A Survey on Hypersensitivity Reactions in Hemodialysis

This survey was conducted from 1982 through 1984 by a cooperative effort among the Health Industries Manufacturers Association, seven dialyzer manufacturers, and the Food and Drug Administration. This article presents an analysis of the 1982-83 survey data and a summary of the 1984 data. Most of the reactions reported (99%) were associated with hollow-fiber dialyzers. About 50% of these reactions were experienced by patients using a dialyzer model for the first time, and greater than 98% of the reactions were related to new (unused) dialyzers. On average, there were 180 reactions reported per year, with greater than 90% being considered severe, including death, by the reporting center. A plot of the number of reactions versus time from 1982 through 1984 shows periods of 12-15 months in which the reaction rate remained practically constant. During these periods, the rate of reported reactions alternated from 60 to 150% of the average. Analysis of the survey data showed a strong correlation of the number of reactions with the race and age of the patients. Blacks and other minorities experience nearly three times as many reactions as white patients. Also, patients under 29 years of age seem to have nearly twice as many reactions as patients in the 30- to 49-year-old range, whereas patients over 50 years old have nearly half the number of reactions of the 30- to 49-year-old range. The average reactivity of the U.S. hemodialysis patient population was calculated to be 3.3 reactions per year per 1,000 patients exposed to hollow-fiber dialyzers and 0.3 reaction per year per 1,000 patients exposed to flat-plate dialyzers.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hypersensitivity to Hemodialysis: The United Kingdom Experience

A postal survey of all U.K. hemodialysis centers was conducted to investigate the prevalence of hypersensitivity in the first use of disposable dialyzers. A total of 117 patients with 243 separate reactions were identified, suggesting that 1 in 20 to 1 in 50 patients may be susceptible to an anaphylactoid reaction to a new hemodialyzer at some time, while the risk of reaction occurring with any single hemodialysis is approximately 1 in 1,000 to 1 in 5,000. No particular brand or type of hemodialyzer nor any identifiable technique of priming procedure was associated with reactions, but in those few patients who suffered repeated reactions further problems were avoided by increasing the volume of saline in the initial rinse of the hemodialyzer or by changing to another brand of hemodialyzer. Although it is likely that many reactions are unrecognized or unreported, the scale of the problem is larger than many British nephrologists had suspected.     

Mediation of Hypersensitivity Reactions During Hemodialysis by IgE Antibodies Against Ethylene Oxide

Sera from 329 hemodialysis patients, 46 of whom had experienced a hypersensitivity-type reaction during hemodialysis, were screened by an enzyme-allergosorbent test (EAST) for IgE antibodies specific for ethylene oxide (ETO). In seven of nine patients who had experienced a severe hypersensitivity reaction (type II or type III), high titers of IgE antibodies against ETO (greater than 3.0 PRU/mL) were found. However, plasma levels of IgE specific for ETO were in the normal range (less than 0.35 PRU/mL) in most (30/37) patients who had experienced a mild (type I) reaction. Selected sera from patients who had experienced severe reactions were further examined for IgE directed against isopropyl myristate (IPM), 2-chloroethanol, and extracts from unsterilized dialyzers. Importantly elevated serum levels of specific IgE against these substances could not be documented. Extracts of an ETO-sterilized, hollow-fiber dialyzer were positive, whereas extracts of an ETO-sterilized dialyzer containing a flat membrane were negative in the EAST. This difference can be explained by the different amounts of ETO present in the dialyzers. We conclude that ETO causes most severe hypersensitivity reactions by an IgE-mediated mechanism. On the other hand, the pathogenesis of mild (type I) reactions is less clearly associated with ETO allergy. Our results also suggest that other potentially allergenic substances in dialyzers (e.g., IPM, 2-chloroethanol) rarely induce specific IgE antibodies in dialysis patients.     

Acute Anaphylactoid Reactions During Hemodialysis in France

A retrospective survey of anaphylactoid reactions during dialysis in France was conducted. In 52 of 112 hemodialysis units surveyed 111 patients who had suffered one or more anaphylactoid reactions during dialysis were identified. According to the Hamilton/Adkinson classification, in 31 patients reactions were minor, in 54 patients moderate, and in 26 patients severe. Four patients died of their reactions. A preponderance of reactions (75 and 11%) occurred with cuprammonium cellulose hollow-fiber and plate dialyzers, respectively. Severe dialyzer reactions were found to occur more frequently after the long (weekend) interdialytic interval. In an in vitro study, six brands of cuprammonium cellulose hollow-fiber dialyzers were rinsed with water and the eluates analyzed by size exclusion chromatography for contaminant particles. Substantial variation in the amount of extractable material was found between dialyzers of different brands, despite the fact that all dialyzers used membranes from the same manufacturer. Previous data by others has suggested that this extractable material is a derivative of cellulose. Results of our epidemiologic survey in France are similar to those previously reported in the United States and suggest an increased incidence of dialyzer reactions with ethylene oxide-sterilized cuprammonium cellulose dialyzers. The presence of cellulose-derived particles in the rinsing fluid of such dialyzers and the possible increased incidence of reactions after the long (weekend) interdialytic interval suggest that allergy to cellulose-derived particles eluted from cellulosic dialyzers may contribute to dialyzer hypersensitivity reactions.     

Differences in Bio-incompatibility among Four Biocompatible Dialyzer Membranes Using in Maintenance Hemodialysis Patients

Abstract

Background: Following the introduction of modified cellulosic and then synthetic membrane dialyzers, it was realized that the dialyzer bio-incompatibility depends on the membrane composition. We designed a prospective, randomized, cohort study of 6 months to determine several parameters of biocompatibility in maintenance hemodialysis (MHD) patients treated with four different membrane dialyzers. Methods: There were 60 MHD patients enrolled in the study. In baseline, synthetic low-flux dialyzer, polysulfone (PS) membrane was used in all patients for at least 3 months. Then the patients were randomly divided into three groups according to different dialyzer membranes. Synthetic high-flux dialyzer group, ployethersulfone membrane, cellulose triacetate (CTA) high-flux membrane, and synthetic low-flux dialyzer, polymethylmethacrylate (PMMA) membrane were used in 6 months. A new dialyzer was used for each study treatment, and there was no dialyzer reuse. The biocompatibility markers and solutes removal markers were detected repeatedly at different time points. Results: The blood levels of highly sensitive C reactive protein, interleukin (IL)-1β, and interleukin (IL)-13 showed no difference among different groups at al time points. However, the blood complement levels and white blood cell counts were significantly different among three groups. When the dialyzers changed from PS to PMMA membrane, C3a levels and white blood cell counts changed significantly (p < 0.05). Moreover, the changes of C5a levels were significantly different between group CTA and group PMMA in month 3 (p < 0.05). Conclusion: There were much more differences on bio-incompatibility among different dialyzer membranes.     

Ethylene Oxide Sensitivity in Hemodialysis Patients

Sera from 138 patients who had experienced hypersensitivity-type reactions while on hemodialysis (reactors) were examined retrospectively by the radioallergosorbent test (RAST) for specific IgE antibody to ethylene oxide (ETO). Seventy-eight hemodialysis patients without a history of reaction were also evaluated as controls. Elevated serum RAST values (greater than 2.0) were more common in reactors (63%) than in controls (11%, p less than 0.001). In a second study, RAST assays were performed using human serum albumin conjugated to ETO (HSA-ETO) as antigen and also using a concentrate of fluid used to rinse ETO-sterilized dialyzers ("dialyzer extract") as antigen. The RAST ratios obtained with HSA-ETO were similar to those obtained using the dialyzer extract (rank order correlation coefficient = 0.829, p less than 0.001). In a third study, RAST inhibition was demonstrated both by HSA-ETO and dialyzer extract. Our results, extending previously published reports, suggest that hypersensitivity to ETO might play an important role in hemodialysis-associated hypersensitivity-type reactions.     

Ethylene Oxide (ETO) as a Major Cause of Anaphylactoid Reactions in Dialysis (A review)

Ethylene oxide (ETO), an alkylating compound of high chemical reactivity, is widely used for gas sterilization, but recently serious ETO side reactions have been recognized. With chronic ETO exposure, increased spontaneous abortion, sister chromatid exchange, and leukemia are observed. After medical use of ETO outside nephrology, contact dermatitis, cardiopulmonary shock (during cardiopulmonary surgery), allergic local reactions to ETO sterilized lenses, and anaphylactoid reactions to ETO sterilized catheters have been described. In numerous dialysis patients widespread hypersensitivity to ETO has been documented by skin prick test and ETO radioallergosorbent test (RAST). Furthermore an anaphylactoid "first-use reaction" was described in dialyzed patients, most of whom were using hollow-fiber dialyzers. After long discussions whether complement activation versus hypersensitivity is the cause of such acute anaphylactoid reactions, more recent studies using either ETO RAST or basophil degranulation tests implicate ETO hypersensitivity as their major cause. The high prevalence of sensitization to ETO and the frequency, unpredictability, and potential danger of anaphylactoid reactions to ETO lead to the conclusion that ETO sterilization of dialyzers should be discontinued, since alternative modalities of sterilization are currently available.     

Plate, Coil, and Hollow-Fiber Cuprammonium Cellulose Dialyzers: Discrepancy Between Incidence of Anaphylactic Reactions and Degree of Complement Activation

During the past 10 years, the incidence of severe anaphylactic reactions during dialysis [type A first-use syndrome (FUS)] at our center has been much lower when using cuprammonium cellulose plate (CC-P) dialyzers (0/37, 750 dialyses) or coil (CC-C) dialyzers (0/32, 500) than when using cuprammonium cellulose hollow-fiber (CC-F) dialyzers (8/21,022 dialyses, p less than 0.005 by Chi-square). To determine if the difference in type A FUS incidence between the three dialyzer types could be explained by differences in complement activation, we compared plasma concentrations of C3a des-arginine (des arg) in patients undergoing dialysis with these three varieties of dialyzers. Plasma C3a des arg values increased markedly in the dialyzer outflow blood with the three dialyzer configurations. The levels were similar with the dialyzer types when results were corrected for membrane surface area. Also, the degree of leukopenia was not markedly different with the three dialyzer types. Our findings suggest that complement activation per unit surface area is similar during dialysis with plate, coil, and hollow-fiber cuprammonium cellulose dialyzers. The lack of correlation between the degree of complement activation and the incidence of type A FUS suggests that membrane-induced complement activation is not of primary importance to type A dialyzer hypersensitivity reactions.     

高通量透析对维持性血液透析患者中医证候的影响

目的：观察高通量透析（HFHD）对维持性血液透析（MHD）患者中医证候以及营养不良和微炎症状态的影响。方法：采用随机对照,A组应用高通量透析,B组应用普通透析,比较治疗前及治疗后中医证候积分（TCM syndromes cores）,及治疗后血红蛋白（Hb、血浆白蛋白（Alb）、前白蛋白（PAB）、超敏C反应蛋白（hs-CRP）、白细胞介素-6（IL-6）、肿瘤坏死因子-α（TNF-α）、肱三头肌皮皱厚度（TSF）、上臂中段肌肉周径（MAMC）等指标变化。结果：（1）治疗4周、8周后,A组中医实证积分、虚证积分、总积分与治疗前相比有降低趋势,但差异尚无统计学意义（P〉0.05）。12周后与治疗前比较,A组中医证候积分均明显下降（P〈0.05）,B组证候积分与治疗前相比差异无统计学意义（P〉0.05）。治疗12周A组临床疗效优于B组（P〈0.01）。（2）治疗12周时,A组Hb、Alb、PAB明显上升（P〈0.05）,hs-CRP、IL-6、TNF-α水平与治疗前相比明显下降（P〈0.01）,TSF升高（P〈0.01）,MAMC有升高趋势,但差异尚无统计学意义。B组患者Hb、Alb、PAB、hs-CRP、IL-6、TNF-α水平与治疗前相比差异无统计学意义（P〉0.05）,两组治疗12周后,A组IL-6水平低于B组患者（P〈0.05）。结论：HFHD可减少MHD患者中医证候临床积分,改善患者营养不良及微炎症状态。     

An Outbreak of Pyrogenic Reactions in Chronic Hemodialysis Patients Associated with Hemodialyzer Reuse

Abstract: In February 1992, 22 patients undergoing chronic hemodialysis at an outpatient dialysis center experienced pyrogenic reactions (PR). The PR rate was significantly greater (p < 0.001) during the epidemic (February 3–5) than the pre-epidemic period (November 1, 1992-February 1, 1992). All patients with PR used dialyz-ers that had been manually reprocessed either on February 1 or 3. These dialyzers contained up to 120.8 EU/ml of endotoxin in the blood compartment. The only dialyzer reprocessed before February 1 that was available for analysis was found to contain no detectable endotoxin, while dialyzers reprocessed during the epidemic period contained a median endotoxin concentration of 52.8 EU/ ml. The bioburden of water used to prepare dialysate was in excess of the Association for the Advancement of Medical Instrumentation (AAMI) standard for water, ≤200 colony forming units (CFU)/ml. Samples of treated water collected in the reuse area were within AAMI standards at the time of the investigation (February 11 and February 26), but before the investigation, water samples were assayed with a culture method that could not detect micro-bial concentrations below 10³ CFU/ml. In addition, the treated water feed line to the disinfectant container may never have been disinfected. However, no samples were collected from this line during the investigation. This outbreak emphasizes the need to use water that meets the AAMI bacteriologic and endotoxin standards of ≤200 CFU/ml and/or 5 EU/ml, respectively, for reprocessing hemodialyzers and to ensure that appropriate culture techniques are used for treated water and dialysate.     

291例儿童药物不良反应的临床分析

目的：分析儿童药物不良反应的情况,指导临床合理用药.方法：对我院2007年1月-2009年12月共291例药物不良反应（ADR）情况,进行分析.结果：引起ADR的药物以抗菌药物为主,占全部ADR的48.8%（142例）ADR类型以皮肤及其附件的损害为主,占49.1%（143例）.结论：加强儿童ADR监测,有利于指导临床合理用药.     

The Incidence of Subclavian Vein Stenosis Using Silicone Catheters for Hemodialysis

Abstract: Complications related to the use of silicone subclavian catheters for hemodialysis were prospectively studied in 21 consecutive patients with acute and chronic renal failure. Between July 1991 and December 1992, 34 double-lumen silicone catheters (Medcomp; 12 French; 20 or 24 cm) were inserted in 21 patients. The mean duration of catheterization was 20 days (range, 2–58 days). Venograms were performed in 16 patients (22 subclavian veins) within 6 months following removal of the catheter. Excluded from angiography were patients whose catheters had been in place less than 1 week or who underwent fewer than 3 dialysis sessions because of minor risk of stenosis. Patients who had ipsilateral repeated catheters were also excluded. Two angiographies showed subclavian vein stenosis, both occurring in the same patient. One showed 50% stenosis with collaterals; one showed 50% stenosis without collaterals. One other complication was a pneumothorax. Catheter thrombosis was observed in 3 patients; catheter sepsis did not occur. We conclude that use of silicone catheters for subclavian cannulation is safe and effective to provide temporary vascular access for acute hemodialysis. The incidence of subclavian vein stenosis is lower compared with polytetrafluoroethylene and polyurethane catheters.     

A Quality and Cost-Benefit Analysis of Dialyzer Reuse in Hemodialysis Patients

Background. To evaluate the benefits of dialyzer reuse for hemodialysis (HD) patients, including the cost of HD treatment and patient's survival, a comparison was made regarding the standard practice of single-use dialysis. Methods. From January 1, 2005, to December 31, 2005, a total of 128,232 successive HD treatments in 822 patients in Chang Gung Memorial Hospital-Kaohsiung Medical Center were included in this study. Results. Approximately 54.25% (446/822) of patients reused dialyzers. The average times of dialyzer reuse was 2.54. The annual hollow fiber cost is reduced by $241,054.08 U.S. dollars (NT $7,834,257.60). The annual cost of hollow fiber was reduced by $540.48 U.S. dollars (NT $17,565.60) in one patient with dialyzer reuse. The mortality rates in dialyzer reuse and single use groups were 3.1% and 10.9% within one year (p < 0.0001). Multiple logistic regressions showed that single use compared with reuse was associated with higher mortality after adjusting co-morbid conditions including age, diabetes mellitus, etc. Conclusions. We concluded that the benefits of dialyzer reuse included safety in our center and reduction in cost during a 12-month period. Dialyzer reuse may be a safe alternative.     

Hemodialysis in children: general practical guidelines

Over the past 20 years children have benefited from major improvements in both technology and clinical management of dialysis. Morbidity during dialysis sessions has decreased with seizures being exceptional and hypotensive episodes rare. Pain and discomfort have been reduced with the use of chronic internal jugular venous catheters and anesthetic creams for fistula puncture. Non-invasive technologies to assess patient target dry weight and access flow can significantly reduce patient morbidity and health care costs. The development of urea kinetic modeling enables calculation of the dialysis dose delivery, Kt/V, and an indirect assessment of the intake. Nutritional assessment and support are of major importance for the growing child. Even if the validity of these urea only data is questioned, their analysis provides information useful for follow-up. Newer machines provide more precise control of ultrafiltration by volumetric assessment and continuous blood volume monitoring during dialysis sessions. Buffered bicarbonate solutions are now standard and more biocompatible synthetic membranes and specific small size material dialyzers and tubing have been developed for young infants. More recently, the concept of ultrapure dialysate, i.e. free from microbiological contamination and endotoxins, has developed. This will enable the use of hemodiafiltration, especially with the on-line option, which has many theoretical advantages and should be considered in the case of maximum/optimum dialysis need. Although the optimum dialysis dose requirement for children remains uncertain, reports of longer duration and/or daily dialysis show they are more effective for phosphate control than conventional hemodialysis and should be considered at least for some high-risk patients with cardiovascular impairment. In children hemodialysis has to be individualized and viewed as an integrated therapy considering their long-term exposure to chronic renal failure treatment. Dialysis is seen only as a temporary measure for children compared with renal transplantation because this enables the best chance of rehabilitation in terms of educational and psychosocial functioning. In long term chronic dialysis, however, the highest standards should be applied to these children to preserve their future cardiovascular life which might include more dialysis time and on-line hemodiafiltration with synthetic high flux membranes if we are able to improve on the rather restricted concept of small-solute urea dialysis clearance.Published on behalf of the European Pediatric Dialysis Working Group. Contributing Members of the European Pediatric Dialysis Working Group EPDWG are: M. Ekim, University of Ankara, Ankara, Turkey; A. Edefonti, I Clinici di Perfezionamento, Milan, Italy; M. Fischbach, Hôpital de Hautepierre, Strasbourg, France; G. Klaus, University of Marburg, Marburg, Germany; K. Rönnholm, University of Helsinki, Helsinki, Finland; F. Schaefer, University of Heidelberg, Heidelberg; C. Schröder, Wilhelmina Kinderziekenhuis, Univ. of Utrecht, The Netherlands; E. Simkova, v Motol, Prague, Czech Republic; C. J. Stefanidis, A&P Kyriakou Childrens Hospital, Athens, Greece; V. Straszdins, University Hospital for Children, Riga, Latvia; J. Vande Walle, University of Ghent, Ghent, Belgium; A. Watson, Nottingham City Hospital, Nottingham, United Kingdom; A. Zurowska, University of Gdansk, Gdansk, Poland     

维持性血液透析患者丙型肝炎病毒感染与营养不良-炎症综合征的相关性

目的:采用营养不良-炎症评分(malnutrition inflammation score,MIS)系统,观察维持性血液透析(mainte-nance hemodialysis,MHD)患者丙型肝炎病毒(HCV)感染与营养不良-炎症综合征(malnutrition-inflammation complex syn-drome,MICS)的关系。方法:对12例HCV感染和112例对照组(无HCV/HBV感染)MHD患者进行MIS评分,了解其营养和炎症状况,包括:人体测量学指标、生化指标(包括血清白蛋白、转铁蛋白、铁蛋白、未饱和铁,总胆固醇、肾功能等)及血常规(红细胞、血红蛋白)、炎症指标(包括超敏C反应蛋白、白细胞介素-6、肿瘤坏死因子-α等)。统计患者进入观察期8个月前后MIS评分情况,分析HCV感染与炎症和营养状态的相关性。结果:HCV感染组较非HCV感染组患者的透析龄[(72.50±40.29)月vs(43.40±44.32)月,P<0.01]、肝硬化发生率(16.67%vs0.01%,P<0.05)、总MIS积分(6.73±2.57vs5.01±2.34,P<0.05)、谷丙转氨酶(ALT)(21.5±17vs14.0±8.0,P<0.01)、谷草转氨酶(AST)(21.0±23.0vs13.0±7.0,P<0.01)和铁蛋白浓度(384.28±132.49vs173.34±89.47,P<0.001)均患者显著增加,而白细胞计数、白蛋白、总胆固醇、低密度脂蛋白(LDL)等则显著低于非HCV感染组;HCV感染仅与透析时程呈正相关(OR:1.14,95%CI:1.04～1.25,P=0.005),而与白蛋白(OR:0.96,95%CI:0.95～0.9,P=0.011)、总胆固醇水平(OR:0.98,95%CI:0.98～0.99,P=0.016)呈负相关;观察结束时总MIS积分(6.95±3.33vs5.50±2.28,P<0.05),MIS6(0.66±0.73vs0.26±0.62,P<0.05)和MIS7(0.98±0.95vs0.53±0.71,P<0.05)评分也显著高于非感染组。结论:伴有HCV感染的MHD患者存在更为严重的MICS,并且随HCV感染时间的增加营养状况有恶化趋势。     

Biocompatibility in Hemodialysis: Clinical Relevance in 1995

Abstract: Hemodialysis therapy for end-stage renal disease is still empirical even after more than 30 years of experience. Although long-term survival can now be assured in selected patients, clinical results tend to be disappointing. Hemodialysis therapy needs to be improved. Zealots of the biocompatibility school believe that this improvement will come from reducing undesirable consequences of blood membrane interaction, particularly complement activation. However, there is controversy over the clinical meaningfulness of biocompatibility when exclusively related to blood membrane interactions. Another dimension needs to be added, namely ultrapure di-alysate to avoid subclinical chronic effects of activation of the cytokine cascade by bacterial fragments present in dialysate. While the pathogenesis of acute anaphylactoid reactions are understood and largely preventable, the relation of the chronic syndromes such as amyloidosis to the use of a particular membrane remain unproven. Prospective studies that will occupy at least a decade will be necessary to decide these issues.     

Morbidity and Mortality in Hemodialysis: The Role of Schedules

Abstract: Hemodialysis is an efficient therapy for end-stage renal failure. This treatment, however, must be used in an optimal fashion, i.e., with the best technology and the most adequate schedules. Unfortunately and especially for economic reasons, these basic therapeutic principles are often not respected. As a consequence, morbidity and mortality in maintenance hemodialysis patients have increased. This article underlines four points that could influence mortality in maintenance hemodialysis patients: nutrition, adequacy of hemodialysis, blood pressure control and treatment time.     

我院196例药品不良反应报告分析

目的：为了进一步了解我院药品不良反应（ADR）发生特点,切实保障公众用药安全,为临床用药和安全监管提供进一步参考。方法对我院2011年上报的196例不良反应报告进行分析统计。结果发生药品不良反应最多的药物是抗微生物类药物,其中多为头孢菌素类,其次是喹诺酮类;药品不良反应的发生男性多于女性,且60岁以上的老人容易发生药品不良反应;药品不良反应发生最多的给药途径为静脉给药。结论临床对老年患者用药时应格外谨慎;尽量避免静脉给药。     

The Clinical Course of Patients with Type 1 Hepatorenal Syndrome Maintained on Hemodialysis

Goal: Report the natural coarse of hepatorenal syndrome in 4 patients who were maintained on chronic hemodialysis. Background: The diagnosis of hepatorenal syndrome carries a grave prognosis with a mortality rate > 90% and a median survival time of < 2 weeks without orthotopic liver transplantation. Study: We report the clinical course of 4 patients with hepatorenal syndrome who underwent long‐term (greater than 3 weeks) hemodialysis in an attempt to bridge them to orthotopic liver transplantation. The etiologies of cirrhosis were: chronic hepatitis C infection (n = 2), alcoholic liver disease (n = 1), and primary sclerosing cholangitis (n = 1). Results: Mean survival time on hemodialysis was 236 days (range: 31 to 460 days). All patients survived their initial hospitalization and were discharged from the hospital. However, only one patient received orthotopic liver transplantation. Mean number of hospital admissions was 11 (range: 4 to 18) while receiving hemodialysis at an average rate of 2.2 (range: 1.1 to 5) admissions/patient month. Mean number of days spent in hospital while on hemodialysis support was 85 days (range: 15 to 199 days) at an average rate of 11.2 (range: 8.3 to 15) hospital days/patient month. An average of 33% (range: 26% to 48%) of the days of the prolonged survival on hemodialysis was spent in hospital. Conclusion: Although our 4 patients with hepatorenal syndrome demonstrated long‐term survival with hemodialysis, their prolonged survival was at the cost of a very heavy burden of morbidity and in‐patient stay. The advisability of maintenance hemodialysis in patients with hepatorenal syndrome should be judged on an individual basis.