American journal of kidney diseases : the official journal of the National Kidney Foundation
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Infraclavicular and internal jugular catheterization are commonly used techniques for hemodialysis access, but may at times be impeded in patients whose anatomy makes cannulation difficult. In an effort to enlarge the spectrum of alternative access sites, we evaluated the supraclavicular approach for large-bore catheters. During an 18-month period we prospectively collected data on success rate and major and minor complications of the supraclavicular access for conventional dialysis catheters as well as Dacron-cuffed tunneled devices in 175 adult patients admitted for various extracorporeal therapies and bone marrow transplantation. ⋯ Difficulty of introducing the catheter via a placed sheath was rarely observed. There was no clinically significant evidence of catheter-induced venous thrombosis or stenosis. We conclude that the supraclavicular route is an easy and safe first approach for large-bore catheters, as well as a useful alternative to traditional puncture sites for precatheterized and anatomically problematic patients.
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Comparative Study
Intradialytic hypotension: is midodrine beneficial in symptomatic hemodialysis patients?
Symptomatic hypotension during hemodialysis is a disabling complication in end-stage renal disease (ESRD) patients, especially in certain groups of patients who are at higher risk for this problem. Autonomic dysfunction is thought to play a significant role. We evaluated the efficacy of midodrine, an oral agent with selective alpha-adrenergic agonist activity used in the treatment of neurogenic orthostatic hypotension, on 10 hemodialysis patients with persistent intradialytic hypotension. ⋯ Other than scalp paresthesia in one patient, no adverse effects were noted. Our results suggest that the administration of a single dose of midodrine before hemodialysis is an effective therapy for intradialytic hypotension. A prospective trial with adequate patient numbers and long-term follow-up would be useful to evaluate this drug's efficacy and safety profile in patients with ESRD.
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Comparative Study
Reticulocyte hemoglobin content predicts functional iron deficiency in hemodialysis patients receiving rHuEPO.
Early detection of iron sufficiency at the level of the erythropoietic cell is necessary to optimize management of uremic anemia with recombinant human erythropoietin (rHuEPO). "Absolute" and "functional" iron deficiency are the most important factors causing resistance to administered rHuEPO. Transferrin saturation and serum ferritin measurements have been noted to be insensitive and inaccurate measures to detect functional iron deficiency. Recently, the reticulocyte hemoglobin content (CHr) has been shown to be a sensitive and specific indicator of functional iron deficiency in nondialysis patients treated with rHuEPO. ⋯ Eighty-two percent of individuals who were iron deficient at baseline responded to intravenous iron with an increase in CHr of greater than 2 pg. Sixty percent of patients who were iron sufficient by usual iron indices also responded to intravenous iron with a CHr rise of greater than 2 pg, suggesting that they were, in fact, functionally iron deficient despite "normal" conventional iron parameters. We conclude that CHr may be a more sensitive marker of functional iron deficiency in rHuEPO-treated hemodialysis patients than percent transferrin saturation and ferritin, particularly in those with "normal" conventional iron parameters.
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Leptospirosis, caused by a spirochete, is the most common zoonosis in domestic or wild animals. Animals excrete infected urine in soil or water and may cause human infections through abrased wound, mucosa, conjunctiva, or by swallowing contaminated water. Clinical presentations of leptospirosis are mostly subclinical. ⋯ Because active surveillance has resulted in 13 cases diagnosed as leptospirosis islandwide thereafter, underestimation and ignorance of leptospirosis as a cause of acute renal failure may occur in Taiwan. Therefore, an area with a low leptospirosis incidence may actually have a very high incidence. Leptospirosis should be suspected in febrile patients with jaundice and renal failure when pathogens cannot be identified by traditional culture for microorganisms.
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Quality assessment efforts to enhance public accountability in dialysis care and to support provider efforts to improve care have lacked patient input. To develop brief patient evaluation or satisfaction surveys suitable for busy clinical settings, knowing patients' priorities can be helpful in deciding which aspects of care should be tracked. We conducted a study to identify salient attributes of dialysis care and to rank the importance of these attributes from the perspective of dialysis patients. ⋯ Patients value certain aspects of dialysis care highly, and these aspects differed in some respects for the relatively small number of hemodialysis and peritoneal dialysis patients studied. Construction of brief questionnaires for quality assessment and assurance requires thoughtful consideration of what questions to include. Knowing patients' priorities regarding the most important aspects of care that have high potential for dissatisfaction may be helpful to continuous quality improvement of end-stage renal disease care.