Rasib M. Raja

Resin Hemoperfusion: A New Treatment for Acute Drug Intoxication

Abstract A resin-column hemoperfusion system was used to treat four patients with profound, life-threatening drug intoxication. The column contained 650 g of pyrogen-free resin, Amberlite XAD-2. The resin is uncharged and has a cross-linked, polystyrene macroreticular structure with particular surface attraction for high-molecular-weight, lipid-soluble molecules. Blood was pumped through the column at a flow rate of 300 ml per minute for three hours. Two patients had secobarbital, one a mixture of glutethimide-butabarbital-ethchlorvynol, and one amobarbital intoxication. In all patients the column clearances of these drugs were markedly superior to known clearances with hemodialysis. A transient, modest fall in blood platelet concentration followed hemoperfusion. No serious clinical toxic effects were noted. The resin-column hemoperfusion system was technically simpler, consistently more effective and clinically superior to hemodialysis.

Epidemiology and Outcome of Infective Endocarditis in Hemodialysis Patients

BackgroundSurvival in patients with infective endocarditis (IE) ranges from 4 to 50% depending on the type of organism, the type of valve involvement and the type of treatment. MethodsWe conducted a retrospective analysis of data in hemodialysis (HD) patients at our center from 1990 to 2000. Demographics, risk factors, and outcome data were extracted in the subgroup of patients with first-episode IE diagnosed primarily by echocardiography. ResultsA total of 2239 patients underwent HD at our center. Thirty-two (1.4%) had IE defined using the Duke Criteria. Permanent and temporary venous dialysis catheters, arteriovenous (AV) grafts, and AV fistulae were used in 19 (59%), 12 (38%), and 1 (3%) patient respectively. Mean access duration was 7.6 ± 7.9 months. Thirty (94%) patients had positive blood cultures, with the majority having Staphylococcus aureus bacteremia. Two (7%) patients had positive echocardiographic findings but negative blood cultures due to the commencement of empiric antibiotic therapy prior to blood cultures. The mitral valve was mainly affected. Transesophageal echocardiography was performed in 23 (72%) patients and detected an intracardiac mass in all 23 patients. One-year mortality was 56.3%. A poor 1-year prognosis was associated with presenting features of low hemoglobin, elevated leukocyte count, hypoalbuminemia, severe aortic and mitral regurgitation, and annular calcification in mitral valve IE. ConclusionThe prevalence of IE in HD patients is 1.4%. One-year mortality was 56.3%. Close observation is required during the first year when patients with severe valvular regurgitation and hematological abnormalities have a high mortality.

Long-term pancreas allograft outcome in simultaneous pancreas-kidney transplantation : A comparison of enteric and bladder drainage

BACKGROUND The optimal pancreatic exocrine drainage method remains controversial. Bladder drainage (BD) is widely used, but associated with a high incidence of urological complications (acidosis, dehydration, pancreatitis, and urinary tract infection). Enteric drainage (ED) avoids this morbidity, but may be associated with inferior graft survival. METHODS We conducted a retrospective study comparing BD and ED in 71 simultaneous pancreas-kidney transplant recipients (37 BD; 34 ED) transplanted between February 1988 and June 1996. RESULTS Five BD and five ED patients experienced early pancreas loss within 3 months after transplantation. The mean follow-up of the remaining 61 patients has been 45.7+/-3.9 and 76.0+/-3.3 months for ED and BD patients, respectively (P<0.005). Both groups had similar pretransplant demographics, co-morbidity, and nutritional and immunological status. The incidence of volume depletion (3.4% vs. 34.3%), acidosis (0% vs. 41.0%), pancreatitis (3.4% vs. 39.7%) and urinary tract infection (26.7% vs. 71%) was lower in ED patients (P<0.005 vs. BD). Of the BD group, 18.7% required conversion to ED for intractable complications. Initial length of stay was equivalent (17.7+/-9 days vs. 18.4+/-10 days) between groups. However, the number of admissions (0.79+/-0.18 vs. 1.38+/-0.14) and in-hospital days/patient/year (6.26+/-1.16 vs. 11.46+/-2.12) was less in ED patients (P<0.05 vs. BD). Actuarial patient and pancreas allograft survival up to 4 years after transplant was similar between groups. CONCLUSIONS Compared with BD, (a) perioperative morbidity is not increased by ED, (b) ED is associated with fewer complications and hospitalizations, and (c) ED is not associated with increased long-term pancreas graft failure. These data suggest that ED is superior to BD and should be considered as the preferred technique for simultaneous pancreas-kidney transplants.

Transhepatic PermCath for Hemodialysis

The establishment and maintenance of a reliable vascular access continues to be a problem in hemodialysis. We report a patient with end-stage lupus nephritis who had no alternative for vascular access and failed peritoneal dialysis. A vascular access device (PermCath, Quinton Instrument Co, Bothell, WA) was inserted using a transhepatic approach. There were no bleeding or thrombotic complications. The catheter was replaced once through the same track due to poor blood flow and reinserted once after 5 days due to infection. The patient has been doing well and receiving adequate dialytic therapy for over 1 year with this form of vascular access.

Thrombotic Complications of Indwelling Central Catheters Used for Chronic Hemodialysis

A new double-lumen silicone-rubber dialysis catheter, designed to be placed surgically in central veins, is now available. There is little published data concerning the long-term use of this catheter for hemodialysis, but a review of the literature suggests that pericatheter thrombus formation with or without occlusion of major veins has been a complication of chronic central venous catheterization with a variety of catheters, in both dialysis and nondialysis settings. We had this catheter placed in four diabetic patients who had severe problems related to maintenance of adequate vascular access. Two of the four patients underwent venography within 3 months of catheter placement because of impaired catheter function and were found to have thrombi on the outside of their catheters. These thrombi could not be dissolved with fibrinolytic agents, and the catheters were removed surgically without incident. The other two patients have no radiologic evidence of thrombus formation 4 and 7 months, respectively, after catheter placement. We suggest that proper selection of patients for this type of vascular access should be the subject of future studies and that patients with malfunctioning catheters undergo venography to rule out the presence of significant catheter related thrombosis.

Recirculation peritoneal dialysis with sorbent Redy cartridge.

Sorbent regeneration of peritoneal dialysate and use of small volume of dialysate for intermittent peritoneal dialysis (IPD) has been shown to be feasible. The present study compares the solute clearance (C) for urea (U) and creatinine (Cr) at varying flow rates in IPD and in recirculation peritoneal dialysis (RPD) utilizing Redy cartridge in ten dogs. Two silastic peritoneal catheters and one Sarns roller pump were used for RPD. CU was 12 +/- 2 ml/min (mean +/- 1SD),18 +/- 2 with IPD and 15 +/- 2,21 +/- 4 with RPD at flow rate of 66 and 100 ml/min, respectively, while CCr was 9 +/- 2,12 +/- 2 with IPD and 10 +/- 2, 13 +/- 3 with RPD. At increasing flow rates of 150,200 and 250 ml/min, CU was 27 +/- 3,31 +/- 4 and 32 +/- 6, and CCr was 17 +/- 2,20 +/- 3 and 22 +/- 3 with RPD. U and Cr were completely removed by the Redy. Glucose was not removed by the cartridge after initial saturation. Serum sodium concentration increased 2-3 mEq/l after 6 h of RPD. The data suggest that at comparable flow rates, RPD is relatively more efficient than IPD (p greater than 0.01). This may be due to continuous exchange across the peritoneal membrane in RPD. At high flow rate in RPD, solute removal is 2-3 times higher than the currently used IPD. RPD with Redy cartridge is mechanically simple, efficient, and may help reduce total peritoneal dialysis time.

Comparison of Subdavian Vein With Femoral Vein Catheterization for Hemodialysis

Subclavian vein catheterization (SVC) is not widely accepted for vascular access because it is considered more invasive than femoral vein catheterization (FVC). The use of FVC and SVC for acute vascular access was compared for 9 mo each. Complications were minimal with both, but access related hospitalizations were lower and the number of out-patient dialyses performed were higher with SVC than FVC. Complications with SVC might have been minimized by using an 18-gauge metallic needle for insertion, avoiding interdialytic infusions and using SVC for less than 4 wk.

Hyperosmotic Coma Complicating Peritoneal Dialysis with Sorbitol Dialysate

Abstract A uremic and severely edematous patient with diabetic nephropathy underwent peritoneal dialysis with hypertonic sorbitol dialysate. Although azotemia and edema improved, he became comatose...

Determination of Inulin and p-Aminohippurate Clearances without Urine Collection

Standard inulin and PAH clearances utilizing blood and urine collections were determined in 50 individuals with chronic kidney disease. Each of these patients, as well as 14 anephric patients, also ha

Plasma refilling during hemodialysis with decreasing ultrafiltration. Influence of dialysate sodium.

Inadequate plasma refilling is an important determinant of vascular instability during hemodialysis. Hypotension is more frequent toward the end of dialysis, as the patient reaches dry weight. This study compared plasma volume changes in 12 patients dialyzed with constant ultrafiltration and a constant dialysate Na of 140 mEq/L (Group A), sequentially decreasing ultrafiltration (50% in first hour, 30% in the second hour, and 20% in the third hour) using constant dialysate Na (Group B), and sequentially decreasing ultrafiltration with sequentially decreasing dialysate Na from 150 to 140 mEq/L (Group C). All of the patients had midweek dialysis with each protocol. Blood pressure, hematocrit, blood urea nitrogen, serum osmolality, and albumin were determined before and hourly thereafter. Ultrafiltration was constant at 12.2 ml/min in Group A but 18.4 ml/min in the first hour, 11.0 in the second hour, and 7.3 in the third hour in Groups B and C. In Group A, plasma volume did not change during the first hour but decreased in the second and third hours (4.9%). In Group B, plasma volume decreased during the first and second hours 5.6% but slightly increased during the third hour 5.3%, whereas in Group C, plasma volume increased during the first hour (2.1%), was unchanged during the second hour, and decreased 1.2% during the third hour. These data suggest that plasma refilling is enhanced during hemodialysis using sequentially decreasing ultrafiltration and high-to-low dialysate Na (Group C); this strategy may be preferred to hemodialysis with constant dialysate Na and ultrafiltration (Group A) or sequentially decreasing ultrafiltration with constant dialysate Na (Group B) when improvement in vascular stability is needed.