Janos Winkler

Compliance in Hemodialysis Patients: A Multivariate Regression Analysis

Successful treatment of patients with end-stage renal failure requires, in addition to dialysis, strict control of dietary, fluid and medication intake. In the present study we measured, in 50 chronic hemodialysis patients, serum potassium (K), serum phosphate (PO4) and interdialytic weight gain as indices of diet, medication and fluid compliance, respectively. Dietary compliance did not correlate with fluid or medication compliance, whereas fluid intake and medication compliance were related (p = 0.01). Age, time on dialysis, place of birth and whether the patient came accompanied or not to the dialysis unit were the main variables affecting serum K levels. Sex, ethnic origin and education significantly affected serum PO4. Sex, place of birth, marital status, number of children and years of education affected fluid intake. The compliance of the hemodialysis patient with different aspects of his regimen is thus multifactorial. Attempts to improve compliance and thus reduce morbidity and mortality should be aimed at identifying the population with low compliance and exposing them to educational programs.

Laparoscopic Sleeve Gastrectomy as a Weight Reduction Strategy in Obese Patients After Kidney Transplantation: Sleeve Gastrectomy in Transplant Patients

Morbid obesity is associated with increased graft loss and shortened graft survival in kidney transplant patients. Treating obesity in transplant patients may improve graft outcomes. Laparoscopic sleeve gastrectomy (LSG), an effective bariatric operation, is relatively unlikely to interfere with absorption of anti‐rejection medications. Data on relevant renal function parameters were collected from all LSGs performed on renal transplant patients at our center (n = 10). The procedure was successful in eight patients, with no mortality, graft rejection or dysfunction. The median age and follow‐up were 57 years and 14 months, respectively. Seven patients had over 1 year of follow‐up. The median preoperative weight and BMI were 119 kg (96–152) and 42 kg/m2 (37–49), respectively. The median hospital stay was 4 days. The median postoperative weight and BMI at 6 months and 1 year were 86 kg and 31 kg/m2 and 83 kg and 29 kg/m2, respectively. Urinary protein excretion and serum creatinine decreased significantly in all patients (p < 0.05). One patient developed two complications, acute renal failure and sleeve stricture, both of which resolved with treatment. LSG provided effective weight loss in renal transplant patients without adverse effects on graft function and immunosuppression.

Adequacy of Dialysis and Nutritional Status in Hemodialysis Patients

Twenty-three nondiabetic end-stage renal failure patients on hemodialysis were studied for adequacy of dialysis and nutritional status. Midweek predialysis blood urea nitrogen was 27.1 +/- 6.4 mmol/l of urea, KT/V, according to urea kinetic modelling, was 1.21 +/- 0.22 and mean normalized protein catabolic rate (nPCR) was 1.15 +/- 0.23 g/kg/day. Only 1 patient had a KT/V less than 1 and 4 patients had an nPCR less than 1 g/kg/day. No correlation was found between the different nutritional parameters. All patients had normal serum albumin. However, some of the patients could be classified as severely malnourished when parameters such as body weight (2 patients), triceps skinfold (5) and total lymphocyte count (3) were taken into account. No correlation was found between adequacy of dialysis and the different nutritional parameters. Furthermore, when patients were divided into low and normal KT/V, no differences were found in their nPCR. We conclude that a global assessment of the nutritional status is required in hemodialysis patients, and at least in patients with an acceptable KT/V, nPCR is not dependent on the adequacy of dialysis.

Bacteremia Complicating Peritonitis in Peritoneal Dialysis Patients

Bacteremia is a rare complication of peritonitis in end-stage renal failure (ESRF) patients treated by peritoneal dialysis. Three of our ESRF patients on peritoneal dialysis developed bacteremia during a peritonitis episode (1/19 peritonitis episodes). In 2 cases, the responsible organism was Escherichia coli and peritonitis was most likely associated with infection of the biliary tract. The 3rd patient had a perforation of the colon and Klebsiella spp. was the infective organism. Only the last patient survived but had to be transferred to hemodialysis. Bacteremia during peritonitis is infrequent in peritoneal dialysis patients and it appears to be related to other intra-abdominal events.

Acute decline in renal function as a consequence of ovarian hyperstimulation syndrome.

Two cases of severe ovarian hyperstimulation syndrome following ovulation induction are described, one of them following in vitro fertilization and embryo transfer, and the other after conventional ovarian stimulation. This condition was associated with an acute reversible decline in renal function. The treatment and the possible pathophysiological mechanisms are discussed.

Biliopancreatic diversion with duodenal switch after renal transplantation

Biliopancreatic diversion with duodenal switch after renal transplantation Inbal Golomb, B.Sc.*, Janos Winkler, M.D., Andrei Keidar, M.D. Department of Surgery, Bariatric Clinic, Beilinson Medical Center, Petach-Tikva, Israel, affiliated to Tel-Aviv University, Tel-Aviv, Israel Department of Nephrology, Beilinson Medical Center, Petach-Tikva, Israel, affiliated to Tel-Aviv University, Tel-Aviv, Israel Received January 25, 2014; accepted January 27, 2014

Renal replacement therapy in the ninth decade of life

We reviewed our experience with seventeen end-stage renal failure (ESRF) patients aged 80 years or older, chronically dialyzed at our institution, during a seven year period. They represented 7% of the total dialysis population. The male:female ratio increased from 1.7:1 before age of 80 to 3.25:1 after 80. The main reason for ESRF was renal hypertensive disease (41% vs 6.6% before 80). Fourteen patients were treated initially with peritoneal dialysis and three with hemodialysis. The one and two year survival were 50 and 7% respectively. The main cause of death was infectious diseases (50% vs 25% before 80). Patients were hospitalized for a mean of 6.2% of treatment time. No patient asked for discontinuation of therapy. Dialysis therapy is feasible even in the very old, even though the overall survival is relatively short.

Bariatric surgery in solid organ transplant patients: Long-term follow-up results of outcome, safety, and effect on immunosuppression

The surgical risk of transplanted patients is high, and the modified gastrointestinal anatomy after bariatric surgery (BS) may lead to pharmacokinetic alterations in the absorption of immunosuppressive drugs. Data on outcomes of BS and the safety and feasibility of maintaining immunosuppression and graft safety among solid organ transplanted patients are scarce. In the current study, weight loss, improvement in comorbidities, and changes in dosage and trough levels of immunosuppression drugs before and after BS were analyzed for all transplanted patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux‐en‐Y gastric bypass (LRYGB) in our institution between November 2011 and January 2017. Thirty‐four patients (13 females, 21 males, average age 53 years) were included in the study. A successful weight loss (>50% excess weight loss in 28 of them [82%]) was recorded at the last follow‐up. Comorbidities improved significantly. Immunosuppressive stability increased from 39% to 47% among all patients. The tacrolimus blood trough levels declined slightly, but remained within therapeutic range. These data suggest that LSG and LRYGB ensure good immunosuppressive maintenance together with significant weight loss and improvement in comorbidities without serious graft rejection or dysfunction. The surgical risk is higher than in the regular BS population.