Vanadium in patients undergoing chronic haemodialysis

The relationships between serum vanadium and serum aluminium, beta 2-microglobulin, silicon, phosphate, red blood cell count, haemoglobin and systolic blood pressure were studied in 80 chronic haemodialysis patients. Vanadium transfer during haemodialysis was also examined. Serum vanadium in 80 patients before haemodialysis was 18.4 +/- 7.6 ng/ml (normal values: 0.4 +/- 0.2 ng/ml). Significant correlations between serum vanadium and serum aluminium, silicon, beta 2-microglobulin, phosphate, red blood cell count, haemoglobin, and systolic blood pressure were found. As ultrafiltrate vanadium was greater than vanadium in the dialysate, vanadium transfers from blood to dialysate. Therefore, serum vanadium before haemodialysis significantly decreased from 18.4 +/- 7.76 ng/ml to 13.0 +/- 5.30 ng/ml, during a 5-h haemodialysis.     

Binocular vision in patients undergoing haemodialysis

Sir, Many patients on chronic haemodialysis (HD) suffer from chroniceye diseases, and the interaction of these diseases with thedialysis procedure can lead to worsening of vision [     

Monocyte phenotype and interleukin-1 production in patients undergoing haemodialysis.

The expression of MHC class II (HLA-DR) and complement receptor (CR1) surface molecules on CD 14+ monocytes were compared with the production of the monokine interleukin-1 beta (IL-1 beta) in patients with endstage renal disease undergoing maintenance haemodialysis (HD) with hollow fibre dialyzers containing cellulose (CE, n = 8) and polysulfone (PS, n = 7) membranes. Monocyte staining was performed in blood samples obtained at the beginning and after 3 h of HD. Analysis of surface marker expression was done by immunofluorescence staining and flow cytometry analysis. Specific fluorescence intensity for both CR1 and class II (HLA-DR) antigens was increased in patients treated with CE membranes at the beginning of a dialysis treatment when compared to healthy control values. Interestingly, after 3 h on dialysis a further increase was noted for CR1 complement receptor expression whereas the increased HLA-DR expression was no longer detectable. In contrast, specific fluorescence intensity for both antigens was not significantly different from controls, either before or after dialysis, in patients treated with PS. The capacity of peripheral blood mononuclear cells to produce IL-1 beta spontaneously in vitro in the two patient groups was found to parallel results on phenotypic expression of surface molecules. The present study demonstrates that functional signs of monocyte activation, as evidenced by an augmented IL-1 beta production, in some patients on long-term HD correlate with an increased expression of two functionally important monocyte surface marker molecules.     

Plasma ghrelin levels in patients undergoing haemodialysis and peritoneal dialysis.

BACKGROUND: Ghrelin has been characterized as a relevant physiologic regulator of appetite and body weight in humans. However, the potential relationships between ghrelin levels, inflammation and malnutrition in dialysis patients have not been adequately studied. METHODS: We used a cross-sectional design to study 20 haemodialysis (HD) and 21 peritoneal dialysis (PD) patients, and compared their plasma ghrelin (PGhr) levels with that of an age-matched control group. We also explored correlations between ghrelin and selected hormonal, renal adequacy, nutritional and inflammation markers in both groups. RESULTS: PGhr levels were higher in HD (median 119.8 pg/ml, range 71.1-333.7, P = 0.001) and PD (99.3, range 45.8-578.5, P = 0.045) patients than in healthy controls (78, range 29-158) (HD vs PD, not significant). Ghrelin levels were strongly and inversely correlated with age (r = -0.46, P = 0.02 for patients; r = -0.61, P = 0.001 for controls). Except for a positive correlation between ghrelin and growth hormone (r = 0.48, P = 0.002), univariate analysis failed to detect associations between PGhr and the measured hormonal values, renal adequacy, nutritional indicators and markers of inflammation. However, multivariate analysis revealed significant inverse correlations between PGhr levels and nutritional markers, including subjective global assessment (P = 0.013), albumin (P = 0.001), transferrin (P = 0.01) and protein nitrogen appearance (as an estimate of protein intake) (P = 0.035), after controlling for the confounding effect of age. CONCLUSIONS: PGhr levels were moderately and similarly increased in patients undergoing HD and PD. Age was a strong determinant of PGhr levels, both in uraemic patients and in healthy controls. Dialysis adequacy, residual renal function and inflammation did not appear to influence ghrelin levels in these patients. The negative correlation between PGhr and nutritional markers suggests that low dietary intake causes increases in ghrelin secretion in dialysis patients.     

Pharmacokinetics of vancomycin in patients undergoing haemodialysis and haemofiltration

Vancomycin is widely used for the treatment of infections with Gram-positive bacteria in patients with end-stage renal disease. The concentration of vancomycin in serum, in ultrafiltrate, and in dialysate was measured during nine haemofiltration and seven haemodialysis procedures with high-permeability membranes. The t1/2 of vancomycin was 101 +/- 19 h in the interdialytic and interhaemofiltration period. There was no significant difference between the haemodialysis clearance (55.2 +/- 18.5 ml/min) and the haemofiltration clearance (66.8 +/- 13.6 ml/min). The redistribution phenomenon was about 25% in the post haemofiltration period and only 10% in the post haemodialysis period. Approximately 270 mg of vancomycin was recovered in dialysate or ultrafiltrate. With high-permeability membranes more commonly used in patients with end-stage renal disease, continuous monitoring of vancomycin therapy is recommended.     

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.     

Accumulation of trimethylamine and trimethylamine-N-oxide in end-stage renal disease patients undergoing haemodialysis.

BACKGROUND: Trimethylamine (TMA) is a short-chain tertiary aliphatic amine that is derived from the diet either directly from the consumption of foods high in TMA or by the intake of food high in precursors to TMA, such as trimethylamine-N-oxide (TMNO), choline and L-carnitine. The clinical significance of TMA may be related to its potential to contribute to neurological toxicity and 'uraemic breath' in patients with end-stage renal disease (ESRD). METHODS: Concentrations of TMA and TMNO in plasma from 10 healthy adults (not on haemodialysis) and 10 adults with ESRD undergoing haemodialysis (pre- and post-dialysis) were determined by gas chromatography-mass spectrometry. RESULTS: The concentrations of TMA and TMNO in pre-dialysis plasma (1.39+/-0.483 and 99.9+/-31.9 microM, respectively) were significantly (P<0.05) higher than the corresponding levels in healthy subjects (0.418+/-0.124 and 37.8+/-20.4 microM, respectively). However, there were no significant differences between post-dialysis and healthy subject plasma concentrations. In the ESRD patients, there was a significant (P<0.05) reduction in plasma TMA (from 1.39+/-0.483 to 0.484+/-0.164 microM) and TMNO (from 99.9+/-31.9 to 41.3+/-18.8 microM) during a single haemodialysis session. CONCLUSIONS: TMA and TMNO accumulate between haemodialysis sessions in ESRD patients, but are efficiently removed during a single haemodialysis session.     

Idiopathic sudden sensorineural hearing loss in patients undergoing long-term haemodialysis

Idiopathic sudden sensorineural hearing loss (ISHL) has been recently recognized and is increasing in frequency in patients undergoing long-term haemodialysis. Although this is one of the annoying complications impairing quality of life in haemodialysis patients, there has been little clinical evidence about ISHL in haemodialysis patients until now. We have examined retrospectively the clinical features of 6 ISHL patients, 3 males and 3 females, with a mean age of 54 years, who underwent regular haemodialysis with a mean haemodialysis duration of 90 months from 1985 to 1989. Although a specific cause for ISHL could not be identified in this study, more precise clinical features of ISHL in patients undergoing haemodialysis have been elucidated. ISHL seemed to develop more frequently in haemodialysis patients and occurred in patients undergoing haemodialysis for a relatively long time, being independent of the high-frequency-deficit type hearing disturbances usually observed in the early course of haemodialysis therapy. Above all, diabetic haemodialysis patients were more susceptible to ISHL, occurring in 4 cases out of 6. Its prognosis was not necessarily bad, showing a recovery rate of 83%, but more effective therapy should be explored for improving the quality of life in haemodialysis patients.     

Two cases of urogenital malignancies in male patients undergoing maintenance haemodialysis

We report two cases of urogenital malignancies, prostatic cancer in a 72-year-old man and urinary bladder carcinoma in a 50-year-old man, that developed during maintenance haemodialysis. The former patient responded to hormonal therapy with diethylstilboestrol and is still alive on maintenance haemodialysis, but the latter patient did not respond to treatment, being past cure in the far advanced stage. There are few clinical symptoms suggesting the existence of urogenital malignancies in dialysis patients and screening methods such as urine cytology or roentgenology must be restricted because of extremely reduced urine volume. However, the high incidence of urogenital malignancies in such patients is well recognized. Screening examinations with ultrasonography and/or CT scan following digital rectal examination or testing for serum prostate-specific antigen should be performed at least every 6 months.     

Evaluation of the upper gastrointestinal tract in uraemic patients undergoing haemodialysis

PURPOSE OF THE STUDY: This study was performed to determine the gastrointestinal symptoms,endoscopic and histopathological findings in patients on maintenancehaemodialysis. STUDY DESIGN: Ninety-two patients on haemodialysis were enrolled in this studyand 100 consecutive dyspeptic patients referred for endoscopyserved as controls. They were interviewed to obtain informationregarding GI symptoms and endoscopy was performed and biopsieswere taken from antral mucosa for histopathological evaluationand helicobacter identification. RESULTS: Prevalence of GI symptoms in the dialysis group was extremelycommon (77%); with more cases in those with periods of dialysislonger than 6 months. Endoscopically observed hiatus herniawas present in 27 patients in the dialysis group versus 14 inthe control group (P<0.02). Duodenal ulcers were presentin three patients of the dialysis group compared with 16 inthe control group (P<0.01). Histologically, chronic superficialgastritis and mucosal atrophy tended to be more common in thedialysed patients, but this difference was not statisticallysignificant. Helicobacter pylori were present in 45 patientsin the dialysis group versus 73 in the control group (P<0.01).     

Genomic damage and circulating AGE levels in patients undergoing daily versus standard haemodialysis.

BACKGROUND: Patients with end-stage renal failure, whether on conservative or haemodialysis therapy, have a high incidence of DNA damage. It is not known if improved control of the uraemic state by daily haemodialysis (DHD) reduces DNA lesions. METHODS: DNA damage in peripheral blood lymphocytes (PBLs) was evaluated in a cross-sectional study of 13 patients on DHD (2-3 h, 6 times/week), 12 patients on standard haemodialysis (SHD) therapy (4-5 h, 3 times/week) and 12 healthy age-matched volunteer controls. The biomarker of DNA damage used was micronucleus frequency. The assessed plasma parameters of microinflammation and oxidative stress were C-reactive protein (CRP), interleukin-6 (IL-6), neopterin, advanced oxidation protein products (AOPP), and homocysteine. We also measured plasma concentrations of the circulating advanced glycation end products (AGEs) MGI (methylglyoxal-derived imidazolinone), CML (carboxymethyllysine), imidazolone A (3-deoxyglucosone-derived imidazolinone) and AGE-associated fluorescence. RESULTS: Compared to SHD, DHD was associated with significantly lower DNA damage, approaching the normal range. Micronuclei (MN) frequency averaged 29.1 MN+/-5.9/1000 binucleated (BN) cells in the SHD group, which is significantly elevated (P<0.01), 14.8 MN+/-4.0/1000 BN cells in the DHD group, and 13.2 MN+/-3.04/1000 BN cells in the controls. CRP and AOPP were in the normal range (and similar between the dialysis groups). In contrast, IL-6 and neopterin were significantly elevated, with lower values associated with DHD as compared with SHD. The increased levels of AGEs tended to be lower in the DHD group, reaching significance for CML and imidazolone A. CONCLUSIONS: Overall, it was found that genomic damage in PBLs is lower in patients on DHD than in those on SHD. Lower plasma concentrations of uraemic toxins, including circulating AGEs, may account for the differences. To confirm these data, prospective clinical trials need to be performed.     

Attenuation of platelet reactivity by enoxaparin compared with unfractionated heparin in patients undergoing haemodialysis.

BACKGROUND: Increased platelet reactivity presages adverse cardiac events. Because both haemodialysis and unfractionated heparin (UFH) can increase platelet reactivity, we compared platelet reactivity during haemodialysis when patients were anticoagulated with UFH or enoxaparin. METHODS: Patients (n = 20) underwent consecutive haemodialysis sessions with either UFH or enoxaparin in a random order. Blood was taken from the arterial end of the haemodialysis circuit at the initiation of haemodialysis before anticoagulation. Subsequently, blood was taken during dialysis from the venous end of the circuit 10 min after treatment with UFH or enoxaparin. Platelet reactivity was assessed with the use of flow cytometry by determining the capacity of platelets to bind fibrinogen and the surface expression of P-selectin in response to adenosine diphosphate (ADP, 0 and 0.2 microM). Results were compared with the use of two-way repeated measure ANOVA. RESULTS: Platelet reactivity in arterial blood obtained at the beginning of dialysis prior to patients being treated with either UFH [0.2 microM ADP-induced capacity to bind fibrinogen = 28+/-15% (SD)] or enoxaparin (30+/-18%) was similar (P = 0.15). In contrast, platelet reactivity was less after treatment with enoxaparin compared with UFH (P = 0.006). The 0.2 microM ADP-induced capacity to bind fibrinogen in venous blood obtained 10 min after anticoagulation was 34+/-11% after treatment with UFH and 22+/-11% after treatment with enoxaparin. CONCLUSIONS: Anticoagulation with enoxaparin during haemodialysis is associated with less platelet reactivity compared with UFH. Accordingly, enoxaparin use may contribute to a lesser risk of cardiac events in patients with end-stage renal disease treated with haemodialysis.     

Purulent pericarditis caused by Staphylococcus aureus in two patients undergoing haemodialysis

Two cases of purulent staphylococcal pericarditis successfully treated in the course of chronic haemodialysis (HD) are reported. Pericardiac fenestration was carried out in both. In the second case the first pericardiac fenestration had yielded a sterile fluid and bacterial pericarditis developed only later. The significance of local therapy, side by side with surgery and chemotherapy, is stressed.     

Glycated albumin levels predict long-term survival in diabetic patients undergoing haemodialysis

Aim: Glycated albumin (GA) is recognized as a reliable marker for monitoring glycemic control particularly in patients with end‐stage renal disease (ESRD). Here, we investigated the impact of GA levels on long‐term survival in diabetic patients with ESRD. Methods: We enrolled ESRD patients with diabetic nephropathy into our single‐centre prospective follow‐up study (n = 98, 66 men and 32 women; age 68.2 12.3 years) with a mean follow‐up period of 47.7 months. All patients had started haemodialysis between December 1992 and November 2003. They were categorized into two groups according to their GA levels at the initiation of haemodialysis; GA < 29% (low‐GA group; n = 54) and GA 29% (high‐GA group; n = 44). Results: Between low‐GA and high‐GA groups, there were no significant differences in various clinical parameters except GA and HbA1c levels. The cumulative survival rate of low‐GA group was significantly higher than that of high‐GA group (P = 0.034, log–rank test). After adjustment for age, sex, total cholesterol, C‐reactive protein and albumin, high‐GA was a significant predictor of survival (hazard ratio 1.042 per 1.0% increment of GA, 95% CI 1.014–1.070, P < 0.05), but not in the case with HbA1c. Cox proportional hazard model demonstrated that high‐GA group was a significant predictor for cardiovascular death (hazard ratio 2.971 (1.064–8.298), P = 0.038). Conclusion: We conclude that poor glycemic control (GA 29%) before starting haemodialysis is associated with increased cardiovascular morbidity and shortened survival in diabetic patients with ESRD.     

Comparison of residual renal function in patients undergoing twice-weekly versus three-times-weekly haemodialysis

Aim:   Patients with end-stage renal disease (ESRD) often start long-term haemodialysis (HD) thrice weekly, regardless of the level of residual renal function (RRF). In this study, we investigated whether ESRD patients having sufficient RRF can be maintained on twice-weekly HD, and how they fare compared to patients without RRF on thrice-weekly HD.
Methods:   We analyzed 74 patients who had undergone long-term HD and maintained on the same dialysis frequency from February 1998 to July 2005, and followed until December 2005. We compared the clinical variables between twice-weekly and thrice-weekly HD patients and a second analysis testing the residual urine output as an independent predictor for twice-weekly HD.
Results:   After a mean follow up of 18 months, twice-weekly HD patients ( n  = 23) had lower serum β2-microglobulin than thrice-weekly HD patients ( n  = 51). Moreover, the twice-weekly group had a slower decline of RRF, as indicated by their higher urine output and creatinine clearance, fewer intradialytic hypotensive episodes, and required less frequent hospitalization. There was no difference between the two groups in cardiothoracic ratio or indices of nutrition and inflammation. Multivariable logistic regression identified age (odds ratio (OR), 1.866; 95% CI, 1.093–3.183), dry body mass index (OR, 0.790; 95% CI, 0.625–0.999), and urine output (OR, 1.093; 95% CI, 1.026–1.164) as predictors for maintaining twice-weekly HD.
Conclusion:   Our data suggest that when patients who have sufficient urine output are given twice-weekly HD, they maintain dialysis adequacy and exhibit better preservation of RRF than patients on thrice-weekly HD.     

Quantitative polymorphism of complement receptor type 1 (CR1) in patients undergoing haemodialysis.

BACKGROUND: The level of complement receptor type 1 (CR1) on erythrocytes (E-CR1) is determined by the presence of high (H) or low (L) expression alleles. We investigated whether acquired loss of E-CR1 occurs in haemodialysis patients and, if so, which factors may contribute to acquired loss of E-CR1 in these patients. METHODS: The E-CR1 level was determined in 195 Japanese haemodialysis patients, and we selected patients with a high or low E-CR1 level. In patients with low E-CR1 expression, sequence analysis of polymorphic sites (A3650G and C5507G) in the CR1 gene was performed. To assess the effect of the type of dialysis membrane used in the patients with low E-CR1 expression, the dialysis membrane was changed from a cellulose membrane to a biocompatible membrane (to a polyacrylonitrile membrane and then to a polysulfone membrane). To evaluate the susceptibility of E-CR1 to proteolysis, erythrocytes were incubated with various concentrations of trypsin, and the level of remaining CR1 on the erythrocytes was determined. RESULTS: Among patients with high E-CR1 expression (n = 30), 87% had HH alleles and 13% had HL alleles. Among patients with low E-CR1 expression (n = 29), 24% had LL alleles, 45% had HL alleles and 31% had HH alleles. Nucleotides 3650G and 5507G in the CR1 gene were associated with the L allele. Nucleotides 3650A and 5507C were associated with the H allele. Only one patient with HH alleles had nucleotides 3650G and 5507C. Three months after changing the haemodialysis membrane, the E-CR1 level significantly increased (P<0.02). The proteolysis curves of E-CR1 of patients with low or high E-CR1 expression and normal controls were similar. CONCLUSION: Use of a non-biocompatible dialysis membrane may contribute to acquired loss of E-CR1 in haemodialysis patients.     

Sexual dysfunction in uraemic patients undergoing haemodialysis: predisposing and related conditions

Chronic kidney disease and sexual dysfunction are common entities in clinical practice in haemodialysis (HD) units. This article is a review of some articles that focus on sexual dysfunction in patients undergoing HD and its possible relationship in multiple ways.