Phosphate mass removal during hemodialysis: a comparison between eKT/V-matched conventional and extended dialysis.

BACKGROUND AND OBJECTIVES: The control of hyperphosphatemia is an unmet need in dialysis care. Compared to conventional hemodialysis (cHD), extended hemodialysis (eHD) appears to more easily control blood phosphate levels in chronically dialyzed patients. Here, we sought to compare eKT/V-matched cHD and eHD procedures in order to quantify the contribution of dialysis prescription and time in the mass removal of phosphate. METHODS: Eight stable hemodialysis patients with negligible residual renal function underwent cHD and eHD sessions adjusted to provide the same eKT/V(urea). Total dialysate, total and hourly partial dialysate and blood samples were collected for comparison of mass extraction of urea, creatinine, and phosphate. RESULTS: Mean eKT/V(urea) was similar in eHD and cHD (1.30 vs. 1.28, p = nonsignificant). Likewise, mass removal of urea and creatinine during cHD and eHD were not significantly different. Conversely, phosphate mass removal was 40% higher with eHD as compared to cHD (1,219 ± 262 vs. 858 ± 186 mg, p = 0.015). Although hourly mass removal of phosphate was higher during cHD, the prolonged period of lesser but continuous removal was responsible for higher total phosphate elimination during eHD. CONCLUSION: In dialysis sessions matched to provide a similar eKT/V(urea), removal of phosphate increases by 40% when time is extended from 4 to 8 h. Urea-based adequacy models cannot be used to predict the amount of phosphorus removal during hemodialysis.

Long-term outcome of renal transplantation at a university center in Rio de Janeiro between 1975 and 2000.

This study reports the 25-year experience of a single university center with respect to the impact of selected variables on long-term survival and half-life of 742 transplants. We calculated 1-, 5-, and 10-year Kaplan-Meier survival rates for grafts and patients, with separate analyses for HLA match and for each quinquennium. We also investigated the impact of cyclosporine administration and OKT3 induction. Global graft and patient survival rates were 85.2%, 61.0%, and 43.5% and 93.0%, 78.9%, and 66.6% for 1, 5, and 10 years, respectively. The half-life of 23.3 years for the 105 HLA-identical transplants was significantly better (P <.0001) than that for all other matches. Half-lives for 319 1-haplotype matched, 116 living-unrelated, and 153 cadaver grafts were 8.2, 5.7, and 5.6 years, respectively. No survival advantage was noted among these other matches. Introduction of cyclosporine in all non HLA-identical transplants and OKT3 induction for cadaver grafts conferred significant survival advantages compared with no use (P =.0002 and P =.009). There has been a continuous improvement in the long-term results in each quinquennium studied.

Is hepatitis C a risk factor to posttransplant diabetes mellitus after renal transplantation in patients using tacrolimus?

The objective of this study was to evaluate the association between previous hepatitis C virus (HCV) infection and the occurrence of posttransplant diabetes mellitus (PTDM) among patients undergoing kidney transplants using tacrolimus (FK). From August 1999 to January 2003, 66 patients (36.4 +/- 15.5 years) underwent kidney transplantation using an immunosuppressive regimen of tacrolimus, mycophenolate mofetil, or azathioprine and steroids. Thirty-four patients (52%) received kidneys from living donors and 32 (48%) from cadaveric donors. The diagnosis of diabetes mellitus was established after two consecutive ambulatory measurements of fasting glycemia > or = 126 mg/dL. Thirty-five percent of the patients (23/66) were HCV+ and 65% (43/66) HCV-. Of the 66 patients, 33% (22) developed PTDM, 19 (82%) from the HCV+ group and only 3 (7%) from the HCV- group. Among those who developed PDTM, the diagnosis was established in the first 2 posttransplant months in most cases (68.2%). The results showed a significant association between HCV and PTDM (P < or = .0001). In this group of patients HCV infection was strongly associated with the development of PTDM. Therefore, additional care is required regarding the immunosuppressive regimen among patients with chronic HCV infection.

Calcium acetate versus calcium carbonate in the control of hyperphosphatemia in hemodialysis patients.

CONTEXT: Hyperphosphatemia has an important role in the development of bone and mineral abnormalities in end-stage renal disease (ESRD). OBJECTIVE: To compare the phosphorus binding power and the hypercalcemic effect of calcium acetate and calcium carbonate in hemodialysis patients. TYPE OF STUDY: Crossover, randomized, double-blind study. PLACE: A private hospital dialysis center. PARTICIPANTS: Fifty-two patients who were undergoing regular hemodialysis three times a week ([Ca++] dialysate = 3.5 mEq/L). PROCEDURES: Half of the patients were started on 5.6 g/day of calcium acetate and, after a 2 week washout period, received 6.2 g/day of calcium carbonate. The other half followed an inverse protocol. MAIN MEASUREMENTS: Clinical interviews were conducted 3 times a week to monitor for side effects. Determinations of serum urea, calcium, phosphorus, hematocrit, Kt/V and blood gas analysis were obtained before and after each treatment. RESULTS: Twenty-three patients completed the study. A significant increase in calcium plasma levels was only observed after treatment with calcium carbonate [9.34 mg/dl (SD 0.91) vs. 9.91 mg/dl (SD 0.79), P < 0.01]. The drop in phosphorus levels was substantial and significant for both salts [5.64 mg/dl (SD 1.54) vs. 4.60 mg/dl (SD 1.32), P < 0.01 and 5.89 mg/dl (SD 1.71) vs. 4.56 mg/dl (SD 1.57), P < 0.01, for calcium acetate and calcium carbonate respectively]. The percentage reduction in serum phosphorus (at the end of the study) per milliequivalent of salt administered per day tended to be higher with calcium acetate but statistical significance was not found. CONCLUSION: Calcium acetate can be a good alternative to calcium carbonate in the handling of hyperphosphatemia in ESRD patients. When calcium acetate is used, control of hyperphosphatemia can be achieved with a lower administration of calcium, perhaps with a lower risk of hypercalcemia.

Thalidomide for the treatment of uremic pruritus: a crossover randomized double-blind trial.

Our observation that thalidomide administration to a dialysis patient with leprosy alleviated his pruritus led us to conduct this short-term study to assess the efficacy of the drug in this regard. From 210 hemodialysis patients, 29 cases of refractory uremic pruritus were entered into the study. Patients were instructed to score their symptoms from 0 to 3, three times a day and assigned to receive thalidomide or placebo at bed time for 7 days. After a washout period of 7 days, drugs were crossed over. Response was defined as a reduction of at least 50% in the pruritus scoring. Eighteen patients finished the study. In the first phase, 55% of patients responded showing a mean reduction in their pruritus scoring of 78% (p < 0.05 vs. placebo); no response to placebo was observed. A similar proportion of patients responded to thalidomide in the second phase with a mean reduction in their pruritus scoring of 81%. In conclusion, thalidomide can be a precious tool in the handling of uremic pruritus unresponsive to available therapy.

Hepatitis C virus in chronic hemodialysis patients with non-A, non-B hepatitis.

Sixteen of 110 hemodialysis (HD) patients fulfilling criteria of non-A, non B hepatitis (NANBH), i.e. alanine aminotransferase (ALT) greater than 50 U/ml in the absence of both serologic markers for acute HBV and HAV infections and clinical evidence of another cause of hepatitis, were tested for the presence of antibodies against hepatitis C virus (anti-HCV) by enzyme immunoassay (Ortho, Diagnostics). All (100%) were anti-HCV-positive. There were 5 patients with a monophasic (M) rise pattern (1 or 2 ALT rises), and 11 cases demonstrated a polyphasic (P) rise elevation pattern (more than 2). The mean ALT value of the M group was 202.3 +/- 209 U/ml and that of the P group was 116.6 +/- 39.1 U/ml. The patients received a mean of 19.1 +/- 16.2 units of packed red cells during the follow-up period (69.9 months). Only 1 patient received no blood transfusion. Six patients had a past HBV infection and 3 became HIV-infected in the course of this study. The high rate of infection of hemodialysis patients with hepatitis C virus in our setting points to the need for improved control measures.

[Infectious endocarditis in patients on periodic hemodialysis]. / Endocardite infecciosa em pacientes em hemodiálise periódica.

Nineteen patients originating from four hemodialysis centers with infectious endocarditis (IE) were studied during the period of 1985-1989. It was observed high proportion of patients with apparent normal cardiac valves preceding the IE; in 68.42% (13 out of 19 cases) there was an association with vascular access infection, the dialysis treatment time had a variation from 5 days to 6 years (median 19.5 months) and the interval between the initial symptoms and the IE diagnosis was from 2 to 30 days with an average of 5 days. The echocardiogram showed vegetation in 18 cases studied. The mostly affected cardiac valves were mitral in 42.1% and aortic in 31.5%. The predominant organism was S. aureus (75%). In 8 cases the primary focus was identified as the hemodialysis catheter and in 6 others as the arteriovenous fistula, one patient presented infection in both access simultaneously. The outstanding clinical manifestations were embolic (12 out of 19 cases) neurological (13 out of 19) and of cardiac failure (13 out of 19). The median hospitalization time was 24 days (4-55 days) and the mortality rate was 68.4%, the majority of sepsis. The authors emphasize the large proportion of cases linked to hemodialysis catheters and propose an increase in the infectious preventive measurements in those patients.

Migracao leucocitaria "in vivo" em pacientes submetidos a dialise peritoneal periodica. / \"In vivo leucocyte migration in patients under chronic peritoneal dialysis

Analisou-se o conteudo celular dialitica drenada da cavidade peritoneal, durante dialise peritoneal, em cinco pacientes com insuficiencia renal cronica. As celulas obtidas mostraram sempre viabilidade maior que 90%, e foram analisadas pelo metodo de Giemsa e metodos citoquimicos para esterase acida e mieloperoxidase. No inicio do procedimento dialitico, observou-se um pico celular composto basicamente por fagocitos mononucleares, linfocitos e eosinofilos. Em tres dos cincos pacientes, apos grande reducao do numero de celulas drenadas da cavidade peritoneal, observou-se um segundo pico celular composto principalmente por neutrofilos, com desaparecimento de outros tipos celulares. Este segundo pico celular nao foi observado em outros dois pacientes, o que sugere a existencia de diferentes padroes de migracao leucocitaria para cavidade peritoneal

Heterogeneidade de resposta do hospedeiro ao virus da hepatite B. / Heterogeneity of host response to hepatitis B virus

O comportamento de 36 pacientes de uma Unidade de depuracao e transplante renal, cuja taxa de ataque pelo virus da hepatite B era 35% ao ano, foi analisado pelo periodo de 3 anos.Pesquisaram-se o antigeno de superficie da hepatite B (AgHBs) e seu anticorpo (anti-HsB) e o anticorpo contra o antigeno central do virus (anti-HBc) no soro e ambos os antigenos AgHBs e AgHBc no tecido hepatico, correlacionando-se estes dados com os aspectos histologicos das biopsias hepaticas. Vinte e dois pacientes mostraram um ou mais dos marcadores imunologicos da hepatite B e sao objeto do presente trabalho. Dezesseis apresentaram AgHBs no soro em algum momento do acompanhamento,sendo que em 11 pacientes houve permanente persistencia da positividade. A biopsia hepatica demonstrou hepatite cronica em 6 destes casos e alteracoes inespecificas ou ausencia de alteracoes nos demais. A concomitancia de AgHBs e AgHBc em tecido so foi observada em casos de Hepatite cronica com uma excecao. AgHBs isolado foi encontrado em lesoes hepaticas e em um caso de hepatite cronica persistente. Hepatite viral aguda, B, clinicamente diagnosticada ocorreu em 4 casos tendo 3 evoluido para cura clinica ou histologica e um para hepatite cronica

Histocompatibility antigens and insulin-dependent diabetes: a study of 20 Brazilian families.

1. The relationship between histocompatibility antigens (HLA) and insulin-dependent diabetes was examined. The relative frequency of HLA and the relative risk were determined for 20 families containing 82 individuals, 23 of whom had insulin-dependent diabetes. The control group contained 102 individuals. 2. The B8, B13, and B15 antigens had the highest relative frequency in the group of diabetic patients, whereas B5, B7 and B12 were lowest. A high relative frequency of histocompatibility antigens was found not only in the diabetic patients, but also in their parents and siblings. There was a predominance of A2B8, A2B15, and A9B15 haplotypes in the diabetic population. The diabetic siblings had identical haplotypes. 3. These data support previous reports suggesting genetic linkage between susceptibility to diabetes and the histocompatibility antigen system.

Histocompatibility antigens and insulin-dependent diabetes: a study of 20 brazilian families

The relationship between histocompatibility antigens (HLA) and insulin-dependent diabetes was examined. The relative frequency of HLA and the relative risk were determined for 20 families containing 82 individuals, 23 of whom hda insulin-dependent diabetes. The control group contained 102 individuals. 2 The B8, B13, and B15 antigens had the highest relative frequency in the group of diabetic patients, whereas B5, B7 and B12 were lowest. A high relative frequency of histocompatibility antigens was found not only in the diabetic patients, but also in their parents and siblings. There was a predominance of A2B8, A2B15, and A9B15 haplotypes in the diabetic population. The diabetic siblings hda identical haplotypes. 3. These data support previous reports suggesting gwenetic linkage between susceptibility to diabetes and the histocompatibility antigen systen

Antigenos de histocompatibilidade e diabetes insulino-dependente: estudo em familias. / Histocompatibility antigens and insulin-dependent diabetes: a study in families

Foram estudadas 20 familias de individuos com diabetes insulino-dependente, em um total de 23 pacientes, visando a determinar a frequencia dos antigenos de historia compatibilidade e calculo do risco relativo. Foi observada maior frequencia dos antigenos B8, B13, e B15 e menor de B5, B7, e B12, na populacao diabetica. Para os antigenos nos quais se observou frequencia superior nos diabeticos, o fenomeno tambem ocorreu entre pais e irmaos. Tal situacao, entretanto, nao se repetiu quando a frequencia era mais baixa entre os diabeticos. Na populacao diabetica, houve predominancia dos haplotipos A2B8, A2B15, A9B13, e A9B15. Todos os irmaos diabeticos apresentavam haplotipos identicos, o que sugere a provavel segregacao de genes de suscetibilidade a doenca com o sistema HLA