Cross-sectional and longitudinal nutritional measurements in maintenance hemodialysis patients.

Fifty-eight nondiabetic maintenance hemodialysis patients entered a continuing nutrition survey. Eighteen were followed at 6 and 18 months. Protein-calorie malnutrition was measured by diet survey, laboratory data, and anthropometric measurements. Of patients 50% ate less proteins/calories than prescribed. Triceps skinfold thickness, transferrin, and total lymphocyte count were subnormal in 72, 81, and 69% of patients, respectively. Weight/height ratio, body mass index, arm muscle circumference, and serum albumin were normal in most. Of the patients 62% had greater than three subnormal nutrition measurements. Only two had all measures normal. Longitudinally there was little change in the patients followed up to 18 months. The study shows that protein-calorie malnutrition is widespread in stable maintenance hemodialysis patients.

Septic and aseptic olecranon bursitis in patients on maintenance hemodialysis.

Over a period of four years, seven of 110 maintenance hemodialysis patients developed olecranon bursitis. In all patients it appeared in the arm on which AV access was constructed but one patient also had bilateral bursitis. None of the patients gave a history of trauma or gout. Despite similar clinical presentation, culture of bursal aspirate demonstrated septic bursitis in two patients. (One diabetic, the other on steroids). Sustained pressure on the olecranon bursa during maintenance hemodialysis and/or milk trauma in the anticoagulated state may be responsible for the lesion. Infection can occur in susceptible individuals despite no visible skin infection. Local steroid instillation and patient education to avoid putting pressure on bursa during dialysis was effective therapy in the aseptic group. Multiple aspirations and antibiotics were necessary in the septic group.

Lymphocyte populations in maintenance hemodialysis patients - reassessment and analysis of B cell subtypes.

Maintenance hemodialysis patients are known to be lymphopenic, and it was previously felt that T and B cells were equally and moderately depressed. With modification of the B cell technique, however, we have shown that MHD patients have a relatively more pronounced depression of B cells, with decreased proportions and markedly reduced total numbers. B cells bearing specific immunoglobulin types are all proportionally reduced. This marked B cell deficiency could be responsible for the increased rate of some infections in MHD subjects. Its relationship to azotemia, malnutrition, toxic or deficiency states, or dialysis itself is unknown, and the stages of cellular maturation or interaction which are affected have not been identified.

A regional end-stage renal disease program: twelve years' experience.

As of 31 December 1978, 558 patients with end-stage renal disease had been treated with transplantation (150), home dialysis (109), and center dialysis (299). Three hundred twenty-eight patients survived--194 (59%) in center, 51 (15%) at home, and 83 (25%) with functioning grafts. The number and age of new patients continue to increase. Significantly more deaths occur among center dialysis patients than among transplant recipients or home patients. Cadaveric donors provide 71% of transplanted kidneys. The increase in new and older patients without a commensurate increase in cadaver organs results in a declining transplantation rate. Home dialysis training has not decreased. Home dialysis and transplantation can treat about 50% of all new patients. Equilibrium in the end-stage renal disease population will occur when 632 patients per million are receiving treatment. Of these, about 500 will be on center dialysis and will need about 100 stations per million population.

Hepatic friction rub in uremia.

Hepatic friction rubs developed in two patients undergoing maintenance hemodialysis. Thorough evaluation, including autopsy in one patient, did not demonstrate any known cause for the rubs except that uremic pericarditis had complicated the course of both patients and one suffered from chronic hemolytic anemia. The clinical course suggests that hepatic friction rubs may be associated with either uremia or maintenance hemodialysis.

Anaerobic urinary tract infection owing to Bacteroides fragilis in a chronic hemodialysis patient.

A chronic maintenance hemodialysis patient with severe oliguria and persistent anaerobic urinary tract infection owing to Bacteroides fragilis is presented. Review of the literature shows that the incidence of anaerobic pathogens in random urine cultures is high but that the incidence of clinically significant infection is low. Since the urethra harbors anaerobic organisms suprapubic aspiration of urine and culture are indicated to confirm true anaerobic urinary tract infection. Anaerobic infections are associated with urinary tract abnormalities and pyuria. The various therapeutic maneuvers that were used to treat the infection are discussed, including antibiotic instillation into the bladder and nephrectomy.

Carpal tunnel syndrome in patients undergoing maintenance hemodialysis.

Five of 62 maintenance hemodialysis patients were found to have carpal tunnel syndrome, and another five had prolonged distal motor latencies. Contrary to previous reports, there was no relation between carpal tunnel syndrome and the site of vascular access. Synovial biopsy specimens from flexor tendons demonstrated edema without inflammation, suggesting that extracellular fluid volume excess in the presence of flexion and immobility during dialysis may be pathogenetically important.

Hypothalamic-pituitary-ovarian axis in uremic women.

Menstrual abnormalities are common with decreasing renal function and uremia. Maintenance hemodialysis therapy partially corrects some of the abnormalities. Since the pathophysiology of the menstural irregularities is unknown, the secretion of LH, FSH, estrogen, and PRL was studied under basal conditions and after provocative testing in 13 women undergoing chronic maintenance hemodialysis. Elevated LH concentrations were found in all six premenopausal (44.1 +/- 26.4 mlU/ml, normal follicular phase 4 to 30) and seven postmenopausal (246.1 +/- 171.4 mlU/ml, normal 35 to 200) women studied. FSH values were normal both in the premenopausal women (7.9 +/- 4.1 mlU/ml, normal 2 to 20) and in postmenopausal women (88.0 +/- 69.0 mlU/ml, normal 40 to 200). FSH and LH levels did not show typical ovulatory spikes in three of four women studied. Pulsatile hormonal release was absent. The pituitary response to LH-RH was adequate and prolonged, but the response to clomiphene citrate was variable. The study documents the existence of abnormalities at various levels of the hypothalamic-putuitary-ovarian axis.

Mannitol and maintenance hemodialysis.

The extensive use of mannitol during maintenance hemodialysis prompted a study of mannitol kinetics. In 17 patients receiving empirical mannitol therapy of mannitol kinetics. In 17 patients receiving empirical mannitol therapy, residual levels range from 19 to 100 mg% In vitro mannitol clearance exceeds 125 ml/min for the CDAK 5 and PF 1.6 dialyzers, while in vivo clearance ranges from 98 to 140 ml/min in the Triex 1, PF 1.6 and CDAK 5. Despite an apparently adequate clearance rate, mannitol administered during dialysis is incompletely removed. Repeated use of mannitol during dialysis leads to mannitol accumulation. Clinical significance of the residual mannitol levels needs further evaluation.

Chromosomal abnormalities in maintenance hemodialysis patients.

Forty bone marrow aspirates from maintenance hemodialysis patients were prepared for chromosomal analyses. Among the 1,187 metaphases studied, only 58% were diploidies. Other abnormalities included: pseudodiploidies (5.8%), acentric fragments (3.6%), translocated chromosomes (1.9%) and one dicentric chromosome. The abnormalities found may be due to abnormal DNA synthesis in chronic renal failure or uremia, or infusion of formaldehyde which can denature DNA. This chemical was used to sterilize dialysis equipment. Incomplete rinsing can introduce this substance into the circulation.

Epidemiology of cytomegalovirus infection in end stage renal disease.

Since primary cytomegalovirus (CMV) infection is a cause of morbidity among renal transplant recipients, we undertook a prospective study of our maintenance hemodialysis patients and personnel to determine whether these sources posed a risk for transmission of CMV. Our study of 85 patients and 49 personnel showed that CMV was detected in eight nontransplanted, older dialysis patients and 13 patients who had lost their allograft. In spite of the presence of CMV on the unit, no patient or staff member developed primary infection from interpersonal transmission or from transfused frozen red blood cells. All primary infections in renal transplant patients could be accounted for by acquisition from the transplanted kidney, thus eliminating the dialysis unit or frozen blood as a risk to either patients or personnel.

Eosinophilia in maintenance hemodialysis patients.

Peripheral blood eosinophilia was noted in 38% of a group of maintenance hemodialysis patients, and documented by bone marrow examination. The prevalence of eosinophilia rose with increasing time on hemodialysis. In 3 subjects the phenomenon appeared to be related to dialysis equipment, but the relationship was less clear in the group as a whole. Severe hypersensitivity reactions during dialysis occurred in 2 patients with marked eosinophilia. Possible causes of sensitization in maintenance hemodialysis patients are discussed.