Peritoneal rest may successfully recover ultrafiltration in patients who develop peritoneal hyperpermeability with time on continuous ambulatory peritoneal dialysis
Nephrology Department, Hospital Geral Santo Antonio, Porto, Portugal.
Adv Perit Dial. 2002; 18: 78-80
Temporary transfer to hemodialysis, as a peritoneal rest, may be a rescue therapy to recover ultrafiltration (UF) in patients who develop peritoneal hyperpermeability as a complication of continuous ambulatory peritoneal dialysis (CAPD). However, peritoneal sclerosis has been reported after peritoneal pause. Since the beginning of our CAPD program in 1985, 12 elective peritoneal pauses have been performed in 11 patients who developed type I ultrafiltration failure (D/P240 creatinine: 0.88 +/- 0.09) after 42 +/- 14 months on CAPD. Eight patients recovered UF and remained on CAPD with standard solutions for 10 +/- 9 months more (minimum: 5 months; maximum: 29 months). Only 3 of those patients were later switched to hemodialysis because of recurring UF failure. One patient remains on CAPD (62 months of follow-up). Four patients failed to respond and were permanently transferred to hemodialysis, without signs of developing encapsulating peritoneal sclerosis. The failed pauses were performed later after the detection of UF failure than were the successful ones (483 +/- 574 days vs. 54 +/- 52 days). In our study, 8 of 12 peritoneal pauses (66.6%) successfully treated type I UF failure and prolonged CAPD retention. If a pause is initiated soon after diagnosis of UF failure, results may improve further. We urge prospective studies to better determine the best and timely therapeutic approach in patients with loss of ultrafiltration.
What should the optimal target hemoglobin be?
Department of Nephrology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.
Department of Nephrology, Hospital SAMS, Lisboa, Portugal
Kidney Int Suppl. 2002; 80: 39-43
Partial correction of anemia in patients with chronic kidney disease (CKD)
improves anemia-related symptoms. However, controversy remains as to whether total correction of anemia provides benefits over and above those afforded by partial correction. There is some evidence showing that normalization of hemoglobin (Hb) concentrations may improve the cardiac hyperdynamic state in CKD patients and reduce the diameter of the left ventricle. Further studies have shown that normalization of Hb improves cognitive function and physical capacities as measured by quality of life (QoL) tests. Large studies have shown that in dialysis patients there is a close inverse relationship between hematocrit (Hct) levels and mortality and morbidity. Moreover, there is evidence suggesting that Hct levels higher than those recommended by European Best Practice Guidelines (EBPG) and the National Kidney Foundation Dialysis Outcome and Quality Initiative (NKF-DOQI provide better outcomes for patients with CKD.
However, when Hb concentrations are increased to normal in selected patients with cardiac disease, congestive heart failure, or ischemic cardiopathy, higher mortality rates are evident. Therefore, while the majority of patients with CKD may experience significant benefits when Hb is normalized, it seems prudent to recommend individualized target Hb concentrations for each patient, taking into account factors such as age, sex, employment status, physical activity, and co-morbidities.
Beta(2)-microglobulin clearance decreases with Renalin reuse
Unidade de Hemodiálise, Serviço de Nefrologia-Hospital S. Pedro, Vila Real, Portugal. email@example.com
Nephron. 2002; 90(3): 347-8
The HEMO study revealed that beta(2)-microglobulin clearance decreases over time with Renalin reuse in the high-flux group. It was suggested that the reuse of polysulfone or cellulose triacetate high-flux dialyzers with Renalin (without bleach) results in degradation of the high-flux capacity. At our haemodialysis unit (Vila Real, Portugal) we reused dialyzers until January 2000 (limited to 10 reuses), with an automatic machine Renatron (Renal Systems, Minntech. All of our 31 patients who started with postdilution haemodiafiltration on-line (HDFol) were always dialyzed with F-80 polysulfone (Fresenius). The reposition rate was 10 litres/session until 1998 and 20 litres/session thereafter. Reuse techniques were abandoned in our country in January 2000 following an EEC directive. Thereafter, we have decided to maintain HDFol with the same dialyzers without reuse. The mean beta(2)-microglobulin predialysis values did not decrease over time until reuse was terminated (1995 with low-flux haemodialysis: 25.4 +/- 6.4 microg/l; 1997: 24.7 +/- 6.6 microg/l; 1998: 29.2 +/- 8.9 microg/l; 1999: 33.7 +/- 4.7 microg/l) whereas beta(2)-microglobulin clearances were reasonable with HDFol (1998: 56.4 +/- 25.9 ml/min; 1999: 47.9 +/- 16.4 ml/min). After stopping reuse we have noticed that predialysis beta(2)-microglobulin values decreased (2000: 23.0 +/- 3.9 microg/l) in accordance with beta(2)-microglobulin clearance duplication (2000: 84.1 +/- 25.0 ml/min; p < 0.01). It is our opinion that the reuse of polysulfone dialyzers with Renalin should be abandoned in the field of high-flux haemodialysis. It causes deterioration in the beta(2)-microglobulin clearance and probably interferes with the high-flux haemodialysis benefits, namely the reduction of dialysis-related amyloidosis. Copyright 2002 S. Karger AG, Basel
PMID: 11867958 [PubMed - indexed for MEDLINE]
RenaGel efficacy in severe secondary hyperparathyroidism
NorDial Centro de Hemodialise de Mirandela Avda. Ntra. Sra. Amparo. Edificio Panorama, r/c esq 5370 Mirandela, Portugal. firstname.lastname@example.org
Nefrologia. 2002; 22(5): 448-55
BACKGROUND: Haemodialysis patients frequently have simultaneous hypercalcemia and hyperphosphatemia, posing a therapeutic dilemma for the traditional calcium--and aluminum--based binders. RenaGel (sevelamer hydrochloride) is an effective phosphate binder without changes in serum calcium or aluminum levels. However being an expensive medication it is currently used mainly for patients with moderate to severe secondary hyperparathyroidism. However most of the previous studies have not included patients with severe secondary hyperparathyroidism. METHODS: Our purpose is to determine RenaGel binder efficacy in haemodialysis patients with severe secondary hyperparathyroidism. As a secondary purpose we have followed the variations of parathyroid hormone, serum calcium, serum lipids [low- and high-density lipoprotein cholesterol, triglycerides and Lipoprotein(a)], uric acid and bicarbonate. All phosphate binders previously used were suspended one week before RenaGel prescription. Our study included 18 adult haemodialysis patients, with PTHi of 810 +/- 330 pg/ml after the "pre-treatment" washout. The binder was administered during 12 weeks, beginning with a mean dose of 2.4 +/- 0.4 g daily and adjusted to obtain serum phosphorus under 6.5 mg/dl (at the end of the study, the mean RenaGel dose was 2.8 +/- 0.6 g daily. RESULTS: The mean changes after RenaGel in serum phosphorus was -0.7 +/- 1.5. mg/dl (P < 0.05), in serum calcium was 0.5 +/- 1.0 mg/dl (P < 0.05) and in calcium x phosphate product of -4.0 +/- 12.4 mg/dl (P = NS). "Post-treatment" the PTHi levels remained stable (820 +/- 360 pg/ml vs 810 +/- 330) but serum alkaline phosphatase increased (14.3 +/- 14.4 U/l; P < 0.01). LDL cholesterol serum levels decreased by -35 +/- 10 mg/dl (P < 0.01), HDL cholesterol showed a trend to increase (3.0 +/- 8.1 U/l; P = NS), triglycerides decreased by 38 +/- 56 mg/dl (P < 0.05) and Lipoprotein(a) remained stable. Serum albumin increased by 0.1 +/- 0.2 g/L (P < 0.05), uric acid decreased -0.8 +/- 1.2 mg/dl (P < 0.05) and bicarbonate remained unchanged. CONCLUSIONS: RenaGel is an effective phosphate binder, even in haemodialysis patients with severe secondary hyperparathyroidism. The lipid profile improved with the treatment, with the exception of Lipoprotein(a) stabilization. Selection of patients with severe secondary hyperparathyroidism at the beginning of RenaGel disposal, for economic reasons is debatable, but could be correct.
PMID: 12497746 [PubMed - indexed for MEDLINE]
An early case of de novo membranous nephropathy on a renal transplant patient
Unidade de Transplante (1), Serviço de Nefrologia (2),
Hospital de Curry Cabral - Lisboa, Portugal
Transplant Proc. 2002; 34(1): 364
Lipoprotein(A) in renal transplant recipients
Department of Nephrology, Santo Antonio Hospital, Porto, Portugal.
Transplant Proc. 2002; 34(1): 370-2
PMID: 11959332 [PubMed - indexed for MEDLINE]