Nocturnal dialysis: Comparing six night/week with alternate night therapy

Hemodialysis Abstracts from the AnnualDialysis Conference

25th Annual Conference on Peritoneal Dialysis,11th International Symposium on Hemodialysis, and

16th Annual Symposium on Pediatric Dialysis

Tampa, FloridaFebruary 28–March 2, 2005

70 ª 2005 International Society for Hemodialysis

Hemodialysis International 2005; 9: 70–103

Access

High output heart failure in patients with upper armA-V fistulae: Diagnosis and treatment

Amerling R., Malostovker I., Dubrow A., Rosero H., Haveson S.

Division of Nephrology and Hypertension, Division of Cardiology,

Division of Vascular Surgery, Beth Israel Medical Center, New

York, NY.

Purpose: Arteriovenous fistula (AVF) is the preferred blood

access for hemodialysis due to its longevity and resistance

to infection. Little attention is given to the long-term

hemodynamic consequences of large left-to-right shunts,

particularly in patients with brachial artery fistulae.

Materials and Methods: We describe 9 patients (8 on

dialysis, 1 post-transplant), aged 25–73, who developed

clinical heart failure, primarily due to large, upper arm

AVFs. Results: 4/9 had access flows in excess of 2 liters/

min, assessed by blood temperature monitoring. 6/9 had

cardiac output measured by right heart catheterization,

before and after shunt compression. One also underwent

left heart catheterization with ventriculography. 3/9 had

surgical reduction of the fistula, either by banding or by

serial interposition of small caliber GoreTex graft. In 2/9

the shunt was ligated. One patient had heart failure in

association with 2 large, upper arm AVFs, one of which

was ligated. After years of improved cardiac symptoms,

heart failure recurred in association with marked hypertro-

phy of his remaining AVF. Resting cardiac output in this

patient was in excess of 11 liters/min. 2/9 experienced acute

onset of heart failure within 1–3 days of angioplasty of a

venous stenosis. One of these, with very poor baseline cardiac

function, expired. Surgical revision or ligation was accompanied

by clinical improvement in the 5 patients so treated. One of

these expired of a stroke after two months of cardiac

improvement. Conclusion: High output heart failure is

under-diagnosed in dialysis patients. Patients with large

upper arm shunts are particularly at risk. Access flow

should be assessed regularly and those with outputs >1.5

liters/min should be monitored closely for development of

heart failure. Surgical correction is beneficial and indicated

in symptomatic patients.

Patientnumber

Age/Sex

Accesstype

Yearswithaccess

Flow(liters/min)

ChangeCO (liters/min) Rx Outcome

1 37/M AVF 8 >2 1.7 Reduction Improved2 26/M AVF 5 >2 2.4 Band Improved3 73/M AVF 3 >2 1.5 Reduction Improved4 45/M AVF 10 n/a 3.2 Reduction Improved5 65/M AVF 4 >2 2.8 Band Improved6 57/F AVG 4 1.2 1.87 39/F AVF 2 n/a n/a Ligate Improved8 66/M AVG 0.3 0.7 n/a Ligate Improved9 69/F AVF 0.25 n/a n/a Expired

Cutting balloon angioplasty for resistant venousstenoses in hemodialysis patients

Jung H.W., Kim Y.O., Song H.H.*, Park J.A., Kim Y.S., Kim S.Y.,

Choi E.J., Chang Y.S., Bang B.K. Dept. of Int. Med., Radiology*,

College of Medicine, The Catholic University of Korea, Seoul,

Korea.

Purpose: To report our initial experience of using cutting bal-

loons angioplasty in the treatment of resistant venous stenoses of

Brescia-Cimino fistulas. Materials and Methods: Forty-eight

patients with Brescia-Cimino fistulas underwent percutaneous

transluminal angioplasty (PTA) of 62 venous stenoses. Of these

48 patients, we encountered 8 venous stenoses (8/62, 12.9%) in 7

patients that were not successfully dilated with 6–8 mm high-

pressure balloons inflated up to 24 atm. In each of 8 stenoses,

peripheral cutting balloons with diameters of 5–8 mm were

employed to dilate resistant stenoses. Results: The locations of

stenoses were 3 at the surgical vein mobilization site (‘‘swing

point’’), 4 at the cephalic vein downstream from the anastomosis,

and 1 at the cephalic arch. The grade of stenosis after high-

pressure balloon angioplasty ranged from 57% to 87% (mean,

76%). Cutting balloons expanded completely in all stenoses

and the residual stenosis after cutting balloon PTA ranged from

0% to 24% (mean, 7%). Residual stenosis was virtually non-

exisistent at the 3 stenoses of ‘‘swing point.’’ A focal rupture

with a large hematoma occurred at the cephalic arch stenosis,

which was treated by a stent placement. One minimal rupture

that did not require any treatment occurred at the stenosis of

downstream cephalic vein. No repeat angioplasty has been

needed during follow-up period (range, 74–249 days).

Conclusion: Our early experience demonstrated that when

high-pressure balloons fail to dilate stenoses of Brescia-Cimino

fistulas, peripheral cutting balloons with diameters of 5–8 mm

can be effectively used to overcome the resistance of stenoses.

Efficacy of percutaneous angioplasty in non-maturingBrescia-Cimino fistulas

Kim Y.S., Kim Y.O., Song H.H.*, Jung H.W., Park J.A., Yoon S.A.,

Lee S.H., Chang Y.S., Bang B.K. Dept. of Int. Med., Radiology*,

College of Medicine, The Catholic University of Korea, Seoul, Korea.

Purpose: To evaluate efficacy of percutaneous transluminal

angioplasty (PTA) in non-maturing Brescia-Cimino fistulas.

Methods: Between January 1997 and December 2003, we treated

22 patients with non-maturing Brescia-Cimino fistulas by PTA.

Retrospective analysis was performed on the findings of fistulo-

gram, techniques and success rate of PTA, and patency

rate. Results: Seventeen segmental stenoses and 5 segmental

occlusions of cephalic veins were identified. Sixteen stenoses

and 2 occlusions were located at the cephalic vein adjacent to

the anastomosis site, and 3 occlusions and 1 stenosis were seen

Hemodialysis International, Vol. 9, No. 1, 2005 25th Annual Dialysis Conference: Abstracts

ª 2005 International Society for Hemodialysis 71

at the proximal vein near the elbow joint. In addition to venous

stenosis, a focal arterial stenosis at the anastomosis site and two

accompanying accessory veins that might hamper maturation of

main cephalic vein was seen in each of two patients, respec-

tively. Simultaneous occlusion of left innominate vein as well as

occlusion of cephalic vein were noted in one patient. Initial

success rate of PTA was 95.5% (21/22). Overall success rate

including 11 additional PTAs performed during follow-up was

96.9% (32/33). No major complication occurred. Primary and

secondary patency rates were 72% and 95% at 3 months, and

50% and 77% at 6 months, respectively. Conclusion: PTA is an

effective and safe method in salvaging non-maturing Brescia-

Cimino fistulas.

Intima-media thickness of radial artery isassociated with early access failure in hemodialysis

patients

Kim Y.O., Choi Y.J.*, Kim J.I.**, Shin M.J., Kim B.S., Song H.C.,

Yoon S.A., Kim Y.S., Kim S.Y., Choi E.J., Chang Y.S., Bang B.K.

Dept. of Int. Med., Clinical Pathology*, Surgery**, The Catholic

University of Korea, Seoul, Korea.

Objective: We have reported that intimal hyperplasia, which

is the pathologic change of the radial artery, is associated

with early failure of arteriovenous fistula (AVF) in hemodialysis

(HD) patients (Am J Kidney Dis, 41:422–428, 2003). Intima-

media thickness (IMT), which represents the whole thickness

of arterial wall, can be easily measured by ultrasonography,

unlike intima thickness. This study was performed to investigate

the impact of IMT of radial artery on early failure of AVF in HD

patients. Methods: Ninety HD patients undergoing radiocepha-

lic AVF operation were included in this study. The AVF was

constructed in an end vein–to–side artery fashion at the wrist by

one vascular surgeon. During the operation, 10-mm long partial

arterial walls were removed with elliptical form for microscopic

analysis. Specimens were stained with trichrome and examined

by a pathologist blinded to the clinical data. AVF patency was

prospectively followed up for 1 year after the operation.

Results: Mean age of the patients was 56� 13 years and the

number of females was 44 (48.9%). Mean IMT was 430�132 mm (133–760 mm). Of the total 90 patients, 31 patients

(34.4%) had AVF failure within 1 year after the operation. Mean

IMT was higher in the failed group (n¼ 31) than in patent

group (n¼ 59) (486� 130 mm vs. 330� 178 mm, p¼ 0.004).

Using a threshold of 500 mm of IMT, AVF patency rate was

compared between these two groups using Kaplan-Meier

method with log rank test. The AVF patency rate within 1 year

after the operation was higher in patients with IMT� 500 mm

(n¼ 26) than in patients with IMT< 500 mm (n¼ 64)

(p< 0.001). The patients with IMT� 500 mm were older and

had higher incidence of diabetes mellitus, compared to the

patients with IMT< 500 mm. There was no difference in sex,

smoking, hypertension, total cholesterol and albumin levels

between the two groups. Conclusion: Our data suggest that

increased intima-media thickness of radial artery is associated

with early failure of radiocephalic arteriovenous fistula in hemo-

dialysis patients.

Central venous stenosis in chronic hemodialysispatients: The effect of percutaneous angioplasty and

stenting

Yoon J.M., Park J.A., Jung H.A., Kim Y.O., Kim Y.S., Yoon S.A.,

Kim S.Y., Chang Y.S., Bang B.K. Department of Internal Medicine,

College of Medicine, The Catholic University of Korea, Seoul,

Korea.

Background: Central venous stenosis in chronic hemodialysis

patients occurs in about 17% of all venous stenosis and it is

associated with central vein catheterization. We evaluated the

effect of percutaneous angioplasty and stenting in the treatment

of central venous stenosis in hemodialysis patients. Methods: We

retrospectively investigated the medical records of a total of 31

dialysis patients who had central venous stenosis. We reviewed

the causes of central venous stenosis, clinical manifestations, veno-

graphic findings, and patency rate of radiological intervention.

Results: Of the total 31 patients, 28 patients had past history of

central vein catheterization ipsilateral to vascular access. Mean

duration of the catheterization was 32� 14 days. Venography

showed complete obstruction of central vein (n¼ 14) and stenosis

(n¼ 17). The site of venous lesion was right subclavian vein

(n¼ 11), innominate vein (n¼ 9), left subclavian vein (n¼ 7),

and superior vena cava (n¼ 14). A total of 30 procedures of

angioplasty with or without stenting were performed in 26 of 31

patients. Initial success rate was 96.1% and there was no severe

complication such as rupture or bleeding. The primary patency rate

at 6, 12, 24, and 48 months after the procedure was 87.3%, 75.6%,

67.9%, and 65.4%, respectively. The cumulative patency rate at

the same time point was 96.0%, 90.6%, 74.0%, and 72.8%,

respectively. Conclusion: Our data suggest that angioplasty with

or without stenting is safe and effective in the treatment of central

venous stenosis in hemodialysis patients.

Effective interventions with chlorhexidine gluconate(CHG) to decrease hemodialysis (HD) tunneled

catheter-related infections

Redman N.1, Schweon S.1, Tokars J.2, Jahre J.1. St. Luke’s Hospital,

Bethlehem, PA1; CDC, Atlanta, GA.2

Purpose: Identify practices to reduce HD catheter access related

bacteremias (ARB). Methods: Data was collected per the CDC

Dialysis Surveillance Network protocol. ARB was defined as a

patient with a positive blood culture with no apparent source

other than the vascular access catheter. ARB’s were calculated in

events per 100 patient months with 3 cohorts. Cohort 1 was

observed for 12 months, Cohort 2 for the subsequent 10 months,

and Cohort 3 for the final 10 months. Cohort 1 had weekly

25th Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 9, No. 1, 2005


transparent dressing changes, cleansing of the skin and 5 min-

ute soaking of the connection lines with 10% povidone-iodine

(PI) solution, and HCW use of clean gloves and face shield

without a mask. Cohort 2 changes consisted of thrice weekly

gauze dressing changes, skin cleansing with ChloraPrep, a 2%

CHG/70% isopropyl alcohol applicator, masks on the patients,

adding a face mask to the shield, and application of 10% PI

ointment to the exit site. Cohort 3 changes included weekly

application of BioPatch (BioP), an antimicrobial dressing with

CHG, sterile glove use, and replacing the PI line soaks with 4%

CHG. Results: The catheter-associated ARB rate per 100 patient

months was 7.9 (17ARB/216 patient months) in Cohort 1, 8.6

(13/151) in Cohort 2, and 4.7 (5/107) in Cohort 3 (p¼ 0.31

compared with Cohorts 1 and 2 combined). During the last 2

months, in Cohort 3, 9 catheter lumen cracks occurred, with one

of the patients having a bacteremia. Conclusions: Addition of

CHG line soaks and BioP reduced tunneled catheter infections,

although this is not statistically significant. The increased

number of catheter lumen cracks raises concern with the use

of CHG line soaks. Further investigation with use of CHG line

soaks and the BioP for decreasing ARB is needed.

Obesity promotes forearm primary arteriovenousfistula creation in chronic haemodialyzed

patients

Weyde W., Porazko T., Kusztal M., Banasik M., Bartosik H.,

Trafidlo E., Letachowicz W., Krajewska M., Klinger M. Dept. of

Nephrology and Transplantation Medicine, Wroclaw Medical

University, Wroclaw, Poland.

The increase in number of obese people seen in the general

population, is also what is seen in the hemodialyzed population.

It is generally believed that the location of deep forearm vessels

in the subcutaneous fat tissue makes primary arteriovenous

fistula (AVF) a disadvantage because of difficulties in vessel

puncturing. For obese patients, it is suggested that a fistula

with PTFE is created or a central catheter inserted, but these

solutions increase already high morbidity rate and significantly

increase mortality rate. Methods: The deep location of veins

situated on the anterior part of the forearm involved 57 patients

(45 female and 12 male) aged 13–87 years (mean 67� 15.2

years). Patients’ body mass index (BMI) ranged from 29.1 to

53.73 (mean 34.6� 7.8). The causes of the renal failure were

diabetic nephropathy in 30 patients, chronic glomerulonephritis

in 4, hypertensive nephrosclerosis in 5, lupus nephritis in 2,

interstitial nephritis in 4, primary amyloidosis in 1, polycystic

kidney disease in 3, and unknown in 3 patients.Two-step sur-

gical procedure was performed in all patients. In the first stage,

the standard distal radiocephalic AVF in the wrist region was

created. In case of its failure, the next attempt was performed

above the point of the first intervention. In the second stage,

superficialization of the venous part of AVF was performed in

the mode described by us (Kidney 2002;.1:1170). Results: The

first stage of the procedure was successful in 46 patients. In 6

cases it was necessary to perform a second attempt, and 2 cases

required three operations. The second stage was undertaken in

all of these patients (n¼ 54), and complete success was

achieved in 51. In 3 cases, in spite of superficialization, AVF

was not suitable for puncturing because of poor blood flow. The

causes of failure of the first stage procedure in 2 patients were

severe arteriosclerosis and venous anomaly. All patients had

non-altered cephalic veins in the wrist region, as opposed to

patients with cannulated veins. In 51 pts (90%) an efficient flow

of the blood through AVF was successfully obtained and

allowed satisfactory dialyses. Conclusions: The primary AVF

creation on the forearm is feasible in 90% of obese patients.

This result is similar to the general population of chronic renal

disease patients of our center (95%) (NDT 1998;13:527) and is

possible thanks to the location of the veins deep in the sub-

cutaneous fat tissue, which protects against repeated cannula-

tion and hence mechanical destruction in the pre-dialysis period.

The economics and practicality of t-PA vs tunnelcatheter replacement for hemodialysis

Cairoli O. Kaiser Permanente. Bellflower, CA.

Introduction: Thrombolytic therapy is an important treatment

modality for thrombosis-related catheter occlusion. Central

venous access devices (CAVDs) are essential tools for the admin-

istration of many therapeutic modalities, especially for patients

requiring lifetime therapy like hemodialysis. There are several

reasons to salvage the occluded catheter. Catheter replacement

results in an interruption of therapy delivery. This interruption

may result in complications such as life-threatening metabolic

and physiologic states. In addition, the patient’s future access

sites for CAVDs may be affected. The data released in the 2001

Annual Report – ESRD Clinical Performance Measures Project

(Department of Health and Human Services, December 2001)

shows 17% of prevalent patients were dialyzed with a chronic

catheter continuously for 90 days or longer. In the pediatric

population the data shows that 31% were dialyzed with a

chronic catheter. The most common reasons for catheter place-

ment included: no fistula or graft created (42%) and fistula and

graft were maturing, not ready to cannulate (17%). Five percent

of patients were not candidates for fistula or graft placement as

all sites had been exhausted. Methods: A short study was done

in our medical center to evaluate the results of t-PA vs. changing

the tunnel catheter. On an average a catheter costs about

$400.00. If you add the cost of specialty personnel such as an

interventional radiologist, radiology technician, radiology nurse,

and the ancillaries such as the room, sutures, gauze, and tape, the

total could reach $2000.00 easily. CathfloTM Activase1 costs

around $60.00 for a single dose. T-PA was reconstituted by

pharmacy personnel in single vials containing 2 mg/2 ml. Now

with Cathflo, vials are stored in the renal clinic’s refrigerator and

when the need arises, the RN reconstitutes the medication. The

RN, using established protocols, will instill Cathflo in the catheter

following the volume requirements of the various tunnel



catheters. After the t-PA is placed, the patient is sent home with

instructions to return to their dialysis center the next day

(arrangements are made by the RN as needed). In seventeen

patients (17) with tunnel catheter malfunctions due to inadequate

flow, not related to placement, t-PA was used. Of those 17

patients 2 were unable to use their catheter on their next dialysis

treatment date, yielding an 88% success rate. This compares with

clinical trials in which there is an 83% success rate with a dwell

time of 4 hours, or an 89% rate on patients having a 2 hour dwell

time (t-PA was repeated a second time if flow was not successfully

restored. Results: 15/17 patients in our retrospective study

showed that Cathflo worked successfully in restoring blood

flow. Two catheters needed to be exchanged. The cost savings

were significant when we compared the average cost of an

exchange ($2000) versus using t-PA ($170 including nursing

time). Conclusion: Cathflo is not just safe and practical to use

but also cost effective.

Shunt surveillance and occlusion, an analysis ofefficiency

Wijnen E. University Hospital, Maastricht, Netherlands.

Introduction: Vascular access failure is one of the greatest

sources of morbidity for chronic hemodialysis patients. Prophy-

lactic and repeated measurement of access flow may be of

importance in preventing clotting. The aim of the study was

therefore to analyse the cost effectiveness of a shunt surveillance

program, which reduces the appearance of occlusion of the

vascular access. Methods: The number of vascular access inter-

ventions (surgery and radiology) in the period 2001 till 2003

(transonic measurement period, TMP; 63 patients) was com-

pared with a reference period (RP, 1996 till 1998) during which

no access flow was measured (58 patients). All measurements

were done with Transonic1 and interventions according to

K/DOQI. Results: During the RP, 123 vascular access opera-

tions (0.71 per patient year) were performed because of

occlusion, whereas in the TMP 58 vascular access operations

(0.3 per patient year) were performed. During the TMP, 298

angiographic measurements were performed (1.6 per patient

year) in the RP 177, (1.0 per patient year). In the TMP, 1652

access flow measurements were performed. In order to prevent

one shunt occlusion, 21 access flow measurements had to be

performed. Total costs in the TMP (summary of angiography,

angiography and PTA, hospitalization days, and operation costs)

are reduced with 31% compared to the RP; costs per patient

year in RP: E2315. Costs per patient year in TMP: E1606.

Conclusion: By means of a shunt surveillance program (based

on access flow measurement), if necessary followed by

angiography, it is possible to reduce the number of acute vas-

cular access occlusions. Although a shunt surveillance program

may take up a lot of time for the nursing staff, the beneficial

effects, lower costs, and reduced morbidity for the patients

outweigh this effort.

Preliminary experience with a new design for atunneled, cuffed catheter for hemodialysis

Bousquet, G.C. Saints Memorial Medical Center, Lowell, MA.

Purpose: The use of tunneled, cuffed central venous catheters

for hemodialysis is associated with poor flow, thrombosis, and

infections due to the transcutaneous nature of these devices. A

new design for a sutureless, tunneled cuffed catheter was eval-

uated in hemodialysis patients to determine the effect of its

design on the incidence of exit site infection. Methods: A poly-

urethane conduit with a uniquely designed cuff and subcuta-

neous skirt covered with Dacron velour was attached to

standard double lumen central venous catheters. Seven (7)

Ash catheters and one (1) Tesio catheter were fitted with the

overtube and skirt and implanted in eight (8) patients under-

going routine hemodialysis. Patients were monitored for exit site

infection, tunnel infection, bacteremia, cuff extrusion, and ser-

osanguineous exudate. Results: Catheters were implanted for 6

to 26 weeks. All catheters remained patent and no cases of

bacteremia were observed. There was no evidence of exit site

or tunnel infection, and no reported serosanguineous exudate

from the exit site. Exit site care consisted of soap and water

cleansing by the patient. Patients were able to shower or bathe 4

weeks post-implant. Conclusions: The new design for a subcu-

taneous cuff and skirt appears to inhibit exit site infection and

other common complications of central venous catheters.

Sodium citrate as a capping for permacaths

Scott G.E. Commonwealth Dialysis Center, Greenfield, WI.

Purpose: Tunneled catheters as chronic dialysis access is a reality

of chronic hemodialysis. Infection of the catheter is an unavoid-

able complication. We researched the possibility of using Na

Citrate as capping because of its anticoagulant effects and bacter-

icidal properties. Methods: Rate of infections per 1000 calendar

days with heparin capping was recorded for an eight month

period before using Na Citrate. Flows <300 ml/min via catheters

were also recorded for an eight month period before Na Citrate

use, using treatments per 1000 calendar days. Both these para-

meters were recorded for an eight month period following the

initiation of Na Citrate 4% for all catheters. Results: Our infection

rate using heparin was 2.2 infections per 1000 catheter days.

Infection rate after use of Na citrate was 1.2 infections per 1000

calendar days. Catheter flows <300 were 5.6 per 1000 calendar

days using heparin, and 9.2 per 1000 calendar days after use of

Na Citrate. There were no reactions related to Na Citrate, and no

symptomatic hypocalcemia. Conclusions: Na Citrate is effective

at reducing the number of infections when used as a capping

solution for tunneled catheters. Na Citrate–capped catheters had

more frequent declines in QB compared with heparin capping.

Because of the availability of anti-thrombolytic agents to preserve

catheter patency, Na Citrate makes a safe option as a capping

agent for long-term catheter capping.



Retrospective analysis of adequacy of hemodialysisusing the Cannon catheter (Arrow International)

DaVanzo W.J. Saint Simons Island, GA.

Currently there is no published data using the Cannon catheter.

Our purpose was to confirm adequacy of hemodialysis using the

Arrow Cannon catheter. This retrospective study used patients

from one nephrology practice, utilizing two dialysis centers. All

patients in a two year period meeting inclusion/exclusion criteria

referred for tunneled catheter placement were included. All

catheters were placed by interventional nephrologist using

ultrasound for vein cannulation and fluoroscopy for placement

confirmation. Pump speed (Qb), venous and arterial pressures,

Kt/V, urea reduction ratio (URR), and dialysis prescriptions/

adherence to the prescription were reviewed at baseline and

monthly for six months. Catheter removal or six months were

the study endpoints. Complications were evaluated from time of

insertion throughout the study period. 38 patients were enrolled

in the study. All patients were treated in the outpatient setting.

Insertion outcome was successful in all 38 patients. The average

dialysis prescription was approximately 400 ml/min, 3.7 hours,

and 3 days a week. The mean average pump speed for all months

evaluated exceeded the K/DOQI guideline of 300 ml/min. by 67.9

–101.4 ml/min. The differences were significant with p< 0.01.

The mean Kt/V and URR% data for each month evaluated

exceeded the K/DOQI guideline values of 1.2 for Kt/V and 63%

for URR% by between .34–.24 and 8%–10%, respectively; the

differences were all at a significant level with p< 0.01. Mean

arterial pressures for all months evaluated ranged from �218.6

to �238.1, and venous pressures averaged between 179.8 to

213.7. Only three patients experienced late complications (all of

which were infections) and no patients required hospitalization

post complication. Two were bacteremic; the other had tunnel

infection without positive blood cultures. This is the first

retrospective study to evaluate the adequacy of hemodialysis

with the Cannon catheter. Our study showed that flow rates

and adequacy of hemodialysis can be reached using the Cannon

catheter, with minimal complications.

Kinetics, dialysis systems, adequacy

Postdialysis rebound in a case of acute methanolpoisoning

Bhakta N.R.1, Grabe D.W.1,2, Haqqie S.2, John L.1 Albany College of

Pharmacy1, Div. of Nephrology, Albany Medical College2, Albany,

New York.

Introduction: Methanol poisoning can lead to complications

that include metabolic acidosis, visual impairment and death.

Treatment options include ethanol, fomepizole, and hemodia-

lysis (HD). Objective: To report on the occurrence of post

dialysis methanol rebound during treatment. Method and

Findings: A 40-year-old male with a history of schizophrenia

and suicide attempts presented to the emergency room after

reportedly ingesting 1 quart of windshield washer fluid. The

patient presented with a preliminary blood chemistry of

methanol 390 mg/dL, ethanol 48 mg/dL, glucose 93 mg/dL, Na

138 meq/L, K 3.8 meq/L, Cl 98 mmol/L, CO2 26 mmol/L, urea

16 mg/dL, creatinine 1.2 mg/dL, and an anion gap of 14 mmol/L.

The patient was started on 1360 mg of fomepizole (12:50

AM) followed by HD for 4 hours. A second dose of fomepizole

(900 mg) was administered at 8:00 AM. In addition, another HD

session was started at 12:00 PM and continued for 4 hours. A

third dose of fomepizole (700 mg) was administered at 8:50 PM.

Finally, a third HD session was started the next day at 3:05 PM

and lasted 3 hours. Table 1 illustrates methanol levels in relation

to each HD session. Findings: Methanol concentration after the

first HD increased from 100 mg/dL to 127 mg/dL (27%) in

5 h 20 m. It also increased from 35 mg/dL to 50 mg/dL (43%)

14 h 45 m after the second HD. Conclusions: Close attention

must be paid to the potential for post dialysis methanol

rebound. It is recommended that methanol levels continue to

be monitored for several hours after HD.

Estimation of backfiltration flow rate in commerciallyavailable high flux dialyzers: Importance of water

purification system for dialysate

Mineshima M.*, Ishimori I.*, Akiba T.** Dept. of Clinical

Engineering* and Dept. of Blood Purification, Kidney Center**,

Tokyo Women’s Medical University, Tokyo, Japan.

Several types of high flux dialyzers were developed and intro-

duced for clinical applications to improve solute removal effi-

ciency. In these dialyzers, internal filtration/backfiltration (IF/

BF) is induced by pressure drop of blood and dialysate flow in a

countercurrent manner under less net filtration. Higher IF/BF

flow rate increased convective transport of the solute in addition

to diffusive transport. In previously published papers, we

reported the effects of IF on solute removal efficiency of the

dialyzer during an analytical and an experimental study and the

measurement of the internal filtration flow rate (QIF) by Doppler

ultrasonography. Average blood flow rate (QBav) at a cross-

sectional plane was measured by pulse Doppler and the long-

itudinal QBav profile along the dialyzer was obtained using a

probe slider that can move the probe in parallel along the

dialyzer. This is a suitable method for a bedside monitoring of

the IF/BF flow rate of dialyzers because it is noninvasive to the

patient and produces reliable data with higher reproducibility.

Internal backfiltration flow rate (QBF) in six types of

Table 1 Methanol levels before and after each hemodialysis

Start HD #1(2:40 AM)

End HD #1(6:40 AM)

Start HD#2(12:00 PM)

End HD#2(4:00 PM)

Next Day(6:45 AM)

Methanol(mg/dL)

324 100 127 35 50

Rebound 27% 43%



commercially available high flux dialyzers, having a higher

50 ml/min of b2-microglobulin clearance (CL-b2 m), were

examined by Doppler ultrasonography under 10 ml/min/m2 of

net filtration flow rate. As a result, a wide range of QBF value,

12.1–28.4 ml/min, was obtained among those dialyzers. It

means a fair amount of BF, 2.9–6.8 liter per session, occurs in

a typical hemodialysis treatment. Strict management of

dialysate purification is required for a dialyzer with a relatively

larger BF. On the other hand, no correlation between the CL-

b2 m value and the QBF value was seen because the CL-b2 m

value depends on not only the IF/BF flow rate but also diffusive

property of the membrane. The BF flow rate in every dialyzer

should be examined to avoid suffering from the invasion of

endotoxin and its fragment for safety.

The effect of dialysis needle size on hemodialysisadequacy

Kim Y.O., Song W.J., Park J.A., Yoon S.A., Kim Y.S., Chang Y.S.,

Bang B.K. Dept. of Int. Med., College of Medicine, The Catholic

University of Korea, Seoul, Korea.

Objective: Dialysis adequacy indexed by Kt/V in hemodialysis

(HD) patients is recommended as a single pool Kt/V at least 1.2

per session thrice weekly. But many patients cannot achieve this

adequacy target. Although dialysis time is the most important

factor influencing Kt/V, it is difficult to prolong dialysis time in

practice because of its economic impact and poor patient com-

pliance. This study was performed to investigate the effect of

increasing dialysis needle size on dialysis adequacy in HD

patients. Methods: This study enrolled 73 patients receiving

HD thrice weekly for more than 3 months with arteriovenous

fistula (AVF) or graft in a single center. Dialysis blood flow rate

was 200 ml/min in 12 patients, 250 ml/min in 32 patients, and

300 ml/min in 29 patients. Surface area of dialyzer was 1.2 m2 in

56 patients and 1.6 m2 in 17 patients. We first performed HD

using a 16-gauge needle. Then we increased needle size up to

15-gauge without change of any other dialysis conditions such

as blood and dialysate flow rates, dialysis time, or distance

between needle insertion sites. We compared compression

time after removing the needles, venous dialysis pressure

(VDP), Kt/V, and urea reduction ratio (URR) between these

two methods. Results: The mean age was 54� 13 years and the

number of patients with diabetes mellitus was 27 (37%). Fifty-eight

patients (79.5%) have native AVF. Mean Kt/V at HD method using a

15-gauge needle was higher than at HD method using a 16-gauge

needle (1.30� 0.18 vs. 1.23� 0.18, p< 0.001). URR at HD

method using a 15-gauge needle was also higher than at HD method

using a 16-gauge needle. In contrast, VDP at HD method using a

15-gauge needle was lower than at HD method using a 16-gauge

needle (88� 22 mmHg vs. 118� 28 mmHg, p< 0.001). There

was no difference in compression time between the two methods.

Conclusion: This study suggests that increasing dialysis needle

size is a safe and effective method in improving dialysis adequacy

without increasing blood flow rate or dialysis time.

Consideration of free coagulant hemodialysis withinour facility

Ishida Y.1, Kasahara M.2, Sakaji I.1, Yoshikawa M.1, Nitta T.1,

Matsushima Y.1, Iwatani Y1, Yoshimoto A.2, Suzuki T.2 Department

of Clinical Engineering1 , Department of Nephrology2 Kobe General

Hospital, Kobe, Japan.

Purpose: Performed free coagulant hemodialysis to patients

having hemorrhage with the hope to avoid aggravation of

bleeding caused by anticoagulant agent from dialysis. Method:

Examined 19 cases of patients with bleeding tendency, whether

it is possible to perform free coagulant hemodialysis by using

PAES membrane, EVAL membrane, PS membrane, Cellulose

triacetate membrane and Vitamin-E modified-dialysis mem-

brane. Result: With PAES membrane, the result showed a

non- blockade rate of 91% after four hours and 100% after

two hours. Therefore, blockade was prevented with a fairly

high rate. In cases of blockade, most of them were possibly

avoidable with a little contrivance as the reason were lack

of establish blood flow rate, faulty position of a needle, etc.

Conclusions: By using PAES membrane, it was possible to

perform free coagulant hemodialysis. In order to completely

have no blockade of blood lines in the future, we must strive

further on.

A case of plasma component exchange usingmembrane plasma separator EVACURETM

Sakaji I.1, Kasahara M.2, Ishida Y.1, Yoshikawa M.1, Nitta T.1,

Matsushima Y.1, Iwatani Y.1, Yoshimoto A.2, Suzuki T.2

Department of Clinical Engineering1, Department of Nephrology2

Kobe General Hospital, Kobe, Japan.

Objective: We report a patient with urosepsis, Lleptospira

syndrome, TTP-HUS syndrome, fulminant hepatic failure,

vasculitis syndrome and TSS treated with plasma compo-

nent exchange. Methods: Conditions for plasma component

exchange were membrane plasma separator (Evacure EC-

3A), substitute fluid (3 % albumin solution), blood flow

rate (150 mL/min), filtration rate (30 mL/min), quantity of

substitute fluid (4,600 mL) and anticoagulant (nafamostat

mesilate 30 mg/hr). Result: Plasma component exchange in

combination with hemodiafiltration induced a rapid remis-

sion of both hepatic toxicity and renal failure caused by

streptococcal sepsis. Membrane plasma separator evacure

EC-3A allowed the use of 3% albumin solution as substi-

tute fluid. Colloid osmotic pressure temporarily increased

after the treatment, but within 24 hours, returned to the

same level as before the treatment. Conclusion: Plasma

component exchange using a membrane plasma separator

may allow the use of albumin instead of fresh frozen

plasma (FFP) as substitute fluid, which results in a lower

risk of infection.



The effects of exercise during hemodialysis onadequacy

Caner, C., Ozlem S., Yavuz Y., Ali Riza S., Ozlen P., Beyhan I.,

Sema O. Camsari Taner Dokuz Eylul University, Izmir, Turkey.

Pedalling during hemodialysis (HD) has been shown to

increase solute clearance in a previous study. In the present

study, we aimed to test whether an easy to perform exercise

program, not requiring a special device, could yield similar

outcomes. Fifteen HD patients with the mean age of

48.4� 3.8 years were enrolled into the study. Patients with

significant access recirculation (>10%), moderate to severe cor-

onary artery disease, moderate to severe heart failure, severe

chronic obstructive lung disease, and history of lower extremity

surgery during last three month period were excluded. All

patients were studied on two consecutive HD sessions with

identical prescriptions. At the first session, standard HD was

applied without exercise, whereas in the second session lower

extremity exercise of 30 minutes duration was added. Reduction

rates and rebound for urea, creatinine, and potassium and Kt/V

were calculated. Wilcoxon signed rank test was applied in

analysis and p< 0.05 was accepted as significance level. All

patients completed the study. When both sessions were com-

pared, mean arterial blood pressure (97� 3 mmHg vs

120� 4 mmHg, p< 0.001) and heart rate (77� 1 beats/min vs

92� 3 beats/min, p< 0.001) were higher in the exercise group.

On the other hand, urea reduction rates, rebound values of urea,

creatinine, and potassium were similar in both groups. Conclu-

sion: In the study, we did not observe any changes in solute

rebound and clearance with the exercise. Shorter duration of the

exercise may be the explanation of failure to achieve desired

outcomes. Increasing patients’ tolerance and fitness levels by

means of steadily increasing exercise programs may be of help.

Additionally, mode of exercise may also be responsible for

different outcomes.

Changing hemodialysis machine data into a usablepatient care with Diascan

Paille L., Nikl K. Surrey Memorial Hospital, Surrey BC Canada.

K/DOQI has set the national standard of adequacy in dialysis.

Clinical practice assesses these standards using ‘routine’ blood

work schedules that vary from every 4–6 weeks and calculates

these results using different urea kinetic formulas. This variance

may result in under-dialysis of our patients that may not be

detected until the next routine blood work. Comparing Kt/V

blood work results using ‘snapshot’ laboratory results versus

total run trending using Integra Diascan monitoring may help

us define adequacy and may identify potential cost savings to

the medical system and the hemodialysis patient. Diascan offers

more than on-line Kt/V monitoring of clearances; it also reports

patient serum plasma conductivity. Serum plasma monitoring

helps to identify potential excess fluid gains which may com-

promise dialysis treatments leading to poor clearances, which in

turn leads to increased morbidity and mortality, as well as

increasing costly dialysis interventions and potential emergent

treatments. The small sampling of patients compared use a

variety of vascular accesses and were examined for some of the

barriers to effective ‘snapshot’ monitoring of Kt/V or PRU versus

trending adequacy to explore the potential benefits and efficacy

of the data obtained.

Full fit sanitary membranes

Brown R.H. Trisep Corporation, Goleta, CA.

The dialysis industry has become increasingly concerned about

microbial contamination of reverse osmosis (RO) systems. Con-

ventional membranes cannot be thoroughly sanitized due to the

use of a peripheral seal which creates a stagnant area between

the pressure vessel inner diameter and the membrane outer area.

Cleaning procedures cannot adequately sanitize this annular

area and control microbiological contamination. Sanitary full

fit membranes ensure that a percentage of the feed water is

free to bypass or flow around the outside of the membrane

element to assure the annular area is continuously flushed and

that there are no stagnant areas not exposed to CIP cleaning and

sanitizing procedures. For this reason, the dairy industry has for

many years used sanitary membranes, which are required by

and approved by the USDA. Of the several full fit sanitary

membranes available, the cage wrap, net wrap, and tail wrap,

only the hard shell TurboCleanTM eliminates the inconsistent

bypass flows inherent in the other designs, controlling the

distribution of cleaning and sanitizing agents and providing

better cleaning and lower microbial levels.

Factors affecting concentration of citrate in dialyzerswhen using citrate hemodialysate in vitro

Baosong G., Ning N., Ganglian Y., Lin G., Liangqi W., Ruijun G.

Second Hospital of Xi’an Jiaotong University, Xi’an, China.

Objective: To observe the factors that affect the citrate con-

centration in hollow fiber when using citrate hemodialysate.

Methods: By modeling hemodialysis in vitro, we studied 6

types of hemodialyzers at different blood flow rates, different

dialysate flow-rate, and different fluids in vitro to detect the

citrate concentration in hollow fiber. Results: The citrate

concentrations in different hemodialyzers were F60> FB-

130UGA>GA-HP130> F6> FB-130AGA>WS-70 in turn.

The concentrations at different blood flow-rates were different

100 mL/min> 200 mL/min. Conclusions: The concentration

of citrate in hollow fiber is affected by different types

of hemodialyzers and different blood as well as dialysate

flow-rates. To achieve anticoagulation when using citrate

hemodialysate, we must select suitable hemodialyzer such as

FB-130UGA.



Dialyzer reuse and clinical outcomes—A 3-yearcomparison between high flux polysulfone and

polyflux1 dialyzers

Sorrill M.A. Blessing Hospital, Renal Dialysis, Quincy, IL.

Purpose: This study evaluated improvements in dialyzer reuse

parameters and clinical outcomes associated with a CQI project

in a hospital-based dialysis center in which high flux polysul-

fone dialyzers were replaced with high flux Polyflux1 dialyzers

(GAMBRO1 Renal Products). Methods: Dialyzers were repro-

cessed using a Renatron1 II Dialyzer Reprocessing System in

conjunction with Renalin1 sterilant (Minntech Corp.). Rena-

log1 RM software was used to track dialyzer reprocessing rates

and failures. Reasons for dialyzer failure included inadequate

dialyzer volume; excess pressure; appearance; clotting during

use; and maximum number of uses reached. The average

number of dialyzer reuses with polysulfone dialyzers between

January and June 2002 were compared to that achieved

with Polyflux1 dialyzers for the same periods in 2003 and

2004. Analysis periods were separated to avoid the impact of

dialyzer transition on clinical parameters. Achievement of

URR goals during these same periods was likewise compared.

Results: Transition from polysulfone to Polyflux1 dialyzers was

associated with a >40% increase in average number of reuses

between 2002 and 2003 and a >63% increase comparing the

2002 and 2004 periods. During the 2002 analysis period with

polysulfone dialyzers the target URR of 65% was achieved in

approximately 75% of hemodialysis patients; this increased to

nearly 95% with Polyflux1 dialyzers in both the 2003 and 2004

periods, despite more reprocessing of these dialyzers.

Conclusions: These results demonstrate an improvement in

both reuse efficiency and clinical outcomes associated with

Polyflux dialyzers. Identifying clinical products through CQI

studies that provide an economic and clinical advantage plays

an important role in the success of hospital-based hemodialysis.

Tandem dialyzers with dual monitors to meet Kt/Vtargets

Sridhar N., Hurst C., Hayes P. KaleidaHealth, Buffalo, NY.

Objective: A large body mass and/or a poorly functioning vas-

cular access predispose to inadequate Kt/V. Double dialyzers in

parallel and tandem have been shown to enhance Kt/V to levels

recommended by K/DOQI. We experienced difficulties with

unintended excessive ultrafitration (UF), positive transmem-

brane pressure (TMP)-triggered pump stoppage, need for large

volume saline infusion (inflating Kt/V), and a high incidence of

clotting of the second dialyzer in tandem. Since blood and

dialysate flow rates are higher in the tandem configuration,

Kt/V should be theoretically higher. We developed a technique

of using the tandem configuration with two monitors in which all

the UF could be limited to the second dialyzer, the TMP of the

two dialyzers independently controlled, TMP reversal elimi-

nated, and saline infusion and unintended UF minimized.

Methods: 3 large male patients with AV grafts (AVG) and 2

with tunneled catheters (TC) had 7 treatments (with Kt/V and

URR calculated using the stop-flow technique in the last 5)

sessions of each of single, double parallel, and tandem config-

urations. Blood (Qb) and dialysate-flow (Qd) were halved with

Y-connectors in the parallel configuration. Qb through both

dialyzers and Qd through the second were controlled with the

first monitor and Qd (TMP set to near zero) through the first

dialyzer controlled with the second monitor using recirculating

saline through its blood pump (with the ‘‘venous’’ pressure

adjusted using an air-filled syringe) in the tandem configuration.

The patient’s blood did not circulate through the blood-pump of

the first machine. Qd was 500 ml/min through each dialyzer in

the single and tandem and 250 ml/min in the parallel config-

urations. Processed blood volume (dialysis time) was exactly

85 L with AVG and 60 L with TC. Heparin dosage was constant.

ANOVA, 2� k tables, and Neuman-Keuls test were used in

analyzing data. Results: Mean Kt/V (%URR) increased from

1.15 (62) with single to 1.35 (68) with parallel (p< 0.02) and

1.48 (71) with tandem (p< 0.001) dialyzers in patients with

AVG but not TC [1.05 (58), 1.02 (55), and 1.25 (64) with

single, parallel, and tandem, respectively]. Tandem dialyzers

met targets for URR (p< 0.001) and Kt/V ( p< 0.05) more fre-

quently than parallel with AVG but not TC. Conclusions: Tan-

dem dialyzers with 2 monitors are more successful than parallel

dialyzers in delivering target Kt/V and URR when Qb is not

compromised.

Impact of flow and surface area on middle moleculeclearance

Eloot S.1, De Vos J.Y.2, Hombrouckx R.2, Verdonck P.1 1Institute

Biomedical Technology, Ghent University, Belgium, 2Dialysis Unit,

AZ Werken Glorieux, Ronse, Belgium.

Urea is still clinically applied as standard marker to quantify

dialysis adequacy. The removal of middle molecules has how-

ever been proven in some studies to have a long-term effect on

mortality. Therefore, the present study is aimed at investigating

the impact of blood and dialysate flow, and membrane surface

area on middle molecule removal in low flux Fresenius F6HPS

dialyzers. Blood and dialysate flows were varied within the

clinical range of 300–500 mL/min and 500–800 mL/min,

respectively, while ultrafiltration rate was kept constant at

0.1 L/h. Single pass tests were performed in vitro in a single

dialyzer (3 tests) and in serially (5 tests) and parallel (3 tests)

connected dialyzers. The blood substitution fluid consisted of

bicarbonate dialysate in which radioactive labeled vitamin B12

(MW1355) was dissolved. Middle molecule concentrations of

samples taken at the inlet and outlet blood line were derived

from radioactivity measurements and were applied to calculate

the dialyzer clearance as well as the reduction ratio. For the

latter, the surrogate middle molecule vitamin B12 was assumed

as distributed according to a two-pool kinetic model. Adding



a second dialyzer in series or parallel ameliorates significantly

overall dialyzer clearance and reduction ratio, except for the

highest applied blood flow rate of 500 mL/min. Better solute

removal is also obtained with higher dialysate flows, while the

use of higher blood flows seemed only advantageous when

using a single dialyzer. Analysis of the ultrafiltration profiles

in the different configurations illustrated that enhancing the

internal filtration rate ameliorates the convective transport of

middle molecules. In conclusion, adequate solute removal

results from a number of interactions, as there are, blood

and dialysate flow rates, membrane surface area, filtration

profile, and concentration profiles in the blood and dialysate

compartment.

Impact of geometrical fiber dimensions on dialyzerefficiency

Eloot S.1, Vierendeels J.2, Verdonck P.1 1Hydraulics Laboratory,2Fluid Mechanics Laboratory Institute Biomedical Technology,

Ghent University, Belgium.

While dialyzer manufacturers only provide information about

their products as a black box, this study aimed at optimizing

dialyzer geometry by looking in detail at transport processes

and fluid properties inside the dialyzer using numerical

modeling. A three-dimensional computer model of a single

hollow fiber with its surrounding membrane and dialysate

compartment was developed. Different equations govern

blood and dialysate flow (Navier-Stokes), radial filtration

flow (Darcy), and solute transport (convection-diffusion).

Blood was modeled as a non- Newtonian fluid with a viscosity

varying in radial and axial direction because of the influence

of local hematocrit, diameter of the capillaries, and local shear

rate. Dialysate flow was assumed as an incompressible,

laminar Newtonian flow with a constant viscosity. The

permeability characteristics of the asymmetrical polysulphone

membrane were calculated from laboratory tests for forward

and backfiltration. The influence of the oncotic pressure

induced by the plasma proteins was implemented as well as

the reduction of the overall permeability caused by the

adhesion of a protein layer on the membrane. Urea (MW60)

was used as a marker to simulate small molecule removal,

while middle molecule transport was modeled using vitamin

B12 (MW1355) and inulin (MW5200). The corresponding

diffusion coefficients were determined by counting for the

fluid and membrane characteristics. Fiber diameter and length

were changed in a wide range for evaluation of solute removal

efficiency. The presented model allowed us to investigate the

impact of flow, hematocrit, and capillary dimensions on the

presence and localization of backfiltration. Furthermore,

mass transfer was found enhanced for increased fiber lengths

and/or smaller diameters, most pronounced for the middle

molecules compared to urea.

Effect of dialyzer reprocessing on glucosehomeostasis

Ibrahim M.A., Labib B., Sallam* T., Sarhan I., El-Damasy H.

Departments of Internal Medicine, Nephrology and Clinical

Pathology*, Faculty of Medicine, Ain Shams University, Cairo, Egypt.

This study was designed to investigate the possible effect of

dialyzer re-use on glucose hemostasis. Twenty patients with

end stage renal failure (including ten non insulin dependent

diabetes mellitus [NIDDM]) on thrice weekly hemodialysis

(using glucose free dialysate), were studied by serial assessment

of blood glucose, C-peptide, interleukin 1-B (IL-IB), Ca, Na and

K at zero, 1 and 4 hours (end of dialysis) during hemodialysis

on new, and then on re-used (first) cuprophane dialyzers. Our

results showed significant rise of C-peptide, IL-1B with drop of

blood glucose in first hour sample (and was symptomatic in

some diabetics) in both groups when using new dialyzers but

these changes were less marked and totally asymptomatic when

using reprocessed dialyzers. In addition there was a significant

positive correlation between IL-1B level and C-peptide at 1 and

4 hour samples and negative correlation between IL-1B and

blood glucose at 1 and 4 hour samples.

Conclusion: Through the effect of IL-1B on insulin release

curophane dialyzers can affect glucose homeostasis especially

in diabetics and hypoglycemia might be part of the first use

syndrome. It may be recommended that measurement of glucose

effect of dialysis membrane on glucose homeostasis might be an

important parameter of membrane bioincompatibility.

Clearance of small molecules in different dialyzerflow configurations

Eloot S.1, De Vos J.Y.2, Hombrouckx R.2, Verdonck P.1 1Institute

Biomedical Technology, Ghent University, Belgium, 2Dialysis Unit,

AZ Werken Glorieux, Ronse, Belgium.

To overcome problems of insufficient clearance, multiple dialy-

zers may be placed in series or in parallel. The present study

aimed to investigate in vitro the overall clearance of small

molecules in different dialyzer configurations in which mutual

flow directions were changed.

Single pass tests were performed with low flux Fresenius F6HPS

dialyzers placed in series (12 tests), in parallel (6) and in

single use (2). As blood substitute, either high concentrated

(45 mS) bicarbonate dialysate (AB solution – MW20-180) or a

trisodiumphosphate (Na3PO4 – MW395) concentration (30 mS)

was used. Standard blood and dialysate flows of 250 and

500 mL/min, respectively, were applied. Furthermore, clearance

was derived from conductivity measurements in the inlet and

outlet bloodline, correcting for the overall ultrafiltration rate of

0.5 L/h (AB) and 0.1 L/h (Na3PO4).

Compared to the standard setup using a single dialyzer with

counter current flows, clearance increases by 3 to 8% (AB) and

by 15 to 18% (Na3PO4) using two dialyzers in parallel and in



series, respectively. With co-current flows in a serial dialyzer

set up, clearance increases by 16% (AB) and 22% (Na3PO4)

compared to the single dialyzer use. Changing subsequently the

counter current flows to co-current in one and both dialyzers in

series, the overall clearance decreases by 2 to 9%, respectively, for

the AB solution, and by 8 to 15% for the Na3PO4 concentration.

With respect to the parallel dialyzer setup, a split dialysate flow

(250 mL/min in each dialyzer) counter current to the blood flow,

increases the clearance by 4 and 12%, respectively.

In conclusion, overall clearance is most ameliorated using two

dialyzers in series with counter current flows.

Urea kinetics are not representative for the behaviorof other small and water-soluble compounds

Eloot S.1, De Smet R.2, Torremans A.3, De Wachter D.1,

Marescau B.3, De Deyn P.P.3, Verdonck P.1, Vanholder R.2.1Institute Biomedical Technology, Ghent University, Belgium,2Nephrology Section, Ghent University Hospital, Belgium3Laboratory of Neurochemistry, University of Antwerp, Belgium.

Scanty data suggests that large solutes show a kinetic behavior

that is different from urea. The question investigated in this

study is whether other small water-soluble solutes such as

some guanidino compounds show a kinetic behavior compar-

able or dissimilar to that of urea.

This study included 7 stable conventional hemodialysis patients

without residual diuresis undergoing low flux polysulphone

dialysis (F8 and F10HPS). Blood samples were collected from

the inlet and outlet blood lines before the dialysis session, after

5, 15, 30, 120 minutes, and immediately after discontinuation

of the session. Plasma concentrations of urea, creatinine (CTN),

creatine (CT), guanidinosuccinic acid (GSA), guanidinoacetic

acid (GAA), guanidine (G), and methylguanidine (MG)

were used to calculate corresponding dialyzer clearances. A

two-pool kinetic model was fitted to the measured plasma

concentration profiles, resulting in the calculation of the

perfused volume (V1), the total distribution volume (Vtot), and

the inter-compartmental clearance (K12); solute generation and

ultrafiltration were determined independently.

No significant differences were observed between V1 and K12 for

urea (6.4� 3.3 L and 822� 345 mL/min) and for the guanidino

compounds. However, with respect to Vtot, GSA was distributed

in a smaller volume (30.6� 4.2 L) compared to urea

(42.7� 6.0 L� P< 0.001), while CTN, CT, GAA, G, and MG

showed significantly larger volumes (54.0� 5.9 L,

98.0� 52.3 L, 123.8� 66.9 L, 89.7� 21.4 L, and

102.6� 33.9 L, respectively). These differences resulted in mark-

edly divergent effective solute removal: 67% (urea), 58% (CTN),

42% (CT), 76% (GSA), 37% (GAA), 43% (G), and 42% (MG).

In conclusion, the kinetics of the guanidino compounds under

study are different from that of urea; hence, urea kinetics are not

representative for the removal of other uremic solutes, even if

they are small and water-soluble like urea.

Quotidian dialysis

Survival in 221 patients treated by short dailyhemodialysis for 315 patient years

Kjellstrand C.1, Ting G.2, Traeger J.3, Sibai-Galland R.4, Blagg C.R.5,

Young B.5 Aksys Ltd, Lincolnshire IL1, El Camino Dialysis, Mountain

View, CA2, Claude Bernard University, Lyon, France3, AURAL – Lyon4,

France, NW Kidney Center and U of Washington, Seattle , WA5.

Daily hemodialysis greatly improves clinical and biochemical

parameters and patient quality of life compared to conventional

thrice weekly dialysis. However, mortality statistics are lacking

as most centers providing daily dialysis have treated only a small

number of relatively selected patients for relatively short obser-

vation times. To study patient survival we pooled experience

from three sources: 51 French and 128 U.S. patients selected for

daily home hemodialysis and 42 U.S. patients selected for short

daily center hemodialysis because of many medical complica-

tions and cardiovascular instability. Results were compared to

age-matched patients from the USRDS 2003 data base. The age

of the patients was 51� 16 (18–89) years; 29% were female;

they had 3.3� 1.8 comorbidities (twice that of USRDS patients);

32% had diabetes or hypertension as cause of renal disease

(USRDS patients 70%); blood access was 61% fistulae, 25%

grafts, and 14% CV-catheters. Mean duration of ESRD treatment

at start of short daily hemodialysis was 6� 7 years. The obser-

vation period was 315 patient years. Patients had been on daily

hemodialysis for a mean of 17� 18 (0–92) months and 11

patients were observed for more than 5 years. 35 of the 221

patients died (16%); deaths were 111 per 1,000 patient years

(53% of expected) and 5-year cumulative survival was 63%

compared to 32% for USRDS patients. Five-year survival was

0% in patients with >3 comorbidities, 75% in patients with <3

comorbidities (p< 0.0001), and in patients aged <53 years was

80% vs. 50% in patients aged >53 years (p¼ 0.0007). On Cox

stepwise hazards analysis, comorbidity alone predicted survival

when used with age. Comorbidity >3 HR¼ 6.00 (95% CI 2.2

–16.3). Conclusions: It is difficult to do survival comparisons

between patient groups. However, these daily dialysis patients

were age-matched with patients from the USRDS database.

There were fewer diabetic and hypertensive patients but the

comorbidity index was twice that of USRDS patients. Survival,

both deaths per 1,000 patient years and cumulative count was

approximately twice that reported by the USRDS and strongly

suggests superior survival with short daily hemodialysis com-

pared to thrice weekly conventional dialysis.

106 Patient-years experience with the Aksys PHDSystem for quotidian home hemodialysis

Kjellstrand C.M.1, Blagg C.R.2,3, Young B.3, Bower J.4,

Twardowski Z.J.5 Aksys Ltd, Lincolnshire IL1, U. Washington,

Seattle WA2, Northwest Kidney Centers, Seattle, WA3, Jackson, MS4,

U. Missouri, Columbia, MO5.



The Aksys PHD System, designed to utilize ultrapure dialyzate

for quotidian hemodialysis at home, uses mechanical cleaning

and hot water sanitization of the blood, dialysate, and water

flow-paths from inlet to outlet. Since January 2000, it has been

used by 110 US patients and 8 UK patients for a total of 106

patient years and more than 30,000 dialyses runs. Of those

treated, 75 patients were male and 43 female; mean age was

52� 25 (range 22–82) years; 65% were white, 25% black, and

10% other; mean weight was 78� 20 (44–125) kg; the cause of

renal failure was primary renal disease (50%), hypertension

(24%), diabetes (19%), and other (4%). Dialysis access

included fistula (61%), graft (25%), and catheter (14%).

Patients had been on ESRD therapy on average of 6� 7 (0

–32) years when starting on PHD dialysis. As of August

2004, patients had dialyzed 11� 8 (1–52) months on the

PHD. Of those, 78 patients remained on the PHD, 12 were

transplanted, 10 died, 7 returned to conventional dialysis at

the end of the original study for the FDA and 7 for medical or

social reasons, 2 returned to quotidian dialysis on other equip-

ment, and 2 stopped during home dialysis training. Patients

dialyzed an average of 145� 27 min, 5.6� 0.6 dialyses/week

with a QB of 376� 45 ml/min and a QD of 545� 170 ml/min.

eKt/V was 0.68� 0.20 and weekly stdKt/V was 2.61� 0.52.

Mean dialyser reuse was 17� 14 times without significant

decline in urea clearance. 23/118 patients (19%) who came

to the PHD from quotidian dialysis on other equipment

thought the PHD twice as easy to use and experienced only

half as many episodes hypotension, cramps, headache, back-

ache, nausea, and arrhythmias (all p< 0.02). They were hospi-

talized only half as many days on the PHD. Cumulative patient

survival was 60% at 4 years, with 94 deaths/1,000 patient

years, relative risk 0.56 compared with age-matched patients

from the USRDS database. Conclusion: This large clinical

experience shows the PHD System is easier to use and delivers

smoother dialysis with better cardiovascular stability than

conventional dialysis machines. It easily fulfills the DOQI

guidelines for adequacy of dialysis, economizes on use of

dialyzers, tubing, and dialysate, results in less hospitalization,

and appears to result in superior patient survival.

A study of 8 hour long night dialysis with the AksysPHD dialysis system

Kjellstrand C.1, Blagg C.R.2, Ing T.S.3, Young B.2 1Aksys Ltd,

Lincolnshire IL, 2NWKC and U. Washington, Seattle, WA, 3Loyola U,

Chicago, IL.

The Aksys PHD system is designed for short quotidian

dialysis employing a 52-liter batch of ultrapure dialysate and

up to 30 in situ hot water reuses of the entire extracorporeal

circuit including a 40-liter physical cleaning before each dia-

lysis. Methods: We studied the effect of the 52-liter tank dur-

ing 108 long 5–8 hour dialysis 3.5–6 times/week in 5 patients

and one 50-liter patient simulator for 4 weeks. Phosphate

(PO4), beta-2 microglobulin (b-2), urea (BUN), and creatinine

(creat) were measured pre-, during, and post-dialysis 86 times

and in total dialysate 74 times during long dialysis. Tank

saturation, Kt/V, and monthly chemistries were also measured.

Results: Patient weight 76� 2 kg, QB 234� 23 ml/min, QD

498� 13 ml/min. Dialysate was recirculated 4.8 times during

8 hours.

Analyte Short Long dialysis p

Pre-BUN 70� 18 49� 15 <0.0001Pre-creat 12� 3 10� 2 <0.0002Pre-PO4 5.2� 1.5 4.1� 1.1 <0.003Pre-b-2 34.0� 5.3 27.8� 4.5 <0.0001

All patients on 8 hrs� 5 dialyses/week stopped phosphate bin-

ders within 3 weeks. eKt/V(urea) rose to 0.5 in one hour and

then slowly to 0.8 at 8 hours.

Weekly stdKt/V:

Dialyses/week/Hrs: 2 5 8

5 2.2 2.7 3.06 2.7 3.4 3.67 3.1 3.8 4.4

At 8 hrs the tank was 99� 8% saturated with BUN, 86� 12%

with creat, 77� 18% with PO4, and only 12� 5% with b-2.

Total removal per dialysis increased 2 gm BUN, 0.4 gm creat,

0.4 gm PO4, and 40 mg b-2. The decline per reuse in conductiv-

ity clearance was only 0.7� 1.2% during short and 1.4� 1.4%

during long dialysis (p¼ 0.11). There was no change in

monthly chemistries or hematologies. Discussion: The data

show that the Aksys PHD is very effective for long 8-hour

dialysis. The data for PO4 and b-2 are the same as reported for

conventional dialysis machines using 5 times as much dialysate,

and the weekly stdKt/V if the PHD is used every night is twice

the standard defined by K/DOQI. The exceptional cleanliness

and biocompatibility by way of the one-per-month reuse should

be a great advantage to patients. The full automatization saves

the patient one hour every night and 30 minutes every morning.

The PHD also economizes on filters and dialysate and is good

for the environment.

Nocturnal dialysis: Comparing six night/week withalternate night therapy

Mahadevan K.*, Pellicano R.z, Reid A.B.*, Kerr P.G.z and Agar J.W.M.*

*Geelong Hospital and zMonash Medical Centre, Victoria, Australia.

The biochemical, haemodynamic, clinical, and nutritional bene-

fits of nocturnal haemodialysis (NHD) compared with (c/w)

4 hr, 3/week conventional haemodialysis (CHD) are well known

and accrue by increasing dialysis time and frequency either for

8 hrs alternate night/week (NHD3.5) or for 8 hrs 6 nights/week

NHD (NHD6). However, there is little data yet comparing

NHD3.5 with NHD6. 13 NHD6 (8.15 hrs/night) were c/w 14



NHD3.5 (7.8 hrs/night), all with similar demographic profiles.

NHD6 had unrestricted diet and fluid intake but NHD3.5 needed

some restriction. Before (b) and after (a) HD phosphate (PO4)

control was ideal though bPO4 levels for NHD6 were lower

(1.64 mmol/l) c/w NHD3.5 (1.83 mmol/l). All NHD6 needed

PO4 supplementation c/w 2/14 NHD3.5 but 5/14 NHD3.5

needed PO4 binders c/w 0/13 NHD6. Both had normal blood

pressures with 3/14 NHD3.5 needing anti-hypertensives c/w 2/

13 NHD6. The bHb was 122.8 g/l (NHD6) c/w 127.7 g/l

(NHD3.5) and the balbumin was 38.3 g/l (NHD6) c/w 37.7 g/l

(NHD3.5). NHD6 had lower b blood urea (10.2 c/w 19.5 mmol/l)

and less interdialytic urea and creatinine fluctuation. NHD6

ultrafiltration rates (UFR) and intradialytic weight gains

(mean� SEM) were significantly lower (248� 22.7 ml/hr

and 2.03� 0.19 kg) c/w NHD3.5 (453� 34.6 ml/hr and

2.85� 0.27 kg): UFR p< 0.10. We conclude that NHD6 offers

the optimum biochemical, volume, and clinical outcome but

NHD3.5 still has a clear and major advantage over CHD and a

dual additional appeal to providers seeking home-based therapy

cost advantages and consumable expenditure control. A flexible

dialysis program should offer all the time and frequency options

of NHD but, in particular, should support NHD at a frequency

sympathetic to the clinical, rehabilitation, and lifestyle

aspirations of individual patients.

Beta-2-Microglobulin in nocturnal hemodialysis – Acomparative study in low and high flux dialysers

Reid A.B., Mahadevan K., Agar J.W.M. The Geelong Hospital, Victoria

Australia.

In end-stage renal failure, impaired renal catabolism leads to

retention of beta 2 microglobulin (ß2M), identified as the major

constituent of hemodialysis (HD) related amyloidosis. It has

been previously shown that, while using a high flux (HF) HD

membrane, nocturnal hemodialysis (NHD) with its increased

time and frequency provides a much higher clearance of ß2M

compared to conventional HD. We compared serum ß2M levels

between low flux (LF) and HF in a group of 9 NHD patients

who dialyse 8 hours 6 nights/week. Fresenius polysulfone LF

membrane size F6-F8 HPS dialyser were used for the first 15

months (mth) of NHD (SA 1.3–1.8 m2). Subsequently, polysul-

fone HF FX80 dialyzer were used (SA 1.8 m2). Blood flow and

dialysate flow rates were unchanged throughout the study. ß2M

levels were measured at 6, 12, 15 mth on LF and at 6, 12 mth on

HF. Albumin, homocysteine (Hcy), and phosphate (Phos)

levels were also recorded at these times. ß2M levels trended

upwards during the 15 mth on LF (36.6� 10.57 at 6 mth vs

47.1� 11.7 at 15 mth). On introduction of HF, there was a

significant fall in ß2M at 6 mth to 12.4� 3.5 (p< 0.003), while

ß2M levels were unchanged at 12 mth of HF. A downward trend

in Hcy levels with the use of HF was noted (12.9� 2.9 at

0 mth Vs 11.1� 3.7 at 12 mth). Plasma albumin and Phos

levels remained unchanged as did the use of Phos supplementa-

tion. Levels of ß2M continued to rise on NHD with LF,

indicating inadequate clearance. With the introduction of HF

there was a significant fall in ß2M levels consistent with

improved clearance. The implications of this are that ß2M

clearance may be time and frequency dependent only if dialyser

membrane flux is adequate.

Infections

Recurrent empyema due to Salmonella enteritidis in apatient on hemodialysis

Hung Y.M., Chou K.J., Chung H.M. Department of Internal

Medicine, Kaohsiung Veterans General Hospital, Taiwan.

Objective: Pleural involvement of salmonella infection is very

rare and we are not aware of any case of salmonella empyema in

hemodialysis patients. The purpose of this study is to report our

experience of recurrent empyema due to Salmonella enteritidis

with bacteremia in a patient on hemodialysis. Case report:

A 53-year-old woman with end stage renal disease, having

been on hemodialysis for 10 days, was brought to the emergency

department due to fever and shortness of breath for 2 days. Her

initial physical examination revealed diminished breathing

sound over right lung field. The chest radiographs disclosed

right pleural effusion and pleural fluid analysis included a

white cell count of 13800(N/L:95/5), LDH 2534 U/L, protein

2.7 g/dL, and sugar 10 mg/dL. Right side empyema was noted.

Sonography revealed splenomegaly. Salmonella enteritidis was

identified from the cultures of blood and pleural fluid. After

antimicrobial therapy with intravenous ceftriaxone for 2 weeks

and pleural pigtail drainage, fever subsided and pleural drainage

tube was removed. However, thoracoscopic debridement was

done later because of recurrent empyema within one week after

removing the drainage tube. Computed tomography revealed

pleural effusion, pericardial effusion, and splenomegaly, but

there was no evidence of aortic aneurysm formation or

infectious process of aorta. Overall the patient received 6

weeks of intravenous ceftriaxone treatment and 3 months of

oral ciprofloxacin. The follow-up CXR revealed minimal pleural

effusion. Conclusion: Nontyphoidal salmonella infection can

present with empyema and bacteremia in patients on hemo-

dialysis. Adequate drainage and antimicrobial therapy may be

necessary to treat such patients effectively.

Ten-year study of bacteremia in hemodialysispatients in a single center

Park J.A., Jung H.A., Yoon J.M., Kim Y.O., Yoon S.A., Kim Y.S.,

Kim S.Y., Chang Y.S., Bang B.K. Dept. of Int. Med., College of

Medicine, The Catholic University of Korea, Seoul, Korea.

Background: The incidence of infection in patients on chronic

hemodialysis in higher than that of the general population.

Infection is known to be a major cause of morbidity and



mortality in these patients. The vascular access is important for

hemodialysis, but infection through this route is the most com-

mon source of bacteremia and can be lethal to the patients.

Despite the high morbidity and mortality of bacteremia in

patients on chronic hemodialysis, the clinical characteristics of

bacteremia in hemodialysis patients is rarely reported yet in

Korea. Methods: We included 696 hemodialysis patients

from January 1993 to December 2003 at Uijongbu St. Mary’s

Hospital. We investigated incidence, source, causative organ-

isms, clinical manifestations, complication, and mortality of

bacteremia. We compared clinical factors, morbidity, and mor-

tality between arteriovenous fistula and central venous catheter

groups. Results: Total 52 cases of bacteremia occurred in 43

patients. The major source of infection was vascular access

(48%). Staphylococcus aureus was most common organism

isolated. Major complications were septic shock (9.6%),

pneumonia (9.6%), infective endocarditis (3.8%), and

aortic pseudoaneurysm (1.9%). Nine patients died from

septic shock (n¼ 4), aspiration pneumonia (n¼ 2), hypoxic

brain injury (n¼ 1), gastrointestinal bleeding (n¼ 1), and

rupture of aortic pseudoaneurysm. The central venous catheter

group (n¼ 22) had higher incidences of vascular access as

a source of infection (81.8% vs 23.3%, p< 0.001) and

staphylococcus as a causative organism (77.2% vs 50.0%,

p¼ 0.042) than the arteriovenous group. Conclusion: This

data shows that bacteremia causes high incidence of fatal

complications and mortality. Therefore, careful management of

vascular access as well as early detection of bacteremia is an

important factor for the prevention of infection and proper

antibiotic therapy should be started early.

High frequency of occult HCV infection in HDpatients

Barril G.1, Castillo I2, Arenas D.3, Rodriguez-Inigo E.2, Espinosa M.4,

Garcia Valdecases J.5, Selgas R.1, Carreno V.2 1Nephrology, H.U.

Princesa, Madrid, Spain; 2Fundacion Estudio Hepatitis Virales,

Madrid, Spain; 3HD Unit, H. Perpetuo Socorro, Alicante, Spain;4Nephrology, H. Reina Sofia, Cordoba, Spain and 5Nephrology,

H. San Cecilio, Granada, Spain.

Occult HCV infection in liver and peripheral blood mononuc-

lear cells (PBMC) of patients with cryptogenic chronic hepatitis

(anti-HCV, serum HCV RNA negative) and no renal diseases,

has been reported (1). In this work we studied the existence of

occult HCV infection in PBMC of HD patients. Inclusion cri-

teria: high ALT (>28 IU/l) and/or gamma-GPT levels, negative

serological HCV and HBV markers (anti-HCV, serum HCV-RNA

and HBsAg negative), and exclusion of other causes of liver

damage. Four Spanish HD units participated in the study and

40 patients were enrolled; 40 (25 males) fulfilled the inclusion

criteria. HCV-RNA in PBMC was tested by RT-PCR and by in

situ hybridization. Occult HCV infection was found in 24/40

(60%) patients by RT-PCR and all cases were confirmed by in

situ hybridization. No differences were found regarding gender,

etiology of renal disease, or fluctuant or persistent abnormal liver

enzymes values. Among patients with occult HCV infection, 4/

24 (16.7%) had only increased ALT levels; 7/24 (29.2.%) GGTP

values; and both enzymes were elevated in 13/24 (54.2%).

In our population, 60% HD patients with persistent or fluctuant

ALT and/or GGTP values of unknown etiology and negative for

serological viral markers (including serum HCV-RNA) have an

occult HCV infection in PBMC and these patients could be

potentially infectious.

(1) J Infect Dis 2004;189: 7–14.

Intermittent and short daily hemodialysisincrease HGF plasma levels and diminish HCV

viral load

Barril G.1, Bartolome J.2, Sanz P.1, Buoncristiani E.3, Traver J.A.1,

Selgas R.1, Carreno V.2, Buoncristiani U.3 1Nephrology, HU

Princesa, Madrid, Spain; 2Fundacion E.Hepatitis Virales, Madrid,

Spain and 3Nephrology, H S.Silvestrini, Perugia, Italy.

Decrease of HCV viral load and HGF plasma levels increase have

been related to HD sessions. Beneficial effects of HGF stimula-

tion in HD on the outcome of HCV liver disease have been

described. Aim was to analyze potential differences between

intermittent (3�week) and short daily (6�week) HD, exam-

ining differences between HCVþ and – pts. We studied 41 pts

from 2 HD centres, 26 on intermittent HD (6 on line HF), 8

HCVþ, and 15 on short-daily HD with 4 HCVþ 40 pts used

synthetic HD membranes (low-flux and high-flux). Among

HCVþwe determined viral load by Amplicor (Roche) pre-

and post- HD. All pts were studied for HGF levels (ELISA)

baseline, 15 min, end, and at start of the following session

viral load is significantly higher preHD and decreases over

session. High-flux membranes were more efficient in reducing

viremia (67% vs 45%), which level was higher pre- and post-HD

principally in patients using low-flux membranes. Viremia in

DHD is lower than in intermittent (470067.3� 663974.5 vs

1015695.5� 1202679.0).

HGF at baseline, at the end of the session, and starting the

following one was significantly higher in HCVþ patients. Max-

imum increase appears always at 15 min. HGF levels were sig-

nificantly higher in daily HD than intermittent. Of the 14 patients

who showed HGF after session higher than 8000, 8 were HCVþ(3 in DHD, 5 high flux), 6 were HCV� (5 DHD and 3 high flux),

14 pts finished HD session with HGF>8000, 8HCVþ (3 DHD,

HCVþ HCV� p

HGF baseline 3261.3� 1904.5 2186.5� 815.7 0.01HGF 15 min 8000.0� 0.0 7774.0� 1129.8 nsHGF end 6142.5� 2262.3 4443.7� 2515.7 0.03HGF start 3391.0� 1680.6 2311.7� 633.6 0.007



5 high flux) and 6HCV� (5 DHD, 4 high-flux). HGF

stimulation appears in daily and intermittent HD, with higher

level in the latter; HCVþ showed higher HGF vs negative,

independently from the HD frequency; HCV viral load

diminishes in all HD sessions, more in those with high-flux

membranes. Short-daily HD with high-flux synthetic mem-

branes seems the best option for HCVþ patients, and when

performed in home precludes nosocomial transmission.

Early onset catheter-associated bacteremia (CAB)

Troidle L., Finkelstein F.O., St. Raphael Hemodialysis, Fresenius

Medical Care, New Haven, CT.

Bacteremia is a common complication for hemodialysis (HD)

patients (pts) with an indwelling central venous catheter (CVC).

We studied our experience with CAB and noted that CAB

occurred at an average of 96� 98 days after CVC insertion.

We wondered what percentage of CAB occurred in the first 21

days after CVC insertion and the spectrum of organisms. We

prospectively collected data on all HD pts from 3 centers with a

CVC who developed bacteremia between 1/1/03 and 8/31/04.

Pts who developed CAB with an identifiable source of bacter-

emia were excluded. 131 episodes of CAB were identified; 34

(25.95%) occurred in �21 days. The mean� SDEV age of

the pts developing CAB> 21 days and �21 days was 63� 17

and 61.5� 15.4 years, respectively. Table 1 outlines the

spectrum of organisms. There was a significantly greater

incidence of CAB with Staphylococcus aureus (SA) and a signifi-

cantly lower incidence of Staphylococcus epidermidis (SE) in the

pts in whom a CAB developed �21 days after insertion.

We conclude that CAB occurs in the first 21 days after CVC

insertion in 25% of our CVC pts. Pts developing CAB in the first

21 days are more likely to develop CAB with SA and less likely

to develop CAB with SE than pts who develop CAB after 21

days. Empiric antibiotic choice and preventative strategies need

to take these data into consideration.

Extrapulmonary tuberculosis with multiplelocalizations in a patient with end-stage renal disease

Sav T., Tokgoz B., Sipahioglu M.H., Mavili E., Oymak O., Utas C.

Erciyes University School of Medicine, Kayseri, Turkey.

The incidence of active tuberculosis among patients on long-

term dialysis is higher than the rate in the general population.

Case: 39-year-old male patient with ESRD was admitted to

hospital with dyspnea, weight loss, cough without sputum and

hemoptysis, and a palpable painless mass under the right areola.

He was on maintenance hemodialysis three times a week for the

last six months. PPD was negative. Chest X-ray examination

revealed a hyperdense lesion. On the computerized tomography

a cystic mass at the inferior lobe superior segment near the

thorasic vertebra was detected. Fine needle aspiration from each

of the mass lesions revealed granulomas and acido-resistant

bacteria. Anti-tuberculous therapy was initiated. After eight months

he came back with paraplegia. Magnetic resonance imaging (MRI)

revealed that the lesion which previously has been described by

CT was extending to the spinal duct and pressing on the spinal

cord. After a biopsy, granuloma was seen; however, mycobacterium

tuberculosis did not grow in the culture. Discussion: Extrapul-

monary tuberculosis is common in patients with ESRD. In the

present case we established that the patient who presented a mass

on the chest wall without pulmonary tuberculosis findings had

indeed a tuberculous cavity mass. It is interesting to note that in

this case this mass had no relationship to the tuberculous cavity in

the lung tissue. Moreover, it is also interesting that paraspinal lesion

occured during the period in which the patient was under

treatment and it quickly progressed and led to paraplegia. Tissue

biopsy with invasive procedures may be necessary. Thus, in areas

with a high prevalence of tuberculosis, renal patients in high-

risk group (renal transplant recipients, hemodialysis and CAPD

patients) should be examined periodically to exclude silent

infection and reduce morbidity and mortality.

Schistosomiasis could play a role in transmission ofHCV infection in dialysis patients

Badawy L., Addullah I., EI Guinaidy M., Aly M., Aziz A., Tarek A.S.,

Abdel R.S. Departments of Nephrology, Gastoenterology, and Hepatology,

Ain Shams University, Bilharz Research Institute, Cairo, Egypt.

Background: Both chronic HCV infection and schistosomiasis are

major health problems in Egypt. The high prevalence of HCV

infection in bilharzial patients had been postulated to be due to

HCV transmission during past anti-bilharzial parental therapy. The

aim of the work was to study the possibility of transmission of

HCV through the life cycle of schistosomiasis. Subject and Meth-

ods: The study included 180 patients divided into four groups:

Group I: Included 40 patients with chronic renal failure (CRF) on

regular hemodialysis (RH) with hepatic schistosmiasis (HS) and

previous history of blood transfusion (BT). Group II: Included

40 patients with CRF on RH with HS and had no previous history

of BT. Group III: Included 40 patients with CRF on RH with no

evidence of HS and no previous history of BT. Group IV: Included

60 patients with HS with normal renal function and no previous

history of BT. In addition 20 healthy persons were included as a

control group. In addition to the routine investigations the patient

groups were subjected to HCV Ab, HBsAg, HBcAb, HBcAg, anti

bilharzial Ab, abdominal ultrasonography, rectal snip for patients

positive for anti bilharzial Ab, and in-situ hybridization (ISH) for

HCV RNA and HBV DNA in the rectal snips positive for living

schistosoma ova obtained from bilharzial patients positive for

Table 1

<21 Days >21 Days P-Value

SA 20 (58.8%) 21 (21.6%) p< 0.01SE 2 (5.9%) 30 (30.9%) p< 0.05Other GP* 7 (20.6%) 15 (15.5%) NSGN^ 9 (26.5%) 40 (41.2%) NS

*GP: gram-positive; GN^: gram-negative



markers of HCV and HBV, respectively. Results: HCV Ab was

detected in 92.5%, 65%, 55%, and 76.7% in groups I, II, III, IV,

respectively, compared to 25% in the control group. Anti-

schistosomal Ab was detected in 75%, 50%, and 71.7% in groups

I, II, and IV, respectively. A highly significant correlation was found

between HCV Ab and anti-schistosomal Ab positivity among all

bilharzial groups (P< 0.01 in group I and P< 0.001 in groups II

& IV). Rectal snips were positive for living schistosoma ova in

76.7%, 90%, and 81.4% of anti-schistosomal Ab positive cases in

groups I, II, and IV, respectively. Moreover, a highly significant

correlation was found between HCV Ab and rectal snip positivity

among the 3 bilharzial patients groups (P< 0.001 in groups I & II

and P< 0.01 in group IV). On the other hand, there was no

significant association between HBs Ag and either anti-schistosomal

Ab positivity or rectal snip positivity. ISH revealed HCV RNA in

26.3% of schistosomal ova-positive rectal snips. In contrast, the

examined biopsies were negative for hybridization of HBV DNA.

Conclusion: Schistosomiasis might play a role in the transmission

of HCV through its life cycle and this also may explain the

significant association between HCV and schistosomiasis.

Effectiveness of catheter hub sanitation prior todialysis

Bousquet G. Saints Memorial Medical Center, Lowell, MA.

Purpose: Contamination of catheter hub connectors is known

to cause catheter-related blood stream infections in patients

undergoing hemodialysis via central venous catheters (CVC).

The effectiveness of cleansing the hub with an antimicrobial

agent was assessed by culturing the surface of the hub following

sanitation. Methods: The CVC hub connectors of 24 patients

were sanitized using the standard hospital protocol of aseptically

swabbing the connectors with a solution of bleach or Betadine,

and then bathing the hub in sterile gauze soaked with the anti-

microbial solution for 5 minutes. The exterior surface of the hub

was then cultured for a broad spectrum of microorganisms.

Patients were monitored for exit site infection, tunnel infection,

and septicemia. In the laboratory, sterile hubs were inoculated

with E. coli, staph. aureus neg., and yeast. Hubs were then immersed

in Betadine for 5, 10, or 30 min. and cultures were taken.

Results: Positive cultures were obtained from the hubs of 17 of

the 24 patients. Seven (7) of the patients with positive results

developed bacteremia from the cultured organism within 7 weeks.

Positive cultures were obtained from 50% of inoculated lab

samples after 5 min, 10% after 15 min, and 0% after 30 min. of

immersion sanitation. Conclusions: The techniques for cleansing

CVC hubs should be revisited.

Chronic hepatitis C infection: Prevalance and effect onclinical status of hemodialysis patients in our center

Ozdemir F.N., Tutal E., Arat Z., Zumrutdal A., Akcay A., Celik H.,

Sezer S., Haberal M. Baskent University Hospital, Department of

Nephrology, Ankara, Turkey.

Hepatitis C virus (HCV) infection affects survival and morbidity

of end-stage renal disease patients and also increases treatment

costs. Aim of this study is to define prevalence of HCV

infection in our hemodialysis (HD) units and documenting past

interventions and clinical status of patients. 711 patients were

included. Patient data were collected from 4 HD units of Baskent

University. Patient records were examined for demograpic

findings, anti-HCV, HCV RNA, liver biopsy, interferon treat-

ment information, last 12 months’ laboratory values (serum

transaminases, albumin, lipid profiles, hemoglobin, C-reactive

protein), and current clinical status, retrospectively. 143 patients

(3%) were anti-HCV positive. These patients’ alanine transferase

levels (23.5� 20.5 vs 15.5� 12.8 U/L, p< 0.0001) and HD

duration (97.9� 58.6 vs 46.3� 35.6 months, p< 0.0001) were

significantly higher. No other significant difference could be

identified between the groups. Analysis of HD duration of anti-

HCV positive patients revealed that prevalance was increasing as

the duration increased. Anti-HCV positivity was known for a mean

of 60.4� 38.8 months while 44 patients (30.7%) were already

infected at initiation of HD. HCV RNA analysis was positive in

26.7% and a liver biopsy was performed in 23% of patients after

19.8� 23.3 months following positive anti-HCV identification.

Minimally active chronic hepatitis C was the most common

pathological diagnosis (70, 3%). Only 18 patients (12.5%)

recieved interferon therapy. None of the patients had chronic

liver disease clinical and physical findings by the time this study

was done. HCV infection is a common problem in HD patients

that increases the need for medical interventions and treatment.

Clinical Experiences

High-flux hemodialysis in the treatment of severevalproic acid overdose: A case report

Chebrolu S.B., Hou S.H., Kjellstrand C.M., Ing T.S. Hines VA

Hospital/Loyola University Medical Center, Chicago, IL.

Introduction: Hemoperfusion, with or without hemodialysis,

has been used to treat patients suffering from severe valproic

acid poisoning. We report a patient suffering from severe

valproic acid intoxication who was treated effectively with

high-flux hemodialysis alone. Case: A 20-year-old man with a

history of bipolar disorder was admitted after having ingested

unknown amounts of valproic acid (Depakote1), prednisone,

and erythromycin. He was agitated and obtunded but hemo-

dynamically stable initially. Serum valproic acid level was

1,028 mg/mL. Urine toxicology screen as well as serum levels

of ethanol, acetaminophen, and acetylsalicylic acid levels were

negative. A gastric lavage was followed by activated charcoal

instillation. Subsequent myoclonic twitchings that progressed to

continuous seizure activity were managed with intravenous

lorazepam therapy and endotracheal intubation. Serum valproic

acid value measured two hours after admission remained

elevated at 1,046 mg/mL. Hemodialysis was performed

continuously for 10.5 hours using a high-flux, polysulfone

dialyzer (Polyflux 21S, Fresenius Medical Care, Lexington,



MA), a dialyzer blood flow of 200–300 mL/min, and a dialysate

flow of 500 mL/min. The therapy brought about a fall in serum

valproic acid level to 110 mg/mL and a complete recovery of the

patient. Discussion: Valproic acid (144 Dalton) is 90–95%

protein-bound at therapeutic serum values. However, in the

face of an overdose, the unbound fraction rises because of

saturation of protein-binding sites. This unbound fraction is

readily dialyzable. We suggest that high-flux hemodialysis is

effective in the treatment of severe valproic acid poisoning.

Spontaneous renal rupture in patients on chronichemodialysis

Park J.A., Jung H.A., Yoon J.M., Kim Y.S., Kim Y.O., Yoon S.A.,

Kim S.Y., Chang Y.S., Bang B.K. Dept. of Int. Med., College of

Medicine, The Catholic University of Korea, Seoul, Korea.

Background: Because of high incidence of acquired renal cyst

and renal malignancy, it is suggested that spontaneous renal

rupture more frequently occurs in patients receiving long-term

hemodialysis than in the general population. This study was

performed to evaluate the clinical characteristics of spontaneous

renal rupture in hemodialysis patients. Methods: This retro-

spective study enrolled 12 hemodialysis patients who developed

spontaneous renal rupture. We investigated primary renal dis-

ease, duration of dialysis, clinical symptoms and signs, radiolo-

gic findings, treatment modalities, and histologic findings.

Result: The mean age of the patients was 54� 10 years old

and the number of male was 9. Primary renal disease consisted

of autosomal dominant polycystic kidney disease (PCKD)

(n¼ 5), chronic glomerulonephritis (n¼ 2), diabetic nephropa-

thy (n¼ 1), hypertensive nephropathy (n¼ 1), unknown cause

(n¼ 3). Presenting symptoms and signs were sudden onset of

flank pain in 9 patients and gross hematuria with mild flank

pain in 3 patients. Mean duration from initiation of hemodi-

alysis to development of spontaneous renal rupture was 53� 36

months. Abdominal computed tomography showed subcap-

sular or perinephric hematoma in all patients. Of the 7 non-

PCKD patients, 6 patients had multiple acquired renal cysts.

Surgical exploration was undertaken in 9 patients. Pathologic

examination demonstrated small sized renal cell carcinoma in 2

of 9 patients. Three patients were only treated with conservative

management including blood transfusion. All 12 patients recov-

ered without recurrence. Conclusion: This study demonstrated

that genetic or acquired renal cyst was an important cause of

spontaneous renal rupture in hemodialysis patients and present-

ing manifestations were sudden onset of flank pain and gross

hematuria.

Hypertension and left ventricular mass index (L.VMI)in patients on regular hemodialysis (RDT)

Papadimitriou M., Pashalidis K., Vakianis P., Diamantopoulou D.

and Chr. Raidis. Interbalkan European Medical Center and Galenos

Kidney Unit. Thessaloniki, Greece.

It has already been established that the most frequent cause

of death in patients (pts) on RDT is cardiovascular. In fact,

more than half of the deaths are related to cardiovascular dis-

ease. The purpose of the study was to investigate in pts with

end-stage renal disease the impact of hypertension on LVMI, a

parameter which has already been found increased in early renal

disease. Two hundred ninety seven pts (174 male) were

included in this study with a mean follow-up of 3 years. Sixty-

six percent of these pts (first group) were on antihypertensive

agents with one or more (in combination up to 4) drugs.

Analytically, as monotherapy or in combination, 29.7% of the

pts were taking a b-blocker, 25.7% an a MEA, 8.9% an angio-

tensin receptor antagonist, 51.5% a calcium channel blocker,

11.9% a centrally active agent and 1% an a-blocker. Forty-four

percent of the pts (secound group) were not on antihypertensive

therapy at any time. Left atrial dimension (LAD) less than 3 cm,

left venticular volume (LVV) less than 150 ml, and left ventricu-

lar mass index (LVMI) less than 130 gm/m2 for male and less

than 100 gm/m2 for female pts were considered as normal

values. The above parameters were measured using 3D Gen.

Electric echocardiograph (Model VIVIO 3). There was no differ-

ence between the 2 groups in sex, age, EPO administration, high

or low flux filter dialysis, and remaining urine volume. On the

other hand, there was a statistically significant correlation

between the systolic blood pressure (BP) and the blood urea

before dialysis (p¼ 0.015) and the increase of body weight in

between dialysis (p¼ 0.03). Finally, there was no statistical

difference between the 2 groups in LAD and LVV, but 37.8%

of the hypertensives had higher LVMI as compared with 23.2%

of the normotensives (x2¼ 3.028, p< 0.05). In conclusion,

mainly the pts who had no compliance with their diet needed

antihypertensive treatment. On the other hand, despite the

clinically efficient antihypertensive therapy, the LVMI remained

high in this group, and possibly this is one of the reasons of

higher morbidity and mortality in this category of patients as it

has already been shown in pts before starting haemodialysis.

Quality of life, self-care and sense of coherence inpatients on hemodialysis: A comparative study

Ageborg M., Allenius B.-L., Cederfjaall C. Dept of Nephrology,

Karolinska University Hospital and Dept of Nursing, Karolinska

Institutet, Stockholm, Sweden.

The number of patients treated for end-stage renal disease

increases in Sweden like the rest of the world. During the last six

years more than 1000 persons a year started renal replacement

therapy. Today hemodialysis patients have the opportunity to

choose different treatment modalities—home hemodialysis, self-

care dialysis, or conventional dialysis. Purpose: The aim of the

study was to investigate differences in patient on home hemo-

dialysis, self-care dialysis, and conventional dialysis regarding

quality of life, self-care, and sense of coherence. Methods: Ques-

tionnaires were used: Short Form (SF-36), Appraisal of Self-Care

Agency (ASA-scale), and Sense of Coherence scale (SOC). 19



patients were included in the study (five patients on home hemo-

dialysis, six self-care patients, and eight patients on conventional

dialysis). Results: The results showed a tendency of higher scores

in quality of life, self-care, and sense of coherence for the home

hemodialysis patients. Conclusion: Since the number of partici-

pants in this study was low, it is necessary to include more

patients in a future study in order to verify the results.

Survival to discharge among patients treated withCRRT

Wald R., Deshpande R., Bell C.M., Bargman J.M. University of

Toronto, Ontario, Canada.

Continuous renal replacement therapy (CRRT) is widely used in

critically ill patients with acute renal failure (ARF). The survival of

patients who require CRRT and the factors predicting their out-

comes are not well defined. We sought to identify clinical features

to predict survival in patients treated with CRRT. We reviewed

the charts of all patients who received CRRT at the Toronto

General Hospital during the year 2002. Our cohort (n¼ 85)

represented 97% of patients treated with this modality in 3

critical care units. We identified demographic variables, under-

lying diagnoses, transplantation status, location (medical-surgical,

coronary or cardiovascular surgery intensive care units), CRRT

duration, baseline creatinine clearance (CrCl), and presence of

oliguria (<400 ml/d) on the day of CRRT initiation. The principal

outcome was survival to hospital discharge. Among those alive at

discharge, we assessed whether there was an ongoing need for

renal replacement therapy. Greater than one-third (38%, 32/85)

of patients survived to hospital discharge. Three (9%) of the

survivors remained dialysis-dependent at the time of discharge.

Survivors were younger than non-survivors (mean age 56 vs

60 y.), were on CRRT for a shorter duration (7 vs 13 d.), and

had a higher baseline CrCl (79 vs 68 ml/min). Patient survival

varied among different critical care units (medical surgical 33%,

coronary 38%, and cardiovascular surgery 45%). Multivariable

logistic regression revealed that shorter duration of CRRT, non-

oliguria, and baseline CrCl> 60 ml/min were independently

associated with survival to hospital discharge (p< 0.05).

Critically ill patients with ARF who require CRRT continue to

have high in-hospital mortality. A shorter period of CRRT

dependence, non-oliguria, and higher baseline renal function

may predict a more favorable prognosis. The majority of CRRT

patients who survive their critical illness are independent from

dialysis at the time of hospital discharge.

Association between serum bicarbonate and death inhemodialysis patients: Is it better to be acidotic or

alkalotic?

Wu D.Y.J., Kilpatrick R.D., Dadres S., McAllister C.J., Kopple J.D.,

Kalantar-Zadeh K. Harbor-UCLA Nephrology; DaVita, Inc; Torrance

and El Segundo, CA.

The optimal acid base status for survival in maintenance hemo-

dialysis (MHD) patients (pts) remains controversial. According

to some reports acidosis is associated with improved survival in

MHD pts, i.e., reverse epidemiology. We examined associations

between baseline (first 3-month averaged) serum bicarbonate

(HCO3), divided into 12 categories, and 2-yr mortality in

56,376 MHD pts across the US after controlling for confounding

effects of malnutrition-inflammation complex syndrome

(MICS). Three sets of Cox regression models were evaluated to

estimate hazard ratios (HR) of death and 95% confidence

intervals (CI): (1) Unadjusted; (2) Multivariate adjusted for

case-mix (age, gender, diabetes, race, insurance, marital status,

vintage, standardized mortality ratio, residual renal function,

dialysate HCO3, and Kt/V); and (3) Additional adjustments for

8 markers of MICS (body mass index, serum albumin,

creatinine, ferritin, TIBC, dietary protein intake, WBC and

lymphocyte counts). See Figure for HR and 95% CI:

We conclude that, although high HCO3 levels appear to be

associated with increased mortality in MHD pts, this paradoxical

effect is almost entirely due to the overwhelming impact of

MICS on survival.

Death in dialysis

Concepcion L.A. Scott & White Hospital, Texas A&M University,

Temple, TX.

Purpose: To analyze all patients who died while on hemodialysis

from a single institution 1995–2004 and determine factors that

influence duration on HD (months). Material and Methods:

Review of the EMR from the dialysis unit for demographics,

treatment parameters, cause of death, laboratory data. Two

main groups those who stop dialysis (SHD) vs non stop

dialysis (NSHD) data as mean and SD. Observations done at

the start/mid/end of the period on dialysis by Kaplan

Meier analysis. Results: 348 deaths, reported SMR for 2000

–93(0.36,0.48,0.72,0.79), average comorbidity index 7.1–16.4;

49.1% male; age 67.6(12.3); 58.2% DM, 117(33.6%) stop

dialysis. Detail analysis from 2000–2004; 187 deaths; 33.6%

catheter, 41.1% AV graft at the time of death; 26% on no BP

meds at the end, 64% 1–2 BP meds at the end.

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

1.6

1.7

<= 17 17–18 18–19 19–20 20–21 21–22 22–23 23–24 24–25 25–26 26–27 > 27

Serum Bicarbonate Group (mEq/L or mmol/L)

Har

zard

Rat

io o

f Dea

th

Unadjusted

Case-Mix Adjusted

Case-Mix & MICS adjusted



Most SHD deaths due to uremia (60%), Cancer 17%, occurred

36% CVA. SHD vs NSHD: older 70.8 (12.9) vs 65.9(12.9)

p< 0.001. No difference in average months in dialysis 41.2

(38.9) vs 48.7(47.7)NS, in URR (start/end), UF during Hd,

predialysis MAP (start/end: 105(15) 196(15)/95 (20) , 96(20))

albumin, phosphorous. Lower creatinine (at the end 6.2(1.5)

7.4(2.4)) higher Kt/V at end 1.47(0.4) vs 1.29(0.3). BMI lower at

star/mid/end of the observation period. Conclusions: A large

proportion of deaths were due to discontinuation of dialysis,

older patient discontinue dialysis more frequently, the length of

time on dialysis (months) is related more to nutritional factors

(creatinine, BMI)

Effects of vitamin E-coated membrane dialyzer onreduction of inflammation

Jainkiatfu K. Phramongkutlao Hospital. Bangkok, Thailand.

Objective: Blood-membrane interaction during hemodialysis may

contribute to inflammatory process, which accelerates the devel-

opment of atherosclerosis in maintenance hemodialysis patients

(MHD). Vitamin E has been widely used against oxidative stress

in MHD. One of the strategies for the utilization of vitamin E in

MHD patients is the usage of vitamin E-coated membrane

dialyzer. We investigated the effects of vitamin E-coated mem-

brane dialyzer on serum C-reactive protein and interleukin-6,

the biomarker of inflammation, compared to polysulfone mem-

brane dialyzer. Methods: Vitamin E-coated membrane dialyzer

(1.5-m2 surface area) and synthetic polysulfone dialyzer (1.5-m2

surface area) were manipulated in a crossover clinical study for

24 weeks in 10 non-diabetic MHD patients. Run-in and wash-

out periods (Cellulose tri-acetate) were performed for 4 weeks

before the treatment. Pre- and post-dialysis blood samples

were taken at the begining and the end of each dialyzer period

(12 weeks). High-sensitivity C-reactive protein (hs-CRP) and

interleukin-6 (IL-6) were examined. Results: Mean age of the

patients was 54.9 years old. CRP and IL-6 levels were similarly

increased after dialysis in both groups (4.8� 0.7 and

37.2� 9.4, respectively). The CRP and IL-6 level in vitamin

E-coated membrane dialyzer treatment were lower than in

polysulfone treatment (5.0� 1.2, p< 0.008 and 67.2� 12.4,

p< 0.04, respectively). Serum albumin, hemoglobin level,

and white blood cell count were not affected by types of

dialyzer membrane. Conclusions: In our study, hemodialysis

stimulated the inflammation as the previous study. Vitamin

E-coated membrane dialyzer may diminish the inflammatory

process in MHD patients and may also prevent further

atherosclerosis.

Hemodialysis-induced acute pancreatitis secondary tokinked hemodialysis blood lines

Abtahi M., Uzan M., Souid M. CHI Poissy-Saint Germain en Laye,

France.

Introduction: Hemolytic reactions developing during hemodialysis

usually are caused by oxidant damage, reduction injury, and

osmolar, thermal, and mechanical injury to the red blood cells.

Mechanical injury due to maloccluded blood pumps, arterial line

collapse, and use of subclavian hemodialysis catheters has been

reported. We report one episode of acute hemolysis due to kinked

hemodialysis blood lines complicated with pancreatitis. Case

Report: An 18-year-old man with end-stage renal failure of

unknown origin had been on hemodialysis since 2002. His past

medical history included asthma and hypertension. He was

admitted to the hospital because of severe abdominal pain, nausea,

and vomiting during the dialysis session. Laboratory examination

showed hematocrit �30 %, platelet count of 131,000 per cubic

mL, LDH �5151 U/L, haptoglobin �0.09 g/L, lipase �919 U/L,

CPK- 260, ASAT �584 U/L, ALAT- 316 U/L, bilirubin �36mmol/

L, and visible schistocytes on smear. Examination of the abdomen

revealed diffuse discomfort and tenderness in epigastrium. The

patient was diagnosed as having hemolysis-induced acute pancrea-

titis. He was treated symptomatically and recovered within a few

days. We found the arterial blood line tightly kinked at the dialyser

inlet port, and we excluded other reported causes of intravascular

hemolysis during hemodialysis. Discussion: Until a critical

pressure is exceeded, despite a kink in the post pump predialyser

blood tubing, the blood pump can maintain sufficient blood flow to

prevent an increase in the arterial pressure with a triggering of

the arterial alarm and a decrease in the venous pressure with a

triggering of the venous alarm. Thus, an excessively high pressure

can be maintained in this silent segment of the dialyser tubing

without activating the pressure alarms, exposing the red blood

cells to high sheer stresses and resulting in clinically significant

hemolysis. Acute hemolysis can cause a life-threatening acute

pancreatitis. The literature indicates that acute pancreatitis is a

complication of massive hemolysis with a prevalence of about

20%. The important role of inflammatory cytokines in the

pathogenesis of acute pancreatitis is well known. Heme released

from hemoglobin after episodes of vascular hemolysis has the

potential to act as a signalling molecule involved in the triggering

of the inflammatory processes associated with massive hemolysis.

Hemolysis itself may induce acute pancreatitis by all or some

pathways of neutrophil activation and chemoattraction, such as

oxidative burst, direct proinflammatory effect, microcirculatory

disturbance, and increased expression of proinflammatory and

immunoregulatory cytokines.

Morbidity and mortality: Profile of patients onrenal replacement therapy in the private sector

Samaai R., Uys H. National Renal Care, Southern Cross Hospital,

Cape Town, South Africa.

Cause Stop No Stop

CV 33(28%) 145(62.7%)Infection 10(8.5%) 41(17.7%)Other 74(63.5%) 45(19.6%)



Introduction: The aim of renal replacement therapy (RRT) is to

achieve a reduction in morbid events and improve quality of life

(QOL). Mortality means the condition of being subject to death.

Morbidity is anything that is abnormal, atypical, exceptional,

and/or aberrant. Morbidity usually occurs as a result of a

treatment (side effects), when treatment is inappropriate or

inadequate. Predictors that may be risk factors for mortality and

morbidity in dialysis patients can be divided into patient-related

and treatment-related categories (Khan, 2000:11). Purpose of the

study: The purpose of this retrospective study was to determine

the morbidity and mortality profile of patients receiving RRT in

the private sector. Research design and method: This study was

contextual and descriptive in nature, based on case analysis of

patients receiving RRT in private dialysis facilities. A checklist was

used that made provisions to record all patient- and treatment-

related factors that might influence mortality and morbidity

profiles of the target population. The target population included

all hemodialysis and peritoneal dialysis patients receiving

treatment in private dialysis facilities of a specific company.

Results: The results indicated the following factors have an

influence on patient morbidity and mortality:

– Patient related: Age, comorbid situations such as peripheral

vascular, cerebrovascular, and cardiovascular disease and also

diabetes mellitus.

– Treatment related: Referral pattern, nutritional status, dialysis

adequacy, anaemia, and blood pressure.

Acute hemolysis and renal failure associated withcharcoal hemoperfusion for valproic acid intoxication

Rahman, M.H., McGoldrick, M.D., Haqqie, S.S. Albany Medical

College, Albany, NY.

Charcoal hemoperfusion is an effective treatment in acute drug

intoxication with small volume of distribution. For certain drugs,

clearance rates are higher with hemoperfusion than hemodialysis.

We describe a patient with severe valproic acid overdose

who developed severe hemolysis and acute renal failure related to

charcoal hemoperfusion treatment. A 50-year-old female was

admitted to the hospital following valproic acid overdose. Initial

valproic acid level was 73.6 mg/L, and she was treated with oral

activated charcoal. Four hours later she developed mental status

changes with valproic acid level at 490.9 mg/L and prolonged QT

interval. Charcoal hemoperfusion was started with blood flow

rate 400 ml/min. Patient developed bleeding with evidence of severe

Before(*C.H.) After (C.H.)

Hemoglobin 12.1 gm/DL 7.6 gm/DLHematocrit 35.5 gm/DL 21.1 gm/DLPlatelet count 268,000 tho/ul 43,000 tho/ulL.D.H 90 IU/L 2494 IU/LValproic Acid 490.9 mg/L 74.1 mg/L

*C.H. (Charcoal Hemoperfusion) Blood – evidence of massive hemolysis

intra-vascular hemolysis, shown in table (no evidence of HUS/

TTP). She received transfusion of packed red blood cells, plate-

lets, and fibrin. Over the next few days she developed oligouric

acute renal failure requiring hemodialysis for 2 weeks. Eventually

hemolysis resolved and the renal function improved (kidney

biopsy was consistent with acute tubular necrosis). To our know-

ledge, this is the first reported case of severe intravascular hemo-

lysis occurring during the charcoal hemoperfusion treatment.

Etiology includes mechanical trauma to the red cells, probably

related to high blood flow rate through the charcoal column.

Baclofen neurotoxicity in chronic hemodialysis

Mercieri A., Mercieri M.,1 Pedrini L. Nephrology and Dialysis Unit,

Bolognini Hospital, Seriate, Bergamo, Italy, Intensive Care Unit,

S. Andrea Hospital, Rome, Italy1.

Baclofen, a GABA agonist, is frequently used to treat muscle

spasticity due to spinal cord injury and multiple sclerosis.

Baclofen overdose can lead to coma, respiratory depression,

hyporeflexia, and flaccidity. Because baclofen is primarily

excreted unchanged through the kidneys, it should be given

with caution, and it may be necessary to reduce the dosage.Signs

of overdose may appear suddenly or insidiously. Acute massive

overdose may present as coma. Less sudden and/or less severe

forms of overdose may present with signs of CNS depression,

excessive salivation, dizziness, nausea and/or vomiting, somno-

lence, and hypotonia. Should overdose appear likely, the patient

should be taken immediately to a hospital. A 46-year-old man,

who was treated by intermittent hemodialysis (three times a

week), was admitted to our unit for signs of CNS depression,

dizziness, vomiting, somnolence, and hypotonia. He was treated

at the relatively low dose of baclofen, 5 mg/day, because of

muscle spasticity due to spinal cord injury. His temperature

was 37 �C, and predialysis laboratory data were hemoglobin

11.4 g/dl, white blood cells 6550/mm3 with normal differential

count, and platelets 330000/mm3. Serum sodium was

134 mmol/l, potassium 6.4 mmom/l, bicarbonate 18.3 mmol/l,

urea 30 mmol/l, creatinine 998 mmol/l, glucose 5.16 mmol/l, and

calcium level 2.4 mmol/l. Serum transaminases were normal. A

brain computerized tomography (CT) scan showed no abnorm-

alities. Baclofen-associated encephalopathy was considered to

be the most likely etiology for this acute neurological picture.

Baclofen was then stopped. Plasma concentration of baclofen

was >600 ng/ml (therapeutic range 80–400 ng/ml) after 2 hours

of hemodialysis and the baclofen level rapidly fell (<200 ng/ml)

at the end of the hemodialysis session. After the first 4-h

haemodialysis session, there was an incomplete recovery of the

neurological status. After a renewed hemodialysis session the

symptoms completely receded.The patient was discharged from

the hospital 72 h later in a good condition. Patients with severely

impaired renal function generally develop baclofen intoxication

soon after the initiation of low-dose therapy. Thus, the admin-

istration of baclofen, regardless of the dosage, in these patients is

not appropriate.



Dose of paricalcitol inversely associates with risk ofhospitalization

Melnick J.Z. Abbott Laboratories, Abbott Park, IL.

Background: Among patients receiving chronic HD, therapy

with paricalcitol (Z) was associated with reduced mortality and

morbidity compared to treatment with calcitriol (C). Further-

more, patients who did not receive any vitamin D therapy

experienced highest mortality and morbidity. This study

examined the hypothesis of a relationship between the dose of

Z and subsequent hospitalization, more specifically, that

patients receiving lower doses of Z would have a higher risk of

being hospitalized. Methods: We performed a retrospective

cohort study of patients new to HD who received treatment

with Z or C between Jan 1999 and Dec 2001 using Poisson

regression models. The primary exposure variable was the aver-

age dose/day, examined as categorical data by quintiles, during a

3-month and then 12-month follow-up period excluding the

days in hospitals. This latter exclusion was made due to uncer-

tainty of the treatment during the period of hospitalization.

Additional covariates included vitamin-D group (Z vs. C), age,

gender, race, and diabetes status, serum albumin, alkaline

phosphatase, calcium, phosphorus, and iPTH. Results: We first

examined dose of Z and C over a 3-month period and then

hospitalizations over the ensuing year. We did not find a dose-

response relationship in these analyses – i.e., dose over the first

three months of dialysis is not associated with increased or

reduced risk of hospitalizations during the ensuing 12 months.

We then examined average dose of Z or C over the entire year and

risk for hospitalization during the same year. Compared to total

doses, average doses (total dose over the entire year divided by

number of dialysis sessions during the same year) are less prone to

bias. Risk of hospitalizations according to dose (lowest dose,

Quintile 1) of injectable vitamin D is shown in the table below:

Quintile HR 95% CI

1 1.093 1.025–1.1652 1.073 1.007–1.1433 1.055 0.990–1.1244 1.050 0.978–1.1165 1.0 REF

Compared to those who received the highest doses of injectable

vitamin D, those receiving the lowest had a 9% increased risk for

a hospitalization. At each level, the risk for hospitalizations was

4% lower with Z compared to C. Conclusion: This pilot study

indicates that higher average doses of Z are associated with a

lower risk of hospitalization and suggests additional beneficial

effects of vitamin D beyond mineral metabolism and PTH control.

Extracorporeal RRT modalities: A systemic review

Kannaiyan R.S. University of Aberdeen, United Kingdom.

Objective: Hemodialysis (HD), hemofiltration (HF), hemodiafil-

tration (HDF), and acetate free biofiltration (AFB) are renal

replacement therapy (RRT) methods in which impurities are

removed from the blood extracorporeally. It has been suggested

that HF, HDF, and AFB may have fewer cardiovascular side-effects

than HD and may reduce incidence of dialysis-related amyloid-

associated complications due to more effective removal of b2-

microglobulin. Methods: We performed a systematic review of

randomized controlled trials (RCTs) comparing these RRT modal-

ities. Out of 1672 abstracts identified by searching MEDLINE,

EMBASE, and Cochrane Controlled Trials Registry, 18 trials (588

patients) were included. Our comparisons were convective mod-

alities (HF/HDF/AFB) vs HD (16 trials); HDF/AFB vs HF (no trials);

and HDF vs AFB (2 trials). Data were extracted by two reviewers

independently on mortality, hypotension episodes, dialysis sessions

associated with ‘‘adverse symptoms’’ (headache, nausea, and vomit-

ing), hospital admissions, adequacy of dialysis, number of patients

with amyloid related complications, b2-microglobulin removal, and

quality of life (QOL). Results: No significant difference was found

with regards to mortality, hospitalization, dialysis-related hypoten-

sion, dialysis-related symptoms, Kt/V, predialysis b2-microglobulin

values between convective modalities (HF/HDF/AFB) and HD, and

HDF and AFB. Quality of life was assessed only in two studies

comparing HF/HDF/AFB and HD. One study that used an unvali-

dated scoring tool showed that patients on convective modalities

scored significantly better than those on HD; whereas, another

study using a validated scoring system, the Kidney Diseases Ques-

tionnaire, failed to show significant differences between the two

groups. Conclusions: While this review summarized the best avail-

able evidence, it is based on very few trials. The trials included in

this review are small and are therefore inadequately powered to

detect differences between effects of the relevant treatments. Over-

all, HF, HDF, and AFB have not been shown to have significant

advantage over HD with regard to clinically important outcomes of

mortality, dialysis-related hypotension and manifestations of

dialysis-related amyloidosis, and therefore, it is not possible to

recommend the use of one modality in preference to the other.

Severe hypercalcemia caused by Milk-Alkali syndromerequiring urgent hemodialysis – Tums by the ton

Rai A., Whaley-Connell A., Khanna R. Department of Internal

Medicine, Division of Nephrology, University of Missouri-

Columbia, Columbia, MO.

An increased frequency of the Milk-Alkali syndrome in the last

several years has been noticed related to increasing use of calcium

carbonate as a phosphate binder in CKD patients, as an antacid or

as calcium supplementation. We present a case of severe hyper-

calcemia secondary to Milk-Alkali syndrome that precipitated

acute renal failure requiring urgent hemodialysis. A 59-year-old

male with history of hypertension, diabetes mellitus, and acid

reflux presented to the ER with confusion, lethargy, nausea,

vomiting, and diarrhea. His family relayed a history of recent

indigestion and relief with Tums. He was taking several tablets



at short intervals to self-treat the indigestion. At the time of

presentation, patient was confused and noted to be dehydrated.

Lab findings were significant for elevated BUN/Cr- 121 mg/dl/

11.1 mg/dl (baseline Cr 1.1 mg/dl few months ago), bicarbonate

38 mg/dl, calcium 16.7 mg/dl, ionized Ca of 1.76 mmol/L,

iPTH 10 pg/ml, PTHrP 0.7 pg/ml. Medical management with

intravenous fluids and furosemide showed no improvement in

renal failure, or calcium level. Patient was then started on

hemodialysis with 2.0 mmol/L calcium in the dialysate the next

day. There was gradual improvement in patient’s mental status,

calcium values, and renal failure over the ensuing 2 weeks.

Discussion and Conclusions: The diagnosis of Milk-Alkali

syndrome is made on the basis of history. Metabolic abnorm-

alities involved in this syndrome are hypercalcemia with low to

normal PTH and Vit. D levels, renal failure, and metabolic

alkalosis. Failed medical management required acute dialysis

in this patient. Acute hemodialysis in such a case could be

life saving. Due to increasing use of calcium carbonate for

dyspepsia and osteoporosis, patients should be made aware

of these severe, potentially life-threatening adverse effects.

A case of Ehrlichiosis mimicking course ofthrombotic thrombocytopenic purpura requiring

hemodialysis

Sowers K., Whaley-Connell A., Khanna R., Katyal A. University

of Missouri-Columbia, School of Medicine, Columbia, MO.

We present an atypical presentation of Ehrlichiosis induced

sepsis requiring hemodialysis. Ehrlichiosis is a common tick-

borne illness in Missouri, and in this case mimicks the course of

thrombotic thrombocytopenic purpura (TTP). A 48-year-old

male with a history of marginal zone lymphoma had received

radiation and chemotherapy with fludarabine. He was admitted

to oncology service for evaluation of nausea and vomiting and

generalized malaise. His initial laboratory data revealed platelet

count 16,000 mm3, WBC 3,800 mm3, AST 327 units/L, ALT 185

units/L, BUN/Creatinine 53 mg/dl/3.8 mg/dl. Because the per-

ipheral smear showed a morulae consistent with human granu-

locytic Ehrlichiosis, intravenous doxycycline 100 mg twice

daily was initiated. Acute renal failure was thought due to

hemodynamic changes, but the role of TTP remained in the

differential diagnosis. On hospital day two, he became confused

and lethargic and continued to be febrile. Hours later, he devel-

oped tonic-clonic seizures and became hypotensive. A clinical

diagnosis of TTP was made. Peripheral smear showed only a few

schistocytes, inconsistent with TTP. Microangiaopthic anemia,

thrombocytopenia, sepsis with DIC, and multi-organ failure

sustained the acute renal failure. Hemodialysis was used for

ARF over the next several days in conjuction with IV doxycy-

cline. The patient improved without plasmapharesis. Kidney

function returned back to normal in due course of time. A

final diagnosis of ehrlichia-induced sepsis with ARF was made.

Conclusion: Ehrlichiosis is endemic in Missouri and usually

presents with thrombocytopenia, leukopenia, and elevated

liver function tests; however it rarely presents with sepsis. The

course of this case was made unusual possibly due to che-

motherapy, fludarabine for the treatment of lymphoma, which

can commonly cause micrangiopathic anemia, myelosuppres-

sion, and even a leukopenia for several years afterwards. This

presentation mimicking TTP can be confusing but has pre-

viously been documented as a complication of severe Ehrlichio-

sis in the immunocompromised state.

Role of bicarbonate dialysis in prevention of seriousarrhythmias in high-risk cardiac patients undergoing

regular hemodialysis

El Sharkawy M.M., Shaalan H.S., Okasha N., El Gendy M.F.

Internal Medicine Department Ain Shams University, Cardiology

Department Ain Shams University, National Heart institute Cairo,

Egypt.

Background: Cardiac arrhythmias are considered as one of the

most important causes of mortality in patients on hemodialysis.

Arrhythmias frequently occur in patients with chronic renal

failure on regular hemodialysis with reported incidences vary-

ing from 30–48% of patients. These abnormalities can span

from supraventricular to severe ventricular arrhythmia. There

is an increased frequency of occurrence and clustering of

arrhythmias around the dialysis time. Aim of the study: To

detect the difference between acetate and bicarbonate dialysis

as regard to the type and frequency of arrhythmia in those patients.

Study design: This study was done on 20 male patients age

51–73, all have history of heart disease. Patients were divided

into 2 equal groups using acetate in group 1 and bicarbonate

in group 2. All patients were on regular hemodialysis (4 hours,

thrice weekly). Careful history and clinical examination were

done. Pre-dialysis investigations included serum creatinine,

blood urea nitrogen, serum sodium, potassium, calcium and

phosphorus, serum albumin, hemoglobin, and arterial blood

gases. Post-dialysis serum potassium and arterial blood gases were

measured. ECG and forty-eight hours ambulatory monitor (Holter

monitor) (before, during, and after hemodialysis, till the end of the

dialysis day and throughout the following day) were performed.

Results: Group 1 showed significantly less post-dialysis

16.7 Calcium (Plasma) Ref Low 8.5 Ref High 10.5

1615141312

ng /d

l

1110

98

7/14/2004 7/16/2004 7/18/2004 7/20/2004 7/22/2004 7/24/2004 7/26/2004 7/28/2004

13.8

10.1

8.88.1 7.3 8.1 7.8

8.27.7

8.6 8.4 8.17.6 7.9 8.2

Cre

atin

ine

(mg/

dl)



supraventricular arrhythmias than in dialysis day (210.9� 236

and 62.3� 14.4), respectively. Significantly less ventricular

arrhythmias in post-dialysis than in dialysis day (30.7� 50.4,

and 106.2� 128.4), respectively. While in Group 2 there were

insignificant differences regarding supraventricular arrhythmias

(21.9� 28.9 and 16.6� 36.3) and ventricular arrhythmias

(22.9þ 7.8 and 29.6þ 12.8) in dialysis day than in post-dialysis

day. There was significantly higher frequency of supraventricular

and ventricular arrhythmias in the dialysis day in acetate

hemodialysis in comparison to bicarbonate hemodialysis.

Conclusion: Bicarbonate hemodialysis is less arrhythmogenic in

comparison to acetate hemodialysis and has better effect on

the blood pH and greater degree of base repletion. Continuous

ambulatory ECG recording (Holter) is a useful tool in detecting

arrhythmias in dialysis patients.

Clinical and laboratory variables in Type 2 diabeticmen with renal failure before and after initiation of

hemodialysis

Bibb J., Servilla K.S., Tzamaloukas A.H. Nephrology Section, New

Mexico VA Health Care System and University of New Mexico,

Albuquerque, NM.

Control of certain clinical and laboratory parameters affects

morbidity and mortality of type 2 diabetic patients with

chronic renal failure (CRF) both before and after initiation of

hemodialysis (HD). To identify areas and stage of renal failure

where control of these critical variables needs improvement,

we compared important clinical and laboratory parameters

6 months before (PRE) and 6 months after starting HD

(POST) in 43 type 2 diabetic men with CRF, who were

69.3� 10.7 years old at HD initiation. Differences, all at

p� 0.05, were found in blood pressure, in mm Hg, at the

physician’s office, both systolic (PRE 154� 16, POST

138� 18) and diastolic (PRE 77� 13, POST 69� 11), serum

cholesterol in mg/dL (PRE 206� 61, POST 159� 40), and

serum creatinine in mg/dL (PRE 4.1� 1.3, POST 7.0� 1.8),

while no differences were noted in blood hematocrit (PRE

36� 7%, POST 34� 9%), blood glycosylated hemoglobin

(PRE 7.4� 1.7%, POST 6.9� 2.3%), serum glucose in mg/dL

(PRE 151� 67, POST 184� 94), serum phosphorus in mg/dL

(PRE 4.5� 0.8, POST 4.6� 1.5), serum calcium in mg/dL

(PRE 8.7� 0.5, POST 8.5� 1.4), and serum albumin in g/dL

(PRE 3.2� 0.5, POST 3.4� 0.6). Compared to the POST cate-

gory, significantly (p� 0.05) higher percentages were found in

the PRE category for systolic blood pressure >150 mm Hg

(PRE 58.8%, POST 26.5%), blood glycosylated hemoglobin

>8% (PRE 33.3%, POST 13.3%), serum cholesterol

>200 mg/dL (PRE 48.4%, POST 19.4%). A lower percentage

was found in the PRE category for serum phosphorus

>5.5 mg/dL (PRE 13.2%, POST 31.6%), while the correspond-

ing percentages for serum albumin <3.0 g/dL (PRE 21.6%,

POST 18.9%) and serum calcium <8 mg/dL (PRE 7.9%,

POST 13.2%) did not differ. In patients with type 2 diabetes

mellitus and renal failure, control of blood pressure, glycemia,

and serum lipids appears to be better; whereas, control of

serum phosphorus is worse in the first year after starting

chronic hemodialysis than in the preceding year. There is

room for improvement, both before and after hemodialysis

initiation, in the control of these variables, which affect the

clinical outcomes of hemodialysis.

Experimental study on a new type citrateanticoagulant hemodialysate in dogs

Baosong G., Ning N., Ganglian Y., Lin, G., Liangqi W., Ruijun G.


Objective: In this study, we initiated a new hemodialysate

with citrate buffer, observed the factors that influence the

citrate concentration of solution in hollow fibers when using

citrate hemodialysate, and observed the anticoagulant effect

and safety of the citrate hemodialysate in the experiment in

dogs. Methods: Ten dogs were given intermittent hemodia-

lysis and were divided into 3 groups according to hemodia-

lysis procedures. Group 1 was saline-flush hemodialysed with

bicarbonate hemodialysate; Group 2 was hemodialysed with

citrate hemodialysis without any anticoagulant; Group 3 was

hemodialysed with bicarbonate hemodialysate and heparin.

ACT, Caþþ, BUN, Cr, ALT, AST, TBIL, DBIL, Naþ, Cl�,

HCO3�, and venous pressure were monitored in the animals

of each group during hemodialysis. Results: During the

hemodialysis in Group 1, venous pressure increased last-

ingly, resulting in the failure of hemodialysis for 2 hours.

Hemodialysis for 2 hours in Group 2 were all finished

successfully. ACT was extended and Caþþ decreased

obviously in the venous end during hemodialysis. And

ALT, AST, Caþþ, Kþ, Naþ, Cl�, HCO3� after the hemodia-

lysis in Group 2 were not changed (P> 0.05). Moreover, the

clearance rate of the dialyzers with citrate dialysate increased

significantly compared with those of saline-flush and heparin

anticoagulation. Conclusions: The anticoagulant and dialytic

effects of the new type citrate hemodialysis are satisfactory

and better than that of saline-flush.

Citrate anticoagulant hemodialysate in renal failurepatients at high risk of bleeding

Baosong G., Ning N., Ganglian Y., Lin, G., Liangqi W., Ruijun G.


Objective: The aim of this study was to observe the anticoagulant

effect of the new type of citrate anticoagulant hemodialysate in

renal failure patients at high risk of bleeding.Methods: 57 patients

at high risk of bleeding were given hemodialysis for 4 hours

and were divided into 3 groups according to hemodialysis

procedures: Group 1 was saline-flush hemodialysed with bicarbonate



hemodialysate. Group 2 was hemodialysed with citrate hemodia-

lysate and with no anticoagulant. Group 3 was hemodialysed

with bicarbonate hemodialysate and with nadroparin calcium

(a low molecular weight heparin, LMWH) as anticoagulant.

Bleeding complication, coagulation of extracorporeal circuit,

venous blood pressure, heart rate, QTC, activated coagulation time

(ACT), ionized-calcium (iCaþþ), total calcium and pH, HCO3�,

Naþ, Kþ, Cl�, BUN, Cr, GPT, GST, TBIL, DBIL, as well as the

blood cell counts were monitored during hemodialysis, and a

scanning electron microscopic (SEM) analysis was used to

investigate the morphology of thrombus formation and cellular

aggregation on the interior surface of hemodialysis membranes.

Results: During the hemodialysis in Group 1, venous blood pres-

sure increased continuously, resulting in the failure of hemodialysis

for 4 out of 19 patients. Hemodialysis for 4 hours in Group 2 were all

successfully fulfilled. No bleeding episodes occurred. No severe

clotting of dialyzers and blood accesses was observed. ACT was

extended and iCaþþ decreased obviously in the venous line, but

ACT and iCaþþ in vivo were normal. pH, HCO3� tended to increase

but not to metabolic alkalosis levels. Naþ, Kþ, Cl�, GPT, GST, TBIL,

DBIL, as well as the counts of blood cells were all within the normal

range. There was no severe thrombus observed by SEM in the hollow

fibers. In Group 3, severe bleeding complication happened to 3 out

of 19 patients, and one of them died. ACT was extended obviously at

the arterial end. Conclusions: The citrate anticoagulant hemodialy-

sate was proved to be practical, safe and effective. So it is indicated for

patients with an active or recently active bleeding focus.

Correction of an anemia in patients with a terminalstage chronic renal insufficiency on haemodialysis

Ismagilov R.Z., Dreizin V.J., Azhitaeva A.S. A.N. Syzganov’s

Scientific Center of Surgery, Almaty, Kazakhstan.

One of the basic symptoms of a terminal stage chronic renal

insufficiency is anemia. From everything, used methods of

correction of an anemia, it is considered the most effective

application of preparations recombinant human erythropoietin

(r-Hu EPO). Since 1994 in the Scientific Centre of Surgery

begins application r-Hu EPO. Application r-Hu EPO in patients

with a terminal stage chronic renal insufficiency in 90–95% of

cases had a positive effect, but 5–10% of patients have

intolerance to erythropoietin, that has induced to search of

new effective methods of correction of anemia. During research

were determined quantity erythrocytes, hemoglobin, reticulo-

cyte in peripheral blood and acid-alkaline condition of blood.

All hematology parameters were defined at the beginning of

treatment, over 5 day and for 15 day of stimulation of a bone

marrow. For 15 days after stimulation of a bone marrow by the

laser there was an authentic increase of quantity erythrocyte,

hemoglobin, hematocrit. The initial contents erythrocytes

made 2.22� 0.1 10� 12, hemoglobin 67.7� 3.2 g/l and

hematocrit 18.2� 1.2%. During treatment by the laser para-

meters erythrocytes have increased up to 2.9� 0.8 10� 12,

hemoglobin up to 89.6� 2.9 g/l and hematocrit up to

28.2� 1.3% (P< 0,005). Hematology parameters in blood of

control group authentically have not changed.

Multiple factors affect 3-year survival of patientson chronic hemodialysis

Sugahara S., Kanno Y., Moriwaki K., Ikeda N., Takane H., Kotaki S.,

Aoki H., Ooshima J., Suzuki H. Department of Nephrology, Saitama

Medical School, Iruma, Saitama, Japan.

Objective: The aim of this study is to determine the factors

contributing to survival of patients on hemodialysis. Methods:

Data were collected from 8 dialysis centers, and 432 patients were

recruited. Among them, patients who underwent hemodialysis

thrice a week for more than 3 years and received antihypertensive

therapy or had systolic blood pressure of more than 160 mm Hg

before dialysis secession were selected. Subsequent survival status

and cause of death were ascertained for the next 3.5 years. The

logistic multivariate regression analysis was used to estimate the

relative risk of death. Variables used for the purpose of this

analysis were patient gender, age, underlying renal disease

(unknown and others (0), CGN (1), DM (2)), medication,

serum albumin, history of having cerebrovascular and/or cardio-

vascular accidents (yes or no), the levels of serum creatinine,

blood urea nitrogen, pre- and post-dialysis blood pressure (sys-

tolic and diastolic), hemoglobin, serum calcium and inorganic

phosphate, b2-microglobulin, intact PTH, and other laboratory

data. Results: First step logistic regression analysis indicated age,

underlying renal diseases, serum creatinine, GOT, b2-microglo-

bulin were associated with increased relative risk (RR) of dying.

According to the formula calculated in this analysis, if the levels of

serum creatinine increased 1 mg/dl, the ratio of dying increased

by 1.210. Also, compared to the patients aged between 50 to 64

years old, the patients aged between 65 to 90 years old had 1.521

times dying ratio. Conclusions: From this study, it is suggested

that age, creatinine, underlying renal diseases, b2-microblobulin,

past history of cerebrovascular disease, serum creatinine, and

GOT were important factors contributing to patients’ survival.

The use of near infrared interactance inhemodialysis

Sarhill N.1, Mahmoud F.3, Khaishgi A.1, Sawhney R.1, Ahsan A.1,

Lanning J.1,2, Christie R.1 1Department of Internal Medicine, St

Vincent Charity Hospital/St Luke’s Medical Center, Case Western

Reserve University, Cleveland, OH. 2Nephrology Department, Case

Western Reserve University, St Vincent Charity Hospital/St Luke’s

Medical Center, Cleveland, OH. 3Department of Internal Medicine,

The University of South Dakota, Sioux Falls, SD.

Forty-one consecutive admissions to a hemodialysis center were

evaluated. Demographic information including age, gender, race,

and diagnosis was collected. Patients, >18 years old, with end

stage renal disease and on hemodialysis for at least one year were



included. Those with edema or known ascites were excluded.

Weight was measured before and after hemodialysis (HD) using

a standard scale and by considering the amount of fluid loss by the

hemodialysis machine. Body composition including total body

water (TBW) was calculated before and after HD using near

infrared interactance (NIR). All measurements were completed

during half hour before and after HD. Forty-one patients included:

men (n¼ 26), women (n¼ 15); median age 58 (range 28–88

years). Twenty-eight were African American and the rest Cauca-

sians. The amount of intravascular fluid taken after HD (assessed

by weight reduction) ranged 0–5 L with median 2.2 L. NIR

analysis for the same patients at the same time showed different

total body water measurements in 91% of cases (P> 0.05).

Moreover, NIR analysis showed increase in total body water in

24% of patients even though the hemodialysis machine showed a

loss of total body water; median of 1.3 (range: 0–3L). The error

in measuring body composition with NIR was both large and

varied (random and not systematic error). We conclude that NIR

analysis cannot be considered as a reliable method to evaluate

body composition, especially total body water, amongst patients

with end stage renal disease undergoing hemodialysis.

Biochemical and imaging alterations of renal bonedisease in newly detected predialysis and on

maintenance dialysis patients

Hossain R.M.1, Hoque M.E.2, Rahman H.1, Rashid H.U.1, Iqbal M.3

1BSM Medical University (BSMMU), Dhaka, Bangladesh, 2Comilla

Medical College and 3SSMC and MH, Bangladesh.

Objective: Bone involvement in chronic renal failure is mani-

fested long before the initiation of dialysis and is more prevalent

in patients receiving inadequate conservative phase manage-

ment. This study aimed at identifying the extent of

renal bone disease among pre-dialysis and maintenance dialysis

patients. Method: Thirty-two patients (gr 1) on maintenance

hemodialysis (HD) for variable period of time were compared

to twenty newly detected, irregularly treated, (gr 2) pre-dialysis

severe renal failure patients for their clinical, biochemical, and

imaging features. Result: Mean age of gr 1 and gr 2 patients was

45� 14 vs. 34� 15 years (p< 0.05). Comparison of blood

biochemistry between group 1 and 2 showed serum creatinine

9.9� 2.9 vs. 13.4� 4.4 mg/dl (P< 0.01), calcium 10� 1.4 vs.

7.4� 1 mg/dl (p< 0.001); phosphate 4.4� 1 vs. 8� 2 mg/dl

(p< 0.008); ionized calcium 4.7� 0.1 vs. 3.9� 0.7 mg/dl

(p< 0.05); alkaline phosphatase 116� 31 vs. 86� 31 IU/l

(p< 0.05); and iPTH 72� 48 vs. 147� 92 pg/ml

(p< 0.05). Radiological changes present in the two groups

were osteopenia-63% vs. 65% (P¼NS); trabecular resorption-

53% vs. 20% (p< 0.05); soft tissue calcification-31% vs. 10%

(p< 0.05); bone cyst-16% vs. 25% (P¼NS) and subperiosteal

bone resorption-16% vs. 20% (P¼NS). Tc 99MDP bone scan

combined in both groups of patients (n¼ 52) showed increased

uptake in wrist joint (29%), tibia-fibula (25%), costochondral

junction, vertebral column (15% each), sternum (13%), radius

and ulna (10%), and calvaria and mandible (8% each). X-ray

finding was positive for bone involvement in 59% cases and Tc

99 scan was positive in 80% (p< 0.05). Association study

showed iPTH had a negative correlation with serum

calcium (r¼�0.5, p< 0.05) and a positive correlation with

serum phosphate (r¼ 0.7, p< 0.05) and alkaline phosphatase

(r¼ 0.9, p< 0.001). Conclusion: It is concluded that pre-

dialysis newly detected renal failure patients may present with

deranged calcium homeostasis and can manifest high prevalence

of bone involvement when compared to maintenance hemo-

dialysis patients.

Vitamin D receptor BsmI and TagI genepolymorphisms in Turkish ESRD populationand influences on parathyroid hormone

response

Sezer S., Ozdemir F.N., Tutal E., Sahin F., Akcay A., Haberal M.

Baskent University Hospital, Department of Nephrology, Ankara,

Turkey.

Background/Aim: Clinical presentation and complications of

end-stage renal disesase (ESRD) patients are under influence of

many enviromental and genetic factors. In this study we aimed to

define frequencies of BsmI and TagI Vitamin D receptor (VDR)

gene polymorphisms and possible influences on clinical presen-

tations in Turkish ESRD population. Methodology and

Patients: 186 patients (111 male, 75 female) who are being

maintained on hemodialysis were included. Genotyping was per-

formed for the insertion/deletion BsmI (B!b, restriction site,

exon VIII!IX), TagI (T!t, 352 exon IX) VDR gene polymorph-

isms. Last 12 months’ laboratory values (C-reactive protein, intact

parathyroid hormone, albumin, calcium, phosphorus, Ca x P pro-

duct) and clinical findings (vitamin D requirement, body weight)

were recorded and analysed retrospectively. Results: Mean age

and follow-up period lengths were 42.1� 12.6 years and

76.3� 43.9 months, respectively. Polymorphism percentages

were as follows: BsmI; BB/Bb/bb: 28.9/65.3/5.8%, TagI; TT/

Tt/tt: 36.7/60.5/2.8%, respectively. Further analysis revealed

that TT variant of TagI was related with hyperparathyroidism

(p< 0.05). Analysis of data after regrouping patients according

to iPTH levels (0–249, 250–499, 500þ pg/mL) and hemodialysis

duration (<60 vs �60 months) revealed that influence of TT

variation on hyperparathyroidism became more frequent in case

of increased hemodialysis duration and iPTH levels (p< 0.005).

Conclusion: TT variation of TagI VDR gene influences the devel-

opment of hyperparathyroidism in HD patients. This influence

becomes more evident in patients with longer HD duration.

The effect of hemodialysis duration on 703hemodialysis patients in our center

Ozdemir F.N., Arat Z., Akcay A., Erdem A., Agca E., Sezer S.,

Haberal M. Baskent University Hospital, Department of Nephrology,

Ankara, Turkey.



There are limited data on demographics, long-term follow-up,

and iron/rHuEPO requirements of hemodialysis (HD) patients

in Turkey. The aim of the study was to analyze the effects of the

HD duration, primary illness, blood pressure, and age on serum

albumin, CRP, blood pressure, iron/rHuEPO requirements,

PTH, and HCV positivity of HD patients. 703 patients (280

women, 423 men, aged 47.8� 15.5 years) from 4 HD units

were included and grouped according to the duration on HD.

The demographic, clinical, and biochemical data of the last 3

months for each patient were recorded retrospectively. When

the groups were compared, patients with a longer HD duration

were younger and percentage of diabetic patients decreased as

the duration increased. Serum albumin and CRP levels were

similar between the groups. When the groups were compared

according to the blood pressure profiles, after the 5th year, a

decline in the systolic blood pressures was observed. Diastolic

blood pressures were similar across the years. There was no

significant difference in need of antihypertensive medicines.

Iron requirements showed a fall after the 5th year, and an

increase in after the 10th year. There was a decline in the

hematocrit levels by the duration on HD but there was no

change in rHuEPO requirements over the years. Parathyroid

hormone levels and HCV positivity tended to increase across

the years. Our results revealed that during the first 10 years, age,

etiology (diabetes, hypertension), and blood pressure control

seemed to be important factors affecting survival. Whereas, after

the 10th year, patients seemed to be more prone to the long-term

complications of HD, such as HCV infection, anemia, secondary

hyperparathyroidism.

Compliance, quality of life, and contributingfactors in renal transplantation waiting list

patients

Akman B., Colak T., Ibis A., Arat Z., Ozdemir F.N, Haberal M.

Baskent University Faculty of Medicine, Department of Nephrology,

Ankara, Turkey.

Poor patient compliance is common during dialysis therapy.

We aimed to study incidence of noncompliance, contributing

factors, and effects on quality of life (QOL) among cadaveric

renal transplantation waiting list patients. We included 86

renal transplantation waiting list patients (56M/30F). Dialysis

duration, previous renal transplantation history, comorbid condi-

tions, interdialytic weight gain, predialysis BUN, creatinine,

potassium, and phosphate were recorded. Noncompliance criteria

were skipping >1 dialysis session or shortening a dialysis ses-

sion>10 min in 1 month, interdialytic weight gain>5.7% of

body weight, predialysis serum potassium >6 mEq/L, and phos-

phate level >7.5 mg/dl. There were 49 noncompliant (age:

46.8� 21.8 years, HD duration: 83.9� 48.7 months) and 37

compliant (age: 42.8� 12.1 years, HD duration: 96.5� 45.2

months) patients. QOL was evaluated by short form 36 and

depression levels by Beck Depression Inventory. Previous renal

transplantation was present in 24.4% and comorbid diseases

in 31.3% of all patients. In depressed patients, 77.8% had

comorbid diseases. No difference was found between the

groups considering age, gender, dialysis duration, previous

transplantation history, and comorbid diseases (p> 0.05).

Noncompliant patients had lower QOL (p< 0.04). Noncompliant

patients had higher degree of depression (p¼ 0.01). QOL and

Beck scores were negatively correlated (p¼ 0.001, r¼�0.561).

Noncompliance to diet and dialysis therapy is associated with

depression, which further decreases QOL in renal transplantation

waiting list patients. Early diagnosis of depression, is possible by

monitoring noncompliance, and therapeutic intervention may

benefit during the transplantation-waiting period.

Acute complicating symptoms during hemodialysissessions have well correlation with deranged blood

pressure regulation

Iqbal M.M.1, Hossain R.M.2, Rahman H.2, Das S.2, Hossain J.2,

Salam A.2, Islam M.N.3, Mohsin M.1 1SSMC and Mitford Hospital,

Dhaka, Bangladesh, 2BSM Medical University, and 3BIRDEM

Hospital, Dhaka, Bangladesh.

Objective: This observational study was undertaken to evaluate

the frequency of acute complications occurring during dialysis

sessions and their association with other clinical and biochem-

ical parameters. Method: Forty-six maintenance hemodialysis

patients were selected and evaluated. Mean of the weekly

evaluations of different parameters over a three-month period

is presented here. Result: Age of study subjects was 39� 13

years and body mass index (BMI) 21� 4 kg/m2. Duration of

hemodialysis was 41� 29 months. Most of the patients were

hypertensive (98%), taking multiple anti-hypertensive drugs.

Mean of the blood pressures before and at the end of dialysis

sessions over the three month period were: systolic blood

pressure (SBP) 159� 18 vs. 163� 22 (p< 0.05) and diastolic

blood pressure (DBP) 92� 13 vs. 87� 7 mmHg (p< 0.003).

Frequency of acute complicating symptoms during dialysis ses-

sions were: headache (75%), rise in blood pressure (73%), leg

cramps (67%), vomiting (60%), palpitation (58%), sweating

(52%), and hypotension (35%). Raised blood pressure showed

a positive correlation with headache (r¼ 0.50, p< 0.01) and

sweating (r¼ 0.53, p< 0.05). Vomiting and palpitation were more

frequent at low post-dialysis blood pressure (vomiting vs. post-

SBP-r¼�0.41, p< 0.05 and palpitation vs. post-DBP-r¼�0.48,

p< 0.05), and these patients were likely to get inadequate

dialysis (hypotension vs. Kt/V-r¼�0.63, p< 0.01). Pre and post

dialysis weight variation was 53� 11 vs. 51� 11 kg

(p< 0.001), average ultrafiltration during dialysis (UF) �2.39

(0.5–4) liter and single session Kt/V was 0.95� 0.38. The

rising tendency of post-dialysis blood pressure correlated posi-

tively with increasing UF (SBP vs. UF-r¼ 0.36, p< 0.01 and DBP

vs. UF-r¼ 0.25, p< 0.05). Conclusion: From this study it may

be concluded that acute complications during dialysis sessions

have a significant correlation with deranged blood pressure



regulation, and optimum control of blood pressure could pro-

vide better dialysis.

Sodium modeling, hypotension, and weightgain in HD

Bland A.C.1,2, Pyszka, L.3, Pflederer, B.R.1,2 1RenalCare Associates,

Peoria, IL, 2Univ. of IL COM @ Peoria 3RCG, Central IL.

Sodium modeling is a strategy to decrease the incidence of

hypotension during hemodialysis. Side effects include

increased interdialytic weight gain. By default, all patients at

our dialysis center are started on HD with sodium modeling.

Purpose: To compare weight gain and blood pressure after

discontinuation of sodium modeling. Methods: Ten patients

using sodium modeling were changed to a standard sodium

bath after a change in attending physician. After IRB approval,

we collected and retrospectively reviewed the change in inter-

dialytic weight gains, episodes of hypotension (defined as an

episode of hypotension requiring staff intervention), and start-

ing and ending blood pressure. Data from one week prior to

Na change (PRE) was compared to one week after Na change

(POST) using a paired samples t-test. Results: Data from 4

men and 6 women with a mean age of 65.2� 13.7 years was

reviewed. ESRD diagnoses included diabetes (n¼ 4) and

hypertension (n¼ 6). Interdialytic weight gain significantly

decreased after discontinuation of sodium modeling (PRE

3.86 kg, POST 3.11 kg, p¼ 0.004). No significant change in

blood pressure at the start (PRE 154/82 POST 156/83,

p¼ 0.745) or end of HD (PRE 123/69, POST 130/67, p¼ 0.201)

was observed. However, the frequency of symptomatic hypo-

tension increased after change to standard sodium bath

(PRE¼ 6%, POST¼ 27%, p¼ 0.031). All episodes of hypoten-

sion occurred in 3 of the 10 study patients. No patient required

cessation of HD or transfer to the emergency department.

The degree of weight gain was not correlated with the likelihood

of intradialytic hypotension. Conclusion: A change from

sodium modeling to standard sodium dialysate lowers inter-

dialytic weight gain but increases the incidence of mild symp-

tomatic hypotension. Further study is needed to determine

whether mild hypotension is preferable to increased interdialytic

weight gain and to determine the relationship of increased

weight gain to complications of volume overload such as LVH

and CHF.

Results of improvement in adequacy of intermittenthemodialysis (IHD) in uremic patients

Grzegorzewska A.E.1,2, Banachowicz W.2 1Dpt. of Nephrology,

University of Medical Sciences, Poznan; 2International Dialysis

Center, Rawicz, Poland.

Increasing number of uremic patients, who need IHD, is a great

challenge for every society but especially for poor and developing

countries. The aim of our study is to look if small (not very

expensive) increase in IHD adequacy is able to improve standard

medical parameters. In 40 patients, treated with IHD for 57.5

(1–185) months, Kt/V was monitored on-line during the middle

IHD session in the week, 4 times in each of 6 consecutive months.

Measurements of Kt/V based on a conductivity method. In the first

month of observation Kt/V was lower (1.09� 0.02, p< 0.0009)

than in later months, in which Kt/V was ranging from

1.13� 0.04 to 1.17� 0.01. Blood morphology was estimated

every month. At the beginning of study period, after 3 months,

and at the end of studies, dry body mass, BMI, the blood pH and

serum concentration of calcium, phosphate, intact PTH, total

protein, albumin, cholesterol, iron, ferritin, urea, and creatinine

were determined. The increase in Kt/V was accompanied by rising

values of Hb (99.1� 16.6 ! 105.1� 12.5 g/l, p¼ 0.022), Hct

(31.6� 5.2 ! 33.8� 3.6%, p¼ 0.004), MCV (95.9� 7.7 !100.7 fl� 5.7, p¼ 0.000), iron (58.2� 29.6 ! 73.2� 27.8mg/

dl, p¼ 0.002), blood pH before (7.26� 0.04 ! 7.41� 0.04,

p¼ 0.000) and after (7.34� 0.05 ! 7.48� 0.05, p¼ 0.000)

IHD session as well as by decreasing values of PTH [918 (38

–3500) ! 420 (15–4341) pg/ml, p¼ 0.036]. Statistically

unchanged parameters included dry body mass (70.4� 15.6 !70.9� 16.1 kg), BMI (28.21� 6.73 ! 28.23� 6.79 kg/m2),

serum concentration of total protein (69.1� 5.7 ! 70.9� 4.8 g/

l), phosphate (5.72� 1.50 ! 5.39� 2.02 mg/dl), cholesterol

(203� 49 ! 191� 62 mg/dl) and ferritin (740� 558 !632� 346 ng/dl) as well as WBC (8.60� 3.89 ! 6.52� 1.50 K/

nl) and PLT (251� 91 ! 195� 60 K/nl). There were correlations

between Kt/V and serum concentrations of phosphate (r¼ 0.370,

p¼ 0.019), PTH (r¼ 0.314, p¼ 0.048), ferritin (r¼ 0.417,

p¼ 0.007), Hb (r¼�0.376, p¼ 0.017), and Hct (r¼ 0.374,

p¼�0.017). Our results indicate that even a small increase in

IHD adequacy leads to beneficial changes in management of

uremic patients (better response on erythropoietin, diminished

laboratory features of secondary hyperparathyroidism, better iron

utilization). Correlation between Kt/V and examined parameters

indicate that higher IHD doses were provided to patients in more

advanced uremic state. It may partially explain advantages

observed with incremental IHD adequacy.

The relationship of insulin resistance and body fat inchronic kidney disease patients.

Satirapoj B., Supasyndh O., Boonyavarakul A., Luesutthiviboon L.,

Chuvicheer P. Division of Nephrology, Department of Medicine,

Phramongkutkloa College of Medicine and Hospital. Bangkok,

Thailand.

Background: Insulin resistance has been associated with type 2

diabetes, hypertension, central obesity, and dyslipidemia, all of

which are important risk factors for progression of chronic

kidney disease (CKD). A greater degree of insulin resistance

may predispose to renal injury by worsening renal hemody-

namics through the elevation of glomerular filtration fraction.

However, there are sparse data on the relationship between

insulin resistance, glomerular filtration rate (GFR), and total



body fat or phase angle in CKD without diabetes. Methods: We

examined 84 non-diabetes CKD patients according to the

K/DOQI definitions; only 79 patients were enrolled into the

study (GFR between 15 and 90 ml/min/1.73 m2). The value of

insulin resistance was obtained by homeostasis model

assessment (HOMA). Bioelectrical impedance analysis was per-

formed to determine the percentage of total body fat or phase

angle. GFR was calculated by the average of creatinine and urea

clearances. Results: The correlation analysis showed that

HOMA-insulin resistance was positively correlated with phase

angle (r¼ 0.35, P< 0.01), percentage of total body fat (r¼ 0.27,

P< 0.01), body mass index (r¼ 0.48, P< 0.01) and serum

triglyceride levels (r¼ 0.32, P< 0.01), but not significantly

correlated with gender (r¼�0.07, P> 0.05), age (r¼ 0.05,

P> 0.05), GFR (r¼�0.006, P> 0.05), and mean arterial

blood pressure (r¼ 0.11, P> 0.05). Conclusion: In non-

diabetic chronic kidney disease patients, the major risk factor

for insulin resistance is the amount of total body fat. The insulin

level is not dependent on the GFR in these patients.

External gamma radiation caused by radon in waterused for home haemodialysis (HHD)

Riitta M.-K., Meeri K., Jyrki H., Tuukka T., Hannu A., Eero H.

Helsinki University Hospital, Division of Nephrology and Radiation

and Nuclear Safety Authority-STUK, Helsinki, Finland.

Background: Radon is a natural radioactive element found

especially in drilled water wells. It may cause problems in

HHD. In this study the occurrence and prevention of radiation

exposure to radon among HHD patients was examined.

Material and methods: Since 1998, 103 patients have been

trained for HHD and drilled wells were used in 7 patients.

Apart from routine analyses, radon concentration was also deter-

mined. Results: High radon concentration was observed in

three drilled wells, in one of these 2000 Bq/L. Water was con-

ducted into the HHD-equipment through a charcoal filter and

reverse osmosis equipment. Radon concentration was less than

50 Bq/L in the purified water. It was thus considered acceptable

for dialysis. As the charcoal filter adsorbs radon, its decay

products build up in the filter and emit gamma radiation. Con-

sidering that the daily through-put of water is about 375 liters,

the estimated dose rate for a radon concentration of 1,000 Bq/L

is 0.4 microSv/h at one-meter distance. At this distance the

annual dose would be 1.8 mSv, expecting a daily occupancy

time of 12 hours. The average background gamma dose rate in

Finnish dwellings is 0.1 microSv/h. National dose constraints of

3 mSv/year for adults and 1 mSv/year for children living in

HHD-households have been recommended. Conclusions:

Waterborne radon must be considered when planning of HHD

in households where drilled wells are used. Elevated radon

concentration should always be removed from household

water. In addition, external gamma radiation from charcoal

filters requires appropriate restrictions in order to achieve a

safe treatment.

Long slow night hemodialysis and quality of life

Hakkarainen P., Kapanen S., Honkanen E., Loflund E. Helsinki.

Univ Hospital, Div. of Nephrol, Helsinki, Finland.

Background: Long slow hemodialysis (LS-HD) improves

many biochemical parameters compared with conventional

HD. However, its influences on quality of life are less well

known. Aims: The objective of this study was to examine the

quality of life of patients on LS-HD performed overnight com-

pared to the patients on standard hemodialysis. This extends the

previous study, conducted in 2001, which examined the LS-HD

patients, quality of life. Patients and methods: We sent ques-

tionnaires to 12 LS-HD (overnight, treatment time 8 h� 3/wk)

patients and 15 day HD (4.5 h� 3/wk) patients, all being treated

using the limited care method. Data was collected using two

different structured questionnaires. One was constructed for a

previous study (2001) and the other one was a standardized set

of questionnaires (RAND-36). Research material was collected

from patient documents, such as the essential biochemical para-

meters, blood pressure, weight gain, and weekly EPO doses were

recorded. Ten of the LS-HD patients (83%) and 13/15 (87%) of

day HD patients returned the questionnaires. Three day hemo-

dialysis patients returned empty questionnaires, which were dis-

qualified. Results: Based on the medical facts, the results showed

that the patients of LS-HD felt better than the patients in another

group. Patients on the LS-HD had higher Kt/V (2.623 vs. 1.577)

and Hb (118 vs. 111) and lower Pi (1.36 vs. 1.63) and EPO dose

(epoietin-beta 2667 ky/week vs. 5833 ky/week; darbepoetin

16 ky/week vs. 37 ky/week). However, their predialysis BP as

well as the weight gain between treatments and salt and fluid

balances caused problems furthermore. The experiences of the

therapy of the LS-HD patients were more positive than of the

control group: they felt their medical condition was better than of

the patients on day HD. However we didn’t observe significant

differences in the replies showing physical or psychosocial

conditions between the two groups. Conclusions: The study

suggests that when patients can themselves make the choice

between treatment modalities, it improves the quality of life of

the patients. Control of anemia is improved in LS-HD overnight

patients with lower doses of EPO. The LS-HD gives the patients

more freedom of diet. However, more attention must be paid to

salt and fluid restriction. The LS-HD makes it possible for many

patients to work normally.

CQI in the acute dialysis setting

Margarita P. Ilumin UC. Davis Health System, Sacramento, CA.

When the acute dialysis program became an in-house operation,

the development and implementation of a CQI program was a

priority. Quality indicators were identified. Clotting in the dia-

lyzer, treatment delays, and catheter-related infections were

tracked. Based on our CQI data, it was clear from the beginning

that there was a high incidence of dialyzer clotting, particularly



on our patients on Extended Daily Dialysis (EDD) who were

on heparin-free dialysis. Heparin-free dialysis is prescribed

for high bleeding risk patients and for patients with

heparin-induced thrombocytopenia. There was a need to explore

an effective way to maintain patency and longevity of the

extracorporeal circuit as clotting not only results to blood loss

but to loss of treatment time, which affects the efficiency and

adequacy of the dialysis therapy. Our policy on no-heparin

dialysis was modified. Hourly saline flushes were changed to a

more aggressive every-15-to-30 minute flushes. In addition,

‘‘heparin rinse’’ or priming the extracorporeal circuits with

5000 units of heparin added to 1-liter bag, except for HIT positive

patients, was immediately implemented. After 2 months, clotting

in the dialyzer on Extended Daily Dialysis was significantly

reduced from 24% to 2%. Conclusion: CQI in the acute dialysis

setting is critical for a continuous cycle of evaluating and improv-

ing patient outcomes. Through the process of CQI, we were able

to identify dialyzer clotting with our EDD as a quality of care

problem and implemented a solution that was effective.

Studies of phosphate dynamics during hemodialysis

Kjellstrand C.M.1, Odar-Cederlof I.2, Ing T.S.3, Blagg C.R4. Aksys

Ltd, Lincolnshire IL1, Karolinska Institute Stockholm, Sweden2,

Loyola U. Chicago IL 3, NWKC and U. Washington, Seattle, WA.4

Regulation of phosphate (PO4) in hemodialysis patients is very

difficult and ideal levels are rarely maintained. A high removal

and a normal phosphate level is important, as high and

low levels are both associated with morbidity and a very high

mortality.

We studied phosphate dynamics and its relation to other small

‘‘uremic’’ molecules in 48 patients by measuring pre- and post-

dialysis levels and all removed phosphate, urea and creatinine

(creat) in all dialysate during 455 dialyses done at different

frequencies (freq): 3.7� 1.2, range 3–6 treatments per week

and durations of dialysis (t): mean: 196� 95, range 80–560 min

and with high (HF) and low flux membranes.

Kt/V-PO4, Kt/V-urea and Kt/V-creat, volumes (Vr) for all solutes

and their relationships to frequency and duration of dialysis,

urea clearance and predialysis phosphate were calculated.

Vr¼ removed solute� (predialysis minus postdialysis concen-

tration.); BW¼ body weight. Uf¼ ultrafiltration. Results: Vr

as a percentage of BW for PO4 was dependent on predialysis

PO4 and rose steeply as predialysis PO4 decreased: Vr%

BW¼ 212� 88� ln (predialysis PO4), (r¼ 0.39, p< 0.0001).

There was no such relationship for Vr for urea or creatinine and

no relation between urea and PO4 Vr, (r¼ 0.07, p¼ 0.141).

In stepwise multiple regression analysis:

Mg PO4 removed per week¼ t� 6.5þ freq� 387þUf� 140þpre-PO4� 273þ PO4stdKt/V� 343�HF� 375� 1824, (r¼ 0.73,

p< 0.0001). Blood flow(QB) and dialysate flow (QD), urea

weekly stdKt/V were not significant variables in the model.

Pre-dialysis PO4¼ 6.8�Hrs/week� 0.07�QB� 0.003þUf�0.26. QD, membrane type or dialyses/week did not enter

the model. Only patients dialyzing>28 hrs/week could stop

phosphate binders within 3 weeks. Conclusions: Phosphate

shows a highly variable dynamic during dialysis. Apparently,

the body maintains extracellular PO4 concentration by releasing

PO4 from unknown compartments when the blood concentra-

tion of PO4 decreases. Vr for phosphate thus varies not only

from patient to patient but also in a patient, depending on

blood concentration of PO4. Kt/V for urea and creatinine are

inaccurate in describing PO4 removal. To remove PO4 efficiently

it is most important to use long and daily dialysis. QB, QD

and membrane type are relatively unimportant in phosphate

removal.

Pediatrics

Access

Problems in hemodialysis with a permanent centralvenous catheter

Muscheites J., Drueckler E., Stolpe H.J. and Wigger M. Paediatric

Nephrology and Dialysis, University of Rostock, Childrens

Hospital, Rostock, Germany.

Hemodialysis is a common treatment of chronic renal failure,

also in childhood. Due to the high standard of technique there

are only few contraindications for this treatment at present. Limita-

tions are given by the vessel access. But in the last years, hemo-

dialysis has been made practicable by the permanent central

venous catheter, however, with more problems. As an example

for potential complications in the treatment with the permanent

catheter we present an unusual case report about a twenty-one-

year-old girl suffering from chronic renal failure due to reflux

nephropathy, Prader-Willi- syndrome, myelonatrophia of undeter-

mined origin with spastic diplegia of the legs, and increasing

sphincter ani dysfunction. We started the renal replacement

therapy when the girl was 15 years old. It was not possible

to create an AV fistula due to very small vessels. Two Gore-Tex 1

implants were clotted in absence of thrombophilia. After-

wards, the hemodialysis was performed by a permanent central

venous catheter. The catheter had to be changed 15 times. The

reasons for changing the catheter were problems of flow during

hemodialysis due to clotting, dislocations, spontaneous removing

Factor/solute: PO4 Urea-N Creatinine

Predialysis mg/dl 5.7� 1.9 73� 24 12� 3Postdialysis mg/dl 3.0� 1.0 33� 15 6� 2100�Vr/BW 63� 78 58� 24 41� 15Kt/V 1.01� 0.66 1.04� 0.32 0.97� 0.26Weekly stdKt/V 1.75� 0.81 2.12� 0.68 1.96� 0.71Removed gm/week 3.1� 1.3 56� 23 6.2� 2.5



of the catheter by herself, and infections. Altogether a sepsis

occurred four times. The first transplantation failed due to a

rupture of the transplanted kidney. A second transplantation

was not possible because of the high BMI. Intermittently, the

girl was treated with peritoneal dialysis (PD) in the hospital,

because the PD couldn’t be done at home due to different reasons.

Only on weekends could the girl go home. The PD had to be

finished after 6 months due to a severe psychotic syndrome. The

girl died at age 21, caused by a sepsis following the 15th change of

the catheter. A huge problem of frequent catheter changing is the

limited availability of vessel accesses – the limits of treatment by

hemodialysis.

Kinetics, Dialysis Systems, and Adequacy

Copper deficiency: A common cause oferythropoietin (rHuEPO) resistant anemia in

children on hemodialysis (HD)?

Warady B.A., Nelms C., Jennings J., Johnson S., The Children’s

Mercy Hospital, Kansas City, MO.

Copper (CU) deficiency, as reflected by a low serum CU and

ceruloplasmin (CER) level, is a rare complication of chronic HD.

When present, common clinical manifestations include anemia and

neutropenia. Anecdotally, CU deficiency has been linked to the use

of sevelamer hydrochloride (SH), a recently introduced phosphate

binding agent. The finding of severe CU deficiency and rHuEPO-

resistant anemia in 3 of our patients (pts) prompted a review of

our entire pediatric HD population for the frequency of CU

deficiency and its possible relationship to SH. An assessment of

serum CU was conducted in 17 pts (male-11; mean age

169.4þ 49.6 mo) who had received HD for 21.5þ 33.9 months.

All pts received three 4-hour HD sessions weekly with mean

single-pool and equilibrated Kt/V values of 2.29þ 2.5 and

1.56þ 0.37, respectively. 14 of 17 (82%) pts had low

serum CU levels with a mean value of 69.1þ 38.3 mcG/DL

(normal¼ 85–150 mcG/DL). 9 of 17 (53%) pts had values

<60 mcG/DL and 3 pts had values <25 mcG/DL with CER

values of 1.2 mg/dL, 0.6 mg/dL, and 1.8 mg/dL, respectively

(normal¼ 24–40 mg/dL). In the latter 3 pts, hemoglobin values

fell to 5.4 gm/dL, 5.2 gm/dL, and 9.2 gm/dL despite regular

rHuEPO dosing and adequate iron stores and all pts responded to

supplemental CU therapy. The mean hemoglobin of the remaining

14 pts was 11.7þ 1.3 gm/dL. Whereas 13 of 14 (93%) CU deficient

pts were receiving SH (142.1þ 112.3 mg/kg/d) for 331.0þ 293.6

days at the time of the CU assessment, there was no significant

relationship demonstrated between the dose of SH or the duration

of SH therapy and the serum CU level. In conclusion, CU

deficiency appears to commonly occur in pediatric HD pts with

extremely low values associated with profound anemia responsive

to CU therapy. While the chronology of CU deficiency and the

introduction of SH suggests an association, additional research is

necessary to address this issue in a more definitive manner.

Infections

Controlling exit site infections: Does it decrease theincidence of catheter-related bacteremia in children

on hemodialysis?

Onder A.M., Chandar J., Coakley S., Abitbol C., Montane B.,

Zilleruelo G. Dept of Pediatric Nephrology, University of Miami/

Jackson Memorial Hospital, Miami, FL.

The most common complication of tunneled-cuffed hemodialysis

catheters is catheter-related bacteremia (CRB), which contributes to

patient morbidity and loss of vascular access. Gram positive micro-

organisms are the most common etiologic agents; coagulase nega-

tive staphylococcus and corynebacterium species are the two most

prevalent strains in our center. These are the common inhabitants

of skin flora, suggesting that infection of catheters occur through

the exit site. The Biopatch is a chlorhexidine impregnated dressing

designed to keep the exit site from colonization with skin flora. This

may decrease the incidence of CRB due to organisms from the skin.

Objective: To investigate whether the application of the biopatch at

the exit site has any effect on the incidence and the etiology of

CRB.Methods: Chart review of 63 pediatric chronic hemodialysis

patients who were dialysed between January 1999 and December

2003 was performed. The mean age at start of hemodialysis was

13.9� 4.6 years. The pre-Biopatch era started in January 1999 till

the end of June 2001, and the Biopatch era started in July 2001 to

December 2003. Biopatch was applied at the beginning of every

dialysis week after Betadine cleansing of the exit site, which was

then covered with a transparent dressing. In the pre-Biopatch era,

the exit site was cleansed with Betadine at every dialysis session

and then covered with a transparent dressing. Results: The use of

the Biopatch at the exit site caused a significant decrease in the exit

site infections. However, contrary to what was expected, there was

no decrease in the incidence of CRB.

Pre-BiopatchEra

BiopatchEra

p value

Gram positive infections % 76% 76% NSGram negative infections % 10% 14% NSPolymicrobial infections % 14% 10% NSTotal number of infections 108

(19 patients)143(29 patients)

NS

Exit site infections-number 20(9 patients)

5(3 patients)

p< 0.05

Conclusion: The use of the Biopatch decreases exit site infec-

tions. However, it fails to decrease the incidence of CRB. It has

no effect on the etiologic agent of the bacterial infection.

Catheter-related bacteremia in a pediatrichemodialysis unit

Onder A.M., Chandar J., Coakley S., Abitbol C., Montane B.,

Zilleruelo G. Dept. of Pediatric Nephrology, University of Miami/

Jackson Memorial Hospital, Miami, FL.



Tunneled-cuffed hemodialysis catheters are frequently used as

long-term vascular access in children due to the technical diffi-

culties in constructing a fistula. Catheter-related bacteremia

(CRB) is still a major complication contributing to patient mor-

bidity and loss of vascular access. Objective: To investigate the

microbiological characteristics of CRB in children on hemodialy-

sis. Methods: Chart review of 63 children who received hemo-

dialysis with a tunneled-cuffed catheter between January 1999

and December 2003 was performed. CRB was diagnosed when

positive blood cultures were obtained in patients with symptoms

of bacteremia, and without an identifiable source. Results: Dur-

ing the 5 year period, a total of 251 CRB were detected with 313

bacterial and 2 candidal growths in the blood cultures. The

distribution of gram positive (Grþ) and gram negative (Gr�)

microorganisms and their sensitivity patterns are shown in the

table. Coagulase negative Staphylococcus was the most common

microorganism, and constituted 62% of all bacterial isolates. All

Grþ microorganisms were sensitive to vancomycin except one

isolate of Enterococcus fecalis. Enterobacter cloacae was the most

common Gr� microorganism, followed by Klebsiella pneumonia.

The sensitivity of Gr� microorganisms to levofloxacin was 100%.

The treatment course was complicated by the growth of a second

microorganism in subsequent blood cultures in 24% of infec-

tions; 54% of these consisted of both Grþ and Gr� isolates. The

etiology of ESRD or the use of immunosuppressive agents had no

effect on the occurrence of CRB. The average number of infec-

tions were 5.8/1000 catheter days, and the recurrence of CRB was

more likely in patients who had two or more CRB in a year.

1999 2000 2001 2002 2003

Grþ growth 80% 88% 87% 85% 73%Oxacillin resistance 84% 73% 82% 68% 75%Gr� growth 20% 12% 13% 15% 27%Tobramycin resistance 21% 50% 25% 20% 13%

Conclusions: Empiric initial treatment for CRB should include

both Grþ, and Gr� coverage. Oxacillin and first generation

cephalosporins are not good choices due to high incidence of

resistance. Levofloxacin is a good alternative for Gr CRB. Novel

preventive measures should be sought in patients who have a

tendency to have recurrent CRB.

Clinical Experiences

Calcium and phosphate balance in children on homenocturnal hemodialysis (NHD)

Hothi D.K., Piva E., Keating L., Harvey E., Geary D.F. The Hospital

for Sick Children, Toronto, Ontario, Canada.

Objective: To evaluate and describe biochemical indices of bone

metabolism in 4 children on NHD. Method: The children, aged

12, 13, 14, and 16 yrs, have been treated exclusively on NHD for

6, 9, 9, and 15 mos. Subsequently, Pt 1 converted to a hybrid

program of 4 nights on home nocturnal plus 1 session of in

center conventional HD per week. Biochemical indices of bone

metabolism have been collected prospectively. Results: All base-

line pre-dialysis calcium levels were within normal ranges and

each patient was started on a dialysis calcium concentration of

3.0 mEq/L. However, over time the number of asymptomatic

biochemical hypocalcaemic episodes increased. The dialysate

calcium concentration was increased to 3.5 mEq/L in one and

decreased to 2.0 mEq/L in another who was hypercalcemic and

receiving concurrent calcitonin for bone pain related to osteo-

porosis. In Pt 1, the dialysate calcium was increased to 3.5 mEq/L

during nocturnal and continued on hybrid therapy. Including an

evaluation of dietary intake, all 4 patients had a net positive

calcium balance, ranging between 9.8 to 23.5 mmol (393

–942 mg). A significant reduction in the predialysis phosphate

level was observed in all 4 patients, and none required dietary

restrictions or the use of phosphate binders within 2 months or

vitamin D within 6 months of HND. In addition, phosphate was

added to provide a dialysate concentration of 2.4–6.1 mEq/L to

prevent hypophosphatemia. This is reflected by significant

reductions in intact PTH levels to the desired range (twice the

normal range) in all 4, but the level continued to drop to the

normal range and below in 2. In Pt 1, after introduction of hybrid

therapy, both levels of phosphate and PTH rose, necessitating

recommencement of phosphate binders and vitamin D. Likewise,

the (Ca� PO4) dropped and remained <55 in all 4 patients

exclusively on NHD, but started to climb in Pt 1 during hybrid

therapy. Conclusion: In our cohort of patients, NHD rapidly

lowered plasma phosphate and PTH levels. With NHD, additional

dialysate phosphate and possibly calcium may be necessary to

prevent chronic losses and development of renal osteodystrophy,

and caution is required to prevent either oversuppression of PTH

and extraskeletal calcification.

Single-dose pharmacokinetics (PK) of ferricgluconate (FG) in iron-deficient pediatric

hemodialysis patients

Warady B.A1. Ferrlecit Pediatric Study Group, 1The Children’s

Mercy Hospital, Kansas City, MO.

Purpose: Limited information exists on the use of any intravenous

iron preparation in pediatric HD patients. This study was designed

to describe the PK parameters of FG, now approved for use in

children on HD. Methods: Iron-deficient pediatric HD pts

(�15 yr) were randomized to 2 doses of FG. Blood samples taken

during a 1 hr infusion and at intervals over 48 hrs were analyzed for

total iron, transferrin-bound iron (TBI), and FG-bound iron (FGI).

Results: 49% of pts were male, 88% white, 57% age 6–12 yr, wt

16.3–63.2 Kg, ht 100–177.5 cm. Mean serum iron concentrations

(total iron and FGI) rapidly increased in a dose-dependent manner,

approximately proportional to the FG dose administered. A rapid

rise in total serum iron was followed by a slower, less prominent

rise in TBI. Single-dose PK of FGI was adequately described

using non-compartmental analytical methods. A standard

2-compartment NONMEM model successfully fit the data and

accurately described the time-course of FGI concentrations.



Conclusions: Cmax values in pediatric HD population were

similar to Cmax values previously reported with similar FG

doses in healthy iron-deficient adults (Ferrlecit1 prescribing

information). In contrast, mean AUC0�1 values were approxi-

mately 2 times greater, and mean Cl rates were 5.4 times slower

in pediatric pts.

Use of argatroban for hemodialysis and continuousveno-veno hemodialysis in a patient with heparin-

induced thrombocytopenia

Lau K.K. University of Tennessee Science Center, Memphis, TN.

Objective: To describe the use of argatroban in a post-cardiac

operation patient with heparin-induced thrombocytopenia

requiring hemodialysis and continuous veno-veno hemodialysis

(CVVH). Case Summary: A 23-year-old Caucasian female with

heparin-induced thrombocytopenia developed acute renal

failure after cardiovascular surgery. Argatroban was used as a

substitute for heparin during hemodialysis and CVVH. Both

activated partial thromboplastin time (aPTT) and activated clot-

ting time (ACT) were used to guide the dosage of argatroban.

The patient was successfully dialyzed without clotting of the

circuit. The dosage required in our patient was much lower than

the manufacturer’s recommendation. Discussion: Argatroban is

a thrombin inhibitor that does not cross react with heparin. It is

metabolized by the liver, and dosage adjustment is recom-

mended in patients with severe hepatic impairment. The correct

dosage for patient with unstable hemodynamics is not known.

Our patient had apparently normal hepatic function at the

initiation of dialysis, but the dosage of argatroban recommended

by the manufacturer resulted in prolonged elevation of the aPTT

and ACT with associated gastrointestinal bleeding. This may be

related to hepatic congestion secondary to poor cardiac function

and/or severe anasarca. And the dosage of argatroban required

during dialysis was much lower than the recommendation.

Conclusions: Argatroban is an effective alternative of heparin

for CVVH. The correct initial dosage in patients with mild

hepatic impairment and unstable hemodynamics is still unclear.

Citrate anticoagulation for pediatric continuousvenovenous hemodiafiltration

Watanabe A., Dantas G.C., Troster E.J., Koch V.H.K. Instituto da

Crianca-HCFMUSP. Sao Paulo, Brazil.

Objective: Feasibility and safety evaluation of citrate anticoagu-

lation for hemodiafiltration (CVVHD) procedure in a pediatric

critical care unit. Patients and Methods: From 08–2002 to 12

–2003, five patients were treated by CVVHD with regional

citrate anticoagulation, age range 1.4–16 yrs, body weight 6.7

–38 kg. Inclusion criteria: oligoanuria and hypervolemia and/

or uremia, hemodynamic instability, and impossibility of

peritoneal dialysis. The patient’s primary diseases were: liver

disease (4/5) and chronic renal disease (1/5). All patients were

on mechanical ventilation and on vasopressor support and

presented with thrombocytopenia. Hepatic dysfunction was

observed in four patients. The CVVHD prescription was:

blood flow rate: 2–5 ml/min, dialysate and replacement flow

rate: 3000 ml/1.73 m2/h. Citrate regional anticoagulation (4%

trisodium citrate) was used according to a previously described

protocol (Bunchman et al., Pediatr Nephrol 2002: 17:150–154).

The duration of each individual procedure was 9–72 hours, and

the total time range of CVVHD was 2 to 19 days. A bicarbonate

based solution (Na 140 mEq/L and bicarbonate 35 mEq/L) was

prepared in our hospital pharmacy. Prisma system (GAMBRO)

and polycrylonitrile M-60 Pre-set hemofilter was used in 4/5

patients and M-10 Pre-set hemofilter in one patient. Results: The

use of M-10 filter was associated with a higher rates of ACD-A and

calcium infusion (ml/h). Metabolic alkalosis was observed in one

patient and hypernatremia in three patients. All patients died of

causes other than renal failure (sepsis and multiple organ

dysfunction syndrome). No bleeding related to citrate occurred.

Conclusion: Citrate anticoagulation proved to be feasible with

minor side effects in pediatric ICU patients. The high mortality

can be related to the severity of multiple organ failure.

Marked functional improvement in a pediatric patienttreated with hemodialysis for scleroderma related

renal failure

Benador N.M.1, Grimm P.C.1, Reznik V.M.1, Mendoza S.A.1,

Ferrara E.2 1University of California, San Diego, 2Naval Medical

Center, San Diego, CA.

Systemic sclerosis (SSc) is a rare autoimmune disease character-

ized by fibrosis and vasculopathy of the skin and visceral

organs. Scleroderma renal crisis (SRC), the most acute and life

threatening complication, occurs in 10–20% of adult patients

with SSc and has not been reported in children. A 10-year-old

girl was diagnosed with SSc when she presented with weakness

and skin thickening. She had positive ANA and anti-Scl 70.

Renal function, urinalysis, and blood pressure were normal.

She was treated with steroids, penicillamin and methotrexate

as well as amlodipine for Raynaud’s phenomenon, but her

diffuse skin thickening and contractures progressed and she

became wheelchair bound and had poor growth despite nutri-

tion through a G-tube. At age 15 (weight 28 kg), when evaluated

for abdominal pain, she was found to have acute renal failure

(BUN 54 mg/dl, creatinine 2.2 mg/dl) and hypertension. Despite

therapy with enalapril, serum creatinine continued to rise and

PharmacokineticParameter

1.5mg/kg FG(n¼22)

3.0mg/kg FG(n¼26)

Cmax (mean� SD, mcg/dL) 1287� 285 2283� 637AUC0–48 (mean� SD, mcg � hr/dL) 9327� 4038 16,830� 6526AUC0–1 (mean� SD, mcg � hr/dL) 9499� 4089 17,087� 6776Tmax (mean� SD, hrs) 1.1� 0.23 1.1� 0.19t1/2 (mean� SD, hrs) 2.0� 0.7 2.5� 1.8Kel (mean� SD, hr�1) 0.43� 0.30 0.39� 0.27Cl (mean� SD, L/hr) 0.69� 0.50 0.66� 0.52Vd (mean� SD, L) 1.6� 0.6 1.9� 1.1



she became oligoanuric, requiring initiation of hemodialysis. BP

was controlled with enalapril and dialysis but she remained

dialysis dependent. Steroid therapy was discontinued and

replaced by low dose cyclosporine. Enalapril was replaced by

losartan because of leukopenia and BP remained normal. Over

the next 2 years, she was treated with hemodialysis and did not

experience any complications. She progressively had an out-

standing overall clinical improvement, marked skin softening,

and was able to walk independently. Renal function did not

improve. 28 months after the SRC, she received LRD renal

transplant. Immunosuppression included cyclosporine, myco-

phenolate and prednisone. Creatinine 2 months post-transplant

is 0.7 mg/dl. SRC in children may progress to end-stage

renal disease but can be treated successfully with dialysis and

transplantation without significant complications.

Not Presented

Puncturing your own fistula

Krutzen L. University Hospital of Lund, Sweden.

When you are working with home HD education you often

meet patients who are very afraid of the moment when they

are going to puncture the fistula themselves. Our experience is

that the patient sometimes can’t concentrate on anything but

this moment. For this reason we let the patient try to puncture

as soon as possible. We also get many questions from colleges,

doctors, and nurses on how to do it. Most of the patients are

very successful and prefer to puncture themselves after having

tried it. They say that it is less painful if you puncture yourself

and we also have a feeling that it is very rare that they are

unsuccessful. To get proof for these feelings we made a small

inquiry among our patients, asking about how it is to puncture

yourself. We sent the inquiry to 30 patients. We also decided to

make a film showing how to puncture yourself. We asked some

of our home HD patients if they wanted to contribute. The result

of this is a video, which is 9 min long, showing how to puncture

in different types of fistulas, underarm, overarm, and grafts.

Experience of application maxipimi at patients with aterminal stage chronic renal insufficiency at

allotransplantation of a kidney

Ismagilov R.Z., Bapiev T.A., Zainalov A.K., Shynybaev T.B.,

Rahimbekov T.I. Syzganov‘s A.N. Scientific Centre of Surgery,

Almaty, Kazakhstan.

The analysis of infectious complications in patients after

allotransplantation of a donor kidney. For the dynamic analysis

of frequency of infection-purulent complications, all patients

were divided into 2 groups. The first, control group included

33 patients who were operated from 2000 to 2002 (men-21,

women-12, adults-28, children-5). The second, basic group

included 35 patients (men-22 and women-13, adult-28, chil-

dren-7), after allotransplantations, which have transferred

operation–transplantations of kidney with 2003 on 2004. In

the first group purulent–septic complications were marked at

9 patients (27.2%), from them two (6%) have died of a sepsis on

a background of antibacterial therapy (cephalosporini 3 genera-

tions). Duration of treatment made from 7 up to 15 days. In the

second group in the postoperative period purulent – septic

complications were marked at 5 of 35 patients (14,2%). All 35

patients in the second group after allotransplantation of a donor

kidney carried out preventive antibacterial therapy maxipimi

(cephalosporini IV generations) on dosage 1 gram 2 times per

day in a combination with amykini intravenously during 7 days.

Cases of development of sepsis in this group of patients were

not observed. Thus, estimating the received results, it is possible

to draw the conclusion, application of antibiotics of a wide

spectrum (cephalosporini IV generations) the patient with a

terminal stage chronic renal insufficiency after allotransplantation

of a donor kidney were lowered with quantity of suppurations of

postoperative wounds and occurrence of infectious complications

on 13%.

Managing ‘‘change’’ in HD unit

Christopoulou S.J. Hellenic Airforce Hospital, Athens, Greece.

In this paper we’ll discuss how change management affects

hemodialysis improvement. As hemodialysis is a technology

dependent method of End Stage Renal Disease (ESRD)

treatment, it is obvious that the need of continuous revisions

in health care practices and researches on staff training are

significant factors for success. ‘‘Change’’ defined as an attempt

to replace existing knowledge with new. Change achievement is

not always a simple procedure. In this study we examine nurses

and patients reactions on changes and how can we accomplish

successful changes every time they are needed. We also examine

how changes in role of health care team can lead the team to our

final destination, which is to provide the best hemodialysis

treatment we can. Leadership, communication, informing,

planning, and adjusting are the main contents for successful

change management. We believe that we can improve

haemodialysis practices and health care by giving learning

opportunities to our nurses. Nursing training development can

help them to follow changes. On the other hand we can get our

patients to come on board with us on any change by encourage-

ment and consistent try. As Hereticus said, ‘‘Nothing that is, has to

be just because it is.’’ Therefore, we should keep thinking about

managing changes all the time!

Venous needle dislodgement during hemodialysis:An unresolved risk of catastrophic hemorrhage

Sandroni S. Allegheny General Hospital, Pittsburgh, PA.

Venous line disconnection or needle dislodgement during

hemodialysis with resultant hemorrhage is a potentially lethal



event. The risk is compounded by the frequent failure of stan-

dard dialysis machines to detect the event, as blood flow

through the venous needle typically creates enough back pres-

sure to prevent venous pressure alarms even if the needle is

completely out of the patient’s AV access. Manufacturers are

well aware of the risk and device literature contains specific

warnings about it. The FDA publishes reports on its website

about these events; so far this year there have been seven

reported events with five deaths. Informal sources indicate that

the actual (unreported) occurrence is much more frequent; we

are aware of four additional events within our region alone.

Efforts to reduce the risk include protocols requiring the access

needles to always be visible, and use of enuresis detection devices.

Anecdotal experience with these efforts suggests they are not highly

effective. Protocols requiring documentation of more frequent

needle site checks or alternate methods of securing the needles

have not been formally evaluated. However, such efforts do not

address the primary problem: there is a need for an engineered

solution to this problem. Requirements for such a solution include:

reliable detection of needle position and blood flow discrepancies, a

useful alarm, and feedback to stop the blood pump. Persistence of

this problem raises issues of regulatory oversight.



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