Does parathyroid hormone affect erythropoietin therapy in dialysis patients?

OBJECTIVE: The objective of this study was to assess the response to recombinant human erythropoietin (rHuEPO) during treatment of anemia in dialysis patients with hyperparathyroidism. SUBJECTS AND METHODS: A total of 118 patients with stage 5 renal failure on dialysis therapy were selected for this study. Anemia was treated with rHuEPO. Laboratory data for each patient included intact parathyroid hormone (iPTH), hemoglobin (Hb), hematocrit (Hct), blood urea nitrogen, serum creatinine, calcium, phosphate, and alkaline phosphatase. Patients with iPTH >32 pmol/l were considered hyperparathyroid. Erythropoietin resistance index (ERI) was expressed as the ratio of weekly rHuEPO dose/Hct level. RESULTS: Of the 118 patients, 83 (70.3%) were on hemodialysis (HD) and 35 (29.7%) were on continuous ambulatory peritoneal dialysis (CAPD). Sixty-three patients (64.3%) with iPTH >32 pmol/l had Hb <11 g/dl, while 34 (54.8%) with iPTH <32 had Hb >11 g/dl (p = 04). Thirty-three (56%) patients with iPTH >32 pmol/l had hemocrit <33%, while 38 (61.3%) with iPTH <32 had hemocrit <33% (p = 0.4). The median value of weekly rHuEPO dose in HD patients (12,000 units) was significantly higher in comparison with CAPD patients (6,000 units; p < 0.0001). ERI was significantly higher in HD than CAPD patients with iPTH <16 pmol/l (p = 0002) as well as with patients with 16-32 pmol/l (p = 0.012). CONCLUSIONS: CAPD patients showed a reduced requirement for rHuEPO and better control of anemia compared with HD patients. ERI was also lower in CAPD than in HD patients. Hyperparathyroidism is a parameter predictive of rHuEPO hyporesponsiveness in dialysis patients.

Hypercoagulability, a serious problem in patients with ESRD on maintenance hemodialysis, and its correction after kidney transplantation.

BACKGROUND: Recurrent vascular access thrombosis (VAT) resulting in failure to continue maintenance hemodialysis (HD) therapy is not an uncommon event. The cause of VAT in these circumstances remains uncertain. We describe results of our studies to identify changes in hemostatic balance in patients on maintenance HD therapy that probably contributed to a hypercoagulable state. METHODS: We studied 82 patients with end-stage renal disease on maintenance HD therapy who underwent HD for 11 to 52 months (39.3 +/- 27.4 months). Forty-nine episodes of VAT occurred in 22 patients; a single episode occurred in 12 patients; and 2 or more episodes, in 10 patients. Blood coagulation studies, including assays of inhibitors and activated protein C (PC) resistance (APCR), were performed using standard techniques. RESULTS: Investigations showed the presence of lupus anticoagulant (LA) in 5.6%, anticardiolipin antibody immunoglobulin G (IgG) in 3.9% and IgM in 5.3%, APCR in 20.5%, and deficiencies in protein S (PS), PC, and antithrombin III (ATIII) in 32.1%, 24.4%, and 19.2%, respectively. When parameters were compared between patients with and without VAT episodes, LA, PC, PS, and APCR levels were significantly abnormal in those who experienced VAT. Sixteen subjects with hypercoagulable states on HD therapy underwent renal transplantation and were evaluated 9.3 +/- 4.2 months posttransplantation. Deficiencies in PC (P = 0.014), PS (P = 0.001), ATIII (P = 0.017), and APCR (P = 0.0001) were completely corrected in all subjects. CONCLUSION: Hypercoagulability is a risk factor for recurrent VAT in HD patients, and renal transplantation successfully corrects these abnormalities.

Viability of home peritoneal dialysis: experience with 100 patients from an Arab population.

BACKGROUND: The viability of home peritoneal dialysis (HPD) is being debated in Arab countries. We therefore undertook the present study to assess the viability of HPD in the Arab culture. PATIENTS AND METHODS: A total of 100 patients with end-stage renal failure were treated with HPD during the period January 1996 to October 2001. RESULTS: Continuous ambulatory peritoneal dialysis (CAPD) was performed in 81 patients (81%), and nightly intermittent peritoneal dialysis (NIPD) in 19 patients (19%). The patient group included 54 men (54%) and 46 women (46%) with a mean age of 54.94 +/- 14.58 years. They were followed for a total of 2118.3 patient-treatment months and had a mean dialysis duration of 21.2 +/- 9.97 months. Peritonitis occurred at the rates of 1 episode every 18.5 patient-treatment months (Bieffe L3 double-bag system: Bieffe Medital, Grosotto, Italy), 1 episode every 22.5 patient-treatment months (ANDY Plus system: Fresenius Medical Care, Bad Homburg, Germany), and 1 episode every 23.7 patient-treatment months (NIPD system Fresenius PD-Night: Fresenius Medical Care, Bad Homburg, Germany). Recurrent peritonitis was the main reason (70.6%) for transfer to hemodialysis. A good level of social well-being and rehabilitation was achieved in 49 patients on CAPD (60.5%) and 13 patients on NIPD (68.4%). CONCLUSIONS: We conclude that HPD is a viable modality of renal replacement therapy in Arab countries. By adopting a strict training model, the peritoneal dialysis team can train even patients or caregivers with limited education, preventing peritonitis and promoting the general well-being of patients.

Infection related renal impairment: a major cause of acute allograft dysfunction.

We prospectively analyzed the impact of post-transplant infections on the renal function in 532 stable renal transplant recipients (M=340; F=192) over a period of 5 years. Their age ranged from 3-75 years (40+14 years). During the follow-up period, 52 patients expired and 64 lost on followup. We defined renal impairment (RI) as a persistent rise in serum creatinine above 20% from baseline value. 495 episodes of RI occurred in 269 recipients. This included 180-36% episodes of acute rejection, 53-10.7% Cyclosporine toxicity, 236-47.7% infection related renal impairment [IRRI] and 26-5.3% others. The severity of renal failure is less in IRRI (100+90.2) than that of acute rejection (166+127.1), but was more than that in cyclosporine toxicity (50+42.2). Sites of infection in IRRI were urinary (33%), respiratory (26.3%), septicemia (15.7%) and others (25.4%). Episode of IRRI occurred more frequently in LURD (159-67.4%) compared to LRD-RTR (50-21.2%). Occurrence of IRRI is more significantly higher in patients on triple drug immunosuppression (IS) (34.3%) than those on two drug IS (13.2%) (P=or<0.01). Ecoli (23.1%), Pseudomonas (11.1%), Salmonella (8.8%), Klebsiella (8.8%) and Staphylococai (8.3%) were the major organisms producing IRRI. IRRI is frequent (27.8%) during the first six months. Present study denotes that IRRI is a major cause of acute failure in RTR.