Successful Practice Transitioning Between Hemodialysis and Hemodiafiltration in Outpatient Units: Ten Key Issues for Physicians to Remember.

Hemodiafiltration (HDF) during chronic renal replacement therapy (RRT) is a relatively new practice phenomenon, emerging over the last two decades. While the technological platforms utilized during chronic RRT are in many cases similar or effectively identical to conventional hemodialysis (HD), significant differences may emerge in daily practice. Several authors of this review moved practice site between the United States and the European Union and transitioned from an HD-based practice to predominantly HDF-practicing networks. In doing so, we became keenly aware of the potential pitfalls nephrologists may be facing during such transitions. This brief review is intended to provide a succinct overview of several practical concerns and complications nephrologists may encounter in daily practice of end-stage renal disease care, including but not limited to management of electrolytes, renal anemia and treatment goals and settings during HDF.

Use of Hemadsorption in a Case of Pediatric Toxic Shock Syndrome.

BACKGROUND: Toxic shock syndrome is a potentially fatal toxin-mediated disease. The role of toxins in this clinical entity made us hypothesize that extracorporeal blood purification with CytoSorb® could play a beneficial role in the clinical management of toxic shock syndrome. This case report describes the successful treatment of toxic shock syndrome using a combination of renal replacement therapy and hemadsorption in a pediatric patient. CASE PRESENTATION: A 5-year-old girl with Down's syndrome presented with an inflamed area surrounding an insect bite, signs of systemic inflammation, and multiple organ failure. As previous attempts of immune modulation therapy were unsuccessful, renal replacement therapy was supplemented by the cytokine absorber CytoSorb. Treatment using this combination was associated with a rapid and significant stabilization in the hemodynamic situation and a decrease in inflammatory mediators within hours after the initiation of therapy. The application of CytoSorb therapy was simple and safe. CONCLUSION: The use of extracorporeal blood purification with CytoSorb proved potentially beneficial by removing toxins and inflammatory mediators in this case and could therefore play a role in the clinical management of toxic shock syndrome. Whether CytoSorb has the potential to even positively influence mortality in patients with toxic shock syndrome still needs to be confirmed.

Relapsing polychondritis with p-ANCA associated vasculitis: Which triggers the other?

Relapsing polychondritis (RP) is a rare autoimmune disease with chronic inflammatory/destructive lesions of the cartilaginous tissues. In one third of the cases it is associated with other autoimmune disorders, mostly with anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV). We report three cases of RP with p-ANCA positive AAV. In the first patient RP developed 1.5 years after the onset of AAV. In the others the signs of RP were present before the onset of severe crescent glomerulonephritis. Patients responded well on steroid and cyclophosphamide. In dialysis dependent cases plasmapheresis was also used successfully. During the 2 and 1.5 years of follow up, they were symptom-free, and had stable glomerular filtration rate. The first patient died after four years of follow-up due to the complications of sudden unset pancytopenia, which raises the possibility of associated hemophagocytic syndrome. In the setting of RP or AAV physicians should always be aware of the possibility of sudden or insidious appearance of the other disease.

[Clinical consequence and significance of anti-neutrophil cytoplasmic antibody positivity in anti-glomerular basement membrane disease]. / Antiglomeruláris bazálmembrán betegségben észlelt antineutrofil citoplazmatikus antitest pozitivitás klinikuma, jelentosége.

INTRODUCTION: Patients with renopulmonary syndrome who have both anti-neutrophil cytoplasmic and anti-glomerular basement membrane antibodies have been described since 1989. AIM: The aim of the authors was to analyse the data of "double positive" patients diagnosed in their department, and compare these with previous studies. METHOD: During the last 16 years, 87 anti-neutrophil cytoplasmic antibody positive and 11 anti-glomerular basement membrane antibody positive patients were diagnosed. Four patients with anti-glomerular basement membrane antibodies (36%) had detectable anti-neutrophil cytoplasmic antibodies, 2 patients were positive for anti-myeloperoxidase and 2 patients for anti-proteinase 3. RESULTS: In comparison with patients having anti-glomerular basement membrane antibodies, the double-positive patients were characterized by older age (median of 46 vs. 24 years), lack of male dominance (50% vs. 71%), more frequent presence of previous extrarenal symptoms (50% vs. 0%), and lower anti-glomerular basement membrane antibody levels (<100EU/ml: 100% vs. 29%). The double-positive patients had more favourable 1-year survival (100% vs. 71%), despite their older age and similar treatment regimen (immunosuppression 100% in both groups, plasmapheresis in 75% vs. 86%), but 1-year renal survival was not different (25% vs. 14%). CONCLUSIONS: In agreement with literature data, about one third of patients with anti-glomerular basement membrane antibodies had detectable anti-neutrophil cytoplasmic antibodies, and the coexistence of the two antibodies may have clinical consequences.

[The epidemic of chronic kidney disease requires the estimation of glomerular filtration rate]. / Az idült vesebetegség epidémiája szükségessé teszi a glomerulus filtrációs ráta számítását.

Nowadays chronic kidney disease has become a major public health problem due to the great increase in atherogenic nephropathies. In the absence of classic renal symptoms, chronic kidney disease is mostly diagnosed when renal failure is already advanced, although it can be revealed by laboratory tests in the earlier stages. When diagnosis is late, the progression to end-stage renal failure is unavoidable and renal replacement therapy is needed. Even early-moderate renal failure significantly increases the risks for atherosclerosis, thereby leading to the deaths of patients from cardiovascular disease before initiation of dialysis. Therefore screening for asymptomatic chronic kidney disease is urgently needed. Estimated glomerular filtration rate has the greatest importance in the screening and in the timely intervention to slow down the progression of renal failure and cardiovascular disease. In 2005, the Hungarian Society of Nephrologists and the Hungarian Society of Laboratory Medicine suggested the automatic estimation and reporting of glomerular filtration rate, each time serum creatinine measurements were made. This practice is used more frequently by laboratories in Hungary. This article aims to help facilitate the utilization and evaluation of estimated glomerular filtration rate.

[Nephrotic syndrome in Hodgkin's disease]. / Nephrosis szindrómával járó Hodgkin-kór.

The authors are presenting a rare paraneoplastic syndrome in Hodgkin's disease. Young female patient presented with symptoms of nephrotic syndrome. Renal biopsy showed mesangiocapillary glomerulonephritis. Remission was achieved with combined therapy. Four months later, when the nephrosis syndrome relapsed, Hodgkin's disease was diagnosed (nodular sclerosing subtype). Hodgkin's disease was staged as III/BS. Polychemotherapy resulted complete remission of both Hodgkin's disease and nephrotic syndrome. Causes of nephrotic syndrome in Hodgkin's disease can include renal vein thrombosis, amyloidosis or paraneoplastic syndrome. Nephrotic syndrome in Hodgkin's disease may relate to dysfunction of T-cells or altered cytokine balance, but the exact pathogenesis is not known. This case attracts attention that a rare cause of nephrotic syndrome can be Hodgkin's disease.

Effect of hemodialysis on the deformability and lipid peroxidation of erythrocytes in chronic renal failure.

Deformability and lipid peroxidation (LP) have been compared in erythrocytes of 45 chronic hemodialysis patients and 30 healthy subjects. The relative cell transit time (RCTT), correlating negatively to deformability, was measured using a St. George filtrometer. Thiobarbituric acid reactive material was measured and expressed as nanomoles of malondialdehyde (MDA) per gram of hemoglobin as a marker of LP. RCTT and MDA were found to be significantly higher not only before but also after HD compared with controls. Weak negative correlations were found between RCTT and the dosage of EPO as well as between RCTT and the daily amount of urine. These observations indicate the importance of residual renal function and the beneficial effect of EPO on erythrocyte deformability. The mean values of results suggest that HD does not affect the erythrocyte injury. The individual modifications of RCTT and MDA are also discussed.

[Acute toxicological cases during a ten-year period in our clinic]. / Akut toxikológiai eseteink klinikánk tízéves beteganyagában.

INTRODUCTION: There's a fact, that Hungary has held the first places in suicidal statstics. METHODS: The authors studied toxicological cases between 1989 and 1998 at the 1st Department of Medicine of the Medical and Health Science Centre, at the University of Debrecen, paying special attention to suicidal poisoning cases. RESULTS: 2% of the patient turnover accounted for acute poisoning cases, the number of which increased during the 10 years in question. 70% of the cases were of suicidal intentions, 20% were unintentional, these poisonings were not committed on purpose, while the proportion of iatrogenic intoxication cases was 10%. Amongst the failed suicide cases there was a higher proportion of women, whereas a higher percentage of men accounted for "successful" suicide cases. When examining auto-intoxication cases it turned out that the medicine most frequently used was meprobamate, besides benzodiazepines. Mortality rate was highest in the glutethimide intoxication cases. Most poisonings with suicidal intentions took place in the 2nd quarter of the year. Most completed suicides were committed on Wednesdays and Thursdays. 81% of the iatrogenic intoxication cases happened to be with digitalis and coumarin overdose. Nearly 50% of the cases turned out to be combined intoxications. 40% of the men took alcoholic drinks during the auto-intoxications. In the case of 135 patients extracorporeal detoxification therapy was applied, which consisted mostly of hemoperfusion. Three quarters of the patients needed psychiatric care and every fourth patient was admitted to the Department of Psychiatry. 6.9% of the poisonings were fatal. CONCLUSIONS: The growing number of toxicological cases--amongst these suicidal poisonings--compels us to pay more attention to the setting up of interdisciplinary based prevention as well as running effective toxicological centres. All physicians have a responsibility to recommend psychiatric care for people suffering from mental problems or depression and for the unsuccessful or potential suicide seeking help for the first time. Family doctors in primary medical care and who meet patients first have an important role in this job.