Chronic dialysis in patients over age 65.

In the United States, persons over the age of 65 are expected soon to become the majority of those people who will require maintenance dialysis therapy. Many of these individuals have numerous comorbid medical complications, which, together with altered physiologic adaptation related to aging, create a great challenge for the nephrologist. Despite a considerably lower group survival rate and increased hospitalization utilization as compared with younger patients, many elderly dialysis patients tolerate therapy very well and appear quite satisfied with the quality of their lives. Both hemodialysis and peritoneal dialysis are suitable treatment modalities for elderly patients, but recommendations regarding type of dialysis must be individualized, taking both medical and psychosocial issues into consideration. Vascular access problems are particularly important for the elderly and contribute to significant morbidity. Malnutrition and cardiovascular complications also require special attention. Withdrawal from dialysis appears to be increasingly common among elderly ESRD patients and highlights the need for the completion of advance directives. A trial of dialysis may allow elderly patients and their families additional time to decide whether long-term dialysis is deemed appropriate.

Glomerulonephritis and sinusitis. Hypocomplementemic glomerulonephritis associated with coagulase-negative staphylococcal pansinusitis and subdural empyema.

A 16-year-old male developed acute hypocomplementemic glomerulonephritis in association with pansinusitis and subdural empyema. Nephrotic-range proteinuria, serum complement, and renal function rapidly returned to normal with antimicrobial therapy and surgical drainage of both infected cavities. Culture of the exudate obtained during drainage of the frontal sinus yielded pure growth of coagulase-negative staphylococcus. This case documents the association of acute hypocomplementemic glomerulonephritis and pansinusitis-subdural empyema due to coagulase-negative staphylococcus, not previously described.

Acid-base and electrolyte changes following maximal and submaximal exercise in hemodialysis patients.

Maximal treadmill exercise was conducted in nine hemodialysis patients and in 15 unconditioned healthy subjects. Exercise capacity in the dialysis patients, as measured by duration of exercise, maximal oxygen consumption (VO2 max), and workload achieved (METS) was approximately 50% of that of the nonuremic volunteers. Four of the dialysis patients were studied on both dialysis (predialysis) and nondialysis days and also at 60% of VO2 max for 30 minutes on a nondialysis day. In these individuals, serum electrolytes, acid-base, and biochemical parameters were analyzed preexercise and at regular intervals following cessation of treadmill exercise. Transient metabolic acidosis and mild hyperkalemia developed after maximal exercise but not after prolonged submaximal exercise. Patients were slightly more acidotic and hyperkalemic on a dialysis day compared to a nondialysis day. Cardiopulmonary performance was similar on both days. These changes in serum electrolytes and acid-base parameters provide documentation of the extent of biochemical changes that develop following exercise in dialysis patients.

Fulminant pneumococcal bacteremia in an asplenic chronic hemodialysis patient.

A chronic hemodialysis patient, previously splenectomized because of trauma in conjunction with gastrectomy, developed bacteremia with type 18 Streptococcus pneumoniae and died within 13 hours of onset of symptoms. Characteristics of this illness were severe hypoglycemia, pneumococci visible on peripheral blood smear, disseminated intravascular coagulation, neutropenia, and in vitro hemolysis. Splenectomy should be considered with caution in uremic patients and in renal transplant recipients because of the increased risk of fulminant bacteremia. Polyvalent pneumococcal vaccine may be helpful in preventing this syndrome in such asplenic patients.

Chronic peritoneal dialysis in a patient with primary amyloidosis, renal failure, and factor X deficiency.

Chronic peritoneal dialysis was used in a patient with renal failure due to primary amyloidosis. Paraprotein was demonstrated in serum and urine, and was removed in peritoneal dialysate. The patient objectively improved as long as he was receiving peritoneal dialysis. When dietary indiscretion necessitated hemodialysis for fluid removal, he died shortly thereafter of subdural hematomas, possibly aggravated by factor X deficiency. Reasons for selecting chronic peritoneal dialysis as the treatment of choice in patients with renal failure associated with overproduction of paraprotein are discussed.

Home dialysis program of the Nashville VA Hospital.

Since 1965, 330 patients have received chronic dialysis treatment at the Nashville VA Hospital. Home hemodialysis training was established in 1968, and a unique class format has been used since 1970. Despite the national trend of fewer patients beginning home dialysis each year, more than 50 percent of our patients have chosen this form of therapy yearly since 1969. A total of 182 patients (55 percent) from 15 states have completed home training with an attrition rate of only 8 percent. Mean distance of patients' homes from the training center is 185 miles. Five-year survival for home hemodialysis patients is 91 percent, compared to 59 percent and 55 percent for patients receiving renal transplant and center dialysis, respectively. Seventeen deaths have occurred in home dialysis patients, half of which were due to cardiovascular disease. Home dialysis offers an excellent mode of therapy for patients with chronic renal failure and probably is particularly suitable for patients over 50 years of age.

Staphylococcus aureus bacteremia in hemodialysis patients.

Fifteen male hemodialysis patients developed 21 episodes of S. aureus bacteremia. Infections involving vascular access were responsible for 65% of initial bacteremias. The arteriovenous fistula was the most prevalent type of access used, and thus was responsible for the majority of these illnesses. Phage typing indicated that recurrent episodes were due to reinfection rather than relapse. Complications included endocarditis, osteomyelitis, septic embolism, and pericarditis. One patient died of infectious complications. It is recommended that hemodialysis patients developing bacteremia due to S. aureus receive at least 6 weeks of beta lactamase-resistant antimicrobial therapy.

Long-term hemodialysis for patients over 50.

Hemodialysis can hodl end-state renal failure at bay and enable patients to lead a relatively normal life-regardless of their age. In a 10 year retrospective study of 574 patients, the 154 patients over 50 had about the same survival rates as younger persons for the first three years of dialysis. After that, the older patients had higher mortality. Patients who dialyzed themselves at home-with a relative or friend to help-had much better results than those who were dialyzed at the center. This in part reflects the selection process, since patients with severe medical problems usually weren't allowed to try self-dialysis. Older patients did particularly well on home dialysis, which was attributed to their maturity and dependability. Older patients with cardiac instability may require carefully monitored dialysis at the center and frequent blood transfusions. In general, though, patients over 50 needed fewer transfusions and fewer days in the hospital than younger patients.