Pathophysiology and management of fluid and electrolyte disturbances in patients on chronic dialysis with severe hyperglycemia

The mechanisms of fluid and solute abnormalities that should be considered in any patient with severe hyperglycemia include changes in the total amount of extracellular solute, osmotic diuresis, intake of water driven by thirst, and influences from associated conditions. The absence of osmotic diuresis distinguishes dialysis-associated hyperglycemia (DH) from hyperglycemia with preserved renal function (HPRF). Mainly because of this absence, comparable degrees of hyperglycemia tend to produce less hypertonicity and less severe intracellular volume contraction in DH than in HPRF, while extracellular volume is expanded in DH but contracted in HPRF. Ketoacidosis can develop in both DH and HPRF. Among DH patients, hyperkalemia appears to be more frequent when ketoacidosis is present than when nonketotic hyperglycemia is present. Among HPRF patients, the frequency of hyperkalemia appears to be similar whether ketoacidosis or nonketotic hyperglycemia is present. Usually patients with severe DH have no symptoms or may exhibit a thirst. Infrequent clinical manifestations of DH include coma and seizures from hypertonicity or ketoacidosis and pulmonary edema from extracellular expansion. Insulin infusion is usually the only treatment required to correct the biochemical abnormalities and reverse the clinical manifestations of DH. Monitoring of the clinical manifestations and biochemical parameters during treatment of DH with insulin is needed to determine whether additional measures, such as administration of saline, free water, or potassium salts, as well as emergency hemodialysis (HD) are needed. Emergency HD carries the risk of excessively rapid decline in tonicity; its benefits in the treatment of DH have not been established.     

Abnormalities of serum potassium concentration in dialysis-associated hyperglycemia and their correction with insulin: review of published reports

The main difference between dialysis-associated hyperglycemia (DH) and diabetic ketoacidosis (DKA) or nonketotic hyperglycemia (NKH) occurring in patients with preserved renal function is the absence of osmotic diuresis in DH, which eliminates the need for large fluid and solute (including potassium) replacement. We analyzed published reports of serum potassium (K⁺) abnormalities and their treatment in DH. Hyperkalemia was often present at presentation of DH with higher frequency and severity than in hyperglycemic syndromes in patients with preserved renal function. The frequency and severity of hyperkalemia were higher in DH episodes with DKA than those with NKH in both hemodialysis and peritoneal dialysis. For DKA, the frequency and severity of hyperkalemia were similar in hemodialysis and peritoneal dialysis. For NKH, hyperkalemia was more severe and frequent in hemodialysis than in peritoneal dialysis. Insulin infusion corrected the hyperkalemia of DH in most cases. Additional measures for the management of hyperkalemia or modest potassium infusions for hypokalemia were needed in a few DH episodes. The predictors of the decrease in serum K⁺ during treatment of DH with insulin included the starting serum K⁺ level, the decreases in serum values of glucose concentration and tonicity, and the increase in serum total carbon dioxide level. DH represents a risk factor for hyperkalemia. Insulin infusion is the only treatment for hyperkalemia usually required.     

Serum myoglobin in patients on intermittent and continuous ambulatory peritoneal dialysis

Serum myoglobin levels were determined in patients maintained on chronic peritoneal dialysis. Eleven intermittent peritoneal dialysis patients had a mean serum myoglobin of 174 +/- 29 ng/ml. In 7 patients tested serially, there was no consistent change in serum myoglobin: the mean level was 154 +/- 36 ng/ml pre-dialysis and 170 +/- 20 ng/ml post-dialysis. Seventeen patients on continuous ambulatory peritoneal dialysis had a mean serum myoglobin of 215 +/- 18 ng/ml. Two patients given oral carnitine supplements had a substantial decrease in their serum myoglobin levels. Patients on peritoneal dialysis, like those on hemodialysis, tend to have elevated serum myoglobin levels, and neither form of dialysis affects serum myoglobin concentration. This hypermyoglobinemia may be due to metabolic changes in muscle.     

Hyponatremia in peritoneal dialysis patients

BACKGROUND: Low serum sodium is uncommon in peritoneal dialysis (PD), which is surprising in view of the important role of normal kidney function to regulate water and sodium balance. METHODS: We report 2 cases of persistent hyponatremia with balance studies in Case 1. We performed measurements of dialysate sodium and volume output over 24 hours in a group of chronic PD patients. RESULTS: The low serum sodium concentration did not vary too much with overall fluid removal via dialysis in patient 1, mainly because large quantities of sodium were removed in the dialysate. In the 24-hour studies, a significant relationship was found between net daily PD sodium removal and net daily dialysate volume removed (r = 0.65). There was no relationship between net daily PD sodium removal and serum sodium concentration. There was a linear direct correlation between serum and dialysate sodium concentration (r = 0.8) as shown by others previously. CONCLUSIONS: These results suggest that the main determinant of PD sodium loss is net dialysate ultrafiltration volume. Water loss via dialysis is necessarily associated with sodium loss. In order to maintain a normal serum sodium concentration salt intake must be proportional to the water loss induced by dialysis. The stimuli that allow dialysis patients to maintain this delicate balance between water and salt intake are of considerable interest but remain undetermined.     

Amyloid urinary-tract calculi in patients on chronic dialysis

Urinary calculi found in 4 patients on chronic hemodialysis or continuous ambulatory peritoneal dialysis (CAPD) were identified as protein calculi by infrared spectroscopic analysis. Positive Congo red staining and immunological assessment revealed that the calculi were composed of amyloid protein derived from beta 2-microglobulin. A comparison of the patients who excreted calculi with 10 patients on chronic dialysis without urinary calculi showed no significant differences in the urinary and serum levels of beta 2-microglobulin. The mechanism of amyloid calculus formation may involve factors independent of the concentration of beta 2-microglobulin in urine or serum. Urinary calculi found in patients on chronic hemodialysis or CAPD were composed of amyloid protein derived from beta 2-microglobulin.     

Temporal profile of serum potassium concentration in nondiabetic and diabetic outpatients on chronic dialysis

We analyzed routine serum potassium concentration measurements and conditions temporally associated with abnormalities in potassium concentration in outpatients on chronic hemodialysis (136 nondiabetics, 36 diabetics) and continuous ambulatory peritoneal dialysis (16 nondiabetics, 10 diabetics). The following potassium concentration frequencies were found: prehemodialysis, nondiabetics: normal 51.3%, severe hyperkalemia (greater than 6.0 mmol/l) 10%, severe hypokalemia (less than 3.0 mmol/l) 0.3%; diabetics: normal 57.8%, severe hyperkalemia 8.7%, severe hypokalemia 0.5%. Peritoneal dialysis, nondiabetics: normal 73.7%, severe hyperkalemia 0.6%, severe hypokalemia 4.9%; diabetics: normal 72.5%, severe hyperkalemia 0.9%, severe hypokalemia 2.9%. Normokalemia and severe hypokalemia were significantly (chi 2 test) more frequent in peritoneal dialysis than in prehemodialysis, whereas severe hyperkalemia was more frequent in prehemodialysis serum samples. No difference was found between nondiabetics and diabetics for either form of dialysis. 50% of prehemodialysis episodes of hyperkalemia were diet-induced. Hyperkalemic drugs and anuria were not associated with a higher risk of prehemodialysis hyperkalemia, but each one of 3 abnormalities, very high BUN (greater than 40 mmol/l), metabolic acidosis (TCO2 less than 15 mmol/l) and, in diabetics, severe hyperglycemia (serum glucose greater than 30 mmol/l), was associated with a statistically higher risk of hyperkalemia.     

Anterior pituitary dysfunction in patients with chronic renal failure treated by hemodialysis or continuous ambulatory peritoneal dialysis

Cortisol, prolactin, and growth hormone responses to insulin-induced hypoglycemia were measured in 20 patients undergoing continuous ambulatory peritoneal dialysis or intermittent hemodialysis. The plasma cortisol responses were normal; however, the increments in serum prolactin and growth hormone concentrations were impaired in most patients. The growth hormone responses were lower (p less than 0.05) in those patients treated by continuous ambulatory peritoneal dialysis, but there were no other significant differences between the two patient groups. These results show that anterior pituitary dysfunction persists in some patients with chronic renal failure despite maintenance dialysis therapy.     

Reversible MRI changes in a patient with uremic encephalopathy.

A 19-year-old patient on chronic ambulatory peritoneal dialysis experienced severe neurologic disturbances caused by uremia. Increased signal intensity was seen bilaterally in the cortical and subcortical areas of the occipital and parietal lobe on cranial magnetic resonance imaging (MRI). Insufficient peritoneal dialysis efficacy was documented and the patient was switched from peritoneal to hemodialysis. Cranial MRI indicated a marked regression of the lesions to nearly normal, confirming the diagnosis of uremic encephalopathy.     

Folic acid status of patients with chronic renal failure maintained by dialysis

Twenty-five uremic patients on chronic hemodialysis were followed over a period of 9 months with regard to hemoglobin, mean corpuscular volume and folate concentration in serum and erythrocytes. The daily dietary intake of folic acid was estimated at 80-90 microgram, and no folic acid supplements were given. None of the patients developed macrocytic anemia. At the end of the period all patients had a normal erythrocyte folate content. Serum folate was normal in 17 and below normal in 8 patients. These 8 patients were in a negative folate balance at the time of investigation. In 7 patients dialyzed with a RP VI dialyzer the maximum loss of folic acid was 75 microgram/dialysis, and in 6 patients on chronic intermittent peritoneal dialysis the maximum loss was 13 microgram/dialysis. Thus there is no need for oral folic acid supplementation in uremic patients on chronic dialysis provided that daily dietary intake of folic acid is adequate.     

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??Curative effect evaluation of 21 abdominal hernia patients with continuous ambulatory peritoneal dialysis undergoing tension-free hernia repair surgery without terminating peritoneal dialysis ZHAO Jian-xin??GAO Guo-xuan??LIU Yin-hua. Breast Disease Center??Peking University First Hospital??Beijing 100034??China
Corresponding author??ZHAO Jian-xin??E-mail??zjxcn@aliyun.com
Abstract Objective To investigate the curative effect of abdominal hernia patients with continuous ambulatory peritoneal dialysis undergoing tension-free hernia repair surgery without terminating peritoneal dialysis. Methods A total of 21 abdominal hernia patients who received continuous ambulatory peritoneal dialysis (CAPD) because of chronic kidney diseases (CKD) from May 2007 to August 2012 in Peking University First Hospital were included in the retrospective analysis. The curative effects were followed up. All of the patients didn’t switch to hemodialysis (HD) and resumed peritoneal dialysis on the first day after operation form low dose and gradually resumed to the dose before operation in 4 weeks. Results All the patients were performed 22 cases of tension-free hernia repair and had no complication. The follow-up was 16 to 79 months and the median of follow-up was 40.3 months. The follow-up rate was 100% and there was no case of recurrence. Among them, 1 case transferred to hemodialysis 1 year after operation because of peritoneal adhesion and died of lung infection 2 years after operation. Another 1 case transferred to hemodialysis 2 year after operation because of peritoneal adhesion Conclusion It is safe for abdominal hernia patients who received CAPD undergoing tension-free hernia repair surgery without transferring peritoneal dialysis to hematodialysis??and it won’t increase complications and recurrence rate after operations.     

Protein losses in children on continuous cycler peritoneal dialysis

. Peritoneal dialysis can result in significant protein losses through the dialysate effluent. Although protein loss in chronic ambulatory peritoneal dialysis has been examined, it has not been extensively studied in patients on continuous cycler peritoneal dialysis. Such losses can contribute to protein calorie malnutrition, especially in infants and children, many of whom are on continuous cycler peritoneal dialysis. We measured protein loss during continuous cycler peritoneal dialysis in patients ranging in age from 2 months to 18 years. There was an inverse correlation between body surface area and peritoneal protein loss, expressed both as milligrams of protein per kilogram body weight per day (P<0.000l) and as milligrams of protein per meter square body surface area per day (P<0.05). Peritoneal fluid protein losses in patients greater than 50 kg were similiar to those previously reported in adults treated with chronic ambulatory peritoneal dialysis. In contrast, infants had nearly twofold greater peritoneal protein losses per meter square body surface area than older children weighing more than 50 kg. Such protein losses in infants impair normal growth and may contribute to permanent loss of growth potential. Infants on peritoneal dialysis require early and aggressive nutritional supplementation with higher caloric and protein intake to compensate for such dialysate protein losses and maximize growth. Received August 21, 1995; received in revised form March 18, 1996; accepted April 8, 1996     

Ethylene oxide (ETO) as a possible cause of an allergic reaction during peritoneal dialysis and immunologic detection of ETO from dialysis tubing

An infant with end-stage renal disease requiring continuous ambulatory peritoneal dialysis (CAPD) had a cutaneous eruption with eosinophilia. This reaction was not associated with any drug administration. An analysis for antibodies against ethylene oxide-human serum albumin (ETO-HSA) was conducted because IgE antibodies have been correlated with allergic reactions during hemodialysis. IgE and IgG antibodies against ETO-HSA were demonstrated in one of two serum samples available. Serologic evidence is presented that ETO may be eluted from the dialysis tubing, react with HSA in the peritoneum, and immunize the dialyzed host. This may be a possible explanation for allergic manifestations in our patient and others undergoing peritoneal dialysis.     

Cutaneous abnormalities in uremic patients

94 uremic patients, 68 on regular hemodialysis treatment (RHT) and 26 on chronic ambulatory peritoneal dialysis (CAPD), were followed for up to 20 months in search of dermatological manifestations. 79% of RHT and 76% of CAPD patients had some kind of cutaneous lesion. The most characteristic features of cutaneous involvement in RHT and CAPD patients were: cutaneous xerosis, pruritus, infectious manifestations and disorders of pigmentation. In 4 RHT patients, precancerous and cancerous manifestations were also observed.     

Iodine retention and thyroid dysfunction in patients on hemodialysis and continuous ambulatory peritoneal dialysis

Povidone-iodine is frequently used as an antiseptic in patients on chronic dialysis. In order to determine if the use of povidone-iodine affects thyroid function in these patients, we measured serum iodine and thyroid hormone levels in dialysis patients prior to and following discontinuation of topical povidone-iodine antiseptics. Serum inorganic iodine levels were elevated initially in nearly 90% of the patients (19 on hemodialysis, 12 on continuous ambulatory peritoneal dialysis [CAPD]). Following discontinuation of povidone-iodine, iodine levels over a 3-month period decreased modestly in patients on CAPD (n = 5) and were unchanged in patients on hemodialysis (n = 5). Total and free thyroxine levels were frequently low but did not correlate with protein-bound or inorganic iodine levels and did not change after discontinuation of povidone-iodine. Thyrotropin levels correlated significantly (r = .62, P less than .01) with inorganic iodine levels in patients on hemodialysis, but not for patients on CAPD. We conclude that abnormal thyroid function tests are common in dialysis patients but are not related to iodine retention or to the routine use of topical povidone-iodine-containing antiseptics.     

血液透析与腹膜透析改善肾性贫血的疗效比较

目的 分析血液透析与腹膜透析对肾性贫血的疗效.方法 回顾性分析2013年1月至2015年6月52例尿毒症维持性透析患者的临床资料,其中维持性血液透析患者28例,维持性腹膜透析患者24例,两组患者均使用促红细胞生成素,联合叶酸、蔗糖铁治疗.比较两组患者治疗3个月后血红蛋白浓度变化.结果 治疗前,维持性血液透析组患者血红蛋白浓度与维持性腹膜透析组相比差异无统计学意义.治疗3个月后,两组患者血红蛋白浓度均较治疗前明显升高,但腹膜透析组患者血红蛋白浓度升高更为明显,与血液透析组患者相比差异有统计学意义.结论 血液透析和腹膜透析均能改善透析患者肾性贫血,但腹膜透析效果更明显.     

A comparison of plasma and muscle carnitine levels in patients on peritoneal or hemodialysis for chronic renal failure

We studied plasma, dialysate, and muscle carnitine levels in patients with stable chronic renal failure on hemodialysis, and intermittent peritoneal, or continuous ambulatory peritoneal dialysis (CAPD). In patients on hemodialysis, plasma carnitine levels fell from 46.2 +/- 4.5 mumol/l (mean +/- SEM) to 18.8 +/- 2.7 mumol/l immediately after the procedure (p less than 0.001). Depletion of muscle carnitine was found after hemodialysis (1,518 +/- 273 nmol/g wet weight of tissue) compared to normal levels of 5,230.5 +/- 142.7 nmol/g tissue (p less than 0.01). However, the plasma and muscle carnitine levels remained in the normal range in patients on intermittent peritoneal dialysis and CAPD. We postulate that the rapid decline in plasma levels of carnitine caused by hemodialysis initiates unilateral transport of the compound from muscle to the plasma, thus depleting the skeletal muscle stores of carnitine.     

Hyponatremia and hypokalemia in patients on peritoneal dialysis

Hypokalemia occurs in up to 60% of patients on peritoneal dialysis (PD) for end-stage renal disease. It can be associated with poor clinical outcomes, including malnutrition and death. New evidence points to a link between hypokalemia and the risk of peritonitis. The serum Na(+) concentration is determined by the ratio of exchangeable Na(+) and K(+) to total body water. Hyponatremia may be caused by excessive thirst, a particular problem in patients on PD. Consistent with the relationship among the serum sodium concentration, total body cation content, and total body water, hyponatremia may also be caused by total body potassium depletion. Ultra-low sodium dialysis fluid may prove to have an important role in management of fluid overload and hypertension in patients on PD. Surprisingly, it is not associated with significant hyponatremia, for reasons that remain to be elucidated.     

Beta 2-microglobulin levels in patients with renal insufficiency

beta 2-microglobulin (beta 2M) has been implicated in the pathogenesis of amyloidosis in long-term dialysis patients. beta 2M levels were measured in patients with chronic renal failure: before and after conventional hemodialysis in 30, before and after high-flux (HF) hemodialysis in 35, and during the first hemodialysis treatment in five patients, as well as in the serum and peritoneal fluid of 13 patients who were receiving continuous ambulatory peritoneal dialysis (CAPD) and in the serum and urine of three patients who had received kidney transplants. Dialysis patients had markedly elevated beta 2M levels; prehemodialysis values were not significantly different for patients receiving conventional v HF hemodialysis. Most of these patients were functionally anephric, and the beta 2M levels did not correlate with age, sex, or time on dialysis. In patients receiving conventional hemodialysis using cellulose acetate membrane, beta 2M levels increased 25.4% after hemodialysis, whereas in patients receiving HF hemodialysis using polysulfone membrane, beta 2M levels decreased significantly (43.0%) after hemodialysis. End-stage renal disease patients dialyzed for the first time had beta 2M values significantly lower than the other two groups because of residual glomerular filtration rate (GFR). CAPD patients also had lower values because they had an estimated loss of 80.4 mg/d of beta 2M in the dialysate fluid. In patients with chronic renal failure, beta 2M levels paralleled the increase in serum creatinine. Patients who received kidney transplants had a dramatic decrease in beta 2M levels that correlated with improvement in GFR. beta 2M correlated with the residual GFR, and its removal was membrane-dependent.(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of coronary artery bypass grafting surgery by continuous ambulatory peritoneal dialysis in a patient with chronic renal failure under hemodialysis

A 64-year-old patient with chronic renal failure underwent coronary artery bypass grafting (CABG) because of the frequent severe angina during hemodialysis. Intraoperative hemodialysis and extra-corporeal ultrafiltration method (ECUM) was used during cardiopulmonary bypass. Postoperative management was successfully performed by continuous ambulatory peritoneal dialysis (CAPD), which made hemodynamics stable and prevented postoperative bleeding, providing with adequate fluid removal and satisfactory control of serum chemistry.