Haemodialysis Cost Reduction by Artificial Kidney Storage: A Simple Effective Technique for Re-use of Coil Kidneys

A simple method of storing and re-using coil dialysers was used in over 700 dialysers without serious complications but mantaining the efficiency of the dialyser. The method can reduce the expense of coil and tubing by as much as 70%, while the total cost of home or hospital dialysis can be reduced by as much as 15 to 25% even when the coil is re-used only once. Coils were re-used as many as 14 times, making the potential reduction in cost much larger. This technique deserves further evaluation in both hospital and home dialysis programmes.     

A Study of Membrane Permeability in Haemodialysis

The efficiency of haemodialysis has been determined when a Watson-Marlow (Kiil) dialyser was used repetitively without changing the membranes. Dialysis efficiency was assessed from the clearance of creatinine and of urea from the patient''s blood. No significant deterioration in dialysis could be detected in six dialyses through the same membrane. Leaving the dialyser unit for up to eight hours before washing it out after the completion of each dialysis did not appear to have any effect on dialysis efficiency.It was concluded that repetitive haemodialysis through the same membranes is possible, but careful monitoring of the patient to assess suitability for such treatment, and subsequently at each dialysis, is essential.     

Meltec Multipoint Haemodialyser

The 0·61 m² Meltec Multipoint dialyser has a performance 25% better than the standard Kiil at clinically important blood flows despite its smaller surface area. With low priming and uptake volumes, adequate ultrafiltration, and a negligible residual blood volume, it is compact and can be assembled by one person. It should replace the Kiil as the standard against which new dialysers are measured.     

Haemostatic Changes during Dialysis Associated with Thrombus Formation on Dialysis Membranes

Platelet counts, coagulation factors, and the fibrinolytic system were studied in seven regular dialysis patients during the course of haemodialysis by parallel flow (Gambro-Alwall) and coil (Travenol Ultra-Flo 100) dialysers. Significant falls in the patients'' platelet counts and rises in their factor V levels were found with both dialysis systems. The changes were more pronounced over the course of a Gambro-Alwall dialysis, when significant falls in the partial thromboplastin clotting time and in the plasminogen levels were also noted. These haemostatic changes were associated with the retention of platelets on the dialysis membranes and, in the case of the Gambro-Alwall dialyser, with the formation of platelet-fibrin thrombus. This thrombus formation may take place in spite of efficient heparin anticoagulation and may cause excessive blood loss to the regular dialysis patient.     

Pyrexial Reactions during Haemodialysis

The characteristics, circumstances, and treatment of 450 pyrexial reactions occurring in 468 patient-months over a period of two and a half years, using a warm single-pass Kiil system, were studied. There is a wide variation in severity of symptoms and morbidity. The incidence of pyrexial reactions has an epidemic pattern within the hospital unit. Patients on dialysis at home have reactions much less often than patients in hospital.Blood cultures taken from patients during each of the 450 reactions showed a growth on 38 occasions, but this was not significantly different from the incidence of positive cultures taken simultaneously from control patients during haemodialysis. Reactions were not correlated with bacterial growth from the blood compartment of the kidney before dialysis. There was no difference in incidence of reactions when using different types of equipment which were either a central tank distribution system with bedside monitors or chemically- or heat-sterilized individual proportioning pump systems. Reactions were also noted with the disposable coil kidney and recirculating single-pass (R.S.P.) system, but presented different features from those of the Kiil kidney.The incidence of reactions was not related to the albuminoid nitrogen content of the water supply. Reactions were not abolished by deionization of the tap-water.     

Bacteriological Studies of the Modified Kiil Dialyser

Bacterial proliferation in dialysis fluid during haemodialysis may be associated with rigors, hypotension, and bacteraemia. Investigations carried out in a period in which rigors were particularly common showed the source of bacteria to be parts of the gasket system of the Kiil dialyser, areas that are inaccessible to disinfectants.     

Disposable Membrane Insert for the Kiil Dialyser

The use of a presterilized, disposable, mesh-supported membrane envelope in the Watson Marlow Kiil dialyser results in a 12% improvement in urea and creatinine clearance. Priming volume, uptake volume, and ultrafiltration rate are unchanged. Residual blood volume remains small. Blood flow resistance is increased. The envelope therefore offers considerable advantages over conventional assembly for dialysis with a blood pump.     

Clinical Evaluation of a Disposable Artificial Kidney

The in-vivo performance of a new disposable parallel flow countercurrent type of artificial kidney has been compared with that of the modified four-layered Kiil dialyser. The dialysance of urea and endogenous creatinine in the former was significantly better than in the latter for similar blood flow rates, and, moreover, unlike the dialysance with the Kiil dialyser it continued to improve over 12 hours. Among 100 disposable artificial kidneys tested no failure occurred from blood leaks despite the use of high negative pressures in the dialysate compartment. No pyrogen reactions were observed.These new artificial kidneys were ready for use in less than one-seventh of the time taken to prepare the conventional Kiil dialyser. Other advantages are their low priming volumes, the lack of a pump in the blood line, and the reduced risk of infection.     

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.     

Evaluation of the EX-O3 Dialyser Cartridge

Fifty-five dialyses were performed using the EX-O3 dialyser cartridge. The performance of the dialyser in respect of urea, creatinine, phosphate, and uric acid dialysance is comparable to that of the Travenol Ultra-Flo 100 (cuprophane). It is rather more compact, is easy to operate, has minimal blood loss, and a low priming volume. Ultrafiltration was quite adequate and the dialyses were uncomplicated by side effects. A failure rate of 7% occurred but none of the patients lost any appreciable quantity of blood.     

Dialysance of Molecules of Different Size in Reused Kiil,Ab-Gambro,and Rh?ne-Poulenc Dialysers

Dialysances of urea, creatinine, ethylenediamine tetraacetic acid, and ouabain were determined in three different flat-bed dialysers during three successive uses on 15 patients. There were no untoward reactions. A significant decrease in dialysing efficiency was observed only with the Ab-Gambro dialyser, in which the dialysance of the small molecules decreased more than that of the large. This is thought to result from blood deposits on the membrane surface inhibiting exchange.     

Reuse of haemodialysis equipment: convenience and cost effectiveness.

The shortage of resources for providing renal replacement makes it essential to reduce revenue costs wherever possible. Assuming that haemodialysis is likely to remain a mainstay of renal replacement, a policy of reusing the expensive disposable dialysers and blood lines could offer substantial cost savings. Such reuse has been shown to be safe and to maintain efficiency, but it must also take account of convenience to the patient, especially those dialysing at home. A survey of patients treated with home dialysis shows that the rate of reuse of the complete extracorporeal circuit was highest for those patients who had automated reuse systems.     

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.     

Cephaloridine Serum Levels in Patients on Maintenance Haemodialysis

Cephaloridine serum half-life was determined in 11 patients undergoing maintenance haemodialysis. Three of them were anephric. The mean cephaloridine half-life was 10·4 hours. There was an inverse correlation between cephaloridine half-life and the duration of maintenance haemodialysis treatment. Reasons for this are discussed.The effect of haemodialysis with the Kiil dialyser on cephaloridine half-life was studied in three patients.Dosage recommendations for patients on maintenance haemodialysis are suggested.     

Effect of intraperitoneal furosemide administration on levels of +proteins+ in plasma and signs of their ability to be dialyzed during intermittent peritoneal dialysis]

The study aimed at evaluating an effect of intraperitoneal furosemide on plasma proteins such as albumins, globulins, IgG and IgA and their loss during dialysis. An experiment involved 18 patients with critical renal failure treated with intermittent peritoneal dialyses. Furosemide was administered intraperitoneally with dialysing fluid (40 mg/1) in a total dose of 240 mg. Each patient underwent 2 dialyses of 14 exchanges each. The first dialysis without furosemide served as a control of plasma protein loss during conventional dialysis with a fluid of 369 mOsm/kg at flow rate 2.4 l/hour. Furosemide was given during the second dialysis during three consecutive exchanges. An effect of furosemide on plasma proteins was compared with the results obtained before and after its administration. It was found that furosemide did not change plasma proteins levels and does not increase their loss during exchanges of dialysing fluid containing this drug; during dialysing fluid exchanges without furosemide some indices of IgG and IgA dialysis are significantly decreased due to an increase in ultrafiltration following furosemide cessation. It is important for the increase in intermittent peritoneal dialyses efficiency with the aid of furosemide that its short-term administration does not increase proteins loss during dialysis, if their molecular weight is not exceeding 69,000.     

Quinton-Scribner Cannulas for Hemodialysis—Review of Four Years' Experience

Data on a study group of 52 maintenance hemodialysis patients cannulated with Quinton-Scribner cannula in a four-year period were analyzed. The average period of dialysis was 11.8 months with either a pumped coil or a pumpless Kiil artificial kidney system. One hundred and forty-five cannulations were performed. The mean arterial cannula survival was 7.8 months and the mean venous cannula survival was 7.2 months. The exceptional longevity of cannula survival occurred despite the high incidence of atherosclerotic changes at operation and the advanced mean age (47 years) of the patients. The cannula longevity may be partially related to the technique used and to meticulous surgical care given the patient before and after cannulation.Complications from cannulation included two deaths, one from septic pulmonary embolism of Staphylococcus origin, and one from acute Pseudomonas endocarditis. A total of 36 infections of cannulas were recognized, the majority being due to Staphylococcus aureus, but 28 percent being secondary to Gram-negative bacteria.     

Acute Zinc Toxicity in Haemodialysis

A country patient on home haemodialysis suffered acute nausea, vomiting, and fever during dialyses when she used water stored in a galvanized tank. She subsequently was found to have severe anaemia with raised plasma and erythrocyte zinc concentrations. Intercurrent hospital haemodialyses and subsequent home dialyses with deionized water were symptom-free.Experimental haemodialyses of dogs against small concentrations of zinc showed a disproportionate rise in plasma zinc and possible uptake of zinc by the liver.     

Factors That Influence Microbial Contamination of Fluids Associated with Hemodialysis Machines

Studies were conducted on the microbiological quality of fluids associated with different types of dialysis systems located in six dialysis centers and 14 homes. Included were (i) single-pass systems employing either parallel flow (Kiil or Gambro) or capillary cartridge dialyzers and (ii) recirculating single-pass and batch recirculating systems using coil dialyzers. Microbiological assays were performed on the water used to prepare dialysis fluid, the concentrated dialysate, and either pre- and postdialyzer dialysate (single-pass systems) or the dialysate contained in storage reservoirs and recirculating cannisters (recirculating systems). The levels of microbial contamination consisting of gram-negative bacteria were directly related to the type of dialysis system, method of water treatment, distribution system, and in some instances, the type of dialyzer. Recirculating single-pass and batch recirculating systems consistently contained significantly higher levels of contamination than single-pass systems. These results were directly related to the design of recirculating systems which permits carbon- and nitrogen-containing waste products dialyzed from the patient to accumulate, be used as nutrients by microorganisms, and subsequently allow for 2- to 4-log increases in contamination levels during a dialysis treatment. In contrast, levels of contamination in single-pass machines were related more to the quality of the water used to prepare dialysis fluid and the adequacy of cleaning and disinfection procedures than to the design of the system.     

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.     

Optimisation of solute transport in dialysers using a three-dimensional finite volume model

Dialyser manufacturers only provide limited information about mass removal under well-defined flow and solute conditions in commercially available dialysers for hemodialysis. This computational study aimed at assessing the solute transport efficiency in a dialyser for different geometries (fiber lengths and diameters). A three-dimensional finite volume model of a single fiber in a high flux polysulphone dialyser (Fresenius F60) was developed. Different equations describe blood and dialysate flow (Navier-Stokes), radial filtration flow (Darcy) and solute transport (convection-diffusion). Fluid and membrane properties were derived from in vitro and in vivo tests as well as from literature data. Urea (MW60) was used as marker to simulate small molecule removal, while middle molecule transport was modelled using vitamin B12 (MW1355) and inulin (MW5200). Keeping the fluid velocity in a single fiber constant, fiber diameter and length were changed in a wide range for evaluation of solute removal efficiency. Clearances were found enhanced by 13% (urea), 50% (vitamin B12) and 89% (inulin) for a fiber twice as long as a standard one and by 5.5% (vitamin B12) and 21% (inulin) for a fiber diameter of 150 mum instead of 200 mum. The impact of fiber dimensions was more pronounced for the middle molecules compared to urea.