Dialysis & Transplantation最新文献

I have worked as a certified hemodialysis technologist/technician (CHT) for about 12 years, and have been in the medical field for almost 20. I've worked with many extraordinary patients over the years, but I have one particular patient who was very special to me—my dad.

Dad went into the hospital to have an aneurysm on his aorta removed. It had been there for years, and we all knew it. It was a triple “A” surgery (abdominal aortic aneurysm) that ended up with a fourth aneurysm found in his groin area that exploded throughout his left leg. To make a long story short, Dad lost circulation in his left leg which then had to be removed below the knee. Then what I thought was my worst nightmare occurred—his kidneys shut down. We had to make another traumatic decision, to start dialysis right away.

I helped set up the machine, and while stringing it I took measures and precautions beyond those I typically do with patients to ensure sterilization because, after all, this was my dad. The catheter placement wasn't the best, but I helped get the dialysis going and, as I sat there watching him, I knew Dad wouldn't want to live like that. But, I took every measure I could to make him comfortable, telling myself it was just an acute setting and that he would bounce back.

During this time that my father was ill, the company I work for had offered me a biomedical position—a job that would take me away from direct patient care—which I was considering. My dad and I were always close, and he was always my hero. He always listened to me and helped me make decisions about different things in my life, and I always went to him for advice. Sitting there with my dad in the hospital, I started to think about all of the patients in my dialysis facility—how they feel, all they go through as dialysis patients, and all of the tough decisions they have to make.

As I had in the past, I took this time talked to my dad about the opportunity, even though I wasn't sure he couldn't hear me as he lay there in the hospital bed. I told him about the offer and, even though he could not talk because of his ventilator, he raised his arm, put his hand on mine, and shook his head “no.” I said, “Dad, do you want me to stay with the patients?” And he nodded his head “yes.”.

This was a very moving moment for me, and I immediately decided to decline my company's offer and stay with patient care. When you set up patients every day, it's easy to become mechanical and just go through the motions. But I now look at every patient as if he or she is my dad, and am careful to string a machine and hook up every patient with the same care and precision as if my dad was in that chair.

My father passed away three years ago. I loved him very much, and I miss him terribly, but he helped me make a decision I've never been sorry for. Thank you, Dad. You were my favorite patient. Love, your son, John.

Dialysis is a fast-moving field and new, important studies come out each month. When you understand some of these common research terms, you'll be better equipped to know what the results may mean for your patients.

We report on a deceased-donor kidney transplant following ethylene glycol-induced brain death. The donor was a 53-year-old man with a history of depression who presented to the emergency department after drinking a “cocktail amount” of windshield wiper fluid each day for the past 3 weeks. Upon presentation he became unresponsive and suffered a seizure. Fomepizole 1.2 g IV followed by emergent hemodialysis was initiated as indicated for acute treat-ment of ethylene glycol poisoning. Unfortunately, the patient never regained consciousness and progressed to brain death. At the time of procurement his urine output was over 250 mL/h, and serum creatinine was 2.2 mg/dL. Renal biopsy following procurement revealed minimal tubule injury without evidence of intratubular oxalate crystals. The kidney recipient was a 76-year-old woman with end-stage renal disease secondary to diabetes and hypertension. Cold ischemia time was 31 hours, 45 minutes. The only postoperative complication was delayed graft function and one episode of mild acute cellular rejection 7 weeks post transplant that resolved with IV methylprednisolone. Two years post transplant the patient continues to do well clinically with a baseline serum creatinine of 2.5 mg/dL.

As the worldwide burden of renal disease increases, it appears that the public's willingness to donate their organs is also growing: According to a 2009 survey by L.D. Horvat, MD and colleagues in the Donor Nephrectomy Outcomes Re-search (DONOR) Network, rates of living donor kidney transplantation have steadily risen in most regions of the world, increasing its global significance as a treatment option for kidney failure. In 2006, the latest year for which numbers are available, 27,000 live-donor transplants were performed around the world. As shown in Table I, Americans donated the greatest number of kidneys in absolute terms, but Saudi Arabians were most altruistic on a perpopulation basis.1

However, the supply of available kidneys from both live and deceased donors still falls greatly short of demand. In 2006, there were roughly 70,000 people on the wait list for organ donors in the United States alone, according to the U.S Renal Data Service. Similar scenarios exist in other countries. Currently, more than 50% of transplanted kidneys in the U.S. are from deceased donors and approximately 90% of these recipients would have undergone dialysis for three to five years prior to receiving that deceased- donor organ. 2

Many of the attempts to increase organ availability focus on broadening the donor pool. In trends such as expanded-criteria donors (ECD) and donation after cardiac death (DCD), kidneys are taken from people who are older and whose health may not be as good as standard-criteria donors (SCD), but whose organsmight still be viable for patients who are themselves older or sicker than average. The blessings associated with ECD kidneys are mixed: Patients who receive those organs live longer than people who remain on dialysis, but not as long as patients transplanted with SCD kidneys. In fact, compared with dialysis, the projected average number of added life-years associated with an SCD kidney is 10 years, but only 5.1 years for an ECD organ. The differences become especially stark with the passage of time: at 5 years post-transplant, average patient survival is 82% with SCD organs and only 70% with ECD organs, and graft survival is 65% and 49%, respectively. No such differences exist in comparisons between donation after brain death (DBD) and DCDkidneys. 2

Since 1996, some surgeons have transplanted both kidneys from donors who are particularly marginal. Dualkidney transplants (DKTs) now account for about 2% of all renal transplants performed in the U.S., or about 320 transplants per year. The criteria for a DKT donor is relatively loose, as long as the donor does not have cancer orAIDS. For example, in a DKT procedure performed at the University of Kansas Hospital in Kansas City last November, the donor was 75 at the time of death and had a history of hypertension and stroke. In this case, the recipient was 88 years old and also hypertensive. Such a patient would p

Post-transplant lymphoproliferative disease (PTLD) is a rare but potentially fatal complication of organ transplanta-tion. Most cases of PTLD represent Epstein Barr virus (EBV)-related B-cell disease in a setting of pharmacological immunosuppression. Post-transplant plasma cell dyscrasia is very rare, and post-transplant plasma cell dyscrasia with extramedullary plasmacytoma is extremely rare. We report here a case of the latter, which to our knowledge is the fourth such reported case in the English literature. A 22-year-old man developed post-transplant plasma cell dyscrasia 20 years after a renal transplant while on immunosuppression. His presentation included retroperitoneal plasmacytoma, which is very rare and is probably the first case in a renal transplant patient. The patient is in complete remission 1 year after receiving five cycles of bortezomib and dexamethasone.

In this review, we will discuss updates in diagnosis, treatment, and primary prevention, as well as unresolved issues and future directions for BK virus nephropathy in renal transplant patients.