"END-STAGE RENAL FAILURE"

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


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


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


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 --


- 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 --


- 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









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


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


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


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


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


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


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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"END-STAGE RENAL FAILURE"