Adequacy of dialysis and nutritional status in CAPD

Urea kinetic modelling (UKM) was used to assess adequacy ofdialysis in 50 CAPD patients. Nutritional status was assessedfrom the measurement of visceral protein status (total protein,albumin, transferrin, immunoglobulins, complement), somaticprotein status (anthropometry), and dietary intake (1 week weigheddietary inventory and normalized protein catabolic rate (NPCR)from UKM). Morbidity was assessed from the peritonitis and admissionhistory. Mean Kt/V (corrected to x3 weekly dialysis) was 0.66 ±0.02. Dietary protein intake estimated from the NPCR (1.08±0.03g kg^–1 day^–1) correlated well (r=0.72, P<0.001)with that estimated from the dietary inventory (1.10±0.04g kg^–1 day^–1). There was a strong correlation betweenKt/V and NPCR corrected for actual weight (r=0.65, P<0.001),but when NPCR was corrected for IBW this correlation was weaker(r=0.35, P<0.05). Patients were divided by Kt/V into twogroups (>0.65, n=22 and <0.65, n=28). There were no significantdifferences in the indices of visceral protein status betweenthe two groups. Weight, height, BMI, fat free mass and arm musclearea were significantly greater in the group Kt/V<0.65. Residualrenal function (creatinine clearance) was higher in the groupKt/V>0.65 (3.8±0.7 versus 1.9±0.5 1/24 h, P<0.05)and plasma creatinine less (913±51 versus 1265±51µmol/l, P<0.001). Hb, potassium, bicarbonate, phosphate,alkaline phosphatase, PTH, and blood pressure were not different.Neither was there any difference between the two groups in anyof the indices of morbidity.     

On-line urea kinetics in haemodiafiltration

BACKGROUND.: Calculation of Kt/V and assessment of nutrition have so farbeen dependent upon off-line urea measurements of blood or dialysatesamples. Here we describe a biosensor for on-line urea measurementduring haemodiafiltration. METHODS.: The biosensor consisted of a cartridge containing covalentlylinked urease placed between two conductivity cells. The biosensorwas placed on the outlet line of a haemofilter in series witha dialyser in order to obtain an aliquot of plasma ultrafiltratefor on-line measurement of urea. RESULTS.: Urea nitrogen concentrations were highly correlated to the difference() in conductivity measured by the two conductivity cells bothin aqueous solutions (in-vitro studies, y=–6.676+32.12x,R²=0.998, P<0.0001) and in ultrafiltrates (ex-vivo studies,y=–6.7+32.01x, R²=0.98, P<0.00001). conductivity washighly reproducible (% variation: 0.8–5.3%) and stable(maximal % variation at 150 mg/dl after 180 min: 0.9±0.3vs initial values). The intradialytic plasma water urea profilewas obtained in 10 haemodialysis patients. To study recirculation,the plasma water urea profile was analysed before and 3 minafter stopping the dialysate flow. The pre- and post-stoppedflow ratio (1.21±0.1, mean±1 SD) was superimposableto conventional blood sampling data (opposite arm venous/arterial:1.22±0.11) and allowed correction for recirculation.A novel approach to urea kinetic modelling was described andused to reliably project end-dialysis and post-dialysis reboundurea concentration as early as 90 min. Projected (29.2±10.4g) or measured (29.8±10.5 g) net urea removal was highlycorrelated with the amount of urea collected in the total spentdialysate (29.7±10.6 g) (R²=0.99, R²=0.97 respectively). CONCLUSIONS.: These results indicate that on-line, real-time analysis of ureakinetics may provide information on delivery of adequate dialysisin high-efficiency techniques.     

Hearing loss in short- and long-term haemodialysed patients

BACKGROUND.: Hearing loss has been described in patients with chronic renalfailure on regular dialysis treatment (RDT) with very differentfrequency, ranging from 20 to 75%; RDT does not seem to worsenhearing function for at least the first 5 years of treatment;no studies are available on patients on RDT for more than 10years. METHODS.: We performed an audiometric evaluation in 91 patients on RDTfor various periods: group I (34 patients), <5 years; groupII (32 patients), 5–10 years; group III (25 patients),> 10 years; patients with histories of chronic otitis, ototoxicdrug treatment, and chronic auditory trauma were excluded; thepossible correlations with some biochemical parameters (urea,creatinine, PTH) were also looked for. RESULTS.: Hearing loss was present in 77% of patients and 69.2% of ears;the percentage of patients with hypoacusia was higher in groupIII (84%) than in group I (76.3%) and II (71.7%), but the differenceswere not statistically significant. Hypoacusia was cochlearneurosensory in 61.5%, conductive in 6.5%, and mixed in 9.0%of patients; the percentage of patients with cochlear neurosensoryhypoacousia was similar in the three groups (I, 61.7%; II, 59.3%;III, 64%). Hearing loss was of slight to moderate degree andnot different in the three groups (I, 22.7±15 dB; II,26.9±6.0 dB; III, 29.1±8.9 dB). There were nocorrelations between hearing loss and plasma creatinine andPTH values; patients with plasma urea >200 mg/dl had higherpercentage of hypoacousia (86%) than patients with plasma urea<200 mg/dl (69%) (P=0.06). CONCLUSIONS.: Hearing loss, mainly cochlear neurosensory in type, is presentin a high percentage of patients on RDT even at the beginningof treatment, but no negative effects on hearing can be correlatedwith the duration of dialysis.     

Further observations on acute renal failure following physical torture

Thirty-four males aged 16–40 (mean 25) years in the periodfrom August 1991 to February 1993 presented in acute renal failure(ARF), 3–14 (mean 5) days after they had been apprehendedand allegedly tortured in Police interrogation centres in Kashmir.All were beaten involving muscles of the body, in addition 13were beaten on soles, 11 were trampled over and 10 had receivedrepeated electric shocks. Patients were studied in three groups: group I, those with evidenceof only myoglobinuria (n=21); group II, those with both myoglobinuriaand haemoglobinuria (n=10); and group III, those with evidenceof only haemoglobinuria (n=3). All had varying degrees of ecchymotic patches on the body andpatients in groups II and III were beaten on soles had ecchymosisof soles. Hypertension was present in 11 and pulmonary oedemain five. Mean haemoglobin, BUN and serum creatinine were notsignificantly different in the three groups. Creatine phosphokinasein groups I, II and III were 985–7516 (1358±368),917–5277 (1431 ±188), and 517–816 (772±69)and lactic dehydrogenase levels were 757–3727 (2191±56),592–3454 (1923±164), and 446–958 (632±115)respectively. All the cases had metabolic acidosis, 20 had hyperkalaemia.Plasma haemoglobin was 11–48 (mean 26) mg/dl in groupII and 26–56 (mean 35) mg/dl in group III. Urine testfor haemoglobin was positive in seven cases in group II andtwo cases in group III. Pigment casts were present in 10, eightand two cases in groups I, II, and III respectively. Only thosewho were beaten on soles had evidence of haemoglobinuria. Twenty-nine cases recovered and five died. Both myoglobinuriaand haemoglobinuria can cause ARF in such a setting and an earlydiagnosis is essential for management.     

VARIATION IN THE DISPOSITION OF MORPHINE AFTER I.M. ADMINISTRATION IN SURGICAL PATIENTS

The disposition of morphine when administered by i.m. injectionwas studied in 36 patients receiving morphine as part of premedicationbefore general anaesthesia, and in five patients who receivedmorphine as a postoperative analgesic after median sternotomyfor coronary artery surgery (PCA group). Maximum plasma concentrationof morphine (Cp_max) was 75.3 ± 6.0 (mean±standarderror (SEM)) ng ml^–1 (range 30–160 ng ml(^–1),mean elimination rate constant (k) 4.85 x 10^–3 min^–1and half-life (T₁₂) = 143 min for the preanaesthetic group.The corresponding values for PCA group were Cp_max = 58.0 ±18.0 ng ml^–1 (range 30–130 ng ml^–1), k = 5.63x 10^–3 min^–1 and T₁₂ = 123 min. Analysis of varianceshowed no differences between the groups. Within the preanaestheticgroup, there was a significant difference in k between males(k = 4.01 x 10^–3 min^–1) and females (6.30 x 10^–3min^–1, P<0.01). The corresponding T₁₂ for males was173 min; and 110 min for females. The variation in the dispositionof morphine is thought to be the result of variations in restingmuscle blood flow and inadvertent injection into adipose tissue.There were no significant differences between males and femalesin the preanaesthetic group with respect to age, CP_max timefrom injection to Cp_max.     

Hyperhomocysteinaemia: a significant risk factor for cardiovascular disease in renal transplant recipients

Moderate hyperhomocysteinaemia has been shown to constitutean independent risk factor for cardiovascular disease (CVD),a frequent cause of morbidity and mortality in renal transplantrecipients (RTR). In these patients few data regarding bothtotal homocysteine levels and their influence on cardiovas cularrisk have been reported. We therefore studied serum homocysteinelevels in deep-frozen sera from 42 kidney transplant recipientswith a follow-up of 11±4.5 years (mean±SD) aftertransplantation. Eighteen patients had one or more ischaemicevents (CVD(+)) and 24 patients had none (CVD(–)). Serumsamples had been drawn 1–6 months prior to the first vascularevent in CVD(+) patients and serum storage time was comparablein both CVD(–) and CVD(+) patients. Serum homocysteinelevels were measured using a radioenzymatic method. Mean homocysteinelevel was significantly higher in 42 RTR males and females (15.5±6.3,13.5±5.5 µM respectively) compared with 35 controlsubjects matched for age and sex (8.7± 1.9, 7.5±l.9µP<0.001). The difference in serum homocysteine levelsbetween CVD(+) and CVD(–) RTR nearly reached statisticalsignificance in male patients (18.6±7.8 versus 13.1 ±3.4µM, P<0.06) but not in female patients (P=NS). In theCVD(+) group 11/18 patients had homocysteine levels > 14µM (the upper limit in healthy controls) versus 7/24 inthe CVD(–) group (P=0.04). In these patients we simultaneouslymeasured in the same serum samples, serum triglycerides, andtotal and HDL cholesterol, and calculated LDL cholesterol. Bystepwise discriminant analysis and by logistic regression analysisin this relatively small patient population, only serum triglyceridesand homocysteine were selected as risk factors associated withCVD. We conclude that signi ficant hyperhomocysteinaemia ispresent in renal transplant recipients and represents a potentialrisk factor for cadiovascular disease in these patients.     

Kinetic modelling and underdialysis in CAPD patients

Kinetic analysis was performed in all 58 patients undergoingstandard CAPD. The urea distribution volume was estimated fromanthropomorphic measurements (Watson formulae). Normalized proteincatabolic rate (NPCR), daily protein leak (PL), urea and creatinineKt/Vs, clearances and peritoneal mass transfer coefficients(Kp) were calculated from measurements on serum, 24-h urineand PD fluid effluent. The mean total (renal+PD) daily creatinine and urea Kt/Vs (KT/V)were 0.31 (range 0.15–0.79) and 0.31 (0.18/0.65). Therewas no relationship between KT/V and serum urea or Kp. The strongestdeterminant of the urea KT/V was the residual renal urea clearance(KrU)(R=079, P<0.001) which decreased with time on dialysis(R=–0.38, P<0.005). There was a significant correlationbetween the hospital admissions per year and both the urea andcreatinine KT/V and KrU (R=–0.30, –0.32, P<0.05).Patients with urea KT/V<0.25 (n=22) had more hospital admissions/yearthan those with KT/V>0.25 (mean of 2.6 versus 1.5, P<0.05).NPCR correlated with urea KT/V (R=0.62, P<0.001) but notwith serum albumin or the PL. Patients identified by UKM to be less well dialysed have a lowerresidual renal function and are more likely to be hospitalized.Undernutrition in CAPD patients appears to be related to underdialysisrather than protein loss.     

Compliance and effects of nutritional treatment on progression and metabolic disorders of chronic renal failure

Low-protein, low-phosphorus diets (LPD) are prescribed to patientswith chronic renal failure (CRF) to slow down the rate of progressionof CRF and to control uraemic symptoms. A satisfactory adherenceof patients to the prescribed diet is needed to meet these twogoals. We studied the compliance of CRF patients to a LPD providingdaily (per kg body weight) 0.3 g protein, 3–5 mg phosphorus,35 kcal, and supplemented with essential amino-acids and ketoanalogues.Forty CRF patients were studied for 23.3±10.8 months(range 12–45). Compliance to LPD was evaluated by dietaryinquiry and protein intake estimated from urinary urea excretion.According to compliance to LPD, patients were retrospectivelyassigned to the compliant (n=27) or the non-compliant (n=13)group. GFR measured by the urinary clearance of [⁵¹Cr]-EDTAwas identical in the two groups at the start of the study: compliantpatients 15.7±5.3 ml/mn, non-compliant patients 15.4±5.9ml/mn. The decrease of GFR was – 0.08±0.22 ml/minper month in compliant patients versus –0.31±0.37ml/min per month in non-compliant patients (P<0.02). Theseresults were not demonstrated if the progression of CRF wasassessed by the linear regressions over time of creatinine clearanceor the reciprocal of creatinine. Serum bicarbonate, serum phosphorusand PTH levels were corrected by LPD in compliant patients (P<0.005 for all parameters) but not in non-compliant patients.These results suggest that evaluation of compliance is necessaryto assess the response of CRF patients to LPD, whether the aimis to slow the progression of CRF or to control its metabolicconsequences. A beneficial effect of compliance to LPD was demonstratedupon these two goals.     

The pulsatility index and the resistive index in renal arteries in patients with hypertension and chronic renal failure

BACKGROUND.: The pulsatility index (PI) and the resistive index (RI) areused as pulsed-wave Doppler measurement of downstream renalartery resistance. Little information is available on theirvalue in chronic renal failure and their correlation to parametersof renal function and haemodynamics. The aim was to comparePI and RI of renal arteries in healthy volunteers and in patientswith hypertension and chronic renal failure, and furthermoreto study the correlation of these indices to measurements ofrenal haemodynamics and function by standard methods in patientswith renal failure and hypertension. METHODS.: Twenty-five hypertensive patients (10 females, 15 males, meanage 52 years (24–74) with a glomerular filtration rate(GFR) less than 50 ml/min and an arterial blood pressure above140 mmHg systolic and 95 mmHg diastolic were included in thestudy. Ten healthy, normotensive volunteers (4 females and 6males, mean age 43 years (30–62)) served as controls inthe Doppler examinations. Doppler examinations were performedin segmental arteries by an Acuson 128. The PI and the RI wascalculated from the blood flow velocities. RESULTS.: Both the PI and the RI were significantly higher in the patientgroup (P) than in the control group (C) (PI, P 1.65 (1.31–1.86),C 1.19 (0.93–1.25), P=0.003; RI, P 0.76 (0.69–0.81),C 0.67 (0.64–0.70), P=0.003). Both PI and RI correlated significantly with effective renalplasma flow (PI: r= –0.5, P=0.02; RI: r=–0.5, P=0.006),renal vascular resistance (PI: r=0.4, P= 0.05; RI: r=0.5, P=0.02),filtration fraction (PI: r=0.6, P=0.005; RI: r=0.5, P=0.01)and clearance of creatinine (PI: r=–0.6, P=0.008; RI:r=–;0.6, P= 0.006). Only RI correlated significantly toGFR (r=–0.5, P=0.02). The indices did not correlate toserum creatinine, or mean arterial blood pressure. CONCLUSION.: PI and RI seems to be closely related to parameters of renalhaemodynamics and clearance of creatinine in patients with chronicrenal failure and hypertension.     

Adynamic bone disease with negative aluminium staining in predialysis patients: prevalence and evolution after maintenance dialysis

Aplastic bone disease (ABD) is a common form of renal osteodystrophyand is characterized by a defect in bone matrix formation andmineralization without an increase in osteoid thickness. Theprevalence and pathogenesis of ABD in predialysis patients islargely unknown. We prospectively studied 92 unselected predialysispatients with a creatinine clearance <10 ml/min/1.73 m² anda mean age of 45±2 years (61 M, 31 F). None of the studypatients had received any form of vitamin D therapy, and CaCO₃was the primary phosphate binder. Aplastic bone disease wasobserved in 30 (32%) patients. Stainable bone aluminium surfacewas <3% in all ABD patients. Patients with ABD were older(52±3 versus 42±2 years; P<0.01) and had reducedserum intact PTH compared to non-ABD patients (199±25versus 561 ±87 pg/ml; P<0.001). Patients with diabetesmellitus showed lower PTH values (179±31 versus 432±62pg/ml; P<0.001) and a lower incidence of advanced by chperparathyroidismbone lesions (16% versus 46%; P<0.05) than non-diabetic patients.However, diabetes was not clearly associated with low bone turnoverdisease (56% in diabetics versus 41% in non-diabetics; P=0.1). A second bone biopsy was obtained in eleven ABD patients aftera period of 16.6±2.2 months on maintenance dialysis witha dialysate calcium of 7 mg/dl. Bone histology was unchangedin 10 patients, and one evolved to mild hyperparathyroidism.Trabecular bone volume did not change (22.7± 1.7 versus20.7±1.7%), and the stainable bone aluminium surfaceremained <3%. In summary, ABD not associated with positive histological stainingfor aluminium is a common finding in asymptomatic end-stagerenal failure patients in the Canary Islands. Older age andrelatively low PTH values are associated with this form of bonedisease. After a period of 12–36 months of dialysis, progressiveosteopenia and other clinical problems do not occur.     

Baseline variables associated with early death and extended survival on dialysis

Patients who die during the first three months on dialysis are not systematically included in the American and European statistics. In contrast, only a few patients survive more than 10 years on this modality of renal replacement therapy. The factors determining these two extreme forms of outcome are poorly understood. We tested the hypothesis that a few variables, easily obtainable at the initiation of dialysis, would identify those individuals at high and low risk of early death. We retrospectively studied 23 patients who died within 90 days of initiating dialysis and 20 patients who survived more than 10 years. These patients were admitted for dialysis to a Brazilian center between July 1, 1976 and February 28, 1997. The baseline variables assessed which were thought to influence survival, were: age, sex, race, body weight, etiology of renal disease, blood pressure, comorbid conditions, hematocrit and serum electrolytes, albumin, creatinine, urea, and urea/creatinine ratio. Univariate analysis showed that patients who died early were older (56.2 ± 15.6 vs. 42.1 ± 10.4 years, p < 0.01), had lower serum creatinine (10.6 ± 2.9 vs. 13.7 ± 3.7 mg/dL, p < 0.01) and albumin (3.3 ± 0.9 vs. 4.0 ± 0.5 g/dL) and a higher urea/creatinine ratio (18.4 ± 5.8 vs. 13.5 ± 4.8, p < 0.01) compared with subjects surviving more than 10 years. Early death patients also had more cases of diabetes (35% vs. 0%, p < 0.01) and less chronic glomerulonephritis (9% vs. 35%, p < 0.05). Multivariate analysis showed that age (p < 0.01, CI 1.02 to 1.15, odds ratio 1.1) and urea/creatinine ratio (p < 0.01, CI 1.03 to 1.38, odds ratio 1.2) were positively and independently related to outcome. In the early death group, malnutrition was an important cause of death (17% of all deaths). Compared to baseline data, long-term survivors, at the last follow up, presented reduced systolic blood pressure and increased hematocrit and unchanged body weight, serum albumin and urea/creatinine ratio. These results, based on easily accessible initial variables, suggest that early death on dialysis is influenced by age and by indices related to the nutritional condition of the patients. They also highlight the importance of a potentially correctable risk factor in a population with an elevated prevalence of premature death.     

Relationship between donor renal interstitial surface and post-transplant function

Forty-three biopsies were performed between 30 and 60 min afterreperfusion. Patients (22 males/21 females, mean age 41 ±12years, mean donor age 32 ±14 years) were treated eitherwith antilymphocytic globulin, cyclosporin, and prednisolone(24 cases), or OKT3, cyclosporin, and prednisolone (19 cases).Ten patients had delayed post-transplant renal function (DPRF),defined as haemodialysis requirements after surgery, and sevenpatients had acute rejection 11 ±16 days post-transplant.Kidneys were perfused with a hypertonic solution containingmannitol. All patients were followed up for at least 30 months.During follow-up, five patients lost their grafts due chronicrejection, two patients due to non-compliance and one due torecurrence of focal seg-mental glomerulosclerosis. One patientdied from heart infarction. Biopsies were stained with H&E,Masson's trichrome, periodic acid-Schiff (PAS) and silver methenamine.Interstitial fibrosis, interstitial oedema, tubular vacuolization,and peritubular capillary oedema were measured using a semiquantitativescale. Five 400 x magnification micrographs of cortical inter-stitiumfrom silver-methenamine-stained sections were used to measurepercentage of interstitial surface with a morphometer. Interstitial surface was 18.7 ±6.2% (range 3.2–35.3%).A positive correlation was found between interstitial surfaceand donor age (r= 0.469, P=0.0015). No relationship was foundbetween warm and cold ischaemia times and tubular vacuolizationor peritubular capillary oedema. Patients with DPRF had a significantlyincreased interstitial surface (23 ±8%) when comparedwith patients without DPRF (17 ±5%), (P=0.014). Therewas a positive relationship between interstitial surface andnumber of days required to achieve a plasma creatinine of 300µmol/1 after surgery, this fitted an exponential curve(r=0.578, P=0.0012). Patients who had an episode of acute rejectionwere not included in this calculation. A positive correlationwas also found between interstitial surface and plasma creatinineat 12 months (r=0.692, P=0.0001), 18 months (r=0.713, P=0.0001),and 24 months (r=0.586, P=0.0023) after surgery. Patients wholost their grafts during follow-up were not included in thiscalculation. The relationship between interstitial surface andplasma creatinine 30 months after transplantation was not significant.There was no relation between tubular vacuolization or peritubularcapillary oedema and number of days required to achieve a plasmacreatinine of 300 µmol/1 or plasma creatinine 12, 18,24, and 30 months after transplantation. We conclude that assessment of donor renal biopsies may helpto predict post-transplant renal function. The increase of interstitialsurface due to pre-existing fibrosis is associated with poorpost-transplant graft performance.     

Late referral to maintenance dialysis: detrimental consequences

Thirty per cent of patients who started maintenance haemodialysisat our institution between January 1989 and December 1991 hadbeen referred at a very late stage of their renal disease. Toassess the causes and consequences of such late referral weretrospectively compared clinical and laboratory features of65 patients who had been referred less than 1 month prior tofirst dialysis (late referral, or LR group) and of 153 patientswho had been previously followed-up by us for more than 6 months(early referral, or ER group). Age, sex ratio, and socioeconomicstatus were similar in the two groups. In the LR group, 38 patientshad never been referred to a nephrology unit, whereas 27 haddiscontinued nephrological surveillance. Fluid overload, severehypertension, and/or pulmonary oedema was present in 57% ofLR versus 15% of ER patients (P<0.001). Mean (±1 SD)systolic and diastolic blood pressure was greater in the LRthan the ER group (173 ± 19/99±12 versus 147±15/84±8mmHg, P<0.001). Mean plasma concentration of creatinine,urea and phosphate was significantly greater, whereas bicarbonate,calcium, haematocrit and albumin were less in the LR than theER group. Most (88%) LR patients started dialysis in emergencyconditions through central vein Catheterization. Total hospitalstay lasted 34.5±16.3 days in LR versus 5.8±3.0days in ER patients (P<0.0001), resulting in an excess costof 0.2 million French francs per LR patient. We conclude thatpatients referred at a late stage of renal failure without previousnephrological follow-up had strikingly more severe uraemic disorders,together with poorer blood pressure control and clinical condition,than patients receiving adequate nephrological care, and neededprolonged hospitalization to recover. Such potentially avoidabledeleterious effects strongly suggest the need for earlier andcloser co-operation between general practitioners and nephrologists.     

Ultrasonographic detection of thickened joint capsules and tendons as marker of dialysis-related amyloidosis: a cross-sectional and longitudinal study

Dialysis-related amyloidosis is characterized by a ß₂-microglobulin(ß₂M) infiltration of joint synovia, tendons and capsules.We report a cross-sectional ultrasonographic evaluation of supraspinatustendon and femoral neck capsule thickness in 49 patients onlong-term haemodialysis. Ultrasonographic evaluation was repeated21±4 (SD) months later in 16 patients. Normal valuesfor the supraspinatus tendon and femoral neck capsule were definedin a group of control subjects without history or signs of jointdisease. Among the 49 patients, aged 21–86 (median 59) years, dialysedfor 1–228 (median 97) months, 33 had at least one abnormaljoint. The prevalence of patients with at least one and at leasttwo abnormal joints, the number of abnormal joints per patient,and the thickness of the supraspinatus tendon and femoral neckcapsule increased significantly with dialysis duration (P<0.001 for all parameters considered). By multiple linear regressionanalysis, mean thickness of the supraspinatus tendon was positivelyrelated to both dialysis duration (P< 0.0001) and age (P= 0.036) independently. All (n=11) patients with radiological and/or histological evidenceof dialysis-related amyloidosis at the time of ultrasonographyhad thickened supraspinatus tendon and/or femoral neck capsule;which were also thickened in an additional 22 patients withoutradiological evidence of dialysis-related amyloidosis. Threedied within 5–10 months of the ultrasonographic investigation: post-mortem examination of the periarticular tissue confirmedthat the detected thickening was due in all three to ß₂Mamyloid infiltration. Sixteen patients underwent a second ultrasonographic evaluation21±4 months later. In nine patients on dialysis for <60months at the time of the first evaluation, mean femoral neckcapsule thickness increased significantly (7.0±0.8 to8.2±2.3mm, P = 0.017) whereas mean supraspinatus tendonthickness increment was not significant (6.6±0.4 to 7±0.8mm, P=0.23). In the seven other subjects dialysed for <60months, neither the supraspinatus tendon nor femoral neck capsulethickness changed. We suggest that ultrasonographic measurement of supraspinatustendon and femoral neck capsule thickness is a useful, non-invasivetool to detect and monitor dialysis-related amyloidosis.     

Should CAPD be the first choice for dialysis in Romania? Audit of the Iasi 'C. I. Parhon' Dialysis Center: 1995-2000.

Peritoneal dialysis was first introduced in Romania in 1995.We are reporting data on patient and technique outcomes, basedon the 5-year experience of one of the first two Romanian continuousambulatory peritoneal dialysis (CAPD) centres. During this period,Romania had the highest rate of increase in renal replacementtherapy (RRT) and CAPD (28 times over baseline) in Europe: CAPDincrease in Romania vs Eastern Europe was 6.7 compared to asimilarly defined ratio of 5.6 for haemodialysis (HD). Between 1995 and 2000, at the ‘C. I. Parhon’ Hospitalin Iasi, 259 patients were started on HD and 102 on CAPD. The90 CAPD patients we followed were treated for a total of 1896months. 86.7% of the patients were alive on 31 July 2000—67.8%continuing on CAPD, 15.6% on HD and 3.3% transplanted. The 61patients still on PD on that date, represented 11.1% of theactual Romanian CAPD population and 31% of our RRT population(compared to 13.7% nationwide). The gross mortality rate was comparable to the mean calculatedfor the HD population nationwide. Mean survival of the CAPDpatients was 45.4±2.6 months (95% CI=40.4–50.4months). One-year and 5-year patient survival rates were 97.5%and 52.7% respectively, superior and similar to mean figuresnationwide. Mean technique survival was 36.6±0.6 months(95% CI=31.5–41.6 months). One- and 5-year technique survivalrates were 83.1% and 34.3% respectively. Technique failure wasmainly due to dialysis inefficiency: 50% of cases. Mean weeklyKt/V for the 5-year period was 1.92±0.21 while mean weeklycreatinine clearance was 61.2±12.4 ml/1.73 m²/week. Eighty-four episodes of peritonitis were recorded in 46 patients(0.25 episodes/patient/year); mean duration to peritonitis was23 months (95% CI=18.2–27.5). Malnutrition was noted (SGAscore) in 25.5% of the cases. Blood pressure (assessed by 24-hABPM) was adequately controlled in 83.3% of the patients. Leftventricular hypertrophy was ubiquitous (77.7%), but left ventriculardilatation and systolic dysfunction (fractioning shorteningindex <25%) were rare—4.4% and 3.3% respectively (similarin prevalence to the Iasi HD population). No statistically significantchanges in echocardiographic parameters were recorded betweenthe first and subsequent years on CAPD treatment. Peritoneal dialysis had a rapid increase in the last 5 yearsin Romania and particularly in the region of Moldova. Outcomesand complication rates are equal or superior to nationwide HDdata and comparable to distinguished centres of CAPD in economicallydeveloped countries. We conclude that, provided that optimalmedical practice is available, CAPD should be the RRT of choicein Romania, and that it represents the only solution to thecountry's limited dialysis resources.     

Serum concentrations and peritoneal loss of growth hormone and growth-hormone-binding protein activity in older adults undergoing continuous ambulatory peritoneal dialysis: comparison with haemodialysis patients and normal subjects

Serum concentrations and peritoneal losses of growth hormone(GH) and of growth-hormone-binding protein (GH-BP) activityin 13 patients undergoing continuous ambulatory peritoneal dialysis(CAPD) were compared with those of 13 patients on haemodialysisand 13 normal subjects. The individuals in the three groupswere matched by age (40–83 years), gender, and serum glucoseconcentration. In addition CAPD and haemodialysis patients werematched by haematocrit, serum creatinine and albumin concentrations,and period of time on dialysis (0.5–127 months). GH inthe serum and in the peritoneal effluent were measured by radioimmunoassay(RIA) and NB2 bioas-say. GH-BP activity was analysed by bindingassay and expressed as a percentage of the specific bindingof GH. In the haemodialysis patients, serum GH was significantlygreater and serum GH-BP activity significantly less than inthe CAPD patients and control subjects. Between the two lattergroups no significant differences in GH or in GH-BP activitywere observed. GH bioactive/immunoactive ratios in the threegroups were similar. Both GH and GH-BP were detected in theperitoneal effluent of CAPD patients, in whom an overnight (8-h)peritoneal loss of GH (8.0±1.4x 10^–3 ug/h/1.73m2) was strongly correlated with serum GH (r= 0.840). CirculatingGH and GH-BP activity were influenced by serum creatinine andhaematocrit. In addition a positive relationship was observedbetween GH-BP activity and body mass index and between GH andtime on dialysis. These data reaffirm that older adults undergoinghaemodialysis, unlike CAPD patients, exhibit persistent abnormalitiesin GH-GH-BP axis. The peritoneal losses of GH and GH-BP thatoccur during CAPD do not affect their respective serum concentrations.     

Similar rate of progression in the predialysis phase in type I and type II diabetes mellitus

Progression of diabetic nephropathy from the stage of macroproteinuriawith near-normal renal function until start of dialysis wascompared in 16 patients with type I and 16 patients with typeII diabetes mellitus. The mean creatinine clearance at the beginningof the study was 89±13 ml/min/l.73 m² in patients withtype I and 81±6 ml/min/1.73 m in those with type II diabetes.Dialysis was started after a mean interval of 77(44–133)months, when creatinine clearance had decreased to 8 ±2 ml/min/1.73 m² in type I diabetic patients. The respectivefigures for type II diabetic patients were 81(40–124)months and 7±2 ml/min/1.73 m² The mean rate of decreasein creatinine clearance was 1.05 ± 0.45 ml/min/monthin type I and 0.91 ± 0.41 ml/min/month in type II diabetes.The mean rate of decrease was 1.46±0.30 ml/min/monthin type I diabetic patients with a systolic BP> 160 mmHgversus 0.80±0.42 ml/mm/month with <160 minHg (P>0.01).In the type II diabetics the respective figures were 1.38±0.40m1/min/monthversus 0.78 ± 0.15 ml/min/month (P>0.01). During theobservation period the prevalence of coronary heart diseaseincreased from 6 to 50% in type I and from 31 to 87% in typeII diabetes. In conclusion, the rate of progression of diabeticnephro pathy during the predialytic phase is similar in typeI and type II diabetes; BP adversely affects the rate of progressionto the same extent in both groups.     

Reduced speed of sound in tibial bone of haemodialysed patients: association with serum PTH level

BACKGROUND: In end-stage renal disease, average bone mineral density hasbeen reported to be normal or only modestly reduced, more soin the cortical bone. The purpose of the present study was toexplore the potential use of quantitative ultrasound, a methodreflecting both quantitative and qualitative properties of bone,in assessing bone status in patients on maintenance haemodialysis. METHODS: We studied 71 patients (age 17–81 years, time on dialysis0–18 years). The speed of sound waves (tSOS; m/s) propagatingalong the cortical bone has been determined at the tibial shaft.tSOS results were expressed as Z scores, i.e. units of standarddeviations from age- and sex-matched normal mean values, andcorrelated with relevant clinical and biochemical variables. RESULTS: SOS Z score averaged –2.0 (range –6.8 to 0.6; P<0.001)and was negative in 93% of the patients. Significant inversecorrelations were found between SOS Z score and both time ondialysis (r=–0.52; P<0.0001) and serum PTH (r=–0.39;P=0.002). Markedly reduced SOS Z score, below –2, wasfound in 80% of the patients whose PTH levels exceeded 34 pmol/l(five times the upper normal limit), compared with 43% of thepatients whose PTH levels were below 34 pmol/l (P=0.04). Comparedto patients with out bone pain (n=51), subjects with bone pain(n=20) had somewhat lower SOS Z scores –2.5±2.0versus –1.8±1.4; n=0.08), but this could be accountedfor by longer time on dialysis. CONCLUSIONS: tSOS is substantially reduced in the majority of haemodialysedpatients and is related to time on dialysis and serum PTH level.The clinical value of this novel method needs further exploration.     

Idiopathic membranous nephropathy in the elderly

In this retrospective non-randomized study we reviewed the outcomefor 41 patients with membranous nephropathy older than 65 yearsat onset and followed for at least 1 year. Twelve of the patientsnever received any specific treatment (group A), 15 were treatedwith a 6-month course of methylpredniso-lone alternated to chlorambucilevery other month (group B), and 14 received corticosteroidsalone for 3–12 months (group C). At the end of a meanfollow-up of 92±61 months in group A, 53±35 ingroup B, and 38±25 in group C there were significantlymore remissions of nephrotic syndrome in group B than in groupA (P=0.035) or in group C (P = 0.010). Moreover patients ingroup B spent a significantly longer period without nephroticsyndrome than patients in group A (P=0.000) and C (P=0.000).Three patients in group A and one in group B died. During thefollow-up six patients of group A, two of group B, and fiveof group C developed renal function deterioration. In patientsfollowed for at least 5 years the mean plasma creatinine increasedfrom a basal of 112±29 to 239±287 µmol/lat the 5th year in group A and from 113±14 to 124±30µmol/l in group B. The mean urine protein excretion remainedunchanged in group A (basal 4.6±2.3 versus 4.8±5.7g/day at 5 years) while it decreased in group B (from a basalof 6.8±3.5 to 1.1±0.4 g/day at 5 years). The natural course of membranous nephropathy in older patientsis similar to that of patients of the second age. Corticosteroidsalone do not modify the outcome. Corticosteroids alternatedwith chlorambucil seem to improve the chances of remission andto protect from renal dysfunction, but elderly patients aremore exposed to the side-effects of this regimen. Thus thistreatment should be limited to patients with severe nephroticsyndrome and/or incipient renal insufficiency, using some particularcautions.