No abstract

In haemodialysis patients, increased concentrations of malonyldialdehyde and decreased vitamin E content indicate lipid peroxidation in the platelets from oxidative damage. The same process has been described in red blood cells and in mononuclear cells in peripheral blood. However, platelet aggregation is within normal limits and does not change after treatment with vitamin E. On the other hand vitamin E supplementation reverts completely the biochemical abnormality of the platelets.

We described previously that in the erythrocytes and mononuclear blood cells from uremic patients on chronic hemodialysis, the membrane concentrations of malonyldialdehyde (MDA), resulting from peroxidation of polyunsaturated fatty acids (PUFA) in the membrane itself increased, and the concentrations of vitamin E (VIT E), the major antioxidizing agent, were lower. In the present study we analysed whether similar oxidative damage is seen in the serum from hemodialysis patients and whether the serum fatty acid pattern is affected. No evidence was found of oxidative damage in the serum during hemodialysis, serum concentrations of MDA and VIT E remaining constant before and after dialysis. No change was observed in serum pattern of PUFA, particularly linoleic acid. We therefore assume that the oxidative damage described in uremic patients is mainly intracellular.

The article about Dialysis Outcome Quality Initiative (DOQI), recently published by the National Kidney Foundation in The American Journal of Kidney Disease provides clear guidelines for adequacy of hemodialysis, peritoneal dialysis, vascular access and treatment of anemia in End-Stage Renal Disease (ESRD). If the dissemination of these guidelines actually increases Kt/V, an early improvement of the outcome of dialysis patients will be expected because there is a close correlation between dialysis dose and mortality. Mortality, unless high, is the main indicator of the efficacy of guidelines in ESRD. Other indicators are needed to assess the effects of the modification in clinical practice induced by DOQI at lower mortality, as in other western European countries. Quality of life adjusted for life expectancy defined Kt/V of 1.3 as the optimal cost-effective dialysis dose; large evidence is missing to support the use of higher doses or of high technology in hemodialysis treatment. Adequacy and uniformity of isolated hemodialysis procedures are accurately defined by DOQI. Quality assessment of integrated actions in overall commitment of ESRD patients (prevention and treatment of co-morbidity of uremia, renal transplantation programs, improvement of the communication with caregivers and family, enhanced fitness and ability to work) has still to be implemented with recommendations and indicators of the outcome. NKF-DOQI defined only dialysis adequacy; further work is necessary to assess the “optimal clinical practice” for ESRD patients.

The choice in the renal replacement therapy of acute renal failure (ARF) should match the patients’ individual needs and the characteristics of available therapies. 141 ARF patients, 65 with ‘isolated’ ARF (group I) and 76 with ARF in multiorgan failure (group II), have been treated. In 33 patients of group I standard bicarbonate hemodialysis was used, while acetate-free biofiltration was used for the others. In group II, 42 patients have been treated by continuous arteriovenous hemofiltration and 34 patients by daily recycled bicarbonate hemodialysis. Our data show that acetate-free biofiltration and bicarbonate dialysis were both highly dependable, but acetate-free biofiltration was better tolerated. Continuous arteriovenous hemofiltration is the method of choice in high-risk patients; daily bicarbonate hemodialysis is preferable only in patients with hemorrhagic diathesis. The average survival time is 55.2% with a statistically significant difference between groups I and II, while no difference has been observed within the same group according to the procedure.