Jozef Penar

A new technique for autogenous brachiobasilic upper arm transposition for vascular access for hemodialysis.

Purpose Conventional brachiobasilic fistula creation consists of the mobilization and preparation of the brachial part of the basilic vein along its whole length, the vein transposition on the anterior surface of the arm and anastomosis using the brachial artery. In case of late thrombosis, the reparation of such a fistula is almost impossible. Methods To avoid total vein clotting in the case of thrombosis we decided to prepare only a short part of the vein in our method and not to mobilize the other part of the vein. The brachiobasilic fistula with our modification was performed as a two-stage procedure in 18 patients (8 females and 10 males), aged from 37–78 yrs (60 ± 13.6 yrs). Results In two patients early thrombosis occurred. The reparation procedure was not performed in two patients (the first patient died due to pneumonia; the second patient did not give his permission for further intervention). In 16 patients brachiobasilic fistula creation was successful. Late thrombotic complications occurred in three patients (in the 3rd, 8th and 12th months). A new successful fistula, a few centimeters proximally to the original one, was performed in 2 patients 24hr and in 1 patient 48hr after fistula clotting. On the following day after the procedure the fistula was ready to be used. The primary, assisted primary and cumulative secondary patency rates after 12 months of follow-up were 74, 89 and 100%, respectively. Conclusion In comparison with standard brachiobasilic techniques our method offers the possibility of a reparation procedure in the case of late thrombosis, which could improve the long-term patency of brachiobasilic fistulas. However, a prospective controlled study is necessary to establish if this new technique is superior to the traditional surgical procedure.

Different mortality predictor pattern in hemodialysis and peritoneal dialysis diabetic patients in 4-year prospective observation.

INTRODUCTION The aim was to identify factors carrying an ominous prognosis in a cohort of diabetic patients (pts) on a hemodialysis (HD) and peritoneal dialysis (PD) program. MATERIALS AND METHODS We analyzed survival rates of 61 diabetic dialysis pts (35 HD/26 PD). The participants were matched in baseline characteristics, standard indicators of dialysis care and laboratory parameters. The studied group was prospectively observed up to 4 years. RESULTS 21 pts (34.4%) survived the whole observation period. The annual mortality rate was 23.2%, with no difference between HD and PD. Irrespective of dialysis modality, the only factor associated with mortality in the Cox proportional hazard model was serum albumin lowering. Referring to dialysis modality, the HD survivors were characterized by lower IL-6 level, higher albumin concentration, and increased serum cholesterol values with higher cholesterol left in multivariate analysis; under PD therapy the only factor significantly associated with mortality was older age. In contrast to HD treatment, elevated cholesterol was a universal finding in PD patients, significantly above levels in HD, with a slight tendency to lower values in PD survivors. CONCLUSIONS 1. A difference in mortality predictor pattern appeared in diabetic patients treated by PD and HD. 2. In the PD group more advanced age had a decisive negative impact on survival whereas in the HD group the outlook was dependent on factors related to nutrition and inflammation. 3. Elevated cholesterol level was associated with survival benefit in HD patients, being a common abnormality in the PD group, without positive prognostic significance.

Serum levels of proANP and albumin are independent predictors of mortality in the high-risk patients (elderly and diabetics) treated by haemodialysis (HD) and continuous peritoneal dialysis in 4-year prospective observation

1.73 m, the mean time to reach CKD stage 5 with dual RAS blockade would be 106 years. Finally, 8502 patients were exposed to dual RAS blockade in the ONTARGET Study, for a median follow-up of 56 months. During this 39 676 patient-year follow-up, the claimed significant increased risk of renal failure requiring renal replacement therapy was due to an excess of 15 cases of acute renal failure, without any difference in the incidence of chronic dialysis [2]. This excess risk of <4 events for 1000 patients treated per year is in fact a rather good tolerance profile for patients with a strong RAS blockade. Nevertheless, we should be aware that treatment strategies aiming at further decreasing glomerular pressure and proteinuria, with uptitration of either RAS blockade or diuretic dosage, requires cautious monitoring to prevent pre-renal failure. The second comment suggests that RAS blockade in combination with diuretics may increase urine volume and subsequently increase fluid intake via drinking, contributing to microalbuminuria reduction [6]. Indeed, the suppression of vasopressin (AVP) by increased water ingestion reduces proteinuria, glomerulosclerosis and tubulointerstitial fibrosis in 5/6 nephrectomized rats [7]. The AVP receptor antagonists also decrease proteinuria in animal models via haemodynamic and non-haemodynamic effects of AVP blockade, but without increasing urinary output because of AVP-resistant downregulation of aquaporin-2 and aquaporin-3 in CKD [8]. Indeed, a defective urine concentrating capacity is a manifestation of CKD. This may explain a post hoc analysis of the Modification of Diet in Renal Disease (MDRD) Study that found an association between high urine volumes and rates of GFR decline, suggesting that high fluid intakes make CKD progression worse [9]. Therefore, the safety and efficacy of increased water intake have yet to be confirmed in a prospective randomized controlled study. Nevertheless, loop diuretics increase diuresis only during the first 2–3 days following treatment institution, until a new equilibrium is attained [10], and may not increase water intake in the long term.

Exhaustion of caregivers of patients on maintenance haemodialysis

Exhaustion of caregivers of patients on maintenance haemodialysis Sir, In the May issue of NDT, we found an interesting paper by Lin-sun Fan et al. [1] on the quality of life of caregivers of patients on peritoneal dialysis (PD). According to our own investigation, the problem of mental and physical exhaustion is not limited to the caregivers of PD patients, but is also of relevance to family members taking care of haemodial-ysis (HD) patients. This issue was examined in 30 care-givers, 24 women and 6 men, aged 38–82 years (mean 65 ± 11.21 years). They were responsible for 30 dialysis patients over 65 years of age (67–83 years, mean 75.5 ± 4.7 years), who were treated with HD (25 persons) and CAPD (5 persons) for a mean of 49 months. There were the following relations between caregivers and patients: 17 spouses, 12 parents and 1 unrelated person. Caregivers were asked to complete the General Health Questionnaire (GHQ-12) for assessment of mental health and the Questionnaire of Caregivers Burden (QCB) elaborated for caregivers of patients with dementia in the Polish population [2]. QCB addresses four aspects of caregiver burden: physical exhaustion, social and economic limitations , negative emotions and lack of energy. The patients were evaluated for mental capacity using the Mini-Mental State Examination (MMSE). Twenty-six caregivers scored above 2 in GHQ-12, which indicated mental derangement. The mean score was 5 (in the scale from 0 to 12). The mean scores of QCB were 20 (maximum 34) demonstrating increased caregiver burden. The results of GHQ-12 and QCB were significantly correlated , P = 0.002. Particular components of caregiver burden also correlated significantly with GHQ-12 (exhaustion, negative emotions and lack of energy, P = 0.002, P = 0.02, P = 0.03, respectively). The results of both tests were not affected by the type of family relation, caregivers gender and educational and socioeconomic status. Higher educational status of the patient was significantly associated with better mental health of the caregiver measured by GHQ-12, P = 0.05. Higher educational status was observed only in a minority (6.7%) of the patients. MMSE revealed dementia in 20 patients (67%, 1 severe dementia, 2 moderate de-mentia, 10 mild dementia and 7 cognitive dysfunctions). Only 10 patients were free of dementia. Increased negative emotions of caregivers measured by QCB correlated with the degree of dementia measured by MMSE (P = 0.0278). There was no correlation between MMSE and …

The possibility of renal function recovery in chronic hemodialysis patients should not be overlooked: Single center experience.

Chronic hemodialysis is implemented when irreversible loss of kidney function occurs. Sometimes renal recovery is overlooked. From January 2005 to December 2014, we identified 28 patients hemodialyzed for more than 3 months who had renal replacement therapy discontinued. The group consisted of 17 (57.7%) males and 11 (42.3%) females. Patients were 18–87 years old. Time of hemodialysis ranged from 3 to 97 months. Of note, 14 (50%) patients were referred from local dialysis units for solution of vascular access problems. In 13 (46.2%) patients dialysis was abandoned within the first 6 months, in 5 (17.8%) patients between 6 and 12 months, and in 10 (35.7%) patients beyond 12 months. Estimated dialysis‐free survival was 94.4% (SE 0.054) and 82% (SE 0.095) at 12 and 24 months, respectively. All physicians must be aware of possible kidney function improvement. In patients with preserved diuresis fall in periodical urea or creatinine measurements might be a sign of renal recovery.

Hepatitis C-associated glomerulonephritis mimicking systemic lupus erythematosus

Hepatitis C virus (HCV) infection is known to be responsible for many autoimmune reactions but its association with systemic lupus erythematosus (SLE) has not yet been established. We present the c...

Lymphocyte function in patients with chronic glomerulonephritis. Tests of suppressive activity generation by concanavalin A and antibody-dependent cellular cytotoxicity.

Lymphocyte suppressive activity after stimulation with Con A and lymphocyte function as the effectors in the ADCC test had been examined in 68 patients with chronic glomerulonephritis (GN) and in 20 healthy controls. Lymphocyte suppressive activity was lower in patients with chronic GN than in the healthy individuals. In regard to chronic proliferative GN and mesangial GN the difference was statistically significant. The lymphocyte efficiency in the ADCC test was generally adequate in patients with chronic GN and none of the morphological types showed significant deviation from the control group. In the general analysis of patients with chronic proliferative, mesangial, membrano-proliferative and membranous GN a decrease of lymphocyte suppressive activity below the lower standard limit has been detected (45% of cases). A similar defect in lymphocyte function in the ADCC test has been found in 18.6%. A statistically significant relationship between the lymphocyte function disorders and the high clinical dynamism of GN has been noticed, although in some cases there was a deviation from this tendency. It is supposed that circulating immune complexes, detected in some patients with chronic GN are not the only decisive factors responsible for defects in lymphocyte function.