Acute barium nitrate intoxication treated by hemodialysis

A 22-year-old male was admitted to hospital with diarrhea and vomiting, cardiac arrhythmias, severe hypokalemia and gradual onset of muscular weakness. A potassium infusion was started, but for several hours serum potassium remained low. Evidence of toxic ingestion was initially lacking. When it became clear -- after a considerable delay -- that the patient had ingested barium nitrate, hemodialysis was started. This resulted in rapid clinical improvement with correction of hypokalemia and restored muscular function. Intoxication with barium causes hypokalemia, arrhythmias, muscular weakness and paralysis, often requiring respiratory support. This patient presented with symptoms typical of severe barium intoxication, non-responsive to potassium supplementation. There are few published reports on the use of hemodialysis in barium poisoning. This case confirms the possible benefit of hemodialysis in severe cases, where potassium supplementation alone is insufficient.     

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.     

Effect of hyperglycemia on serum sodium concentration and tonicity in outpatients on chronic dialysis

When serum glucose concentration is nearly normal, serum sodium concentration and tonicity are usually normal in ambulatory outpatient diabetics on chronic hemodialysis or peritoneal dialysis. In hyperglycemia, patients on hemodialysis do not undergo osmotic diuresis and are able to nearly normalize their serum tonicity by increasing the intake of water. Patients on peritoneal dialysis differ from hemodialysis patients because of continued loss of water in the peritoneal dialysate and achieve only partial correction of tonicity by water consumption. The model currently used to predict changes in serum sodium concentration and in tonicity from hyperglycemia assumes no changes in external balance of body water or solute during development of hyperglycemia and, therefore, is not applicable in ambulatory dialysis patients with intact thirst mechanism, because of water retention. In ambulatory patients on chronic dialysis, clinical manifestations of hyperglycemia include thirst, water intake, and weight gain. Neurologic manifestations due to hypertonicity are usually absent.     

Repeated cat-associated peritonitis in a patient on automated nocturnal intermittent peritoneal dialysis

A 49-year-old man had three episodes of bacterial peritonitis in the 8 months after he started nocturnal intermittent peritoneal dialysis (NIPD) at home, using an automated cycler device. When peritonitis was first diagnosed, Enterobacter agglomerance was cultured in his peritoneal fluid. In the second and third episodes, Pasteurella multocida and alpha-Streptococcus were isolated, respectively. These bacteria are unusual pathogens in continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Detailed questioning revealed that a domestic cat had bitten the dialysis tube before the patient experienced the second episode of peritonitis. Pasteurella multocida is part of the normal oral flora in cats and dogs. We isolated Pasteurella multocida from the teeth of the patient's cat. Enterobacter agglomerance is part of the common bacterial flora in animal's alimentary tract, and alpha-Streptococcus is commonly found in animal's respiratory tracts. Since the patient removed the cat from his bedroom, he has had no peritonitis. NIPD is a very convenient sysytem for patients in the final stage of renal failure; however, patients must be aware of the risks associated with keeping pets in their homes. This case is the first report of cat-associated peritonitis in Japan. Received: July 9, 1998 / Accepted: September 24, 1998     

Pulmonary function in renal transplant recipients and end-stage renal disease patients undergoing maintenance dialysis

The aim of this study was to reveal the pulmonary function status of renal transplant recipients and chronic renal failure patients on hemodialysis or continuous ambulatory peritoneal dialysis. The study involved 73 subjects, including 49 patients who were either on peritoneal dialysis (n = 22) or hemodialysis (n = 27), and 24 renal transplant recipients. The spirometry results revealed significantly higher residual volume and total lung capacity in the hemodialysis and peritoneal dialysis groups than in the transplantation group. Forced expiratory flow between 25% and 75% of vital capacity was slightly below normal in the dialysis patients. Preservation of diffusion capacity of the lung for carbon monoxide was noted in the hemodialysis group (112.4%). Inspiratory and expiratory muscle strength was reduced in all groups. Only type of dialysis was correlated with this reduction. Inspiratory muscle strength in the peritoneal dialysis group (49.9%) was significantly lower than in the transplantation and hemodialysis groups (54.7% and 66.5%, respectively). The spirometry findings suggest that small-airway disease causes increased residual volume and total lung capacity (hyperinflation) in hemodialysis and peritoneal dialysis patients and that this airway obstruction subsides after renal transplantation. Preserved diffusion capacity in the hemodialysis group was attributed to the use of biocompatible dialyzer membranes. Renal failure complications may be the main explanation for global respiratory muscle weakness in dialysis patients, whereas corticosteroid therapy might be the primary cause in kidney graft recipients. Significantly lower inspiratory muscle strength in the peritoneal dialysis group suggests that presence of intra-abdominal dialysate might interfere with diaphragmatic contraction.     

Acute hyperkalemic paralysis in a uremic patient

Hyperkalemia is a less-recognized life-threatening cause of paralysis. We describe a 38-year-old uremic man on regular hemodialysis (HD) without interruption who suffered from muscle weakness progressing to ascending symmetric paralysis, and inability to masticate. Physical examination revealed flaccid paralysis with areflexia of the four limbs. Computed tomography of the brain and cervical spine did not demonstrate any organic lesions. Laboratory investigations revealed serum K+ 8.1 mmol/L, urea nitrogen 32 mmol/L, creatinine 919 micromol/L. Of note, electrocardiography (ECG) did not show typical features of hyperkalemia. Emergent HD with low K+ dialysate (1.0 mmol/L) rapidly normalized serum K+ (4.7 mmol/L) and reversed all neuromuscular symptoms within one hour. Upon reviewing his food and medication history, he admitted drinking 750 ml of raw coconut juice per day (K+ concentration 44.3 mmol/L) to quench his thirst for three consecutive days. Hyperkalemia should be born in mind in the differential diagnosis of acute paralysis despite no ECG changes. Hidden sources of K+ intake, such as coconut juice, should not be overlooked, especially in patients with impaired renal function.     

Effect of starting with hemodialysis compared with peritoneal dialysis in patients new on dialysis treatment: a randomized controlled trial

BACKGROUND: Up-until-now, the survival and health-related quality of life of hemodialysis and peritoneal dialysis patients has only been compared in observational studies. These studies have reported small and opposing differences between both modalities. The aim of this study was to compare the outcome of hemodialysis as initial chronic dialysis treatment with that of peritoneal dialysis in a randomized controlled trial. METHODS: All new dialysis patients from 38 dialysis centers in The Netherlands without indications against either modality were invited to participate. Patients were assigned to start with hemodialysis or peritoneal dialysis. The primary outcome was mean quality-adjusted life year (QALY) score. Secondary outcome was survival. RESULTS: Due to the low inclusion rate, the trial was prematurely stopped after which 38 patients had been randomized: 18 patients to hemodialysis and 20 to peritoneal dialysis. The mean QALY score in the first 2 years was 59.1 (SD 12) for hemodialysis patients versus 54.0 (SD 19) for peritoneal dialysis patients, which constitutes a small difference in favor of hemodialysis of 5.1 (95%CI -7.3 to 17.6) After 5 years of follow-up, nine hemodialysis and five peritoneal dialysis patients had died, a significant difference in survival; hazard ration of hemodialysis versus peritoneal dialysis of 3.8 (95%CI 1.1 to 12.6). After adjustment for age, comorbidity, and primary kidney disease the hazard ratio was 3.6 (0.8 to 15.4). CONCLUSION: Only a small difference in QALY score was observed between patients who started with hemodialysis compared to patients who started with peritoneal dialysis, lending support for the equivalence hypothesis. The significant difference in longer-term survival, which favored peritoneal dialysis in this small group of patients, could be used to posit that incident dialysis patients might benefit from starting on peritoneal dialysis.     

Ischemic colitis in chronic intermittent peritoneal dialysis

A 6-year and 8-month-old boy on chronic intermittent peritoneal dialysis for end stage kidney disease presented with severe diarrhea, abdominal distension, cramps, tenesmus and vomiting. Barium enema showed rigidity and irregularity of the mucosa of the sigmoid and distal descending colon, with 'thumb print like' appearance, findings compatible with ischemic colitis. The institution of hemodialysis and discontinuation of the peritoneal dialysis resulted in a marked clinical and radiological improvement. Kidney transplantation performed a month later was associated with a complete cure of his intestinal disease.     

Acute Renal Failure in Severe Hypothermia

A patient who developed acute renal failure associated with severe hypothermia is reported. Warm peritoneal dialysis was initiated for core rewarming followed by intermittent hemodialysis till he entered the diuretic phase. The factors which led to acute renal failure in this patient included hypovolemia, hypotension, and acute pancreatitis.     

Acute renal failure in severe hypothermia.

A patient who developed acute renal failure associated with severe hypothermia is reported. Warm peritoneal dialysis was initiated for core rewarming followed by intermittent hemodialysis till he entered the diuretic phase. The factors which led to acute renal failure in this patient included hypovolemia, hypotension, and acute pancreatitis.     

Perforation of small intestine diverticulum in a maintenance hemodialysis patient

We report perforation of a small intestine diverticulum in a maintenance hemodialysis patient. The patient was a 57-year-old male. He was undergoing continuous ambulatory peritoneal dialysis (CAPD) for chronic glomerulonephritis (CGN) since 1984. In 1992, his dialysis therapy was changed from CAPD to hemodialysis (HD) because of peritonitis. On September 29, 2007, he developed abdominal pain, and on October 2, 2007, he complained of more severe pain and muscular tenderness and was positive for Blumberg's sign. He was admitted in emergency. Abdominal CT scan revealed some free air in the endoperitoneum. Emergency laparotomy was performed following the diagnosis of panperitonitis due to intestinal perforation. We found a perforation measuring 1 mm in diameter at the actinal side approximately 10 cm from the Bauhin valve, however, no other abnormalities were detected in the abdominal cavity. Partial bowel resection was performed, and a segment approximately 50 cm in length, including the perforated lesion, was excised. The postoperative course was uneventful, and he was discharged on October 17, 2007. Pathological findings of the resected specimen revealed a perforation of diverticulum with inflammatory changes. Such perforation of small intestine diverticulum in a hemodialysis patient has rarely been reported in the literature, and we emphasize that prompt laparotomy is necessary for the prevention of severe complications.     

Anaesthetic management of a patient with familial normokalaemic periodic paralysis

Purpose

We describe the anaesthetic management of a patient with the autosomal dominant inherited disease, normokalaemic periodic paralysis. The disease results in intermittent bouts of limb and respiratory muscular weakness in association with hypothermia, stress, prolonged fasting or exercise. Unlike hypokalaemic and hyperkalaemic periodic paralysis, the more common variants of the disease, normokalaemic periodic paralysis is not accompanied by alterations in the plasma potassium concentration.

Clinical features

A five-year-old boy presented for emergency scrotal exploration. He had a family history of periodic paralysis and had experienced previous episodes of weakness, two of which had required hospitalization for respiratory distress. On admission there was no evidence of weakness and serum potassium concentration was 4.2 mMol · L^?1. A spinal anaesthetic was performed and the procedure was uncomplicated by muscle paralysis above the level of the spinal block.

Conclusion

Avoidance of known precipitating factors and judicious use of neuromuscular blocking drugs has been advocated in patients with this disorder presenting for surgery. In appropriate circumstances, spinal anaesthesia represents a useful option in patients with normokalaemic periodic paralysis.     

Intoxication aluminique en hémodialyse chronique. Un diagnostic rarement évoqué de nos jours. Illustration par un cas clinique et revue de la littérature

Aluminum intoxication in chronic hemodialysis patients has virtually vanished over the last decade. Therefore, the diagnosis is rarely advocated at present. Aluminum intoxication in dialysis patients associates to different degrees with dialysis encephalopathy, bone disorders and microcytic anemia. We report here the observation of a patient receiving intermittent hemodialysis therapy who presented with acute encephalopathy. It turned out to be caused by aluminum intoxication secondary to a defect in dialysis water treatment. Whatever the therapeutic approach, the prognosis of this dramatic complication in hemodialysis patients remains poor. In severe cases, only renal transplantation can be able to improve clinical outcome. Major sources of aluminum are tap water used for dialysis together with a defective water treatment system, and to a minor extent oral aluminum-containing phosphate binders and antacids. In the absence of a bone biopsy, the diagnosis can be made by measuring serum aluminum or better after a desferrioxamine test. Prevention of aluminum overload is of utmost importance. It is the responsibility of dialysis centers to provide aluminum-free water and dialysis fluid. In case of proven aluminum intoxication, the K/DOQI guidelines indicated how to best treat hemodialysis patients, based on long-term desferrioxamine infusions during the hemodialysis session. It is recommended to implement a stepwise increasing desferrioxamine dosage to prevent an acute decompensation with irreversible neurological lesions.     

Pregnancy during hemodialysis: perinatal outcome in our cases

The perinatal outcome of patients undergoing chronic hemodialysis has been improved in recent years. In this report we review the treatment and outcome of seven pregnancies in women undergoing chronic hemodialysis before and during pregnancy between 2000 and 2002. The hemodialysis schedule was increased from 4 hours twice weekly to 4 hours four to six times weekly. Hemodialysis was performed using a high-flux dialyzer with volume-controlled ultrafiltration. The patients were followed in close collaboration between the obstetrician and the nephrologist. Monitoring of fetal well-being was started after 24 weeks' gestation, using cardiotocography by a nonstress test twice weekly and by weekly Doppler flow measurements. All patients underwent uterine contraction monitoring immediately after the dialysis. The mean gestational age at delivery was 32 weeks (range, 26 to 36 weeks). The causes of preterm delivery were premature contractions, premature rupture of membranes, preeclampsia, and intrauterine growth restriction. The outcomes were two pregnancies complicated by polyhydramnios and six pregnancies, that resulted in live births, all of whom survived. There was one neonatal death. The mean newborn birthweight was 1400 g (range, 420 to 2640 g) and the 1- and 5-minute Apgar scores ranged from 2/8 and 4/10, respectively one infant at 29-weeks gestation experienced respiratory distress syndrome but did well after 12 days. Cesarean section was performed in four pregnancies. The mothers were discharged on postoperative days 3 to 5. It is well known that the management of pregnant patients undergoing chronic hemodialysis is difficult. However, advances in dialysis, obstetrics, and neonatal care have improved the outcomes.     

Quality of life in patients treated with hemodialysis or peritoneal dialysis: what are the important determinants?

BACKGROUND: Patients with end-stage renal disease (ESRD) have significant impairments in health-related quality of life (HRQOL). In part, this is due to the intrusiveness of the treatment (hemodialysis or peritoneal dialysis) that is required. It is unclear whether hemodialysis or peritoneal dialysis is associated with a higher HRQOL. METHODS: 192 prevalent patients who self-selected treatment with hemodialysis (either in-center, satellite or home/self-care hemodialysis) or peritoneal dialysis were studied to determine whether treatment with hemodialysis or peritoneal dialysis is associated with a higher HRQOL. Demographic, laboratory and clinical information (including the presence of comorbid conditions using the Charlson comorbidity index) was assessed at baseline. The outcome of interest was HRQOL, which was measured using the Kidney Disease Quality of Life-Short Form (KDQOL-SF), the Short-Form 36 (SF-36) and the EuroQol EQ-5D at baseline and after 6 and 12 months of follow-up. RESULTS: There was no significant difference in HRQOL scores for the SF-36, the EQ-5D and for 9 of 11 KDQOL dimensions for patients treated with hemodialysis or peritoneal dialysis at baseline. As expected, HRQOL was significantly lower for patients who had more comorbid disease, required assistance with their daily care, and for patients with less than a grade 12 education. After controlling for the effect of other important variables, HRQOL (as measured by the EQ-5D visual analog or index scores) did not differ between hemodialysis and peritoneal dialysis patients. HRQOL was stable over time, both for patients who started on hemodialysis or peritoneal dialysis. CONCLUSIONS: There is no significant difference in HRQOL for prevalent ESRD patients treated with hemodialysis or peritoneal dialysis. It will be important to determine if this finding holds true for incident patients treated with hemodialysis or peritoneal dialysis.     

Chronic peritoneal dialysis.

Since the introduction of the permanent peritoneal catheter, interest in chronic peritoneal dialysis is increasing. The automatic peritoneal dialysis cycler and the reverse osmosis peritoneal dialysis machine have been other development that made chronic peritoneal possible. Chronic peritoneal dialysis is indicated for the children, the elderly, those without hemodialysis access sites, those living along (for home dialysis) and the diabetics, whose retinopathy seems to progress less on peritoneal dialysis than on hemodialysis. Patients awaiting a kidney transplant can be maintained equally satisfactorily on peritoneal dialysis as on hemodialysis. Because of its simplicity almost any patient can be trained for home peritoneal dialysis, and a high incidence of rehabilitation can be achieved. A flow rate of 4 1/hr with 21 exchanges, 40 hours a week, seem to the ideal dialysis requirements. Complications of chronic peritoneal dialysis include those related to the permanent catheter such as one or two way obstruction and those related the dialysis itself. The latter can be either acute (i.e. peritonitis etc.) or chornic such as neuropathy, renal osteodystrophy, anemia etc. Integrated with hemodialysis and transplantation, peritoneal provides the nephrologists with the ability to treat his patients with the most appropriate treatment.     

Selection bias explains apparent differential mortality between dialysis modalities

The relative risk of death for patients treated with peritoneal dialysis compared with those treated with hemodialysis appears to change with duration of dialysis therapy. Patients who start dialysis urgently are at high risk for mortality and are treated almost exclusively with hemodialysis, introducing bias to such mortality comparisons. To better isolate the association between dialysis treatment modality and patient mortality, we examined the relative risk for mortality for peritoneal dialysis compared with hemodialysis among individuals who received ≥4 months of predialysis care and who started dialysis electively as outpatients. From a total of 32,285 individuals who received dialysis in Ontario, Canada during a nearly 8-year period, 6,573 patients met criteria for elective, outpatient initiation. We detected no difference in survival between peritoneal dialysis and hemodialysis after adjusting for relevant baseline characteristics. The relative risk of death did not change with duration of dialysis therapy in our primary analysis, but it did change with time when we defined our patient population using the more inclusive criteria typical of previous studies. These results suggest that peritoneal dialysis and hemodialysis associate with similar survival among incident dialysis patients who initiate dialysis electively, as outpatients, after at least 4 months of predialysis care. Selection bias, rather than an effect of the treatment itself, likely explains the previously described change in the relative risk of death over time between hemodialysis and peritoneal dialysis.     

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.     

Modern detoxication methods in surgical patients

The therapeutic possibilities of peritoneal dialysis, hemodialysis, and hemo- and lymphosorption in the treatment of the intoxication syndrome were studied in 786 patients. The causes of the intoxication syndrome were as follows: postoperative peritonitis (98), acute renal insufficiency of various etiology (493), acute hepatorenal insufficiency with exogenous poisoning (178), diffuse purulent peritonitis (11), pancreatogenic peritonitis (6). Enzymatic lavage and peritoneal dialysis were applied in 98 patients, hemodialysis methods in 493, hemosorption was conducted 360 times in 178 patients and lymphosorption in 17 patients. The efficacy of the modern methods of detoxification of the organism was demonstrated, which was evaluated from the patients' improved general condition, improvement of the values of hemodynamics, concentration of toxic metabolites and middle-mass molecules in the blood, and the results of the paramecium test.     

Long-term follow-up of thoracoscopic pleurodesis for hydrothorax complicating peritoneal dialysis

BACKGROUND: Massive hydrothorax is a significant complication of continuous ambulatory peritoneal dialysis (CAPD) and its ideal management remains undefined. Conservative management in the form of intermittent peritoneal dialysis had limited success. The use of conventional pleurodesis and open thoracotomy were associated with morbidities and limitations. We retrospectively reviewed the long-term outcome of 8 patients with massive hydrothorax complicating CAPD, 6 of whom received thoracoscopic pleurodesis. METHODS: Among 397 patients undergoing continuous ambulatory peritoneal dialysis during the period from 1994 to 1998, hydrothorax developed in 8 patients. Four patients were first treated with temporary intermittent peritoneal dialysis using 1-L exchange cycles. Three of them had a recurrence of the hydrothorax whereas only one could resume continuous ambulatory peritoneal dialysis successfully. Two patients then underwent conventional pleurodesis but failed. One of them was switched to hemodialysis. Thoracoscopic pleurodesis was performed for the remaining 2 patients together with 4 other patients with hydrothorax once this complication developed. There were no gross abnormalities including pleuroperitoneal communication sites identified. Talc poudrage was performed in 2 patients and mechanical rub pleurodesis in the other 4 patients. All had uncomplicated procedure and uneventful recovery. RESULTS: One patient after thoracoscopic pleurodesis was soon switched to hemodialysis for an unrelated reason. The other 5 patients resumed continuous ambulatory peritoneal dialysis with no recurrence of hydrothorax for a mean period of 50 months (range 19 to 84). CONCLUSIONS: With thoracoscopic pleurodesis, patients resumed continuous ambulatory peritoneal dialysis without recurrence of hydrothorax on long-term follow-up.