Effects of Citrate Acid Concentrate on Hemodialysis Adequacy, Reuse, and Quality of Life: A Prospective Randomized Crossover Trial.

We conducted a randomized crossover trial to identify whether the use of citrate dialysate (CD) for bicarbonate hemodialysis is beneficial compared to regular acetate dialysate (AD) in terms of adequacy, reuse, and quality of life. Thirty-two stable end-stage renal disease patients on twice-weekly maintenance hemodialysis were randomly assigned to CD or AD fluid in a single-blinded randomized prospective crossover trial of 1-year duration. The primary outcomes studied were the impact of CD in comparison with AD on hemodialysis adequacy, reuse of dialyzer, and quality of life. Secondary outcomes studied were the effect on intradialytic hypotension, acidosis correction, and episodes of symptomatic hypocalcemia. A total number of 28 patients underwent a total of 1456 sessions of hemodialysis with CD over 6 months and 1456 sessions with AD over 6 months. There was a significant increase in dialyzer reuse with the use of CD (P = 0.02). There was no difference in dialyzer adequacy as measured by Single pool Kt/V (spKt/V) (P = 0.840) and urea reduction ratio (%) (P = 0.90). Quality of life did not differ between the two groups. No statistically significant difference was observed in predialysis arterial pH (P = 0.23) serum bicarbonate (0.17) and calcium change (P = 0.16). CD is safe and equally effective as compared to AD. It significantly improves the reuse of dialyzer but it does not offer any added advantage in terms of improvement in hemodialysis adequacy and quality of care.

Angioplasty and stenting of arterial stenosis affecting renal transplant function.

PURPOSE: To evaluate the efficacy of percutaneous angioplasty and stenting in cases of artery stenosis of the transplanted kidney or proximal iliac artery stenosis causing transplant dysfunction and/or increase of the arterial blood pressure. MATERIALS AND METHODS: Between January 1999 and June 2007, we evaluated 24 patients who had undergone renal transplantation and subsequently were diagnosed with refractory hypertension and transplant dysfunction for signs of possible renal transplant artery stenosis. Color Doppler ultrasonography and magnetic resonance angiography preceded the intrarterial angiographic investigation, with false-negative results in 18.2% and 13.6% of patients, respectively. In 2 of the 24 patients, angiography did not reveal arterial stenosis affecting the transplanted kidney. Two patients had severe ipsilateral iliac artery stenosis and the remaining 20 had transplant artery stenosis. Successful angioplasty and stenting were performed in these 22 patients. RESULTS: The method was technically feasible in 100%. The procedure-related morbidity was 0%. During the follow-up period (range: 3 to 104 months), two patients died with normal transplant function, two suffered transplant failure, and the remaining 18 still have normal transplant function and easily controlled hypertension. CONCLUSION: Percutaneous angioplasty and stenting in cases of arterial stenosis affecting the renal transplant function are safe and effective procedures. Even more, the strong clinical suspicion must lead to angiographic investigation regardless of the results of other imaging approaches.

Diagnosis of herpes simplex virus-1 keratitis using Giemsa stain, immunofluorescence assay, and polymerase chain reaction assay on corneal scrapings.

AIMS: To evaluate three tests used routinely for the diagnosis of herpes simplex virus (HSV) keratitis. METHODS: Corneal scrapings from 28 patients with clinically typical dendritic corneal ulcer suggestive of HSV keratitis, and 30 patients with clinically non-viral corneal ulcers, were tested by (i) Giemsa stain for multinucleated giant cells, (ii) immunofluorescence assay (IFA) for HSV-1 antigen, and (iii) polymerase chain reaction (PCR) for HSV-1 DNA, by investigators masked to clinical diagnosis. The control subjects were also investigated by smears and cultures for bacteria, fungus, and Acanthamoeba. RESULTS: The specificity and positive predictive values of all three tests for the diagnosis of HSV keratitis were between 95-100%. The sensitivity of IFA and PCR was 78.6% and 81.2%, respectively, and the difference was not significant; however, their sensitivity and negative predictive value were significantly higher than Giemsa stain. CONCLUSIONS: While a combination of IFA and PCR constitute the choice of tests in clinically suspected cases of HSV keratitis, multinucleated giant cells in Giemsa stain can pre-empt testing by IFA and PCR in otherwise atypical cases of HSV keratitis.

Middle-ear myoclonus.

Tinnitus produced by repetitive contraction of the middle-ear muscles is a rare condition. We present an interesting case of bilateral middle-ear myoclonus causing incapacitating tinnitus in a patient with multiple sclerosis. Otological examination demonstrated rhythmic involuntary movement of the tympanic membrane. These movements correlated with a rhythmic 'rushing wind' noise perceived by the patient. Oropharyngeal examination showed no evidence of palatal myoclonus. Impedance audiometry confirmed rhythmic change in the middle-ear volume. Medical management was unsuccessful. The patient's tinnitus was subsequently cured with bilateral sectioning of the tensor tympani and stapedial tendons.