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To the Editor. —Medicare's end-stage renal disease (ESRD) program has been subject to renewed critical interest in recent years. The effectiveness of the program has been judged largely by patient survival and less so by objective measures of quality of life such as employment status; neither of these have reached physician or societal expectations. The article by Dr Ifudu and colleagues 1 describes "dismal" rehabilitation in geriatric inner-city hemodialysis patients. Despite the authors' claim to the contrary, we are concerned that this article may present a short-sighted interpretation of the data and provide ammunition for those who wish to institute age-based rationing of hemodialysis. 1 As determined by modified Karnofsky scores, the authors report a significant reduction in overall functional status compared with 2 years before the initiation of maintenance hemodialysis (mean, 5.3 years; up to 11 years previously). It is unclear how much of this decline in functional status

PATIENTS who pretend to be sick and willingly undergo intrusive procedures, including surgery, have been seen at every medical center. The motives for this bizarre behavior often remain obscure, even when the patient is studied thoroughly. Reviews of chronic factitious illness or Munchausen's syndrome emphasize the heterogeneity of the underlying psychiatric conditions, but also indicate a marked preponderance of patients with personality disorders, and with histories of early childhood trauma and deprivation.1,2In a study of factitious illness, Spiro identified three clinical types: sociopathic, hysterical, and schizophrenic.2Major factitious illness is rare in childhood and adolescence, although malingering with factitious fever3and other simulated symtoms can occur. We report the case of an adolescent boy who for nearly a year succeeded in simulating an enterovesicular fistula by contaminating his urine with feces and foodstuff, at times by retrograde injection of foreign substances into his bladder. The case

This is a retrospective study of 133 episodes of bacteremic infection in 112 hemodialysis patients. The frequency of bacteremic infection was 9.5% in patients with chronic renal failure and 10.9% in patients with acute renal failure. In patients with acute renal failure, pneumonia and intra-abdominal abscess were the most frequent sources of septicemia. Sepsis was usually due to Gram-negative organisms and mortality was high. In patients with chronic renal failure, infection of the shunt or fistula was the most common cause, was frequently due to Staphylococcus organism, and had a more favorable survival rate. Gram-negative septicemia from a nonaccess source in patients with chronic renal failure was associated with a higher mortality. Bacterial endocarditis and septic pulmonary emboli occurred in 3.6% of septic episodes and 0.35% of patients at risk and had very low mortality. A low threshold for obtaining blood cultures and early antibiotic treatment are believed to be important in the treatment of bacteremic infections in patients undergoing long-term hemodialysis. ( Arch Intern Med 139:1255-1258, 1979)

Hypertension is a frequent and early component in the uremic syndrome. Extracellular volume expansion causes hypertension in approximately 75% of patients with chronic renal failure and therefore is responsive to hemodialysis. The other major cause of hypertension in uremic patients is hyperreninemia. The degree of hypertension in this small group of patients is more extreme, is not responsive to volume manipulations by dialysis, and often will require bilateral nephrectomy. The route of excretion and drug-dosage alteration in hypertension treatment before initiation of dialysis are important. Indications for hemodialysis and bilateral nephrectomy for complicated hypertension and in preparation for renal transplantation vary in different programs. The increased incidence of cardiovascular death in chronic hemodialysis patients should modify these indications to obtain earlier and better control of hypertension.

• Patients undergoing chronic hemodialysis receive multiple blood transfusions and, thus, are susceptible to infections transmitted through blood and blood products, including infection with human immunodeficiency virus (HIV). To determine the prevalence of antibody to HIV among patients undergoing chronic hemodialysis in Baltimore and Boston in 1985, we conducted a cross-sectional seroprevalence study. Repeatedly enzyme-linked immunosorbent assay (ELISA)—positive serum samples were tested by Western blot analysis. Among 435 patients in Baltimore, 12 (2.8%) were seropositive by both ELISA and Western blot techniques. Among 90 patients In Boston, three (3.3%) were seropositive. Among 100 frozen serum samples obtained from another Boston hemodialysis population In 1980, only one was seropositive. Many repeatedly ELISA-positive specimens were observed in each of the three groups studied, especially the serum samples that had been stored at -30°C to -70°C for four years. Most were nonspecifically reactive as demonstrated by reactivity with an H9-control ELISA plate. Patients undergoing hemodialysis, many of whom have received frequent transfusions in the past, are at increased risk for prior infection with HIV. Serologic testing for either screening or case-finding purposes must be conducted with great attention to specificity; serum samples frozen for prolonged periods are especially likely to be nonspecifically ELISA positive. These findings have implications concerning case-finding purposes, dialysis procedures, renal transplantation, and seroepidemiologic research. ( Arch Intern Med 1988;148:617-619)

To the Editor. —Dr. Koretz has aptly pointed out the major difference of opinion between our two basically dissimilar papers. There is no real difference of opinion regarding the question of primary azathioprine hapatotoxicity. Although this condition probably does exist, there is still no conclusive evidence that it is a major cause of clinical liver disease in kidney transplant recipients. Patients described in our paper and in that of Ireland et al accounted for virtually all instances of recognized liver disease in transplant recipients at one institution over a ten year period; in none could azathioprine be implicated as the primary agent. With regard to Dr. Koretz's question as to whether azathioprine should be continued in the face of acute or chronic hepatic injury, there is a difference of opinion. (I suspect that this difference of opinion is not unique to our institution.) It is not surprising that the liver

Thirty-eight cases of hepatitis affecting dialysis and transplant patients, medical personnel, and one patient's spouse were recognized from March 1969 through July 1970. Dialysis patients were usually symptomatic; almost one half were jaundiced, one died of hepatic failure, and persistence of Au antigenemia was not the rule. The immunosuppressed posttransplant patient had a benign clinical course compared with both dialysis patients and contact cases. Azathioprine therapy adversely influenced the course of hepatitis in some posttransplant patients, and its temporary discontinuation was associated with rapid clinical and biochemical recovery and with a change from positive to negative test results for Australia (Au) antigen in two of four patients. Six posttransplant patients had chronic Au antigenemia, but only two of them had chronic elevation of serum glutamic oxaloacetic transaminase values. Three other posttransplant patients have had intermittently elevated transaminase values without a positive Au antigen reaction.

Thirty-six patients with chronic renal failure due to polycystic kidney disease have been placed in the dialysis-transplant program at the Peter Bent Brigham Hospital since 1960. Hematuria and pyelonephritis occurred more frequently in this group of patients and sometimes required bilateral nephrectomy for control. When compared with other patients receiving dialysis, polycystic patients who did not undergo nephrectomy maintained higher hematocrit values and required fewer transfusions. Polycystic patients had posttransplant courses similar to those of other transplant patients, and extrarenal polycystic disease is not a contraindication to transplantation. These patients are usually good candidates for long-term hemodialysis or renal transplantation or both.