Survival of patients on maintenance haemodialysis over a twenty-year period.

Patient survival is a key index of the overall adequacy of treatment in most chronic diseases. Analyses of survival of patients undergoing haemodialysis is very important, as it may offer clues and ideas for prolonging survival of patients with end-stage renal disease (ESRD). The aims of this study were to describe the characteristics of the patients on maintenance haemodialysis therapy over a period of 20 years, to determine the survival rate of these patients according to ages at the onset of haemodialysis, the primary renal diseases, and the cause of death, and to determine the survival rate at five, ten, fifteen and twenty years of haemodialysis treatment at our centre. The charts of 518 unselected patients, 282 male and 236 female, treated with maintenance haemodialysis therapy in a period of 20 years (1985-2005) were reviewed. At the time of evaluation, 164 patients were currently being treated, and 354 patients overall had been diseased. Statistical analysis was performed to evaluate the relationship between survival and patient characteristics such as age, gender, primary renal disease, and age at dialysis onset. Actual survival rates were determined by the Kaplan-Meier method. The survival rate of our patients treated with maintenance haemodialysis was 60% at 5 years, 37% at 10 years, 25% at 15 years and 9% at 20 years. Female patient survival was superior to male. Patients aged under 40 at the start of dialysis had a better survival probability compared to older patients. Patients with diabetes mellitus and nephroangiosclerosis, had a lower survival rate compared to patients with glomerulonephritis and with adult dominant polycystic kidney disease. Cardiac death was the most common cause of death in patients involved in the study. About 52% of the patients died from cardiovascular disease. Death is the most severe consequence of inadequate dialysis and can be used as an index of the adequacy of the dialysis therapy. Treatment factors that may improve outcomes include an early start of dialysis therapy, a high dose of dialysis (Kt/V over 1.2), correction of anemia, adequate protein and caloric intake, control of calcium and phosphate metabolism, and the use of biocompatible dialyzers.

[Hemolytic uremic syndrome in twin pregnancy at 32 weeks gestation with HELLP syndrome. Case report]. / Sindrome uremico emolitica in gravidanza gemellare alla 32(a) settimana con HELLp syndrome. Descrizione di un caso clinico.

Renal failure occurring in pregnancy or post partum is an unusual but well-described complication. Acute renal failure seems to be associated more often with HELLP syndrome rather than with pre-eclampsia or chronic hypertension. Probable overlapping of HELLP and hemolytic uremic syndrome in pregnancy or postpartum should be taken into consideration when treating pregnant women who show signs of proteinuria, hypertension, hematuria, increase of reticulocytes, decrease of haptoglobin with thrombocytopenia and microangiopathic hemolytic anemia. Our case refers to a 32 year old woman at 32 weeks gestation in twin pregnancy who presented with HELLP syndrome and renal failure. Immediately postpartum oliguria was noted and the laboratory analyses suggested the coexistence of HELLP and hemolytic uremic syndrome. In patients with gestosis and/or HELLP syndrome presenting oliguria combined with a decrease of hemoglobin level not due to intraoperative hematic leaks it is always necessary to ask for haptoglobin dosage. In treating hemolytic uremic syndrome it is very important to use a high dosage of plasma and sometimes plasmapheresis. HELLP syndrome contributes to various complications which are sometimes responsible for kidney or maternal mortality. In treating these patients early diagnosis combined with a specific treatment can considerably reduce kidney and maternal mortality.

Survival of patients on chronic hemodialysis: single center experience.

Patient survival from our hemodialysis (HD) center over the past 11 years was analyzed. Four hundred four patients, 212 female and 192 male, were treated by chronic intermittent HD. Patients were offered standard acetate-cellulosic membranes of 1.0-1.3 m2. During this period 181 patients died. One hundred three patients were transferred to other HD centers, and some were transplanted. One hundred twenty patients are still on HD treatment. The 5 year survival rate of patients treated in our center was 58%. Women lived longer than men, and age correlated significantly with survival rate. Patients with chronic glomerulonephritis and adult polycystic kidney disease had the best survival rates while diabetic patients and those with post hypertensive nephropathy had the poorest survival rates. Forty-four percent of patients had a cardiac related cause of death, cerebrovascular accident was the cause in 15%, and 11% died due to septic condition (infection) while 8% died due to liver disease.

Bioelectric impedance in the estimation of hemodynamic and fluid status in dialysis patients.

In order to estimate the hemodynamic and fluid changes, "dry body weight" and intradialytic stability, electric bioimpedance cardiography was performed in 37 dialysis patients during dialysis procedure, i.e. before, at 2 h and after dialysis. The following parameters were estimated: systemic vascular resistance index-fl. Ohm/m2 (SVRI), mean arterial pressure-Torr (MAP), thoracic fluid conductivity/Ohm (TFC), cardiac index-L/min/m2 (CI), left cardiac work index-kg m/m2 (LCWI) and ejection fraction % (EF). Results were compared with changes in total body water estimated by the urea kinetic model (UKM). The patients were divided into three groups: normotensive (n = 12), hypertensive (n = 15) and hypotensive (n = 10). EF was increased in all the three groups, but only in hypotensives this change was significant (from 40.5 +/- 9.1 to 50.2 +/- 5.41, p < 0.01). The changes in other hemodynamic parameters (CI, LCWI, SVRI) did not reach statistical significance. TFC decreased significantly in all the three groups: normotensive from 0.056 +/- 0.009 to 0.048 +/- 0.009 (p < 0.001), hypotensive from 0.043 +/- 0.009 to 0.035 +/- 0.058 (p < 0.001) and hypertensive from 0.054 +/- 0.016 to 0.045 +/- 0.014 (p < 0.001). These changes were accompanied by a significant decrease in total body water (TBW): from 34.05 +/- 4.19 to 32.72 +/- 4.51 in the hypotensive group, from 34.06 +/- 7.18 to 32.91 +/- 7.27 in the normotensive group, and from 38.92 +/- 7.06 to 37.59 +/- 7.04 in the hypertensive group. The technique was found to be simple, noninvasive and helpful for the estimation of individual hemodynamic changes during dialysis procedure.

[The importance of the metacarpal bone index in the evaluation of uremic osteopathy]. / Znacaj indeksa metakarpalnih kostiju u procenu uremijske osteopatije.

71 patients with chronic renal failure were analysed. The patients were treated (N1 = 32) and not treated (N2 = 39) with chronic intermittent hemodialysis. In all analysed patients and in the control group of 20 patients sex and age matched to the examined groups) the outside (D) the inner diameter of the middle II metacarpal bone of the dominant hand was measured (a precision of 0.1 mm was reached using Yashio, Japan, magnifying glass) and the following "metacarpal" indexes were calculated: 1. Garn's Index:--thickness in the cortical bone in mm (D-d) 2. Nordin's score:--percentage of the cortical bone [formula: see text] 3. Garw's area:--cortical bone surface [formula see text] 4. The quantity of the corical bone thickness and the bone surface [formula: see text] From the results received by the analysis it could be noted that the tested patients with chronic renal failure, regardless of chronic intermittent chronic dialyses, showed a negative interdependence on the relation: "PTH-metacarpal index", that indicates the conclusion that the bone destruction is greater if the levels of plasma C-iPTH are higher. The similar can be noticed with the comparison of the C-iPTH-value of the periostitic lacunas in the cortex of the iliac bone (r = 0.64, i.e. higher concentration of C-iPTH agrees with larger surface of lacunar periostitis). Finally, the thickness of the outer cortex of the iliac bone is smaller if the values of C-iPTH are higher (r = 0.12, patients treated with hemodialysis).

[beta-Interferon in the therapy of cervico-vaginal papilloma virus (HPV) infection associated with cervical intraepithelial neoplasia (CIN)]. / beta-interferone ed infezioni cervico-vaginali da papilloma virus (HPV) associate a neoplasia cervicale intraepiteliale (CIN).

58 patients suffering from HPV infection associated with CIN were treated using human fibroblast interferon, via an intramuscolar route, with positive results (87.9% of cases).

Hantaan virus infection with acute renal failure.

We report on 10 patients with acute renal involvement in Hantaan virus infection observed at the Department of Nephrology, Faculty of Medicine, Skopje, Republic of Macedonia, during a period of 3 years (October 1987-July 1990). Eight patients were male and 2 were female, aged 37.5 +/- 4.8 years. The diagnosis of Hantaan virus infection was proven by an indirect immunofluorescent and ELISA test with a significant increase of the titer after a week to ranges from 1:512 to 1:2,048. Percutaneous renal biopsy was performed in 3 cases using standard procedures for optical and immunofluorescent microscopy. Fever, weakness, headache, conjunctival injection, hematuria, and lumbar pain were clinical features all patients had in common. Complete anuria was noted in 7 out of 10 and oliguria in the other 3 of the 10 cases with serum levels of creatinine 967 +/- 152.6 mumol/L. Other following laboratory findings were leukocytosis in 10 out of 10 patients, with neutrophylia, and reduction of serum sodium and potassium in 8 out of 10, and a decrease in serum complement C3 in 3 out of 10 patients. Percutaneous renal biopsy confirmed interstitionephritis in 2 out of 3 biopsied patients and acute diffuse proliferative glomerulonephritis in the third. Interstitial mononuclear infiltration with dominant T cells proven with monoclonal antisera (direct immunoperoxidase method) was present in all 3 cases. The outcome of the disease was good in 8 of the 10 patients with a development of polyuric phase and complete recovery of renal function later. One patient with interstitial lesions on biopsy developed chronic renal failure, and the other with a concomitant brucellosis died during the polyuric phase of the disease.

Analysis of heart morphology and function following erythropoietin treatment of anemic dialysis patients.

In a two-way study, we treated renal anemia in chronic hemodialysis patients with recombinant human erythropoietin (rh-EPO) and followed heart morphology and function dynamics by echocardiography. Thirty-eight patients were randomly divided in two equal groups: the therapy group, treated with rh-EPO for 24 months, and the control group, not treated during the first 12 months and treated with rh-EPO during the second 12 months. Anemia was corrected, and hematocrit was maintained between 30 and 35 vol% by subcutaneous rh-EPO administration. Echocardiographic assessment was performed at the end of the untreated control phase and was repeated after 12 months of rh-EPO treatment in the control group and after 12 and 24 months of treatment in the therapy group. The results revealed significant morphologic, hemodynamic, and eventually functional changes. After 12 months of rh-EPO treatment, the end-diastolic volume (EDV) decreased from 135.8 +/- 23.7 to 109.8 +/- 25.3 ml, p < 0.001; stroke volume (SV) from 91.9 +/- 17.6 to 71.3 +/- 12.4 ml, p < 0.001; left ventricular mass-Devereux (LVMD) from 297.2 +/- 57.8 to 218.0 +/- 50.4 g, p < 0.01; cardiac output (CO) from 7,279 +/- 1,932 to 5,711 +/- 1,276 ml/min, p < 0.002; total peripheral resistance (TPR) rose from 1,330 +/- 390 to 1,707 +/- 373 dynes x s/cm5, p < 0.007. After 24 months, LVMD decreased further from 224.6 +/- 43.1 to 195.7 +/- 46.3 g, p < 0.004. The relaxation time index (RTI) decreased from 64.7 +/- 20.4 to 52.4 +/- 18.0 ms, p < 0.045, suggesting improved diastolic function.(ABSTRACT TRUNCATED AT 250 WORDS)

Autonomic nervous system dysfunction and volume nonresponsive hypotension in hemodialysis patients.

Studies were conducted in 9 dialysis patients with volume-nonresponsive hypotension, 6 dialysis patients with volume-responsive hypotension and in 10 normal subjects in an effort to evaluate the role of dysfunction of the autonomic nervous system (ANS) in the genesis of volume-nonresponsive hypotension. ANS function was evaluated by the Valsalva maneuver, handgrip exercise, and by the response of heart rate and blood pressure to change of posture from a supine to a standing position. Patients with volume-nonresponsive hypotension displayed significant derangements in the function of ANS as compared to normal subjects and to patients with volume-responsive hypotension. Data show that dysfunction of ANS plays an important role in the genesis of volume-nonresponsive hypotension in dialysis patients.

Hypersensitivity reactions to ethylene oxide: clinical experience.

A hypersensitivity reaction occurring in the first minute of the dialysis procedure was observed in seven haemodialysis patients in one day. Hollow-fibre dialysers were used, five made of saponified cellulose ester (SCE) and two of cuprammonium cellulose (CC). All were sterilised with ethylene oxide (ETO) and used for the first time. The severity of the reactions was grade 2. The whole series of dialysers was examined for the presence of ETO concentration. A significantly higher concentration of ETO was found in the polyurethane potting than in the capillaries. The ETO concentrations were 122, 185, 440, 274, 342, and 280 p.p.m. in the following dialysers: Cordis Dow (cellulose acetate CA), Cordis Dow-Plivadial (SCE), Fresenius C-1.3 (CC), Fresenius E-2 (CC), Fresenius E-3 (CC), and Travenol-Medial S 11 flate plate (CC) respectively. According to the clinical signs, ETO concentrations in the dialysers and the lack of reaction when extensive rinsing was used, it can be presumed that these reactions are related to ETO although other mechanisms cannot be excluded.

Cervical intraepithelial neoplasia. Therapeutical trends.

CIN is an intraepithelial alteration of unpredictable development. Its presence may require in the case of CIN 1 only periodical colposcopy and cytology, while in the presence of CIN 2 or CIN 3 a complete removal of the lesion is necessary. Surgery must be "personalized". Sometimes when the excision is large, it may be necessary to follow with hemostatic suture in order to reconstruct the portio.

Toxoplasmosis. Two observations and a specification.

On the basis of two interesting observations of toxoplasmic disease the Authors attempt to interpret the various pathological pictures, comparing two different formulations of toxoplasmic disease: that of Sabin and that of more modern AA.