John F. Sullivan

Hypertension is Not Adequately Controlled in Hemodialysis Patients

To examine the adequacy of hypertension control, we monitored the blood pressure (BP) of 53 hemodialysis patients who received treatment for hypertension. BP measurement using an ambulatory BP monitor began 1 hour before dialysis and continued every 30 to 60 minutes for 48 hours until the next dialysis. Diet, medications including antihypertensive drugs, and hemodialysis prescription were not changed during this study. Each patient had a mean of 68 BP measurements during the monitoring period. Mean (+/- SD) systolic and diastolic BP levels of all patients over 48 hours were 158.6 +/- 22.7 mm Hg and 88.7 +/- 16.6 mm Hg, respectively, without diurnal variations. In these, BP loads (the percentage of systolic BP exceeding 150 mm Hg and diastolic BP exceeding 90 mm Hg) were 58.4% and 39.4%, respectively, suggesting that hypertension was inadequately controlled for more than half of the study period. Eight patients (15%) maintained BP within normal ranges at all times. All patients lost weight (2.9 +/- 0.9 kg) at the end of dialysis by ultrafiltration. However, only 27 patients (51%) had a greater than 5% decrease in mean arterial BP post-dialysis, which returned to predialysis levels within 12 to 24 hours. Reduction of BP postdialysis was significantly more common among black patients (72%) than white patients (30%) (P less than 0.01). However, there was no difference in age, cause of kidney disease, amount of ultrafiltration, and BP loads between those whose BP decreased and those whose did not. BP monitoring was repeated in eight patients, 2 to 3 months after adjustment of their antihypertensive regimens.(ABSTRACT TRUNCATED AT 250 WORDS)

Pruritus in Dialysis Patients Treated with Parenteral Lidocaine

Pruritus is one of the most disturbing and poorly understood symptoms in patients on chronic hemodialysis,1 2 3 4 its reported prevalence varying from 15 to 86 per cent. Except for a few case repor...

Thiobarbituric Acid Reactive Material in Uremic Blood

The thiobarbituric acid (TBA) assay was applied to uremic blood. Significant TBA-reactive material was found in patients with chronic renal failure compared to normal controls. The presence of TBA-reactive material correlated with the degree of renal failure, and was removed by hemodialysis. The reactive material is not 2-deoxyribose or sialic acid. In addition, the presence of TBA-reactive material in uremic blood is not abolished by prior aspirin ingestion, suggesting it is not related to active prostaglandin synthesis. The possible origin of the TBA-reactive material in uremic blood is discussed.

Systemic lupus erythematosus in patients with chronic renal failure

The clinical courses of 36 patients with systemic lupus erythematosus (SLE) in whom chronic renal failure developed and who required dialysis for more than three months were studied. At the time dialysis was initiated, 14 of 36 patients (38.9 percent) had clinically active SLE, but only three of 24 (12.5 percent) had activity in subsequent years while receiving dialysis therapy. In the majority of patients, however, renal disease progressed to end-stage despite clinical quiescence of SLE. During the follow-up period (mean +/- SD, 36 +/- 39.8 months), eight patients died--six from infections and two from cardiac disease. Actuarial survival rates at one, two, and five years after dialysis treatment were 91.1, 78.8, and 68.9 percent, respectively. This study suggests that the progression of renal disease to end-stage in patients with SLE may be mediated by nonimmunologic mechanisms as well as SLE-related immunologic insults. In most of these patients undergoing long-term dialysis, SLE remains clinically inactive despite persistent serologic abnormalities. Survival of the patients undergoing dialysis is comparable with that of the general dialysis population.

Deceased-donor kidney transplantation: improvement in long-term survival

BACKGROUND Despite marked improvement in short-term renal allograft survival rates (GSR) in recent years, improvement in long-term GSR remained elusive. METHODS We analysed the kidney transplant experience at our centre accrued over four decades to evaluate how short-term and long-term GSR had changed and to identify risk factors affecting graft survival. The study included 1476 adult recipients of a deceased-donor kidney transplant who were transplanted between 1963 and 2006 and who had received one of five distinct immunosuppressive protocols. RESULTS Five-year actual GSR steadily improved over the years as immunosuppressive therapy evolved (22-86%, P < 0.001) in spite of an increasing trend in the transplantation of higher-risk donor-recipient pairings. For those whose grafts functioned for the first year, subsequent 4-year GSR (5-year conditional GSR) also improved significantly (63-92%, P < 0.001). Acute rejection and delayed graft function (DGF) were the most significant risk factors for actual graft survival, while acute rejection was the only significant risk factor for conditional GSR. Use of kidneys from expanded-criteria donors (ECD) was not a risk factor, compared to the use of standard-criteria donor kidneys for either 5-year actual or conditional GSR. There was an impressive decline in the incidence of acute rejection events (77.4-5.8%, P < 0.001). While the DGF rate had decreased, it still remained high (68.7-38.5%, P < 0.001). CONCLUSIONS We found a significant improvement in both short-term and long-term GSR of deceased-donor kidney transplants over the last four decades. These improvements are most likely related to the decreased incidence of acute rejection episodes. Minimizing acute rejection events and preventing DGF could result in further improvement in the GSR. Our experience in the judicious use of ECD kidneys suggests that this source of kidneys could be expanded further.

Clinical effects of bilateral nephrectomy

The effects of removal of all renal tissue on hematopoiesis, osteodystrophy, blood pressure regulation and metabolic functions are reviewed; and, the indications for, and results of, bilateral nephrectomy are discussed. Nephrectomy results in a more severe anemia in dialysis patients which is poorly responsive to androgen therapy. No differences were detected in the severity of osteodystrophy between nephric and anephric patients. However, bilateral nephrectomy can occasionally result in the acute onset of hypocalcemia. Blood pressure regulation must be accomplished in the absence of a functioning renin-angiotensin system. This is largely on the basis of volume, but changes in vascular tone may also be significant. Little is known about the metabolic consequences of nephrectomies. The effect on substances metabolized by the kidney is an area for further investigation. Kidney tissue should be preserved, if at all possible, and nephrectomy performed only for specific indications.

Kidney Transplantation: Improvement in Patient and Graft Survival

Patient and graft survival were reviewed in a series of 249 kidney transplants done from 1963 to March 1973. Patient survival was calculated by the life table method for the periods 1963-1970, and 1970-1973, since in 1970 a formal Kidney Center was established and mortality rates changed. Graft survival was analyzed in terms of donor source, HL-A matching and immune responsiveness to HL-A antigens. Three-year predicted mortality for cadaver kidney recipients was 62% between 1963 and 1969 (42 patients) and 8% between 1970 anid 1973 (67 patients). Similar predicted mortality for related living donors was 30% between 1963 and 1969 (52 patients) and 14% between 1970 and 1973 (85 patients). Mortality has continued to decrease and there has been only one death in the last 87 consecutive transplants, including 57 consecutive cadaver transplants. Oneyear predicted kidney survival for the 10-year period is 44% for cadaveric, 60% for non HL-A identical related living and 90% for HL-A identical sibling donors. In the cadaver group, those sharing 2 or more HL-A antigens had the same kidney survival as the non HL-A identical related living donor grafts. Since cadaver graft recipients are on dialysis for a longer period of time, immune responsiveness can be detected by their response to blood transfusions, whereas this determination could not be made in our related living donor group. Non-responsive cadaver kidney recipients had 80% one year kidney survival. We conclude that transplant mortality can be reduced to less than 10% by the Center approach to treatment of renal disease, dialysis does not adversely affect future transplantation, and excellent (80%) kidney survival can be expected in properly selected cadaver graft recipients.

Single-Needle Venous Dialysis: A Comparison of Three Systems

Single-needle dialysis with femoral vein access was performed on three patient groups using a pressure/time (Vital-Assist) device, a time/time device (Gambro, AK10), and a pressure/pressure device (Cobe Double Blood Pump). Each patient was dialyzed using the same parallel plate dialyzer (PPD 1.3). For each treatment, recirculation was calculated and the clearance of urea and creatinine was determined, both from dialysate content and A-V concentration differences. Recirculation was high (38%) with the Vital-Assist but under 10% with both AK10 and Double Blood Pump. The relatively higher blood flow of the Vital-Assist (180 ml/min) and lower blood flow of the AK10 (100 ml/min) resulted in comparable clearances of urea (80 ml/min) and creatinine (60 ml/min) for these two systems. The Double Blood Pump, with a blood flow of 140 ml/min achieved urea and creatinine clearances of 110 and 80 ml/min. The clearances actually measured were in good agreement with those predicted from theoretical considerations of recirculation and blood flow in a countercurrent dialysis system.

The Problems of Vascular Access for Hemodialysis in Juvenile Diabetics with End-Stage Renal Disease:

* The author is presently a Senior Post-Doctoral Research Fellow in Nephrology & Transplantation. He is a Nephrologist, Assistant Attending Physician, and Assistant Director of the Division of Hemodialysis at The New York Hospital-Cornell Medical Centre. † Formerly. Instructor of Clinical Medicine & Assistant to the Chief, The New York Medical College, Flower-Fifth avenue Hospitals and Bird S. Coler Memorial Hospital. From the Division of Hemodialysis. The Rogosin Kidney Centre. The New York Hospital-Cornell University Medical College. 525 E. 68th St., New York, N.Y. 1002