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Background Patients with end-stage renal disease (ESRD) undergoing hemodialysis experience a rapid decline in skeletal muscle mass and strength. Hemodialysis removes amino acids (AAs) from the circulation, thereby lowering plasma AA concentrations and stimulating proteolysis. Objectives In the present study, we evaluate the impact of intradialytic protein ingestion at rest and following exercise on AA removal and plasma AA availability in patients with ESRD. Methods Ten patients (age: 65 +/- 16 y, male/female: 8/2, BMI: 24.2 +/- 4.8 kg/m(2), serum albumin: 3.4 +/- 0.3 g/dL) with ESRD undergoing hemodialysis participated in this randomized controlled crossover trial. During 4 hemodialysis sessions, patients were assigned to ingest 40 g protein or a placebo 60 min after initiation, both at rest (PRO and PLA, respectively) and following exercise (PRO + EX and PLA + EX, respectively). Spent dialysate and blood samples were collected every 30 min throughout hemodialysis to assess AA removal and plasma AA availability. Results Plasma AA concentrations declined by 26.1 +/- 4.5% within 30 min after hemodialysis initiation during all interventions (P < 0.001, eta(2)(p) > 0.79). Protein ingestion, but not intradialytic exercise, increased AA removal throughout hemodialysis (9.8 +/- 2.0, 10.2 +/- 1.6, 16.7 +/- 2.2, and 17.3 +/- 2.3 g during PLA, PLA + EX, PRO, and PRO + EX interventions, respectively; protein effect P < 0.001, eta(2)(p) = 0.97; exercise effect P = 0.32, eta(2)(p) = 0.11). Protein ingestion increased plasma AA concentrations until the end of hemodialysis, whereas placebo ingestion resulted in decreased plasma AA concentrations (time effect P < 0.001, eta(2)(p) > 0.84). Plasma AA availability (incremental AUC) was greater during PRO and PRO + EX interventions (49 +/- 87 and 70 +/- 34 mmol/L/240 min, respectively) compared with PLA and PLA + EX interventions (-227 +/- 54 and -208 +/- 68 mmol/L/240 min, respectively; protein effect P < 0.001, eta(2)(p) = 0.98; exercise effect P = 0.21, eta(2)(p) = 0.16). Conclusions Protein ingestion during hemodialysis compensates for AA removal and increases plasma AA availability both at rest and during recovery from intradialytic exercise. Intradialytic exercise does not compromise AA removal or reduce plasma AA availability during hemodialysis in a postabsorptive or postprandial state.

BACKGROUND AND AIMS: Studies examining kidney failure patients with COVID-19 reported higher mortality in hemodialysis patients than in kidney transplant recipients. However, hemodialysis patients are often older and have more comorbidities. This study investigated the association of type of kidney replacement therapy with COVID-19 severity adjusting for differences in characteristics. METHOD: Data were retrieved from the European Renal Association COVID-19 Database (ERACODA), which includes kidney replacement therapy patients diagnosed with COVID-19 from all over Europe. We included all kidney transplant recipients and hemodialysis patients who presented between February 1st and December 1st 2020 and had complete information reason for COVID-19 screening and vital status at day 28. The diagnosis of COVID-19 was made based on a PCR of a nasal or pharyngeal swab specimens and/or COVID-19 compatible findings on a lung CT scan. The association of kidney transplantation or hemodialysis with 28-day mortality was examined using Cox proportional-hazards regression models adjusted for age, sex, frailty and comorbidities. Additionally, this association was investigated in the subsets of patients that were screened because of symptoms or have had routine screening. RESULTS: A total of 1,670 patients (496 functional kidney transplant recipients and 1,174 hemodialysis patients) were examined. 16.9% of kidney transplant recipients and 23.9% of hemodialysis patients died within 28 days of presentation. In an unadjusted model, the risk of 28-day mortality was 33% lower in kidney transplant recipients compared with hemodialysis patients (hazard ratio (HR): 0.67, 95% CI: 0.52, 0.85). However, in an age, sex and frailty adjusted model, the risk of 28-day mortality was 29% higher in kidney transplant recipients (HR=1.29, 95% CI: 1.00, 1.68), whereas in a fully adjusted model the risk was even 43% higher (HR=1.43, 95% CI: 1.06, 1.93). This association in patients who were screened because of symptoms (n=1,145) was similar (fully adjusted model HR=1.46, 95% CI: 1.05, 2.04). Results were similar when other endpoints were studied (e.g. risk for hospitalization, ICU admission or mortality beyond 28 days) as well as across subgroups. Only age was found to interact significantly, suggesting that the increased mortality risk associated with kidney transplantation was especially present in elderly subjects. CONCLUSION: In this study, kidney transplant recipients had a greater risk of a more severe course of COVID-19 compared with hemodialysis patients when adjusted for age, sex and comorbidities.

Fluid status is crucial for dialysis patients. Volume overload is a major cardiovascular risk factor. Nevertheless, volume depletion is associated with myocardial stunning and cerebral ischaemia. For decades, many diagnostic tools have been proposed for increased accuracy in evaluation of volemia, considering that clinical assessment is unreliable. Lung ultrasound and bioimpedance analysis emerged as the most useful tools, although randomized clinical studies are lacking to implement their universal use. Early management of hydration may improve clinical outcomes, as it allows personalized dialysis prescriptions and nutritional support info:eu-repo/semantics/publishedVersion

Vascular calcification (VC) is an active process, resulting from the disturbance of balance between inhibitors and promoters of calcification, in favor of the latter. Matrix Gla Protein, a powerful inhibitor of VC, needs vitamin K to become active. In vitamin K depletion, plasma levels of the inactive form of MGP, dephosphorylated, uncarboxylated MGP (dp-ucMGP) are increased and associated with VC and cardiovascular (CV) outcomes. End Stage Renal Disease (ESRD) patients have increased circulating dp-ucMGP levels and accelerated VC. VItamin K In PEritoneal DIAlysis (VIKIPEDIA) is a prospective, randomized, open label, placebo-controlled trial, evaluating the effect of vitamin K2 supplementation on arterial stiffness and CV events in ESRD patients undergoing peritoneal dialysis (PD). Forty-four PD patients will be included in the study. At baseline, dp-ucMGP and pulse-wave velocity (PWV) will be assessed and then patients will be randomized (1:1 ratio) to vitamin K (1000 μg MK-7/day) or placebo for 1.5 years. The primary endpoint of this trial is the change in PWV in the placebo group as compared to the treatment group. Secondary endpoints are the occurrence of CV events, mortality, changes in PD adequacy, change in 24-hour ambulatory blood pressure indexes and aortic systolic blood pressure and changes in calcium/phosphorus/parathormone metabolism. VIKIPEDIA is a new superiority randomized, open label, placebo-controlled trial aiming to determine the effect of vitamin K2 supplementation on VC, CV disease and calcium/phosphorus metabolism, in PD patients. Trial registration: The protocol of this study is registered at ClinicalTrials.gov with identification number NCT04900610 (25 May 2021).

Peritoneal dialysis (PD) has often been considered as a renal replacement method that is not feasible for the elderly population. Numerous recent studies have shown that this method is in fact very well, if not better tolerated by elderly patients. In Switzerland and abroad, its economic advantages have also been underlined during the past ten years. As a consequence, the use of PD is increasing, and primary care physicians are more often confronted to PD patients. Therefore, they have to be aware of some basic treatment principles, which are reviewed in this article.

BackgroundAnemia is a major comorbidity of patients with end-stage renal disease and poses an enormous economic burden to health-care systems. High dose erythropoiesis-stimulating agents (ESAs) have been associated with unfavorable clinical outcomes. We explored whether mixed-dilution hemodiafiltration (Mixed-HDF), based on its innovative substitution modality, may improve anemia outcomes compared to the traditional post-dilution hemodiafiltration (Post-HDF).MethodsWe included 174 adult prevalent dialysis patients (87 on Mixed-HDF, 87 on Post-HDF) treated in 24 NephroCare dialysis centers between January 2010 and August 2016 into this retrospective cohort study. All patients were dialyzed three times per week and had fistula/graft as vascular access. Patients were matched at baseline and followed over a one-year period. The courses of hemoglobin levels (Hb) and monthly ESA consumption were compared between the two groups with linear mixed models.ResultsMean baseline Hb was 11.9±1.3 and 11.8±1.1g/dl in patients on Mixed- and Post-HDF, respectively. While Hb remained stable in patients on Mixed-HDF, it decreased slightly in patients on Post-HDF (at month 12: 11.8±1.2 vs 11.1±1.2g/dl). This tendency was confirmed by our linear mixed model (p = 0.0514 for treatment x time interaction). Baseline median ESA consumption was 6000 [Q1:0;Q3:16000] IU/4 weeks in both groups. Throughout the observation period ESA doses tended to be lower in the Mixed-HDF group (4000 [Q1:0;Q3:16000] vs 8000 [Q1:0;Q3:20000] IU/4 weeks at month 12; p = 0.0791 for treatment x time interaction). Sensitivity analyses, adjusting for differences not covered by matching at baseline, strengthened our results (Hb: p = 0.0124; ESA: p = 0.0687).ConclusionsResults of our explorative study suggest that patients on Mixed-HDF may have clinical benefits in terms of anemia management. This may also have a beneficial economic impact. Future studies are needed to confirm our hypothesis-generating results and to provide additional evidence on the potential beneficial effects of Mixed-HDF.

Se analiza la respuesta inmunitaria celular y humoral en 30 pacientes en régimen de hernodiálisis periódica, haciendo hincapié en si la mayor permanencia en programa determina o no una mayor deficiencia inmunitaria. Así mismo, se comparan los resultados con los obtenidos en 30 individuos sanos utilizados como grupo control. Las conclusiones obtenidas son las siguientes: 1. En la totalidad de los pacientes de hemodiálisis existe una clara y significativa deficiencia inmunocelular. 2. No encontrarnos grados de deficiencia inmunitaria dependientes de la etiopatogenia. 3. La vertiente inmunitaria humoral se encuentra conservada. 4. Aquellos pacientes con más de 2 años en programa evidenciaban una mayor disminución del valor absoluto de linfocitos T/mm3 y, por lo tanto, mayor deficiencia inmunocelular.

As part of a reorganisation of the delivery of health care in Denmark therapies for chronic medical conditions are moved out of hospitals and disease-specific patient education programmes instituted to train patients to assume responsibility for treating their disease at home, that is, perform tasks and functions traditionally done by healthcare professionals. Drawing on video-recordings (90:25h) from a programme for self-management of end-stage renal disease through automated home peritoneal dialysis, the study employs conversation analysis to examine nurses’ instructional practices for providing patients with the necessary knowledge, skill and competences. Showing training to rely on an error-based monitoring strategy, the study demonstrates that rather than solely waiting for random errors to emerge, nurses on occasion steer patients towards specific errors to bring about particular instructional opportunities. Surprising given the seriousness of the therapy, this elicitation of error is shown to reflect a deliberate instructional choice; nurses promote select errors to impart patients with an understanding of the procedural logic behind the therapy and medical technology. The study argues that training patients for chronic disease self-management and providing them with a proficiency level, normally associated with certified professionals, necessitates pushing patients beyond what is strictly accurate and exposing them to medically delicate events.

Hyperphosphatemia is known as one of the more challenging conditions in end-stage renal disease patients. This study set out to present and evaluate a healthcare-oriented decision support tool in the management of hyperphosphatemia within hemodialysis therapy. A prototype module was designed to fit into the interface of a modern dialysis machine (Fresenius 5008). The prototype included three main functions: 1) immediate bedside blood sample access, 2) a model based prognosis tool with estimates of P-phosphate and 3) an overview of the user's phosphate related activities during dialysis treatments. The prototype was evaluated by a) heuristic evaluation with five human computer interaction experts and b) user testing with think-aloud by three users as (clinical) domain experts. The two evaluation procedures identified a total of 103 usability problems and led to some specific amendments to improve its practical potential. The overall results will guide further development of the decision support tool to ensure that the functions will support the user's needs. In conclusion, the prototype was evaluated to be relevant and potentially beneficial in the management of hyperphosphatemia in hemodialysis patients. Furthermore, it was found that some of the functions could be used for educational purposes or as decision support for some patient groups, e.g. for patient doing home-dialysis.

BACKGROUND: As outcome data for prune belly syndrome (PBS) complicated by end-stage renal disease are scarce, we analyzed characteristics and outcomes of children with PBS using the European Society for Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry data.METHODS: Data were available for 88 male PBS patients aged RESULTS: Median age at onset of RRT in PBS was lower [7.0; interquartile range (IQR) 0.9-12.2 years] than in COU (9.6; IQR: 3.0-14.1 years) and RHD (9.4; IQR: 2.7-14.2 years). Unadjusted 10-year patient survival was 85% for PBS, 94% for COU, and 91% for RHD. After adjustment for country, period, and age, PBS mortality was similar to that of RHD but higher compared with COU [hazard ratio (HR) 1.96, 95% confidence interval (CI) 1.03-3.74]. Seventy-four PBS patients (84%) received a first kidney transplant after a median time on dialysis of 8.4 (IQR 0.0-21.1) months. Outcomes with respect to time on dialysis before transplantation, chance of receiving a first transplant within 2 years after commencing RRT, and death-censored, adjusted risk of graft loss were similar for all groups.CONCLUSIONS: This study in the largest cohort of male patients with PBS receiving RRT to date demonstrates that outcomes are comparable with other congenital anomalies of the kidney and urinary tract, except for a slightly higher mortality risk compared with patients with COU.

Worldwide, diabetes has become the most common cause of end-stage renal disease (ESRD), yet Swiss data are largely lacking. This observational study examined ESRD patients with diabetes mellitus (ESRD-DM) at end of 2009 and 2014. The prevalence and characteristics of ESRD-DM patients were collected in all dialysis facilities in the Canton of Vaud of Switzerland in 2009 and in 2014, and the 5-year mortality rate was assessed. A total of 107 and 140 ESRD-DM patients underwent dialysis at end of 2009 and 2014, respectively. Within the 5-year period a total of 167 incidental ESRD-DM patients required dialysis, corresponding to an estimated incidental rate of 0.84/1000 person-years in the diabetic population. In 2009, all patients with ESRD-DM underwent haemodialysis, decreasing to 96.2% in 2014, with 3.8% on peritoneal dialysis. Age, sex, body mass index, type of diabetes, duration of diabetes, cause of ESRD, dialysis duration, dialysis frequency, vascular access, and glycosylated haemoglobin levels did not differ between 2009 and 2014. In 2014, macrovascular comorbidity was reported more often than in 2009, but not amputations. Haemoglobin level decreased significantly from 117.9 g/l to 112.3 g/l. Calcium-containing phosphate binder and angiotensin-converting enzyme inhibitor use significantly decreased, whereas iron therapy significantly increased with time. The 5-year mortality rate was 61.7%. Five-year survivors were significantly younger and had a higher body mass index. The growing prevalence of ESRD-DM emphasises that prevention of chronic kidney disease and its progression should be a public health priority in Switzerland.

Encapsulating peritoneal sclerosis (EPS) is a potentially devastating complication of peritoneal dialysis\ud (PD). Diagnosis is often delayed due to the lack of effective and accurate diagnostic tools. We\ud therefore examined peritoneal effluent for potential biomarkers that could predict or confirm the\ud diagnosis of EPS and would be valuable in stratifying at-risk patients, and driving appropriate\ud interventions. Using prospectively collected samples from the Global Fluid Study and a cohort of\ud Greek PD patients, we utilized 2D SDSPAGE/ MS and iTRAQ to identify changes in the peritoneal\ud effluent proteome from patients diagnosed with EPS and controls matched for treatment exposure. We\ud employed a combinatorial peptide ligand library to compress the dynamic range of protein\ud concentrations, to aid identification of low-abundance proteins. In patients with stable membrane\ud function, fibrinogen γ-chain and heparan sulphate proteoglycan core protein progressively\ud increased over time on PD. In patients who developed EPS, collagen-α1(I), γ-actin and Complement\ud factors B and I were elevated up to five years prior to diagnosis. Orosomucoid-1 and a2-HSglycoprotein chain-B were elevated about one year before diagnosis, while apolipoprotein A-IV and\ud α1-antitrypsin were decreased compared to controls. Dynamic range compression resulted in an\ud increased number of proteins detected with improved resolution of protein spots, compared to the full\ud fluid proteome. Intelectin-1, dermatopontin, gelsolin and retinol binding protein-4 were elevated in\ud proteome-mined samples from patients with EPS compared to patients that had just commenced\ud peritoneal dialysis. Thus, prospective analysis of peritoneal effluent uncovered proteins indicative of\ud inflammatory and pro-fibrotic injury worthy of further evaluation as diagnostic/prognostic markers.

BACKGROUND: Chronic kidney disease (CKD) accelerates vascular stiffening related to age. Arterial stiffness may be evaluated measuring the carotid-femoral pulse wave velocity (PWV) or more simply, as recommended by KDOQI, monitoring pulse pressure (PP). Both correlate to survival and incidence of cardiovascular disease. PWV can also be estimated on the brachial artery using a Mobil-O-Graph; a non-operator dependent automatic device. The aim was to analyse whether, in a dialysis population, PWV obtained by Mobil-O-Graph (MogPWV) is more sensitive for vascular aging than PP. METHODS: A cohort of 143 patients from 4 dialysis units has been followed measuring MogPWV and PP every 3 to 6 months and compared to a control group with the same risk factors but an eGFR > 30 ml/min. RESULTS: MogPWV contrarily to PP did discriminate the dialysis population from the control group. The mean difference translated in age between the two populations was 8.4 years. The increase in MogPWV, as a function of age, was more rapid in the dialysis group. 13.3% of the dialysis patients but only 3.0% of the control group were outliers for MogPWV. The mortality rate (16 out of 143) was similar in outliers and inliers (7.4 and 8.0%/year). Stratifying patients according to MogPWV, a significant difference in survival was seen. A high parathormone (PTH) and to be dialysed for a hypertensive nephropathy were associated to a higher baseline MogPWV. CONCLUSIONS: Assessing PWV on the brachial artery using a Mobil-O-Graph is a valid and simple alternative, which, in the dialysis population, is more sensitive for vascular aging than PP. As demonstrated in previous studies PWV correlates to mortality. Among specific CKD risk factors only PTH is associated with a higher baseline PWV. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02327962.

症例1(83歳男).CAPD導入100日後に右鼠径部の膨隆を認め, 右鼠径ヘルニアの診断でヘルニア根治術を行った.術前, 術後の透析については, 血液透析管理としていたが, 術後4日目に患者本人の自己判断にて, CAPDを施行し翌日来院した.理学所見では, 下腹部および鼠径部に膨隆, 浮腫などを認めず, その後5回の血液透析を施行した後, 術後16日目にCAPDを再開した.症例2(73歳女).CAPD導入248日目頃より右鼠径部の膨隆を自覚し, 右鼠径ヘルニアの診断でヘルニア根治術を行った.術後6日目よりCAPDを再開した.術後3ヵ月経過したが, 再発を認めず, 現在もCAPDを継続している, We report two cases of subacute inguinal swelling in uremic patients on continuous ambulatory peritoneal dialysis (CAPD). Computed tomography, scintigraphy demonstrated a mass in the right groin. Surgical repair of an inguinal hernia resulted in complete resolution of the inguinal swelling. Both patients could restart continuous ambulatory peritoneal dialysis, without complication.

This is a case report of a 43-year-old Caucasian male with end-stage renal disease being treated with hemodialysis and infective endocarditis in the aortic and tricuspid valves. The clinical presentation was dominated by neurologic impairment with cerebral embolism and hemorrhagic components. A thoracoabdominal computerized tomography scan revealed septic pulmonary embolus. The patient underwent empirical antibiotherapy with ceftriaxone, gentamicin and vancomycin, and the therapy was changed to flucloxacilin and gentamicin after the isolation of S. aureus in blood cultures. The multidisciplinary team determined that the patient should undergo valve replacement after the stabilization of the intracranial hemorrhage; however, on the 8th day of hospitalization, the patient entered cardiac arrest due to a massive septic pulmonary embolism and died. Despite the risk of aggravation of the hemorrhagic cerebral lesion, early surgical intervention should be considered in high-risk patients.

2000年4月からの19ヵ月間に行った18例24回のPTAについてretrospectiveに検討した.男性11例, 女性7例, 平均63歳であった.狭窄部位は, 吻合部5病変, シャント静脈22病変, 計27病変であった.手技的成功率は82.5%, また一次開存率は1ヵ月で82.6%, 3ヵ月で74.5%, 半年で67.5%であった.5例で二次PTAを施行し, その開存率は一次開存率と有意差を認めなかった.また一次PTA群と外科的再建群での開存率に有意差を認めなかった, Percutaneous transluminal angioplasty (PTA) has gained wide acceptance as an effective technique for the dilatation of stenoses in the arterial tree. We evaluated the long-term results of vascular access in a group undergoing hemodialysis, in particular the effects of PTA. Twenty-four percutaneous procedures were performed on 18 patients. Detection was based on physical examination, flow rate measurements, venous pressure, and analytical determinations performed at dialysis. The initial success rate was 87.5%, with 1-, 6-, and 18-month patency rates of 82.6, 67.5, and 38.5%, respectively. There was no difference between primary and secondary patency rates. The assisted primary patency rates for PTA and surgical revision were not significantly different. Although neither surgical nor endovascular management resulted in long-term function for the majority of shunts after stenosis or thrombosis, endovascular treatment can extend the life of dialysis shunts with results similar to surgical revision. Transluminal dilatation may be performed in appropriate cases to obviate the need for surgery.

Autoantibodies to apolipoprotein/A-1 (anti-ApoA-1 IgG) have pro-atherogenic properties in patients at high cardiovascular risk, but its prevalence in patients with end-stage kidney disease is unknown. The aims of this single-center, cross-sectional study were to assess the prevalence of anti-ApoA-1 antibodies in patients on maintenance hemodialysis (MHD), and to examine its correlation with inflammatory biomarkers related to atherosclerotic plaque vulnerability and dialysis vintage. To this purpose, anti-ApoA-1 IgG levels and the concentrations of interleukin-6 (IL-6), interleukin-8 (IL-8), monocyte chemoattractant protein-1 (MCP-1), metalloproteinase-9 (MMP-9), tumor necrosis factor-α, and C-reactive protein (CRP) were assessed in the sera of 66 MHD patients (mean age: 68 ± 14 years, 36% women, 32% diabetics). Anti-ApoA-1 IgG positivity (defined as a blood value ≥ 97.5(th) percentile of the normal distribution as assessed in healthy blood donors) was 20%. Circulating levels of anti-ApoA-1 IgG correlated positively with dialysis vintage, but not with cardiovascular risk factors or previous cardiovascular events; no significant correlations were found between the anti-ApoA1 IgG levels and circulating levels of IL-6, IL-8, MCP-1, MMP-9, CRP, or low-density lipoprotein-cholesterol. In multivariable linear regression, adjusted for age and sex, only dialysis vintage remained positively and independently associated with anti-ApoA-1 titers (β = 0.05, 95% CI: 0.006; 0.28, P = 0.049). In conclusion, the prevalence of anti-ApoA-1 IgG is raised in the MHD-population, and positively associated with dialysis vintage, a major determinant of cardiovascular outcome. Whether antiApoA-1 antibodies play a role in the pathophysiology of accelerated atherosclerosis in the MHD-population merits further study.

At present there are no nephrology facilities in Greenland. Greenlandic patients with renal failure needing dialysis thus have to travel to Denmark to obtain treatment. For patients in haemodialysis this necessitates a permanent residence in Denmark. Our study was aimed at examining Greenlanders' preferences for establishing nephrology facilities in Greenland at Queen Ingrid's Hospital in Nuuk, and to estimate the associated change in welfare. Preferences were elicited using a discrete choice experiment (DCE). A random sample of 500 individuals of the general population was sent a postal questionnaire in which they were asked to consider the trade-offs of establishing nephrology facilities in Greenland as opposed to the current situation. This involved trading off the benefits of having such facilities in their home country against the costs of the intervention. Besides including a payment attribute described in terms of incremental tax payment, the DCE included two interventions attributes related to (1) the organisation of labour, and (2) the physical settings of the patients. Respondents succeeded in answering the DCE despite cultural and linguistic disparity. We found that all the included attributes had a significant effect on respondents' choices, and that respondents' answers to the DCE were in keeping with their values as stated in the questionnaire. DCE data was analyzed using a random parameter logit model reparametrized in willingness-to-pay space. The results showed that establishing facilities in Greenland were preferred to the current treatment in Denmark. The welfare estimate from the DCE, at DKK 18.74 million, exceeds the estimated annual costs of establishing treatment facilities for patients with chronic renal failure. Given the estimated confidence interval this result seems robust. Establishing facilities in Greenland therefore would appear to be welfare-improving, deriving positive net benefits. Despite the relatively narrow policy focus, we believe that our findings provide some insight into individuals' preferences for decentralization of public services and on citizens' views of 'self-governance' that go beyond the case of Greenland. More generally, this paper illustrates how DCE can be applied successfully to developing countries with culturally, demographically, and geographically distinct features.

In order to clarify the influence of serum potassium, serum sodium and plasma angiotensin II concentrations on aldosterone release during hemodialysis (HD), six chronic hemodialysis patients were studied during HD with varying dialysate sodium concentrations and different buffers. Plasma aldosterone concentrations were higher during acetate than bicarbonate HD, during low sodium compared to high sodium HD, and were correlated inversely to serum sodium concentrations. The decline in plasma aldosterone concentrations during HD paralleled the decrease in serum potassium concentrations, and plasma aldosterone concentrations were correlated with serum potassium concentrations. In addition, plasma aldosterone and plasma angiotensin II concentrations were correlated significantly. It is proposed that serum potassium and the renin-angiotensin system are the main factors of aldosterone release during hemodialysis, while serum sodium per se seems to be of less importance. The dialysate buffer employed also plays a role in aldosterone regulation (via the renin-angiotensin system)

BACKGROUND: Various laparoscopic techniques have been described for the insertion of peritoneal dialysis catheters. However, most use 3 to 4 ports, thus multiplying the potential risk for abdominal wall complications (hemorrhage, hernia, leaking). METHODS: A Tenckhoff catheter was placed laparoscopically, using just 1 port, in 13 consecutive patients with end-stage renal failure. All catheters were fixed in the abdominal cavity with no additional ports for this purpose. RESULTS: After a follow-up of 76 patient-months, all catheters are working properly. There were no postoperative wall hemorrhages, early leaking, or hernias. There was 1 case of catheter migration and 2 cases of late leaking in 2 patients in total, due to severe constipation. There were no exit site or tunnel infections. One episode of peritonitis was successfully treated with antibiotics. CONCLUSION: The simplicity and the rapidity of the method justifies serious consideration for its use as the standard Tenckhoff catheter placement. Am J Surg

Objectives: To determine whether voriconazole dosage adjustment is required during continuous veno-venous haemodiafiltration (CVVHDF). Methods: Voriconazole pharmacokinetics were studied in a critically ill patient under CVVHDF. The analysis was carried out for 12 h following a 6 mg/kg dose. Voriconazole concentrations were measured by HPLC in blood inlet and outlet lines and in dialysate. Results: The total body clearance of voriconazole was 20.3 L/h, with a terminal half-life of 13.7 h and a distribution volume of 399 L. The estimated sieving coefficient was 0.53 and the filtration-dialysis clearance 1.2 L/h. Conclusions: CVVHDF does not significantly affect voriconazole disposition and requires no dosage adjustment.

♦ Objectives Mesothelial cell (MC) injury caused by continuous exposure to unphysiological peritoneal dialysis (PD) fluid and by episodes of peritonitis can eventually lead to peritoneal adhesions and peritoneal fibrosis. In the present study, we evaluated the possibility of using autologous genetically modified MCs for transplantation after the induction of peritoneal injury by acute inflammatory mediators or chronic instillation of PD fluid. ♦ Methods Rats were injected intraperitoneally either once with N-formyl-methionyl-leucyl-phenylalanine (fMLP), or thioglycollate, or PD fluid [ i.e., Dianeal (Baxter Healthcare, Deerfield, Illinois, USA) or Physioneal (Baxter, Nivelles, Belgium)], or chronically (up to 8 weeks) with Dianeal. From 2 to 48 hours later, animals were injected with syngeneic MCs genetically modified to express the LacZ reporter gene. Rats were sacrificed 2 days later and expression of β-galactosidase (β-Gal) was visualized by X-Gal staining of excised tissues. Quantification of the percent area of β-Gal–positive MCs on part of the parietal peritoneum was performed using computerized image analysis. ♦ Results The highest numbers of repopulated genetically modified MCs were observed 8 hours after a single thioglycollate injection, approximately 0.66% of a representative 2-cm2 area selected for study (corresponding to approximately 10% of the peritoneal surface). The number of genetically modified MCs found to repopulate the peritoneal surface following short-term injury varied with inflammatory mediator (thioglycollate > PD fluid > fMLP) and duration of exposure. No obvious difference's were observed between the two PD fluids tested. Reimplantation of syngeneic genetically modified MCs was also observed after chronic instillation of PD fluid. ♦ Conclusions These data demonstrate that transplanted genetically modified MCs repopulate the denuded areas on the peritoneal surface that were caused by acute or chronic inflammation. This technique opens possibilities of MC transplantation and gene therapy in order to prevent complications relevant to the continuous ambulatory PD setting.

Two patients with end-stage renal disease secondary to multiple myelomas were treated with combined kidney and bone marrow transplantation in an effort to achieve donor-specific allotolerance through the induction of mixed lymphohematopoietic chimerism.Two female patients (55 and 50 years of age) with end-stage renal disease secondary to kappa light-chain multiple myelomas received a nonmyeloablative conditioning regimen that consisted of 60 mg/kg cyclophosphamide intravenously (IV) on days -5 and -4; 15 mg/kg equine anti-thymocyte globulin (ATGAM) IV on days -1, +1, and +3; and thymic irradiation (700 cGy) on day -1. On day 0, the recipients underwent kidney transplantation, followed by IV infusion of donor bone marrow (2.7x10(8) and 3.8x10(8) /kg nucleated cells, respectively) obtained from a human leukocyte antigen (HLA)-matched sibling. Cyclosporine A was administered IV at a dose of 5 mg/kg on day -1, then continued orally at 8 to 12 mg/kg per day until days +73 and +77, respectively, after which no further immunosuppression was given. Donor leukocyte infusions (1x10(7) /kg CD3+ T cells) were administered in an attempt to enhance the graft-versus-myeloma effect (days +66 and +112 in the first patient and day +78 in the second patient). Hematopoietic chimerism was monitored weekly by microsatellite assays.Multilineage lymphohematopoietic chimerism (5%-80% donor CD3+ or CD3- cells, or both) was first detected during the second posttransplant week and was maintained for approximately 12 weeks, after which there was a gradual decline to undetectable levels (1% donor cells) after day 105 in the first patient and after day 123 in the second patient. In both recipients, the blood urea nitrogen and creatinine levels returned to normal within 3 days. No rejection episodes have occurred. Quantification of urinary kappa light chains revealed a decline from 28 mg/dL to undetectable levels (2.5 mg/dL) within 29 days in the first case and from 99.8 mg/dL to10 mg/dL within 50 days in the second case. Both patients continue with normal kidney function and sustained anti-tumor responses, while receiving no immunosuppression for nearly 4 years and 2 years, respectively.This nonmyeloablative regimen followed by combined HLA-matched donor bone marrow and renal allotransplantation is the first example of an intentional and clinically applicable approach to inducing renal allograft tolerance and achieving potent and sustained antitumor effects in patients with multiple myeloma.

Summary: Pneumococcal arthritis generally presents as non-destructive monoarthritis, although some underlying metabolic disorders such as liver failure and diabetes have been suggested to represent a risk factor for severe joint disease. Here we report a case of destructive pneumococcal arthritis of the left hip joint in a patient suffering from chronic renal failure treated with hemodialysis for ten years. Inspite of effective anti-pneumococcal antibiotic treatment, the patient with pre-existing renal osteopathy and a mild osteoarthritis continued to suffer from severe and disabling pain of the left hip. This case demonstrates that pneumococcal joint infection in patients with underlying uremic bone disease can lead to quick deterioration of the affected joint

The handling of low, middle and high molecular weight markers was examined in seven stable dialysis patients during hemofiltration with different membranes. Four membranes were examined in a randomized, crossover order (polysulfone, polyamide, AN69 polyacrylonitrile, Asahi polyacrylonitrile) by measuring plasma and dialysate concentrations of phosphate, creatinine, vitamin B12, β2-microglobulin, furanic acid, hippuric acid, retinolbinding protein, alpha-1-antitrypsin, and albumin. Sieving coefficients and plasma clearances of β-microglobulin or retinol-binding protein were markedly or slightly lower during hemofiltration with the Asahi polyacrylonitrile membrane than with the other membranes (highest removal with polysulfone/AN69 polyacrylonitrile membranes). No differences of obvious clinical relevance could be seen between the four membranes. A high β2-microglobulin removal rate might be important to prevent dialysis-associated amyloidosis.

So far for renal insufficiency, exchange or substituting blood transfusions, peritoneal perfusion, intestinal-loop perfusion, administration of ion exchange resin, blood dialysis with artificial kidney and renal transplantation have been tried to eliminate serum nitrogencontaining substances, to maintain electrolyte balance and to correct acid-base balance. However, renal transplantation has failed to obtain satisfactory result due to rejection phenomenon and artificial kidney has restricted its repeated uses because of expensive burden on patients although it has excellent dialysance. It is suspected that life prolongation of patient with renal insufficiency can be achieved with use of artificial kidney in proper combination with organ perfusion, although cf which dialysance is less excellent. Experimentary studies were performed on dogs to perfuse the lung, int e s tine and stomach with an identical condition and serum electrolytes and nitrogen containing substances were measured to compare the effectiveness of perfusion. The results indicated that the lung perfusion is the most excellent way of dialysis. It was also demonstrated on the isolated intestinal perfusion for hyperpotassemia that a use of ion exchange resin, Amberlite IPR-64 is effective biochemically when it is suspended in perfusing fluid. In addition the results of isolated intestinal perfusion done in 4 patients with chronic renal insufficiency proved its therapeutic effects when the procedure is carried out in combination with other kinds of therapy.

Importance of the arterio-venous shunt necessary for hemodialysis with an artificial kidney is a well known fact. Material of the shunt, operative technique and care after formed were here discussed. Patency of the shunt is a requirement for satisfactory dialysis especially in the patients under chronic hemodialysis. Sufficient blood flow through the shunt guarantees a good dialysis efficiency. Care of the shunt must be accomplished not only by an adequate guidance from the medical staffs but by the daily endeavors and attention of the patients. Social return of the patients under chronic hemodialysis should become possible in such a condition.

350 times of hemodialysis were performed at Department of Urology, Hiroshima University Hospital during two years period, April 1967 to March 1969, with a modified Kiil dialyzer. Dialysis methods consisted of two-layer dialysis, two-layer dialysis with infusion of hypertonic solution, and one-layer dialysis. Clinical disequilibrium syndrome observed under the above methods was studied in conjunction with pre-and postdialysis BUN, serum osmolar changes, amount of water extraction and changes in acid-base balance.

1) EX-01 disposable dialyzer cartridge is a no-blood prime cuprophan dialyzer and cheape than Kolff's twin coil dialyzer. EX-01 dialyzer is better than dialyzer of other types with regard to dialysance, acid-base balance, ultrafiltration and effect on hematocrit. 2) We used 1% xylitol solution as a solution of dialysate. This is useful for diabetic renal failure, but care should be taken about various intestinal disorders. 3) Using EX-01 dialyzer, the Kolff type artificial kidney is well utilized even under today's Japanese medical situation in which shortness of hospital workers is a big problem.

Intermittent peritoneal dialysis with solution made by OTSUKA Seiyaku Co. was done on 5 patients with acute renal insufficiency and on 9 patients with chronic renal insufficiency. A total of 20 intermittent peritoneal dialysis was attempted and its results were discussed. An average decrease of 18.1 mg/dl of serum urea-N, 2.5 mg/dl of serum creatinine, 1.0 mEq/L of serum potassium and 2.7 mEq/L of serum phosphorus were found with one course of intermittent peritoneal dialysis. The average number of frequency, duration of dialysis and amount of solution used per one course were 16 times, 31 hours and 19 liters respectively. Serum sodium and chlorine were also improved. From the results, the intermittent peritoneal dialy s is appears to be inferior than Kolff Twin-Coil artificial kidney on dialytic efficiency of Urea-N and creatinine. It compares, however, favourably with the artificial kidney on the improvement of serum electrolytes, and it also gives less damage to patients and it has an advantage of simplicity of use on severe patients. The clinical use of intermittent peritoneal dialysis for the patient with renal insufficiency seems to be valuable.

Three patients with acute renal failure and 9 patients with chronic renal failure were treated by hemodialysis with the Kiil-type artificial kidney. During 2 year-period of April 1967 to March 1969, 350 hemodialyses in total were performed. Two of these patients with acute renal failure were relieved and 4 patients with chronic renal failure are still now being treated by hemodialysis. From these experiences, we investigated 1) method of dialysis, 2) efficiency of dialysis, 3) complications during dialysis, 4) suitability of dialysate.

1) Hemodialysis should be conducted with much less cost and personal labor under today's Japanese medical and social situation. 2) It was speculated that improvement of the carbohydrate metabolism during hemodialysis is related with escape of insulin antagonists and autoregulation of body fluid of uremic patients.

350 times of hemodialysis were performed at Department of Urology, Hiroshima University Hospital during two years period, April 1967 to March 1969, with a modified Kiil dialyzer. Dialysis methods consisted of two-layer dialysis, two-layer dialysis with infusion of hypertonic solution, and one-layer dialysis. Clinical disequilibrium syndrome observed under the above methods was studied in conjunction with pre-and postdialysis BUN, serum osmolar changes, amount of water extraction and changes in acid-base balance.

1) Hemodialysis should be conducted with much less cost and personal labor under today's Japanese medical and social situation. 2) It was speculated that improvement of the carbohydrate metabolism during hemodialysis is related with escape of insulin antagonists and autoregulation of body fluid of uremic patients.

1) EX-01 disposable dialyzer cartridge is a no-blood prime cuprophan dialyzer and cheape than Kolff's twin coil dialyzer. EX-01 dialyzer is better than dialyzer of other types with regard to dialysance, acid-base balance, ultrafiltration and effect on hematocrit. 2) We used 1% xylitol solution as a solution of dialysate. This is useful for diabetic renal failure, but care should be taken about various intestinal disorders. 3) Using EX-01 dialyzer, the Kolff type artificial kidney is well utilized even under today's Japanese medical situation in which shortness of hospital workers is a big problem.

Importance of the arterio-venous shunt necessary for hemodialysis with an artificial kidney is a well known fact. Material of the shunt, operative technique and care after formed were here discussed. Patency of the shunt is a requirement for satisfactory dialysis especially in the patients under chronic hemodialysis. Sufficient blood flow through the shunt guarantees a good dialysis efficiency. Care of the shunt must be accomplished not only by an adequate guidance from the medical staffs but by the daily endeavors and attention of the patients. Social return of the patients under chronic hemodialysis should become possible in such a condition.

Three patients with acute renal failure and 9 patients with chronic renal failure were treated by hemodialysis with the Kiil-type artificial kidney. During 2 year-period of April 1967 to March 1969, 350 hemodialyses in total were performed. Two of these patients with acute renal failure were relieved and 4 patients with chronic renal failure are still now being treated by hemodialysis. From these experiences, we investigated 1) method of dialysis, 2) efficiency of dialysis, 3) complications during dialysis, 4) suitability of dialysate.

Intermittent peritoneal dialysis with solution made by OTSUKA Seiyaku Co. was done on 5 patients with acute renal insufficiency and on 9 patients with chronic renal insufficiency. A total of 20 intermittent peritoneal dialysis was attempted and its results were discussed. An average decrease of 18.1 mg/dl of serum urea-N, 2.5 mg/dl of serum creatinine, 1.0 mEq/L of serum potassium and 2.7 mEq/L of serum phosphorus were found with one course of intermittent peritoneal dialysis. The average number of frequency, duration of dialysis and amount of solution used per one course were 16 times, 31 hours and 19 liters respectively. Serum sodium and chlorine were also improved. From the results, the intermittent peritoneal dialy s is appears to be inferior than Kolff Twin-Coil artificial kidney on dialytic efficiency of Urea-N and creatinine. It compares, however, favourably with the artificial kidney on the improvement of serum electrolytes, and it also gives less damage to patients and it has an advantage of simplicity of use on severe patients. The clinical use of intermittent peritoneal dialysis for the patient with renal insufficiency seems to be valuable.

So far for renal insufficiency, exchange or substituting blood transfusions, peritoneal perfusion, intestinal-loop perfusion, administration of ion exchange resin, blood dialysis with artificial kidney and renal transplantation have been tried to eliminate serum nitrogencontaining substances, to maintain electrolyte balance and to correct acid-base balance. However, renal transplantation has failed to obtain satisfactory result due to rejection phenomenon and artificial kidney has restricted its repeated uses because of expensive burden on patients although it has excellent dialysance. It is suspected that life prolongation of patient with renal insufficiency can be achieved with use of artificial kidney in proper combination with organ perfusion, although cf which dialysance is less excellent. Experimentary studies were performed on dogs to perfuse the lung, int e s tine and stomach with an identical condition and serum electrolytes and nitrogen containing substances were measured to compare the effectiveness of perfusion. The results indicated that the lung perfusion is the most excellent way of dialysis. It was also demonstrated on the isolated intestinal perfusion for hyperpotassemia that a use of ion exchange resin, Amberlite IPR-64 is effective biochemically when it is suspended in perfusing fluid. In addition the results of isolated intestinal perfusion done in 4 patients with chronic renal insufficiency proved its therapeutic effects when the procedure is carried out in combination with other kinds of therapy.

The hormones of the renin angiotensin aldosterone system were measured during regular haemodialysis with acetate or bicarbonate at dialysate sodium concentrations of 135, 140, 145, and 150 mmol/l. Plasma renin activity and aldosterone concentration were higher during acetate haemodialysis than during bicarbonate haemodialysis. At lower dialysate sodium concentrations, plasma renin activity (acetate dialysis and bicarbonate dialysis) and aldosterone concentration (only acetate dialysis) were higher than they were at higher dialysate sodium concentrations. Plasma renin activity increased during acetate dialysis, but did not change during bicarbonate dialysis. Aldosterone and potassium concentrations were positively correlated. Aldosterone decreased during haemodialysis (increase to predialysis values at the end of haemodialysis (4 h) at lower dialysate sodium concentrations). It is concluded that the renin angiotensin aldosterone system is activated more during acetate dialysis than during bicarbonate dialysis. Aldosterone concentrations seem to be related more closely to serum potassium than to renin-angiotensin-aldosterone system and to serum sodium intradialytically.

The pharmacokinetic profile of recombinant human erythropoietin (rHuEpo) was studied after a single intravenous dose of 150 U/kg in ten patients with various degrees of renal function: group I, creatinine clearance greater than 80 ml/min, n = 2; group II, creatinine clearance 10-50 ml/min, n = 6; group III, creatinine clearance less than 3 ml/min (patients undergoing haemodialysis) n = 2. Erythropoietin concentrations in serum and urine samples obtained over 48 h were measured by RIA. rHuEpo was cleared from circulation in an exponential fashion, the half-life ranged from 6.5 to 12.7 h (mean 9.03 h) and was not different between the groups. The apparent volume of distribution varied from 0.041 to 0.099 l/kg (mean 0.070 l/kg) this corresponds to 1.5 times the plasma volume and was unrelated to kidney function. Renal clearance (groups I, II) accounted for less than 3% of total body clearance, both parameters were unaffected by decreasing renal function. These results indicate that, in accordance with animal data, the elimination of rHuEpo occurs mainly through non-renal mechanisms.

End-stage renal diabetic patients undergoing dialysis through an arteriovenous graft (AVG) often present with multiple graft complications which demand a combined therapeutic approach. We report a case of a male suffering from a pseudoaneurysm and venous outflow stenosis of his thigh AVG, as well as from critical limb ischemia caused by multiple significant stenoses of the femoropopliteal arterial segment. The patient was managed in a single session with a combination of classic open surgical and endovascular techniques in order to treat his aneurysm, salvage the AVG and to revascularize his leg. This case illustrates the prospect of combining classic open surgical and endovascular techniques for the optimal management of complicated AVGs. Using the hybrid approach in these cases one can succeed in optimizing the result, while simultaneously minimizing the overall risk for the patient. J Vasc Access