Survival rates of 2,728 patients with end-stage renal disease.

This multicenter regional study analyzes survival of a large group of patients who began chronic dialysis or received their first renal transplant during the 5 1/2-year period that ended in June 1983. Survival was determined from the onset of renal replacement therapy, irrespective of changes in treatment modality. Univariate life-table analysis was used to examine more than 35 risk factors. Age of patients at entry into the therapeutic program significantly affected survival. General survival rates were lower for patients with diabetes than for nondiabetics, irrespective of treatment modality, with the exception of those older than 60 years of age. Five-year graft survival was lower for diabetics than for nondiabetics in all age groups, irrespective of source. Patients with systemic lupus erythematosus, focal glomerulosclerosis, or glomerulonephritis had the highest survival rates, whereas those with primary renal malignant lesions, primary hypertensive disease, or diabetes mellitus as the cause of renal failure had the lowest. Concurrent morbid conditions that adversely affected survival included arteriosclerotic heart disease, peripheral vascular disease, noncutaneous malignant lesions, chronic pulmonary disease, and multiple coexisting morbid conditions. Although the objective of this study was to analyze survival for single patient characteristics, irrespective of treatment modality, analyses of survival rates by treatment modality for a control group indicated that minimal differences were evident by the third year among the four treatment groups: in-center hemodialysis, home hemodialysis, living related donor transplantation, and cadaver transplantation; however, recipients of cadaver grafts had lower survival rates than all other groups, even those maintained by in-center hemodialysis (P = 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)

Dialyzer ultrafiltration coefficients: comparison between in vitro and in vivo values.

This study describes a simple, convenient method for the in vivo measurement of the ultrafiltration coefficient of hemodialyzers. The method is based on a scheme of isolated ultrafiltration, i.e., ultrafiltration without dialysate flow through the dialyzer. Results with this method indicate that it is more accurate than the conventional bed scale technique. Measurements on three different dialyzers demonstrate that the in vivo ultrafiltration coefficient is only between 1% and 10% lower than the corresponding in vitro value. This is in contrast to the rule of thumb used by some manufacturers that in vivo coefficients are 30% lower than in vitro values. The deviation of the in vivo value from the in vitro one seems to be higher with higher dialyzer ultrafiltration coefficients. Based on these results, it is recommended that to estimate ultrafiltration rates in the clinical setting, the in vitro ultrafiltration coefficient be used, transmembrane pressures being corrected for the colloid osmotic pressure of plasma proteins.

Severe renal failure in multiple myeloma.

Twenty-four patients with multiple myeloma and renal failure severe enough to require dialysis were retrospectively analyzed. Most patients initially presented with renal failure and multiple myeloma was subsequently diagnosed. Intravenous pyelography precipitated irreversible renal failure in 2 patients. Absence of light chain disease and treatment with peritoneal dialysis were associated with increased recovery of renal fraction. The one year survival rate of myeloma patients on chronic dialysis was similar to the general myeloma population but was much worse than a group of age matched non-myeloma chronic dialysis patients. Survival rate was diminished in patients with elevated serum calcium levels.

Hepatitis B immune globulin: final report of a controlled, multicenter trial of efficacy in prevention of dialysis-associated hepatitis.

In a randomized, double-blind multicenter trial, 284 patients and 282 staff members of renal dialysis units who lacked detectable hepatitis B surface antigen (HBsAg) and antibody to HBsAg (anti-HBs) were randomly assigned to receive two 3-ml injections of immune serum globulin with high, intermediate, or low titers of anti-HBs four months apart. The incidence of infection with hepatitis B and of development of HBsAg was significantly lower in both patients and staff who received the high-titer material than in subjects who received the low-titer preparation eight but not 12 months after randomization (P less than 0.01 for patients and P less than 0.04 for staff, low-titer vs. high-titer at eight months). The high-titer hepatitis B immune globulin preparation did not appear to affect the severity of the cases of hepatitis that did occur, the proportion of subjects who developed persistent antigenemia, or the magnitude or timing of primary anti-HBs responses.

Irreversible acute renal failure in idiopathic nephrotic syndrome.

In five adult patients (aged 44 to 74 years) with idiopathic nephrotic syndrome, irreversible acute renal failure developed. Prior renal disease, associated systemic illness or occlusion of major renal vasculature was not present. All patients continued to excrete large amounts of proteins (8.6 to 15 g/24 hours) despite a minimal glomerular filtration rate and severe oliguria. One patient died after five months without recovering renal function. Four patients have required hemodialysis for a period of 12 to 58 months. The failure to recover renal function could not be explained by the light microscopic findings. It is suggested that the irreversibility of the renal failure may be related to either permanent alterations in renal blood flow or ultrastructural changes, or to both. Clinically, adult patients in whom acute renal failure develops during the course of idiopathic nephrotic syndrome seem to have a grave prognosis. Protracted oliguria or irreversible renal failure can be expected to occur.

Innovations in health care delivery for patients with end-stage renal disease (ESRD).

Increasing requirements for dialysis treatment, financial restraints, quality control and the need to increase the efficiency of professionals involved in the delivery and supervision of chronic dialysis services have stimulated the development of innovative techniques in dialysis health care delivery. The Regional Kidney Disease Program, located at Hennepin County Medical Center, has pioneered the development and application of several innovations to achieve more effective regional delivery of dialysis therapy. Three of the major innovations we have developed are described. They include a computerized automated medical information system, an unique multimedia modified programmed learning training program for allied health personnel and a dialysis nurse practitioner program. Several of these innovations have potential application as models for other developments in modern health care delivery.

Radiation-induced renal disease. A clinicopathologic study.

Radiation injury to the renal parenchyma is an unusual cause of renal insufficiency. Light, immunofluorescence and electron microscopic studies were performed on the renal tissue from two patients in whom renal insufficiency developed within a year after they received abdominal irradiation. The glomerular lesion in both patients was similar. Mild endothelial cell swelling and basement membrane splitting were noted consistently on light microscopy. The electron microscopic examination revealed marked subendothelial expansion with electron-lucent material associated with deposition of basement membrane-like material adjacent to the endothelial cells. In some capillary loops, the endothelial cell lining appeared to be completely lost. The pathogenesis of radiation-induced renal injury is still uncertain. It is speculated that local activation of the coagulation system with consequent thrombosis of the renal microvasculature may be extremely important.

A reassessment of the prognosis of diabetic patients treated by chronic hemodialysis (CHD).

Our early results in 25 diabetics treated by CHD prior to 1972, compared to results in a further 66 diabetics starting CHD since 1972, show an improvement in survival related to a reduction in deaths from myocardial infarction and sepsis. There has been a reduction in complications requiring hospital admission, related to a lower incidence of sepsis. Access survival has been markedly improved since the introduction of the bovine fistula.

Hepatitis B "immune" globulin: effectiveness in prevention of dialysis-associated hepatitis.

A randomized, double-blind, multicenter study of hepatitis prevention by immune serum globulin with high anti-HBs titer ("hepatitis B immune globulin") was carried out among 318 new patients and 296 staff members of renal dialysis units. Three milliliters of high titer globulin, repeated at four months, was compared with equal doses of intermediate or normal titer globulin. Among staff members, the cumulative percentages developing hepatitis or HBs Ag, or both, within eight months were 6.9, 11.7, and 11.1 in the high, intermediate, and normal titer groups respectively. The lower incidence associated with high titer globulin was not significant (P greater than 0.05). However, among the patients the respective percentages were 7.9, 21.3, and 23.1 and the lower incidence in the high titer globulin group was significant.