Short-term small-dose intravenous iron trial to detect functional iron deficiency in dialysis patients.

BACKGROUND/AIM: Management of renal anemia in end-stage renal disease requires careful evaluation of the iron status before and in particular during erythropoietin treatment. However, there is no simple and practical iron index accurately predictive of functional iron deficiency in these patients till now. The purpose of this prospective study, therefore, is to evaluate whether a short course of low-dose intravenous iron challenge can detect functional iron deficiency in hemodialysis patients. METHODS: Twenty-four patients with baseline serum ferritin levels between 100 and 500 ng/ml were treated with intravenous saccharated ferric oxide, 960 mg over 24 hemodialysis treatments, and the hemoglobin level was checked every week. RESULTS: Patients whose hemoglobin value increased at least by 1 g/dl within the 8-week period were classified as having functional iron deficiency or as responders (n = 26; 81.2%). All other subjects were classified as having adequate iron levels or as nonresponders (n = 6; 18.8%). There were no significant differences in age, sex, dialysis years, Kt/V, dialyzers, hemoglobin, and basal and final transferrin saturation and ferritin between responders and nonresponders. In addition, there were no iron indices with acceptable levels of sensitivity and specificity. On the contrary, the cutoff value of increments of hemoglobin of at least 0.2 g/dl after a 2-week intravenous iron trial had a sensitivity of 96.2% and a specificity of 100% in all patients (n = 32) and a sensitivity of 100% and a specificity of 100% after patients with transferrin saturation <20% were excluded (n = 24). These values had the greatest utility of the tests studied in this work. CONCLUSION: A 240-mg intravenous iron challenge during a 2-week period may be a simple, accurate, and straightforward method to detect a functional iron deficiency status in hemodialysis patients undergoing erythropoietin therapy.

Total creatinine appearance as indicator of risk of infectious complication in peritoneal dialysis.

Peritonitis and exit-site infections are the main causes of complications in peritoneal dialysis. Death due to infectious complication is also one of the major causes of drop-out. The underlying cause of infection may include malnutrition. Total creatinine appearance (TCA) may reflect overall nutritional status. We determined TCA from the daily dialysate, urine, and estimated gut creatinine of patients and normalized it to actual body weight (nTCA). We examined the relationship between nTCA and the incidence of infection, and between nTCA and infection-related survival. The study included 323 adult patients in a single dialysis center. The mean nTCA of all patients was 19.73 +/- 4.75 mg/kg/day. The patients with an nTCA below 1 standard deviation from the mean (nTCA < 14.98 mg/kg/day) had a significantly higher peritonitis and exit-site infection rate (p < 0.01) and a higher chance of drop-out owing to infection-related complications (p < 0.0001). Our study concluded that the adult patient with malnutrition (nTCA < 14.98 mg/kg/day) has higher risk of infection.

Pre-dialysis glycemic control is an independent predictor of mortality in type II diabetic patients on continuous ambulatory peritoneal dialysis.

OBJECTIVE: To evaluate the impact of pre-dialysis glycemic control on clinical outcomes for type II diabetic patients on continuous ambulatory peritoneal dialysis (CAPD). MATERIALS AND METHODS: One hundred and one type II diabetic patients receiving CAPD for at least 3 months were enrolled in a single institute. The patients were classified into two groups according to status of glycemic control. In the good glycemic control group, more than 50% of blood glucose determinations were within 3.3-11.0 mmol/L and glycosylated hemoglobin (HbA1C) levels were within 5%-10% at all times. In the poor glycemic control group, less than 50% of blood glucose determinations were within 3.3-11.0 mmol/L, or HbA1C levels were above 10% at least 6 months before peritoneal dialysis was started. In addition to glycemic control status, pre-dialysis serum albumin, cholesterol levels, residual renal function, peritoneal membrane function, and modes of glycemic control were also recorded. RESULTS: The patients with good glycemic control had significantly better survival than those with poor glycemic control (p < 0.01). There was no significant difference in pre-dialysis morbidity between two groups. No significant differences were observed in patient survival between patients with serum albumin above 30 g/L and those with serum albumin under 30 g/L; between those with cholesterol levels above or below 5.2 mmol/L; and between those with different peritoneal membrane solute transport characteristics as evaluated by a peritoneal equilibration test (PET). Furthermore, there was no significant difference in survival between patients who controlled blood sugar by diet and those who controlled it by insulin. Cardiovascular disease and infection are the major causes of death in both groups. Although good glycemic control predicts better survival, it does not change the pattern of mortality in diabetic patients maintained on CAPD. CONCLUSIONS: Glycemic control before starting dialysis is a predictor of survival for type II diabetic patients on CAPD. Patients with poor glycemic control predialysis are associated with increased morbidity and shortened survival.

Aluminum utensils contribute to aluminum accumulation in patients with renal disease.

Presently, aluminum utensils are widely used in the world, especially in the developing countries. However, whether aluminum leaching from such utensils contributes to aluminum accumulation or causes any damage in patients with renal disease remains unknown. We designed a prospective study to evaluate this problem. After excluding patients who were not examined at follow-up or who poorly complied during the study period, the opened randomized study consisted of 42 patients with chronic renal insufficiency (creatinine clearance <60 mL/min and >10 mL/min). All patients had not taken any aluminum-containing agents for 3 months, but used aluminum kitchen utensils for more than 1 year. Twelve patients comprised the control group; the other 30 patients comprised the study group. The aluminum kitchen utensils used by the study group patients were replaced with stainless steel utensils for 3 months, but those used by the control group were not. After 3 months, the decrements of serum aluminum (5.5 +/- 4.6 microg/L v 2.1 +/- 3.5 microg/L; P = 0.012) and daily urine aluminum excretion (14.3 +/- 15.2 microg/d v 2.1 +/- 5.6 microg/d; P = 0.005) in the study group patients were greater than those in the control group patients. The increments of transferrin saturation of the study group patients (1.8% +/- 9.5% v -3.7% +/- 9.5%; P = 0.052) were greater than those of the control group patients. In addition, the increments of iron (r = 0.368, P = 0.035) and transferrin saturation (r = 0.345, P = 0.049) positively correlated with the decrements of daily aluminum excretion in all patients. The study group patients with greater decrements of serum aluminum (>5.5 microg/L) had greater serum iron levels (90.2 +/- 27.7 microg/dL v 71.9 +/- 27.8 microg/dL; P = 0.047) and transferrin saturation (30.5% +/- 11.0% v 23.0% +/- 9.5%; P = 0.046) than those with less decrements of serum aluminum (<5.5 microg/L) after the study. Our study demonstrates that aluminum kitchen utensils may be the important aluminum exposure source for patients with chronic renal insufficiency who are not taking aluminum-containing agents, and hints that the long-term exposure of aluminum leaching from aluminum utensils probably affects iron levels in patients with chronic renal insufficiency. Further studies are clearly needed to confirm this observation.

Poor pre-dialysis glycaemic control is a predictor of mortality in type II diabetic patients on maintenance haemodialysis.

BACKGROUND: In type II diabetic patients, a better glycaemic control has been reported to slow down the progression of nephropathy. The effect of pre-dialysis glycaemic control on the long term prognosis in type II diabetics on haemodialysis is still uncertain. The purpose of this study is to evaluate the effect of glycaemic control before starting maintenance haemodialysis on the clinical outcome in type II diabetic haemodialysis patients. METHODS: One hundred and thirty-seven type II diabetics receiving regular haemodialysis in a single university hospital were enrolled. The patients were classified as either good or poor glycaemic control group according to their glycaemic control within 6 months before starting haemodialysis. Serum albumin, haematocrit, cholesterol, triglyceride, residual renal function, diabetic complications, and patient survival were analysed in both groups. RESULTS: There was no significant difference in age, gender, predialysis albumin level, cholesterol level, triglyceride level, and residual renal function between the two groups. The 1-year (94.5% vs 80.0%), 3-year (82.9% vs 58.1%), and 5-year (75.8% vs 21.8%) cumulative survival rates were lower in the poor glycaemic control group than in the good glycaemic control group (P < 0.001). The poor glycaemic control group also had more cardiovascular morbidity during the period of dialysis (P < 0.001). The increase in cardiovascular complications also accounted for the increased mortality during the course of haemodialysis. CONCLUSIONS: We conclude that poor glycaemic control before starting dialysis is a strong predictor of cardiovascular morbidity and survival for type II diabetics on haemodialysis. These results imply that better glycaemic control before dialysis might be important in improving the long-term prognosis in type II diabetics on haemodialysis.

Hepatitis B vaccine in hemodialysis patients with hepatitis C viral infection.

Patients on hemodialysis therapy are at a relatively high risk of exposure to hepatitis B virus (HBV) infection. The prevalence of hepatitis C virus (HCV) infection is even higher and was reported as 33.2% in Taiwan. Although the efficacy of hepatitis B vaccine was well documented, the vaccination schedule in hemodialysis patients is not clearly defined. And under such a high prevalence of HCV infection, little is known about the influence of HCV imposing on HBV vaccination. We studied 50 chronic hemodialysis patients who were serologically negative for the hepatitis B surface antigen (HBsAg), the antibody to the hepatitis B surface antigen (anti-HBs) and the antibody to the hepatitis B core antigen (anti-HBc); 26 of them were positive for the antibody to hepatitis C virus (anti-HCV) test. Recombinant hepatitis B vaccine (Engerix-B) 40 micrograms per dose was administered by the intramuscular route at deltoid region at 0, 1, 2, 6 and 12 months respectively to all the patients. Forty-six patients had completed the study. The effective seroconversion rate (serum anti-HBs titer > 10 mIU ml-1) at 1 month after the final vaccine was 76.1% (35/46). The effective conversion rates of the anti-HCV(+) group to the anti-HCV(-) were 75% versus 77.3% (P = 0.857). Geometric mean anti-HBs titers were 177.67 mIU ml-1 versus 189.28 mIU ml-1 (P = 0.867). Our results showed that five-dose injections of HBV vaccine do not present a superior outcome to the four-dose regimen comparing to published data. The status of positivity of anti-HCV do not pose an suboptimal effect on HBV vaccination of hemodialysis patients.

Predialysis glycemic control is an independent predictor of clinical outcome in type II diabetics on continuous ambulatory peritoneal dialysis.

OBJECTIVE: To evaluate the correlation between predialysis glycemic control and clinical outcomes for type II diabetic patients on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: Sixty type II diabetic patients on CAPD were classified into 2 groups according to the status of glycemic control. In group G (good glycemic control), more than 50% of blood glucose determinations were within 3.3-11 mmol/L and the glycosylated hemoglobin (HbA1C) level was within 5-10% at all times. In group P (poor glycemic control), fewer than 50% of blood glucose determinations were within 3.3-11 mmol/L or HbA1C level was above 10% at least once during the follow-up duration. In addition to glycemic control status, predialysis serum albumin, cholesterol levels, residual renal function, peritoneal membrane function, and the modes of glycemic control were also recorded. SETTING: Dialysis Unit, Department of Nephrology of a single university hospital. PATIENTS: From February 1988 to October 1995, 60 type II diabetic patients receiving CAPD for at least 3 months were enrolled. MAIN OUTCOME MEASURES: Morbidities before and during the dialysis period, patient survival, and causes of mortality. RESULTS: The patients with good glycemic control had significantly better survival than patients with poor glycemic control (p < 0.01). There was no significant difference in predialysis morbidity between the two groups. No significant differences were observed in patient survival between the patients with serum albumin greater than 30 g/L and those with less than 30 g/L (p = 0.77), with cholesterol levels greater or less than 5.18 mmol/L (p = 0.73), and with different peritoneal membrane solute transport characteristics evaluated by peritoneal equilibration test (p = 0.12). Furthermore, there was no significant difference in survival whether the patients controlled blood sugar by diet or with insulin (p = 0.33). Cardiovascular disease and infection were the major causes of death in both groups. Although good glycemic control predicts better survival, it does not change the pattern of mortality in diabetics maintained on CAPD. CONCLUSIONS: Glycemic control before starting dialysis is a predictor of survival for type II diabetics on CAPD. Patients with poor glycemic control predialysis are associated with increased morbidity and shortened survival.

Hemostatic and fibrinolytic response to desmopressin in uremic patients.

Desmopressin (DDAVP) 0.3 micrograms/kg was infused in 20 uremic patients with prolong bleeding time. Prior to infusion, the uremic patients had a reduced level of tissue plasminogen activator (t-PA), normal levels of von Willebrand factor antigen (vWF:Ag) and ristocetin cofactor activity (vWF:RCo) and elevated level of factor VIII coagulant activity (FVIII:C). Patients with lower hematocrit or t-PA levels tended to have a longer bleeding time. One hour after DDAVP infusion, the bleeding time was shortened significantly. This improvement was significant in all patient groups irrespective of the high or low initial levels of factor VIII complex components. Plasma levels of FVIII:C, vWF:Ag, vWF:RCo and t-PA all increased significantly. The magnitude of increase in these factors, however, was not significantly correlated with the extent of bleeding time shortening. The multiple regression model for predicting the extent of bleeding time shortening suggested only two variables, viz initial bleeding time and posttreatment FVIII:C activity to be of significance. The present results indicate that the hemostatic response to DDAVP is uniform in uremic patients, regardless of whether the initial activities of factor VIII complex components are high or low. Posttreatment FVIII:C activity appears to play a significant role in the hemostatic action of DDAVP. Furthermore, a depressed fibrinolytic activity was generally observed to concur with the hemostatic defect in uremic patients.

Aluminium-containing agents may be toxic in predialysis chronic renal insufficiency patients.

OBJECTIVE: To investigate the possible toxic effects of long-term low dose aluminium (Al) exposure in predialysis chronic renal insufficiency (CRI) patients (serum creatinine > 1.4 mg dL-1). DESIGN: An open, random, and prospective clinical study. SETTING: The study was carried out at Chang Gung Memorial Hospital, a medical centre of Chang Gung Medical College. SUBJECTS: Seventy CRI patients who have regularly attended a nephrology out-patient department participated in this study. After a 3-month wash-out period 50 were given an Al loading test and 20 received no Al-containing agents. INTERVENTIONS: We used a low dose of Al(OH)3 (one tablet three times day-1, about 302 mg aluminium day-1) for 3 months as an Al loading test. MAIN OUTCOME MEASURES: The study was divided into two phases: phase 1. a basal study to measure serum Al, iron, ferritin, daily urinary Al excretion and renal function status; and phase 2, in which an Al loading test was performed. The phase 1 parameters were measured again after the Al loading test to compare the differences between pre- and post-study in the two groups. RESULTS: We found significant increments of serum Al and daily urinary Al excretion in all study group patients after the Al loading test. The increments of serum Al correlated with basal creatinine clearance (Ccr: r = -0.352, P < 0.05) and basal serum ferritin (r = -0.302, P < 0.05). Serum ferritin was significantly reduced after the Al loading tests, and the reduction (r = 0.357, P < 0.05) positively correlated with the increments of daily urinary Al excretion in the study group patients. However, no significant changes of serum Al, ferritin, and daily urinary Al excretion were noted in the control group patients. CONCLUSIONS: A long-term low dose Al exposure can cause significant Al accumulation and iron store depletion in CRI patients. Therefore, Al-containing agents should be used with caution in patients with CRI.

Clinical experience of recombinant human erythropoietin in uremic children: report of three cases.

Anemia due to decreased erythropoietin production is one of the major complications in uremic patients. The aim of the study is to evaluate the clinical efficiency and safety of rHuEPO in the treatment of anemia in uremic children receiving regular hemodialysis. Three uremic children, age 8, 12, and 14 year-old, under maintenance hemodialysis with hematocrit (Hct) value lower than 20% were observed for 6 months. rHuEPO 50 u/kg were given intravenously three times a week initially. Hct value of 30% was the target of therapy. All 3 children responded to the therapy and reached the target Hct value within 11 to 18 weeks. They received no further transfusion after the therapy. The maintenance dose to keep Hct value around 30% is 75 to 120 u/kg/wk. The serum biochemistry examination showed no difference before and after the therapy. The physical endurance, body weight and height increased in all children. The left ventricular end-diastolic dimension in echocardiography decreased and the ejection fraction increased after 6 months of the treatment. Serum ferritin concentrations decreased in all children. Mild hypertension developed in one child. Heparin dose was increased when the target Hct value was around 30% in 2 children. We suggested that low dose rHuEPO therapy was safe and effective in uremic children, but close monitoring for the development of hypertension and iron deficiency was mandatory.

High flux peritoneal membrane is a risk factor in survival of CAPD treatment.

A high dropout rate is a major problem of continuous ambulatory peritoneal dialysis (CAPD) treatment. Serum albumin is both a significant parameter of dropout in CAPD and a predictor of peritoneal transport category based on the peritoneal equilibration test (PET). High flux peritoneal membrane (HFPM) may lose more protein in the dialysate. We examined the effect of HFPM on the survival of treatment of CAPD. The study was composed of 171 adult patients who had standard PET. The peritoneal transport category was based on their first PET after starting CAPD. The HFPM was defined as the dialysate-to-plasma creatinine concentration ratio (D/P) of more than one standard deviation of the mean (0.702 +/- 0.114; D/P > 0.816). Twenty-two patients had HFPM. The other 149 patients were categorized as the non-high flux group. The high flux group had a significantly lower serum albumin at PET (3.07 +/- 0.15 vs 3.68 +/- 0.05 g/dL, respectively p < 0.0001) and lower mean serum albumin during treatment than the non-high flux group (3.40 +/- 0.20 vs 3.70 +/- 0.04 g/dL, respectively, p = 0.020), and lower net drainage volume (p = 0.0007), but age, diabetes, total Kt/V, and total normalized weekly creatinine clearance were not different between groups. The risk of dropout was higher in the high flux group (p = 0.0127, Cox-Mantel log rank test), and the risk increased, especially after 1.5 years of treatment. Corrected for other risk factors, patients who had HFPM have two times the risk of dropout compared to the non-high flux groups (p = 0.0401, Cox proportional hazards model).

Effect of long-term low-dose aluminum-containing agents on hemoglobin synthesis in patients with chronic renal insufficiency.

To investigate the possible toxic effects of long-term low-dose exposure to A1-containing agents in 55 patients with chronic renal insufficiency (CRI), 37 patients received A1(OH)3 1 tablet 3 times per day (about 302 mg/day of elemental A1) for 3 months and another 18 were used as a control group. The hematological, iron status and A1 data were measured before and after the study. CRI patients who had ingested A1-containing agents for 3 months had significant decreases in hematological parameters and increases in serum A1 and daily urinary A1 excretion. Serum ferritin negatively correlated with serum A1 (r = -0.586, p < 0.0005), and hemoglobin (Hb) positively correlated with renal A1 clearance (r = 0.573, p < 0.0005) and logarithmic transformation of serum A1 (r = -0.437, p < 0.01) in these patients, despite no significant correlations between initially basal hematological and A1 parameters. But there were no significant differences between variables of A1 and hematological parameters before and after 3 months of follow-up in the control group. All factors correlating with Hb were measured with stepwise regression analysis; renal A1 clearance, creatinine clearance (Ccr) and serum iron were the most significant correlation factors with Hb. After Ccr and serum iron had been adjusted, Hb (b = 0.069 +/- 0.02; p < 0.05) still positively correlated with renal A1 clearance. Comparing patients who had reduced Hb (at least 0.5 g/dl) and those who did not, the response group had a lower basal (Ccr, a higher serum A1 and a lower renal A1 clearance after A1 loading for 3 months. In conclusion, A1 does play a role in the significant reduction of Hb and hematocrit in CRI patients after A1 loading for 3 months, and patients with a lower Ccr may easily develop A1-induced hematologically toxic effects. A1-containing agents should be used with care in long-term therapies of CRI patients.

Superinfection with hepatitis C virus in hemodialysis patients with hepatitis B surface antigenemia: its prevalence and clinical significance in Taiwan.

A survey of hepatitis B surface antigen (HBSAG) and antibodies against hepatitis C virus (anti-HCV) in 173 patients undergoing hemodialysis in Taiwan revealed that 15 (9%) patients were positive for both HBSAG and anti-HCV, 106 (61%) were positive for anti-HCV alone, and 14 (8%) were positive for HBSAG alone. Most HBSAg positivity was acquired before the onset of hemodialysis. Anti-HCV positivity, however, was mainly acquired via the hemodialysis procedure. Patients with dual markers were younger (43.7 +/- 3.3 years old, p = 0.0274), had the longest period on hemodialysis (6.6 +/- 1.3 years, p < 0.001), and more severe liver dysfunction. When compared with those who were negative for both markers, patients with both HBSAG and anti-HCV had an increased incidence of chronicity (5/15 vs. 2/38; p < 0.05), ultrasonographic cirrhosis (5/15 vs. 1/38; p < 0.05), and clinical decompensation (2/15 vs. 0/38; p < 0.05). Their risk for developing ultrasonographic cirrhosis and clinical decompensation was also greater than that of patients with anti-HCV alone (5/15 vs. 8/106 and 2/15 vs. 2/106; p < 0.05 for both). The presence of HBSAG alone, however, did not increase the incidence of liver dysfunction. The presence of anti-HCV alone was only associated with a greater elevation of serum alanine aminotransferase (44.2 +/- 5.5 vs. 19.1 +/- 2.5 U/l; p < 0.05) and an increased incidence of chronicity (30/106 vs. 2/38; p < 0.05). Our results indicate that a high prevalence of HCV superinfection impose a significant risk on a large population of HBSAG-positive hemodialysis patients in Taiwan. As the coexistence of anti-HCV and HBSAG is associated with more severe liver dysfunction, it is urgent to devise effective methods to prevent HCV circulation in a hemodialysis environment-especially in a hepatitis B virus endemic area such as Taiwan.

Recovery of respiratory function in survivors with paraquat intoxication.

The purpose of this study was to investigate chest radiograms and respiratory function changes, including pulmonary function tests and alveolar-arterial oxygen difference, in survivors with paraquat intoxication. Chest radiograms and pulmonary function tests for 21 paraquat-poisoned patients were performed 10 d after paraquat intoxication; 3 mo later, the tests were repeated in 16 patients who survived. Forced vital capacity, forced expiratory volume in 1 s, diffusing capacity of the lung, and alveolar-arterial oxygen difference were compromised after paraquat intoxication. Forced expiratory volume in 1 s and forced vital capacity correlated significantly with initial platelet counts (r = .453 and .443, respectively) 10 d after intoxication. The alveolar-arterial oxygen difference also correlated significantly with peak serum total bilirubin concentrations (r = .443) and initial platelet counts (r = .469). The follow-up data for respiratory functions forced expiratory volume in 1 s; 74.33 +/- 27.1% versus 97.89 +/- 16.39%; forced vital capacity: 71.44 +/- 26.03% versus 93.22 +/- 13.92%; diffusing capacity of lung: 60.11 +/- 27.61% versus 81.67 +/- 24.56%; alveolar-arterial oxygen difference: 37.95 +/- 24.32 mm Hg versus 7.75 +/- 9.94 mm Hg) and chest radiograms of survivors with moderate to severe paraquat poisoning showed significant improvements 3 mo after intoxication. The results demonstrated that paraquat-induced respiratory function impairments could recover significantly, at least partially, with time. In addition, pulmonary structure damage improved, as shown in the follow-up chest radiographs.

Human recombinant erythropoietin and phlebotomy in the treatment of iron overload in uremic patients.

Six chronic hemodialysis patients suffering from iron overload (serum ferritin ranged between 2053-15704 mu g/L) were treated with human recombinant erythropoietin (EPO) alone for eighteen months. An initial rapid decrease of serum ferritin was observed in all six patients when the loading dose of EPO was given. Three patients (Cases 4, 5, 6) who suffered from chronic blood loss maintained a continuous decline of serum ferritin in the subsequent stage of maintenance dose EPO therapy, however, the decrease of serum ferritin became sluggish under a maintenance dose in the other three patients (Cases 1, 2 and 3). The serum ferritin eventually decreased to a satisfactory level (975-1761 mu g/L) in Cases 4, 5 and 6, whereas it remained high (4232-8196 mu g/L) in Cases 1, 2, and 3 who had higher basal levels of serum ferritin (5641-15704 mu g/L) and a plateau of response under a maintenance dose of EPO. These three patients were then treated with EPO and phlebotomy. Their serum ferritin decreased quickly from 6752 +/- 1264 mu g/L to 2454 +/- 482 mu g/L after six months of phlebotomy therapy; it was a dramatic improvement in contrast to the stagnant response under a maintenance dose of EPO alone. Our experience indicates that EPO therapy alone has its limitations in treating severe iron overload. Although there is an initial rapid decrease of serum ferritin during the period of the loading dose, the response might become stagnant during the period of maintenance dose. Phlebotomy effectively eliminated the excessive iron stores in these refractory cases. Therefore, we suggest that phlebotomy be considered in severe iron overload if a stagnant response is observed under a maintenance dose EPO therapy.

Comparison for four techniques of catheter insertion in patients undergoing continuous ambulatory peritoneal dialysis.

OBJECTIVE: To compare four different ways of implanting catheters for continuous ambulatory peritoneal dialysis (CAPD) in an effort to reduce the incidence of complications. DESIGN: Retrospective study. SETTING: Teaching hospital, Taiwan. SUBJECTS: 166 Patients who had 180 catheters inserted between 1985 and 1993. INTERVENTIONS: 49 Catheters were inserted through midline incisions (in 24 of which the catheter was fixed with an additional suture) and 131 were inserted through paramedian incisions (in 88 of which the catheter was fixed with an additional suture). MAIN OUTCOME MEASURES: Morbidity, particularly the incidence of migration of the catheter and incisional hernia. RESULTS: 8/68 Catheters migrated in patients in whom no additional fixing suture had been used, compared with 2/112 in whom an additional suture had been used (p = 0.007). There were 4 incisional hernias in 49 midline, compared with 0/131 paramedian, incisions (p < 0.0001). Significantly more catheters had to be removed after midline than after paramedian incisions (35/49 compared with 56/131, p = 0.0008); chi square for independence 15.02, df 3, p = 0.0018. CONCLUSION: For the implantation of catheters for CAPD the paramedian incision is associated with significantly fewer complications than the midline incision and the incidence is even lower if the catheter is fixed to the lower peritoneum with an additional suture.

Urologic cancers in uremic patients.

From 1981 through 1990, 21 urologic cancer cases were discovered in 21 uremic patients at our hospital. This constituted 55% (11 of 20) of the total malignancies in nondialyzed uremic patients, 41% (nine of 22) of the total in chronic hemodialysis patients, and 50% (one of two) of those in patients on continuous ambulatory peritoneal dialysis. No cases of urologic cancer were found in kidney transplant recipients. When compared with the general population, the standardized incidence ratio of kidney cancer in chronic hemodialysis patients was found to be 24.1 (P < 0.01) and that of bladder cancer was found to be 16.4 (P < 0.01). Multiple underlying renal diseases contributed to the development of the urologic cancer cases, including four analgesic nephropathy-associated transitional cell carcinoma cases, two acquired cystic kidney disease-associated renal cell carcinoma cases, two chronic pyelonephritis-associated (stone and tuberculosis) squamous cell carcinoma cases, and one xanthogranulomatous pyelonephritis-associated transitional cell carcinoma case. Uremia per se may be an important promoting factor. Hematuria (17 of 21 cases) was the most common presenting feature despite the fact that most of the patients were anuric. The clinical diagnosis of renal parenchymal tumors was based on ultrasonography (five of five cases), whereas most urothelial tumors were detected by cystoscopy or retrograde pyelography (14 of 16 cases). The survival rate of the 17 aggressively treated patients was 82% at 2 years and 45% at 5 years. We conclude that uremic patients are at greater risk of developing urologic cancer.(ABSTRACT TRUNCATED AT 250 WORDS)