Red cell alloimmunization in chronic renal failure patients undergoing hemodialysis

Posttransfusion alloimmunization to red cell antigens was studied in a group of 98 chronic renal disease patients treated solely with hemodialysis. Clinically significant red cell antibodies were formed in only 6.1% of transfused patients, and only 1 patient formed more than one antibody. We do not recommend extended red cell phenotyping, beyond ABO and Rh(D), in patients with end-stage renal disease who may require transfusion.     

Hand contamination with hepatitis C virus in staff looking after hepatitis C-positive hemodialysis patients

BACKGROUND: Hepatitis C virus (HCV) is a major cause of hepatitis in hemodialysis (HD) patients. Routes other than blood transfusion play a role in the spread of HCV in HD patients. Molecular studies of HCV implicate nosocomial transmission of the virus in HD units. We conducted a clinicovirological study in our HD unit to investigate if the hands of dialysis personnel could represent a mode of transmission of HCV among HD patients. METHODS: One liter of sterile water was used for each handwashing of dialysis personnel. The washing was collected in a sterile container and tested for HCV-RNA by polymerase chain reaction (PCR) within 3 h of collection. Eighty handwashings from nurses dialyzing HCV-positive patients (groupe A) and 100 handwashing from nurses dialyzing HCV-negative patients (group B) were tested for HCV-RNA. As a control, 60 handwashings were collected from the dialysis personnel before entering the dialysis unit (group C) and tested for HCV-RNA. RESULTS: HCV-RNA was positive in 19 (23.75%) of samples of group A, in 8 (8%) of samples of group B (p < 0.003) and in 2 (3.3%) of samples of group C (p < 0. 35). These two positive samples of group C were from nurses who had dialyzed HCV-negative patients. CONCLUSION: These results indicate the presence of HCV-RNA on the hands of some dialysis personnel in our HD unit, in spite fo adherence to the standard precautions. The hands of dialysis personnel are therefore a potential mode for facilitating transmission of HCV between HD patients.     

Diagnostic accuracy of the fibrotest in hemodialysis and renal transplant patients with chronic hepatitis C virus

BACKGROUND: An accurate diagnosis of hepatitis C virus (HCV)-related liver lesions is mandatory in dialysis patients and kidney recipients to better define the treatment of and contraindications to kidney transplantation. The aim of this study was to assess the diagnostic accuracy of the fibrotest (a noninvasive method to assess liver fibrosis in HCV on a scale from 0 to 1) in hemodialysis and renal transplant patients infected by chronic HCV. METHODS: In all, 110 patients with biopsy-proven HCV (60 renal transplant recipients and 50 hemodialysis patients), determined using the METAVIR scoring system, were studied. RESULTS: Forty-six percent of patients had fibrosis > or =F2. A positive predictive value of a score >0.6 for the presence of significant fibrosis by comparison with liver biopsy was 71%, and an negative predictive value of < 0.2 for excluding significant fibrosis was 77%, respectively. The areas under the ROC curves for the diagnosis of significant fibrosis were 0.66, 0.47, and 0.71 in the global population, hemodialysis patients, and renal transplant patients, respectively. In all, 75% of patients were correctly classified using the fibrotest. If biopsy was restricted to scores in the intermediate range (< 0.6 and >0.2), the index could reduce the indication for biopsy by 47%. The results did not differ significantly in hemodialysis and renal transplant patients. CONCLUSION: The fibrotest has a diagnostic value in hemodialysis and renal transplant patients which is similar to that reported in the general population (75%) and its use could avoid 32% of liver biopsies if it were interpreted in detail in nephrology patients.     

Erectile dysfunction in chronic renal failure patients undergoing hemodialysis in Egypt

In clinical practice, the attention given to sexual problems in patients with end-stage renal disease is low. In order to evaluate the erectile function in chronic renal failure patients undergoing hemodialysis (HD) as a renal replacement therapy in upper Egypt, we used the abridged version of the International Index of Erectile Function (IIEF-5). In all, 75 HD patients were subjected to clinical and laboratory investigations. The controls were 948 healthy males representing the general Egyptian population. The prevalence of erectile dysfunction (ED) among the HD patients was 82.5% compared to 30% among controls. The prevalence of ED in HD group was significantly higher than in controls. The prevalence of ED in HD patients <50 y was 80% and it was 88% in those > or =50 y, while the prevalence of ED among controls was 28 and 69.8%, respectively. The prevalence of severe degree of ED was significantly higher in both groups compared to controls, while moderate degree of ED showed a statistical significance compared to controls in age groups <50 y and mild degree of ED showed a statistical significance compared to controls in age groups > or =50 y. [corrected] Age (r=-0.3368, P<0.01), serum urea (r=-0.5974, P<0.001), and creatinine level (r=-0.5804, P<0.001) have a significant negative correlation with the presence of ED among HD patients, while serum hemoglobin (r=0.3396, P<0.001) and years of HD age (r=0.3147, P<0.01) have a significant positive correlation with the presence of ED among the HD patients. In view of the observed high prevalence of ED among the HD patients, we believe that a complete health evaluation of male HD patients should include a discussion about erectile function in the standard clinical care program of patients with renal disease.     

Tuberculous spondylitis in patients with end-stage renal disease undergoing chronic hemodialysis therapy

Tuberculosis of the spine is not rare in immunocompromised patients and particularly in those with end-stage renal disease (ESRD). Furthermore, the possible vascular compromise of the spinal cord in patients with diabetic nephropathy may result in symptoms of neurological involvement that could lead to deterioration and paralysis. We report a series of 4 patients with ESRD undergoing dialysis that developed tuberculous spondylitis of the thoracic spine. Diabetic nephropathy was the primary cause for chronic kidney disease in 2 patients; 3 of these patients were treated conservatively with anti-tuberculous medication and orthotic splints and were cured. The fourth patient with diabetes mellitus and clinically evident signs and symptoms of severe vascular insufficiency has additionally developed incomplete paraplegia. A complete sensory recovery and partial recovery of the hip flexors and abductors within 3 months occurred, following decompression of the spine and drainage of the abscess, in combination with long-term anti-tuberculous treatment and spinal orthosis.     

Rights of chronic renal failure patients undergoing chronic dialysis therapy.

The Patient Advocacy Committee of the International Federation of Kidney Foundations (IFKF) has developed a document proposing a set of rights for individuals with end stage renal failure (ESRF). These rights have been approved by the Board of Directors of the IFKF. Twenty rights have been developed and are organized into the following categories: (i) need of treatment and choice of patients; (ii) treatment of ESRF by haemodialysis; (iii) treatment of ESRF by peritoneal dialysis; and (iv) renal transplantation. It is the hope of this Committee and the IFKF that this document will provide a stimulus to more scientific inquiry and discussion as to what rights do patients possess with regard to treatment of chronic kidney disease, regardless of where they live or what may be their economic, social, ethnic or political status.     

Hepatitis C virus in chronic hemodialysis patients with non-A, non-B hepatitis.

Sixteen of 110 hemodialysis (HD) patients fulfilling criteria of non-A, non B hepatitis (NANBH), i.e. alanine aminotransferase (ALT) greater than 50 U/ml in the absence of both serologic markers for acute HBV and HAV infections and clinical evidence of another cause of hepatitis, were tested for the presence of antibodies against hepatitis C virus (anti-HCV) by enzyme immunoassay (Ortho, Diagnostics). All (100%) were anti-HCV-positive. There were 5 patients with a monophasic (M) rise pattern (1 or 2 ALT rises), and 11 cases demonstrated a polyphasic (P) rise elevation pattern (more than 2). The mean ALT value of the M group was 202.3 +/- 209 U/ml and that of the P group was 116.6 +/- 39.1 U/ml. The patients received a mean of 19.1 +/- 16.2 units of packed red cells during the follow-up period (69.9 months). Only 1 patient received no blood transfusion. Six patients had a past HBV infection and 3 became HIV-infected in the course of this study. The high rate of infection of hemodialysis patients with hepatitis C virus in our setting points to the need for improved control measures.     

Course of patients with chronic hepatitis C virus infection undergoing heart transplantation

OBJECTIVE: The objective of this study was to describe the clinical course of patients with chronic hepatitis C virus (HCV) infection undergoing heart transplantation (HT). MATERIALS AND METHODS: Among 499 patients transplanted in our hospital between January 1989 and September 2006, 11 subjects (2.2%) had chronic HCV infection. We analyzed liver function laboratory parameters pretransplantation as well as at 3, 6, 12 months, and last available, pre- and postsurgical hepatobiliary ultrasounds, and mortality. The mean time since HT was 32 +/- 23 months. RESULTS: No abnormalities in the liver parenchyma were observed on the ultrasound examinations performed before or after transplantation. There were 3 deaths (27%), none of which was related to HCV infection. Liver function laboratory parameters remained stable during the follow-up. CONCLUSIONS: The clinical course of patients with chronic HCV infection undergoing HT whose presurgical assessment did not show significant liver damage was favorable. No morphological or laboratory abnormalities were observed that would suggest reactivation of the infection during the follow-up.     

Fibronectin in patients with chronic renal failure undergoing dialysis

Fibronectin (FN) levels were determined in 64 cases with chronic renal failure (CRF), some of whom were undergoing dialysis. FN levels were 14.9 +/- 7.6 mg/dl in CRF (n = 20), 13.4 +/- 4.3 mg/dl in patients on continuous ambulatory peritoneal dialysis (CAPD) (n = 20) and 16.7 +/- 7.2 mg/dl in patients on hemodialysis (HD) (n = 24). All the levels were significantly lower than in normal subjects (23.1 +/- 4.6 mg/dl). Serum FN was compared with some nutritional indices. Positive correlations were found between serum FN and nitrogen balance (BN), serum prealbumin (PreA) and transferrin (Tf) in all the patients. With serum albumin (Alb), however, this correlation was only found in patients undergoing dialysis. Negative correlations were found between serum FN and the ratio of serum urea to serum creatinine (Surea/Scr) in CAPD and HD patients. In 10 CAPD patients, the low serum FN levels went up after increased protein intake. This indicates that it was the result of malnutrition due to decreased protein intake. Serum FN level reflects a negative BN earlier and better than serum PreA, Tf and Alb. It is a sensitive, reliable and simple index for judging the nutritional protein status and the effect of nutritional treatment in patients with CRF undergoing dialysis.     

Cholesterol metabolism in patients with chronic renal failure on hemodialysis

Premature atherosclerosis is a major concern in patients on chronic dialysis and the identification of risk factors is important for preventive and interventional strategies. Other than the recognized atherogenic lipoprotein levels, little is known about overall cholesterol metabolism in patients on chronic hemodialysis (HD) and the best therapeutic intervention is still being debated. Therefore, we investigated intestinal cholesterol absorption, cholesterol and bile acid synthesis, and non-cholesterol plasma sterols in eight patients on dialysis and compared the results to those of 16 healthy male controls matched for body mass index and dietary cholesterol intake. Total, low-density lipoprotein (LDL) cholesterol, and triglycerides did not differ between the groups, but dialysis patients had a significantly lower high-density lipoprotein (HDL) cholesterol level (39 +/- 11 mg/dL vs. 48 +/- 10 mg/dL, p < 0.045). However, fractional cholesterol absorption, was significantly lower in dialysis patients (42.8 +/- 10.9% vs. 53.4 +/- 11%, p < 0.035), whereas plasma plant sterol concentrations and their ratios to cholesterol did not differ. Bile acid and total cholesterol synthesis were lower in dialysis patients (40% and -25%, respectively), although the differences were not significant. In contrast, lathosterol and its ratio to cholesterol in plasma was significantly lower in dialysis patients (0.176 +/- 0.084 mg/dL vs. 0.251 +/- 0.102 mg/dL, p < 0.024 and 0.733 +/- 0.353 microg/mg vs. 1.172 +/- 0.407 microg/mg, p < 0.017, respectively), indicating reduced hepatic de novo cholesterol synthesis. It is concluded that reduced HDL cholesterol and reduced bile acid synthesis contributes to atherosclerosis pathogenesis in dialysis patients, whereas intestinal cholesterol absorption and hepatic cholesterol synthesis did not seem dominant in this process at this stage of disease. Consequently, treatment with bile acid binding resins could be preferable to treatment with cholesterol absorption and synthesis inhibitors.     

维持性血液透析患者感染乙型和丙型肝炎的分析

目的为了评价血液透析（血透）患者乙型和丙型肝炎（HBV、HCV）感染状态及对临床情况和肝功能的影响。方法对62例血透患者应用ELISA法和RT-PCR法检测抗-HCV和HCVRNA，采用斑点杂交法和固相放免法检测HBV标志，并检测肝功能和血浆蛋白电泳。结果62例患者中，抗-HCVIgM阳性27例（43．6％），抗-HCVIgG阳性29例（46．8％），HCVRNA阳性34例（54．8％），三项任一项阳性37例（59．7％），5例（8．1％）HBsAg阳性，其中HBeAg和HBVDNA阳性3例。结论向透患者中HCV感染严重，临床情况及预后差，检测血浆蛋白和电泳较肝功能酶学能更好地作为肝炎诊断和反映病情的指标。     

Anemia in patients with chronic kidney failure undergoing systematic hemodialysis treatment

A study of 24 patients with chronic renal failure and varying degrees of uremia and clinical symptoms was carried out in order to assess the mechanisms of anemia developing in patients on systematic hemodialysis for chronic renal failure. Blood clinical and biochemical parameters were evaluated. Sternal bone marrow puncture was performed to assess erythron status. Proliferative activity of bone marrow erythroid cells was assessed by autoradiography. Ineffective erythropoiesis was studied using MacManus' PAS test. The results of the study suggest that proliferative activity of bone-marrow erythroid cells is reduced while ineffective erythropoiesis is increased in patients with terminal chronic renal failure, treated by systematic hemodialysis, and largely explain the mechanism of anemia in these patients.     

Tumor markers in chronic renal failure and hemodialysis patients

Serum levels and the incidence of elevated levels of several tumor markers were measured in 30 patients with chronic renal failure (CRF) of different degrees, as well as in 36 hemodialyzed (HD) patients without clinical evidence of neoplasia. The tumor markers evaluated were carcinoembryonic antigen (CEA), CA 125, CA 15.3, CA 19.9, CA 50, alpha-fetoprotein, neuron-specific enolase (NSE), squamous cell carcinoma antigen (SCC), prostatic acid phosphatase and prostatic-specific antigen. Serum levels of CEA were above the cutoff limit in 33% of patients with CRF and 47% of HD patients, CA 50 was higher than normal values in 37 and 44% of patients, respectively. SCC was elevated in 43 and 72% of patients, respectively. Serum levels of CA 125 were elevated in 18% of patients with CRF and NSE in 36% of HD patients. In CRF several tumor markers (CEA, SCC, CA 50 and NSE) show a high false positive rate and may be unreliable for monitoring malignancies in uremic patients, while the other markers evaluated appear to maintain their specificity in this situation.     

Risk of sudden death in patients with chronic renal failure and hemodialysis

Cardiovascular mortality in uremic patients treated by hemodialysis overrates ten times cardiovascular mortality in general population. Approximatively 40% of patients on iterative hemodialysis die from cardiac diseases, half of cases by sudden death. Several risk factors for sudden death are well known: QTc interval prolongation, decrease of RR interval <750 msec, decrease of heart rate variability, presence of late ventricular potentials (LVP), presence of high risk ventricular extrasystoles, decrease of ejection fraction (EF) <40 %, presence of left ventricular hypertrophy. Our study evaluated the above-mentioned risk factors for sudden death in patients with chronic renal failure on hemodialysis. We studied 37 patients, 22 males and 15 females, with mean age of 42 years old, without diabetes, heart failure and arrhythmias, without myocardial ischemia on ECG, being on hemodialysis (HD) programme for minimum 1 year (HD parameters are: 4 h x 3/week, qB = 300 ml/min, buffer = bicarbonate, Ca dialysate = 1.75 mmol/l, K dialysate = 2.1 mmol/l, conductivity = 135 mS). The patients were evaluated by echocardiography, standard and Holter ECG. Statistics evaluation was performed in SPSS v.9.0. Program. The results proved that 80% of patients on HD have risk factors for sudden death, which are closely related with age and hyperhydration. Statistics proved that presence of high-risk arrhythmias is connected with heart rate variability and prolongation of QTc interval (favored by HD). 50% of our patients have 2 to 4 risk factors for sudden death, which increase incidence of sudden death in patients on HD.     

维持性血液透析患者合并慢性丙型肝炎的治疗新体会

目的探讨苦参素治疗维持性血液透析患者合并慢性丙型肝炎的效果、不良反应。方法收集维持性血液透析合并慢性丙型肝炎患者26例,随机分为治疗组和对照组,每组13例。治疗组给予聚乙二醇干扰素α -2a 180μg,肌肉注射,每周1次,疗程6个月,联合苦参素葡萄糖注射液100ml静滴3个月。对照组仅给予聚二醇干扰素α -2a 180μg,肌肉注射,每周1次,疗程6个月。观察治疗后12周、24周及停药后随访24周血清丙型肝炎病毒-RNA滴度中位数水平及丙型肝炎病毒-RNA阴转率,同时观察治疗前、后不良反应。结果治疗组丙氨酸氨基转移酶下降程度及丙型肝炎病毒RNA阴转率均高于对照组,同时不良反应低于对照组。结论苦参素在促进肝功能恢复、抑制丙肝病毒复制方面具有一定疗效,而且不良反应小,患者耐受性好。