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Universidad Nacional Autónoma de Nicaragua SCHOOL OF MEDICAL SCIENCES
“END-STAGE RENAL FAILURE”
(A RETROSPECTIVE STUDY ON FREQUENCY,
DIAGNOSIS, TREATMENT, EVOLUTION AND PROGNOSIS)
T H E S I S
Presented by
Flor de María Cardoza Amador
For attaining the Degree
of
DOCTOR IN MEDICINE AND SURGERY
Managua, Nicaragua, C. A.
─ 1983 ─
ABSTRACT
The study involved 142 patients with end-stage renal
failure treated at the Department of Nephrology of Hospital
Berta Calderón during a 3-year period. Ages ranged from 10
to 90 years, including 91 males and 51 females. The
majority of the patients were from Managua, Leon and
Chinandega. The most common etiology was chronic
glomerulonephritis (45.7%) and many patients did not have
any specific diagnosis (37.3%). Most common complications
were cardiovascular. A total of 108 patients (76%)
underwent peritoneal dialysis upon request, 23 patients
(16.1%) underwent hemodialysis, and 5 patients have been
managed in a newly started CAPD program. All hemodialysis
patients died, as well as one CAPD patient. No conclusion
can be made concerning peritoneal analysis patients because
the withdrawal rate was very high. The maximum time was 6
months in hemodialysis and 6 months in CAPD.
- 1 -
INTRODUCTION
“Uremia”, a term coined by Pierry in 1840, literally means
urine in the blood, and has been used to describe the
consequences of an excess of urea and other nitrogenous
waste in the blood(1).
It is also known as chronic kidney failure, which consists
of a multi-symptom clinical condition resulting from
progressive deterioration of the renal anatomical
structure, interfering with “homeostasis” maintenance, and
producing endogenous, permanent, and deadly poisoning (2).
In a more accurate definition, uremia is a set of symptoms
and signs reflecting dysfunction of all organ systems when
kidneys fail to regulate body fluid composition and volumes
(1).
The most important aspect of this disease is that chronic
kidney failure (CKF) is a public health issue that is
becoming more evident as new therapeutic methods provide
uremic patients with longer and better survival rates,
which increasingly exceeds any actual or planned physical
capacity for providing care to these patients (3).
The above was taken from a paper by Dr. Emilio Exeire
Mured, member of the kidney transplant team at the General
Hospital of the National Medical Center (IMSS) in Mexico,
presented at the 22nd National Assembly of Surgeons in
November 1976, in which can be noted the evident concern of
the countries that have sufficient economic resources,
- 2 -
well-trained medical staff and state-of-the-art technical
diagnosis developments to engage in the comprehensive
management of these patients, including kidney transplants.
To give an idea of the growing importance of nephropathies
as a cause of morbidity and mortality, some statistics on
prevalence in other countries are mentioned: In Mexico,
8,718 people die every year from nephritis or nephrosis
(14.5 per 100 thousand); 3,956 from renal infections (6.4
per 100 thousand); 2,975 (4.9 per 100 thousand) from other
nephropathies, and 225 (0.4 per 100 thousand) from
prostatic hyperplasia. While these figures are alarming,
they are not real because, even in uremia cases, death is
often attributed to other causes, mainly cardiovascular
diseases, concomitant infections, or central nervous system
diseases, which are often the final event in these patients
(4).
U.S. statistics on mortality by renal diseases in Mexico
showed that approximately 3.5% (20,000) of annual deaths
are caused by renal diseases and some 2,350,000 persons
were currently affected by kidney diseases (5).
It is currently estimated that each year 400 people per
million inhabitants are affected by primary nephropathies
(glomerulonephritis, membranous or autoimmune, infectious,
tubulointerstitial, hereditary, congenital, toxic, etc.) or
secondary nephropathies (diabetic glomerulosclerosis,
amyloidosis, lupic, lithiasic, metabolic, etc.), of which
20% (80 cases per 1,000,000 inhabitants per year) develop
chronic renal failure (6,7,8,9,10,11). In our country, with
a population of 2,500,000, it is feasible to think that
1,000 new cases of nephropathy occur each year and that we
- 3 -
will have 200 new patients with chronic renal failure. If
we add to this the monthly cost of US$1,907.70 for
maintaining a patient in hemodialysis and US$494.70 per
month for post-transplant maintenance (12), I believe
terminal chronic renal failure is undoubtedly a real and
serious public health issue and provides a strong basis for
the statement made by R. M. Kral in 1962: “Chronic renal
diseases and their treatment can develop into a huge
financial, emotional, and social burden capable of
destroying patients, their families, and even the state”
(3).
In Nicaragua, until a few years ago, patients with terminal
chronic renal failure were automatically classified as
unrecoverable cases and, in addition to a diuretic-based
treatment and diet, they were marginalized and seen as a
burden by hospital staff, their own families and society,
and were doomed to hopelessly die from uremia.
It was not until early 1979 that the first hemodialysis
programs were initiated, at first only for acute cases, but
over the years chronic patients were included in
maintenance programs. Programs for peritoneal dialysis upon
request were also started and were the only two
alternatives available to our uremic patients, without any
other kind of support, since a team is required, made up of
psychiatrists, psychologists, nutritionists and social
workers, specializing in caring for this type of patients.
To date, no retrospective research is available in
Nicaragua from which we can draw information on the
incidence of this disease, in order to know the exact
- 4 -
etiological causes, monitor the evolution of the patients,
and understand the types of treatment used and outcomes. It
is definitely important to understand this data as a basis
for implementing screening, prevention, and research
programs and projects targeted towards the most common
renal diseases, in order to provide timely treatment for
potentially curable ailments, reduce morbidity and
mortality of diseases already identified with a poor
prognosis, and assess resources for uremia treatment,
according to the most common type of patient. The foregoing
were the most important reasons that motivated me to
conduct this study.
- 5 -
MATERIAL AND METHODS
We reviewed the clinical history of all patients admitted
to the Department of Nephrology at Hospital Bertha Calderon
with a diagnosis of terminal chronic renal failure during
the 1980-1982 period, extracting data on the age, sex,
place of origin, etiological diagnosis, type of treatment
received and main laboratory tests for a total of 142
patients.
Statistical yearbooks for the aforementioned years were
consulted at the Statistics Department of the same
hospital.
We reviewed all the files at the hemodialysis unit, from
its inception in 1979 through 1982, taking into account
such data as the number of hemodialysis processes, the time
that patients underwent hemodialysis, the type of
arteriovenous fistula used, heparinization, major
complications, etc.
A review was also made of all files of patients that
underwent continuous ambulatory peritoneal dialysis (CAPD)
at this hospital’s Intensive Care Unit.
All this data was tabulated and then analyzed and compared
with the results of other studies, all of which was led to
the final results and conclusions of this study.
- 6 -
R E S U L T S
TABLE 1
TERMINAL CHRONIC RENAL FAILURE
INCIDENCE BY SEX
Sex No. of Cases %
Male 91 64.08
Female 51 35.91
TOTAL 142 99.99
- 7 -
TABLE 2
TERMINAL CHRONIC RENAL FAILURE
INCIDENCE BY AGE
Age Group No. of Cases %
0 ─ 9 years 1 0.70
10 ─ 20 years 10 7.04
21 ─ 30 years 33 23.07
31 ─ 40 years 20 14.08
41 ─ 50 years 28 19.71
51 ─ 60 years 24 16.90
61 ─ 70 years 19 13.38
71 ─ 80 years 6 4.22
81 ─ 90 years 1 0.70
TOTAL 142 99.88
- 8 -
TABLE 3
TERMINAL CHRONIC RENAL FAILURE
INCIDENCE BY DEPARTMENT
DEPARTMENT No. of Cases %
Managua 52 36.61
Leon 21 14.78
Chinandega 14 9.85
Granada 9 6.33
Masaya 9 6.33
Rivas 6 4.22
Matagalpa 6 4.22
Carazo 5 3.52
Esteli 4 2.81
Madriz 3 2.11
Boaco 3 2.11
Zelaya 2 1.40
Chontales 2 1.40
Nueva Segovia 1 0.70
Unknown 5 3.52
TOTAL 142 99.91
- 9 -
TABLE 4
TERMINAL CHRONIC RENAL FAILURE
ETIOLOGICAL DIAGNOSIS
Type of Lesion No. of Cases %
Chronic
Glomerulonephritis 65 46.77
Tubulointerstitial
Nephritis 24 16.90
No Etiological
Diagnosis 53 37.32
TOTAL 142 99.99
- 10 -
TABLE 5
TYPE OF GLOMERULONEPHRITIS
CAUSING CKF IN THE STUDY
Type No. of Cases %
Primary or
Idiopathic 59 90.76 (41.54%)
Secondary 6 9.23 (4.22%)
TOTAL 65 99.99 --
Red: Percentage of a total of 142 patients in the study.
- 11 -
TABLE 6
PRIMARY DISEASES RESULTING IN SECONDARY GN
Disease No. of Cases %
Diabetes 5 83.33 (3.52%)
SLE 1 16.66 (0.70%)
TOTAL 6 99.99 --
Red: Percentage of a total of 142 patients in the study.
- 12 -
TABLE 7
TYPES OF TUBULOINTERSTITIAL NEPHRITIS
RESULTING IN CKF
Type of Lesion No. of Cases %
Chronic
Pyelonephritis 22 91.66 (15.49%)
Tuberculosis 2 8.33 (1.40%)
TOTAL 24 99.99 --
Red: Percentage of a total of 142 patients in the study.
- 13 -
TABLE 8
MOST COMMON CLINICAL SIGNS IN THE STUDY
Sign No. of Cases %
Hyporexia or Anorexia 142 100.00
Nausea and Vomiting 119 83.80
Anemia 126 88.73
High Blood Pressure 99 69.71
EDEMA 100 70.04
Cardiac Failure 36 25.35
Behavioral Changes 26 18.30
Bleeding 25 17.60
Muscle Soreness 18 12.67
Acute Pulmonary Edema 11 7.74
Lethargy 11 7.74
Seizures 8 5.63
Coma 8 5.63
Pericarditis 1 0.70
- 14 -
TABLE 9
STATISTICAL SIGNIFICANCE OF PATIENTS WITH RENAL PROBLEMS
AT HOSPITAL BERTHA CALDERON (1981 and 1982)
Total Hospital Admissions 15,338 100.00%
A)
Total Nephrology Admissions 405 2.64%
Total Internal Medicine Admissions 2,732 100.00%
B)
Total Nephrology Admissions 405 14.82%
Total Hospital Outpatients 198,343 100.00%
C)
Total Nephrology Outpatients 4,973 2.50%
Total IM Service Outpatients 23,165 100.00%
D)
Total Nephrology Outpatients 4,973 14.82%
Total Terminal CKF Patients in the 3-year study
E)
( 1980 – 81 and 82 )
142
- 15 -
TABLE 10
MOST COMMONLY USED ANTIBIOTICS
Antibiotic Types No. of Cases %
Ampicillin 56 39.43
Gentamicin 13 9.15
Trimethoprim-Sulphamethoxazole 7 4.92
Dicloxacillin 5 3.52
Procaine Penicillin 5 3.52
Crystalline Penicillin 4 2.81
Cephalosporins 2 1.40
Chloramphenicol 2 1.40
INH 1 0.70
Ethambutol 1 0.70
Streptomycin 1 0.70
TOTAL 97 68.25
- 16 -
TABLE 11
MOST COMMONLY USED DIURETICS
Diuretic No. of Cases %
Furosemide 116 81.69
Amiloride-Thiazide 9 6.33
TOTAL 125 88.02
- 17 -
TABLE 12
MOST COMMONLY USED DIGITALIS DRUGS
Digitalis Drug No. of Cases %
Digoxin 47 33.09
Lanatocid C 11 7.74
- 18 -
TABLE 13
MOST COMMONLY USED ANTIHYPERTENSIVE AGENTS
Antihypertensive No. of Cases %
Alpha-Methyldopa 92 64.78
Hydralazine 28 19.71
Propanolol 7 4.92
Guanetidine 7 4.92
Diaxozide 2 1.40
- 19 -
TABLE 14
MOST COMMONLY USED GASTROENTEROLOGY DRUGS
Drug No. of Cases %
Aluminum Hydroxide 100 70.42
Dimenhydrinate 32 22.53
Diphenoxylate-Atropine 14 9.85
Methoclopramide 13 9.15
Butylhyoscine 5 3.52
Metronidazole 5 3.52
Cimetidine 4 2.81
- 20 -
TABLE 15
MISCELLANEOUS DRUGS
Drug No. of Cases %
Oral Polyvitamins 83 58.45
Allopurinol 17 11.97
Isosorbide 17 11.97
Benzodiazepines 9 6.33
Aminophylin 7 4.92
Antirheumatic Drugs 7 4.92
Prednisone 2 1.40
Oral Glucose Lowering Agents 2 1.40
Insulin Crystal 3 2.11
Calcium Gluconate 13 9.15
Potassium Chloride 4 2.81
- 21 -
TABLE 16
LABORATORY TEST RESULTS
Type of Test No. of Cases %
Positive Urine Culture
Proteinuria 74 51.7% 52.11
Hemoglobinuria 46 32.39
Erythrocyturia 44 30.98
Hyperuricemia 113 80.00
Hypocholesterolemia 22 15.49
Hypercholesterolemia 7 4.92
Prolonged PT 21 14.78
Thrombocytopenia 11 7.74
Hypocalcemia 87 61.26
Hyperphosphatemia 106 75.00
Prolonged Clotting Time 6 4.22
Shortened PTT 18 12.06
Hypoproteinemia 58 41.04
Hypoalbuminemia 58 41.04
Increased ESR 113 80.00
C-Reactive Protein + 3 (9) -
LE Cells + 1 (3) -
Urine AARB + 2 (4) -
Hyponatremia 10 (18) 55.05
Hypernatremia 8 (18) 44.04
Hypopotassemia 12 (21) 57.01
Hyperpotassemia 9 (21) 42.08
Hyperglycemia 15 (118) 12.07
Hypoglycemia 60 (118) 50.08
- 22 -
TABLE 17
MOST COMMON BACTERIA IN URINE CULTURES
Bacterium Type No. of Cases %
Escherichia coli 13 (29) 44.82
Enterobacter 6 20.68
Proteus spp. 11 37.93
Staphylococcus epidermidis 4 13.79
Klebsiella 3 10.34
- 23 -
TABLE 18
ELECTROCARDIOGRAPHIC FINDINGS IN 71 EKGs
Normal 35 49.29
Hyperkalemia 16 22.53
HBP Cardiopathy 14 19.71
Extrasystolia 3 4.22
Hypokalemia 2 2.81
Pericarditis 1 1.40
- 24 -
TABLE 19
RADIOLOGICAL FINDINGS IN 101 CHEST X-RAYS
Pulmonary Congestion 61 60.39
Cardiomegaly 54 53.46
Normal 12 11.88
Fibrosis 4 3.96
Pericardial Effusion 1 0.99
- 25 -
TABLE 20
RADIOLOGICAL FINDINGS IN 4 IV PYELOGRAMS
Lithiasis 2 50
Megaureter 1 25
Hydronephrosis 1 25
Polycystic Kidneys 1 25
% of patients that had IV Pyelogram 2.81%
- 26 -
TABLE 21
FREQUENCY OF PATIENT HOSPITALIZATION
No. of Hospitalizations No. of Cases %
1 Hospitalization 73 51.40
2 Hospitalization 24 16.90
3 Hospitalization 13 9.15
4 Hospitalization 7 4.92
5 Hospitalization 8 5.63
6 Hospitalization 4 2.81
7 Hospitalization 5 3.52
8 Hospitalization 3 2.11
9 Hospitalization 5 3.52
TOTAL 142 99.96
- 27 -
TABLE 22
NUMBER OF PERITONEAL DIALYSES PROCEDURES
No. of Dialyses No. of Cases Total No. of
Dialyses
1 Dialysis 38 38
2 Dialysis 24 48
3 Dialysis 12 36
4 Dialysis 10 40
5 Dialysis 7 35
6 Dialysis 2 12
7 Dialysis 1 7
8 Dialysis 2 16
9 Dialysis 9 81
Over 10 3 30
TOTAL 108 343
- 28 -
SUMMARY OF WORK PERFORMED BY THE HEMODIALYSIS UNIT IN 1979
Sex Diagnosis Type of Fistula Average Number
of Sessions
Average
hemodialysis
time
M
7
F
4
AKF
9
CKF
2
EXT.
9
INT.
2
AKF
3.4
CKF
14
AKF
9.6
days
CKF
2.5
months
(2–3)
TOTAL: 11 11 11
AGE OF HEMODIALYZED PATIENTS IN 1979
AKF CKF
10-20 years 1 0
21-30 years 0 0
31-40 years 1 1 42.1
41-50 years 4 1
51-60 years 3 0
61-70 years 0 0
TOTAL 9 9
- 29 -
SUMMARY OF WORK PERFORMED BY THE HEMODIALYSIS UNIT IN 1980
Sex Diagnosis Type of Fistula Average Number
of Sessions
Average
Hemodialysis
Time
M
14
F
11
AKF
15
CKF
10
EXT.
21*
INT.
11*
AKF
2.9
CKF
17.2
AKF
3.8
days
(8-35)
CKF
3.7
months
(1–6
months)
25 25 32
(*) Some patients started hemodialysis with an external and then and internal fistula
AGE OF HEMODIALYZED PATIENTS IN 1980
AKF CKF
10-20 years 1 1
21-30 years 1 2
31-40 years 0 2
41-50 years 8 5
51-60 years 4 0
61-70 years 1 0
TOTAL 15 10
- 30 -
SUMMARY OF WORK PERFORMED BY HEMODIALYSIS UNIT IN 1981
Sex Diagnosis Type of Fistula Average Number
of Sessions
Average
Hemodialysis
Time
M
6
F
2
AKF
1
CKF
7
EXT.
1
INT.
7
AKF
2 d
CKF
20.7
(1-35)
AKF
4 days
CKF
3.2
months
(1 day
–6
months)
8 8 8
AGE OF HEMODIALYZED PATIENTS IN 1981
AKF CKF
10-20 years 0 0
21-30 years 0 4
31-40 years 0 1
41-50 years 0 1
51-60 years 1 0
61-70 years 0 1
TOTAL 1 7
- 31 -
SUMMARY OF WORK PERFORMED BY HEMODIALYSIS UNIT IN 1982
Sex Diagnosis Type of Fistula Average Number
of Sessions
Average
Hemodialysis
Time
M
6
F
2
AKF
2
CKF
6
EXT.
2
INT.
6
AKF
3.0
CKF
19.5
(1-34)
AKF
2.5
days
CKF
3
months
(1 day–
5
months)
8 8 8
AGE OF HEMODIALYZED PATIENTS IN 1982
AKF CKF
10-20 years 0 0
21-30 years 1 3
31-40 years 1 2
41-50 years 0 0
51-60 years 0 1
61-70 years 0 0
TOTAL 2 6
- 32 -
TABLE 27
MOST COMMON PROBLEMS
DURING HEMODIALYSES (52 PATIENTS)
Problems No. of Cases %
Hypotension 32 61.5
Chills 13 25.0
Nausea and Vomiting 12 23.0
Filter Rupture 9 17.3
System Clotting 8 15.3
Cannulation Site Bleeding 6 11.5
Fever 5 9.6
Refractory HBP 5 9.6
Cramps 5 9.6
Precordial Pain 4 7.6
- 33 -
TABLE 28
CAPD PATIENTS
No. Sex Age DX Catheter CAPD
Time
1 M 63 Diabetic Nephropathy Tenckhoff 4 months
2 M 53 Diabetic Nephropathy Tenckhoff 6 months
3 F 78 CPN Tenckhoff 3 months
4 M 56 CGN Tenckhoff 4 months
5 M 53 Painkiller Nephropathy Tenckhoff 2 months
Complications: Catheter Obstruction 2
Catheter Replacement 2
- 34 -
DISCUSSION
A total of 142 patients were studied during a 3-year
period, resulting in an annual average of 47.3 patients, in
line with an average of 40 new terminal CKF cases according
to international forecasts (6, 7, 8, 9, 10, 11).
In our study we found a significant predominance of
terminal CKF among males, at 64.8% (Table 1). Other studies
have not shown any sex predominance (13, 14, 15, 16), and
no significant sex differences were found in a study of 211
children (2). We do not believe that the difference found
in our study is real. It is probably influenced by the
idiosyncrasy of our women, which leads them to stoically
tolerate all sorts of diseases without seeking medical
help. Very few studies have found some predominance among
females (17).
With respect to the incidence of terminal CKF by age, we
found it was higher in the 21-60 years age bracket, and
slight more marked from 21 through 30 years, at 23.07%
(Table 2). In this regard we match the results of other
studies, which found that the average age is 52.9 years
with a range from 16 to 86 years (13). Others found the
mean age to be 41.1 years with a range of 12 to 76 years
(16). Yet another study found a mean age of 56.4 years with
a range of 36 to 76 years (15). In a Cuban study of 201
patients treated over a period of 5 years, the mean average
was 36 years, with ages ranging from 10 to 55 years (18).
The incidence of terminal CKF is remarkably high in people
from the capital city with a total of 52 patients, and 35
- 35 -
patients from the western part of the country (León and
Chinandega), accounting for 36.61% and 24.63%, respectively
(Table 3). In this region there no other studies with which
to compare our results, but we concluded that it is
necessary to begin an etiological research program with
renal biopsies, either open or preferably percutaneous. It
is worth mentioning that, although there are sufficiently
trained people in the country, this program has not been
implemented due to several factors, including: a) lack of
tissue-analyzing immunofluorescence techniques required to
diagnose most renal diseases, particularly since it has
been determined that these high risk procedures should not
be performed without these techniques as patients would be
exposed and there is a high probability that accurate
diagnoses would not be obtained; b) lack of pathologists
properly trained in reading abnormal kidney tissues. Once
these elements are obtained, we will be able to follow
these procedures and determine the most common histological
lesion, and thus get to know more about the reasons why
patients from these regions have a high incidence of
nephropathy (8).
With respect to the type of disease leading to terminal
CKF, we found that the most common disease is chronic
glomerulonephritis, with a total of 65 cases (45.77%). It
was surprising to find 53 patient files (37.32%) with no
definitive diagnosis (Table 4). This is readily explained
because none of the patients underwent any renal biopsy due
to the aforementioned reasons. We hope this procedure,
which is mandatory in every nephrology unit, will be
performed in the near future, so that this branch of
medicine becomes more scientific as it is in other
- 36 -
countries. Criteria used to classify the type of disease
are basically of a clinical nature, assisted with a few
laboratory tests performed at the hospital where these
patients are being treated. These criteria are for CGN in
young patients with azoate retention, edema, high blood
pressure, major edemas and anemia, with a clearly nephritic
urine. For tubulointerstitial nephritis, particularly of
the CPN type, criteria are for old patients without high
blood pressure and that conserve good urine volumes because
of poor sodium management, and with rare or absent edemas
(Table 4). In all the other centers in the world there are
very comprehensive protocols for screening terminal CKF
patient that seldom do not render a definitive DX (19,20).
Nonetheless, results match other studies that found
glomerulopathies as the number one cause of terminal CKF:
33.3% (18); 75% (29); 39% (20). With respect to CPN,
results are varied in the different studies, 21% (20); 29%
(13); 15% (21); 12.5% (19). Other causes found in other
studies were: diabetic nephropathy (45%), polycystic
kidneys (15%), Alport disease (9%), nephroangiosclerosis
(29 and 3%). (13,18,20)
Tables 5, 6, and 7 only show a subdivision of the different
diseases that could be identified, although, as we stated
before, most were identified under eminently clinical
parameters, and we found that the highest percentage of
glomerulopathies were primary, with 59 out of 65 diagnosed
cases, or 41.54% of the total cases studied. This diagnosis
was made when no other primary disease could be proven,
such as SLE, diabetes, etc. In this regard, we coincided
with other large series that found up to 33.3& (18) and 39%
(20).
- 37 -
We only found 5 cases of diabetes (3.52% of total), whereas
results of other large series show an incidence of up to
43% (13). This difference is probably due to the fact that
in other countries the average evolution of diabetes has
lasted up to 16.5 years as a consequence of using insulin,
oral glucose lowering agents, and adequate management of
disease complications. As a result, renal lesions now ranks
as the primary cause of death in these patients, since
diabetic nephropathy develops after 13 years of evolution
of the disease (22), and it is very likely that statistics
of other countries, including our own country, are modified
when the survival rate of diabetic patients is extended.
We only found one case of SLE and 22 CPN cases, accounting
for 15.49% of the total cases, matching most reviewed
series. Renal TB was found in just 2 cases, matching other
series that have found a maximum figure of up to 3% (20).
The Harvard Medicine Department, in a 12-year study, found
72 patients with genitourinary tuberculosis, 41 of which
had it anatomically located in the kidneys, urethra and
bladder (23), and of those only 5 patients (12%) had azoate
retention; however, it was only possible to prove in 2 of
them that there were no other CKF causes, apart from
tuberculosis.
In respect of the most common clinical signs, we found the
following in decreasing order: hiporexia or anorexia
(100%), nausea and vomiting (83.8%), anemia requiring
transfusion (88.7%), edema (70.4%), and high blood pressure
(69.7%). (See Table 8) In this regard, we matched the
results of all the studies since the manifestations of
uremic syndrome are practically the same in all patients,
- 38 -
regardless of CKF etiology, given that physiopathological
mechanisms are dependent on kidney failure to maintain
homeostasis, thus leading to an endogenous and permanent
poisoning condition, which results in an anatomical and
physiological imbalance of our entire organ system. (2) The
most common and important life-threatening complications
for end-stage renal failure patients included: high blood
pressure and anemia. There are several well-acknowledged
factors involved in the development of the former, such as
hipervolemia, increased activity in the renin-angiotensin-
aldosterone system, and decreased activity of the
prostaglandins in the kinin-kallikrein system. High blood
pressure leads to more serious complications, such as heart
failure and acute pulmonary edema, which is one of the most
common causes of death in end-stage renal failure patients,
second only to infections. There are three factors involved
in anemia: decrease erythropoietin production in the
kidneys, diminished RBC mean life, and finally an inhibited
RBC production in the bone marrow, independently from
erythropoietin (24). The other major problem in uremic
patients is a tendency to bleed that may result in massive
digestive tract hemorrhages and subsequent death. This
complication is explained by an abnormal platelet function
resulting from an abnormal coagulation Factor III mediated
by medium molecules without decreased platelet count (24, 25).
Lastly, other serious complications in uremic patients that
may lead to death are of a neurological type and may range
from simple behavioral changes to seizures and coma, and
may be explained by hydroelectrolytical imbalances and
acid-base disequilibrium (23). In comparing other reports, we
found Cubans reported an incidence of 93.1% (18) in high
blood pressure (HBP), Mexicans found an HBP incidence of
- 39 -
71%, 76% of edema, 51% of heart failure, and we found 33%
in varying degrees (13). Other studies found HBP in 75% of
the cases, edema in 100% of the cases, anemia in 100% of
the cases,(19) and as mentioned above, we matched all studies
(16,17,20).
On Table 9 we see that renal disease patients, in general,
and end-stage renal failure patients, in particular, are a
serious health issue since total revenues accruing to the
Nephrology Department account for 2.64% of total hospital
revenues and 14.82% of Internal Medicine revenues. This is
aggravated by the fact that Nephrology Service only has
five hospital beds available, and thus many nephrology
patients are hospitalized in the Internal Medicine Service.
Consequently, the expected annual figure of 200 end-stage
renal failure patients, according to international
statistics forecasts for our country, is reached and
probably surpassed, since patients without CKF are studied
as outpatients in the service (6, 7, 8, 9, 10 and 11).
Nephrology outpatients account for 2.50% of total hospital
outpatients and 14.82% of internal medicine patients, while
a total of 142 end-stage renal failure patients were
admitted during the three years of the study. Statistical
comparisons are not possible because there were not
sufficient statistics at the hospital for 1980 probably
because statistics were not kept or were lost in the days
immediately following the triumph of the revolution.
Table 10 shows the most common antibiotics used on these
patients, in decreasing order, as follows: ampicillin,
gentamycin and trimethoprim-sulfamethoxazole. This is no
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surprise since infections are the most common cause of
death in end-stage renal disease patients, as mentioned in
all references, and the only comment is that any antibiotic
may be used on these patients, regardless of its
nephrotoxicity or kidney clearance, provided
recommendations are followed as to creatinine clearance,
age, sex, and weight. (See normograms in Annexes)(26, 27, 28)
On Table 11 we found that 88.0% of patients received
diuretic therapy, the most commonly used being furosemide,
at 81.6%, and the least used was a potassium-sparing
thiazidic diuretic. At this point it is worth recalling
some well-established scientific issues that prove this
therapy to be a mistake. Pharmacokinetic studies have shown
that thiazidic diuretics are ineffective in patients with
creatinine clearance higher than 30 ml/min and are not
indicated in patients with end-stage renal failure. The
same contraindication exists for potassium-sparing
diuretics, such as amiloride, triamterene, and
spirinolactone, due to their high risk of hyperkalemia. As
regards furosemide, it is ineffective with CrC values lower
than 10 ml/min, and for anyone to be considered an end-
stage renal failure patient creatinine clearance must be
under the above figure. The use of diuretics on CKF
patients would thus be limited to furosemide and ethacrynic
acid, and to cases like HBP management with 10-50ml/min CrC
values and major sodium retention, since its over-depletion
could lead to a faster deterioration of residual renal
function (29).
Table 12 only shows that common use of digitalis drugs on
these patients is correlated to the fact that heart failure
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is a relatively common complication. What can be said is
that impregnation is exactly the same as in non-renal
patients and what needs to be seen is the time interval
between maintenance dosages, according to patient
creatinine clearance values (30).
Table 13 shows the wide range of antihypertensive drugs
used on these patients, correlated to the fact HBP is an
extremely common complication in this type of patients, and
the primary cause of their renal disease
(nephroangiosclerosis) in a high number of cases. According
to various studies, propanolol is the starter drug of
choice to manage HBP in CKF patients (29). Alpha-methyldopa
used to be considered the first-line treatment, but it has
been replaced by propanolol, due to its many side effects,
particularly at the level of the nervous system, such as
lethargy, drowsiness, and depression, symptoms that are
already present on account of uremia itself. Nevertheless,
it is a good drug and should be left as a second choice.
Ideally, several drugs acting at different levels should be
prescribed, in order to use the lowest possible doses.
On Table 14 the wide variety of medication useful in
gastroenterological problems can be seen. The most
frequently used is aluminum hydroxide WITHOUT magnesium,
although its usefulness is not as an antacid, but rather to
prevent re-absorption of phosphates, given their high
values in CKF (24). Again, it should not contain any
magnesium because it leads to hypermagnesemia that can be
fatal. While nausea and vomiting are very common symptoms,
anti-emetics do not seem to be used very often because
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these symptoms are caused by uremia and quickly decrease
with dialysis (24).
From Table 15 it can be inferred that practically all drugs
may be taken by uremic patients, provided they are
administered according to their serum creatinine values.
Polyvitamins are routine drugs for these patients (19, 24).
Urine cultures were made for only 56 patients, 29 of them
being positive for urinary tract infections (51.7%).
Table 16. It has already been mentioned that infection
anywhere in the body is one of the most frequent
complications in uremic patients, and urinary tract
infections are the most important. Other studies found a
27% incidence (13), while yet another found figures of up to
82.3% (31), indicating incidence has a wide range, but it is
always important. Proteinuria and hematuria, microscopic or
macroscopic, are the most common laboratory findings in
kidney failure patients, particularly glomerulopathies
(24.31), with proteinuria incidence running as high as 100%
of cases and hematuria up to 58.9%. In our study we found
proteinuria incidence to be 52.1%, while hematuria stood at
30.9%. Hyperurecemia is a common complication in patients
with renal function deterioration due to kidney failure to
excrete uric acid. In our study we found it in up to 80% of
cases. This problem is also magnified by the frequent use
of diuretics. Hypercholesterolemia goes together with
hypoalbuminemia in patients with nephrotic syndrome. In our
study we found an incidence as low as 4.92%.
Hyperphosphatemia is a frequent finding due to secondary
hyperparathyroidism developed by uremic patients, up to 75%
(24) in our study. Hypoproteinemia with hypoalbuminemia is
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also a relatively frequent finding on account of glomerular
lesions developing into proteinuria up to a nephrotic range
(24.31). A high rate of erythrocyte sedimentation caused by
anemia was found in 80% of patients in our study, and it
was not corrected.
Electrolytic disorders are a very frequent complication,
and although tests were made for only very few patients,
due to lack of reagents at the hospital, their incidence
was: hyponatremia 55.5%, hypernatremia 44.4%, hyperkalemia
42.8%, and hypokalemia 57.1%. These variations are
influenced by such factors as hyperhydration and dialysis,
in addition to CKF (Table 16).
The most frequent bacterium isolated in urine cultures was
Escherichia coli, found in 13 of 29 cultures performed, at
44.8%. This agrees with findings in all studies reporting
E. coli as the most frequent bacterium capable of causing
urinary tract infections, which ranged from 80 to 90% (21)
(Table 17).
Electrocardiogram findings are the result of main uremia
complications, such as HBP and hyperkalemia, which are very
frequent, as mentioned above. In the study of 71 EKGs
performed, we found that most common results were
hyperkalemia and hypertensive cardiopathy (Table 18). In
chest X-rays we found cardiomegaly and pulmonary
congestion, always secondary to HBP, which in some cases
led to heart failure. There was a very low incidence of
pericardial lesions, which are very frequent in this kind
of patients (Table 19).
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Only four pyelogram reports were found, and their results
are not statistically significant. Additionally, end-stage
renal failure patients are not candidates for this type of
test because their kidneys are incapable of holding the
contrast medium (32) (Table 20).
A total of 108 patients (76%) underwent peritoneal dialysis
and 343 procedures were performed, with very few patients
completing more than 10 dialysis sessions (3). Most of them
were dialyzed 1, 2 or 3 times (74 patients). This is
partially explained by these patients’ survival still being
very short in our country (Table 22). Survival in this kind
of programs in other units surpasses 36 months, and 40% of
patients undergo peritoneal dialysis (33). Most patients
withdrew. Hemodialysis started in Nicaragua in early 1979
and at first was practically used only for acute renal
failure patients. That year 11 persons were hemodialyzed,
9 of them with acute failure and 2 with chronic failure, 7
males and 4 females, and the longest period of time in the
program was 3 months for chronic patients (Table 23). As
expected, and since hemodialyzed patients are hemodialyzed
for a short time, most of them had external fistulas (7) and
only 2 chronic patients had an internal Brescia-Cimino type
of fistula.
As early as 1980, chronic patients began to be more
frequently admitted in this kind of program, and we found
that out of a total of 25 hemodialyzed patients, 15 were
acute and 10 chronic, 14 women and 15 men, and the longest
survival time for chronic patients in this program
increased to 6 months (Table 24).
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In 1981, the number of patients joining the program was
significantly smaller, just eight, due to the new policy
whereby only patients with transplant potential were able
to enter these programs, and transplants are not performed
in this country. A clear predominance of chronic patients
was observed, at 7, and only one acute patient. This is
because the latter are currently undergoing peritoneal
dialysis, after this treatment was introduced for patients
after only 48 hours of surgery. At this time the longest
period of time chronic patients remained in the program was
6 months (Table 25). In 1982, the situation is virtually
the same as during the previous year and for the same
reasons (Table 26).
In short, during its 4 years of operation, the hemodialysis
program of Hospital Bertha Calderón has admitted 52
patients, 25 chronic and 27 acute, 22 females and 30 males.
The longest time in the program has been 6 months; 33
external and 26 internal fistulas have been placed, the
latter being the Brescia-Cimino type. The most frequent age
bracket has been 31-60 years. All chronic patients died.
During the years of the study (1980-81 and 1982), a total
of 23 end-stage renal disease patients were hemodialyzed
(16.1%), which leads us to conclude that 92.1% of CKF
patients underwent dialytic procedures and 7.9% were
managed with conservative medical CT. In other centers,
survival in these programs averages three years (10,13).
The most frequent hemodialysis complications were, in
decreasing order, the following: hypotension, chills,
nausea and vomiting (Table 27), and these are consistent
with those found in other centers (10, 13).
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In the second half of 1982, the Tenckhoff-catheter
continuous ambulatory peritoneal dialysis (CAPD) program
was initiated. Thus far, 5 patients have been admitted: 4
men and 1 woman, the only patient who has passed away.
Other patients are still alive and in the program. Longest
time in the program is 6 months, and all of them are above
50 years of age, and 2 are diabetics. The program is just
beginning and patients have been in the program for a very
short period, so conclusions cannot yet be drawn. This
should be the subject of another study, but CAPD is a
technique used worldwide and promises uremic patients a
good future (15, 16, 17, 19, 30) (Table 8).
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CONCLUSIONS
1. Regardless of its etiology, renal disease is a public
health issue throughout the world. In Nicaragua, with
a population of 2.5 million inhabitants, according to
international statistics, 1,000 new nephropathy cases
are expected each year, 200 of which will result in
chronic renal failure.
2. A total of 142 patients (91 men and 51 women)
diagnosed with end-stage renal failure were managed at
Hospital Bertha Calderón during the three years of the
study.
3. Departments with higher CKF incidence were Managua,
León, and Chinandega.
4. Main CKF causes in study patients were: primary or
idiopathic chronic glomerulonephritis and chronic
pyelonephritis. An accurate diagnosis was not possible
for a large number of patients because renal biopsies
were not yet performed.
5. Total revenues at the Nephrology Service amount to
2.64% of total hospital revenues, and nephrology
outpatients account for 2.50%.
6. Cardiovascular problems are the most frequent
complication in end-stage renal failure patients.
7. The three ways for treating end-stage renal failure
patients are, in decreasing order of frequency:
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peritoneal dialysis upon request, chronic
hemodialysis, and continuous ambulatory peritoneal
dialysis.
8. A total of 108 patients underwent peritoneal dialysis
upon request, 23 patients underwent hemodialysis, and
the CAPD program began in 1982. To date, 5 patients
have been managed.
9. All patients admitted to hemodialysis have since died.
As regards dialysis, no conclusion can be reached
because many patients withdrew from the service.
10. The longest time patients remained in hemodialysis was
just 6 months.
11. Most patients were admitted to the hospital with
advanced kidney failure, and their poor socioeconomic
and cultural level was the reason for late diagnosis,
poor ailment control, and hospital dropouts.
12. In Nicaragua, survival of end-stage renal failure
patients is too short, compared to other centers.
13. Nephrology in Nicaragua does not virtually have any
support from laboratory, pathology, X-ray, and other
services to assist in reaching an accurate diagnosis,
as well as an adequate control and management of end-
stage renal failure patients.
14. Programs need to be established and international
contacts should be made so that in a not too distant
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future we may have in Nicaragua the means necessary so
that nephrological patients may have a better future.
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BIBLIOGRAPHY
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Recommended