Statins are competitive inhibitors of hydroxy-methyl-glutaryl coenzyme A (HMG-CoA) reductase and are the most commonly used drugs to treat hyperlipidaemia. Muscle toxicity is an adverse effect reported with a low incidence and rarely associated with acute renal failure due to rhabdomyolysis. We describe two patients with chronic renal failure treated with pravastatin and simvastatin who suffered rhabdomyolysis and acute renal failure. One patient started pravastatin several days after cessation of bezafibrate and developed acute renal failure without needing dialysis. The other was treated with simvastatin three years ago and suffered rhabdomyolysis when renal function was impaired after indomethacin was prescribed for backache. He needed hemodialysis because of acute cardiac failure and died from a respiratory infection while on mechanical ventilation. Myopathy was reversible in both patients. We recommend starting statins with the lower doses in chronic renal failure and monitoring muscle enzymes when renal function changes or when new drugs with potential interactions are prescribed.

Statins are competitive inhibitors of hydroxy-methyl-glutaryl coenzyme A (HMG-CoA) reductase and are the most commonly used drugs to treat hyperlipidaemia. Muscle toxicity is an adverse effect reported with a low incidence and rarely associated with acute renal failure due to rhabdomyolysis. We describe two patients with chronic renal failure treated with pravastatin and simvastatin who suffered rhabdomyolysis and acute renal failure. One patient started pravastatin several days after cessation of bezafibrate and developed acute renal failure without needing dialysis. The other was treated with simvastatin three years ago and suffered rhabdomyolysis when renal function was impaired after indomethacin was prescribed for backache. He needed hemodialysis because of acute cardiac failure and died from a respiratory infection while on mechanical ventilation. Myopathy was reversible in both patients. We recommend starting statins with the lower doses in chronic renal failure and monitoring muscle enzymes when renal function changes or when new drugs with potential interactions are prescribed.

Biocompatible hemodialysis membranes induce a smaller inflamatory response in hemodialysis patients, and remove a larger amount of higher molecular weight retention products, then cellusosic membranes. These phenomena could improve uremic anemia in hemodialysis patients. The objective was to evaluate the effects of biocompatible AN69 membranes on anemia in hemodialysis patients. Twenty-five stable patients undergoing hemodialysis with cuprophan membrane for more than 6 months were studied prospectively. These patients were stratified in 2 groups. Group I (GI): 14 patients switched over to a more biocompatible dialyzer (from cuprophan to AN69) and Group II (GII): 11 patients continued treatment with the same cuprophan membrane. The study lasted 5 monts. Baseline hematocrit (%), ferritin (ng/mL), transferrin saturation (%), KTV, PCR (g/kg/day) and dose of Erythropoietin (EPO) (Ul/week) were measured and were revised monthly. Target hematocrit was 33%-35%. A significant increase of hematocrit became obvious after 2 months in Cl without changes in dose of EPO and intensity of dialysis, meanwhile GII remains stable. Conclusion: Hemodialysis using AN69 membranes increases hematocrit without modifying intensity of dialysis.

UNLABELLED:Biocompatible hemodialysis membranes induce a smaller inflammatory response in hemodialysis patients, and remove a larger amount of higher molecular weight retention products, then cellulose membranes. These phenomena could improve uremic anemia in hemodialysis patients. The objective was to evaluate the effects of biocompatible AN69 membranes on anemia in hemodialysis patients. Twenty-five stable patients undergoing hemodialysis with cuprophane membrane for more than 6 months were studied prospectively. These patients were stratified in 2 groups. Group I (GI): 14 patients switched over to a more biocompatible dialyzer (from cuprophan to AN69) and Group II (GII): 11 patients continued treatment with the same cuprophan membrane. The study lasted 5 months. Baseline hematocrit (%), ferritin (ng/mL), transferrin saturation (%), KTV, PCR (g/kg/day) and dose of erythropoietin (EPO) (UI/week) were measured and were revised monthly. Target hematocrit was 33%-35%. A significant increase of hematocrit became obvious after 2 months in GI without changes in dose of EPO and intensity of dialysis, meanwhile GII remains stable.CONCLUSION:Hemodialysis using AN69 membranes increases hematocrit without modifying intensity of dialysis.

Introduction: The hyperphosphatemia, hypocalcemia and low calcitriol levels are pathogenic factors for secondary hyperparathyroidism in chronic renal failure. The phosphorus control is essential to prevent secondary hyperparathyroidism. There are not comparatives studies to test the efficacy of control of phosphorus binders in predialysis patients. Aim: To compare the efficacy of calcium carbonate vs calcium acetate as phosphate binder in predialysis patients. Material and methods: The present study includes 28 patients with chronic renal failure (mean clearance of creatinine 21 ml/min). Patients were separated into two groups: Group 1: (n = 14) received calcium carbonate 2,500 mg/day (1,000 mg of calcium); Group 2: (n = 14) receives calcium acetate 1,000 mg (254 mg of calcium). Calcium and phosphorus were determined every 4 months; i-PTH, alkaline fosfatase and clearance of creatinine were determined every six months. Results: Both groups were comparable regarding age, renal function, calcium, phosphorus, alkaline fosfatase and i-PTH on basal situation and the end of study were not different. The serum calcium increased, not significantly in the calcium carbonate group (group 1) [from 9.2 to 9.8 mg/dl (p = 0.05)], however it was not modified in the calcium acetate group (group 2). The serum phosphorus decreased significantly (p ( 0.05) in both groups, independently of the calcium levels. Alkaline fosfatase and i-PTH not was modified during the study period. Conclusions: 1) Both calcium carbonate and calcium acetate are similarly effective as phosphate binder. 2) The carbonate group required four fold greater doses of calcium that acetate group. 3) The calcium acetate has less hypercalcemic effect than calcium carbonate.

INTRODUCTION:The hyperphosphatemia, hypocalcemia and low calcitriol levels are pathogenic factors for secondary hyperparathyroidism in chronic renal failure. The phosphorus control is essential to prevent secondary hyperparathyroidism. There are not comparatives studies to test the efficacy of control of phosphorus binders in predialysis patients.AIM:To compare the efficacy of calcium carbonate vs calcium acetate as phosphate binder in predialysis patients.MATERIAL AND METHODS:The present study includes 28 patients with chronic renal failure (mean clearance of creatinine 21 ml/min). Patients were separated into two groups: Group 1: (n = 14) received calcium carbonate 2,500 mg/day (1,000 mg of calcium); Group 2: (n = 14) receives calcium acetate 1,000 mg (254 mg of calcium). Calcium and phosphorus were determined every 4 months; i-PTH, alkaline phosphatase and clearance of creatinine were determined every six months.RESULTS:Both groups were comparable regarding age, renal function, calcium, phosphorus, alkaline phosphatase and i-PTH on basal situation and the end of study were not different. The serum calcium increased, not significantly, in the calcium carbonate group (group 1) [from 9.2 to 9.8 mg/dl (p = 0.05)], however it was not modified in the calcium acetate group (group 2). The serum phosphorus decreased significantly (p < 0.05) in both groups, independently of the calcium levels. Alkaline phosphatase and i-PTH not was modified during the study period.CONCLUSIONS:1) Both calcium carbonate and calcium acetate are similarly effective as phosphate binder. 2) The carbonate group required four fold greater doses of calcium that acetate group. 3) The calcium acetate has less hypercalcemic effect than calcium carbonate.

Iron deficiency is the most important cause of resistance to erythropoietin in hemodialysis patients. In order to avoid it Lye need to know iron stores, iron required to achieve target hemoglobin and efficacy of iron administered. Objective: To assess the distribution of sodium-ferric-gluconate (Na - Fe - gluconate) given intravenously. Patients and methods: Forty nine hemodialysis patients with initial serum ferritin < 200 ng/ml or transferrin saturation (TS) < 20% were treated with Na-Fe-gluconate during the period of two months. Patients with ferritin < 50 ng/ml received 1,500 mg divided in 24 IV doses, patients with ferritin > 50 received 500 mg divided in 8 doses. Hemoglobin, ferritin, TS and iron stores were measured al base line and they were revised two months later. Iron stores were estimated by the empirical formula of Cook modified by Anastassiades: Iron stores = 400* [Ln(ferritin i)- Ln(50)]. Iron needed for new hemoglobin synthesis was calculated on the basis that a rise of 1 g/dl in circulating hemoglobin uses 150 mg of iron. Results: All the variables measured increased significatively at the end of the study. A total amount of 915.8 +/- 457.4 mg of iron was administered; 119.9 +/- 238.7 mg (15%) were used for hemeglobin synthesis and 574.6 +/- 507.4 mg (57%) increased iron stores; 221.5 +/- 423.1 mg (28%) was not accounted for. It could be due to dialyser and gastrointestinal losses characteristic of hemodialysis patients. Conclusion: More than 70% of iron administrated as sodium-ferric-gluconate was accounted for as increased iron stores or was used for hemoglobin synthesis.

The optimal haemopoietic response to recombinant human erytropoietin (rHu-EPO) requires an adequate supply of iron. Oral iron is a safe form of substitution but frequently it does not suffice and intravenous iron is necessary. The objective of our study was to evaluate the efficacy and safety of intravenous iron, given as sodium ferric gluconate (Na-Fe-G), for maintenance iron therapy in hemodialysis patients undergoing rHuEPO treatment. Patients and methods: Eighty-five stable hemodialysis patients with initial serum ferritin < 200 ng/ml and receiving rHuEPO were treated with intravenous Na-Fe-G during three months. Patients with ferritin < 50 ng/ml received 187 mg weekly, divided in to 3 intravenous doses, patients with ferritin > 50 received 62.5 mg weekly in one dose. Patients were stratified in 3 groups according to serum ferritin baseline values. Group I: ferritin < 50 ng/ml (19 patients), Group II: ferritin 50-100 ng/ml (25 patients) and Group III: ferritin > 100 ng/ml (41 patient). rHuEPO dose was adjusted to maintain hemoglobin within 9.5-10 g/dl. At baseline hemoglobin, Hct, ferritin and transferrin saturation were measured and were repeated 2 and 3 months after. Results: A significant decrease of mean weekly rHuePO dose became obvious after I month in all groups. At study completion it had fallen by 60.2% (Group I), 38.4% (Group II) and 27.0% (Group III), and 19 patients: 7 (26%) of Group I, 7 (28%) of Group II and 5 (12%) of Group III maintained hemoglobin > 9.5 g/dl without the use of rHuEPO. Target hemoglobin was maintained in all groups. Hemoglobin and Hct increased from baseline in Group I and Group III while Group II reimaned stable. Group I had the highest final hemoglobin and maximal decrease of rHuEPO. There were no adverse effects. Conclusions: Intravenous Na-Fe-G: 1) Is an effective and safe way of administering iron. 2) Optimises haemopoietic response to rHuEPO allowing the reduction of rHuEPO doses required to maintain target hemoglobin in hemodialysis patients with serum ferritin < 200 ng/ml. 3) Causes the greatest response in patients with initial ferritin > 50 ng/ml.

Most venous catheters used in ambulatory patients of long-term haemodialysis are placed in jugular or subclavian veins. Femoral catheters are thought to require hospitalization and to limit walking and normal life. In our service we use femoral catheters as initial vascular access in all patients, sparing jugular or subclavian veins for a later arteriovenous fistula. The aim of this study was to review our experience with femoral catheters and to assess the incidence of major complications and them duration in ambulatory patients on long-term haemodialysis. One hundred and nineteen catheters were placed in femoral veins in 1994 (115 single lumen, 3 double lumen, 1 permanent catheter) and only 12 subclavian and 14 jugular catheters. They were placed in 49 patients, 26 males (53%), 56 +/- 15 (16-81) years old and 22.2 +/- 41.5 (0-166) months on dialysis.The reasons for their placement were: 60 catheters (50,4%) as the first access in patients without arteriovenous fistula, 56 (47%) in patients with not-functioning fistula and 3 catheters (2.5%) in patients changing from peritoneal dialysis to haemodialysis. The reasons for removing catheters were: low flow in 54 cases (45.4%), a functioning arteriovenous fistula in 26 cases (22%), catheter infection in 13 cases (11%), change to peritoneal dialysis in 7 cases (5.9%), death in 5 patients (4.2%), placement of a permanent catheter in 4 cases (3.4%) and femoral thrombosis in 1 patient (0.8%). As complications we found 4 cases of septicemia with one death, 2 thigh haematomas, 1 femoral thrombosis and 1 accidental puncture of the femoral artery that required prolonged local compression. Hospitalization was necessary in 6 cases with infection, one with femoral thrombosis and 2 with thigh haematomas. Sixty-eight percent of catheters removed were cultured. Staphylococcus epidermidis was the most frequent bacterium recovered. Nine patients of the thirteen catheters removed for infection had fever and no other infectious focus. In 4 other patients we observed clinical complaints of sepsis with one fatality. The mean duration of femoral catheters was 40 +/- 36 (2-196) days, which was not significant difference from subclavian catheters (45 +/- 42 days). The median was 27 days, the 25th percentile was 12 days and the 75th percentile was 67 days. Catheter duration was 27 +/- 24 days when they were removed for low flow 31 +/- 36 days in case of infection but 55.2 +/- 41.7 days in those removed for other causes, mainly a functioning arteriovenous fistula (Kruskal-Wallis p < 0.001). We conclude that femoral catheters have as good duration, in long-term ambulatory haemodialysis patients, similar to those of jugular or subclavian catheters. They cause an acceptable incidence of infections and their complications are similar to catheters placed in other localizations. We think they can be used as a temporary but long duration vascular access and they let us preserve subclavian and jugular veins untouched, until a definitive vascular access is established.

The use of catheters as vascular access in chronic haemodialysis has been increasing in recent years in nephrology units. This is due to the ageing of people entering chronic dialysis programs, rising proportion of diabetic patients and, in our case, a real difficulty to have a vascular surgeon available. Our aim was to measure the cost of maintaining reviewed patients or chronic dialysis using catheters until the fistula has been done. We reviewed the catheters placed in 1994 and estimate the cost of the use of antibiotic and urokinasa, hospital days due to catheter insertion and complications and one extra hour dialysis in case of single needle or low flow. We implanted 145 catheters in 57 patients, 58 +/- 16 years old and 20.6 +/- 39.8 months in dialysis. There were 134 temporary catheters (TC), 131 single and 3 double lumen, and II permanent catheters (PCI. Most of TC were femoral with acceptable duration. The mean cost of the catheter and expenses of its placement amounted to double lumen 11,424 +/- 798 ptas. for single lumen, 25,282 +/- 918 ptas. for Mahurcar and to 68,518 ptas. for PC. The expenses of one extra hour of haemodialysis in case of single needle or low flow in the PC totalled 134,498 +/- 118,567 ptas. for single lumen and 19,466 +/- 34,091 ptas. for PC (p < 0,01). The expenses of hospitalization were similar. The total mean cost was 168,965 +/- 151,682 ptas. per single lumen catheter and 128,041 +/- 61,204 ptas. per PC (not significantly different). However, when we corrected the price according to the duration of each catheter, the cost was 5,356 +/- 3,652 ptas. for single lumen and nic dialysis patients using TC is an extra expense that should be kept in mind and encourage to obtain a vascular access as soon as possible.

We report a grave case of metabolic alkalosis during haemodialsis with bicarbonate, in which the connections of the two components A and B were exchanged. This complication was resolved without any consequences by rapid diagnosis and the continuation of the haemodialysis with acetate. We comment on the characteristics of both dialysis fluids, when studied in simulated dialyses.

The aim of this study was to survey adequacy of dialysis prescription with hemodialysis (HD) and different modalities of hemodiafiltration (HDF) and treatment outcomes in Spain. A questionaire of dialysis prescription was send to all National dialysis units. A total of 3361 questionaires of patients on maintenance dialysis were received. To be included into the study: age, time on dialysis, lenght of dialysis in hours/week, blood flow, type of dialyzer, mid-week BUN pre and post-dialysis, potassium, phosphorus, creatinine, hemoglobin, weight, height and number of days of hospitalization/year were required. Only 2282 who fulfilled all criteria were selected. Kt/V and pcr (corrected by residual renal function), TAC and body surface area were calculated. The patients were treated with HD (n = 2112): 1125 with Acetate (HDAc) and 987 with Bicarbonate (HDBi); and HDF (n = 170): 103 in Biofiltration (BIO), 33 in Acetate-free BIO (AFB) and 34 in Paired Filtration Dialysis (PFD). The patients treated with HDBi were older than HDAc, AFB and PFD. Time on dialysis was slightly increased in patients on HDBi when it was compared to HDAc. The length of dialysis was higher in HD (>10.6 hours) versus HDF (< 9.5 hours, p < 0.001). Kt/V and pcr were higher in AFB patients. There was a significant increase of Kt/V in HDBi and BIO in comparison to HDAc and PFD (p < 0.05). The pcr was lower in HDAc than in HDBi (p < 0.05). A significant decrease in mean arterial pressure during the dialysis procedure was observed in both types of HD (p < 0.05), remaining stable in the three different HDF modalities. The morbidity rate was similar in all procedures evaluated. These data suggest that the different modalities of HDF evaluated provide an adequate therapy, with a significant reduction in the length of dialysis and a better cardiovascular tolerance.

The appropiate dose of dialysis prescription remains controversial. According to urea kinetic modeling (UKM) Kt/V and pcr are the most accurate index of dialysis adequacy. The purpose of the present study was to evaluate the role of UKM in the dose of dialysis prescription and its influence on morbidity, considering the recent modifications introduced into the routine dialysis procedure, such as: synthetic membranes, increase in blood flow rate, new modalities of hemodiafiltration, etc. Questionaries were mailed to all National Dialysis Units, 3,361 were returned and 2,703 selected which supplied the following requested information: age, sex, weight, height, months on dialysis, hours/week of dialysis, blood flow, type of dialyzer, mid-week BUN pre and post-dialysis, standard biochemistry (creatinine, hemoglobin, potassium and phosphorus), urine urea and volume, admissions and total number of days of hospitalization/year. Upon data collection, body surface area, Kt/V, pcr and TAC were always calculated by the same researcher. The urea distribution volume was estimated from anthropomorphic measurements (Watson formula). According to the values of Kt/V (1.08), pcr (1.14) and TAC (54), the majority of patients were on a recomended dialysis prescription, in spite of a reduced number of hours, 10.6 hours/week. The main cause of hospitalization was related to vascular access complications (21 %). Patients who were more at risk of being hospitalized were older, had less Kt/V, lower, serum creatinine levels, and had spen more time on dialysis.

The prevalence of antibodies to hepatitis C virus (HCV) was investigated in 231 renal transplantation recipients, by a first- and second-generation EIA assay and a second-generation immunoblot assay (4-RIBA). Before transplantation, prevalence of anti-HCV was 22.6% and was related to the time on dialysis (p < 0.01), transfusions (p < 0.01) and previous history of chronic liver disease (p < 0.01. Following transplantation, 32 patients (13.9%) were anti-HCV positive by the first-generation enzyme immunoassay (EIA) and it increased to 57 patients (24.7%) when anti-HCV was measured by the second-generation EIA. The 4-RIBA assay confirmed the positivity in 46 patients (80.7%), 11 patients (19.3%) were indeterminate. Seroconversion after grafting was observed in 7 negative patients, and another 7 patients became negative after the procedure. The presence of anti-HCV antibody after transplantation was determined by the patient status on dialysis, 80% of them being positive before surgery. Twenty-one 4-RIBA-positive transplantation patients (45.7%) had persistently or intermittently abnormalities on liver function tests, suggesting chronic liver disease. A liver biopsy performed on 10 of these patients showed; chronic active hepatitis in 6, chronic persistent hepatitis in 2, and chronic lobular hepatitis in the other 2 patients. Another 23 4-RIBA-positive transplantation patients had normal alanine aminotransferase levels despite long follow-up (66.2 +/- 32.2 months). The prevalence of anti-HCV antibody can be underestimated if the antibody is measured by first-generation EIA alone. About 50% of patients with anti-HCV had chronic liver disease, and the histological findings suggested a possible evolution to cirrhosis.(ABSTRACT TRUNCATED AT 250 WORDS)