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Aims: To examine the possible relationships between recombinant human erythropoietin (rhEPO) therapy, serum folic acid and homocysteine levels in a cohort of stable, chronically hemodialyzed patients., Material and Methods: The study was cross-sectional in its first phase and consisted of 3 groups of subjects (group 1:6 healthy controls; group 2:7 dialyzed patients not receiving rhEPO; group 3: 14 patients on rhEPO therapy). Hematological and biochemical parameters were taken after an overnight fast in all subjects. The second phase of the study was prospective, and included 8 dialyzed patients, and investigated the effects of a 6-month period of folic acid supplementation (10 mg, 3 times a week) on the same parameters examined in the first phase of the study., Results: In the first part of the study hemoglobin levels were near-normal, or normal, in all patients. No differences in hemoglobin or hematocrit values were observed in the 3 groups. 80% of all hemodialyzed patients had low serum folic acid levels, irrespective of whether they were receiving rhEPO. Serum erythropoietin level was elevated in group 3 (23.3+/-10.4 mIU/ml). In group 2, serum erythropoietin level was not different from that of the healthy controls (13.5+/-11.2 vs. 8.0+/-5.4 mIU/ml, p = n.s.). Total serum homocysteine levels were elevated in all dialyzed patients (group 2: 24.7+/-9.2 micromol/l; group 3: 31.6+/-14.4 micromol/l), with a significant difference seen when comparing controls and those dialyzed patients on rhEPO therapy (8.7+/-2.2 vs. 31.6+/-14.4 micromol/l; p<0.05). Significant correlations (ANOVA) were observed between serum erythropoietin and folic acid levels (r = -0.382; p = 0.049), and between folic acid and homocysteine levels (r = -0.560; p = 0.002). In the second part of the study folic acid supplementation led to a highly significant reduction in homocysteine levels (20.9+/-4.9 vs. 11.9+/-2.5 micromol/l; p<0.0005). Two of 3 patients receiving rhEPO therapy, had rhEPO discontinued after commencing folic acid, as hemoglobin levels remained adequate, even without rhEPO., Conclusions: In hemodialyzed patients, the presence of a near-normal hemoglobin level, irrespective of rhEPO therapy, implies efficient erythropoiesis. Without adequate folic acid reserves, folic acid deficiency may develop in these patients and this will aggravate already high homocysteine levels. Therefore, folic acid supplementation is warranted in hemodialyzed patients, especially in those patients with hemoglobin levels approaching normal. This treatment is safe and effective in reducing homocysteine levels, especially when given in high doses for prolonged periods of time.

A hemodialysed patient with abdominal pain, severe lactic acidosis and prolonged hypoglycemia is described. The diagnosis of acute necrotizing pancreatitis was delayed and the patient died from both systemic and peripancreatic complications of the acute pancreatitis. The article deals with the problem of diagnosing acute pancreatitis in an end-stage renal failure (ESRF) patient; on the possible surgical options open to the physician in the management of acute pancreatitis and on a pathophysiological explanation behind both the lactic acidosis and hypoglycemia in this patient.

In recent years, adenocarcinoma of the colon mucosa has become a recognized complication of ureterosigmoidostomy and in most cases the tumor arises at the site of ureterocolonic anastomosis. We report a case of a 29-year-old renal transplant recipient who developed two colonic carcinomas at the site of ureterosigmoidostomy 25 years after the urinary diversion and 15 years after conversion to an ileal conduit. This case emphasizes the need for a careful life-long follow-up of all patients who undergo ureterosigmoidostomy.

Erythropoietin (EPO) therapy is widely used to correct the anemia of end-stage renal disease. It has been reported that this treatment affects various hormonal systems. The aim of the present study was to evaluate the effects of EPO therapy on glucose tolerance. Anemia was corrected with EPO in 10 patients on chronic hemodialysis therapy. Oral glucose tolerance tests (OGTT) were performed before and after correction of anemia. The following measurements were made: the areas under the glucose curves (AUCglue), the areas over basal glucose values (OABVglue), the areas under the insulin curves (AUCins) and the areas over basal insulin values (AOBVins). Hemoglobin concentration increased from 70 +/- 1.4 milligrams to 111 +/- 1 milligram. Fasting plasma glucose, insulin and glucagon levels were were not affected by correction of the anemia. Following administration of EPO, AOBVglue increased by 19%, from 2101 +/- 243 to 2508 +/- 230 mmol.min/l (p < 0.02), while AOBVins remained unchanged. AUCins and AUCglue remained unchanged. These data show that correction of anemia with EPO in hemodialyzed patients causes an increase in the glycemic response to an oral glucose load while not affecting the insulin response.

The transcapillary escape rate of albumin (TERalb) is often elevated in patients with diabetic microangiopathy. The objective of this study was to examine the effect of enalapril on the TERalb of diabetic patients with albuminuria and normal or mildly elevated blood pressure. Seventeen diabetic patients with diabetic retinopathy, albuminuria, a diastolic blood pressure below 100 mmHg and increased TERalb participated in the study. Blood pressure and TERalb were measured before and after 14 days of therapy with enalapril, 20 mg daily for 14 days. Systolic and diastolic blood pressure fell from 168 +/- 6 to 155 +/- 6 (p < 0.001) and from 87 +/- 2 to 81 +/- 2 mmHg (p < 0.005) respectively. Mean arterial pressure declined from 114 +/- 3 to 105 +/- 3 mmHg (p < 0.0001). The elevated TERalb decreased from 9.5 +/- 0.5 to 7.2 +/- 0.5%/hr (p < 0.005). In the hypertensive subset, systolic, diastolic and mean arterial pressure decreased significantly by 15, 7 and 10 mmHg (p < 0.005, p < 0.005 and p < 0.005 respectively); TERalb decreased from 9.5 +/- 0.6 to 7.3 +/- 0.6 (p < 0.03). In the normotensive subset, arterial pressure remained unchanged and TERalb decreased from 9.0 +/- 0.8 to 6.8 +/- 1.0%/hr (p < 0.03). Plasma fructosamine decreased from 373 +/- 23 to 347 +/- 20 (p < 0.05) in the hypertensive group and remained unchanged in the normotensive patients. No correlation could be demonstrated between variation in TERalb and changes in blood pressure. In conclusion, enalapril decreases microvascular albumin leakage in patients with diabetic microangiopathy and normal or mildly elevated blood pressure.

Accepted criteria for the diagnosis of peritonitis in CAPD include: 1. symptoms and signs of peritoneal irritation; 2. a cloudy effluent with white blood cell (WBC) count greater than 100/microliters and; 3. a positive culture. In fact, the earliest suggestive sign of peritonitis is a turbid effluent. However, symptomatology of peritoneal irritation may precede the development of a cloudy fluid. We hereby report on two CAPD patients with culture proven peritonitis whose initial presentation was that of an acute abdomen. Although diffuse rebound tenderness was elicited the initial effluent, after an overnight dwell, was clear with a WBC count of 80 and 70/microliters, respectively. Working diagnoses on admission included a ruptured cyst and a perforated peptic ulcer. Both patients were in line for a laparotomy. After a period of 7 and 12 hours, respectively the ensuing effluents turned turbid with WBC counts of 6,400 and 2,500/microliters. Cultures eventually grew Staphylococcus aureus and Streptococcus viridans. Appropriate antibiotic treatment resulted in full recovery.

The element content of the fingernails of 16 patients with chronic renal failure (CRF) treated by hemodialysis was examined by dispersive microanalysis. In comparison with matched controls, the results showed a statistically significant decrease in the percentage of Cu, Fe and Zn and an increase in S. The Al content did not differ significantly from that of the controls. There was no correlation between the serum values of Al, Fe and Zn and their content in the fingernails of the patients. On the other hand, Cu was found to be low both in the sera and in the fingernails of the CRF patients.

A 45-year-old woman on CAPD developed pneumococcal peritonitis. This is the second such case of Streptococcus pneumoniae peritonitis complicating CAPD. The role of an indwelling intrauterine device (IUD) in producing ascending infection into the peritoneum is discussed, especially in women with evidence of retrograde menstruation. A review of the literature concerning pneumococcal peritonitis associated with IUD is given. Possible contraception to women on CAPD is briefly mentioned.