Membrane therapeutic plasma exchange with and without heparin anticoagulation.

BACKGROUND: Administration of an anticoagulant during therapeutic plasma exchange (TPE) is necessary to avoid circuit clotting and impaired treatment effectiveness. Citrate is the preferred anticoagulant for apheresis worldwide, and unfractionated heparin (UH) is the second most preferred, yet there are only a few published studies regarding the use of UH during TPE. There are even fewer studies regarding the use of low-molecular-weight heparin (LMWH) and TPE performed without anticoagulation. MATERIALS AND METHODS: We retrospectively analyzed the database of the Department of Nephrology at Zagreb University Hospital Center from 1982 to 2014 to test the safety of various heparin anticoagulation in TPE. We grouped procedures according to anticoagulation type (UH, LMWH, and no anticoagulation) and compared differences in the use of anticoagulants during our study period, patient populations, replacement fluids, and complications. RESULTS: Complications were recorded during 11.1% of the 9,501 procedures. The incidence of any recorded complication was significantly higher in the LMWH group (21.2%) compared to the group with no anticoagulation (16.3%) and the UH group (9.5%) (P < 0.001). Similarly, the blood clotting in the extracorporeal circuit was most common in the LMWH group (LMWH, 12.0%; no anticoagulation, 6.3%; UH, 2.4%; P < 0.001). Incidents of bleeding complications were very low and occurred during or after 13 TPE sessions (0.1% of all procedures). CONCLUSIONS: Our findings indicate that TPE procedures can be conducted safely with UH and, when necessary, without anticoagulation. The use of LMWH was associated with more complications when compared with use of UH and to TPE done without anticoagulation. Further studies are necessary to study its use during TPE procedures.

The Different Impacts on the Long-Term Survival of Tunneled Internal Jugular Hemodialysis Catheters Based on Tip Position and Laterality.

BACKGROUND/AIMS: The aim of this study was to examine the impact of different catheter tip positions on the life of the catheter, dysfunction, infection, and quality of hemodialysis and possible differences between the access site laterality in jugular-tunneled hemodialysis catheters. METHODS: Catheters were evaluated for the following parameters: place of insertion, time of insertion, duration of use, and reason for removal. In all patients, the catheter tip position was checked using an X-ray. RESULTS: The mean duration of implanted catheters with the tip placed in the cavo-atrial junction and right atrium was significantly longer. There were no differences in catheter functionality at follow-up or complications based on catheter laterality for each catheter tip position. CONCLUSION: According to our results, the localization of the catheter tip in superior vena cava still remains the least preferable method. Our results showed that the main factor responsible for better catheter functionality was not laterality but the depth to which the catheter tip is inserted into the body.

Therapeutic Plasma Exchange-Does Age Matter? A Single-Center Study.

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique designed for the removal of substances with large molecular weight from the plasma. However, it is not commonly performed in children and the elderly because of concern of potential complications. The Department of Nephrology at Zagreb University Hospital Centre's database (8335 procedures, 981 patients) was retrospectively analyzed from 1982 to 2011 to record indications, applications, and safety of TPE use in children (≤18 years), adults (>18 and <65 years), and elderly patients (≥65 years). Indications, blood access, replacement fluid, and anticoagulation during TPE differed among age groups. Significantly more complications were recorded in the youngest and eldest patients compared with the adults (12.2% and 12.7% vs. 9.9%, respectively), while the severity of complications did not differ significantly among the age groups. Our results indicate that TPE may be performed relatively safely in all age groups when the patients' differences are acknowledged prior to prescribing the procedure.

[Temporary and permanent central venous catheters for hemodialysis]. / Primjena trajnih i privremenih centralnih venskih katetera za hemodijalizu.

The usage of temporary and permanent dialysis catheters for hemodialysis vascular access has been on continual increase. The reason for this increase is aging population on hemodialysis with blood vessels inappropriate for arteriovenous fistula creation. Complications may occur during catheter insertion as well as in the already inserted catheters, e.g., thrombosis and infections. The severity of complications is determined by experience of the operator as well as the quality and localization of blood vessels. Monitoring of dialysis catheter function, choice of the site of catheter insertion and methods of salvaging catheters from thrombosis and treating catheter-related local and systemic infections are described in this paper. Constant evaluation, proper care and hygiene of dialysis catheters are highly recommended.

Changes in indications for therapeutic plasma exchange over the last 27 years in Croatia.

Results from recent trials and advances in the fields of medicine and technology have altered the spectrum of indications for use of therapeutic plasma exchange. In this article we analyze changes in indications for therapeutic plasma exchange that have occurred during 27 years in Croatia. We retrospectively analyzed the database of the Department of Dialysis at the University Hospital Center, Zagreb (678 patients; 6596 procedures), for changes in indications for therapeutic plasma exchange from 1982 to 2008. The number of patients and procedures increased several-fold during the follow-up period, but the mean number of procedures per patient per year did not change significantly. Neurological disorders constituted the largest group of indications for therapeutic plasma exchange (66% of all indications), followed by hematological (16%), nephrological (6%), and rheumatological disorders (6%). Myasthenia gravis was the most frequent indication during the entire follow-up period, but the pattern of other indications changed, with the most frequent at the beginning of follow-up becoming the least frequent at the end of follow-up. The five most frequent indications represented 62.2% of all indications at the beginning of follow-up, whereas during the 1990s, this percentage increased to more than 90% of all indications. Since the year 2000, the spectrum of indications has grown, and the percentage of the five most common indications decreased to 79.9%. Despite changes in indications for therapeutic plasma exchange, this procedure is still applicable in various medical fields, either traditional or newly created with the development of medicine and technology.

[The role of arterial hypertension in developement of chronic renal failure]. / Uloga arterijske hipertenzije u nastanku kronicnog zatajenja bubrega.

The link between the kidney and hypertension has been considered a villain-victim relationship because of the potential two-way causality between high blood pressure (BP) and chronic kidney disease (CKD). Arterial hypertension (AH) per se, but also together with diabetes mellitus, is the most important cause of CKD and end-stage renal disease (ESRD) in the developed world. Pathophysiologicaly, the increment in systemic BP leads to the rise in glomerular pressure. Glomerular hypertension results in glomerular capillary wall stretch, endothelial damage and a rise in protein glomerular filtration. These processes, in turn, cause changes of mesangial and proximal tubular cells, ultimately resulting in the replacement of functional by non-functional connective tissue and the development of fibrosis. One of the most important factors in the progression of CKD is activation of the renin-angiotensin system (RAS). Its effect is not only elevated BP, but also the promotion of cell proliferation, inflammation and matrix accumulation. The terms that clinicians use to identify renal damage associated with hypertension are nephrosclerosis, benign nephrosclerosis, hypertensive kidney disease, or nephroangiosclerosis. Many studies, first in experimental animals and later in humans, have shown that the lowering of BP (and proteinuria) is associated with a slower progression of CKD. It seems that angiotensin-converting enzyme inhibitors (ACEI's) are more renoprotective than other antihypertensives (the protection beyond the antihypertensive effect), although some studies have also confirmed a comparatively beneficial effect of non-dihydropiridine calcium channel blockers (CCBs) and angiotensin II receptor blockers (ARBs). Moreover, it seems that a combination of antihypertensives (e.g. ACEI, CCB, and ARB) has a more effective action than either of the drugs alone. The effects depend first on the degree of BP reduction. The strict BP control has been considered the basis of therapy for slowing renal deterioration.

[Thrombotic microangiopathy after kidney transplantation]. / Tromboticka mikroangiopatija nakon transplantacije bubrega.

The term thrombotic microangiopathy (TMA) encompasses different disturbances that are usually classified as thrombotic thrombocytopenic purpura (TTP) or haemolytic-uraemic syndrome (HUS). These syndromes are characterized by thrombocytopenia, microangipathic haemolytic anaemia, neurological deficits and renal failure. Etiology of TMA include exotoxins, drug toxicity (cyclosporin, tacrolimus, ticlopidine, clopidogrel, mitomycin), but also familiar forms associated with deficiency of factor H (HUS) or vWF protease activity (TTP). TMA in renal transplant recipients may evolve de novo or may recur in patients who were diagnosed with TMA as the primary renal disease. We present a case of renal transplant recipient with ESRD of unknown etiology, who was diagnosed with TMA 3 years after transplantation. After discontinuation of cyclosporine, she was treated with therapeutic plasma exchange (TPE). Cytomegalovirus reactivation demanded discontinuation of the chronic program of TPE, what was followed by worsening of graft function and demand for dialysis one year after the diagnosis of TMA. Patients with TMA should be carefully followed-up after renal transplantation for the signs of disease recurrence. Withdrawal of precipitating factors is of outstanding importance. TPE is used to limit the endothelial damage and to limit the microangiopathic process. However, its efficacy is unclear. Our case demonstrates that TPE may improve graft survival, with the possibility of inducing opportunistic infections. International registries are needed to establish the guidelines for follow-up and treatment of renal transplant recipients with TMA.