Emergency Department Presentation of Chronic Peritoneal Dialysis Patients

Background. The patterns of emergency department (ED) presentation of chronic peritoneal dialysis (PD) patients have not been well documented. This study was designed to analyze the ED presentation, evaluation, and disposition of these patients. Materials and Methods. We retrospectively reviewed the charts of all chronic PD patients who had been treated for more than 1 month at our dialysis center between January 1995 and December 2003. We included patients who visited the ED during this period. Data were collected on demographics, etiology of renal failure, chief complaint , diagnosis, length of stay, and disposition. Results. A total of 68 chronic PD patients (26 male, 42 female) were treated at our center during this period. Eight patients were not studied because of incomplete medical records. In addition, 18 patients never visited the ED. The remaining 42 patients made 96 ED visits. The most common presenting complaints were abdominal pain, dyspnea, and nausea/vomiting. The major diagnoses were peritonitis, respiratory tract infection, hypovolemia associated with excessive ultrafiltration, and acute gastroenteritis. Symptomatic hypokalemia was also seen in 5% of patients visiting the ED. Among the patients, 58.3 % were admitted. The average duration of admission was 172 + /- 41.2 days. Conclusion. The patients on PD had a different clinical picture of ED presentation than did the patients on hemodialysis. PD-associated complications-especially peritonitis- constitute major reasons for ED visits. Aggressive patient education and monitoring are recommended to reduce the number of ED visits by these patients

Hemorrhagic Stroke in Chronic Dialysis Patients

Aims: This study was designed to retrospectively investigate the clinical profiles, disease course and management of hemorrhagic stroke in chronic dialysis patients. We emphasized on the factors affecting the prognosis. Patients and Methods: We retrospectively studied (January 1991-June 1999) the chronic dialysis patients who were admitted to our facility with a diagnosis of acute hemorrhagic stroke. The medical results were reviewed in detail and the clinical characteristics, laboratory data and management records of each individual were collected for analysis. Results: There were 16 patients analyzed in total, 9 males and 7 females. The average age was 59.4 +/- 13.3 years old. Before admission, 14 patients received chronic hemodialysis (HD) and two patients peritoneal dialysis (PD). The co- morbidities included hypertension (16/16), Diabetes Mellitus (DM) (9/ 16), previous cerebrovascular accidents (9/16) and hyperlipidemia (5/16). The locations of cerebral hemorrhage( CH) were: the putamen (6/16), brain stem (3/16), thalamus ( 3/16) and others (4/16). Among the 14 HD patients, 8 remained on HD after onset of CH, while 6 switched to PD. Those who received PD before their development of CH continued to perform PD. The overall mortality was 44% (7/16 ). One of the 8 patients who continued on HD died (mortality 12.5%). Among the 8 patients who received PD, 6 died ( mortality 75%). Two patients who underwent surgical intervention also passed away. The major cause of death was neurological deterioration. The interval between the onset of CH and death was short (15 +/- 13 days, range 2-39 days). Conclusion: The overall prognosis of CH in the chronic dialysis population is poor. Patients with lower hemoglobin levels upon presentation and those performing PD after CH may have even worse prognosis

Altered Monocytic Phenotypes are Associated with Uraemic Pruritus in Patients Receiving Haemodialysis

Uraemic pruritus is one of the most bothersome symptoms in patients receiving haemodialysis. A total of 175 patients receiving maintenance haemodialysis, with 74 patients experiencing uraemic pruritus, were prospectively recruited to assess the influence of the phenotype of blood monocytes and various cytokines on uraemic pruritus. The phenotype of blood monocytes was determined by flow cytometry as classical (CD14++CD16−) monocytes, non-classical (CD14+CD16++) monocytes, and intermediate (CD14++CD16+) monocytes. Eight cyto­kines, including interleukin (IL)-2, interferon-γ, IL-12p70, IL-4, IL-5, IL-6, tumour necrosis factor-α, and IL-10, were simultaneously detected with a multi­plex bead-based immunoassay. Multivariate linear regression analysis showed that a higher percentage of intermediate monocytes (effect estimate 0.08; 95% confidence interval 0.01–0.16) were independent predictors of a higher visual analogue scale score for pruritus intensity. No differences were noted for all 8 cytokines between patients with and without uraemic pruritus. The results of this study indicate that altered monocytic phenotypes could play a role in uraemic pruritus

Relationship between Fetuin A, Vascular Calcification and Fracture Risk in Dialysis Patients

<div><p>Background</p><p>Fractures are a common morbidity that lead to worse outcomes in dialysis patients. Fetuin A inhibits vascular calcification (VC), potentially promotes bone mineralization and its level positively correlates with bone mineral density in the general population. On the other hand, the presence of VC is associated with low bone volume in dialysis patients. Whether the fetuin A level and VC can predict the occurrence of fractures in dialysis patients remains unknown.</p><p>Methods</p><p>We performed this prospective, observational cohort study including 685 dialysis patients (629 hemodialysis and 56 peritoneal dialysis) from a single center in Taiwan for a median follow-up period of 3.4 years. The baseline fetuin A level and status of presence of aortic arch calcification (VC) and incidence of major fractures (hip, pelvis, humerus, proximal forearm, lower leg or vertebrae) were assessed using adjusted Cox proportional hazards models, recursive partitioning analysis and competing risk models.</p><p>Results</p><p>Overall, 177 of the patients had major fractures. The incidence rate of major fractures was 3.29 per 100 person-years. In adjusted analyses, the patients with higher baseline fetuin A levels had a lower incidence of fractures (adjusted hazard ratio (HR), 0.3; 95% CI, 0.18‒0.5, fetuin A tertile 3 <i>vs</i>. tertile 1 and HR, 0.52; 95% CI, 0.34‒0.78, tertile 2 <i>vs</i>. tertile 1). The presence of aortic arch calcification (VC) independently predicted the occurrence of fractures (adjusted HR, 1.95; 95% CI, 1.34‒2.84) as well. When accounting for death as an event in competing risk models, the patients with higher baseline fetuin A levels remained to have a lower incidence of fractures (SHR, 0.31; 95% CI, 0.17‒0.56, fetuin A tertile 3 <i>vs</i>. tertile 1 and 0.51; 95% CI, 0.32‒0.81, tertile 2 <i>vs</i>. tertile 1).</p><p>Interpretations</p><p>Lower baseline fetuin A levels and the presence of VC were independently linked to higher risk of incident fractures in prevalent dialysis patients.</p></div

Prognostic importance and determinants of uremic pruritus in patients receiving peritoneal dialysis: A prospective cohort study.

BACKGROUND:Uremic pruritus is a common and frustrating symptom among patients receiving peritoneal dialysis (PD). This study aimed to examine the prognostic importance of uremic pruritus and to identify the determinants for higher pruritus intensity in PD patients. METHODS:We conducted a prospective cohort study of patients receiving maintenance PD. A visual analogue scale (VAS) score was used to measure the intensity of uremic pruritus. The composite endpoint of PD technique failure or all-cause death was assessed using a multivariable Cox proportional hazards model. The determinants for the VAS score of uremic pruritus was assessed using a multivariable linear regression model. RESULTS:Among the 85 PD patients, 24 (28%) had uremic pruritus. During a median follow-up of 28.0 months, 12 patients experienced technique failure, and 7 died. We found that a higher VAS score of pruritus intensity was an independent risk factor for technique failure or death (hazard ratio, 1.64; 95% confidence interval, 1.18 to 2.28; P = 0.003) after adjusting for a variety of confounding factors. We also found that a weekly total Kt/V of less than 1.88, a longer duration of dialysis, a higher dietary protein intake, and higher blood levels of intact parathyroid hormone and high-sensitivity C-reactive protein were independent determinants of higher VAS scores of pruritus intensity. CONCLUSIONS:Our results show that uremic pruritus is an independent risk factor of technique failure and death in patients receiving PD. We also found that a weekly total Kt/V < 1.88 is associated with higher intensity of uremic pruritus in PD patients

Baseline characteristics of the all patients and the patients by fetuin A tertile.

<p>Baseline characteristics of the all patients and the patients by fetuin A tertile.</p

Baseline characteristics of the patients undergoing hemodialysis (HD) and peritoneal dialysis (PD) and patients with and without vascular calcification (VC).

<p>Baseline characteristics of the patients undergoing hemodialysis (HD) and peritoneal dialysis (PD) and patients with and without vascular calcification (VC).</p

Competing risk analysis of the relative hazard of major fracture by fetuin A tertile (death is the competing event).

<p>Competing risk analysis of the relative hazard of major fracture by fetuin A tertile (death is the competing event).</p