RESUMEN
OBJECTIVE: To determine the safety and efficacy of intravenous total dose iron (TDI) replacement in patients treated with home renal replacement therapy. DESIGN: Prospective open-label study on end points in the population studied. SETTING: Institutional outpatient home dialysis program. PATIENTS: The study included 20 end-stage renal disease (ESRD) patients, performing chronic peritoneal or home hemodialysis, with iron deficiency defined as ferritin < 100 ng/mL and/or an iron saturation < 20%. INTERVENTION: The total dose of iron dextran was calculated and infused at a rate not exceeding 6 mg/min. Hemoglobin, hematocrit, iron studies, and liver function tests (LFTs) were obtained before and 3 to 4 weeks after TDI infusion. Hematocrit of patients failing to achieve an increase in Hct over this period was re-examined 2 to 4 weeks later looking for a delayed response. MAIN OUTCOME MEASURES: Primary end points for efficacy were changes in Hct, ferritin, and iron saturation. Toxicity was measured as reported immediate and delayed symptoms and elevated transaminases and/or alkaline phosphatase levels. RESULTS: A median iron dose of 1000 mg (range, 325-1500 mg) was administered. The infusions were generally well tolerated. Clinical adverse effects were seen in 2 patients weighing less than 50 kg. No increase in LFT results was seen. Hematocrit increased 2.2% (95% CI, 0.5%-3.9%) from 29.0% to 31.2% (p = 0.01) within 4 weeks of infusion. Significant increases also occurred in iron saturation (from 13% to 22%, p = 0.001) and ferritin (from 234 to 305 ng/mL, p = 0.008). Among the 9 patients who did not respond with a significant increase in Hct, 2 had a delayed response, increasing the overall response from 63% at 4 weeks to 71%, 8 weeks after TDI. Inadequate erythropoietin dosing and low-grade infectious/inflammatory disorders may have contributed to a poor response in several patients. CONCLUSION: Total dose iron is a safe and effective means of restoring iron and erythropoietic response in ESRD patients weighing more than 50 kg who receive their renal replacement therapy at home.
Asunto(s)
Anemia Ferropénica/tratamiento farmacológico , Hematínicos/administración & dosificación , Hemodiálisis en el Domicilio , Complejo Hierro-Dextran/administración & dosificación , Fallo Renal Crónico/terapia , Diálisis Peritoneal , Femenino , Hematínicos/efectos adversos , Hematínicos/uso terapéutico , Hematócrito , Humanos , Infusiones Intravenosas , Complejo Hierro-Dextran/efectos adversos , Complejo Hierro-Dextran/uso terapéutico , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
To investigate whether hypoxia extends into the post-hemodialysis period, nine clinically stable-end stage renal disease patients were dialyzed against bicarbonate and one against an acetate batch, all with bioincompatible dialyzers. None had clinical evidence of cardiopulmonary overload on the day of the study. Using an oximeter with internal memory, oxygen saturation was monitored continuously at the beginning, during, and for four hours after hemodialysis. Hypoxia was defined as oxygen saturation less than 85%. Three patients had no hypoxia during or after dialysis. Hypoxia occurred in five patients both during and after dialysis, and in two patients only in the post-dialysis period. Episodes of hypoxia were of longer duration and severity in post-dialysis period. We conclude that significant hypoxia can occur in the post-hemodialysis period.
Asunto(s)
Hipoxia/etiología , Fallo Renal Crónico/terapia , Diálisis Renal/efectos adversos , Acetatos/metabolismo , Adulto , Anciano , Bicarbonatos/metabolismo , Femenino , Humanos , Hipoxia/sangre , Hipoxia/fisiopatología , Masculino , Persona de Mediana Edad , Oximetría , Oxígeno/sangre , Factores de TiempoRESUMEN
From May 1977 to June 1983, 198 patients were accepted as candidates for renal transplantation at our university. We review our experience with 14 consecutive patients who underwent selective pre-transplant nephrectomy during this interval. Indications for this procedure included recurrent or chronic pyelonephritis, structural abnormalities of the urinary tract predisposing the patient to infection, malignant or renin-dependent hypertension, Goodpasture's disease, certain cases of rapidly progressive glomerulonephritis and selected patients with polycystic kidneys. All patients underwent dialysis 1 day preoperatively. Perioperative fluid losses were measured carefully with prompt and vigorous replacement therapy. Patients received an average of 5,890 cc fluid replacement before postoperative dialysis. All patients underwent dialysis within 29 hours postoperatively. There were no postoperative deaths and 8 complications. Selective pre-transplant nephrectomy has spared 93 per cent of potential renal transplant candidates from a major surgical procedure. No patient has required removal of the original kidneys during the post-transplant period. Our experience has shown that the reluctance to hydrate these patients is unwarranted and that prompt postoperative dialysis, if required, is safe. Since some end stage kidneys are physiologically active and the associated surgical risk is high, pre-transplant nephrectomy should be performed only in carefully selected patients. In contrast to previous reports, which advocated minimal fluid administration and delayed postoperative dialysis, our recent experience indicates that vigorous fluid replacement therapy, carefully monitored with serial vital signs, weights, serum electrolytes and central venous pressure readings, will avert many of the complications encountered previously.
Asunto(s)
Trasplante de Riñón , Nefrectomía/métodos , Cuidados Preoperatorios/métodos , Adolescente , Adulto , Anestesia/métodos , Niño , Enfermedad Crónica , Femenino , Glomerulonefritis/cirugía , Hemodinámica , Humanos , Fallo Renal Crónico/cirugía , Masculino , Persona de Mediana Edad , Enfermedades Renales Poliquísticas/cirugía , Pielonefritis/cirugía , Infecciones Urinarias/cirugía , Reflujo Vesicoureteral/cirugíaRESUMEN
We studied 23 patients with renal functional deterioration after intravenous pyelography; 16 were nondiabetic. Nondiabetic patients at risk are often elderly and have preexisting renal disease. The course of acute renal failure is fairly characteristic; most patient recover, but some do not. Estimates suggest that the syndrome is not uncommon in susceptible nondiabetic subjects. Pyelography cannot be considered absolutely safe for this group, and alternative diagnostic procedures or caution with contrast dosage and patient preparation may be wise.
Asunto(s)
Lesión Renal Aguda/etiología , Diabetes Mellitus , Urografía/efectos adversos , Lesión Renal Aguda/complicaciones , Lesión Renal Aguda/orina , Adulto , Anciano , Complicaciones de la Diabetes , Diabetes Mellitus/orina , Humanos , Persona de Mediana Edad , Oliguria/etiología , Diálisis Renal , Sodio/orinaRESUMEN
Seventy seven patients, thirteen younger than 20 years of age, were followed up prospectively for the first three months after renal transplant for evidence of infection and illness due to cytomegalovirus (CMV). Thirty-two developed reactivation of latent CMV and 29 did not develop any CMV infection and wn, five had pneumonia, and four underwent nephrectomy. Of these, 16, eleven received a kidney from a parent, whereas of the other 61 patients, five received parental kidneys (P less than .001). Hence, CMV seronegative individuals who received a kidney from a CMV seropositive parent developed clinical illness and sometimes lost the allograft.
Asunto(s)
Infecciones por Citomegalovirus/complicaciones , Trasplante de Riñón , Complicaciones Posoperatorias , Adolescente , Adulto , Factores de Edad , Anticuerpos Antivirales , Aspartato Aminotransferasas/sangre , Citomegalovirus/inmunología , Infecciones por Citomegalovirus/inmunología , Infecciones por Citomegalovirus/transmisión , Femenino , Técnica del Anticuerpo Fluorescente , Estudios de Seguimiento , Rechazo de Injerto , Humanos , Terapia de Inmunosupresión/efectos adversos , Masculino , Estudios Prospectivos , Donantes de Tejidos , Trasplante HomólogoRESUMEN
Fifty-four patients who received a renal allograft between October 1971 and October 1974 were followed prospectively to correlate pretransplant serum antibody to cytomegalovirus (CMV) with shedding of CMV following transplantation. Twenty-five of 54 patients had antibody demonstrable to CMV using immunofluorescent techniques, but only 20 of 54 using complement-fixing techniques. All 24 who had antibody and survived one month or longer, and seven of nine without antibody but who received a kidney from a seropositive donor shed virus after transplantation, whereas none of 12 individuals without antibody and who received a kidney from a seronegative donor (P less than 0.005) shed virus. Three of eight other seronegative patients for whom donor sera were not available for analysis shed virus. Viremia occurred in eight of ten individuals who developed new antibody after transplantation, versus seven of 24 with antibody prior to transplant (P less than 0.02), and virus shedding in seroconverters from other sites was significantly more persistent than in pretransplant antibody-positive patients. Thus, CMV infection was due either to reactivation of latent infection or was transmitted along with the renal allograft and manifested as a primary infection.