World apheresis association--world apheresis registry.

In 2002 WAA decided to start a world-wide apheresis registry to gain insight into the extent of treatment, adverse events, and to facilitate contacts among centers when treatment indications are rare and experience limited. Stem cell and other blood products collections intended for therapeutic application can also be entered. The WAA planned to use the French Registry. Its translation into English has not been accomplished and the fiscal obligations for that registry has not, as yet, been determined or considered and approved by the WAA Board. From Dec 2002 the proposed registry (a merged version of the French, Canadian and Swedish registries) can be immediately implemented. We now cordially invite all centers to join that registry. Please, also inform colleagues at other centers in your country to join. E-mail and address lists of colleagues in your country who have not registered will be welcomed. The site is at: Go to World Apheresis Registry; Login code to test the Registry is: al61tms. Then apply for a specific login code for your center. We welcome you to this registry for your input of data. You will not be charged any registration fee. The registry includes a randomization system that can be used for local or multi center studies (randomization by in-center basis allows you to make your own studies). It includes a formula that increases the chance to get a more even distribution between groups also for smaller sample sizes.

A case for cellulosic membrane hemodialyzers.

Regenerated cellulose membranes have been held responsible for a variety of ill effects in dialysis patients. Many of these effects (hypotension, changes in well-being) have not been supported by studies, while other effects were more likely due to ethylene oxide. The lower cost of dialyzers composed of these membranes may allow implementation of otherwise cost-prohibitive lifesaving therapy in some countries.

Use of clinical guidelines for treatment of anemia among hemodialysis patients.

Changing financial incentives have strongly influenced dosing patterns of recombinant human erythropoietin (rHuEPO) since its introduction in 1989. Although guidelines for prescribing rHuEPO exist, the extent to which they are adhered to is unknown. Using a retrospective cohort observational study design, the factors influencing the initial dosing of rHuEPO prescribed to 413 hemodialysis patients in 1994 were examined. Patient weight, the only recommended guideline, was not found to be a significant predictor of dosing of rHuEPO after controlling for selected patient demographic and clinical characteristics. The strongest predictor for initial rHuEPO dosing was hematocrit followed by White race (p < 0.05). Finally, each subsequent month was associated with a significantly larger initial rHuEPO dose, reflecting the general trend in increasing dose since 1991 (p < 0.001). In conclusion, despite the recent DOQI guidelines for treatment of anemia among persons with chronic renal failure, providers are not using patient weight as an independent criterion for determining dosing of rHuEPO.

Fatal cervical spondyloarthropathy in a hemodialysis patient with systemic deposition of beta2-microglobulin amyloid.

Destructive spondyloarthropathy is a serious complication in patients with end-stage renal disease. We report a case of fatal cervical spondyloarthropathy in a patient on hemodialysis who presented with severe pain in the cervical area. Magnetic resonance imaging (MRI) of the cervical spine showed a soft tissue mass at the cervico-occipital hinge with spinal cord compression and destructive lesions of the cervical vertebrae. The patient became quadriplegic during the MRI procedure and died a few days later. Postmortem examination showed deposition of beta2-microglobulin in the cervico-occipital hinge. A unique feature of this case was the documented presence of systemic beta2-microglobulin amyloid deposits involving the spleen that to our knowledge has not been reported previously. Clinical suspicion and early detection of lesions caused by dialysis-related amyloidosis (DRA) may help to prevent significant morbidity and mortality in long-term dialysis patients.

Filling hemodialysis catheters in the interdialytic period: heparin versus citrate versus polygeline: a prospective randomized study.

Heparin and saline are commonly used to fill hemodialysis central venous catheters to prevent their thrombosis during the interdialytic period. The purpose of this prospective clinical study was to evaluate whether replacing heparin with citrate or polygeline could ensure satisfactory catheter function without exposing patients to the risk of systemic heparinization. Thirty end-stage renal disease (ESRD) patients with subclavian or jugular single lumen catheters as temporary vascular access for hemodialysis were enrolled. After the insertion of the catheters, the patients were randomly assigned to one of the following three filling groups: Group A, heparin; Group B, citrate; Group C, polygeline. Before each dialysis, the filling solution was aspirated and clot volume, if present, was measured. The catheter usage time and the clot volume were 23 +/- 24 days and 0.052 +/- 0.035 ml in Group A, 51 +/- 36 days and 0.059 +/- 0.032 ml in Group B, and 32 +/- 10 days and 0.056 +/- 0.038 ml in Group C, respectively. Our results indicate that citrate or polygeline can replace heparin effectively as a filling solution for single lumen temporary hemodialysis catheters.

Hyperbaric oxygenation, plasma exchange, and hemodialysis for treatment of acute liver failure in a 3-year-old child.

A girl aged 3 years and 4 months weighing 16 kg was treated with plasma exchange (PE), hemodialysis (HD), and hyperbaric oxygenation (HBO) for acute hepatic failure and coma. She was given a total of 13 PEs, 13 HD sessions, and 9 HBO treatments over a period of 1 month. The initial 4 PEs were followed by HD sessions while the other 8 PE treatments were given simultaneously with HD. There was no renal failure; HD was instituted to improve ammonia elimination. In 1 HD session, 20% human albumin (370 ml) was used as the dialysate to enhance bilirubin elimination. Three volumes of plasma (2,000 ml) per PE were exchanged and replaced with fresh frozen plasma (FFP). The Bellco BL 791 plasmapheresis monitor and Gambro PF1000 and PF2000 plasma filters were used. Heparin was added to prevent clotting. A dual lumen pediatric HD catheter (7 Fr) placed percutaneously into the femoral vein was used as a blood access. The Fresenius 2008 C HD monitor and the Filtral 10 dialyzer were used for HD. PE and HD were instituted simultaneously to prevent the tetanic (hypocalcemic) cramps observed with 2 previous PEs due to citrate in the FFP. The extracorporeal circuit was primed with a mixture of concentrated red cells, human albumin, and saline solution and was discarded at the end of the procedure. The average blood flow rate in PE and/or HD circuits was 80 ml/min. During HBO, the girl breathed 100% oxygen at 2.5 atm for 90 min. Throughout the treatment, the patient was in good clinical, physical, and mental condition, but she was dependent on blood purification procedures. She was referred to a liver transplant center and successfully transplanted. The etiology of liver failure has not been clarified.

Clinical use of profiled hemodialysis.

The new population on dialysis today consists mainly of high risk patients (the elderly, diabetics, etc.) with high cardiovascular scores, and such vascular pathology is the most important predisposing factor for the occurrence of a frequent intradialytic clinical complication, vascular instability syndrome, which covers a range of clinical problems. Recently a new dialysis technique, profiled hemodialysis (PHD), has been set up and proposed for routine use. PHD consists of the clinical use of preestablished individual dialysis profiles aimed at antagonizing the changes in intradialytic plasma osmolarity by continuous modulation of dialysate sodium concentration throughout the whole extracorporeal session. In particular, PHD aims at reducing the fall of plasma osmolarity in the first half of the session (when it is higher) by reducing the sodium removal rate through increasing its dialysate concentration while taking into account the desired individual sodium balance to be reached at the end of the session. In this work, we report clinical experience with PHD compared to standard hemodialysis with constant sodium dialysate (SHD) in terms of its efficacy to maintain a more stable intradialytic blood volume (BV) and more stable hemodynamics. The PHD used in this work has been implemented by a mathematical model for computing the individual dialysate sodium profile which we have recently validated (Ursino M, Coli L, La Manna G, Grilli Cicilioni M, Dalmastri V, Guidicissi A, Masotti P, Avanzolini G, Stefani S, Bonomini V. A simple mathematical model of intradialytic sodium kinetics: "in vivo" validation during hemodialysis with constant or variable sodium. Int J Artif Organs 1996;19:393-403.). Eleven uremic patients affected by hypotension at the beginning of dialysis treatment were studied. Each patient first underwent an SHD treatment and 1 week later a PHD treatment. The 2 extracorporeal sessions (one on SHD and the other on PHD) were performed in each individual patient under identical operative conditions including the sodium mass removal by the end of the session and the ultrafiltration rate. The crit line and Doppler echocardiography were used to determine BV, cardiac output (CO), and stroke volume (SV) throughout the sessions. The mean blood pressure (MBP) and heart rate (HR) were simultaneously monitored. PHD was associated with a more stable intradialytic BV and more stable hemodynamics compared to SHD. The higher stability of BV and cardiac function (in terms of SV and CO maintenance) which was obtained above all in the first half of the PHD session was associated with a higher stability of the MBP and the HR. This resulted in an enhancement in cardiovascular tolerance to ultrafiltration throughout the session in all tested patients. In contrast, SHD in the same patients was characterized by early significant changes in BV and cardiovascular parameters resulting in a significant decrease of the MBP and a significant increase of the HR throughout the session and also 1 h after the end of dialysis. Our results indicate that PHD may represent an efficient approach for the treatment of patients suffering from intradialytic vascular instability. If long-term clinical practice confirms the efficacy of PHD in controlling dialysis intolerance symptoms, it will have great scope as a routine procedure.

Geographic factors and plasma selenium in uremia and dialysis.

The importance of selenium (Se) as an essential trace element for man has been increasingly recognized. Blood Se levels in chronic uremic patients are frequently reported to be lower than in controls. Definitive determination of the Se status in uremic patients, however, is hampered by the wide range of blood Se content in humans from different parts of the world. The present study was designed to assess and compare the Se status in two European populations from Rostock (Germany) and Chieti (Italy). Plasma Se levels were evaluated in healthy controls, chronic renal failure nondialyzed patients (CRF) and hemodialysis patients (HD). All Se determinations were performed in a single laboratory. The Se concentration was significantly higher (p < 0.005) in Italian healthy controls than in German healthy controls. In contrast, Se levels were similar in both CRF and HD patients from both cities. In both countries, the Se concentration in CRF and HD patients was significantly lower (p < 0.001) than in their corresponding controls, but no difference between CRF and HD was found. CRF and HD patients from the two countries showed quite similar laboratory and anthropometric data. In CRF patients in Chieti, a significant (p < 0.05) negative correlation between plasma Se and serum creatinine was found. In both HD groups, the length of time on HD and type of membrane dialyzer used did not influence the Se status. A significant positive correlation (p < 0.01) between Se levels and the protein catabolic rate was found in both HD groups. Uremia seems to be a strong factor which overrules the difference in Se levels that is present in healthy adults from different European countries. Uremia in itself may influence and level the Se concentration in patients with geographic diversity.

[Changes in the picture of chronic diseases on long-term hemodialysis treatment]. / Izmeneniia v kartine khronicheskikh zabolevanii pri dlitel'nom lechenii gemodializom.

New data published in the literature provided evidence for appearance of an unknown variant of amyloidosis recorded in patients with a 5-15-year history of hemodialysis. Such amyloidosis may result from high blood levels of beta-2-microglobulin unremovable at standard hemodialysis. Even highly permeable membranes which permit beta-2-microglobulin penetration fail to produce negative balance of this metabolite as the procedure stimulates leukocyte activity and, consequently, beta-2-microglobulin production. In spite of the fact that contact of the blood with synthetic materials during hemodialysis is not longer than 3-5 hours, blood elements and endothelial cell metabolism, homeostasis undergo serious alterations. These effects of biocompatibility provoke the condition of enhanced activation similar to chronic inflammation. Thus, we deal with a new phenomenon in the field of hemodialysis. The efforts of investigators should be aimed at studying long-term adaptation of the body which rings atypical picture of chronic diseases.

Leukocyte adhesion molecules as biocompatibility markers for hemodialysis membranes.

Comparative flow cytometric measurement was used to evaluate the significance of leukocyte adhesion molecule (LAM) activity changes during hemodialysis (HD) with different cellulosic and non cellulosic membranes. Six hemodialysis patients (men) who were in a maintenance program for more than 6 months were treated consecutively with five different dialyzers (cuprophan, hemophan, 2 types of cellulose acetate, and polysulfone). During each study HD, blood was sampled from the arterial line at 0, 15, and 60 min and from the venous port at 3 min to harvest leukocytes immediately after the first cell-membrane contact. After whole blood lysis preparation, leukocytes were incubated with fluorescent antibodies to label LAM CD 11A/18 (LFA-1), CD 11B/18 (Mac-1), CD 11C/18 (p150/95), and CD 54 (ICAM-1) (Becton-Dickinson, San Jose, CA). Data were acquired for the granulocyte, monocyte, and lymphocyte population based on forward and 90 degrees scatter light measurements. Accuracy of gating was verified by CD 14/45 staining for all samples. Baseline integrin expression for the selected populations before biomaterial contact was found to be heterogeneous for different patients, but underwent changes for the same patient during HD treatment. The fluorescent intensity corresponding to specific integrins was characterized by different patterns of up/down regulation with maximal deviations occurring at 3 min. Fluorescent intensity of the granulocyte and monocyte populations sampled at 15 min was 40-50% lower as compared with those sampled immediately after the first biomaterial contact. Based on the basal fluorescence levels and values recorded after the first biomaterial contact and those at 15 min, two coefficients were generated to compare membrane properties.