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Control of certain clinical and laboratory parameters affects morbidity and mortality of type 2 diabetic patients with chronic renal failure (CRF) both before and after initiation of hemodialysis (HD). To identify areas and stage of renal failure where control of these critical variables needs improvement, we compared important clinical and laboratory parameters 6 months before (PRE) and 6 months after starting HD (POST) in 43 type 2 diabetic men with CRF, who were 69.3 ± 10.7 years old at HD initiation. Differences, all at p ≤ 0.05, were found in blood pressure, in mm Hg, at the physician's office, both systolic (PRE 154 ± 16, POST 138 ± 18) and diastolic (PRE 77 ± 13, POST 69 ± 11), serum cholesterol in mg/dL (PRE 206 ± 61, POST 159 ± 40), and serum creatinine in mg/dL (PRE 4.1 ± 1.3, POST 7.0 ± 1.8), while no differences were noted in blood hematocrit (PRE 36 ± 7%, POST 34 ± 9%), blood glycosylated hemoglobin (PRE 7.4 ± 1.7%, POST 6.9 ± 2.3%), serum glucose in mg/dL (PRE 151 ± 67, POST 184 ± 94), serum phosphorus in mg/dL (PRE 4.5 ± 0.8, POST 4.6 ± 1.5), serum calcium in mg/dL (PRE 8.7 ± 0.5, POST 8.5 ± 1.4), and serum albumin in g/dL (PRE 3.2 ± 0.5, POST 3.4 ± 0.6). Compared to the POST category, significantly (p ≤ 0.05) higher percentages were found in the PRE category for systolic blood pressure >150 mm Hg (PRE 58.8%, POST 26.5%), blood glycosylated hemoglobin >8%(PRE 33.3%, POST 13.3%), serum cholesterol >200 mg/dL (PRE 48.4%, POST 19.4%). A lower percentage was found in the PRE category for serum phosphorus >5.5 mg/dL (PRE 13.2%, POST 31.6%), while the corresponding percentages for serum albumin

The ideal normalization parameter for urea and creatinine clearance is not yet known. The best current practices are to normalize urea clearance by anthropometric V, corrected for certain conditions such as edema, and creatinine clearance by BSA. Normalization parameters should be calculated using the actual weight. In addition, the ideal weight also should be used in underweight individuals.

The Jos University Teaching Hospital (JUTH) has dialyzed >320 patients with ESRD since 1993. Objective: To identify differences, and their causes, in the practice of dialysis between Nigerian state-owned dialysis units and U.S.A. Methods: We analyzed the characteristics of chronic dialysis at JUTH. Results: At JUTH, chronic dialysis is started at development of frank uremia (K/DOQI standard: creatinine clearance >10 mL/min, no overt uremia). Frequency of hemodialysis was 3 times weekly in 2 patients, twice weekly in 1 and once weekly or longer in 7 patients. Breakdowns in the dialysis machinery, which is outdated, forced additional decreases in the frequency of dialysis. Duration of a dialysis session was 4 h by prescription, but much longer in several sessions because of dialysis machine breakdown during the session (US standard: 4 h). 2 patients were dialyzed through arterio-venous fistulas and 8 patients were dialyzed though temporary femoral vein dialysis catheters removed after each dialysis session. A vascular surgeon was unavailable. The urea reduction ratio was 45.38.6% (U.S.A target: 65%). The cost of the first dialysis session at JUTH is $160. With reuse of dialysis supplies, including dialyzers, dialysis tubing, femoral catheters, and guide wires, the cost of each subsequent dialysis session is $33. The minimal cost of dialysis with 3 dialysis sessions weekly and a new dialyzer every week is $501 per month. The cost of dialysis is borne exclusively by the patient. For comparison, average monthly income is $74 for unskilled laborers, $222 for dialysis technicians, $296 for dialysis nurses, and $889 for academic nephrologists. The low dose of dialysis has adverse effects on patient quality of life (frequent admissions with uremia). Despite notable exceptions (2 patients on dialysis for 12 and 9 years, respectively), survival of dialysis patients at JUTH appears to be poor. Conclusions: Underdialysis is frequent in Nigeria and is the consequence of socioeconomic conditions and technologic deficits. Removal of the economic burden of dialysis from the patients with ESRD is the first logical step toward correction of underdialysis.

Background: Peritonitis is a common problem for patients receiving continuous ambulatory peritoneal dialysis. Episodes that do not respond to antibiotics within 96 hours are associated with substantial morbidity and mortality. The purpose of this study was to develop a method for identifying these patients at the time of hospital admission. Methods: We reviewed all cases of peritonitis associated with continuous ambulatory peritoneal dialysis that occurred at the Albuquerque (NM) Veterans Affairs Medical Center during a 10-year period. Episodes of peritonitis were randomly assigned to a training set or a validation set. Persistent infections were those lasting more than 96 hours. For training cases, stepwise logistic regression was used to develop a predictive model for persistent infection using information available at the time of hospital admission. The model was then used to assign validation cases to "high-" and "low-risk" categories. The group difference in the proportion of persistent cases was tested by X 2 analysis. Results: Sixty patients had 120 episodes of peritonitis during the study period. Of 63 episodes assigned to the training set, 26 (41.3%) lasted more than 96 hours (persistent cases) and 37 were cured in 96 hours or less (usual cases). Compared with usual cases, persistent episodes were characterized by a higher age at presentation and a greater decline from preinfection values for hemoglobin and serum potassium, serum urea nitrogen, creatinine, albumin, and calcium. Advanced age and marked declines in serum potassium and albumin levels were identified by logistic regression as independent risk factors for persistent infection. The model identified 28 of 57 validation cases as high risk. Compared with low-risk cases, these episodes were much more likely to be persistent (64.3% vs 24.1%; P =.002) and result in death (32.1% vs 3.4%; P =.005). Conclusions: Advanced age and marked declines in serum albumin and potassium levels are poor prognostic signs in peritonitis associated with continuous ambulatory peritoneal dialysis. Patients with these findings should be treated aggressively. (Arch Intern Med. 1993;153:2317-2321)

The morbidity and mortality of 11 femoral neck fractures were analyzed to compare operative and conservative management of femoral neck fractures in dialysis patients. All fractures occurred in older men with severe cardiac, pulmonary, gastro-intestinal, and neurologic conditions and with advanced renal osteodystrophy. Six of the seven operated patients survived the surgery and achieved varying degrees of ambulation. Stability of the operated hip was excellent in each case. Post-operative complications included transient confusional state related to narcotics, pneumonia, decubitus ulcers, and severe hypoalbuminemia. All four patients who were managed conservatively died from complications of the fracture. Progressive deterioration was noted in each nonoperated patient, with confusion caused by narcotics and analgesics, pneumonia, hepatic coma, decubitus ulcers, severe depression, and severe hypoalbuminemia. Therefore, operative management was superior to conservative management for femoral neck fractures of patients receiving chronic dialysis with multiple medical problems and advanced renal osteodystrophy. Narcotics must be used with great caution, and efforts should be directed toward prevention of malnutrition and decubitus ulcers.

In six anuric dogs infused in two steps with isonatremic (= having the same sodium concentration as each dog's initial extracellular space) sodium chloride solutions, stable chloride space was computed by mass conservation and was compared to radiosulphate space. There was close agreement between estimates of pre-infusion extracellular volume by radiosulphate and stable chloride spaces. Computed increases in radiosulphate and stable chloride spaces agreed with the infused volumes in each step.

We computed by linear kinetics predicted equilibrated plasma concentrations, elimination parameters and availability of ethanol for fasting anesthetized dogs who received the same dose (11 mmol/kg) of ethanol twice, once intragastrically and once intravenously. Agreement between predicted (y) and observed (x) equilibrated plasma levels above 3 mmol/l was for intragastric ethanol y = 0.031 + 1.008x (r = 0.973) and for intravenous ethanol y = 0.2 + 0.99x (r = 0.992). Linear elimination (elimination rate, clearance, time of disappearance of half the dose) was significantly slower and Widmark's ratio r was significantly greater for intragastric than for intravenous ethanol. Apparent availability of intragastric ethanol, computed by dividing the intragastric by the intravenous plasma ethanol concentration at zero time (both values extrapolated from the linear portion of the blood alcohol curve), was 0.739 +/- 0.125. Considerable ethanol residuals were present in the stomach four hours after intragastric instillation. We conclude that retention of ethanol in the stomach, probably because of anesthesia, created the apparent differences in elimination of ethanol between intragastric and intravenous administration. Despite gastric retention, decrease of ethanol levels was linear above 3 mmol/l after intragastric instillation.

The authors studied hyperglycemia occurring in insulin-dependent diabetic patients on chronic dialysis to determine the types of associated acid-base disorders, their treatment, and any differences from hyperglycemia in diabetic patients with intact renal function. Eighty-eight episodes of serum glucose greater than 25 mmol/L were observed, 23 in hemodialysis patients and 65 in patients on continuous peritoneal dialysis. Treatment consisted of low-dose insulin in 77 episodes and low-dose insulin plus saline in 11; no base was administered. Seventeen episodes (19%) presented with ketoacidosis. Arterial blood gas determinations were carried out at presentation in 37 of the episodes without ketoacidosis. Of these, 12 had respiratory alkalosis, six had respiratory acidosis and severe pulmonary edema, 14 had other single or mixed acid-base disorders, and only five had normal acid-base status. Insulin corrected the ketoacidosis in all instances and both pulmonary edema and respiratory acidosis in five of six instances. In eight cases metabolic alkalosis developed during treatment, without external acid loss. At the completion of treatment respiratory alkalosis was present in half the cases. No difference was noted between patients treated with hemodialysis or peritoneal dialysis. Insulin alone is sufficient for the management of hyperglycemia in dialysis patients. Certain acid-base disorders persist, but do not need further treatment. Hyperglycemia in patients on dialysis is characterized by infrequent development of metabolic acidosis and frequent presentation with respiratory alkalosis, by respiratory acidosis that is corrected by insulin, and by metabolic alkalosis developing during treatment without external cause.

We infused 11 mmol/kg of intravenous ethanol into dogs with either intact renal function (n = 5) or ureteral ligation (n = 7), and studied by frequent blood sampling and by urine collection the time and mode of ethanol equilibration, the elimination parameters, and the comparison of observed equilibrated plasma ethanol levels to levels predicted either by linear or by nonlinear kinetics. Equilibration time was 25 min or less, renal fraction of elimination was less than 5% of total elimination, and both linear (elimination rate) and nonlinear (Vmax and Km) elimination parameters were not different between dogs with intact renal function and dogs with anuria. Serum sodium concentration did not change throughout the experiments, eliminating the hypothesis that acute ethanol load creates clinically significant temporary osmotic water transfer from the intracellular into the extracellular compartment. Distribution volumes of ethanol from linear kinetics were slightly, but not statistically, greater than volumes from nonlinear kinetics. Equilibrated plasma ethanol levels predicted by linear kinetics agreed closely with observed levels greater than 4 mmol/liter, but underestimated observed levels less than 4 mmol/liter. Equilibrated plasma ethanol levels predicted by nonlinear kinetics agreed with observed levels throughout the range of observed concentrations. The use of linear kinetics to predict blood ethanol levels should be limited to the pseudolinear portion of the blood alcohol curve.

Two men on CAPD for renal failure from diabetic nephropathy developed three episodes of severe hyperglycemia (blood glucose greater than 50 mmol/l), which were treated with insulin alone. During treatment, the serum bicarbonate rose; in the first patient from 27 to 31 mmol/l; in the second patient from 24 to 31 in the first episode, and from 20 to 26 mmol/1 in the second episode. Corresponding changes in arterial pH were 7.47 to 7.57, 7.48 to 7.67 and 7.47 to 7.59. Contraction of the extracellular compartment during correction of hyperglycemia could account for the total increase in serum bicarbonate in the first patient, but only for about one-half of the increase in the second patient.

Serum albumin in continuous peritoneal dialysis: Its predictors and relationship to urea clearance. We investigated the predictors of serum albumin and the relationship between serum albumin and urea kinetic indices in continuous peritoneal dialysis (CPD). In a training set (TS) of 143 urea kinetic studies performed in 92CPD patients, stepwise logistic regression identified high/high-average peritoneal solute transport, diabetes, advanced age and high daily drain volume normalized by body water as predictors of low serum albumin (< 35 g/liter). This analysis was then substantiated in a validation set (VS) of 187 kinetic studies performed in another 102CPD patients. The calculated area under the receiver operating characteristic (ROC) curve by this logistic regression model was 0.782 (95%CI, 0.745 to 0.819). Logistic regression was repeated in the TS using only the first kinetic study from each patient, and it identified high/high-average peritoneal solute transport, diabetes, and advanced age as predictors of low albumin. Using only the first kinetic study from each patient in the VS, the second logistic regression model calculated an area under the ROC curve equal to 0.850 (95% CI, 0.810 to 0.890). The relative risk (RR) of serum albumin < 35 g/liter was computed for all kinetic studies after combining the TS and the VS and using non-diabetic CPD subjects aged ≤ 61 years with low/low average peritoneal solute transport as the reference group. The RR with only one risk factor present ranged from 1.076 (age > 61 years) to 6.792 (high/high-average transport). The RR with two risk factors present ranged from 5.200 to 9.729. The RR with all three risk factors present was 9.100 (95%CI, range 3.923 to 21.111). A subset of 37CPD patients had a second urea kinetic study 8 ± 5 months after an increase in the amount of dialysis due to low urea clearance and/or uremic symptoms. The weekly KT/V urea increased from 1.40 ± 0.24 to 2.10 ± 0.31 after the increase in the CPD dose. With the increase in dialysis, the protein catabolic rate increased substantially; however, the mean serum albumin remained stable (from 33.9 ± 4.6 to 33.3 ± 6.2 g/liter; decrease 18; increase 15; same 4). In comparison to the subjects who had a decrease in serum albumin after the increase in KT/V, those with the increase in serum albumin were younger (44.2 ± 11.2 vs. 54.3 ± 16.2 years, P = 0.044) and had a higher serum urea after the increase in the dose of CPD (22.4 ± 7.8 vs. 17.0 ± 6.0 mmol/liter, P = 0.037). We conclude that the major predictors of low serum albumin in CPD are advanced age, diabetes, and high/high-average peritoneal solute transport, but not urea kinetic studies. An increase in the dose of dialysis does not cause a consistent rise in serum albumin in underdialyzed CPD subjects. However, a subset of younger patients may be able to increase their serum albumin in response to the increase in KT/V.

Linear elimination parameters were computed after intravenous administration of the same dose (11 mmol/kg) of intravenous ethanol in anesthetized dogs twice with a period of 7–8 days (group A, n=10) or 6 hours (group B, n=8) between the two studies. For rate of elimination, clearance and time of disappearance of half the dose, routine statistical methods (paired t -test, correlation) showed no difference between the first and the second study of either group; however, for each of these three elimination parameters, quantitative analysis showed significant disparities between the first and second studies of each group. For Widmark ratio r, which is a measurement of ethanol distribution rather than elimination, both the routine statistical methods and the quantitative analysis showed no difference between the first and second study of either group. In dogs, the assumption that blood alcohol curve is reproducible in individuals may not be valid.

Severe hyperkalemia (serum potassium level >6 mmol per liter [mEq per liter]), often with electrocardiographic disturbances, was noted at presentation in 30% of 73 hyperglycemic episodes (serum glucose concentration >25 mmol per liter [455 mg per dl]) observed in 15 in-hospital patients with insulin-dependent diabetes mellitus who were receiving long-term hemodialysis or peritoneal dialysis. Serum glucose concentration and total carbon dioxide content correlated significantly with the presenting serum potassium concentration. Treatment with parenteral insulin alone resulted in a decrease of the serum glucose value from 41 ± 14 (standard deviation) to 11 ± 5 mmol per liter (P

A patient presented with acute hemorrhagic pancreatitis complicated by both renal cortical necrosis and Purtscher's retinopathy. Either of these two complications is rare and never before have both been reported in the same patient. The patient's renal insufficiency required hemodialysis; it gradually improved over two years when dialysis could be discontinued. The patient's retinopathy included bilateral hemorrhages and cotton wool spots; visual fields and acuity remained normal. Fundiscopic lesions disappeared by three months after the acute event. These two rare vasculoocclusive complications of pancreatitis simultaneously occurring in one individual might suggest complement-mediated leukostatic mechanisms.

This communication contains a model describing osmotic phenomena that result from an osmotic disturbance (gain or loss of non-isotonic solutions from the extracellular compartment), if cells function as perfect osmometers. This model (a) predicts the changes in extracellular water and in solute concentration, if the magnitude of the disturbance is known; (b) computes the amount of a solution of a given osmolality necessary to create a desired change in extracellular water; (c) estimates, by osmometric calculations, initial extracellular and total body water; (d) estimates the 'new' solute that is created by anuria and by dilution of extracellular solute controlled by hormonal feedback. Anuria and extracellular expansion are experimental conditions usually accompanying the osmotic disturbance. The model is, therefore, suitable for precise in vivo studies of osmotic disturbances.

When serum glucose concentration is nearly normal, serum sodium concentration and tonicity are usually normal in ambulatory outpatient diabetics on chronic hemodialysis or peritoneal dialysis. In hyperglycemia, patients on hemodialysis do not undergo osmotic diuresis and are able to nearly normalize their serum tonicity by increasing the intake of water. Patients on peritoneal dialysis differ from hemodialysis patients because of continued loss of water in the peritoneal dialysate and achieve only partial correction of tonicity by water consumption. The model currently used to predict changes in serum sodium concentration and in tonicity from hyperglycemia assumes no changes in external balance of body water or solute during development of hyperglycemia and, therefore, is not applicable in ambulatory dialysis patients with intact thirst mechanism, because of water retention. In ambulatory patients on chronic dialysis, clinical manifestations of hyperglycemia include thirst, water intake, and weight gain. Neurologic manifestations due to hypertonicity are usually absent.

Fourteen episodes of peritonitis complicating chronic peritoneal dialysis were treated with intravenous injections of 1 gm of vancomycin weekly for 4 successive weeks. Peak (one hour after completion of injection) and trough (immediately before the next injection) serum and dialysate vancomycin levels were measured. Vancomycin treatment resulted in a cure in 12 episodes (85.7%). Serum vancomycin levels were always above therapeutic range, but did not rise, with subsequent injections, to toxic range. Dialysate vancomycin levels were therapeutic for more than 85% of the measurements. One patient, who failed to respond to vancomycin plus cephalosporins, was cured with intraperitoneal streptokinase plus the same antibiotics. In another patient, a relapse was cured with vancomycin plus oral rifampin. Dialysate vancomycin levels were therapeutic in the last two patients. Peritoneal catheters were not removed. No significant side effects of vancomycin treatment were observed.

We analyzed causes and clinical associations of hemodialysis performed during the course of CAPD in 71 patients (34 diabetic) on CAPD between 1978 and 1988. Thirty seven patients had at least one hemodialysis during CAPD. Causes (multiple for some patients) included poor compliance with CAPD (20 patients), peritoneal catheter loss from infection (16 patients), and miscellaneous other conditions (18 patients). Hemodialysis rates were similar between diabetic and non-diabetic CAPD patients. Compared to non-hemodialyzed patients, CAPD patients hemodialyzed for poor compliance had higher rates of peritonitis (one episode per 8.3 patient months vs one episode per 23.4 patient months, p less than 0.001) and catheter loss (one loss per 27.7 patient months vs one loss per 112.0 patient months, p less than 0.001), and exhibited a trend towards more deaths (annual mortality 30.9% vs 14.3%, p = 0.067). Hemodialysis performed in CAPD patients because of poor compliance is associated with higher rates of peritonitis and catheter loss, and, probably, with increased mortality.

Mathematically rigorous formulae of apparent sodium volume of distribution for body water and of stable sodium chloride space for extracellular volume were derived and applied to data from five anuric dogs infused with hypertonic saline. The error of the formula used in the past to compute apparent sodium volume of distribution was also computed and the errors introduced in the calculation of sodium chloride space by the experimental methods applied were corrected. Apparent sodium volume of distribution, computed from a correct formula, is a measure of body water and corrected estimates of sodium chloride space agree with radio-sulphate space estimates of extracellular volume.

Soft tissue complications (STC) involving the catheter tract and exit site continue to be a significant source of morbidity (40%) and cause for catheter removal (8%). Inner cuff infections, accompanied by peritonitis and managed with catheter removal, occurred in 6% of catheters. All other STC can be managed without catheter removal. STC presenting without peritonitis have not been associated with an increase in peritonitis related catheter loss.