Intraperitoneal administration of recombinant human growth hormone in children with end-stage renal disease

Recombinant human growth hormone (GH) therapy has been shown to be effective in the treatment of growth failure related to growth hormone resistance among children with chronic renal failure. The traditional route of administration is subcutaneous injection. This study was designed to evaluate the effectiveness and tolerability of intraperitoneal (IP) administration of GH in prepubertal peritoneal dialysis patients. Nine subjects were enrolled. Eight completed 24 months of therapy with GH. Baseline height standard deviation scores (SDS) and growth velocity for the prior year were used for comparison. Peak serum GH was achieved 4 h after administration and serum half-life was 4.6 h. Mean height SDS was –3.1 at baseline, –2.5 at 1 year, and –2.3 at 2 years (NS) of GH therapy. Mean height velocity increased from a baseline of 4.6 cm/yr to 8.5 cm/yr in year 1 (P<0.05) and 6.1 cm/yr in year 2 (NS) of IP GH therapy. Peritonitis infection rates were not increased from overall center rates. This research suggests that the intraperitoneal route of administration of GH can be utilized in the treatment of short stature among children requiring maintenance peritoneal dialysis therapy. Received: 8 February 1999 / Revised: 24 May 2000 / Accepted: 25 May 2000     

Quality of life after organ transplantation in type 1 diabetics with end-stage renal disease

Quality of life (QOL) should be an important consideration while choosing therapeutic options for patients with type 1 diabetes mellitus (DM) and end-stage renal disease (ESRD) including dialysis, cadaver (CKT) or living kidney transplant (LKT) or simultaneous pancreas-kidney (SPK) transplant. METHODS: QOL was assessed in four groups of patients with history of type 1 DM and ESRD: recipients of SPK (n = 43), CKT (n = 43), LKT (n = 11) and wait listed (WL) patients (n = 23). Diabetes Quality of Life (DQOL), Short Form-36 (SF-36) and Quality of Well-Being (QWB) questionnaires were utilized. A subset of SPK (n = 19) and CKT (n = 12) recipients underwent longitudinal QOL evaluation. RESULTS: On DQOL questionnaire, SPK group had better satisfaction subscore compared with CKT (1.8 +/- 0.5 vs. 2.2 +/- 0.6, p < 0.01) LKT (1.8 +/- 0.5 vs. 2.4 +/- 0.7, p < 0.05) and WL (1.8 +/- 0.5 vs. 2.6 +/- 0.6, p < 0.001) groups and better impact subscore compared with CKT (1.7 +/- 0.6 vs. 2.1 +/- 0.6, p < 0.05) and WL (1.7 +/- 0.6 vs. 2.3 +/- 0.6, p < 0.01) groups. There were no significant differences on physical/mental composite scores of SF-36. QWB score was better in SPK group vs. WL group (0.62 +/- 0.11 vs. 0.55 +/- 0.04, p < 0.05). Longitudinal decline in satisfaction (2.3 +/- 0.5 vs. 2.6 +/- 0.9, p = 0.058) and impact (2.0 +/- 0.5 vs. 2.2 +/- 0.5, p = 0.019) subscores of DQOL were noted in CKT group. There were no significant changes in the composite scores of SF-36 in both groups. QWB scores declined in the CKT group (0.67 +/- 0.10 vs. 0.61 +/- 0.05, p = 0.01). CONCLUSION: QOL was better in type 1 diabetics with ESRD following transplantation when compared with remaining on WL. SPK transplantation had significant positive effect on diabetes-related QOL which was sustained longitudinally but it was difficult to show an overall improvement in general QOL.     

The dilemmas of patient treatment for end-stage renal disease

In past years, physicians responsible for the treatment of chronic uremia have faced dilemmas that have been methodologic and economic while attempting to provide good patient care. These have been overcome, but in the course of time a larger one has developed. The current dilemma is one of high costs for end-stage renal disease (ESRD) management and the failure of current treatment programs to adequately rehabilitate the ESRD patient. In spite of widespread concern about this dilemma, few current data and even fewer projections exist about the eventual costs for their care. Existing data demonstrate several problems that are the basis of this dilemma: (1) the projections of incidence and prevalence of ESRD patients have been too low; (2) renal transplantation has failed to develop into a dominant (and least costly) form of ESRD therapy; (3) home dialysis programs have failed to offset the rapidly expanding in-center dialysis population; and (4) prevalence of and costs for chronic hemodialysis have increased far beyond expected levels. Using current data for the US population as to the incidence and overall mortality rate of ESRD patients, it is apparent that the dialysis population is only 39% of the way toward a steady state-corresponding to only the 4th year of a calculated 25-year growth curve. Although the current costs for maintenance of ESRD patients exceeds $1.3 billion, based upon such projections with the current distribution of patient treatment modalities, the overall annual cost will be in excess of $3.3 billion before a steady state is achieved. Improvement in mortality rates or increases in the incidence of patients will increase the steady state prevalence and the overall costs. Renal transplantation, unless kidney survival rate is increased so that it approximates patient survival, is unlikely to offset the rapidly increasing costs. New technology that would reduce the costs for center-based chronic hemodialysis has not been identified. Emphasis upon home dialysis modalities as a method of increasing patient rehabilitation and reducing costs appears to be a short-term necessity. Increased research and development in prevention of ESRD and in achieving better transplant kidney survival appear to be extremely important as long-term goals.     

Evaluation and treatment of coronary artery disease in patients with end-stage renal disease

Evaluation and treatment of coronary artery disease in patients with end-stage renal disease. Patients with end-stage renal disease (ESRD) are at increased risk of death from coronary artery disease (CAD). The metabolic milieu that results from renal dysfunction appears to accelerate the atherosclerotic process by decades in patients with ESRD. The extremely high prevalence of atherosclerosis in patients with ESRD mandates risk factor identification and treatment. Traditionally, CAD in this patient population has been treated conservatively. Analysis of large databases has highlighted the scope and complexity of this problem; nonetheless, there is a paucity of randomized, controlled trials of CAD in patients with ESRD. In this paper the following issues related to evaluation and treatment of patients with chronic kidney disease are addressed: (1) optimal CAD risk management; (2) evaluation for CAD in patients with ESRD, including the identification of coronary calcification; (3) treatment of CAD with medical therapy and revascularization; (4) relative merits of percutaneous coronary intervention versus bypass surgery. In general, an aggressive approach to medical management of CAD is warranted, even in the setting of subclinical CAD. A low threshold for diagnostic testing should be employed in patients with ESRD. When significant CAD is identified, ESRD patients appear to benefit more from revascularization compared to conservative medical management. Thus, if clinically reasonable, patients with ESRD and CAD should be managed aggressively to improve survival and reduce the incidence of future cardiac events.     

胰肾联合移植治疗Ⅰ型糖尿病合并终末期肾病

目的 探讨胰肾联合移植治疗Ⅰ型糖尿病合并终末期肾病的临床效果。方法 ８例Ⅰ型糖尿病合并终末期肾病的患者接受胰肾联合移植,平均年龄４３．４６岁,２例合并视网膜病变,双目失明,病史２～２２年。胰腺移植于右髂窝,胰腺外分泌经膀胱引流,肾脏移植于左髂窝。免疫抑制方案开始四联用药,以后三联用药继续治疗。结果 ８例虱其中７例术后即不需要应用胰岛素,空腹血糖可维持在正常范围,１例术后应用胰岛素４０ｄ后停用。１例     

Two cases of penile necrosis in diabetics with end-stage renal failure

Distal penile necrosis associated with renal failure is a rare entity; only a few cases have been reported in the literature. Penile necrosis can frequently be a difficult management problem, the etiology of which is infectious, traumatic, or vascular. Physiological abnormalities are usually found in association with this condition, including diabetes, hyperparathyroidism, and peripheral vascular disease. Penile necrosis is a poor prognostic factor associated with high morbidity. We report two cases of this condition, presenting the clinical and pathophysiological background.     

A critical look at survival of diabetics with end-stage renal disease. Transplantation versus dialysis therapy

The survival of 100 consecutive patients with diabetic nephropathy after treatment with hemodialysis, peritoneal dialysis, or renal transplantation was reviewed at our institution from 1976 to 1982. Standard actuarial survival analysis revealed an overall survival of 83% and 61% at one and two years, respectively. Coronary angiography was used as a screening procedure for renal transplantation. In the dialysis group, 27 patients were considered acceptable transplant candidates on the basis of the coronary angiography but were not transplanted for other reasons. When the survival analysis was limited to those "transplant candidates" the survival rates were 78%, 51%, and 8% at 1, 2, and 5 years, respectively. In comparison, survival after transplantation was 81%, 67%, and 45%, at 1, 2, and 5 years, respectively. In order to eliminate bias, survival comparisons were subsequently made using the Cox Proportional Hazard Model to take into account the time the transplant patients spent on dialysis prior to renal transplantation. When this analysis was performed, there was no significant difference in survival between transplantation and dialysis for the first two years, but overall survival after five years was significantly better after renal transplantation even when the comparison was limited to acceptable transplant candidates who remained on dialysis (P = .04). Survival for patients with significant coronary disease (greater than 70% stenosis of a coronary vessel or moderate to severe left ventricular dysfunction) was analyzed according to therapeutic modality. Although overall prognosis was poor in this group as a whole (1, 2, and 5 year survivals were 76%, 45%, and 19%, respectively), the cardiac patients had a trend to better survival after renal transplantation than when maintained on dialysis (P = .22). In addition to other factors such as quality of life, rehabilitation, and progression of other diabetic complications, the benefit of renal transplantation on patient survival must be considered when deciding between renal transplantation and maintenance dialysis therapy for diabetic patients with renal failure.     

Prevention and treatment of renal osteodystrophy in children with chronic renal insufficiency and end-stage renal disease

Histologic features associated with secondary hyperparathyroidism remain the predominant skeletal lesion in adults and children with chronic renal failure. When instituted early, vitamin D therapy has been shown to ameliorate the development and progression of the biochemical, radiographic, and histologic evidence of secondary hyperparathyroidism in patients with chronic renal insufficiency. Aggressive parathyroid hormone suppression, however, has led to the increased prevalence of adynamic bone. Adynamic bone has been attributed partly to aggressive calcitriol therapy, administration of high amounts of exogenous calcium either as a phosphate binding agent or during dialysis therapy, presence of diabetes, older age, or previous parathyroidectomy. Several vitamin D analogues are currently being evaluated in patients with chronic renal failure to prevent complications associated with calcitriol therapy. In addition, calcium-free phosphate binding agents and the use of calcimimetic drugs may play a significant role in the effective management of secondary hyperparathyroidism in children with chronic renal failure.     

Optimal dialysis for the end-stage renal disease patient with cardiovascular disease

The increasing incidence and prevalence of end-stage renal disease (ESRD) that requires renal replacement therapy has placed a focus on the dialysis procedure itself with respect to its hemodynamic and cardiovascular complications. More than 50% of patients with ESRD will die of cardiovascular disease (CVD). A considerable contribution to cardiovascular events occurs with the dialysis procedure itself. This paper explores the intradialytic complications of hemodialysis as they relate to the cardiovascular system and highlights opportunities for research and improved quality of care.     

Peritoneal dialysis compared with hemodialysis in the treatment of end-stage renal disease

Whether to use peritoneal dialysis (PD) or hemodialysis (HD) is a major decision in terms of clinical outcome and management implications; the final choice is difficult because of the conflicting results of comparisons reported in the literature. A review of studies comparing survival shows either superiority of HD, or superiority of PD, or equivalence of the two techniques, but an analysis of the comparisons as a whole brings to light two clear phases in the survival curves. In the first, residual renal function (RRF) gives PD an advantage, or at least puts it on the same level as HD. In the second phase, the reduction in Kt/V as RRF declines gives PD a potential risk. After a few years of PD treatment a sharp watch is therefore necessary to detect signs of under-dialysis promptly and to shift the patient to HD. In patients without RRF it is more difficult to control hypertension with PD and they are more prone to hyperhydration. Despite a widespread belief in the Eighties that PD was the treatment modality of election for diabetics, HD is in fact preferable in these patients, except younger ones. High-turnover and low-turnover bone lesions are more frequent respectively in HD and PD patients. Anemia is better controlled with PD. Blood lipids and nutritional indices are less well controlled with PD. Despite poor technical survival, the "pool" of patients treated with PD frequently reaches 20-30% because it is indicated as first treatment in a large proportion. PD preserves renal function better than HD and is useful while awaiting renal transplantation, with faster postoperative restoration of diuresis. The quality of life with PD as home treatment is usually better than with HD. In conclusion, dialytic centers should establish an integrated PD/HD programme as the two methods are not competitive but are different tools for the treatment and rehabilitation of uremic patients.     

Therapeutic camping for children with end-stage renal disease

Therapeutic camping experiences for children with end-stage renal disease (ESRD) have proliferated in the United States and abroad. This report is based on the results of a survey designed to accumulate data on the development and implementation of 20 such camps. Children attending camp ranged in age from 1 year to 19 years. Single disease-specific camps were most common, while camps for children with a variety of chronic illnesses, including ESRD, and mainstream camps were also conducted. Facilities were available for hemodialysis and continuous ambulatory peritoneal dialysis, but not automated peritoneal dialysis, in the majority of surveryed camps. Dialysis nurses, pediatric nephrologists, dietitians and social workers were the medical personnel that most frequently participated in the camps. On average, 32 dialysis/transplant patient campers (range 6–100) attended camp for a 1-week session. Therapeutic camping experiences for children with ESRD are extremely successful and attempts to increase the availability of similar camps should be encouraged.Presented in part at the 13th Annual Conference on Peritoneal Dialysis, 7–9 March 1993, San Diego, California, USA.     

Exercise for children with chronic kidney disease and end-stage renal disease

It is well known that adults suffering from chronic kidney disease (CKD) experience muscle wasting and excessive fatigue, which results in a reduced exercise capacity and muscle weakness compared to their healthy counterparts, but research suggests that this can be improved through exercise. There is very limited data available regarding exercise tolerance in children with CKD and even less on the effects of exercise training programs. However, the available evidence does suggest that like adults, children also suffer from poor exercise capacity and reduced muscle strength, although the reasons for these limitations remain unclear. Studies that have attempted to implement exercise training programs in pediatric CKD populations have experienced high dropout rates, suggesting that the approach used to implement such programs in children needs to be different from the approach used for adults. This review summarizes the current knowledge regarding exercise capacity and muscle strength in children with CKD, the methods used to perform these assessments, and the possible causes of physical limitations. The results of exercise training studies, and the potential reasons as to why training programs have proved relatively unsuccessful are also discussed.     

Pregnancy tests with end-stage renal disease

Tests to ascertain pregnancy status are often obtained during preoperative evaluation, especially when there is a history of uncertain pregnancy or suggestion of current pregnancy. A serum pregnancy test, a beta-human chorionic gonadotropin (β-HCG) level, was preoperatively obtained from a woman of childbearing age with end-stage renal disease (ESRD) with an unreliable history of irregular menstruation coupled with unprotected sexual activity. The β-HCG was elevated in the range indicating pregnancy. Further work-up showed that this hormonal elevation was secondary to ESRD without pregnancy.     

Ascites associated with end-stage renal disease

Patient characteristics, clinical outcomes, and proposed pathophysiologic mechanisms are reviewed in 138 patients reported in the literature to have had ascites associated with end-stage renal disease. Contributing mechanisms may include fluid overload, peritoneal membrane changes (not necessarily related to peritoneal dialysis), hypoproteinemia, and lymphatic drainage disturbances. In 15% of cases, extensive evaluations may reveal an underlying disease. The most effective therapy may be kidney transplantation.     

The adolescent with end-stage renal disease

The adolescent with ESRD is frequently immature in relationship to chronological age. Growth and pubertal development are major concerns for the adolescent with ESRD. If renal failure had its onset prior to adolescence, it is likely that puberty will be delayed and ultimate adult height retarded for the patient requiring ESRD care during the adolescent period. Non-compliance with the therapeutic regimen is a major clinical problem encountered in the management of the adolescent. Significant morbidity can result from non-compliance with the dialysis regimen and non-compliance is a major cause of allograft loss in the adolescent transplant recipient. The special needs of the adolescent must be considered if ESRD care is to be successful.     

Dialysis therapies for end-stage renal disease

End-stage renal disease (ESRD) has various causes that may differ according to country and racial group. Whatever the cause, unless the water, salt, electrolytes, and waste products excreted by normal kidneys are removed, their accumulation will result in death. Removal of these products can be variably achieved by either hemodialysis or peritoneal dialysis. The principles and outcomes of these techniques are described, as are their complications. It is important that these two different methods of treatment are not regarded as competitive, but are integrated, together with renal transplantation where appropriate, into the management of patients with ESRD to optimize both outcome and quality of life.     

Preferences of nephrologists among end-stage renal disease treatment options

We surveyed 49 practicing nephrologists in North Carolina and determined their preferences among eight currently available end-stage renal disease treatment modalities using the method of paired comparisons. We also obtained background information about the nephrologists and their practices and data from the North Carolina Network about actual assignment of patients to treatment during the year prior to the survey. There was a striking congruence (p less than 0.001) of treatment preferences among the nephrologists. Although transplantation modalities were clearly preferred over both home and facility dialysis, and home hemodialysis was the preferred dialysis modality, relatively few patients received transplants or were trained for home hemodialysis. The elements contributing to treatment selection other than physician preference are discussed.     

New approaches for the treatment of genomic damage in end-stage renal disease.

OBJECTIVE: Patients with end-stage renal disease (ESRD) exhibit an enhanced genomic damage which may have pathophysiological relevance for cancer development and cardiovascular complications. The DNA damage has been shown both in the pre-dialysis and dialysis phase by micronucleus (MN) frequency test and single cell gel electrophoresis in peripheral blood lymphocytes (PBLs). A major cause of DNA damage is oxidative stress, which may be induced by various uremic toxins, including advanced glycation end products (AGEs), as well as by activation of the renin-angiotensin system. RESULTS: Genomic damage of ESRD patients can be ameliorated by daily hemodialysis (DHD), as observed in a cross-sectional study. Patients on DHD showed a reduced genomic damage in the MN frequency test in PBLs compared to those treated with standard hemodialysis. Another way to decrease DNA damage in ESRF seems to be the chronic administration of angiotensin II type 1 (AT)1 receptor blockers. In 15 maintenance hemodialysis patients, treatment with candesartan resulted in a significant improvement of DNA damage. According to our in vitro data, these beneficial effects may be a consequence of preventing the genotoxic actions of angiotensin II. Vitamin B1 (benfotiamine) was found to be able to reduce the amount of circulating AGEs in animal experiments. We could show in a pilot study that the application of benfotiamine significantly reduced the genomic damage of dialysis patients. CONCLUSION: There are several possibilities of lowering genomic damage in dialysis patients, which in the long run might lead to lower cancer incidences.