Altered Lung Vascular Permeability During Intermittent Haemodialysis

Hypoxia is known to develop during intermittent haemodialysis.To investigate if increased pulmonary capillary permeabilityto protein contributes to this phenomenon, a dual-isotope techniqueusing Indiumlabelled transferrin and Technetium-labelled redblood cells was used. Lung vascular permeability was measuredin eight patients with dialysis-dependent chronic renal failureimmediately before and during intermittent haemodialysis withcuprophane membranes. As a group there was a significant increasein lung vascular permeability during the early stages of haemodialysis,compared to predialysis values (P <0.05) and this increaseoccurred during the period when the patients were leucopenicand maximally hypoxic. During the haemodialysis period, butnot the predialysis period, the permeability index was alsosignificantly increased compared to a group of eight controls(P<0.05). These results suggest that increased vascular permeability maycontribute to dialysis-induced hypoxia and that this may relateto neutrophil activation within the pulmonary vascular bed.     

Haemodialysis and haemofiltration on cardiopulmonary bypass.

Over a three year period we have used haemodialysis and haemofiltration in parallel with cardiopulmonary bypass in 26 patients. Impaired renal function and excessive fluid retention have been the main indications. Patients on haemodialysis programmes for end stage renal failure did not require further dialysis until at least the third postoperative day, when they could tolerate the haemodynamic disturbance of dialysis. In the other patients these techniques proved valuable in reversing the effects of haemodilution and in controlling the concentration of serum potassium. Our experience has confirmed that haemodialysis and haemofiltration in parallel with cardiopulmonary bypass are useful adjuncts in the perioperative management of patients with impaired renal function undergoing open heart surgery. The techniques are also effective in correcting the fluid retention and biochemical imbalance in patients with congestive cardiac failure, including those with heart transplants.     

Acquired Cystic Disease of the Kidney in Patients with End-Stage Chronic Renal Failure: A Study of Prevalence and Aetiology

Renal ultrasound scanning was performed in 100 patients withend-stage renal failure treated by both haemodialysis and continuousambulatory peritoneal dialysis (CAPD). Each kidney was assessedfor the presence of acquired cystic disease and solid lesions.The appearances were divided into five grades from grade 0 (nocysts detected) to grade 4 (>15 cysts per kidney). Otherintra-abdominal organs were also scanned for the presence ofcysts. The findings were then correlated with possible aetiologicalfactors, including the type of dialysis used. Sixty-three percent of all the patients had acquired cysticdisease of the kidney (ACDK). No solid lesions were found andno cysts were detectable in other organs. The presence and gradeof ACDK did not correlate with the age or sex of the patient,the nature of the underlying renal disease, or the durationof chronic renal failure. There was a significant correlationbetween the grade of ACDK and the duration of both haemodialysis(P<0.001) and CAPD (P<0.01). The presence of residualrenal function did not influence the development of cysts. ACDKhad no effect on haemoglobin or other laboratory parametersmeasured.     

Predictors of acute renal failure requiring renal replacement therapy post cardiac surgery in patients with preoperatively normal renal function

Acute renal failure requiring continuous renal replacement therapy post cardiac surgery carries a high mortality. Most studies have focused on patients with impaired renal function preoperatively but little is known about predictors of such a complication in patients with preoperatively normal renal function. This is a retrospective review of a prospective collected database. A total of 1609 patients underwent cardiac surgery over a 4-year period. Dialysis was required in 47 patients (2.9%). Univariate analysis identified the following as significant risk factors: age, female gender, chronic obstructive pulmonary disease, congestive cardiac failure, creatinine clearance, Euro, Parsonnet and Cleveland clinic scores, body mass index, non-isolated CABG, cardiopulmonary bypass time, extubation time and pulmonary complications (P<0.05). Multivariate analysis identified EuroSCORE, congestive cardiac failure, insulin-dependent diabetes, emergency surgery, postoperative extubation time and pulmonary complications as independent risk factors (P<0.05). In-hospital mortality and length of stay (P<0.0001) were higher in dialysis group. Acute renal failure requiring dialysis post cardiac surgery is associated with a higher mortality and prolonged hospital stay. By identifying higher risk patients, early planned preventative measures should be readily available to both reduce the incidence of such a complication and improve utilisation of hospital resources.     

Plasma Met-Enkephalin and Leu-Enkephalin in Chronic Renal Failure

Plasma met-enkephalin and leu-enkephalin has been measured ina group of 28 patients with chronic renal failure, to discoverwhether these opioids are affected by standard haemodialysisand haemofiltration. Met-enkephalin was markedly higher (P<0.001) in uraemic patientsthan in a group of 13 normal subjects, and was directly relatedto plasma creatinine (r=0.60; P<0.01) and to plasma urea(r=0.36; P=0.06). In contrast, leuenkephalin was suppressedin uraemic patients (P<0.001). Met-enkephalin fell slightlybut significantly (P<0.02) after both haemodialysis and haemofiltration;however, on average it remained at concentrations four timeshigher than normal. No changes in plasma leu-enkephalin wereobserved after haemodialysis and haemofiltration. The cause(s)of the altered plasma concentrations of these opioid substancesremains to be clarified.     

Response to the hepatitis B virus vaccine in haemodialysis patients: influence of malnutrition and its importance as a risk factor for morbidity and mortality

OBJECTIVE.: To assess if malnutrition influences the response to the hepatitisB virus vaccine in haemodialysis patients and whether this correlateswith morbidity and mortality in these patients. DESIGN.: A 4-year prospective open study. SETTING.: Haemodialysis unit of a 434-bed University Hospital. PATIENTS.: Sixty-four patients with end-stage chronic renal failure onmaintenance haemodialysis. INTERVENTIONS.: Three-dose vaccination series with recombinant hepatitis B virusvaccine. MEASUREMENTS.: Antibody formation against the vaccine, predialysis serum urea,serum albumin and prealbumin, dialysis efficacy (Kt/V), proteincatabolic rate (PCR), arm muscle circumference, triceps skinfold,serum parathyroid hormone concentration, mortality and morbidity(hospital days per year of dialysis). RESULTS.: Increase in age negatively influences the formation of antibodies(P=0.01), whereas serum albumin (P=0.008) and predialysis bloodurea concentration (P=0.004) are positively correlated withthe formation of antibodies. Responders had significantly higherlevels of serum albumin and prealbumin and predialysis bloodurea than non-responders. The percentage of non-responders washigher (70%) in the group with predialysis blood urea concentrationbetween 90 and 125 mg/dl than in those with predialysis bloodurea concentrations between 176 and 225 mg/dl (14.2%). Patientswith serum albumin levels between 3 and 3.5 g/dl were non-respondersin a higher percentage (87.5%) than those with serum albuminlevels between 4.5 and 5 g/dl (18.8%). After a 4-year follow-up, survival was 20% higher in the respondergroup (P<0.05). Morbidity, expressed as hospital days peryear of haemodialysis, was markedly lower in the responder group(10.4±2 versus 32±14 days, P=0.03). CONCLUSIONS.: Malnutrition negatively influences the response to the hepatitisB virus vaccine in haemodialysis patients. Non-responders havehigher morbidity and mortality than responders, and thereforethe absence of response to the hepatitis B vaccine can be consideredas a risk factor in the haemodialysis population.     

Comparative Effects of Haemodialysis and Haemofiltration on Plasma Atrial Natriuretic Peptide

The effects of 4 h haemodialysis (15 patients) or 4 h haemofiltration(five patients) on plasma concentrations of atrial natriureticpeptide (ANP) were compared by means of a sensitive radioreceptorbinding assay, and related to accompanying changes in body weight,blood pressure and plasma renin activity. Before dialysis, plasmaANP concentrations were considerably elevated: haemodialysisgroup 10–484 pmol/l (mean 156 pmol/l); haemofiltrationgroup 72–320 pmol/l (mean 170 pmol/l). Although plasmaconcentrations of ANP fell markedly with treatment in both groups:post-haemodialysis 2–187 pmol/l (mean 67 pmol/l); post-haemofiltration47–135 pmol/l (mean 79 pmol/l), after treatment it remainedabove the normal range in 14 of the 20 patients. Pretreatmentplasma ANP was related to systolic blood pressure (r=0.459;P<0.05) but bore no relationship to mean or diastolic bloodpressure, or plasma renin activity. The fall in plasma ANP concentrationduring treatment correlated with the postural blood pressuredrop after dialysis (r=0.505; P<0.05), but was unrelatedto changes in weight or plasma renin activity with haemodialysisor haemofiltration. Plasma ANP concentrations rose rapidly againin the 60 min after dialysis treatment, without change in bodyweight. These results show that high levels of biologically active ANPcirculate in end-stage renal disease. The fact that these arenot reduced to normal by haemodialysis or haemofiltration, despiterestoration to normovolaemic or hypovolaemic state, suggeststhat the increased levels of ANP in end-stage renal failureare due to both hypervolaemia and other factors, which may includeoccult cardiac dysfunction and loss of renal clearance.     

Atrial natriuretic peptide (ANP) in patients with chronic renal failure on maintenance haemodialysis

Atrial natriuretic peptide (ANP), a recently discovered cardiac hormone, is an important regulator of body fluid homeostasis. Twenty patients with established chronic renal failure and on maintenance haemodialysis were studied before and after dialysis with capillary dialysers. ANP was determined by RIA after extraction. Mean (±SD) pre-dialysis ANP concentration was 146±51 pg/ml and decreased significantly during dialysis to 68±38 pg/ml (p<0.001). Per cent and absolute changes in plasma ANP level correlated significantly with concomitant changes in body weight (r=0.764; p<0.001 and r=0.558; p<0.01, resp.) but not with changes in serum creatinine, blood pressure or serum electrolytes. The obtained results indicate that ANP levels in patients with chronic renal failure are elevated mainly due to fluid overload, and the rapid fall in ANP concentration observed during haemodialysis is caused by the removal of excess fluid from the body.     

Determination of total body water in uraemic patients by bioelectrical impedance

The measurement of total body water by bioeiectrical impedancein a group of renal patients was evaluated against the tritiumdilution method. The effect of haemodialysis and the presenceof peritoneal dialysate on the impedance were also investigated.The correlation between the two methods is r = 0.90 with a residualstandard deviation of 3.7. The standard devi ation of the differencesbetween the two methods against the means was 3.66 which meansthat total body water (TBW) estimated by the bioelectrical impedance(BEI) method may be 6.181 (X ± 2 SD) above or 8.381 belowthe ³H₂O method. The BEI method overestimated the actual weightloss after haemodialysis (3.87±1.71 versus 2.43±1.81)but underestimated the volume of peritoneal dialysate in situThe BEI method would not be appropriate for use in assessingtotal body water and monitoring acute volume changes in patientswith renal failure who are on strict fluid restriction.     

High dose enalapril impairs the response to erythropoietin treatment in haemodialysis patients

Background: The resistence to recombinant human erythropoietin (rHuEpo) therapy in haemodialysis (HD) patients has multifactorial aetiologies; erythropoietin insufficiency, dialysis insufficiency, iron deficiency, and secondary hyperparathyroidism. Angiotensin-converting enzyme (ACE) inhibitors induce anaemia in patients with essential hypertension, congestive heart failure, chronic renal insufficiency, and renal transplants. Data exist suggesting that ACE inhibitors impair erythropoiesis in HD patients. Therefore the aim of this study was to investigate the impact of enalapril on rHuEpo requirement. Methods: In the present prospective non-randomized study of 12 months, we compared the effects of enalapril and nifedipine on rHuEpo requirement in 40 hypertensive patients receiving rHuEpo for more than 6 months on maintenance haemodialysis. Twenty normotensive rHuEpo-dependent patients served as a control group. All patients with severe hyperparathyroidism or iron deficiency were excluded. The mean (±SD) haemoglobin concentration was >10 g/dl in all groups. The mean weekly rHuEpo dose increased in the enalapril group (P<0.0001 vs before) and remained constant in the nifedipine and control groups (P=NS vs before). Statistically, there was no differences with regard to iPTH levels, dialysis parameters, iron status, and underlying renal diseases among all groups. Conclusion: High-dose enalapril increases rHuEpo requirement and should be reserved for dialysis patients with hypertension uncontrollable with other antihypertensive medications or dialysis patients with cardiac failure.     

Peritoneal dialysis catheters: a comparison between percutaneous and conventional surgical placement techniques

Percutaneous peritoneal dialysis catheter (PDC) placement isa well-tolerated, rapidly performed side-room procedure thatallows the rapid initiation of dialysis without the delay imposedin co-ordinating a surgeon, theatre time, and theatre staff.We retrospectively reviewed the clinical outcome of 230 PDCinserted over a 30-month period. Fifty were placed percutan-eously(group P) and 180 were placed using conventional surgical techniques,107 in patients commencing CAPD (group A) and 73 in patientspreviously established on CAPD (group B). Total experience accumulatedwas 2563 patient months: 270 patient months group P, 1381 patientmonths group A, 912 patient months group B. Percutaneous PDCinsertion was non-elective, and reserved for patients unfitfor general anaesthesia or haemodialysis. Group P patients wereolder (P<0.001) and had increased early mortality (P<0.005)due to underlying pathology. Death and early mechanical failurecontributed to a shorter mean duration of catheter use in groupP (9.0 ± 2.3 months compared to 15.3 ± 9.6 monthsgroup A and 17.3 ±9.7 group B) (P<0.05). The peritonitisrate was similar in group P (1 per 6.75 patient months) andgroup B (1 per 7.4 patient months) but significantly lower ingroup A (1 per 15.7 patient months) (P<0.01). We concludethat percutaneous PDC placement provides a safe, reliable accessfor peritoneal dialysis and is especially suitable for ill patientswho would not tolerate general anaesthesia.     

Increased plasma levels of soluble tumor necrosis factor-receptors in uraemic patients: effects of dialysis, type of membrane, and anticoagulation method

Enhanced levels of soluble TNF-receptors (sTNF-R) have beenreported in patients with chronic renal failure. The aim ofthe present study was to evaluate the effects on sTNF-R levelsin plasma of haemodialysis patients of the anticoagulation methodand of the type of membrane used, as well as the variabilityof predialysis sTNF-R levels during time. All haemodialysispatients tested (n = 35) showed increased levels of both sTNF-R55(72.4 ± 5.7 ng/ml, P<0.001) and sTNF-R75 (18.2±2ng/ml,P<0.00l) before dialysis, as compared with normal healthycontrols (<2.5 ng7sol;ml for both sTNF-R), confirming previousobservations. sTNF-R levels were determined before and duringhaemodialysis at different time intervals in patients receivingeither heparin (2500 U, 5000 U, or 10000 U), low molecular weightheparin, or periodic saline flushing to prevent coagulationof the extracorporal circuit. A transient, small decrease inboth sTNF-R levels occurred at the beginning of haemodialysis(t=15 mm) with all anticoagulation methods used. At the endof haemodialysis, sTNF R55 and sTNF-R75 concentrations wereonly minimally affected (P<0.05). Predialysis sTNF-R levelswere similar in patients dialysed on either cellulose diacetateor polyacrylonitrile. Finally, there were only minimal variationsin predialysis sTNF-R levels in individual patients during the1 week observation period. Although the biological consequencesof the increased TNF-binding ability of serum from haemodialysispatients is still unclear, it could play a role in the compleximmunological perturbations of uraemic patients.     

Odour perception in chronic renal disease

Background: The sense of smell plays an important role in the quality of life. Many studies have shown a declining odour perception in the elderly, as well as in subjects in poor health or nutritional state. Considering the high prevalence of poor nutritional state in renal disease and the importance of odour perception in nutrition and health, the relationship between renal function, nutritional state, and odour perception is explored in this study. Method: A total of 101 patients with chronic renal failure participated in the study. Thirty-eight haemodialysis patients (mean age=64.3 years) were evaluated both before and after dialysis. Sixteen patients on peritoneal dialysis treatment (mean age=64.0 years), 28 transplanted patients (mean age=53.5 years, mean creatinine clearance=64.0 ml/min) and 19 patients with varying degrees of renal insufficiency were also included (mean age=63.7 years, mean creatinine clearance=29.5 ml/min). Patients with cognitive deficits or upper respiratory airway diseases were excluded. A validated objective procedure was used to measure odour perception, by determining the detection threshold for isoamyl acetate (banana odour) as the lowest detectable odour concentration. Results: Healthy control persons had significantly lower odour thresholds compared to patients on peritoneal (P=0.001) and haemodialysis (P=0.02). No significant difference was observed in odour perception between patients on peritoneal and haemodialysis (P=0.779) and for patients on haemodialysis before and after a dialysis session. Transplanted patients had significantly better odour perception compared to matched patients on dialysis (P <0.001). Odour perception of transplanted patients and matched healthy control persons was similar (P-0.81). In patients with varying degrees of renal insufficiency, including healthy controls and transplanted patients, a significant positive correlation was found between odour perception and creatinine clearance (P=0.02). A significant negative correlation was found between odour perception and serum concentration of urea (P <0.001), serum phosphorus (P=0.022) and protein catabolic rate (P <0.05). Other parameters measuring nutritional status (albumin, BMI) were not correlated with odour perception. Conclusion: Our results show that the ability to smell is severely impaired in patients with chronic renal failure and is related to the degree of renal impairment and the degree of accumulation of uraemic toxins. After renal transplantation, patients have a normal odour perception, indicating the capacity of the olfactory system to recover once the concentration of uraemic toxins remains below a critical threshold. Acute removal of uraemic toxins by dialysis does not correct olfactory disturbances, suggesting a long lasting effect of uraemia on olfactory function.     

Human Recombinant Erythropoietin in Anaemic Patients on Maintenance Haemodialysis. Secondary effects of the Increase of Haemoglobin

Twelve anaemic patients on haemodialysis were treated with recombinanthuman erythropoietin, starting with 72 IU/kg/week. The dosewas doubled after 2 weeks until an increase of 2 g/dl of haemoglobinwas observed. The effects on various parameters were studiedduring a 3-month period. Haemogiobin increased from 6.70±0.74to l0.49±1.04g/dl (mean±SD, P<0.00l), potassiumfrom 5.51±0.50 to 6.06±0.65mmol/1 (P<0.005),phosphate from 1.78±0.40 to 2.17±0.4Ommol/1 (P<0.001)and the calcium phosphorus product from 4.3 to 5.2 (P<0.001)Three patients developed marked periarticular inflammation dueto calcified deposits with a high calcium-phosphorus productof 6.8. An increase in arterial blood pressure was observedin three previously well-controlled hypertensive patients, oneof whom developed hypertensive encephalopathy. We conclude thatrecombinant human erythropoietin is very effective in treatingthe anaemia of end-stage renal failure on haemodialysis. Regularestimations of serum potassium and phosphate are mandatory.In hypertensive individuals a further increase in blood pressureis possible.     

Arterial changes in paediatric haemodialysis patients undergoing renal transplantation

Background. The relationship between primary renal diseaseand arterial wall changes in paediatric haemodialysis patientshas been little studied. The aim of the present work was todetermine the influence of primary renal disease on arterialwall pathology in uraemic paediatric patients. Methods. Twelve paediatric haemodialysis patients (sevengirls, five boys) aged 11–17 years were included in thestudy. The primary renal diseases were urinary malformationsin six patients (uropathy group) and acquired glomerular diseases(glomerulopathy group) in six patients. Age, sex distribution,duration of chronic renal failure, duration of haemodialysis,blood pressure, serum glucose, triglycerides, cholesterol, fibrinogen,calcium, phosphorus and parathyroid hormone levels were compared.Internal iliac artery samples were obtained at the time of related-donorrenal transplantation. Artery samples were fixed in formaldehydeand sections were stained separately with haematoxylin and eosin,Orcein, Verhoef–van Gieson, and Masson trichrome. Results. Five arteries had fibrous or fibroelastic intimalthickening, medial mucoid ground substance and disruption ofthe internal elastic lamella. Two of these had microcalcificationin the intimal layer; another two demonstrated atheromatousplaques; the remaining five were normal. These pathologicalchanges were found in the arteries of all six patients withuropathy, whereas of the six patients with glomerulopathy onlyone had arterial changes (P<0.001). The duration of chronicrenal failure was 4.8±1.9 years in the uropathy groupand 2.2±1.2 in the glomerulopathy group (P<0.05).The two groups were comparable in terms of serum glucose, triglycerides,cholesterol, fibrinogen, calcium, and parathyroid hormone levels,presence of hypertension, sex distribution, and duration ofhaemodialysis. Plasma phosphorus and the calciumxphosphate productwere higher in the uropathy group than in the glomerulopathygroup (P<0.05). Conclusions. This study demonstrated that pathologicalchanges are common in the arteries of uraemic paediatric patients,and that calcification and atherosclerosis are integral to thisdisease process. In our study, these alterations were more commonin the patients with uropathy. We speculate that the patientswith uropathy are more prone to these alterations due to slowerprogression and a longer duration of renal insufficiency.     

Effect of autonomic neuropathy on ventilatory response to progressive hypercapnia in dialysis patients

The impact of autonomic neuropathy (common in patients on haemodialysis)on ventilatory response to hypercapnia has been studied. We investigated cardiac reflex tests in 20 patients on chronichaemodialysis (8 patients were found with and 12 without neuropathyof the autonomic nervous system). Using the hyperoxic CO₂-rebreathingmethod (according to Read), we tested the above-mentioned twogroups of patients and compared them with 14 healthy controlsubjects. Accumulation of CO₂ in blood with hyperoxic CO₂ rebreathingstimulates central chemoreceptors, and therefore causes a progressiverise in minute ventilation. In patients with autonomic neuropathy (n=8), ventilatory responseto increasing pCO₂ was significantly lower than that in thecontrols (1.7±0.3 versus 3.2±0.5 l/min/mmHg, P<0.001).On the other hand ventilatory response in patients without autonomicdamage (n=12) showed no significant difference when comparedto controls (3.1±0.8 l/min/mmHg). There were no differencesin lung function, arterial blood gas analysis, blood chemistry,duration on dialysis, and demographic data when comparing thepatients with and those without autonomic damage. Our analysis shows different patterns of ventilatory responseto increasing pCO₂ in patients on haemodialysis. Autonomic neuropathyhas to be considered when rebreathing tests are interpreted.The clinical relevance of these findings needs further investigation.     

Fluid recruitment from shell tissues of the body during haemodialysis

Patients with kidney failure are prone to accumulate fluidswithin the superficial tissues, leading to a puffiness of theface, hands, and feet. After dialysis these symptoms disappear.It was the aim of this study to quantify these changes. Withthe help of A-mode ultrasound in 49 patients (20 females, 29males) the tissue thickness in the forehead and tibia was measuredduring dialysis. In the forehead the tissue thickness beforedialysis was 4.01 mm (females) and 3.87 mm in the males, decreasingcontinuously during dialysis by 13.6% and 12.8% respectively(P<0.001). In the tibia the tissue thickness was 3.87 mm(females) and 3.07 mm (males) and decreased by 12.8% and 23.9%respectively. The sex difference was significant (P<0.05).From these values it was calculated that 45% of fluid withdrawncame from the superficial shell tissues of the body. It wasconcluded that these tissues serve as water stores in the interdialyticphase.     

Plasma Exchange and Immunosuppression for Rapidly Progressive Glomerulonephritis: Prognosis and Complications

Rapidly progressive glomerulonephritis frequently leads to deathor dialysis. In 21 cases treated by plasma exchange and immunosuppressionwe observed seven deaths, with 12 others progressing to chronicrenal failure within 3 months. Patients who died were olderthan those who survived (57.5±17.7 vs 40.5±16.5years, mean ±SD, P=0.05), but had similar clinical symptoms(hypertension, haematuria, proteinuria, extrarenal signs) andbiochemical presentation (initial creatininaemia). They requiredthe same degree of haemodialysis, of plasma exchanges and ofbolus methylprednisolone. The causes of death were infection(three cases), cardiac arrhythmia (two cases) and gastrointestinalbleeding (two cases). Among the 14 remaining patients, onlytwo recovered normal renal function. Twelve had chronic renalfailure, six of them requiring chronic dialysis or transplantation.Severe renal failure at entry and anuria were more frequentlyobserved in patients whose renal function did not improve duringtreatment. Plasma exchange and steroid bolus infusions alsoseemed to have a beneficial effect on renal function.     

Changes in pulmonary clearance of technetium labelled DTPA during haemodialysis.

An index of pulmonary epithelial permeability has been studied in 12 patients with chronic renal failure during haemodialysis. It was assessed by the half time clearance from lung to blood (t 1/2 LB) of a nebulised solution containing technetium labelled diethylene triamine pentacetic acid (99mTc DTPA). Six patients were cigarette smokers and six were non-smokers. The non-smokers had greater predialysis permeability (mean 37.7, range 24-54 min) than non-smokers without renal disease (mean 60.2, range 38-99 min; p less than 0.025). The t 1/2 LB was measured before dialysis and during the first half hour and the last half hour of dialysis in all 12 patients and also during other periods of dialysis in 10 of them. Dialysis lasted for five hours in 11 patients and four hours in one patient. There was no significant change in the t 1/2 LB of 99mTc DTPA during early dialysis; but as dialysis progressed there was a statistically significant increase in t 1/2 LB, suggesting a reduction of pulmonary epithelial permeability. These results show no increase in an index of pulmonary epithelial permeability in association with the pulmonary sequestration of neutrophils that occurs in early haemodialysis. They also suggest that in chronic renal failure the epithelial permeability is increased and that this can be modified by haemodialysis.     

Prognostic value of stress myocardial perfusion imaging using adenosine triphosphate at the beginning of haemodialysis treatment in patients with end-stage renal disease

Background. Non-invasive detection of coronary artery disease(CAD) remains difficult in patients with end-stage renal disease(ESRD). This study evaluated the ability of pharmacologic stressmyocardial perfusion imaging to predict cardiac events in patientswith ESRD. Methods. A prospective study was carried out in 49 consecutivepatients with ESRD. Thallium-201 single photon emission computedtomography (SPECT) using high-dose adenosine triphosphate (ATP)was performed within 1 month of the beginning of haemodialysis.The study end-point was a cardiac event or the 1-year anniversaryof the SPECT study. Results. Twenty-four patients (17 diabetics, 57% and seven non-diabetics,37%) had myocardial perfusion defects. The remaining 25 patientshad normal perfusion images. Fifteen patients had non-fatalcardiac events and two patients died of a cardiac cause. Allpatients who had non-fatal cardiac events underwent myocardialrevascularization and survived until the end of follow-up. The1-year cardiac event-free survival rate was 34% among patientswith perfusion defects and 96% among patients without perfusiondefects (P<0.001). The presence of a myocardial perfusiondefect was the only independent predictor of 1-year cardiacevents both in overall (HR, 49.91; 95% CI, 5.15–484.00;P<0.001) and in diabetic patients (HR, 33.72; 95% CI, 2.96–383.5;P = 0.005). Diabetes and an increased C-reactive protein wereassociated with the progression of CAD. Conclusions. Normal myocardial perfusion imaging by stress thallium-201SPECT using high-dose ATP performed within 1 month after thebeginning of haemodialysis treatment is a powerful predictorof cardiac event-free survival in patients with ESRD.