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Calciphylaxis is a disabling and life-threatening complication that primarily affects patients who are dialysis dependent. This disease entity is characterized by calcification, intimal hypertrophy, and thrombosis of small vessels, which results in necrotizing, nonhealing ulcers. The development of these lesions portends a grim prognosis, as they are often accompanied by severe and sometimes fatal infectious complications. Although several strategies aimed at treating and preventing this affliction have been reported in the literature, the outcome for most patients with calciphylaxis remains quite poor. We describe an anuric hemodialysis patient who developed severe calciphylaxis that proved refractory to conventional treatment. Following extensive debridement of several wounds, intravenous sodium thiosulfate was utilized as an adjunctive therapy four times a week. Within 6 months, excellent wound healing ensued as well as a dramatic improvement in the lesions that were not previously resected. Aside from occasional nausea, these treatments were well tolerated, despite the development of an anion gap metabolic acidosis. After 34 months of continued treatment the patient remains free from disease recurrence and has demonstrated no untoward effect of prolonged therapy. In an effort to delineate the pharmacokinetics of this drug in a hemodialysis patient, serum thiosulfate levels were obtained 15 minutes after infusion as well as before and after subsequent dialysis treatments. Consistent with prior studies in anuric canines, we found measurable quantities of the drug more than 50 hours after treatment, in addition to a markedly elevated half life of 478 minutes. However, given the lack of significant toxicity, as well as a dramatic clinical improvement, we feel that sodium thiosulfate may have an important adjunctive role in the treatment of calciphylaxis in dialysis patients.
Semin Dial
PMID:Long-term intravenous sodium thiosulfate in the treatment of a patient with calciphylaxis. 1619 Nov 85

Encapsulating peritoneal sclerosis (EPS) is recognized as a serious complication of continuous peritoneal dialysis. A preliminary diagnosis of EPSis usually based on clinical signs and symptoms, which commonly include abdominal pain, nausea, vomiting, anorexia, abdominal fullness, an abdominal mass, bowel obstruction, and radiologic findings, including abdominal roentgenogram, contrast studies, ultrasound studies, and computed tomography. The diagnosis is confirmed by laparoscopy or laparotomy showing the characteristic gross thickening of the peritoneum enclosing some or all of the small intestine in a cocoon of opaque tissue. A variety of therapeutic approaches to EPS have been reported. This review discusses medical treatment of EPS and includes an overview of the clinical features and diagnostic aspects of the condition.
Perit Dial Int 2005 Apr
PMID:Encapsulating peritoneal sclerosis--a clinician's approach to diagnosis and medical treatment. 1630 Feb 70

Leukocytapheresis (LCAP) is a therapeutic strategy for extra corporeal immunomodulation that has been used to treat several immunological disorders, including ulcerative colitis (UC), with encouraging results, inducing remission in steroid-resistant patients. However, we have experienced some complications during or after LCAP therapy. Common adverse effects include fever, chills, nausea, vomiting, and hypotension. One of the reasons for these adverse effects might be the use of nafamostat mesilate (NM) as an anticoagulant. In the present study, 75 patients with UC were divided into two groups, an NM group and a dalteparin sodium (DS) group. The clinical efficacy of these treatments, improvement after treatment, changes in leukocyte differential count, and adverse effects after LCAP therapy were then compared. The clinical efficacy, improvement after treatment, and changes in leukocyte classification were not significantly different between the two groups, while some adverse effects were observed in the NM group but not in the DS group. In conclusion, LCAP therapy is a useful therapy for patients with moderate to severe UC who fail to respond to glucocorticoid therapy, however, a safe anticoagulant should be used to avoid its related adverse effects.
Ther Apher Dial 2006 Feb
PMID:Leukocytapheresis for ulcerative colitis: a comparative study of anticoagulant (nafamostat mesilate vs. dalteparin sodium) for reducing clinical complications. 1655 37

Transient bacteremia during and after endoscopic procedures is a well-documented phenomenon. Streptococcus viridans peritonitis is frequently associated with peritoneal dialysis, and the infection is probably attributable to hematogenous spread, dental procedures, or transluminal contamination with oral flora. To our knowledge, no reports exist of peritonitis occurring after gastroscopy in peritoneal dialysis patients. Here, we report the case of a 69-year-old male patient receiving automated peritoneal dialysis who required emergency gastroscopy and sclerotherapy plus heat-probe coagulation to control active bleeding from a duodenal ulcer The next day, this patient developed nausea and abdominal pain. The diagnosis of peritonitis was made based on a cloudy peritoneal effluent and a leukocyte count of 11,500 cells/microL with 98% neutrophils. S. viridans was identified in the peritoneal fluid culture. The patient received ceftazidime for 14 days, followed by clarithromycin for 7 days, and he recovered successfully. Patients receiving peritoneal dialysis who undergo esophagogastroduodenal endoscopy are at risk to develop peritonitis, and so antibiotic prophylaxis is desirable.
Adv Perit Dial 2005
PMID:Streptococcus viridans-associated peritonitis after gastroscopy. 1668 85

The scientific knowledge base that supports clinical decisions about perioperative fluid management continues to evolve. However, despite these advancements in the understanding of the physiology of fluid replacement, the definition of ''optimal'' perioperative fluid management remains a matter of clinical judgment. With an appreciation of the many factors, both sensible and insensible, that contribute to changes in blood and extracellular fluid volume during surgery, clinicians have tried to create reproducible and generally applicable formulas for replacement of fluid during surgery. These formulas have been challenged recently by the introduction of new tools for monitoring cardiopulmonary function, by the implementation of monitor-guided protocols for fluid management, and, more recently, by clinical data suggesting that fluid restriction may improve surgical outcomes in some clinical settings. The relative ease of pre-identified fluid replacement protocols is being slowly replaced by data-guided interventions that take into account a variety of factors. Clinicians are therefore required to tailor their fluid replacement strategies based on preoperative patient characteristics, the type of surgery and even the type of anesthetic that is utilized. Some of the benefits of this new approach range from relatively ''minor'' outcomes such as diminished nausea after surgery to preventing postoperative complications such as wound breakdown and cardiopulmonary failure.
Semin Dial
PMID:Perioperative fluid management: current consensus and controversies. 1715 47

Accidental loss of tunneled hemodialysis catheters has been observed in chronic hemodialysis patients. Although a new catheter could be inserted using a fresh site, catheter insertion can also be accomplished by utilizing the existing exit site. In this analysis, we report 10 cases of an extruded tunneled hemodialysis catheter. The catheters had been in place for 2-6 months. The time elapsed after catheter extrusion ranged from 6 to 72 hours. None of the patients demonstrated any evidence of exit site or tunnel infection. Patient age ranged from 45 to 77 years. Diabetes mellitus was the cause of renal failure in 40% of the cases. Catheter insertion was accomplished by inserting a guidewire into the exit site and navigating it through the tunnel to the central venous system and into the right atrium. A diagnostic catheter was then navigated over the wire and contrast study performed to confirm the position. The wire was reinserted and a new tunneled hemodialysis catheter fed over the wire and into the atrium. Nine catheters were successfully placed using this technique. One patient had nausea and hiccups upon wire insertion into the atrium. There were no hemodynamic consequences. The wire was removed and a new catheter inserted on the other side using the left internal jugular vein. All of the catheters inserted using this technique functioned appropriately. There were no exit site or tunnel infections for up to 4 weeks' follow-up. We conclude that patients with catheter extrusion can receive a new catheter through the existing exit site, tunnel, and venotomy.
Semin Dial
PMID:New tunneled hemodialysis catheter placement through the old exit site. 2456 17

Multiple sclerosis (MS) is the most common cause of neurological disability. Therapeutic plasma exchange (TPE) has been used in the management of patients with MS with equivocal efficacy. With this work we would like to present our experience with 10 patients (seven male and three female, mean age 34 years [range 27-53 years]) with secondary progressive MS, who were treated with immunomodulating agents and who also underwent TPE. The patients' expanded disability status scale (EDSS) score of entry to the study varied from 5.0 to 6.5. One year before study entry all patients showed a marked deterioration (12 months before starting TPE they had been rated 4.5-5.5 on the EDSS). TPE was performed three times a week for two weeks and thereafter once a week, or once a month for the stable patients. The machine used was the Cobe Spectra and albumin 5% was the replacement fluid. Peripheral veins were used in nine patients and indwelling vascular access was required in one patient. Eighteen months later, patients stopped taking the immunomodulating agent therapy and continued only with TPE. No side-effects occurred during the TPE session. After 36 months of TPE therapy, five patients were stabilized in their disability, while two patients showed a minor progression of the disease (an additional 0.5 degree in disability as determined by the EDSS). No relapses occurred during TPE. Three patients stopped the therapy: one patient because of persistent nausea and two patients for reasons unrelated to TPE. Periodic TPE was associated with reduced accumulation of neurological deficits (as documented by EDSS) in patients with secondary progressive MS.
Ther Apher Dial 2008 Apr
PMID:Therapeutic plasma exchange combined with immunomodulating agents in secondary progressive multiple sclerosis patients. 1838 57

Dialysis Disequilibrium Syndrome (DDS) is characterized by neurological symptoms caused by rapid removal of urea during hemodialysis. It develops primarily from an osmotic gradient that develops between the brain and the plasma as a result of rapid hemodialysis. This results in brain edema that manifests as neurological symptoms such as headache, nausea, vomiting, muscle cramps, tremors, disturbed consciousness, and convulsions. In severe cases, patients can die from advanced cerebral edema. Recent advancements in cell biology implicate the role of urea disequilibrium (with a smaller contribution from organic osmolytes) as the pathophysiological mechanism responsible for this syndrome. In this review, we discuss the pathogenesis, clinical features and prevention of DDS.
Semin Dial
PMID:Dialysis disequilibrium syndrome: a narrative review. 1876 99

The Kidney Disease Outcomes Quality Initiative (K/ DOQI) 2006 recommended a minimum weekly Kt/V of 1.7 for peritoneal dialysis (PD) patients while emphasizing the importance of keeping the patient free of uremic symptoms. We examined a symptom score index [Pittsburgh Symptom Score (PSS)] designed to evaluate uremic symptoms to determine if the score improved in the first year of PD. The PSS is a 10-symptom (fatigue, trouble sleeping, difficulty concentrating, restless legs, change in taste, loss of appetite, nausea or vomiting, pruritus, bone pain, muscle pain or weakness) questionnaire that uses a Likert scale of 0 (none) to 5 (severe). From January 1, 2003, to December 31, 2006, incident PD patients completed the PSS at 0, 3, 6, 9, and 12 months. Patients were excluded from analysis if they had been on PD for less than 6 months or on hemodialysis 6 months or more before starting PD. Prevalences of individual symptoms at 1 year and at baseline were compared using the chi-square test. Differences in PSS at the various time intervals were compared using the sign test. The study included 45 patients [51% women; 31% African Americans; 33% with diabetes; mean age: 58.0 years (range: 30 - 89 years); mean initial Charlson Comorbidity Index: 5 (range: 2 - 11)]. Initial median total score improved to 8 from 12 (p = 0.005) by 3 months, with no further improvement. Improvements occurred in change in taste (p = 0.029 at 3 months), difficulty concentrating (p = 0.04 at 6 months), itching (p = 0.007 at 3 months), loss of appetite (p = 0.009 at 3 months), muscle pain or weakness (p = 0.002 at 3 months), sleep disturbance (p = 0.04 at 9 months), and restless legs (p = 0.026 at 9 months). Fatigue, bone pain, and nausea or vomiting scores were low at the start and did not significantly change over the first year. Significant decreases in symptom prevalence were seen in difficulty concentrating (p = 0.03), change in taste (p = 0.005), loss of appetite (p = 0.04), and muscle pain or weakness (p = 0.02) at 1 year. Initiation of PD results in improvement in the prevalence and severity of most uremic symptoms by 3 to 9 months and is maintained at 12 months. We recommend routine checklist evaluation of symptoms at regular clinical intervals.
Adv Perit Dial 2008
PMID:Improvement in Pittsburgh Symptom Score index after initiation of peritoneal dialysis. 1898

Lanthanum carbonate is a non-calcium-based phosphate binder for hyperphosphatemia in patients with chronic kidney disease (CKD). The efficacy and safety of lanthanum carbonate (LaC) on hyperphosphatemia in patients has been well documented in clinical trials in Western countries and recent relatively short-term clinical trials in Japan. Evidence supporting its safety and efficacy in Japanese patients for longer-term treatment is now desired for clinical practice. A non-controlled, open-label, multicenter, one year study of LaC to assess safety and its effect on the levels of serum phosphate, serum calcium and parathyroid hormone was performed with Japanese dialysis patients. Lanthanum carbonate was administered to patients at variable doses for a period of 46-52 weeks. Evaluation of the safety and efficacy of LaC in reducing serum phosphate was performed, in addition to extensive and systematic monitoring of the laboratory parameters related to bone turnover and cardiac health. A significant reduction in the serum phosphate level was demonstrated throughout the treatment period (P < 0.05), without any increase in the frequency or severity of drug-related adverse events such as vomiting, nausea, and stomach discomfort. There was no clinically relevant change in vital signs, or electrocardiograms for a period. The profiles for parathyroid hormone, bone alkaline phosphates, and osteocalcin were stable in the patients concomitantly treated with vitamin D. This study provides further evidence that the administration of LaC over a period of one year is safe and effective for the reduction of serum phosphate levels in CKD patients undergoing hemodialysis.
Ther Apher Dial 2010 Feb
PMID:One year efficacy and safety of lanthanum carbonate for hyperphosphatemia in Japanese chronic kidney disease patients undergoing hemodialysis. 2043 15


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