Is decreased treatment time in hemodialysis patients harmful if solute clearance is maintained?

An association between decreased duration of hemodialysis and increased morbidity and mortality in patients has been suggested. Whether this is due only to decreased solute clearance is unclear. In this prospective randomised study the effect of reducing treatment time whilst maintaining constant solute clearance was examined in fourteen patients. The study lasted for a period of 36 weeks (3x12 week study periods) and used a crossover design. The patients dialysis prescription (KW) was not changed on entering the study and was maintained during short (150 minutes) and long dialysis (240 minutes) by varying blood flow, dialysate flow and dialyzer surface area. The delivered KW was kinetically assessed. Fractional urea clearance was also measured during each treatment period by measurement of urea concentration in spent dialysate and total body water using 3H2O. At the end of each treatment period a full biochemical and hematological profile, nutritional intake and status, 24 h ambulatory blood pressure, nerve conduction studies, and quality of life questionnaire were performed. Within patients the delivered single pool KW was uniform throughout the 3 treatment periods and fractional urea clearance did not vary. However, Kt/W assessed using equilibrated models (Daugardis and Smye) was significantly lower in the short dialysis period. No differences between short and long dialysis sessions were noted in any of the measured variables. Thus, over a 36 week period there is no evidence to suggest that hemodialysis patients are adversely affected by decreased duration of treatment provided that solute clearance is maintained.

Long-term follow-up of kidney donors: a longitudinal study.

BACKGROUND: Kidney donors are not adversely affected by compensatory hyperfiltration of the remaining kidney in the early years after nephrectomy, but longterm longitudinal studies are lacking. METHODS: The renal function and blood pressure of 75 donors was evaluated in 1984, 1.4-20.7 years after surgery. Forty-seven of the original cohort (23 male, age 38-80 years) underwent repeat study a decade later (12-31 years post-nephrectomy), using identical laboratory techniques. RESULTS: Glomerular filtration rates (GFR) as measured by 51Cr EDTA clearance was relatively unchanged a decade later with 41 of 47 subjects (87%) having EDTA clearance within the normal laboratory reference range at review. The change in GFR in the remaining six subjects was statistically not significant. No correlation between GFR and time after nephrectomy was detected. Albumin excretion rate (AER), on timed overnight urine collections, was increased (> 20 micrograms/min) in 16 subjects (34%), although 14 of these individuals were also hypertensive. The prevalence of hypertension was significantly increased compared with age/sex matched data from epidemiological studies of the general population (both in the UK and the US), especially in those over the age of 55 years. CONCLUSION: This study demonstrates that the function of the solitary kidney is not adversely affected by prolonged compensatory hyperfiltration, although there appears to be an increased prevalence of microalbuminuria and hypertension. Regular follow-up of kidney donors is recommended in order to manage their complications effectively and to detect hypertension and or renal impairment early in those who may develop it.

Withdrawal of renal replacement therapy in Newcastle upon Tyne: 1964-1993.

BACKGROUND: Termination of renal replacement therapy (RRT) is common in North America and Australia but is considered to be rare in Europe. METHODS: In order to review the phenomenon of RRT termination in all patients treated in Newcastle upon Tyne between 1964 and 1993 a retrospective study of clinical case notes was undertaken. In all RRT patients sex, age at start of RRT, renal diagnosis and history of RRT were recorded. In addition, mortality data and marital and residential status were recorded in all patients who died, and Karnofsky index, bodyweight, complications, history of bereavement, place of death, overall survival, survival after withdrawal of treatment, other medical problems, higher mental function and surgical history in all patients stopping treatment. RESULTS: 1639 patients started RRT between 1964 and September 1993 inclusive. Eighty-eight patients were identified in whom death was a result of treatment being stopped (17% of all deaths). The first was in 1985. In these patients, age was greater (62 vs 47 years, P < 0.001) and diabetes was more prevalent (15 vs 7%, P < 0.03) than in the total RRT population. The Karnofsky index was 70 at the start and 33 at withdrawal of treatment (P < 0.001). The Karnofsky index at the start of RRT was weakly related to that at withdrawal and overall survival (r = 0.36 and 0.28 respectively, P < 0.01). The Karnofsky index at treatment withdrawal correlated with the following survival (r = 0.40, P < 0.001). The median survival of patients stopping treatment was significantly lower than in all RRT patients (16 vs 74 months, P < 0.001) and the majority survived less than 2 years. After dialysis withdrawal the median survival was 8 days, 15 patients survived 3 days or less and 19 more than 10 days. The majority (80%) received terminal care in hospital. At treatment withdrawal 11 patients were demented and 34 showed signs of early dementia. Seventy-eight patients (89%) stopped treatment as a consequence of multiple medical problems. The possibility of dialysis withdrawal was raised by physicians in 50.5%, the patient in 23.8% and the patients' relatives in 21.9% of cases. Four patients (3.8%) committed suicide. CONCLUSIONS: Death from dialysis termination is a relatively common cause of death in RRT patients in Newcastle upon Tyne. These patients are older with a higher prevalence of diabetes. In 89% of cases the decision to stop treatment was related to multiple medical problems with a recent deterioration. Physicians raised the issue of withdrawal in the majority of cases and most patients subsequently received terminal care in hospital.

A comparison between oral ciprofloxacin and intraperitoneal vancomycin and netilmicin in CAPD peritonitis.

This report describes a prospective, randomized comparison of oral ciprofloxacin and intraperitoneal vancomycin/netilmicin in the treatment of 50 consecutive episodes of CAPD peritonitis in 35 patients. Successful cure of peritonitis was achieved in 76% of subjects taking oral ciprofloxacin and 72% of those given intraperitoneal antibiotics. Satisfactory concentrations of ciprofloxacin in dialysate were achieved in all patients. Failure of ciprofloxacin was due to persistence of an isolate of intermediate sensitivity (1), to persistence with acquisition of resistance (1), and to relapse/reinfection in the remaining four cases (with resistant or moderately sensitive strains in three cases). Ciprofloxacin was well tolerated in the majority of cases. A significant rise in serum creatinine was noted in almost all patients taking oral ciprofloxacin. The advantages of oral drug administration indicate that oral ciprofloxacin is the preferred first-line treatment of CAPD-associated peritonitis.

Renal replacement treatment for diabetic patients in Newcastle upon Tyne and the Northern region, 1964-88.

OBJECTIVES: To review the experience of renal replacement treatment in diabetic patients treated in Newcastle upon Tyne and the Northern region from 1964 to 1988, and to compare the morbidity and mortality of diabetic patients treated with dialysis or transplantation with those of matched controls of non-diabetic patients. DESIGN: Retrospective study of clinical case notes. SETTING: Renal units of the Northern region, particularly that in Newcastle upon Tyne. PATIENTS: All 65 diabetic patients treated by renal replacement treatment in Newcastle upon Tyne from 1964 to 1987; 42 diabetic patients were matched with 42 non-diabetic patients according to age, sex, year of starting treatment, and type of treatment (dialysis or transplantation). MAIN OUTCOME MEASURES: Sex, age, renal biopsy findings, blood pressure, history of diabetic treatment, and plasma creatinine concentration at the start of renal replacement treatment. History of renal replacement treatments, suitability for transplantation, history of transplantation, cumulative survival, and cause of death during follow up. Survival of technique, cumulative survival of the first peritoneal catheter and history of peritonitis in patients treated with continuous ambulatory peritoneal dialysis; source of graft, histocompatibility antigens, duration of associated stay in hospital, and graft survival in patients receiving renal or pancreatic transplant. RESULTS: 1259 Patients with chronic renal failure were accepted for renal replacement treatment in Newcastle upon Tyne, of whom 65 (5%) had diabetes. The first was accepted in 1974, and between 1974 and 1980 another 15 were treated (mean age 42 years; 4% of new patients). From 1981 to 1987, 49 diabetic patients (mean age 44; 9% of new patients) were treated. Fifty patients (77%) had insulin dependent diabetes and the remaining 15 (23%) non-insulin dependent diabetes. On average, the patients were aged 25 (range 5-57) when diabetes was first diagnosed and 44 (range 24-70) at the start of renal replacement treatment. The mean age at the start of treatment was 40 for patients with non-insulin dependent diabetes and 58 for patients with non-insulin dependent diabetes. Transplantation was performed in 33 of the diabetic patients, whose mean age was lower than that of those who did not receive a transplant (41 v 48 respectively, p less than 0.05). Comparison between the 42 diabetic patients and matched controls showed that the overall survival at five years was 46% and 77% respectively. The three year survival of the diabetic patients who did not receive a transplant was poor (41% v 79% respectively). Of patients transplanted, survival at five years was 73% in the diabetic patients and 90% in the controls. However, there was no significant difference in the five year graft survival (64% v 46% respectively). CONCLUSIONS: Diabetes adversely affects morbidity and mortality in patients having renal replacement treatment, but renal transplantation seems to be the best option for treating diabetic patients with end stage renal failure.

Long term survival on haemodialysis in primary hyperoxaluria.

Results of treatment of end-stage renal failure (ESRF) in patients with primary hyperoxaluria have been generally poor, largely due to the inability of any treatment regime to match the endogenous overproduction of oxalate. The severity of the disease varies widely, as reflected by the differences in age at onset of ESRF. This variability may influence the results of treatment of ESRF in these patients. The longest reported survival on haemodialysis of a patient with primary hyperoxaluria is eight and a half years. We report a patient who survived for eleven years on haemodialysis after reaching ESRF due to primary hyperoxaluria, and suggest that this prolonged survival was due to relatively mild disease severity rather than exceptional treatment.

Mediastinal haematoma caused by subclavian catheterisation for haemodialysis.

A 59 year old woman developed a mediastinal haematoma after placement of a subclavian haemodialysis catheter. Vascular perforation by the guide wire used during catheterisation was the probable cause. The use of guide wires with a flexible J-shaped terminal portion is recommended to minimise this risk.

Effect of a high protein diet in patients with the nephrotic syndrome.

1. Twelve patients with the nephrotic syndrome were prescribed for 4 week periods a normal protein diet (NPD) containing 1 g of protein/kg ideal body weight. They were then prescribed for further 4 week periods in random order diets with high (HPD) and low (LPD) protein contents, respectively 2.0 and 0.5 g/kg ideal body weight. 2. Compliance was confirmed by dietary history and measurement of urinary excretion. 3. Serum albumin was the same on all diets. Twenty-four hour urinary protein excretion increased progressively with increasing dietary protein (LPD 6.1 g. NPD 8.2 g. HPD 9.2 g). Recumbent plasma renin activity and serum phosphate were significantly increased on HPD (plasma renin activity: LPD 5.7, NPD 4.6, HPD 8.2 pmol of angiotensin I min-1 1(-1); serum phosphate: LPD 1.27, NPD 1.26, HPD 1.41 mmol/l). 4. There was no evidence of protein-induced hyperfiltration or hyperperfusion: 51Cr-ethylenediaminetetra-acetate and [125I]iodohippurate clearances were similar on all three diets. 5. Since proteinuria, increased plasma renin levels and hyperphosphataemia may contribute to progression of renal failure and because HPD did not improve hypoalbuminaemia, the use of HPD in the nephrotic syndrome should be abandoned. 6. Until it can be established that LPD, which is accompanied by the least proteinuria, does not, with long-term feeding, lead to malnutrition, NPD should be used in the treatment of the nephrotic syndrome.

End-stage renal failure due to multiple myeloma--poor survival on peritoneal dialysis.

This report describes five subjects with end-stage renal failure due to multiple myeloma. All of the patients died within seven months of commencing chronic peritoneal dialysis. Complications were frequent during the dialysis period. Our experience supports the opinion that patients with multiple myeloma and a high tumour cell mass should not be offered dialysis.

Urinary enzyme excretion after donor nephrectomy.

A number of recent studies of long-term kidney donors have reviewed glomerular function and blood pressure. Little attention has been paid to the potentially damaging effects of compensatory hyperfiltration on renal tubular cells after donor nephrectomy. The urinary excretion of high-molecular-weight enzymes is a sensitive indicator of renal tubular cell damage. This study compares the urinary excretion of four enzymes (alanine aminopeptidase, alkaline phosphatase, N-acetyl-beta-D-glucosaminidase, and lactate dehydrogenase) in a group of 77 subjects who had undergone unilateral nephrectomy up to 21 years previously with 52 healthy non-nephrectomized controls. The urinary excretion for all four enzymes by the remaining kidney after contralateral nephrectomy in the kidney donors was significantly greater than the enzyme excretion per single kidney in the control group (p less than 0.001). No correlation was found between the degree of enzymuria and either glomerular filtration rate or time since nephrectomy. The elevated activity of urinary enzymes in kidney donors may be related to increased metabolism by the renal tubular cells after contralateral nephrectomy. This study suggests that long-term compensatory hyperfiltration does not damage tubular cells, at least over this time scale.

Renal replacement therapy in patients aged over 60 years.

The availability of dialysis for patients with end-stage renal failure in the United Kingdom has lagged behind that in most of the rest of Europe and USA, although there has been considerable improvement over recent years. Concern about prognosis and quality of life on renal replacement therapy, together with shortage of facilities has meant that some elderly people have been denied treatment. A retrospective study of all patients commencing renal replacement therapy in Newcastle between 1974 and 1985 was performed. The five year survival of patients aged more than 60 years at the start of treatment (n = 122) was 53%, compared with 68% for a cohort of individuals aged less than 60 years (n = 632). A questionnaire sent to the 62 elderly patients surviving at the end of the follow-up period revealed that most were married, independent, active and lived in their own home. They were not lonely, generally enjoyed life and were happy with their mode of renal replacement therapy. These results show that elderly patients make good dialysis candidates and they should not be denied treatment on the basis of age alone. Greater funding of renal services is necessary to accommodate these patients.

Successful treatment with trisodium phosphonoformate for primary cytomegalovirus infection after heart transplantation.

Primary cytomegalovirus infection in the patient who is receiving immunosuppression therapy is associated with a high morbidity and mortality. We report a patient who developed primary cytomegalovirus infection 37 days after heart transplantation with a rapidly deteriorating course. Treatment with the new antiviral drug trisodium phosphonoformate (Foscarnet-Astra) was initiated as a lifesaving measure with rapid, dramatic improvement in the patient's condition and subsequent recovery.

Four methods to recruit renal functional reserve.

The acute changes in creatinine clearance (Ccr) in response to intravenous amino acid infusion and to oral meat and milk protein meals were studied in seven healthy control subjects (Acute study). Para-aminohippurate clearance (CPAH), Ccr, inulin clearance (Cin), and plasma renin activity (PRA) were measured in seven different healthy control subjects following 1 week of low-protein diet, 0.7 g/kg per day, and again after one week of high-protein diet, 2.0 g/kg per day (Chronic study). In the acute study Ccr increased to a similar extent with each of the three stimuli, 20.1 +/- 6.2% (SD), 12.6 +/- 6.2% (SD) and 19 +/- 6.2% (SD) with amino acid infusion, 80-g meat protein and 80-g milk protein meals respectively. In the chronic study Ccr was 21%, Cin 26%, CPAH 8%, and filtration factor (FF) 14% greater during the high-protein diet than the low-protein diet, while PRA was increased by 43% on the high-protein diet. We conclude that an 80-g protein oral meal is probably sufficient to elicit the maximum acute increase in Ccr, since all three acute responses were similar, and similar in degree, to those previously reported, and may therefore be of value in measuring maximal filtration capacity. In contrast to one previous report, meat and milk proteins induced similar changes in Ccr. Thus milk protein cannot be regarded as a dietary substitute for meat in any diet designed to reduce glomerular hyperfiltration. Renin may play a part in the increase in glomerular filtration rate through the action of angiotensin II on the efferent arteriole, increasing filtration fraction.