Raymond Rault

A Comparison of Reported Sleep Disorders in Patients on Chronic Hemodialysis and Continuous Peritoneal Dialysis

There are few data about the prevalence and characteristics of reported sleep disorders in chronic dialysis patients and, although insomnia is often used as a marker of uremia, there are few data relating complaints of sleep to adequacy of dialysis. We therefore surveyed 48 hemodialysis (HD) patients, 22 continuous peritoneal dialysis (PD) patients, and 41 healthy control subjects about disordered sleep. The questionnaire included demographic data, questions characterizing the reported sleep problems, and linear analogue scales quantitating the severity of the sleep disturbance and feelings of anxiety, worry, and sadness. Kt/V determinations were also made for each dialysis patient. Fifty-two percent of the HD, 50% of the PD, and 12% of the control subjects reported problems sleeping (P less than 0.001, all dialysis patients v controls). No differences between HD and PD in characteristics of sleep problems were seen. Sleep severity scale results confirmed sleep disorders (7.2 in those with v 0.95 in those without sleep disorders, where 0 = sleep a little problem and 10 = a big problem, P less than 0.001). Caffeine intake (P less than 0.05) and worry (P less than 0.004) were the only factors associated with reported sleep disturbances. Kt/V values (1.4 +/- 0.3) did not predict reported sleep problems. Mean reported hours of sleep per night (5.5 +/- 2 v 5.8 +/- 1.4) and desired hours of sleep per night (8.3 +/- 2 v 7.6 +/- 1.3) were similar among dialysis patients and controls reporting sleep problems. Dialysis patients and controls without self-reported sleep disorders slept a mean of 7.1 +/- 2.4 and 7 +/- 1.1 h/night, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors influencing dialysis patients' completion of advance directives

Although chronic dialysis patients support the use of advance directives, they rarely complete them. We asked 80 chronic dialysis patients (60 receiving in-center hemodialysis and 20 receiving peritoneal dialysis) why they had not completed an advance directive, and gave them the opportunity to complete a dialysis-specific living will and to designate a health care proxy. Questionnaires containing the dialysis-specific living will, patient demographic information, and questions about advance directives were distributed during a routine hemodialysis session or peritoneal dialysis clinic visit by a nurse working in the unit. Forty-one hemodialysis patients and 14 peritoneal dialysis patients completed the questionnaires (69% response rate). The mean age was 53 +/- 15 years and the mean time on dialysis was 5 +/- 5 years. Fifty-eight percent of the patients were women, 57% were white, 67% were hospitalized in the past year, 23% were employed, 70% had children, and 21% lived alone (43% lived with a partner and 11% lived with parents). All patients thought advance directives were a good idea, but only 35% had completed one and only seven (14%) had discussed wishes for life-sustaining therapy with their nephrologist; 34 patients (67%) had discussed their wishes with their family. Most said they had not completed an advance directive because their family knew what they would want (12 of 32 patients [38%]). Thirty-nine patients who completed the questionnaire also completed the dialysis-specific living will (71%). Those who did not complete the dialysis-specific living will chose not to because they were not sure what they would want done (12 of 16 patients [75%]). The only demographic factor that influenced completion of the dialysis-specific living will was having children: more patients with children did not complete the will (12 of 37 patients [32%] with children v two of 16 patients [13%] without children; P = 0.02). The dialysis-specific living will asks about choices for life-sustaining treatment (cardiopulmonary resuscitation and dialysis) based on ones health state (current health; permanent coma; terminal illness; mild, moderate, or severe stroke; dementia). Using patient-specific advance directives that focus on health states rather than life-sustaining interventions (eg, the dialysis-specific living will) and repeated discussion of advance directives and advance care planning initiated by dialysis unit staff may improve the completion of advance directives by chronic dialysis patients. The appropriate focus of such issues should include family involvement and health states rather than treatment interventions.

Glomerulonephritis and Non-Hodgkin's Lymphoma: A Report of Two Cases and Review of the Literature

Two cases of glomerulonephritis associated with non-Hodgkins lymphoma (NHL) are described. The first patient presented with the nephrotic syndrome and normal renal function, whereas the second suffered from recurrent acute renal failure together with a unique pattern of IgM deposition within glomerular capillaries. Our review of the literature suggests that this association, although rare, has been documented in a sufficient number of cases to show that it is more than coincidental. Whereas the most common renal lesion associated with Hodgkins disease is minimal change disease, more advanced glomerular changes are found in the patients with NHL. This is reflected in the higher incidence of renal failure in the latter patients. Treatment of the lymphomas has been shown to result in improvement or even cure of the renal disease, although long-term follow-up is rarely available in the reported cases.

Case Report: Hyponatremia Associated with Nonsteroidal Antiinflammatory Drugs

The effects of renal prostaglandins on medullary blood flow, active chloride transport, and antidiuretic hormone are important in urine dilution. It is surprising, therefore, that drugs that inhibit prostaglandin synthesis rarely cause hyponatremia. A patient in whom hyponatremia developed during ibuprofen administration is described and other reported cases of this association in adults are reviewed. The previous case reports fall into two well defined groups: first, neonates treated with indomethacin for patent ductus, and second, adults, often elderly, who usually have other diseases that impair urinary dilution. Although hyponatremia is a rare consequence of therapy with prostaglandin inhibitors, certain individuals are at increased risk and should be monitored for this side effect.

Candida Peritonitis Complicating Chronic Peritoneal Dialysis: A Report of Five Cases and Review of the Literature

Five patients with Candida peritonitis complicating chronic peritoneal dialysis are described and the literature reviewed. Previous bacterial peritonitis treated with multiple courses of antibiotics is the major predisposing factor in these patients, although immunosuppressive therapy and bowel perforation are also important associations. The treatment of this disorder includes systemic and intraperitoneal antifungal agents with early removal of the indwelling catheter in patients who fail to respond promptly to such therapy.

The effect of parathyroidectomy on hematocrit and erythropoietin dose in patients on hemodialysis.

Hyperparathyroidism has been implicated as a cause for resistance to erythropoietin therapy, based on a limited number of studies. The authors retrospectively surveyed the effects of parathyroidectomy on hematocrit and erythropoietin dose in patients with end-stage renal disease. The study group included 10 patients (4 men, 6 women) on long-term hemodialysis, 9 of whom were receiving erythropoietin intravenously during dialysis. Parathyroidectomy resulted in a decrease in mean parathormone levels from 15 times normal preoperatively to 2.3 times normal at follow-up. The hematocrit values increased, and the weekly erythropoietin dose decreased significantly when values 1 month before surgery were compared with those 6 months after surgery. From this, the authors conclude that secondary hyperparathyroidism is a cause of worsening anemia and increased erythropoietin requirements in patients on hemodialysis, and that parathyroidectomy is effective in reversing these abnormalities.

Upper arm graft fistula for hemodialysis

The repeated failure of forearm hemodialysis access grafts in patients with end-stage renal failure often requires the use of an upper arm graft fistula. During a 7-year period, 20 upper arm graft fistulas were placed in 15 patients. The 5-year patency rate by life-table analysis, including graft fistula salvage by thrombectomy, is 53%. The mean survival from graft insertion until revision or thrombectomy is 36 months. Twenty of the twenty-two thrombectomies performed (91%) were successful in reestablishing graft fistula patency. Six grafts required more than one thrombectomy, and seven grafts required revision of the venous anastomosis. Only one arterial anastomosis required revision. We conclude that the upper arm graft fistula is an acceptable method of hemodialysis access in those patients without suitable forearm access sites. However, an aggressive approach to both graft fistula thrombectomy and the revision of stenotic anastomoses is necessary to maintain a satisfactory patency rate.

Symptomatic urinary tract infections in patients on maintenance hemodialysis

15 episodes of symptomatic urinary tract infection are described in 11 patients on maintenance hemodialysis. The diagnosis was confirmed by clean-catch or simple voided urine samples where possible, urethral catheterization and bladder washout being used only in anuric patients. Treatment with oral antibiotics proved successful in 13 episodes but 2 patients with polycystic kidneys were admitted to hospital for intravenous therapy. Urinary tract infections are common in dialysis patients including those who are anuric, and patients with polycystic kidneys have an increased risk of serious complications.

Efficacy of Different Hepatitis B Vaccination Strategies in Patients Receiving Hemodialysis

Patients with end-stage renal disease have an impaired immune response to vaccination against Hepatitis B. The efficacy of different vaccines and vaccine schedules was studied in a group of patients receiving long-term hemodialysis. All patients received an initial 6 month course of intramuscular vaccine with either three doses of Recombivax (48 patients) or four doses of Engerix B (50 patients). This was successful in 71% and 74% of patients, respectively. In 10 patients unresponsive to 4 doses of Engerix B, a second course (2-4 doses) was successful in 5, thus increasing the overall success rate to 84%. Repetitive doses of vaccine intradermally were used as an alternative approach in eight patients who were unresponsive to intramuscular vaccination resulting in seroconversion in six. Finally, booster doses of intramuscular Engerix B have been used in 26 patients who lost their antibodies after successful vaccination.

The United States' Perspectives on Home Dialysis

Home dialysis in the United States, both home hemodialysis and peritoneal dialysis, peaked in the early 1990s. Since then, there has been a striking increase in the numbers and proportion of patients on in-center home hemodialysis (HD). As of 2008, there were approximately 27,000 patients on peritoneal dialysis (PD) and 2,455 on home HD with over 300,000 on in-center HD. There are multiple barriers to home dialysis in the United States, including lack of adequate patient education on modalities prior to starting dialysis, physician competence with home dialysis, lack of infrastructure in many programs for home dialysis, and a misinterpretation of literature and research with selection bias that suggests higher mortality on PD versus in-center HD. These barriers to home dialysis can be overcome.