Bring me home: Renal dialysis in the Kimberley

SUMMARY:   The incidence of end-stage renal failure (ESRF) in the Kimberley region at the top end of Western Australia far exceeds known national rates and trend analysis demonstrates a close parallel to what is occurring in the Northern Territory. Dialysis prevalence in the Kimberley has nearly tripled in the last decade and has increased at a much faster rate than the rest of Western Australia. Almost all of these people with ESRF are Aboriginal Australians living in remote communities.
In January 2004, the Western Australia Country Health Service and Kimberley Aboriginal Medical Services' Council, under the auspices of the Kimberley Aboriginal Health Planning Forum, embarked upon a review of renal disease in the Kimberley funded by the Western Australia Department of Health. The main purpose of the review was to identify the scope of the problem and make projections upon which to base programme and service development over the next 10 years.
This paper outlines the findings of the Review of Renal Disease in the Kimberley and presents, for the first time, regional data analysis and comparisons. In addition, future projections on the impact of ESRF and recommendations for improving current service delivery are discussed. Given the challenges of remoteness and individuals' desire to return home, this review recommends development of locally-based expertise capable of providing training and support to patients and their families, reinvigoration of community-based dialysis modalities, and the initiation of planning for a second satellite service in the Kimberley.     

Severe Refeeding Hypophosphatemia in a CAPD Patient: A Case Report

Refeeding syndrome is defined as severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished, refeeding patients. Hypophosphatemia is its predominant concern, though its occurrence is unusual in uremic patients due to the concomitant hyperphosphatemia. This case study reports a 56-year-old woman on continuous ambulatory peritoneal dialysis (CAPD) therapy who was admitted for peritonitis. Ileus and diarrhea developed during admission; enteral feeding was given initially and then shifted to total parenteral nutrition (TPN) because of poor digestion. A lower concentration of phosphate was administered in the TPN formula initially due to high initial serum phosphate level. However, severe hypophosphatemia (0.3 mg/dL) developed on the second day after TPN supplementation. Continuous intravenous phosphate (total 6 mmol of phosphate) was supplied immediately. Unfortunately, the sudden onset of conscious loss and cardiac arrest happened on the third day of TPN. It should be emphasized that severe refeeding hypophosphatemia can also develop early in uremic patients with hyperphosphatemia.     

Superoxide Dismutase and Catalase Activities in Patients Undergoing Hemodialysis and Continuous Ambulatory Peritoneal Dialysis

In this study, superoxide dismutase (SOD) and catalase activities were determinated in the erythrocytes (RBC) from patients with chronic renal failure. The study included healthy subjects (n = 7), patients on hemodialysis (HD) using polyacrylonitrile-type dialysis membrane (before and after HD) (n = 10), patients on HD using cuprophane-type dialysis membrane (before and after HD) (n = 6), and patients on continuous ambulatory peritoneal dialysis (CAPD) (n = 11). A significant decrease in SOD activity was found in HD groups using polyacrylonitrile- or cuprophane-type dialysis membrane. SOD activity was found to increase in patients undergoing CAPD. We have found that CAT activity is higher in all the CRF groups in respect to the control: with polyacrylonitrile-type dialysis membrane, with cuprophane-type dialysis membrane, and in CAPD treatment.     

Changes in bone mineral content during long-term CAPD. Indication of a sex-dependent bone mineral loss

Change in bone mineral content (BMC) was evaluated in a longitudinaltrial comprising 12 women and 11 men with chronic renal diseasetreated with CAPD and 1-alpha-OH-D3 for 2 years. The patientsserved as their own controls. No patients were treated withsteroids. Median age was 54 and 60 years for women and men respectively.No significant difference in 1-alpha-OH-D3 dosage or serum 1,25(OH)₂D3was found between the genders in the study period. Bone mineral content at the distal radius deteriorated significantlyin the females with a median decrease of 12% over 2 years, i.e.approximately 6% per year (P<0.001 and 95% confidence limits8–20%). No significant change was noted in the males.There was no correlation between age and BMC change. Serum total alkaline phosphatase decreased nonsignificantlyin both sexes. Total serum calcium increased significantly (P<0.05)and serum phosphate decreased significantly (P<0.05) in thewomen. Serum albumin and body weight decreased significantlyin the males (P<0.01 and P<0.05) while no change was seenin the females. The demonstrated decrease in BMC in the female patients of approximately6% per year exceeds the commonly observed loss of 1–2%per year in healthy women when measured with the same technique.Tentatively, the severe mineral loss in the women could indicatea sex-hormone-related disturbance in bone metabolism of uraemicfemales.     

Correction of CAPD catheter displacement using alpha-replacement method

Background Malposition of the tip of a continuous ambulatory peritoneal dialysis (CAPD) catheter may impede a dialysis, and an invasive method, such as open or laparoscopic surgery, is necessary to correct its position. The alpha-replacement method is a nonsurgical procedure; however, the reported clinical experience has been limited. We thus reviewed our 19 cases to clarify the efficacy of this method.Method The alpha-replacement method was used in 19 patients [mean age, 50 ± 14 years old; male/female ratio, 13/6; duration of catheter insertion, 23.7 ± 23.9 months; total, 29 times in 19 patients (once in 13 patients, twice in 3, three times in 2, four times in 1 patient)]. All patients received a swan-neck J-type catheter. The procedure was carried out by using a special guidewire within 1–2 weeks after dislocation of the tips.Results The procedure was successfully performed 22 times in 14 patients (success rate, 78% in each performance). Required time was only 5–10min in most successful cases. No evident complications were encountered in any case.Conclusions The alpha-replacement method for a displaced CAPD catheter proved to be effective and safe.     

An in vitro evaluation of the glycation potential of a natural disaccharide,trehalose

Background. Glucose, an osmotic agent generally used in continuous ambulatory peritoneal dialysis (CAPD) dialysate, has a critical characteristic of forming advanced glycation endproducts (AGEs). We undertook this study to investigate whether a possible osmotic agent, trehalose, formed fewer AGEs than glucose. Methods. Hemoglobin (Hb), a counter-protein of AGE, was incubated in four kinds of medium; glucose-phosphate buffered saline (PBS), autoclaved glucose-PBS, trehalose-PBS, and autoclaved trehalose-PBS, for 3, 7, 14, and 30 days, respectively. Polymerization of the Hb molecule was detected by sodium dodecylsulfate-polyacrylamide gel electrophoresis (SDS-PAGE), and carboxymethylated Hb was detected by Western blotting, using specific mono-clonal antibody for carboxymethylated N-terminal valine-Hb (CMV-Hb). Results. PBS containing glucose showed bands of polymerized Hb molecule, a phenomenon which was markedly exaggerated by autoclaving. Likely, PBS containing glucose showed the formation of CMV-Hb in the long incubation of 30 days, and PBS containing autoclaved glucose showed accelerated formation of CMV-Hb in an incubation as short as 3 days. By contrast, PBS containing trehalose showed much less increase in a band of 30k Dalton and in CMV-Hb formation even in autoclaved medium. Conclusions. Our present in vitro study clearly showed the superior characteristic of trehalose to produce fewer AGEs. Based upon the results of this study, we propose that the application of trehalose should be considered for CAPD solution.     

家庭CAPD患者的健康教育

ＣＡＰＤ是指持续不卧床腹膜透析,它的问世使慢性肾功能衰竭患者的治疗进入了一个新的阶段。ＣＡＰＤ具有设备简单、操作易掌握、安全有效、对中分子物质的清除较ＩＰＤ和血透更有效、治疗费用低等优点,尤其是可训练患者在家里自己作透析,提高了患者的生活质量［１］。...     

居家连续非卧床腹膜透析患者自护的现状评估

目的 评估居家连续非卧床腹膜透析（Continuous Ambulatory Peritoneal Dialysis,CAPD)患的自护现状。方法 应用描述性研究设计,通过便利抽样,应用统一的观察记录表对30例出院需进行CAPD患的换液操作、自护知识及其居家环境进行实地观察评估。结果 50％的患能够自己进行CAPD操作。需要家人帮助进行的30％,由保姆操作的为20％。居家透析环境和设计基本能符合腹膜透析要求;能够掌握无菌操作的仅为37．0％;能够掌握腹膜炎知识的仅为20％。70％的研究对象有血压监测措施,有50％的患完全依从治疗方案。多数家庭成员能提供帮助。结论 居家CAPD患自护现状还存在许多问题,特别是无菌操作的观察,透析液的观察,并发症的观察等。     

Lead intoxication in an anuric patient: management by intraperitoneal EDTA

Treatment of lead intoxication with intravenous ethylene-diamine-tetra-acetic acid (EDTA) depends on the urinary excretion of chelated lead. This route of excretion was absent in a 48-year-old patient with childhood lead exposure and end stage renal failure who developed encephalopathy and a rapidly progressive neuropathy thought to be due to acute lead intoxication. Diagnosis was confirmed by lead chelation with EDTA and neurophysiological studies. EDTA was added by the patient to her chronic ambulatory peritoneal dialysis (CAPD) fluid each week and chelated lead excreted in the dialysate. Intraperitoneal administration of EDTA was 70% as efficient in removing lead as intravenous administration. Four months of home chelation therapy was associated with resolution of the encephalopathy but no improvement in the peripheral neuropathy.