The superimposition of human immunodeficiency virus (HIV) infection, associated opportunistic infections, and anti-retroviral therapy further worsens the severity of anemia in patients also suffering from end-stage renal disease. A major cause of anemia in renal failure is a deficiency of erythropoietin. The causes of anemia in HIV disease include direct and indirect stem cell inhibition by the virus, increased peripheral destruction of red blood cells, and bone marrow suppression by various opportunistic infections and therapeutic drugs, particularly zidovudine. We compared the efficacy of recombinant human erythropoietin (rHuEPO) therapy in improving the anemia in HIV-infected end-stage renal disease patients (group I) with that in nondiabetic (group II) and diabetic (group III) hemodialysis patients without HIV infection. All three groups of patients were comparable in dialysis prescription and serum iron studies. Iron supplementation was prescribed to all patients, and none received blood transfusions. After 8 weeks of rHuEPO therapy (administered intravenously in a dose of 100 U/kg body weight thrice weekly), the mean increase in hematocrit was similar in all responders (5.8% increase in hematocrit in 23 of 30 HIV patients and 6.7% increase in 24 of 30 non-HIV patients). Response in hematocrit was noted in HIV patients despite the presence of opportunistic infections in 15 and zidovudine administration in 11. Seven HIV-positive patients and six non-HIV patients failed to respond to rHuEPO. Irrespective of the HIV status, the baseline serum EPO levels in patients responding to rHuEPO were significantly lower than those in nonresponders.(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS-Associated Nephropathy↗

PubMed1995

Dermal angiopathy in hemodialysis patients: the effect of time.

We studied skin biopsies from 14 patients after 6 months to 18 years on hemodialysis (HD) to discern any effect of duration of treatment on skin and dermal capillaries. Patients selected for biopsy were without evidence of other diseases known to affect vasculature such as diabetes mellitus. Pathological changes compared with duration of HD were: capillary wall thickening, endothelial proliferation and new capillary formation, lipid content, and epidermal atrophy. Severity of morphologic changes were graded from 0 to 4+ by a pathologist who had no knowledge of HD duration. The earliest change observed was reduplication of the capillary basement membrane. Narrowing of capillary lumina due to endothelial cell proliferation and new capillary formation were noted after five years of HD; lipid droplets were noted in capillaries by five years; and epidermal atrophy by 10 years. Progressive severity of each finding was associated with length of time on HD. Neither amyloid nor Ca++ deposits were observed in any specimens. By clinical observation, easy bruisability and increased skin fragility were worse the longer the patient was on HD. Capillary occlusion inducing tissue ischemia could be a cause of the atrophic skin changes noted. However, no patient manifested dermal necrosis. While pathogenesis of the capillary changes in uremic skin is unknown, the changes have been shown to stabilize following successful kidney transplantation.

Adult↗

PubMed1994

Outcomes of older patients receiving chronic dialysis.

Explore the source record for details and available documents.

Activities of Daily Living↗

PubMed1994

Measuring, managing, and improving quality in the end-stage renal disease treatment setting: committee statement.

The Institute of Medicine (IOM) committee that organized the conference reported in this issue of the journal on assessing quality of care and quality of life, wishes to emphasize that it regards the task of measuring quality as one that can be approached systematically, albeit with caution. Outcomes of end-stage renal disease (ESRD) care by dialysis and transplantation (and variations of outcomes among treatment units) and related processes of care need to be measured in ways useful to clinicians. In addition to clinical measures of outcome, the committee also favored giving greater attention to functional outcomes and health-related quality of life. The interest in maintaining and improving quality in the treatment setting reflects an underlying need to encourage its systematic assessment on a sustained basis, with appropriate weight devoted to practical issues.

Humans↗

PubMed1994

Salvage of clotted jugular vein hemodialysis catheters.

Jugular venous catheters (JVC) provide rapid, vascular access for both emergency and maintenance hemodialysis in both acute and end-stage renal disease. Clotting and occlusion of JVC is a common problem necessitating alternate vascular access. Urokinase will declot 80-90% of central venous catheters; however, recurrence of catheter occlusion is frequent. We successfully employed a guide wire insertion technique to salvage occluded JVC after failed urokinase infusion. In 24 patients JVCs, inserted for either temporary or permanent vascular access, clotted within 6-55 days of initiating hemodialysis. Urokinase (5,000 IU) instilled into both arterial and venous limbs of the catheter had been unsuccessful in restoring patency. In these patients, we inserted a soft-tipped guide wire into both lumina. In 21 of 24 patients (87.5%), guide wire insertion opened the occluded JVC, permitting immediate initiation of hemodialysis. We conclude that for clotted JVC unresponsive to urokinase infusion, guide wire insertion can salvage most catheters thereby facilitating hemodialysis.

Adult↗

PubMed1994

The role of the nephrologist in patient rehabilitation.

The justification for the enactment of the End-Stage Renal Disease (ESRD) Program in 1972 was to provide the lifesaving potential of dialysis and transplant to patients with terminal renal failure. Implied as a return on cost was that many of those whose lives were prolonged would contribute to society through work and taxes. It is not surprising at a time of growing concern about health-care costs that vocational rehabilitation for patients undergoing dialysis and transplant has again come to the attention of Congress and others. The nephrologist, the leader of the health-care team caring for patients on dialysis and outpatients with transplants, plays a crucial role if an increasing number of patients are to be rehabilitated. The attitudes of the nephrologist can establish the belief in staff and suitable patients for or against the possibility of attending school, retraining, or working. Identification of medical problems as impediments to rehabilitation and their resolution, where possible, is an essential function of the nephrologist and other team members. Any process that seems at first glance to be difficult requires an evangelist if success is to come. The nephrologist must be the primary motivator. There are a number of extrinsic barriers to rehabilitative success including employer health insurance, disability regulations, and attitudes toward people with disabilities. The nephrologist, as a respected figure and patient advocate, must be willing to deal aggressively with these barriers whenever the occasion arises.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗

PubMed1994