Recurrent intradialytic heparin induced anaphylaxis: workup and management.

Heparin has been widely used for intradialytic anticoagulation since the 1940s. Heparin induced anaphylaxis can be life threatening, mandating early recognition and intervention. However, due to its relative rarity many physicians remain unaware. We report the case of a 70-year-old woman requiring dialysis, who developed recurrent anaphylaxis to intradialytic heparin. We describe a systematic approach to confirm the suspected heparin allergy, which must include an evaluation of predisposing factors, the dialysis equipment and concomitant medications. Further workup for safe alternatives employing skin prick and intradermal tests, as well as provocation tests are discussed.

Novel trends in haemodialysis: where are we heading?

The mortality and morbidity of end-stage renal failure patients undergoing conventional thrice weekly in-centre haemodialysis remain alarmingly high despite continuing advances in haemodialysis technologies and improvements in clinical care. Home haemodialysis continues to be under-utilised in many parts of the world despite the reported benefits. Alternative haemodialysis regimens including longer and/or more frequent dialysis (e.g. nocturnal haemodialysis and short daily haemodialysis), haemodiafiltration and the use of high flux dialysers have become more widespread in recent years as nephrologists struggle to improve the dismal survival figures. Whilst most of the encouraging data have come from observational studies, many randomised controlled trials which will provide more robust data are already underway. This review aims to provide a concise update of the recent and novel trends in haemodialysis.

High dose Losartan and ACE gene polymorphism in IgA nephritis.

Background/aims Several studies have reported varying results of the influence of ACE gene on ACEI/ARB therapy. The efficacy of high dose ARB and its influence on ACE gene have not been explored. This is a 6 year randomised trial in IgA nephritis comparing high dose ARB (Losartan 200 mg/day) with normal dose ARB (Losartan 100 mg/day), normal dose ACEI (20 mg/day) and low dose ACEI (10 mg/day). Results Patients on high dose ARB had significantly lower proteinuria, 1.0 +/- 0.8 gm/day compared to 1.7 +/- 1.0 g/day in the other groups (P = 0.0005). The loss in eGFR was 0.7 ml min(-1)year(-1) for high dose ARB compared to 3.2-3.5 ml min(-1)year(-1) for the other three groups (P = 0.0005). There were more patients on high dose ARB with improvement in eGFR compared to other three groups (P < 0.001). Comparing patients with the three ACE genotypes DD, ID and II, all three groups responded well to therapy with decrease in proteinuria (P < 0.002). Only those on low dose ACEI (10 mg/day) with the I allele had increased in ESRF (P = 0.037). Conclusion High dose ARB is more efficacious in reducing proteinuria and preserving renal function when compared with normal dose ARB and ACEI, and also obviates the genomic influence of ACE gene polymorphism on renal survival.

Predictors of hospitalization in patients on peritoneal dialysis: the Missouri experience.

BACKGROUND: We analyzed a large number of demographic and biochemical variables to identify predictors of hospitalization in subjects on peritoneal dialysis (PD). METHODS: All patients initiated on PD at our center from January 1990 through December 1999 were included. The following variables at the initiation of PD were included: demographics, clinical data, nutritional and adequacy parameters, transport characteristics, and various co-morbidities. Co-morbidities were graded for severity using a modified version of the Index of Coexistent Disease. Variables included during the course of PD consisted of weighted time average of a number of laboratory, adequacy, and nutritional parameters along with the number of peritonitis episodes per year. Stepwise linear regression was used following a univariate screening procedure to identify independent predictors of the outcome of hospitalization days per month on PD. RESULTS: The subject population consisted of 191 subjects (105 men, 86 women; 180 Caucasians, 10 African-American, 1 Asian). The mean age was 61 +/- 13 (SD) years and mean duration of follow-up was 21 +/- 18 months. The baseline variable analysis revealed that the presence of partner to perform PD predicted increased hospitalization (p < 0.0001). Additionally, the presence and severity of peripheral vascular disease and residual renal Kt/V at baseline (negative association) predicted increased hospitalization. In the analyses of ongoing variables, stepwise linear regression solely identified weighted time average albumin as a strong negative predictor of hospitalization (p < 0.0001). CONCLUSION: A comprehensive analysis of a large number of variables revealed that serum albumin during the course of PD (negative association) and the need for partner to perform PD strongly predicted increased hospitalization in PD subjects.

Predictors of death in patients on peritoneal dialysis: the Missouri Peritoneal Dialysis Study.

BACKGROUND: The study was designed to identify predictors of death in subjects on peritoneal dialysis (PD). METHODS: The population consisted of patients initiated on PD at the University of Missouri-Columbia and Dialysis Clinic Incorporated from January 1, 1990, through December 31, 1999. Baseline variables included demographics, clinical data, initial measures of nutritional status, adequacy, and transport characteristics. Co-morbidities were scored using a modified version of the Index of Coexistent Disease. Ongoing (during the course of PD) variables consisted of clinical characteristics and weighted time average of a number of laboratory, adequacy, and nutritional variables. The variables were screened using a univariate procedure, and then analyzed using stepwise logistic regression to evaluate their independent relation to death. RESULTS: There were 105 men and 86 women--180 Caucasians, 10 African-American, 1 Asian, mean age 61 +/- 13 (SD) years, and mean duration of follow-up 21 +/- 18 months. Eighty-two patients suffered the outcome of death. Lean body mass (LBM) at the initiation of PD was negatively associated with the risk of death (p < 0.01). In addition, the need for a partner to perform PD, total morbidity count, and the summated severity score of all co-morbidities were associated with an increased risk of death. The analysis of ongoing variables revealed that serum phosphate (negative association, p = 0.02) and number of hospitalization days per month on PD (p = 0.0006) were associated with an increased risk of death. CONCLUSION: Phosphate levels and LBM are strong negative predictors of death in PD subjects. Further, patients who need the assistance of a partner to perform PD have decreased survival.