Raymond Vanholder

European guidelines on when to start dialysis: check the facts first before commenting

To the Editor: In his article commenting on the European Renal Best Practice (ERBP) position statement on when to start dialysis,1 Steven Rosansky disagrees with the European guidelines2 and proposes his own recommendation that dialysis should not be started until the patient is symptomatic.

Myoglobinuric Acute Kidney Failure

Myoglobinuric acute kidney failure (AKF) is a variant of acute kidney dysfunction due to rhabdomyolysis, while rhabdomyolysis is the disintegration of striated muscles resulting in the release of muscular cell contents into the extracellular fluid. Rhabdomyolysis may result from nontraumatic and traumatic etiologies; its clinical spectrum varies from asymptomatic elevations in serum creatine kinase, to AKF and multiorgan failure, i.e., the crush syndrome. Most important laboratory findings include myoglobinuria, increased serum levels of myoglobin, creatine kinase, and hyperkalemia. Vigorous hydration by isotonic saline followed by alkaline solutions and mannitol are useful in the prophylaxis of myoglobinuric AKF. Usually, dialysis is required in patients with established kidney failure; intermittent hemodialysis is the preferred renal replacement therapy.

Diseases of the native kidneys in dialysis and transplanted patients

The native kidneys in patients on dialysis or after kidney transplantation tend to be overlooked until problems occur in relation to them. These problems can be variable and do not bear any consistent relationship to the cause of the renal failure, although in some cases, such as polycystic kidney disease, there are specific changes to be seen. This chapter will review several issues that are related to either functional or structural alterations that occur in the native kidneys in patients treated with either hemodialysis, peritoneal dialysis (PD) or kidney transplantation.

Hemodialysis, Ultrafiltration, and Hemofiltration

The treatment of end-stage renal failure by extracorporeal circulatory support is a well-recognized and widely practiced therapeutic option. If this option is not applied, a progressive deterioration of clinical condition will finally result in undernourishment, enhanced morbidity, coma, and death; these events are largely attributed to the accumulation of uremic retention solutes that in health are eliminated by the functioning kidneys. Hemodialysis and related strategies (hemofiltration, hemodiafiltration) are today the most widely used methods of extracorporeal circulatory support in end-stage renal failure; a number of improvements have been made over the past decades by the introduction of more biocompatible membranes, bicarbonate buffering of the dialysis fluid, measures to estimate and to improve the adequacy of dialysis, and the availability of various alternative access methods.

Prevention, amelioration and conservative therapy of acute renal failure in the elderly

The practice of medicine in the western world will in the future be profoundly influenced by the health care needs of a rapidly enlarging elderly population.

Acute illness superimposed on chronic renal failure

Acute renal failure (ARF) can be defined as a clinical syndrome characterized by a precipitous deterioration in renal function over a period of hours or days. In patients with the most severe ARF, dialysis will be required. The evolution is different from what is defined as chronic renal failure (CRF), where the decline in renal function takes place over several months to years. Despite the fact that ARF carries a high morbidity and mortality, the potential reversibilty of many entities of ARF mandates a rapid diagnosis and treatment.