Successful use of indwelling cuffed femoral vein catheters in ambulatory hemodialysis patients.

Three hemodialysis patients with multiple upper extremity vascular access complications and central vein stenosis were treated for as long as 3 months using an indwelling femoral vein catheter having a buried felt cuff in its subcutaneous tunnel. Four catheters were placed in these three patients. In one case, initial failure due to poor flow and clotting occurred using a straight catheter with its tunnel crossing the inguinal ligament and exiting caudally on the anterior thigh. Otherwise, each patient had successful placement of a 180-degree, curved catheter that exited the femoral vein in the usual fashion but had a subcutaneous tunnel and skin exit pointing cephalad in the inferior portion of the right lower quadrant. The three successful devices functioned immediately after placement, having acceptable outflow pressures and recirculation values. One of three catheters was removed 3 weeks after placement when persisting infection was thought to reside on the device. No other bleeding, thromboembolic, or infectious complications occurred in these patients. In conclusion, short-term indwelling femoral vein access may be feasible in ambulatory hemodialysis patients with previous access difficulties that complicate temporary dialysis treatment.

Reflux nephropathy and primary vesicoureteric reflux in adults.

We have studied the clinical features and course of adults with reflex nephropathy and/or primary vesicoureteric reflux, paying particular attention to the differences between males and females, and the presenting features that influence prognosis. In our series of 293 patients, females outnumbered males in the ratio 5:1 and most presented with urinary infection, whereas males most commonly presented with features of renal damage such as proteinuria, hypertension or renal failure. Males more commonly had bilateral scarring and persistent reflux. One hundred and forty-seven patients were followed for two years or more (range 2-19 years); deterioration in renal function occurred in 55 (37 per cent). Risk factors for a rise in plasma creatinine were, in descending order, the presence of proteinuria, an elevated plasma creatinine concentration, bilateral scarring, male sex and the presence of hypertension. Stepwise multiple regression analysis showed that the independent risk factors were proteinuria, elevated plasma creatinine concentration and hypertension; gender and the presence of persistent reflux had no independent influence on the course of renal failure.

Morphometric aspects of reflux nephropathy.

We have studied the relationships between renal size, glomerular hypertrophy and sclerosis and renal function in adults with reflux nephropathy. A digitizer was used to measure the renal surface areas in intravenous pyelogram films. This was then corrected for patient size by dividing by the area of the first three lumbar vertebrae. In renal biopsies, glomerular surface area and the proportion of segmentally and globally sclerosed glomeruli were measured and compared with a control group of 17 renal donors. Of 57 patients studied, 45 had intravenous pyelogram films and 32 had renal biopsy tissue available from the time of presentation, 20 had both. Thirty-one were followed for two years or more (median 6 years, range 2 to 11 years). There were positive correlations between corrected renal size and renal function, and inverse correlations between these and maximum glomerular size, the proportion of sclerosed glomeruli and vascular wall thickness. Proteinuria correlated best with the proportion of segmentally sclerosed glomeruli. As a prognostic guide, the strongest correlations were between rate of functional decline and percent segmental sclerosis, urine protein excretion and creatinine clearance at presentation. These studies confirm expected relationships between renal size, glomerular size and renal function and suggest that the severity of segmental sclerosis is a major factor in eventual decline into renal failure.