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It is estimated that >50% of patients with end-stage kidney disease (ESKD) in low-resource countries are unable to access dialysis. When hemodialysis is available, it often has high out-of-pocket expenditure and is seldom delivered to the standard recommended by international guidelines. Hemodialysis is a high-cost intervention with significant negative effects on environmental sustainability, especially in resource-poor countries (the ones most likely to be affected by resultant climate change). This review discusses the rationale for peritoneal dialysis (PD) as a more resource and environmentally efficient treatment with the potential to improve dialysis access, especially to vulnerable populations, including women and children, in lower-resource countries. Successful initiatives such as the Saving Young Lives program have demonstrated the benefit of PD for acute kidney injury. This can then serve as a foundation for later development of PD services for end-stage kidney disease programs in these countries. Expansion of PD programs in resource-poor countries has proven to be challenging for various reasons. It is hoped that if some of these issues can be addressed, PD will be able to permit an expansion of end-stage kidney disease care in these countries., (Copyright © 2024 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Peritoneal dialysis (PD) offers lifestyle advantages over in-center hemodialysis (HD) and is less costly. However, in the United States, less than 12% of end-stage kidney disease (ESKD) patients are maintained on this modality. In this brief review, we discuss some of the factors underlying the low prevalence of PD. These include inadequate patient education, a shortage of sufficiently well-trained medical and nursing personnel, absence of infrastructure to support urgent start PD, and lack of support for assisted PD, among other factors. Understanding and addressing these various issues may help increase the prevalence of PD in the United States and globally., (© 2023 International Society of Nephrology. Published by Elsevier Inc.)

The prevalence of kidney failure continues to rise globally. Dialysis is a treatment option for individuals with kidney failure; after the decision to initiate dialysis has been made, it is critical to involve individuals in the decision on which dialysis modality to choose. This review, based on evidence arising from the literature, examines the role of shared decision-making (SDM) in helping those with kidney failure to select a dialysis modality. SDM was found to lead to more people with kidney failure feeling satisfied with their choice of dialysis modality. Individuals with kidney failure must be cognizant that SDM is an active and iterative process, and their participation is essential for success in empowering them to make decisions on dialysis modality. The educational components of SDM must be easy to understand, high quality, unbiased, up to date, and targeted to the linguistic, educational, and cultural needs of the individual. All individuals with kidney failure should be encouraged to participate in SDM and should be involved in the design and implementation of SDM approaches., (© 2021 International Society of Nephrology. Published by Elsevier Inc.)

Prevention and early detection of kidney diseases in adults and children should be a priority for any government health department. This is particularly pertinent in the low-middle-income countries, mostly in Asia, Africa, Latin America, and the Caribbean, where up to 7 million people die because of lack of end-stage kidney disease treatment. The nephrology workforce (nurses, technicians, and doctors) is limited in these countries and expanding the size and expertise of the workforce is essential to permit expansion of treatment for both chronic kidney disease and end-stage kidney disease. To achieve this will require sustained action and commitment from governments, academic medical centers, local nephrology societies, and the international nephrology community., (© 2020 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Substantial heterogeneity in practice patterns around the world has resulted in wide variations in the quality and type of dialysis care delivered. This is particularly so in countries without universal standards of care and governmental (or other organizational) oversight. Most high-income countries have developed such oversight based on documentation of adherence to standardized, evidence-based guidelines. Many low- and lower-middle-income countries have no or only limited organized oversight systems to ensure that care is safe and effective. The implementation and oversight of basic standards of care requires sufficient infrastructure and appropriate workforce and financial resources to support the basic levels of care and safety practices. It is important to understand how these standards then can be reasonably adapted and applied in low- and lower-middle-income countries., (© 2020 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Introduction: Calcium oxalate supersaturation is regularly exceeded in the plasma of patients with end-stage renal disease (ESRD). Previous reports have indicated that hemodialfiltration (HDF) lowers elevated plasma oxalate (P Ox ) concentrations more effectively compared with hemodialysis (HD). We reevaluate the therapeutic strategy for optimized P Ox reduction with advanced dialysis equipment and provide data on the effect of extended treatment time on dialytic oxalate kinetics., Methods: Fourteen patients with ESRD who underwent HDF 3 times a week for 4 to 4.5 hours (regular HDF; n = 8) or 7 to 7.5 hours (extended HDF; n = 6) were changed to HD for 2 weeks and then back to HDF for another 2 weeks. P Ox was measured at baseline, pre-, mid-, and postdialysis, and 2 hours after completion of the treatment session., Results: Baseline P Ox for all patients averaged 28.0 ± 7.0 μmol/l. Intradialytic P Ox reduction was approximately 90% and was not significantly different between groups or treatment modes [F(1) = 0.63; P  = 0.44]. Mean postdialysis P Ox concentrations were 3.3 ± 1.8 μmol/l. A rebound of 2.1 ± 1.9 μmol/l was observed within 2 hours after dialysis. After receiving 2 weeks of the respective treatment, predialysis P Ox concentrations on HD did not differ significantly from those on HDF [F(1) = 0.21; P  = 0.66]. Extended treatment time did not provide any added benefit [F(1) = 0.76; P  = 0.40]., Discussion: In contrast to earlier observations, our data did not support a benefit of HDF over HD for P Ox reduction. With new technologies evolving, our results emphasized the need to carefully reevaluate and update traditional therapeutic regimens for optimized uremic toxin removal, including those used for oxalate.

Most patients with end-stage kidney disease value their health-related quality of life (HRQoL) and want to know how it will be affected by their dialysis modality. We extended the findings of two prior clinical trial reports to estimate the effects of frequent compared to conventional hemodialysis on additional measures of HRQoL. The Daily Trial randomly assigned 245 patients to receive frequent (six times per week) or conventional (three times per week) in-center hemodialysis. The Nocturnal Trial randomly assigned 87 patients to receive frequent nocturnal (six times per week) or conventional (three times per week) home hemodialysis. All patients were on conventional hemodialysis prior to randomization, with an average feeling thermometer score of 70 to 75 (a visual analog scale from 0 to 100 where 100 is perfect health), an average general health scale score of 40 to 47 (a score from 0 to 100 where 100 is perfect health), and an average dialysis session recovery time of 2 to 3 hours. Outcomes are reported as the between-treatment group differences in one-year change in HRQoL measures and analyzed using linear mixed effects models. After one year in the Daily Trial, patients assigned to frequent in-center hemodialysis reported a higher feeling thermometer score, better general health, and a shorter recovery time after a dialysis session compared to standard thrice-weekly dialysis. After one year in the Nocturnal Trial, patients assigned to frequent home hemodialysis also reported a shorter recovery time after a dialysis session, but no statistical difference in their feeling thermometer or general health scores compared to standard home dialysis schedules. Thus, patients receiving day or nocturnal hemodialysis on average recovered approximately one hour earlier from a frequent compared to conventional hemodialysis session. Patients treated in an in-center dialysis facility reported better HRQoL with frequent compared to conventional hemodialysis., (Copyright © 2017 International Society of Nephrology. All rights reserved.)

Management of older people on dialysis requires focus on the wider aspects of aging as well as dialysis. Almost all frail and older patients receiving dialysis will default to in-center hemodialysis, although the availability of assisted peritoneal dialysis enables dialysis at home. As with any disease management decision, patients approaching end-stage renal disease need all the appropriate facts about their prognosis, the natural history of their disease without dialysis, and the resulting outcomes and complications of the different dialysis modalities. Hemodialysis in the older age group can be complicated by intradialytic hypotension, prolonged time to recovery, and vascular access-related problems. Peritoneal dialysis can be difficult for older patients with impaired physical or cognitive function and can become a considerable burden. Use of incremental dialysis, changes in hemodialysis frequency, and delivery and use of assistance for peritoneal dialysis can ameliorate quality of life for older patients. Understanding each individual's goals of care in the context of his or her life experience is particularly important in the elderly, when overall life expectancy is relatively short, and life experience or quality of life may be the priority. Indeed, some patients select the option of no dialysis or conservative care. With multifaceted assessments of care, physicians should be able to give individual patients the ability to select and continue to make the best decisions for their care., (Copyright © 2016 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Capacity building is key to the advance of health care in the developing world, but capacity building can take several forms, and it is not yet clear which forms and funding models are most effective. The International Society of Nephrology (ISN) has developed and sustained a portfolio of global outreach programs that make a unique contribution at low cost to the appropriate training and continuing support of nephrologists throughout the developing world. We describe the programs and present encouraging findings of their outcomes. Finally, we reflect on how the ISN interventions and evaluations measure up against recommended approaches in the literature and consider lessons for ISN and other organizations involved in planning, evaluating, and benchmarking similar programs.

Although in some parts of the world acute and chronic kidney diseases are preventable or treatable disorders, in many other regions these diseases are left without any care. The nephrology community needs to commit itself to reduction of this divide between high-income and low-income regions. Moreover, new and exciting developments in fields such as pharmacology, genetic, or bioengineering, can give a boost, in the next decade, to a new era of diagnosis and treatment of kidney diseases, which should be made available to more patients., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

In the developing world, the emphasis of care for the patient with chronic kidney disease is, in general, focused on the basics of care and patient survival; attention is not primarily focused on quality of life assessments. However, this arena is beginning to attract more attention. It is important to determine if standardized instruments are valid in the developing world and which unique assessments need to be utilized in individual cultural settings.

Patients with chronic kidney disease treated by in-center conventional hemodialysis (3 times per week) have significant impairments in health-related quality of life measures, which have been associated with increased morbidity and mortality. FREEDOM is an ongoing prospective cohort study measuring the potential benefits of at-home short daily (6 times per week) hemodialysis. In this interim report we examine the long-term effect of short daily hemodialysis on health-related quality of life, as measured by the SF-36 health survey. This was administered at baseline, 4 and 12 months after initiation of short daily hemodialysis to 291 participants (total cohort), of which 154 completed the 12-month follow-up (as-treated cohort). At the time of analysis, the mean age was 53 years, 66% were men, 58% had an AV fistula, 90% transitioned from in-center hemodialysis, and 45% had diabetes mellitus. In the total cohort analysis, both the physical- and mental-component summary scores improved over the 12-month period, as did all 8 individual domains of the SF-36. The as-treated cohort analysis showed similar improvements with the exception of the role-emotional domain. Significantly, in the as-treated cohort, the percentage of patients achieving a physical-component summary score at least equivalent to the general population more than doubled. Hence, at-home short daily hemodialysis is associated with long-term improvements in various physical and mental health-related quality of life measures.

Depression is a common, under-recognized, and under-treated problem that is independently associated with increased morbidity and mortality in CKD patients. However, only a minority of CKD patients with depression are treated with antidepressant medications or nonpharmacologic therapy. Reasons for low treatment rates include a lack of properly controlled trials that support or refute efficacy and safety of various treatment regimens in CKD patients. The aim of this manuscript is to provide a comprehensive review of studies exploring depression treatment options in CKD. Observational studies as well as small trials suggest that certain serotonin-selective reuptake inhibitors may be safe to use in patients with advanced CKD and ESRD. These studies were limited by small sample sizes, lack of placebo control, and lack of formal assessment for depression diagnosis. Nonpharmacologic treatments were explored in selected ESRD samples. The most promising data were reported for frequent hemodialysis and cognitive behavioral therapy. Alternative proposed therapies include exercise training regimens, treatment of anxiety, and music therapy. Given the association of depression with cardiovascular events and mortality, and the excessive rates of cardiovascular death in CKD, it becomes imperative to not only investigate whether treatment of depression is efficacious, but also whether it would result in a reduction in morbidity and mortality in this patient population.

The paper by Fischer et al. focuses attention on the striking prevalence of depressive symptoms in non-dialyzed chronic kidney disease patients. The presence of depressive symptoms correlated with various health-related quality of life measures and economic status. These findings suggest that our view of providing care needs to broaden to incorporate not only thorough medical care, education, and dietary support, but also psychosocial assessments. They also underscore the importance of providing this care to those who are most vulnerable.

The compromised health-related quality of life (HRQOL) of patients with chronic kidney disease is now well documented. The recent mandate by the Center for Medicare Services in the United States that all dialysis units monitor HRQOL as a condition of coverage has focused attention on the importance of these measures. The challenge for the nephrology care team is understanding how to interpret and utilize the information obtained from these HRQOL measurements. Can HRQOL of these patients be improved? The present review addresses this issue by commenting on strategies that have been used to improve the HRQOL of chronic kidney disease patients. A systematic approach is suggested for nephrology care providers to attempt to evaluate and improve the HRQOL of CKD patients.

The need to educate patients in order to enable them to participate in making appropriate choices for all therapeutic options in end stage renal disease would seem obvious yet there are many barriers to providing such information. We measured 'perceived knowledge' of the therapeutic options for end stage renal disease in a cohort of patients with chronic kidney disease in established treatment programs. A self administered questionnaire was given to 676 patients with stage 3-5 chronic kidney disease as part of the CRIOS study designed to identify trends in practice patterns and outcomes over a 4 year period. The median patient age was 66, about three-fourths were Caucasian and almost half were diabetic. When patients were asked to rate their level of knowledge, about one-third reported limited or no understanding of their chronic kidney disease and no awareness regarding their treatment options. A significant and substantial number of patients indicated they had no familiarity with transplant, hemodialysis, and continuous ambulatory or automated peritoneal dialysis. Perceived knowledge improved with the progression of kidney disease and frequency of nephrology visits; however, only about half of patients with 4 or more nephrology appointments in the prior year reported knowing of hemodialysis, continuous ambulatory peritoneal dialysis or transplant. Age, gender and disease had no impact on levels of patient knowledge, but African-Americans reported having significantly less understanding than Asians or Caucasians. These findings suggest that the lack of perception concerning the treatment options chronic kidney and end stage renal disease reflects, in part, problems with the education of patients by nephrologists and not a lack of referral of these patients to nephrologists for care. The discrepancy of perceived knowledge between African-Americans and other races needs special attention.

Hedayati et al. document a 26.5% incidence of clinical depression and a strong association between depression and hospitalizations and mortality in hemodialysis patients. We can no longer ignore the impact of depression on end-stage renal disease patients. Appropriate therapeutic regimens and trials need to be explored.

Background: The prevalence of chronic kidney disease in an HIV-infected population during the highly active antiretroviral era has not been fully evaluated., Methods: A retrospective chart review of HIV-infected patients seen in 2004 was conducted to determine the prevalence of chronic kidney disease (CKD), using the 2004 National Kidney Foundation's CKD staging criteria. Glomerular filtration rate (GFR) was calculated, using the Modification of Diet in Renal Disease formula. Univariate analyses were performed comparing individuals with normal kidney function and those with CKD. Multivariate analysis was conducted including all variables with a value of P < 0.1., Results: We found evidence of CKD in 24% of the patients. Forty patients (10%) had stage 1 CKD, 19 patients (4%) stage 2, 29 patients (7%) stage 3, 4 patients (1%) stage 4, and 8 patients (2%) stage 5. Patients with CKD are more likely to be African American (AA), older, have AIDS, lower CD4 counts and higher HIV viral loads. Patients with CKD were also more likely to have hypertension (HTN), diabetes mellitus (DM), or both. Indinavir or tenofovir exposure was associated with CKD. In multivariate analysis HTN, AA race, or HTN and DM were the only significant predictors of CKD. Physicians did not identify CKD in 74% of patients. Renal biopsies were done in 10 patients; 5 had HIV-associated nephropathy., Conclusions: Substantial minorities of HIV-infected patients have CKD. AA race or the presence of HTN or HTN and DM is associated with CKD. Clinicians often do not note the presence of CKD in this population.

Background: The National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI) clinical practice guidelines have suggested minimal weekly Kt/V urea and creatinine clearance goals for peritoneal dialysis patients maintained on continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). Achieving these goals may present problems, particularly in larger patients whose residual renal function declines. Thus, modifications of the dialysis regimen, such as tidal peritoneal dialysis (TPD), have been developed. However, the ability of TPD to improve the efficiency of the dialysis procedure remains uncertain., Methods: Stable, cycling peritoneal dialysis patients were placed into two groups to study the effectiveness of different TPD prescriptions on peritoneal clearances of urea and creatinine. The volume of dialysis solution used and the duration of therapy were fixed in the two groups. Comparisons were made to conventional APD using multiple hourly cycles in which spent dialysis solution was completely drained with each cycle. Group I patients received a total of 15 L of PD solution over 9.5 hours in the dialysis unit. These patients received 10, 25, and 50% TPD and APD on four separate days. Group II patients received 24 L of PD solution over 9.5 hours. These patients received 25 and 50% APD on separate days in the dialysis unit. Peritoneal dialysis clearances for urea (pKt/V) and creatinine (pCCr) levels were calculated for both groups. The results were then analyzed to determine whether there was any significant difference among the various prescriptions., Results: The data in the group I patients indicated a mean daily pKt/V of 0.22 +/- 0.03 with 10% TPD, 0.23 +/- 0.02 with 25% TPD, 0.25 +/- 0.02 with 50% TPD, and 0.26 +/- 0.02 with APD. Paired t-test analysis for pKt/V demonstrated that 10 and 25% TPD resulted in significantly lower values than 50% TPD and APD (P < 0.05). Mean daily pCCr L/24 h/1.73 m2 was 6.03 +/- 0.72 for 10% TPD, 6.34 +/- 0.83 for 25% TPD, 6.65 +/- 0.51 for 50% TPD, and 7.01 +/- 0.96 for APD; these differences were not significantly different. The data in the group II patients demonstrated a mean daily pKt/V of 0.28 +/- 0.03 with 25% TPD, 0.29 +/- 0.05 with 50% TPD, and 0.30 +/- 0.05 for APD. The mean daily pCCr was 6.69 +/- 0.47 for 25% TPD, 8.09 +/- 1.30 for 50% TPD, and 7.63 +/- 1.13 for APD. There were no statistical differences for pKt/V and pCCr within the 24 L group., Conclusion: When the duration of therapy and volume of dialysate volume are kept constant, TPD does not result in an improvement in clearances compared with conventional APD, at least with dialysate volumes up to 24 L.

Background: A variety of factors can adversely impact chronic peritoneal dialysis (CPD) as an effective renal replacement therapy for patients with end-stage renal disease. These factors include peritonitis, poor clearances, loss of ultrafiltration, and a variety of anatomic problems, such as hernias, peritoneal fluid leaks, loculations, and catheter-related problems caused by omental blockage. This study reviews our experience with peritoneal scintigraphy for the evaluation of some of these difficulties., Methods: From 1991 to 1996, 50 peritoneal scintigraphy scans were obtained in 48 CPD patients. Indications for scintigraphy were evaluated, and the patients were placed into four groups: group I, abdominal wall swelling; group II, inguinal or genital swelling; group III, pleural fluid; and group IV, poor drainage and/or poor ultrafiltration. A peritoneal scintigraphy protocol was established and the radiotracer isotope that was used was 2.0 mCi of 99mtechnetium sulfur colloid placed in two liters of 2.5% dextrose peritoneal dialysis solution., Results: Ten scans were obtained to study abdominal wall swelling, with seven scans demonstrating leaks; six of these episodes improved with low-volume exchanges. Twenty scans were obtained to evaluate inguinal or genital swelling, and 10 of these had scintigraphic evidence for an inguinal hernia leak (9 of these were surgically corrected). One of four scans obtained to evaluate a pleural fluid collection demonstrated a peritoneal-pleural leak that corrected with a temporary discontinuation of CPD. Sixteen scans were obtained to assess poor drainage and/or ultrafiltration. Five of these scans demonstrated peritoneal location, and all of these patients required transfer to hemodialysis. The other 11 scans were normal; four patients underwent omentectomies, allowing three patients to continue with CPD., Conclusion: Peritoneal scintigraphy is useful in the evaluation and assessment of CPD patients who develop anatomical problems (such as anterior abdominal, pleural-peritoneal, inguinal, and genital leaks) and problems with ultrafiltration and/or drainage.

Nine episodes of chronic peritoneal dialysis (CPD)-associated peritonitis with vancomycin resistant enterococci (VRE) were described between November 1993 and February 1996 in our dialysis unit. During the time period, 216 patients were treated for 227 episodes of peritonitis. Of the patients developing peritonitis with VRE the mean age +/- SD was 56.3 +/- 9.7 years. There were 5 females, 4 males, 5 Caucasians and 4 African-Americans. Diabetes mellitus, cardiovascular disease and gastrointestinal disease were present in 7, 8 and 7 of the 9 patients with VRE peritonitis, respectively. Patients were maintained on CPD therapy for an average of 29.9 +/- 19.2 patient months before developing VRE peritonitis. The prior rate of CPD associated peritonitis in the patients developing VRE peritonitis was significantly higher than the rate noted in the CPD patients not developing peritonitis with VRE (1 episode in 6.3 patient months vs. 1 episode in 12.5 patient months, P < 0.05). All 9 patients had used vancomycin in the six months prior to the development of VRE peritonitis and 78% had used a cephalosporin. The antimicrobial therapy used to eradicate peritonitis with VRE varied among the 9 patients with chloramphenicol used in 4 patients. The Tenckhoff catheter was removed in 6 of the 9 patients and was successfully reinserted in one patient. The catheter was not removed in 3 patients and 2 of these patients expired. Five of the 9 patients expired while being treated for VRE, 2 transferred to hemodialysis and 2 continued CPD therapy. VRE peritonitis is a major concern for patients maintained on CPD therapy. Future studies are needed with case controls to determine the significance of prior vancomycin and cephalosporin therapy, fecal VRE carriage and certain demographic data on the acquisition of VRE peritonitis. Furthermore, the optimal therapy and outcome may be better clarified through such a review.

A retrospective analysis of 39 HIV infected patients with ESRD cared for in New Haven from 1987 to June 1992 was performed. All patients had evidence for HIV infection at the start of CAPD therapy. Cumulative technique survival at one and two years was 43% and 27%, respectively. Only eight patients transferred to center dialysis. One and two year patient survival on CAPD was 58% and 54%, respectively. Mortality was higher in patients with advanced infection than in those with asymptomatic HIV infection. Hospitalization rates were also higher in patients with advanced infection. HIV infected patients had higher rates of peritonitis (3.9 episodes/outpatient CAPD year) compared to non-HIV infected patients (1.5 episodes/CAPD year), especially for pseudomonal and fungal infections. Active injection drug use and use of the "straight set" system were associated with increased rates of peritonitis. CAPD deserves consideration as a therapy for HIV infected patients with ESRD.

In 68 consecutive renal transplant biopsies, histopathologic changes and clinical status of the graft recipient, both at the time of biopsy as well as one month later, were evaluated by independent observers. Nine histologic features were graded semiquantitatively (scale, 0 to 4): glomerular endothelial swelling, proliferation, exudation and necrosis; interstitial edema and infiltrate: vascular endothelial edema, infiltration and necrosis. The total score for each biopsy was termed the acute rejection index (ARI). The validity of the ARI as a means of evaluation rejection reactions was established by correlating the ARI with a second, overall histopathologic categorization. Clinical status at the time of biopsy was classified by retrospective analysis of all clinical data except the biopsy. The mean ARI of patients with an acute clinical rejection was significantly higher than those of patients with just a chronic clinical rejection or no clinical rejection. The utility of the biopsy in predicting the response of the graft recipient to therapy was evaluated in those 46 patients in whom an acute rejection was diagnosed clinically and in whom a full and complete course of therapy for the acute clinical rejection was given. Of the 28 patients whom the pathologist predicted would response to therapy, 27 did show substantial improvement of their renal function up to one month following institution of treatment. Of the 18 patients whom the pathologist predicted would not respond to therapy, 15 had no clinical response. The data suggest that the transplant biopsy is helpful in 1) establishing the diagnosis of an acute rejection and 2) indicating whether or not the graft recipient will respond to standard immunosuppressive treatment for an acute rejection,

A model for performing peritoneal dialysis in the rat was established which permitted the consistent measurement of dialysis clearances. The effects on urea and inulin clearances of interperitoneal vasodilators and 4.25% dextrose were compared. Isoproterenol, nitroprusside, histamine, and bradykinin, when added to 1.5% dextrose dialysate for three consecutive exchanges, all produced approximately a 20% increase in urea and inulin dialysis clearances. These increases in clearances persisted in the three subsequent exchanges when no drugs were added to the dialysate. The addition of isoproterenol, nitroprusside, or histamine to six consecutive exchanges did not produce a further increment in clearances. The use of 4.25% dextrose dialysate for three exchanges produced approximately a 50% increase in urea and inulin clearances. Clearances remained about 35% greater than control values in the subsequent three 1.5% dextrose exchanges.

In addition to the somatic problems associated with uremia and dialysis it is apparent that successful hemodialysis is dependent upon psychological adjustment to this type of therapy. While previous studies have focused on the patient or spouse as individuals, patterns of marital interactions and conflicts have not been systematically evaluated. These factors ere examined in 17 medically stable patients maintained on hemodialysis for a mean duration of 22 +/- 4 SE months. Standardized pssychiatric evaluation forms ere used to examine mood and cognition disturbances in all patients and spouses, and a deailed marital questionnaire, which each patient and spouse filled out independently, was used to evaluate fundamental aspects of the marital relationship...