Role of sodium in dialysis.

The total amount of sodium present in the body conditions the extracellular compartment volume. In advanced renal failure and in dialysis the sodium balance becomes positive and the extracellular volume inflates. This leads to hypertension and to direct cardiac and vascular changes that explain for a large part the excessive cardiovascular morbidity and mortality in dialysis patients. Controlling body sodium content and extracellular volume allows to reduce hypertension, cardiovascular changes and to improve dialysis patients survival. This can be achieved by reducing the sodium input (low sodium diet and reasonably low sodium dialysate) and/or by increasing sodium output (ultrafiltration by convection in hemodialysis or hemofiltration and osmotic drive in peritoneal dialysis). The intermittent nature of hemodialysis (and hemofiltration) conditions the saw-tooth volume fluctuations that drove to conceiving and implementing the concept of a dry weight, corresponding to normal extracellular volume and blood pressure.

Diabetes mellitus in Tassin, France: remarkable transformation in incidence and outcome of ESRD in diabetes.

The incidence and prevalence of diabetes mellitus (DM) in the dialysis population in Europe, and more especially in France, have been lagging behind the impressive United States and Japanese rates. For a decade, things have been changing, and the incidence of DM in hemodialysis (HD) reached almost 40 in Tassin, France in 1999. The prevalence has followed the same trend but increased more slowly. The increase in incidence and prevalence is almost totally accounted for by type 2 DM explosive outbreak and development. The morbidity on dialysis (hypotensive episodes, hospitalization number, and duration) was significantly worse in diabetic patients (without difference between type 1 and 2) than in nondiabetic patients. The mortality rate was higher in diabetic patients than in nondiabetic patients (mean half-life 3 and 13 years, respectively), even after adjustment for age and comorbidity. The mortality rate was higher in type 2 than in type 1 (mean half-life 2.7 and 5.2 years, respectively), a difference which disappears when adjusting for age and comorbidity. Specific causes of death were different in diabetic and nondiabetic HD patients; in diabetics there was a six-fold higher cardiovascular (CV) and three-fold higher infectious mortality, but there was the same mortality from cancer. A strong difference was observed between type 1 and type 2 DM: in type 1 there was no increased infectious mortality and a moderately increased CV mortality compared with nondiabetic patients. Type 2 diabetic patients had a four-fold increased infectious and an eight-fold increased CV mortality. Altogether, the eruption of DM in our unit over the last decade has drastically increased the crude mortality, but the standardized mortality ratio using the USRDS mortality table remained unchanged, about 45 of expected mortality.

Malnutrition in long-term haemodialysis survivors.

BACKGROUND: Long survival is now common in patients with end-stage renal disease owing to improvement in dialysis techniques and kidney transplantation. As malnutrition is commonly reported in dialysis patients, we evaluated the nutritional status of patients treated with haemodialysis (HD) for more than 20 years. METHODS: Ten patients (59.5 years old; 4F/6M; HD treatment for 304 months; group A) underwent an extensive nutritional examination and were compared to a control group of 10 patients treated with HD for an average of 51 months and strictly matched for age (58.6 years old), gender, and height (group B). The patients were treated on a similar basis (long-duration HD, cellulosic membranes, Daugirdas index >2). RESULTS: The body weight (BW) in group A had decreased gradually from the 11th year of HD treatment, whereas it had increased by an average of 1.9+/-4.4% since the beginning of the HD treatment in group B. The body mass index (BMI) was lower in group A (19.3 +/- 2.3 vs 21.4 +/- 2.8 kg/m(2); P = 0.05). The arm-muscle circumference (AMC), the arm-muscle area (AMA), and triceps skinfold (TSF) were lower in group A than in group B. The fat mass assessed with anthropometry (10.8 +/- 4.0 vs 14.8 +/- 4.2 kg) was significantly lower in group A. The deviation of actual BW from ideal BW (IBW) was significantly lower in group A than in group B (80.6 +/- 10.7% vs 89.6 +/- 9.0%; P = 0.028); The deviations of actual BW, TSF, and AMA from standard values of the NHANES II study were more marked in group A than in group B. On the other hand, daily energy and protein intakes (DEI and DPI) were identical in both groups and met the recommendations for dialysis patients when normalized to the actual BW. When normalized to the IBW, the DEI appeared low. Energy expenditure was not different between groups, and not different from the resting metabolism calculated from the Harris and Benedict formula. Average albumin, prealbumin, and IgF-1 were normal and not different between groups. Branched-chain amino acids (BCAA), and especially leucine, were correlated with BMI in group A but not in group B. Serum total and free carnitine were low in both groups. Three patients had ascorbic acid deficiency in group A but none in group B. CONCLUSIONS: Hence, despite adequate dialysis dose and protein intake, patients treated with HD for a long period of time became malnourished, whereas the classical nutritional markers remained in normal ranges. Among the potential causes leading to malnutrition, inadequate energy intake and micronutrient deficiencies were found in these patients.

Segmental necrosis of ascending colon in haemodialysis patients.

A segmental necrosis of the ascending colon sometimes affecting the terminal ileum was observed 13 times in 12 end-stage renal disease patients over a 5400 patient-years observation period. In all but three cases the patient was operated within 24 h of onset of the abdominal pain. Three patients had a bowel perforation; nine had a limited intestinal necrosis. All underwent a partial resection or colectomy. Two died within 1 month. In all cases the mucosa was necrotic, the submucosa small vessels were congested and the mesenteric vessels were normal. Ischaemic bowel disease has been previously reported in uraemic patients, but our cases do not fit with the usual reported features of this complication. The absence of typical mesenteric infarction, vascular thrombosis, stenosis or major atherosclerotic lesions is surprising. The ascending colon topography of the lesions is very unusual. Ischaemia, constipation and other factors may play a role.