Chaim Charytan

Cholesterol crystal embolization-associated renal failure after therapy with recombinant tissue-type plasminogen activator

We report the occurrence of renal failure due to cholesterol crystal embolization following thrombolytic therapy with intravenous recombinant tissue-type plasminogen activator (t-PA). No invasive vascular procedure had been performed. Although there is one case report of cholesterol crystal embolization following t-PA therapy with only extrarenal manifestations (N Engl J Med 321:1270, 1989), this is the first reported case of atheroembolic acute renal failure following t-PA therapy.

Comparison of Eosinophilia in Patients Undergoing Peritoneal Dialysis and Hemodialysis

Eosinophilia (E) has been noted in hemodialysis (HD) patients, but its etiology is not clear. In an effort to clarify this phenomenon, we prospectively studied patients initiating dialysis in our outpatient HD and peritoneal dialysis programs. Rate of E was greatest for a small group of four continuous cycling peritoneal dialysis patients (75%), less for 63 HD patients (41%), and least for 66 continuous ambulatory peritoneal dialysis (CAPD) patients (21%, P less than .05, HD v CAPD). Increasing E rates among the groups paralleled increased frequency of tubing changes. There were no differences in etiology of renal disease, medications, types of dialyzers, types of access, or transfusion frequency that could account for the E. IgE levels did not correlate with E. The data suggest that the dialysis procedure or the tubing changes may be causing the E, but the possibility that uremia, itself, is important in the pathogenesis of dialysis E is also discussed.

Percutaneous transluminal dilatation for vascular access.

The application of percutaneous transluminal angioplasty to vascular access stenosis is described. These access problems were discovered by the technique of retrograde venous fistulography. 13 dilatations were attempted in 12 patients. Functional success was achieved in seven attempts. This resulted in a significant prolongation of access survival in these patients. Angioplasty is recommended as a nonsurgical approach to vascular access stenosis.

SEVERE MALNUTRITION: IV

increased PCR, prevented decreases in serum albumin concentrations, and reversed weight loss. Orally administered essential amino acid supplements also have a positive effect on PCR, total serum protein, and albumin concentrations. A neutral nitrogen balance in stable chronic maintenance hemodialysis patients requires 38.5 Kcallkg ideal body weightlday. In chronic renal failure, a highly significant positive correlation is observed between caloric intake (within the 35-55 Kcal/kg range) and nitrogen balance. Thus, a high caloric intake is of particular importance for its proteinsparing effect, especially during episodes of acute illness. The recent availability of recombinant human growth hormone has added a new dimension to the treatment of persistent malnutrition in ESRD patients. Preliminary studies in chronic hemodialysis patients have demonstrated substantial improvements in nitrogen balance with the use of recombinant human growth hormone in association with a 75% increase in circulating ICF-I levels. In summary, persistent malnutrition in chronic hemodialysis patients mandates an integrated therapeutic approach including optimization of the hemodialysis prescription, nutritional counseling, prescription of enteral supplements, and interventional nutrition support, including intradialytic hyperalimentation, cyclic enteral nutrition, and cyclic parenteral hyperalimentation.

Prognostic Indicators of Hernia Development in Patients Undergoing CAPD

Among 157 patients trained for CAPD, 81 hernias developed in 44 of them. The hernias were 30% incisional, 38% umbilical, 17% inguinal and 15% ventral. Most hernias developed within the first year. Parous females, patients with polycystic kidney disease, and those with prior hernia surgery were at highest risk of this complication and deserve special vigilance. Hernias should be treated promptly to avoid incarceration which occurred in 19% of this series.

Continuous Ambulatory Peritoneal Dialysis: Establishment and Growth of a Program in a Large Metropolitan Area

We describe our experience at the Booth Memorial Medical Center with the development and growth of a Continuous Ambulatory Peritoneal Dialysis program. This initial experience includes the training and close follow-up of 41 patients with End Stage Renal Disease over a period of 15 months. The status of our program with respect to medical complications encountered and their management is described. Our results, in terms of biochemical control, success with training, and patient satisfaction with CAPD are outlined.

Should Hemodialysis Fluid Be Sterile

It is clear that neither the water to prepare the dialysate nor the dialysate itself needs to be sterile. Microbial contamination, however, should be maintained at a low level. If the level of contamination of the water used to prepare dialysate exceeds 200 bacteria/ml, a potential problem exists because these concentrations can be amplified in other parts of the system. If the level of contamination of the dialysate exceeds 2000 bacteria/ml, there is an increased risk of pyrogenic and septicemic complications. For those treatments where high backfiltration is suspected, the dialysate should be ultrafiltrated. A high-flux dialyzer attached to the delivery system can be used for this purpose. This dialyzer should be changed every 3 months (Fig. 1).

Technique for Implantation of the Toronto-Western Catheter at the Booth Memorial Medical Center

The proper placement of the chronic peritoneal dialysis catheter is pivital to the early, as well as continued success of dialysis therapy with Continued Ambulatory Peritoneal Dialysis. We describe our current technique for the implantation of the Toronto-Western catheter. The success of any particular technique is dependent upon the incidence of complications. The latter is described elsewhere in this symposium.

A New Aspiration-Needle Syringe for Percutaneous Renal Biopsy

We report a renal biopsy technique utilizing the disposable Jamshidi Aspiration Needle-Syringe. The equipment and procedure described greatly simplify and speed up the procedure while ensuring adequate sampling of tissue and decreasing the likelihood of complications.