Tuberculous spondylitis in patients with end-stage renal disease undergoing chronic hemodialysis therapy

Tuberculosis of the spine is not rare in immunocompromised patients and particularly in those with end-stage renal disease (ESRD). Furthermore, the possible vascular compromise of the spinal cord in patients with diabetic nephropathy may result in symptoms of neurological involvement that could lead to deterioration and paralysis. We report a series of 4 patients with ESRD undergoing dialysis that developed tuberculous spondylitis of the thoracic spine. Diabetic nephropathy was the primary cause for chronic kidney disease in 2 patients; 3 of these patients were treated conservatively with anti-tuberculous medication and orthotic splints and were cured. The fourth patient with diabetes mellitus and clinically evident signs and symptoms of severe vascular insufficiency has additionally developed incomplete paraplegia. A complete sensory recovery and partial recovery of the hip flexors and abductors within 3 months occurred, following decompression of the spine and drainage of the abscess, in combination with long-term anti-tuberculous treatment and spinal orthosis.     

The efficacy of udenafil in end-stage renal disease patients undergoing hemodialysis

Introduction Erectile dysfunction (ED) is frequently observed in end-stage renal disease (ESRD) patients on hemodialysis (HD) compared to non-uremic patients. This situation causes severe psychogenic problems in patients and disrupts the quality of life. Different phosphodiesterase type 5 (PDE-5) inhibitors have been used, and efficacies revealed, for the treatment of ED in HD patients; however, there are no studies related to udenafil use or results for HD patients. This study retrospectively evaluated the efficacy and reliability of udenafil for HD patients. Materials and methods The laboratory findings, side effects after treatment, and International Index of Erectile Function (IIEF) scores before and after treatment were compared and evaluated for HD patients who applied to our urology clinic with ED complaints and were treated with udenafil. Results The results showed that in the HD patient group with ED, apart from ED, there were severe rates of other sexual dysfunction. In our patient group, there was a statistically significant improvement in all scores for erectile function (p?=?0.033), orgasmic function (p?0.001), sexual desire (p?0.001), relationship satisfaction (p?0.001), and general satisfaction (p?0.001) after treatment. The reported side effects were headache in one patient and dyspepsia in one patient. Conclusion We concluded that udenafil is an effective and reliable treatment approach for HD patients; however, our results require support from prospective randomized crossover studies with sildenafil.     

Permanent hemodialysis vascular access survival in children and adolescents with end-stage renal disease

BACKGROUND: Transplantation is the optimal therapy for pediatric end-stage renal disease (ESRD) patients, but in a subset of patients with peritoneal membrane failure, failed transplants or poor social situations, chronic hemodialysis (HD) remains the only option. Long-term survival of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) in pediatric patients has not been well described. METHODS: We studied the survival of permanent vascular access in 34 pediatric ESRD patients treated with chronic HD at our institution between 1/1/89 and 12/1/95 and followed to 12/31/2000. RESULTS: Twenty-four AVFs and 28 AVGs were created in 19 and 23 patients, respectively. Mean age and weight at insertion were 15.1 years (range 7.1 to 20.9) and 46 kg (18 to 81) for AVFs and 13.3 years (3.8 to 21.1) and 41.5 kg (10.5 to 145) for AVGs. Fifteen patients weighed <35 kg at the time of access creation (7 AVFs in 5 patients, 14 AVGs in 13 patients). Excluding primary failures, one-year, three-year and five-year patency rates for AVFs (74%, 59%, 59%) and AVGs (96%, 69%, 40%) were not significantly different. Patency did not correlate with patient weight or age at access creation. Primary access failure occurred more often (P < 0.01) in AVFs (8/24) compared to AVGs (1/28). Access thrombosis, stenosis and infection occurred more frequently in AVG (P = 0.02). CONCLUSIONS: Both AVF and AVG function well even in small pediatric patients and have survival rates equivalent to adult series and longer than cuffed venous catheters in pediatric patients. Both AVFs and AVGs are preferable for long-term HD access in pediatrics.     

Intraoperative versus routine hemodialysis in end-stage renal disease patients undergoing open-heart surgery.

Of 13 chronic hemodialysis end-stage renal disease (ESRD) patients undergoing open-heart surgery, 7 received intraoperative hemodialysis (IHD) during cardiopulmonary bypass and 6 received hemodialysis on a routine basis (RHD). Within the groups, IHD patients had significantly lower post-operative mean serum potassium and mean plasma creatinine concentrations compared to mean preoperative values. Postoperative mean BUN tended to decrease and mean serum bicarbonate concentration was unchanged as compared to mean preoperative values. In the RHD group, however, post-operative mean serum potassium concentration tended to increase, mean serum bicarbonate concentration significantly declined and mean BUN was unchanged as compared to mean preoperative values. An average of 2.1 +/- 0.5 liters of fluid was removed from the IHD patients during cardiopulmonary bypass. Post-operatively, 0 of 7 IHD patients versus 4 of 6 RHD patients required parenteral sodium bicarbonate therapy (chi 2, p less than 0.01). On average, RHD patients required hemodialysis 1 day after surgery, whereas IHD patients were hemodialyzed 2 days after surgery (p = 0.009). We conclude that IHD lessened postoperative hyperkalemia and metabolic acidosis and delayed postoperative hemodialysis by an additional day. IHD should be considered as an adjunct to RHD therapy in the management of ESRD patients undergoing open-heart surgery.     

Intensive hemodialysis for cardiomyopathy associated with end-stage renal disease

Heart and kidney dysfunction often coexist, and increasing evidence supports the interaction of these two organs, as demonstrated by the clinical condition known as cardiorenal syndrome (CRS). We report a pediatric patient with end-stage renal disease (ESRD) who developed a dilated cardiomyopathy and decompensated heart failure after undergoing unilateral nephrectomy and while on maintenance peritoneal dialysis. He showed marked improvement in his cardiac function with the addition of intensive hemodialysis. We discuss the pathophysiology of cardiorenal syndrome in patients with ESRD and suggest that intensive dialysis may be an effective therapy for this condition.     

Depression in end-stage renal disease hemodialysis patients

Depression has been identified as a complicating comorbid diagnosis in a variety of medical conditions, including end-stage renal disease (ESRD). Despite this, the psychological health of hemodialysis patients is understudied. The purpose of this paper is to review the research and issues involved in the assessment of depression and its sequelae in ESRD. Accurate estimation of the prevalence of depression in the ESRD population has been difficult due to the use of different definitions of depression and varied assessment techniques, the overlap of depressive symptomatology with symptoms of uremia, and the confounding effects of medications. We suggest that depressive affect is a more important construct to study than diagnosis of depression syndromes per se in patients with chronic kidney disease. The Beck Depression Inventory is a reasonable measure of depressive affect in the ESRD population, if a higher than usual cutoff score is used or if its somatic components are omitted. Several pathways link depression and ESRD, and are probably bidirectional. As such, treatment of depressive affect could impact medical as well as psychological outcomes. The need for treatment intervention trials is great. Limited evidence regarding the safety and efficacy of treatment of hemodialysis patients with selective serotonin reuptake inhibitors is available, and cognitive behavioral therapy holds promise as an intervention for depression in this complex medical population.     

终末期肾病血液透析患者感染死亡事件调查

目的 探讨终末期肾病血液透析（血透）患者感染死亡的临床特点及防治措施。 方法 回顾性调查1998年至2008年在本院血透中心登记透析并随访死亡的终末期肾病患者的资料,分析感染作为直接死因及促进因素在死亡患者中的作用。 结果 共252例死亡,其中男性162例（64.29%）,女性90例（35.71%）,死亡年龄为（63.48±14.77）岁,紧急透析者占59.52%。首位基础疾病为原发性肾小球疾病（27.23%）,其次为糖尿病肾病（16.90%）和高血压肾病（14.55%）。17.4%患者直接死因为感染,17.4%患者为感染促进死亡。首位死因为脑血管事件,占23.6%,心血管事件占13.4%。在老年患者组（≥65岁）,感染作为直接死因和促进因素者分别占18.63%和21.57%。与感染有关死亡者年龄显著高于非感染相关死亡者。因感染死亡患者及因感染促进死亡患者中存活<3个月者分别占48.15% 和38.71%,高于非感染相关死亡患者的30.34%。存活>2年者中,前两者比例分别为22.22%和32.26%,低于非感染相关死亡患者中比例（37.93%）。死亡患者最常见的感染为肺部感染（77.59%）,其次为血行感染（10.34%）,导管相关性感染（5.17%）。58.62%感染有关死亡者病原检出阳性,以革兰阴性杆菌居多（38.24%）,50%检出者合并真菌感染。 结论 感染是终末期肾病血透患者重要直接死因及死亡促进因素,且是老年患者和透析开始3个月内的主要死因。引起血透患者死亡的感染以肺部感染最常见。致病菌以革兰阴性杆菌多见,且半数患者合并真菌感染。应重视血透患者感染的防治,尤其在老年患者和透析初期。     

Results of recombinant growth hormone treatment in children with end-stage renal disease on regular hemodialysis

Children with chronic kidney disease are at high risk for growth retardation and decreased adult height. Growth hormone (GH) treatment is known to stimulate growth in children with short stature suffering from chronic kidney disease. However, the extent to which this therapy affects final adult height is not known. This study was performed on 15 patients with end-stage renal disease (ESRD) on regular hemodialysis to detect the effect of using recombinant human growth hormone (rhGH) on growth of patients with ESRD on regular hemodialysis and comparing this effect with the growth velocity in the same group without using rhGH in the year before therapy. There were eight females and seven males with mean age 10.6 ± 2.8 (range 5-14 years). For each patient, recombinant GH was given for one year, three-times weekly. The data of these 15 patients was compared with the year before treatment versus data of the same group of patients after six months and after one year of rhGH therapy. Our results showed that, in the year before therapy, height of these patients increased from a mean of 112.1 ± 11.6 cm to 112.7 ± 11.5 cm, which is a non-significant increase statistically (P >0.05) as well as clinically (mean growth velocity 0.6 cm/year), while height of these patients increased from a mean of 112.7 ± 11.5 cm at the start of therapy to 116.8 ± 11 cm after therapy for one year, which, although statically not significant (P >0.05), was of clinical significance as it makes rate of increase, i.e. the mean growth velocity, 4.1 cm/year close to the normal growth velocity, which is 5 cm/year, before puberty. rhGH therapy for patients with ESRD on regular hemodialysis is helpful in height gain and catch-up growth even when given three-times per week instead of five- or six-times per week. We recommend giving rhGH therapy as a routine supplementation to pediatric patients before epiphyseal closure.     

Quality of life in children with end-stage renal disease undergoing renal replacement therapy: a cross-sectional survey

Objective To evaluate the quality of life (QOL) of children with uremia who underwent renal replacement therapy (RRT) and identify the influencing factors for QOL in order to improve the QOL of children with uremia. Methods Children with ESRD who underwent dialysis or kidney transplantation (KT) at Children's Hospital of Fudan University between November 2016 and October 2017 were enrolled. The children and/or their parents completed and returned the Pediatric QOL Inventory Measurement Models (PedsQLTM) 4.0 questionnaire. Moreover, the clinical data of these children were collected. According to the way of RRT, children were divided into dialysis group and KT group. The differences of scores between two groups were compared. Multiple linear regression analysis was used to analyze the factors affecting the QOL of children. Results A total of 79 children undergoing RRT were enrolled. Among them, 48 cases in the dialysis group and 31 cases in the KT group. For children in KT group, the total PedsQL scores of child-self and parent-proxy assessment were higher than those in dialysis group (P＜0.05). The total scores for the QOL of child-self and parent-proxy assessment were roughly the same for KT children (P＞0.05). The total scores for the QOL of child-self and parent-proxy assessment were different for dialysis children (P=0.05). Short stature (height＜3th percentile) and elevated left ventricular mass index (LVMI) were the independent influencing factors for the QOL of child-self and parent-proxy assessment in children undergoing KT, respectively (B=12.162, t=2.681, P＜0.05; B=-0.240, t=-4.276, P＜0.01). Conclusions QOL was higher in children undergoing KT than those on dialysis. Short stature and elevated LVMI were the independent influencing factors for QOL in children undergoing KT.     

FGF-23 in patients with end-stage renal disease on hemodialysis

BACKGROUND: Fibroblast growth factor (FGF)-23 is a recently identified circulating factor which causes renal phosphate wasting disorders. Although the mechanism of regulation of FGF-23 secretion is unknown, plasma FGF-23 level may be regulated or affected by serum phosphate levels because of its hypophosphatemic effect. METHODS: We tested the hypothesis that plasma FGF-23 levels may be increased in hyperphosphatemia in patients with end-stage renal disease (ESRD) on maintenance hemodialysis. We measured plasma FGF-23 levels in 158 male uremic patients on maintenance hemodialysis. Plasma samples were obtained before starting dialysis sessions to determine FGF-23 levels by enzyme-linked immunosorbent assay (ELISA). RESULTS: Plasma FGF-23 level exhibited significant and positive correlations with inorganic phosphate, intact parathyroid hormone (PTH), corrected calcium, and duration of hemodialysis on simple regression analyses. All these associations remained significant in multiple regression analyses. CONCLUSION: Serum phosphate, calcium, and intact PTH could be regulators of FGF-23 levels in uremic patients on maintenance hemodialysis. Our results may provide new insights into the pathophysiologic effects of FGF-23 on calcium-phosphate homeostasis.     

Exercise evaluation of children with end-stage renal disease

The use of exercise testing in the assessment and management of various pediatric disorders has increased significantly during the past three decades. With age-appropriate equipment and exercise protocols, a well-trained and enthusiastic staff can evaluate patients as young as 3 to 4 years of age. Pediatric exercise testing may be conducted using either a cycle ergometer or a treadmill. The decision of which method to use is based on the parameters to be evaluated during the test, physical stature of the child, administrator preference, and availability of equipment in the laboratory. For children with renal disease, who are often short and may have poor leg muscle mass, the treadmill is used most often. The exercise testing protocols should use slow initial speeds and no grade, increase in small increments, and have stages of 1 to 2 minutes' duration. The benefits of testing in children with renal disorders include its ability to provide valuable information regarding the overall functional capacity of the patient, efficacy of pharmacological or surgical interventions, and outcome of rehabilitation programs.     

终末期肾脏病血液透析患者不安腿综合征

不安腿综合征属周围神经系统疾病,分原发性和继发两种类型。大多发生于终末期肾脏病(ESRD)或患者开始透析治疗以后,症状较原发性患者重。但具体发病机制迄今仍然尚不清楚。本文就终末期肾病透析患者不安腿综合征病因、发病机制、临床表现、检查、诊断、治疗及目前进展情况作一综述。     

Oxalate removal by hemodialysis in end-stage renal disease

Because of mounting evidence of precipitation of calcium oxalate in the soft tissues of patients with end-stage renal disease (ESRD) on maintenance hemodialysis, the plasma oxalate concentrations and calculated dialysis removal of oxalate were studied in seven patients without evidence of either primary or absorption hyperoxaluria prior to ESRD. A reversed-phase high-pressure liquid chromatographic method was developed to quantitate serum oxalate. Mean value +/- SE in four healthy controls was 28 +/- 5 mumol/L, and in the seven patients it was 187 +/- 15 mumol/L predialysis and 89 +/- 11 mumol/L postdialysis. Oxalate deposition in the soft tissues of ESRD patients is the consequence of sustained hyperoxalemia. Oxalate removal by dialysis was calculated from the four-hour oxalate clearance. Since the ionic radii of phosphate and oxalate are similar, total oxalate clearance was calculated midpoint of dialysis. Mean oxalate removal/dialysis was 3.01 +/- 0.283 mmol. On a daily basis this value was 1.645 +/- 0.155 mmol, which is about threefold the normal oxalate excretion rate. It is not significantly different from the excretion rate in absorption oxalurias but is less than that in primary hyperoxaluria. Therefore, it is concluded that hyperoxalemia in ESRD results from loss of renal excretion, failure of hemodialysis to remove enough oxalate to maintain a normal serum concentration, and increased intestinal absorption of oxalate and/or increased endogenous production.     

Long-term outcomes of children with end-stage renal disease

Long-term survival of children with end-stage renal disease (ESRD) has increased in the last 20 years, but the mortality rate remains high. Cardiovascular disease accounts for 40 to 50% of all deaths, infectious disease for about 20%. A prolonged period of dialysis versus having a renal graft and persistent hypertension are mortality risk factors. The prevalence of the various morbidities is high among those who have reached adulthood. Nearly 50% of all these patients suffer from left ventricular hypertrophy and life-threatening vascular changes; nearly one third has clinical signs of metabolic bone disease. This accounts for both dialysis and transplant recipients. The chance of getting cancer is increased ten times compared to the general population; skin cancer and non-Hodgkin lymphomas are most commonly reported. A long period of dialysis at childhood is associated with impairment of both cognitive and educational attainment. However, despite all these negative outcomes, the health perception of young adults with childhood onset ESRD is positive. Research and therapy in children with ESRD should focus not only on prevention of graft failure, but also on prevention of co-morbidity, especially cardiovascular disease, life-threatening infections and malignancies. Early transplantation, more extended forms of frequent hemodialysis in those who can not be transplanted, a more rigorous treatment of hypertension, avoidance or at least dosage reduction of calcium-containing phosphate binders, reduction of the chronic inflammatory state, and tailor made anti-rejection therapy after transplantation may all be targets to improve the outcome in future patients.     

School adjustment of children with end-stage renal disease

We examined adjustment to school of children with end-stage renal disease (ESRD) and the psychological condition of their mothers; 30 children on continuous ambulatory peritoneal dialysis (CAPD), 35 children with a transplant and 33 healthy children were studied. A factorial ANOVA statistic found that the mean scores for non-academic problems (psychological factors) differed significantly across the three groups, being highest in CAPD children and lowest in healthy children. No significant differences between CAPD and transplant children were found for school maladjustment with academic problems, although the prevalence differed significantly across the groups, being highest in transplant children and lowest in healthy children. The mothers of children with ESRD were prone to feel various anxieties and dependency.     

Therapeutic camping for children with end-stage renal disease

Therapeutic camping experiences for children with end-stage renal disease (ESRD) have proliferated in the United States and abroad. This report is based on the results of a survey designed to accumulate data on the development and implementation of 20 such camps. Children attending camp ranged in age from 1 year to 19 years. Single disease-specific camps were most common, while camps for children with a variety of chronic illnesses, including ESRD, and mainstream camps were also conducted. Facilities were available for hemodialysis and continuous ambulatory peritoneal dialysis, but not automated peritoneal dialysis, in the majority of surveryed camps. Dialysis nurses, pediatric nephrologists, dietitians and social workers were the medical personnel that most frequently participated in the camps. On average, 32 dialysis/transplant patient campers (range 6–100) attended camp for a 1-week session. Therapeutic camping experiences for children with ESRD are extremely successful and attempts to increase the availability of similar camps should be encouraged.Presented in part at the 13th Annual Conference on Peritoneal Dialysis, 7–9 March 1993, San Diego, California, USA.     

Growth failure,risk of hospitalization and death for children with end-stage renal disease

Growth failure remains a significant problem for children with chronic renal insufficiency and end-stage renal disease (ESRD). We examined whether growth failure is associated with more-frequent hospitalizations or higher mortality in children with kidney disease. We studied data on prevalent United States pediatric patients with ESRD in 1990 who were followed through 1995. Patients were categorized according to the standard deviation score (SDS) of their incremental growth during 1990: severe (<–3 SDS), moderate growth failure (>–3 and <–2 SDS), and normal growth (>–2 SDS). Among 1,112 prevalent pediatric dialysis and transplant patients (<17 years, Tanner I–IV), those with severe and moderate growth failure had higher hospitalization rates {relative risk (RR) 1.14 [95% confidence interval (CI) 1.1, 1.2] and 1.24 [95% CI 1.2, 1.3]} respectively than those with normal growth after adjustment for age, gender, race, cause and duration of ESRD, and treatment modality (dialysis or transplant) in 1990. Kaplan-Meier survival analysis showed 5-year survival of 85% and 90% for patients with severe and moderate growth failure, respectively, compared with 96% for patients with normal growth (P<0.001, log-rank). Cox proportional hazards analysis revealed that those with severe (RR 2.9, 95% CI 1.6, 5.3) and moderate growth failure (RR 2.01, 95% CI 1.1, 3.6) had an increased risk of death compared with youths with normal growth, after adjustment. A higher proportion of deaths in the severe and moderate growth failure groups were attributed to infectious causes (22% and 18.7%, respectively) than in the normal growth group (15.6%). We conclude that growth failure is associated with a more-complicated clinical course and increased risk of death for children with kidney failure. Received: 15 August 2001 / Revised: 14 January 2002 / Accepted: 15 January 2002     

Complications of joint arthroplasty in patients with end-stage renal disease on hemodialysis

The mortality and morbidity after hip and knee arthroplasty were reviewed retrospectively during a 3-year period in 14 patients who had chronic renal failure and who were receiving hemodialysis. The patients had a primary total hip or knee replacement, or a revision arthroplasty or resection arthroplasty. Four of the patients (29%) died in the hospital during the postoperative period. One of the seven patients (14%) having a primary joint replacement died, whereas three of the seven patients (86%) having a revision or resection died. Every patient had multiple medical comorbidities, and every patient had a complication. The results indicate that arthroplasty procedures, especially revisions and resections, in this patient population are associated with a high rate of complications and death, and that in-depth informed consent should be provided for all patients contemplating these procedures. Meticulous treatment of medical comorbidities is mandatory. Finally, data in the literature and in the current report question whether joint arthroplasty procedures should be done in patients with end-stage renal disease who are receiving hemodialysis.