Male Fertility in Uremia: Restoration by Renal Allografts

Spermatogenesis has been studied in eight chronic uremic patients on hemodialysis and in 11 recipients of well-functioning renal allografts. Sexual activity, semen analysis and testicular biopsy are abnormal in chronic uremic patients. Spermatogenesis remains “arrested” even when uremia is well controlled by intermittent hemodialysis. Marked improvement occurs in sexual performance, semen analysis and testicular biopsy after successful kidney transplantation. Immunosuppressive treatment, at dosages used six months after allografting, does not appear to affect male fertility adversely.     

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 Clinical Evaluation of Peritoneal Dialysis

A total of 18 peritoneal dialyses were performed on 14 patients at the Hamilton Civic Hospital over a period of 11 months. Nine of these patients were in uremia, four had non-nephrotoxic intoxication, and one had hepatic coma. Patients with chronic uremia may present with acute renal failure which may be treated by peritoneal dialysis with resultant significant prolongation of life. A decreased mortality rate might be expected in acute renal failure if dialysis is implemented before the classical picture of uremia develops. Many non-nephrotoxic intoxicating substances are readily dialysable. Considerable benefit to the patient and decreased time in hospital may result from the use of this procedure in cases of intoxication with such substances. Peritoneal dialysis may be of value in treatment of intractable congestive heart failure. This procedure may eventually provide another means of treating hepatic coma.     

Peritoneal Dialysis in Acute and Chronic Renal Failure

Clinical experience with peritoneal dialysis in eight cases of acute and four cases of chronic renal failure is presented. Seven of the acute cases survived but in some of these hemodialysis was also employed. The relatively simple technique of peritoneal dialysis was found to be effective, although slower than hemodialysis. In three of the cases it was selected in preference to hemodialysis. Its main advantages are that it does not require elaborate arrangements, or the use of blood or anticoagulants. The authors conclude that when the peritoneum is intact the method can be employed whenever the use of a temporary kidney substitute is indicated.     

Volatile Organic Compounds in Uremia

Background

Although “uremic fetor” has long been felt to be diagnostic of renal failure, the compounds exhaled in uremia remain largely unknown so far. The present work investigates whether breath analysis by ion mobility spectrometry can be used for the identification of volatile organic compounds retained in uremia.

Methods

Breath analysis was performed in 28 adults with an eGFR ≥60 ml/min per 1.73 m², 26 adults with chronic renal failure corresponding to an eGFR of 10–59 ml/min per 1.73 m², and 28 adults with end-stage renal disease (ESRD) before and after a hemodialysis session. Breath analysis was performed by ion mobility spectrometryafter gas-chromatographic preseparation. Identification of the compounds of interest was performed by thermal desorption gas chromatography/mass spectrometry.

Results

Breath analyses revealed significant differences in the spectra of patients with and without renal failure. Thirteen compounds were chosen for further evaluation. Some compounds including hydroxyacetone, 3-hydroxy-2-butanone and ammonia accumulated with decreasing renal function and were eliminated by dialysis. The concentrations of these compounds allowed a significant differentiation between healthy, chronic renal failure with an eGFR of 10–59 ml/min, and ESRD (p<0.05 each). Other compounds including 4-heptanal, 4-heptanone, and 2-heptanone preferentially or exclusively occurred in patients undergoing hemodialysis.

Conclusion

Impairment of renal function induces a characteristic fingerprint of volatile compounds in the breath. The technique of ion mobility spectrometry can be used for the identification of lipophilic uremic retention molecules.     

Continuous ambulatory peritoneal dialysis: no longer experimental.

Many patients with end-stage renal disease have now been maintained for 5 years or more with continuous ambulatory peritoneal dialysis (CAPD). Viewed initially as an experimental alternative to be used only when hemodialysis was not feasible, CAPD is now seen as the treatment of choice in an increasing number of situations. CAPD is suitable for self-care. The main concern in the early years--peritonitis--is now less frightening and less frequent (one episode occurring every 18 patient-months as compared with every 8 initially), and this has allowed chronic complications of CAPD, such as malnutrition and loss of the peritoneum''s capacity for ultrafiltration, to come to light. As would be expected, among patients of advanced age and those who have heart disease or diabetes, survival rates tend to be lower than among other CAPD patients. However, hypertension seems to be more easily controlled, pre-existing anemia can be significantly ameliorated, and young children grow more normally than they do with hemodialysis. Diabetes-related changes in vision stabilize in most CAPD patients, and control of the blood glucose level is good; insulin is administered intraperitoneally. CAPD is thus showing itself to be a feasible form of long-term treatment for end-stage renal disease.     

USE OF THE ARTIFICIAL KIDNEY—Its Place in the Treatment of Acute Renal Failure

Of 57 patients with severe, but potentially reversible, acute renal failure who were observed during a recent four-year period, some had dialysis with an artificial kidney and some did not.Twenty survived with the standard “conservative” management alone; 19 survived with a combination of “conservative” and “intensive” (that is, artificial kidney) treatment; 18 patients died.One error that was made in the management of all 18 patients who died, was excessive delay in the use of the artificial kidney.Hemodialysis should be used whenever serious electrolyte abnormality exists, whenever the blood urea nitrogen exceeds 150 mg. per 100 cc. or whenever clinical signs of uremia first appear. One or more of these indications will usually, but not always, become evident between the fifth and the eighth day of virtual anuria.     

Acute and chronic influence of hemodialysis according to the membrane used on phagocytic function of neutrophils and monocytes and pro-inflammatory cytokines production in chronic renal failure patients

This work evaluated the phagocytic capacity of monocytes and neutrophils, and tumor necrosis factor-alpha, interleukin 6, 1 and 8 serum levels in chronic renal failure patients under peritoneal dialysis and hemodialysis treatment, compared with chronic renal failure patients without dialysis treatment and healthy individuals, in order to contribute to a better understanding of the action of these therapies on the evolution of chronic renal failure patients. All patients with chronic renal failure (under dialysis or not) showed decreased phagocytic capacity of neutrophils and monocytes. All those in hemodialysis (cellulose acetate or polysulfone membranes) showed a decreased phagocytic capacity. The phagocytic index for neutrophil was 13 times lower than that of the control group for both membranes, whereas for monocytes, only those using polysulfone membrane showed a significant decrease of 4.9 times in phagocytic capacity. There was an acute stimulation of the phagocytosis by neutrophils after a single session of dialysis with both types of membrane, while only cellulose acetate membrane decreased the phagocytic index of monocytes after the hemodialysis session. Patients using cellulose acetate showed a chronic increase in tumor necrosis factor-alpha serum levels, while those using polysulfone showed a chronic increase in interleukin 6. After a single hemodialysis procedure, no acute effect of the treatment on tumor necrosis factor-alpha and interleukin 6 levels was identified. The decreased phagocytic function of neutrophils and monocytes may account for the high levels of susceptibility of chronic renal failure patients to infections with pyogenic bacteria and tuberculosis. Furthermore, inflammatory activity may occur with both types of membrane studied, suggesting that it will be useful for these patients to evaluate some anti-inflammatory or anti-cytokine therapies against tumor necrosis factor-alpha and interleukin 6, in order to avoid cardiovascular complication.     

Molecular pathways in peritoneal fibrosis

Peritoneal dialysis (PD) is a renal replacement therapy for patients with end-stage renal disease that is equivalent to hemodialysis with respect to adequacy, mortality, and other outcome parameters, yet providing superior quality-of-life measures and cost savings. However, long-term usage of the patient's peritoneal membrane as a dialyzer filter is unphysiological and leads to peritoneal fibrosis, which is a major factor of patient morbidity and PD technique failure, resulting in a transfer to hemodialysis or death. Peritoneal fibrosis pathophysiology involves chronic inflammation and the fibrotic process itself. Frequently, inflammation precedes membrane fibrosis development, although a bidirectional relationship of one inducing the other exists. This review aims at highlighting the histopathological definition of peritoneal fibrosis, outlining the interplay of fibrosis, angiogenesis and epithelial-to-mesenchymal transition (EMT), delineating important fibrogenic pathways involving Smad-dependent and Smad-independent transforming growth factor-β (TGF-β) as well as connective tissue growth factor (CTGF) signaling, and summarizing historic and recent studies of inflammatory pathways involving NOD-like receptor protein 3 (NLRP3)/interleukin (IL)-1β, IL-6, IL-17, and other cytokines.     

The arthropathy of maintenance intermittent peritoneal dialysis.

Among 61 patients undergoing maintenance peritoneal dialysis for an average of 20 months, 13 (21%) had a history of attacks of acute arthritis and 19 (31%) were found to have tender and often swollen joints. Deposits of calcium pyrophosphate dihydrate crystals in articular cartilage were identified in four patients and inflammation probably induced by hydroxyapatite crystals was noted in one. Periarticular calcification was observed in 12 patients and subperiosteal resorption of the phalanges in 20. The average calcium X phosphorus product was significantly higher (P < 0.025) in patients with a history of attacks of acute arthritis or with inflamed joints (58 +/- 12) than in those without (50 +/- 12). In the 19 patients whose treatment was changed to continuous ambulatory peritoneal dialysis there was a significant decrease (P < 0.025) in the calcium X phosphorus product but not in the proportion of patients with attacks of acute arthritis or with inflamed joints. The results indicate that articular complications are frequent among patients undergoing maintenance peritoneal dialysis and may be more common than with long-term hemodialysis.     

Substitutes for renal function. Technical trends and logistics of treatment

In France about 50 new patients per million of inhabitants per year with end stage renal disease (ESRD) require treatment with dialysis and/or transplantation. For the last few years new dialysis methods as hemofiltration and continuous ambulatory peritoneal dialysis have been extended. It is too early to predict what will be the role and the future of such methods as compared to hemodialysis, the gold standard. Appropriate logistics of treatment of ESRD rely on an integrated dialysis-transplantation program. In France the percentage of some modes of therapy, including home dialysis and transplantation, should be increased.     

Survival of patients treated for end-stage renal disease by dialysis and transplantation.

The results of treatment in 213 patients with end-stage renal disease who underwent hemodialysis, peritoneal dialysis or transplantation, or a combination, between 1962 and 1975 were analysed. Comparison by censored survival analysis showed significantly better (P less than 0.01) patient survival with the integrated therapy of dialysis and transplantation than with either form of dialysis alone. There was no significant difference in survival of males and females but survival at the extremes of age was poorer. Analysis of survival by major cause of renal failure indicated best survival in patients with congenital renal disease. Graft and patient survival rates at 1 year after the first transplantation were 42% and 69%. The major cause of death in this series was vascular disease but infection was responsible for 50% of deaths after transplantation. While integration of dialysis with transplantation produces best patient survival, this course is possible only when sufficient cadaver kidneys are available.     

Genotoxicity evaluation in chronic renal patients undergoing hemodialysis and peritoneal dialysis, using the micronucleus test

Patients with chronic renal disease have an increased incidence of cancer. It is well known that long periods of hemodialysis treatment are linked to DNA damage due to oxidative stress. This genotoxic effect may cause the loss of chromosome fragments, or even entire chromosomes, which form micronuclei after cell division, and can be detected by the micronucleus test. In the present case-control study, we evaluated the genotoxic effect of hemodialysis treatment in 20 patients undergoing hemodialysis, and 20 subjected to peritoneal dialysis, matched for gender and age with 40 controls. Genetic damage was assessed by examining the frequency of micronuclei in 2000 exfoliated buccal cells per individual. Our results revealed that patients undergoing hemodialysis treatment have a significantly higher frequency of micronucleated cells (MNC; 5.60 +/- 5.31) compared to control subjects (1.50 +/- 2.01, p < 0.01). Interestingly, the same was not observed for the peritoneal dialysis patients who showed no significant differences in MNC (2.85 +/- 2.96) frequency compared to control individuals (3.25 +/- 3.85). In addition, we evaluated the possible association between creatine levels, smoking, alcohol intake, age, duration of treatment, and incomes of the individuals (separately analyzed according to their gender) and the frequency of micronuclei. The results reported here indicate that the duration of treatment is the only factor associated with increased MNC frequency among hemodialysis patients (Spearman coefficient of 0.414, p = 0.01). The number of MNC found in individuals with six years or less of treatment was significantly lower (2.91 +/- 2.74) compared to patients with seven or more years of treatment (8.89 +/- 5.96, p < 0.05). Overall, peritoneal dialysis may be a safer choice of treatment, but further studies need to be performed to investigate the risks and benefits of both treatments.     

Proteomics in extracorporeal blood purification and peritoneal dialysis

Extracorporeal blood purification and peritoneal dialysis are widely used in renal replacement therapy for patients with end-stage renal disease (ESRD) and acute kidney injury (AKI). Additionally, extracorporeal blood purification can be used also for treatment of non-renal disorders to remove endogenous or exogenous toxins from the blood circulation. Efforts have been made to characterize these toxins removed by diffusion (dialysis), convection (ultrafiltration), and/or adsorption (toxins are adsorbed onto the dialysis membrane and are thus removed) using different types of dialysis membrane. This review summarizes important findings obtained from recent proteomic studies applied to extracorporeal blood purification and peritoneal dialysis in settings of ESRD, AKI and hepatic failure.     

NONOBSTRUCTIVE OLIGURIA—Differential Diagnosis

A review is presented of ten years'' experience with the differential diagnosis of oliguria, utilizing the standard tests of renal function with the addition of the phenolsulfonphthalein excretion and urinary chloride measurements. The histories of 60 patients seen in consultation because of 24-hour urinary volume of less than 400 ml were studied in order to clarify the value of these tests. Particular attention was given to the postoperative “dilution state,” the oliguria of which tends to mimic that of “acute tubular necrosis.”In only 25 per cent of the 60 cases was “acute tubular necrosis” responsible for the oliguria. In the remaining 75 per cent of patients, oliguria was due either to the effects of simple dehydration without tubular damage, or to tubular dysfunction on a physiologic rather than an organic basis. Thus, three out of four patients with oliguria required aggressive and specific fluid-electrolyte therapy, often with the intensive use of potassium. One out of four required the opposite in therapy—controlled dehydration without added potassium and, on occasion, peritoneal or extracorporeal dialysis, in order to allow six to ten days for tubular repair.     

血液透析和腹膜透析对终末期肾病患者预后的影响及其安全性比较

目的:分析和比较血液透析和腹膜透析终末期肾病患者预后的影响及其安全性。方法:选取2010年1月至2016年4月本医院收治的透析患者246例作为研究对象,将其分为血液透析组和腹膜透析组,比较两组患者治疗后的生存情况及并发症的发生情况。结果:两组患者死亡原因是心力衰竭、消化道出血、重度感染、脑梗死,两组的病死率及死因构成比较差异均无统计学意义(P0.05)。腹膜透析组患者1年、3年、5年生存率均显著高于血液透析组(P0.05),两组患者7年生存率比较差异无统计学意义(P0.05)。首次透析年龄超过60岁的终末期肾病患者中,腹膜透析组1年、3年、5年、7年生存率均显著低于血液透析组(P0.05)。血液透析组心力衰竭、动静脉内瘘闭塞发生率显著高于腹膜透析组(P0.05),腹膜透析组腹膜炎的发生率显著高于血液透析组(P0.05),血液透析组总并发症发生率明显高于腹膜透析组(P0.05)。结论:血液透析和腹膜透析各有优缺点,对终末期肾病患者应个体化选择透析方式,减少并发症,提高生活质量及生存率。     

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.     

Increased Risk of Acute Pancreatitis in Patients with Chronic Hemodialysis: A 4-Year Follow-Up Study

Background

The risk of acute pancreatitis in patients on long-term peritoneal dialysis is higher as compared to the general population. However, the relationship between long-term hemodialysis and acute pancreatitis has never been established.

Objectives

We investigated the incidence of acute pancreatitis among patients on long-term hemodialysis in Taiwan to evaluate if there is a higher risk of acute pancreatitis in comparison to the general population.

Methods

We utilized a National Health Insurance (NHI) claims data sample containing one million beneficiaries. We followed all adult beneficiaries from January 1, 2007 until December 31, 2010 to see if they had been hospitalized for acute pancreatitis during this period. We further identified patients on chronic hemodialysis and compared their risk of acute pancreatitis with the general population.

Results

This study included 2603 patients with long-term hemodialysis and 773,140 patients without hemodialysis. After controlling for age, gender, Charlson Comorbidity Index Score, geographic region, socioeconomic status and urbanization level, the adjusted hazard ratio was 3.44 (95% Confidence interval, 2.5–4.7).

Conclusions

The risk of acute pancreatitis in patients on long-term hemodialysis is significantly higher in comparison to the general population.     

A large regional hospital's experience with treatment of end-stage renal disease.

During the first 10 years of the treatment program for end-stage renal disease at the Saint John (New Brunswick) Regional Hospital 164 adults were treated by hemodialysis (with or without renal transplantation, performed outside of the province) or peritoneal dialysis. The primary causes of renal disease were not significantly different in men and women except for glomerulonephritis, which was twice as common in men as in women. Life-table analysis showed that the younger transplant recipients had the highest survival rate, but that the prognosis was almost as good among the much older patients who received continuous ambulatory peritoneal dialysis. Probably because they tended to be younger and their renal disease was caused by less threatening conditions, men survived longer than women. The survival rates were significantly related to the primary cause of the renal disease; patients with diabetes or systemic disease had the worst prognosis. Overall, these results compare well with those obtained in major university centres.     

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.