Dialysis and Kidney Transplantation

This paper aims to evaluate the role that personal appeals for organ donations have played throughout the history of transplantation, with particular attention to the diverse relationships such appeals have had with public policy regarding organ transplantation—at times seeming to animate policy developments, while at other times assuming an antagonistic role vis-à-vis the medical and legal establishments—and the further ethical issues implicated by the advent of social media as a tool to facilitate these exchanges. In Part I, I will recount the history of modern treatment for kidney disease, and how its development set up a paradigm that deeply entwined the federal government and the medical establishment. I will discuss the complex history of the earliest widely-used treatment for kidney failure—dialysis—paying special attention to the issues of scarcity and allocation that have complicated this treatment since the opening of the first long-term dialysis clinics in the early 1960s. I will discuss how the success of kidney transplantation created new problems of supply and demand that resemble those associated with dialysis in the past. I will recount the history of legislation related to kidney disease and organ donation, including a discussion of the role that personal emotional appeals have played in shaping public policy related to the treatment of kidney disease, even before transplantation became the preferred method of treatment. In Part II, I will provide statistics to illustrate the gravity of the issues that characterize our current system of regulating organ transplantation. Then, I will describe the values that motivate our organ donation and allocation system, and the conflicts they can engender. In Part III, I aim to further elucidate the profound moral issues implicated in organ transplantation by discussing the experience of having end stage renal disease, and relating the reality of this experience to an analysis of the rhetoric surrounding kidney transplantation in the United States. Part IV will address various issues concerning directed donations from living organ donors. First, I will discuss the notable absence of regulation with regard to organ donations from living donors, explaining why this regulatory gap exists, and how it has led to further controversy and dysfunction within the organ transplantation system. Second, I will discuss concerns unique to living kidney donation, and how the medical and legal establishments have responded to these concerns in crafting the transplant process as it operates today. Next, I will analyze trends in living donation, specifically the increasing popularity of non-related directed donations. I will discuss the ethical issues implicated in this trend, including the permissibility of directed donation, how certain types of directed donation conflict with the values that constitute the backbone of our current organ transplantation system, and the question of risk to both donor and recipient. I will then specifically address the role of social media and the Internet in facilitating this trend, and the ways in which new social media platforms to facilitate living donation may serve to exacerbate inequalities in organ allocation. In Part V, I will propose a way to harness the power of social media in order to facilitate increased donation, and make several suggestions for improving our policy regarding living organ donation.

BACKGROUNDHypoglycemia is the principle adverse effect of sulfonylurea, especially in patients with renal failure. Conventional treatment consists of hypertonic dextrose, sometimes combined with glucagon. However, paradoxically both agents can stimulate insulin secretion and induce rebound hypoglycemia.Hypoglycemia is the principle adverse effect of sulfonylurea, especially in patients with renal failure. Conventional treatment consists of hypertonic dextrose, sometimes combined with glucagon. However, paradoxically both agents can stimulate insulin secretion and induce rebound hypoglycemia.PATIENTWe present the case of a hemodialysis patient with relapsing gliclazide-induced hypoglycemia in the context of sepsis.We present the case of a hemodialysis patient with relapsing gliclazide-induced hypoglycemia in the context of sepsis.RESULTSOur patient failed to respond to regular infusions of hypertonic dextrose and oral carbohydrates. His hypoglycemia only resolved after a single dose of octreotide. The pathophysiology of recurrent sulfonylurea-induced hypoglycemia and the challenges of current therapies are discussed. The somatostatin analogue octreotide inhibits insulin release and has been proposed as an antidote for sulfonylurea overdose.Our patient failed to respond to regular infusions of hypertonic dextrose and oral carbohydrates. His hypoglycemia only resolved after a single dose of octreotide. The pathophysiology of recurrent sulfonylurea-induced hypoglycemia and the challenges of current therapies are discussed. The somatostatin analogue octreotide inhibits insulin release and has been proposed as an antidote for sulfonylurea overdose.CONCLUSIONSWe propose that octreotide has a clinical role in the treatment of patients with renal failure and sulfonylurea- induced hypoglycemia.We propose that octreotide has a clinical role in the treatment of patients with renal failure and sulfonylurea- induced hypoglycemia.

OBJECTIVEThe purpose of this review was to study the prevalence of and establish an association between biochemical markers and the underlying rate of bone turnover in renal osteodystrophy.The purpose of this review was to study the prevalence of and establish an association between biochemical markers and the underlying rate of bone turnover in renal osteodystrophy.METHODSUsing the PubMed database, we undertook a systematic review of literature using studies that included bone histology in combination with serum biochemical markers among chronic kidney disease (CKD) patients, published between 1985 and 2007. Studies having at least 3 of 7 serum biochemical markers were chosen for this review.Using the PubMed database, we undertook a systematic review of literature using studies that included bone histology in combination with serum biochemical markers among chronic kidney disease (CKD) patients, published between 1985 and 2007. Studies having at least 3 of 7 serum biochemical markers were chosen for this review.RESULTSOf the dialysis patients who were recipients of 1,701 bone biopsies, 41% had hyperparathyroid bone disease, 5% had osteomalacia, and 33% had adynamic bone disease. Among CKD patients not on dialysis, of a total of 1,316 bone biopsies, 34% had hyperparathyroid bone disease, 19% had osteomalacia, and 8% had adynamic bone disease. Dialysis patients who had high-turnover bone disease compared with those with low bone turnover had significantly higher levels of parathyroid hormone, serum alkaline phosphatase, bone-specific alkaline phosphatase, and osteocalcin. A similar relationship was observed among CKD patients not on dialysis. There was significant individual variation in bone turnover biochemical markers.Of the dialysis patients who were recipients of 1,701 bone biopsies, 41% had hyperparathyroid bone disease, 5% had osteomalacia, and 33% had adynamic bone disease. Among CKD patients not on dialysis, of a total of 1,316 bone biopsies, 34% had hyperparathyroid bone disease, 19% had osteomalacia, and 8% had adynamic bone disease. Dialysis patients who had high-turnover bone disease compared with those with low bone turnover had significantly higher levels of parathyroid hormone, serum alkaline phosphatase, bone-specific alkaline phosphatase, and osteocalcin. A similar relationship was observed among CKD patients not on dialysis. There was significant individual variation in bone turnover biochemical markers.CONCLUSIONSA combination of serum biochemical markers might predict underlying renal osteodystrophy better than would individual biochemical markers. A predictive model using bone histology and biochemical markers can be developed in the future.A combination of serum biochemical markers might predict underlying renal osteodystrophy better than would individual biochemical markers. A predictive model using bone histology and biochemical markers can be developed in the future.

BACKGROUNDVascular calcification is increasingly appreciated as an important risk factor for cardiovascular morbidity and mortality.Vascular calcification is increasingly appreciated as an important risk factor for cardiovascular morbidity and mortality.AIMSTo assess (1) the evolution of coronary calcification and (2) the relationship of the progression of coronary calcification with risk factors and adverse cardiovascular events.To assess (1) the evolution of coronary calcification and (2) the relationship of the progression of coronary calcification with risk factors and adverse cardiovascular events.METHODSWe performed repeated 16 row multidetector computed tomography (CT) with an interval of 1 year on 33 patients on chronic hemodialysis.We performed repeated 16 row multidetector computed tomography (CT) with an interval of 1 year on 33 patients on chronic hemodialysis.RESULTSProgression of coronary artery calcification was found in 70% of patients with a mean significant difference of calcium score. Patients older than 65 years demonstrated a higher progression of coronary calcification and patients who received non-calcium phosphate binder treatments demonstrated less progression. During the year, 6 adverse cardiovascular events occurred. A total of 22% of patients with progression of coronary calcification had a cardiovascular event (p = .003). Factors associated with adverse cardiovascular events included diabetes, male gender, history of cerebrovascular and coronary disease, secondary hyperparathyroidism, hyperphosphatemia, and calcification of circumflex and right coronary arteries.Progression of coronary artery calcification was found in 70% of patients with a mean significant difference of calcium score. Patients older than 65 years demonstrated a higher progression of coronary calcification and patients who received non-calcium phosphate binder treatments demonstrated less progression. During the year, 6 adverse cardiovascular events occurred. A total of 22% of patients with progression of coronary calcification had a cardiovascular event (p = .003). Factors associated with adverse cardiovascular events included diabetes, male gender, history of cerebrovascular and coronary disease, secondary hyperparathyroidism, hyperphosphatemia, and calcification of circumflex and right coronary arteries.CONCLUSIONSCoronary artery calcification progression is common, represents a risk factor to adverse cardiovascular events, and is associated with modifiable risk factors in chronic hemodialysis. Multidetector CT seems to be an effective and readily applicable method to assess and quantify the progression of coronary artery calcification.Coronary artery calcification progression is common, represents a risk factor to adverse cardiovascular events, and is associated with modifiable risk factors in chronic hemodialysis. Multidetector CT seems to be an effective and readily applicable method to assess and quantify the progression of coronary artery calcification.

Postoperative perinephric collections are known complications of a transplant kidney with decapsulation injury being one of its rare etiologies. It can be early onset due to capsular injury during laparoscopic donor nephrectomy or late onset usually due to immunosuppressive medications or spontaneous in nature. We report a rare case of late onset decapsulation injury following insertion of a percutaneous nephrostomy drain for treating hydronephrosis. It was subsequently treated with marsupialization of the collection and creating a peritoneal window. Complete resolution of the perinephric collections was noted on follow up. On review literature, it was found that there is no unanimous management protocol related to decapsulation injuries. We have made an attempt to concise various treatment approaches mentioned in the literature for such cases and their outcomes. In case of patients with late onset decapsulation injuries such as ours, marsupialization has shown success in majority of cases obviating the need for nephrectomy. We suggest that marsupialization can form a reliable first line treatment following late onset decapsulation without any clear etiology, in majority of cases. Arch Clin Med Case Rep 2017; 1 (3): 76-83 76

Objective.The aim of this study was to assess and explore medical students' attitudes toward tissue and organ donation and their willingness to donate their own organs or those of a deceased relative in a setting without well-organized organ donation programs and education.The aim of this study was to assess and explore medical students' attitudes toward tissue and organ donation and their willingness to donate their own organs or those of a deceased relative in a setting without well-organized organ donation programs and education.Methods.Medical students from all 6 years of medical studies were surveyed using a questionnaire that included attitude and willingness measures. We also asked the medical students about the feelings they would expect to experience if they had the responsibility of asking family members of a recently deceased patient about donating the patient's organs.Medical students from all 6 years of medical studies were surveyed using a questionnaire that included attitude and willingness measures. We also asked the medical students about the feelings they would expect to experience if they had the responsibility of asking family members of a recently deceased patient about donating the patient's organs.Results.Participants had highly positive attitudes toward tissue and organ donation and a great willingness to donate tissues and organs. Students in this study were more willing to donate if the purpose was helping others than if the purpose was to help the development of science, and they were more willing to donate their own organs than those of a deceased family member. Although students were willing to donate all organs, the organ they were most willingness to donate after death was the kidney. Participants who had signed donor cards held more positive attitudes about organ donation and were more willing to donate organs than were participants who had not signed donor cards. More than half the medical students said they would feel uncomfortable if in a situation of asking others for organ donation.Participants had highly positive attitudes toward tissue and organ donation and a great willingness to donate tissues and organs. Students in this study were more willing to donate if the purpose was helping others than if the purpose was to help the development of science, and they were more willing to donate their own organs than those of a deceased family member. Although students were willing to donate all organs, the organ they were most willingness to donate after death was the kidney. Participants who had signed donor cards held more positive attitudes about organ donation and were more willing to donate organs than were participants who had not signed donor cards. More than half the medical students said they would feel uncomfortable if in a situation of asking others for organ donation.Conclusion.These findings suggest there is a constant need for structured education of medical students in the practical, legal, and ethical aspects of organ and tissue donation.These findings suggest there is a constant need for structured education of medical students in the practical, legal, and ethical aspects of organ and tissue donation.

OBJECTIVEAnemia is a major clinical problem in patients receiving dialysis therapy and has a substantial impact on morbidity and mortality. Iron metabolism is impaired in chronic kidney disease. Hepcidin functions as a key regulator of iron metabolism. The aims of this study were to compare the serum pro-hepcidin levels in patients with either peritoneal dialysis (PD) or hemodialysis (HD) and control subjects and to evaluate pro-hepcidin and C-reactive protein (CRP), iron parameters, and hemoglobin levels in PD and HD patients with normal serum CRP levels.Anemia is a major clinical problem in patients receiving dialysis therapy and has a substantial impact on morbidity and mortality. Iron metabolism is impaired in chronic kidney disease. Hepcidin functions as a key regulator of iron metabolism. The aims of this study were to compare the serum pro-hepcidin levels in patients with either peritoneal dialysis (PD) or hemodialysis (HD) and control subjects and to evaluate pro-hepcidin and C-reactive protein (CRP), iron parameters, and hemoglobin levels in PD and HD patients with normal serum CRP levels.METHODSWe studied 85 PD patients, 43 HD patients on regular follow-up, and a control group that was comprised of 41 volunteers in this cross-sectional study. Pro-hepcidin and CRP were studied using commercially available kits. Iron status was assessed by measuring serum iron, transferrin saturation, and ferritin.We studied 85 PD patients, 43 HD patients on regular follow-up, and a control group that was comprised of 41 volunteers in this cross-sectional study. Pro-hepcidin and CRP were studied using commercially available kits. Iron status was assessed by measuring serum iron, transferrin saturation, and ferritin.RESULTSPro-hepcidin levels were significantly higher in dialysis patients than the control subjects (p < .001). Hemodialysis patients had higher pro-hepcidin levels than PD patients; but, this difference was not statistically significant (393.4 ± 157.3 versus 361.3 ± 40.1, p = .19). There were no correlations between pro-hepcidin levels and CRP, and hemoglobin level and iron parameters in PD and HD patients.Pro-hepcidin levels were significantly higher in dialysis patients than the control subjects (p < .001). Hemodialysis patients had higher pro-hepcidin levels than PD patients; but, this difference was not statistically significant (393.4 ± 157.3 versus 361.3 ± 40.1, p = .19). There were no correlations between pro-hepcidin levels and CRP, and hemoglobin level and iron parameters in PD and HD patients.CONCLUSIONThe present results suggest that dialysis therapy is associated with elevated pro-hepcidin levels and not directly related to CRP, indices of iron metabolism, or hemoglobin levels. Peritoneal dialysis patients have relatively lower pro-hepcidin levels than HD patients, but larger-scale studies are needed to confirm the possibility of impact on various dialytic modalities.The present results suggest that dialysis therapy is associated with elevated pro-hepcidin levels and not directly related to CRP, indices of iron metabolism, or hemoglobin levels. Peritoneal dialysis patients have relatively lower pro-hepcidin levels than HD patients, but larger-scale studies are needed to confirm the possibility of impact on various dialytic modalities.

BackgroundTreatment of patients receiving hemodialysis who have anemia varies considerably despite the availability of established practice guidelines from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI).Treatment of patients receiving hemodialysis who have anemia varies considerably despite the availability of established practice guidelines from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI).ObjectiveTo compare actual use of erythropoietin (EPO) and intravenous (IV) iron with that recommended in KDOQI guidelines.To compare actual use of erythropoietin (EPO) and intravenous (IV) iron with that recommended in KDOQI guidelines.MethodsA budget impact model was used to calculate costs per member per month (PMPM) for actual practice versus recommended practice were calculated using Medicare reimbursement rates for EPO and IV iron. A sensitivity analysis tested the impact of varying the recommended dosages by  ± 50%.A budget impact model was used to calculate costs per member per month (PMPM) for actual practice versus recommended practice were calculated using Medicare reimbursement rates for EPO and IV iron. A sensitivity analysis tested the impact of varying the recommended dosages by  ± 50%.ResultsFor EPO, a net savings PMPM of $257 (if administered by IV ) or $252 (if administered subcutaneously) could be achieved with adherence to KDOQI guidelines. Adherence to KDOQI recommendations for IV iron would increase Medicare reimbursements for this drug by an estimated $6 PMPM. Sensitivity analysis revealed a significant potential savings even if the dose of EPO used in practice was increased by 50%.For EPO, a net savings PMPM of $257 (if administered by IV ) or $252 (if administered subcutaneously) could be achieved with adherence to KDOQI guidelines. Adherence to KDOQI recommendations for IV iron would increase Medicare reimbursements for this drug by an estimated $6 PMPM. Sensitivity analysis revealed a significant potential savings even if the dose of EPO used in practice was increased by 50%.ConclusionsIn the face of limited resources and changing reimbursement policies, dialysis providers will need to find ways of reducing costs without compromising the quality of care. Clinical practice guidelines such as KDOQI can be used to assist providers in meeting this challenge. Among Medicare patients who have anemia of chronic kidney disease, adherence to KDOQI treatment recommendations could translate into a significant savings for Medicare. Our findings provide incentive for payers and dialysis centers to examine their current practices and improve the quality and efficiency of anemia treatment in this population.In the face of limited resources and changing reimbursement policies, dialysis providers will need to find ways of reducing costs without compromising the quality of care. Clinical practice guidelines such as KDOQI can be used to assist providers in meeting this challenge. Among Medicare patients who have anemia of chronic kidney disease, adherence to KDOQI treatment recommendations could translate into a significant savings for Medicare. Our findings provide incentive for payers and dialysis centers to examine their current practices and improve the quality and efficiency of anemia treatment in this population.

Introduction Staphylococcal infection of endogenous origin is an important cause of morbidity and mortality in patients who receive hemodialysis (HD). The risk of such infections in nasal carriers of the organism is well defined. Extranasal carriage of the organism at extranasal sites may pose similar risks. Methods A total of 70 patients about to undergo internal jugular vein catheterization for HD were enrolled in this prospective observational study. Swab cultures were obtained from anterior nares, posterior pharynx, axillae, toe web spaces, and vascular access sites at baseline and 1 week later. A patient was defined as a persistent carrier when the same organism was grown in both samples. Staphylococcus aureus bloodstream infections were assessed by blood and catheter tip cultures over a 90-day period. Findings The mean age of the patients was 43.71 6 16.2 years. Persistent S. aureus carriage at anterior nares, throat, axilla, toe web spaces, vascular access site, and all sites was documented in 27.9%, 11.4%, 40%, 32.9%, 4.3%, and 64.2% of patients, respectively. Fifteen patients developed S. aureus infections. Catheter related S. aureus infections (CRI) were more likely in persistent carriers than nonpersistent carriers with odds ratios (95% CI) of 10.2 (2.8–37.1), 8.6 (1.7–42.2), 17.3 (3.4–86.0), 3.0 (0.9–9.8), and 1.9 (0.2–22.4) for anterior nares, throat, axilla, toe web spaces, and vascular access site carriers, respectively. The probability of developing CRI in persistent S. aureus carriers was 55% compared to none in noncarriers at 90 days (P 5 0.04). Discussion Extranasal S. aureus carriage is as significant a risk factor as nasal carriage for staphy-lococcal infections in patients on HD through catheters. The study is limited by lack of molecular phenotyping.

Background. Due to the invasive nature of bone biopsy, efforts have been made to predict indirectly, via serum assays, the type and severity of renal osteodystrophy. The purpose of this study was to determine the predictive value of nonivasive parameters with regard to differentiation of the histological types of renal osteodystrophy, and to determine the plasma level of parathormone associated with optimal bone histology in hemodialysis patients. Methods. The study involved 35 hemodialysis patients (20 M, 15 F) with a mean age (± SD) of 48 ± 23 yr and a mean duration of hemodialysis treatment of 8.3 ± 3.8 yr. Bone biopsy and histomorphometric analysis were done after double tetracycline labeling. Noninvasive parameters included serum ionized calcium, phosphorus, total alkaline phosphatase, and intact parathormone (iPTH). Bone mineral content was measured via bone densitometry Results. The prevalence of the different types of bone diseases found was as follows: hyperparathyroid bone disease (HPTBD) in 16 patients, mixed bone disease (MxBD) in 6 patients, aplastic bone disease (ABD) in 8 patients, and osteomalacia (OM) in 3 patients; 2 patients had undergone parathyroidectomy 2 yr prior to the bone biopsy. A discriminant analysis using histomorphometric parameters showed a 96.9% success rate of correctly classifying grouped cases. When noninvasive parameters were used, there was an 84.8% success rate in correctly classifying grouped cases. The noninvasive variables with the greatest significance on classification were iPTH, followed by ionized calcium. The sensitivity, for an iPTH cut-off level of &gt; 300 pg/ml was 91.3%, with a specificity of 100%. and a positive predictive value of 100% in the prediction of bone diseases with high bone turnover (HPTBD and MXBD). The sensitivity for iPTH levels 300 pg/ml were associated with abundant fibrosis volume (&gt;5%). Conclusion. Intact PTH is a useful diagnostic indicator in predicting renal bone disease, but bone biopsy still remains the gold standard, especially in patients with low bone turnover disease. The optimal iPTH range to avoid both low and high turnover bone diseases in hemodialysis patients appears to be 120-300 pg/ml, which is 2 to 4 times the upper limit of normal PTH.

The stress a patient is subjected to during dialysis treatment can be reduced by using a synergetic approach by the medical team. The integration into therapy of the positive psychical resources such as: active positive coping mechanisms, individual or family mental resilience, improvement of the image and self-esteem, better tolerance to frustration can represent an important part in the improvement of the patient's quality of life, determination of a positive approach of the situations both for him and close friends and relatives.