Results of 12 years' treatment of chronic renal failure by dialysis and transplantation.

The survival of 305 patients with chronic renal failure treated at the Vancouver General Hospital by centre and home peritoneal dialysis, centre and home hemodialysis and cadaver renal transplantation over a 12-year period was analysed. There was decreasing survival with age except in patients undergoing home dialysis. Hypertension and analgesic nephropathy as primary causes of renal disease were associated with a poor prognosis. Hence age and diagnosis appear to be two of the main determinants of survival. Cardiovascular disease was the commonest cause of death but seven deaths were due to dialysis dementia. The results compare favourably with other published statistics.     

Long-term home hemodialysis in children

Experience with chronic hemodialysis as a definitive form of therapy is described for six children aged 11 to 15 years at the onset. Duration on dialysis in the home has been between one and 4½ years. All patients are alive and rehabilitated without serious complications. It is concluded that although transplantation is the most desirable form of treatment for children, long-term hemodialysis is an alternative acceptable second choice.     

Integrated dialysis and renal transplantation: small is beautiful.

Many patients in Britain with chronic renal failure suitable for renal replacement treatment die because not enough treatment facilities are available. Moreover, the number of renal transplants performed is insufficient to meet even present needs, so the number of patients on dialysis is rising. The integrated dialysis and transplant unit in Aberdeen, which has a population base much smaller than the average British unit, meets community needs for dialysis and transplantation. The problem of harvesting cadaver kidneys has been solved; the present supply has not only enabled the number of patients on dialysis to remain stable but has resulted in a net export of kidneys. The Aberdeen unit shows how estimated needs for chronic dialysis and renal transplantation may be met.     

Risk of mortality in patients with end-stage renal disease: the role of malnutrition and possible therapeutic implications

The mortality rate of dialysis patients is still considerably high. Beside the traditional risk factors, specific uremia-related risk factors are identified. Among them, hypoalbuminemia and malnutrition have a strong association to mortality in chronic dialysis patients. Various studies document a strong relation between reduced calorie and protein uptake and mortality in uremic patients. Several factors responsible for malnutrition in dialysis patients have been identified. These factors may be dialysis-associated, due to intercurrent illnesses or are associated with uremic complications (e.g. hyperparathyroidism, anemia, acidosis, etc.). Malnutrition is treatable and can be avoided by several means. Beside the increase in the dose of dialysis and adequate protein and calorie intake, intradialytic nutrition is an additional choice. The combination with specific drugs (e.g. growth hormone) may potentiate the success of the modified treatment modalities, particularly in patients who need nutritional support during an intercurrent illness. Further studies are required to measure the impact of for example growth hormone supplementation on mortality rate and quality of life in malnourished patients on chronic dialysis.     

The permanent Tenckhoff catheter for chronic peritoneal dialysis.

Over a 3 1/2-year period the permanent Tenckhoff catheter was used in 66 patients (32 men and 34 women) maintained on chronic peritoneal dialysis for periods from 2 1/2 to 36 1/2 months; 57 patients had dialysis in hospital for 20 to 24 hours twice a week and the other 9 had dialysis at home for 10 to 12 hours four times a week. While the Tenckhoff catheter was in place 14 patients received a renal transplant; for 13 who required peritoneal dialysis during the post-transplant phase the Tenckhoff catheter was used. In nine patients abdominal surgery did not interfere with the continuation of peritoneal dialysis via the Tenckhoff catheter. From a total of 5067 dialyses 40 positive cultures were reported (0.8%). Peritonitis was clinically evident on only 14 occasions (0.28%). Permanent catheter obstruction developed in 16 patients, in 11 of whom it was related to peritonitis. With the introduction of the permanent Tenckhoff catheter long-term peritoneal dialysis has become a simple, safe and painless procedure, suitable for virtually all patients who require maintenance dialysis.     

Home peritoneal dialysis: 3 years' experience in Toronto.

From November 1972 to November 1975, 52 males and 39 females aged 11 to 71 years were trained for home peritoneal dialysis. Dialysis was performed through a permanent catheter 4 nights a week. The first 11 patients used the manual system, exchanging 2 / of dialysate solution every 50 to 60 minutes. Subsequently 73 patients used the automatic cycler and commercially available dialysate and 7 patients used Tenckhoff''s reverse osmosis peritoneal dialysis machine. The average duration of training was 15, 11.6 and 15 dialysis days, respectively, for the three methods. For the 83 patients followed up, the average duration of home dialysis was 8.3 months (range, 0.5 to 33 months); the total number of dialyses at home was 10 571. Ten received a transplant, 20 were transferred to hospital peritoneal dialysis or hemodialysis, 8 died and 48 continued with home dialysis. Twenty-three patients had a total of 33 episodes of peritonitis, an incidence of 27.7% among the patients in the program for up to 3 years or 0.3% among all the dialyses. By November 1975, 46 patients had returned to their predialysis lifestyle, 18 were working part-time, 10 were able to work but were not doing so, and 9 were unable to work or care for themselves.     

Impact of Weaning from Acute Dialytic Therapy on Outcomes of Chronic Kidney Disease following Urgent-Start Dialysis

Discontinuation of acute, unplanned dialysis is always an important therapeutic goal in dialysis-requiring patients with existing chronic kidney disease. Only a limited proportion of patients could be weaned off dialysis and remained dialysis-free. Here we performed a multicenter, observational study to investigate factors associated with successful weaning from acute dialysis, and to explore the potential impact of weaning itself on outcomes of patients with chronic kidney disease following urgent-start dialysis. We recruited 440 chronic kidney disease patients with a baseline estimated glomerular filtration rate <45 ml/min per 1/73 m2, and used propensity score-adjusted Cox regression analysis to measure the effect of weaning from acute dialysis on death during the index hospitalization and death or readmission after discharge. Over 2 years, 64 of 421 (15.2%) patients who survived >1 month died, and 36 (8.6%) were removed from dialysis, with 26 (6.2%) remaining alive and dialysis-free. Logistic regression analysis found that age ≧ 65 years, ischemic acute tubular necrosis, nephrotoxic exposure, urinary obstruction, and higher predialysis estimated glomerular filtration rate and serum hemoglobin were predictors of weaning off dialysis. After adjustment for propensity scores for dialysis weaning, Cox proportional hazards models showed successful weaning from dialysis (adjusted hazard ratio 0.06; 95% confidence interval 0.01 to 0.35), along with a history of hypertension and serum albumin, were independent protectors for early death. Conversely, a history of stroke, peripheral arterial disease and cancer predicted the occurrence of early mortality. In conclusion, this prospective cohort study shows that compared to patients with chronic kidney disease who became end-stage renal disease after acute dialysis, patients who could be weaned off acute dialytic therapy were associated with reduced risk of premature death over a 2-year observation period.     

Successful treatment of middle aged and elderly patients with end stage renal disease.

Many patients over the age of 55 with end stage renal disease in the United Kingdom are denied dialysis or transplantation. Although the reasons are complex, anticipation of a poor prognosis for these patients might explain why most British renal units impose an arbitrary age limit on the acceptance of patients for treatment. A study was therefore conducted to examine the prognosis and quality of life of 84 patients (mean age 59.6 years, range 55-72) accepted into our renal replacement programme from the beginning of 1975. The five year survival of the patients was 62.0% with 78.1% of the survivors either having successful transplants or caring for themselves using home haemodialysis or continuous ambulatory peritoneal dialysis. The results show that in terms of survival, economics, and rehabilitation it is both feasible and reasonable to treat middle aged and elderly patients with end stage renal disease. These patients should therefore not be denied dialysis or transplantation on the basis of age alone, and the lack of resources and other factors that allow this state to persist in Britain should be rapidly redressed.     

Renal Dialysis Center Operational Plans

The Southern California region has available a Renal-Dialysis Center at the University of Southern California School of Medicine and the Los Angeles County General Hospital. The center is prepared to carry out dialysis, transplantation, research and education in nephrology.Patient selection for dialysis will be randomized among optimum candidates.The high cost of dialysis per patient might be reduced through home dialysis and by successful homotransplantation. The center plans to arrange transplantation of cadaver kidneys matched by tissue typing to a recipient undergoing hemodialysis. Such an approach will keep a constant turnover of patients and will help in research efforts toward better understanding of problems in nephrology.     

Preventive SNP–SNP interactions in the mitochondrial displacement loop (D-loop) from chronic dialysis patients

Chronic dialysis association study involving individual single nucleotide polymorphisms (SNPs) in the mitochondrial displacement loop (D-loop) has previously been reported. However, possible SNP–SNP interactions for SNPs in the D-loop which could be associated with a reduced risk for chronic dialysis were not investigated. The purpose of this study was to propose an effective algorithm to identify protective SNP–SNP interactions in the D-loop from chronic dialysis patients. We introduce ISGA that uses an initialization strategy for genetic algorithms (GA) to improve the computational analysis for protective SNP–SNP interactions. ISGA generates genotype patterns with combined SNPs (SNP barcodes) for chronic dialysis. Using our previously reported 77 SNPs in the D-loop, the algorithm-generated protective SNP barcodes for chronic dialysis were evaluated. ISGA provides the SNP barcodes with the maximum frequency differences of occurrence between the cases and controls. The identified SNP barcodes with the lowest odds ratio (OR) values were regarded as the best preventive SNP barcodes against chronic dialysis. The best ISGA-generated SNP barcodes (two to nine SNPs) are more closely associated with the prevention of chronic dialysis when more SNPs are chosen (OR = 0.64 to 0.32; 95% confidence interval = 0.882 to 0.198). The cumulative effects of SNP–SNP interactions were more dominant in ISGA rather than in GA without the initialization strategy. We provide a fast identification of chronic dialysis-associated protective SNP barcodes and demonstrate that the SNP–SNP interactions may have a cumulative effect on prediction for chronic dialysis.     

Factors Associated with Unplanned Dialysis Starts in Patients followed by Nephrologists: A Retropective Cohort Study

The number of patients starting dialysis is increasing world wide. Unplanned dialysis starts (patients urgently starting dialysis in hospital) is associated with increased costs and high morbidity and mortality. Risk factors for starting dialysis urgently in hospital have not been well studied. The primary objective of this study was to identify risk factors for unplanned dialysis starts in patients followed in a multidisciplinary chronic kidney disease (CKD) clinic. We performed a retrospective cohort study of 649 advanced CKD patients followed in a multidisciplinary CKD clinic at a tertiary care hospital from January 01, 2010 to April 30, 2013. Patients were classified as unplanned start (in hospital) or elective start. Multivariable logistic regression was used to identify variables associated with unplanned dialysis initiation. 184 patients (28.4%) initiated dialysis, of which 76 patients (41.3%) initiated dialysis in an unplanned fashion and 108 (58.7%) starting electively. Unplanned start patients were more likely to have diabetes (68.4% versus 51.9%; p = 0.04), CAD (42.1% versus 24.1%; p = 0.02), congestive heart failure (36.8% versus 17.6%; p = 0.01), and were less likely to receive modality education (64.5% vs 89.8%; p < 0.01) or be assessed by a surgeon for access creation (40.8% vesrus78.7% p < 0.01). On multivariable analysis, higher body mass index (OR 1.07, 95% CI 1.02, 1.13), and a history of congestive heart failure (OR 2.41, 95% CI 1.09, 5.41) were independently associated with an unplanned start. Unplanned dialysis initiation is common among advanced CKD patients, even if they are followed in a multidisciplinary chronic kidney disease clinic. Timely education and access creation in patients at risk may lead to lower costs and less morbidity and mortality.     

Comparison of Coil and Kiil Dialysers

To assess the comparative efficiency, safety, and cost of maintenance dialysis, the treatment of 13 patients with a Kiil dialyser (representing 1,477 hospital and 735 home dialyses) was compared with that of 11 patients using a coil dialyser (898 hospital and 396 home dialyses). Kiil and coil dialysers proved equally satisfactory from a medical standpoint and equally acceptable to the patients. The capital costs of home dialysis were considerably reduced without any threat to safety or efficiency. The running costs of coil dialysers approximate to those of Kiil dialysers.     

Composition of the domestic water supply and the incidence of fractures and encephalopathy in patients on home dialysis.

Of the 202 patients undergoing home dialysis in the Trent region, 11 developed dialysis encephalopathy, 21 suffered spontaneous fractures, and 36 who had undergone dialysis for over four years had neither of these complications. Because the incidence of complications seemed to be unevenly distributed the water supplies were analysed. Water supplied to the homes of the patients with fractures or encephalopathy contained significantly less calcium and fluorine and significantly more aluminium and manganese than that piped to patients without these complications. The high aluminium concentrations in the bone of patients with encephalopathy was confirmed, but aluminium concentrations in the brains from three patients with encephalopathy were not increased. Patients who undergo dialysis in areas where water contains high aluminium concentrations should be supplied with deionisers.     

Inhibitory effects of beta 2-microglobulin on in vitro calcification of osteoblastic cells

Elevated levels of aluminum and beta 2-microglobulin have been demonstrated in chronic dialysis patients. The role of aluminum in the pathogenesis of renal osteodystrophy has also been shown. We report on the effects of beta 2-microglobulin on calcification in vitro using osteoblastic cells, clone MC3T3-El. At concentrations comparable to those in plasma of chronic dialysis patients, both beta 2-microglobulin and aluminum suppressed calcification while collagen synthesis and alkaline phosphatase activity were maintained. These observations may be related to the impaired bone mineralization frequently observed in chronic dialysis patients.     

Blood level of free serotonin, catecholamines and the renin-angiotensin-aldosterone system in patients with primary hypertension]

Two subgroups of patients were selected out of those dialysed for chronic renal failure. Group A included patients without arterial hypertension before dialysis, and group B patients with arterial hypertension before dialysis. Blood endogenous digoxin-like substance (DLS) has been assayed. Its blood levels were not increased in hypertensive patients either before or after dialysis. No correlation was found between DLS and mean arterial pressure in the whole group of patients with chronic renal failure. The obtained results do not suggest that arterial blood pressure in patients with chronic renal failure is related to the presence of DLS in the blood.     

Chronic Homework in Emerging Borderlands of Healthcare

The task of caring for those with chronic illnesses has gained a new centrality in health care at a global level. We introduce the concept of “chronic homework” to offer a critical reflection on the treatment of chronic illnesses in three quite different national and local contexts: Uganda, Denmark, and the United States. A major challenge for clinicians, patients, and family caregivers is how to navigate the task of moving health care from clinic to home. By “chronic homework,” we refer to the work patients and families are expected to carry out in their home contexts as part of the treatment of chronic conditions. Families and patients spend time receiving training by clinical experts in the various tasks they are to do at home. While this “colonization” of the popular domain could easily be understood from a Foucauldian perspective as yet another emerging mode of governmentality, this a conceptualization can oversimplify the way specific practices of homework are re-imagined and redirected by patients and significant others in their home surroundings. In light of this re-invention of homework in local home contexts, we foreground another conceptual trope, describing chronic homework as a borderland practice.     

The Effects of Peritoneal Dialysis on the Physiological Disposition of Oxacillin,Ampicillin and Tetracycline in Patients with Renal Disease

Seven patients with acute or chronic renal failure who were receiving intermittent peritoneal dialysis and who required parenteral oxacillin, ampicillin or tetracycline were studied to determine the disposition of these antibiotics in severe renal disease and the effects of peritoneal dialysis. While severe renal impairment markedly prolongs persistence in the serum of ampicillin and tetracycline, there is little effect on oxacillin. Whereas required doses of ampicillin and tetracycline are lower in the presence of severe renal disease, oxacillin should be given in doses equivalent to those used for patients with normal renal function. Peritoneal dialysis does not alter these dosage requirements.Four patients receiving ampicillin or tetracycline in the infusing solution during peritoneal dialysis were studied to determine the amount of systemic absorption. Local prophylaxis alone is not achieved with this method of administration, since small amounts of both antibiotics are absorbed systemically from the infusing solution. The serum concentration of tetracycline attained is inadequate for treatment of systemic infections but is probably significant, with repeated use in intermittent dialysis, in causing adverse effects. Tetracycline should be abandoned in the local prophylaxis of peritonitis during peritoneal dialysis.     

A Survey of Chronic Renal Failure in Southeastern Ontario

A survey of all physicians in southeastern Ontario was conducted to determine the potential number of patients with chronic uremia who would be candidates for a chronic dialysis program. Four hundred and sixty-four replies were received from the 1391 physicians who received the questionnaire. With the data provided it was calculated that the period prevalence rate of persons suffering from chronic uremia in the area surveyed ranged from 2.2 to 3.3/100,000 population. On the basis of these figures it was estimated that dialysis facilities might be required for six new patients each year in this area.     

Pulmonary hypertension in patients with chronic kidney disease on dialysis and without dialysis: results of the PEPPER-study

Pulmonary hypertension (PH) is common in patients with dialysis-dependent chronic kidney disease and is an independent predictor of mortality. However, specific hemodynamics of the pulmonary circulation, changes induced by hemodialysis and characterization into pre- or postcapillary PH have not been evaluated in patients with chronic kidney disease. We assessed consecutive patients with end-stage chronic kidney disease in WHO FC ≥ II with dyspnea unexplained by other causes on hemodialysis (group 1, n = 31) or without dialysis (group 2, n = 31) using right heart catheterization (RHC). In group 1, RHC was performed before and after dialysis. In end-stage chronic kidney disease, prevalence of precapillary PH was 13% (4/31), and postcapillary PH was discovered in 65% (20/31). All four cases of precapillary PH were unmasked after dialysis. In group 2, two cases of precapillary PH were detected (6%), and postcapillary PH was diagnosed in 22 cases (71%). This is the first study examining a large cohort of patients with chronic kidney disease invasively by RHC for the prevalence of PH. The prevalence of precapillary PH was 13% in patients with end-stage kidney disease. That suggests careful screening for precapillary PH in this selected patient population. RHC should be performed after hemodialysis.     

Sequence-based polymorphisms in the mitochondrial D-loop and potential SNP predictors for chronic dialysis

Background

The mitochondrial (mt) displacement loop (D-loop) is known to accumulate structural alterations and mutations. The aim of this study was to investigate the prevalence of single nucleotide polymorphisms (SNPs) within the D-loop among chronic dialysis patients and healthy controls.

Methodology and Principal Findings

We enrolled 193 chronic dialysis patients and 704 healthy controls. SNPs were identified by large scale D-loop sequencing and bioinformatic analysis. Chronic dialysis patients had lower body mass index, blood thiols, and cholesterol levels than controls. A total of 77 SNPs matched with the positions in reference of the Revised Cambridge Reference Sequence (CRS) were found in the study population. Chronic dialysis patients had a significantly higher incidence of 9 SNPs compared to controls. These include SNP5 (16108Y), SNP17 (16172Y), SNP21 (16223Y), SNP34 (16274R), SNP35 (16278Y), SNP55 (16463R), SNP56 (16519Y), SNP64 (185R), and SNP65 (189R) in D-loop of CRS. Among these SNPs with genotypes, SNP55-G, SNP56-C, and SNP64-A were 4.78, 1.47, and 5.15 times more frequent in dialysis patients compared to controls (P<0.05), respectively. When adjusting the covariates of demographics and comorbidities, SNP64-A was 5.13 times more frequent in dialysis patients compared to controls (P<0.01). Furthermore, SNP64-A was found to be 35.80, 3.48, 4.69, 5,55, and 4.67 times higher in female patients and in patients without diabetes, coronary artery disease, smoking, and hypertension in an independent significance manner (P<0.05), respectively. In patients older than 50 years or with hypertension, SNP34-A and SNP17-C were found to be 7.97 and 3.71 times more frequent (P<0.05) compared to patients younger than 50 years or those without hypertension, respectively.

Conclusions and Significance

The results of large-scale sequencing suggest that specific SNPs in the mtDNA D-loop are significantly associated with chronic dialysis. These SNPs can be considered as potential predictors for chronic dialysis.