Robert I. Lynn

Basilic vein transposition: an underused autologous alternative to prosthetic dialysis angioaccess

PURPOSE Provision of lifelong angioaccess for hemodialysis generally requires multiple procedures. To extend the availability of each extremity as an access site, we have used the transposed basilic vein for fistula construction since 1988. Our purpose is to present our initial experience, with follow-up of 30 months. METHODS We have used the transposed proximal basilic vein in 65 procedures to construct an autogenous arteriovenous fistula (AVF) to the brachial artery in 58 patients without suitable superficial venous anatomy. There were 25 males and 33 females, with a mean age of 47 years (range 10 to 77). The basilic vein transposition was the initial angioaccess procedure in only 25% of cases and secondary in 75%. Three additional patients underwent exploration of an inadequate basilic vein with subsequent prosthetic grafting. RESULTS There were no operative deaths. Two postoperative complications included a wound infection and a transient steal syndrome. The actuarial life-table patency rate for all successfully completed AVFs was 49% at 30 months. Late revisions with continued patency were required in 11 cases, including repair of a focal stenosis in six, pseudoaneurysm resection in two, and thrombectomy in one. Sixty-seven percent of patients who required subsequent prosthetic grafting for a failed basilic vein AVF had an ipsilateral procedure. Patient preference for the opposite arm was the usual indication for contralateral grafting in the remainder. CONCLUSIONS The transposed basilic vein AVF was technically feasible in 95% of cases, can frequently be performed in patients with multiple previous access procedures, does not compromise the arm for future prosthetic grafting, and has a long-term patency rate that is comparable to more traditional autologous AVFs. This underused procedure should be considered before placement of polytetrafluoroethylene graft for long-term angioaccess.

LIPID HISTOCHEMISTRY AND ELECTRON MICROSCOPY IN ADULT NIEMANN-PICK DISEASE.

Abstract A nineteen year old male subject with Niemann-Pick disease is described. The bone marrow and lymph nodes contained foam cells. The histiocytic lipid inclusions were made up of lamellated multiple membranes with a 45 to 50 A periodicity as seen by the electron microscope. These abnormal cytosomes are considered to be the result of the spatial orientation of complex lipid molecules in relation to water, rather than a degradation of mitochondria or lysosomes. The relationship of Niemann-Pick disease to Gauchers disease and to Tay-Sachs disease is discussed.

Acute renal dysfunction during interleukin-2 treatment: suggestion of an intrinsic renal lesion.

Adoptive immunotherapy with interleukin-2 (IL-2) and lymphokine-activated killer (LAK) cells has been effective in treating some advanced malignancies in animals and humans. One complication of this treatment is a reversible, oliguric, acute renal failure, which has been ascribed to renal hypoperfusion and resultant prerenal azotemia. We serially studied renal function in 10 patients receiving high-dose regimens of recombinant interleukin-2 (rIL-2) to attempt to delineate further the nature of the renal dysfunction caused by IL-2 treatment. Renal plasma flow was computed from iodine 131 (I-131 Hippuran; Mediphysics, Paramus, NJ) orthoiodohippurate, excretion curves, and glomerular filtration rate (GFR) was determined by creatinine clearance. Studies done prior to and on day 4 of treatment showed that GFR fell in nine of 10 patients, with a mean decrease of 43% +/- 8%, and renal plasma flow fell in five of the 10 patients with a mean decrease of 5% +/- 10%. The average pretherapy filtration fraction was calculated to be 23% +/- 1% and after 4 days of treatment, decreased to a mean value of 15 +/- 2%. The BUN to creatinine ratio also declined in all patients. These findings collectively suggest that IL-2 nephrotoxicity may result from an intrarenal defect in addition to the previously described prerenal azotemia. Additionally, radionuclide studies of renal function are a reliable and reproducible noninvasive method of assessing these changes in renal function.

Pseudomonal and candidal peritonitis as a complication of continuous ambulatory peritoneal dialysis in human immunodeficiency virus-infected patients

PURPOSE To our knowledge, there has been no report documenting the spectrum of peritonitis in human immunodeficiency virus (HIV)-infected persons. We therefore analyzed our records to confirm our previous observation of a higher incidence of pseudomonal and fungal peritonitis in a group of HIV antibody-positive (HIV+) patients undergoing continuous ambulatory peritoneal dialysis (CAPD). PATIENTS AND METHODS During a 22-month period, we retrospectively studied 71 patients with end-stage renal disease undergoing CAPD. Of these, seven were HIV+, five were at high risk for HIV infection but antibody-negative, and 59 were at low risk for HIV infection. Organisms isolated in episodes of peritonitis were classified microbiologically as one of the following: gram-positive, non-pseudomonal gram-negative, pseudomonal, fungal, or culture-negative. RESULTS The total peritonitis rate was higher in both the high-risk (p less than or equal to 0.01) and the HIV+ (p less than or equal to 0.02) groups when compared with that in the low-risk population. These differences were attributable to the following: (1) the high-risk groups two-fold increase in gram-positive infections (p less than or equal to 0.01), and (2) a 24-fold increase in pseudomonal (p less than 0.001) infections and seven-fold increase in fungal (p less than 0.005) infections in the HIV+ group. These infections were invariably associated with catheter loss and frequently resulted in conversion to hemodialysis. CONCLUSION We believe that the use of CAPD in HIV+ patients may be limited by this increased occurrence of pseudomonal and fungal peritonitis.

Acute Renal Failure Associated With Ioxaglate, a Low-Osmolality Radiocontrast Agent

Iodinated radiocontrast agents may cause acute renal failure, particularly in patients with preexisting renal failure, heart failure, or diabetes. The low-osmolality contrast agents cause less hypersensitivity, but substantial nephrotoxicity has not been noted. We report three high-risk patients who developed acute renal failure after one of these new agents, ioxaglate, was administered for coronary arteriography and ventriculography. The renal failure was severe: two of the patients required dialysis. We could find no previously reported cases of acute renal failure associated with ioxaglate. Despite their theoretical advantages, the low-osmolality contrast agents may cause acute renal failure in patients who are at risk and should be used with the same precautions as the conventional agents.

Determinants of Serum Creatine Kinase Activity in Dialysis Patients

Elevated creatine kinase (CK) has frequently been described in patients on chronic dialysis, but little is known about its cause and distribution. We, therefore, measured CK in 105 patients on hemodialysis and continuous ambulatory peritoneal dialysis and compared it with biochemical, nutritional, and anthropometric data obtained at the same time. In the entire group, CK was 130.3 +/- (SEM) 15.0 IU/l. Thirty patients had elevated levels of enzyme (greater than 130 IU/l). Isoenzymes determined in patients with elevated CK levels were all more than 97% MM fraction. Men had significantly higher (p less than 0.001) CK values (166.0 +/- 25.8 IU/l) than women (82.4 +/- 9.0 IU/l). Blacks had higher CK values (158.8 +/- 21.7 IU/l; p less than 0.001) than whites (92.6 +/- 12.5 IU/l). Men and blacks had significantly higher weight and midarm muscle circumference than women and whites, respectively. A positive correlation was found between CK and lactic dehydrogenase (p less than 0.001) and between CK and midarm muscle circumference (p less than 0.05), and a negative correlation (p less than 0.01) was found with age. Predialysis and postdialysis CK was measured in 10 patients and did not rise. Three of the patients with elevated CK who have undergone successful renal transplantation showed normalization of CK levels. We conclude that CK is elevated in both hemodialysis and continuous ambulatory peritoneal dialysis patients, particularly in men and blacks, that CK levels are probably related to muscle mass, and that CK declines with advancing age. Although blacks have higher CK values as a whole, normalization of CK values after renal transplantation suggests a contributory role of renal dysfunction.

Priapism and Dialysis

Ninety-three dialysis units located in the tri-state area were surveyed for the prevalence of priapism. Seventeen of 3,337 male patients experienced an episode of priapism. All of these episodes occurred either during or 2-7 h after dialysis, suggesting a cause-and-effect relationship. The use of heparin during dialysis seemed to play a role in its induction; none of the patients on peritoneal dialysis experienced priapism, and heparin was not used in their exchanges. Eleven of 17 patients also received androgen therapy which might have been a contributing factor. Additional considerations included dialysis-induced hypoxemia and acidosis which have been known to precipitate priapism in patients with sickle cell disease or trait. In our study, 2 of 10 patients, including our case report, were black males with sickle cell trait. The calculated prevalence in the male population is 1:196, and in blacks and Caucasians 1:128 and 1:293, respectively. Except for 2 cases of sickle cell trait in the 10 black males, no particular subpopulation at risk was identified. In view of the absence of a proven etiologic agent and the relatively low prevalence of priapism we do not recommend changes in dialysate, anticoagulant, or the use of androgen therapy.

The effect of a change in epoetin alfa reimbursement policy on anemia outcomes in hemodialysis patients

In 1997, the Health Care Financing Administration Hematocrit Measurement Audit (HMA) program initiated use of a 3‐month rolling average hematocrit (Hct) level for reimbursement of epoetin claims in hemodialysis patients, with denial of payment when this value exceeded 36.5%. This study evaluated the impact of the HMA program on anemia‐related outcomes in hemodialysis patients. An observational, retrospective study of 987 hemodialysis patients from 11 dialysis centers in the United States was performed, collecting data between October 1996 and December 1997. Centers were selected from a pool of nearly all facilities in the United States, which during May 1997 satisfied one of two criteria: greater than 75% of patients at the facility had mean Hct level of ≥33% (Group A) or fewer than 50% of patients at the facility had mean Hct level of ≥33% (Group B). Each facility maintained its own anemia management practices without specific anemia management interventions as part of this study. Hct level, hemoglobin (Hb) level, and epoetin dose were analyzed to compare the pre‐HMA period (October 1996 to May 1997) to the HMA period (June to December 1997) and/or for each of the five quarters of the study period. The primary study endpoint was the percentage of patients with Hct levels of ≥33% during each study quarter. The mean Hct level at baseline was 34% in Group A and 33.4% in Group B (p = 0.01). Hct levels, which were increasing before implementation of the HMA program, decreased during the HMA period (p < 0.001 and p = 0.013 in Groups A and B, respectively). The percentage of patients in Groups A and B with mean quarterly Hct levels of ≥33% decreased during the last quarter of the HMA implementation period compared to the quarter immediately preceding the start of the HMA program (p < 0.001 for both comparisons). Changes in Hb levels were similar to those seen in Hct levels. The mean epoetin dose administered decreased from 13,090 U/week at the start of the study to 11,884 U/week immediately before the HMA program took effect (p < 0.05). The HMA program adversely affected anemia treatment outcomes, regardless of whether dialysis units before HMA implementation had <50% of patients with a Hct level of ≥33% or had >75% of patients with a Hct level of ≥33%. The decline in mean weekly dose of epoetin was likely a result of withholding doses out of concern among providers about risk of reimbursement denial.

Percentage body fat determination in hemodialysis and peritoneal dialysis patients: A comparison

OBJECTIVE To evaluate percentage body fat in hemodialysis (HD) and peritoneal dialysis (PD) patients. DESIGN A prospective study of 20 HD patients and 20 PD patients. SETTING Sol Goldman Renal Therapy Center, Lenox Hill Hospital, New York, NY; Baumritter Kidney Center Albert Einstein College of Medicine, Bronx, NY; Body Composition Unit, St Lukes Roosevelt Hospital, Columbia University, New York, NY. PATIENTS Twenty HD (10 men, 10 women) patients, mean age 41.8 +/- 2.4 years and 20 PD (12 men, 8 women) patients, mean age 48.6 years +/- 3.0 years. INTERVENTION This is a noninterventional study. PATIENTS signed consent to undergo dual-energy x-ray absorptiometry, total body potassium counting bioelectrical impedance analysis, total body water determination, and anthropmetric evaluation. MAIN OUTCOME MEASURES Present and compare percentage body fat between HD and PD patients as determined by the methods used. RESULTS Percentage fat is not different between HD and PD patients. Differences in absolute values of percent fat between techniques exist. CONCLUSION HD patients and PD patients may be evaluated by the methods of body composition used. Percentage body fat will vary among techniques; therefore the same method should be used to follow a patient over time.

Interstitial Nephritis in a Patient Receiving Adoptive Immunotherapy with Recombinant Interleukin-2 and Lymphokine-Activated Killer Cells

A patient receiving adoptive immunotherapy with recombinant interleukin-2 (IL-2) and lymphokine-activated killer (LAK) cells for metastatic melanoma developed acute renal insufficiency out of proportion to the decrease in her renal perfusion after 4 days of receiving IL-2. On the 8th day of IL-2 and the 3rd day of LAK cell infusion she expired suddenly from an acute intra-abdominal hemorrhage due to rupture of a metastasis. Postmortem examination of the kidneys showed an interstitial infiltrate consisting largely of lymphocytes and concomitant tubulitis. Immunoperoxidase staining of the infiltrating cells with a panel of lymphocyte-specific monoclonal antibodies showed the majority of cells to be T lymphocytes (70-75%), with a more focal infiltrate of B lymphocytes (25-30%) and rare monocytes, granulocytes and natural killer cells. This patient represents the first reported case of acute interstitial nephritis associated with IL-2 immunotherapy. Our finding is consistent with the hypothesis that the acute renal failure that accompanies this therapy may sometimes be due to intrinsic renal disease as well as the usual pre-renal failure. Nephritis may be caused by IL-2-mediated effects on lymphocytes, resulting in renal parenchymal infiltration.