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A high prevalence of malnutrition has been reported in dialysis patients. Anorexia and vomiting associated with the uraemic state and increased protein breakdown induced by acidosis are some of the factors suggested to contribute to the development of malnutrition in these patients. There is evidence that the haemodialysis procedure per se promotes increased net protein catabolism. In healthy subjects, the passage of blood through a cuprophane dialyser without circulating dialysate leads to increased efflux of amino acids from muscle tissues, indicating that accelerated protein breakdown may be caused by the interaction between blood and regenerated cellulose membranes. The use of more biocompatible membranes, such as polysulfone and polyacrylonitrile, does not result in increased muscle protein catabolism. Loss of nutrients to the dialysate during clinical haemodialysis has been considered as an additional catabolic factor. Some recent reports indicate that, compared to low flux dialysers, the use of high flux membranes results in greater disturbances of plasma amino acid caused by increased loss to the dialysate. Thus, not only bioincompatibility but also the physical properties of the dialysis membrane seem to be involved in haemodialysis-related protein catabolism.
Nephrol Dial Transplant 1996
PMID:Protein catabolism in maintenance haemodialysis: the influence of the dialysis membrane. 880 8

Intradialytic vascular instability continues to be one of the most frequent complications in elderly haemodialysis patients. Signs of impending hypotension such as sweating, apprehension, tachycardia, nausea, or vomiting may be infrequent in the geriatric population. The onset of hypotension in the elderly may be sudden and profound and may lead to serious consequences such as myocardial infarction, stroke, or aspiration if not treated promptly. Prevention of vascular instability is extremely important in the elderly. Avoiding rapid ultrafiltration sedatives, or antihypertensive medications and food intake may be beneficial. Optimal dialysate composition (dialysate sodium, bicarbonate, and calcium concentration) is important. Dialysate sodium profiling may be useful in the elderly to reduce intradialytic hypotension. Step sodium profiles result in better plasma volume refilling in early dialysis, while linear dialysate sodium profiles have greater plasma volume in late dialysis, suggesting that dialysate sodium profiles may need to be individualized for optimal response. Sodium profiling could also result in sodium retention, and long-term studies are needed in the elderly before their widespread use is recommended. Use of newer modalities such as continuous monitoring of plasma volume with Crit Line, and determination and monitoring of body-fluid compartments with bioimpedance may further improve vascular stability in the elderly.
Nephrol Dial Transplant 1996
PMID:Sodium profiling in elderly haemodialysis patients. 904 40

Upper gastrointestinal (GI) symptoms are frequently observed in continuous ambulatory peritoneal dialysis (CAPD) patients. We conducted esophageal manometry and 24-hour esophageal pH monitoring in 4 CAPD patients (Group I) who had upper GI symptoms such as nausea and vomiting and compared them with 9 patients (Group II) who did not. The mean age in Group I was 48.5 +/- 13.7 years, and the male-to-female ratio was 1:3. One patient was diabetic. There were no significant differences in clinical and biochemical data between the two groups. Comparing the results of esophageal manometry, supine lower esophageal sphincter pressure (LESP) at 2000 mL of infused dialysate was significantly lower in Group I than in Group II (23.2 +/- 4.4 vs 31.2 7.1 mmHg, P < 0.05), but supine LESPs at empty state and sitting LESPs were not different. Group I had a significantly higher total number of reflux episodes (89.0 +/- 16.5 vs 26.5 +/- 19.4, P < 0.05), number of reflux episodes longer than 5 minutes (2.3 +/- 2.6 vs 0.3 +/- 0.5, P < 0.05), total time of pH < 4.0 (75.5 +/- 55.5 vs 11.0 +/- 6.8, P < 0.05), and total reflux score (19.7 +/- 10.2 vs 4.2 +/- 2.3, P < 0.05) in 24-hour esophageal pH monitoring. Three of 4 Group I patients met the criteria for abnormal gastroesophageal reflux set by the DeMeester scoring system. CAPD patients with upper GI symptoms such as nausea, vomiting, and epigastric discomfort should be evaluated for gastroesophageal reflux disease with esophageal manometry and pH monitoring.
Adv Perit Dial 1998
PMID:Gastroesophageal reflux disease in CAPD patients. 1064 2

A specialist pediatric renal nursing service provides a link between hospital and home. Such support aims to reduce hospitalization and disruption to schooling and family routine. A 3-year prospective study monitored the progress and documented the nursing support to and contacts with 13 children (5 of whom were under 5 years of age) who commenced continuous cycling peritoneal dialysis (CCPD). Mean duration of CCPD was 14 months. Home and clinic contacts included telephone calls (65% of contacts), home, school, nursery, respite care, and community visits. Nine families received respite care from a home-care pediatric renal nurse, with children under 5 years receiving 68% of such visits. A total of 388 inpatient days were recorded. These included admission for catheter and dialysis training (125 days). hypertension (83 days), dialysis-related admissions (66 days), peritonitis (43 days), vomiting (31 days), and surgical procedures and infections (40 days). Nine peritonitis episodes occurred in 8 children (incidence 1 per 20 patient-months), and one death (cardiovascular collapse) occurred on CCPD. Seven children received a transplant, with the median waiting time for transplant being 7 months (range: 3-14 months). This study documents the spectrum of nursing support we have evolved to support children on CCPD and their families in the hope of reducing morbidity and hospitalization.
Adv Perit Dial 1998
PMID:Nursing contacts and outcomes in a pediatric CCPD program. 1064 41

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

A 59-year-old-woman received related non-myeloablative allogeneic peripheral blood stem cell transplantation (PBSCT) subsequent to autologous PBSCT in our hospital five years after she was diagnosed as oligo-secretory myeloma. She was admitted to our hospital because of vomiting and grayish diarrhea 4 months after non-myeloablative allogeneic PBSCT (mini-alloPBSCT). Although her initial symptoms improved after admission, she gradually showed thrombocytopenia, anemia, and oliguria during the 2 weeks after admission. Our diagnosis was thrombotic thrombocytopenic purpura (TTP) and acute renal failure (ARF) secondary to mini-alloPBSCT. After cessation of cyclosporine administration, we began to treat her with plasma exchange (PE) and hemodialysis. During the three and a half months after we started PE, the TTP gradually improved. Although PE had been reported to be ineffective for TTP post bone marrow transplantation, we could finally discontinue PE. In contrast, since her anuria continued, she was managed with hemodialysis. One month after PE was started, her activity of von Willebrand factor-cleaving protease was 41% (normal range, >50%) and the ultrasonographic investigation of both kidneys was normal. She could be discharged after four and a half months hospitalization and lived well as an outpatient for a further two months. She died shortly after readmission from multiple organ failure without the relapse of TTP. The patient's clinical course would suggest that TTP post mini-alloPBSCT could be treated with PE in some cases, despite the development of dialysis-requiring severe ARF being a poor prognostic factor.
Ther Apher Dial 2007 Oct
PMID:A case report of thrombotic thrombocytopenic purpura and severe acute renal failure post non-myeloablative allogeneic peripheral blood stem cell transplantation treated with plasma exchange and hemodialysis. 1784 2

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

Peritoneal calcification in three patients on continuous ambulatory peritoneal dialysis (CAPD) was reviewed, and the relation between the localization and extent of calcium deposits detected by abdominal computed tomography (CT) and clinical signs was evaluated. Case 1 was a 48-year-old man with abdominal pain, hemoperitoneum and secondary hyperparathyroidism after receiving CAPD for seven years. An abdominal CT revealed linear peritoneal calcification in the pelvic cavity and liver surface, and his symptoms resolved after switching to hemodialysis. His clinical course and pathological findings were compatible with those in progressive calcifying peritonitis. Case 2 was a 26-year-old man presenting with abdominal pain, vomiting and fullness two years after switching to hemodialysis, because of uncontrolled overhydration following 13 years of CAPD. Plaque-like calcification outlining the small intestine and parietal peritoneum was noted on CT. Case 3 was a 59-year-old man who had abdominal distention, vomiting and diarrhea three months after switching to hemodialysis due to loss of peritoneal function following 10 years of CAPD. CT revealed diffuse sheet-like calcification surrounding the bowel and mesentery, adherent dilated bowel loops and ascites. These CT findings suggested the existence of encapsulating peritoneal sclerosis (EPS) in cases 2 and 3. Findings from our three patients indicate that peritoneal calcification is not always accompanied by EPS; however, monitoring peritoneal calcification and other findings by abdominal CT, even after cessation of CAPD, is crucial to maintain vigilance on whether the subclinical signs, which are temporally diagnosed as progressive calcifying peritonitis, advance to EPS.
Ther Apher Dial 2008 Oct
PMID:Localization and extent of peritoneal calcification in three uremic patients on continuous ambulatory peritoneal dialysis. 1893 28

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


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