Renata Klak

Application of Extracorporeal Photopheresis in Kidney Transplant Recipients: Technical Considerations and Procedure Tolerance

BACKGROUND Extracorporeal photopheresis (ECP) is considered to be a promising immunomodulatory therapy in diseases caused by aberrant T lymphocytes. ECP has been used in patients with graft-versus-host disease and systemic scleroderma as well as in solid organ rejection. Herein we report our experience with 148 ECP procedures performed in 10 kidney transplant recipients (12-19 sessions per patient). In 2 subjects, ECP was introduced because of a steroid-resistant rejection episode, and in 8 as supportive treatment in addition to standard immunosuppression in the first 3 months after transplantation. ECP procedures were performed using the UVAR XTS device (Therakos, Exton, PA), an automated closed system for white blood cell separation and photoactivation (ultraviolet light A) with methoxsalen. RESULTS Vascular access was arteriovenous fistula (n=99), permanent catheter (n=16), peripheral vein (n=25), or polytetrafluoroethylene graft (n=8). Mean blood flow rate was 35.5±5 mL/min. Single ECP procedures lasted 175.5±35 min (range, 120-277), including photoactivation (33.3±30 min). Treatment volume (buffy coat) was 228.4±34 mL per session. Total fluids administered per session were 449.5±60 mL, and mean heparin dose was 5,979±530 IU. ECP-related side effects were transient hypotonia (n=2), increased body temperature (up to 37.5°C; n=4) and red blood cell loss due to a clotted kit or a technical problem with reinfusion (∼100 mL; n=3). CONCLUSIONS Vascular access for ECP was established in all transplant recipients, using even peripheral veins. Side effects associated with ECP were fairly tolerable by kidney allograft recipients. Caution must be paid to patients with fluid restriction (∼450 mL saline infusion) or the risk of bleeding due to anticoagulation.

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 …