RESUMEN

The purpose of this study was to describe the life-sustaining treatment preferences of dialysis patients and to compare the acceptability of two generic and a disease-specific advance directive (AD). Of 532 potentially eligible hemodialysis patients, 95 (17.9%) participated in the study. These patients completed two generic (the Centre for Bioethics Living Will and the Medical Directive) and one disease-specific (the Dialysis Living Will) AD in a randomized cross-over trial. Treatment preferences were measured by using the Centre for Bioethics Living Will. Acceptability of the AD was measured by using a 13-item advance directive acceptability questionnaire (ADAQ) for each AD, and the advance directive choice questionnaire (ADCQ) to elicit participants' preferred AD. Twenty-five percent of the participants wanted to continue dialysis in case of severe stroke, 19% in severe dementia, and 14% in permanent coma. Averaged across treatments, proportions of participants wanting treatment in various health states were: current health (86%), mild stroke (84%), moderate stroke (60%), severe stroke (21%), mild dementia (78%), moderate dementia (51%), severe dementia (14%), terminal illness (41%), and permanent coma (10%). Averaged across health states, proportions of participants wanting various types of treatment were: dialysis (58%), antibiotics (53%), transfusion (53%), surgery (48%), cardiopulmonary resuscitation (48%), respirator (47%), and tube feeding (41%). Mean ADAQ scores were: Dialysis Living Will, 71%; Centre for Bioethics Living Will, 70%; and Medical Directive, 60% (F = 8.27, P < 0.001 (repeat measures analysis of variance); the Dialysis Living Will and Centre for Bioethics Living Will scored significantly higher than the Medical Directive). The proportion of participants who said they would choose to complete each AD was: Dialysis Living Will, 28%; Centre for Bioethics Living Will, 38%; Medical Directive, 31%; and unsure, 3% (chi 2 = 1.465, df = 2, P = 0.48). In conclusion, twenty-five percent or less of hemodialysis patients want to continue dialysis in three specific health states: severe stroke, severe dementia, and permanent coma. Health states and illness severity, far more than treatment descriptions, influence preferences. Dialysis patients should be offered a generic AD, and some generic AD are more acceptable than others. Only a minority of dialysis patients will complete any AD, but the completion of written AD forms is only one element in the process of advance care planning.

Asunto(s)

RESUMEN

Patients using long-term double-lumen silastic jugular catheters for haemodialysis access frequently require oral anticoagulants to maintain patency of the catheter. It may be difficult or impossible to obtain peripheral vein blood samples for PT measurements to regulate the oral anticoagulant dose. Our studies have shown that removal of 3 mls of blood from the catheter limb containing the heparin (to be discarded) followed by 10 mls as a heparin wash-out (to be returned to the patient) allows blood to be taken from the arterial limb of the catheter for PT measurement. The PT measurement obtained from the arterial limb after a 10 ml wash-out is nearly always identical with the PT measurement on blood obtained from a peripheral vein. If the simultaneously measured aPTT is normal the PT is predictably and consistently accurate. If the aPTT is raised due to traces of residual heparin then the PT may be inaccurate and should be repeated. This method is easy and reliable and can be recommended as an aid to regulation of the oral anticoagulant dose.

Asunto(s)

RESUMEN

CVVHD is an effective treatment of choice applicable to all critically ill unstable patients with CARF. It is a technique that offers clinical advantages. It is easily initiated. It offers good clearance. Its closed dialysate circuit offers accurate control of UF that is adaptable to the patient's needs. The use of a blood pump reduces the risks of heparin-induced bleeding and arterial cannulation. In all patients, the blood flow rate was maintained at 100 ml/min. or more regardless of systemic BP. The UF removed per hour was between 100-200 mls/hour. Fluid removal on overloaded patients was easily accomplished with stable hemodynamic status. Adequate parenteral nutrition was able to be maintained to meet the requirement of the patients. The accuracy of the UF pump, no large volume fluid replacement and the safeguard of a closed system facilitates the work of the ICU nurses who have few or no adjustments to perform. Experience with CVVHD has proven that nurses working in the ICU are willing to be trained to take responsibility for this mode of treatment.

Asunto(s)

RESUMEN

We describe the long term use for haemodialysis of the PermCath (Quinton, Seattle, Washington) dual lumen, jugular venous catheter (DLJVC) in 21 patients who had no apparent alternative means of access. The nineteen patients maintained in this manner for periods of 30 to 600 days (mean 233.2) included 6 patients dialyzed for over 12 months. Blood flows exceeded 250 mls/min and recirculation rates averaged 5.9%. Infection and insufficiency due to thrombosis were the major problems. In 8 patients (38.1%) infection required DLJVC removal; in three the catheter was immediately replaced over a guidewire along the same track under antibiotic cover and infection has not recurred. Insufficiency occurred in 10 patients (47.6%) and was successfully managed with oral anticoagulants, local instillation of urokinase (4 cases), systemic streptokinase (2 cases) or by changing the DLJVC over a guidewire (2 cases). We believe that the DLJVC is the long term access method of choice for patients in whom conventional access cannot be constructed.

Asunto(s)

RESUMEN

Over 11 1/2 years, 420 percutaneous needle biopsies were obtained from the transplanted kidneys of 205 patients at one institution. The procedure was performed by one nephrologist and 55 nephrology trainees. No limit was placed on the number of biopsies performed on one kidney, and the highest number was seven. The complications were macroscopic hematuria in 28 biopsies, prolonged hematuria (greater than 24 hours) in eight, transient anuria in five, and prolonged anuria requiring surgical intervention in one. Perinephric hematoma occurred in three patients; retroperitoneal hematoma led to compression of the iliac vein in one. None of these complications led to loss of the transplant. It is suggested that the freedom from serious complication is related to the safety of the technique and the precautions applied to preparation of the patient. These are described in detail.

Asunto(s)

Asunto(s)

RESUMEN

With the aim of improving the diagnosis and treatment of subclavian vein thrombosis, associated with subclavian cannulation for hemodialysis, we performed Doppler examination of the subclavian vein and clinical inspection of the ipsilateral arm at every dialysis in 50 consecutive patients who received subclavian hemodialysis catheters over 1 year. Edema of the arm and disappearance of the subclavian vein bruit correctly detected 3 cases of subclavian vein obstruction which were confirmed by X-ray venograms. All 3 cases failed to respond to systemic heparin, but were successfully recanalized within 36 h with continuous local streptokinase infusion at a rate of 10,000 U in 1 ml/h. In 4 other cases of edema of the arm, Doppler examination correctly predicted patency of the vein, also confirmed radiologically. In 2 cases of thrombosis, there was an underlying stenosis of the left innominate vein close to its union with the superior vena cava. These were dilated by balloon angioplasty; the stenosis recurred in both cases without recurrent thrombosis, and the angioplasty was repeated. Doppler surveillance seems to be a promising aid to the detection of subclavian vein thrombosis from hemodialysis catheters. Local streptokinase infusion is effective in treating thrombosis. Underlying venous stenosis should be looked for because this may be at least partly remediable by balloon angioplasty.

Asunto(s)

RESUMEN

This is an analysis of the outcome of 35 patients with end-stage autosomal dominant polycystic kidney disease (ADPKD) at Toronto Western Hospital (TWH) during a 10-year period. The primary treatment in each case was hemodialysis. In the 15 patients managed exclusively with hemodialysis the one- and five-year actuarial survival was 93% and 77% respectively. Twenty patients ultimately received a total of 26 cadaveric renal allografts. Graft survival at one year was 76%. One- and five-year patient survival was 92% and 73% respectively. Beyond 5 years a trend towards increased survival in the transplant group was seen, compared with the exclusively hemodialyzed group. Bilateral nephrectomy prior to transplantation was associated with high morbidity and mortality, and did not change either graft or patient survival. In view of the similar survival and because it is accepted that transplantation offers the highest quality of life amongst the modalities of treatment for end-stage renal failure, transplantation should be considered the treatment of choice for end-stage ADPKD. There is no justification for routine bilateral nephrectomy before renal transplantation.

Asunto(s)

RESUMEN

This paper describes a simple system for the performance of slow continuous hemodialysis (SCHD) as a means of treating difficult and complicated cases of oliguric acute renal failure. The method, which employs access to the circulation via a double-lumen central venous catheter and a BSM 22 blood systems module, can be performed safely in the intensive care unit of a general hospital if closely supervised by a trained nephrologist. The results of treating 16 consecutive cases of complicated acute renal failure in a large general hospital without a hemodialysis unit are described. The method, whose simplicity makes it suitable for intensive care unit nurses without previous hemodialysis training, was not associated with any serious accidents or complications, and was tolerated well by even the most critically ill and hemodynamically unstable patients. The advantages of this approach over more traditional continuous arteriovenous hemofiltration (CAVH) are discussed.

Asunto(s)

RESUMEN

Single-lumen silastic catheters were placed in the jugular veins of 12 patients to provide vascular access for hemodialysis. In all cases construction of arteriovenous fistulas had been difficult or impossible. The catheters have provided adequate dialysis with a single needle system for periods up to 32 months. Only one case of blood stream infection occurred, in a confused patient who damaged his catheter. There has been no evidence of venous thrombosis or other complications. Jugular vein catheters should be considered as long-term alternatives when A-V fistula construction is not possible.

Asunto(s)

Asunto(s)

RESUMEN

Muscle wasting may occur in patients with chronic renal failure (CRF). To determine whether this is due to a decrease in the synthesis or an increase in the breakdown of muscle protein, we evaluated postabsorptive whole-body protein breakdown, oxidation, and synthesis rates at steady state during a primed, continuous infusion of 13C-leucine. This was done in seven subjects on chronic maintenance hemodialysis (MHD) and in seven normal control subjects. The protein breakdown rate in MHD was not different from that in controls (103 +/- 19 and 106 +/- 19 mumol leucine.kg-1.h-1, respectively). In MHD, however, the protein oxidation rate was 43% greater than that in controls (20 +/- 6 and 14 +/- 4 mumol leucine.kg-1.h-1, p less than 0.05), whereas net protein synthesis was less (p less than 0.05). Reduced net synthesis and increased oxidation rates of protein in the postabsorptive state may therefore contribute to the muscle-wasting syndrome in patients with CRF.

Asunto(s)

RESUMEN

Two cases of temporary loss of function following percutaneous renal biopsy are reported. The mechanism was probably restriction of renal perfusion brought about by the compression of the perirenal hematoma.

Asunto(s)

RESUMEN

In two patients right atrial ball thrombi developed following prolonged subclavian cannulation for hemodialysis. One patient died, the other had the ball thrombus removed by open heart surgery. It appears that repeated friction of the catheter tip may have damaged the endothelium of the right atrial wall. This hitherto unrecognised complication might be prevented by ensuring that subclavian hemodialysis catheters are never allowed to reach as far as the right atrium.

Asunto(s)

Asunto(s)

RESUMEN

To determine whether skeletal muscle function testing (SMF) provides an index of nutritional status in patients with chronic renal failure (CRF), two groups with comparable CRF were studied. In 48 well-nourished (WN) and 17 malnourished (MN) patients with stable CRF, and in 33 WN nonazotemic controls, adductor pollicis function was assessed. The force at 10 Hz was expressed as a % of force at 100 Hz (F10/F100), and maximal relaxation rate (MRR) as % force loss/10 ms. Standard nutritional assessment was also performed. The WN group was not significantly different from controls for either F10/F100 or MRR. The F10/F100 of the MN group was significantly greater than either the WN group or controls (p less than 0.001), while MRR was less (p less than 0.001). Significant malnutrition by conventional parameters was shown in patients with abnormal F10/F100, and also in patients with abnormal MRR. Hence, SMF as described is unaffected by azotemia, and provides a functional measure of nutritional status in CRF.

Asunto(s)

Asunto(s)

RESUMEN

In a crossover, double-blind comparison, circulatory changes induced by hemodialysis with bicarbonate versus acetate dialysate were evaluated at the first exposure as well as after 2 weeks of acclimatization to each dialysate. Hemodialysis with bicarbonate dialysate resulted in only minor changes in blood pressure and left ventricular (LV) function as assessed by M-mode echocardiography. In contrast, the first exposure to acetate resulted in significant decreases in systolic (30 mm Hg) and diastolic (17 mm Hg) blood pressure as well as in LV end-diastolic and end-systolic dimensions (5-6 mm) and a rise in ejection fraction. After acclimatization, tolerance developed for the arterial vasodilatory effects of acetate, but not for the venous vasodilatory effect (persistent decrease in LV end-diastolic dimension). These results indicate that some of the circulatory changes induced by hemodialysis may be related more to the acetate infused than to fluid losses or relative autonomic insufficiency.

Asunto(s)

RESUMEN

A 19-year-old woman died when a subclavian catheter that had provided vascular access for plasmapheresis penetrated her right atrium, pericardium, and parietal pleural, causing a hemothorax. Precautions are recommended to minimize the risk of this complication in patients in whom subclavian catheters are used as a vascular access route for hemodialysis or plasmapheresis.

Asunto(s)

RESUMEN

The severity and incidence of subperiosteal and intracortical bone resorption were evaluated from fine-detail hand radiographs at X 8 magnification in relation to age and sex in 239 chronically dialyzed adult renal failure patients. The severity of subperiosteal resorption decreased significantly with advancing age in both sexes and the incidence decreased somewhat more in males than in females; no such trends were apparent for intracortical resorption. Although the mean values for the grades of subperiosteal and intracortical resorption were significantly higher in females than in males, when the effect of age and duration of follow-up were taken into consideration, this sex difference remained significant only for intracortical resorption. It is concluded that when studying certain aspects of renal osteodystrophy, differences due to age, sex, and duration of follow-up should be considered in the final interpretation of data.

Asunto(s)