American journal of kidney diseases : the official journal of the National Kidney Foundation
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Case Reports
Successful treatment of bleeding from colonic angiodysplasias with tranexamic acid in a hemodialysis patient.
Colonic angiodysplasias are a common source of gastrointestinal bleeding in patients with end-stage renal disease (ESRD). It is well known that bleeding from angiodysplasias can be a difficult therapeutic problem. ⋯ A successful management of both the acute and chronic bleeding was achieved. No complications in terms of arterial or venous thrombosis were observed.
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Withholding and withdrawing dialysis are subjects of major concern to nephrologists, because both result in a significant number of end-stage renal disease (ESRD) patient deaths. The medical literature on withholding dialysis is extremely limited, and that on withdrawing dialysis consists mainly of retrospective studies from the 1980s. The present study was conducted to identify ways to improve dialysis decision making by providing a current understanding of how decisions to withhold or withdraw dialysis are being made and by examining whether some patients who might benefit from dialysis are not being referred. ⋯ In deciding not to refer a patient for a dialysis evaluation, 25% of primary care physicians did not consult a nephrologist; 60% cited age as a reason not to refer. These findings suggest that dialysis decision making might be improved by educating nephrologists about the ethics and law of withdrawing dialysis and about how to implement successfully advance care planning so that advance directives will be present and helpful when decisions need to be made for incapacitated dialysis patients. Education of primary care physicians about when to refer patients with chronic renal failure for a dialysis evaluation might also result in more referrals for patients who will benefit from dialysis.
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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.