Considerations in the treatment of patients with renal disease.

Renal function includes maintenance of fluid pH, electrolyte and fluid balance, influence on blood pressure, excretion of fluid and metabolic soluble wastes after filtration or reabsorption, and production of erythrocyte stimulating factor and the active form of vitamin D. These processes involve sensory mechanisms in the kidney, as well as the ability to respond to sensed changes, to maintain body homeostasis. Decrease in or failure of renal function induces abnormalities in many other systems, requiring a modified approach that is individual to each patient, and includes alteration of medications used and a re-evaluation of their doses. Some patients may require a regimen of dialysis or eventual renal transplantation, each with attendant advantages and risks. Careful evaluation and consultation with a nephrologist is required when local or systemic treatment is contemplated.

Osmotic disequilibrium causing ascites during chronic hemodialysis.

UNLABELLED: Ascites formation is a recognized complication of chronic hemodialysis (CHD). The cause is an enigma after tumors, tuberculosis, and heart, liver, and pancreatic diseases are excluded. A 55-year-old patient who developed intractable ascites about 6 months after starting CHD was studied. The premise was that osmotic disequilibrium during HD may be the causative factor. Other causes of ascites were excluded. The study method relied on determining simultaneous serum and ascites osmolality (Sosm and Aosm) at the start and finish of a standard 4 hour HD session. THE RESULTS: Sosm and Aosm at the start averaged 310 and 309 mosm/L, respectively. At the end, Sosm averaged 285 and Aosm averaged 301 mosm/L, giving a 16 mosm concentration gradient. Two days later, Sosm and Aosm were equal again. It is concluded that the osmotic gradient at the end of 4 hours of HD favors movement of water from the intravascular space into the ascitic fluid space until osmotic equilibrium is once again achieved.

Tuberculous arthritis in a hemodialysis patient.

Tuberculosis (TB) is a relatively common infectious complication in the dialysis population. Most cases are extrapulmonary and pose a diagnostic dilemma for the clinician. Tuberculous arthritis is a rare form of extrapulmonary TB occurring in approximately 1% of cases in nonuremics. Only 1 case in a dialysis patient (not proven by positive synovial fluid culture) has been reported. We report here a culture-proven case of tuberculous arthritis in a hemodialysis patient which masqueraded as an acute septic arthritis. TB should be considered early as an etiologic agent along with synovial biopsy when the exact cause of a monoarthritis has not been discovered, thus avoiding delay in initiation of appropriate therapy.