Refractory DKA as first presentation of acromegaly and a potential role for continuous venovenous hemofiltration in its successful management.

Diabetic ketoacidosis is rarely encountered in acromegaly. We present a unique patient with refractory diabetic ketoacidosis (DKA) as a first presentation of acromegaly. In addition to an insulin drip and intravenous fluids, our patient was managed with octreotide therapy. As he developed acute renal failure in the context of renal hypoperfusion, continuous venovenous hemofiltration (CVVH) was instituted. After only three days of therapy, the growth hormone (GH) level dropped circa fourfold and insulin growth factor 1 (IGF-1) level dropped ninefold. We postulate a hypothetical role of CVVH in removal of plasma GH and IGF-1, similar to the clearance of other medium size molecules such as brain natriuretic peptide and procalcitonin. If this is confirmed in future studies, CVVH may have therapeutic implications for the above category of patients.

Self-performed peritoneal dialysis in prisoners.

Peritoneal dialysis (PD)for renal replacement therapy (RRT) is safe and effective in patients with end-stage renal disease (ESRD). Currently, no data exist for the same in patients at correctional institutions [Department of Corrections (DOC)]. We compared demographic characteristics of, and the efficacy and outcome of self-administered continuous ambulatory peritoneal dialysis (CAPD) in, DOC patients with data from the U.S. Renal Data System for the free-living population (FLP). We retrospectively reviewed the charts of DOC patients opting for CAPD (n = 10) in the last 7 years. Baseline data (age, race, cause of ESRD, serum chemistries, anemia, bone profiles, and Kt/V) were obtained for dialysis start and 6 - 12 months after dialysis start. Major events, including switches to hemodialysis (HD), hospitalizations, and deaths, were also studied. The median age of the DOC patients was 45 years. The group was 40% black, 30% white, and 30% Hispanic. Cause of renal failure was diabetes in 30%, HIV-associated nephropathy in 30%, primary glomerular disease in 20%, and hypertension or unknown in 20% of patients. The DOC patients had higher levels of blood urea nitrogen (BUN) at presentation, but better anemia profiles than did the FLP. Complications included peritonitis, fluid leaks, and cardiac events. Median age at dialysis start is lower for DOC patients, and HIV-associated nephropathy is more common than in the FLP. Levels of BUN/creatinine were much higher in DOC patients, but hemoglobin levels were similar to those in the FLP. Hospitalization rates for peritonitis were comparable; cardiac disease was common in both groups. Self-CAPD can be safely and effectively performed in DOC patients.

Blood pressure measurement in dialysis patients.

The best method and timing of blood pressure (BP) measurement in end-stage renal disease are subject to controversy. This issue is especially relevant in hemodialysis patients, where unique causes of inaccuracy may exist. The lack of standardization of BP measurement in the dialysis unit may lead to misdiagnosis, so close attention must be paid to technical methods to obtain BP. A composite of BP measurements over a period of 1 to 2 weeks rather than isolated readings should be used for guidance. Interdialytic BP monitoring with an ambulatory BP monitor is the most reproducible method and is thought to best represent BP in dialysis patients. If available, ambulatory BP is a useful tool to evaluate the quality of BP control in the interdialytic period. Alternative forms of BP measurement, such as home BP, 20-minute postdialysis BP, and short (3-hour to 4-hour) ambulatory blood pressure monitoring (ABPM), could prove useful when feasible or available. In this paper, we discuss the evidence regarding BP measurement in dialysis patients, new techniques under development, and recommendations for clinical practice.