bluuebunny/crossref_metadata_2025 huggingface dataset:
Infant as a consumer: what to consume?
Authors: Yasmin Hena
Published: January 2005

Infancy is the period in life from birth to the age of 1 year. An infant becomes a child and then an adolescent, passes through his/her parents’ lives and disappears into adulthood, a fully fledged person, with a life and a future all his/her own. What an infant eats at this stage is crucial to his/her future health. There are several feeding practices pertaining to infants, including breast‐feeding, artificial feeding, mixed feeding, formula feeding and weaning. A detailed comparative study of these feeding practices concludes that breast‐feeding is the best practice for infant feeding. It makes a unique fundamental contribution to the health and nutrition of infants. The ideal food for the young infant is human milk. It has specific characteristics that match the growing infant's nutritional requirements during the first year of life.
Appetizing learning in Swedish comprehensive schools: an attempt to employ food and tasting in a new form of experimental education
Authors: Jonsson Inger M. , Ekström Marianne P. , Gustafsson Inga‐Britt
Published: January 2005

The word taste has several meanings: biopsychological, and cultural and social. Taste also influences food choice, though there is a widespread belief that tasty food is not synonymous with healthy eating patterns. In Sweden compulsory school daily meals are provided and Home Economics is a compulsory subject, while tasting lessons form an additional experimental form of education. The aim of this study has been to make a general evaluation of tasting lessons in four fifth‐year classes. The focus of the results is on pupils’ learning about, and interest in, food, and the opinions and reflections of teachers, catering staff and school heads. The participants were three professional focus groups comprising staff from four schools, and 48 pupils (eight groups with boys and girls in separate groups) from the same schools. Results showed that the children wereprepared to be exposedto different foodstuffs, and the adultswere prepared to be exposedto new educational methods. Two stages of children's learning have been described in connection with tasting:practice and experience,andverbalization and reflection.
Dual inverse effects of lipoprotein(a) on the dementia process in Japanese late‐onset Alzheimer's disease
Authors: IWAMOTO Toshihiko , WATANABE Daisuke , UMAHARA Takahiko , SAKURAI Hirofumi , HANYU Haruo , KANAYA Kiyoshi
Published: January 2005

Background: The role of lipoprotein metabolism in the dementia process has attracted increasing attention. It is universally accepted that apolipoprotein E4 (ApoE) is a risk factor for late‐onset Alzheimer's disease, however, the role of lipoprotein(a) (Lp(a)) remains unclear. Therefore, we conducted the present study to clarify the association between Lp(a) and dementia.

Methods: Lipoprotein(a) serum concentrations were examined in relation to ApoE phenotypes and periventricular lucency (PVL) on brain computed tomography in 150 patients with late‐onset Alzheimer's disease (AD group), compared with 46 patients with vascular dementia (VaD group) and 150 controls without dementia.

Results: The incidences of hypertension, hypercholesterolaemia, and severe PVL were significantly higher in the VaD group than in the AD group. The distributions of Lp(a) concentrations showed left‐skewed deviation in each group, but we found the concentration of 40 mg/dL to be the best cut‐off point to distinguish the frequency of Alzheimer's disease from that of the controls. Compared with the frequency of high Lp(a) concentrations of 40 mg/dL or more in the controls (16.7%), that in the AD group (10.0%) was significantly lower, while that in the VaD group (45.7%) was significantly higher. Separating the AD group according to the presence or absence of ApoE4, the same findings were recognized. However, severe PVL was more frequent in the AD group with high Lp(a) concentrations (53.3%) than in the AD group without high Lp(a) concentrations (7.4%) (P < 0.01).

Conclusions: These findings suggest the possibility of dual inverse effects of Lp(a) on the occurrence of Japanese late‐onset Alzheimer's disease, via suppression of Alzheimer's related processes and promotion of PVL formation presumably caused by ischemia.
Urea kinetics are not representative for the behavior of other small and water‐soluble compounds
Authors: Eloot S. , De Smet R. , Torremans A. , De Wachter D. , Marescau B. , De Deyn P.P. , Verdonck P. , Vanholder R.
Published: January 2005

Scanty data suggests that large solutes show a kinetic behavior that is different from urea. The question investigated in this study is whether other small water‐soluble solutes such as some guanidino compounds show a kinetic behavior comparable or dissimilar to that of urea.

This study included 7 stable conventional hemodialysis patients without residual diuresis undergoing low flux polysulphone dialysis (F8 and F10HPS). Blood samples were collected from the inlet and outlet blood lines before the dialysis session, after 5, 15, 30, 120 minutes, and immediately after discontinuation of the session. Plasma concentrations of urea, creatinine (CTN), creatine (CT), guanidinosuccinic acid (GSA), guanidinoacetic acid (GAA), guanidine (G), and methylguanidine (MG) were used to calculate corresponding dialyzer clearances. A two‐pool kinetic model was fitted to the measured plasma concentration profiles, resulting in the calculation of the perfused volume (V1), the total distribution volume (Vtot), and the inter‐compartmental clearance (K12); solute generation and ultrafiltration were determined independently.

No significant differences were observed between V1 and K12 for urea (6.4 ± 3.3 L and 822 ± 345 mL/min) and for the guanidino compounds. However, with respect to Vtot, GSA was distributed in a smaller volume (30.6 ± 4.2 L) compared to urea (42.7 ± 6.0 L − P < 0.001), while CTN, CT, GAA, G, and MG showed significantly larger volumes (54.0 ± 5.9 L, 98.0 ± 52.3 L, 123.8 ± 66.9 L, 89.7 ± 21.4 L, and 102.6 ± 33.9 L, respectively). These differences resulted in markedly divergent effective solute removal: 67%(urea), 58%(CTN), 42%(CT), 76%(GSA), 37%(GAA), 43%(G), and 42%(MG).

In conclusion, the kinetics of the guanidino compounds under study are different from that of urea; hence, urea kinetics are not representative for the removal of other uremic solutes, even if they are small and water‐soluble like urea.
Quotidian dialysis  Survival in 221 patients treated by short daily hemodialysis for 315 patient years
Authors: Kjellstrand C. , Ting G. , Traeger J. , Sibai‐Galland R. , Blagg C.R. , Young B.
Published: January 2005

Daily hemodialysis greatly improves clinical and biochemical parameters and patient quality of life compared to conventional thrice weekly dialysis. However, mortality statistics are lacking as most centers providing daily dialysis have treated only a small number of relatively selected patients for relatively short observation times. To study patient survival we pooled experience from three sources: 51 French and 128 U.S. patients selected for daily home hemodialysis and 42 U.S. patients selected for short daily center hemodialysis because of many medical complications and cardiovascular instability. Results were compared to age‐matched patients from the USRDS 2003 data base. The age of the patients was 51 ± 16 (18–89) years; 29% were female; they had 3.3 ± 1.8 comorbidities (twice that of USRDS patients); 32% had diabetes or hypertension as cause of renal disease (USRDS patients 70%); blood access was 61% fistulae, 25% grafts, and 14% CV‐catheters. Mean duration of ESRD treatment at start of short daily hemodialysis was 6 ± 7 years.

The observation period was 315 patient years. Patients had been on daily hemodialysis for a mean of 17 ± 18 (0–92) months and 11 patients were observed for more than 5 years. 35 of the 221 patients died (16%); deaths were 111 per 1,000 patient years (53% of expected) and 5‐year cumulative survival was 63% compared to 32% for USRDS patients. Five‐year survival was 0% in patients with >3 comorbidities, 75% in patients with <3 comorbidities (p < 0.0001), and in patients aged <53 years was 80% vs. 50% in patients aged >53 years (p = 0.0007). On Cox stepwise hazards analysis, comorbidity alone predicted survival when used with age. Comorbidity >3 HR = 6.00 (95% CI 2.2–16.3). Conclusions: It is difficult to do survival comparisons between patient groups. However, these daily dialysis patients were age‐matched with patients from the USRDS database. There were fewer diabetic and hypertensive patients but the comorbidity index was twice that of USRDS patients. Survival, both deaths per 1,000 patient years and cumulative count was approximately twice that reported by the USRDS and strongly suggests superior survival with short daily hemodialysis compared to thrice weekly conventional dialysis.
106 Patient‐years experience with the Aksys PHD System for quotidian home hemodialysis
Authors: Kjellstrand C.M. , Blagg C.R. , Young B. , Bower J. , Twardowski Z.J.
Published: January 2005

The Aksys PHD System, designed to utilize ultrapure dialyzate for quotidian hemodialysis at home, uses mechanical cleaning and hot water sanitization of the blood, dialysate, and water flow‐paths from inlet to outlet. Since January 2000, it has been used by 110 US patients and 8 UK patients for a total of 106 patient years and more than 30,000 dialyses runs. Of those treated, 75 patients were male and 43 female; mean age was 52 ± 25 (range 22–82) years; 65% were white, 25% black, and 10% other; mean weight was 78 ± 20 (44–125) kg; the cause of renal failure was primary renal disease (50%), hypertension (24%), diabetes (19%), and other (4%). Dialysis access included fistula (61%), graft (25%), and catheter (14%). Patients had been on ESRD therapy on average of 6 ± 7 (0–32) years when starting on PHD dialysis. As of August 2004, patients had dialyzed 11 ± 8 (1–52) months on the PHD. Of those, 78 patients remained on the PHD, 12 were transplanted, 10 died, 7 returned to conventional dialysis at the end of the original study for the FDA and 7 for medical or social reasons, 2 returned to quotidian dialysis on other equipment, and 2 stopped during home dialysis training. Patients dialyzed an average of 145 ± 27 min, 5.6 ± 0.6 dialyses/week with a QB of 376 ± 45 ml/min and a QD of 545 ± 170 ml/min. eKt/V was 0.68 ± 0.20 and weekly stdKt/V was 2.61 ± 0.52. Mean dialyser reuse was 17 ± 14 times without significant decline in urea clearance. 23/118 patients (19%) who came to the PHD from quotidian dialysis on other equipment thought the PHD twice as easy to use and experienced only half as many episodes hypotension, cramps, headache, backache, nausea, and arrhythmias (all p < 0.02). They were hospitalized only half as many days on the PHD. Cumulative patient survival was 60% at 4 years, with 94 deaths/1,000 patient years, relative risk 0.56 compared with age‐matched patients from the USRDS database. Conclusion: This large clinical experience shows the PHD System is easier to use and delivers smoother dialysis with better cardiovascular stability than conventional dialysis machines. It easily fulfills the DOQI guidelines for adequacy of dialysis, economizes on use of dialyzers, tubing, and dialysate, results in less hospitalization, and appears to result in superior patient survival.
Beta‐2‐Microglobulin in nocturnal hemodialysis – A comparative study in low and high flux dialysers
Authors: Reid A.B. , Mahadevan K. , Agar J.W.M
Published: January 2005

In end‐stage renal failure, impaired renal catabolism leads to retention of beta 2 microglobulin (ß2M), identified as the major constituent of hemodialysis (HD) related amyloidosis. It has been previously shown that, while using a high flux (HF) HD membrane, nocturnal hemodialysis (NHD) with its increased time and frequency provides a much higher clearance of ß2M compared to conventional HD. We compared serum ß2M levels between low flux (LF) and HF in a group of 9 NHD patients who dialyse 8 hours 6 nights/week. Fresenius polysulfone LF membrane size F6‐F8 HPS dialyser were used for the first 15 months (mth) of NHD (SA 1.3–1.8 m2). Subsequently, polysulfone HF FX80 dialyzer were used (SA 1.8 m2). Blood flow and dialysate flow rates were unchanged throughout the study. ß2M levels were measured at 6, 12, 15 mth on LF and at 6, 12 mth on HF. Albumin, homocysteine (Hcy), and phosphate (Phos) levels were also recorded at these times. ß2M levels trended upwards during the 15 mth on LF (36.6 ± 10.57 at 6 mth vs 47.1 ± 11.7 at 15 mth). On introduction of HF, there was a significant fall in ß2M at 6 mth to 12.4 ± 3.5 (p < 0.003), while ß2M levels were unchanged at 12 mth of HF. A downward trend in Hcy levels with the use of HF was noted (12.9 ± 2.9 at 0 mth Vs 11.1 ± 3.7 at 12 mth). Plasma albumin and Phos levels remained unchanged as did the use of Phos supplementation. Levels of ß2M continued to rise on NHD with LF, indicating inadequate clearance. With the introduction of HF there was a significant fall in ß2M levels consistent with improved clearance. The implications of this are that ß2M clearance may be time and frequency dependent only if dialyser membrane flux is adequate.
Infections  Recurrent empyema due to Salmonella enteritidis in a patient on hemodialysis
Authors: Hung Y.M. , Chou K.J. , Chung H.M
Published: January 2005

Objective: 
Pleural involvement of salmonella infection is very rare and we are not aware of any case of salmonella empyema in hemodialysis patients. The purpose of this study is to report our experience of recurrent empyema due to Salmonella enteritidis with bacteremia in a patient on hemodialysis. Case report: A 53‐year‐old woman with end stage renal disease, having been on hemodialysis for 10 days, was brought to the emergency department due to fever and shortness of breath for 2 days. Her initial physical examination revealed diminished breathing sound over right lung field. The chest radiographs disclosed right pleural effusion and pleural fluid analysis included a white cell count of 13800(N/L:95/5), LDH 2534 U/L, protein 2.7 g/dL, and sugar 10 mg/dL. Right side empyema was noted. Sonography revealed splenomegaly. Salmonella enteritidis was identified from the cultures of blood and pleural fluid. After antimicrobial therapy with intravenous ceftriaxone for 2 weeks and pleural pigtail drainage, fever subsided and pleural drainage tube was removed. However, thoracoscopic debridement was done later because of recurrent empyema within one week after removing the drainage tube. Computed tomography revealed pleural effusion, pericardial effusion, and splenomegaly, but there was no evidence of aortic aneurysm formation or infectious process of aorta. Overall the patient received 6 weeks of intravenous ceftriaxone treatment and 3 months of oral ciprofloxacin. The follow‐up CXR revealed minimal pleural effusion. Conclusion:  Nontyphoidal salmonella infection can present with empyema and bacteremia in patients on hemodialysis. Adequate drainage and antimicrobial therapy may be necessary to treat such patients effectively.
Early onset catheter‐associated bacteremia (CAB)
Authors: Troidle L. , Finkelstein F.O.
Published: January 2005

Bacteremia is a common complication for hemodialysis (HD) patients (pts) with an indwelling central venous catheter (CVC). We studied our experience with CAB and noted that CAB occurred at an average of 96 ± 98 days after CVC insertion. We wondered what percentage of CAB occurred in the first 21 days after CVC insertion and the spectrum of organisms. We prospectively collected data on all HD pts from 3 centers with a CVC who developed bacteremia between 1/1/03 and 8/31/04. Pts who developed CAB with an identifiable source of bacteremia were excluded. 131 episodes of CAB were identified; 34 (25.95%) occurred in ≤21 days. The mean ± SDEV age of the pts developing CAB > 21 days and ≤21 days was 63 ± 17 and 61.5 ± 15.4 years, respectively. Table 1 outlines the spectrum of organisms. There was a significantly greater incidence of CAB with Staphylococcus aureus(SA) and a significantly lower incidence of Staphylococcus epidermidis(SE) in the pts in whom a CAB developed ≤21 days after insertion.

Table 1

<21 Days
>21 Days
P‐Value

SA
20 (58.8%)
21 (21.6%)
p < 0.01

SE
 2 (5.9%)
30 (30.9%)
p < 0.05

Other GP*
 7 (20.6%)
15 (15.5%)
NS

GN^
 9 (26.5%)
40 (41.2%)
NS

*GP: gram‐positive; GN∧: gram‐negative

We conclude that CAB occurs in the first 21 days after CVC insertion in 25% of our CVC pts. Pts developing CAB in the first 21 days are more likely to develop CAB with SA and less likely to develop CAB with SE than pts who develop CAB after 21 days. Empiric antibiotic choice and preventative strategies need to take these data into consideration.
Chronic hepatitis C infection: Prevalance and effect on clinical status of hemodialysis patients in our center
Authors: Özdemir F.N. , Tutal E. , Arat Z. , Zümrütdal A. , Akcay A. , Celik H. , Sezer S. , Haberal M.
Published: January 2005

Hepatitis C virus (HCV) infection affects survival and morbidity of end‐stage renal disease patients and also increases treatment costs. Aim of this study is to define prevalence of HCV infection in our hemodialysis (HD) units and documenting past interventions and clinical status of patients. 711 patients were included. Patient data were collected from 4 HD units of Baskent University. Patient records were examined for demograpic findings, anti‐HCV, HCV RNA, liver biopsy, interferon treatment information, last 12 months’ laboratory values (serum transaminases, albumin, lipid profiles, hemoglobin, C‐reactive protein), and current clinical status, retrospectively. 143 patients (3%) were anti‐HCV positive. These patients’ alanine transferase levels (23.5 ± 20.5 vs 15.5 ± 12.8 U/L, p < 0.0001) and HD duration (97.9 ± 58.6 vs 46.3 ± 35.6 months, p < 0.0001) were significantly higher. No other significant difference could be identified between the groups. Analysis of HD duration of anti‐HCV positive patients revealed that prevalance was increasing as the duration increased. Anti‐HCV positivity was known for a mean of 60.4 ± 38.8 months while 44 patients (30.7%) were already infected at initiation of HD. HCV RNA analysis was positive in 26.7% and a liver biopsy was performed in 23% of patients after 19.8 ± 23.3 months following positive anti‐HCV identification. Minimally active chronic hepatitis C was the most common pathological diagnosis (70, 3%). Only 18 patients (12.5%) recieved interferon therapy. None of the patients had chronic liver disease clinical and physical findings by the time this study was done. HCV infection is a common problem in HD patients that increases the need for medical interventions and treatment.
Morbidity and mortality: Profile of patients on renal replacement therapy in the private sector
Authors: Samaai R., , Uys H.
Published: January 2005

Introduction: 
The aim of renal replacement therapy (RRT) is to achieve a reduction in morbid events and improve quality of life (QOL). Mortality means the condition of being subject to death. Morbidity is anything that is abnormal, atypical, exceptional, and/or aberrant. Morbidity usually occurs as a result of a treatment (side effects), when treatment is inappropriate or inadequate. Predictors that may be risk factors for mortality and morbidity in dialysis patients can be divided into patient‐related and treatment‐related categories (Khan, 2000:11). Purpose of the study: The purpose of this retrospective study was to determine the morbidity and mortality profile of patients receiving RRT in the private sector. Research design and method: This study was contextual and descriptive in nature, based on case analysis of patients receiving RRT in private dialysis facilities. A checklist was used that made provisions to record all patient‐ and treatment‐ related factors that might influence mortality and morbidity profiles of the target population. The target population included all hemodialysis and peritoneal dialysis patients receiving treatment in private dialysis facilities of a specific company. Results: The results indicated the following factors have an influence on patient morbidity and mortality:

Patient related: Age, comorbid situations such as peripheral vascular, cerebrovascular, and cardiovascular disease and also diabetes mellitus.

Treatment related: Referral pattern, nutritional status, dialysis adequacy, anaemia, and blood pressure.
Acute hemolysis and renal failure associated with charcoal hemoperfusion for valproic acid intoxication
Authors: Rahman M.H. , McGoldrick M.D. , Haqqie S.S.
Published: January 2005

Charcoal hemoperfusion is an effective treatment in acute drug intoxication with small volume of distribution. For certain drugs, clearance rates are higher with hemoperfusion than hemodialysis. We describe a patient with severe valproic acid overdose who developed severe hemolysis and acute renal failure related to charcoal hemoperfusion treatment. A 50‐year‐old female was admitted to the hospital following valproic acid overdose. Initial valproic acid level was 73.6 mg/L, and she was treated with oral activated charcoal. Four hours later she developed mental status changes with valproic acid level at 490.9 mg/L and prolonged QT interval. Charcoal hemoperfusion was started with blood flow rate 400 ml/min. Patient developed bleeding with evidence of severe

Before(*C.H.)

After (C.H.)

Hemoglobin
12.1 gm/DL
7.6 gm/DL

Hematocrit
35.5 gm/DL
21.1 gm/DL

Platelet count
268,000 tho/ul
43,000 tho/ul

L.D.H
90 IU/L
2494 IU/L

Valproic Acid
490.9 mg/L
74.1 mg/L

C.H. (Charcoal Hemoperfusion) Blood – evidence of massive hemolysis

intra‐vascular hemolysis, shown in table (no evidence of HUS/TTP). She received transfusion of packed red blood cells, platelets, and fibrin. Over the next few days she developed oligouric acute renal failure requiring hemodialysis for 2 weeks. Eventually hemolysis resolved and the renal function improved (kidney biopsy was consistent with acute tubular necrosis). To our knowledge, this is the first reported case of severe intravascular hemolysis occurring during the charcoal hemoperfusion treatment. Etiology includes mechanical trauma to the red cells, probably related to high blood flow rate through the charcoal column.
Baclofen neurotoxicity in chronic hemodialysis
Authors: Mercieri A. , Mercieri M. , Pedrini L.
Published: January 2005

Baclofen, a GABA agonist, is frequently used to treat muscle spasticity due to spinal cord injury and multiple sclerosis. Baclofen overdose can lead to coma, respiratory depression, hyporeflexia, and flaccidity. Because baclofen is primarily excreted unchanged through the kidneys, it should be given with caution, and it may be necessary to reduce the dosage.Signs of overdose may appear suddenly or insidiously. Acute massive overdose may present as coma. Less sudden and/or less severe forms of overdose may present with signs of CNS depression, excessive salivation, dizziness, nausea and/or vomiting, somnolence, and hypotonia. Should overdose appear likely, the patient should be taken immediately to a hospital. A 46‐year‐old man, who was treated by intermittent hemodialysis (three times a week), was admitted to our unit for signs of CNS depression, dizziness, vomiting, somnolence, and hypotonia. He was treated at the relatively low dose of baclofen, 5 mg/day, because of muscle spasticity due to spinal cord injury. His temperature was 37 °C, and predialysis laboratory data were hemoglobin 11.4 g/dl, white blood cells 6550/mm3 with normal differential count, and platelets 330000/mm3. Serum sodium was 134 mmol/l, potassium 6.4 mmom/l, bicarbonate 18.3 mmol/l, urea 30 mmol/l, creatinine 998 μmol/l, glucose 5.16 mmol/l, and calcium level 2.4 mmol/l. Serum transaminases were normal. A brain computerized tomography (CT) scan showed no abnormalities. Baclofen‐associated encephalopathy was considered to be the most likely etiology for this acute neurological picture. Baclofen was then stopped. Plasma concentration of baclofen was >600 ng/ml (therapeutic range 80–400 ng/ml) after 2 hours of hemodialysis and the baclofen level rapidly fell (<200 ng/ml) at the end of the hemodialysis session. After the first 4‐h haemodialysis session, there was an incomplete recovery of the neurological status. After a renewed hemodialysis session the symptoms completely receded.The patient was discharged from the hospital 72 h later in a good condition. Patients with severely impaired renal function generally develop baclofen intoxication soon after the initiation of low‐dose therapy. Thus, the administration of baclofen, regardless of the dosage, in these patients is not appropriate.
Severe hypercalcemia caused by Milk‐Alkali syndrome requiring urgent hemodialysis – Tums by the ton
Authors: Rai A. , Whaley‐Connell A. , Khanna R.
Published: January 2005

An increased frequency of the Milk‐Alkali syndrome in the last several years has been noticed related to increasing use of calcium carbonate as a phosphate binder in CKD patients, as an antacid or as calcium supplementation. We present a case of severe hypercalcemia secondary to Milk‐Alkali syndrome that precipitated acute renal failure requiring urgent hemodialysis. A 59‐year‐old male with history of hypertension, diabetes mellitus, and acid reflux presented to the ER with confusion, lethargy, nausea, vomiting, and diarrhea. His family relayed a history of recent indigestion and relief with Tums. He was taking several tablets at short intervals to self‐treat the indigestion. At the time of presentation, patient was confused and noted to be dehydrated. Lab findings were significant for elevated BUN/Cr‐ 121 mg/dl/11.1 mg/dl (baseline Cr 1.1 mg/dl few months ago), bicarbonate 38 mg/dl, calcium 16.7 mg/dl, ionized Ca of 1.76 mmol/L, iPTH 10 pg/ml, PTHrP 0.7 pg/ml. Medical management with intravenous fluids and furosemide showed no improvement in renal failure, or calcium level. Patient was then started on hemodialysis with 2.0 mmol/L calcium in the dialysate the next day. There was gradual improvement in patient's mental status, calcium values, and renal failure over the ensuing 2 weeks.

Discussion and Conclusions: 
The diagnosis of Milk‐Alkali syndrome is made on the basis of history. Metabolic abnormalities involved in this syndrome are hypercalcemia with low to normal PTH and Vit. D levels, renal failure, and metabolic alkalosis. Failed medical management required acute dialysis in this patient. Acute hemodialysis in such a case could be life saving. Due to increasing use of calcium carbonate for dyspepsia and osteoporosis, patients should be made aware of these severe, potentially life‐threatening adverse effects.
A case of Ehrlichiosis mimicking course of thrombotic thrombocytopenic purpura requiring hemodialysis
Authors: Sowers K. , Whaley‐Connell A. , Khanna R. , Katyal A.
Published: January 2005

We present an atypical presentation of Ehrlichiosis induced sepsis requiring hemodialysis. Ehrlichiosis is a common tick‐borne illness in Missouri, and in this case mimicks the course of thrombotic thrombocytopenic purpura (TTP). A 48‐year‐old male with a history of marginal zone lymphoma had received radiation and chemotherapy with fludarabine. He was admitted to oncology service for evaluation of nausea and vomiting and generalized malaise. His initial laboratory data revealed platelet count 16,000 mm3, WBC 3,800 mm3, AST 327 units/L, ALT 185 units/L, BUN/Creatinine 53 mg/dl/3.8 mg/dl. Because the peripheral smear showed a morulae consistent with human granulocytic Ehrlichiosis, intravenous doxycycline 100 mg twice daily was initiated. Acute renal failure was thought due to hemodynamic changes, but the role of TTP remained in the differential diagnosis. On hospital day two, he became confused and lethargic and continued to be febrile. Hours later, he developed tonic‐clonic seizures and became hypotensive. A clinical diagnosis of TTP was made. Peripheral smear showed only a few schistocytes, inconsistent with TTP. Microangiaopthic anemia, thrombocytopenia, sepsis with DIC, and multi‐organ failure sustained the acute renal failure. Hemodialysis was used for ARF over the next several days in conjuction with IV doxycycline. The patient improved without plasmapharesis. Kidney function returned back to normal in due course of time. A final diagnosis of ehrlichia‐induced sepsis with ARF was made. Conclusion: Ehrlichiosis is endemic in Missouri and usually presents with thrombocytopenia, leukopenia, and elevated liver function tests; however it rarely presents with sepsis. The course of this case was made unusual possibly due to chemotherapy, fludarabine for the treatment of lymphoma, which can commonly cause micrangiopathic anemia, myelosuppression, and even a leukopenia for several years afterwards. This presentation mimicking TTP can be confusing but has previously been documented as a complication of severe Ehrlichiosis in the immunocompromised state.
Experimental study on a new type citrate anticoagulant hemodialysate in dogs
Authors: Baosong G. , Ning N. , Ganglian Y. , Lin G. , Liangqi W. , Ruijun G.
Published: January 2005

Objective: 
In this study, we initiated a new hemodialysate with citrate buffer, observed the factors that influence the citrate concentration of solution in hollow fibers when using citrate hemodialysate, and observed the anticoagulant effect and safety of the citrate hemodialysate in the experiment in dogs. Methods: Ten dogs were given intermittent hemodialysis and were divided into 3 groups according to hemodialysis procedures. Group 1 was saline‐flush hemodialysed with bicarbonate hemodialysate; Group 2 was hemodialysed with citrate hemodialysis without any anticoagulant; Group 3 was hemodialysed with bicarbonate hemodialysate and heparin. ACT, Ca++, BUN, Cr, ALT, AST, TBIL, DBIL, Na+, Cl−, , and venous pressure were monitored in the animals of each group during hemodialysis. Results: During the hemodialysis in Group 1, venous pressure increased lastingly, resulting in the failure of hemodialysis for 2 hours. Hemodialysis for 2 hours in Group 2 were all finished successfully. ACT was extended and Ca++ decreased obviously in the venous end during hemodialysis. And ALT, AST, Ca++, K+, Na+, Cl−, after the hemodialysis in Group 2 were not changed (P > 0.05). Moreover, the clearance rate of the dialyzers with citrate dialysate increased significantly compared with those of saline‐flush and heparin anticoagulation. Conclusions: The anticoagulant and dialytic effects of the new type citrate hemodialysis are satisfactory and better than that of saline‐flush.
Multiple factors affect 3‐year survival of patients on chronic hemodialysis
Authors: Sugahara S. , Kanno Y. , Moriwaki K. , Ikeda N. , Takane H. , Kotaki S. , Aoki H. , Ooshima J. , Suzuki H.
Published: January 2005

Objective: 
The aim of this study is to determine the factors contributing to survival of patients on hemodialysis. Methods: Data were collected from 8 dialysis centers, and 432 patients were recruited. Among them, patients who underwent hemodialysis thrice a week for more than 3 years and received antihypertensive therapy or had systolic blood pressure of more than 160 mm Hg before dialysis secession were selected. Subsequent survival status and cause of death were ascertained for the next 3.5 years. The logistic multivariate regression analysis was used to estimate the relative risk of death. Variables used for the purpose of this analysis were patient gender, age, underlying renal disease (unknown and others (0), CGN (1), DM (2)), medication, serum albumin, history of having cerebrovascular and/or cardiovascular accidents (yes or no), the levels of serum creatinine, blood urea nitrogen, pre‐ and post‐dialysis blood pressure (systolic and diastolic), hemoglobin, serum calcium and inorganic phosphate, β2‐microglobulin, intact PTH, and other laboratory data. Results: First step logistic regression analysis indicated age, underlying renal diseases, serum creatinine, GOT, β2‐microglobulin were associated with increased relative risk (RR) of dying. According to the formula calculated in this analysis, if the levels of serum creatinine increased 1 mg/dl, the ratio of dying increased by 1.210. Also, compared to the patients aged between 50 to 64 years old, the patients aged between 65 to 90 years old had 1.521 times dying ratio. Conclusions: From this study, it is suggested that age, creatinine, underlying renal diseases, β2‐microblobulin, past history of cerebrovascular disease, serum creatinine, and GOT were important factors contributing to patients’ survival.
Vitamin D receptor BsmI and TagI gene polymorphisms in Turkish ESRD population and influences on parathyroid hormone response
Authors: Sezer S. , Özdemir F.N. , Tutal E. , Sahin F. , Akcay A. , Haberal M.
Published: January 2005

Background/Aim: 
Clinical presentation and complications of end‐stage renal disesase (ESRD) patients are under influence of many enviromental and genetic factors. In this study we aimed to define frequencies of BsmI and TagI Vitamin D receptor (VDR) gene polymorphisms and possible influences on clinical presentations in Turkish ESRD population. Methodology and Patients: 186 patients (111 male, 75 female) who are being maintained on hemodialysis were included. Genotyping was performed for the insertion/deletion BsmI (B→b, restriction site, exon VIII→IX), TagI (T→t, 352 exon IX) VDR gene polymorphisms. Last 12 months’ laboratory values (C‐reactive protein, intact parathyroid hormone, albumin, calcium, phosphorus, Ca x P product) and clinical findings (vitamin D requirement, body weight) were recorded and analysed retrospectively. Results: Mean age and follow‐up period lengths were 42.1 ± 12.6 years and 76.3 ± 43.9 months, respectively. Polymorphism percentages were as follows: BsmI; BB/Bb/bb: 28.9/65.3/5.8%, TagI; TT/Tt/tt: 36.7/60.5/2.8%, respectively. Further analysis revealed that TT variant of TagI was related with hyperparathyroidism (p < 0.05). Analysis of data after regrouping patients according to iPTH levels (0–249, 250–499, 500 + pg/mL) and hemodialysis duration (<60 vs ≥60 months) revealed that influence of TT variation on hyperparathyroidism became more frequent in case of increased hemodialysis duration and iPTH levels (p < 0.005). Conclusion: TT variation of TagI VDR gene influences the development of hyperparathyroidism in HD patients. This influence becomes more evident in patients with longer HD duration.
Sodium modeling, hypotension, and weight gain in HD
Authors: Bland A.C. , Pyszka L. , Pflederer B.R.
Published: January 2005

Sodium modeling is a strategy to decrease the incidence of hypotension during hemodialysis. Side effects include increased interdialytic weight gain. By default, all patients at our dialysis center are started on HD with sodium modeling. Purpose: To compare weight gain and blood pressure after discontinuation of sodium modeling. Methods: Ten patients using sodium modeling were changed to a standard sodium bath after a change in attending physician. After IRB approval, we collected and retrospectively reviewed the change in interdialytic weight gains, episodes of hypotension (defined as an episode of hypotension requiring staff intervention), and starting and ending blood pressure. Data from one week prior to Na change (PRE) was compared to one week after Na change (POST) using a paired samples t‐test. Results: Data from 4 men and 6 women with a mean age of 65.2 ± 13.7 years was reviewed. ESRD diagnoses included diabetes (n = 4) and hypertension (n = 6). Interdialytic weight gain significantly decreased after discontinuation of sodium modeling (PRE 3.86 kg, POST 3.11 kg, p = 0.004). No significant change in blood pressure at the start (PRE 154/82 POST 156/83, p = 0.745) or end of HD (PRE 123/69, POST 130/67, p = 0.201) was observed. However, the frequency of symptomatic hypotension increased after change to standard sodium bath (PRE = 6%, POST = 27%, p = 0.031). All episodes of hypotension occurred in 3 of the 10 study patients. No patient required cessation of HD or transfer to the emergency department. The degree of weight gain was not correlated with the likelihood of intradialytic hypotension. Conclusion: A change from sodium modeling to standard sodium dialysate lowers interdialytic weight gain but increases the incidence of mild symptomatic hypotension. Further study is needed to determine whether mild hypotension is preferable to increased interdialytic weight gain and to determine the relationship of increased weight gain to complications of volume overload such as LVH and CHF.
Managing “change” in HD unit
Authors: Christopoulou S.J.
Published: January 2005

In this paper we’ll discuss how change management affects hemodialysis improvement. As hemodialysis is a technology dependent method of End Stage Renal Disease (ESRD) treatment, it is obvious that the need of continuous revisions in health care practices and researches on staff training are significant factors for success. “Change” defined as an attempt to replace existing knowledge with new. Change achievement is not always a simple procedure. In this study we examine nurses and patients reactions on changes and how can we accomplish successful changes every time they are needed. We also examine how changes in role of health care team can lead the team to our final destination, which is to provide the best hemodialysis treatment we can. Leadership, communication, informing, planning, and adjusting are the main contents for successful change management. We believe that we can improve haemodialysis practices and health care by giving learning opportunities to our nurses. Nursing training development can help them to follow changes. On the other hand we can get our patients to come on board with us on any change by encouragement and consistent try. As Hereticus said, “Nothing that is, has to be just because it is.” Therefore, we should keep thinking about managing changes all the time!
Central venous stenosis in chronic hemodialysis patients: The effect of percutaneous angioplasty and stenting
Authors: Yoon J.M. , Park J.A. , Jung H.A. , Kim Y.O. , Kim Y.S. , Yoon S.A. , Kim S.Y. , Chang Y.S. , Bang B.K.
Published: January 2005

Background: 
Central venous stenosis in chronic hemodialysis patients occurs in about 17% of all venous stenosis and it is associated with central vein catheterization. We evaluated the effect of percutaneous angioplasty and stenting in the treatment of central venous stenosis in hemodialysis patients. Methods: We retrospectively investigated the medical records of a total of 31 dialysis patients who had central venous stenosis. We reviewed the causes of central venous stenosis, clinical manifestations, venographic findings, and patency rate of radiological intervention. Results: Of the total 31 patients, 28 patients had past history of central vein catheterization ipsilateral to vascular access. Mean duration of the catheterization was 32 ± 14 days. Venography showed complete obstruction of central vein (n = 14) and stenosis (n = 17). The site of venous lesion was right subclavian vein (n = 11), innominate vein (n = 9), left subclavian vein (n = 7), and superior vena cava (n = 14). A total of 30 procedures of angioplasty with or without stenting were performed in 26 of 31 patients. Initial success rate was 96.1% and there was no severe complication such as rupture or bleeding. The primary patency rate at 6, 12, 24, and 48 months after the procedure was 87.3%, 75.6%, 67.9%, and 65.4%, respectively. The cumulative patency rate at the same time point was 96.0%, 90.6%, 74.0%, and 72.8%, respectively. Conclusion: Our data suggest that angioplasty with or without stenting is safe and effective in the treatment of central venous stenosis in hemodialysis patients.
The economics and practicality of t‐PA vs tunnel catheter replacement for hemodialysis
Authors: Kaiser Permanente Cairoli O.
Published: January 2005

Introduction: 
Thrombolytic therapy is an important treatment modality for thrombosis‐related catheter occlusion. Central venous access devices (CAVDs) are essential tools for the administration of many therapeutic modalities, especially for patients requiring lifetime therapy like hemodialysis. There are several reasons to salvage the occluded catheter. Catheter replacement results in an interruption of therapy delivery. This interruption may result in complications such as life‐threatening metabolic and physiologic states. In addition, the patient's future access sites for CAVDs may be affected. The data released in the 2001 Annual Report – ESRD Clinical Performance Measures Project (Department of Health and Human Services, December 2001) shows 17% of prevalent patients were dialyzed with a chronic catheter continuously for 90 days or longer. In the pediatric population the data shows that 31% were dialyzed with a chronic catheter. The most common reasons for catheter placement included: no fistula or graft created (42%) and fistula and graft were maturing, not ready to cannulate (17%). Five percent of patients were not candidates for fistula or graft placement as all sites had been exhausted. Methods: A short study was done in our medical center to evaluate the results of t‐PA vs. changing the tunnel catheter. On an average a catheter costs about $400.00. If you add the cost of specialty personnel such as an interventional radiologist, radiology technician, radiology nurse, and the ancillaries such as the room, sutures, gauze, and tape, the total could reach $2000.00 easily. Cathflo™ Activase® costs around $60.00 for a single dose. T‐PA was reconstituted by pharmacy personnel in single vials containing 2 mg/2 ml. Now with Cathflo, vials are stored in the renal clinic's refrigerator and when the need arises, the RN reconstitutes the medication. The RN, using established protocols, will instill Cathflo in the catheter following the volume requirements of the various tunnel catheters. After the t‐PA is placed, the patient is sent home with instructions to return to their dialysis center the next day (arrangements are made by the RN as needed). In seventeen patients (17) with tunnel catheter malfunctions due to inadequate flow, not related to placement, t‐PA was used. Of those 17 patients 2 were unable to use their catheter on their next dialysis treatment date, yielding an 88% success rate. This compares with clinical trials in which there is an 83% success rate with a dwell time of 4 hours, or an 89% rate on patients having a 2 hour dwell time (t‐PA was repeated a second time if flow was not successfully restored. Results: 15/17 patients in our retrospective study showed that Cathflo worked successfully in restoring blood flow. Two catheters needed to be exchanged. The cost savings were significant when we compared the average cost of an exchange ($2000) versus using t‐PA ($170 including nursing time). Conclusion: Cathflo is not just safe and practical to use but also cost effective.
Preliminary experience with a new design for a tunneled, cuffed catheter for hemodialysis
Authors: Bousquet G.C
Published: January 2005

Purpose: 
The use of tunneled, cuffed central venous catheters for hemodialysis is associated with poor flow, thrombosis, and infections due to the transcutaneous nature of these devices. A new design for a sutureless, tunneled cuffed catheter was evaluated in hemodialysis patients to determine the effect of its design on the incidence of exit site infection. Methods: A polyurethane conduit with a uniquely designed cuff and subcutaneous skirt covered with Dacron velour was attached to standard double lumen central venous catheters. Seven (7) Ash catheters and one (1) Tesio catheter were fitted with the overtube and skirt and implanted in eight (8) patients undergoing routine hemodialysis. Patients were monitored for exit site infection, tunnel infection, bacteremia, cuff extrusion, and serosanguineous exudate. Results: Catheters were implanted for 6 to 26 weeks. All catheters remained patent and no cases of bacteremia were observed. There was no evidence of exit site or tunnel infection, and no reported serosanguineous exudate from the exit site. Exit site care consisted of soap and water cleansing by the patient. Patients were able to shower or bathe 4 weeks post‐implant. Conclusions: The new design for a subcutaneous cuff and skirt appears to inhibit exit site infection and other common complications of central venous catheters.
Kinetics, dialysis systems, adequacy  Postdialysis rebound in a case of acute methanol poisoning
Authors: Bhakta N.R , Grabe D.W. , Haqqie S. , John L.
Published: January 2005

Introduction: 
Methanol poisoning can lead to complications that include metabolic acidosis, visual impairment and death. Treatment options include ethanol, fomepizole, and hemodialysis (HD). Objective: To report on the occurrence of post dialysis methanol rebound during treatment. Method and Findings: A 40‐year‐old male with a history of schizophrenia and suicide attempts presented to the emergency room after reportedly ingesting 1 quart of windshield washer fluid. The patient presented with a preliminary blood chemistry of methanol 390 mg/dL, ethanol 48 mg/dL, glucose 93 mg/dL, Na 138 meq/L, K 3.8 meq/L, Cl 98 mmol/L, CO2 26 mmol/L, urea 16 mg/dL, creatinine 1.2 mg/dL, and an anion gap of 14 mmol/L. The patient was started on 1360 mg of fomepizole (12:50 AM) followed by HD for 4 hours. A second dose of fomepizole (900 mg) was administered at 8:00 AM. In addition, another HD session was started at 12:00 PM and continued for 4 hours. A third dose of fomepizole (700 mg) was administered at 8:50 PM. Finally, a third HD session was started the next day at 3:05 PM and lasted 3 hours. Table 1 illustrates methanol levels in relation to each HD session. Findings: Methanol concentration after the first HD increased from 100 mg/dL to 127 mg/dL (27%) in 5 h 20 m. It also increased from 35 mg/dL to 50 mg/dL (43%) 14 h 45 m after the second HD. Conclusions: Close attention must be paid to the potential for post dialysis methanol rebound. It is recommended that methanol levels continue to be monitored for several hours after HD.

Methanol levels before and after each hemodialysis

Start HD #1

 (2:40 AM)
End HD #1

 (6:40 AM)
Start HD#2

 (12:00 PM)
End HD#2

 (4:00 PM)
Next Day  (6:45 AM)

Methanol (mg/dL)
324
100
127
35
50

Rebound

27%

43%
Impact of geometrical fiber dimensions on dialyzer efficiency
Authors: Eloot S. , Vierendeels J. , Verdonck P.
Published: January 2005

While dialyzer manufacturers only provide information about their products as a black box, this study aimed at optimizing dialyzer geometry by looking in detail at transport processes and fluid properties inside the dialyzer using numerical modeling. A three‐dimensional computer model of a single hollow fiber with its surrounding membrane and dialysate compartment was developed. Different equations govern blood and dialysate flow (Navier‐Stokes), radial filtration flow (Darcy), and solute transport (convection‐diffusion). Blood was modeled as a non‐ Newtonian fluid with a viscosity varying in radial and axial direction because of the influence of local hematocrit, diameter of the capillaries, and local shear rate. Dialysate flow was assumed as an incompressible, laminar Newtonian flow with a constant viscosity. The permeability characteristics of the asymmetrical polysulphone membrane were calculated from laboratory tests for forward and backfiltration. The influence of the oncotic pressure induced by the plasma proteins was implemented as well as the reduction of the overall permeability caused by the adhesion of a protein layer on the membrane. Urea (MW60) was used as a marker to simulate small molecule removal, while middle molecule transport was modeled using vitamin B12 (MW1355) and inulin (MW5200). The corresponding diffusion coefficients were determined by counting for the fluid and membrane characteristics. Fiber diameter and length were changed in a wide range for evaluation of solute removal efficiency. The presented model allowed us to investigate the impact of flow, hematocrit, and capillary dimensions on the presence and localization of backfiltration. Furthermore, mass transfer was found enhanced for increased fiber lengths and/or smaller diameters, most pronounced for the middle molecules compared to urea.