Hemodynamic effects of peritoneovenous shunts in hemodialysis patients with ascites.

Ascites in hemodialysis patients has been reported in association with systemic diseases, such as cirrhosis or congestive heart failure, and as an idiopathic form. Regardless of the etiology, these patients often are refractory to treatment with intradialytic ultrafiltration because of recurrent hypotensive episodes. In this report we describe the hemodynamic effects of peritoneovenous shunts (PVSs) in three hemodialysis patients with ascites refractory to conventional treatment. One patient had idiopathic ascites and the other two had associated liver disease. Patients were monitored for lowest blood pressure, number of intradialytic hypotensive episodes, number of grams of albumin infused to treat hypotensive episodes, interdialytic weight gain, and hemodynamic stability (defined as the difference between the predialysis mean arterial pressure and the lowest intradialytic mean arterial pressure). In all three patients the hemodynamic parameters stabilized after PVS placement despite equal or greater ultrafiltration during dialysis (due to a significant increase in the lowest measured intradialytic blood pressure). The total number of hypotensive episodes decreased from 219 prior to PVS placement to zero after shunt placement. The need for albumin infusion during hemodialysis (for blood pressure support) decreased (significantly in two patients), as did the volume of ascites in all three patients. One patient required PVS replacement secondary to infection, which was the only complication. We believe that refractory ascites in end-stage renal disease patients can be successfully treated by placement of a PVS, which often results in relief of the ascites and significant improvement in intradialytic hemodynamic stability.

The incident patient cohort study design with uncontrolled dose. Substantial over-estimation of mortality as a function of peritoneal dialysis dose?

In the Canada-USA (CANUSA) Study, the dialysis dose was neither randomized nor held constant, was measured at 6 month intervals, and the relative risk of mortality (R) was found to correlate linearly to mean values of weekly peritoneal plus renal urea clearance normalized to volume, (KprT/ V)m, ranging from 1.5 to 2.3. A risk/dose (R/D) function was derived for continuous ambulatory peritoneal dialysis from kinetic criteria for dose equivalency in hemodialysis (HD) and peritoneal dialysis (PD) and the HD R/D function. This PD R/D function was nonlinear with breakpoint from steep to shallow slope at (KprT/V)ud = 2.00, where ud refers to uniform single doses in contrast to mean doses with wide variances on the mean. The predicted decrease in renal urea clearance KrT/V per 6 months of CANUSA follow-up was computed from serial measured KrT/V in the Randomized Dialysis Prescription and Clinical Outcomes Study and showed it to be 0.21 +/- 0.34. The CANUSA (KprT/V)m values were corrected for the distributed values of 3 months decrements in KrT/V, and the population mortality risk at each (KprT/V)m dose level reported in CANUSA was computed from summation of the product of the R/D curve and fractional distribution of (KprT/V)ud values. From these calculations, the authors conclude that maximum (KprT/V)ud level achieved in CANUSA was 2.00, and the study does not define R/D response above this level.

The use of tissue plasminogen activator to declot arteriovenous accesses in hemodialysis patients.

Thrombosis is the most common complication of arteriovenous (A-V) access, resulting in malfunction or total failure. We describe the first use of the thrombolytic agent tissue plasminogen activator (t-PA) to declot the A-V access in 15 hemodialysis patients (14 A-V grafts and one fistula). The t-PA was infused directly into the A-V access in 10-mg doses, at 2-hour intervals, to a maximum of 30 mg. As determined by angiography, t-PA infusion resulted in a dramatic decrease in clot volume in all cases and complete lysis, with return of bruit and thrill, in 10 patients. Eight of the 10 were able to be treated with hemodialysis via the A-V access the following day. In these patients, angiography demonstrated stenosis at the venous end of the A-V access in eight of nine A-V grafts (the one fistula did not have a venous stenosis). Three patients reclotted within 24 hours, and one had bleeding 5 days later after dialysis requiring compression of the A-V access, which resulted in reclotting. Five patients had functioning A-V grafts 1 to 15 months after t-PA treatment (with angioplasty of the venous stenosis required in three of these), and one patient was lost to follow-up. All five patients in whom t-PA infusion was only partially successful had venous stenosis. One patient died before surgery (unrelated to t-PA). Thus, venous stenosis was present in 13 of 15 A-V accesses studied, the highest incidence reported to date.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaphylactoid reactions in hemodialysis patients treated with the AN69 dialyzer.

During an 11 week period (May to July, 1990), we observed six anaphylactoid reactions (AR) in six different hemodialysis patients occurring at the onset of treatment with a new AN69 hollow-fiber dialyzer. Four patients required cardiopulmonary resuscitation and one of these expired. Four patients were also receiving an angiotensin converting enzyme (ACE) inhibitor while the other two were not on medication known to affect the renin-angiotensin system. Only patients treated with AN69 dialyzers were affected. A review of the literature indicated that out of 1087 patients reported, 72 patients were on the combination of an AN69 dialyzer and ACE inhibitor therapy and 41 (57%) demonstrated AR. Only two patients (0.4%; both from our series) treated with an AN69 dialyzer without ACE inhibitor therapy developed AR. AR did not occur in patients treated with a variety of other dialyzers during this 11 week period, with or without ACE inhibition. Possible causes for AR are discussed and include: (1.) blood-AN69 membrane interaction leading to the production of bradykinin and other vasodilators, the breakdown of which may be delayed by the presence of ACE inhibitors; (2.) hypersensitivity to ethylene oxide; (3.) passage of bacterial products from dialysate to blood; (4.) changes in membrane manufacturing specifications. Recommendations are proposed for the prevention and treatment of AR.

The incidence and epidemiology of human immunodeficiency virus infection in 320 patients treated in an inner-city hemodialysis center.

From January 1, 1986 through June 30, 1989, 320 maintenance hemodialysis patients treated at The Brookdale Hospital Medical Center were tested for the presence of antibody to the human immunodeficiency virus (HIV) using the enzyme-linked immunosorbent assay (ELISA) and Western blot assays. Thirty-nine patients (12%) tested positive for HIV antibody (HIV+) with both the ELISA and Western blot, 24 (62%) of whom were known intravenous drug abusers (IVDA). Of the remaining non-IVDA patients, unanticipated HIV+ results were found in 10 (25%). Thirty-four (87%) of the 39 HIV+ patients were asymptomatic at the start of the study, while two had acquired immunodeficiency syndrome (AIDS) and three others, AIDS-related complex (ARC). Four patients subsequently developed AIDS 20 +/- 4.9 weeks (range, 12 to 32) after testing, three of whom initially had ARC. One patient developed ARC 7 months after testing. Sixteen HIV+ patients died, including five of the six with AIDS, one with ARC, and two others from Mycobacterium tuberculosis. The eight other deaths were from causes unrelated to HIV disease and occurred 12 +/- 2.3 months (range, 1 to 24) after testing. Two HIV+ patients were lost to follow-up. Twenty-one HIV+ patients (54%) are alive and 20 (51%) asymptomatic 15 +/- 2.4 months (range, 1 to 42) after HIV testing. Thus, despite HIV positivity, 28 patients (72%) had an asymptomatic period lasting 14 +/- 1.9 months (range, 1 to 42). Seventy-two of the 281 HIV-negative (HIV-) patients died during the study. None of the HIV- patients manifested ARC or AIDS, confirming that there was no false-negative HIV test.(ABSTRACT TRUNCATED AT 250 WORDS)

Sorbent recycling of ultrafiltrate in man--a 45-week crossover study.

Chronic hemofiltration as a treatment for end stage renal disease has been shown to have several advantages over standard hemodialysis including: improvement in well being, increased strength, decrease in hypotensive episodes during treatment and decrease in the degree of hypertension between treatments. The major drawback of hemofiltration as practiced today is the need to replace the large quantities of ultrafiltrate formed with sterile, pyrogen-free replacement solution. We have solved this problem by passing the ultrafiltrate through a sterile REDY Sorbent Cartridge to remove urea, creatinine and "uremic toxins" prior to returning it to the patient via a closed system. We have called this system SRUF for Sorbent Recycling of Ultrafiltrate and have carried out an A-B-A, B-A-B cross-over study (15 week periods) comparing SRUF with standard hemodialysis in 8 ESRD patients previously treated with hemodialysis. Clinical and laboratory parameters measured included: hemoglobin, hematocrit, blood transfusion requirement, electrolytes, aluminum levels, liver function tests, enzymes, lipids, glucose, cardiac function studies, weight, blood pressure, urea generation, urea space, incidence of hypotension and muscle cramps, and questionnaires on well being. The results of these studies can be summarized as follows: SRUF can be performed by the hemodialysis staff as a routine, outpatient procedure for ESRD patients utilizing the machinery and tubing developed as part of this protocol. SRUF, when used as a chronic treatment for ESRD patients, has no deleterious effects and is associated with many of the same benefits ascribed to routine hemofiltration, including improvement in well being, decrease in cramping and decrease in symptomatic hypotension during treatment as compared to hemodialysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute nonlymphocytic leukemia following treatment of malignant glioma. Report of two cases.

Two patients with malignant brain tumors who developed acute nonlymphocytic leukemia after treatment with radiation and chemotherapy are described. Both patients survived more than 2 years after diagnosis of the brain tumor. Survival following the diagnosis of leukemia was short, and both patients died of hemorrhage secondary to thrombocytopenia. A review of the literature reveals that leukemia after combined-modality treatment of malignant brain tumors is rare. A prolonged survival period from diagnosis of the primary tumor, treatment with nitrosoureas and radiation, plus the development of a preleukemic myelodysplastic syndrome are all important features of therapy-related nonlymphocytic leukemia.

Retroperitoneal fibrosis presenting as spontaneously reversible renal failure.

Three patients are reported who presented with severe oliguric renal failure due to retroperitoneal fibrosis and obstructive uropathy in whom spontaneous diuresis and recovery of renal function took place, a course resembling acute tubular necrosis. There were, however, several clinical and laboratory findings that provided clues to the presence of obstructive uropathy. Two of the three patients had low back or abdominal pain. All three patients presented with anemia and significant hyperkalemic, hyperchloremic metabolic acidosis with only a small increase in anion gap and two of the patients had an inappropriately high urine pH. Neither tubular cell casts nor pigmented granular casts were identified in the urine in any of the patients. In all three patients the urine output increased from oliguric levels to 1400 - 2000 ml/day within 1 day associated with rapidly improving renal function. This report demonstrates and reinforces the need to rule out obstruction in all patients with renal failure of unknown etiology and adds retroperitoneal fibrosis to the list of diseases associated with renal failure and spontaneous recovery.

Infusion intravenous pyelography and renal function. Effect of hypertonic mannitol in patients with chronic renal insufficiency.

In a previous prospective study, we reported that infusion intravenous pyelography (IVP) in 40 patients with chronic renal insufficiency resulted in acute renal failure (ARF) in 28 patients (70%). In an attempt to prevent this complication, we have evaluated the conditions of another group of 37 patients with chronic renal insufficiency treated in a similar manner except that each patient received 250 mL of 20% mannitol 60 minutes after infusion of the IVP dye (diatrizoate sodium, 300 mL of a 30% solution). These patients were similar to those in the previous study with regard to age, sex, renal function, and incidence of diabetes. Only eight (22%) of the 37 patients had ARF develop after infusion IVP in this study. This incidence was significantly lower compared with 70% in the previous study. We conclude that administration of hypertonic mannitol 60 minutes after administration of the radiographic contrast material is highly effective in preventing ARF after infusion IVP in patients with chronic renal insufficiency.

Pulmonary calcification in hemodialyzed patients detected by technetium-99m diphosphonate scanning.

Metastatic pulmonary calcification, a well-known complication in patients with chronic disease, has been demonstrated postmortem in patients with a negative chest X-ray. Recently, scintigrams with bone-seeking radionuclides have been used to detect such subclinical pulmonary calcium deposits. We describe 23 patients on maintenance hemodialysis with no evidence of pulmonary calcification on chest X-ray who were prospectively studied by lung scanning with a bone-seeking radionuclide and pulmonary function testing. Of the 23 patients, 14 (61%) had a positive technetium-99m diphosphonate (99mTc-DP) scan (group 1). These patients were on dialysis 38 +/- 5 months compared with 12 +/- 4 months in 9 patients with a negative scan (group 2) (P less than 0.01). Age, sex, blood pressure, hematocrit, serum calcium, phosphorous, bicarbonate, magnesium, and calcium X phosphorus product, as well as parathyroid hormone level did not differ between the two groups. Of 10 group-1 patients tested, 7 had abnormal pulmonary diffusion capacity compared with non in 5 group-2 patients tested (P = 0.014). Histologic examination of the lung in 1 group-1 patients who expired revealed calcification (amorphous on X-ray diffraction), whereas none was found in 1 group-2 patients autopsied. These observations suggest that in patients on maintenance hemodialysis, pulmonary scanning with 99mTc-DP is a sensitive method for detecting pulmonary metastatic calcification, which may be associated with an abnormality in pulmonary diffusion capacity.

Uterine and renal renin release after ligation of the uterine arteries in the pregnant rabbit.

Uteroplacental ischemia is associated with uterine renin release in pregnant nephrectomized rabbits. In the present study, uterine and renal renin release after uteroplacental ischemia were investigated in 10 Australian white rabbits at 24 to 28 days' gestation. Pentobarbital was administered, and both uterine arteries were ligated close to their origins. Blood samples were taken for plasma renin activity (PRA) determinations from the femoral artery, uterine vein, and right renal vein before ligation and at 30 and 60 minutes after ligation. Mean arterial blood pressure (MAP) was monitored throughout. In five additional pregnant rabbits renal blood flow (RBF) was measured with an electromagnetic flowmeter. The preligation uterine vein-artery PRA difference was not significant (1.9 +/- 1.1 ng/ml/hr). Postligation uterine vein-artery PRA was 11.4 +/- 3.2 at 30 minutes and 6.6 +/- 1.9 ng/ml/hr at 90 minutes (p less than 0.02). Preligation renal vein-artery PRA was 32.3 +/- 10.5 ng/ml/hr (p less than 0.02) and did not change significantly after ligation. MAP remained stable and RBF was unchanged after uterine artery ligation. These observations confirm the finding that the kidney is the primary source of renin in the normal pregnant rabbit and demonstrate that following acute uteroplacental ischemia there is significant uterine renin release even when the kidneys are intact.

Low-dose heparin in routine hemodialysis monitored by activated partial thromboplastin time.

To evaluate the use of the activated partial thromboplastin time (APTT), as measured by the Coag-A-Mate semi-automatic unit, in lowering the dosage of heparin in stable chronic hemodialysis patients, four protocols for anticoagulation were utilized. Ten patients were dialyzed five times with each protocol. In protocol I, clotting time was performed baseline, 2 and 4 hours and in protocol II, baseline and every 30 minutes, with heparin administered by bolus to keep the clotting time at 2-2 1/2 times normal. In protocols III and IV the APTT was performed every 30 minutes, with heparin given by bolus in protocol III and infusion in protocol IV, to keep the APTT 1 1/2-2 times normal. Protocol I required 6000 +/- 543 U of heparin with the dose decreasing significantly to 3694 +/- 158 U in protocol II, 2634 +/- 139 U in protocol III and 2013 +/- 117 U in protocol IV (P less than 0.05- less than 0.001). Three episodes of clotting occurred, one in protocol III and two in protocol IV. There was no bleeding, and clearances of urea, creatinine, phosphate and uric acid at 1 and 5 hours were similar in all protocols. APTT, as measured by the Coag-A-Mate unit, provides a simple means of lowering heparin requirements in routine dialysis patients.

Infusion intravenous pyelography and renal function. Effects in patients with chronic renal insufficiency.

Acute renal failure (ARF) following infusion intravenous pyelography (IVP) has been reported in patients with chronic renal insufficiency, particularly diabetics. Renal function was evaluated before and after infusion IVP in 40 patients with chronic renal insufficiency. In 11 of 12 (92%) diabetics and 17 of 28 (61%) nondiabetics, a 25% or greater increase in serum creatinine values and/or decrease in creatinine clearance was noted after IVP despite adequate hydration in all patients. The maximum decrease in kidney function occurred within three days and usually returned to or near pre-IVP levels in seven to ten days. At least 70% of the patients had hypertension and/or evidence of vascular disease. The data suggest that preexisting vascular disease in the kidney, possibly associated with the known vasoconstricting effects of contrast media, may be an important factor in the ARF following infusion IVP.

Arteriovenous fistula as a complication of percutaneous femoral vein catheterization for hemodialysis.

Sudden onset of congestive heart failure due to development of a femoral arteriovenous fistula in a hemodialysis patient is reported as a complication of repeated femoral vein catheterization for access. Closure of the fistula led to disappearance of signs and symptoms of congestive heart failure.

Shipboard dialysis.

With better understanding of the pathophysiology of uremia, the development of more efficient dialysis techniques and more portable machinery, a larger number of patients on maintenance dialysis are not stable enough to undertake travel to places where a regular hemodialysis center may not be availabel or to travel on a ship for a relatively long period of time. Ten stable patients were taken on a 7 day cruise utilizing the relatively lightweight and portable REDY Dialysis System. The medical team consisted of 2 nurses, 2 technicians and 1 physician. The ship's infirmary was converted to a 4 bed hemodialysis unit. Complications were minimal and easily handled by the medical staff.

Acute renal failure secondary to ureteral fungus ball obstruction in a patient with reversible deficient cell-mediated immunity.

A patient with a single functioning kidney and anuria due to ureteropelvic obstruction by a Candida fungus ball is described. During treatment with amphotericin B administered via a nephrostomy tube the drug was not detected in the serum, indicating that absorption from urothelium was not significant. Immunological studies demonstrated a lack of cell-mediated immunity which was probably brought about by a long course of prednisone and later restored when this drug was discontinued. This immunosuppression was evident even with a relatively small dosage of prednisone (5 mg daily). The literature concerning renal candidiasis and predisposing factors is reviewed.