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Five severe reactions occurred in four maintenance hemodialysis patients 1 to 5 minutes after initiating dialysis with Cuprophan capillary dialyzers. All reactions were life-threatening and one resulted in death. Inadequate rinsing of the dialyzers was probably the cause of the reactions. The severe reactions were managed by immediate discontinuation of dialysis and the institution of supportive treatment. Antianaphylactic measures were also attempted, but their therapeutic effectiveness remains to be determined.

While filamentous fungi are a rare cause of peritonitis in peritoneal dialysis patients, there is increasing recognition of Paecilomyces species as pathogens in such patients. We herein report a case of fungal peritonitis secondary to the filamentous Paecilomyces variotii species. The patient had a long and ultimately fatal course of illness despite catheter removal, discontinuation of peritoneal dialysis, recurrent intraabdominal abscess drainage, and prolonged courses of antifungal therapy. Our experience with this case and a review of the literature suggests that infection with this fungus can cause substantial morbidity and is probably best treated with prompt catheter removal, aggressive antifungal therapy and vigilant observation for complications.

Continuous ambulatory peritoneal dialysis was successfully carried out in 6 end-stage renal failure patients using self-made, ultrafiltration-sterilized dialysis solutions. A Y-set was used to deliver the above solutions to sterile plastic bags.

Expeditious diagnosis of peritonitis remains a significant goal in the management of patients maintained on peritoneal dialysis. Several attempts to use leukocyte esterase reagent strips to diagnose peritonitis have been described. In this study we examined the usefulness of a new reagent strip, the PeriScreen Test Strip, in the diagnosis of peritonitis. A series of 72 peritoneal effluent samples obtained from 22 maintenance peritoneal dialysis patients is reported. In this study, the test strips had a sensitivity of 100% and a specificity of 98.3% as compared to an abnormal leukocyte count. Thus, in the diagnosis of peritonitis we believe that the PeriScreen Test Strip can be used as a simple bedside screening test to exclude peritonitis in peritoneal dialysis patients.

Exposure of human neutrophils to a conventional, acidic, lactate-containing peritoneal dialysis solution (PDS) resulted in the development of a prompt and substantial intracellular acidosis. It is possible that this intracellular acidosis contributes to cellular dysfunction.

A new subcutaneous device (Dialock; Biolink Corp., Middleboro, MA) provides vascular access to patients who currently require hemodialysis (HD). The device consists of a port-like valve, implanted subcutaneously below the clavicle, which provides a linear flow passage to two catheters placed in the right atrium via the jugular vein. The valve is accessed percutaneously with needle-cannulas that functionally convert the device to twin catheters for connecting the patient to the HD lines. Interdialytic patency is maintained using a standard heparin lock. The device has been implanted in 10 outpatients under local anesthesia, with almost immediate use for HD (median, 3 days) and has functioned successfully for more than 6 months (mean +/- SD, 4.0 +/- 1.7; > 400 dialysis sessions). Blood flows over 300 ml/min were consistently achieved (average, 320 +/- 50) with venous and arterial pressures of 197 +/- 42 mmHg and -241 +/- 31 mmHg, respectively. After 40 patient-months, condition of the needle puncture sites remains satisfactory. Four systemic infections have occurred in three patients; all have resolved without the need for device removal. There have been no infections at the puncture sites. One patient whose heparin lock was not changed for 23 days (for reasons unrelated to the device) required fibrin sheath stripping of his catheters. Patient and nurse acceptance has been excellent. The device may offer substantial improvement over conventional devices for HD access.

Background: Advantages associated with an increased frequency of hemodialysis have been reported previously. However, previous studies were either small or not controlled and did not detail early clinical, biochemical, quality-of-life, urea kinetic, and dynamic changes when patients switched from a conventional (3 times/wk) dialysis regimen to "daily" (6 times/wk) dialysis therapy when total weekly dialysis time was unchanged. Methods: A prospective sequential study with 21 patients as their own controls was performed. A 4-week period of conventional thrice-weekly dialysis (N = 240 treatments) was followed immediately by a 4-week period of daily (ie, 6 times/wk) dialysis (N = 480 treatments), in which each treatment was half the length of a conventional dialysis treatment session. Clinical parameters and symptoms during and between dialysis treatments were graded, and urea-related parameters, blood chemistry results, and nutritional data were determined. Results: Within 4 weeks of switching to this daily dialysis regimen, there were improvements in blood pressure, dialysis "unphysiology," intradialytic and interdialytic symptoms, and urea kinetics and dynamics. There were fewer machine alarms and less need for nursing interventions during dialysis. Nutrition and quality of life began to improve. There was no increase in blood access complications and no significant changes in blood chemistry results, hematologic parameters, or use of medications. Conclusion: In this short-term study, daily dialysis appears to be a safe, better, and more physiological method to deliver dialysis care to patients with end-stage renal disease.

Each of seven hypophosphatemic hemodialysis patients was dialyzed with a phosphorus-enriched, bicarbonate-buffered dialysate. The latter was prepared by the introduction of sodium phosphate salts to the “acid concentrate” of a bicarbonate-buffered dialysate delivery system. The patients tolerated the procedure well and their hypophosphatemia improved.

To improve vascular access for hemodialysis, a new device (Dialock Hemodialysis Access System, Biolink Corporation, Middleboro, MA) has been developed. Implanted subcutaneously, the device is accessed by percutaneous puncture. Attached to the device are two catheters that are implanted into the superior vena cava or right atrium. Clinical results thus far have been promising. However, use of this device is not free from infectious complications. In the present pilot study, 25 maintenance hemodialysis patients were implanted with 26 Dialock devices. The incidence of bacteremia was 2.9/1,000 catheter days. In 14 episodes of bacteremia in 8 patients the infection was successfully treated with a combination of systemic antibiotic treatment and adjunctive antibiotic/anticoagulant lock therapy. The lock therapy entailed the instillation of both an antibiotic and an anticoagulant into the device. We believe that the antibiotic/anticoagulant lock technique is an effective, adjunctive therapeutic modality in the treatment of infections related to the use of indwelling vascular access devices.

We performed acute peritoneal dialysis on eight end-stage renal disease patients using a bicarbonate-containing solution sterilized by ultrafiltration through polyamide filters. The patients tolerated the procedure well; their azotemia and metabolic acidosis improved.

Initial results of a new access device for hemodialysis Background. A new subcutaneous device (DIALOCK y ) provides vascular access to patients who currently require hemodialysis (HD). The device consists of a port-like valve, implanted subcutaneously below the clavicle, which provides a linear flow passage to two catheters placed in the right atrium via the internal or external jugular vein. The valve is accessed percutaneously with needle-cannulas that functionally convert the device to twin catheters for connecting the patient to the HD lines. Methods. The device was implanted in 10 outpatients under local anesthesia. Patients used the device during dialysis 3 times/ week, and data were collected on blood flow, pressures, adverse events and patient and nurse satisfaction. Results. The device was used for HD almost immediately (median 3 days after implantation) and functioned successfully for more than nine months (mean 6 SD 7.3 6 1.5) in all but one patient who died of unrelated causes after one month; there were .800 dialysis sessions total. Blood flows over 300 ml/min were consistently achieved (average 326 6 40) with venous and arterial pressures of 200 6 44 and 2246 6 29 mm Hg, respectively. After 66 patient-months, condition of the needle puncture sites remained satisfactory. Five systemic infections occurred in four patients, producing 2.3 bacteremic episodes per 1000 patient-days. All resolved without the need for device removal. There were no infections at the puncture sites. Two patients required fibrin sheath stripping of their catheters, one whose heparin lock was not changed for 23 days (for reasons unrelated to the device). Patient and nurse acceptance was excellent. Conclusion. The device represents a positive improvement in the area of HD access.

During the past 3 decades, we have witnessed remarkable changes in the clinical manifestations of uremia in patients suffering from acute renal failure (ARF). For example, in the past, acute gastrointestinal (GI) hemorrhage was a deadly and feared complication in patients with ARF. Indeed, GI bleeding was the second leading cause of death in patients with ARF prior to 1970 [1, 2]. Overall mortality rates of patients with ARF have since improved, probably because of advances in critical care support and in renal replacement therapy [3, 4]. The reduction in GI bleeding as a cause of death has been even more dramatic. In a recent series of patients with ARF treated between 1980 and 1989, only one of 214 deaths was attributed to GI bleeding [5]. The dearth of GI hemorrhage as a cause of death in ARF in recent years may be related to prophylactic therapy with H2-receptor blockers, and to better control of the uremic bleeding tendency by dialysis [5]. The role of dialysis in reducing uremic bleeding was previously suggested by Kleinknecht et al. [1], who, in a retrospective study using historical controls, had reported that prophylactic dialysis could reduce mortality due to GI hemorrhage.

The best approach to treatment of pericarditis accompanied by substantial pericardial effusion in end-stage renal disease (ESRD) patients is unknown. In a review of our experience, we found that ESRD patients with moderate-to-large or large (circa 250 mL or larger) pericardial effusions usually failed to improve with intensive dialysis and ultimately required surgical drainage of the effusion. Multivariate analysis revealed that effusion size was by far the most important factor predicting need for surgery. Since early pericardial drainage obviates the risk of sudden tamponade, we recommend that surgery without prior intensive dialysis therapy be considered in such patients.

Controlled comparison of hemodialysis and peritoneal dialysis: Veterans Administration multicenter study. We measured mortality and morbidity among 114 patients assigned randomly to home hemodialysis (HD) and home intermittent peritoneal dialysis (IPD). Data were collected during the time of home training and for 12 months after initiation of home dialysis. Training time was shorter for the IPD than for the HD patients (P < 0.001) with median time 1.8 months for IPD and 3.9 months for HD. Switching to the alternative mode of treatment was more frequent for the IPD group (29/59 vs. 5/55, P < 0.001). Survival time was not different, perhaps because of the modality change. More IPD patients were hospitalized in the first 6 months (20 for IPD vs. 9 for HD, P = 0.02), but they had fewer troublesome cardiovascular events in the first year (0 vs. 12, P < 0.001). The HD patients maintained better nutritional status as reflected in body weight and arm muscle circumference and possibly in urea appearance rate. Thus, these data suggest that for most patients, IPD is a less satisfactory form of therapy than HD, but certain advantages of IPD did emerge. Applications of this information to the currently more popular mode of CAPD await further study.Comparaison contrôlée entre l'hémodialyse et la dialyse péritonéale: Étude multicentrique de l'Administration des Veterans. Nous avons mesuré la mortalité et la morbidité chez 114 malades, pris au hasard, en hémodialyse à domicile (HD) ou en dialyse péritonéale intermittente à domicile (IPD). Les données ont été recueillies pendant l'entrainement à domicile et pendant les 12 mois suivant le début de la dialyse à domicile. La durée d'entrainement était plus brève pour les malades en IPD que pour ceux en HD (P < 0,001), avec un temps médian de 1,8 mois pour l'IPD et de 3,9 mois pour l'HD. Le changement pour l'autre mode de traitement était plus fréquent pour le groupe IPD (29/59 contre 5/55, P < 0,001). La durée de suivi n'était pas différente, peut-être à cause du changement de modalité. Plus de malades en IPD ont été hospitalisés dans les 6 premiers mois (20 en IPD, contre 9 en HD, P = 0,02), mais ils ont eu moins d'ennuis cardiovasculaires gênants au cours de la première année (0 contre 12, P < 0,001). Les malades HD conservaient un meilleur état nutritionnel, reflété par le poids corporel, la circonférence musculaire du bras, et probablement la vitesse d'apparition de l'urée. Ainsi ces données suggèrent que pour la plupart des malades, l'IPD est une forme de traitement moins satisfaisante que l'HD, mais certains avantages de l'IPD sont apparus. Les applications de cette information au mode actuellement le plus répandu de CAPD requièrent d'autres études.

We hypothesized that intraperitoneal air might be one of the causes of peritoneal fluid eosinophilia. To test our hypothesis, we injected 100-500 ml of sterile air intraperitoneally into 5 patients receiving continuous ambulatory peritoneal dialysis (CAPD). All patients responded with a transient increase in peritoneal fluid nonerythrocyte cell count (peak counts ranging from 23 to 335 cells/mm3, mean peak count 140 +/- 125) lasting 4 days (after injection of 100 ml of air) to 7 weeks (after injection of 500 ml of air). In 2 patients, the cells were predominantly monocytes (80 +/- 6.5%), whereas in 3 patients, eosinophils predominated (63 +/- 12%), while monocytes (30 +/- 19%) also increased. Resolution of peritoneal fluid pleocytosis correlated temporally with absorption of subdiaphragmatic air. Our results suggest that intraperitoneal introduction of air into CAPD patients can induce peritoneal fluid eosinophilia and/or monocytosis.

Antibody responses to influenza vaccination in patients with chronic renal failure. A bivalent type A inactivated influenza virus vaccine containing both sets of H3N2 and HSW1N1 antigens was given to patients with chronic renal failure and to control subjects. The patients were divided into an azotemic group in whom dialysis was not yet required and a hemodialyzed group. Hemagglutination-inhibition (HI) antibody responses were measured at time intervals of 1, 3, and 4 weeks after vaccination. We found that the mean postvaccination HI titers against both sets of antigens in the patients as a group did not differ significantly from those found in the control subjects as a group. The proportion of responders showing a fourfold or greater increase in post-vaccination antibody responses over prevaccination antibody values for either set of antigens was similar in both groups of patients and the group of control subjects. In general, an inverse correlation was found between prevaccination antibody levels and postvaccination antibody responses in both patients and control subjects. The only exception to this trend was the response of two of the azotemic patients to the H3N2 antigens who failed to respond despite low prevaccination antibody levels. These were the patients with the highest serum creatinine values.

During the past 10 years, the incidence of severe anaphylactic reactions during dialysis [type A first-use syndrome (FUS)] at our center has been much lower when using cuprammonium cellulose plate (CC-P) dialyzers (0/37, 750 dialyses) or coil (CC-C) dialyzers (0/32, 500) than when using cuprammonium cellulose hollow-fiber (CC-F) dialyzers (8/21,022 dialyses, p less than 0.005 by Chi-square). To determine if the difference in type A FUS incidence between the three dialyzer types could be explained by differences in complement activation, we compared plasma concentrations of C3a des-arginine (des arg) in patients undergoing dialysis with these three varieties of dialyzers. Plasma C3a des arg values increased markedly in the dialyzer outflow blood with the three dialyzer configurations. The levels were similar with the dialyzer types when results were corrected for membrane surface area. Also, the degree of leukopenia was not markedly different with the three dialyzer types. Our findings suggest that complement activation per unit surface area is similar during dialysis with plate, coil, and hollow-fiber cuprammonium cellulose dialyzers. The lack of correlation between the degree of complement activation and the incidence of type A FUS suggests that membrane-induced complement activation is not of primary importance to type A dialyzer hypersensitivity reactions.

Peritoneal sclerosis, a disorder similar to that previously identified in nonuremic patients, is being noted in peritoneal dialysis patients with increasing frequency. The etiology in dialysis patients remains unknown. An association with previous or ongoing peritoneal inflammation or irritation suggests that the incidence of peritoneal sclerosis could be reduced by rapidly controlling peritonitis and by eliminating the irritant properties of catheters, dialysate, and other materials used in performing peritoneal dialysis. If peritoneal sclerosis does supervene, weight loss, abdominal pain, and intestinal obstruction may occur and further peritoneal dialysis may become impossible because of abdominal pain or poor fluid and solute transfer.

To study the fate of amantadine hydrochloride in patients with renal failure, we gave 100 mg orally to 12 such patients immediately after hemodialysis. Plasma levels did not decrease between 24 and 44 hours after drug ingestion, suggesting an extremely poor total body clearance. Apparent volume of distribution was 5.1 +/- 0.2 (SEM) L/kg of body weight. Between 44 and 48 hours, as a result of 4 hours of hemodialysis, the mean plasma drug level decreased from 268 to 225 ng/mL (P less than 0.001). Dialyzer clearance was 67.0 +/- 3.9 mL of plasma per minute. The total quantity of drug removed by the dialysis treatment, however, was only 3.9 +/- 0.25 mg. The average half-life of amantadine in eight patients studied while receiving maintenance hemodialysis was 24.3 +/- 2.4 h of dialysis administered over approximately 13 days. Plasma half-life in six nonuremic control subjects was 12.2 +/- 1.6 h. Amantadine is poorly excreted in dialysis patients and has a large volume of distribution. The amount removed by a single dialysis is only a small fraction of the total body store.

An adult male with idiopathic membranous glomerulonephropathy who developed crescentic glomerulonephritis after an episode of streptococcal pharyngitis is described.

Twelve patients underwent hemodialysis using dialysate containing 130 mEq/L sodium, and, on a separate occasion, dialysis using a dialysate of constantly decreasing sodium concentration (from 150 to 133 mEq/L). Hydrostatic ultra-filtration during dialysis was performed at a constant rate (900 ml/hr) during both treatments, and was continued until a substantial drop in mean arterial pressure (-15%) or symptoms were observed. A double-blind comparison of the two treatment modalities was thus achieved. At the end of ultrafiltration, significantly more fluid had been removed using decreasing sodium dialysate (2.9 +/- 0.3 kg) than when using the low-sodium dialysate (1.9 +/- 0.2 kg, P

Hemofiltration using the postdilution technique and a modified saline solution as the replacement fluid succeeded in treating the metabolic alkalosis of two patients with renal failure.

An 'epidemic' of aseptic peritonitis occurred in our peritoneal dialysis unit, affecting 5 of 20 patients. Acute and convalescent viral titers were normal in all 5. The peritoneal fluid of the affected patients was not tested for endotoxin, but endotoxin was found in subsequent dialysis fluids from two machines in the unit. This endotoxin might have been the causative agent of this outbreak. Rapid recovery ensued in all patients following peritoneal lavage.

The formula -In (R - 0.03 - UF/W), where R is the ratio of the postdialysis to predialysis plasma urea nitrogen level, UF the ultrafiltrate volume per session, and W the postdialysis weight, has been shown by us to estimate K.t/V accurately. We audited the amount of dialysis being administered in a moderate size outpatient unit in which urea kinetic modeling was not being done and in which 4 hr dialysis at a 250 or 300 ml/min blood flow rate was routinely prescribed. R was determined once per month on each of six successive months, and standard three point urea kinetic modeling was done on all patients once. R was quite reproducible in each patient, with a coefficient of variation of 6.6% +/- 3.2 standard deviation (SD). The R:UF:W-derived K.t/V averaged 0.91 +/- 0.19; the R:UF:W-derived K.t/V correlated with the modeled K.t/V (r = 0.98), with a mean percent error of only 0.12% +/- 3.6. A negative correlation (r = -0.56) was present between the R:UF:W-derived K.t/V and postdialysis weight; 9 of 40 patients had K.t/V values below 0.8 and 7 of these 9 weighed more than 85 kg. In 13 other patients, K.t/V was between 0.8 and 0.9. After inclusion of residual renal function (Kru) to calculate KT, KT was still below 0.9 in 19 patients. The main cause of underdialysis was inadequate prescription. The results suggest that monthly monitoring of R, with inclusion of UF and W to estimate K.t/V, is one useful quality assurance tool to assess the amount of dialysis being administered.

• To determine the prevalence of blood eosinophilia in patients receiving maintenance peritoneal dialysis, routine peripheral WBC counts of 49 such patients were reviewed. In 29 patients, blood eosinophilia was noted. Elevations in blood eosinophil counts tended to be mild and episodic. They were often associated with concomitant elevation of peritoneal fluid eosinophil counts. Possible predisposing factors included recent peritoneal catheter insertion and antibiotic therapy for peritonitis.

• Five patients receiving maintenance peritoneal dialysis (duration, three months to four years) required surgical exploration of the abdomen for various reasons. Four had a prior history of bacterial peritonitis, and four of aseptic peritonitis. At laparotomy, the peritoneal membrane was found to be markedly thickened and sclerotic in all patients, and loops of bowel were bound together in a dense, opaque casing. On microscopic examination, an increase in fibroconnective tissue in the peritoneum was observed. (Arch Intern Med 140:1201-1203, 1980)

• In 216 patients with end-stage renal disease (ESRD) undergoing 406 major operations, surgery was elective in 143 cases (mortality, 1.4%) and nonelective in 263 (mortality, 11.1%). Of 82 patients who received 105 pretransplant operations to prevent posttransplant complications, eg, gastrointestinal hemorrhage, urinary tract sepsis, and azathioprine intolerance, surgical mortality was 1.9%, with 80 patients becoming active candidates for transplantation. Sepsis requiring surgical care occurred in 54 patients, in 36 of these in the posttransplant period. Parenteral and enteral hyperalimentation was used as a therapeutic adjunct in 40 of these patients. Overall mortality in those with septic complications was 35.2%, 22.5% in the nutritional support group and 71.4% in the group not receiving hyperalimentation. Improved survival rates can be achieved for surgical emergencies in ESRD, particularly in the posttransplant immunosuppressed patient, if both definitive surgical intervention and nutritional support are actively applied. ( Arch Surg 1981;116:634-640)

• Sixteen patients receiving maintenance hemodialysis in whom moderate-to-large pericardial effusions developed were treated with short-term drainage via a large-bore tube implanted into the pericardial sac. Drainage tubes were implanted using a subxiphoid approach (subxiphoid pericardiostomy) while the patient was under local anesthesia. In seven patients, triamcinolone hexacetonide was instilled into the pericardial sac through the drainage tube at regular intervals. In all patients, a drainage period of two to four days, with or without instillation of nonabsorbable steroids, was associated with resolution of the pericardial effusion. Only one recurrence of effusion was demonstrable over a follow-up period extending from three months to eight years (median, 4.2 years). Complications of subxiphoid pericardiostomy were minor (incisional hernia, wound infection, and small pneumothorax) and easily treatable. Our results suggest that short-term drainage via a surgically implanted drainage tube is an effective and safe treatment of moderate-to-large hemodialysis-associated pericardial effusion. ( Arch Intern Med

In ten patients undergoing maintenance peritoneal dialysis, large numbers of eosinophils were found in the peritoneal fluid. A few of the affected patients complained of episodic abdominal pains, but there was no correlation between abdominal symptoms and the number of peritoneal fluid eosinophils. Microorganisms failed to grow on cultures of the peritoneal fluids, and results of tests for endotoxin were negative. The cause of eosinophilia could not be determined. Peritoneal fluid eosinophil counts were noted to be elevated soon after catheter insertion and initiation of peritoneal dialysis. In some patients, peritoneal fluid eosinophil counts spontaneously returned to normal despite continued peritoneal dialysis. (Arch Intern Med1981;141:1172-1173)

• Studies of fluoride metabolism were carried out in patients with chronic renal failure by determining fluoride balances for several weeks. The fluoride intake was due to the analyzed fluoride content of the diet and of the drinking water. The effect of aluminum hydroxide on fluoride metabolism was investigated because this antacid is commonly used therapeutically for these patients. Studies have shown that urinary fluoride excretion in patients with chronic renal failure was significantly lower than that in patients with normal renal function, resulting in a significantly higher retention of fluoride. Although the fecal fluoride excretion in patients with chronic renal failure was slightly but significantly increased, this change did not compensate for the decrease of the urinary fluoride excretion. The intake of aluminum hydroxide resulted in a significant increase of fecal fluoride excretion and in a significant decrease of net absorption and retention of fluoride in patients with chronic renal failure. ( Arch Intern Med 140:1331-1335, 1980)

In an attempt to standardize conditions for quantitating proteinuria, we examined the effect of water loading and intravenous administration of furosemide on protein excretion in man. Urine volume, protein excretion, and creatinine clearance increased in both studies, and there was significant correlation between percentage changes in protein excretion and creatinine clearance. We recommend that protein excretion rate should be determined during short periods under standard conditions of posture, hydration, and ideally, without interference by drugs.