Objectives: The treatment of myoglobinuric acute renal failure by convective dialysis techniques allows a higher removal of myoglobin (20 kD) than achieved by standard dialysis. High cut-off (HCO) ...dialyser membranes developed in the last years allow the passage of molecules up to 60 kD molecular weight We evaluated the removal of myoglobin by hemodiafiltration with the use of the HCO membrane. Methods: Nine patients were treated by 14 hemodiafiltration procedures with high cut-off membrane (HCO HDF) for severe myoglobinuric acute renal failure. Rhabdomyolysis was caused by infection in two patients, and by a nontraumatic crush in three patients, it was statin-induced in two, and followed cardiovascular surgery in two patients. HCO HDF were performed with a high cut-off hemofilter at dialysate flow 500mL/min, and blood flow within 250-300mL/min, with citrate anticoagulation and postdilutional fluid substitution of 2-3 L/h. Albumin losses were replaced by infusion of human albumin solution. Results: Pre-procedure blood myoglobin concentration averaged 81mg/L (range, 7.3-223.9mg/L, mean, 58.2mg/L). Serum myoglobin decreased exponentially during the procedure with an approximate half-time of 1h. The myoglobin reduction ratio was 79.4% (range, 76% to 89%). An excellent clearance of 92mL/min (range, 42-131 mL/min) was achieved. The highest cumulative amount observed of myoglobin removed into diarysate in the course of the procedures was almost 5 grams. Three of the patients died. Four of the survivors remained anuric for a period of 1-4 weeks, and mostly regained their renal function afterwards. The remaining patients begun to pass urine already at the end of the procedure. Conclusions: Highly efficient myoglobin removal by high cut-off membrane hemodiafiltration was demonstrated in our patients.
Erythropoietin was applied subcutaneously to 49 patients, 41 have been treated by hemodialysis, 3 by continuous ambulatory peritoneal-dialysis, 5 had chronic progressive renal failure. Mean initial ...dose of erythropoietin was 139.4 U/kg/week and maintenance dose 115.9 U/kg/week. In 43% of patients serum ferritin was decreasing during treatment, and in 20% it was low before the commencing of the treatment. During erythropoietin therapy vitamin B12 was decreasing in 22% of the patients, and the substitution was necessary in 18%. Only in 1 patient it was necessary to substitute also folic acid. There were no nonresponders among erythropoietin treated patients. Elevation of blood pressure was observed in half of the patients, hypertensive encephalopathy in 1, and thrombosis of arterio-venous fistula in 3.
Background Anemia frequently accompanies chronic renal failure in patients treated with hemodialysis (HD). Despite treatment with erythropoetin up to 10% of patients still present with pronounced ...anemia. In the present study we wanted to identify simple laboratory parameters or clinical characteristics, associated to anemia in patients treated with erythropoetin.
Methods During May 2003 we screened all patients at our hemodialysis center for the presence of severe anemia (Hemoglobin (Hb) 100 or lower, Group 1) and compared them to the patients without anemia (Hb 120 or higher, Group 2). Patients with chronic bleeding or the ones receiving transfusion were excluded. Basic demographic characteristics, blood pressure, and several biochemical markers were obtained for the enrolled patients. All data were tested for significance using Student's t‐test.
Results Out of 177 patients, 34 (Group 1) and 38 (Group 2) met the inclusion criteria. There was no difference in age, gender, time on HD and blood pressure (148 ± 22/81 ± 13 mm Hg vs. 151 ± 33/81 ± 15 mm Hg). Next to significant difference all hematological parameters (Hb 92 ± 8 vs. 127 ± 6; Ht 0.29 ± 0.03 vs. 0.40 ± 0.02; Ery 3.04 ± 0.32 vs. 4.17 ± 0.32; P < 0.001 for all) patients with anemia received a higher weekly dose of erythropoetin (12000 ± 5205 IE vs. 7825 ± 4829 IE, P < 0.001), had lower albumin (35.6 ± 3.4 vs. 38.1 ± 2.8, P < 0.001) and creatinine concentration (798 ± 218 vs. 932 ± 266, P < 0.005). For other markers such as ferritin, iPTH, folic acid, and vitamin B12 we observed a trend to higher values in anemic patients.
Conclusions Our data suggest that malnutrition and low muscle mass are associated to poor response of treatment with erythropoetin in patients with chronic renal failure treated with HD. Larger sample and prospective follow up could identify further simple markers of inadequate response to the treatment of anemia.
: The objective of the study was to evaluate and compare the safety and effectiveness of epoetin omega (produced in baby hamster kidney cells) and epoetin alfa (produced in Chinese hamster ovary ...cells) in sustaining the correction of anemia in maintenance hemodialysis patients. The study, a prospective and controlled crossover, was completed in 38 stable patients treated with both epoetins for 24 weeks. Group A (17 patients) started with epoetin omega, and Group B (21 patients) started with epoetin alfa. After 24 weeks, a 4 week crossover (wash out) was made: Group A was switched to epoetin alfa and group B to epoetin omega for the next test period of 24 weeks. Both epoetins were administered subcutaneously after each dialysis. Doses were adjusted with the aim of maintaining a target hemoglobin level between 10 and 12 g/dl (hematocrit 30% to 35%). The mean weekly dose of epoetin omega/kg body weight (BW) was 67 ± 43 U. The mean weekly dose of epoetin alfa/kg BW was 86 ± 53 U. The average of all mean values of hemoglobin (Hb) during treatment with epoetin omega was 11.4 ± 0.7 g/dl (hematocrit 34 ± 2%), and during treatment with epoetin alfa was 11.3 ± 0.7 g/dl (hematocrit 33 ± 2%) (not significant). Thromboses of vascular access occurred in 3 patients during an epoetin omega treatment and in 3 patients during epoetin alfa treatment. At the site of injection, only 1 patient described a mild pain when treated with epoetin omega and only 6 patients when treated with epoetin alfa. In conclusion, both epoetin omega and epoetin alfa were effective in correcting the anemia of all studied patients. However, lower doses of epoetin omega were needed to maintain the same target hemoglobin level. No serious side effects with either epoetin were noted. The authors believe that additional comparisons of different epoetin preparations should be performed and will provide better insight into their biological activity and clinical responsiveness.
Background Serum triglyceride concentrations above 11 mmol/L can precipitate attacks of acute pancreatitis, although the pathogenesis of inflammation in this setting is unclear. In children with ...inherited disorders of lipoprotein metabolism that are associated with severe hypertriglyceridemia, attacks of acute pancreatitis can be prevented by lowering their serum triglycerides to less than 2.2 mmol/L. Some reports revealed favorable effects of membrane plasma exchange in severe hypertriglyceridemia and severe acute pancreatitis. The aim of our retrospective clinical study was to evaluate the efficacy of membrane plasma exchange (MPE) therapy in adult patients with severe hypertriglyceridemia and acute pancreatitis in terms of reduction of serum lipids, clinical improvement and reliability of the procedure itself.
Methods 25 patients (pts; 24 men, 1 woman), aged 31–59 years (mean 44.6 ± 8.0) have been treated with MPE and LDL apheresis (one procedure) for severe hypertriglyceridemia and acute pancreatitis. Fresenius‐Excorim PE monitor and PF 2000 plasmafilter were used for MPE and Kaneka LDL monitor with dextran sulphate columns for LDL apheresis. Vascular access was via femoral catheter and peripheral vein in 16/25 pts (64%), 2 femoral catheters in 8/25 pts (32%), and 2 peripheral veins in 1/25 pt (4%). The anticoagulant used was heparin in 24/25 pts (96%) and citrate in 1/25 (4%). The replacement solution was a mixture of human albumin and hemofiltration solution. One to two volumes of plasma were exchanged per procedure.
Results In total 42 procedures, 41 MPE and 1 LDL apheresis were carried out, mean 1.68 ± 1.0 per patient, one procedure in 14/25 pts (56%), 2 procedures in 7/25 pts (28%), 3 procedures in 3/25 pts (12%) and 5 procedures in 1/25 pt (4%). One volume of plasma was exchanged in 9/25 pts (36%), 1.5 volumes in 7/25 pts (28%) and 2 volumes in 9/25 pts (36%). From 3000–7200 mL of plasma was exchanged per procedure, mean 4724 ± 1806 mL. Mean running time was 185 ± 64 min., range 95–440 min. Triglyceride concentration before and after MPE was 53 ± 29 mmol/L (range 15.3‐109 mmol/L) and 12.9±10 mmol/L (range 1.5‐33.1 mmol/L), respectively. Total cholesterol before and after MPE was 18.9±8.2 mmol/L (range 8‐35) and 7.5 ± 5.4 mmol/L (range 0.6–22.6 mmol/L), respectively.
Technical side effects were hemolysis in 1/42 MPE and plugging of the plasma filter with lipids, with substantial drop of plasma filtration rate in 3/42 MPEs. Hematoma after cannulation of the peripheral vein occurred in 2/42 MPE. Three patients had signs of hypocalcemia and were given Ca gluconate or calcium chloride.
Conclusions In 25 patients with severe hypertriglyceridemia and acute pancreatitis substantial reduction of triglyceride and cholesterol serum concentration was achieved during plasma exchange therapy, along with clinical improvement of the patients.
Background In chronic hemodialysis patients with exhausted arteries and veins in whom AV fistula or AV graft can not be performed any more, hemodialysis catheters become the last resort, either ...tunneled, so called “permanent”, or non‐tunneled, so called “temporary” catheters which can be usefully used for a longer period of time than a permanent vascular access.
The aim of our clinical study was to asses temporary, precurved, jugular catheters as permanent vascular access in chronic hemodialysis patients.
Methods Thirty chronic hemodialysis patients, 15 men, 16 women, mean age 65.3 ± 13.5 years (range 30–90), with average dialysis treatment time of 6.3 ± 8.1 years (range 1 month−30 years), have had single lumen, “temporary” precurved nontunneled jugular catheters (Medcomp, USA) as permanent vascular access. Catheters were placed into right internal jugular vein, by Seldinger's technique, in local anesthesia (2% lidocain), locking solution was 4% trisodium citrate. Catheters were placed by experienced nephrologists, with ultrasound assistance, dressing was performed by dialysis nurses. Mupirocin was applied at the exit site after each hemodialysis. In the case of malfunction, thrombosis or infection, the catheter was replaced with the new one, using a guidewire. Prophylactic ceftazidime in a single dose was used after the catheter`s exchange. Unfractionated or fractionated heparin was anticoagulant.
Results Hemodialysis catheters were used for vascular access on average for 9.1 ± 6.5 months, range 1–22.7 months, total 271.7 months or 8151 days. Average catheter running time was 3.1 ± 1.9 months, range 0.5–10 months. Total number of side effects was 57, 7.0/1000 catheter days; 26 thrombosis, 3.2/ 1000 catheter days; 9 ruptures of the catheter, 1.1/1000 catheter days; 15 malfunction, 1.8/1000 catheter days; 2 exit site infections, 0.2/1000 catheter days; 2 bacteremias, 0.2/1000 catheter days; 1 avulsion of the catheter, 0.1/1000 catheter days; and 2 catheters were removed because AV fistula was successfully used.
In 21 patients single needle hemodialysis was performed, mean blood flow 251 ± 16 mL/minute, range 250–300, mean KT/V 0.96 ± 0.16, range 0.72–1.27and in 9 patients double needle hemodialysis was performed (catheter and peripheral vein) with mean blood flow 252 ± 14 mL/minute, range 200–300, mean KT/V 1.63 ± 0.25, range 1.21–1.96.
Conclusions ‘Temporary’ jugular single lumen non‐tunneled hemodialysis catheters provide good long term vascular access with acceptable functioning time and low infection rate. KT/V for single needle hemodialysis was rather low, however it significantly improved when double needle hemodialysis was performed. The main reasons for catheter removal was thrombosis, malfunction, and mechanical damage of the catheter.
Continuous ambulatory peritoneal dialysis (CAPD) has become an accepted alternative to chronic hemodialysis in the treatment of end-stage renal disease. The method utilizes the diffusion of drugs ...from the blood through the peritoneal membrane to the peritoneal cavity if administered intravenously (IV) and perorally (PO) and in the opposite direction if applied intraperitoneally (IP). The present work uses an open, two-compartment pharmacokinetic model reversibly linked with the compartment representing the peritoneal cavity and an analog-hybrid computer to simulate drug levels in sampled and unsampled compartments under conditions of various routes of administration (IV, IP and sequential IV, IP and PO) and different clinical status (presence and absence of peritonitis). The drug chosen for simulation was ciprofloxacin (CIP), a new synthetic antibacterial agent of the 4-quinolone group. Eight patients were included in the study, and CIP concentrations in plasma and dialysate were obtained by HPLC analysis to assess the reliability of the model and the efficiency of the sequential dosing scheme. CIP plasma and dialysate levels were adequate for the majority of microbes causing CAPD peritonitis. The proposed regimen was efficient in 85% of cases.
