as regards the calculation of the D/Do ratio: this change simplifies the manipulation with the outlet dialysate and does not affect the result of the test. A total of 22 examinations were made. Based on the results, four patients were included in category H (high peritoneal permeability), 11 into category HA (high average peritoneal permeability) and 2 into category LA (low average permeability). The patients with a higher peritoneal permeability had a lower serum protein concentration (r = -0.63, p < 0.001), and the proteinaemia correlated indirectly with protein losses into the dialysate (r = -0.54, p < 0.01). Intermittent treatment which was prescribed to patients with a high average peritoneal permeability could reduce the total protein losses into the dialysate. CONCLUSIONS: The peritoneal equilibration test is an available method which makes it possible to evaluate the functional properties of the peritoneum.

[Hypofibrinolysis after venous occlusion in patients treated with long-term hemodialysis]. / Hypofibrinolýza po zilní okluzi u nemocných lécených dlouhodobou hemodialýzou.

BACKGROUND: Haemodialysis patients with chronic renal failure suffer not only from thromboses of the vascular access but frequently also from atherosclerosis with thrombotic complications. Knowledge of the etiopathogenesis of thrombotic complications in haemodialysis patients are incomplete. The aim of the present study was to evaluate fibrinolysis at the level of plasminogen activation under conditions of a dynamic test, using methods which reflect sensitively and specifically the activity of the tissue-type plasminogen activator (t-PA) and the activity of the inhibitor of the tissue-type plasminogen activator (PAI-1). METHODS AND RESULTS: The group of examined subjects was formed by 16 patients (9 men and 7 women, mean age 42 years, range 26-63) who suffered from chronic renal failure (causes: 9x chronic glomerulonephritis, 6x interstitial nephritis, 1x polycystic kidneys) treated by long-term haemodialysis on average for 52 (20-110) months; the control group of 11 healthy volunteers was very close as regards age distribution. t-PA and PAI-1 were examined after stimulation by venous occlusion (VO). In healthy subjects VO significantly raises the t-PA activity (first value before, second after VO: t-PA 0.81-2.19 IU/ml, p < 0.01), specific t-PA activity (0.19-0.31 IU/ng, p < 0.05) and t-PA/PAI (0.06-0.24 IU/U, p < 0.01, decreases PAI activity (11.80-10.98 U/ml, p < 0.05) and specific PAI activity (0.52-0.40 U/ng, p < 0.01). In the group of haemodialysis patients VO did not change significantly the t-PA activity (p = NS), the specific t-PA activity (p = NS), nor the ratio of t-PA/PAI (p = NS); the PAI declined significantly (13.78-10.65 U/ml, p < 0.05), similarly as the specific PAI activity (0.97-0.65 U/ng, p < 0.01). From comparison of the results of fibrinolysis from healthy and dialysis subjects ensues that the response to VO in dialysis patients differs from that in healthy subjects. CONCLUSIONS: Dialysis patients have impaired fibrinolysis manifested by a lacking rise of activity of the plasminogen tissue activator after stimulation by venous occlusion. The small rise of t-PA activity after venous occlusion can contribute to the development of thrombotic complications in haemodialyzed patients.