Morphologic changes in the peritoneal membrane of patients with renal disease.

This study examined the morphologic features of the parietal peritoneal membranes of 130 patients undergoing peritoneal dialysis (PD) and compared them with the features of the peritoneal membranes of normal individuals, uremic predialysis patients, and patients undergoing hemodialysis. The median thickness of the submesothelial compact collagenous zone was 50 microm for normal subjects, 140 microm for uremic patients, 150 microm for patients undergoing hemodialysis, and 270 microm for patients undergoing PD (P < 0.001 for all versus normal subjects). Compact zone thickness increased significantly with the duration of PD therapy [0 to 24 mo, 180 microm (n = 58); 25 to 48 mo, 240 microm (n = 24); 49 to 72 mo, 300 microm (n = 13); 73 to 96 mo, 750 microm (n = 16); >97 mo, 700 microm (n = 19)]. Vascular changes included progressive subendothelial hyalinization, with luminal narrowing or obliteration. These changes were absent in samples from normal subjects but were present in 28% of samples from uremic patients and 56% of biopsies from patients undergoing PD. In the PD group, the prevalence of vasculopathy increased significantly with therapy duration (P = 0.0001). The density of blood vessels per unit length of peritoneum was significantly higher for patients with membrane failure and was correlated with the degree of fibrosis (P = 0.01). For the first time, a comprehensive cross-sectional analysis of the morphologic changes in the peritoneal membranes of patients undergoing PD is provided. The infrequency of fibrosis in the absence of vasculopathy suggests that vasculopathy may predispose patients to the development of fibrosis. This study provides a sufficiently large cohort of samples to allow structure-function relationships to be established, as well as providing a repository of tissue for further studies.     

The patient with renal disease

Chronic kidney disease has a wide spectrum of multisystem effects and patients suffering with this ever more prevalent condition present for elective and emergency surgery at all hospitals, not just specialist renal centres. It is therefore important for all surgeons and anaesthetists to be aware of the potential problems associated with the renal dysfunction but also with the underlying cause of the disease. The perioperative management of these patients is complex and requires careful planning to ensure that no acute kidney injury occurs leading to a deterioration in the chronic condition. We summarize the multisystem effects of chronic kidney disease, outline the pre-, peri- and postoperative approach to ensure maintenance of renal blood flow and perfusion pressure and discuss the implications of the disease on drug handling pertinent to the common medications used in the perioperative period including analgesia, anaesthetic agents and antibiotics.     

The patient with renal disease

The incidence of chronic renal failure is increasing throughout the world. The perioperative management of patients with chronic kidney disease (CKD) is complicated by both the underlying renal dysfunction, with associated disturbances of fluid and electrolyte homeostasis and altered drug clearance, and the presence of associated comorbid conditions. Preoperative assessment for these complex patients requires multidisciplinary approach from anaesthetic, surgical and nephrology teams. Preservation of normal physiology along with prevention of further kidney injury are central to the management of patients with CKD. This article focuses on the perioperative care of patients, including pharmacological considerations of common medications used.     

Angiographic progression of coronary artery disease in patients with end-stage renal disease.

BACKGROUND: Patients with end-stage renal disease have an increased risk of developing coronary artery disease (CAD). The cardiovascular mortality of dialysis patients is 10-15 times higher compared with the general population. The aim of our study was to evaluate the morphological progression of coronary arteriosclerosis in this cardiovascular high-risk group by visual assessment and quantitative coronary angiography. Methods and results. In 26 patients with chronic renal failure (age, 47+/-11 years; 15 male; duration of dialysis, 23+/-25 months) the severity of CAD and degree of coronary stenoses were assessed in two coronary angiograms after a mean follow-up interval of 30+/-15 months (12-60). Baseline angiography revealed CAD in 13/22 patients (59%). The second angiography was performed as screening procedure prior to renal transplantation (n=20) and/or as follow-up angiography after coronary angioplasty (n=10). Visual assessment showed a progression defined by the development of haemodynamically relevant stenosis of >50% luminal diameter in 13 patients. Quantitative angiographic evaluation was performed in a total of 45 segments showing >25% narrowing at the second angiogram. A progression (>15% luminal reduction) was found in 17 of 45 segments, a new lesion (initial luminal diameter <20%) was detected in nine segments, resulting in progression or new lesion in 16 patients (62%). Patients with or without progression did not differ in age, duration of dialysis treatment, number of cardiovascular risk factors, or serum total cholesterol and fibrinogen levels. After percutaneous transluminal coronary angioplasty (PTCA) a restenosis was seen in seven of 16 primarily successfully dilated segments. After the second angiography, myocardial revascularization was performed in eight patients (1 PTCA, 7 coronary artery bypass graft). CONCLUSIONS: Patients with end-stage renal disease have a high prevalence of CAD. In line with the clinical course, CAD patients on maintenance dialysis undergo rapid angiographic progression of CAD, which results in a high rate of subsequent myocardial revascularizations.     

Unilateral renal cell carcinoma with coexistent renal disease: a rare cause of end-stage renal disease.

BACKGROUND: Renal cell carcinoma (RCC) is a disorder encompassing a wide spectrum of pathological renal lesions. Coexistence of unilateral RCC and associated pathology in the contralateral kidney is an unusual and challenging therapeutic dilemma that can result in renal failure. So far, data on unilateral RCC with chronic renal failure necessitating renal replacement therapy have not been published. The aim of the present study was to evaluate the incidence of end-stage renal disease (ESRD) from unilateral RCC, and to assess the associated pathology and possible pathogenic factors. METHODS: In 1999, a survey of the 350 patients treated by chronic dialysis in Asturias, Spain, was carried out to identify and collect clinical information on patients with primary unilateral RCC whilst on their renal replacement programme. RESULTS: Seven patients were identified as having ESRD and unilateral RCC, giving an incidence of 2% of patients treated by dialysis. There was a wide spectrum of associated disease and clinical presentation. All patients underwent radical or partial nephrectomy and were free of recurrence 6--64 months after surgery. Six patients were alive and free of malignancy recurrence for 6--30 months after the onset of haemodialysis. CONCLUSION: ESRD is rare in association with unilateral RCC, but does contribute to significant morbidity. However, the data presented here are encouraging and suggest that cancer-free survival with renal replacement therapy can be achieved in such patients.     

Statural growth of children with renal disease.

Growth retardation occurs in 35 to 65% of children with kidney disease. It is especially common in children with congenital diseases of the kidney, anomalies, and inherited disorders. Acquired disease, however, also may impair growth, particularly where renal function (GFR) is below 25 ml/min/1.73 m2. Therapy used in renal disease, notably prednisone, also impairs growth. Chronic dialysis therapy, both hemodialysis and peritoneal, are associated with poor growth. Several specific changes in renal disease are associated with growth failure. These include, in addition to azotemia, acidosis, hyposthenuria, renal osteodystrophy, endocrine disorders and resistance to hormone action, and nutritional disturbances.     

Parathyroidectomy for hyperparathyroidism associated with renal disease.

Between 1969 and 1993, 123 patients were accepted in this unit for surgery for refractory hyperparathyroidism associated with chronic renal failure. Subtotal parathyroidectomy was the procedure of choice. At operation, four or more parathyroids were identified in 75% of patients. Methylene blue localised additional parathyroids in 32% of initial explorations in which it was used. Coincidental thyroid pathology was found in 8.3%, including papillary carcinoma in 2.4%. No further parathyroid surgery was required in 90% of patients at a mean of 6.6 years after operation. Reoperation (10%) was more likely to be required (14.3%) when less than four glands were found than when four or more were found (8.5%). Patients continuing on dialysis were more likely to need reoperation than those with functioning renal transplants.     

Lower-extremity peripheral arterial disease among patients with end-stage renal disease.

Peripheral arterial occlusive disease (PAOD) accounts for significant morbidity and mortality among end-stage renal disease (ESRD) patients but has not been as extensively studied as other kinds of atherosclerotic disease in this population. The current epidemiology and management of PAOD in ESRD patients is here reviewed and target areas for future research are identified. The prevalence of PAOD appears to be much higher among ESRD patients than in the general population. Risk factors for disease among ESRD patients are not well understood but probably include both conventional and dialysis or uremia-associated risk factors. Standard diagnostic techniques used to identify PAOD in the general population may not be as helpful in ESRD patients because many of these tests are inaccurate in the settings of vascular calcification and small-vessel disease. Despite the fact that this is a common disease in ESRD patients, most of these patients are not screened for PAOD. Interventions that have proven effective in the prevention and treatment of PAOD in the general population, such as smoking cessation, preventive foot care, and exercise, have not been systematically applied to ESRD patients. Furthermore, the optimal management of ischemic ulceration and gangrene in ESRD patients is quite controversial, and better algorithms for the prevention and management of PAOD in ESRD patients are needed. In conclusion, PAOD is common in ESRD patients. Future research should identify risk factors for disease in this population, and efforts should be made to develop strategies for the effective prevention and management of limb ischemia in this population.     

Cardiac surgery in patients with dialysis-dependent renal disease.

This study was designed to evaluate the operative outcome of dialysis patients undergoing cardiac surgery. A retrospective review was performed of 28 consecutive patients with end-stage renal disease dependent on maintenance hemodialysis (n = 26) or peritoneal dialysis (n = 2) who underwent cardiopulmonary bypass (CPB). The operations included isolated coronary artery bypass grafting (CABG) (n = 21), aortic valve replacement (n = 4) and CABG plus aortic valve replacement (n = 3). Seven operations were emergent or urgent. In 23 patients, a heparin-coated (HC) circuit with reduced systemic heparinization was used for CPB. The hospital mortality was 7.1%. Complications occurred in 13 patients (46%). Although thoracotomy for bleeding was required in 3 patients, only 1 had undergone CPB with an HC circuit. There were 7 late deaths. All survivors showed improvement in symptoms and overall functional status. The actuarial survival rates were 78% and 58% at 1 and 4 years, respectively. In the 10 patients with diabetes mellitus, the 4-year survival rate was 50%. In the patients who underwent non-elective surgery, the survival rate was 29%. Cardiac surgery can be performed with increased but acceptable mortality in dialysis patients. Good symptomatic relief can be expected. Surgery should be performed before the general condition deteriorates.     

Predictors of coronary disease in patients with end stage renal disease.

Patients with end stage renal disease have a high prevalence of cardiovascular disease and coronary arteriography is often routinely performed prior to kidney transplantation. However, the value of the conventional risk factors and non-invasive markers of coronary artery disease (CAD) in triaging patients for coronary arteriography has not been fully examined. 116 patients with end stage renal disease were evaluated. Coronary arteriography was performed in all patients either for a suspicion of CAD or as part of a routine pre-transplant evaluation. Lesions causing > or = 50% luminal diameter stenosis in any of the three major coronary artery systems were considered significant. The mean age was 53.3 +/- 9.3 years. Significant CAD was present in 69 patients (60%). Increasing age, family history of premature ischemic heart disease, the presence of angina, abnormal Q waves on the ECG or abnormal ST segment depression and the presence of coronary calcification were significant markers of coronary artery disease. However male gender, diabetes mellitus and obesity did not correlate with coronary disease. Even though hypertension, hypercholesterolemia and smoking were also not useful predictors these could have been modified by the renal failure. In conclusion increasing age, a family history of premature ischemic heart disease and some non-invasive markers were useful predictors of coronary disease.     

Skeletal status in patients with chronic renal disease.

The bone mineral content (BMC) was measured in 17 patients with chronic renal failure. The patients as a group had a mean BMC of 89% compared with 127 normal subjects. The investigation failed to disclose any significant correlation between BMC and the stage of renal diseases.