abstracts haemodialysis nephrology dialysis transplantation vol

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AbstractsHaemodialysis

Nephrology Dialysis Transplantation Vol. 14 n.9 1999

RIBATM HCV SEROTYPING SIA IN HD PATIENTS: A COM-PARISON WITH GENOTYPING ASSAYF. Fabrizi, P. Martin, S. Quan, V. Dixit, M. Brezina, A. Polito, andG. GitnickDepartment of Medicine, Los Angeles, UCLA, Chiron Corpora-tion, Emeryville, Nephrology Division, Lecco, Italy

Specific HCV genotype may be a predictor of disease progres-sion and interferon responsiveness in chronic HCV infection.However, PCR-based methods are routinely unsuitable for rou-tine diagnostic use. A novel assay, RIBA™ HCV serotyping SIA,has been recently developed for HCV serotyping; it consists ofan nitrocellulose solid support on which there are five lanes ofserotype-specific HCV peptides from the genomes of HCV types1, 2 and 3. AIM: We compared the RIBATM HCV serotyping SIAvs. genotyping by RT-PCR in a large (n=107) cohort ofHCV-infected patients on chronic hemodialysis (HD) in the greaterLos Angeles area in view of the high prevalence of HCV in thispopulation. All patients tested anti-HCV positive by ELISA 2.0assay and by RIBATM HCV 2.0 SIA. We successfully serotyped79 (74%) of 107 HD patients. There was a remarkable concord-ance (65/70=93%) between RIBA™ HCV serotyping SIA andgenotyping (LiPA) techniques (kappa value, 0.786) with serafrom viremic patients infected with a known genotype. Therewere some patients (28/107=26%) who were not typed by RIBATM

HCV serotyping SIA; most of them were successfully (24/28=86%) genotyped. It was possible to assess serotype reactiv-ity in some patients (9/107=7%) who were unsuccessfullygenotyped. In summary, we found a good agreement betweenserotyping and genotyping methods; the impaired immuno-competence conferred by uremia may limit serotyping analysisin some HCV-infected patients on HD. RIBATM serotyping SIAis a simple, inexpensive and highly reproducible assay to obtaininformation about HCV types among HD patients with HCV.

PRE-OPERATIVE DUPLEX EXAMINATION OF VESSELS IMPROVE PAT-ENCY RATES OF NATIVE ARTERIOVENOUS FISTULAS FOR HAEMODI-ALYSISMalovrh M.Department of Nephrology, University Medical Center, Ljubljana, Slovenia

Background. Certain morphological and functional parameters of vessels canpredict whether arteriovenous fistula (AVF) will fail or succeed after surgeryand also predict the period of AVF maturation. Prospectively duplex sonography(DS) as objective and noninvasive method for assessing the quality of patients’vessels was used in order to define those factors that correlate with successfulAVF construction and maturation.Methods. Arteries and veins at the distal part of the upper arms were evaluatedby DS prior AVF construction. The artery internal diameter (AID), the resist-ance (Rl) and pulsatility index (PI) before and at reactive hyperemia, the arterialblood flow (ABF), and the internal diameter of the vein before and after com-pression were measured. The measurements of AID and ABF were continued 24hours, once weekly for three weeks, again 8 and 12 weeks after AVF surgery.Results. At 116 pts (62 females, 54 males), mean age 51.4 yrs (range 15 to 81)before and at reactive hyperemia AID was 0.24±0.8 and 0.27±0.9 cm, RI 1.16±0.13and 0.55±0.17, PI 2.7 ±0.98 and 1.1±0.46, ABE 48.5 mL/min and 79.5 mL/min,respectively. Internal diameter of veins (IDV) was 0.23±0.07 cm, and after com-pression 0.33±0.18 cm. In group of successful AVF construction (93/116)(80.2%)AID was 0.26±0.07, RI and PI at reactive hyperemia were 0.51±0.14, and1.03±0.48, ABF was 54.5±22.8 mL/min, IDV was changed for 59%. In group offailed AVF (23/116)(19.8%) AID was 0.16±0.1 cm (p<.001), Rl and PI at reactivehyperemia were 0.76±0.2 (p<.001), and 1.37±0.31 (p<.01), ABF was 24.1±16.8mL/min (p<.001), IDV was changed for 12.4% (p<.001 ). Patency rate aftersurgery in group of pts with AID > 0.16 cm was 93% (85/91) (group A), and ingroup with AID £ 0.16 cm 32% (8/25)(p<.01) (group B). In group with RI atreactive hyperemia < 0.7 patency rate was 95.3% (81/85) (group C), and in RI³0.7 it was 38.7% (12/31)(p<.01) (group D). Useful AVF artery flow 300 mL/min was achieved in group A and group C after one week, in group B between3 and 8 weeks, and in group D between 8 and 12 weeks.Conclusions. AID >0.16 cm, ABF >25mL/min, RI and PI at reactive hyperemia<0.7 and <1.4 are important for predicting of AVF success. The study demon-strate thatsonographical measurements provide morphological and functionalcharacteristics of the arteries and veins. Based upon these measurements, themost adequate location for AVF construction as well as time of optimal fistuladevelopment can be determined, particularly at risk pts like elderly and diabet-ics.

S: Haemodialysis

CARDIOVASCULAR RISK FACTORS AND PREVALENT CVD INHD PATIENTSM Boaz, Z Matas, A Biro, Z Katzir, M Green, M Fainaru and S Smetana.E. Wolfson Medical Center, Dept. of Nephrology and BiochemistryLaboratory, Holon; Israel Centers for Disease Control, Tel Hashomer;Internal Medicine Unit A, Beilenson Medical Center, Rabin Campus,Petach Tikvah; Sackler School of Medicine, Tel Aviv University, RamatAviv, Israel.

Hemodialysis patients have accelerated cardiovascular morbidity andmortality rates compared to the general population. Identifying thosefactors that predict major coronary events in this population can directthe focus on prevention. This cross-sectional study compares knownand suspected cardiovascular risk factors in hemodialysis patientswith and without prevalent CVD.In 76 hemodialysis patients (n=44 with prevalent CVD), serum lipids,lipoproteins, apolipoproteins and plasma fibrinogen, tissue plasmino-gen activator (tPA), plasminogen activator inhibitor (PAI-1) and factorVII were measured using standard kits. Serum malondialdehyde(MDA, a marker of oxidative stress) was measured using spectropho-tometry. Predictor variables were compared using ANOVA and chisquare tests as appropriate. CVD prevalence was modeled usingmultiple logistic regression analysis and odds ratios were calculated.Serum lipid, lipoprotein and apolipoprotein levels and plasma tPA,PAI-1 and factor VII values did not differ significantly from laboratorynorms, nor did they discriminate for prevalent CVD in HD patients.Plasma fibrinogen levels were significantly elevated in HD patientscompared to laboratory norms (369.4 ±130.02 vs. 276.7±77.7, p< 0.0001)but were not significantly different in HD patients with and withoutprevalent CVD. Serum MDA, both pre-and post the midweek HDtreatment, was significantly elevated in all HD patients compared tolaboratory norms (pre-treatment 2.6±0.8, post-treatment 2.1±0.3 vs.0.91±0.09 nmol/ml, p<0.01) and was significantly elevated in HDpatients with prevalent CVD compared to those without (pre-treat-ment: 2.8±0.6 vs. 2.4±0.4 nmol/ml, p<0.01; post-treatment: 2.3±0.4vs. 1.94±0.2 nmol/ml, p<0.01). Only serum MDA both pre- and postthe midweek treatment contributed to the explanation of variation inCVD prevalence. Odds ratio for CVD in the highest vs. the lowesttertile of pre-treatment MDA was 2.71 (95%CI 1.42-5.19). Odds ratio forCVD in the highest vs. the lowest tertile of post-treatment MDA was3.65 (95%CI 1.6-8.32).Serum MDA contributed to the explanation of variation in CVD preva-lence while serum lipids, lipoproteins and apolipoproteins as well asserum hemostatic factors did not. This finding is consistent with thetheory of oxidative stress as a factor in the accelerated CVD rate ob-served in HD patients.

PREDICTORS OF NEWLY DEVELOPED ATRIAL FIBRILLA-TION DURING HEMODIALYSIS SESSIONSM Schulte-Vorwick, M van der Giet, W Zidek, M TepelUniv.-Klinik Marienhospital, Medizinische Klinik I,Ruhr-Universität-Bochum, Germany.

We evaluated the causes predicting the appearence of atrialfibrillation during hemodialysis sessions. Patients with end stagerenal failure on regular bicarbonate hemodialysis for 4 to 5 hoursthree times weekly were investigated. During a 2 year periodwith 45711 hemodialysis sessions 54 events of newly developedatrial fibrillation occured during the hemodialysis session (1.18per 1000 dialysis sessions). Compared to control subjects onregular hemodialysis with similar duration of end stage renalfailure (48.5±4 months vs 51.3±8.8 months, mean±SEM, p=0.24)the patients who developed atrial fibrillation had significantlyhigher age (69±1 y vs 57±1 y, p<0.0001), lower hemoglobin con-centration (10.0±0.1 g/dL vs 9.2±0.2 g/dL, p<0.01), and lowerserum potassium concentrations (4.98±0.06 mmol/L vs4.67±0.11 mmol/L, p<0.01). Multivariant regression analysisshowed that the development of atrial fibrillation duringhemodialysis was significantly related to age (p<0.0001), coro-nary heart disease (p<0.0002), low hemoglobin concentration(p<0.001), low serum potassium concentration (p<0.05), andelevated systolic blood pressure (p<0.05). It is concluded that inelderly patients with coronary heart disease care should be takento avoid low hemoglobin or serum potassium concentrations inorder to prevent the development of atrial fibrillation duringhemodialysis sessions.

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EPIDEMIOLOGY OF GBV-C/HGV INFECTION IN CHRONICDIALYSIS PATIENTS: A SEROLOGIC SURVEYF. Fabrizi, G. Lunghi, C. Pozzi, F. Tentori, M. Corti, A. Pagano,and F. LocatelliNephrology and Dialysis Division, Lecco Hospital and HygieneInstitute, Milan University, Italy

It has been recently reported that chronic dialysis patients havea high frequency of GBV-C/HGV viremia. However, scarce in-formation exists about serology of GBV-C/HGV. Recently, aprototype enzyme immunoassay has been developed to detectantibodies against the putative envelope protein (E2) located onthe surface of the GBV-C/HGV virion particle. 158 patientswere analyzed by RT-PCR and anti-HGV E2 antibody; 136 blooddonors were the control group. The anti-HGV E2 frequency washigher in dialysis patients vs. controls, 18% (28/158) vs. 9%(12/136), P=0.023. Most anti-HGV E2 patients (27/28=96%)did not show HGV RNA in serum, the total prevalence of GBV-C/HGV RNA and anti-HGV E2 positive patients was 25% (39/158). Ordinal logistic regression analysis did not show any asso-ciation between anti-HGV E2 antibody and age, gender, time ondialysis, HBsAg, aetiology of renal failure, anti-HCV, HCV geno-type, HGV RNA, AST, ALT, and type of dialysis. In the group ofanti-HGV E2 positive patients, the frequency of co-infectionwas 43% (12/28); one patient was HBsAg and anti-HCV posi-tive, 11 anti-HGV positive; many anti-HGV E2 positive patients(9/17=53%) had received transfusions. In conclusion, the fre-quency of anti-HGV E2 antibody in dialysis is very high;seroconversion for anti-HGV E2 is usually linked with clearanceof HGV RNA from serum; nosocomial transmission appears animportant route of GBV-C/HGV acquisition. No associationbetween anti-HGV E2 and aminotransferase was found. Theclinical significance of GBV-C/HGV in dialysis is unclear; how-ever, GBV-C/HGV spread may serve as a marker of unrecog-nised parenteral exposure within dialysis units suggesting theneed to stimulate ‘universal precautions’.

ARTERIAL HYPOTENSION IN DIALYSIS AND ESTIMATION OF DRY WEIGHT: THEROLE OF ECOGRAPHY MEASUREMENT OF THE INFERIOR VENA CAVAGagliardi G.M. Gerace G. Cassani S. Martire V. Tosti F. Vocaturo G. Migliozzi G.P. De NapoliN.(Nephrology and Dialysis DPT Annunziata Hospital Cosenza Italy)

Arterial hypotension during hemodialysis is a frequent complication which is character-ized by multifactorial etiopathogenesis often reducing the compliance of the patients tothe treatment itself. The purpose of this work is to evaluate the use of ecography tomeasure the diameter of the inferior vena cava. (VCD mm/mq) for determining dryweight in a group of hemodialyzed patients. Twenty patients participated in this studyand were subdivided into two groups:Group A included 10 patients under hemodialytic treatment three times a week (4M: 6Fage 40.42 +/- 15.7 years old; period of dialytic treatment 44.50 +/-21.23 months) withfrequent episodes of dialytic hypotension. Group B included 10 patients (7M: 3F) withnormal blood pressure (age 56.20 +/-9.98 years old; period of dialytic treatment 54+/-12.60months). For every patient was measured the diameter of the inferior vena cava beforeand immediately after dialysis and the blood volume was established (∆BE) by measuringthe hematocrit (HCT) with a Crit-Line (In line Diagnostic USA). The data of the valuesobtained are shown in

Table IGroup A Pre-dialysis Post- dialysisVCD 9.43 +- 1.65 5.69 +- 1.69 S (p<0.001)∆VCD -4.15+-077 S (p<0.001)HCT 27.21 +- 3.58 35.32 +- 6.16 N.S.∆HCT 7.46 +- 2.70 S (p<0.05>0.01)∆BV -19.63+-4.14 S (p<0.001)Group B Pre- dialysis Post-dialysisVCD 9.78 +-1.75 7.65 +- 1.57 S (p<0.001)∆VCD -2.15 +- 087 S (p< 0.001)HCT 29.66 +- 2.94 34.83 +- 3.40 NS∆HCT 5.27 +- 1.49 S (p< 0.05<0.001)∆BV -12.46 +- 3.48 S (p<0.001)

The reduction in the diameter of the inferior vena cava before and after the dialysis wasstatistically significant. However, this reduction in Group A was significantly greater withrespect to Group B. The same results were obtained with ∆BV and ∆HCT values.We, therefore, conclude that for the VCD ≤ 2.15 ± 0.87 mm/m2 ∆BV ≤ 12.46 ± 3.48 and∆HCT ≤ 5.27 ± 1.48 values, the patients had normal blood pressure and were euvolaemic,while for higher values, patients had low blood pressure with possible dehydration. There-fore, ecography measurement of the diameter of the inferior vena cava, is a simple tech-nique and reliable in determining dry weight in hemodialyzed patients.

EFFECTIVE CORRECTION OFHYPERHOMOCYST(E)INEMIA IN HEMODIALYSIS PA-TIENTS BY FOLINIC ACID THERAPYM. Touam*, Z. Oualim*, R. Orozco*, J. Zingraff*, P. Jungers*, B.Chadefaux-Vekemans°, C. Fumeron*, T. Drüeke*, Z. Massy*.*Service de Néphrologie A, INSERM U 90, °Laboratoire deBiochimie B Hôpital Necker, Paris. France.

Background. Folic acid supplementation is only partially effica-cious in correcting moderate elevation of plasma totalhomocyst(e)ine (tHcy) concentration observed in hemodialysis(HD) patients. Experimental and clinical data have suggestedthat this partial efficacy may be due to impairment of folic acidmetabolism to 5-methyltetrahydrofolate (MTHF), and of MTHFtransmembrane transport as well. To bypass these difficulties,we assessed the efficacy of intravenous (i.v.) folinic acid, a readlyprecursor of MTHF, on reducing plasma tHcy concentrations inHD patients.Methods. In a cohort of 37 patients on intermittent HD tratment,plasma tHcy concentrations were determined before and duringi.v. supplementation of folinic acid (50 mg once a week), to-gether with i.v. pyridoxine, to prevent vitamin deficiencyparticulary in those treated by recombinant erythropoietin.Results. Folinic acid i.v. supplementation was given 11,2 ± 2,45months (range 7,5- 17 months). Mean plasma tHcy levels de-creased significantly from 37,3± 5,8 mM at baseline to 12,3± 5,4mM under folinic acid treatment (p < 0,001). Moreover, 29 of the37 patients (78%) had normal plasma tHcy levels at the end offollow-up (i.e. < 14,1 mM, mean 9,8 mM range 6,2 - 13 mM Noadverse effects attribuable to folinic acid treatment were ob-served during this time.Conclusions. i.v. folinic acid supplementation (50 mg) once aweek appears to be an effective and safe strategy to normalizeplasma tHcy levels in the majority of chronic HD patients.

NO DIFFERENCE IN CYTOKINE INDUCTION BETWEENPATIENTS ON ON-LINE HEMODIA-FILTRATION (HDF)AND LOW-FLUX HDR.L. Vaslaki, C.Weber*, R. Mitteregger§, D. Falkenhagen§

Erzsebet Hospital Sopron, Hungary. *Fresenius MedicalCare, Bad Homburg. Germany. §Danube University Krems,Austria

Chronic inflammation causes various long-term complica-tions of ESRD patients and may increase mortality. Influx ofmicrobial substances from contaminated dialysis fluid (DF)and on-line substituate is a major source of cytokine induc-tion, the initial inflammatory process. We have comparedpatients on online HDF and low-flux HD with respect to (a)spontaneous and (b) LPS-induced in vitro whole bloodIL-1Ra and TNF@ synthesis, and (c) cytokine productioncapacity. Both groups (n = 15) were treated with ultrapureDF and polysulfone membranes. Cytokine induction wasfound elevated in ESRD patients compared to healthy sub-jects, with no differences between the treatment modalities.Intradialytically, white blood cells became slightly, albeitnot significantly activated, as measured by LPS-inducedcytokine synthesis. There was no decline in cytokine pro-duction capacity of leukocytes during the treatment, indi-cating that the proportion of less mature or functionallyimpaired cells did not increase as a result of stimulated cellseWe conclude that infusion of large volumes of on-linesubstituate does not provoke chronic inflammation.

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CARDIAC TROPONIN T IN END- STAGE RENAL DISEASEPATIENTS UNDERGOING HAEMODIALYSISMY Hassan, O Elbahy*, KM Khedr**, TF Moghazy#, SS ElbanawyDepartment of Nephrology, Cardiology*, Chemical Pathology#,Medical Research Institute - Alexandria - Egypt and Depart-ment of Cardiology** - Faculty of Medicine - Alexandria - Egypt

We studied the cardiac troponin T (cTnT) in addition to otherconventional cardiac enzymes (CK-MB, LDH, AST) in 40 pa-tients with ESRD patients: 20 undialyzed and 20 on mainte-nance HD for more than 6 months. 20 subjects of comparableage and sex were studied as controls. ECG and echocardiographywere performed to all the studied cases to exclude those withmyocardial ischaemia or left ventricular hypertrophy.All the patients (undialyzed and dialyzed) showed normal lev-els for conventional cardiac enzymes. The level of cTnT waswithin normal range in all patients except in 2 dizlyzed patients(10%) who had abnormally high levels before dialysis sessions.Immediately after dialysis, 4 patients (20%) showed abnormallyhigh cTnT levels. Dobutamine stress, echocardiograms were doneto those 4 patients with elevated cTnT. It showed no segmentalwall motion abnormalities.It could be concluded that in a subset of patients on chronicmaintenance HD, cTnT may be increased without evidence ofcardiac ischaemia and this could not be attributed to the urae-mic state per se but to the dialysis procedure itself which maylead to subclinical minor myocardial cell injury. Clinicians mustbe cautious not to overinterpret minor increase of the cardiactropnins in patients with ESRD under maintenance HD.

DES-ARG9-BRADYKININ METABOLISM IN PATIENTS WHOPRESENTED HYPERSENSITIVITY REACTIONS DURINGHEMODIALYSIS.A. Adam1, C. Blais, Jr.1, J. Marc-Aurèle1, W. H. Simmons4, G.Loute3, P. Thibault2 and R. A. Skidgel5.1Université de Montréal, 2CNRC, Canada; 3Centre Hospitalier deSainte-Ode, Belgium; 4Loyola University and 5University of Illi-nois at Chicago, USA.

Bradykinin (BK) has been proposed as the principal mediator ofhypersensitivity reactions (HSR) in patients dialysed using nega-tively charged membranes and concomitantly treated withangiotensin-converting enzyme (ACE) inhibitors. We investigatedthe metabolism of exogenous bradykinin (BK) added to the seraof 13 patients dialysed on an AN69 membrane with a history ofHSR (HSR+ patients) and 10 others who did not present such areaction (HSR- patients) while dialyzed under the same condi-tions. No significant difference in the half-life (t½) of BK wasfound between the patient groups. However, the t½, of generateddes-Arg9-BK was significantly increased (2.2-fold) in HSR+ pa-tients compared to HSRsubjects. Preincubation of the sera withan ACE inhibitor (enalaprilat) significantly increased the t½ ofboth BK and des-Arg9-BK in both groups. There was no signifi-cant difference between the groups with respect to the t½ of BK,but there was a significantly greater increase (3.8-fold) in the t½of des-Arg9-BK in HSR+ patients compared to HSR- subjects.The level of serum aminopeptidase P (APP) activity showed asignificant decrease in the HSR+ sera when compared to HSR-samples. In HSR- and HSR+ patients, a significant inverse rela-tion (r2 = 0.6271; p < 0.00005) could be calculated between APPactivity and des-Arg9-BK t½. In conclusion, HSR in hemodialyzedpatients who are concomitantly treated with a negatively chargedmembrane and an ACE inhibitor can be considered as a multi-factorial disease in which a decreased APP activity resulting inreduced degradation of des-Arg9-BK may lead to the accumu-lation of this B1 agonist which could be responsible, at least inpart, for the signs and symptoms of HSR.

LIPID CHANGES IN HEMODIALYSIS IN COURSE OF ANTICOAGULATIONWITH FRAXIPARIN (F).Duranti E.Sezione di Nefrologia e Dialisi, Ospedale di Montevarchi , Arezzo -Italia-

Low molecular weight heparins beyond to have a more modulated anticoagu-lation, with respect to standard heparin (E), seem to have also an hypolipidaemiceffect. To the aim of auditing such presuppositions, that could find an interestingopening like a support in the therapy of dyslipidemia in hemodialysis, we havestudied in a group of hemodialysi pts, the effect on the lypidic picture, of F, respectto precedent data obtained during E anticoagulation.21 chronic uremic pts (13 M, 8F: age = 66±13 yrs ) in hemodialysis treatmentfrom 75±65 months, were studied. Of these, 12 pts (8M, 3F) showedhypertriglyceridemia and/or hypercholesterolemia, in dietary and pharmaco-logical treatment with fibrates and/or statines; the other pts (7 M, 3 F ) didn’thave lipid alterations. In all pts it was considered, retrospectively, a period ofobservation of 12 months, during which, for each dialysis session, standard Ehad been employed. In a second period of observation of the same duration,during which, type of dialysis, dietary behaviour and pharmacological therapywere unmodified, employed F came to similar dosing. In all pts, quarterly con-trols of Triglycerides (T), Cholesterol (C), HDL, LDL, KT/V and nPCR wereperformed. As controls, 15 pts (9M and 6F) had been studied, for periods ofsimilar observation, with comparable age and dialysis time: 8 pts (5M and 3 F)that showed lipid alterations and 7 pts (4 M and 3 F) in which lipids were in thenorm.During E period, C, T and LDL were significantly (p<0.001) increased in the 2groups of dislipidemic pts, respect to the 2 groups of normolipemic pts. But in thesecond period of observation the pts that went on to F, highlighted a significant% decrease (p<0.001) of C (21%), LDL (18%) and T (36% ). The group of control,in treatment with E, maintained significantly higher values (p<0.001), respectto the normolipemic pts and to the pts in tratment with F.No expressive change in the normolipemic pts, happened during the 2 antico-agulative regimens. HDL, KT/V and nPCR did’nt suffer modifications in nogroup and in no period.In conclusion we confirm the positive effect of F, respect to E, on the lipid metabo-lism, for which it could find an indication in the pts with evident lipids altera-tions, in association to the dietary and/or pharmacological measures.To our seem is necessary periods of observation of at least 5 yrs, for can settle onthe clinical piano F, like all the other low molecular weight heparins, might help,respect to E, to reduce the atheroslerotic complications in dialysis pts.

RESPONSE OF VASOACTIVE SUBSTANCES TO BLOOD PRESSURECHANGES DURING HEMODIALYSIS IN HYPERTENSIVE URAEMIC PA-TIENTS.J. Witkowicz, F. Kokot, T. Irzyniec, J. Chudek, R. FicekDept. of Nephrology, Endocrinology and Metabolic Diseases, Silesian Univer-sity School of Medicine, Katowice, Poland

Ultrafiltration during hemodialysis (HD) may be the cause of blood pressure(BP) decline due to reduction of blood volume. In some patients, however, BPdoes not decrease or even rises during HD.The aim of the study was to answer the question: do uraemic hypertensive pa-tients, showing a decline of mean blood pressure (MAP) during HD session(group A) differ from those showing a stable MAP during HD session (group B)with respect to hormonal profile of aldosterone (ALD), vasopressin (AVP), atrialnatriuretic peptide (ANP), endothelin-1,2 (ET-1,2), blood nitric oxide (NO) andplasma renin activity (PRA) ?A total of 39 hemodialysed, hypertensive patients (17 female, 22 men) werestudied. 24 patients (group A) showed a MAP decline of 10 mmHg or more,while 15 patients (group B) showed MAP changes of less than ± 10 mmHgduring HD session. PRA, ALD, AVP, ANP, ET-1,2, and NO concentrations wereassessed in blood samples withdrawn from the arterial blood line before HDand after 60,120,180 and 240 minutes of HD session. Plasma ET-1,2 and bloodNO concentration were also assessed after 30 minutes of HD. BV was continu-ously monitored with a Crit-Line equipment, BP was measured before and every30 minutes on HD.Before HD session both examined groups showed similar baseline plasma lev-els of ALD, AVP, ANP, ET-1,2, NO and MAP. A 4-hours HD induced a significantincrease in plasma ALD and AVID concentration and a significant decline inANP level in both groups of patients. In group A, PRA and blood NO concentra-tion increased significantly, while plasma ET-1,2 level did not change duringHD. In group B, no significant changes in PRA and blood NO level were noticed,while plasma ET1,2 rose markedly. In addition, in group B a significant positivecorrelation was found between MAP and plasma ET-1,2 level changes, but asignificant negative correlation between MAP and blood NO level changes.Conclusion: Patients with a decline of MAP over 10 mmHg during HD differfrom those with a stable MAP by a different response of plasma ET and bloodNO to HD induced volume changes.

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CAN BE C-REACTIVE PROTEIN CONSIDERED AS AN WELLBEING PRE-DICTOR FOR HEMODIALYSIS PATIENTS?S. Costantini, C. Massimetti, S. Feriozzi, L. Meschini, *M.T. Muratore, E. AncaraniNephrology, *Laboratory, Belcolle Hospital, Viterbo, Italy

The use of C-reactive protein (CRP) as an outcome of survival in regular dialysistreatment (RDS) has been recently proposed. The aim of this study was to evalu-ate the possible role of CRP also a predictor of wellbeing and cardiovascularstability in pts on RDS. A cohort of 85 non-randomized pts were prospectivelyenrolled in the study for six months. Blood C-rective protein concentrations hasbeen weekly measured and the pts were subdivided in 4 groups (G1-G4), accord-ing clinical criteria summarized:G1 Cardiovasculary stability; pre/post dialysis wellbeingG2 Hypotensive events in <30% of dialysis, generally without impor-tant therapeutic intervention (saline e/o hypertonic solutions); no infective prob-lemsG3 Hypotensive events > 30% of dialysis, regarding therapeutic inter-ventions (Trendelemburg, plasma expanders, stop of HD session); infective prob-lems managed ambulatoryG4 Cronically and sympomatic hypotensive events with angina or majorarrhythmia’s; frequently infective problems; frequently admission to hospital

RESULTS:G1 (n.18) G2 (n.29) G3 (n.22) G4 (n.16) p

Age (aa) 57±12 62±13 61±15 68±8 nsCare(months) 37±38 61±43 80±45 51±44 0.02Kt/V 1.14±0.12 1.16±0.13 1.10±0.12 1.07±0.12 nsPCR (g/Kg/die) 1.18±0.15 1.17±0.13 1.08±0.18 1.05±0.15 0.05TAC (mg/dl) 57.8±12.4 55.9±9.2 51.1±11.8 48.3±10.1 nsAlbumin (g/dl) 4.09±1.1 4.12±1.6 3.98±1.5 3.87±1.4 nsHospitalized (d) 0 11±9 19±6 23±10 0.05Dead 0 4 3 7 nsCRP 5.93±4.2 9.84±9.1 19.8±13.1 32.4±21.9 0.001

CRP is related to cytokine-mediated acute phase processes because associatedwith IL-6 release. CRP could be useful in the monitoring of cardiovascularyinstability with low expense (CRP dosage=Ε:1.10).

CARDIAC ARRHYTMIAS DURING CENTRAL VENOUS CATHETER INSERTIONSFOR ACUTE HEMODIALYSIS ACCESSZ. Civan, B. Canbakan, C. Yüksel, H.V. Atalay, S. AdanalýAnkara Numune Training and Research Hospital

Cardiac arrhytmias are frequently documented during various central venous catheter(CVC) insertion. In this study, we aimed to define the frequency and risk factors of cardiacarrhytmias during CVC replacement for hemodialysis vascular access.A total of 58 CVC procedures for hemodialysis vascular access (47 procedures in chronicand 11 procedures in acute renal failure patients) were performed in 41 renal failurepatients who needed acute hemodialysis procedure (31 chronic, 10 acute renal failurepatients)The site of insertion was subclavian vein in 39 procedures and femoral vein in19 procedures. Electrocardiographic rhythm strips were taken before and during thecatheter replacement. The maximum length of inserted guidewire was estimated usinga sterile metal ruler. BUN, serum creatinine and electrolyte levels and arterial blood gaswere analysed just before the procedures.New arrhytmias were documented in 28 cases (48%); 19 cases (33.6%) had new ventricu-lar arrhytmias (VA) and 14 cases (24%) had new supraventricular arrhytmias (SVA). Totalarrhytmia, SVA and VA frequencies increased significantly compared with baseline val-ues (p<0.01, p<0.001 and p<0.05 respectively). The type of the renal failure (acute/chronic) didn’t significantly affect the occurrence of new SVA’s and VA’s. New ventricu-lar arrhytmias were found significantly more frequent in subclavian vein catheter proce-dures, compared with femoral vein catheter procedures. The guidewire length remain-ing inside the patient was significantly higher in cases with new VA’s and new SVA’scompared with cases without new VA’s and new SVA’s (p<0.01 and p<0.05). Serum Calevels were lower, arterial pH and arterial O2 saturation was higher in cases with newSVA’s as compared with cases without new SVA’s; while serum K levels were lower andarterial oxygen saturations were higher in cases with new VA’s compared with caseswithout new VA’s. However, these statistically significant results were not found to beclinically significant. Differences in other variables (age, sex, BUN, serum creatinine, Na,Mg, inorganic P levels, hypoxia, preexisting cardiac disease and utilization of proarrhytmicdrugs) didn’t significantly affect the frequencies of new VA’s and new SVA’s. All newarrhytmias resolved spontenously soon after guidewirewithdrawn. Symptomaticarrhytmias developed in 2 cases (3.4%). Another patient died as a result of atrial fibrillation30 minutes after catheterization, but factors other than catheterization were supposed tobe responsible from this death.Our study suggest that new cardiac arrhytmias frequently occur in renal failure patientsduring CVC procedures for hemodialysis. We suggest that the routine use of cardiacrhythm monitorization will be beneficial in these procedures. Guidewire overinsertion isthe main risk factor for these arrhytmias. By measuring the length of the guidewire outsidethe patient with a sterile metal ruler and hence, preventing the guidewire insertion morethan needed for catheter insertion, we suggest that the frequency of cardiac arrhytmiaswith malignant potential may be decreased.

HEPATITIS C VIRUS GENOTYPE IN anti-HCV POSITIVEHAEMODIALYSED PATIENTSS. Pljesa, I. Pljesa, Lj. Lambic, G. PerunicicNephrological Ward of Internal Service University teaching Hos-pital, Zemun-Belgrade

Dialysis patients, to day, are at increased risk of hepatitis Cvirus infection.The prevalence of anti-HCV in our healthy population is similarto those in other parts of Europe, 0.27%, with genotype 1b in54.5%, 2b in 18.1%, 1a in 9%, as the prevalence in the age groupfrom 35-49 years.Prevalence of anti-HCV (testing was performed by 2nd and 3rd

generation ELISA tests), in our 78 haemodialysis patients is26.8% and we tested 19 of them with PCR technik. Genotypingwas successfully performed in 15 samples. The isolation of RNAgenetic material of HCV was done by Chomczynsky and Sacchimethod whit some modification.Results are shown in following table:

HCV genotyp % M/F Age HD duration (in months)1a 46.6 4/3 53.8 98.11b 13.3 1/1 41 903a 13.3 2/0 45 52.51a/1b 13.3 2/0 44.5 711b/2a 6.6 1/0 58 1641a/1b/3a 6.6 0/1 52 114

In our dialysis patients anti-HCV prevalence is on the same levellike in other Mediterranean countries in Europe, with predomi-nant 1a genotype (46.6%) which is different from literature dataand from genotype structure in our healthy population. Thefinding can indicate on possible nosocomial transmission andcan influence the correct choice of hepatitis C therapy, consider-ing the specific characteristics of certain C virus genotypes inanswer on interferon therapy.

INFLUENCE OF VITAMIN C INFUSION AND VITAMIN EMODIFIED MEMBRANE ON MARKERS OF OXIDATIVESTRESS DURING HEMODIALYSIS1J Racek, 2J Eiselt, 1L Trefil, 2K Opatrný Jr1Inst. of Clinical Biochemistry and Laboratory Diagnostics and2Dept. of Internal Medicine I, Charles University Hospital, Pilsen,Czech Republic

Hemodialysis is accompanied with an oxidative stress causedpredominantly by free radicals production in leucocytes duringtheir contact with a dialyzing membrane. The aim of our studywas to evaluate the influence of antioxidative vitamins (vitaminE bound to dialysis membrane and vitamin C in infusion) onmarkers of oxidative stress in hemodialyzed patients.24 regularly hemodialyzed patients were treated both with themembrane modified by vitamin E (Terumo CL E15NL) andwith the conventional membrane (Terumo CL C15NL). Thehemodialysis on both membrane types was performed eitherwith a simultaneous infusion of 500 mg ascorbic acid/4 h orwithout it. Influences of these hemodialysis types on markers ofoxidative stress during the hemodialysis were compared with apaired t-test.Dialysis without vitamin C infusion lead to a significant de-crease of vitamin C concentration from 21 ± 7 to 17 ± 6 umol/l,p < 0.01 on conventional membrane and from 25 ± 16 to 19 ± 8umol/l, p < 0.05 on vitamin E-modified membrane. At the sametime, a significant increase of malondialdehyde from 3.8 ± 0.5 to4.2 ± 0.6 umol/l, p < 0.01 on conventional membrane only wasobserved. Supplementation with vitamin C during the dialysismaintained its concentration constant and prevented from in-crease of MDA by use of both membrane types. Activities ofantioxidative enzymes (superoxide dismutase and glutathioneperoxidase) and reduced glutathione concentration in erythro-cytes remained unchanged during all types of dialysis proce-dure.The results show that membrane modification with vitamin Eleads to a lower degree of oxidative stress during hemodialysis.Similar results can be obtained with a conventional membraneand a simultaneous infusion of vitamin C.

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HOMOCYSTEINE AND VASCULAR ACCESS THROMBOSISIN HEMODIALYSIS PATIENTS1R Hojs, 2M Gorenjak, 1R Ekart, 1B Dvoršak, 1B Pecovnik-Balon.1Dept. of Nephrology and 2Clinical Chemistry, Teaching Hospi-tal Maribor, Maribor, Slovenia

Vascular access remains the Achilles’s heel of successfulhemodialysis and thrombosis is the leading cause of vascularaccess failure. Hyperhomocysteinemia is common inhemodialysis patients and is associated with venous and arte-rial thrombosis.In our study 65 hemodialysis patients with native arteriovenousfistula were included, 24 women and 41 men. Two groups ofpatients were defined: group A including 45 patients (17 womenand 28 men; average age 52,5 years) who had their vascularaccess either never or only once thrombosed, and group B in-cluding 20 patients (7 women and 13 men, average age 55,0years) who had two or more thromboses of their vascular ac-cess. Average duration of hemodialysis treatment in group Awas 57,4 months (ranging from 12 to 217 months), and in groupB it was 46,6 months (ranging from 12 to 138 months). Thevascular access failure in less than 1 month after constructionwas considered to be surgical failure and was not included as athrombotic event in this study. Patients with diabetes were ex-cluded.We determined serum levels of homocysteine (immunoassay,Abbott) in our patients and in 63 (96,9 %) patients hyper-homocysteinemia was present. There was no statistically sig-nificant difference in the two groups regarding age, gender andduration of hemodialysis treatment. Average homocysteine con-centrations were 42,1 ± 18,6 µmol/l in group A and 36,1 ±18,1 µmol/l in group B. The difference was not statisticallysignificant.In summary, we did not find significant difference in homo-cysteine concentrations between thrombosis prone and throm-bosis non prone group. Our results suggest that thrombosis ofarteriovenous fistulas may not be caused byhyperhomocysteinemia.

THE INCREASE OF THE QTc DISPERSION FOLLOWINGDIALYSIS IS DEPENDENT OF POTASSIUM REMOVALCupisti A, Galetta F, Caprioli R, Tintori GC, Sposini S, MancaRizza G, Franzoni F, Lippi A, Rindi P, Barsotti G.Dip. Medicina Interna, Div. Nefrologia ASL, Università di Pisa,Italia

It was demonstrated that hemodialysis increases QTc disper-sion (QTcD), a marker of risk of ventricular arrhythmias. How-ever, the role of ultrafiltration or of diffusive process, andexpecially of plasma K+ changes, occurring during hemodialysiswere not investigated. To this aim, QTcD was hourly measuredin 10 uncomplicated uremics (5m, 5f, aged 50±13 yrs), duringtwo different types of hemodialysis schedules. Study A: onehour of isolated high rate ultrafiltration preceded the standarddiffusive procedure.Study B: during the first hour of standard bicarbonatehemodialysis, the decrease of plasma potassium concentrationwas prevented by increasing K+ concentration in the dialysate.Results. Study A: QTcD did not change after the ultrafiltrationperiod (30±7 vs 34±5 ms) despite ECG signs of increased sym-pathetic nervous system activity and higher catecholamines se-cretion. Instead QTcD increased one hour after the start of thediffusive hemodialysis (47±9 ms, p<0.01), progressing till theend of the dialysis session (58±15 ms, p<0.001). Study B: afterthe first hour of standard hemodialysis with constant plasma K+

levels (from 5.4±0.7 to 5.6±0.7 mmol/L), the QTcD did notchange (33±9 vs 32±12 ms), whereas it increased 1 hour after theK+ dialysate fluid concentration was restored to 2 mmol/L (53±16ms, p<0.001) to lower plasma K+ levels (4.1±0.4 mmol/L), andthen the QTcD reached the highest value at the end of the session(64±16 ms).This study provides evidence that the increase of the QTcDoccurring on hemodialysis is mainly related to the diffusiveprocess, more precisely to the K+ removal. This is one morereason to focus attention on K+ removal rate especially whenhemodialysis treatment is given in uremics affected by severecardiac diseases or with high risk of ventricular arrhythmias.

THE IMPORTANCE OF THE TIME ON DIALYSIS DELIVERYESTIMATED BY PARTIAL DIALYSATE COLLECTIONN A Hadjinicolov, S AntonovClinical Center of Haemodialysis, State University“Aleksandrovska”, Sofia, Bulgaria

The purpose of this study was to reveal how prolongation of thetime influences on dialysis delivery. Twelve anuric stable pa-tients were investigated. Each of them underwent two dialyses:short (3.5h) and long (4.5h) on the second dialysis session of theweek. The parameters used during the two procedures wereequal: blood flow 250ml/min, dialysate flow 500ml/min, F6dialysers and UF rate 3000ml. The blood samples for urea andcreatinine analyses were performed at the beginning, at the endand 30 minutes after finishing dialysis. The spent dialysate wascollected using our modification of Ing’s metod for partial dia-lysate collection (PDC). Results:

Urea URR% URR% Kt/V(gr/session) 30 min (Daugirdas)

3.5h HD 29.1±8.0 63.3±5.3 58.4±4.3 1.10±0.154.5h HD 36.5±11.8 71.1±4.5 66.7±4.5 1.39±0.17

The additional purification of urea attained with the prolonga-tion of time with one hour was 20.3% using PDC metod (p<0.01),11% estimated by URR (p<0.001) and 20.9% by Kt/V (p<0.001).The postdialysis urea rebound was 13.8±6.2% for short dialysisand 15.5±4.7% for long dialysis. An excellent correlation be-tween predialysis urea blood concentration and the urea re-moved per session in the spent dialysate was found (r=0.98),(p<0.001). We concluded that dialysis efficacy has remainedalmost linear in the last hour of dialysis.

ARTERIO–ARTERIAL GRAFT AS AN ALTERNATIVE VAS-CULAR ACCESS FOR DIALYSIS.I Kruzhilin, A Gorelik, I Pisarenko, S Korneeva, A NikonenkoDept. of Transplantation, Zaporozhye Regional Hospital,Ukraine

The impact of volume overload on the course of chronic cardiacfailure in dialyzed patients with arterial-venous fistula (AVF)has been evaluated and a new approach to vascular access fordialysis has been proposed. AVF with blood flow more than 900ml/min resulted in developing or worsening of cardiac failure in102 from 358 dialyzed patients carried in our center from 1992to 1998. Clinical evidences were arterial hypertension (BP172±10,5 mm Hg), tachicardia (HR 92±9,7 beats/min), lower-ing of myocardial contractility and stroke fraction, left ventricleenlargement, dyspnoe at rest, hepatomegaly, peripheral edema.The elevated blood pressure was poorly controlled with ultrafil-tration and antihypertensives.The suggestion was proved by evaluation of central circulationbefore and after compression of AVF.Arterio-arterial autovenous grafting was performed in 35 pa-tients of this group. The autograft (V. Saphena magna) has beenplaced on contralateral arm between brachial artery in cubicalfosse and radial artery in low third of forearm. AVF was clampedafter starting dialysis with new vascular access (e.g. in 2 weeks).Blood flow through the graft was 300-400 ml/min. Averageterm of the graft usage was 11,4±2,3 month and term of obser-vation was up to 20 month. Thrombosis of the graft has beenobserved in 10 (27%) patients and thrombectomy has been per-formed successfully in 3 patients.Lowering of arterial pressure (140,4±15,5 mm. Hg.) and heartrate (HR 70,4± 6,5 beats/min.), improving of cardiac perform-ance, hepatomegaly and peripheral edema disappearing wasobserved after AVF close at running autograft. Successful kid-ney allografting has been performed in 12 patients with runningarterial-arterial shunt.Autovienous arterio-arterial graft can be used as an alternativevascular access for dialysis in patients at high risk of cardiacfailure.

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BENEFITS OF FUZZY-CONTROLLED INFUSION AND UL-TRAFILTRATION ON HEMODIALYSIS PATIENTSR Schmidt, O Roeher1, H Hickstein, S Korth2

Department of Internal Medicine, Rostock University, Rostock,1Dresden, 2Erfurt, Germany

Biofeedback control of ultrafiltration (UF) and infusion (INF) ofhypertonic saline (20% NaCl) enables the mechanisms of con-vective (UF) and diffusive (INF) fluid transfer to adapt selec-tively to patient´s blood pressure behaviour during hemodialysis(HD). Due to multifactorial causes of HD-induced hypotensionwe used adaptive fuzzy control of UF- and INF-profiles toanalyze their specific benefits on blood pressure stabilization inpatients prone to develop hypotension during HD.Results of our comparitive study (291 HD-sessions, 15 patients)to be presented have proven that BP-guided fuzzy control of UFand INF provides essential benefits in comparison with conven-tional hemodialysis (CHD):1. Decrease of intervals with low BP<90 mmHg from 100%(CHD) to <33% (total session) resp. <5% (final hour),2. Increase of sessions with stable and arising BP during the finalhour from 32.4% (CHD) up to 95.6%,3. Fuzzy control of hypertonic saline infusion prevents patientsfrom increase of postdialytic blood sodium,4. Initial UF-rates up to 200% of average rates are well toleratedand allow UF-rates <35% in the final hour.In conclusion, HD-machines enabling selective adaption of UF-and INF-profiles by BP-guided biofeedback control will providea new quality of HD adequacy for patients prone to developHD-induced hypotension frequently.

ANAMNESTIC DYSMOTILITY-LIKE DYSPEPSIA SCORE(ADDS) IN CHRONIC HEMODIALYSIS PATIENTS: DEFINI-TION, PREVALENCE AND CORRELATION WITH GASTRICEMPTYING.B. Van Vlem, R. Schoonjans, R. Vanholder, M. De Vos, W.Vandamme, A. Elewaut, N. Lameire

Many hemodialysis patients report dyspeptic complaints, oftenleading to malnutrition, which is associated with increased mor-bidity and mortality. To assess the degree of dyspepsia in thesepatients, we developed and validated an ADDS.Complaints of dysmotility-like dyspepsia (nausea, vomiting,abdominal distension and early satiety) were gradedanamnestically by the same investigator as absent (0), sporadic(1), daily (2), especially postprandial (score +1 if present in nausea,vomiting or abdominal distension) or improving withgastroprokinetics (score +1 for early satiety) in 72 patients (me-dian age 68y, range 32-84y) on chronic hemodialysis. To vali-date the clinical relevance of this ADDS, the C-13 octanoic breathtest was performed to measure gastric emptying of solids ontwo consecutive days, the mean value of the Gastric EmptyingCoefficients (GEC) was calculated per patient.Of all 72 hemodialysis patients of our dialysis center, 52(72%)had an ADDS of 0 or 1 (“normal”); 20(28%) had an ADDS of 2to 12 (“dyspeptic”). Of 20 patients performing the 2 gastricemptying breath tests on 2 consecutive days, 7 (35%) had amean GEC < 2,9 (“gastroparetic”), 13 (65%) had a mean GEC >2,9 (“normal”). There was a highly significant correlation be-tween ADDS and mean GEC: χ2= 10,8 (p=0,001), SpearmanR=-0,77 (p=0,0001). For predicting gastroparesis, the ADDShas a sensitivity of 100% and a specificity of 77%. This defines anegative predictive value of 100% and a positive predictive value(given a prevalence of 35%) of 70%. In conclusion, an ADDSwas defined in hemodialysis patients and validated by demon-strating a significant correlation with the gastric emptying ratefor solids. The very high negative predictive value makes theADDS a valuable screening tool for gastroparesis in hemodialysispatients.

PARATHORMON AND LEFT VENTRICULAR HYPERTRO-PHY IN NORMOTENSIVE HEMODIALYSIS PATIENTS.P. Stroecki, A. Adamowicz, 1G. Odrow-Sypniewska, 2E.Nartowicz, J. ManitiusDepts. of Nephrology, 1Clin. Chemistry, 2Cardiology, The LudwikRydygier Medical University, Bydgoszcz, Poland

Experimental and clinical studies strongly suggest that second-ary hyperparathyroidism (HPT) contributes to left ventricularhypertrophy in hemodialysis (HD) patients (pts). The aim of thestudy was to estimate end-diastolic interventricular septumthickness (IVS), left ventricular posterior wall thickness (PW)and left ventricular mass (LVM) in normotensive HD pts (BP <160/90 before HD, without antihypertensive drugs) with HPT.Echocardiography was performed in 34 HD pts: F=16, M=18,aged 23-74 (mean 48) yrs, for 46 months on HD. Twenty five ptshad PTH > 200 pg/ml (210-1508 pg/ml) – HPT group, and 9pts had PTH < 200 pg/ml (28,2-148 pg/ml) – low PTH group.Results were as follows (mean ± SD).

Low PTH group HPT group PPTH (pg/ml) 82 ± 40 622 ± 395 < 0,001IVS (mm) 12,0 ± 1,2 14,1 ± 2,8 < 0,01PW (mm) 10,7 ± 0,8 11,9 ± 1,7 < 0,01LVM (g) 158,1 ± 40,6 202,9 ± 60,4 < 0,05

Hematocrit, blood pressure, left ventricular end-diastolic diam-eter and ejection fraction did not significantly differ between lowPTH group and HPT group. We found positive correlation be-tween: PTH and LVM (r=0.36, P < 0,05, n=34), PTH and PW(r=0.33, 0.1 < P < 0,05, n=34) but not PTH and IVS in the wholeanalysed group.Our results seem to confirm that elevated PTH concentrationscontribute to left ventricular hypertrophy in normotensive HDpts.

INTRA-DIALYTIC RELEASE OF OF PROTEIN-BOUND SOLUTES AND OFFREE FATTY ACIDS FROM THEIR BINDING SITES IS AN IN VITRO ARTI-FACT.R De Smet, N Lameire, AM Dhondt, R Vanholder.Nephrology Dpt, University Hosp, Gent, Belgium.

Several studies report a rise in free fraction of protein-bound compounds duringheparinisation, which is currently attributed to the activation of lipoproteinlipase, resulting in the release of free fatty acids (FFA) and their competition atalbumin binding sites. Such a release can be supposed to result in enhancedtoxicity. This study was undertaken to evaluate: 1) whether a rise in free fractionof protein-bound uremic toxins occurred during hemodialysis (HD) with heparinas anticoagulant; 2) whether such a rise was not an artifact provoked by contin-ued activity of lipase in the test tube after blood sampling. The free fraction ofp-cresol, a toxin with immune suppressive activity, was measured by reversedphase HPLC, in 27 patients (age 65±14, 10 males). Both anticoagualtion withStandard Heparin (SH) and Low Molecular Weight Heparin (LMWH) resultedin a rise of free p-cresol at 30 min of HD when samples were kept at roomtemperature before analysis: from 0.1.1±0.06 to 0.33±0.24 for SH (p<0.05) andfrom 0.10±0.06 to 0.36±0.26 mg/100 mL for LMWH (p<0.05). Heparin-free HDand HD with sodium citrate showed no rise in free p-cresol. Other protein-bounduremic toxins, such as indoxyl sulfate, showed a similar behavior. There was adirect correlation between FFA and free p-cresol at 30 min (n=12, r=0.80, p<0.01).However, when samples were kept at 4°C after collection, or when protaminewas added to the samples immediately after collection, the rise in free p-cresolwas markedly less pronounced. Total neutralization of lipase activity by theaddition of tetrahydrolipstatin (2mg/2mL - Roche, Basel) immediately aftersample collection, revealed no change in free p-cresol (from 0.08±0.07 to0.07±0.06, p=NS) nor in FFA. Ultrafiltrate collected at the 30th minute of dialy-sis revealed a p-cresol concentration comparable to the pre-dialysis free p-cresol.When radiolabelled diphenylhydantoin was added to serum collected duringHD, free drug rose from 18.8±2.6 to 22.6±4.4 % for untreated sera (P<0.01),whereas no change occurred after the addition of tetrahydrolipstatin. It is con-cluded that free concentration of protein-bound solutes does not increase duringHD and that earlier reported increases of free solute and FFA are probably ar-tifacts, because of continuing lipase activity in the test tube.

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THE GRAFT VASCULAR ACCESS DRAINING INTO DEEPVEIN FOR CHRONIC HEMODIALYSISK. Hayakawa, M. Matsumoto, K. Miyaji, T. Aoyagi, H. Ishikawa,M. Hata.Dept. of Urology, Ichikawa General Hospital, Tokyo DentalCollege, Chiba, Japan

We developed a new method for graft vascular access draininginto deep vein for chronic hemodialysis. [Surgical Methods] Theprocedure to create a loop graft in the forearm is as follows: Atransverse skin incision was made 2 or 3 cm distal to the antecu-bital crease. A radial artery was identified at near its origin. Oneof the radial veins, which run parallel to both sides of the radialartery, was mobilized, including its tributories, for a distance of3-4 cm. Subsequently, all of these veins were ligated with 4-0 silkand then divided. After clamping the central point of the veintrunk under heparinization, plasty of radial vein stump wasconducted in order to make a wide opening suitable for end-to-end anastomosis with the polyurethane graft. After a subcuta-neous loop tunnel was created, end-to-side graft-to-artery anas-tomosis was performed in the usual fashion. All grafts used inthis study were 5mm in diameter, and an anastomosis wasmade with continuous sutures, using 7-0 polypropylene. [Re-sult and Discussion] From January 1998 to December 1998, 11patients, 4 men and 7 women, with ages ranging from 47 to 72years (average, 59.8 years) were submitted to our protocol. Meanoperation time was 168±23 min. Cumulative patency rate was100 and 77.8% at 3 and 6 months, respectively. The advantagesof using deep vein are: (1) acceptance of even those patientswhose subcutaneous peripheral vessels are completely ruined(2) end to end vein anastomosis providing us with smooth bloodflow contributing to longer graft patency.

ESTIMATION OF THE EFFECTIVENESS OF HAEMODIALY-SIS BY SPIN LABEL METHODFinin V.S., Soklakov V.I.Belarusian State University, National Nephrological Center,Minsk, Belarus

Spin label set consisting of marked fatty acid with 5,12 and 16chain length and benzo-γ-carboline (BC) zond were used. Fattyacid label bind selectively with the corresponding serum albu-min (HSA) sites. Their binding depends on the “loading” HSAmolecule with metabolites, toxins, drugs, etc. Besides HSA sorp-tion BC has considerable greater affinity to blood serumlipoproteins fractions. The most valid diagnostic informationwas received by using only two zonds – doxyl laurat (DL) andBC. Blood for analysis was taken before and after haemodialy-sis procedure. Each group composed six patients. Mean valueof spin label distribution parameters (K

app for DL and C

free for BC

in µM) in blood serum are given below.Group of Before dialysis After dialysispatients DL BC DL BCHypotonia 295±25 0,95±0,11 285±20 0,85±0,10Hipertensia 320±20 1,35±0,14 290±15 0,85±0,13Stablehemodinamics 290±20 1,25±0,14 265±25 1,00±0,15Control groups 125±10 2,35±0,20The investigation revealed reduction of binding fatty acid spinlabel and increases BC sorption in serum of kidney patients. Theresults testify that programmed haemodialysis can’t removeeffectively pathological metabolites.The spin label method can serve as a convenient instrument forthe development of the methods of cleaning blood of endogenintoxication products.

NUTRITIONAL STATUS AND DIALYSIS ADEQUACY VER-SUS IMMUNOLOGICAL FUNCTION (SERUM LEVELS OFCIRCULATING CYTOKINES) IN HEMODIALYSIS (HD) PA-TIENTSW. Zaluska, A. KsiazekDepartment of Nephrology, Medical Univ. School, Lublin, Po-land

Although the protein calorie-malnutrition and dialysis inad-equacy are important predictors of mortality in patients onchronic hemodialysis, the impact of immunological parameterson survival in such patients is still unclear. In our study in 50nondiabetic HD patients we tested nutritional status using bio-chemical parameters (serum total protein, serum albumin, se-rum transferrin). The dialysis adequacy parameters included:percent reduction of urea (PRU), (equilibrated) eKt/V and(nPCR). The nutritional, and kinetic parameters were comparedto immunological variables including circulating cytokines[interleukin IL-2 IL-2R, IL6, IL6R, and tumor necrosis factor(TNF-R)].Results: The mean serum albumin (g/dl) concentration was3.66±0.37, mean transferrin (mg/dl) 259±57, mean nPCR(g/kg/day) was 0,95±0.16, and mean eKt/V 1.05±0.35. Patientsserum albumin significantly correlated with nPCR, and Kt/V,and their circulating IL-2, Il-6, and IL-6R levels, but negativelywith circulating TNF-R levels, and didn’t correlate with IL-2Rlevels. Immunological variables were highly intercorrelated ex-cluded circulating IL-2R value (ANOVA test). In all of cases themean level of circulating cytokines were higher in HD patients,than in normal control group.Conclusion : Our report indicating direct correlation betweennutritional parameters, and circulating cytokines may suggest,that malnutrition, and inadequatedialysis dose contribute toreduced immune responsiveness in HD patients. The mecha-nism underlying the relationship of immune functionand nutri-tional status should be studied looking for individual cytokineschanges.

EFFECT OF DIALYSIS DOSE ON NUTRITIONAL STATUS OFCHILDREN ON CHRONIC HEMODIALYSIS (HD)O Marsenic, G Bigovic, A Peco-Antic, O. JovanovicUniversity Children’s Hospital, Belgrade, Yugoslavia

It had been suggested that higher HD doses in children couldresult in better appetite, higher protein intake, better nutritionalstatus and better growth. We investigated how different HDdoses affect protein intake and nutritional status of children onchronic HD. Indices of nutritional status used were normalisedprotein catabolic rate (nPCR) calculated by formal 3-sampleurea kinetic modeling as a measure of protein intake and serumalbumin level.Forty standard pediatric HD sessions in 15 stable patients(M:6,F:9) aged 14.5±3.28 years were investigated. HD lasted3.81±0.44 hours. Average single pool Kt/V as a measure of HDdose was 1.69±0.42 (0.60-2.69). HD sessions were divided into3 groups based on delivered HD dose: group I (n=5) -inad-equate (Kt/V<1.3), group II (n=12) - adequate (Kt/V=1.3-1.6)and group III (n=23) - high (Kt/V>1.6). Body mass index in allpatients was above the 3rd percentile for age and gender.Serum albumin level was adequate in all patients with a meanof 43.77±2.28 gr/l (39.7-47). Average nPCR was 1.38±0.28 gr/kg/day (0.87-2.22) and it differed between groups dependingon Kt/V. In group I with Kt/V of 0.93±0.22, nPCR was lowest1.10±0.28 gr/kg/day and significantly different (p=0.01) fromthat in group II. In group II with Kt/V of 1.48± 0.09, nPCR washigher 1.42±0.22 gr/kg/day and did not significantly differ(p>0.05) from nPCR in group III, 1.42± 0.29, where Kt/V was1.97±0.26. A week positive correlation was found between Kt/Vand nPCR (r=0.443, R2=0.196).We conclude that adequate dialysis (delivered Kt/V=1.3-1.6)needs to be achieved in order to insure good protein intake ofchildren on HD. However, there does not seem to be any addi-tional benefit from very high HD doses (Kt/V>1.6) when nutri-tional status of children on chronic HD is concerned.

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THE PREVALENCE OF TRANSFUSION TRANSMITTED VI-RUS (TTV) IN HEMODIALYSIS PATIENTS1M Adorati, 2M Pirisi, 2P Toniutto, 1M Artero, 1A Caberlotto, 1DRomanini1Nephrology Serv., ASS 4 “Medio Friuli”, Cividale del Friuli andSan Daniele del Friuli; 2Dept. Int. Medicine, Univ. of Udine, Italy

After the discovery of hepatitis viruses C and G, a new viralparticle (TTV) has recently been isolated in patients withpost-transfusion hepatitis non-A, non-B, and non-C. The DNAgenome consists of a single-stranded helix of at least 3700 basepairs. Its pathogenetic mechanism is currently unknown, and ithas been isolated from 10-38% of diverse populations of healthyand diseased subjects, without significant statistical differencesbetween groups in terms of prevalence. The purpose of the presentstudy was to determine the prevalence of the virus in a popula-tion of 46 patients (52 per cent male, age range 25-89 years) inhemodialysis from five months to 20 years. No patient waspositive for HBsAg whereas nine patients (19.5%) were positivefor anti-HCV antibodies, six of whom with circulating HCVRNA. The presence of the virus was detected in serum withsemi-nested PCR using specific primers.TTV was detected in six patients (13%), four of whom wereanti-HCV positive (two HCV RNA positive). Increased SGOT,SGPT and other hepatic enzymes were present in a singleTTV-positive patient, who also suffered from alcohol depend-ence. No correlation was found with HBsAb status. Three posi-tive patients had histories of blood transfusions.The prevalence of TTV in hemodialysis patients is significantlyhigher than that reported in blood donors in Scotland (1.9%) andin the general populations of Japan and UK (10%), but lowerthan that of subjects with chronic liver disease (25%). Our re-sults did not indicate correlation with infection of otherparenterally-transmitted viruses nor with evidence of hepaticcellular damage, in agreement with data from other preliminarystudies.

THE EFFECT OF PARATHORMON ON THE INSULIN RESISTANCE IN THEHEMODIALYSIS PATIENTSH Cakir, M Güllülü, K Dilek, M Yavuz, A Ersoy, E Dalkilic, M Usta, M YurtkuranUludag University Nephrology Department, Bursa, Turkey

The main cause of the disturbance of carbonhydrate metabolism in patients with chronicrenal failure is insulin resistance. Besides in the presence of factors that inhibit insulinrelease and effect may deteriorate more the carbonhydrate metabolism in uremic pa-tients. The effect of parathormon on glucose metabolism is uncertain in animal and hu-man studies. Therefore, we investigated the relationship between the parathormon andthe plasma glucose, insulin levels and the areas under the glucose and insulin curveswhich were obtained during intravenous glucose tolerance test (IVGTT).The patients were divided into three groups regarding the parathormon levels:Group-I, nPTH (normal parathormon, 12 ± 17 pg/ml) (n: 7)Group-II, hPTH (high parathormon, 263 ± 108 pg/ml) (n: 8)Group-III, vhPTH (very high parathormon, 993 ± 406 pg/ml (n: 13)The plasma calcium, ionized calcium and phosphate levels were determined before IVGTT.

nPTH hPTH vhPTHThe areas under the glucose curves 18450 ± 6392 19013 ± 4881 18605 ± 6567

Among the three groups thereas no statistically significant difference between groupswhen the plasma glucose levels and areas under glucose curves concerned.

nPTH hPTH vhPTHThe areas under the insulin curves 7895 ± 2599 4545 ± 1302a 12821 ± 6036a,b

a p < 0.05, compared to the nPTH groupb p < 0.001, compared to the hPTH group

The plasma insulin levels and the areas under insulin curves in group-II were statisticallylowest than group-I and group-III and these values were also lower in group-I than ingroup III. The plasma calcium levels in the group-I were statictically higher than thelevels of the group-II and III. No significant difference was observed between the ionizedcalcium levels of three groups.The results suggest that the moderately high parathormon levels in the hemodialysispatients do not affect the insulin resistance and the insulin release from the pancreasindependently from the calcium, ionized calcium and phosphate levels. In addition, wecame to the conclusion that the highest parathormon levels increase the insulin resistanceby elevating the insulin levels.

THE EFFECT OF INCREASED KT/V VALUES ON INSULIN RESISTANCE IN THEHEMODIALYSIS PATIENTSH Cakir, M Güllülü, K Dilek, M Yavuz, E Ertürk, A Ersoy, Y Karakoc, M Usta, M YurtkuranUludag University Nephrology Department, Bursa, Turkey

Hemodialysis therapy can improve insulin resistance in the patients with chronic renalfailure. But, this improvement can never reach to the levels in normal healthy subjects.Urea kinetic modelling demonstrates the dialysis efficacy best. In the literature, we do notcome across a study which investigates the effect of the dialysis efficacy on insulin resist-ance and therefore,we proposed to study this object.28 stable (15M/13F) hemodialysis patients were included in the study. The mean age ofthe cases was 37 ± 15 years. The mean duration of dialysis was 83 ± 44 months. All cases tooka 1.2 gr/kg/ day protein diet. 18 cases who had a mean KT/V value a 1.0 with the ureakinetic modelling were selected as the study group. 10 cases with the mean KT/V valueof 1.1 were selected as control group. Among groups, there was no difference in terms ofage, sex, the duration of dialysis, parathormon, calcium, phosphate and potassium values.No change was done the medical treatment and the diet of the patients. Intravenousglucose tolerance test (IVGTT) was performed in all cases. The KT/V values of the pa-tients in the study group were elevated to 1.5 by increasing the pump rate and the dialysisduration. The KT/V values in the control group were kept constant.

Study Group Control GroupPre-Study Post-Study Pre-Study Post-Study

Total area under glucose curve 18180±1465 12057±602a 16457±1647 15791±1437Total area under insulin curve 8567±1368 5674±902b 5510±734 5515±657a p < 0.001, compared to prestudy valuesb p < 0.05, compared to prestudy values

After 12 weeks, IVGTT was repeated in both of the groups. The serum glucose and insulinlevels and the changes in areas under the insulin and glucose curves before and after thetreatment were statistically compared. In the study group, these parameters were signifi-cantly decreased when compared with the control group.

The changes in areas under the curves in two groupsThe Study Group The Control Group

Glucose -6123±1181a -666±1280Insulin -3212±1158b +4.5±616

a p < 0.01, compared to the control groupb p < 0.05, compared to the control group

The changes in areas under the insulin and glucose curves in the study group before andafter the treatment were significantly decreased when compared with the control group.As a result, the hemodialysis therapy which elevated the KT/V values by urea kineticmodelling increased the insulin sensitivity.

THE CORRECTION OF INSULIN RESISTANCE BY INCREASING EFFECTIVE-NESS OF DIALYSIS DOES NOT AFFECT TUMOR NECROZIS FACTOR-αLEVELSM Güllülü, A Ersoy, H Cakir, B Oral, F Budak, M Yavuz, K Dilek, M YurtkuranUludag University Nephrology and Immunology Departments, Bursa, Turkey

It is known that chronic renal failure patients have insulin resistance that can beimproved with effective hemodialysis therapy. Many toxins that are removedwith hemodialysis therapy are blamed for this resistance. But the tumor necrozisfactor-alpha (TNF-α) expression which is known to be strongly correlated withinsulin resistance especially in obese patients has not yet been investigated inhemodialysis patients. In this study, we aim to investigate the relation betweenTNF-α level and insulin resistance with increased dialysis effectiveness.28 hemodialysis patients 15 male, 13 female were included in the study. Theirmean age was 37 ± 15 years. 18 cases with an average KT/V value of 1.0 withthe urea kinetic model were included in the study group and 10 cases with anaverage KT/V value of 1.1 were included in the control group. There was nodifference between groups when age, sex, dialysis duration, parathormon, se-rum calcium and phosphate levels were considered. After all cases had intrave-nous glucose tolerance test (IVGTT), the KT/V value of the study group wasincreased to 1.5. No change was done in the control group. After 12 weeks bothgroups again had an IVGTT and glucose, insulin, TNF-α levels and area underthe curves of glucose and insulin were compared before and after the study.

High KT/V Group Control GroupPre-Study Post-Study Pre-Study Post-StudyTNF-α pg/ml 9.18±6.03 9.91±7.1 8.68±6.66 9.78±8.0Total area under insulin curve 8567±1368 5674±902a 5510±734 5515±657Total area under glucose curve 18180±1465 12057±602b 16457±1647 15791±1437a p < 0.05, compared to prestudy valuesb p < 0.001, compared to prestudy values

Although there was a statistically significant decrement in area under the curvesof glucose and insulin in the study group at the end of 12 weeks, the changes inTNF-α levels were not different in both groups.As a result, we came to the conclusion that the increment in hemodialysis effec-tiveness did not affect TNF-α levels much and upon this point we thought thatTNF-α level was not an important factor for insulin resistance in these patients.

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TREATMENT OF ANAEMIA WITH INTRAVENOUS IRON INPATIENTS WITH END-STAGE RENAL FAILURE BEING ONHEMODIALYSISDimkovic N., Popovic J., Cuckovic C., Mirkovic M., DragicevicP., Lazic N., Radmilovic A.Institute for Renal Diseases, Zvezdara University Hospital, Bel-grade, Yugoslavia

According to DOQI recommendation, sufficient iron is neces-sary to achieve the target Hct/Hgb level in-patients with CRF.That means TSAT of > 20% and a serum ferritin level of > 100ng/ml. Dialysis patients frequently are not able to maintainadequate iron status with oral supplement therapy and intrave-nous iron is recommanded especialy in those being onerytropoietin therapy.The aim of the study was to evaluate the efficiency of differentprotocols of intravenous (i.v.) iron therapy (ferrogluconat, 62mg) in regular in hospital HD patients with or withoutEritropoetin (EPO) therapy.I.v. ferrogluconat was applied in 75 patients (30% out of all incenter patients) age: 55.1±10.5. Among them, 32 (52%) were onEPO therapy. Initial doses was <10 single doses (5.3%); 10-20doses (40%); 20-30 doses (28%); > 30 doses (18.6%) and un-known 8%. Initial iron therapy was given on every consecutiveHD (74%), on alternative HD (18.6%) and once weekly (6.6% ofpatients). Patients on EPO therapy received higher doses duringinitial therapy.After therapy, Hct/Hgb levels improved significantly in pa-tients without EPO therapy (Hct from 21.8±4.5 to 29.1±6.1;Hgb from 6.0±1.2 to 7.3±0.9%). Higher values of ferritin werenecessary for establishing desired values of Hct/Hgb (from88.5±28.1 to 356.7±190.6). After desired values was achieved(no further improvement with higher doses of iron) one weeklydose (62 mg) was continued further. EPO resistance was notdependent on iron therapy in majority of patients. No adverseeffects of therapy were registered.I.v. iron is safe and efficient therapy of anemia in HD patientswith or without EPO. Protocol of therapy may be adjustedaccording to patient subjective choice but with regular followingof all laboratory parameters.

CAN HYPERPARATHYROIDISM INFLUENCE CARDIO-VASCULAR MORBIDITY IN PATIENTS WITH END-STAGERENAL FAILURE?Dimkovic N, Markovic N, Paunic Z, Dimkovic S, Stankovic N,Damjanovic T, Dragicevic P.Institute for Renal Diseases, Zvezdara University Hospital Bel-grade, Yugoslavia

Hyperparathyroidism is well known complication especially inlong-lasting chronic renal failure. Apart from bone disease, PTHmay act as an uremic toxin exerting multiorgan effects mainlydue to intracellular Ca++ toxicity. There is evidence that cardio-vascular (C-V) morbidity and mortality is stressed by hyper-parathyroidism too.The aim of the study was to evaluate C-V morbidity in 33patients with laboratory proved hyperparathyroidism (PTH340±512, alkaline phosphatase 114.5±35.8). Main HD durationwas 9.15±7.6 years and age: 53.2±6.8 years.According to the echocardiography results, 45% of patients hadreduced ejection fraction, 40% sclerotic Aorta, 40% tricuspidinsufficiency, 30% thickened pericard, 25% pericardial effusion,20% LV dilatation, 20% calcifications on tricuspid valves, 20%LV hypertrophy, 15% RV dilatation.Exercise stress test was positive in 13.4%, borderline in 20% andnegative in 66.6% of patients.Dopplersonography of leggs revealed obliteration of peripheralblood vessels in 36.4%, rigid blood vessels in 54.5% and normalfindings in 9.1% of patients.In conclusion, HD patients with hyperparathyroidism are proneto C-V morbidity: about 50% have some pathologic findingaccording to echocardiography. Exercise stress test gave impor-tant data in 33.4% of previously symptomatic but also in asymp-tomatic patients. Dopplersonography results confirmed fre-quent complications of peripheral blood vessels (in 86.4%).Early control of hyperparathyroidism and non-invasive C-Vscreening are of great importance for better outcome of dialysispatients.

SERUM CYTOKINES LEVELS (IL-2, IL-6, TNFα, IL-2 sRα, IL-6 sR, sTNFRI) IN CHILDREN WITH CHRONIC RENAL FAIL-URE (CRF) UNDERGOING HEMODIALYSISZwolinska D., Medynska A.Dpt. of Pediatric Nephrology, Medical University, Wroclaw,Poland

The immunodeficient state in patients with CRF coexists para-doxically with activation of most immunocompetentent cells.Thepreactivation of this cells leads to release of cytokines, whichproduction and functioning are disturbed in these patients.The aim of the study was to estimate the serum concentrationof Il-2, Il-6, TNFα and their soluble receptors in hemodialysischildren and to evaluate the influence of the hemodialysis itselfand the kind of membrane dialyzers.All measurements were done by ELISA method with R&D com-mercial kits. Study included 16 children with CRF receivinghemodialysis aged 11-22 yr (mean 16,1 yr). Study was per-formed with single-use hollow-fiber dialyzers equipped acuprophane or a polysulfone membrane. Fifteen healthy chil-dren served as the control group. Results are shown in the table.

Cytokines Controls HD children p(pg/ml) x SD x SDIL-2 3,92 2,08 8,46 5,55 p<0,001IL-2 sRα 1532 605,4 6136 1880 p<0,001IL-6 9,80 1,80 11,17 4,21 NSIL-6 sR 35731 8044 58380 16091 p<0,001TNFα 3,78 1,83 12,54 5,27 p<0,001sTNF RI 2281 439,1 8809 3552 p<0,001

Conclusions: The elevated serum cytokines levels in patientsundergoing HD constitute one of the elements of the disorderedbalance net of cytokines. Any kind of modification of serumcytokines levels either at the start nor at the end of the dialysissession and the influence of kind of membrane dialyzers hasbeen observed.

HEMODIALYSIS (HD) ACCESS RECIRCULATION (AR)MEASURED BY CRIT-LINE IIIN Tarif, J AL Wakeel, A H Mitwalli, A AskarDepartment of Medicine, Division of Nephrology, King KhalidUniversity Hospital, Riyadh, Saudi Arabia

AR in some patients may be high enough to cause inadequatedialysis. 5 patients undergoing chronic HD for more than oneyear x 3 per week were evaluated. 4 patients had AVF and onepatient with polytetraflouroethylene Arterio-Venous Graft (AVG).One patient had aneurysmal dilatation of her AVF and minimalstenosis of subclavian vein.AR by the slow flow urea based method: Ultrafiltration (UF)discontinued, venous (V) and arterial (A) samples at regularblood flow (Qb) were obtained. Qb was then decreased to 50ml/min; 15 seconds later clamp applied at the (A) port and 10seconds later sample obtained proximal to it.CRIT-LINE III (Inline dignostics, UT, USA) method: It meas-ures the AR by changes in Hematocrit (HCT) during saline infu-sion. Sterile plastic chamber is attached to the arterial end ofdialyzer. UF turned off and 15 ml of saline was injected in the(V) port over a period of exactly 10 seconds evenly spacing overtime, 60 seconds later 15 ml of saline was injected in the (A) portsimilarly. For AVG a 5 minute interval was given after the (V)injection. Machine then prints out measurement along withgraphs.

Patient (n) Urea based method CRIT-LINE III1 1.3% <4%2 5.5% <4%3 4.6%(AVG) <4%4 1.9% (Aneurysm and SCV stenosis) <4%5 2.6% <4%

The HCT measurement was also accurate in all five patients byCRIT-LINE III correlating with the samples sent to the labora-tory. Practice was however needed to inject into (A) and (V)ports especially due to the negative pressure and resistancerespectively.

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LONG-TERM OUTCOME OF CORONARY EVENTS INHEMODIALYSED PATIENTS YOUNGER AND OLDER THAN65 YEARS OF AGE: A PROSPECTIVE 70-MONTHS FOLLOW-UP STUDYH Hase, N Joki, K Saijyo, R Nakamura, M Fukazawa, H Inishi,Y Tanaka, H Ishikawa, M Nakamura, T Yamaguchi,3rd Dep of Int Med Toho Univ Ohashi Hospital, Tokyo, Japan

It has been reported that coronary event was the leading causeof mortality in hemodialysed (HD) patients. The aim of thisstudy is to examine prospectively the in-hospital and the long-term outcomes of HD patients with coronary events. 70 con-secutive HD patients with coronary events (9 AMI and 61AP)had been registered to this study. All patients were performedcoronary angiography. Patients were classified into elderly (>=65,n=33) and younger (<65, n=37) groups based on their age at thetime of the event. 39 patients (19 vs 20) were performed inter-ventional therapy. 64% of elderly group and 41% of youngergroup were experienced those events in the first year of HD. Thenumber of diseased vessel was not significant in two groups(2.2 vs 1.9 per patient). The complicated rate of stroke after amajor event was significant higher (14 vs 4; p=0.0025) in theelderly than in the younger group. 21 elderly patients (11 hadcardiac death, 5 had stroke, 4 had cancer) and 9 younger pa-tients (8 had cardiac death, 1 had stroke) died during the 70-months follow-up. 70-months survival rate was significant lower(21% vs 65%, p=0.0423) in the elderly group than in the youngergroup.These results suggest that not only coronary heart disease butalso stroke influence long-term survival in elderly HD patientswho experienced coronary events.

PROGRESSION OF CORONARY ATHEROSCLEROSIS IS AC-CELERATED IN HEMODIALYSED (HD) PATIENTS THANCHRONIC RENAL INSUFFICIENCY (CRI) PATIENTSN Joki, H Hase, M Fukazawa, R Nakamura, H Ishikawa, YTanaka1, Y Inishi1, T Saijyo, M Nakamura, T Yamaguchi.Third Dept. of Int. Med., Toho Univ. Ohashi Hosp. 1Division ofCardiology, Omori Red-Cross Hosp., Tokyo, Japan.

Whether or not hemodialysis (HID) therapy per se acceleratesatherogenesis is controversial. To clarify the atherogenesis of HDpatients, we examined the expression of de novo coronary athero-sclerotic lesions of patients after starting HD comparing withthat of chronic renal insufficiency (CRI) patients (Cr 1.8mg/dl)by coronary angiography (CAG). We evaluated the change ofprogression of coronary atherosclerosis comparing first CAGwith follow-up CAG in 15 HID patients (69 years, 10 males, 10had DM) and 17 CRI patients (64 years, 12 males, 9 had DM).The frequency of follow-up CAG was once per 5.9 months inHID patients and 7.6 months in CRI patients in 3 years fromfirst CAG. The de novo coronary atherosclerotic lesions weredefined as an change of stenosis of at least 50% over the baselinevalue from first to follow-up CAG, only the stenotic lesionswhich were performed angioplasty was excluded. Nine of 15(60%) HID and 5 of 17 (29%) CRI patients had de novo stenoticlesions in 3 years. Cumulative rate of the expression of de novolesions in 3 years from first CAG was high in HID patients thanCRI patients. The curves for the expression of de novo lesions inHD and CRI patients began to diverge after 5 months from firstCAG (log-rank test, p=0.067). None of the clinical andhematologic factors, which were examined at first CAG, evalu-ated differed significantly between HID and CRI patients.These results suggest that coronary atherosclerosis may moreaccelerate after starting HID than pre-HD phase of CRI. Thepossibility remains that HID therapy per se accelerates the coro-nary atherogenesis.

HELICOBACTER PYLORI AND GIARDIA LAMBLIA INFEC-TIONS IN HEMODIALYSIS PATIENTSM. Boran, S. CetinDept. of Nephrology, Hemodialysis and Transplantation, TurkiyeYuksek Ihtisas Hospital, Ankara, Turkey

Gastrointestinal complaints are frequent in hemodialysis pa-tients. This study was performed to examine the prevalence ofH. pylori positive hemodialysis patients coinfected with G. lambliaand to detect its role in the pathogenesis of dyspepsia, in thisgroup of patients. Gastroduodenoscopies were performed, gas-tric antral biopsies were obtained for urease test and histologicanalysis and duodenal aspiration were carried on 50 hemodialysispatients (M:F 31.19, mean age 43.2 ± 10.4 yrs, mean hemodialysisduration 52.6 ± 21.4 months). Urease and histological changesin biopsy matherials and duodenal aspiration patterns (A bile, Bbile) under light microscopy were examined. In 50% of the pa-tients urease test was positive and H. pylori was seen in biopsyspecimens. In 76% (n= 19) of H. pylori positive patients G. lambliawas seen in aspiration patterns. Omeprazole 40 mg (30 day),Amoxicillin 2 g(10 day), Clarithromycin 1g(10 day) Ornidazole1g (10 day) were prescribed to the patients who were both H.pylori and G. lamblia positive (n=19). A repeat endoscopy, bi-opsy and aspiration were performed in these patients. Treat-ment was followed by the disappearance of H. pylori and G.lamblia in 100% of these subjects. Dyspeptic symptoms had alsodisappeared in all the patients. Therefore, a combination ofproton-pump inhibitor (Omeprazole) and antibiotics(Amoxicillin, Clarithromycin and Ornidazole) provides astraightforward approach for the benefit of our patients with H.pylori and G. lamblia infection. In conclusion we suggest thatdiagnosis and treatment of G. lamblia infection, which can existtogether with H. pylori infection, is very important to control thedyspeptic complaints in hemodialysis patients.

SIMILAR PREVALENCE OF SIGNAL-AVERAGED ECG ABNORMALITIESIN HAEMODIALYSIS PATIENTS AND ESSENTIAL HYPERTENSIONM. Covic1, A. Covic1, L. Panaghiu1, L. Lucaci2, M. Arsenescu2, G. Georgescu2

1IVth Medical Clinic-Nephrology, 2Cardiology Center, “C. I. Parhon” Hospital,Iasi, Romania

Late potentials (LP) on the signal-averaged electrocardiogram (SAECG) havebeen reported recently to appear in a significant (25%) proportion of dialysispatients, related to coronary artery disease and left ventricular dysfunction(Morales et al, NDT, 1998, 13:668). Our aim was to describe the LP’s prevalenceand risk factors in a younger dialysis population and to compare it with an ageand left ventricular mass (LVM) matched essential hypertensive population.SAECG was recorded immediately before and within 30 minutes after the endof dialysis in 35 patients (21M/14F, age = 42.2+/-10.3 years, dialysis duration= 62.5+/-35.9 months) in synus rhythm, free of conduction disturbances on ECG.An echocardiographic examination was performed before the mid-week HDsession. 35 hypertensive, age, sex, and LVM matched patients were used as con-trols. All subjects had also a 24 hours Holter ECG and ABPM.LP were detected in 14% HD patients on the SAECG before dialysis and in 11%hypertensives. ECG 24 hours Holter abnormalities were detected in 60% of theHD population compared with only 20% in the non-renal, hypertensive subjects(P<0.05). All HD patients with LP had significant ventricular rhythm distur-bances, evident only on Holter examination. There were no significant differ-ences between dialysis subjects with LP on SAECG and those without, in bio-chemical (pre and post-HD) and dialysis parameters or in ECG, ABPM andecocardiographic data. There was no previous history of myocardial infarctionin our group, and only 6 subjects had clinically evident angina and/or ECGabnormalities suggestive of coronary artery disease – 1 of these had also LP’s.Our study demonstrates that in relatively young dialysis patients LP have arather low and similar prevalence with that recorded in age, sex and LVM –matched non-renal hypertensives. If significant ischemia is absent there is noother evident (biochemical, dialysis-related, cardiac structure abnormalities)cause. LP may contribute to the higher incidence of clinically silent rhythmdisturbances seen in dialysis patients.

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IMPACT OF EMERGENT FIRST DIALYSIS ON ONEYEAR PATIENT SURVIVALM. Kessler, L. Frimat, M. Foret, P. Nicoud, J.Ph.Ryckelynck, J.P. Ortiz, V. Lemaître, F. ButelCooperative French study and Roche Laboratory

Mortality among chronic dialysis (CD) patients (p) isinfluenced by a number of factors. Among these, theneed for emergency first D has received little attentionbut could significantly affect mortality. In 1997 duringa 4-month period 700 consecutive newly dialyzed p in90 representative French centers were included in aprospective study designed to evaluate referral to ne-phrologist and conditions of dialysis initiation. Oneyear survival was obtained for 556, aged 63 ± 15 yr.During the first year 90 p died (16.2 %). Main causes ofdeath were cardiovascular disease (45.9 %), malig-nancy (16.1 %), dialysis withdrawal (6.9 %) and infec-tion (3.5 %). Mortality rates were similar according tosex, dialysis modality, timing of referral, creatinineclairance at start and Hb level. Using a Cox propor-tional model 8 parameters were shown as predictorsof death in an univariate analysis: age, CV disease,other major morbid events, diabetes, original renal dis-ease, emergency ! first D, low creatinine and albuminelevels. Using a multivariate analysis only 3 candidatevariables were independent predictors of mortality: age(< 70, 70-80, > 80 yr), RR = 1.8 (1.3 - 5.4), CV disease RR= 2.2 (1.2 - 3.8) and albumin levels ( > 35 < 35 g/l)) RR= 1.7 (1.1 - 2.8).This prospective study adjusted for most covariatesknown to affect mortality shows that initiation of D inemergency is strongly correlated with age, comorbidfactors and nutritional status and is no longer an inde-pendent risk factor of mortality at one year.

CONTINUOUS HEMATOCRIT MONITOR (CRIT-LINE) INHEMODIALYSIS INDUCED HYPOTENSIONK. Andou, A. Kitamura, M. Matayoshi, T. Maeda, Y. Kuroda, K.TabeiDept of Clinical Engineer and Dept of Nephrology, Omiya Medi-cal Center, Jichi Medical School, Saitama, Japan.

Hematocrit (Ht) was monitored continuously by CRIT-LINE toinvestigate the mechanisms of hemodialysis (HD) induced hy-potension.In 67 cases with maintenance HD, 187 times of CRIT-LINEmonitoring were performed.In 25 cases whose dry weight (DW) were suitable by clinicalindexes, Hts were concentrated linearly from 25.5±0.6 to 26.8±0.7,27.8.±0.7, 28.6±0.7 29.5±0.9 % in every 60 min. and the changesin calculated blood volume (%BV) was -4.7±0.5, -8.2±0.6,-11.4±0.6, -13.7±0.8 in every 60 min, when body weight (BW)decreased from 52.7±2.1 to 50.4±2.0 kg. The mean ratio of %BV/%BW was -3.3±0.2, i.e. the water removal of 1 % of BW induces3.3 % of BV reduction. Blood pressure dropped markedly when%BV was more than 15 % in most cases.In 10 cases, the patters of %BV were much different from others.In a case, the blood pressure dropped in 30 min, and %BV was-15 %, even though the water removal was only 300 ml. After thechange of dialyzer to PMMA membrane, %BV showed liner asseen in others. In other 5 cases with hyponatremia, blood pres-sure dropped in the first one hour with marked reduction of%BV. In 2 cases with hypoalbuminemia, and in 2 cases after theuse of contrast media, blood pressure dropped in the first onehour with marked reduction of %BV.These findings lead us to conclude that the continuous hematocritmonitor is useful to determine the reason of hemodialysis in-duced hypotension.

MALNUTRITION AND CARDIOVASCULAR DISEASE (CVD) INHEMODIALYSIS PATIENTSM.G. Chiappini, T. Ammann, G. Selvaggi, P. Traietti, *G. SplendianiDialysis Unit, AFaR-CRCCS-Fatebenefratelli Hospital, *Tor Vergata Univer-sity, Rome, Italy

In order to evaluate the influence of CVD on nutritional status we studied 123hemodialysis (HD) patients (p) (mean age 62±14 yrs), 59 with CVD and 64without. P were also subdivided according to HD membrane: CVD = 38 cellulosic(CM) and 20 synthetic (SM); Other = 40 CM and 25 SM. Nutritional status wasevaluated by BIA and standard assessment: Anthropometric Index (AI), Vis-ceral Protein Compartment Index (VPCI), Immunological Index (II), NutritionalIndex (NI). In 88 (48 with CVD, 40 without) of the 123 p, serum levels of IL2,IL2R, CD4, CD8, IL1β, IL6, TNF were also evaluated.TABLE I CM SM

CVD Other CVD OtherAI 78.8±11.6 92.9±20.1@ 90.6±13.6 94.9±13.8VPCI 85.4±12.6 99.9±9.4@ 92.4±10.3 98.7±8.4 #II 63.9±19.4 83.1±14@ 72.8±21.9 84.5±18.5 #NI 76.2±9.4 92.2±9.5@ 81.1±12.9 90.1±7.6 #PA 4.5±1.0 6.0±1.0@ 5.1±0.7 6.1±1.1@BCM% 27.5±3.8 35.2±5.1@ 30.3±4.3 35.3±4.2@ECM/BCM 1.4±0.3 1.0±0.2@ 1.3±0.2 0.9±0.3@IL2 (nv<10) 29.1±11.3 23.6±8.2 15.4±4.5 12.3±5.5IL2R (nv<400) 4232±645 2855±251* 2250±737 1764±351 #CD4(nv<35) 105±17 95.4±29.2 101±28.8 90.2±18.6CD8 (nv<400) 1078±246 822±164* 757±281 627±133IL1 β(nv<8) 27.5±7.3 22.3±7.8 # 23.3±8.4 15.1±7.9 #IL6 (nv<10) 63.1±27.3 40.7±15.6 # 36.3±14.9 27.8±5.2 #TNF (nv<30) 53.1±16.4 41.2±12.3 # 45.7±14 33.8±10.8## p <.02; * p <.01; @ p <.001; PA = Phase angle; BCM% = Body Cell Mass; ECM =Extracellular Mass.

CVD p were older tran the other p (mean age 68±8 and 53±15, p<.001). Never-theless nutritional indexes were significantly higer in p without CVD than inthose with CVD also when we considered only p with age > 55 yrs in bothgroups.Our results indicate that CVD should be a cause of malnutrition in HD p prob-ably due to a major increase in cytokine production. The use of bioincompatiblemembranes in CVD p seems to have a deleterious effect in cytokine productionand nutritional status.

MALNUTRITION (M) IN HEMODIALYSIS (HD) PATIENTS (P): COM-PARISON OF DIFFERENT METHODS FOR EVALUATIONM.G. Chiappini, T. Ammann, G. Selvaggi. P. Traietti, R. Sodo, *G.SplendianiDialysis Unit, AFaR-CRCCS, Fatebenefratelli Hospital, * Tor VergataUniversity, Rome, Italy

In order to evaluate the prevalence, the degree and the prognosticvalue of M we studied 156 stable HD p (mean age 61+14 yrs) compar-ing: subjective global assessment (SGA); standard nutritional assess-ment (SNA) including Anthropometric Index (AI), Visceral Proteincompartment Index (VPCI), Immunological Index (II); Bioelectricalimpedance analysis (BIA). 91 p were folowed up for 60 months. Ac-cording to SGA p were subdivided in Normal (A=57%), mild-moder-ate M (B=26%), severe M (C=17%) (table).

A B CAI (%) 97.5±17.7 82.2±12.4 * 75.9±9.0 @VPCI (%) 99.5±9.1 91.5±9.9 * 79.4±10.6 *II (%) 79.6±15.7 67.7±17.6* 52.1±18.4 #PHASE ANGLE (PA) 6.0±1.1 5.0±0.9 * 4.4±0.9BODY CELL MASS (BCM%) 34.1±5.0 30.2±4.7 § 28.2±3.8 @FAT MASS (FM%) 31.0±6.3 26.8±7.9 # 27.5±6.0 FREE FAT MASS (FFM%) 68.2±8.2 73.1±7.9 # 72.5±6.0 (* p<.001; # p<.005; § p<.01; @ p<.05)BCM% was reduced in a high percentage of p (78% of A p, 100% of Band C p), in spite of normal BMI and a less reduction of body fat. Thehighest prevalence of M was observed in p with cardiovascular dis-ease. SGA significantly correlated with the parameters derived fromSNA (p<.001) and BIA (p<.001). Fat mass indexes obtained by SNA andBIA significantly correlated (p<.001). AI inversely correlated with FFM%and TBW (p<.001).During the follow-up mortality rate was 31%. M pshowed the highest mortality rate (p<.001). Survival significantly cor-related with age, comorbidity, SGA, albumin, prealbumin, skin test,total lymphocyte count, PA. Multivariate analysis indicated that theparameters independently correlated eith survival were albumin andprealbumin. In conclusion: 1) M is widespread in HD p negativelyinfluencing their clinical outcome. 2) SGA is an useful and simply toolfor clinical assessment of nutritional status. 3) BIA provides a lot ofinformations on the body composition not obtainable by AI. The in-crease of FFM% observed in malnourished p should be considered anindirect sign of a relative increase of the fluid space due to a reductionof BCM%. The reduction of BCM% and PA with normal AI is mostconsistent with protein depletion with adequate energy stores. 4) Themost useful informations obtained by SNA derive from VPCI and II.Albumin and prealbumin are the most sensitive nutritional indexesthat should be employed as significant predictors of mortality.

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COMPARISON OF DIFFERENT METHODS OF VON WILLEBRANDFACTOR (vWF) MEASUREMENT IN HEMODIALYSIS PATIENTS.J Borawski, K Pawlak, M MysliwiecDept. of Nephrology and Internal Medicine, University School of Medi-cine, Bialystok, Poland.

vWF endothelium-derived glycoprotein abnormalities and/or defi-ciency are involved in the hemostatic disturbances of uremia. vWFplasma measurements can be done by ELISA methods. Antigen con-centration assay (vWF:Ag) uses polyclonal antibodies to human vWFwhile activity measurement one (vWF:Act) employs mouse mono-clonal antibodies (moAB) specific to platelet integrin GPIb. The lattertest is claimed to be correlated to vWF activity estimation by ristocetin-induced platelet aggregation (RIPA). As described, moAB-bindingELISA is related to vWF:Ag but not to vWF-ristocetin cofactor activitywhen assessing structurally intact plasma vWF in healthy subjects(Thromb Res 1998;91:39-43).We studied 70 maintenance HD pts divided into 2 subgroups: 38 EPO-treated v. 32 non-EPO pts. vWF:Act (ELISA), vWF:Ag (ELISA) andRIPA in whole blood (RIPA WB) (electric impedance method) andplatelet-rich plasma (RIPA PRP) (optical aggregometry) were mea-sured in order to establish their reciprocal relationships. Shapiro-Wilk’W test for data distribution, nonparametric Kendall tau test for regres-sion analysis and Kruskall-Wallis ANOVA by ranks and Median testsfor testing differences between the subgroups were used.

Total EPO-treated Non-EPO PvWF:Act 113.52 # 133.08 # 93.99 # 0.003vWF:Ag 120.96 ± 23.90 117.33 ± 24.46 125.27 ± 21.51 0.016RIPA WB 10.44 ± 4.25 10.89 ± 5.27 9.90 ± 5.23 NSRIPA PRP 40.25 # 45.19 ± 18.89 44.15 ± 21.45 NSValues are mean ± 1SD. # geometric mean.Correlations were found between vWF:Ag and RIPA WB (r=0.267,P=0.018) in the EPO-treated group, and vWF:Act and vWF:Ag (r=0.381,P=0.002) in the non-EPO one.Concluding: moAB-binding ELISA for vWF has limited value for as-sessing vWF activity in HD pts. In EPO-treated subjects, it ratherreflects actual vWF antigen concentration than vWF activity as com-pared to ristocetin-using methods. EPO treatment, due to its profoundeffects on endothelial cells results in higher plasma vWF activity mea-sured by moAB-binding ELISA, no change as assessed by RIPA inboth whole blood and platelet-rich plasma, and lower vWF antigenconcentration.Supported by a grant (No 4 PO5B 014 15) from the KBN, Poland.

LEFT VENTRICULAR FUNCTION AT REST ANDDURING EXERCISE IN CHRONIC HEMODIALYSISPATIENTS- AN ASSESSMENT WITHRADIONUCLIDE VENTRICULOGRAPHYN. Topuzovic, 1V. Rupcic, A. Rusic, I. KarnerDepts. of Nuclear Medicine and 1Dialysis, Osijek Uni-versity Hospital, Osijek, Croatia

The aim of this study was to investigate left ventricularfunction and exercise capacity in chronic hemodialysispatients by means of maximum exercise testing andequilibrium radionuclide ventriculography.Forty patients having regular hemodialysis (mean du-ration 5.3±3 yr) were examined, and compared to 37age-matched normal volunteers.Increase in heart rate during exercise was lower inpatients (from 73±11 to 113±15 vs. 72±8 to 135±14beats/min, p<0.01). At peak stress patients had a lowerworkload (30%) and lower exercise duration (27%),and mean blood pressure were significantly higherthan in controls. Ejection fraction (EF) at rest was higherin patients, 59±10 vs. 53±8%, p<0.05, and % rise in EFduring stress was significantly lower in patients. Peakejection rate (PER) and time to PER at rest did not differfrom control values. At stress PER was lower in pa-tients, 3.8±1.4 vs. 5.0± 1.4 EDV/s, p<0.05. Patients hadsignificantly lower peak filling rate (PFR) at rest, 2.28±0.76 vs. 2.76±0.75 EDV/s, p<0.05, while time to PFRwas not significantly different. During exercise indexesdid not differ from controls value.In conclusion, hemodialysis is accompanied by de-crease in exercise capacity and impairment in leftdiastolic function, despite of preserved systolic func-tion.

BOOLD VOLUME PERCENT CHANGES (∆BV) MONITORING DURINGSTANDARD HEMODIALYSIS (HD).M. Pasquali, L. Onorato, F. Rubino, A. Flammini, W. Di Giandomenico, S.Mazzaferro (*).ABC-Dialisi; (*)Cattedra di Nefrologia Università “La Sapienza”, Roma

Continuous intradialytic monitoring of ∆BV is theoretically aimed at improv-ing HD tolerance, but clinical data are still scanty. We report our preliminaryobservations on the intradialytic monitoring of ∆BV and tolerance in 40 pts(aged 60±13 years; 21M, 19F; HD since 66±56 months). ∆BV was measured bymeans of a biosensor (Hemoscan, Hospal-Dasco) while blood pressure (BP),hearth rate (HR) and body weight changes (∆bw) were registered automatically(software Dialmaster). Symptoms were recorded by nurses. During a monthof clinical stability, data of ten consecutive HD were obtained from each pt and,based on these 400 HD treatments’ records, 13 were judged symptomatics(∆DiastolicBP>-15mmmHg and/or symptoms) and 27 asymptomatics. In thewhole pts, mean total ∆bw was -3.2±0.7 kg, with the following ∆BV: -5.6±1.6;-7.6±1.8; -9.7±2.6 and -11.3±2.7 % respectively after 1, 2, 3 and 4 hours of HD. Ifwe separate pts with a ∆BV>-11%(n=20) and those with a ∆BV<-11% (n=20) nodifference can be found in terms of HD tolerance (χ2 =0.48). Moreover mean ∆BVwas lower in symptomatics than in asymptomatics (-9.8±3.2% vs -12.2±3.1%;p<0.04) even with similar ∆bw (-2.9±0.6 vs -3.4±0.7 kg; p=ns). HR was invari-ably similar between groups. We finally analysed the ∆BV (see table) expressedas percentage of the final targeted value, separately in the two groups. Thesedata clearly show that ∆BV, is higher at the beginning of HD specifically insymptomatics, suggesting the presence of a less affective mechanism of refilling(from interstitial fluids) as compared to asymptomatics.

HD times ½ h 1 h 2 h 3 h 4 hSymptomatics -40 -59 -74 -87 -100%Asymptomatics -30(*) -45(“) -64(^) -83 -100%

(*)p<.001 (“)p<.0003 (^)p<.001

In conclusion, given the variable response to UF, it is not possible to define ab-solute values of ∆BV potentially associated with symptoms during HD. On thecontrary different profiles of ∆BV must be searched for to optimize ultrafiltra-tion in the individual pt.

THE EFFECT OF PERCUTANEOUS ANGIOPLASTY ON THETREATMENT OF STENOSIS AND OBSTRUCTION OF VAS-CULAR ACCESS IN THE HEMODIALYSIS PATIENTS.YO Kim, HC Song, SA Yoon, YS Kim, EJ Choi, and BK Bang,Dept. of Internal Medicine, College of Medicine, The CatholicUniversity of Korea, Seoul, Korea

Providing satisfactory vascular access for hemodialysis remainsone of the most challenging problems confronting nephrologists.Dysfunction of vascular access may be due to acute thrombosisor chronic vascular access stenosis. We evaluated the effect ofpercutaneous angioplasty (PTA) on the treatment of stenosisand obstruction of vascular access in the chronic hemodialysispatients. Twenty-six dilatations of stenotic or occluded lesionsin vascular access were performed in 25 hemodialysis patients.The type of vascular access was an arteriovenous fistula (AVF)in 19 cases and a graft in 7 cases. The lesions involved fore armveins in 16 cases and upper arm veins in 10 cases. Indicationsfor angioplasty included acute obstruction of blood flow (9cases), increased venous dialysis (VDP) or urea recirculationratio (URR) (8 cases), arm edema or difficulty in needle place-ment (6 cases), poor maturation before first needling (3 cases).The PTA initially succeeded in 23 of 26 cases (88.5%) and 3month patency rate was 80.5%. In 8 patients with increasedVDP or URR, both VDP and URR significantly decreased afterPTA (VDP ; 118.1±20.7 mmHg vs 89.5±23.8 mmHg, p=0.04,URR; 23.9±18.4% vs 7.5± 6.1%, p=0.02). The complications ofPTA were vessel rupture (1 case) and hematoma (2 case). Inconclusion, PTA seems to be effective therapy of in the treatmentof stenosis and obstruction of vascular access without seriouscomplications in the chronic hemodialysis patients.

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COAGULATION AND PLATELET ACTIVATION ARE STIMU-LATED BY HEMODIALYSIS DESPITE APPARENTLY AD-EQUATE ANTICOAGULATION TREATMENT.Sagedal S1, A Hartmann1, K Sundstrom1, S Bjornsen2, P Fauchald1,F Brosstad2.Depts. of Internal Medicine, National Hospital, Oslo, Norway.

Anticoagulation treatment is necessary for prevention of clotformation during hemodialysis (HD). A single bolus of dalteparin(Fragmin), a LMW heparin at start of HD may suffice. How-ever, subclinical activation of platelets and coagulation mayoccur. We examined the relationship between clinical clottingand markers of platelet activation and coagulation during HD.We prospectively examined the effect of tapered doses ofdalteparin during 72 HD sessions (4-4,5 hours) in eight pa-tients. The normal dose of dalteparin was reduced down to 50%of initial dose if no clotting was observed. Clinical clotting wasevaluated by visual inspection after blood draining of the airtrap each hour. Activation, markers for platelets and coagula-tion were examined before, during and at the end of dialysis andrelated to clinical clotting. Altogether 217 measurements wereperformed.Thrombin-antithrombin (TAT) and prothrombin 1+2 (PF1+2),coagulation markers, correlated significantly to clinical clotting(R=0.49 and 0.47, P<0.001). β-Thromboglobulin (β-TG), a markerof platelet activation, was also correlated to clot formation innot warfarin treated patients (R=-0.25, P=0.032). All param-eters except TAT were elevated at start of HD and all of themincreased significantly during the sessions (TAT, PF1+2 β-TG,P<0.001). When measurements during clinical clotting episodeswere excluded, all parameters were still markedly increasedcompared to normal levels. Warfarin treated patients had nor-mal levels of TAT and PF1+2 both at baseline and during HD,but β-TG was markedly increased also in this group.Despite effective clinical antiocoagulation by dalteparin mark-ers of platelet activation and coagulation are stimulated byhemodialysis with potential adverse long-term consequences.Warfarin treatment (INR=2.6) reduces -clinical and subclinicalclot formation.

A WAY TO REINFOND NEOPLASTIC ASCITES IN CIRRHOTIC URAEMIC(CU) PATIENTS DURING HAEMODIALYSIS (HD)Bordin V, Fabbian F, Di Landro D, Catalano C, with the technical help of BertoA and Corrain O.Renal Unit, Monselice, Padova, Italy

The reinfusion-ultrafiltration of ascitic fluid (AF) during standard HD in CUpatients with tense ascites represents a palliative treatment of established util-ity. This is the case especially in hypotensive patients in whom by reinfusing theAF is the only solution that permits an adequate administration of the dialysisprocedure (Am J Kidney Dis 32:164; 1998). The presence of neoplastic or “sus-pect” ascites constitutes a peculiar situation in which ascites reinfusion (AR) isconsidered “contraindicated” because of the risk of neoplastic dissemination.These patients are “terminal”; however their survival may be relatively long.Thus the clinician should be prepared to perform adequate HD sessions forperiods ranging weeks or months. We observed a CU patient with neoplastictense ascites (6-8 litres) in whom it was not possible to perform adequate HDdue to severe intradialytic hypotension even if HD was performed with thepatient lying in the Trendelemburg position, without weight loss and with gen-erous infusions of albumin and plasma expanders. In order to reinfuse the pro-teins of the AF without reinfusing the cells, during standard HD (QB 300 ml/min), the AF was pumped out of the abdomen and passed through a plasmafilter(PF) at the speed of 2000 cc/h. The protein-rich ultrafiltrate was continuouslyinfused in the bubble trap preceding the HD coil, whilst the concentrated cell-rich AF exiting the coil was discharged. The patient again developed tense as-cites after a week; thus this procedure was performed twice during two consecu-tive weeks. When HD was coupled with AR the procedure lasted the scheduled3½ hours and mean blood pressure (MBP) was 100 mmHg. Urea reduction ratewas 65%. On the other hand, standard HD could not last more than 2 hours withan average MBP of 70 mmHg. Microscopy of both AF and of the liquid exitingfrom the PF showed atypical cells, lymphocytes and mesothelial cells. No cellwas detectable in the ultrafiltrate that was reinfused. Although this strategylooks expensive because of extras cost of PF, we consider that this additionalexpense is largely repaid by the possibility of managing such extreme casesduring the standard dialysis session, avoiding hospitalisation and without in-fusing albumin or plasma expanders.

THROMBOSIS OF THE SUPERIOR VEIN CAVA IN UREMICCHRONIC PATIENT IN HAEMODIALYSIS, WITHOUT VAS-CULAR ACCESSE AND PERFORMING HYDROTORAX POST-CAPD: THERAPEUTIC DILEMMA.R. Bonofiglio, A. Mollica, F. Tosti, G. Vocaturo, N. De NapoliDept. Nephrologia, Hospital Annunziata, Cosenza, Italy

Vascular access is a long term serious problem in uremic chronicpatients treated with haemodialysis (HD). For many years thewidespread use of central venous catheter has been an effectivechoice in haemodialytic patients, even if thrombosis andlor ste-nosis of the vessels is a usual complication of the long-termcatheterization of the veins. We report the case of 62 year oldfemale patient with endstage renal disease, who following re-current thrombotic events of vascular accesses on upper andlower limbs, passed to continuous ambulatory peritoneal dialy-sis (CAPD). After six weeks, she developed a massive right-sidedhydrothorax by abnormal pleuroperitoneal communication. Thenshe was switched to HD after insertion of right subclavian dialy-sis dual-lumen catheter. Two months later, she presented a pain-ful oedma of the neck, the face and the right arm, with dispnea.Nuclear Magnetic Resonance (RNM) of heart and of the centralvenous system was soon performed showing thrombosis of thesuperior vein cava. Because of the inhability to perform anothervascular access and surgical option, after catheter removal, shewas started, contemporary, on pharmacological thrombolytictherapy and daily automatized peritonea dialysis (APD), using1-L-exchange cycle with low dose glucose solution, keeping sittinposition. Because of haemorrhagic events, we immediatelystopped thrombolytic therapy; however, after more than oneyear, the patient still follows APD treatment maintaining a gooduremic state control. She was no recurrence of the hydrothoraxand, at a recent NMR of central venous system, the vein cavathrombus has completely resolved.

ABSENCE OF EPICARDIAL CORONARY VASODILATORCAPACITY IN PATIENTS ON CHRONIC HEMODIALYSIST Koga, H Tsuruta, N Kawazoe, S Sadoshima, K OnoyamaDept. of Cardiology, Nippon Steel Yawata Memorial Hospital,Kitakyushu, Japan.

We assessed the vasodilator capacity of epicardial coronaryartery in hemodialysis (HD) patients. Diameters of both proxi-mal left anterior descending and circumflex coronary artery weremeasured by quantitative coronary angiography in 18 HD pa-tients and 36 control subjects. Measurements were performed atbaseline and after 2.5mg intracoronary isosorbide dinitrate(ISDN). Basal coronary diameter was significantly larger in HDpatients than in control subjects. When the diameter was in-dexed to left ventricular mass, a significant difference was notobserved. There was an inverse relation between diameter andhematocrit. After ISDN, coronary diameter significantly in-creased in control subjects, whereas any significant change wasnot observed in HD patients. The increase in diameter afterISDN was smaller in calcified arteries. There was an inverserelation between the increase in coronary diameter after ISDNand basal coronary dimension or the plasma level of atrial natriu-retic peptide (ANP). However, the increase in coronary diameterwas not correlated with cardiac output, blood pressure or theplasma level of endothelin. Conclusion: Epicardial coronary va-sodilator capacity is not existed in HD patients. Coronary calci-fication, elevation of ANP and basal coronary dilatation maycontribute to the absence of coronary vasodilator capacity. Ba-sal coronary dilatation in HD patients may be due to LVH andanemia.

z

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NON-INVASIVE MEASUREMENTS OF ACCESS FLOW (Qac) AND CARDIACOUTPUT (CO) IN HEMODIALYSIS PATIENTS.T. Cao Huu, C. Suty-Selton1, M.Bellou, L. Frimat, Y. Juillière1 & M. KesslerNéphrology & Cardiology1 Departments, C.H.U Nancy, 54500 - France

High-output cardiac failure due to excessive Qac (but with variable values: >1.5to 4.65L/mn) in hemodialysed patents have been reported. Ultrasound velocitydilution [TRANSonic system] and Echocardiographic Doppler US[VINGMED-system-V] have been used by the authors to measure CO and TRANSto measure Recirculation (Rac) and Qac in 38 patients (17M+21 F, aged: 68±12y,dialysed for 54±60m). The accesses were composed of 24 FAV, 9 permanentcatheters (KT) and 5 PTFE grafts. Rac, Qac and TRANS-CO were performed atthe first hours and Echo-CO performed by the same specialist MD before thetreatment. 25p. with FAV/PTFE were surveyed by TRANS + Echo, 9p. with KTonly by Echo and 4p. with FAV/PTFE only by TRANS.0% of Rac was showed in all patients. 73 Qac were obtained with TRANS in 29p(24FAV + 5PTFE). Mean Qac for Brachial FAV was 903±685ml/mn, proximalRadial FAV: 940±707ml/mn vs distal Radial FAV: 664±281ml/mn. 7p (24%)showed low Qac (452±121ml/mn) with confirmed stenoses and treated byangioplasty before thrombosis events, TRANS-CO (n:46) and Echo-CO (n:61)values showed good agreement in Bland & Altman test (limits: 0.35±1.96SD)and no significant difference in t-test.

All pat. FAV PTFE KTQaC ml/mn 791±504 812±531 685±375 NDTRANS-CO L/mn 4.0 ± 0.9 3.9 ± 1.3 3.4 ± 0.7 NDEcho-CO L/mn 3.8+1.2 4.1 ± 1.0 3.5±0.7 4.1±0.9

Qac showed significant relation with Echo-CO(R=0.59,p<0.002) and TRANS-CO(R=0.45,p<0.016). In 4p, high Qac (1.5-2.7L/mn) with TRANS-CO at 4.4±1L/mn and Echo-CO at 5.3±0.8L/mn did not show cardiac failure.Conclusions: 1) TRANS is a reliable bed-side method to survey Rac, Qac, accessstenoses and CO. 2) TRANS-CO were comparable to Echo-CO. 3) High Qacshould not be the only factor of the high-output-cardiac failure

VASCULAR ACCESSES (Acc) FOR ELDERLY PATIENTS (S65) INHEMODIALYSIS (HD): A FIVE-YEAR-RETROSPECTIVE STUDY.T. Cao Huu, M. Ladrière, L. Frimat, M. Bellou, V. Panescu, J. Hubert1, & M. KesslerNéphrology & Urology1 Departments, C.H.U Nancy - 54500, France

Increasing of the elderly population (S65) and their Acc difficulties were ob-served in center-hemodialysis (HD). The authors report here a 5-year study,from 1994 to 1998, concerning 206 Ace performed in 72 patients (30F+42M,aged: 66±14y) with 1.7 to 71m of follow-up. S65 patients aged 74±6y concerned62.5% (45) and younger (<65) patients aged 52±12y concerned 37.5% (27) of allpatient. 45 patients (62.5%) were in live with follow-up at 27±15m and 27p diedat 18±17m from the HD-initiation. 22p were diabetic and 40p showedarteriopathy.The total of 206 performed Ace were composed of: 31.2% (40) temporary cath-eters (KTt) + 31.2% (62) permanent silicone catheters (pKT) + 19.4% (40) distalwrist fistulas (FAVd) + 10.7% (22) elbow FAV (FAVprox) and 7.8% (16) PTFEgrafts (PTFE). Only 69 Acc (33.5%) of the total were recorded as the last andfonctional Ace and composed of 29 (42%) pKT + 19 (27.5%) FAVd + 15 (21.7%)FAVprox + 7 (10.1 %) PTFE These last Ace corresponded to 43.3% pKT + 47.5%FAVd + 68.2% FAV prox + 43.8% PTFE of each Acc correspondant total. Thesuccess rate of these last Ace according to age was:

pKT FAVd FAVprox PTFE<65 (29Acc) 68.8%(11) 68.8%(11) 33.3%(2) 62.5%(5)S65 (40Acc) 37.0%(17) 41.7%(10) 68.8%(11) 25.0%(2)

S65 seem to need longer time to obtain last Ace without significant t-test:

1st Acc. 2nd Acc 3rd Acc 4th Acc last Acc<65 (27) days -18±55 53±103 291±502 251±256 156±213S65 (45) days -21±59 88±179 261±305 344±214 182±279Diabetic (22) days -09±25 44± 68 148±327 131±165

Conclusions :1) FAVprox seems to be adapted better to the elderly patients than<65. 2) pKT were used as a good alternative for long term Ace and mostly at theHD initiation and in Ace impasses or patients refusal. 3) PTFE showed betterresults in <65 patients than in elderly.

INFLUENCING FACTORS OF DEPRESSION AND SUICIDALIDEATION IN CHRONIC HEMODIALYSIS PATIENTSM Congevel, TR Evrenkaya, S Ebrinc, EM Atasoyu, MY Tulbek,M CetinDepts. of Psychiatry and Nephrology, Gulhane Military MedicalAcademy, Haydarpasa Training Hospital, Istanbul, Turkey

It has been hypothetised that hemodialysis patients have seri-ous psychological problems due to the life threatening chronicdisease. In this study, we aimed to find the levels and influenc-ing factors of depression and suicidal ideation in 93 hemodialysis(HD) patients (30 female, 60 male, mean age 46). Patients wereapplied Semi-structured interview, Beck Depression Inventory(BDI). Beck Hopelesness Scale (BHS), Suicidal Ideation Scale(SIS), Perceived Social Support-Family (PSS-fa) and PerceivedSocial Support- Friend (PSS-fr) scales. Mean scores were 17.9±9.8for BDI, 7.4±5.1 for BHS, 4.7±4.0 for SIS, 30.1±6.9 for PSS-fa,and 26.4±6.5 for PSSfr. When the cut-off point of BDI was takenas 17, rate of depression was 51.7% for HD patients. We identi-fied seven variables as statistically significant predictors of in-creased depression levels in HD patients (increased duration ofilness, increased duration of HD, low educational level, living ina crowded family, high hopelessness level, perceived low-familysupport, perceived low-friend support) and six variables asstatistically significant predictors of high levels of suicidal idea-tion in HD patients (increased duration of ilness, low educa-tional level, having nonrenal comorbid diseases, high hopeless-ness level, perceived low-family support, perceived lowfriendsupport). In order to alleviate the effects of both low educa-tional level and low-perceived family support, which we foundto be influencing depression and suicidal ideation, it is impor-tant for the staff to develop close relationships not only with thepatient but also with the patient’s fan-Lily. With this kind of anapproach, the patient and his/her family will be informed aboutthe characteristics and requirements of disease and its’ treat-ment, moreover. significance of needed support for the patientwill be explained to the family members.

SAFETY AND EFFICACY OF THE HEMOCONTROLTM BIOFEEDBACK SYS-TEM: A PROSPECTIVE MEDIUM - TERM STUDYC Basile, R Giordano, L Vernaglione, A Montanaro, P De Maio, F De Padova, ALMarangi, L Di Marco, D Santese, A Semeraro, VA Ligorio.Nephrology and Dialysis Unit, Hospital of Martina Franca, Italy

In order to avoid the appearance of destabilising hypovolaemias during haemo-dialysis (HD) a biofeedback control system for intra-HD blood volume changesmodelling has been developed (HemocontrolTM , Hospal Italy) (HBS). It is basedon an adaptive controller incorporated in the monitor IntegraTM (Hospal Italy).Thus, 19 hypotension-prone uraemic patients (mean age 64.5 ± 3.0 SEM years,on maintenance HD since 80.5 ± 13.2 months), volunteered for the present pro-spective study aiming to compare the safety and efficacy of bicarbonate HDtreatment equipped with HBS, as a whole (HBS), with the golden standard,bicarbonate treatment, equipped with a volumetric control of ultrafiltration(BD). The study included: PHASE I with 2 periods of 6 months each: a 6-monthperiod of BD always preceding a 6-month period of HBS tratment; PHASE 2: all19 patients, after ending the one-year study of Phase 1, continued on HBS treat-ment. The present analysis of Phase 2 data has been done on 12 patients, whohave completed 20 months on HBS.Results specific of PHASE 1: The overall occurrence of symptomatic hypoten-sion and muscle cramps was significantly less in HBS treatment. It was respec-tively 31.8 ± 0.4% and 8.0 ± 0.2% in BD vs 21.0 ± 0.3% and 4.8 ± 0. 1% in HBStreatment (p < 0.0001, one-way analysis of variance). Self-evaluation of intra-and inter-HD symptoms made by the patients (the worst score 0, the best one 10)did reveal a statistically significant difference, as far as post-HD asthenia isconcerned (6.2 ±0.2 in HBS vs 4.3 ± 0.1 in BD, p< 0.0001).Results common to both PHASE 1 and 2: no change in the monthly blood bio-chemistry (notably pre - run serum sodium) was observed in any of the param-eters under study, when comparing BD with HBS treatment. No difference be-tween the two treatments was observed when comparing preand post-HD lyingsystolic, diastolic bood pressure and heart rate (both pre- and post-run), pre-runbody weight, inter-HD body weight gain and intra-HD body weight loss.In conclusion, HBS treatment is an effective treatment by allowing a hypovol-aemia - associated morbidity lesser than in standard BD treatment; further-more, it is a safe tratment in the medium - term because these results are achievednot through potentially harmful changes in blood pressure, body weight andserum sodium.

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PROGNOSTIC FACTORS FOR THE LONG-TERM SURVIVALOF ARTERIOVENOUS FISTULA IN DIALYSIS PATIENTSM Fukagawa, A Komemushi, S Komemushi, S Yamauchi, TKurihara, and T KurosawaTokyo Teishin Hosp, Univ Tokyo, Kinki Univ, Kansai Med Univ,KDL, Inc., and Sumiyoshi Clnic & Hospital, Mito, Japan

Survival of blood access is one of the most important determi-nants of the Quality of Life in chronic dialysis patients. To as-sess the prognostic factors for the survival of blood access, wecompared clinical and laboratory data prior to the stenosis ofarteriovenous (AV) fistula in stenosis group (SG) with those inevent-free group (EG).In 23 years, 842 AV fistulas were made exclusively by a singleoperator in 568 dialysis patients at Sumiyoshi Clinic & Hospi-tal. Among them, 562 AV fistulas became occluded after 6months of operation or later with mean survival time of 45.8months, while 280 fistulas survived throughout the study pe-riod.Concerning the type of anastomosis of blood vessels, side-to-side fistulas had shorter survival than end-to-end or end-to-sidefistulas.Hematocrit was rather higher in EG (32.5%) than in SG (25%)with higher dose of erythropoietin and with less dose of heparin.Instead, the change of hematocrit larger than 2% per 2 weekssignificantly preceded the stenosis of AV fistula. In addition tolower maximal blood flow (< 175 ml/min), stenosis took placemore often in patients with more volume replacement or insuf-ficient ultrafiltration due to systemic hypotention duringhemodialysis, and in those with higher CTR due to chronic vol-ume overload.These data suggest that constant maintenance of high hematocritby erythropoietin is not a risk factor for the stenosis of AV fis-tula, and that stable systemic hemodynamics and volume con-trol may be important for the longer survival of blood access inchronic dialysis patients.

BIOPROSTHESIS: A NEW APPROACH WITH LOOP VAS-CULAR ACCESS IN HEMODIALYSIS PATIENTSG. Bacchini, G Pontoriero S. Andrulli, L. Del Vecchio, F. LocatelliNephrology and dialysis Division, Hospital of Lecco-Lecco Italy

Prosthetic surgery, for hemodialysis vascular access (VA) wasonly used in our department, for patients (pts) with impairmentof distal and proximal fistula. 22 (9.3 %) out of 235 pts, havinga graft as VA. From 1991 to 1998 we prospectively evaluated, ,51 pts (34 F, 17 M, age 68±10 years, on dialysis for 68±11 months)in who PTFE (n=51), reinforced PTFE (n=8) and biological (n=18,mesenteric bovine vein Procol) grafts materials were placed.We performed 136 operations for VA (77 constructions and 59revisions). VA survival was measured by Kaplan-Meyer analy-sis. The primary and secondary cumulative graft survival (PP,SP)of all materials was 25 % and 77% after 1 year respectively. Wealso evaluated the PP and SP, by separating PTFE survival fromthat of biological devices. At 1 year, the PP was 25 %, for PTFEdevices, and 40% for biological ones. The SP of PTFE was 20 %at 50 months; the SP of biological devices was 90 % at 12 months.During the follow-up period, 12 month patient survival, (KaplainMeier method) was 70 %; this high mortality can be explained bythe negative selection occurring in this population: arteriovenousgrafts were performed only as the last choice, usually in verycomplicated patients. To have a patent vascular graft, the pa-tients have an expectation of two vascular operationsevery year,at a 5 month interval.A preliminary experience in sixteen patients with a relativelyshort follow-up (1 year), showed a better survival of biologicaldevices in comparison with PTFE. To confirm these results inOctober 1998 we started a randomized trial aimed at compar-ing PTFE vs biological materials.

A COMPARISON OF METHODS FOR THE MEASUREMENT OF HAEMODI-ALYSIS (HD) ACCESS RECIRCULATION (AR)C Basile, G Ruggieri, L Vernaglione, MG Schiavone, A Montanaro, R Giordano.Nephrology and Dialysis Unit, Hospital of Martina Franca, Italy

Assessment of AR is crucial to avoid inefficiency of HD. Non-urea based meth-ods have been developed (ultrasound dilution Transonics Hemodialysis Moni-tor -TRANS -, Transonics Systems Incorporated, Ithaca, USA); although theyare more accurate than the three needle revised slow-stop flow BUN recirculationmethod (BUN) (Kapoian T et a], Kidney Int 52: 839, 1997), they require expen-sive specialised devices. Thus, a method is needed that yelds a highly accurate,fast, easy and economical AR measurement. Two tests having such characteris-tics have been recently described (Gallieni M et al, JASN: 9, 172A, 1998; YamajiY et al, JASN: 9, 187A, 1998). A blood sample is obtained from the arterial needleat the time of needle insertion for the measurement of serum potassium (K),haemoglobin (Hb) or haematocrit (Hct) (respectively K1, Hb1 and Hct1). Theblood circuit is connected and the pumping of blood is started at 200 ml/min.After 18 seconds, blood samples are drawn from the arterial line sampling port(K2, Hb2, Hct2). At this time, if AR is present, part of the saline entering the bloodstream will dilute K2, Hb2, Hct2. AR (%) is =100 x (1 - Hb2/ Hb 1) in the case ofHb.Aim of this study was to validate these tests versus the gold standards (TRANSand BUN). Forty adult HD patients were selected to participate in this study; allhad autogenous forearm fistulae. AR studies were performed at the start of RD(for K, Hb and Hct), during the first 30 min for the TRANS method (performedin triplicate) and at 30 min for BUN method.AR (means ± SEM, Student’s t test) was absent when measured by means of theTRANS method and statistically different from AR measured by means of theother methods (p < 0.0001). Among the latter, the closest to the TRANS methodwere those based on Hb and Hct, that were significantly different from thosebased on K and BUN (p < 0.0001). Bland-Altman analysis showed a good agree-ment between these methods and the gold standard TRANS.TRANS Hb Hct K BUN0 ± 0 3.0 ± 0.3 3.1 ± 0.3 4.4 ± 0.4 5.5 ± 0.8

In conclusion, the tests employing the dilution of K, Hb and Hct, similarly toother dilutional methods, are not influenced by cardiopulmonary recirculationor venovenous disequilibrium; they are highly accurate (particularly Hb andHct), fast, easy and economical (only two blood samples at the start of the ses-sion) and can be performed in any busy HD unit.

THE KINESIOLOGIC ANALYSIS OF THE PATIENTS ON RE-NAL DIALYSIS THERAPY (RDT).H. Fischerova, A. Stablova*Dept. Medicine Strahov, University General Hospital & FirstMedical Faculty, Prague, Czech Republic. *Faculty of the Physi-cal Education and Sport of the Charles University, Prague, CzechRepublic.

A lower kinetic activity of RDT patients is above all die result ofthe fault of the metabolism.The deviations in functional movements were investigated in thegroup of twenty five patients (12 women and 13 men) whosemean age was 65 years (in the range of 35-85) and the durationof dialysis treatment was 1,5 - 162 months (mean 49,8).Our Investigation revealed following results:1. The movement of joints of the extremities was limited inshoulders, hips and elbows in 13 patients (64%).2. The functional movement of spinal column was limited in 22cases in cervical and thoracal parts - first of all in flexis (88%).3. The movements ‘ stereotypes were injured in 16 patients -ex-tension and abduction in the hips (64%).4. The shortening of the muscles, above all m. triceps surraebilat., flexors of hips, flexors of knees, m. trapezius, m. levatorscapulae and m. sternocleidomastoideus has been observed in23 cases (92%).5. Decreasing sensitivity occured in 12 cases (48%) as thehypesthesia on the upper extremities particularly on the sidewith a - v fistula (avf) and on the inferior extremities from thelower 1/3 of the middle leg.6. Taxes and coordination of the movements were affected inaccordance with dysmetria and dyscoordination especially onthe side with avf in 10 cases (40%).7. The strength of the muscles was depressed mostly on theupper extremity on the side with avf in 12 cases (48%) and onthe inferior extremity in talocrural joint by the eversion of thefoot in 8 cases (32%).The comparison was made with fysiology norms.

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TUNNELLED CENTRAL VENOUS CATHETER AS DIALYSIS VASCULARACCESS: FIVE YEAR EXPERIENCE WITH TESIO CATHETERG. Forneris, M. Formica, M. Pozzato, G.M. Iadarola, A. Vallero, *P. Magistroni,F. QuarelloNephrology and Dialysis Dept., Giovanni Bosco Hospital, Turin. Italy. *Univer-sity of Turin

Tunnelled central venous catheters as temporary and permanent vascular ac-cess have been increasingly utilized in the last few years in dialysis units as avalid alternative to arterovenous fistulas. Nevertheless, even if overall positiveresults were reported, most papers were based on retrospective studies andsmall population. Moreover, major complications have been reported.We refer the results of a prospective study on placement and use of Tesio cath-eters in our centre from July 1993 up to December 1998. One hundred-sixty-eight double catheters (Tesio Kit, Medcomp) have been placed in 141 patients(mean age 65 years, range 23-89, M:F 60:81) and monitored for a period en-compassing 1,038 patient-months. In 150 cases placements were performedin right internal jugular vein (RJIV), 12 in LJIV, 6 cases in femoral vein. Per-manent indications were given in 64 patients and temporary in 104. Mainintraoperatory complications were: 1 death due to cardiac arrest from vagalnerve stimulation, 1 mild air embolism, 4 hematomas, 9 tunnel bleeding, 1supraventricular arrhythmia.Mean catheter duration was 187 days (range 1-1,848). Mean catheter survival,calculated according to Kaplan-Meier, was 18 months. Main causes of end us-age were: patient’s death in 57 cases (40%), fistula construction in 33 (20%),infection in 14 (8%), untreateable thrombosis in 11 (6,5%), transfer to CAPD in6 (3,6%), renal transplantation in 4 (2,4%). The probability of being free frominfection was 86% at 12 mos and 72% at 18 mos. The probability of being freefrom untreatable thrombosis was 89% at 12 mos and 78% at 18. No catheterrelated deaths were observed in the follow-up.In conclusion, in our experience Tesio catheters turned out to be a useful tool tosolve vascular access problems in dialysis patients. Nevertheless, placementindications should be accurately evaluated, because of a not negligible amountof complications.

PROGNOSTIC VALUE OF TROPONIN T (TNT) AS A PRE-DICTOR OF DEATH IN CHRONIC HAEMODIALYSIS PA-TIENTSG. Gamper, P. LechleitnerDept. of Internal Medizine, BKH Lienz, AT

The cardiac isoform of Troponin T, TNT, is a powerful pre-dictor of events in patients with coronary artery disease.Since cardiac disease is the main cause of death in haemodi-alysis patients, we investigated the prognostic perform-ance of TNT as a predictor of death. 34 chronic haemodialy-sis patients (11 female, average age 55a ± 16,8) were inves-tigated over a mean period of 16,5 months. TNT samples(TNT enzyme-immunoassay, Roche/BMC) were drawnevery 3 months.Of the 20 haemodialysis patients whose serum TNT levelsexceeded the cut-off value of 0,1 µg/l 7 were dead after 2years. Causes of death were sudden cardiac death (n=4),acute myocardial infarction (n=2) or cerebral haemorrhage(n=1). Two patients who never exceeded the cut-off valuedied of sepsis under immunosupression. The sensitivity andspecifity to detect cardiovascular death in haemodialysispatients was 77% and 52% respectively. In our study, el-evated serum TNT levels proved to be valuable for identi-fying chronic haemodialysis patients at risk for future death.

EFFECT OF DIALYZER REPROCESSING ON GLUCOSEHOMEOSTASISIbrahim M.A, Labib B., Salam* T., Sarhan I., and El DamasyH.Departments of Internal Medicine, Nephrology and Clini-cal Pathology*, Ain Shams University, Cairo, Egypt

Abstract: This study was designed to investigate the possi-ble effect of dialyzer reuse on glucose homeostasis. 20 pa-tients with end stage renal failure (including 10 NIDDM) onthrice weekly hemodialysais (using glucose free dialysate)were studied by serial assessment of blood glucose, C-pep-tide, Interleukin 1-β (IL-1 β), Ca, Na and K at zero, 1 and 4hour (end of dialysis) during hemodialysis on new and thenon reused (first) cuprophane dialyzers. Our results showedsignificant rise of C-peptide, IL-1 β with drop of blood glu-cose in first hour sample (and was symptomatic in somediabetics) in both groups when using new dialyzers butthese changes were less marked and totally asymptomaticwhen using reprocessed dialyzers. In addition there was asignificant positive correlation between IL-1 β level and C-peptide at 1 and 4 hour samples and negative correlationbetween IL-1 β and blood glucose at 1 and 4 hour samples.Conclusion: through the effect of IL-1 β on insulin releasecuprophane dialyzers can affect homeostasis especially indiabetics and hypoglycemia might be part of first use syn-drome. It is recommended that measurement of glucoseeffect of dialysis membrane on glucose homeostasis mightbe an important parameter of membrane bioincompatibility.

HEMODIAFILTRATION WITH SIMULTANEOUS PRE- AND POST- DILU-TION (pre-post-HDF) :Pedrini L, De Cristofaro V.Nephrology and Dialysis Unit, Ospedale di Sondrio, Italy.

In post-dilution HDF (post-HDF) high blood viscosity & transmembrane pres-sure (TMP) limit convective removal of medium-high MW solutes. Pre-filterreinfusion (preHDF) may overcome this problem, but plasma dilution may af-fect the efficiency of the technique.In this study we showed that pre-post-HDF may couple advantages and avoiddrawbacks of the other two common modes of infusion.Six RRT patients underwent randomly two runs of each infusion mode (total 36runs) with Qb 400 ml/min, Qd 800 ml/min, time 180’ Rate of infusion fluid,produced on-line, was 120 ml/min in pre- and post-HDF, 60+60 ml/min in pre-post-HDF. By direct quantification total solute removal (MR), % extraction (R)and eff. clearance (Kdq) for urea (U), creatinine (Cr), P and β2-m were measured(p<0.05):

post pre-post pre post pre-post pre post pre-post pre MR (g) Kdq (ml/min) R (%)U 39.3 39.4 38.7 218 210 202 * 73 73 71Cr 2.01 2.00 1.90 152 149 141 * 72 71 68 *P 0.89 0.79 0.84 153 161 163 62 61 60β2 0.198 0.204 0.202 71 65 65 74 71 70

In post-HDF Kuf drop during sessions (40.6ml/h/mmHg at 5’-> 18.7 at 180’),trans-filter increase in Ht (31.8%->46.9%) and Tot.Prot. (6.4->12.9 g/dl), and thehuge rise of TMP (203 mmHg at 5’-> 421 at 180’) indicated compromised hy-draulic membrane permeability, risks of filter clotting and blood cells andmembrane damage due to high TMP, absent with pre- and pre-post-dilution.Permeability to high MW solutes also declined during sessions (β2-m sievingcoeff. 0.71->0.51 in post-HDF vs 0.68->0.56 in pre-HDF, p=ns).In conclusion, simultaneous pre- and post-filter infusion avoids risks due tooverly high UF and TMP, without affecting solutes removal as in pre-HDF. Pre-post-HDF allows higher UF rates and is further ameliorable by optimizing theratio of pre/post infusion to get higher FF, and could be the more efficient andsafe mode in routine HDF.

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NOVEL HEMODIALYSIS PROCEDURE UTILIZING ANTIOXIDANTS DE-CREASES OXIDATIVE STRESS DURING EX-VIVO CIRCULATION OFBLOOD.O. Ziouzenkova1), L. Asatryan1), M. Akmal2), M. L. Wratten3), C. Tetta3), and A.Sevanian1).Department of Molecular Pharmacology and Toxicology, School of Pharmacy1),and Department of Nephrology, University of Southern California, USA, Clini-cal and Laboratory Research Department, Bellco S.p.A., Italy 3)

Oxidative stress induced by hemodialysis (HD) can modify LDL, and, therefore,accelerate atherogenesis in HD patients. We found that levels of mildly oxidizedLDL (LDL-) in blood of HD patients were 2.6 fold higher than the levels inhealthy subjects. LDL modification was studied during ex-vivo blood circula-tion for 4 hrs at 37°C in a model system resembling clinical HD, to avoid theexchange between body fluids and dialysate, and possible metabolic responses.Circulation progressively increased hemoglobin (Hb) levels in blood (~300% ofinitial level). Partial destruction of erythrocytes may contribute to the increasein cholesterol levels (P<0.01) in blood as suggested by correlation between in-crease in Hb and cholesterol (P<0.001). Free Hb appears to induce oxidativereactions, reducing plasma ascorbate levels (P<0.03) in circulated compared tothose in non-circulated blood (NC). Furthermore, during circulation LDL- levelswere enhanced up to 324 % compared to NC (P<0.007). LDL- levels were notassociated with lipid peroxidation. Neither MDA nor lipid hydroperoxide con-tent in LDL was increased during circulation. Vitamin E and β-carotene contentof LDL were not affected by circulation. On the other hand, we found a correla-tion between LDL- and Hb levels in plasma (P<0.001). Formation of LDL- wasmimicked by circulation of plasma containing nmol Hb levels. Taking into ac-count the increase in bityrosine LDL content (P<0.02), characteristic for ferryl-Hb catalyzed reactions, we suggest that LDL- increase is due to the formation ofHb-LDL conjugates during circulation.The harmful increase in LDL- fraction was abolished or decreased using anti-oxidant-containing liposomes in the dialysate circuit. Vitamin E in the lipo-somes decreased the plasma Hb levels. This has a beneficial effect by reductionof blood cholesterol, as compared to blood circulated without antioxidants.Remarkably, vitamin E in the liposome circuit decreased the LDL- formation tolevels similar to that in NC. Similar effects were also found for liposome circuitscontaining vitamin E and C. Lipohemodialysis using vitamin E circuits ap-pears to reduce levels of such atherosclerosis risk factors as oxidized LDL andcholesterol.

HEMOLYSIS AND LDL MODIFICATION DURING EX-VIVO CIRCULATION OF BLOODIS REDUCED IN AN IMPROVED TYPE OF HEMODIALYSIS: HEMOLIPODIALYSIS(HLD)O. Ziouzenkova1), L. Asatryan1), M. Akmal2), M. L. Wratten3), C. Tetta3), and A. Sevanian1).Department of Molecular Pharmacology and Toxicology, School of Pharmacy1), and De-partment of Nephrology, University of Southern California, USA, Clinical and LaboratoryResearch Department, Bellco S. p. A., Italy 3).

Anemia and atherosclerosis are common complications of hemodialysis (HD), which areassociated with the oxidative stress. We identified hemoglobin (Hb) as an importantcatalyst of cellular membranes and lipoproteins oxidation. Hb-mediated reactions lead tocross-linking of proteins increasing the permeability of erythrocytes and hemolysis. Thisreactions also leads to the modification of LDL fractions and convert it to more electrone-gative subfraction (LDL-) characterized by 50% reduced uptake via ApoB/E receptorand high oxidzability resulting in complete elimination of the lag-period of oxidation inpresence of 10µMCu2+ from 110 to 0 min. More than 2-fold elevated LDL- levels in HDpatients can promote the oxidative processes in the artery wall, thereby, account for highprogress of atherosclerosis in HD patients. Hb-mediated oxidation take place during ex-vivo blood circulation for 4 hrs at 37°C in a model system resembling clinical HD, where itmediated ~300 % increase in hemolysis as well as in LDL- formation compared to the initiallevel. While the endogenous plasma and LDL antioxidants cannot prevent these harmfulprocesses, special combinations of vitamin E and C delivered by liposomes in the dialysatecircuit can decrease both hemolysis and LDL modification. This type of HD was definedas HLD. The protective effect of HLD was dependent on the vitamin E and C concen-tration. Low and high vitamin E levels in circuit can reduce the hemolysis up to 60 %compared to the regular HD, while LDL- formation was completely abolished using highvitamin E levels but was similar at low vitamin E concentrations. These beneficial effectsof lipo-HD were also observed using the combination of high vitamin E with vitamin C.Such combination of vitamins prevent also the loss of vitamin C in circulated plasma aswell as the vitamin E oxidation in the circuit. In contrast, vitamin C alone appears to bea strong pro-oxidant increasing the hemolysis, LDL- formation and impairing permeabilityof the dialysis membrane. These effects can potentially take place during the oral supple-mentation with vitamin C and need to be further investigated. Combination of vitaminE with high vitamin C in the circuit reverses the pro- to antioxidative effects due to theinteraction of these antioxidants. Thus, the lipo-HD using specific antioxidants is a prom-ising approach to avoid or substantially decrease oxidative stress induced during the ex-vivo circulation.

EPIREL: A MULTICENTER PROSPECTIVE STUDY OF NE-PHROLOGY REFERRAL OF PATIENTS WITH ESRDM. Kessler, V. Panescu, F. Ait-Chalal, L. Frimat, J.L. André, H.Terrasse, S Briançon and The EPIREL Cooperative group. Uni-versity Hospital of Nancy France

The timing of referral to the nephrologist could significantlyaffect morbidity and mortality in dialysis (D) patients (p).From June 1997 to June 1998 all p starting their first RRT inLorraine (French region of 2.3 millions inhabitants) were includedin a prospective multicenter study. 238 p (141 M, 97 F, aged61.6±16.9 yr) were treated with HD (80.6%), PD (18.5%) orpreemptive RT (0.8%). Considering timing of referral they wereclassified in 4 groups: very early (VE) >6 months before RRTand Screat <177mmol/l (17.6%), early (E) <6 months (45.4%),late (L) 1-6 months and Screat> 177mmol/l (14.7%) and verylate (VL) <1 month (22.3%). Comparison of the 4 groups showedthat VL had significantly more males (75.5% vs 50% in VE) andmore elderly (65.6±14.2 yr vs 48.9±17.4 yr in VE). More p haddiabetes in L and VL and cardiovascular disease in E, L and VL.The prevalence of emergent D decreased linearly with referraltiming (88.7% in VL and 33.3% in VE). 16.8% of VE had pulmo-nary edema vs 32.1% of VL. Creat Cl was similar in the 4 groupsbut bicarbonate, calcium, albumin and cholesterol levels de-creased inversely with timing. During the 6 month follow-up 43p (18.1%) died. Death rates were 7.1% in VE, 15.7% in E, 28.6%in L and 24.5% in VL. Duration of hospitalization for D initia-tion decreased with timing (30 days in VL, 21 in L, 18 in E, and17 in VE).Conclusion: delayed referral is more frequent in elderly, males,diabetics and p with CV disease. It leads to more frequent emer-gent dialysis and is associated with increased mortality andprolonged first hospitalization.

INITIATION OF DIALYSIS IN EMERGENCY INFLUENCESMORBIDITY AND MORTALITY IN ESRD PATIENTSV. Panescu, S. Briançon, F. Ait-Chalal, L. Frimat, J.L. André, H.Terrasse, M. Kessler and the EPIREL Cooperative group.University Hospital of Nancy France

Many patients with ESRD arrived with life-threatening uremicsymptoms requiring emergency rescue dialysis but little is knownabout the influence of this condition on morbidity and mortality.A prospective multicenter study was conducted from June 1997to June 1998 in all patients starting their first RRT in Lorraine(French region of 2.3 millions inhabitants). 238 p (141M and 97F, aged 61.6±16.9 yr) were treated with HD (80.6%), PD (18.5%)or preemptive RT (0.8%). 112 p had planned (P) first dialysis(FD) and 116 unplanned (UP). Comparison of the 2 groupsshowed that age, gender, diabetes prevalence and distributionof ESRF causes were similar. Timing of nephrology referral (R)was strongly associated with conditions of D initiation. 88.7%of late (< 1 month), 51.4% of intermediate R (1 to 6 month) and21.4% of early R (> 6 months) had UP FD. Mean Screat was253±137 in P and 337±227 mmol/l in UP (p<0.00001). UP phad significantly more pulmonary edema and neurological dis-turbances. Sodium, bicarbonate, hemoglobin, calcium, albuminand cholesterol levels were lower and phosphorus higher in UP pcompared to P (p< 0,005). PD was first modality choice in30.3% of P and in 6% of UP. In HD p 93.6% of UP needed centralvenous catheter vs 32.5% in P (p<0,0001). During the 6 monthfollow-up 43 p (18%) died 25.9% in UP and 10.7% in P (p<0.002).11 p (4.6%) received a RT (1.7% in UP and 7% in P). Mean lengthof hospital stay for dialysis initiation was longer in UP p (36days) than in P (14 days).Conclusion: Emergent D is strongly associated with timing ofreferral. It has a negative impact on the clinical and metabolicsituation at D initiation and influences the choice of first modal-ity treatment and the 6 month survival.

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IS EUROPE PROVIDING A HEMODIALYSIS CARE DIFFERENTFROM USA ?C. Ronco1 D. Marcelli2, A. Brendolan, G. La Greca1 Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy, 2

ESRD Registry of Lombardy, Italy

It has been demonstrated that mortality rate among dialysis patients isunacceptably high in the US. Several factors have been claimed tojustify a mortality rate higher 20%. Despite different strategies forinfluencing outcomes, mortality rate has only slightly been reducedover the years. In contrast, low rates of mortality have been reported indifferent european countries. Doubts may then arise concerning howdata are collected and what level of reliability can be considered forvarious registries. Data collection and evaluation must prevent biasedanalyses of databases and results non representative of the average.To avoid a sterile and extensive review of databases which are easilyavailable we tried an original approach to answer a few questionsconcerning dialysis outcomes and practice around the world. To pre-vent personal interpretation of database results, we selected a group ofworldwide experts in the field and we submitted a simple question-naire. Experts were 14 (7 from US and 7 from different Europeancountries).13 experts (7 EU and 6 US) sent back the questionnaire. From differentanswers we may summarize that 10 individuals (6 EU and 4 US ) saidthat EU care and outcomes are superior even when mortality rates areadjusted. 2 said no (1 EU and 1 US), and 1 was uncertain. Among thefactors suggested to explain better outcomes, higher score was given tothe quality of procedures and medical training. Financial issues in-cluding the amount reimbursed per procedure and the structure of thehealthcare system were at the second place. The time spent by thephysician at patient’s bedside was suggested as a third factor implyingthat in Europe physicians are more involved in daily clinical activities.Social issues including patient’s education and compliance, the struc-ture of the society, the public services and the psychological aspects ofthe patient were reported at the fourth place. Less importance wasgiven to inadequacy of data collection assuming that results reportedin the databases are reliable and true. All these factors were thananalyzed and matter of further analysis in the questionnaire. In con-clusion, although discrepancies and mistakes may be present in thedatabases of different countries, it seems that even after adjustment forcase mix, mortality rates in US are still elevated. Differences in dialysispractice emerged from the international questionnaire and differencesin healthcare organization and therapeutic approaches have also beendemonstrated. Time of referral, acceptance rates, geographical andsocial issues may play a further role in the different observed out-comes.

TECHNICAL AND CLINICAL EVALUATION OF A NEW TYPE OF HIGH FLUXPOLYSULFONE MEMBRANEC. Ronco*, A. Brendolan*, M. Ballestri**, G. Cappelli**, P. Inguaggiato**, G. La Greca*.*Department of Nephrology, St. Bortolo Hospital, Vicenza – Italy, **Department of Neph-rology, University of Modena, Italy

Different high flux membranes have been recently developed. The present study is aimedat describing the technical features and the clinical performances of a new high fluxpolysulfone membrane (T-sulfone, Toray, Japan). The study has been carried out on twodifferent dialyzers (surface area = 1.3 and 1.8 m2). The filters have been tested in vitrounder definite experimental conditions and in vivo during hemodialysis andhemodiafiltration.The hydraulic flow resistance, the pressure drop in the blood compartment and thehydraulic permeability have been determined in a wide range of in vitro experimentalconditions. The in vitro sieving coefficients for various solutes have also been determinedutilizing human blood. The in vivo study was carried out on 12 ESRD patients on regularhemodialysis treatment. The protocol was reviewed and approved by the local ethicalcommittee.Hydraulic permeability was found in the range of 28.4 ml/h/mmHg/m2 and sievingcoefficients were between 0.96 and 1.0 for all low molecular weight solutes. The sievingcoefficient for inulin was 0.95. The pressure drop in the filter at 300 ml/min of blood flowwas 95 mmHg for the 1.3m2 and 57 mmHg for the 1.8m2. The filters are then designed tooperate in the presence of high blood flows without excessive resistance in the bloodcompartment. The blood compartment analyzed by means of a special radiological se-quence obtained with a helical scanner after dye injection confirmed the homogeneousdistribution of the blood flow in several cross sections of the bundle. Adequate distributionof dialysate was confirmed with a similar method applied to the dialysate compartment.The in vivo clearances (K) at 300 ml/min of blood flow are reported in the following table:

Surf. Area Treatment Urea Creatinine Phosphate Inulin Beta-2-m1.3 HD 227 141 139 80 381.8 HD 240 143 142 91 401.3 HDF 224 145 151 83 491.8 HDF 231 148 154 96 56

Beta-2-m reduction ratio exceeded 50% in all sessions. Beta-2-m mass balance executedby collection of spent dialysate and elution from the used filters evidenced that removalis obtained mostly by filtration while absorption is negligible. Excellent tolerance andhemocompatibility was observed in all the studied sessions. The new imaging techniquesutilized were greatly helpfull to determine adequacy of filter design and flows distribu-tion.

DIALYSATE FLOW DISTRIBUTION ANALYZED BY SEQUENTIAL HELICAL SCAN-NING IN HOLLOF FIBER HEMODIALYZERS WITH DIFFERENT DIALISATE PATHSTRUCTURE: COMPARISON OF “MOIRE” STRUCTURE AND SPACING FILAMENTSTRUCTURE WITH STANDARD CONFIGURATION.C. Ronco, A. Brendolan, M. Scabardi**, G. Cappelli, M.Ballestri, P. Inguaggiato, G. LaGreca.Department of Nephrology, St. Bortolo Hospital, Vicenza, *Cattedra di Nefrologia,Università di Modena, **Radiology Department, Casa di Cura Eretenia, Vicenza,Italy

Hollow fiber dialyzers geometry has always been studied in detail mostly as far as the bloodcompartment was concerned. Very few studies have been designed to evaluate theadequacy of the design of the dialysate compartment. Recently, new designs have beenproposed for the dialysate compartment aiming at reducing channelling problems andinadequate distribution of dialysate flow. In this view, spacing filaments have been placedexternal to fibers or a special “moiré” structure has been created (fibers are wawed in orderto prevent contact of adjacent surfaces) to prevent loss of surface area or poor perform-ance.This study is designed to analyze the performance of dialyzers with similar surface areaand characteristics but differing in the design of the dialysate compartment (Surf. area 1.3m2; group 1= standard structure; group 2= moiré structure; group 3= spacing filamentsconfiguration).For this purpose, a special imaging technique was utilized. Dialyzers were analyzed duringa simulated in vitro circulation at 300 ml/min of blood flow and 500 ml/min of dialysateflow. Dialyzers were placed in vertical position and a cross longitudinal section 1 cm thickwas analyzed in sequence by a last generation helical scanner. Dye was injected in thedialysate compartment and the progressive distribution was evaluated by sequantialdensitometrical measures carried out automaticaly by the machine. Additionally, six dialy-sis sessions were carried out with each type of the studied dialyzers for the duration of 180minutes at a standardized blood flow of 300 ml/min and dialysate flow of 500 ml/min .Urea clearance was determined at 30 and 150 minutes from the beginning of the sessionboth from the blood and dialysate side.The sequential images analyzed by the scanner demonstrated a significant reduction ofthe channelling phenomenon in the dialyzers of group 2 and 3. In particular, thedensitometrical peaks and valleys detected at different levels of the length of the dialyzerswere significantly reduced in groups 2 and 3. Results were confirmed by the clearanceresults. Urea clearance was significantly greater in groups 2 and 3 (+ 21% and + 19%respectively) compared to group 1.We may conclude that the new design of dialysate compartment is effective in increasingand optimizing the performance of hollow fiber dialyzers. The new imaging techniqueutilized in this study is an excellent tool to evaluate these aspects in hollow fiber dialyzers.

NEWS INSIGHTS IN THE ATHEROSCLEROSIS IN HEMODIALYSISPATIENTSCianciolo G, Colì L, De Pascalis A, Iannelli S, Isola E, Mosconi G,Raimondi C, *Boni P, Stefoni S.Department of Clinical Medicine and Applied Biotechnology, *CentralLaboratory, St. Orsola University Hospital, Bologna, Italy

Transforming growth factor (TGF-β) is a multifunctional cytokine ableto inhibit the proliferation and migration of smooth muscle cells fromthe media to intima: a hallmark of atherogenesis. Lipoprotein a, Lp (a),which level is high in hemodialysis patients, seems to block TGF- βactivation. Some authors have related the atherogenic effect of Lp (a) toan inflammatory process which seems to play an important role incardiovascular damage. By the light of this was analized the associa-tion between circulating plasma TGF- β and Lp (a), C-reactive protein(CRP), sialic acid (SA) in a group of 62 hemodialysis patients on RDTfor over 12 months. The running HD modalities were the same for allpatients: bicarbonate buffer, heparin as anticoagulant, cellulose acetateor polisulphone hollow-fiber as dialyzer. Among the 62 hemodialysispatients, 32 (Group A) had a previous story (clinical and instrumental)of coronary artery disease (CAD) and/or severe vasculopathy and 30(Group B) had neither CAD nor peripheral vasculopathy. A group of18 healty volunters was also studied to provide control data (Group C).The three groups were comparable for age, mean blood pressure,lipidic pattern, smoking. For the study were measured serum TGF- βand Lp (a) (by Elisa method), CRP (by immunoassay sistem), SA (byan enzymatic method). In dialysis patients blood samples were drawnat the start and the end of the treatment. Results showed: TGF- βvalues were lower in dialysis patients (further decreasing at the end ofsession), particularly in group A: 29.8±10.3 ng/ml compared withGroup B (38.4±8.3 p<0.001) and Group C (42.3±5.6 p<0.001). Lp (a)values were higher in Group A, 38.9±8.8 mg/dl, than in Group B,22.0±6.4 (p<0.001) and in Group C, 10.3±7.5 (p<0.001). The levels ofCRP in group A resulted increased compared both to Group C (2.2±0.4vs 0.5±0.2; p<0.001) and to Group B (1.1±0.6; p<0.001). Again SA levelsresulted higher in dialysis patients (Groups A and B; 63±4 and 59±7mg/dl, respectively) than in Group C (54±2; p<0.001 vs A). In GroupA the TGF- β levels resulted inversely correlated with Lp (a) (r=-0.62)and CRP and SA (r=-0.66 and -0.48 respectively). The Lp (a) levelswere positively correlated with those of CRP (r= 0.415) and SA (r=0.426). In conclusions the results show that TGF- β levels are lowerthan controls in hemodialysis patient (Group A and B), mainly in thosewith atherosclerotic disease (Group A). These lower levels are closelyrelated both with Lp (a) and CRP, these last reflecting the general levelof inflammatory activity. This characteristic pattern in hemodialysispatients may be related with the evolution of atherosclerotic lesions,alongside the other well-known dialysis risk factors.

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MONITORING QUALITY IN DIALYSIS ACCESSSURGERY(DAS)D. Bonucchi, A. Di Felice, P. Inguaggiato, A. Ciuffreda, G.Cappelli, S. Fiorenza, A. Albertazzi.Division of Nephrology, Dialysis and Transplantation. Univer-sity Hospital, Modena-Italy.

Vascular access (VA) care is of utmost importance in the man-agement of dialysis program: patient’s (pts) quality of life andcost containment are both heavily affected by VA-related com-plications. Amongst factors influencing outcome of DAS, earlyreferral of pts and surgeon’s skill are commonly recognised, butrarely measured.Since 1996 our Dialysis Centre (DC) monitor DAS by means ofprocess (P) and outcome (O) quality indicators (QI). As PQI weanalyse the prevalence of acute-temporary access at first dialy-sis of ESRD pts (ATA1st) and the prevalence of central venouscatethers (%CVC) in chronic dialysis; as OQI we evaluate theMinimum Success Rate (MSR), defined as the minimum pro-portion of functioning VA after elective procedures and settledat 90%.ATA1st was around 30% in 1998. %CVC was 22 in hospital and7.3 in limited-care DC during 1997; in 1998 %CVC was 20.5 and7.3 respectively. MSR was 91.7% (n=99/108) in 1996; 95.8%(92/96) in 1997, 94.2% (138/146) in 1998.ATA1st is high in our DC, suggesting that late-referral is a prob-lem to be addressed, since it can affect the vascular burden ofESRD pts and hinder the timely creation of VA. In comparisonwith data from a national survey, %CVC in our DC is too highand is explained only in part by the age of our pts (>70 years =51%): reevaluation of pts with CVC for an internal VA is manda-tory. Performance of nephrologists devoted to DAS is satisfac-tory: this QI should be used to accreditate team and singlesurgeon. It fits well with the guidelines of the UK Renal Associa-tion. Taken together, these QI could be helpful in planning cor-rective measures aimed to improve the management of VA.

CLINICAL ANALYSIS OF THROMBOCYTOPENIA INCHRONIC DIALYSIS PATIENTSY Iwamoto, M Ando, K Tsuchiya, H NiheiDepartment of Medicine, Kidney Center, Tokyo Women’s Medi-cal University, Tokyo, Japan

Thrombopoietic status in dialysis patients is controversial. Thisstudy addressed this issue analyzing factors associated withthrombopoiesis. Two hundred and seven dialysis patients (171HD and 36 CAPD) and age-matched 43 control subjects werestudied. Thrombocytopenia was defined if the platelet countswere less than 150 x 109 /L. Reticulated platelets (RET), amarker for marrow megakaryopoiesis, were measured usingthiazole orange dye by flow cytometry. Serum thrombopoietin(TPO) level was measured by ELISA. Hepatitis C virus (HCV)antibody, platelet-associated IgG (PAIgG), and other clinicalparameters were examined in the patients. The platelet countsin the HD patients were significantly lower than those in theCAPD or controls. The incidence of thrombocytopenia was 27.3%in the HD patients. Thrombocytopenia was more prominant inthe HCV-infected HD patients in whom PAIgG was mostlypositive (94%) and its titer was remarkably high (97.2 +/- 82.9pg/ml). The platelet counts showed a significant correlationwith the RET counts (r =0.557) in the overall HD patients. Therewere significant differences in the RET counts between the pa-tients with and without thrombocytopenia and between the pa-tients with and without HCV. Neither of other parameters suchas iPTH, beta-2 microglobulin, Kt/V nor all prescribed drugswere related to thrombocytopenia. Serum TPO was significantlyhigher in the HD patients (138.9 +/- 69.3 pg/ml) than in thecontrols (97.3 +/- 56.0 pg/ml) and showed a significant inversecorrelation with RET counts in the HD patients (r = -0.328). Inconclusion, thrombocytopenia is frequent in HD patients, espe-cially in HCV-infected HD patients. Reduced marrowmegakaryopoiesis is most responsible for thrombocytopenia andperipheral destruction of platelets could be in part involved.Mild elevation of serum TPO possibly indicates a counter-re-sponse to decreased mass of megakaryocyte in bone marrow.

FACTORS ASSOCIATED WITH CHRONIC METABOLIC ACIDOSIS IN HEMODIALYSISPATIENTSMC Sánchez Perales, MJ García Cortés, JM Gil Cunquero, FJ Borrego Utiel, P Pérez delBarrio, J Borrego Hinojosa, A Liébana Cañada, V Pérez BañascoServicio de Nefrologia. HGE Ciudad de Jaén “ Jaén, Spain

Chronic metabolic acidosis has deleterious effects and is associated with significant pa-tient morbidity. One of the many goals of hemodialysis (HD) is the correction of uremicacidosis. Despite such treatment, acidosis remains common in HD patients. The objectivewas to evaluate factors associated with metabolic acidosis and that affecting intradialyticbicarbonate gain. We studied 61 stable HD patients. Sex: 32 M. Age: 55.1∀17.5 yrs. Monthson HD: 59.75∀58.2.They had not previous Diabetes and not were taking glucocorticoids.All patients were on conventional bicarbonate 3 2-4 h. HD thrice weekly. Dialysate: HCO3:34 mEq/l, acetate: 3 mEq/l. PAN membranes: 36 %, Cellulose: 64% (2,1m2).17 patientsremain residual renal function. (RRF) Previously to HD session at midweek, acid-baseparameters and anion Gap were measured. We analysed nutritional parameters and Kt/V as index of dialysis adequacy. Patients were divided in two groups according to predialysisbicarbonate: GI:<21 mEq/l; GII:∃21mEq/l and then were compared for: demographicscharacteristics, body mass index, Kt/V, normalized protein catabolic rate (nPCR, gr/Kg/d), serum albumin (gr/dl), Urea, Creatinine (mg/dl) and dietary protein intake (gr/kg/d) obtained by dietary history, average of 3 day recollections. The intradialytic bicarbonategain and its correlation with dialyzer, Kt/V, minutes of dialysis session, net ultrafiltrationand percent ultrafiltration (relative to patient´s body weight) were studied34 patients (55 %) had a mean predialysis serum Bicarbonate< 21 mEq/l. GI and GII hadsimilar RRF, time on HD and sex distribution. Boths groups had similar Kt/V: GI:1.27∀0.24,GII:1.27∀0.25 (ns). GI was younger: GI: 51.02∀17, GII: 60.15∀19 (p<0.05). Acidotic pa-tients had: 1º) Higher nPCR: GI:1.17∀0.22, GII: 0.95∀0.21 (p<0.001), serum albumin: GI:4.68∀0.23, GII: 4.52∀0.28 (p<0.05) and dietary protein intake: GI: 0.98∀0.22, GII: 0.82∀0.31(p<0.05).2º) Higher creatinine: GI: 9.73∀1.8, GII 8.55∀1.9(p<0.05) and urea GI: 169.19∀26.7 GII:137.25∀27.6 (p<0.001).3º) Higher increase intradialytic Bicarbonate (%): GI: 33.56∀9.1, GII: 18.94∀7.5 (p<0.001).The intradialytic Bicarbonate gain showed a linear inverse relationship with predialysisserum Bicarbonate: r= -0.70 (p<0.001).Conclusions: 1) A greater acidosis is associated with more dietary protein intake and betternutritional state. 2) Intradialytic bicarbonate gain is related with serum bicarbonatepredialysis (diffusive gradient) and is not related with ultrafiltration rate (convectivetransport), dialysis dose or dialyzer used.

TF AND TFPI AS MARKERS OF ENDOTHELIUM INJURY INHAEMODIALYSISB. Naumnik, J. Malyszko, K. Pawlak, M. MysliwiecDepartment of Nephrology and Internal Medicine, Bialystok,Zurawia 14, Poland.

TFPI (tissue factor pathway inhibitor), expressed primarily bythe microvascular endothelium appears to be the majorphysiologic inhibitor of TF (tissue factor)-induced coagulation,which also plays an important role in the pathophysiology ofmany diseases i.e. atherosclerosis and thrombosis. Cardiovas-cular events related to thrombosis are a predominant cause ofdeath and account for an important morbidity in uremic pa-tients. Since TFPI is considered to be a marker of endothelial cellinjury, the aim of the study was to assess TFPI and TF levels inpatients maintained on hemodialysis. The studies were per-formed on 30 chronically hemodialyzed patients (16 men, 14women, age range 26-72) undergoing 4-5 h of HD 3 times aweek for over 5 months. 20 healthy volunteers served as a con-trol group. TF and TFPI assays were performed using commer-cially available kits from American Diagnostica, USA. All theresults are presented in the Table.

Control group before HD after HDTF activity (nM) 0.06± 0.03 0.07±0.04# 0.08±0.03TF:Ag (pg/ml) 0.00±0.00*** 292.4±91.9 305.5±105.7TFPI activity (IU/ml) 0.9±0.37 0.95±0.45 0.97±0.31TFPI:Ag (ng/ml) 83.55±19.1** 110.05±34.4** 136.6±32.5

##* p<0.01, ** p<0.005, ***p<0.001 vs control# p<0.1, ##p.<0.001 before vs after HDHigh TFPI and TF concentration may reflect endothelial dam-age in dialyzed patients. A significantly higher TFPI concentra-tion after hemodialysis suggest further endothelial damage inthese patients. On the other hand, elevated TFPI levels may alsoserve as a protective mechanism against hypercoagulable stateobserved in uremia.

z✻

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TELEMATIC MANAGEMENT OF TWO PERIPHERAL DIALY-SIS CENTERS (PDC) BY REMOTE CONTROL: 24 MONTHS’sEXPERIENCEM. Briganti, G. Emiliani, A. Montanari, P.P. Manzini*, M.Zaccarelli*, M. Fusaroli.Div. of Nephrology-Dialysis, S.M. delle Croci Hospital - Ra-venna, *Hospal-Bologna, Italy

The critical patients are increasing in PDC and their manage-ment became more and more complex for medical and nursestaff. For this reason we evaluated the clinical and operativeimpact of a telematic system located in two PDC, rispectively at45 and 25 Km from the main center (MC). The architecture of thesystem includes 12 dialysis monitors, type “Integra” (Hospal),wich is able to send data machine and patients parameters(systolic and diastolic blood pressure, cardiac frequency, hae-moglobin, blood volume), through RS232 to a local personalcomputer (PC) provided with a special software able to receiveand manage all data (Dialmaster-MS-Windows 95©). The infor-mation stored in the local PC are sent by a Router through ISDNline (2x64Kbps) to thePC-server at the MC.The PC-server of the MC has access to the files of recorded andon-line treatments and gives the opportunity to change the di-alysis prescription for the next treatments as well. Up to now wehave registrated more than 13000 dialysis sessions, the mostfrequent on line interventions were due to: 38% prevention andtherapy of hypotensive episodes, 32 % variation in body dryweight, 10% blood flow, 5% variation of conductivity, 6% heparinmodifications, 5% pharmacological therapies, 4% others, in the0.8% of dialytic sessions technical problems related to telematicmanagement were found.Telematic management of PDC seems useful and lead to theconsideration that allows to reduce waste of time in the proce-dures executed by the staff; there’s a reduction in medical ad-missions to PDC of 1/4, while for the nurse there’s a saving of 5-6 minutes for each patient treated. In conclusion the telematicmanagement sets up an efficient system in order to improve thequality of dialytic treatment and the safety in remote centres.

HIGH ADENOSINE PLASMA LEVELS IN HEMODIALYSISPATIENTSI Sampol, G. Bechis, R. Guieu, H. Rochat, E. Fenouillet, J.L.Mege, C. Capo, D. Lerda, Ph. Brunet, Y. Berland, B. Dussol.Laboratoire de Biochimie, Hôpital Nord et Service deNéphrologie, Hôspital Sainte Marguerite, Marseille, France.

Adenosine (ADO) is a strong vasodilator andimmunosuppressor that may participate in infections and hy-potension in hemodialysis (HD) patients. ADO is transformedinto inosine by plasmatic ADO deaminase (ADA) and mono-nuclear cell ADO deaminase (MCADA). ADO is also uptakenby erythrocytes. The aims of this study were 1) to measure ADOplasma concentrations in patients (pt) before HD and comparethem with those of peritoneal dialysis pt, chronic renal failure(CRF) pt, and healthy controls 2) to evaluate ADA and MCADAactivities and the influence of HD on ADO uptake by erythro-cytes 3) to investigate the potential role of ADO on humanmononuclear cell activation and on rat blood pressure. The re-sults are: 1) Before HD, ADO plasma concentration was higherin hemodialyzed pt (N=14) than in controls (N=14) and in peri-toneally dialyzed pt (N=9). ADO plasma concentration for CRFpt (N= 11; ADO= 0.79±0.16 mM) was in the same range ascontrols (n=14; 0.73± 0.19 mM). 2) ADA activity was higher inHD pt than in controls. ADA activity in the CRF pt (222± 80 IU)was in the same range as controls (219±48 IU). MCADA activityin HD pt was lower than in controls. There was an inverse corre-lation between ADO plasma concentration and MCADA activ-ity in HD pt and controls. HD did not modify ADO erythrocyteuptake. 3) ADO inhibited mononuclear cell proliferation andIFNg production in humans and decreased systolic blood pres-sure in a dose dependent manner in rats. Our conclusion is thatHD induces a drop in MCADA activity and an increase in ADOplasma concentration. Both high ADO plasma concentrationand low MCADA activity may be involved in dialysis-inducedimmune system failure and hypotension.

SEARCHING FOR POST-DIALYSIS UREA EQUILIBRATEDKT/V IN 8 HOURS HAEMODIALYSIS WITHINTRADIALYTIC UREA SAMPLES.G Jean, B Charra, C Chazot, G Laurent.Centre du Rein Artificiel de Tassin, France.

Measuring Post-dialysis urea rebound (PDUR) requires a 30 or60 min postdialysis sampling that is inconvenient. The aim ofthis study was to compare different methods for Kt/V estima-tion in long haemodialysis and to find out the best intra-dialyticurea sample time which fits best with PDUR.The study included 21 patients, mean age 71.9 years,hemodialysed for 60±60 months, three times 8-hour. The bloodurea samples were obtained at onset then at 17, 33, 50, 66, 75,80, 85 100% of the dialysis session time, after 30 sec low-flow,then at 60 min postdialysis. We compared the different formu-las of Kt/V: Kt/V-smye with a 33% urea sample, two poolsequilibrated eKt/V, Kt/V-std (Daugirdas-2) obtained with animmediate post-dialytic sample and the different intradialyticurea samples Kt/V, with the equilibrated-60 min PDUR Kt/V(Kt/V-r-60) as the reference method.The mean PDUR was 17.2±9%, leading to an overestimation ofKt/V-std by 12.2%. Kt/V-r-60 was 1.68±0.34. Kt/V-std was1.88±0.36 (delta 12.2±4.8%, r =0. 8), eKt/V was 1.77±0.3 (delta5±5%, r=0.96), Kt/V-smye was 1.79±0.47 (delta 5.2±14%, r=0.9).The best time for the intradialytic sampling was 80% (i.e. 6 hrs24 min). The Kt/V-80 was 1.64±0.3 and best fitted with Kt/V-r-60 (delta - 1. 8 ± 8%, r=0.91). The mean intra-dialytic ureaevolution showed a three exponential rate, in discrepancy withthe two exponential rate theoretical model.These results confirm a significant post-dialysis rebound in8-hour dialysis. An intra-dialytic urea sample at 80% of thesession time allows to estimate the 60 min Kt/V-rebound with-out delayed sample with better accuracy than eKt/V or espe-cially Kt/V-smye. This may be related to the particular ureakinetics curve on long dialysis that need to be further studied.

MICROVOLT T-WAVE ALTERNANS (TWA) IN HEMODIALYSIS (HD) PA-TIENTSA. Deligiannis1, E. Kouidi1, E. Konstantinidou1, A. Tourkantonis2.1Laboratory of Sports Medicine, 2A Internal Medicine Clinic, Aristotle Univer-sity of Thessaloniki, Thessaloniki, Greece

Microvolt TWA is an accurate predictor of ventricular arrhythmias vulnerabil-ity in cardiac patients. However, it is still unknown if the presence of TWA is asensitive marker of electrical instability in HD patients, who appear a signifi-cant high risk of arrhythmia events and sudden cardiac death. Therefore weinvestigated the incidence of the positive TWA in HD patients, as well as therelationship between TWA and clinical, biochemical, haemodynamic param-eters, autonomic balance indices, aerobic capacity and arrhythmias (>Lown II).Thirty end-stage renal disease patients on HD (mean age 47.5±6.5 years), free ofany other systemic disease, underwent a spiroergometric, echocardiographic,24-h ECG holter monitoring and TWA study on a non-dialysis day; TWA wasevaluated using a spectral analysis technique during a bicycle exercise protocol.Thresholds for noise, bad beats, respiration, pedaling frequency and heart ratevariability (HRV) were determined; so, only high fidelity recordings were ex-amined (positive TWA>1.9 µV and 1 min duration). There were 18 TWA studies(60 %) with positive results, 4 (13%) with indeterminate and 8 (27 %) withnegative results.

TWA positive TWA neg or ind. p(n=18) (n=12)

Age (yrs) 48±7 47±6 >.1Years on HD 6±2 6±1 >.1Blood pressure (mean, mmHg) 105±10 106±12 >.1Ht (%) 32±5 32±4 >.1K (mEq/L) 5.8±1.3 5.7±1.2 >.1VO

2peak (ml/kg/min) 17±5 16±5 >.1

LV EDV (ml) 185±31 176±28 >.1LV Mass (g) 228±48 234±35 >.1LV EF (%) 49±9 48±9 >.124-h HRV (index) 24±6 23±2 >.124-h arrhythmias (>Lown II, No=) 16/18 7/12 <.05

A high number of HD patients appear positive TWA recordings; TWA is anindependent marker of other significant prognostic variables in chronic uremicpatients, except arrhythmias. These results support the clinical value of TWA inrisk stratification in HD patients.

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DIALYSIS IN THE ELDERLY PATIENTS (EP): A NEW CHAL-LENGE FOR NEPHROLOGISTF. Caccetta, M. Caroppo, F. Musio, C. Cossa, S. Ramundo, V.Nuzzo.Unit of Nephrology and Dialysis “Panico Hospital” Tricase(Lecce) Italy

The number of EP beginning HD is going to augment. In the last5 years, the mean incidence in our Center has been of 40.6% witha significant increase of the mean age (MA) (1994: 54.6±15.9yrs, 1998: 59.5 ± 15.2 yrs p<0.05) and at present the EP aged>65yrs represent the 45.6%. The aim of this study was to ap-praise the forbearance of EP on HD and the approach of themedical and nursing staff in treating a large number of EP. 81pts were divided in two groups: Group A, 44pts (29M-15F),MA48.2 ± 11 yrs, duration of dialysis (DD) 70.2±63.3 months;Group B, 37 pts (24M-13F), MA 73±4.7 yrs, DD 53 ± 39.6 months.We appraised the following parameters from 2025 HD sessionsoccurred in two consecutive months: dry body weight (BD),interdialytic weight gain (WG), ultrafiltration rate (UF), meanarterial pressure (MAP), number and incidence of hypotensiveepisodes (BE), number and percentage of therapeutic interven-tions (TI). Monthly we appraised the Kt/V and nPCR. The meanvalues of Hb, HCO-

3, serum albumin (SA), ferritin and rHuEpoweekly dose were referred to the last six months. Finally wereported the number of hospitalizations (NH) in the last year. Atthe end of the study the pts of group B presented a greaterincidence of HE (8% vs 22.9% p<0.001) with a higher number ofTI (172/1188 vs 260/837, p<0.001). The WG was lesser in groupB (%BD 5.7 ±1.39 vs 5.04 ± 1.45, p<0.02) such as the UF (1.05 ±0.21 vs 0.86 ± 0.23, p<0.0001). The nutritional status, expressedby nPCR (1.17±0.2 vs 0.9+0.22, p<0.01) and SA (4.08 ± 0.2 vs3.9 ± 0.23, p 0.01) was different too. At last the NH was greaterin the group B (0.29/pt/yr vs 0.54/pt/yr, p<0.02). The otherparameters weren’t statistically different. In conclusion, the EPare exposed to a higher risk of malnutrition and cardiovascularinstability in spite of the remarkable technological successes.Consequently the increasing number of EP requires the greatestsurveillance and care by medical and nursing staff.

WRIST/BRACHIAL PRESSURE INDEX - A SIMPLE METHODFOR ASSESSING STEAL SYNDROME AFTER PROXIMALARM AV FISTULAEA Bakran1, U P Singh1, A Ahmed1, TV How2, GM Bell1

Dialysis Access and Transplant Unit1, Department of ClinicalEngineering2 Royal Liverpool University Hospital, Liverpool, L78XP, UK.

Introduction Steal syndrome, with it attendant symptoms ofpain, neuropathy, coldness of fingers and cyanosis is a wellrecognised complication of vascular access surgery. It primarilyaffects patients with av fistulae in the arm rather than forearm,and reconstructive surgery or ligation of the fistula is usuallyrequired to reduce symptoms or prevent gangrene We have in-vestigated the use of doppler radial artery pressure at the wristin assessing/quantifying steal in patients after av fistulae whichuse the brachial artery as the inflow vessel.Method Patients in renal failure with a proximal vascular accessprocedure were included in the study. Systemic blood pressurewas measured using the contralateral brachial artery andpost-operatively ipsilateral doppler radial artery wrist pressureswere performed and the ratio expressed as the wrist/brachialpressure index (WBPI). Patients were divided into symptomaticand asymptomatic groups clinically.Results n mean WBPI SD SEAsymptomatic group 24 0. 82* 0.10 0.03Symptomatic group 9 0.43* 0.17 0.02 *p< 0.001 Mann Whitney U testNo symptomatic patient had a WBP1 > 0.6.Conclusion This simple test aids detection of steal syndromeand has been used to guide surgical revision of av fistulae toresolve symptoms. A ratio of < 0.6 would suggest symptomaticsteal syndrome will occur and revision of the fistula necessary.

THE USE OF THE WRIST/BRACHIAL PRESSURE INDEX TOPREDICT AND PREVENT STEAL SYNDROME AFTER PROXI-MAL AV FISTULAA Bakran1, UP Singh1, A Ahmed1, TV How2 and GM Bell1

Dialysis Access and Transplant Unit1, Department of ClinicalEngineering2 Royal Liverpool University Hospital, Liverpool L78XP, UK.

Introduction Steal syndrome is a well known complication of avfistulae which use the brachial artery as the inflow vessel, and iscaused by a reduction in blood flow to the hand/forearm. Whilstrevision of the fistula is commonly performed post-operatively,an intraoperative method would be preferable. We describe sucha method here with examples. Method Preoperative brachialartery and doppler radial artery pressure at the wrist were per-formed and the wrist/brachial pressure index (W13P1) deter-mined. Brachiocephalic av fistulae were then performed using astandard technique followed by palpitation of the radial arterypulse and repeat WBPI. Fistulae were then plicated to reduceflow until the WBPI was > 0.7. Examples A female patient inrenal failure had a side- to-side brachio-cephalic av fistula.Pre-operative WBPI was 1.3. On release of the av fistula, theWBPI fell to 0.37. On clamping the distal outflow vein it rose to0.73 and clamping both outflow limbs, resulted in 1 a returnWBPI of 1. 1. The patients distal outflow vein was ligated andpost-operatively the patient was asymptomatic with a goodfistula flow. In a second patient who had symptoms of steal anda weak radial pulse following a brachio-cephalic av fistula, revi-sion surgery was necessary. Post-operative WBPI was 0.4 afterthe initial operation. At revision surgery, the fistula was plicatedto produce a WBPI of 0.7 intraoperatively. Post-operatively hersymptoms resolved completely. Conclusion The measurementof W13P1 appears to be a valuable method for the revision of avfistulae that cause steal syndrome and can be usedintraoperatively to prevent the syndrome developing at the ini-tial operation. Its use should be encouraged.

EXERCISE RENAL REHABILITATION PROGRAMS: TRAINING DURINGHEMODIALYSIS COMPARED TO THE ONE ON THE OFF-DIALYSIS DAYS.E. Kouidi1, S.Vassiliou2, D. Grekas2, A. Deligiannis1, A. Tourkantonis2

1Lab. of Sports Medicine, 2A Internal Medicine Clinic- Renal Unit, AristotleUniversity of Thessaloniki, Thessaloniki, Greece

It is known that the reduced aerobic capacity, the skeletal muscle weakness andthe cardiac autonomic dysfunction in the hemodialysis (HD) patients are mainpredisposing factors for their poor functional ability. This study assesses theeffects of an Exercise Renal Rehabilitation Program during hemodialysis (in-ERRP) on the above parameters, in comparison with another one on the off-dialysis days (off-ERRP).We studied 20 HD patients (aged 51.2±11.8 years) who completed a 6-monthtraining program with stationary bicycles during their HD sessions. The re-sults of this treatment were compared with those of 20 other HD patients(50.8±11.2 years), who participated in a 6-month off-ERRP, consisting of threeweekly sessions of supervised regular exercise training. All 40 patients werefree of any other systemic disease. Following both rehabilitation programs allHD patients had significant improvements in exercise capacity (VO

2 max, as

estimated by spiroergometric study), parasympathetic cardiac activity (as cal-culated by 24h heart rate variability - HRV), and muscle strength of the lowerlimbs (as evaluated from the ratio among peak isokinetic knee extension/flexionat 120°/sec measurements -Peak Torque). However, off-ERRP results weregreater than in-ERRP (Table):

Groups Months VO2 max Exercise time HRV Peak Torque

(ml/Kg/min) (min) (index) (%)In- 0 16.3±5.4 15.1±3.8 21.6±6.5 44.2±3.4ERRP 6 19.1±4.8* # 18.8±3.7* # 25.2±7.4* # 50.1±4.3* #

Off- 0 16.7±6.1 15.5±4.1 21.9±6.8 44.6±3.6ERRP 6 22.9±7.3 22.2±4.3 28.4±8.6 57.4±4.8

Mean±SD,*p<.05 compared to pre-training,#p<.05 compared to off-ERRPWe conclude that exercise training during the hemodialysis session improvesphysical fitness in a comparative manner with exercise on off-dialysis days. Inaddition, this rehabilitation model is more convenient for the HD patients andrepresents a feasible and safe therapeutic modality.

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EXTRACELLULAR WATER REDUCTION (ECW) OBTAINED BY STANDARD(SHD) OR BY DAILY HEMODIALYSIS (DHD) ALLOWS BLOOD PRESSURECONTROL IN HYPERTENSIVE HD PATIENTSRM Fagugli, G Ciao, B Cicconi, F Pasticci, A Selvi, G Quintaliani, U BuoncristianiNephrology Unit, Silvestrini Hospital, Perugia, Italy

The cause of hypertension in HD patients is controversial: a relation with fluidoverload was not clearly demonstrated. DHD seems to ensure a normalizationof BP in the majority of pt. probably by ECW% reduction like reported by ourgroup. With this prospective study we wanted to investigate if SHD and DHDallows indifferently BP reduction by ECW% decrease.In 20 hypertensives on SHD we studied 24 hr. ambulatory BP, ECW% and KT/V. During a period of 3-6 months we reduced ECW% in 10 pt. by DHD and in theother 10 by SHD (from 56.2±14.4 to 45.2±6.7, p<0.001). At the end we monitoredagain BP, ECW%, KT/V and pharmacological therapy. Patients who remainedon SHD need a longer session (4,5h x 3/week) to achieve a reduction of ECW.Systolic BP decreased from 155.9±17.4 to 132.8±14.6 mmHg and diastolic BPfrom 78.5±10.3 to 70.2±8.3 mmHg (p<0.001). No differences were reported onSystolic and Diastolic BP reductions between patients on SHD and DHD (SystolicBP 22.2±18.9 for pt. on SHD and 24.05±12.9 mmHg for pt. on DHD; Diastolic BP10.7±5.9 mmHg and 5.9 ±4.2 mmHg). Number of anti-hypertensive drugs wassignificantly decreased after ECW% reduction (1.95 ±1.27 vs 0.25±0.3, p<0.001).KT/V did not significantly change in patients undergoing DHD, but increasedsignificantly in patients who remained on SHD (3.5±0.64 vs 4.33±0.94, p=0.01).Analyzing by ANOVA model the weight of covariates HD age, inter HD weightgain, KT/V and ECW% on variable systolic BP, a significance was reported forinter HD weight gain (p=0.014) and for ECW% (p=0.022).In conclusion, the reduction of ECW% allows the normalization of BP in themajority of patients on hemodialysis, meaning that this population is affectedby a chronic fluid overload. SHD and DHD are able to permit the achievementof the ideal dry body-weight, and therefore the normalization of BP, but whenpatients are treated by 3 time weekly HD, each session must be longer than 4hour.

EVALUATION OF NUTRITIONAL AND CLEARANCE PARAMETERS INHEMODIALYSISPapadogiannakis A., Bizas E., Tsirakis G., Kostakis K., Dermitzakis A., BalalisK., Papachristoforou K.Hemodialysis Unit, Venizelion Hospital, Heraklion, Greece

It has been mentioned that parameters correlated with nutritional status andclearance, such as nPCR, Kt/V, serum cholesterol (Chol) and albumin (Alb),may influence the quality of life and mortality in hemodialysis (HD) patients.We set the following questions: a) Are those parameters correlated? b) Is thereany relationship between nPCR, Kt/V and mortality? c) Are nutritional statusand clearance adequacy affected by personal features (sex, age, weight)? In or-der to answer to these questions we performed independent sampling in our unitby the following way. 1) In 74 patients we measured simultaneously Kt/V,nPCR, Alb, Chol. Correlation analysis showed that there was positive correla-tion between nPCR (mean:1.177 +/- 0.287) and Kt/V (mean:1.210 +/- 0.264)(r=0.573, p<0.001) and between nPCR and Chol (mean:181.47 +/- 36.1 mg/dl)(r=0.263, p=0.023). 2) In 74 patients (mean age:62.34 +/- 12.92 years) we meas-ured Kt/V, nPCR, Alb and Chol for one year period. Analysis revealed that ageshows negative correlation with nPCR (mean:1.163 +/- 0.209, r=-0.346, p=0.003)and Alb value (mean:3.96 +/- 0.22 g/dl, r=-0.280, p=0.019). 3) In two similarlyfor age patient groups (group A:47 men, group B:35 women) we compared an-nual mean values of Kt/V and nPCR. There was significant difference only inKt/V value (men:1.103 +/- 0.144, women:1.246 +/- 0.234, t=3.196, p=0.002)(nPCR values: men:1.107 +/- 0.172, women:1.204 +/- 0.25). 4) In 67 patients wecalculated Mass Body Index (MBI), Kt/V and nPCR. We did not find any corre-lation between MBI and Kt/V or nPCR. 5) In two groups of patients, matched forage and sex, (group A: 38 alive, group B: 19 deceased) we calculated Kt/V andnPCR for one year period (for group B, it was the year of death). We did not findany significant difference (group A: Kt/V: 1.159 +/- 0.157, nPCR:1.113 +/- 0.16,group B: Kt/V:1.15 +/- 0.248, nPCR:1.085 +/- 0.242). Our data suggest that: 1)nPCR value shows positive correlation with Chol value and clearance adequacy.2) Age correlates negatively with nPCR and Alb but it does not affect Kt/V. 3)MBI does not affect Kt/V and nPCR. 4) Kt/V and nPCR values did not differbetween deceased and alive patients. 5) Women show better Kt/V probablybecause of smaller distribution volume of urea.

EXTRACELLULAR WATER (ECW) DECREASE OBTAINEDBY STANDARD (SHD) OR DAILY HEMODIALYSIS (DHD)ALLOWS CARDIAC HYPERTROPHY REDUCTION IN HY-PERTENSIVE HD PATIENTSRM Fagugli, G Ciao, B Cicconi, F Pasticci, P Pasini*, G Quintaliani,U BuoncristianiNephrology and *Cardiology Units, Silvestrini Hospital, Perugia,Italy

The cause of cardiac hypertrophy in HD patients is controver-sial and a relationship with fluid overload was not clearly dem-onstrated. DHD seems to allow a reduction of cardiac diam-eters through the reduction of Blood Pressure (BP) and ECW.With this prospective study we wanted to compare SHD(4h x3/week) and DHD(2hx6/week) in the reversal of cardiac hyper-trophy by the decrease of ECW.In 20 hypertensives on SHD we studied left ventricle end diastolicdiameter (LVeDD) and left ventricle mass index (LVMi), ECW%,24 hrs BP monitoring and KT/V. After 3-6 months we reducedECW% in 10 patients by DHD and in 10 patients by SHD (from56.2±14.4 to 45.2±6.7, p<0.001). At the end we monitored againLVeDD, LVMi, BP, ECW%, KT/V and pharmacological therapy.Patients maintained on SHD required a longer hemodialysissession (4,5h x 3/week) to reduce ECW%. Mean BP decreasedsignificantly from 104.3±10.8 to 91.1±8.7 mmHg (p<0.001). Thesame did LVeDD and LVMi, with no statistical differences be-tween the group on DHD and SHD (LVeDD: from 54.8±7.5 to46.8±6.3 mm, p=0.001; LVMi: from 276.8±119.1 to 192.8 ± 66.4,p=0.001). The number of anti-hypertensive drugs prescribeddecreased significantly after ECW% reduction (1.95±1.27 vs0.25±0.3, p<0.001). KT/V did not significantly change in pa-tients undergoing DHD, but increased significantly in patientswho remained on SHD (3.5± 0.64 vs 4.33±0.94, p=0.01).Analyzing by ANOVA model the weight of covariates HD age,inter HD weight gain, KT/V, ECW%, Systolic and Diastolic BPon variables LVeDD and LVMi, a significance was observed forECW% (p=<0.001).In conclusion, the achievement of ideal dry body-weight allowsthe reduction of cardiac hypertrophy, linked primarily to fluidretention. Both SHD and DHD are able to guarantee a reversalof cardiac hypertrophy in hypertensive HD patients, but pa-tients on SHD need a longer dialytic session.

KIDNEY DISEASE AND QUALITY OF LIFE (KDQOLTM) ASSESSMENT INPATIENTS UNDERGOING DAILY HEMODIAYSISU. Buoncristiani, R.M. Fagugli, C. Ciao, A. Selvi, B. Cicconi, H. KulurianuNephrology Unit, Silvestrini Hospital, Perugia, Italy

The impact of Hemodialysis on psychological and social life of ESRD patientsis detrimental, although in the last years techniques are continuously perfecting.Reports on differences between standard HD (SHD = 4h x 3/week) and dailyhemodialysis (DHD = 2h x 6/week) are interesting because DHD seems to in-duce a better quality of life, previously empirically reported by our group. There-fore, we wanted to assess by KDQOLTM if DHD is able to permit a better qualityof life than SHD.We analyzed on 28 patients Kidney Disease and Quality of Life (KDQOL TM)during SHD and after switching to DHD (13 pts performed DHD at home and 15in hospital). In all the patients an increase of the total score was reported(7430±2028 during SHD and 9064±2459 during DHD, p<0.01). In particulargeneral health score increased (from 930±336 to 1212±414, p=0.001), and socialfunction (from 81±53 to 118±54, p=0.001), symptoms/problem list (2264±616vs 2670±653, p<0.01), and sleep (644±265 vs 808±265, p<0.01) did the same.Concerning the differences between patients treated at home and in hospital, wereported an increase of total score (from 8155±2099 to 10855±1501, p<0.01),general health score (from 1096±292 to 1515±282, p=0.001), social function(from 87±56 to 142±28, p=0.01), and symptoms/problem list (2487±515 vs3085±308, p<0.01) in pts undergoing Home DHD. Pts treated in Hospital byDHD showed a score increase only for social function (from 76±52 to 100±63,p=0.03) and for sleep (sleep (571±276 vs 723±257, p<0.01). This differences couldbe due to the fact that patients on Home DHD were younger (42.7±12,1 vs 63.9±12yrs, p<0.01) with a different psychological attitude like we can argue from thehigher basal total score (9189±2350 vs 6872±1860, p<0.01). Moreover, psycho-logical and social difference due to the home environment must be taken intoaccount. After 6 months of DHD treatment, patients on Home DHD had a higherincrease of total score than the other group (10871±1425 vs 7686±2159, p<0.001).In conclusion, DHD seems to guarantee a better quality of life than SHD, and thisincrease is particularly remarkable if patients are treated at home.

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A 3-YEAR PROSPECTIVE STUDY OF THE OUTCOME OFPATIENTS DIALYZED AT HOME OR IN SELF-CARE UNITSChauveau P., Larroumet N., Desvergnes C., Montoriol J, CombeC., Aparicio M.AURAD-Aquitaine, Bordeaux, France.

The difference in survival between home and in-centerhemodialysis patients (pts) can be only partially explained bypt selection and co-morbid conditions. Woods et al. (Kidney Int1996) from the USRDS data, showed that pts with training hadlower mortality risk. In a 3-year prospective study begun inJanuary 96, we analyzed data from 1139 pts dialyzed at homeor in self-care satellite units (minimal nursing supervision). Af-ter 3 years of follow-up (Jan 99) only 14 pts died (10%), 22(16%) were transplanted. 98 pts were still alive but 9 pts (6.5%)had to be referred to in-center treatment. Characteristics of thepatients at the inclusion including age, time on dialysis, nutri-tional parameters (total protein, albumin and prealbumin, urea,creatinine, HCO3, PCR, BMI) parameters of adequacy (eq Kt/V- Smye formula), dialysis time, werre studied using nonparametrisurvival analysis and analysis of variance when patients weregrouped according to their outcome. The equilibrated Kt/V was1.16 ± 0.28 and nPCR 1.22 ± 0.33 g/kg/day, albumin 41.9 ± 6.2g/L and prealbumin 0.366 ± 0.09 g/L. Dialysis time is 12 ± 1.2hours per week with high-flux membrane in 50% of patients.Age, time on dialysis, dialysis time and eKt/V significantlyinfluence the outcome but survival analysis shows that 80% ofpatients older than 70 years were still alive at 3 years.Although pts were selected to be treated in a self-dialysis pro-gram, these results indicate that a high-survival rate associatedto improved autonomy can be obtained with such mode ofhemodialysis therapy which can be performed with high-qualitytechnical standards.

NEURAL NETWORKS MODEL FOR STUDYING UREA KINETICS ANDPREDICTION OF THE TIME OF HEMODIALYSIS SESSION IN CHRONICHEMODIALYSIS PATIENTS.A. Akl 1, M. Sobh 1, Y. Enab 2, J. Tattersal 31.Urology & Nephrology center, Mansoura, Egypt, 2.Faculty of Engineering,Mansoura university, Egypt, 3.Lister hospital, stevenge, U.K.

The effect of dialysis on patients is conventionally predicted using a formalmathematical model. This approach requires many assumptions of the processinvolved and validation of these may be difficult. The validity of dialysis ureamodeling using a formal mathematical model has been challenged. In particu-lar, there is still controversy over the precise mechanism of multi-compartmentand disequilibrium effects. No known mathematical model has been fully vali-dated for other solutes than urea.Recently, artificial intelligence using neural network (NN) have been used tosolve complex problems without needing a mathematical model or any under-standing of the mechanisms involved. In this study, we have applied (NN) modelto study and predict the concentrations of urea during and after hemodialysissessions of varying duration and intensity. We measured the blood concentra-tions of urea at 30 minutes intervals during the session and at 2,7,15,35 minutesafter hemodialysis session (In 30 chronic hemodialysis patients) the (NN) modelwas trained to recognize the evolution of the measured urea concentration andwas subsequently, able to predict the actual time of the hemodialysis sessionneeded to reach a target Kt/v in patients not previously studied by the NN model.Comparing the results of the NN model with the direct dialysate quantificationmodel (DDQ) the standard error was 0.17% at blood flow 200 ml/min & 0.15%at blood flow 400 ml/min. When comparing the mathematical model with(DDQ) the standard error was 10% at blood flow 200 ml/min & 31.9 % at bloodflow 400 ml/min. The results confirm that the neural networks model wasmore accurate in predicting the actual time of hemodialysis session at differentblood flow rate than the traditional mathematical models. In theory this ap-proach can easily be extend to other solutes and neural networks model is con-sidered a step forward to achieve “intelligent Dialysis control”.

INFECTIONS WITH HEPATITIS VIRUSES B, C AND D INPATIENTS ON MAINTENANCE HEMODIALYSIS IN ROMA-NIA AND IN EASTERN EUROPEAN COUNTRIES: YELLOWSPOTS ON A BLANK MAPVladutiu D*, Cosa A**, Gherman M*, Patiu IM*, Dulau I****Clinic of Nephrology and Dialysis, Cluj, **Sanitary Inspector-ate, Cluj, ***Dialysis Center Targu-Mures, Romania

In order to complete the lack of published research on hepatitisB, D and C in patients hemodialyzed in Romania and in otherformer communist countries, we have studied prospectively,between 1993-1998, the prevalence and incidence of the HBs-,HBe- and HVD-antigens, and of the anti-HBc, anti-HBs, anti-HBe, anti-HVD and anti-HVC antibodies, in 180 patients withchronic renal failure, dialyzed in the Nephrological Clinic Cluj.The HBV and HCV markers had an impressive prevalence (anti-HBc antibodies 60-88%; HBs antigen 9-25%; anti-HCV antibod-ies 74-100%; simultaneous occurence of HBs antigen and anti-HCV antibodies 4-21%) in the group of patients who were al-ready on hemodialysis in 1993 and had been treated for thelongest periods, of 6.8±4.8 years. The lowest prevalences (anti-HBc antibodies 2-3%; HBs antigen 0-2%, anti-HCV antibodies0-2%; HBs antigen and anti-HCV antibodies 0-2%) were foundin 1996, in those patients included in the hemodialysis programbetween 1993 and 1996, being hemodialyzed for only 1.1±1.2years. Patients included after 1996 had again a high prevalenceof the markers (HBs antigen 22%, anti-HVC antibodies 29%),despite the short duration of hemodialysis, of 1.6±1.2 years. Theinfections’ incidence was high before 1993, diminished between1993-96 (0 for the HBs antigen and 6.7%/year for the anti-HCVantibodies) and rose sharply between 1996-98 (10.2%, respec-tively 29%/year), not correlating with the patients’ age, butdepending, up to 1993, on the quantity of blood transfused. Thelink between the duration of the hemodialysis and the preva-lence of HBV and/ or HCV infection proved a nosocomial trans-mission. The very high prevalence and incidence of HBV andHCV infections (exceeding not only Western, but even “develop-ing” countries, endemic for these infections), is characteristic forsome former communist countries. A radical reform of the soci-ety, including the medical system, is the only way to amelioratethe situation.

THE ROLE OF SONOGRAPHY IN LIVER INVESTIGATIONIN HAEMODIALYSIS [HD] PATIENTSD. Bunea-Jivanescu, V. Has, C. DunceaUniversity Hospital V, Cluj, Romania

The patients in chronic HD present a high incidence of chronichepatopathies [CH] especially with virus B and C, by compari-son with control population. Our purpose was to establish therole of bidimensionale [BD] and doppler hepatic ultrasonogra-phy to find out in early stages and to evaluate the severity of CHat patients in HD.It was registered the following sonographyc parameters: thesize and the structure of liver and spleen, the congestion index ofportal vene [IC], the resistence index [IR] and the pulsatilityindex [IP] of hepatic artery. The presence of hepatic biochemicalsyndromes [citolysis, cholestasis and hepatocellular synthesisfailure] and the serological markers for hepatitis B [HB] andhepatitis C [HC] was also noted.The following results were recorded: 84,3% of patients presentedBD-ultrasound sugestive images for HC; pathological values ofdoppler index were registered as follows: IC at 34,6% of pa-tients, IP at 94,7% and IR at 73,7%. The frequency of pathologicIP and IR at patients with positive serological markers for HBand HC [42% of all cases] was 87,5%, respectively 100%; alsofor those with at least one pathologic hepatic biochemicalsyndrom [68,4% of all cases] was 84,6% for IP and 69,2% for IR.These results, especially IR and IP confirme the value ofsonography in portal hypertension at HD patients with HC andHB.

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HEMODIALYSIS ASCITES AND HEMODIALYSIS AD-EQUACY.J W Noh, D H Kang, K Y Park, J R Koo, G H Kim, R W Chun, HJ Kim, D W ChaeDept. of Nephrology, College of Medicine, Hallym UniversityHospitals, Seoul, Korea

Hemodialysis ascites (HA) is known as unknown origin asciteswhich develops mainly in chronic renal failure patients on main-tenance hemodialysis. Because HA has characteristics of exuda-tive ascites, any discernable causes of exudative ascites shouldbe ruled out before the diagnosis of HA is made. Pathogenesis ofHA is not well known, yet. Frequently accompanied chronic liverdisease among chronic renal failure patients on maintenancehemodialysis, chronic inflammation of peritoneal membrane dueto uremic toxins and so on were suggested as possible causes ofHA. Hemodialysis adequacy (Kt/V) is a relatively well knownprognostic marker of chronic renal failure patients on mainte-nance hemodialysis. But determination of hemodialysis ad-equacy (Kt/V) in patients with HA has never been tried before.So, as a trial of elucidating pathogenesis of HA, authors checkedKt/V and weekly Kt/V in seven patients with HA and twenty-three chronic renal failure patients on maintenance hemodialysiswithout HA. No peripheral edema was seen in all patients ofboth groups. Serum albumin and other laboratory findings ex-cept serum total protein (HA group: 7.24±0.85g/dl, non HAgroup: 6.11+ 0.49g/dl) (p<0.05) were comparable in both groups.Though there was no significant difference in Kt/V between twogroups (HA group:1.09±0.22, non HA group:1.24±0.26) (p>0.05),weelky Kt/V was significantly lower in HA group (2.61±0.85)than non HA group (3.48±0.90) (p<0.05). And five out of sevenHA patients were improved with more elevation of weekly Kt/V through increased dialysis dose after initial study. So it isregarded that dialysis adequacy can be another cause or factorparticipating partly at least in the pathogenesis of hemodialysisascites.

INDICATIONS FOR POSITIONING PERMANENT CENTRALVENOUS CATHETERS IN HEMODIALYSIS: FIRST VASCU-LAR ACCESS ?R Cardelli, E Stramignoni, A Serra, M D’Amicone and Piedmont-Valle-D’Aosta dialysis Centers.Dept. of Nephrology, Ospedale Maggiore, Chieri (TO), Italy.

Indications for permanent central venous catheters (PCVC) areyet under discussion and many authors report in addition toexhaustion of periferal access, severe cardiac failure, diabetes,methastatic cancer, myeloma, age over 75 years.Aim of the present study was to evaluate indications for posi-tioning PCVC in Piedmont and Valle D’Aosta 23 dialysis Centers,italian regions with about 4.500.000 inhabitants by a question-naire. Data were collected at June 30 1998. At June 30 1998,2389 pts were on chronic hemodialysis, 83,06% with arteriov-enous fistula, 9,28% with graft fistulas, 1,46% with temporarycentral venous catheter, 6,2% with PCVC (149 pts, 67 M, 82 F).Double catheters were 64,4%, 27,5% double lumen, the remain-ing single lumen (10 or 12 french). Treatment modality was 81%standard hemodialysis, 16% hemodiafiltration, 3%hemofiltration. 40 patients (mean age 73,1 yrs) had PCVC asthe first vascular acces: the indications were severe heart diseaseand/or vasculopaty in 32%, age over 75 years in 23%, diabetesin 12%, impossibility to create an arteriovenous fistula in 13%and others causes such as cachexia, HIV, dementia and neo-plasm in 20% of the remaining cases. 109 patients had PCVC as“secondary” vascular access and the most important indicationwas the progressive exhaustion of peripheral access (87% ofcases).Our opinion is that, also in the light of their good survival time,PCVC can be used as the first vascular access in selected cases.This might be the case when the expected duration of emodialysisis short, for example age over 75 yrs or short life expectancybecause of severe comorbidity.

ACUTE AND LONG-TERM RESPONSE TO α-INTERFERONFOR HEPATITIS C IN CHRONIC HEMODIALYSISJ. Slavicek, Z. Puretic, R. Ostojic, S. Glavaš-Boras, Lj. Bubic-Filipi, R. Šmalcelj, S. Kalenic, B. Rebrovic, I. Barišic, I. Hršak, S.Thune.Dialysis Center, Urology Department, UHC Zagreb, Croatia.

Studies on the action of α-interferon (INF) in patients (pts) onhemodialysis (HD) are scarce.The aim of the study was to estimate the long-term action andtoleration of INF in the treatment of hepatitis C in HD pts.Included were 14 anti HCV+(13 HCV RNA+) HD pts, 10 ofwhich completed the study, 2 dropped out and in 2 the study isstill in progress. At the beginning of the investigation transami-nase values were increased in 9/14. Bioptically confirmed chronicactive hepatitis (CAH) was present in 7/8, chronic persistenthepatitis (CPH) in 1. Viral load went up to 7.5x105 copies/ml(Amplicor-Roche). Genotype 1b was present in 11 pts, 1a in 2. In1 pt it was not determined. Patients were treated with3x3MU,3x5MU of α-INF for 6-12 months. A positive biochemi-cal response (normal transaminase values) occurred in 6/8. In 1pt transaminase values increased transitorily. A complete pri-mary response (transaminase level and the withdrawal of HCV-RNA at the end of the treatment) was observed in 6/10 (60%)pts. In 1 pt HCV-RNA clearance developed 12 mos. after thetherapy. HCV-RNA remained negative in the serum of a femalept with a kidney transplant 8 mos after the INF treatment. Asustained response 6-34 mos later was present in 4/9 (44%). In5 pts the disease reappeared 1-7 mos. after the treatment.The study shows that the response to INF therapy is better inHD pts than in HCV+ ones with normal renal function. The pts.generally well tolerated the treatment, except in 2 cases when thetherapy was withdrawn and permanently reduced in 1 becauseof hematological adverse drug reactions. In spite of a high price,the authors consider INF treatment justified in HCV-RNA+ pts,particularly in candidates for transplantation.

THE HAEMODIALYSIS MACHINE AS PATIENT: FINDINGS FROM A TECH-NICAL RATHER THAN CLINICAL ENTITY.E Goutcher, C Bartlett, S Farey, EJ Will.Dept. of Renal Medicine, St. James’s University Hospital, Leeds UK

Renal patients at St. James’s have had records stored on a clinical database(Proton) since the early 1980s. Later versions of the database allowed the crea-tion of other ‘entities’ within the system. A second entity was established forequipment managed by the department’s technical staff. Screens were estab-lished to record the ‘demographics’ of the equipment, ‘chemistry’ results, ‘treat-ments’, and a diary to record ‘appointments’ – planned (servicing) and unplanned(repairs). The technical staff maintain these data and the chemistry results areentered via a lab link from pathology. The electronic dialysis machine record(EMR) = electronic patient record (EPR).The ‘treatment’ screen is time related and records the actions taken by technicalstaff, the location and a coded field for the cause of the problem. The diary recordsequipment requiring action and the time. From these data audits can be carriedout, for example comparing equipment at different locations performing thesame function but supplied by different manufacturers. One analysis looked atthree locations between 01.01.98 and 31.12.98. At each location only one makeof equipment was used in rotation.

Manuf/Yr. No. Mach. Mean Hrs run Mean hrs betweenbreakdown

A/1992 12 3143(2800-3500) 733(234-1750)B/1994 8 1657(1150-1960) 131(98-165)C/1996 8 2110(650-2950) 396(50-725)

This retrospective analysis showed wide differences, although the machineswere operating in similar clinical and technical environments. The applica-tions of an EMR are not fully explored, but this result suggests economies de-pending on machine make. The reverse consideration, of patient management ina framework of systematic maintenance and troubleshooting, is an obviouslogical step.

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A NEW SIMPLE SCREENING TEST OF RECIRCULATIONBASED ON GLUCOSE INFUSION (GIT) COMPARED TOUREA TEST (UT).A Magnasco, S Alloatti*, F Coppello#, P Solari,Nephrology Dialysis Dept.Hospital Sestri Levante (Genoa) and*Aosta; # Hospital S. Martino (Genoa).

Vascular access recirculation (AR) is an important cause of di-minished dialysis efficiency. We propose a new screening testbased on glucose bolus as a tracer of AR. The protocol of GITincludes a basal blood sample (A) from the arterial port, a 5 mlbolus of glucosate 20% (Glucose 1 gr) into the venous chamber(time 0) followed by a second sample (B) withdrawal in 4”(from 13° to 17° s with QB of 300 ml/min) from the previousport. The blood glucose level is determined at the bedside on Aand B by an accurate reflectance photometer (One Touch IIHospital, Lifescan, USA) with a CV of 1.8%. The interpretationof the test is straigthforward: if B = A there is no AR, while if B> A, AR can be calculated from the regression equation AR =0.046 × (B-A) + 0.07 obtained by in vitro tests reproducingartificial AR at 0-5-10%. To validate in vivo this new method, wecompared the GIT to UT on 39 hemodialysis patients (pts). Wegot a good correlation (r = 0.93) and the two tests were consid-ered positive (AR present) when the 95% confidence intervals(CI) of the results are over 0%. By this analysis we can distin-guish three groups of pts. Group without AR (17/39 pts) inwhich the GIT results was near to zero (0.06% ± 0.1) while UTwas negative too but inaccurated (1% ± 2.3). In the group withAR (14/39) both GIT and UT detected AR with respective val-ues of 18.6% ± 9.3 and 21.6% ± 9.1. The last group includes 7 ptswith AR

GIT positive (5.0% and mean value of B-A = 107 mg/dL)

while ARUT

(5.5%) was statistically not different from zero be-cause of the CI < 0 (minimal UT limit detection under 10%).In conclusion GIT proved to be more sensitive (detection limit <0.5%), simpler and immediate in the results compared to UT. Itis an accurate and low cost technique to screen and follow-upthe vascular access in a dialysis unit.

THE EFFECTS OF HAEMODIALYSIS OVER THE QT INTER-VAL IN CHILDREN WITH CHRONIC RENAL FAILUREA. Dimitriu1, N. Nistor1, O. Brumariu1, C. Jitareanu1, M.Munteanu1, M. Covic2, C. Gavrilovici1, M. Frasin11.-Dept. of Pediatrics, 2.-Dept. of Nephrology, University ofMedicine Iasi, Romania

Aim of the study: to oneself the modifications of the QT intervalmeasured on surface electro-cardiography before and afterhaemodialysis (HD) in children with chronic renal failure (CRF).In 14 children with end-stage CRF with a chronic HD programewe evaluated the values of different segments of QT interval: Q-oTc (beginning of QRS complex to onset of T wave), Q-aTc(beginning of QRS complex to apex of T wave), Q-eTc (begin-ning of QRS complex to end of T wave) and correlated withserum calcium (Ca) and kalium (K) concentrations, before (I)and after HD (II).

Q-oTc(ms) Q-aTc(ms) Q-eTc(ms) Ca(mEq/l) K(mEq/l)I. 0,25+/- 0,30+/- 0,38+/- 4,8+/- 5,97+/-0,035 0,035 0,035 0,7 0,21II.0,20+/- 0,29+/- 0,42+/- 5,7+/- 4,91+/-0,034* 0,043NS 0,038* 0,6* 0.62**p<0,05 NS = not significant

The modifications of Q-aTc interval was minor (NS) but weobserved a significant shortening of Q-oTc interval and a signifi-cant prolongation of Q-eTc interval. The shortening of Q-oTcinterval was correlated with the increased serum Ca concentra-tions and prolongation of Q-eTc interval with decreased serumK concentrations after HD.Prolongation of QT interval being a risk factor for cardiacarrhythmias in children with CRF,t he measurement of its im-proved values after HD has a great importance. Significant cor-relation of Q-oTc and Q-eTc with the values of serum Ca and Klevels permit an efficient electrocardiographic surveillance oftheir modifications induced by HD.

EFFECTS OF A NEW VITAMIN E-COATED DIALYTIC MEM-BRANE. ON GLYCO-AND LIPOXIDATIONRobaudo C., Angeletti S., Sofia A., Gurreri G., Valentini S.,Garibaldi S., Odetti P., Deferrari G.Department of Internal Medicine, University of Genoa, Genoa,Italy.

Glyco- and lipoxidation markers have been evaluated in eightpatients undergoing chronic hemodialysis (HD) with a stan-dard biocompatibile membrane and after the shift to a newvitamin E-coated cellulosic membrane (Excebrane, Terumo).Patients (6M and 2F; 63±4 yrs old) have been on HD treatmentfrom 4.4±1.2 yrs. None had diabetes mellitus or evidence ofother significant illness. HD efficiency (extraction of urea, phos-phorus, uric acid, potassium), removal of advanced glycationend products (Pentosidine, HPLC), and acute oxidative insult(malondialdehyde (TBARS), HPLC; protein carbonyl groups,dinitrophenylhydrazine method (Levine)) have been evaluatedbefore, during and after the HD session (mean duration 228±6min.). Qb and Qd remained steady in both HD. Data are re-ported as mean ± SEM.The new membrane has been well tolerated and undesideredadverse effects have been observed. Excebrane had a HDefficiency similar to the conventional membrane (extraction ofurea 70±2 %, phosphorus 51±4%, uric acid 72±2%, potassium32±3%). There was a non significant increase in pentosidine levelswith standard biocompatibile membrane (32.5±7.2 pmol/mg ofprotein at the beginning of treatment vs 39.1±4.9 at the end), anda small decrease with Excebrane (41.1±2.3 vs 36.5±1.9); no changewas observed for protein carbonyl groups with both membranes.Malondialdehyde (TBARS) levels were unchanged during HDwith standard membrane (1.7±0.2 vs 1.8±0.2 nmol/ml), whereasa significant decrease with Excebrane filters (1.6±0.1 vs 1.3±0.1,p< 0.04) was found. In conclusion, Vitamin E-coated membraneprovides good HD efficiency and it seems useful in reducingacute lipoxidative stress. The positive trend in removal ofglycation end products must be confermed with further extendedstudies to understand the potential advantages.

PERIGRAFT SEROMA IN GRAFT ARTERIOVENOUSFISTULAAI Lo Monte, V Cuccia, M Airò Farulla, C Labruzzo, N Napoli,G Buscemi.Cattedra di Chirurgia generale II, Trapianti d’organo, Nefrologiaed Emodialisi, Università degli studi di Palermo.

Seroma formation is a well known complication of graft arterio-venous fistulae used as secondary vascular access for haemodi-alysis in chronic renal patients. Seroma consist of a perigraftswelling due to a collection of clear, sterile fluid within to a nonsecretive fibrous pseudomembraneOver two thousand vascular accesses were created in our Insti-tution in the last 25 years. If we consider only the bridge fistulae,namely vascular accesses construeted with prosthetic materi-als, we can report more than 400 cases. They were performed invarious sites and configurations (straight or loop) in the limbs.In more than 80% we used the upper limbs and the most were inthe straight configuration. We used in the most cases ePTFEgrafts (IMPRA or GORETEX), that is the choice material for allthe vascular access surgeonsWe reported 7 cases of perigraft seroma in about 400 bridgefistulas, with an incidence of 1,7%. The site of formation was atthe arterial anastomosis in all the cases. In two cases this com-plication occurred within 2 months of implantation.The nature of the fluid collection evaluated by analysis showeda composition similar to serum with the exceptions of totalprotein and albumin which were below the normal range. Onlyin 2 cases multiple aspiration or surgical intervention resolvedthe problem. In the other case it was necessary to remove thePTFE graft.Seroma formation has a multifactorial etiology, but all the causesare not yet well known. If we consider that in the most casesseroma occurred in patients receiving PTFE vascular grafts fora.v. fistulae and the swelling appeared near the arterial anasto-mosis it has been supposed the rate of weeping is proportionalto the increase of velocity of bloodl flow. Another factor is thecompliance of the prosthetic material with the surrounding tis-sue. In some cases etiologic considerations include graft defectsor dameged caused by eparinized solution infused during im-plantation.

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A PROSPECTIVE STUDY OF COMPLICATIONS ASSOCIATED WITH DUALLUMEN HAEMODIALYSIS CATHETERS (HC)MA Little, K Abraham, A O’Riordan, B Lucey, JJ WalsheDept of Nephrology, Beaumont Hospital, Dublin 9, Ireland

Tunneled catheters are becoming the primary means of haemodialysis (HD)access for many patients. Their use is complicated by frequent failure secondaryto thrombosis and catheter-related sepsis (CRS). We aimed to determine theoutcome of all catheters inserted over a two-year period, with focus on the du-ration of catheter survival, incidence and aetiology of CRS and frequency of tPAusage.Data on 305 catheters in 208 patients were inserted prospectively into a data-base. The HC used was Soft cell, Quinton Permcath and Bard Hickman in 147(48.2%), 135 (44.3%) and 23 cases (7.5%) respectively. Each line was followeduntil removal or end of the study. Mean duration of follow-up was 211.5 days(range: 1-1028), with 38 catheters (12.5%) still functioning at the end of thestudy. Mean catheter survival in those removed was 158.9 days, the commonestreasons for removal being a non-functioning catheter (36%), patient death (16.5%)and maturation of an arteriovenous fistula (14.2%). The incidence of CRS was1.08 episodes / 1000 catheter days (0.68 definite, 0.33 probable, 0.06 possible).Organisms identified were S aureus (62.5%), coagulase negative Staphylococ-cus (28.1%), Group A Streptococcus (3.1%) and one case each of Strep. bovis,Enterococcus and E. coli. Of the S. aureus isolates 15% were MRSA (overallprevalence 9.4%). There were three further complications definitely associatedwith CRS (one case each of osteomyelitis, endocarditis and septic arthritis) andCRS was implicated as contributing to death in six cases (9.4%). The incidenceof tPA usage was 1.6 / 100 dialysis sessions, while 66.5% of lines required notPA. In those requiring tPA the incidence of use was 5.01 / 100 dialysis sessions.Bard Hickman catheters had a shorter survival (123.5 days, P=0.015) and ahigher incidence of CRS (1.76 episodes / 1000 catheter days, P<0.01). We con-clude that the commonest reason for removal of a HC was non-function and thatuse of tPA is concentrated in a small sub-group of patients. CRS was a majorcause of morbidity and mortality and a significant number of organisms aremulti resistant.

ECHOSONOGRAFICALY ASSESSED POSTDIALYSISASIMPTOMATIC PERICARDIAL EFFUSION (PAPE) INHAEMODIALYSIS (HD) PATIENTS IS AN EASY OBTAINEDPARAMETER OF HYPERVOLEMIAZ Paunic1, N Markovic2, N Dimkovic2, N Vavic1

1Military Medical Academy, 2Zvezdara Hospital, Belgrade, Yu-goslavia

Our clinical impression was that PAPE, an incidental findingduring ultrasound abdominal examination of HD patients (pts),is not rare. It was easy obtained by a subcostal scan. The aim ofthis study was to test this observation and its significance. Echo-cardiographic screening was performed by the same cardiolo-gist in 85 asymptomatic pts (mean age: 51.3+9.7yr, range 25-77; 57.6% M) and 15.7+9.4 h after regular HD. From the studywere excluded pts with clinically obvious hypervolemia, or HDtreatment less than 6 months. PAPE was defined as anenddiastolic echo free space between pericardial walls rangingfrom 2 to 10 mm.Echo findings included: global hypocontractility (37.6%), seg-mental wall hypo/akynesion (11.7%), left ventricular dilatation(22.3%), left ventricular hypertrophy (32.3%), valvular heartdisease (37.6%), sclerosis of the aortal wall (41%), diastolic dys-function (52.9%), PAPE (24.7%). In addition, Inferior Vein Cavacollapsibility index (IVCci=1-IVCinspir/IVCexpir) was meas-ured by subcostal scan within 2 cm from RA origin of IVC, andwas < 50% in 21.7%. Usual laboratory analysis was also per-formed and data were correlated with Echo findings.There were statistical significant correlation of PAPE with: du-ration of HD treatment less than 1 yr (p<0.01), female gender(p<0.05) and polycystic kidney disease (p<0.01). Also, signifi-cant correlation was found between PAPE and IVCci<50%(p<0.01). There were no significant correlation between seasonalchanges, heart systolic and diastolic dysfunction and labora-tory/serologic values including Kt/V (1.25 + 0.35 pts withoutPAPE and 1.26+0.25 in pts with PAPE).This study confirms that PAPE was frequent finding in our HDpts. It is an important, reliable and easy reproducible parameterof dialysis volemic inadequacy.

EFFECTS OF THE AUTOMATIC BLOOD VOLUME (BV) CONTROL ONINTRADIALYTIC HYPOTENSION (IDH) .A. Santoro, E. Mancini, M. Atti*, M. Polacchini*, M. Piantanida, on behalf of theItalian Multicenter BVT study.Malpighi Nephrology and Dialysis Department, *Hospal, Bologna, Italy.

In a prospective, randomized, multicenter study, we evaluated the effect of anautomatic BV control system (BVT, blood volume tracking) on the incidence ofIDH in 10 italian dialysis units. BVT is based on an adaptive controller, directlyinstalled in a dialysis monitor (Integra-Fisio, Hospal), which can change boththe ultrafiltration rate and dialysate conductivity in order to take under controland modify the intradialytic BV trajectories. An intra-patient cross-over designwas adopted, alternating one-month lasting periods of conventional HD (treat-ment A), and BVT-HD (treatment B). Thirty-five patients (pts) with IDH inci-dence ranging from 10 to 70% were enrolled and randomly assigned to twosequences: ABAB or BABA. At the end of the study a significant reduction of IDHepisodes was observed: from 33% in periods A to 22% in periods B (p<0.004). Inperiods B, even the interdialysis symptoms (hypotension, fatigue, arrhythmias...)decreased, moving from 3.7/pt to 2.1/pt (p<0.004). The IDH reduction was di-rectly related to the individual frequency: the higher the IDH incidence in periodsA, the better the positive response in B. As shown in figure, in periods B, up to a70% IDH reduction was observed in those pts with an incidence over 30% dur-ing treatment A.

01020304050607080

0 10 20 30 40 50 60 70 80

A Treatment (%)

B T

reat

me

nt

(%)

y = 0,54 x + 5r2 = 0,45p < 0,001

To conclude, BVT could be a useful and safe measure for the IDH prevention,along with other already known remedies, such as the sequential HD as well asan tailored sodium dialysis.

ANALYSIS OF THE BLOOD VOLUME (BV) INTRADIALYTICTREND IN PATIENTS WITH DIALYSIS HYPOTENSION (DH):MULTICENTER STUDY.E Mancini, A Santoro, M Piantanida, M Atti*, M Polacchini*, onbehalf of the Italian Multicenter Study on BVT.Malpighi Nehrology Department, *Hospal, Bologna, Italy.

Continuous intradialytic BV monitoring was proposed as anadditional system in the surveillance of the patient’s hemodynamicresponse to treatment and in the prevention of DH. To verify thisassumption, and to study the BV variability, we carried out amulticenter study (10 Italian HD Units), with 31 pts (14 M, 17F; age 67.5+1.7 years; dialytic age 41.9+7 months), previouslyclassified as “DH prone” (at least one DH event in 30% of thesessions, during the 2 months before the enrollement in thestudy). Each pt was studied throughout his/her usual HD ses-sions (bicarbonate HD) along 2 months, with continuous BVintradialytic monitoring as well as blood pressure and heart ratemonitoring. An overall number of 455 HD sessions was ana-lysed, 110 of which complicated by DH. At the DH onset, in allthe pts but two, the BV change in itself did not appear signifi-cantly different from the one observed at the end of the HDsessions without DH (8.9+4.2% vs 9.1+3.5%; p=ns). Instead, in9 out of 21 pts, the ratio between BV and the percentage changein body weight (BV/BW%), expression of the vascular refilling,was found significantly higher (p<0.05) than at the end of thesessions without DH episodes. Moreover, many pts showed asubstantial repeatability of the ratio BV/BW% (evaluated bycomparing the percentage standard deviations of the mean valueof BV/BW% in the different pts) at the DH appearance.To conclude, data concerning the BV changes alone, expressionof the crash crit phenomenon suggested by other Authors, do notseem to have a relevant weight in the identification of potentiallycritical moments during treatment. The evaluation of the ratioBV/BW%, indicating the instant individual vascular refillingcapacity, seems to be more accurate, because, at the DH onset,it turned out to be highly repeatable in many pts. Moreover, TheBV/BW% index could represent a useful element for preventivemeasures for DH such as the ultrafiltration and sodium profil-ing, as well as the BV automatic control.

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ORTHOSTATIC HYPOTENSION (OH) AND EFFECT OF L-THREO-3,4- DIHYDROXYPHENYLSERINE (DOPS) INCHRONIC HEMODIALYSIS (HD) PATIENTS.Y Tsubakihara, A Suzuki, T Hayashi, T Shoji, M Togawa, NOkadaDept. of Nephrology, Osaka Prefectural Hospital, Osaka, Ja-pan.

OH is a serious complication observed after HD, as well ashypotensive episode during HD, in HD patients. DOPS, a syn-thetic precursor amino acid of norepinephrine (NE), is convertedinto NE in the body after oral administration and is effective forOH of Shy-Drager syndrome or amyloidpolyneuropathy.In this study, we assessed the severity of OH and NE concentra-tion in 10 min. standing test immediately after HD session.ADL was evaluated by questionnaire in 141 HD patients (f/m;76/65, age; 56.7±12.5, diabetic; 44, mean weight gain; 4.7±0.3%). DOPS (200-400 mg) were administerd to symptomatic pa-tients 30 min. before the initiation of HD. As results, meansystolic blood pressure (SBP) was 145.4±24.8 mmHg (supine),and was reduced to 125.2±25.1 mmHg, 129.1±26.1 mmHg,131.4±24.9 mmHg after standing for 0 minutes, 5 minutes and10 minutes, respectively. In seventytwo patients, SBP decreasedmore than 20 mmHg and 30 cases revealed OH symptoms afterstanding. NE concentration in symptomatic patients were sig-nificantly lower than that of other patients at all points afterstanding. Significantly correlation between interdialytic ADLscores and SBP reduction on postural change suggested that thedegree of SBP reduction after HD is a useful parameter for ADLassessment. Mean NE concentration over 1 ng/ml was observedfor more than 24 hrs. after DOPS administration.DOPS resulted in significant improvement of SBP reduction instanding test as well as OH symptoms after HD.From these results, it is concluded that interdialytic ADL levelswere severely influenced by OH and DOPS was effective for OHin HD patients.

CONTINUOUS INTRAVENOUS INTRADIALYSIS (CONT)VERSUS INTRAVENOUS POSTDIALYSIS (BOLUS)RECOMBINANT HUMAN ERYTHROPOIETIN (rHuEPO)THERAPY IN CHRONIC HEMODIALYSIS (HD) PATIENTS.Y Tsubakihara, A Suzuki, T Hayashi, T Shoji, M Togawa, NOkadaDept. of Nephrology, Osaka Prefectural Hospital, Osaka, Japan

Liani M et al reported that CONT rHuEPO could reducedrHuEPO dose to less than 1/3 (75 U/kg/week to 21 U/kg/week) while keeping the Hct level unchanged, compared withBOLUS rHuEPO (Nephron,69:189,1995).However, we experienced some patients who kept the Hct levelunchanged in spite of decrease or stop of rHuEPO dose.In this study, we verified that a change of medication to CONTcan increase Hct beyond the BOLUS period counterpart.Subjects were stable eleven chronic HD patients with more thantwo or three times of BOLUS rHuEPO per week (mean rHuEPOdose; 75.7±13.5U/kg/week). BOLUS was changed to CONTwith the same dose and interval for 2 months.As a result, rHuEPO was not dialysed or absorbed during CONTwith a usual dialyser at all. However, Hct value did not increaseduring the CONT period at all (Hct; 30.5±0.8%→30.3±0.9%).Recently, Rocha JL et al reported similar data (NDT,13:89,1998).From these findings, it is concluded that CONT proved to be notmore effective than BOLUS. However, from the report of LianiM et al., we must try to economize the dose of rHuEPO whilekeeping the Hct level unchanged.

COMPARISON BETWEEN LOW MOLECULAR WEIGHTHEPARINS AND UNFRACTIONATED HEPARIN (UFH) ASANTICOAGULANT IN CHRONIC HAEMODIALYSIS (CHD)N. Ursea, C. Verzan, G. Mircescu“Dr Carol Davila” Teaching Hospital of Nephrology, Bucharest,Romania

Objective. The minimal necessary dose of enoxaparine (Clexan®),reviparine (Clivarin®) and UFH was examined during 12 weeks(3 sessions/week, 4.5h/session, 1745 sessions, 36 sessions/pt.)in 77 pts. who received: (a) enoxaparine (n=51, single bolus,initial dose 66.8 IUaXa/kg); (b) reviparine (n=12, single bolus,initial dose 71.6 IUaXa/kg); (c) UFH (n=14, continuous infu-sion; mean dose 6140IU/session).Methods. According to a coagulation score, the extracorporealcircuit pressure and to the residual volume of dialyser at the endof the session - evaluated objectively and subjectively - the dosewas titrated by stepwise changes. The safety was analysed bythe compression time at arterial/venous puncture sites and byregistration of adverse effects.Results. In case of enoxaparine, the initial dose was maintainedin 31 pts. (60.8%) (group I) and increased to 80.6±15.3 IUaXa/kg in 20 pts. (39.2%)(group II). In case of reviparine and UFH,the dosage needed not to be changed. Neither bleeding episodesnor adverse events were reported. In terms of efficacy, the orderis: enoxaparine>reviparine>UFH; in terms of safety:enoxaparine=reviparine >UFH.The optimal dose correlated positively to: UF, Hb, HD duration[r=0.36, 0.32, 0.34; p<0.05 (enoxaparine) and r=0.41, 0.39, 0.37,F=7.41, 6.98, 5.6, p<0.05 (reviparine)]. The relative risk of throm-botic incident was higher in case of cellulose membranes ascompared to polysulphone membranes (1.1; p<0.05).Conclusion. In patients on CHD, 70 IUaXa/kg enoxaparine and75 IUaXa/kg reviparine, given as a single bolus, effectively pre-vented extracorporal clotting during HD session, similarly to6140 IU UFH, did not have toxicological risks, and, under thestudy conditions, were adequate for a 4.5hr session. Consider-able individual variations in the minimal and optimal dosesexisted, imposing individual dosage adjustment.

URAEMIC CARDIOMYOPATHY: PREVALENCE, RISK FAC-TORS, CLINICAL AND ECHOCARDIOGRAPHIC ASPECTSS. Alecu, N. Ursea, L. Petrescu, S. Stancu, M. Alecu“Dr Carol Davila” Teaching Hospital of Nephrology, Bucharest,Romania

To evaluate risk factors, clinical manifestations andechocardiography patterns of heart involvement in haemodialy-sis patients, a transversal study was conducted in 80 pts [gen-der: 34F/46M; aged 12.3-47.3 years; mean HD duration 7.8 yrs(0.5-19)] treated in a haemodialysis center of a large tertiaryhospital.Dyspnea (48.7%), palpitations (45%), retrosternal pain (36.2%),cardiomegaly (17.5%), arrhytmias (32.5%), gallop rhythm (10%),congestive heart failure (10%) were the clinical most relevantfindings.Echocardiography and echoDoppler examinations revealed: leftventricular (LV) hypertrophy (78.7%): concentric (31.7%) eccen-tric (47.0%), isolated IVS hyperthrophy (15.0%), systolic dys-function (23.7%), dilated cardiomyopathy (6.6%) and aorticvalvular calcifications (37.5%). LV mass index was higher inmales and in pts with high blood pressure, and a negative corre-lation with calcemia was found (r=0.42;p<0.01). LV volumewas negatively correlated with hemoglobine and albuminemia,and pozitively with serum PTH. Mean LV volume was higher inpts with arterio-venous fistula flow>5L/min. LV dilatation wasmore prevalent in males and in anemic patients. Patients withLV systolic disfunction had higher PTH levels than those with-out (452.3 vs 256.0pg/mL; p<0.05). Dilated cardiomiopathywas more frequent in males, in pts with elevated PTH and withhigher levels of apoptosis.Conclusion: the most frequent abnormalities in our patientsseemed to be eccentric LV hypertrophy, gender male, high bloodpressure, anemia and hyposerinemia being the dominant riskfactors. PTH was a main risk factor for both systolic and dilatedcardiomiopathy, possible by an apoptotic mechanism.

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OUTBREAK OF ACUTE HEPATITIS C INVOLVING STAFFIN A DIALYSIS CENTER: GENOTYPING IS MANDATORYA. Kolta1, B. Viron1, N. Pham2, F. Degos3, F. Mignon1

1Service de Néphrologie, hôpital Bichat, 2Laboratoired’immunologie, 3Service d’hépatologie, hôpital Beaujon, Paris,France

Despite the high rate of HCV carriage among haemodialysis(HD) patients (pts), contamination of nurses has been rarelyreported. On the other hand, patient-to-patient transmissioncan be prevented by the so called universal precautions. Al-though 15 % of the 143 pts dialysed in our unit since opening inNovember 96 were ELISA +, no seroconversion was observedduring the first year. In December 97, acute hepatitis C occurredsimultaneously in a patient dialysed in room 1 and a nurseworking in room 2.Methods : All pts having undergone ≥ 1 HD session in the unit atany time between June and December 97 were tested both byELISA and PCR, all staff members by first-line ELISA, followedby PCR whenever positive. Genotyping was performed in everycase of positive PCR.Results :

ELISA + PCR + Genotype1a 1b 2 3a

pts (n = 96) 16 11 2 3 3 3staff (n = 16) 1 1 - 1 - -

Discussion: The patient with acute hepatitis had genotype 1a,different from other HCV + pts in room 1. He might have beencontaminated during his holidays.One of the pts the nurse had in charge in room 2 shared the samegenotype 1b. The nurse acknowledged having neglected barrierprecautions (not putting gloves when dealing with fistula nee-dles in the course of dialysis). Multiple digital abrasions causedby her sculpture hobby might have favoured viral transmission.Conclusion: Multiple cases of de novo hepatitis C can be coinci-dental. Only genotyping can rule out nosocomial transmission.

HEPATITIS B & HEPATITIS C IN ESRD ON RENALREPLACEMENT THERAPY IN A TERTIARY CARE CENTERIN A DEVELOPING COUNTRYJ. Mutreja, Padma, G. Abraham, P. Soundararajan, V. PanickerDept. of Nephrology and Pathology, Sri Ramachandra UniversityHospital, Chennai, India

The aim of our study is to assess 1) the prevalence of HepatitisB & C infection & risk factors for infection among our dialysispatients. 2) Impact of infection on clinical outcomes inhemodialysis patients 3) Role & Efficacy of interferon therapyon Hepatitis B & C infection in ESRD.A total of 786 ESRD patients from urban and rural populationwere screened by third generation ELISA for Hepatitis B & C onentry into our dialysis unit and at regular intervals. Among thetotal number of 786 patients, 47 patients (5.97%) were found tobe either Hepatitis B or C positive (Hepatitis B – 35 (4.45 %),Hepatitis C- 12 (1.5%)). Their age ranged from 24 to 72 years(mean age- 43.27 years). Among the HbsAg positive cases, fourwere also found to be HbeAg positive. Four (0.5%) were foundto be both Hepatitis B & C positive. Except 3 patients, all hadelevated alkaline phosphatase levels (180-661 IU/l) on entry tohemodialysis. Among the hepatitis positive patients, 43 hadreceived multiple blood transfusions previously. Six among the12 Hepatitis C positive patients underwent liver biopsy for pre-transplant assessment. Six were given interferon therapy 3.0mu, thrice weekly (48-72 doses) and subsequently underwentlive related transplantation successfully.1) The prevalence of Hepatitis B has found to be 4.45 % andHepatitis C - 1.5 % among our ESRD patients. 2) Liver biopsyis used for the presence and assessing the severity of liver dis-ease 3) LFT normalized in patients given interferon therapy andhad successful transplantation. 4) Transfusion is a major riskfactor in developing countries for transmission of hepatitis Band C.

PREDICTORS OF MORTALITY IN HOSPITALIZEDHEMODIALYSIS PATIENTSS Sezer, FN Özdemir, S Sengül, M Isitman, M Turan, N Bilgin, MHaberalBaskent University Faculty of Medicine, Dept. of Nephrology,and Biochemistry, Ankara, Turkey

Despite the improvements in the quality of hemodialysis (HD)treatment, a small ratio of patients with renal failure survivelong term due to complications. We designed this retrospectivestudy to determine the predictory risk factors for mortality andcauses of death in hospitalized HD patients.Among 400 patients on regular and 200 on temporary HD pro-gramme 113 patients were hospitalized in 1998. The total numberof hospitalizations was 220/year (mean 1.95 hospitalizations/patient/ year) and a mean lenght of hospitalization was17.54±15.51 days and mortality ratio was %26. The major causesof death were sepsis (46%), cardiovascular disease (27%),serobrovascular accident (16%), and GIS hemorrage (10%) inour patients. The laboratory and echocardiographic parametersof the patients at the time of hospitalization were recorded todetermine if they can be predictory of mortality.The results aredemonstrated below.table I Age HD duration CRP ferritin

(years) (months) (mg/dl) (ng/ml)patients survived 46.27±15.25 45.88±35.52 75.09±71.46 499.1±464.6patients died 60.56±11.92 45.78±46.92 45.90±100.74 439.0±328.6p 0.001* 0.4 0.1 0.5

table II PTH t.protein albumin LDH EF%(pg/ml) (g/dl) (g/dl) (U/dl)

patients survived 134.1±192.1 5.99±1.3 2.97±0.78 821.9±837.1 46.6±4.9patients died 148.0±195.3 6.99±0.5 3.94±0.38 413.1±128.7 48.0±4.0p 0.7 0.001* 0.001* 0.012* 0.1Older age, low albumin and total protein levels and increasedLDH levels strongly correlated with mortality risk of HD pa-tients at the time of hospitalization. This study emphasizes onthe influence of old age, and malnutrition and presence of infec-tions on mortality risk of hospitalized HD patients.

INTIMAL CAROTID ARTERY THICKNESS CORRELATESWITH PLASMA HOMOCYST(E)INE LEVELS INHEMODIALYSIS PATIENTS.C Libetta, S Pirrelli, G Villa, F Centore, F Chierichetti, T Rampino,MS Parsapour, A Salvadeo, A Dal Canton.Units of Nephrology and Vascular Surgery, Policlinico SanMatteo, and Division of Nephrology, Fondazione S. Maugeri,Pavia.

Accelerated atherosclerosis is the leading cause of death and amajor cause of morbidity in patients on regular dialysis treat-ment (RDT). Homocyst(e)ine is a risk factor for atherosclerosisand thrombosis independent of hypertension, smoking anddyslipidemia. Since homocyst(e)ine accumulates in uremic pa-tients, we evaluated whether in patients on RDT plasmahomocyst(e)ine levels correlate with an index of atherosclerosis,i.e. intimal carotid artery thickness. We studied 22 patients (age62.0±11.3) on RDT for at least 1 year. Venous blood sampleswere collected in EDTA-containing tubes just before starting adialytic session, and plasma levels of homocyst(e)ine were meas-ured by HPLC. All patients underwent ultrasound examination(Acuson instrument, 7.5 MHz) to evaluate intimal thickness ofcommon carotid artery (measured 10 mm proximal to bifurca-tion). Plasma homocyst(e)ine levels were increased in patientson RDT (average 41.2±36.0 µM/L, range 5.4 to 183.8, median34.2 µM/L; only 3 out of 22 patients had values below uppernormal limit, 15 µM/L). Intimal thickness of carotid artery aver-aged 0.60±0.13 mm on the right and 0.64±0.13 on the left. Linearregression analysis showed a significant positive relationshipbetween homocyst(e)ine levels and carotid thickness (r=0.752P<0.01). These results suggest that hyperomocyst(e)inemia is amajor risk factor for atherosclerosis in patients on RDT.

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HYPERPARATHYROIDISM, ANEMIA AND ERYTHROPOIETIN: EFFECTSON SYSTOLIC FUNCTION OF DIALYSIS PATIENTS1GM Trovato, 1G Carpinteri, 1S Spina, 1R Squatrito, 1D Catalano, 2E Iannetti1Medicina Interna e Terapia Medica, Università di Catania, 2Ambulatorio diNefrologia ed Emodialisi “DELTA”, Catania, Italy

Hyperparathyroidism of long-term hemodialysis patients is currently consid-ered a factor of reduced response to rHuEPO and of impaired myocardial func-tion. Moreover hyperparathyroidism is associated with nutritional disturbancesthat variously affect both degree of anaemia and ventricular dilatation andinsufficiency.We studied 45 patients (20 m, 25f), age 61.81±11.6, in dialysis since 45.7±56.9months.Patients were assessed by echocardiography (LVEDV, EF%, mVCF, A/E ratio,and LVMM) and by four elecrtode multi-frequency BIA (bio-impedance analy-sis) (Human-Im Scan, Dietosystem, Milan, Italy) (TBW%, ECW%, ICW%, FAT%and FFM%) before and after dialysis sessions, considering the averages of threesets of measurement obtained at six months intervals.As already reported, we found a significant correlation between higher degreeof anaemia and hyperparathyroidism, and significant higher rHuEPO require-ments in patients with more elevated concentrations of i-PTH. Moreover, rHuEPOrequirements were inversely correlated (p<0.001) with haemoglobin (r=-0.48)and left ventricular ejection fraction (r=-0.62).i-PTH was not significantly correlated with any echocardiographic measure-ment before dialysis. Considering post-dialysis measurements, i-PTH showeda positive correlation with left ventricular dilatation (p<0.005), and left ven-tricular myocardial mass (p<0.01) and a negative correlation with ejection frac-tion (p<0.001) and mVCF (p<0.001). No correlation was observed with diastolicfunction measurements. Moreover i-PTH was correlated with TBW% (p<0.01)FAT% (p<0.01) and PCR/Kg/24 h (p<0.001).Patients with lower degree of hyperparathyroidism have a better functionaland anatomical left ventricular adaptation to body fluid hyper-hydration.Moreover, hyperparathyroidism seems to interfere unfavorably with severalinter-related functions including erythropoiesis, hypercatabolic disposition andreduced left ventricular contractility. Left ventricular function impairment isnot observed when the degree of hydration of anuric patients is maximal, i.e.before dialysis, conceivably concurrently with more expanded blood volume.After dialysis, when body fluid and blood volume is maximally shrinked, thedetrimental effects of more severe hyperparathyroidism become evident, as it isthe worse clinical adaptation (hypotension, cramps) of these patients to relativehypovolemia and consequent circulatory modifications induced by hemodialysis.

RED BLOOD CELLS IN CHRONIC RENAL FAILURE ARECHARACTERISED BY HIGHER SENSITIVITY TO OXIDATIVESTRESSK Gwozdzinski[1], A Jasik[1], M Luciak[2][1]Dept. of Molecular Biophysics, University of Lodz, Poland;[2]2nd Department of Internal Medicine, WAM, Lodz, Poland

Lifespan of red blood cells in chronic renal failure patients isreduced to 50-75% of normal. Recent reports showed oxygenfree radicals generation (detected by EPR spectroscopy) in bloodof CRF patients during hemodialys is and we concluded thatRBC are damaged in patients undergoing hemodialysis. Theplasma membrane damage is an important factor of RBCdeformability in blood flow, mainly in the microcirculation aswell as in cell hemolysis. Aim of the present research was toevaluate red blood cell sensitivity on oxidative stress in CRFpatients compared to normal.The electron paramagnetic resonance and spectrophoto-metricmethods were used for estimation of alterations in plasma mem-brane of CRF red blood cells in oxidative stress induced byhydrogen peroxide. The increase in lipid membrane fluidity inCRF red blood cells was approx. 40% higher after H2O2 treat-ment in comparison to normal cells, as indicated by two spinlabeled fatty acids. Similarly to lipid fluidity, the increase (approx.20%) in membrane protein mobility was observed in CRF-RBCtreated with hydrogen peroxide. The osmotic fragility of RBCwas approx. 15% higher in RBC of CRF patients compared tonormal subjects.These results showed that RBC in chronic renal failure are moresensitive for the attack of reactive oxygen species than in normals.RBC, and probably also other cells, are permanently damagedduring hemodialysis, so their lifespans are significantly shorterthan RBC from healthy subjects.

TRANSPOSITION OF A NATIVE ARTERIOVENOUS FIS-TULA. NEW SURGICAL APPROACH TO THE CORRECTIONOF VASCULAR ACCESS.W. Weyde, M. Krajewska, M. Klinger.Wroclaw Univ. of Medicine, Dept. of Nephrology, Wroclaw, Po-land

It is commonly known, that primary arteriovenous fistula on theforearm is the best vascular access for the chronic haemodialy-sis, connected with the lowest morbidity. Our experience showsthat creation of the native arteriovenous fistula is feasible in 95%of patients (256 patients, 14.5% diabetic patients, 12.5% pa-tients over 65 years. (Nephrol Dial Transplant 1998, 13, 527).Occasionally, even the native arteriovenous fistula is difficult topuncture, because of too deep position caused by thick layer ofsubcutaneous tissue.This problem appeared in our 3 patients (females aged 40, 61and 74 years) and was solved by below described surgical pro-cedure.Under local anaesthesia with 1% Mepivacain the incision 10-12cm over and slightly laterally to fistula was made (to avoidpuncturing of the fistula through postoperative scar). Thearterialized median antebrachial vein was exposed and mobilised.Due to precise ligature of collaterals and suturing of the veinbed the superficial transposition of the vessel above all subcuta-neous fat was achieved. Subsequently the skin was typicallyclosed.After 3 weeks transposed vein was well visible superficiallyunder the skin and easy to puncture.Conclusion: Subcutaneous transposition of arterialized medianantebrachial vein is a simple and effective method to overcomedifficulties of primary fistula puncturing caused by too pro-found location of vascular access.

EFFECTS OF SHORT-TERM SUPPLEMENTATION WITH LEVO-CARNITINE(L-C) IN CHRONIC HAEMODIALYSIS (HD) PATIENTSCatalano C, Bordin V, Fabbian F, Di Landro D, with the technical help of FortinB and Buson G.Dialysis Unit, Montagnana, Padova, Italy

HD patients are often malnourished, anaemic and have lipid abnormalities.Survival is affected by these factors. Malnutrition is in part related to lack ofappetite (AP). L-C deficiency is related to L-C loss during the HD session and hasbeen associated to lipid abnormalities, to the nutritional state and to asthenia(AS). The aim of our study was to assess whether a short course (1 month) withL-C might influence lipids, anaemia, AP and AS in chronic HD patients. Westudied ten HD patients (M=7;F=3). Mean age was 68 years (range 65-75 years)and mean duration of HD treatment was 7.5 years (range 1-18 years). We per-formed a 4 months double blind crossover randomised trial composed of four1-month periods. Five patients were allocated to L-C (1 gram intravenously)and five to placebo (PL) during the second month. Patients allocated to L-C weretreated with PL and patients allocated to PL were treated with L-C during theforth month. A washout was performed during the first (WS-1) and third (WS-2) months. At the end of each month period, we checked full blood cell count,lipids, total proteins, serum albumin, urea reduction rate (URR). AP and ASwere measured by means of visual analogic scales (graded from 0, minimumAP or AS to 10, maximum AP or AS), completed by the patients before eachdialysis during the last two weeks of each month period. Any therapeutic ordialysis (modality, duration) change would have caused the patient’s with-drawal. However, all patients completed the study. We did not observe any sig-nificant change between L-C and PL for what dry body weight (60.9 ± SD15.5 vs60.9 ± 15.7 Kg), Hb (10.9 ± 1.5 vs 10.6 ± 1.5 gr/dl), cholesterol (211 ± 48 vs 210± 53 mg/dl), triglycerides (209 ± 66 vs 200 ± 80 mg/dl), total proteins (7.3 ± 0.6vs 7.2 ± 0.6 gr/dl), serum albumin (4.1 ± 0.2 vs 4.0 ± 0.4 gr/dl), URR (0.71 ± 0.07vs 0.68 ± 0.09), and AS (5.8 ± 1.9 vs 5.7 ± 1.2) were concerned. We observed amodest increase in HDL-cholesterol at the end of L-C, compared to PL and to thewashout periods (L-C 56 ± SD 5 vs PL 49 ± 8 (p = 0.04), vs WS-1 46 ± 8 (p = 0.005),vs WS-2 46 ± 7 (p > 0.01). AP increased slightly at the end of L-C period comparedto placebo and washout periods (6.6 ± 1.9 vs 5.8 ± 1.8 (p =0.02), vs WS-1 5.7 ± 2(p = 0.04), vs WS-2 5.8 ± 2 (p = 0.01). Our study shows that short term supplemen-tation with L-C has a little but significant impact on HDL and AP in chronic HDpatients.

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INCIDENCE OF HEPATITIS C AFTER PREVENTIVE MEAS-URES IN A HAEMODIALYSIS UNITMR. Bouali, J. Hmida, MF. Khediri.Depts. of Gastroenterology and Haemodialysis, Military Hospi-tal, Tunis, Tunisia.

We evaluated the incidence and risk factors of hepatitis C in ahaemodialysis unit. All chronic haemodialysed patients presentin this unit between 1992 and 1997 were included in this study(72 M, 38 F, age =49±15 years).The average length of haemodi-alysis was 44±45 months (range 2 to 229). Liver enzymes weretested on a monthly basis. Every 3 months, a test was per-formed looking for anti-hepatitis C virus (HCV) antibodies. Allanti-HCV positive patients used separate machines. Beginningin 1994, these patients were isolated in a separate setting. Use ofseparate health personnel was initiated in 1996.The global prevalence of anti-HCV antibodies was 45 % (50/110). HCV RNA was detected in 84% of cases. In health person-nel, anti-HCV antibodies were only detected in one training doc-tor. A nosocomial origin of the infection is very likely in patientswho were never transfused (10%) or who received a small numberof screened blood products. The prevalence of anti-HCV anti-bodies in these patients was 24% versus 75% in patients whowere transfused with non-screened blood (p < 10-5). 27 cases ofanti-HCV seroconversion were observed (incidence density =1.2%). In 74% of the patients a hepatic cytolysis appeared 1 to12 months before the appearance of anti HCV antibodies. In1996, the incidence of hepatitis C increased (10 cases).This coin-cided with an increase in the work load for the personnel, butthis incidence decreased in 1997(3 cases, 2 of which were nevertransfused).Chronic haemodialysed patients have a high prevalence of hepa-titis C, with a nosocomial origin more evident in the last fewyears; and separation as a preventive measure (patients, per-sonnel) is ineffective if universal hygiene measures are not re-spected.

THIRST PERCEPTION IN HAEMODIALYSIS PATIENTS.MJ Wright, G Woodrow, NA King1, JE Blundell1, AM Brownjohn,JH Turney.Renal Unit, Leeds General Infirmary and 1Department of Psy-chology, Leeds University, Leeds, UK.

Some haemodialysis patients (HD) consume excessive volumesof fluid between treatments. This can lead to hypertension, leftventricular dysfunction and pulmonary oedema. It is assumedthat these patients experience excessive thirst, although datasupporting this is limited. We measured thirst perception in 46HD patients (31M, 15F: mean age 60.4) and 29 healthy controls(HC) (11M, 18F: mean age 48.3) using a novel device. The Elec-tronic Appetite Rating System (EARS) uses a modified elec-tronic personal organiser to collect serial visual analogue scores.We collected thirst scores at hourly intervals, beginning during amorning dialysis session (day 1) and continuing until the end ofthe following interdialytic day (day 2) for HD subjects. HCentered data for one day only.There were considerable differences between thirst scores on day1 and day 2 (mean (SD) day 1, 32.4 (11.6) vs. day 2, 42.0 (12.9);P<0.0001). The profile for day 2 is similar to that of HC (meanscore 37.4 (13.5)), whilst day 1 returns a relatively flat profile.Thirst did not correlate with weight gain, but did correlate withintradialytic change in mean blood pressure (Day 1 r = 0.299,P=0.049; day 2 r = 0.320, P=0.034).We expected that the rapid change in ECF volume occurringduring dialysis would cause an early rise in thirst following re-equilibration. Our results show that thirst perception is lowthroughout the day of dialysis but comparable with healthyindividuals during the interdialytic day suggesting that haemo-dialysis suppresses thirst. The reasons for this are not clear butmay be linked to changes in blood urea. Further studies with theEARS could assess the importance of various factors such asdrugs on thirst perception.

THE ELECTRONIC APPETITE RATING SYSTEM: A NOVELTECHNIQUE FOR THE INVESTIGATION OF DISORDEREDAPPETITE.MJ Wright, G Woodrow, NA King1, JE Blundell1, AM Brownjohn,JH TurneyRenal Unit, Leeds General Infirmary and 1Psychology Depart-ment, Leeds University, Leeds, UK

Malnutrition is common among dialysis patients partly due toreduced nutrient intake. It has been assumed that this reflectspoor appetite related to uraemia, but data supporting this islimited. We have used a novel technique to describe the appetiteprofile in 46 haemodialysis (HD) patients (31M, 15F: mean age60.4) and 29 healthy controls (HC) (11M, 18F: mean age 48.3).The Electronic Appetite Rating System (EARS) uses a modifiedelectronic personal organiser to collect visual analogue scores atpredetermined intervals. We collected data on hunger, “desire toeat” (DtE) and fullness at hourly intervals. HD subjects entereddata during and after a morning dialysis session (day 1) and thefollowing interdialytic day (day 2). HC entered data for one day.HC demonstrated peaks of appetite at 12:00 and 17:00. Peakswere also detected for HD but scores were lower on day 1 thanday 2. Fullness scores showed similar peaks later than hunger,with HD higher on day 1. HD scores were similar to HC. Resultsare shown as mean percentage (SD).

HD Day 1 HD Day 2 HC ANOVAHunger 31.35 (10.94)1 37.61 (12.33) 33.50 (10.49) P=0.030DtE 32.12 (12.28)1 40.63 (12.70) 34.19 (11.58)2 P=0.004Fullness 54.21 (10.41)3 51.49 (8.17) 52.43 (9.43) P=0.3761P<0.0001, 2P=0.03 & 3P=0.04 vs. HD Day 2.

Our data indicate that a dialysis session reduces appetite andinduces a sense of satiety. The data suggest that established HDpatients normalise appetite perception at a lower level of nutri-ent intake, although further investigations comparing dietaryintake are needed to verify this.

RELATION BETWEEN SERUM UBIQUITIN LEVELS ANDKT/V IN CHRONIC HEMODIALYSIS (HD) PATIENTS (PTS)E Akarsu, I Pirim*, Y Selçuk, F Polat*, H Z Tonbul, R ÇetinkayaDepartments of Internal Medicine and Genetic*, Faculty of Me-dicine, University of Atatürk, Erzurum, Turkey

Ubiquitin which is localised within nucleus and cytoplasm ofeukaryotic cells comprises 76 aminoacids with a molecular weightof 8.6 kDa. Serum ubiquitin levels have been found out to behigh in HD patients and it has been proposed that it was partiallyassociated with decreased elimination of ubiquitin by kidneys.In this study, the relation between serum ubiquitin levels inchronic HD patients and KT/V values were investigated. Thestudy was involved in 24 pts (9 F, 15 M; ranging ages 23 –62years) and 20 healthy control (7 F, 13 M; ranging age 34 – 56years). The aetiology of chronic renal failure was chronic glom-erulonephritis (n=8), chronic pyelonephritis (n=12) and hyper-tension (n=4). Urine volume was 0–100 ml/day for all pts. Thevalue of KT/V was calculated according to – ln (R – 0.03 UF/W). Serum ubiquitin was measured by ELISA using monoclonaland polyclonal anti-ub antibodies. Wilcoxon test was used forstatistical analysis. The mean concentration of serum ubiquitinwas significantly high as compared to healthy control (23.3 ± 4.8µg/ml vs 9.03 ± 2.4 µg/ml; p< 0.001) The serum concentrationof ubiquitin was higher in pts (n= 11) with the last month meanKT/V < 1 than pts (n= 13) with KT/V > 1 (25.9 ± 3.4 µg/ml vs13.7 ± 2.4µg/ml; p< 0.01). As the values of KT/V reached tonormal in pts with KT/V < 1, the significant decrease was ob-served in serum ubiquitin from the levels of 25.9 ± 3.4 µg/ml to13.7 ± 2.4 µg/ml (p< 0.01).As a result, we considered that serum levels of ubiquitin inchronic HD pts could be associated with both adequate HD andprognosis.

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BODY MASS INDEX (BMI), % IDEAL BODY WEIGHT (%IBW)AND Kt/V VALUE IN CHRONIC HEMODIALYSIS PATIENTSE. Mesic, V. Habul, M. Tabakovic, N. MehmedovicNephrology and Dialysis Department of Medical Faculty Tuzla,Bosnia and Herzegovina

We have tested 71 chronic hemodialysis patients, average age45.71± 19.33 years, 28 males (M) and 43 females (F) with differ-ent renal diseases that are on chronic hemodialysis for an aver-age of 71.20± 59.97 months. According to the Kt/V, the patientsare categorized into 4 groups: I group: Kt/V > 2.0, II group: Kt/V 1.5 – 2.0, III group: Kt/V 1.0 - 1.5 and IV group: Kt/V < 1.0.In the first group there have been 9 patients (12.85%) of averageage 42.44± 15.45 years, 3M, 6F. They have had average %IBW113.27± 28.01 and BMI 0.19± 0.04. In 11 patients (15.71%) of thesecond group (average age 45.27± 15.71 years, all females),average %IBW has been 102.18± 17.23, and BMI 0.17± 0.03. Inthe third group there have been 35 patients (49.30%) of averageage 48.33± 15.22 years, 14 M, 21 F, with average %IBW of103.25± 17.69 and BMI 0.19± 0.03. In the fourth group therehave been 16 patients (22.53%) of average age 42.19± 9.59 years,11M, 5F, with average %IBW of 98.57± 11.87 and BMI of 0.18±0.02. There were no statistically significant differences betweenthe groups in the values of %IBW and BMI. Excessive bodyoverweight was found in 21 patients (29.58%), 31 patients(43.66%) had adequate body weight, 16 patients (22.53%) werelightly underweight, and only 3 patients (4.22%) were signifi-cantly underweight. Majority of the patients (64.79%) had BMIlesser than 20, 23 patients (32.39%) had BMI in adequate val-ues, and only 2 patients had BMI over 25. There have been 4patients (5.63%) with serum albumin bellow 30, 8 patients(11.27%) with serum albumin 30-35, and majority of the pa-tients (83.10%) with serum albumin above 35 mmol/l. We didnot find significant correlation of %IBW and BMI and Kt/Vvalues. Nevertheless, it is our opinion that %IBW and BMI aresignificant antropometric indexes also in the population ofchronic dialysis patients because they make easier the assess-ment of dry body weight.

HYPERHOMOCYSTEINEMIA [HHcy] IS NOT ASSOCIATEDWITH ELEVATED PLATELET ANNEXIN V [PLT A-V] EX-PRESSION IN MAINTENANCE HAEMODIALYSIS [HD] PA-TIENTSV Sepe, 1G Patrucco, 2A Santagostino, 2V Bolis, 2R Caminiti, PCecere, S Ottone, P Colombo, O Filiberti, C PeonaDepartments of Nephrology, 1Biochemistry and 2Haematol-ogy, S. Andrea Hospital, 13100 Vercelli, Italy

An association between HHCy, vascular degeneration and stimu-lation of procoagulant factors has recently been recognized.Current data have also showed an increased synthesis of annexinII in homocysteine-treated endothelial cells, suggesting thatannexin modulation by homocysteine could be implicated inatherothrombosis. The aim of our preliminary study was toevaluate total homocysteine [THcy] and PLT A-V expression inHD patients with [Th+] or without [Th-] recent episodes ofarteriovenous fistula [AVF] thrombosis. In total 28 HD patientswere randomly enrolled; 6 of them [Th+] had 1 or 2 AVF throm-bosis episodes over the last year. In all patients Thcy plasmalevels were measured and HHcy was defined as values greaterthan 15 umol/l. PLT A-V expression was analysed by dual-colour flow cytometry using A-V and CD41 monoclonal anti-bodies. Four healthy individuals were tested as controls. PLT A-V positive cells were expressed as a percentage of the totallabeled PLTs. HHcy was present in all but 2 HD patients.Overall THcy levels were 33±22 [M±SD], Th+ [n=6] vs Th- [n=22]THcy levels were 38±15 vs 32±23 respectively [p=ns]. PLT A-Vexpression was 1.0±0.5 in HD patients and 0.9±0.3 in controls[p=ns]. Th+ vs Th- were 1.4±0.6 vs 0.9±0.4 respectively [p=ns].Our preliminary data are consistent with previous reports show-ing high levels of THcy in HD patients. Nevertheless their PLTsdo not display abnormal A-V levels. Interestingly, HD patientswith recent episodes of AVF thrombosis did not show higherTHcy and/or higher PLT A-V expression when compared withTh- patients.

ACCURANCY AND SAFETY OF ONLINE CLEARANCE MONITORINGBASED ON CONDUCTIVITY VARIATIONU Kuhlmann1, R Goldau2, N Samadi1, T Graf2, G Orlandini2, Lange H1

1Dept. of Nephrology – University of Marburg - Germany, 2Fresenius MedicalCare – Schweinfurt - Germany.

125 dialysis sessions (duration 216 ± 28min + 30min of Bergstrom dialysis,blood flow 196±11ml/min, high flux polysulfone dialyzer) in patients withESRD (age 59.4±16.0 years, 6 F) were performed to test the accuracy and patient’ssafety of an electrolyte based urea Online Clearance Measurement (OCM). Threetimes per session a balanced ±10% Dialysate Conductivity (DCd) variation wasapplied. Using the POLASCHEGG formula the correspondence of measuredinstantaneous electrolyte clearance (inst Cl

electr) to the references inst Cl

urea blood

side / dialysate side has been investigated. Further Kt/V according to equili-brated single pool variable volume kinetic model (SPVVKM) and Kt/V accord-ing to direct quantification of spent dialysate was compared to electrolyte basedKt/V if mass balance error did not exceed 10%.

Variable Mean+SD ninst Cl

electr(155.7 ± 12.3) ml/min 175

Bloodside Inst. Clurea

(159.1 ± 9.4) ml/min 175Dial. Side Inst. Cl

urea(159.6 ± 9.6) ml/min 175

Kt/V (Clelectr

, VSPVVKM

) 0.84 ± 0.26 (Gurea

negl.) 69Kt/V (Cl

urea , V

SPVVKM) 0.86 ± 0.26 (G

urea negl.) 69

Kt/V (DQ) 0.90 ± 0.28 47 Deviation 95% CI (%) SD (%) Reference - -2.1±0.8(p=0.05) ± 5.4 - -2.5±1.0(p=0.05) ± 6.6 - -1.7±1.5(p=0.05) ± 6.0 Kt/V(Cl

electr, DQ)-Å 2.2±3.8(p=0.05) ±12.8

The patients residual Kt/V fraction of 0.45 per session is not included.

No adverse effect (thirst, muscle cramps, headache, nausea and vomiting) werereported. Serum sodium before HD remained unaffected in comparison to thebaseline. A small (138.4±1.4 / 138.6±1.4 mmol/l, p<0.002) but significant in-crease of serum sodium was seen after the impulse, but no significant signs dueto fluid overload (blood pressure body weight arterial pO2) could be observedduring the study period of 10 consecutive.In conclusion, the OCM option of the hemodialysis machine provides a safe andaccurate useful tool for continuous online monitoring of Cl urea without addi-tional blood sampling.

CORONARY REVASCULARIZATION IS A HIGH RISK PROCEDURE IN DI-ALYSIS PATIENTSC Rollino, M Formica, 1M Minelli, G Beltrame, F Bonello, A Pignataro, S Borsa,F Quarello.Department of Nephrology and 1Cardiology. Giovanni Bosco Hospital. Turin.Italy.

Cardiovascular disease accounts for almost half of the total mortality in pa-tients (pts) with end stage renal disease (ESRD). It has recently been debatedwhether coronary revascularization has the same rate of risks and successes inthis cohort of pts compared to pts without renal disease.Since 1991, 14 dialysis pts were submitted to coronary revascularizaton in ourcenter. Nine pts were following a peritoneal dialytic treatment, 5 were in hemo-dialysis. Four pts were submitted to percutaneous transluminal coronaryangioplasty (PTCA) and 10 to surgical revascularization (CABG).In 4 pts the coronary lesion was unique, in the others stenosis of multiple vesselswere found. Six pts were diabetic.The mean age at the onset of the coronary artery disease (CAD) was 55.2±11.7years. The mean time elapsed from the onset of the CAD and the performance ofthe PTCA or CABG was 32.5±38.1 months. The mean time from beginning ofdialysis treatment to revascularization was 49.2±42.9 months. Mean hemoglo-bin values were 9.5±1 g%, mean phosphorus values were 5.2±0.9 mg%.The procedure was technically successful in all pts.Mean survival time was 22.9±29.8 months. Five pts died by one month: 2 ptsdied after 1 day and 1 after 2 days for complications relied to the procedure (2PTCA, 1 by-pass).Survival at one year was 57.1%, while literature data show 76% and 88% sur-vival at 5 years after PTCA in non-renal failure pts with and without diabetesrespectively (Barsness et Al. Circulation, 1997;96:2551). There was neither sig-nificant difference between pts submitted to PTCA and those submitted to CABG,nor between diabetic and non-diabetic pts.In conclusion, coronary revascularization in our experience is a high risk pro-cedure in dialysis pts. The reasons for this could be the severe general conditionsof these pts affected with diffuse vasculopathy and the long time elapsed sincethe onset of the ischemic cardiopathy. Thus, our results could suggest the oppor-tunity of performing earlier screening and revascularization treatment in CADdialysis pts.

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PLASMA NITRIC OXIDE (NO) CONCENTRATIONS DURIND DIALYSIS IN-DUCED HYPOTENSIONM Koç, 1 S Kare, S Tuglular, Ç Özener, A Bihorac, 1 S Bilsel, E AkogluNephrology Division and 1Dept of Biochemistry, Marmara University Schoolof Medicine and, Istanbul University, Istanbul, Turkey.

Hypotension is a common event during hemodialysis that contributes to themorbidity of procedure. The pathogenesis of hypotension during hemodialysisis multifactorial. Although conflicting results are present increased NO produc-tion during hemodialysis has been suggested in the etiology of dialysis inducedhypotension.In this study we assessed the relationship between plasma NO3 concentrationand hypotension during hemodialysis. All patients were in stable condition andreceived maintenance hemodialysis 3 times weekly. At the beginning of dialy-sis, patients received a 5000 U bolus dose of heparin. Hemodialysis was per-formed with cuprophan dialyzers for 4 hours. Patients were divided into nor-motensive (n=7) and hypotensive (n=5) groups. In hypotensive group at the endof dialysis post dialysis mean arterial pressure (MAP) decreased greater than20 mmHg. NO metabolites were determined by Griess technique. No differenceswere found in the %reduction of body weight between the two groups during thedialysis. MAP significantly decreased in hypotensive group but it did not de-creased in normotensive group. Although plasma NO3 concentrations decreasedsignificantly in both groups, % decline of plasma NO3 concentrations betweenthe two groups was not different.

BasalMAP 4th –h MAP Basal 4th–hmm Hg mm Hg NO3 NO3

µmol/L µmol/LHypotensive (n=5) 110±4.7 81±6.4* 123±17 53±17*Normotensive (n=7) 98±7.3 94±7.0 130±11 68±6.2* *p<0.01 basal vs 4th-h,

Predialysis plasma NO3 concentrations did not show any correlation withpredialysis and post dialysis MAP. There was also no correlation between %decline in MAP and % decline in plasma NO3 concentrations and post dialysisNO3 concentrations and postdialysis MAP.

RISK FACTORS FOR ATHEROSCLEROSIS IN CHRONICHEMODIALYSIS PATIENTSFN Ozdemir, S Sengul, G Güz, S Sezer, M Isitman, A Haberal, NBilgin, M HaberalBaskent University Faculty of Medicine Dept. of Nephrology,Biochemistry Ankara, Turkey

Many factors may potentially promote atherosclerosis in dialy-sis patients in addition to the well known risk factors. We de-signed a retrospective study to investigate the possible risk fac-tors for atherosclerosis in our HD patients.Seventy one patients with coronary arterial disease (CAD), cer-ebral vascular disease (CVD) or peripheral vascular disease(PVD) and in the control group 42 patients who had no evidenceof atherosclerosis were included in this study. The study groupswere homogenized for the classical risk factors for atherosclero-sis in terms of gender, diabetes mellitus, smoking, hypertension,except for age. We investigated the influence of the serum lipidprofile, nutritional assesment, PTH, acute phase reactants, pres-ence of hepatitis C virus positivity, cryoglobulinemia,anticardiolipin antibodies (aCL) positivity, history of smoking,and presence of diabetes mellitus on CAD, CVD and PVD inour patients. The statistically significant results are summa-rized in table I:Table I Atherosclerosis + Atherosclerosis - pNumber of patients 71 42Female/male 29/42 19/23 NSage(years) 57 ± 11 50 ± 10 p<0.05HD duration(mo.) 77 ± 51 55 ± 43 p<0.05CRP (mg/dl) 35 ± 33 18 ± 23 p<0.05Sedim.rate (mm/sa) 55 ± 25 45 ± 24 p<0.05alb (g/dl) 3,69±0,26 3,93±0,33 p<0.05IgG-aCL(GPLu/ml) 15,57± 10 9,53 ± 8,2 p<0.05In our study we found that IgG-aCL positivity and elevatedCRP levels and hypoalbuminemia corralated with the risk ofatherosclerosis. In conclusion, the acute phase response andIgG-aCL positivity are important promoters in the devolopmentof atherosclerosis in HD patients.

QUALITY OF PATIENT CARE AND IMPROVEMENT OF SURVIVAL RATESIN BASKENT UNIVERSITY HEMODIALYSIS CENTERFN Özdemir, S Sezer, G Güz, M Turan, M HaberalBaskent University Faculty of Medicine Dept of Nephrology, Biochemistry andGeneral Surgery Ankara-Turkey

There have been a worldwide improvement in mortality and morbidity ratesof hemodialysis (HD) patients in recent years with the quality improvement inHD follow-up. We present one year data concerning mortality and survivalrates of HD patients and information about activities about patient care in ourcenter. We will discuss the improvement of survival rates through continuousquality improvement programme.Baskent University Ankara HD center works in collaboration with six satelliteHD (Istanbul, Adana, Ayas, Izmir, Yalova, Iskenderun). By the end of 1998, in ourcenters regular hemodialysis therapy was administered to total number of 1577patients. Meanwhile in our dialysis centers, the other dialysis facilities suchhemodiafiltration, plasmapheresis, CAPD, APD, hemoperfusion are also per-formed. In our dialysis centers the marked increase in dialysis sessions per yearfrom 7000 sessions in 1982 to 135 000 sessions in 1997. Gross mortality rate ofdialysis patients in 1997 was 8.86%. The one-three-and-five years survival prob-abilities were found to be 96%, 75% and 63 % respectively. The estimated sur-vival time in our center was 7.2 years. The data in July 1988 about patients in HDand PD were as follows: 457 patients (410 in the routine HD programme and 47accepted temporarily) received HD and 75 PD treatment. The mean number ofpatients receiving HD per day was 170 ±16. Three hundred and fifty new pa-tients were accepted in the out patient department and 60 in the emergency roomof nephrology and 60% of these patients were referred from centers outsideAnkara.To achieve a good quality control and improve survival rates we have plannedweekly education programme of the hospital team, a separate HD and PD fol-low-up data for the nurses and the doctors, a regular supervision schedule, selfcontrol working system and improvement in the coordination of the staff, out-patient education and regular visit of the patients by the nephrologist and thedietition. We believe that a good team work-up will improve the survival prob-abilities of patients.

DOES LOW INTERDIALYTIC WEIGHT GAIN INDICATEMALNUTRITION?S Sezer, FN Özdemir, S Sengül, P Özyigit, T Ünal, Z Arat, MTuran, M HaberalBaskent University Faculty of Medicine, Dept. of Nephrology,and Biochemistry, Ankara, Turkey

Since it has been revealed that high interdialytic weight gain isassociated with increased risk of hypertension and cardiovascu-lar disorders in hemodialysis (HD) patients, the aim of the at-tending physician is to prevent large weight gain duringinterdialytic period. This study was designed to analyze thedifferences in nutritional status and laboratory andechocardiographic parameters between dialysis patients withlow interdialytic weight gain (<2 L/session) (Group I) and highinterdialytic weight gain (>3 L/session) (Group II) over a 6-month period.Group I was made up of 27 patients (13 males, 14 females) ofmean age 46.8 ± 21.1 years, while Group II consisted of 42patients (21 males, 20 females) of mean age 40.9 ± 11.3 years.We found that Group I had a significantly lower body massindex than Group II (22.16 ± 3.17 and 20.08 ± 2.43, respectively;p=0.006). Classifying patients as lean, normal body weight, andoverweight showed that 51% of patients in Group I and 34% inGroup II were lean. Patients in Group I had significantly higherfibrinogen levels than those in Group II (442.6 ± 142.8 (mg/dl)and 359.1 ± 90.1 (mg/dl), respectively, p=0.044), and the meanHD duration of Group I was significantly shorter (Group I 27.55± 40.0 months; Group II 55.86 ± 38.6 months; p=0.006). Theincidence of cardiovascular disorders (left ventricular hypertro-phy, diastolic dysfunction, systolic dysfunction) were signifi-cantly higher in Group II.In conclusion, low interdialytic weight gain without residualrenal function can be considered an indicator of malnutritionand chronic inflammation. This may also be associated withincreased mortality risk. We suggest that malnutrition criteriasshould be assessed on follow-up of patients with lowintradialytic weight gain.

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A NEW SUBCUTANEOUS ACCESS DEVICE FORHEMODIALYSIS (HD)J Moran 1, G Posen 2, G Beathard 3

1 VascA, Inc, Tewksbury MA, 2 Ottawa Civic Hospital, 3 USVascular Access Centers

The VascA LifeSite Hemodialysis Access System is a sub-cutaneous valve with an internal pinch clamp that is actu-ated with a standard 14-ga dialysis needle, connected to asingle lumen 12F cannula placed in the central venous circu-lation for HD.Methods – The LifeSite system (2 valves) was implanted in23 patients with immediate dual needle HD. The cannulaswere placed in either the jugular (preferred) or the subcla-vian veins and tunneled to the subcutaneous valves placedbelow the clavicle.Results – Median device survival to date is 5.4 months. Pre-scribed HD blood flow rates averaging 384 + 97 mL/minwith a venous pressure of 212 mm Hg +62 mm Hg weremeasured during the first 3 months. After 133 patient-months, device removal due to infection has occurred at arate of 1.24 per 1000 days and there have been no devicesremoved due to poor flow.Conclusions – This clinical study has validated the applica-bility of the Vasca LifeSite Hemodialysis Access System asan access for hemodialysis. It is easily implanted, easily used,provides safe and effective dialysis, and is well accepted bypatients. It is a new alternative for long-term use in patientsin whom a peripheral dialysis access is not feasible.

HCV INFECTION IN HEMODIALYSIS PATIENTS AND FOL-LOW-UP AFTER CESSATION OF α-IFN TREATMENTFN Özdemir, S Sezer, G Güz, T Ünal, Z Arat, S Boyacioglu, AHaberal, M HaberalBaskent University Faculty of Medicine, Dept. of Nephrology,Gastroenterology and Biochemistry, Ankara, Turkey

Hepatitis C virus (HCV) infection is the major cause of liverdisease among hemodialysis (HD) patients. We designed thisstudy to determine the prevelance, status of HCV infection andthe results of interferon (α-IFN) treatment in our HD unit. Wealso compared the mean aminotranseferase levels of the HCVinfected patients with ferritin levels. The prevalance of antibodyto hepatitis C virus (Anti-HCV) was detected by using secondgeneration ELISA technique and confirmed by third generation.We used PCR technique to detect the HCV-RNA positivity.There were 99 HCV infected patients (61 male, 38 female, meanage 45±12.34 years, mean HD duration: months) (24% of thetotal number of patients) in our HD unit. HCV RNA was posi-tive in 36% of the patients. Twenty three of the patients (23.2%)who were candidates for renal transplantation recieved inter-feron treatment a mean dose of 17.2± 5.37 million/week and amean duration of 6.50±5.97 months. α-IFN treatment wasstopped in 5 (21.7%) of the patients due to side effects. Theremaining 18 patients completed α-IFN treatment. The meanperiod of follow-up of the patients after the cessation of α-IFNtreatment was 20.3±18.2 months. The aminotranseferase levelsreturned to normal limits in 88%, and HCV RNA became nega-tive in 70% of the patients during α-IFN treatment. Among theresponder group, after follow-up of 6 months after the cessationof α-IFN treatment, aminotransferase levels were in normal lim-its in %70 and HCV RNA was negative in %35. HCV RNAbecame negative in two patients whose HCV RNA remainedpositive during α-IFN treatment during two years of follow-up.Ferritin levels independently correlated with mean ALT, ASTlevels in all of the patients (p<0.05).In conclusion, α-IFN treatment has promising results, with alow relapse risk in HD patients. Ferritin levels independentlycorrelated with mean ALT and ALT levels in HCV infected pa-tients.

CAUSES OF IMPAIRED DELIVERY OF HEMODIALYSIS PRE-SCRIPTIONC. Fourtounas1,2, I. Kopelias1,2, G. Dimitriadis1, B. Agroyannis2.Lefkos Stavros Renal Unit1 and Department of NephrologyAretaieon University Hospital2, Athens, Greece.

Urea kinetic modeling (Kt/V) is used to assess adequacy ofdialysis. However, serial Kt/V measurements may vary duringtime in the same patient, making the interpretation of the resultsdifficult. The aim of the present study was to find the frequencyand the causes that account for these fluctuations of Kt/V.We prospectively analyzed the results of 59 patients’ monthlyKt/V values, during a six months period. Their mean (SD) agewas 64,4±12,9 and they were on hemodialysis for 4,49±3,6 years.Their baseline Kt/V was 1,28±0,21 and 1,34±0,15 at the end ofthe study. Any decline or increase >0,2 from previous averagevalues, was defined as abnormal. During the study period (354measurements) 38 Kt/V values (10,7%) met the study criteria.24 measurements (6,7%) revealed lower and 14 (3,9%) higherKt/V values. Supervised sampling, complying with the pre-scribed dialysis dose, was applied for all abnormal measure-ments, a week later. Among the low values group, 9 were due tono compliance with dialysis time (shorter dialysis), 4 due tolower blood flow (Qb), 4 due to reversed needles and 1 due tofistula thrombosis. Finally, in 6 cases no problem could be iden-tified, and repeated measurements could not reveal low values.In the high values group, 9 cases were expected, as there was aneffort to increase dialysis dose prescription (higher Qb, longerdialysis, increased dialyzer surface) and 5 cases were due tofalse post dialysis sampling (“venous samples”).In summary, 29 measurements (8,1%) were in real disagreementwith dialysis prescription. Lower than expected values, are quiteoften due to reduced blood processing (shorter dialysis, lowerQb, recirculation) and higher, due to bad post dialysis sam-pling. Although this percentage is rather low, it should also betaken under consideration, before any clinical decision aboutdialysis prescription is made.

THE USE OF “BRIDGE” PTFE GRAFTS IN OPERATIONS FORRESCUE OF NATIVE A-V FISTULAS.J. Bokos, G. Zavos, S. Kyriakidis, S. Garbis, S. Papadoukakis G.Sotirchos, K. Diles, E. Karanikola, D. Stamatiadis, A. Kostakis.General Surgery and Renal Transplant Division, “Laikon” Gen-eral Hospital, Athens, Greece.

A well functioning A-V fistula is essential for adequatehaemodialysis in ESRD pts. Beyond the classic operations forA-V fistula repair, there are several others based on the indi-vidual findings of each patient.The aim of our study is to present our experience and results ofthe use relatively short portions of PTFE grafts as “bridge” forA-V fistula repair.The last 8 yrs 43 pts (24 M, 19 F) with a mean age of 43±14 yrs,underwent rescue procedures of native A-V fistulas functioningfor 33±12 mo, which was the 1st for 32 and the 2nd or 3rd for therest 11, with the use of short PTFE grafts. Although operationswere based at individual findings, they can be classified in threebasic categories: A/ graft interposition between radical arteryand cephalic vein in 12 pts, B/ graft interposition between bra-chial artery and cephalic vein, below or above the elbow, in 23pts, and C/ replacement with graft of a specific damaged veinportion in 8 pts. The results, concerning successful operationand established blood flow, was 75% (9pts), 91.3% (21pts), and66.5% (4pts) for groups A, B and C. The 6 and 12 mo survivalwas 100% and 89% for group A, 100% and 82.5% for group B,while for group C was 100% and 75%.In conclusion we believe that several vascular accesses forhaemodialysis can be rescued with the use of “bridge” PTFEgrafts with a relatively good outcome and survival rate.

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NOT-FOR-PROFIT vs FOR-PROFIT CHRONIC DIALYSIS CARE: IS THEREAN ADDITIONAL COST FOR THE PATIENT ?V. Bellizzi, V. Terracciano, F. Perrone*, B. Di IorioUnità Nefrologia Ospedale di Lauria; Ufficio Sperimentazioni ClinicheControllate, Istituto Nazionale Tumori di Napoli*, Italia

Chronic maintenance dialysis exposes the patient to an additional cost repre-sented by physical and temporal encumbrance due to diagnostic and therapeuticprocedures. Such a cost influences life stile and may affect the quality of life ofdialysis patients. In order to estimate these additional costs in not-for-profit(nPR) and for-profit (PR) dialysis care system, we analyzed a specific question-naire mailed to all Italian dialysis centers. Modalities of medical prescriptionsand reservations, waiting time for instrumental tests and modalities of drugsproviding were analyzed.247 centers (42% of total in Italy), 177 nPR (72%) and 70 PR (28%), replied to thequestionnaire. They provide dialysis care for 14.842 patients (87% nPR), 86%on hemodialysis and 14% on peritoneal dialysis. Hemodialysis is allowable inpatients self-conducted manner in 74 nPR (42%) and 10 PR centers (14%, p<0.001),and in a home-provided manner in 40 nPR (23%) and 1 nPR centers (1%, p<0.001).Peritoneal dialysis is offered in 106 nPR (60%) and 4 nPR centers (6%, p<0.001).In 73 nPR (41%) and 67 PR centers (96%, p<0.001), medical prescriptions fordialysis, diagnostic tests, specialist consults and drugs are needed; patient askedto provide such prescriptions are 50% and 95% (p<0.001), in nPR and PR centers,respectively. Moreover, reservations for diagnostic tests and specialist consultsare on charge to the patient in 6% of nPR and 20% (p<0.001) of PR centers. Asregard waiting time for instrumental tests, in nPR and PR centers it takes 2 vs 4days (p<0.001) for lung Rx, 7 vs 11 days (p=0.06) for gastroscopy and 14 vs 13days (NS) for echocardiography. Finally, intra-dialytic drugs, phosphorus bind-ers and nutritional supplements are directly provided by the center respectivelyin 93, 54 and 63% of nPR and 14, 14 and 10% of PR (p<0.001).To summarize, in Italy: 1) not-for-profit dialysis care system allows a widerchoice of treatment modalities; 2) for-profit system charges the patient of highercost due to diagnostic and therapeutic procedures. Further studies should ad-dress whether such a cost affects the quality of life in dialysis.

ANTIOXIDANT STATUS IN HEMODIALYSIS PATIENTSWITH ACUTE AND CHRONIC RENAL FAILUREL. Tozija, K. Cakalaroski, T. Gruev, .Stojceva, Z. Antova, N.Ivanovski,Department of Nephrology and Biochemistry, Clinical center-Skopje, R of Macedonia

The increment of reactive oxygen species (ROS) may be a resultof many diseases (cardiovascular, cancer) as well ashypercatabolic states such as sepsis and repeated hemodialysis.The aim of our study was to see the changes of ROS expressedthrough the serum total antioxidant status (S-TAS) in relationto dialysis therapy. S-TAS was performed on patients (pts) onmaintenance hemodialysis or acute renal failure patients treatedwith hemodialysis. 26 pts were included in the study (12 ptswith acute renal failure and 14 pts with chronic renal failure). S-TAS normal range was 0,00 to 1,49 mmol/l and it was meas-ured at the beginning of hemodialysis, after first hemodialysistreatment and after 5 treatment with antioxidant drugs. De-crease of the value of S-TAS has been observed in 22 pts inregard of prehemodialysis values, and the mean percentage ofdecrease was 25%. It must be emphasized that theprehemodialysis values of S-TAS were above normal values in23 patients (from slightly increased to a 68% above the normalvalues.). The decreased of S-TAS during the first hemodialysisis partly due to the dialisability of many components of S-TAS(ascorbic acid, uric acid, partially tocoferols). But in 2 pts werenoticed increased values (from 2 to 13 %) from the predialysisperiod and also in 2 pts were not noticed changes in the values.After the third measurement the values of S-TAS were slightlyincreased in 6 pts and in the other there were not big differencesin comparison with the second measurement, When the level ofascorbic acid is reduced, the capacity of vitamins E radicals tobind ROS is diminished. Therefore, the authors consider that adietary supplementation of antioxidant medications, particu-larly ascorbic acid, is needed in hemodyalysis patients and fur-ther follow-up of its effect.

DIALYSIS OUTCOMES AND PRACTICE PATTERNS STUDY(DOPPS): A WORLDWIDE HEMODIALYSIS STUDY.PJ Held, EW Young, DA Goodkin, RA Wolfe, BJ Maroni, MLKeen, KK Chen, FK Port, DL Mapes.University Renal Research and Education Association (URREA)and University of Michigan, Ann Arbor MI, USA; Amgen Inc.,Thousand Oaks, CA USA.

The worldwide DOPPS is a prospective, observational study ofnationally representative samples of HD patients from Euro-pean countries, Japan, and the United States. Extensive profilesof patient demographic features, comorbid diseases, laboratoryvalues, and HD practice patterns are collected to seek associa-tions with mortality, hospitalization, vascular access outcomes,and quality-of-life scores, using multivariate techniques. Crudemortality rates vary widely among HD centers around the world,but previous studies collected insufficient data to adjust thor-oughly for case-mix. The goal of DOPPS is to identify and pub-licize practice patterns that optimize patient outcomes. Detailsof HD prescription and delivery, water treatment and composi-tion, staffing practices, medication use, and nutritional care willbe included in the database. Over 9,000 patients will be fol-lowed for two years, with replacement of those who drop out. InEurope, 20 facilities have been enrolled in each of five nations,under the guidance of local investigators (France: B Canaud, CCombe; Germany: J Bommer, E. Hecking; Italy: V Andreucci, FLocatelli; Spain: L Piera, F Valderrabano; United Kingdom: RGreenwood, H Rayner) and two at-large investigators (N Levin,S Ringoir). Sixty facilities will participate in Japan and 161 in theUnited States (30 patients per facility, on average). Preliminaryresults reveal significant differences in the distributions of age,sex, race, cause of renal failure, comorbid conditions, and typeof vascular access between countries. Initial quality-of-life scoresfrom this large sample will yield valuable normative standardsfor international research. DOPPS will provide new insights intoHD patient characteristics, practice patterns, and outcomes.

BIA (BODY IMPEDANCE ANALYSIS) vs STA (SOFT TISSUE ANALYSIS) DURINGHEMODIALYSIS TREATMENTFarinelli R, De Paoli Vitali E, La Torre C, Bergami M, Malacarne F, Soffritti S, Storari A.Renal Unit, S. Anna Hospital - Ferrara - Italy

Whole body bioimpedance is considered helpful in monitoring of hydration duringhemodialysis. In this study we compare the traditinal bioimpedance with a new methodSTA method, deviced by Akern (Italy), based on bioimpedance. It allows direct determi-nation of the body cell mass (BCM) in Kg. and extracellular water (ECW) in percent oftotal body water (TBW). The method is suitable for checking nutritional status and forestimating the hydration.Methods - During the hemodialysis treatment, in the morning, we evaluated 24 pts., 18males and 6 females, aged 68±11,6 yrs. (range34-86), weight 66,3±8,52 Kg. (46,5-97), height1,67±0,11 m. (1,5-1,8). The determinations were almost simultaneously with both method,170±35 min from the start of treatment, in good emodinamical condition hemodialysis.Results

STA: BCM Kg. 19,6±5,4; ECW% 53,5±6,7;BIA: BCM Kg. 21,1±6; ECW% 54±8,9;

The value for the traditional BIA were: R 570,5±76,1; Xc 46±12. The test has been per-formed with the Bodycomp-software, provided with the device. The statistical differ-ences were not significative.Discussion - STA is the new method based on BIA impedance which gives the directdetermination of BCM in Kg. without knowing the total weight of the patient and theECW%, without computing by a PC the resistance and the reactance: it is possible toevaluate the immediate indication of nutritional and hydration status of the pts, so with-out any previous preparation except for the usual ones.These data of a limited and not-selected sample, similar to the usual situation in ahemodialysis room, show the same results.The “traditional” BIA method is less handy because it also requires the presence of a PCto get a response; the STA response is complete and the values are immediately displayedin Kg. and in ECW%. The only condition in which we have seen a difference is in mal-nutrition: the ECW% measured by STA is costantly lower in malnutrition than in BIAvalues. The method used for malnutrition evaluation was the BROCA-method. Theresults of STA are more similar to those corrected when basal metabolic rate (BMR) is lessthan 1000 Cal. Nevertheless the BROCA correction method must be done anyway, for theevaluation of the hydration situation. The hydration measured by ECW% in malnutritionis lower in STA, but does not reach the adjustement based on the BROCA method. Ifmalnutrition is present there is risk of dehydration.

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THE MAXIMUM ALLOWABLE LEVELS OF ALUMINIUM INDIALYSIS FLUID. EVOLUTIVE ANALYSIS DURING THELAST 10 YEARS.JL Fernández-Martín, A Canteros, M Naves, C Díaz-Corte, JBCannata.Bone and Mineral Research Unit. Instituto Reina Sofia deInvestigación. Hospital Central de Asturias. Oviedo. España.

Despite the extensive measures to control the aluminium expo-sure, chronic and acute episodes of aluminium intoxication stilloccur. The objective of this study was to analyse the evolution ofthe aluminium content in the dialysis fluid and its effect onserum aluminium in different dialysis centres throughout thelast decade.For this purpose, the aluminium content in dialysis fluid andserum samples (N=7461) from 17 dialysis centres were ana-lysed during 10 years (1988-1998). During that period, the per-centage of dialysis fluid samples with adequate levels of alu-minium (<2µg/l) increased from 0% in 1988 to 84.6% in 1998.The percentage of dialysis fluid samples with high aluminiumlevels (>6 µg/l) decreased from 37.5% in 1988 to 0% in 1998.During the same period the improvement in the quality of thedialysis fluid resulted in lower values in serum aluminium lev-els. The percentage of low (“normal”) serum aluminium levels(<20 µg/l) increased from 16.5% in 1988 to 56.4% in 1998.Throughout the period of study, in each centre every year, themean serum Al levels correlated with the mean dialysis fluid Al(r=0.50, p<0.001, N=86). The higher correlation was found whenAl in dialysis fluid was higher than 4 µg/l (r=0.716, p<0.001)and no correlation was found when Al in dialysis fluid waslower than 4 µg/l.Even taking into account that the dialysis fluid is not the onlysource of aluminium in dialysis patients, our study clearly dem-onstrated a close relationship between the dialysis fluid and theserum aluminium when the former exceeded 4 µg/l. Our resultsemphasize the need of maintaining the Al levels in dialysis fluidbelow the threshold of 2 µg/l.

CALCIUM (Ca) CONCENTRATION IN DIALYSIS FLUIDS (DF): A CRITICALPOINT OF VIEW.Díaz Corte C, Naves ML, Rodríguez A, Gómez C, Fernández Martín JL andCannata JB (on behalf of the 171 collaborating centres).Bone and Mineral Research Unit. Instituto Reina Sofía de Investigación. Hospi-tal Central de Asturias. Oviedo. Spain.

Since the beginning of dialysis as permanent replacement therapy we havemanipulated the Ca concentration in DF to improve the management of the renalosteodystrophy. During last year several reports have suggested the use of Caconcentrations lower than 3 mEq/l facilitates the use of calcitriol to controlsecondary hyperparathyroidism meanwhile other authors claimed about therisk of using indiscriminately this strategy which frequently worsens thesecondary hyperparathyroidism. In this abstract we summarised the resultsobtained in 171 centres of dialysis regarding the Ca concentrations used routinelyin DF and its correlation with the biochemical markers of renal osteodystrophyin patients from these centres.The table shows that patients from centres using Ca of 2.5 mEq/l (44% of cen-tres) have a significant lower serum Ca and consequently a significant highermean PTH levels and a significant greater percentage of patients with severehyperparathyroidism (PTH>500 pg/ml). The use of vitamin D in this groupwas higher than in the other two groups (+13%) but not enough to counterbal-ance the effect of the lower Ca in the dialysis fluids.The use of 3.5 mEq/l of Ca (26% of centres) did not mean a better control of PTHthan using 3.0 mEq/l (28% of centres), but in contrast, the percentage of patientswith PTH in the “adynamic” range was greater in the 3.5 mEq/l group than inthe other two groups.

Ca in DF Serum Ca PTH % PTH % PTH % of N(mEq/l) (mg/dl) (pg/ml) >500 <60 Vit D2.5 9.6±0.02* 316±7.2* 19* 21 51%* 30693.0 9.7±0.02 277±7.5 15 22 38% 20213.5 9.8±0.02 274±9.1 16 26* 38% 1585Data are expressed as mean ± standard error. *p<0.05

These results strongly suggest the most appropriate Ca concentration to be usedroutinely is 3 mEq/l. The use of Ca concentrations lower than 3 mEq/l shouldbe always associated to others forms of Ca supplementation (and vitamin D),otherwise in long-term, the secondary hyperparathyroidism progresses.

HEMODYNAMIC MONITORING DURING HEMODIALYSIS USING SPEC-TRAL ANALYSIS OF HEART RATE VARIABILITYB Fahna, G H Wirnsbergerb, H Scharfettera, H Huttena

a Institute of Biomedical Engineering, Technical University Grazb Departmentof Internal Medicine, Karl-Franzens University Graz

Parametric spectral analysis of heart rate variability was proposed in litera-ture to evaluate the efficiency of the autonomic response to dialysis-inducedhypovolemia. LF/HF, the ratio between the powers in the LF (0.04-0.15 Hz) andHF band (0.15-0.4 Hz) is considered to be an index of the sympatho-vagal bal-ance.Eight dialysis patients were included in the study, which were primarily clas-sified as hemodynamically stable during treatment period. Patient data (mean± SD): age 51±15 yrs; body mass 74.7±7.9 kg; fluid loss 2.8±1.2 kg; duration:259±36 min; M:F 5:3. In one case, cardiovascular collapse after 235 min of treat-ment resulted in pre-termination of dialysis (unstable session). From the re-corded ECG, consecutive RR-intervals were extracted offline by R-wave detec-tion and further processed to obtain a tachogram equally sampled in time, whichwas splitted into epochs of 3 min length. Epoch by epoch, the parameters of anautoregressive model and power spectral density were calculated. LF/HF wastherefrom determined by integration. Mean value (mean) and standard devia-tion (std) of LF/HF during each session are listed in the table below (US:unstablesession)

Case: 1 2 3 4 5 6 7 8(US)LF/HF(mean) 3.79 6.82 3.86 8.53 18.27 3.98 3.08 0.34LF/HF(std) 2.42 4.11 1.68 6.04 7.33 2.55 2.14 0.18

LF/HF was subject to large fluctuations in each case. LF/HF was >1 during allstable sessions, but it was <1 from the start of dialysis until the onset of cardio-vascular collapse during the unstable session. This supports findings reportedin literature, where LF/HF was used to discriminate between hypotension-proneand stable patients during stable dialysis sessions. LF/HF<1 was observedduring an unstable session (Nr.8) although the patient was classified as hemo-dynamically stable. Our data emphasize the important role of LF/HF for therisk assessment of hypotensive episodes during hemodialysis.

HEPATITIS C VIRUS MOLECULAR EPIDEMIOLOGY IN DI-ALYSIS PATIENTS CONFIRMS NOSOCOMIAL INFECTION:A MULTICENTER STUDYJ. Slavicek, M. Jakic, Belavic, M. Crnogorac, B. Vurušic, S. Kalenic,B. Rebrovic, B. Grahovac, Z. Puretic, B. Heinrich, Z. Marekovic.UHC Zagreb, Croatia

Hepatitis C virus (HCV) infection is highly prevalent in dialysispatients. After the screening blood products for HCV has beenintroduced, the risk decreased, but new cases of HCV are stillbeing documented, especially in patients on hemodialysis (HD).Sera from 155 anti HCV+ patients (pts) undergoing mainte-nance HD from 6 dialysis centers (2 UHC and 4 district hospitalunits) in Croatia were analyzed by RT-PCR for HCV viremiaand by line probe assay technology for HCV genotyping.HCV seroprevalence in these units was as follows: 54,31,50,30,11and 11%. 112/155 pts were HCV RNA+(72%). Genotype 1bwas found in 81% HCV RNA + pts. In center A 4 different HCVgenotypes were found. Type 1b was dominant (72.5%), fol-lowed by type 3 (20%). Type 1a was found in 1 and type 4 in 1pt. Center A is a referential center for all complications and hasa high patient turnover. In the remaining 5 units only one HCVgenotype was found (B - type 1b, C - type 1b, D - type 1b and E- type 3,F- type 1b). There was no difference between the pa-tients’ clinical or demographic features or in the number of trans-fusions. HCV+ patients are dialyzed on separate machines in 3units, but in 3 units they are in separate rooms. Similar preven-tion measures and machine disinfection after each session areapplied in all units except in one. HC markers are assessed 1-4times yearly.Croatia is a country with a relatively high prevalence of HCV inHD patients. Genotype 1 b is predominant in HD population aswell as in general population. This predomination of exclusivelyone type of HCV in an entire dialysis unit speaks for a nosoco-mial spread of HCV.

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PLASMA LEPTIN CONCENTRATION INHEMODIALYSIS PATIENTSD. Grekas, M. Karamouzis, I. Kalevrosoglou, H.Kampouris, S. Vassiliou, A. TourkantonisFirst Medical Department, Renal Unit, University Hos-pital AHEPA, Thessaloniki, Greece.

Leptin, is produced by adipose tissue and involved inthe regulation of appetite and energy balance. Previ-ous studies have reported that uremic patients haveelevated plasma leptin concentrations, but the causeand significance of high plasma leptin levels are un-known. We studied 56 hemodialysis (HD) patients, 32males and 24 females with a mean age 57.65± 14.7 and59.75± 9.17 years and a mean body mass index (BMI)29.32± 4.70 Kg/m2 and 28.35± 9.06 Kg/m2 for malesand females respectively. Plasma leptin concentrationswere measured at 8a.m. by radioimmunoassay method(IRMA, DSL Texas). The control group consisted of 20healthy subjects (12 males and 8 females, mean age49.4± 12.5 years and mean BMI 26.11± 7 Kg/m2).Plasma leptin concentrations were 17.77± 12.41 ng/ml in men HD patients and 28.84± 17.69 ng/ml inwomen HD patients, compared with 7.5± 6.1 ng/ml innormal men and 18.3± 17.2 ng/ml in normal women.A positive correlation was found between BMI andleptinemia (r=0,59 for men and r=0,49 for women HDpatients), but no correlation was found betweenleptinemia and age, plasma albumin, serum creatinineand serum total cholesterol levels. These results dem-onstrate that HD patients have hyperleptinemia and itprovides further evidence of cause-effect relationshipbetween renal failure and abnormal leptin metabolism.

FOLATE AND HOMOCYSTEINE (Hcy) METABOLISM: EFFECTS OF HIGH-FLUX/HIGH-EFFICIENCY (HF/HE) DIALYSISC. Lasseur1, P. Chauveau1, F. Parrot2, C. Level1, C. Combe1.1Service de Néphrologie & Hémodialyse, Hôpital Saint-André, 2Laboratoire deBiochimie, Hôpital Pellegrin, Bordeaux, France.

HF/HE dialysis has been shown to have detrimental effects on micro-nutri-ents and water-soluble vitamins, such as vitamin B6 (Kasama, AJKD 96).The impact of HF/HE dialysis on homocysteine extraction and metabolismhave not been extensively examinated. We have therefore investigated the ef-fects of membrane permeability on folate and Hcy metabolism in dialysis pa-tients (pts) before and after folate supplementation (FA).Twelve pts (3 M/ 9 F, 61 ± 12 yrs), without any folate supplementation treatedby dialysis for a mean of 5.9 years (1 to 20 years) on low flux membranes havebeen studied at T0. A HF 1.5 m2 cellulose triacetate membrane was used there-after, pts were studied after 1 month without FA (T1) and after 2 months of 5 mgper day with FA (T4). Plasma and erythrocyte folate, plasma Hcy, Hcy extrac-tion ratio and vitamin B12 concentrations were determined before and after a4 hours dialysis session. Dialysis efficiency was evaluated by the mean of 3consecutive Kt/V determinations.

Low-flux T1 T4Plasma folate nM 32 ± 18 18 ± 5# 485 ± 546#

Erythrocyte folate nM 584 ± 286 685 ± 259# 3524±2496Homocysteine µM 47 ± 18 45 ± 12 33 ± 12#

Hcy extraction % 35 ± 15 43 ± 15 43 ± 10Kt/V 1.6 ± 0.27 1.74 ± 0.33£ 1.67 ± 0.4

# p<0.05 vs initial values. £p<0.01 vs initial values

The increased dose of dialysis with a HF membrane decreased plasma folatelevels. Plasma Hcy levels decreased only after the combination of HF/HE dialy-sis and FA suplementation.Since folate deficiency can induce other various potential detrimental effects(dyserythropoiesis, membrane protein damage, increase in homocysteine lev-els), folate supplementation is mandatory for patients dialyzed with HF/HEmembranes.

HAEMODIALYSIS MEMBRANE BIOCOMPATIBILITY DOES NOT IMPACTON THE MORTALITY OF PATIENTS WITH ACUTE RENAL FAILURE: APROSPECTIVE RANDOMIZED INTERNATIONAL MULTICENTER TRIALA Jörres1, C Dobis1, G Gahl1, M Polenakovic2, K Cakalaroski2, B Rutkowski3, EKiselnicka3, D Krieter4, W Rumpf4, C Guenther5, J Hoegel6, W Gaus6 and themulticenter study group*1Nephrology & Med. Intensive Care, Charité Berlin; 4Univ. Göttingen; 5Mem-brana, Wuppertal; 6Univ. Ulm, Germany; 2Univ. Skopje, Macedonia; 3Univ.Gdansk, Poland

The question if haemodialysis (HD) membrane biocompatibility may influencethe clinical course and mortality of patients with acute renal failure (ARF) iscurrently discussed controversially. We therefore performed a prospectiverandomized (central telephone randomization) international multicenter trialin patients with dialysis-dependent ARF treated either with Cuprophan®(CUPRO) or polymethylmethacrylate (PMMA) low-flux membranes (1.2 sqmsurface area).Overall, 160 patients with ARF were evaluated. Main patient characteristicsand outcome measures are indicated in the table below:

CUPRO PMMA TOTALEvaluable patients (f/m) 76(29/47) 84(29/55) 160 (58/102)Mean age (min-max) 56.3 (19-87) 61.7 (18-87) 59.1 (18-87)Surgical/trauma pts. 24(32%) 26(31%) 50(31%)Mean APACHE 11 (range) 23.3 (10-37) 24.4 (10-47) 23.9 (10-47)Pts. with initial oliguria 30 (39%) 28(33%) 58 (36%)Pts. with mechanical ventilation 41 pts/143 d 44 pts/162 d 85 pts/305 dSurviving pts. 44(58%) 50(60%) 94(59%)Mean no. of HD sessions 5.1 (1-47) 5.1(1-47) 5.1(1-47)Mean hours on HD 19.3 (2-200) 19.0(2-214) 19.1 (2-214)

The 95% confidence intervals for the probability of survival ranged from 46.0%to 69.1% with CUPRO and from 48.3% to 70.1% with PMMA. The odds ratio fornot surviving for CUPRO vs. PMMA was 1.07 with a 95% confidence intervalsranging from 0. 54 to 2.11, resulting in a p value of 0.87 (Fisher’s two sidedExact Test). The corresponding odds ratio was 1.35 in oliguric and 0.92 innon-oliguric patients (p=ns). Moreover, no difference between CUPRO andPMMA was detected when age and APACHE II score were entered as possibleconfounders in a logistic regression model. In summary, this controlled, pro-spective randomized trial did not reveal any differences in the clinical course ormortality of dialysis-dependent ARF patients treated with CUPRO vs. PMMAmembranes.This study was supported by Membrana, GmbH, Wuppertal, Germany

HYDROGEN-PEROXIDE INDUCED HEMOLYSIS IN ADULTHEMODIALYSIS PATIENTS.N Platteeuro, A Vanhille, E Boulanger, ML Ferrier, D Pagniez, PDequiedt.Néphrologie B, Hôpital Calmette CHRU. 59 037 Lille France.

Acute hemolysis due to Hydrogen Peroxide (HP) contaminateddialysis water has been reported only once (Am J Nephrol1990;10:123-127 ) in a pediatric hemodialysis center. We reporton similar cases occurring in 4 adult patients.During the same hemodialysis session, 4 out of 10 patients hadonset of general discomfort, one had lumbar pain and anotherone had severe thirst. Mean hemoglobin level fell to 5.8 g/dl, andhaptoglobin was undetectable in this 4 patients. Mechanicalcauses of acute hemolysis, such as plication of dialyser lines, orcompression by blood pumps, were excluded. Moreover, simul-taneous occurrence of hemolysis in several patients suggested adialysate chemical abnormality. The search for usual toxic sub-stances or metabolic situations (hypo/hyper osmolar or over-heated dialysate, nitrates, aluminium, zinc, copper, formalde-hyde, sodium hypochorite..) were excluded too.Contamination of water treatment system by HP was consid-ered as hemolysis occurred after using exceptional double doseof a preparation which contained: peracetic acid (0,5 %), aceticacid (6 %) and HP (10 %). Double concentration was used todecrease endotoxins and germs nearly european pharmacopoeialimits.We considered that HP water contamination had been due toinadequate rinsing of this contaminant from water treatmentsystem, or due to release of HP. Surprisingly, little is knownabout haematological toxicity of HP. Some patients may havean higher susceptibility to the toxic effect of HP.

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CURRENT PRACTICE IN VASCULAR ACCESS IN THE UKD. de Takats1, M. J. Kumwenda2, A. Bakran3 and G. Owens3

1HMCB, University of Sheffield Medical School S10 2RX, UK,2Glan Clwyd Hospital, Bodelwyddan, LL18 5UJ, UK and 3RoyalLiverpool University Hospital, Liverpool L7 8XP, UK

In this study 3 postal questionnaire surveys conducted inde-pendently have been amalgamated to provide an overview ofcurrent practice in vascular access in the UK. Together theyreceived replies from 54 of 72 adult UK renal units (75%).Quantitative and qualitative findings follow: At their firsthaemodialysis 51% patients have established functioning vas-cular access and a further 15% have previously had failed pro-cedures; 49% require urgent access. For temporary lines the mostpopular site for first insertion is jugular (66%) with operatorstrying to prevent subclavian stenosis whilst a third of units usethe subclavian vein first, citing operator familiarity and patientpreference. 44% of units now use visualisation techniques (ul-trasound or fluoroscopy) for catheter placement.In stable HD patients 74% dialyse via arteriovenous fistulas,18% via tunnelled catheters and 8% via grafts. Radial fistulasare the most popular, but half of these fail over time.Tunnelled catheters are inserted equally often by physicians andsurgeons. Warfarin is rarely used routinely but is used for pro-phylaxis once blockages have occurred. Clots are treated acutelywith thrombolytics. Though infection rates and annual removalrates of tunnelled catheters run at 15-20% few units have formalongoing audit to monitor access complications.Patients wait on average 35 days for access procedures. 64% ofunits are satisfied with their access service. Those not satisfiedsuggested areas for improvement ranging through technical,training and resource issues, to simple administrative changes.We have quantified common deficiencies and probed attitudes.Problems revealed range from poor practice to inadequate re-sources. Such data can help focus improvement strategies.

SYSTOLIC TIME INTERVALS IN HEMODIALYSIS PATIENTSWITH NORMAL EJECTION FRACTIONST. Tukek1, V. Akkaya1, A. Yildiz2, A.B. Sozen1, H. Kudat1, D.Atilgan1, M.S. Sever2, F. Korkut1

1Cardiovascular Research Center, 2Dept. of Int.Med., Div of Ne-phrology, Istanbul School of Medicine, Istanbul, Turkey

In this controlled study, systolic time intervals (STI) were inves-tigated in hemodialysis patients (HDp) with normal myocar-dial systolic function as assesed by conventionalechocardiographic indicators like global ejection fraction (EF).Echocardiographic findings in 86 HDp with normal EF (M:F47:39, mean age 36±13 years) and 51 healthy controls (MY 22:29,mean age 37±10 years) were compared for STI parameters(prejection period (PEP), left ventricular ejection time (LVET)and STI index (PEP/LVET)). PEP (114 ± 21 ms vs. 95 ± 4 ms,p<0.05) and STI index (0.41 ± 0.11 vs 0.34 ±0.22, p<0.05) werehigher in the HDp compared to controls. No significant differ-ence for PEP (115 ± 22 ms vs 113 ± 20 ms p>0.05) and STI index(0.41 ± 0.92 vs 0.42 ± 0.12, p>0.05) were found for HDp with orwithout left ventricular (LV) hypertrophy (LV mass index >I 10gr/m2 in female or >131 gr/m2 in males). Overlap group ofHDp and controls with LV mass between 150-250 gr were com-pared for STI parameters in order to exclude the effect of LVhypertrophy on STI. In the overlap groups, PEP (11 1± 21 ms vs94±3 ms, p<0.001) and STI index (0.39±0.1 vs 0.34 ± 0.02,p=0.01) were significantly higher in HDp. No significant differ-ence in PEP and STI index were found between HDp with orwithout hypertension. HDp without hypertension still had sig-nificantly longer PEP (115 ± 20 ms vs 95 ± 4 ms, p<0.05) andhigher STI index (0.41 ± 0.99 vs 0.34 ± 0.22, p<0.05) comparedto controls.It was concluded that STI indexes deteriorated before an overtsystolic dysfunction (normal EF) and this deterioration in HDpwas independent of LV mass or hypertension. Deteriorated STIparameters may be a marker of myocardial fibrosis and / orlatent sistolic dysfunction.

NUTRITIONAL STATUS IN DAILY HEMODIALYSIS.R. Galland, J. Traeger, W. Arkouche, E. Delawari.Association Utilisation Rein Artificiel (A.U.R.A.L.) Lyon France.

In order to estimate the consequence of daily hemodialysis onthe patient’s nutritional status, seven patients age 42.14 ± 15.58yrs (21-67) who had been on standard hemodialysis (SHD) 4-5hrs, 3 times/week from 10.43 ±6.3 5 yrs (1-17). These patientswere converted to daily hemodialysis (DHD) 2-2.5 hrs, 6 times/week from 16.57 ± 7.72 months (6-24). For each type of treat-ment similar modalities were applied. The average daily intakeof calories (DCI) and proteins (DPI) were estimated using 4days food record data every 3 months; serum albumin,prealbumin and transferrin were measured every 3 months; nor-malised protein catabolic rate (nPCR) was performed once amonth; Anthropometry every 6 months included body dryweight, four-site skinfold thickness. The equivalent fat content(FBM) was calculated form the Durnin.

SHD DHD pDry weight(kg) 55 ± 8.62 57.14 ± 9.79 0.009BMI 20.34 ± 2.23 21.23 ± 2.25 0.0031DPI (g/kg) 1.32 ± 0.25 1.64 ± 0.49 0.031DCI (kcal/kg) 37 ± 10.48 43 ± 9.95 0.011nPCR (g/kg/day) 1.11 ± 0.24 1.42 ± 0.26 0.001Albumin (g/L) 39.11± 2.55 42.20 ± 2.69 0.009Prealbumin (g/L) 0.36 ± 0.051 0.39 ± 0.054 0.021Trasferrin (g/L) 1.97 ± 0.33 2.15 ± 0.54 0.051LBM (kg) 49.23 ± 4.70 50.83 ± 5.931 0.051FBM (kg) 10.53 ± 5.22 10.70 ± 5.67 0.038

Conclusion: Daily hemodialysis improve the nutritional status.The amelioration of appetite is due to sensation of well being,less dietetic rules, diminution of drugs prescription, reductionof urea retention and increase of dialysis performance.

HEART RATE VARIABILITY DURING ORTHOSTATIC LOAD-ING IN HAEMODIALYSIS PATIENTSS Abe1, M Toyoda1, M Yoshizawa2, N Nakanishi3, M Honda4

1Dept of Int Med, Keio Univ, 2Yoshizawa Clinic, 3Miyoshi RenalClinic, Tokyo, 4Tanaka Hosp, Yokohama, Japan.

To evaluate the autonomic function of the cardiovascular sys-tem, the effects of active changes in posture on heart rate vari-ability were studied in 15 patients with chronic non diabeticrenal failure.The patients were under 60 years of age and had undergonemaintenance haemodialysis (HD) at outpatient clinics. Theiraverage age was 50 ± 6 years (38~58 years), and the averageduration of HD was 86 ± 39 months (18~136 months). Immedi-ately before maintenance HD, an ambulatory ECG was recorded,first in the resting supine position and then in the standing posi-tion, and spectral analysis of heart rate variability was per-formed by the maximum entropy method. In the supine posi-tion, the spectral power of heart rate variability showed lowvalues in both the low frequency (LF: 0.05~0.15 Hz) and highfrequency (HF: 0.2~0.4 Hz) components, and these values wereobviously lower than those of healthy subjects. Changing posi-tion from supine to standing was associated with a slight de-crease in average RR intervals from 882 ± 101 to 799 ± 98 msec,however, no significant changes were observed either in the val-ues of the LF and HF components or the mean blood pressurevalues.The above data suggest that vagal and sympathetic modula-tion of the heart rate was affected in patients with end-stagerenal failure undergoing maintenance HD, which may be a con-tributing risk factor for cardiovascular complications.

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MEASURING HEMODIALYSIS (HD) ACCESS FLOW (AF) BYDILUTION (Overview of 4 years experience)N.M. KrivitskiTransonic Systems Inc., Ithaca, NY USA

In 1995 (Kidn.Int.48:), a new dilution method was introducedfor routine measurement of AF during HD by brief line reversal.During these 4 year period this approach became widely ac-cepted and generated more then 50 papers and more than 80abstracts. The changes in ultrasound, thermal, electrical andoptical blood and dialysate properties were used to measure AFat the reversed line position. Artificial grafts, may be consideredas rigid tubes and create ideal sites for mixing and measure-ments. Their inner diameter is limited (4 - 6 mm) so that venousoutflow mixes immediately with AF throughout the entire crosssectional area of the access. Native Fistulae, pose two problems:first, the cross-sectional area of the fistula may be significantlygreater than that of grafts; second, multiple venous branchingmay occur and complicate the measurements. To ensure com-plete mixing, the arterial needle should be placed in the maintrunk facing the incoming flow.Literature analysis and Transonic archive data (more then 6,000measurements) showed that average flows in grafts (940 ml/min) and fistulas (930 ml/min) were close, but distribution offlows was different. 31% of fistulae have flow less then 600 ml/min, but only 21% of grafts have access flow less than 600 ml/min. This confirms the recently developed opinion that graftswith flow less than 600 ml/min are prone to clot and needimmediate attention for possible intervention, yet a differentdanger level is indicated for fistulae, which may remain patentlonger with lower flows.Summary: Access flow measurements have become an impor-tant part of routine hemodialysis treatment and vascular accessmanagement. Experience gained in the last 4 years has shownthat blood flow through the access device most accurately pre-dicts access thrombosis and allows for timely intervention torestore flow and prevent clotting.

THE TRUE COMPARISON (C) OF SURVIVALS (S) OFUREMIC PATIENTS (UP) TREATED EITHER WITH HD ORPD CAN BE DONE ONLY ACCORDING TO COMORBIDITYINDEX (CI).D.A. Procaccini(1), M. Querques(2), A. Pappani(2), G. DiFrancesco(2), G. Procaccini(3), P. Strippoli(4), G.F.M. Strippoli(5).Dept. of Nephrol. S. Severo(1), Foggia(2), Brindisi(4) and Uni-versity of Foggia (3) and Bari (5) - Italy.

An accurate identification of CI is of great importance in evalu-ating S of ageing patients such as UP. Our approach to theproblem was reported elsewere (ASAIO TRANS vol.38 n.3, 1992M291-M295).286 UP treated only with HD (150) or PD were subdivided,according to CI (1-3), (performed by a single examinator at thebeginning of treatment) and to the periods (P) of observation(1st 1976-1986; 2nd 1987-1998). HD UP had a dialytic index of14ñ.8 hrs/m2/week PD UP had a creat. cl. of 50 l/week/1.73BSA.The S analysis (Kaplan-Meier) showed a better S of UP treatedwith HD in the medium and high risk groups (log-rank test)(RF=1:p =.4; RF =2: p =.00002; RF =3: p =.009).Comparing S of UP treated with the same tecnique in differentP, it wasn’t observed any statistical difference between 1st and2nd P, either in HD or PD in all RF groups:(RF =1: HD 1st vs 2nd p =.94; PD 1st vs 2nd p = .54);(RF =2: HD 1st vs 2nd p =.24; PD 1st vs 2nd p = .65);(RF =3: HD 1st vs 2nd p =.41; PD 1st vs 2nd p = .59).Conclusion: the HD gives better S than PD in medium and highrisk UP. The improvement of tecniques, HD or PD, haven’t grantedbetter S, in the 2nd period.

ACQUIRED RENAL CYSTIC DISEASE (ARCD) IN LONG TERMHEMODIALYSIS AND RENAL TRANSPLANT PATIENTS: A PRELIMINARYREPORTB Yidit, T Yalti, I Titiz, F Türkmen, Ç Aydin, I Berber, O Krand, M Aydýn, P Yidit,M Esen, Y Özel.Departments of Hemodialysis and Transplantation, Radiology, Urology,Haydarpasa Teaching Hospital, Istanbul, Turkey

Introduction: The incidence of acquired renal cystic disease (ARCD) in end stagerenal disease patients treated by long term hemodialysis is reported to be 35 -95%. Patients with ARCD may present with hemorrhage of the cyst and retro-peritoneal hematoma, and in 4-7% of ARCD population renal cell carcinomadevelops. The aim of this study is to question the necessity of serial investigationof the natural kidneys of the hemodialysis and renal transplant (RT) patients.Patients and Methods: Natural kidneys of 16 patients on long term hemodialysisand 28 patients with RT after long term hemodialysis were evaluated and fol-lowed serially by ultrasonography (US). In equivocal cases CT and/or MRIwere added to the evaluation.Results: The mean age of the hemodialysis group was 36.5 and the meanhemodialysis period was 4.7 years. In this group, US revealed cysts in 62.5% ofthe patients of whom the cysts were bilateral in 70%. In one case (6.1%), a ret-roperitoneal hematoma was found. In 5 patients CT and/or MRI were neededadditionally. Of these, one patient (6.1%) with renal cell carcinoma was evalu-ated. The mean age of the RT group was 33 and the mean pretransplanthemodialysis period was 3.1 years. In this group, ARCD was evaluated by USin 28% of the patients of whom the disease was bilateral in 80%. Additional CTand/or MRI was required in 4 patients of whom one (3.6%) was proved to be arenal cell carcinoma.Conclusion: The incidence of ARCD is quite high in patients who received longterm hemodialysis and patients with ARCD are usually young and asympto-matic. It is therefore necessary to follow the disease by US for early detection ofcomplications. CT and/or MRI are helpful diagnostic tools for detecting malig-nancy in suspected cases.

IMPACT OF BIOFEEDBACK-INDUCED CARDIOVASCULAR STA-BILITY ON EFFICIENCY OF HEMODIALYSIS TREATMENT IN UN-STABLE PATIENTS.C. Ronco, A. Brendolan, G. La Greca.Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy

Hypotension and cardiovascular instability are generally caused by adrop in circulating blood volume during ultrafiltration. Drop in bloodpressure is followed by a peripheral vasoconstriction with reducedperfusion in several districts of the body. In this study we carried out aprospective controlled crossover study on 26 hemodialysis sessionscarried out with two different modalities: a) Acetate freehemodiafiltration carried out with standard ultrafiltration control andno further controls, and b) Acetate free hemodiafiltration carried outwith continuous monitoring of blood volume and automatic biofeed-back loop with consequent machine-driven adjustments on ultrafiltra-tion and dialysate conductivity such to meet the required weight losstarget. In all sessions we measured urea Kt/V and equilibrated Kt/V(after 30minutes), measurement of urea rebound and measurement oftotal urea removal. Total urea removal was also normalized by initialurea concentration or initial content in the body (Solute removal In-dex). The number of hypotensive episodes and interventions for salineinfusion was recorded. A bioimpedance analysis was carried out at thebeginning of the study to make sure that dry body weight was prop-erly adjusted in the patient. In group B we recorded a significantlylower number of hypotensive episodes (2 Gr.B versus 10 in gr A) andno medical interventions were required. Saline infusion was requiredin 5 cases in group A sessions. Urea Kt/V resulted in the similar rangeat the end of the session (1.26 in group A vs 1.21 in group B) butequilibrated Kt/V resulted much higher in group B (1.23 versus 1.06in group A). This was explained by a significantly higher reboundobserved in group A (15%) in respect to group B (6%). The underlyingmechanism depends on solute sequestration during hemodialysis ses-sions with high incidence of hypotensive episodes. After dialysis aphysiological vasoconstriction occurs but when hypotension intervenes,the solute distribution volume to which dialysis can have access isfurther reduced by a severe vasoconstriction in peripheral districtsincluding muscles, skin and liver. This results in a higher apparentefficiency which however is flawed by the remarkable rebound ob-served after the session. Solute removal is also reduced when hypoten-sion is present and aan overal superior efficiency of the treatment canbe therefore observed when dialysis is carried out smoothly and car-diovascular stability is maintained. We conclude that new systems forblood volume monitoring and automatic biofeedback loops controllingultrafiltration and conductivity, not only may reduce the amount ofhypotensive episodes during dialysis, but also may contribute to in-crease significantly the effective efficiency of the treatment as far assolute removal and Kt/V are concerned. Solute removal and soluteremoval index may be an excellent parameter to monitor these phe-nomena in severely unstable, hypotension-prone patients.

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IgE ANTIBODIES AND ANAPHYLACTOID REACTIONS INHEMODIALYSIS AND IN THEPAPEUTIC PLASMAPHER-ESIS.Kalevrosoglou J, Grekas D, Kabouris C, Geropoulou E,Tsavdaridou V, Sioulis A, Tourkantonis A.First Medical Department Renal Unit, University HospitalAHEPA, Thessaloniki.

Hemodialysis (HD) patients on treatment with or without ACEinhibitors, may develop anaphylactoid reactions when dialysismembranes are sterilized by ethylene oxide. The aim of thisstudy was to identify the specific IgE-ETO in a group of HDpatients and their association with the anaphylactoid reactions.Twenty-eight HD patients, aged 26-76 years (mean 56,8) under-went hemodialysis from 4-242 months (mean 101,9). They weretreated with hemophan membrane dialyzers which were steri-lized by ETO. The housing of dialyzer was made frompolycarbonate. Blood was drawn from HD patients foreosinophils count, total amount IgE and specific IgE antibodiesagainst to ETO, formaldeyde (FA) and Isocyanate (ISO) deter-mination. In 5/28 patients specific IgE to ETO, FA and ISO indifferent titers was shown. Elevated total IgE titers (>100IU/ml) were found in 8/28 patients. Eosinophilia (>200/mm3)was found in 5/28 patients. 11/28 patients were treated withACE inhibitors. 3/28 patients were treated by therapeutic plas-mapheresis (TP) with immunoadsorption (thyptophan column)inorder to reduce the anti-HLA antibody titers before renal trans-plantation. TP was interrupted during the first half hour of thesession because they developed anaphylactoid reactions (hypo-tension, vomiting, diarrhoea, upper airway angio oedema). Thefilters, which were used for TP were sterilized by ETO, too. Thepresence of IgE-ETO was observed in 7,2% of the HD patients,whereas 17,8% presented specific antibodies against ETO, FAand ISO. It is suggested that: 1) the anaphylactoid reactionsshown in hemodialysis patients may due to the ETO steriliza-tion of membranes, 2) specific IgE antibody titers were not asso-ciated to the anaphylactoid reactions and eosinophils count, 3)the anaphylactoid reactions shown in TP may due to the in-creased production of bradykinin from the combination nega-tively charged membrane surfaces and ACE inhibitors.

EXERCISE TRAINING IN HD PATIENTS DURING THEHEMODIALYSIS TREATMENT: METABOLIC AND IMMU-NOLOGIC ALTERATIONS.Kalevrosoglou J, Kabouris C, Daniilidis M, Agouridaki C, KouidiE, Grekas D, Tourkantonis A.First Medical Department Renal Unit, University HospitalAHEPA, Thessaloniki.

Available studies indicate that exercise capacity in hemodialysis(HD) patients is low, compared with age-predicted values. Four-teen maintenance HD patients age 36-62 years were examinedand those who having serious cardiovascular problems, (diabe-tes melitus and other certain diseases) were excluded from thestudy. All HD patients participated in a 6-month pilot programof training exercise. A stationary bicycle “Motomed-Letto” wasadapted to HD chair. The exercise was performed during thefirst hour of HD session. Serum from those HD patients wasexamined for lactic acid aldolase, renin, aldosterone, ß-endorphine, CD4+ CD8+ lymphocytes and IgG. We found 1) anincrease of lactic acid from 30,72 (±13,3) mg/dl to 33,02(±18,10)mg/dl and a reduction of aldolase from 5,64IU/L (±2,9)to 5,18IU/L (±1,59). 2) Elevation of renin from 6,49ng/,l (±7,2)to 8,48ng/ml (±7,98) and aldosterone from 428,05pg/ml (±0,86)to 439,08pg/ml (±731,7). ß-Endorphin was elevated from 99,23(±47,9)pg/ml to 104,75 (±53,34)pg/ml.

3) CD4+ CD

8+ total IgG CD

16+/

56+

Before 47,57 (±6,0) 24,67(±5,8) 10,45(±2,9) 3,0%After 50,0 (±8,5) 25,12(±5,8) 11,6(±3,0) 3,1%

CD4/CD8 ratios before and after training period increase from2,08 to 2,12. We conclude that: a) the application of an aerobicexercise during the HD session is an effective method forrehabilization of those patients improving the exercise capacity.b) Hormonal elevation could be compared with the correspond-ing of healthy individuals. c) Some amelioration in parametersof the Th-I type immune response of the HD patients was ob-served.

HIGH BICARBONATE OF DIALYSATE MAY REDUCE LEVELS OFAMADORI PRODUCTS AND AGEs IN NON-DIABETIC HAEMODIALYSISPATIENTSN Kobayashi, A Yoshida, K Kamata1), Y Tanaka1), H Tatsumi1), K Ishihara1),M Higashihara1), K Yokota2), M Okubo3)Sagami Junkanki Clinic, Kitasato University1), JR Tokyo General Hosp.2), SanoKosei Hosp.3)

We previously reported on significantly higheer levels of amadori productssuch as glycated albumin(GA) and fructosamine(FRA), and of advancedglycation end products (AGEs), such as pentosidine(Pent), in haemodialysis(HD) patients (pts).The purpose of this pilot study was to investigate whether metabolic acidosismay affect the production or removal of amadori products and AGEs in pa-tients.Forty three stable HD out-patients and 19 age-matched normal volunteers (C)were enrolled in this study. All pts were non-diabetic, their age (mean+/-SD)was 51.9+/-9.9 yrs, and the duration on HD was 12.5+/-5.8 yrs.After low-bicarbonate dialysate (25 mEq/L) was used for 6 months, it wasswitched to high-bicarbonate dialysate (30 mEq/L) and was continued for 4months.Sixteen pts were haemodialyzed using high flux(HF) membrane, while low flux(LF) membrane was used in the remaining twenty seven pts during the study.Serum FRA was measured by colorimetric method. GA and Pent were analyzedby HPLC.Overall mean bicarbonate content of arterial gas significantly increased from22.1+/-2.1 to 23.7+/-2.6 mEq/L (P<0.0001, by paired t test).GA concentrations during HD using both HF (15.4+/-1.1 to 14.2+/-0.9 %,P=0.0005) and LF (15.4+/-1.0 to 14.7+/- 1.1 %, P<0.0001) membranes signifi-cantly decreased following the increase in dialysate bicarbonate, while FRA’sin both HF (287+/-24 to 278+/-24 micromol/L, P=0.053) and LF (285+/-26 to280+/- 27 micromol/L, P=0.09) remained unchanged. Significant differencewas observed in the level of Pent in HD pts using LF membrane (17.6+/-5.4 to15.9+/-4 pmol/mg, P=0.031), while the difference in those using HF membrane(15.7+/-1.1 to 14.9+/- 5.2 pmol/mg, P=0.23) was not significant between low-and high bicarbonate HD’s. The levels of FRA, GA and Pent in HD pts weresignificantly higher than those in C. In conclusion, correction of metabolic aci-dosis may reduce the production of amadori products and AGEs in HD pts.

EARLY DEATHS IN ELDERLY PATIENTS ON HAEMODIALYSIS.J. Bonal1, E. Vela2, M. Clèries2 and Renal Registry Committee1Hospital Universitari Germans Trias i Pujol. Badalona, 2Renal Patients Regis-try of Catalonia (RMRC), Catalan Health Service, Barcelona, Spain.

In the 1990’s there has been a rapid rise in acceptance rate for renal replacementtherapy (RRT). This increase from a more liberal selection criteria has resultedin a rise in mean age and comorbidity.We analysed the mortality within 90 days of elderly patients who started RRTwith haemodialysis.Between 1990 and1997, all new elderly patients who started RRT in Cataloniawere selected (n= 2,474). Statistical analysis was performed using c2 for propor-tion comparison, t-test for mean comparison and logistic regression to assessearly mortality (death in first 90 days on RRT) risk factors. Functional au-tonomy degree (FAD) was measured with the Karnofsky activity scale adaptedby Gutman for patients on dialysis. Data source: RMRC.

Univariate analysis Multivariate analysisn Early mortality (%) OR p

Gender: Male 1,430 7.6 1 -Female 1,044 6.1 0.75 0.095

Age (in years) 2,474 - 1.04 0.006PRD Others PRD 1,856 6.4 1 -

Diabetic 447 7.4 1,18 0.430Multi-system dis. 171 11.7 2.17 0.004

FAD Normal 730 2.6 1 -Limited 1,168 6.8 2.43 0,0008Special care 476 12.8 4.39 <0.00001

Cardiomyopathy 694 10.4 1.60 0.007Tuberculosis 69 18.8 2.82 0.002

The incidence of deaths within 90 days in elderly patients was 7.0%.There were more cardiac and social causes among the early deaths.The mean age of patients who die in the first 90 days was significantly higher(74.3 yrs versus 72.7 yrs).Gender and diabetes have no effect on early mortality. Deaths rose significantlywith an increase in age, multi-system primary renal disease (PRD), cardiomy-opathy and tuberculosis comorbidity, and limited or special care in functionalautonomy degree.

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VITAMIN C IN COMBINATION WITH VITAMIN E COMPLETELY ATTENU-ATES OXIDATIVE STRESS INDUCED BY I.V. IRON IN PATIENTS ONHEMODIALYSIS (HD).J.M. Roob, G. Khoschsorur, A. Tiran, H. Holzer, B.M. Winklhofer-Roob.Div. of Clin. Nephrology & Hemodialysis, Dept. of Surgery, Dept. of Lab. Medi-cine, Inst. of Biochemistry, Univ. of Graz, Austria.

High iron demands in HD patients treated with erythropoietin can only be metby i.v. iron, a potent prooxidant that might induce lipid peroxidation (LPO). HDtreatment depletes patients of vitamin C, re-sulting in low plasma concentra-tions. We tested the hypothesis that 1200 IU of oral vitamin E taken 6 h prior toHD and 500 mg i.v. vita-min C given at the start of HD will attenuate oxidativestress induced by 100 mg i.v. Fe(III) hydroxide sucrose complex 30 min after thestart of the HD session. In a cross-over design, 22 patients with nor-mal vitaminE (plasma α-tocopherol, 27.6 ± 11.8 µmol/L) but low vitamin C status (plasmavitamin C, 20.5 ± 17.3 µmol/L) received either none or iron with or withoutvitamin E or iron with vitamin E plus vitamin C. At 0, 30, 60, 90, 135, and 180min after the start of the HD session, serum Fe, transferrin saturation (TSAT),bleomycin-detectable iron (BDI, index of redox-active iron), plasma vitamin Eand C, as well as malondialdehyde (MDA) and total peroxide (POX) concentra-tions (markers of in vivo LPO) were determined. Upon iron infusion, serum ironconcentrations and TSAT increased rapidly and peaked at 30 min, as did plasmaMDA concentrations; BDI was not present prior to the iron infusion, but becamedetectable at 30 min. The increase in MDA was explained by BDI (r = 0.53, P =0.01). Plasma MDA and POX concentrations were significantly higher thanwithout Fe (P < 0.001). The vitamin E dose increased plasma α-toco-pherolconcentrations to 47.8 ± 20.5 µmol/L; the vitamin C dose in-creased plasmavitamin C concentrations to 120 ± 73.2 µmol/L (at 30 min). Vitamin E alonesignificantly reduced MDA (P = 0.004) and POX concentrations (P = 0.002).Vitamin E plus C completely attenuated the increase in MDA; POX concentra-tions were lowest when vitamin C concentrations were highest (at 30 min).Thus, oxidative stress due to i.v. iron is efficiently neutralized by vitamin E plusC.Supported by Austrian Science Foundation, P8612 & P11690-MED.

REMOVAL OF PROTEIN-BOUND UREMIC TOXINS BY AL-BUMIN-DIALYSIS - IN VIVO RESULTSS Mitzner, J Stange, A Dillmann, R E Winkler1, A Michelsen1, MKnippel2, R SchmidtDept. Nephrology, 2Dept. Clinical Research, University of Rostock,1Dialyse Nord e.V., Rostock, Germany

There is growing evidence that protein-bound metabolites sub-stantially contribute to the group of uremic toxins of the mid-dle-molecule type. Protein-bound organic acids accumulate inESRD patients and are not removed by haemodialysis (HD). 3-Carboxy-4-methyl-5-propyl-2-furanpropionic acid (CMPF) istransported by albumin (binding ratio 98%). CMPF inhibits eryth-ropoiesis, mitochondrial respiration and drug binding to albu-min (Niwa 1994). We investigated the possibility to removeCMPF using standard dialysis membranes and the influence onrenal anemia in the patients treated.CMPF was found to be markedly increased in long term-HDpatients (n=100) compared to normal controls (88,9±61,5µmol/l vs. 14±7,0µmol/l). A total of 8 patients (pts.) were treated withan albumin-dialysis ones every 14 days. Therefore, in additionto the standard dialyzer of the patient a second dialyzer wasintegrated into the blood circuit. Therefore, either a polysulfon(PS, 6pts.) or a polyamid (PA, 2pts.) high-flux-membrane wasused and an albumin containing dialysate (2450ml, c

Alb.3,7g/

dl), that was recirculated in a closed loop circuit.While no CMPF was detected in the dialysate after standard HDand after albumin-dialysis with PS, a clearance between 221and 511 ml/4h was found with the PA. Haematokrit (Hk) wasnot changed in a standard HD control and PS group after sixmonths, whereas an increase from 0,37 to 0,4 resp. from 0,4 to0,42 was seen after 2,5 months in the PA patients (all datacorrected for fluid removal during HD). Results indicate theprincipal possibility to remove strongly albumin-bound uremictoxins using non-albumin-leaking membranes and that this mighthave beneficial effects for long term- HD patients.

EFFECT OF DIALYSIS ULTRAFILTRATION VOLUME (DUFV)ON THE AORTIC DISTENSIBILITY (AoD) OF PATIENTS (pts)ON CHRONIC HEMODIALYSIS (CHD)L.P Soubassi1, A. Vourliotou1, E. Grapsa1, A. Skoutelis1, S.Moutafis1, G. Bougatsos1, P. Soubassis2, P. Toutouzas2, N.Zerefos1

1Renal Unit “Alexandra” Hos., 2Dept of Cardiology Univ. ofAthens, GR.

The AoD, an important parameter of left ventricular function, isreduced in pts with end-stage chronic renal failure and is knownto improve by hemodialysis (HD).We evaluated the relationship between DUFV during HD andits influence on the AoD of the ascending aorta. Twenty nine pts(16 M and 13 F, age range 21-65 y.o., mean age 42), on regularCHD for more than one year, were studied. The AoD was meas-ured before and at the end of the same HD session. All pts wereon bicarbonate HD, received EPO and did not smoke. Sixteenpts were hypertensive. The pts were divided in two groups onthe basis of their DUFV: group I, DUFV < 2 Kg; group II, DUFV≥2Kg. No differences were observed between the two groups re-garding: age, sex, hematocrit, serum creatinine, cholesterol,triglycerides, HDL-C, LDL-C, ApoA, ApoB, Lp(a) and post-HD pulse pressure. The AoD was calculated by the formula:AoD=2x (S-D)/(DxPP) where S is the systolic and D the diastolicaortic diameter and PP the pulse pressure. The aortic diameterswere evaluated with the m-mode in the parasternal long axisview. Pressures were obtained by sphygmomanometry at thebranchial artery.The difference of AoD (cm2 x dyn-1 x 10-6) in group I was 1.15±0.47and in group II = 0.54±0.51. The comparison between the changesof AoD in the two groups showed a statistically significantdifference (student’s t-test, p=0.0003). The above results wereconfirmed by the Mann-Whitney test (p=0.002).In conclusion, the difference of the AoD is impressively im-proved in pts that are mildly fluid overloaded, while it is lesspronounced in severely fluid overloaded pts. The mechanismsas well as the short and long term hemodynamic consequencesof this effect need further evaluation.

LOSS OF VITAMIN C IN DIALYSIS PATIENTSS Maffei, C Canavese, L Sandri, 1A Marciello, S Barbieri, A Messuerotti, GMangiarotti, A Pacitti, D Hamido, A Grill, G Martina, 2P Massarenti, 2MALeonardi, 1U Malcangi, G Piccoli.Dept of Nephrology and 2Gastroenterology-University of Turin, 1NephrologyUnit-Pinerolo, Italy

The absence of an “intelligent” tubule allows a loss in essential elements asvitamins in hemodialysis (HD) patients (pts) treated with mixed dialytic meth-ods employing convection. Ascorbic acid (AA) and dehidroascorbic acid (DHA)serum level determination in 108 HD pts showed deficit in AA (2.1±1.9 mg/l; nv2.6-10 mg/l ) with increasing ratio DHA/AA, which is a peroxidative index(17%, nv <1%). In CAPD pts this ratio was similar (16%).In a perspective study, in 11 pts submitted to three different types of HD inrandomized sequence, we have shown an intradialytic lowering of AA up to70% and an increasing of DHA up to 50%.The total ascorbate (AA+DHA) concentration in ultrafiltrate was highter in ptssubmitted to mixed and convective methods on basal and during intradialyticadministration of 250 and 500 mg of vitC.

In conclusions: 1) an important deficit of AA is frequent in HD pts; 2) it is evidenta peroxidation of the same entity in HD and CAPD; 3) convection increases lossof AA; 4) it is mandatory a regular supplementation, optimized on the basis ofdialysis method.

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HIGH-PERFORMANCE DIALYSIS MEMBRANES ARE USE-FUL IN REMOVING AN ENDOCRINE DISRUPTERDI-ETHYLHEXYL PHTHALATE ELUTED FROM BLOOD CIR-CULATORY TUBESA Ohashi*, J Naito*. H Katsumata, K Murakami, M Hasegawa,M Tomita, H Hasegawa, M Shikano, S Kawashima.Fujita Health Univ College*, Dept of Nephrology, Fujita HealthUniv, Japan

This study was designed to clarify whether high performancemembranes are effective for the removal of di-ethylhexyl phtalate(DEHP), an endocrine disrupter. In vitro experiments, albuminsolution was recirculated in blood tubes for 4 hours and theDEHP concentration in albumin solution was measured byHPLC.The amount of DEHP eluted from the tubes was 0.95 mg.Albumin solution was then recirculated in blood tubes con-nected to regenerated cellulose membranes (CU) and cellulosetriacetate membranes (CTA). The amount of DEHP was 0.72mg for the case of CU membranes (AMFP110) and 0.17 mg forthe case of CTA membranes (FB90U).Thereafter, two different model of CTA dialyzer FB-E55 andFB-F75 were compared in order to examine the influence ofdifferent pore sizes on DEHP removal. The amount DEHP was0.47 mg in the case of FBE and 0.29 mg in the case of FBF, thevalue being smaller for the membrane with the larger pore size.In vitro experiments, DEHP levels were measured in the serumof chronically dialyzed patients before and after HD sessionsusing CU, CTA and PS membranes. DEHP was not detected inthe serum of any of the patients before the HD sessions. How-ever, DEHP was detected in the serum in all the patients afterHD, and the concentrations were 0.69 ± 0.31 mg/l for the case ofCU, 0.4±0.07 mg/l for CTA and 0.25±0.21 mg/l for PS, thelevels being significantly lower for CTA arid PS compared tothat for CU.In conclusion, high-performance membranes are useful for theremoval of DEHP eluted from blood circulation tubes.

OLFACTORY DYSFUNCTION AND DEPRESSION ONHAEMODIALYSIS PATIENTSE. Grapsa*, Ch. Papageorgiou**, N.G. Christodoulou***, E.Samoulidou*, N. Zerefos*, S. Stamatelopoulos*, G.N.Christodoulou**.*Alexandra Hospital Athens, **Psychiatric Dept. University ofAthens Eginition Hospital, ***University College London, Medi-cal School.

In most species odor signals play a critical role in feeding, mat-ing, reproduction and social organization. Olfactory dysfunc-tion has been reported in samples of depressive patients. Ratesof depression which vary between 48% and 100% have beenreported in chronic haemodialysis patients. On the ground ofthese facts, the present study was designed to investigate thefollowing. First, whether the dialysis patients exhibit olfactoryidentification impairments and second to examine the relation-ship between the olfactory identification performance and de-pression in a sample of chronic renal patients before dialysissessions.In order to accomplish the above-mentioned purposes we ini-tially compared 32 patients (16 male and 16 female average age52±2 and on HD for more than 3 months (average 55±9 months).Twenty six (13 male and 13 female) normal controls (averageage 42 years) were matched for sex and age using the Universityof Pennsylvania Smell Identification Test (UPSIT). Addition-ally, the patient group has been divided in two subgroups usingthe Zung rating scale for depression. The analysis has shownthat patients had significantly lower UPSIT scores than the con-trols (p=0.001) and that the depressive dialysis patients hadpoorer olfactory identification ability than the nondepressivepatients (p=0.025).The findings suggest that olfactory deficits do exist in chronicrenal failure patients. This dysfunction may be a critical variablein understanding depression in this medical condition.

INTRAOPERATIVE (INTRAOP) DIALYSIS INHEMODIALYSIS (HD) PATIENTS UNDERGOING CARDIACSURGERYJ D Barata1, M Bruges1, P Branco1, J Q Melo2

S. Nefrologia1, Cirurgia Cardiotoracica2 H. Sta Cruz-Portugal

Purpose: HD patients often need dialysis within the first 24hafter cardiac surgery, the period with more hemodynamic insta-bility (AmJNephrol 1997; 17:435-39). Our purpose was to verifyif intraop HD could delay the posoperative HD.Methods: We studied 17 consecutive HD patients submitted tocardiac surgery with cardiopulmonar bypass and extracorpor-eal circulation (ECC). They were randomly allocated m 2 groupsaccording to the day of the intervention: G1 (n=5) was submit-ted to a classic protocol with only preoperative HD 12h beforeECC; G2 (n=12) was submitted to the same preoperative proto-col plus intraop HD. The intraop HD was performed duringECC, connected to cardiac pulmonary bypass with HD Qb of10% of ECC Qb, with low flux polysulfone dialyser and bicarbo-nate dialysate with K = 3 mEq/l. The criteria to the firstposoperative HD were fluid overload or serum K >5,5 mEq/l.Statistical analysis was perfomed using unpaired t test.Results: Both groups were identical in age (G1=55y vs G2=53y),time on HD (G1=63'±86 vs G2=31'±42), duration of surgery(G1=175'±75 vs G2=211'±61), duration of ECC (G1=81'±37 vsvs G2=123'±81), volume of high K cardioplegia (G1=1240±327mlvs G2=1190±317ml), preoperative HD time (G1=195'±49 vsG2=180'±39) and interval between preoperative HD and sur-gery (G1=19h±5 vs G2=18±6h). Emergency surgery (non elec-tive) occurred only m G2 (3/12); valvular surgery versus coro-nary artery bypass predominate in G2 (6/12 vs 115). Lenght ofentubation time, ICU stay, hospitalization time, blood transfu-sion units and mortality were similar m both groups. Intervalbetween surgery and the need for the first posoperative HD wassignificantly longer in G2 (G1=20±6h vs G2=42±24h) p<0.05.Conclusion: intraoperative HD had an homeostatic effect delay-ing significantly the time for the first posoperative HD.

TARGETS FOR VITAMIN B12 (B12) AND FOLATE (P) TO TREATHYPEROMOCYSTEINEMIA (HYPEROMO) IN DIALYSIS PATIENTS.1A Marciello, L Sandri, C Canavese, S Barbieri, A Messuerotti, Z Hollò, GMartina, 2P Massarenti, 2MA Leonardi, 1U Malcangi, G Piccoli.Dept of Nephrology and 2Gastroenterology–University of Turin, 1NephrologyUnit-Pinerolo, Italy

Actually, the efficacy of B12 and P in lowering homocysteine (HOMO) serumlevels in hemodialysis patients (HD pts) is widely documented. Nevertheless itis necessary to identify the optimal therapeutics “targets” assuring a constantcontrol of HYPEROMO. Two perspective studies have been performed in twocohorts of HD pts: Study 1: in 20 pts, sequential protocol, before performing onlywith P 15 mg x 3/weekly x 3 months (A), then washing-out for 2 months, thenP ev 15 mg x 3/weekly + B12 2 mg/monthly x 3 months (B); Study 2: protocolB for 3 months in other 50 HD pts (33 M, 17 F, 63±13 yrs, 113±96 HD months).Study 1 showed that only the association with B12 allowed the correction ofHYPEROMO.Study 2 showed the lack of efficacy in increasing B12 over 1000 pg/ml and inmaintaining P< 20 ng/ml.

In conclusion, serum levels of B12 of 800-900 pg/ml and of P of 20 ng/ml couldbe therapeutics “targets” to reach and maintain in order to control HYPEROMOin HD pts.

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ON-SITE RAPID EVALUATION OF CONTAMINATION INDIALYSIS FLUID BY MONITORING BACTERIAL ATP WITHFIREFLY LUCIFERIN-LUCIFERASE BIOLUMINESCENCESYSTEM1M. Furukawa, 1M.A. Suzuki, 1I. Aoike, 1Y. Hirasawa, 2H.Tubokawa, 2M. Nakajima.1Kidney Center, Shinraku-En Hospital, and 2Kikkoman Co. Ltd.

Because of recent great attention to bacterial contamination indialysis fluid, maintenance of clean dialysate is thought to beimportant. But more than 24 hours need for ordinary culturemethod. For the rapid and on-site check for contamination, weuterized the newly developed concept to monitor the bacterialATP with firefly luciferin-luciferase (L-L) bioluminescence (LL/BL) system. Principle of L-L/BL system depends on theenzymatic reaction among L-L, ATP and Mg ion, which pro-duces BL. BL intensity, evaluated by the lumitester, depends onbacterial ATP amount.The aseptic bacteria trap filter, bacterial ATP extracting fluid,and L-L reacting fluid were prepared in easy-to-use kit bykikkoman Co.Ltd. In fact, 10 ml of dialysate specimen was ableto be checked its bacterial contamination on-site in minute order.As our preliminary results, BL intensities, indicating bacterialATP amounts in relative luminescence unit (RLU), showed posi-tive relationship to bacterial counts in CFU/mI (n=14, R=0.7322,p<0.005). And BL intensities also showed positive corelationshipto the endotoxin (ET) levels in IU/I (n=14, R=0.7778, p<0.0005).In 5 clinical dialysis sessions, ATP amounts (RLU) in dialysisfluid at outlet port of dialyzers increased as follows: 208 ± 136(0 Hr), 460±147 (1 Hr), 497 ± 148 (2 Hr), 991 ± 820 (4 Hr)respectively.In conlusions, L-L/BL system can provide the on-site and rapiddicision of the bacterial contamination in dialysis fluid in minuteorder. And BL intensities (bacterial ATP amounts) also can indi-cate the bacterial counts and ET levels in minute order.

HOMOCYSTEINE IS THE USEFUL MARKER FOR EVALUA-TION OF ATHEROSCLEROSIS IN PATIENTS ONHEMODIALYSISOishi K, Nagake Y, Yamasaki H, Wada J, Makino HDepartment of Medicine III, Okayama University Medical Schhol,Okayama, Japan

Atherosclerotic diseases are the major cause of mortality andmorbidity in patients on hemodialysis (HD). To evaluate thesignificance and usefulness of atherogenic factors, we examinedlipoprotein (a) (Lp(a)), remnant like particles cholesterol (RLP.C),homocysteine (Hcy), cardiac troponin T (TnT), and ankle-armblood pressure index (AABI) in patients on HD. We measuredthese indices in 114 patiens on HD (male 79, female 35; age 62.1± 1.3 year). Stepwise multiple regression analysis was used toassess the influence of multiple variables on atherosclerotic dis-ease (ASC), including coronary artery diseases (CAD), cerebrov-ascular diseases (CVD) or peripheral vascular diseases (PVD).As a result, TnT and AABI in patients with diabetes mellitus(DM) (n=33) were significant higher compared with those with-out DM (n=81). In patients with CAD, TnT and AABI weresignificant higher compared with patients without CAD. In pa-tients with CVD, RLP.C, Hcy and AABI were significant highercompared with patients without CVD. In patients with PVD,Hcy and TnT were significant high values as compared withpatients without PVD. Multiple regression analysis showed thatDM, Hcy and age were independent factors associated withASC; as follows. ASC= -0.348+0.426 XDM+0.005 XHcy+0.010X Age (p<0.001)In conclusion, presence of DM and high age are major determi-nants for atherosclerosis. In addition, Hcy is an independent riskfactor for atherosclerosis in the presence or absence of DM.

PROFILED HEMODIALYSIS AND INTRADIALYTIC HYPOTENSION.Colì L, De Pascalis A, La Manna G, Dalmastri V, Isola E, **Ursino M, *Zacà F,Stefoni S.Department of Clinical Medicine and Applied Biotechnology; *Department ofInternal Medicine, Cardioangiology and Hepatology, St. Orsola UniversityHospital, Bologna; **Department of Electronics, Computer Science and Sys-tems, University of Bologna

Symptomatic hypotension is today the most frequent intradialytic complica-tion. Recently the profiling of some hemodialysis operative parameters, such assodium dialysate concentration and UF, has been proposed for routine use inorder to prevent intradialytic hypotension. In the last few years we set up amathematical model which allows a rational choice of sodium dialysate con-centration and UF profiles on the basis of the patient clinical needs (sodiummass to be removed and weight loss to be reached at the end of the session).This work aims to clinically validate the Profiled Dialysis (PHD), based on ourmathematical model, testing its ability, as against Standard Dialysis (SHD), tomaintain a more stable intradialytic BV. 12 uremic patients affected byintradialytic hypotension were selected for the study. Each patient underwent aSHD and a PHD session in a randomized sequence and with identical operativeconditions, including sodium mass removal and total ultrafiltration volume.The crit-line and doppler-echocardiography were used to determine blood vol-ume (BV), cardiac output (CO) and stroke volume (SV) throughout the sessions.Mean blood pressure (MBP) and heart rate (HR) were measured directly.Tests were made at 0', 15', 60', 240' and at 1 hour after the session end. Thestatistical analysis was made by means of the Paired T Student Test. PHD re-sulted significantly more stable in terms of intradialytic BV, SV and CO ascompared to SHD in all patients. The higher stability of BV, SV and CO whichwere obtained above all in the first half of PHD session were associated with anensuing higher stability in MBP and in HR. SHD, compared to PHD, was char-acterized by early significant changes in BV, SV and CO resulting in a signifi-cant decrease of MBP and in an ensuing HR increase during the whole sessionand till one hour after the end of dialysis.In conclusion, results show that PHD represents an efficacious approach, alter-native to SHD, for the treatment of intradialytic intolerance.

DIFFERENCES IN VASCULAR REACTIVITY BETWEEN ISOLATED ULTRAFILTRATION(I-UF) AND HAEMODIALYSIS COMBINED WITH ULTRAFILTRATION (UF+HD):COMPARISON BETWEEN THERMAL ENERGY BALANCE (TEB) AND DIFFERENTDIALYSATE TEMPERATURES (TD).FM van der Sande, U Gladziwa1, G Bocker1, JP Kooman, KML Leunissen.Dept of Internal Medicine, University Hospital Maastricht, The Netherlands and1Kuraturium fur Dialyse, Wurselen, Germany

Haemodynamic stability is better maintained during i-UF compared to standard UF+HD.This might be explained by multiple factors during UF+HD and especially by differencesin TEB. In contrast to i-UF, body temperature (BT) increases during UF+HD, which mightbe responsible for the impaired vascular reactivity. It is however not known whether BTshould remain stable or decrease in order to achieve the same vascular reactivity duringUF+HD as in i-UF. In this study, we assessed changes in forearm vascular reactivity (DFVR,mmHg/ml/dl/min; strain-gauge plethysmography), mean arterial pressure (DMAP,mmHg), and BT (DBT, 0c) in 10 chronic HD patients. Changes in TEB (DTEB, kJ) werestudied with a Fresenius Blood Temperature Monitor (BTM), according to the formula:TEB = c ⋅ ρ ⋅ Qb ⋅ (Tv - Ta) . time, [c=specific heat capacity of blood (3.64 kJ/(kg ⋅ °C), ρ =blooddensity (1052 kg/m3), Qb=blood flow, Tv and Ta=temperature in the venous and arterialblood line]. The BTM can also be used to model BT and TEB during HD. At differentoccasions, all patients were studied in a randomized order during 1 hour with the follow-ing treatment modalities: i-UF, UF+HD (Td 37.5°C), UF+HD (Td 35.5°C), UF+HD (TEB-set) with a pre-set TEB at the same level found for that particular patient during i-UF, andUF+HD (BT-set) in which the BTM was programmed to keep BT stable. All patients werestudied at the same UF-rate (1000 ml/hour). All parameters were assessed before andafter 1 hour of treatment. A p value < 0.05 was considered significant. Data are given inmean (SD).

Results: i-UF UF+HD 37.5 UF+HD 35.5 UF+HD TEB-set UF+HD BT-setDFVR +20.3(15.9)*# +6.8(21.0) +9.1(10.7)* +22.1(29.8)+# +14.5(13.3)*#DMAP -0.4(11.8) - 9.8(16.6) +7.5(14.4) +1.0(10.3) +3.2(13.2)DTEB -96.8(14.9)*# +1.8(12.1) -64.6(12.3)*# -100.1(18.8)*# -33.6(22.4)*#DBT -0.5(0.3)*# +0.1(0.1)* +0.0(0.2) -0.3(0.2)*# +0.2(0.1)*(Before vs after: * p<0.05. Compared to UF+HD 37.5: # p<0.05)

Conclusion: FVR increased significantly during all treatment modalities except for UF+HD(Td 37.5°C), and was highest during i-UF and UF+HD (TEB-set), suggesting that the mostoptimal vascular reactivity is achieved with a more negative TEB and/or decrease in BT.However, in contrast to UF+HD (Td 37.5°C), FVR also increases when the rise in BT duringUF+HD is prevented, suggesting that the increase in BT during UF+HD (Td 37.5°C) islargely responsible for the impaired haemodynamic stability during this treatment modal-ity. Energy modeling might enable us to individualize the dialysis prescription with regardto the maintenance of haemodynamic stability.

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THE DP/DT (max) DERIVED FROM ARTERIAL PULSE WAVEFORMS: APPLICATIONSIN THE HEMODIALYSIS (HD) SETTINGJ Kyriazis, J Glotsos, G Georgiopoulos.Dept. of Nephrology, General Hospital of Chios, Chios, Greece

A new noninvasive technology (Dynapulse 5000A) can provide measurements of isolatedpressure and rate of pressure change. Given the existing good correlation between pe-ripheral dp/dt (max) and left ventricular dp/dt(max), obtained invasively (Am J Cardiol,80: 323-330), the arterial pulse’s derivative can be conceived as an index of cardiaccontractility. In the present study, we investigated the associations between brachialpulse’s dp/dt (max) and other hemodynamic parameters, taken by echocardiography(ECHO) and transthoracic electrical bioimpedance (TEB) in the HD population.In study 1, eighteen HD patients, aged 64±15 years, underwent ECHO evaluation andhad their blood pressure measured with a pulse dynamic (PD) monitor on the day preced-ing HD. Dp/dt (max) was obtained by analyzing the arterial waveform. In studyD2, a TEBmonitor was used to assess systemic hemodynamics, before HD and at one-hour intervalsduring HD, in 4 HD patients. At the same time blood pressure was taken with the samePD monitor, for dp/dt (max) calculation.

Study 1parameter SBP EF FS ESS/ESV PP VFC

(mmHg) (%) (%) (mmHg) (circ/sDP/dt(mmHg/s) 0,631** 0,478* 0,467* 0,631** 0,861*** 0,172r, *=p<0,05,**=p<0,01, ***=p<0,001, SBP= systolic blood pressure, EF=ejection fraction,Fs=fiber fractioning, ESS/ESV= end systolic meridional stress/end systolic volume,PP=pulse pressure, VCF=velocity of circumferential fiber shortening.

Study 2parameter SBP EF SI LCWI PP ACI

(mmHg) (%) (ml/m2 (Kgm/ m2 (mmHg) (sec2)

Dp/dt(mmHg/s 0,608** 0,512* 0,537* 0,571* 0,674** 0,459*r, *=p<0,05,**=p<0,01, SI= stroke index, LCWI=left cardiac work index, ACI=accelerationindex

In both studies, the peripheral pulse’s dp/dt (max) correlated significantly with almostall indices of cardiac contractility, SBP, LCWI, and PP, an inverse determinant of arterialcompliance.Our results show that the brachial pulse’s dp/dt (max), obtained with the use of a singlecuff sphygmomanometer, can be used as an additional parameter to assess cardiovascularfunction. It may prove to be a valuable tool to monitor hemodynamic changes during HDand may be adopted in the evaluation of the effects of therapeutic interventions oncardiac function.

VARIABILITY OF RELATIVE BLOOD VOLUME DURINGHEMODIALYSISHP Krepel, RW Nette, E Akçahüseyin, W Weimar, R Zietse.Dept. of Internal Medicine I, University Hospital Rotterdam-Dijkzigt, Rotterdam, the Netherlands.

A decrease in blood volume is thought to play a role in dialysisrelated hypotension. Changes in relative blood volume (RBV)can be assessed by means of continuous hematocrit measure-ment. We wanted to study the variability of RBV changes, andinvestigate the relation between RBV and ultrafiltration volume(UV), blood pressure, heart rate, and inferior caval vein diam-eter (ICVD). In ten patients on chronic hemodialysis, RBV-meas-urement was performed using the Crit-line device (In-line Diag-nostics) during a total of 100 hemodialysis sessions lasting 4hours. Blood pressure was measured at 5-minute intervals. ICVDwas assessed at the start and at the end of dialysis using ultra-sonography. The changes in RBV showed considerable inter-individual variability. The average change in RBV ranged from -0.5 to –8.2 % at 60 min. and from –3.7 to – 14.5 % at 240 min.(coefficient of variation (CV) 0.66 and 0.35 respectively). Intra-individual variability was also high (CV60 0.93 and CV2400.33). We found a significant correlation between RBV and UVat 60 (r = -0.69; p<0.001) and at 240 min. (r = -0.63; p<0.001).There was a significant correlation between RBV and heart rate(r = -0.39; p<0.001), but not between RBV and blood pressure.The level of RBV reduction at which hypotension occurred wasalso highly variable. ICV-diameter decreased from 10.3 ± 1.7mm/m2 to 7.3 ± 1.5 mm/m2. The change in ICVD showed awide variation. There was a slight, although significant, correla-tion between ICVD and RBV (r = 0.23; p<0.05).We conclude that RBV changes show considerable intra- andinter-individual variability. Part of this variability may be causedby differences in UV. No correlation was observed betweenchanges in RBV and either blood pressure or the incidence ofhypotension. As heart rate was significantly correlated with RBV,the critical level of reduction in RBV at which hypotension oc-curs depends on cardiovascular defense mechanisms such assympathetic drive.

CALCIUM PROFILING(CP) DURING HEMODIALYSIS(HD)J Kyriazis, J Glotsos.Dept. of Nephrology, General Hospital of Chios, Chios, Greece

Low dialysate calcium (LdCa) is being used as a means to prevent or treat HD inducedhypercalcemia. However, LdCa has been shown to decrease blood pressure (BP) duringHD. The goal of our study was to explore the possibility that CP can ameliorate LdCainduced intradialytic hypotension.In a randomized cross over design, six HD patients underwent one 4- hour HD sessionwith LdCa (1.25 mmol/l) and one 4-hour HD session with LdCa during the first 2 hoursand HdCa (1.75 mmol/l) during the remaining 2 hours. Before HD and at four 60' inter-vals during the HD session, the hemodynamic parameters, shown in table, were meas-ured noninvasively, with a thoracic bioimpedance monitor (NCCOM3-R7S). Blood sam-ples were drawn at 0', 120' and 240' for determination of ionized serum calcium (iCa)Mean UF-rate was 290 ml/hr on both study days

LdCa-HdCa groupTIME min 0 60 120 180 240MAP mmHg 87±7 87±8 80±3 83±7 89±7CI L/min/ m2 3,8±1,1 3,7±1,4 3,7±1,4 4±1,6 4,1±1,5SSVRI FL.Ohm.m2 168±103 176±111 157±72 158±81 167±88LCWI Kgm/m2 59±21 55±20 50±23 59±30 58±20iCa mmol/l 1,19±0,9 1,15±0,5 1,27±0,6MAP=mean arterial pressure, CI=cardiac index, SSVRI=stroke systemic vascular resist-ance index, LCWI=left cardiac work index.

LdCa groupMAP mmHg 91±7 84±6 86±7 83±10 76±7CI L/min/ m2 3,9±1,1 3,9±1,3 3,7±1,2 3,7±1,1 3,5±0,9SSVRI F.Ohm.m2 167±92 162±83 167±88 170±92 154±66LCWI Kgm/m2 60±24 58±20 49±16 48±14 44±10iCa mmol/l 1,19±0,6 1,15±0,4 1,16±0,5

Anova for repeated measures showed that MAP (p<0,05), LCWI (p<0,05) and iCa (p<0,001)increased significantly during the last 2 hours in the ldCa- HdCa group as compared toLdCa group. Likewise, CI increased but not significantly, whereas no changes in SSVRIwere noticed. In the LdCa-HdCa group, iCa correlated significantly with CI (r=0,512,p<0,05)Our results show that the BP drop observed, during the last two hours of HD, in the LdCagroup, was abolished in the LdCa-dCa group. This later was accomplished via an increasein cardiac output, due to an iCa-induced increase of myocardial contractility. Therefore,CP, by individualizing the dCa concentration and timing of switching, may improveintradialytic BP instability, in HD patients, who are in need to be dialyzed with LdCa.

REMOVAL OF AGES BY HEMODIALYSIS, HEMODIA-FIL-TRATION AND HEMOFILTRATION - A COMPARISONA Gerdemann1, R. Schinzel1, G Münch1, A Heidland2, U. Bahner2,E. Quellhorst3, R Pohlmeier4, J Vienken4,1Univ. Wuerzburg, Physiologische Chemie I, 2KHD Wuerzburg,3Nephrolog. Zentrum, Hann. Münden, 4Fresenius Medical Care,Bad Homburg, FRG

Advanced Glycation Endproducts (AGEs) are considered to beinvolved in many complications of diabetes and of ESRD. Pa-tients on hemodialysis show increased levels of AGEs and, con-sequently, removal of AGEs should reduce AGE-mediated com-plications. In this study the efficiency of different dialysis mo-dalities to remove AGEs was investigated using fluorescencespectroscopy (dialysate and serum), ELISA (serum) and gelfiltration with fluorescence detection (serum and dialysate) asmethods. Analysis of the MW distribution of AGEs in serumshows that the majority of AGEs are linked to proteins with aMW above 20,000 and therefore cannot be reduced by standarddialysis or filtration procedures. HD, HF and HDF remove mol-ecules with a MW below 3,000 efficiently, but these compoundscomprise only for about 5% of the total fluorescence in serum.The AGE-typical fluorescence in the dialysate was reduced downto 40-50% by all three methods in the course of a dialysis ses-sion. This reduction was accompanied by a corresponding 50%decrease of the low-MW fraction of serum AGEs, while the over-all AGE level is only reduced by about 10% by either of thedialysis methods used. However, the steady state serum AGElevels in patients on HF and HDF appear to be 25% and 30%lower, respectively, than in patients on HD, which might be ex-plained by a lower generation rate using these modalities.

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HYPERHOMOCYSTEINAEMIA AND LIPID PEROXIDATIONIN HAEMODIALYSIS: PREVENTIVE ROLE OF FOLIC ACID.Bayés B, Bonal J, Pastor C, Juncà J, Romero R.Hospital Universitari “Germans Trias i Pujol”. Badalona. Spain.

Patients on haemodialysis (HD) are at high risk for cardiovas-cular disorders. Hyperhomocysteinaemia is an independent riskfactor for atherosclerosis and homocysteine (Hcy) auto-oxida-tion favours LDL (low-density lipoprotein) peroxidation. Folicacid administration reduces plasma homocysteine (Hcy) levels.Objective: To study the effect of folic acid onhyperhomocysteinaemia and lipid peroxidation in patients onchronic HD. Malonyldialdehyde (MDA) and antibodies anti-oxidized LDL (IgG-oxLDL) were determined as lipidperoxidation parameters.Patients and Methods: Sixteen stable patients (11 men, 5 women;mean age: 54.3 years) on conventional HD received 10 mg folinicacid e.v. at the end of HD for four weeks. Plasma Hcy and MDAwere monitored by FPIA and the fluorimetric method of Yaggi,respectively. The presence in plasma of IgG-oxLDL was as-sessed by an ELISA method. Statistical study: Wilcoxon’s test.

Results:n=16 s-fol Ery-fol Vit B12 Hcy MDA IgG-

ng/ml ng/ml pg/ml µmol/l µmol/ml oxLDLHD 7±3 301±143 532±327 44.3±25 4.6±1.4 3.5HD+Fol 17±3 392±91 648±398 19.4±7 3.8±1.3 3.3

*p=0.01 *p=0.02 *p=0.04 *p=0.03 *p=0.01 *p=0.02s-fol: serum folic acid; ery-fol: erythrocytic folic acid; vit B12: vitamin B12.

Conclusions: Folinic acid improves hyperhomocysteinaemia,preventing lipid peroxidation in HD patients. The decrease in-duced in homocysteinaemia and IgG-oxLDL levels can improvecardiovascular prognosis.

LIPID PEROXIDATION IN HAEMODIALYSIS: EFFECT OF VITAMIN E SUP-PLEMENTATION.Bayés B, Bonal J, Pastor C, Romero R.Hospital Universitari “Germans Trias i Pujol”. Badalona.

Cardiovascular diseases are the first cause of death in haemodialysis (HD)patients and hyperhomocysteinaemia is an independent cardiovascular riskfactor. Oxidative stress may induce an increase in LDL (low-density lipopro-tein) oxidation, thus contributing to atherogenesis. The organism possessesmechanisms to block oxidative stress, with α-tocopherol (vit E) being the mainantioxidant vitamin.Objective: The effect of vitamin E supplementation on lipid peroxidation andhyperhomocysteinaemia was studied. We monitored the presence of antibodiesanti-oxidized LDL (IgG-oxLDL).Material and Methods: The study group was composed of 12 stable patients(mean age: 49 years) on standard haemodialysis. All patients underwent e.v.treatment with erythropoietin and iron. They received 400 mg of vitamin Eorally at the end of HD for 3 months. Blood samples were drawn in the morningafter overnight fast and prior to dialysis. Plasma vit E was analysed by high-resolution liquid chromatography (HRLC). MDA was determined by thefluorimetric method of Yaggi et al. Plasma IgG-oxLDL was assessed by anELISA method and plasma homocysteine by FPIA. Statistical study: Wilcoxon’stest.Results are shown in the table.

n=12 LDL mmol/L Vit E µg/dl IgG-oxLDL Hcy µmol/lHD 2.72 1015 3.2 46HD+vitE 2.80 2076 2.4 33

*p<0.01 *p<0.02 p=0.2

Conclusions:Vitamin E improves lipid peroxidation in HD patients. Since IgG-oxLDL andhomocysteine levels decrease, the risk of atherogenesis is lower, thereby pre-venting or delaying cardiovascular complications.

DAILY HEMODIALYSIS (HD) IMPROVES Na/H EX-CHANGE (NHE) IN LYMPHOCYTES OF HD PA-TIENTS.1S Rovidati, 1F Galli, 1J Bianchi, 1F Canestrari, 2UBuoncristiani.1”G.Fornaini”Institute of Biological Chemistry, Univer-sity of Urbino; 2Nephrology and Dialysis Unit, “R.Silvestrini” Hospital, Perugia.

We evaluated intracellular pH (pHi) and Na+/H+ ex-changer activity in peripheral lymphocytes from pa-tients on both weekly (wHD) and daily HD (dHD).pHi was measured using the fluorescent probe BCECF(2’,7’-bis-(2-carboxyethyl)-5(6)-carboxyfluoresceinacetoxymethyl ester) in nominal absence of bicarbo-nate (Hepes solution, pH 7.2). We found that predialysispHi was lower in weekly HD patients than in the dailyones and controls. These results suggest thatlymphocytes of wHD patients have an ineffective pHiregulation, which can be caused by a reduced NHEactivity. In fact, when lymphocytes were incubated withdimethylamiloride, a specific Na+/H+ antiporter in-hibitor that causes acidification in cells, the decreasein pHi was lower in the wHD patients than in dHDones (0.03+/-0.02 vs 0.07+/-0.01; p<0.05). This evi-dence suggests that in dHD there is a better regulationof pHi than in wHD.

CARDIAC OUTPUT (CO) AND CENTRAL BLOOD VOLUME(CBV) MEASUREMENTS DURING HEMODIALYSISN. Krivitski1, V. Kislukhin1, J. Snyder1 A. Reasons2, T. Depner2,1Transonic Systems Inc., Ithaca, NY and 2University of Califor-nia, Davis, USA

The methodology of recent introduced indicator dilution methodfor measuring CO and CBV (volume of blood in heart and lungs:CBV=CO(MTT where MTT is mean transit time of the salinebolus through the cardiopulmonary system) was examined forsources of error and their correction. This method uses arterialand venous sensors (HD01, Transonic Systems, Inc., Ithaca,NY) to measures the change in ultrasound velocity induced by a30 ml bolus of normal saline injected into the venous line. Foursources of error were identified: (1) access recirculation (AR), (2)second pass of the indicator through the cardiopulmonary cir-cuit, (3) long injection time, and (4) the additional time requiredfor the indicator to pass through the blood lines.AR causes a portion of the injected bolus to short-circuit thecardiopulmonary route. This problem was solved first by iden-tifying AR; second by eliminating AR (reducing the pump flow).The second pass of the indicator deceptively increases the areaunder the dilution curve, causing an underestimation of CO.Since the second pass appearance time is the same as the first,timing measurement were used to separate these curves. Pro-longing the injection time of the venous bolus caused poor sepa-ration of the first and second dilution curves. An analysis ofmore then 3,000 curves showed satisfactory separation if theinjection was completed within 7 seconds. A customized ve-nous line disposable allows a quick 30 ml injection.Summary: After the algorithm was adjusted for the abovesources of error, the reproducibility of CO and CBV measure-ments, expressed as the absolute percent deviation from theaverage of duplicates (3488 values duplicated within 5 min-utes) was 4.3±3.8% for CO and 4.1±3.8% for CBV. We concludethat cardiac output and central blood volume can be routinelyand reliably measured during hemodialysis.

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MECHANICAL THROMBECTOMY AS A TREATMENT OF THROMBOSISOF VASCULAR ACCESS FOR HAEMODIALYSIS.JL Górriz, J. Martinez-Rodrigo1, A. Sancho, J. Palmero1, A. Avila, L. de la Cueva2,JF Crespo, I. Blanes3, E. Caballero2, LM Pallardó.Departments of Nephrology, Radiology1 Nuclear Medicine2 and Vascular Sur-gery. Hospital Universitario Dr. Peset. Valencia. Spain.

Percutaneous treatment of thrombosis of occluded vascular access (VA) forhaemodialysis (HD) has been considered as an alternative to surgical and phar-macological treatments, but long term results has not well defined. The aim ofour study was to evaluate the results of mechanical thrombectomy (MT) with-out urokinase for the treatment of recent VA thrombosis.From February 1996 to December 1998, 72 MT were performed in 51 consecu-tive patients referred to our hospital because recent thrombosis of VA. Clot wasmacerated and pushed into the central circulation with angioplastic ballooncatheters (Medi.tech®, Boston Scientific Corp.). In 20 cases pulmonary perfu-sion scintigraphy was performed before and after MT. Underlying lesions weredilated or stented if they were present. After the procedure, 7 (9.7%) were re-ferred to the surgeon to perform a new VA due to the presence of aneurismaticfistulae or stenosis longer than 6 centimeters, and they were exclude from thestudy. Then, we analized 65 MT in 44 patients. There were 10 Brescia-Ciminofistulae (23 %) and 34 PTFE grafts (77%). Patients characteristics: mean age: 62± 18 years (range: 14-84), previous VA: 3,3 ± 2,4 (0-9). The mean follow-up afterMT was 10.5 ± 8.6 months (range: 3-34).MT was able to remove the clots in all cases, detecting stenosis more than 60%in all but one (98.7%). Three cases (6.8 %) showed early thrombosis (< 48 hours).In the follow-up one patient received a kidney transplant (2.3%), 4 died (9.1%),16 showed thrombosis in a mean of 7.3 ± 8.4 months (0-34), and 20 VA are stillpatent (45.5 %). Thirteen patients (29.5%) required two o more procedures. Pri-mary patency was 42 %, 30 % and 18 %, and cumulated patency was 60 %, 46%and 40% at 6, 12 and 18 months respectively. There were not relevant undesir-able effects related to the technique neither symptomatic pulmonary embolism.Only two patient’s scintigraphy (10 %) showed minimal changes after proce-dure, without clinical significance.In conclusion, MT has been an efficacious treatment of clotted VA for HD, pre-serving the VA with long-term satisfactory results. The procedure is relativelyinexpensive, safe, and well tolerated.

VASCULAR ACCESS IN PATIENTS OVER 65 YEARS OF AGE. IS THE NA-TIVE ARTERIOVENOUS FISTULA THE FIRST ANGIOACCESS CHOICE?W. Weyde, W. Letachowicz, M. Krajewska, G. Laskowska, M. Szwedko, M.KlingerDept. of Nephrology, Univ. of Medicine, Wroclaw, Poland

Demographic changes in the developed countries modify their age profile. Regu-lar increase in percentage of people over 65 in population corresponds withpatients over 65 years of age requiring haemodialysis treatment. Difficulties increating the permanent vascular access in this group are caused by, among otherthings higher incidence of diabetes mellitus and vascular diseases.Recently significant increase (approximated 75%) in creation of native arterio-venous fistulas on the forearm of patients over 65years is visible (Nephron1996,73:342).We would like to describe our experiences in 79 haemodialysis patients over 65years of age (40 females, 39 males, aged on an average 70 years, max.84 years).Primary renal disease of patients starting haemodialysis was interstitial neph-ropathy of 22 cases, chronic glomerulonephritis of 5, adult polycystic renaldisease of 8, vascular nephropathy of 20, diabetic nephropathy of 18 and un-known origin of 4 and others of 2 patients. Native arteriovenous fistula (Cimino-Brescia) was attempted in all patients. Because of destroyed superficial veins in2 patients the transposition of ulnaris vein to the anterior aspect of the forearmwas made. The perforating vein was used in 4 patients and in 1 patient ulnarisfistula was performed. Only in 1 patient AV fistula on the arm was created.Because of no possibility to create vascular access 1 patient was transferred toCAPD. On the whole, the functioning arteriovenous fistula was created in 78patients, in whom 94 operations were performed (1.2 operations per patient).These results are comparable to our remaining haemodialysed population(Nephrol Dial Transplsnt 1998; 13 : 528 )Conclusion: Our data prove that a native arteriovenous fistula on the forearmis the technically feasible permanent vascular access in the majority of chronichaemodialysis patients over 65years of age.

INCREASE IN BLOOD VOLUME DURING DIALYSIS WITH-OUT ULTRAFILTRATIONRW Nette, E Akçahüseyin, HP Krepel, W Weimar, R Zietse.Dept. of Internal Medicine Ι, University Hospital Rotterdam-Dijkzigt, Rotterdam, The Netherlands.

Combined dialysis and ultrafiltration leads to more frequentepisodes of hypotension than isolated ultrafiltration. It is gener-ally assumed that during hemodialysis without ultrafiltration anet fluid shift takes place from the extracellular to the intracellu-lar compartment that is due to urea and sodium kinetics. There-fore, a even larger decrease in plasma volume takes place due tovolume shifts in combination with ultrafiltration. The changes inblood volume during dialysis without ultrafiltration have notbeen reported. We therefore studied six patients on chronichemodialysis (three times four hours a week, using bicarbonateas a buffer and polysulfone membranes), in which ultrafiltra-tion was not necessary. Relative blood volume (RBV) was con-tinuously monitored by means of hematocrit measurement(Critline device) and by means of total protein concentrations(BVM device). To exclude a change in erythrocyte volume, wemeasured mean corpuscular volume (MCV) at the beginningand end of each treatment. In all patients relative blood volumeincreased significantly during the first two hours of treatmentby 2.39 ± 1.36 and 2.45 ± 0.81 % respectively. Comparing RBVmeasurements using hematocrit and protein estimations showedno significant differences. The observed increase in RBV did notresult from a change in MCV (91 ± 3.7 vs. 92 ± 2.8 fL). Norelation was found between change in RBV and initial sodiumand urea concentrations. Systolic blood pressure and heart rateremained unchanged during the procedure (141 ± 35 vs. 148 ±39 mmHg and 84 ± 9.8 vs. 87 ± 8.8 bpm respectively).We conclude that during dialysis without ultrafiltration relativeblood volume increases rather than decreases, as would havebeen predicted by classical solute kinetics. The hypotensive ef-fect of diffusive dialysis does not result from intercompartimentalfluid shifts but rather from changes in vascular reactivity.

WHOLE AND REGIONAL BODY COMPOSITION IN HAEMODIALYSIS PA-TIENTSA. Gerakis, A. Barbatsi, I. Pappas, A. Rousakis D. Valis.Renal Unit and Medical Imaging Department, Diagnostic and Therapeutic Centerof Athens “Hygeia”, Athens, Greece.

Body composition in fat mass (FM), lean soft tissue mass (LSTM) and bonemineral content (BMC) can be easily and accurately measured by dual-energyX-ray absorptiometry (DEXA), not only in the whole body but also in three bodyregions (arms, legs and trunk). Since such data are scarce in haemodialysis (HD)patients, we examined 69 patients, 42 men and 27 women, with body mass index24±3.6 kg/m2 (mean±SD), 59±13 years old, who were on HD for 47(range: 6-207) months. Whole and regional body composition was determined in all pa-tients after HD session by DEXA. Trunk FM to arms and legs FM ratio (%) isused as an index of fat distribution. Results are expressed in Kg and in % (ofmeasured area) (table).

Body regions FM LSTM BMCKg % Kg % Kg %

Arms 4.6±2.9 39±14 6.3±2.2 61±14 0.32±0.1 3.1±1.2Legs 6.5±2.5 32±9 13.6±3 67±9.5 0.86±0.3 4.6±3.3Trunk 9.3±3.8 31±9 20±4.5 69±8.6 0.66±0.2 2.2±0.5Whole body 21.6±9 32±10 42.3±8.2 64.6 ±9 2.31±0.6 3.5±0.6

There was preponderance of FM (%) in women compared to men in whole body(37±9.7 vs 29±8, p<0.001) and in the other regions. Age and duration on HD,apart from a negative correlation with BMC (r=-0.35, p<0.01), did not correlatewith body compartments. After adjustment for scale artifact, only arm LSTMshowed a week correlation with arm BMC (0.4, p<0.001). Finally, trunk FM toarms and legs FM ratio (%) was higher in men compared to women (102±25vs68±16, p<0.001).In conclusion, DEXA can be easily used to measure not only the whole but alsothe regional body composition of HD patients. However, data from a large poolof general population is needed to compare with that of HD patients, in order todetermine DEXA’s clinical usefulness in assessing nutritional and metabolicdisorders.

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ETIOLOGY OF PORPHYRIA CUTANEA TARDA IN PATIENTSON MAINTENANCE HEMODIALYSIS AND KIDNEY TRANS-PLANT RECIPIENTS.J. Šperl, E. Krejcová, M. Jirsa, M. Summerová, V. Nemecek, J.Kašlíková, Š. Vítko.Inst Clin Exp Medicine, Prague, Czech Republic.

Aim: The aim of the study was to elucidate the altered porphy-rin metabolism and its relationship with porphyria cutanea tarda(PCT) in patients on maintenance hemodialysis. Methods: Theactivity of uroporphyrinogen-decarboxylase in erythrocytes(URO-D), total plasma porphyrins (PP) and porphyrin concen-trations in urine and feces were determined in 19 patients withchronic renal insufficiency (CRI) on conservative therapy, 77patients on maintenance hemodialysis (HD), 54 patients afterkidney transplantation (TX) and 10 healthy volunteers. Results:PP were significantly higher in patients on HD compared withother groups (p<0.01). No difference in URO-D activity wasfound between the groups of patients with CRI, on HD andcontrols, but higher values were found in patients after TX. Noclinical signs of decreased liver URO-D activity were present, nofecal isocoproporphyrin was detected and no significant differ-ences were found in other parameters. Chronic HCV infectiondid not influence URO-D activity in erythrocytes. Conclusion:Occurrence of PCT in hemodialyzed patients is thus not only acomplication of hemodialysis, but ineffective elimination ofplasma porphyrins in patients on HD may lead to clinical mani-festation of hitherto latent URO-D deficiency.

Controls CRI HD HD HD TX TX TXNumber 10 19 52 12 13 33 6 8anti-HCV - - - + + - + +HCV-RNA - - - - + - - +URO-D 28.5 43.6 26.4 27.6 28.1 51.7 56.9 25.8(nmol/mL/hr) ± 4.2 ± 25.4 ±13.2 ± 11.6 ± 11.7 ± 31.0 ± 23.7 ± 5.5Plasma por. 1.4 3.6 12.9 12.4 16.9 2.2 2.9 2.3(nmol/L) ± 0.4 ± 2.2 ± 8.8 ± 8.9 ± 6.6 ± 1.0 ± 1.4 ± 2.2

ARE ADVANCED GLYCATED END PRODUCTS (AGES) INVOLVED IN THEDEVELOPMENT OF PRURITUS IN HEMODIALYSED PATIENTS (HD)?E. Golan, G. Rashid, S. Benchetrit, E. Zeltzer, P. Oss, S. Gavrieli, Y. Benshushan,J. BernheimDept. of Nephrology and Hypertension, Sapir Medical Center, Meir Hospital,Kfar-Saba and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Is-rael

In vitro studies have recently shown that AGEs stimulate mast cells activity. Asmast cells are involved in allergic reactions and pruritus, pruritus is a frequentand disabling complaint in HD and AGEs are elevated in blood of HD patientswe carried out this study looking for the possible involvement of AGEs in thedevelopment of pruritus in HD patients.We measured blood level of AGEs and histamine in 38 chronic stable HD pa-tients (24M, 14F, age 64.9±14yrs) treated trice weekly, 4hr/session, using bicar-bonate buffer, polysulfone or triacetate dialyzers without reuse. Pruritus was amajor complaint in 16 patients (10M, 6F). Non had allergic, skin or autoimmunediseases.AGEs were measured by spectrofluorometry (with excitation/emission 370/440nm), histamine by ELISA. Normal values: AGEs 0.66±0.11 u/mg protein,histamine ≤ 1 ng/ml. Histamine blood level was within the normal range in allbut one patient (1.07ng/ml). The blood level of AGEs was elevated, 2.14±0.53,confirming previous reports. In the 16 patients with pruritus AGEs blood levelwas 2.36±0.45 as compared to 1.99±0.53 in the 24 patients without pruritus.This difference is statistically significant, p<0.03. There was no difference inhistamine blood levels, 0.42±0.14 vs 0.47±0.27 ng/ml. Gender, time on HD andage did not affect the levels of AGEs and histamine in blood.In summary, AGEs are elevated in the blood of all HD patients. In patients withpruritus AGEs are significantly more elevated compared to a control group ofpatients without pruritus. On the other hand, histamine blood level is withinnormal range and does not differ between these two groups. We conclude thatAGEs might have a significant role in the development of pruritus in this groupof patients, acting locally, at the level of the skin mast cells, without influence onthe level of histamine in the circulation.

HAEMODIAFILTRATION WITH SUBSTITUTION OF FLUID PREPARED ON-LINEDECRASES rHuEPO CONSUMPTIONP. Grillo, G.Bonforte, I. Baragetti, R. Scanziani, B. Dozio, M. Surian.Division of Nephrology and Dialysis DESIO Hospital (MI) Italy

Haemodiafiltration (HDF) is an alternative option to standard haemodialysis in order toincrease middle molecules clearance by convective method. By producing on line substi-tution fluid from ultrapure dialysate, HDF-OL is simplified and economically affordable.HDF-OL permits easily acidosis correction, haemodynamic tolerance improvement andhigher β2-microglobulin extraction. Up to now there are just few descriptions about anae-mia and eritropoietin therapy (rHuEPO).We studied 31 patients (pts) treated for at least 9 months by HDF-OL. Pts were dividedin four groups according to primary nephropathy: diabetic (DIAB, n=5), chronic glomeru-lonephritis (GN, n=14), chronic pielonephritis and vascular nephropathy (PNC+V, n=9)and adult polycistic kidney disease (APDK, n=3). Haemoglobin, haematocrit, rHuEPOdoses (U/Kg/sett), urea Kt/V, iron statement and serum albumin were assessed for eachpatient at HDF OL beginning and after 3, 6 and 9 months. All DIAB pts were in rHuEPOtreatment, while all APDK pts were not; among GN and PNC+V there were respectively4 (28.5%) and 2 (22.2) patients without rHuEPO therapy.

At HDF-OL start there were no significant different Hb values among pts, even if rHuEPOconsumption to maintain such values was significant different (Fig 1) (p=0.02). Interest-ingly we noted a progressive decreasing of rHuEPO consumption in all groups even if notstatistically significant, probably due to few patients for group. We have also to point outthat at 9 months of HDF OL we found a significant difference in Hb values among the fourgroups (p=0.01, Fig 2) sustained above all by an Hb increase in APDK group. Since iron,ferritin, trasferrin, urea Kt/V, serum albumin and body weight did not change signifi-cantly during the follow up in each group, we excluded that anaemia improvement wasdue to such factorsConclusions: 1) HDF OL reduces rHuEPO consumption in independently of primarynephropathy. 2) HDF OL increases Hb values in pts who do not assume rHuEPO. 3) HDF-OL permits to maintain permanently similar haemodialysis standard haemoglobin valuewith a significant reduction of rHuEPO and consequently of the cost.

DIAGNOSIS OF ARTERO-VENOUS FISTULAE (AVF) STENOSIS BY ACCESSFLOW MEASURED BY DILUITIONAL METHOD (TRANSONIC™)G. Bonforte, P. Grillo, I. Baragetti, *R. Corso, *G. Rovere, R. Scanziani, B. Dozio,M. Surian.Division of Nephrology and Dialysis * Radiology, DESIO Hospital (MI) Italy

Access flow measurement is fundamental to diagnose significant hemodinamicstenosis that can impair the right function of AVF for haemodialisys. Diluitionalmethod (TRANSONIC ™) permits easily and reproducible access flow (AF) andrecirculation determinations during a haemodialytic run. In graft vascular accessit is always possible to draw both parameters, while in native AVF it is notalways easy to obtain access flow data since their natural conformation.We have monitored access flow to diagnose early the presence of a stenosis.Among 115 patients (with a total of 825 access flow measurements) we haveselect 63 pts, all with distal AVF (Anatomical Snuffbox-AS=25 and CiminoBrescia variant-CB=38), since just in these ones it was possible to determinewith accuracy the access flow without moving needles from a run to another. Ineach run (QB 384±64 ml/min, QB effective 350±54 ml/min) access flow wasmeasured for at least three times and at the end of the follow up (12 months) wehad for each pt enrolled three measurements in different runs (AF1, AF2 e AF3).Pts were classified according to an adeguate AF (A) and inadeguate AF (B),considering the AVF type, the anastomosis, the AVF age and a reduction >20%of AF2 vs AF1.

AF1 AF2 PTA OR NEW AVF AF3CB A (n=30) 1190±875 1088±747 No 898±229CB B (n=8) 344±162 263±114* Yes 1028±499°AS A (n=16) 702±353 655±344 No 700±251AS B (n=9) 524±452 313±179* Yes 856±322°* p<0.05 vs AF2 A °p=ns vs AF3

During the follow up no thrombotic event were observed. B pts (17) underwentangiography. In all pts (100%) we were able to find a stenosis >50%. We treatedsuccessfully, by percutaneous anigioplastic, 11 pts (65%) during angiography,while in 6 pts (35%) resolution was surgical.The post stenosis correction exam (AF3) documented the return to the adeguatevalues also for these pts (CB 1028±499 vs 263±114 ml/min, p=0.01 and AS856±322 vs 313±179 ml/min, p=0.02)Our data show that access flow monitoring by Transonic™ permit the earlydiagnosis of stenosis at least for distal fistulae .

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DOES EXIST A CRITICAL ACCESS FLOW FOR STENOSIS DIAGNOSIS INNATIVE FISTULAE ?P. Grillo, G. Bonforte, I. Baragetti, *R. Corso, *G. Rovere, R. Scanziani, B. Dozio,M. Surian.Division of Nephrology and Dialysis * Radiology, Desio Hospital (MI) Italy

Periodic monitoring of access flow (AF) of grafts fistulae permits early diagno-sis of stenosis that are responsible for thrombosis. It has already been shownthat prothesic grafts with AF <600 ml/min have a higher rate of thrombosisthan grafts with AF >600 ml/min. Fewer data are available about native artero-venous fistulae (nAVF), although an AF of 500 ml/min has beeen advocated ascut-point. For this reason we studied AF on nAVF with diluitional method (Tran-sonic ™). We enrolled 68 HD patients (Mean age 59±14 y) with AVF built onradial artery (Anatomical snuffbox. AS=16, Cimino-Brescia, CB=33 and To-ledo Pereira, TP, at radial artery origin=19). The AF determination was per-formed at least for three times in the same HD run and we considered the meanvalue for statistical analysis. We analyzed AF considering the site of nAVF (AS,CB and TP), the age (< and > 2 years), sex, blood pressure (systolic, diastolic andmean) and the anastomosis type (side to side, SS, side to end, SE).AF were significant different considering the site (AS=523±315 ml/min,CB=941±599 ml/min and TP=1222±590 ml/min, p=0.0022). The nAVF age wasalso important to detrmine AF since nAVF <2 y (729±568 ml/min) had a lowerAF than AVF >2y (1035±586ml/min) (p=0.03). L-L nAVF had higher AF(1228±561 ml/min) than L-T nAVF (777±571 ml/min) (p=0.02).No difference in AF was found considering both sex and blood arterial pressure.To study the relative importance of the previous variables in determining AF weperformed a multivariate analysis.This analysis showed a pivotal role of site (F=11.42, p=0.001) followed by anas-tomosis type (F=10.03, p=0.002) and nAVF age (F=4.11, p=0.04).Conclusions: 1) An AF lower than 500 ml/min is often found in our AS and CBnAVF, especially if young (<2 y) and with SE anastomosis; in spite of this we didnot find any thrombosis event in 12 months of follow-up. 2) Considering thedifferent variables which can influence AF (site, anastomosis type and nAVFage) we conclude that while a single cut point value for AF exist for prothesicAVF it is not possible to determine a single AF cut point for nAVF. We suggest themonitoring of AF as the best screening method in order to diagnosis of stenosis.

PLASMA LEVELS OF IL-1 AND TNFα IN DIALYSIS PATIENTS: RELATIONSHIP WITHBONE HISTOLOGY AND SERUM BONE MARKERS.Th Apostolou1, V Kapsimali2, V Koumoustiotis1, EA Pappa2, A Galinas1, N. Nikolopoulou1,Ch Papasteriades2, A. Billis1.Nephrology1, Immunology and Histocompatibility2 Departments of “Evangelismos” Gen-eral Hospital, Athens, Greece.

The role of various cytokines in the process of bone remodeling has been demonstrated inseveral studies. Interleukin-1 (IL-1) and Tumor Necrosis Factor α (TNFα) are potentactivating factors of bone resorption and they have been implicated in the pathogenesisof bone loss in malignancy, Paget’s disease and osteoporosis. Their role in the pathogenesisof renal bone disease remains to be defined. The purpose of this study was a) to verify thepresence of elevated plasma IL-1, TNFα levels and b) to define if there is any correlationbetween these plasma levels with bone histology and serum bone markers in patientsundergoing dialysis. Fifteen patients (8 males), 55 ± 14 years of age who were underhaemodialysis treatment (12 pts) or CAPD (3 pts) for a period of 75 ± 59 months werestudied. A transiliac bone biopsy was performed in all patients and measurements ofcirculating levels of IL-1 TNFα (ELISA, R&D Systems), intact-PTH, and osteocalcin weredone. All patients suffered from high turnover bone disease (hyperparathyroid bonedisease 11 pts, mixed bone disease 4 pts) while in 4 of them there was heavy bone alu-minium deposition. Laboratory findings are shown in table1.Table 1. Laboratory findings

Normal valuesTotal serum calcium (mg%) 9.7 ± 0.9 8-10.5Phosphate serum levels (mg%) 5.3± 0.7 2-4.5Serum Alkaline Phosphatase (IU/L) 241 ± 226 -110Osteocalcin (ng/ml) 395 ± 389 7.7 -31iPTH (pg/ml) 652 ± 605 10-65IL-1 (pg/ml) 29 ± 5.7 <1TNFα (pg/ml) 21±3.8 <4.4

Results: All patients in comparison with normal controls had elevated circulating levelsof the cytokines under investigation. Regression and multivariate analysis did not revealany correlation of these elevated plasma levels with bone histology and histomorphometricindices of these patients.In conclusion, a) patients under dialysis treatment have elevated circulating levels of IL-1 and TNFα and b) elevated circulating levels of these cytokines have a limited diagnosticvalue for the investigation of their mechanism of action in renal bone disease. Futureresearch for the role of cytokines in the pathogenesis of renal osteodystrophy must bedirected towards in situ cytological studies.

PROXIMALIZED CIMINO-BRESCIA: AN INNOVATIVE APPROACHTO PERMANENT VASCULAR ACCESS IN THE ELDERLY.I. Baragetti, P. Grillo, G. Bonforte, R. Scanziani, B. Dozio and M.Surian.

Distal vascular accesses at the wrist need good native vessels. Elderlyis often affected by diabetes mellitus, heart failure, atherosclerosis andneoplasms, so is not possible to apply a distal vascular access. Graftsare at higher risk of thrombosis. Proximal upper arm accesses often arecomplicated by higher incidence of heart failure and steal syndrome.For this reason we studied an innovative approach doing an anastomo-sis between the antecubital veins and the proximal tract of radialartery (Cimino-Brescia proximalized: CBP). In our population the pri-mary choice for CBP fistulae was dependent by more than two riskfactors: diabetes, neoplasms, coagulation disorders, severe atheroscle-rosis, obesity, previous peritoneal dialysis, heart failure and necessityto begin hamodialysis early. Since 1/1/91 until 31/3/97 we have 134vascular accesses in 99 elder patients (mean 74.4±6.7 y, range 65-91 y).The placements were distal (n° 112, 83.6%): 47 classical Cimino Brescia(CBC) (35%) and 65 (48.5%) CBP. 50 of these were of first choice inpatients with more than two risk factors. Proximal AV fistulae, on thebrachial artery, were just 22 (16.4%). Non grafts were performed.

At the end of follow up (31/3/98, range 12-92 months) early thrombo-sis and survival (evaluated with Kaplan-Meyer analysis) of CBP weresignificantly different from CBD (p=0.01), in spite of higher presenceof risk factors (p<0.007).Conclusions. 1) AV fistulae on radial artery remain the option (83.6%)in the elder patients without apply to proximal AV or AV grafts. 2) Thefirst choice CBP survives more than CBD, although it was performed tohigh risk patients. So, it remains an attractive option for elder patientsto avoid high access flow, as proximal fistulae instead do, and permitadequate dialytic treatments.

ACID-BASE BALANCE (ABB) AFTER ON LINE HAEMODIAFILTRATION (HDF-OL)I. Baragetti, G. Bonforte, P. Grillo, B. Dozio, R. Scanziani, M. SurianDepartment of Dialysis and Nephrology, Desio Hospital (Milan), Italy

Introduction: a better pre dialysis control of acidosis with post dialytic simptoms absencewas shown by previous works in patients in HDF-OL treatment. This advantage is notcomplicated by an increased risk of post dialytic symptoms, as can be sometimes observedin standard bicarbonate dialysis with bigger filter and longer treatment. Neverthelessthere are no data about metabolic alkalosis after HDF-OL treatment, in spite of a betteracid-base controll, neither there data about O2 and CO2 movement.We studied the dialytic ABB at the beginning and at the ending of each of the three HDF-OL treatment of one week.Patients and methods: we examined 27 patients (18 M, 9 F), mean age 55.7±2.9 y, meandialytic age 88.2±15.58 months, with 30.07±3.82 HDF-OL months of treatment (bicarbo-nate and acetate in dialysate and reinfusate 31.5-34 mEq/l and 3-3.5 mmol/l, filter surface1.8-2 mq, treatment time 232.2±3.03 min, QB 426±11.9 ml/min, KT/V 1.65±0.05, nPCR1.18±.0.05, mean weight loss for each treatment 3.04±1.14 L, mean reinfusate volume foreach treatment 19.7±1.23 L).Results: ABB data are reported in the following table (mean±SEM). These data showabsence of significant post dialytic alkalosis. In spite of this we observed a significantreduction of PO2 without variations of PCO2.

I treatment II treatment III treatmentbegin HDF end HDF begin HDF end HDF begin HDF end HDF

pH 7.38±0.01 7.45±0.007** 7.4±-0.009 7.44±0.007** 7.4±0.01 7.44±0.01**HCO3 mmol/L 23.08±0.7 27.05±0.53** 23.6±0.65 26.6±0.34** 24.1±0.56 26.9±-0.51**pCO2 mmHg 37.7±0.8 37.5±0.51 ns 36.8±0.56 37.87±0.59ns 38.15±0.89 38.11±0.58 nspO2 mmHg 96.4±4.06 88.7±3.02* 97.9±3.7 89±2.6* 92.6±2.45 83.6±2.8****: P<0.001 FD vs ID, *: p between 0.001 e 0.05 FD vs ID, ns: not ignificative FD vs ID.Plasma bicarbonate and pH positively correlated with KT/V (r2= 0.18, p<0.05 and r2=0.23, p<0.05,respectively).

Conclusions: a higher dialytic performance in HDF-OL permit a better pre dialytic correc-tion of acidosis without significant post dialytic metabolic alkalosis, as can be found inpatients undergoing standard bicarbonate dialysis. This can be due to a more physiologychandling of bicarbonate in HDF-OL patients because of the replacing of the more bicar-bonate loss through the filter by the bicarbonate reinfusion. The reinfusion is in dynamicequilibrium with the loss.Hypoxiemia, not relevant as in standard bicarbonate dialysis, is probably due to centralrespiratory centers activity redyction, due to acidosis correction instead of a loss of CO2

(CO2 is always supplied by the high rate of reinfusion of bicarbonate).

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GRANULOCYTE ACTIVITY -THE INFLUENCE OF DIALYSIS MEMBRANEAND EPOS.C. Zmonarski1, M. Klinger1, A. Puziewicz-Zmonarska2, W. Kopec1, D. Wendycz1,W. Weyde1.Department of Nephrology1, Department of Pediatric Nephrology2, WroclawUniversity of Medicine, Poland

There are conflicting data concerning a linkage between biological intra-hemodialytic reactions and the clinical consequences in the patient.The aim of study was to estimate the influence of erythropoietine treatment onintensity of blood-dialysis membrane reaction using hemodialysis membranesof different level of biocompatibility.The study group consisted of 35 pts. 21 pts received EPO at doses necessary toobtain Ht 28-32% (EPO+ pts); In EPO+ group 10 pts was dialysed with less BM(EPO+BIO- pts) and 11 with more BM (EPO+BIO+ pts). In EPO- group 7 pts wasdialysed with less BM (EPO-BIO- pts) and 7 with more biocompatible mem-branes (EPO-Bio+ pts). Following membranes were included as mostbioincompatible: cuprophane, cellulose acetate, cellulose diacetate. To morebiocompatible membranes were included: hemophane and polysulphone. Weassessed the activity of granulocyte by measuring spontaneous (SP) and FMLPstimulated reduction of c cytochrome by granulocyte before and after 60 min ofHD. All HD were performed using standard bicarbonate dialysis fluid.In the EPO-BIO+ group the SP granulocyte activity was lower than in EPO+BIO-group (p=0,06). The mean % change of SP activity within first 60 min of HD was+12% and –22% respectively. The difference between these values is significant(p=0,027). Before HD in EPO-BIO+ group FMLP stimulated activity was lowerthan in EPO+BIO- group (p=0,023).The presented data may suggest that EPO treatment is concerned with the pres-ence of two functionally different populations of granulocytes in blood. The firstpopulation, highly active, within first 60 min of HD disappears from bloodstream. The second granulocyte population, more stabile, is preserved in bloodstream.

NEW HIGHLY EFFECTIVE TECHNIQUE TO ENHANCE THECLEARANCE PERFORMANCE IN MODERN DIALYZERSC. Günther, W. Ansorge, B. Blümich*, P. Blümler*, C. Chwatinski*,B. v. Harten, H.-D. Lemke+

Membrana GmbH, Wuppertal, Germany, *University of Aachen(RWTH), Department for Macromolecular Chemistry, Aachen,Germany, +Acordis Research GmbH, Obernburg, Germany.

The clearance performance is still one of the most relevant pa-rameter for the choice of a dialyzer. Currently, a new PerformingEnhancing Technology (P.E.T.) has been described for hollow-fiber dialyzers. Layers of membrane capillaries are combinedwith cross layers of a multifilament yarn. To examine the con-cept of P.E.T. we compared the in vitro clearance performance ofidentical dialyzer types with and without yarn. The use of P.E.T.results in a significant increase in the clearance performance ofdialyzers (1.3 m², n=5) with cellulose-based membranes (meanincrease of clearance: urea +16.4 %, creatinine +14.3 %, phos-phate +11%) and of dialyzers (1.3 m², n=5) with synthetic mem-branes (mean increase of clearance: urea +6.4%, creatinine +6.2%,phosphate +5.4%, vitamine B12 +4.8%). In addition, the exami-nation of a steam-sterilized dialyzer revealed that the use ofP.E.T. prevents the dialyzer from loosing performance duringthermic treatment. The effectiviness of P.E.T. could be also dem-onstrated by NMR spectroscopy. We compared the inner flowpattern of dialyzers with and without P.E.T. by analysis of theflow rate distribution over the sectional area of each dialyzer.The analysis clearly showed that the flow rate of the dialysatefluid is much more evenly distributed in dialyzers with P.E.T.than in dialyzers without P.E.T.. Conclusion: The yarn’s crosslayers used in P.E.T. keep the individual capillaries apart andstabilize the entire fiber bundle within the dialyzer housing. Theeffective membrane surface accessible to the dialysate fluid isenhanced. Moreover, P.E.T. optimizes the dialysate flow ratedistribution over the sectional area of a dialyzer. P.E.T. is ahighly effective technique to increase the clearance performanceof modern state-of-the-art dialyzers.

CHARACTERIZATION OF CARDIAC DYNAMICS INHEMODIALYSIS PATIENTS BY MEANS OF THE LYAPUNOVEXPONENTSG Enzmann1, A Garcia Lanz2, JL Hernandez Caceres2, L GarciaDominguez2, A Gonzalez21Servizio di Emodialisi “G Sai”, Trieste, Italy, 2Center of Cyber-netics Applied to Medicine, La Habana, Cuba

Aim of this study was to characterize cardiac dynamics of uremicpatients during HD by means of the Lyapunov exponents (L)and to ascertain whether the observed patterns correlate withhemodynamic behaviour during HD-induced hypovolemia.We studied 10 hypotension-prone patients (HP: 2-12 out of thelast 12 HD were complicated by collapse - C) and 10hemodynamically stable patients (SP: 0 C). Percent changes ofblood volume (BV; optical hemoglobinometer) and the R-R in-tervals (I) series were continuously recorded during a HD endedwithout C. The I series was then split up in subsets of 200 I,which were fitted to the following autoregressive nonlinearstochastic model: In=F (In-1,In-2,...,In-k)+e. F was computedwith the Naradaya method and that value of k was chosen,which yelded a global minimum error in a cross validation pro-cedure. Then from F a noise free realization of 1700 points wasgenerated and from the last 700 the greatest L was computed(Wolf method). A positive L marks chaotic dynamics.BV changes were similar in SP and HP: 81.4+4.5% and 84.8+3.6%respectively (NS). The percentage of sequences with positive L(%s+L) was 31.3+18.1% in SP (range 3.2-69.7) but only 3.6+2.8%in HP (range 0-8.2%): p<0.01. Moreover the %s+L was inverselyproportional to the number of HD complicated by C: nHDC=5.1-0.12*%s+L (r=-0.59; p<0.01). The %s+L was lower than 10% inall HP but only in 1 SP, the remaining having greater values:sensibility 100%, specificity 90%.In conclusion a low %s+L characterizes HP and hence may be anuseful tool for the assessment of the risk of cardiovascular in-stability during HD-induced hypovolemia.

AVOIDANCE OF INFECTION OF A NEW SUBCUTANEOUSPORT SYSTEM BY AN ANTI-SEPTIC LOCK SOLUTIONK Sodemann, B Feldmer, H Polaschegg, P Thon, V Wizemann, EKeller, H Löffler, D Kiss, I Lubrich-Birkner, J BaumertDialysis Center Lahr/Ettenheim, Lahr/Schwarzwald, Germany

Vessel exhaustion is an increasing problem in hemodialysis pa-tients. As an alternative to implanted indwelling catheters asubcutaneous titanium port (DIALOCK™) has been developedconnected to 2 silicone catheters. To reduce the risk of infection,the device is filled with a new heparin-free lock solution contain-ing taurolidine as an anti-infective substance and citric acid/sodium citrate for inhibition of coagulation.In a prospective multi-center pilot trial starting June 1998 31ports were implanted in 19 female and 12 male patients (meanage 66, min. 30, max. 81 yr). Besides the acceptance of the newdevice the aim of the study was the avoidance of infection sup-ported by the completely atoxic mixture with excellent efficacyagainst any germs even with multi-resistance.In 10 participating centers no port was lost since the start of thestudy (3,847 days of implantation). Despite high comorbidityonly 2 patients experienced blood-stream related infections(staph. aureus). Total observed infection was 0.5/1,000 days.Systemic antibiotic treatment was successful. Pre-existing cath-eter-related sepsis occurred in 5/31 pat., no relapse occurred inthe DIALOCK™ patients.Hospitalization was short and access was used just after im-plantation. The acceptance was high even in patients whoswitched from catheter to port (12/31). In 6/31 pat. an ex-change by guide-wire was possible. The usual placement tech-nique was Seldinger applied by 3 nephrologists. The preferredvessel was the right int. jug. vein (18/31), but all other centralveins were used.Compared to the disadvantages of catheters the port systemallows bathing and is very safe. Combined with the new locksolution the risk of infection is low and allows a puncture tech-nique similar to a graft. Lifetime of the device needs to be estab-lished.

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CLINICAL SIGNIFICANCE OF THE FRACTAL COMPONENT(FC) OF HEART RATE VARIABILITY IN HEMODIALYSISPATIENTSG Enzmann1, A Garcia Lanz2, JL Hernandez Caceres2, L GarciaDominguez2, A Gonzalez21Servizio di Emodialisi “G Sai”, Trieste, Italy, 2Center of Cyber-netics Applied to Medicine, La Habana, Cuba

Aim of this study was to ascertain whether the pattern of the FCof heart rate variability correlate with hemodynamic behaviourduring HD-induced hypovolemia.20 uremic patients were studied, whose propensity to collapse(C) during HD was assessed by means of the number of HDcomplicated out of the last 12. During a HD, which ended with-out C, the R-R intervals (I) series was continuously recorded.The trend was subtracted from the first 8192 I (linear regression)and then a spectral analysis (FFT) was carried out on the result-ing time series. The sympathovagal balance (SVB) was meas-ured as the ratio of the integrals of the power spectral density(PSD) function in the frequency (f) ranges 0.04-0.15 Hz and0.15-0.4 Hz respectively.The presence of a FC in our records was confirmed by the factthat the function PSD=a*f^-b fitted in all cases very well (andbetter than a linear one) the data in the range <0.04 Hz(p<0.05)(Saul, 1988). In a multiple regression the propensity toC correlated well with both the SVB and the exponent b of thepower function: n.HDC=1.83-1.03*SVB-1.42*b (R=0.61; p<0.05).The difference from 0 was significant for both coefficients(p<0.05), i. e. the two variables provided indipendent informa-tions. Moreover the correlation coefficient was greater than thoseobtained from both single regressions: 0.48 and 0.44 respec-tively.In conclusion this study shows that the value of the exponent inthe power relationship PSD vs f in the range <0.04 Hz providesan information about the risk of C during HD, which isindipendent and supplemental with respect to that given by theSVB.

NUTRITIONAL STATUS IN HEMODIALYZED PATIENTSC Donadio, A Lucchesi, M Ardini, R Caprioli, A Lippi, P Rindi.Nefrologia, Dipartimento di Medicina Interna, Università di Pisa,Nefrologia e Trapianto, Ospedale di Pisa, Pisa, Italy

The aim of this study was to evaluate the nutritional status inhemodialyzed patients.Body composition was analyzed in 81 hemodialyzed patients(F37, M44, aged 26-79 years; dialysed since 0-32 years) and forcomparison in 70 renal patients without renal failure (F35, M35,aged 17-76 years; creatinine clearance 40-128 ml/min). Bodymass index (BMI, kg/m2) was calculated. Fat mass (FM), fat-free mass (FFM), body cell mass (BCM), and extracellular fluids(ECF) were measured in all patients by means of a tetrapolarimpedance plethysmograph (Akern, Firenze). The values wereexpressed, similarly to BMI, as kg/m2 of height: FMI, FFMI,BCMI, and ECFI. Plasma concentration of albumin (ALB) wasmeasured in 77 dialyzed patients.A reduction of BMI, FMI, FFMI and BCMI and an increase ofECFI were observed in dialysis patient in comparison with renalpatients. These variations were correlated with the duration ofdialysis in years. A significant correlation was found betweenthe values of BCMI and plasma concentration of albumin.

DIALYSIS Pts RENAL Pts Ccr>40 ml/minFemales Males Females Males

Number 37 44 35 35BMI 24.8±4.2*** 25.5±3.5 28.3±4.2 26.8±4.2FMI 7.9±2.6*** 5.7±2.2** 10.5±2.5 7.2±2.3FFMI 16.8±2.2* 19.8±2.1 17.9±1.9 19.6±2.0BCMI 6.7±1.3*** 8.8±1.9* 8.2±1.1 9.7±1.3ECFI 6.4±1.7** 7.0±1.4*** 5.4±0.7 5.8±0.7

(*p<0.05; **p<0.01; ***p<0.001)Malnutrition and overhydration occurr in dialyzed patients andare more pronounced in patients dialyzed for longer periods oftime.

FEMORAL VEIN AS AN UNUSUAL PERMANENT ACCESSWITH A NEW SUBCUTANEOUS PORT SYSTEMK Sodemann, A Sodemann, B Feldmer, H PolascheggCommunity Hospital Ettenheim, Ettenheim, Germany

Failure of vascular access even in young patients may limit thesurvival with kidney transplantation or CAPD. A 30 year oldwoman suffering from Goodpasture-Syndrome started HD in1985. She had lost 4 renal transplants, the last one in 1998 froma living non-related donor. In the past she was implanted withmore than 15 Perm-Caths due to vessel exhaustion after numer-ous unsuccessful attempts with fistulas and grafts on botharms. One year ago she was treated over a semi-rigid catheter inthe right int. jug. vein with an average blood flow of 180 ml/min. As an emergency with clinical signs of sepsis (E.coli) shewas admitted to our hospital in order to implant a titaniumport system (DIALOCK™) connected with two silicone cath-eters.In pre-operative status the left int. jug. vein was occluded, theright showed an inflammation. In duplex sonography both sub-clavian veins had a good flow. Intra-operatively the upper venacava was obstructed over a length of 15 cm with a residual innerlumen of 1 mm documented by DSA. Dilation was impossible.Therefore 2 catheters (12 French) were introduced into the rightfemoral vein positioned with the tips in the inferior vena cavanear the hepatic vein resp. the bifurcation of both iliacal veins.The DIALOCK™ was implanted 15 cm below the groin in thethigh.The puncture technique is simple and nearly painless. Recoverywas very fast period, the blood flow was up to 350 ml/min. Thepatient is treated as a preventive measure by oral anticoagu-lants. The implantation of a graft connected to the femoral ar-tery was not possible, because the systolic blood pressure wasbetween 50-70 mm Hg due to bilateral nephrectomy.The DIALOCK™ in this placement may be an alternative indesperate cases.

TREATMENT OF CATHETER RELATED INFECTIONS WITH CEFAZOLINAND GENTAMICIN AND OUTCOME OF ATTEMPTED CATHETER SAL-VAGEA. Ventura, J. Queirós, J. Santos, G. Rocha, J. Pimentel, A. Cabrita, S. GuimarãesNephrology Department, Hospital Geral de Santo António, Porto, Portugal

The infections related to central venous catheters remains a significant cause ofmorbidity and mortality in hemodialysis patients. The appropriate manage-ment for catheter related bacteremia has not been clearly defined. Vancomycineresistant pathogens are emerging leading to the need of judicious use of antibi-otics.We report a prospective clinical trial to assess the efficacy of catheter salvage,where in community-acquired infections therapy was initiated with cefazolineand gentamicin, reserving vancomycin and gentamicin for nosocomial infec-tions.Between September 1997 and October 1998 103 tunnelled cuffed catheters wereinserted. 23 patients, age 64±15 years, developed catheter related infection in thesame period (M:10, F:14). 19 catheters were inserted in the right jugular vein and4 in the left jugular vein. In 3 cases catheter was promptly removed because ofmaturation of alternate vascular access, so they were excluded from the analy-sis. Patients underwent hemodialysis with dual-lumen cuffed catheter for40,7±60,3 months. Infection was community-acquired in 13 patients and noso-comial in 7. Community-acquired infections were due to Staphylococcus sp.(n=11), 3 of witch (27%) were meticilin-resistent (MR), Corynebacterium (n=1)and no agent was identified in one case. Nosocomial infections were due toStaphylococcus sp. (n=4), 2 of witch (50%) were MR, Acinetobacter (n=1),Pseudomonas (n=1) and no agent was identified in one case.Catheter was removed in 7 patients (35%). The reasons for this removal werefailure of therapy in 2 cases, recurrent infection in 1 case and tunnel abscess in4 cases; one of witch was due to contamination during insertion. We needed tochange antibiotic therapy in 3 patients because resistance of the identified agent.All of these 3 patients had been admitted in the hospital in the last 3 months. Onepatient died with clinical evidence suggestive of prosthetic valve endocarditis.During the follow-up period (179±89 days) none of the other 13 patients devel-oped recurrent infection.Conclusions: Thirteen catheter related infections were successfully treated withcatheter salvage, with a success rate of 65%.

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THE IMPACT OF COMORBIDITY (ICED) ON QUALITY OF LIFE(QoL) OF PATIENTS UNDERGOING DIALYSIS.D.A. Procaccini*, C. Avanzi*, R. dell’Aquila*, A. Nicolucci§, M.Querques°, G. DiFrancesco° on behalf of the Apulia Nephrology Qualityof Life Study Group (ANQoLS)*Nephrology O. U. San Severo (FG), °Foggia, § Mario Negri SudInstitute. S.Maria Imbaro (CH)-Italy

AIM: To evaluate the effect of coexistent diseases on Quality of Life ofPatients undergoing dialysis.MATERIAL AND METHODS: Overall 367 patients (M: 203, F: 164;age 56±14 years; months on dialysis 71±63) were enrolled in 10 dialy-sis units. All sujects filled the SF-36 questionnaire at home .The indexof Coexistent Disease (ICED) was employed to measure comorbidity.Its range was from 0 to 3 corresponding to none, mild, moderate andsevere comorbidity.STATISTICAL ANALYSIS: in order to control for the potential con-founding effect of other than ICED variables (age, sex, months ondialysis, SGA, BMI, Albumin)QoL domains were investigated with a series of logistic regressionanalysis where questionnaire scores, dychotomised using the medianvalue as cut-off, were the depend variables. Results are thus expressedin terms of Odds Ratio.RESULTS: median values with ranges of the SF-36 domains in the twogroups (ICED 0-1 and ICED 2-3) and their significant association withICED are reported in table

SF-36 domains ICED:0-1 ICED:2-3 ICED(2-3vs0-1)n.pts:229 n.pts:138 Odds ratio

General health 35(5-92) 27(5-100) 1.9Role physical 65(5-100) 35(5-100) 1.8Physical function 75(25-100) 50(25-100) 2.7Role emotional 83(33-100) 67(33-100) 1.6Social function 62(12-100) 50(12-100)Bodily Pain 52(10-100) 41(10-100) 2.1Emotional w.being 50(5-100) 30(5-95)Energy/fatigue 56(4-100) 40(4-100) 2.0

CONCLUSION: the domains of physical performance are more signifi-cantly affected by comorbid conditions than those of mental functions.Comorbidity, considered not only in terms of presence/absence butalso of severity of disease, is a powerfull independent factor determin-ing, other than survival, also QoL of pts undergoing dialysis.

COPING WITH DIALYSIS: RESULTS OF RORSCHACH TESTGB Piccoli, Y Garofletti, B Martino, AM Iadarola, D Favero, P Anania, E Mezza, M Vischi,F Bechis, C Iacuzzo, D Ubaldeschi, L Valente TorreCattedra di Nefrologia, Dipartimento di Psicologia, University of Torino - Italy

Long term treatment of uremia requires the patients to accept their disease and its limi-tations. This tremendously difficult adaptation requires an effort, similar to the one de-scribed for people living in a civil war: an apparently endless, painful and dangerouscondition. Several psychological approaches have been proposed in the study of person-ality of patients on dialysis to elucidate these coping mechanism; however results arescattered and non conclusive, due to differences in cohorts treated and in tests employed.Moreover, the effort of building specific tests (functional or projective) for uremic pa-tients makes comparison with normal population often impossible. Rorschach’s test is thecornerstone of psychological and psycho-diagnostic evaluation. According to a “projec-tive” test, the person “projects” his/her internal world (unconscious thoughts, needs,etc) by describing the black or coloured ink spots of R. test, thus revealing the main featuresof his/her personality. This long term validated and established tool has the advantage ofcomparison with wide normal population, and is presently used with increasing fre-quency in the study of psychological problems in chronic diseases. The test was proposedto 30 dialysis patients (mean age 51, range 23-75 years; M 21, F 9) by the same two operators(psychologists); 15 patients were on out-of-hospital hemodialysis, 15 on CAPD/CCPD.Patients were randomly selected; all patients asked, agreed to participate. No mentaldisease was found, despite the presence of few psychotic tracts, insufficient for definingthe presence of a pathology. Overall, patients kept a stable balance between anguish,anxiety and removal; coping however lead to modified perception of daily life in the senseof a more “detected” and “global” gestalt, with a lesser attention to the daily problems andchores. While in the older group of patients on peritoneal dialysis social life was limited andoften difficult, younger patients on hemodialysis, mostly working or studying, showed anormal social approach; in both cases, however, relationships occur with same emotionalconstrains, witnessing the difficult of sharing the crucial and often secret experience ofdisease. Even if both peritoneal dialysis (presumably via the catheter) and hemodialysis(the fistula, the machine) were implicated in a disturbed perception of the corporealscheme, dependence upon the dialysis machine was not reported in the selected group.Even if this random sample of patients with a remarkably different follow-up (3 months- 20 years) is insufficient to assess the timing of coping, it may be of interest to notice thatin all cases adaptation was firmly established. These observations underlined the impor-tance of the predialysis phase. In any case, the finding of an overall positive and efficientcoping is in favour of the importance of a psychological approach that may lead to focaliseactions towards enhancing patient’s great potentialities instead of looking for eventualdeficits or mental diseases.

THE IMPACT OF ATHEROSCLEROSIS-INDUCED DISEASESON SURVIVAL OF ESRD PATIENTS UNDERGOING DIALY-SIS.D.A. Procaccini*, M. Querques°, A. Pappani°, G. Di Francesco°,P. Strippoli”, G.F.M. Strippoli^, G.Procaccini*U. O. Nefrologia e Dialisi San Severo*, Foggia°, Brindisi”, Uni-versity of Bari^

OBJECTIVE- To analyze the impact of atherosclerosis-induceddiseases on survival of patients (PTS) with end-stage renal dis-ease (ESRD) undergoing dialysis.DESIGN- Cohort retrospective studyPATIENTS- 385 PTS (213 males,172 females; median age 54years, range 8-81) followed in the same centre over a 20 yearperiod (median follow-up 39 months, range 1-277)METHODS- A four-level score of Index of CardiovascularComorbidity (ICC) was assigned as a measure of severity ofcoexistent disease for the following pathologies; ischemic heartdisease (IHD), cerebral vascular accident (CVA) and peripheralvascular disease (PVD), using information recorded at the timeof admission to the first sitting of dialysis.RESULTS- A total of 70 PTS showed at least one atherosclero-sis-induced pathology. Cox proportional hazard model wasapplied to evaluate the association of various PTS descriptorswith the probability of death. Mortality risk was significantlyassociated with PTS age (RR=2.61 for PTS aged 45-65; RR=5.22for PTS over 65 compared to PTS under 45), with the initialcondition leading to renal failure (RR=4.82 for diabetes com-pared to primary renal disease), and with ICC (RR=2.6 for PTSscoring 3-4; RR=1.5 for PTS scoring 1-2, compared to PTS withno cardiovascular comorbidity): Sex and type of dialysis werenot associated with mortality risk.CONCLUSIONS- We conclude that the severity of Atheroscle-rosis-induced pathologies is a powerful indipendent prognosticfactor in determining ESRD PTS mortality. They should be closelymonitored for their considerable impact on PTS undergoig di-alysis.

LONG-TERM RENAL REPLACEMENT THERAPY: A CLINICAL ANDPSYCHOLOGICAL PROFILEPiccoli GB, Pacitti A, Messina M, Martina G, Torazza MC, Guarena C,Fop F, Anania P, Iadarola AM, Vischi M, Mezza E, Segoloni GP, PiccoliG .Dialysis Centers of Piemonte; Cattedra di Nefrologia, University ofTorino - Italy

An observational-descriptive study was performed on a cohort of 188pts treated for ≥20 years with dialysis and/or transplantation; thiscohort gathers all pts on treatment in a single region with such a longfollow-up. The study included revision of clinical charts a clinicalcontrol, and interview performed by 3 trained operators. Male/femaleratio was 60/40%. Age at start (mean 31.3±10.3; median 30.2; ad datam:53.7±10.3; median 53.2) reflected selection policy of the ‘70s. Meanfollow up was 22.4±2.3 yrs. On the basis of clinical history pts weresorted into: group 1: 56 pts always treated by dialysis; group 2: 40 ptspreviously grafted, presently on dialysis; group 3: 92 pts presentlygrafted. Age differed in 1st vs 2nd and 3rd groups (59.5±11.5 vs 51.5±7.9and 51±9) reflecting selection in itinere, allowing transplantation forbest and younger pts. Glomerulonephritis was the main cause ofESRD (58%). Overall prevalence of comorbid factors was high (88.3%).Only 22 pts (11.7%) had no major comorbidity (severe cardiac, vascu-lar, liver or bone disease, neoplasia). 63/188 pts (33.5%) had a cardiaccomorbid condition: most ischaemic (43 pts) and valvular disease (10).Prevalence of hypertension was low, higher in group 3 (31%) than in 1(7.4%) and 2 (15%). 24 neoplasias were recorded in 22 patients (12%),most commonly cutaneous tumours in grafted pts (69%); 2 Kaposisarcoma were reported. However, nutritional status was overall good(SGA: 64% well nourished, 30% moderately, 6% severely malnour-ished). The 10 pts with severe malnutrition had ≥1 cardiovascularcomorbid factor. Despite the high prevalence of HCV (73.6%) and ofHBsAg (10%) clinical liver disease was rare (11 pts).Results of functional evaluation according to Karnofsky scale (Ks) weregood, better in group 3 (Ks 88.1±15) vs group 1-2 (Ks 67.9±21.9 and75.5±18). Quality of life, according to Spitzer test, directly evaluated ona 0-10 score in 171 pts, resulted as optimal (score 10) in 31% of pts, good(score 8-9) in 31% and poor (score ≤5) in only 12% of cases. While thisbright outlook may also represent a coping mechanism, these resultsunderline, in any case, both good clinical and psychological status. Inconclusion, from this observational study a clinical profile of long termRRT pts may be attempted. A good or optimal clinical status is notexceptional; even if comorbid factors, vasculopathy in primis, markersof the earlier ageing of uraemic pts, are highly prevalent, most pts arestill in a phase in which biochemical and imaging signs precedesevere clinical impairment; the optimistic outlook and good copingmay represent further important factors in long-term survival.

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EFFICACY AND SAFETY OF PERCUTANEOUS THROM-BOLYSIS IN ARTERIOVENOUS GRAFTSE. Coll, M. Vera, L. Pérez, E. Bergadà, J. Lopez-Pedret, A. Darnell,M. Real, X. Montanyà, A. Cases.Nephrology & Angioradiology Units. Hospital Clinic. IDIBAPS.Barcelona. Catalonia. Spain.

Acute thrombosis of arteriovenous grafts is a frequent compli-cation in patients on maintenance haemodialysis. Until recentyears surgical thrombectomy was the only solution. The aim ofthis study is to assess the efficacy and safety of percutaneousthrombolysis after thrombosis of arteriovenous PTFE grafts.We analyzed 43 thrombolytic procedures in 23 patients withendstage renal disease (13M: 10 F, mean age 56.5±13.76 years,mean time on HD 61.79 ±55.7 months, mean±SD). In all casesthe arteriovenous access was a PTFE vascular graft. Throm-bolysis was performed within 3 days after thrombosis in allcases.The median survival of the PTFE graft after surgical implanta-tion was 14.5 months (range 1-70 in). The primary patency rateof the procedure was 71%. The efficacy of first thrombolysiswas higher than for the 2nd or 3rd event (85%, 60% and 20%respectively, p=0.008). The survival rate at 90 days after a 1rstthrombolysis was 52%, and after 2nd thrombolysis was 33%(log-rank test p= 0.15, NS). Complications after the procedurewere observed in 10 of 43 patients (23%), the most frequentlycomplication being local haematoma.Percutaneous thrombolysis is an alternative to surgical proce-dure in vascular grafts thrombosis, with great efficacy and safetyin the shortterm. However, in terms of long-term efficacy andeconomy we consider that only the first thrombolysis is usefulbecause after the second procedure the efficacy and survival isclearly decreased.

Kt/V: A MARKER FOR SYSTOLIC DYSFUNCTION INHEMODIALYSISP. Stella, M. Melandri, D. Ciurlino, G. Bigatti, G. Vezzoli, G.Slaviero, D. Spotti, G. BianchiChair of Nephrology, Milan University, S. Raffaele Hospital,Milan, Italy

Cardiovascular diseases are the main causes of death in uremicpatients. The reduced excretion of cardiomyotoxic metabolitescould be involved in the development of cardiovascular dis-eases in uremic patients.Aim of this study is to investigate a possible relation betweendialytic adequacy and systolic function in hemodialyzed pa-tients. We studied 46 hemodialyzed patients (30M & 16F).Dialytic adequacy was measured as Kt/V. Telesystolic volume(VTS), telediastolic volume (VTD) and ejection fraction (FE)were evaluated by bidimensional echocardiography.All data were expressed as mean±standard error of the mean.Patients were 54.9±2.3 years old, were dialyzed from 29.8±4.4months.Kt/V was directly related to FE (p=0.0001; R2 =31.4%) and toVTS (p=0.008; R2 = 14.9%). No relation was found between Kt/V and VTD. To exclude the possible confounding effects of sex,body mass index, duration of dialysis and blood pressure amultiple regression was performed. VTS variability resulted re-lated only to Kt/V (R2 =20.0%), while FE variability resultedrelated both to Kt/V (R2 =40.0%) and duration of dialysis (R2=6.9%). Patients with systolic dysfunction, defined as FE≤50%had a KT/V significantly reduced (p=0.0018) when comparedwith patients wtin normal systolic function (≥65%): (1.0±0.3 vs1.4±0.2)Dialitytic adequacy is related to systolic function and seems tobe predictive of systolic dysfunction when Kt/V is ≤1.0. BecauseVTS is expression of cardiac inotropism and VTD is expressionof body volume overload, the improvement of systolic dysfunc-tion obtained by a good dialytic treatment seems to be mediatedby an improvement on cardiac conctractility independently onpreload conditions.

EFFECT OF THE ORAL PROTEIN SUPPLEMENT“NUTRIDIAL” ON THE PLASMA AMINOACID POOL INMALNOURISHED HD PATIENTSE. Vazelov1, F. Ribarova2, S. Krivoshiev1

1Hemodialysis Centre, University Hospital “Queen Giovanna”;2National Institute of Hygiene, Medical Ecology and Nutrition,Sofia, Bulgaria

Plasma amino acid (AA) concentrations are a reliable marker ofrenal function and a criteria for assessment of protein-energymalnutrition (PEM).The aim of this investigation is to analyze the changes in plasmaAA in hemodialysis (HD) patients on a protein supplementeddiet. 28 patients, mean age 43,64 (24-67 years) with signs ofPEM were included in the study for a period of 6 months(16F:12M). The oral supplement “Nutridial” (62% protein con-tent mathematically modeled mixture of soya concentrate, fullpowdered cow’s milk and oats, flour) was added to the dailyration in quantity of 0,3 g protein/kg./day.The levels (mean +/- SD) in mcg/ml of some critical AA pre,during and one month after the study are shown on a table.

pre 3Mo. 6Mo. 7Mo.Val. 24,1+/-5,1 31,3+/-9,1 30,9+/-6,8 30,3+/-6,7Leu. 15,5+/-3,9 21,1+/-6,6 20,1+/-4,7 18,4+/-4,2Ileu. 9,1 +/-2,0 11,6+/-4,3 12,7+/-4,4 10,9+/-2,8Ser. 14,7+/-3,3 18,3+/-7,1 21,9+/-5,1 18,6+/-4,9Met. 5,4 +/-1,6 9,1 +/-2,3 11,0+/-2,2 7,9 +/-1,9

The supplemented protein intake during the investigation re-sulted in statistically significant elevation in branched chain AA(usually low), Serin and Methionin. The inclusion of the oralsupplement “Nutridial” in the daily ration of the studied HDgroup affected positively plasma aminoacid pool even one monthafter the stop.

THE ARTERO-VENOUS FISTULAE (AVF) FOR HAEMODI-ALYSIS: A RETROSPECTIVE ANALYSIS OF A THIRTY-YEAROPERATING, CASESMancini G., *Chiti E, Bandini S., **Seracini D., **Lavoratti GC.,Salvadori M.Nephrology Unit- Careggi-Florence; *Vascular Surgery Univer-sity of Florence; **Paediatric Meteorology Unit- Meyer Hpt Flor-ence

In the period between January 1970 and December 1998, weremade 5285 operation of AVF construction in 3163 pts (1412males and 2751 females; mean age 45±29, range 19-84 years).When there was the necessity, it was used a synthetic prosthesisalways in PTFE; the operating technique was the same sug-gested by Cimino e Brescia, with termino-lateral anastomosisbetween the vein and the artery. About the anatomic place of theAVF we had: wrist 40.7% (of which 3.4% with PTFE); elbow50.9% (cephalic vein 40.8%, basilic vein 45. 1 %, ME 14.1 %);armpit 5.2% always with ME; thigh 5.9% (saphena vein 52.7%,PTFE 47.3%). The complications turned up within thirty daysfrom the construction of AVF were considered early complica-tions (49 events, 61.3% bleeding; 32.6% suppuration; 2% femo-ral artery thrombosis). We had 406 late complications (4.6%ischemic limb; 43.1% AVF stenosis; 4.9% hyperafflux syndrome;29.3% aneurysm ulceration; 10% suppuration; 7.9%pseudoaneurysm). From our experience come out some consid-erations which became as line of conduct for this kind of opera-tion. The approach to the pts needs a close clinical examinationto search and to value the arterial pulses and the superficialvenous reticulum, to measure the blood pressure.About the upper limbs, it is useful to look for the exchangecirculation of the palmar arches using the specific tests. Theevaluation of the age and the general health state of the pts, if heis already an operated pts, can guide the choice of the proximalor the distal area for the AVF construction. In selected pts it isuseful to study the coagulative order. The Echocolor Doppler ofthe vascular system is necessary before operating. It is better tomoderate the use of prosthesis because of the higher incidence ofcomplications.

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USE OF STAPLE DEVICE FOR CREATION OF AV FISTU-LAS AND BRIDGE GRAFTS FOR ANGIOACCESSP. Misthos, K. Koutsoumanis, G. Androulakis, I. Kakavas1st Department of Propaedeutic Surgery, Hippocration Hos-pital, University of Athens

This is a prospective, randomized study conducted toindentify the possible benefits of an anastomosis done withthe use of titanium staples in comparison to the traditionalsuture method.The study involved totally 79 cases of AV fistulas and grafts,41 done with sutures and 38 with staples, ie 41 autologous(21 with sutures and 20 with staples) and 38 PTFE grafts (20with sutures and 18 with staples) The created fistulas werefollowed during the 1st, 6th and 12th postoperative month.In this poster is presented the mean anastomotic time foreach method, the incidence of bleeding and also the earlyand late patency rate. Besides we expose our surgical tech-nique.In coclusion our results make us believe that the stapler ismuch more technically easier to use. We demonstrate thatwith the use of stapled as compared to sutured anastomo-sis, there is: 1) shorter operating time, 2) less bleeding inci-dence, 3) improved patency rate in time.We believed that may be this is the way vascular anastomo-sis will be created in the future.

SUPERFLUX-DIALYSER AND THE GENIUS SYSTEM: THE EFFECT OF IN-TERNAL FILTRATION ON BETA-2-MICROGLOBULIN ELIMINATION.F. Dellanna, H. Lagendijk, A. Westhoff, W. Kleophas and G. van Endert,Dialysis Center Karlstraße Düsseldorf

The Genius Dialysis System is a single pass batch system and provides due to itshygienic concept ultrapure water as dialysate. This puts it at an ideal positionfor use of highly permeable membranes with a high amount of internal filtra-tion. The study was carried out to investigate effects of altered internal filtrationon solute clearances. Internal filtration is defined as water flux across the mem-brane without any net UF. In this study a group of 20 stable hemodialysis pa-tients was randomized for either dialysis with the new Superflux (F500 S) ver-sus a regular highflux filter with comparable surface area (F 60 HPS). QB = 250ml/min and QB = 250 ml/min were kept constant for all measurements, Soluteclearances (Cl) of creatinine, BUN, phosphate and ß2-M at 30 after start at zeronet ultrafiltration were measured. Additional analysis from the whole collecteddialysate (75 l) were analysed for total extraction of the solutes and for loss ofalbumin

Fiber Cl (BUN) CI (ß2M) Cl (creat.) CI (PO4)µm ml/min ml/min Ml/min ml/minSuperflux 196,8 92,1 186,2 196F 60 BPS 191,3 57,1 190’1 196

Solutes clearances were very similar in the smaller molecular range whereasthere is a highly significant difference in clearance of larger molecules as ß2-Mwith the Superflux. We can show that the smaller inner fiber diameter enhancesinternal filtration and thereby a better removal of beta-2-microglobulin. Thelower dialysate flow has no significant effect on clearance of ß2-M as comparedto former experiments with dialysate flow of 500 ml/min. There was nomedicalor technical problem associated with the new dialyser in combinationof the Genius system. Albumin loss is between 800 mg and 2200 mg, perdialysissession. Ongoing experiments will show the long term effect on serum levels ofß2-M and albumin with constant use of the Superflux.

NO ASSOCIATION BETWEEN C-REACTIVE PROTEIN (CRP)AND CHLAMYDIA PNEUMONIA ANTIBODIES (CHA) INEND STAGE RENAL DISEASE PATIENTS (ESRD)G. L. Kissinger, T. Sures, M. Pollok, H. M. Steffen, C. A. BaldamusMedical Clinic IV, University of Cologne, Köln, Germany

Cardiovascular disease is a major cause of mortality in ESRD.Recent studies have suggested that chronic infection with espe-cially chlamydia pneumonia may be a risk factor for coronaryartery disease. CRP, a marker for systemic inflammation, pre-dict risk of myocardial infarction and thromboembolic stroke.CRP levels are elevated in hemodialysis patients compared tonormals. The aim of the study was to determine whether there isa relationship between CHA and CRP.We prospectively measured CRP levels (by highly sensitiveELISA) and chlamydia pneumonia antibodies (IgG, IgA, IgMby ELISA) in 85 patients with different etiology of ESRD (70hemodialysis patients [HD], 15 peritoneal dialysis patients[CAPD]). Mean age was 59.8 ± 16.3 years. Mean CRP waselevated 25.8 ± 15.3 mg/l. The total prevalence of chlamydiaIgG-AB in HD was 54%, IgA-AB 38% and combined IgG+IgA-AB 31%. Seroprevalence in CAPD was IgG-AB 30%, IgA-AB28% and IgG+IGA-AB 19%. Patients positiv for CHA had nosignificant higher CRP levels than those seronegativ for CHA.There was no difference in the HD and CAPD population be-tween he negativ relationship of CRP and seroprevalence ofchlamydia pneumonia antibodies.Our results indicate no statistical link between CHA and CRPlevels in ESRD patients. Patients with CHA had no higher CRPlevels. Nevertheless there is a high seroprevalence of CHA in HDpatients.

BLOOD PRESSURE INFLUENCES THE OCCURRENCE OF ST-SEGMENTDEPRESSION IN CHRONIC HEMODIALYSIS PATIENTSG. L. Kissinger, H. M. Steffen, C. A. BaldamusMedical Clinic IV, University of Cologne, KöIn, Germany

Blood pressure changes and arrhythmias are very common in end stage renalfailure patients on maintenance hemodialysis (HD). They are important factorsof the high cardiovascular mortality rate in patients on the renal replacementprogram. We investigated the prevalence and circadian distribution ofST-segment depression and ist relation to blood pressure (BP) and heart ratevariations.40 HD outpatients (29 male, 11 female), dialysis duration more than 1 year, witha mean age of 60.1 ± 18.4 years underwent 24 hour ambulatory monitoringusing Kontron AM monitor which simultaneously records a continous Holterelectrocardiogram (ECG) and intermittent BP measurements at 15-minute in-tervals during day and 30-minute intervals during night, with extra measure-ments triggered by detection of a horizontal or downsloping ST depression (>1min and >60 seconds). The recordings begun 30 minutes before the start of HDfor a 24-hour period. Cardiovascular risk factors were evaluated in all patients.18 patients (45%) experienced a total of 144 episodes of ST depression. Durationof the episodes was 168 ± 81 seconds and amplitude was 2.11 ± 0.84 min. Thecircadian distribution showed one peak at 1 hour after starting HD and a secondpeak 2 hours after HD. ST-segment depression during HD often occured after ahypotensive episode followed by tachycardia. During the ST-depression epi-sode the systolic (10±12 mm Hg) and diastolic BP (8±10 min Hg) as well as heartrate (12±19 beats/min.) increased. The mean ambulatory BP (137±11 vs 128±13and 86±7 vs 76±9 mm Hg) and predialysis BP (155±16 vs 139±18 and 94±9 vs78±10 mm Hg) was higher in patients with ST-segment depression (p<0.01).Patients with ST-segment depression were more frequent non-dippers comparedto patients without ST-segment depression (79 vs 45 %).Combined 24-hour Holter/blood pressure monitoring revealed ST-depressionepisodes in 18 of 40 patients (45%) on maintenace hemodialysis. Ambulatoryblood pressure was higher in these patients. BP variations during hemodialysis,especially hypotensive episodes may trigger ST-segment depression.

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THE ROLE OF RENAL RESIDUAL FUNCTION (RRF) ON THE PREVENTIONAND CONTROL OF SECONDARY HYPERPARATHYROIDISMS. Feriozzi, C. Massimetti, E. AncaraniCentro di Riferimento di Nefrologia e Dialisi, ASL Viterbo, Italy

RRF is believed to be important in: maintaining kidney endocrine activity, pre-vention of beta 2microglobulin (β2-m) amyloidosis and hyperaluminemia, andnutritional status of hemodialysis (HD) patients (pts). Nevertheless, impact ofthe RRF on the control of calcium and phosphorus scrum levels and on iPTHsecretion has not been well defined. Therefore, we studied 34 HD pts with sig-nificant RRF, assessed by urea (Krur) and creatinine (Krcr) clearance. All ptswere investigated for Kt/V, CaT, PO4, PTH, t-ALP, Hb, and mean dosages em-ployed of Ca(CO)3 (gr/d), Al(OH)3 (gr/d), calcitriol (1,25D) p.o. (µg/d), andr-HuEPO (IU/w), at basal and at follow up, meanly after twelve months. Serumβ2-m levels were determined once at basal of the study. At follow up 22/34(Group A) maintained a significant diuresis (384 ± 240 vs 618 ± 354 ml/24 h; p< .05). On the contrary, 12/34 pts became anuric (diuresis at basal 410 ± 318 ml/24 h).

Group A Group BBasal Follow-up Basal Follow-up

Krur, ml/m’ 2.64±1.89 1. 76±1.4° 1.84±1.79 0Krcr, ml/m’ 4.02±3 2.8±2.1° 2.89±2.24 0CaT, mg/dl 9.1±0.6 9.5±0.6° 8.9±0.5 9.1±0.5°PO4, mg/dl 5.2±1.1 5.4±1.2° 5.2±1 6.4±1.1°PTH, pg/ml 281±231 139±112* 239±151 354±280°tALP, mU/ml 228±85 198±64° 201±77 239±84°Ca(CO)3, gr/d 1.9±0.4 2.1±0,8° 1.2±0.7 2±0.6°Al(OH)3, gr/d 0.27±0.36 0.27±0.3° 0.56±0.62 1.11±0.85 °1,25D, µg/d 0.12±0.16 0.21±0.27° 0.11±0.16 0.16±0.18°Hb, gr/dl 9,4±15 10.6±1.4^ 9.6.±9.8 9.8±1.0°Follow-up vs basal: °ns; *.05; ̂ .01

In pts of group A mean r-HuEPO dosage was reduced from 5089 ± 4621 to 3714± 3288 IU/w (ns), while in the group B it was increased from 3916 ± 3088 to5500 ± 2540 IU/w (ns). Moreover, serum β2-m levels increased with reductionof diuresis (r = -.424; p = .017) and of Krcr (r = -.463; p =.009).These results suggest persisting RRF is associated with a more easy control ofcalcium and phosphorous metabolism, as a less degree of renal anemia, and thatit would have a protective role in β2-m pathology.

LEFT VENTRICULAR MASS AND CARDIAC NATRIURETIC PEPTIDES IN PATIENTSWITH CHRONIC RENAL FAILURECREED Investigators: F. Mallamaci*, F.A. Benedetto°, G. Tripepi°, G. Bonanno§, V. Can-dela**, G. P. Fatuzzo§, F. Rapisarda§, G. Seminara°°, B. Stancanelli°°, G. Giacone+, E. Cottini+,I. Bellanuova+, A. Cataliotti+, S. Cutrupi*, M. Postorino*, S. Parlongo*, R. Tripepi*, L.Malatino+, C. Zoccali*.CNR Centro Fisiologia Clinica and Div. Nefrologia OORR* and Div. Cardiol. OspedaleMorelli°, Reggio Cal, Ist. Clinica Medica+, Div. Nefrologia Chirurgica§, Ist. Med.Int. eGeriatria°°, Università di Catania, Centro Dialisi, Ospedale Melito Porto Salvo** Italy

It is well established that the plasma concentration of ANF and BNF is raised inpatientson chronic dialysis. However the relationship between these substances and the altera-tion in heart geometry and function has received little attention in these patients. Toidentify the determinants of plasma concentration of natriuretic peptides (ANF andBNF) in uremic patients on chronic dialysis and to determine whether these measure-ments are useful in identifying or excluding LV hypertrophy and LV dysfunction in thesepatients we performed cross-sectional study in 277 dialysis patients without clinical evi-dence of heart failure. Subjects enrolled in this study represented about the 70% of pa-tients who were being treated in two dialysis centres linked to a National Research Centreand to an Academic Unit.Natriuretic peptides were measured by RIA (intra-assay CV <6%, interassay <10%).Determinants of plasma natriuretic peptides were identified by stepwise multivariableregression analysis and diagnostic threshold levels by a discriminant analysis.Echocardiographic parameters of heart geometry and left ventricular function weremeasured by standard methods.In a multivariable model plasma ANF was predicted (R=0.61, P=00001) by Left Ventricu-lar Mass Index (LVMI) (r=0.28; P=0.003), E/A ratio (r=0.25, P=0.0001), Left atrial volume(r=0.20, P=0.003). Ejection Fraction (EF) (r=-0.20, P=0.002) and age (r=0.16, P=0.013).Similarly, the E/A ratio (r=0.35, P=0.00001), EF (r=-0.25, P=0.0002), LVMI (r=0.22, P=0.0009),atrial volume (r=0.16, P=0.014), age (r=0.16, P=0.016) and Mean arterial Pressure (r=0.16,P=0.018) were all independent and strong predictors of plasma BNF (multiple R=0.63,P=0.00001). Plasma BNF and ANF resulted to be sensitive indicators of left ventricularhypertrophy in dialysis patients (positive predictive value: 94% and 92% respectively),however their negative predictive value was low (BNF 34%, ANF 31%). Both natriureticpeptides were useful for excluding systolic dysfunction (negative predictive value:BNF=84%, ANF=78%) although their sensitivity was low (positive predictive value 30%and 34%).This study shows for the first time that plasma ANF and BNF are strongly and independ-ently linked to left ventricular mass in dialysis patients without overt heart failure andthat this link is much stronger than that with atrial and ventricular volume. Thus, besidesaccumulation due to renal failure, raised cardiac mass appears of major importance indetermining the plasma concentration of these peptides in dialysis patients. Furthermore,the measurement of the plasma concentration of cardiac natriuretic hormones may beuseful in identifying dialysis patients with left ventricular hypertrophy or for excludingsystolic dysfunction.

ANGIOTENSIN AT1 RECEPTOR ANTAGONIST (LOSARTAN) REDUCEDLEFT VENTRICULAR MASS (LVM) IN NORMOTENSIVE HEMODIALYZEDPATIENTSC. Massimetti, *D. Pontillo, S. Costantini, *A. Capezzuto, E. AncaraniCentro di Riferimento di Nefrologia e Dialisi, *Cardiologia, Azienda USL,Viterbo, Italy

Recent studies showed angiotensin II (Ang II) is a permissive factor in the gen-esis of LV hypertrophy (LVH). Ang II has been implicated in stimulating myo-cyte growth in vitro (Sil P; Hypertension 1997), and it may takes a role in reduc-ing coronary blood flow reserve (Nunez E; Hypertension 1997); losartan im-proves coronary hemodynamics and blocks the stimulatory effect of Ang II. Toevaluate effects of losartan on LVH 11 stable hemodialyzed patients (pts), age58±12 years, in HD from 55±42 months, were studied. Pts were characterizedby: increased LVM index, spontaneous normotension, assessed by blood pres-sure (BP) measurement before each dialytic session and by a baseline 24-hambulatory BP monitoring, Hct > 30% throughout least 6 months prior thestudy, Kt/V steadily> 1, iPTH < 200 pg/ml (n.v. 9-63), interdialytic weight gain(DBW) steadily < 5% b.w., no history of coronary or valvular heart disease, andof sistemic disease. All pts underwent a complete doppler echocardiographicstudy, afterwards were treated with losartan as starting dose of 25-50 mg/d,according to BP values. At follow-up, on average after 7.1±1 months,echocardiographic study was performed again.

Baseline Follow-up PSystolic BP, mmHg 130 ± 15.4 112.6 ± 20.9 n.s.Diastolic BP, mmHg 72.9 ± 8.6 66.3 ± 9.2 n.sMean BP, mmHg 91.6 ± 9.8 81.8 ± 12.8 n.s.LVEDD, mm/m2 28.8±14 27.4 ± 4.1 n.s. IVST, mm 12.3 ± 3 10.9 ± 2.8 n.s.LVPWT, mm 12.4 ± 4.4 10.1 ± 1.8 n.s.LVMi, gr/m2 185.5 ± 78.4 123.7±30.1 0.02Hct, % 35.8 ± 3.9 36.3 ± 2.1 n.s.iPTH, pg/ml 109 ± 53 124± 117 n.s.

LVMi reduced in all pts, but in 5/11 normalized.Our results suggest losartan is able to reduce LVM with effects unrelated tosystemic blood pressure control.

IMPACT OF DIETETIC PRESCRIPTION AND OF INCREMENT OF DIALYTICDOSE ON NUTRITIONAL STATUSC. Massimetti, F. Luchetta, S. Costantini, S. Feriozzi, *M.T. Muratore, E. AncaraniCentro di Riferimento di Nefrologia e Dialisi, *Laboratorio, Viterbo, Italy

We aimed to evaluate effects of increment of dialysis (HD) dose and of dieteticcorrection of nutritional intake on some nutritional, parameters. 21 clinicalstable HD patients (pts) with protein intake < 1 g/kg/d and/or caloric intake <30 Kcal/Kg/d, and one or. more anthropometric measurements reduced whencompared to a sex-and agematched ideal standard were studied. All pts receiveddietetic prescription containing 35 Kcal/Kg/d of calorie and 1.2 g/Kg/d ofprotein. At baseline and after 12 months pts were investigated for BMi, TSFthickness, MAMC, prealbumin, and PTH; BUN, creatinine, Kt/V, nPCR, URR,albumin TLC, colesterol, transferrin, and Hb were determined monthly. To ob-tain a significant increment of Kt/V, Qb and/or time of HD session and/orsurface area of dialyzers were increased; throughout the study type of mem-brane was no modified.

Baseline Follow-up PKt/V 1.02±0.13 1.30±0.09 <. 001nPCR, g/Kg/d 0.99±0.17 1.07 ± 0.19 n.s.BUN, mg/dl 69±19 67 ± 25 n.s.sCr, mg/dl 8.9 ± 1. 9 10. 2 ± 1. 9 <. 01Prealbumin, mg/dl 36 ± 8.7 38.5± 9.5 n.s.BMi, Kg /m2 23.9 ± 2.8 23.3±2.9 n.s.MAMC, cm 23.5 ± 2.9 25.2±2.5 n.s.TSF, mm, 12.5 ± 7.1 11.9±6.3 n.s.

We did not find significant correlations between Kt/V nPCR and nutritionalintake, anthropometric parameters, and nearly all umoral indices. Significantcorrelation there were between BUN and nPCR (r=.669; p<.001), nPCR and Kt/V (r=.485; p<.001), BUN and protein intake (r=.501; p<.05), pealbumin and nPCR(r=.322; p<.05), sCr and Kt/V (r=.507; p<.001), and sCr and nPCR (r=.589; p<.001).Although, only in 5/21 pts baseline Kt/V was inadequate (<I), significant in-crease of dialytic dose and dietetic prescription were no able to ameliorate nu-tritional status, likely none had overt malnutrition. Nevertheless, it is no

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THE IMPACT OF PHYSICAL ACTIVITIES ON CHRONICHEMODIALYSIS PATIENTST Yamauchi1,2, T Kuno1, H Takada2, S Takahashi1, KKanmatsuse12nd Dept. of Internal Medicine, Nihon University1 and Dept. ofhemodialysis, Toshima chuo hospital2, Tokyo, Japan.

The purpose of this study is to evaluate the impact of activity ofdaily life (ADL) on several parameters for dialysis adequacy inpatients maintained on regular dialysis treatment. 56 stable outpatients (37 male, 19 female) in our dialysis center participatedin this study. Using walking-calorie meter (TANITA, Tokyo),ADL of the patients were evaluated by the average of their totalwalking steps during 3 days. They were divided into 2 groups;low ADL group and high ADL group (2858±1268 vs. 7474±2105steps/day) and evaluated. Percent body fats (%Fat) as a markerfor nutritional status were measured by bioelectrical impedanceanalysis methods.Results are shown as “Low ADL vs. High ADL”.TAC-BUN (mg/dl): 43.4±5.9 vs. 48.5±6.8; p<0.01PCR (g/kgBW/day): 1.18±0.17 vs. 1.28±0.16; p<0.05G-Urea (mg/kgBW/day): 330.5±55.4 vs. 362.4±53.8; p<0.05Kt/V-Urea: 1.25±0.18 vs. 1.22±0.16; NS%Fat tended to be lower in high ADL group.Conclusions: 1) Kt/V-Urea, which does not affect ADL is noteligible for the assessment of dialysis adequacy. 2) Since physi-cal activity seems to strongly affect the protein metabolism and/or the nutritional status, ADL should be monitored for the qual-ity control of dialysis therapy

HEMODIALYSIS WITH LOW-CALCIUM DIALYSATE IN-CREASES QTc DISPERSIONSE Näppia, HTH Sahaa,b, VK Virtanenb, JT Mustonena,b, AIPasternacka,b

aUniversity of Tampere, Medical School, bTampere UniversityHospital, Tampere, Finland.

The risk of ventricular arrhythmias increases during HD treat-ment, but the cause of this phenomenon has remained unsolved.QT dispersion (=QT

max–QT

min) reflects heterogeneity of cardiac

repolarization, and an increased QT dispersion is known to pre-dispose the heart to ventricular arrhythmias.We studied the effect of dialysate calcium concentration on car-diac electrical stability during HD treatment in 23 HD patients(20 M and 3 F, age 24-84 years). All patients underwent threeHD treatments with dialysate Ca++ concentrations of 1.25 mmol/l (dCa++1.25), 1.5 mmol/l (dCa++1.5) and 1.75 mmol/l (dCa++1.75).QT

c interval and QT

c dispersion were measured before and after

these three study HD sessions.With dCa++1.5 and dCa++1.75 dialyses, serum Ca++ increased andthe QT

c interval remained stable (dCa++1.5) or decreased

(dCa++1.75), but no significant change was found in QTc disper-

sion. With dCa++1.25 HD, serum Ca++ decreased (from 1.24±0.11to 1.20±0.09 mmol/l, p<0.05), and both the QT

c interval (from

403±27 to 419±33 ms, p<0.05) and QTc dispersion (from 38±19

to 49±18 ms, p<0.05) increased. The change in QTc interval cor-

related inversely with the change in serum Ca++ (r=-0.68,p<0.0001). Except for serum Ca++ and plasma iPTH, pre- andpostdialysis values in other blood chemistry, BP, heart rate, bodyweight and total UF were equal in the three HD sessions.This study is the first to demonstrate that HD increases QTinterval and QT dispersion if a low-calcium (dCa++1.25) dia-lysate is used. Accordingly, the use of low-calcium dialysatemay predispose HD patients to ventricular arrhytmias, andperhaps should be avoided at least when treating patients withpre-existing cardiac disease.

ANATOMICAL LESIONS OF HAEMODIALYSIS VASCU-LAR ACCESS WITHOUT CLINICAL SYNDROMES OFFAILURE1R Pietura, 2K Janicki 2L Janicka, 1M Szczerbo-Trojanowska1Dept. of Interventional Radiology, 2Dept. of Nephrology,Medical University of Lublin, Lublin, Poland

Dialysis fistula remains the most common type of vascularaccess for hemodialized patient.The aims of the present study were to evaluate frequencyof anatomical lesions occurrence and blood flow pattern inwell-functioning of haemodialysis vascular access in colourDoppler ultrasound imaging.Ultrasound examination was performed in 75 patients (33women and 42 men) in the age from 15 to 73, mean 43years without clinical syndromes of haemodialysis vascu-lar access failure.Only 8 (10%) patients had no anatomical lesions. In 67 (90%)patients there were: 39 stenoses (52%) (29 close to anasto-mosis 38%; 6 close to aneurysm 8%; 4 another anatomiclocation 5%), 43 aneurysms (57%), 28 kinking of vessels(37%), 16 calcifications (21%), 3 hematomas (4%), 12 wallirregularities (16%), 5 partial thromboses (7%), 4 chronicvenous occlusions (5%), 5 steal syndromes (7%), 6 collateralveins (8%), 3 small vessels (4%). Normal parameters of bloodflow in well-functioning haemodialysis vascular access werecalculated (mean flow volume =1306 ml/min ± 626ml/min(300-2800ml/min). Most well-functioning haemodialysisvascular access may have many different anatomical le-sions.

DOES SODIUM RAMPING IMPROVES INTRADIALITIC MORBIDITY? ATWHAT COST?SM Guimarães, R Campos, E Pereira, AM Sarmento, S GuimarãesCentro Médico Doenças Renais, Porto, Portugal

We prospectively compared two sodium ramping profiles in 14 unstable HDpatients. After 2 sessions with no profiling, either a linear (group A) and pro-gressively (group B) decreasing sodium concentration were used during 4 ses-sions, both beggining at 148 and ending at 138 mEq/l. After 4 sessions, groupswere switched. We obtained a sample of 140 HD sessions, being 28 with noprofiling and 56 with each one of those groups. Data registered was: intradialyticmorbidity: hipotension, hypertension, cramps, chest pain, need for saline of hyper-tonic NaCl, blood pressure at beggining, 30, 60, 120 and 180 minutes, weightloss, blood glucose at beggining and end, and post dialytic complications andcomplains: weight gain, thirst, headache, cramps.

Results:No profiling Group A Group B Sig.

Hypotension 71.4% 57.1% 50%Hypertension 10.7% 8.9% 14.3%Cramps 0% 19.6% 7.1%Chest pain 3.6% 0% 1.8%Need for NaCl 0,9% 60.7% 44.6% 41.1%Need for NaCl 30% 35.7% 10.7% 10.7%Weight Loss 2.89±1.03 3.48±1.22 3.66±1.34 p=0.28Average BP 0’ 115±21 116±22 116±24 nsAverage BP 60’ 103±21 104±22 106±23 nsAverage BP 120’ 91±20 94±20 99±23 nsAverage BP 180’ 80±18 92±22 93±22 p=0.22Blood Glucose 0’ 144±42 150±54 142±43 nsBlood Glucose end 132±40 122±44 126±35 nsWeight gain after 3.32±1.36 3.53±0.92 3.57±1.43 nsThirst after 53.6% 67.3% 67.3%Headache after 17.9% 24.5% 16.3%Cramps after 28.6% 22.4% 18.4%

We conclude that sodium ramping improves

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ELEVATED PLASMA VON WILLEBRAND FACTOR ANTI-GEN IN HEMODIALYZED SUBJECTS WITH END-STAGERENAL FAILURE AND A HISTORY OF PULMONARY EM-BOLISME Wieczorek-Surdacka, A Surdacki, W Sulowicz, H KolanowskaChair and Department of Nephrology, Jagiellonian University,Cracow, Poland

End-stage renal failure (ESRF) predisposes to both endothelialdysfunction and thromboembolic complications. Von Willebrandfactor is known to participate in platelet adhesion and aggrega-tion. Our aim was to estimate if increased incidence of throm-boembolic episodes in hemodialyzed ESRF subjects is associ-ated with elevated plasma levels of von Willebrand factor anti-gen (vWfAg) (a marker of endothelial dysfunction) and/or re-duced plasma natural coagulation inhibitors.Predialysis vWfAg concentrations in plasma were measured in30 ESRF patients with a history of pulmonary emboli (group A)and 30 ESRF controls without thromboembolic complications(group B). Both groups were matched for age (group A: 51 ± 12vs group B: 47 ± 12 years), sex, time on dialysis therapy (5 ± 5 vs7 ± 5 years), serum cholesterol (4.6 ± 1.5 vs 4.8 ±1.1 mmol/l)and triglycerides (2.8 ± 2.1 vs 2.6 ± 1.4 mmol/l) levels. PlasmavWfAg was higher in group A (120 ± 47 %) as compared togroup B (78 ±29 %) (p < 0.01) (results are expressed as percent-age of reference plasma). Platelet count (group A: 2.03 ± 0.91 vsgroup B: 2.12 ± 0.50 x 1011/l), predialysis plasma levels offibrinogen (3.3 ± 0.7 vs 3.2 ± 0.6 g/l), antithrombin III antigen(70 ± 16 vs ± 21 %) and protein C antigen (77 ± 24 vs 82 ± 20 %)were comparable in the two groups.It is concluded that elevated plasma von Willebrand factor maybe involved in the pathogenesis of pulmonary embolism inhemodialyzed ESRF subjects. There is no evidence of a similarpathogenetic role of decreased concentrations of naturalcoagulationl inhibitors such as antithrombin III and protein C.

ZINC DEFICIENCY AND PERIPHERAL NEUROPATHYIN PATIENTS ON RDTP. Iotova, A. Koteva, D. Ionova, K. TzachevAlexandrovska University Hospital, Sofia, Bulgaria

Uraemic Polyneuropathy (UPN) is an often complication ofESRD and it is also considered a sign of adequacy of dialysistreatment. Changes in Zinc (Zn) metabolism and particu-larly Zn deficiency is proven to be a cause of nervous sys-tem injuries in animal models. The aim of the study was toestimate the influence of oral Zn aspartate supplementa-tion on Zn deficient pts with signs of UPN. 25 pts (10 malesand 15 females), mean age 48,3+-9.2 years, mean durationof RDT 102+-16.4 months were included in the study. All ofthem had Electromiography (EMG) sign of UPN (slownerve conduction velocity and/or prolonged Distal Latency(DL) of n.tibialis and/or n.fibularis). At the begining of thestudy all of the patients had low serum Zn levels (9.97+-1.64umol/l). After 6 months supplementation with Zn aspar-tate a significant in:crease occurred (12.02+-1.60 umol/l;p<0.005). In control EMG study we observed shortening ofDL for both n.tibialis (P<0.05) and n.fibularis (P<0.005). Theresult of Zn supplementation was a significant increase oflow Zn levels and a good therapeutic effect of the symp-toms of UPN which allow us to recommend Zn aspartate asa part of complex treatment in our efforts to achieve betteroutcomes for the pts on RDT.

FUTURE OF HAEMODIALYSIS PATIENTS AFTER MEMBERAMPUTATIONF Bourdon, D Mercier, R Bousselmi, J VallinDept. of Nephrology and Haemodialysis, CMUDD, Saint Hilairedu Touvet, France

The aim of this study was to determine the evolution of haemo-dialysis (HD) patients after member amputation (amp).We reported our 3 last years experience in 11 HD patients under-going member amp, hospitalized to fit with a prosthesis, andre-education.This population was divided in 2 subgroups : diabetics (D) andno-diabetics (nD).

D nDn patients 5 6Age (years) 49 ± 10 57 ± 14Sex (M/F) 5/0 4/2Time on HD (months) 26 ± 10 168 ± 78 p < 0,02Prosthesis 60 % 83 %Walk recovery 60 % 67 %Death 2/5 0Follow-up (months) 45 ± 42 39 ± 50Kt/V 1,22 ± 0,2 1,27 ± 0,1

An interval time of 116 ± 104 days was necessary to fit with aprosthesis in nD patients, 75 ± 45 days in D patients. Transi-tional prosthesis facilitates healing with putting the stump oncharge.In this population, amputation member was not a fatal event.This study emphasizes importance to take care of HD amppatients with optimization of dialysis parameters and treat-ment to decrease healing’s time and to improve the quality oflife.

PROGNOSTIC VALUE OF PLASMA VON WILLEBRANDFACTOR ANTIGEN IN HEMODIALYZED SUBJECTS WITH,END-STAGE RENAL FAILURE - A PRELIMINARY REPORTE Wieczorek-Surdacka, A Surdacki, W Sulowicz, H KolanowskaChair and Department of Nephrology, Jagiellonian University,Cracow, Poland

Cardiovascular disease is the leading cause of death in dialyzedend-stage renal failure (ESRF) subjects. Elevated plasma, vonWillebrand antigen (vWfAg) levels have been shown to be a riskfactor for coronary artery disease as well as they exhibit a pre-dictive value of acute coronary syndromes in patients with sta-ble angina. Our aim was to assess the prognostic value of plasmavWfAg concentrations in hemodialyzed ESRF subjects.Predialysis vWfAg concentrations in plasma were measured in60 ESRF subjects (age: 49 ± 12 years) on maintenancehemodialysis. From among the study group, 7 patients diedowing to cardiovascular causes during a 3-year follow-up.Plasma vWfAg levels were higher in those who died (143 ± 65 %)as compared to the subjects who survived (91 ± 29 %) (p=0.02)(results are, expressed as percentage of reference plasma). Bothgroups exhibited: no significant differences in primary cause ofrenal disease, time on dialysis therapy, prevalence of hyperten-sion, serum concentrations of total cholesterol, triglycerides, cho-lesterol within low-density and high-density lipoproteins as wellas plasma fibrinogen and immunoreactive parathormone levels.Plasma concentrations of natural coagulation inhibitors - anti-thrombin III antigen and protein C antigen - were also similarirrespective of clinical outcome.These preliminary results suggest that elevated plasma levels ofvon Willebrand factor antigen may help to identify ESRF sub-jects at high risk of cardiovascular death.

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SERUM IMMUNOREACTIVE LEPTIN CONCENTRATIONSIN HEMODIALYSIS (HD) PATIENTSY Erten, FN Ozdemir, Z Arat, A Haberal, M Turan, M HaberalBaskent University Faculty of Medicine Dept of Nephrology,Ankara-Turkey

The obesity (ob) gene protein, known as leptin regulates bodyweight. As the kidneys are important in clearing several peptidehormones, it is suggested that leptin accumulates in the case ofrenal failure due to reduced renal clearance. Another possiblereason for elevated leptin levels in renal failure is chronicinflamation. Since leptin is thought to be an inhibitor of appetite,it has been speculated that elevated serum leptin could contrib-ute to anorexia and poor nutrition in patients with renal failure.The present study aimed to asses serum leptin level in HDpatients and relationship with age, hemodialysis duration, bodymass index and laboratory parameters including haemoglobin,haematocrit value, serum urea, creatinin, albumin, total choles-terol, trygliseride, parathormon, free T3, free T4, thyroid stimu-lating hormone, ferritin and CRP levels. Blood samples for leptinwere withdrawn in the morning after overnight fasting immedi-ately before a subsequent haemodialysis session.Fifthy-six male (mean age 45±15 years, mean HD duration 47±30months) and 55 female (mean age 50±15 years, mean HD dura-tion 55 ±3 6 months) were included in this study. Serum leptinlevel was found to be high 34 of males (mean 18.6±14)(normalrange 3.8±1.8) and 20 of females (25.2±12.7) (normal range7.4±3.7). Interestingly in the rest of the patients mean leptin levelwas lower than normal range (22 of males mean 1.6±1.07, 25 offemales mean 3±2.1) We have found no relationship betweenage and HD duration with high serum leptin level in each group.Leptin levels were high in male patients with higher body massindex and lower ferritin levels. Mean leptin level was high infemale patients with lower thyroid stimulating hormone level.Conclusion: According to our study, serum leptin level isn’televated in all HD patients. We have found no relationship be-tween high leptin levels with poor nutrition and inflamation. Sothat another mechanism that cause leptinemia in HD patientsmust be searched.

EVALUATION OF GLUCOCORTICOID ACTION IN AMILOIDOSIS PATIENTSWITH END STAGE. RENAL DISEASEIN Ozdemir, S Ozdal, N Guvener, S Sezer, Y Erten, M HaberalBaskent University Faculty of Medicine, Dept of Nephrology, Endocrinology,and Biochemistry, Ankara Turkey

Amiloidosis is an important etiological factor of ESRD in Turkey. Especially,IMF amiloidosis is seen frequently (18% of all ESRD patients). Because of organsystem involvement, amiloidosis patients have a poor survival from the start ofdialysis. Apart from major targets as cardiovascular, respiratory, andgastrointestinal system adrenal gland can also be involved so we planned thisstudy to compare the adrenal activity in hemodialysis (HD) patients with sec-ondary amiloidosis (Group 1) (13 patients) and the patients without (Group II)(13 patients).We performed a short stimulation test to the patients with 1 mg intramuscularlyadministered synacten (synthetic ACTH). Blood was drawn from the patientsbefore the test for ACTH and 1st, 2nd and 3rd hours for cortisole levels. We meas-ured ACTH levels by Radioimmunoassay (Diagnostis Systems Lab, USA) andcortisole levels by TDx Microparticular Enzymeimmunoassay (Abbot lab,USA).We found that patients with secondary amiloidosis were significantly younger(32.8±11.4 years, 53.6±15.4 years, p=0.01), had a shorter HD duration (13.9±10.9months, 42.3±31.7 months, p=0.02) and a lower BMI (19.5±2.2 kg/m2, 22.9±2.5km2, p=0.001). The results were as follows:There was no difference between basal ACTH and cortisole levels between thegroup I and II (34.9±17.2 pg/ml, 30.1±14.8 pg/ml (p>0.05) and 17.9±13.3 µg/dl,23.1 ±11.1 µg/dl (P>0.05). Following the administration of synacten measuredcortisole levels of Group I and Group II were; 1st hour: 24.3 ±15.4 µg/dl, 39.4±10.9µg/dl (p=0.008), 2nd hour: 29.2±15.9 µg/dl, 44.1±12.8 µg/dl (p=0.014), 4th hour:35.2±17.2 µg/dl, 50.4±12.4 µg/dl (p=0.017) respectively. According to results ofour study, there was no difference between basal ACTH and cortisole levelsbetween HD patients with amiloidosis and those without. Patients withamiloidosis had significantly depressed cortisole response to synacten test.In conclusion, short synacten test should be performed to amiloidosis patientswith renal failure to evaluate their adrenal gland capacity since subnormalresponses to the ACTH stimulation test indicate lack of responsiveness tohypoglisemia, stress, surgery, and acute illness.

ELEVATED LEVELS OF COAGULATION FACTOR VII INHEMODIALYSIS PATIENTS: A 5-YEAR PROSPECTIVESTUDY.S. De Marchi, E. Cecchin, E. Falleti, N. Bortolotti, G. Stel, F.Zanello, G. Sepiacci, P. Spulzaro, M. Adorati, L. Sechi, E. Bartoli.Department of Internal Medicine, University of Udine.

Coagulation factor VII is a cardiovascular risk factor in thegeneral population. We performed a 5-year prospective studyto explore the pathophysiological and clinical significance of theelevated levels of factor VII in patients with end-stage renaldisease on hemodialysis. We measured the plasma levels offactor VII as well as a variety of lipid-derived cardiovascularrisk factors, cytokines and chain-breaking antioxydants involvedin the pathogenesis of atherosclerosis in 88 hemodialysis pa-tients and 90 healthy subjects. The outcomes of the study werevascular access stenosis and mortality from atherothromboticevents. The mean value (±SD) of factor VII in hemodialysispatients (144 ± 27%) was higher than that in the control group(98 ± 31%; P<0.001). In these patients the levels of Factor VIIcorrelated with the plasma concentration of triglycerides (r=0.473,P<0.01), and the ratios total cholesterol/HDL-cholesterol(r=0.78, P<0.001) and apolipoprotein A-I/apolipoprotein C-III(r=-0.54, P<0.001). In addition, Factor VII showed a stronginverse correlation with the plasma concentration of thiol groups(r=-0.57, P<0.001), a major chain-breaking antioxydant, and apositive correlation with the monocyte chemoattractant protein1 (r=0.448, P<0.01), a chemokine produced by endothelial cellswith a pivotal atherogenetic role. The Cox proportional hazardsregression indicated that factor VII was a significant predictorof vascular access stenosis and mortality from atherothromboticevents.In conclusion, in hemodialysis patients an elevated value ofFactor VII represents a risk factor for vascular disease. Such anincrease of Factor VII may be related either to the uremicdyslipidemia or to the endothelial dysfunction which may, atleast in part, be due to a defect in the defence system ofchain-breaking antioxydants.

IS THERE ANY EFFECT OF APOLIPOPROTEIN EPOLIMORPHYSM ON SERUM LIPID, LIPOPROTEINS ANDATHEROSCLEROSIS IN HEMODIALYSIS PATIENTS?G Guz, FN Ozdemir, I Isiklar, Z Arat, M Turan, M HaberalBaskent University, Faculty of Medicine, Dept. of Nephrology,Ankara - Turkey

Atherosclerosis and cardiovascular disease are the major causesof death in hemodialysis (HD) patients. Presence of the ApoE4allele has been associated with increased serum lipids and coro-nary, carotid artery atherosclerosis. We investigated possiblerelationship between ApoE polimorphysm with atherosclerosisrisk factors.In our study, 269 HD patients (115 F, 154 M) were included thestudy The patients mean age and HD duration were 45.8±15.3years and 52.6±40.6 months, respectively. Testing was done onall patients to determine ApoE genotype and serum levels ofTCho, LDL-C, high density cholesterol (HDL-C), triglycerides(TG), lipoprotein(a) (Lpa), intact parathormon (iPTH), and fi-brinogen. ApoE genotype was identified using by polimerasechain reaction. Carotid artery intima-media thickness on ultra-sonography was used to diagnose atherosclerosis. Additionally,ApoE polimorphysm and the other possible risk factor such asage, sex, duration of hemodialysis, smoking, hypertensionanalyzed in relation to presence of atherosclerosis.Serum T-Cho and LDL-C levels were higher in patients with theApoE4/3 phenotype versus those with ApoE3/3 and ApoE3/2 phenotypes (p<0,05). However, there was no statistically sig-nificant link between serum levels of TG, HDL-C, or LP(a) andApoE polimorhysm (p>0,05). Apart from a relationship withage (p<0.05), we found no significant association between athero-sclerosis with ApoE polymorphysm and the other risk factorsanalyzed (p>0,05).In conclusion, altough ApoE polimorphysm significantly af-fects serum levels of TCho and LDL-Cho in HD patients, thisstudy indicates that it is not associated with the presence ofatherosclerosis in these individuals. The high incidence of athero-sclerosis in these patients underlines the need for further re-search of other possible etiologic factors.

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LIPID AND APOLIPOPROTEIN (Apo Al, Apo B, Apo CIII, Apo E) ABNOR-MALITIES IN CHRONIC HAEMODIALYSIS PATIENTS (HD) AND RENALTRANSPLANT PATIENTS (TX)Janicki K1, Bednarek-Skublewska A.2, Solski J.3, Kimak E.3, Janicka L.2, KsiazekA.21Dept. of Surgery, 2Dept. of Nephrology, 3Dept. of Clinical Analytics, Univ. Schoolof Medicine, Lublin, Poland

Atherosclerotic cardiovascular disease is one of the Major cause of death inrenal replacement therapy, Lipoprotein abnormalities are often present in renaltransplant patients. Serum lipid and apolipoprotein profiles including triglyececeride (TC), total cholesterol (TC), high density lipoprotein cholesterol(HDL-C), low density lipoprotein cholesterol (LDL-C), apolipoproteins (apoAI, apo B, apo CIII and apo E) among 40 HD patients, 12 TX patients and 40healthy subjects were determined.Ratjos of TG/HDL-C and of LDL-C/HDL and of HDL-C/Apo AI, and of ApoCIII non B and Apo CIII:B, and of Apo AI/CIII and also of Apo B/CIII in thesegroups were also evaluated.There significant increase of ratios of TG and of Apo CIII, and of Apo E, and ofApo CIII non B and of Apo CIII:B as well as decrease of ratios of HDL-C/Apo AI, and of Apo AI/Apo CIII and Apo B/Apo CIII compared of HD patients to thecontrol group.Results indicate increased ratios of TG and of Apo CIII and of Apo CIII non B andof Apo B/Apo CIII and also decreases ratios of Apo AI/Apo CIII in renal trans-plant patients compared to control group. Otherwise, there were significantlyhigher levels of HDL and of Apo AI and HDL/Apo AI, and of Apo CIII non B andlower levels of Apo E and of Apo E/Apo B, and of Apo CIII:B in renal transplantpatients compared to these of HD patients.There were significant inverse correlation between TG and HPL/Apo AI ratio(r= -0.58; p< 0.05 ). A significant positive correlation was found between serumTG and Apo E (r=0.57; p<0.05) and also Apo E:B (r = 0.60; p<0.05) in renaltransplant patients.The results of the trials described above support the following conclude that HDpatients exhibit a more atherogenic lipid and profile of apolipoproteins than TXpatients. These more atherogenic lipid profiles may be one of the more frequentcardiovascular events.

ABNORMALITIES OF THE NATURAL ANTICOAGULANTPROTEIN C SYSTEM IN HEMODIALYSIS PATIENTS.S. De Marchi, E. Cecchin, R. Giacomello, F. Zanello, R. Colaone,G. Sepiacci, M. Adorati, L. Sechi, E. Bartoli.Department of Internal Medicine, University of Udine.

Protein C is one of the major natural inhibitors of coagulation.Following activation of the zymogen by thrombin, activatedprotein C (APC), in cooperation with its cofactor protein S,proteolytically cleaves Factors Va and VIIIa (two importantaccelerators of coagulation) to inactive forms. Decreased levelsof protein C and protein S and a defect of the anticoagulantresponse to activated protein C (APC resistance) are risk factorsof thrombosis in the general population. The purpose of thisstudy was to investigate the pathophysiological significance ofthe abnormalities of the natural anticoagulant protein C systemin patients with endstage renal disease on hemodialysis.Thirty hemodialysis patients and 30 healthy subjects were en-rolled in a crosssectional study. Protein C and protein S levelsand APC resistance were measured using functional clottingassays. Screening for Factor V Leiden, a single point mutation infactor V resulting in a loss of sensitivity of factor Va to activatedprotein C, was carried out as described by Bertina et al. (Nature1994).The mean value (±SD) of protein C in hemodialysis patients(109 ± 23%) was lower than that in the control group (130 ± 29%;P<0.05). Moreover, these patients showed an increased APCresistance (2.01 ± 0.32 vs 3.01 ±0.31; P<0.01). Factor V LeidenAnalysis for Factor V Leiden was negative in all patients. Inhemodialysis patients APC resistance correlated inversely withthe plasma concentration of total cholesterol (r=-0.61, P<0.001),LDLcholesterol (r=-0.46, P<0.025) and triglycerides (r=-0.45,P<0.025).In conclusion, the decrease in the protein C level, and a defect ofthe anticoagulant response to activated protein C correlatedwith the degree of hyerlipoproteinemia, may contribute to theprothrombotic state of hemodialysis patients.

PLASMA ADRENOMEDULLIN LEVEL IN HEMODIALYSISPATIENTS: RELATIONSHIP WITH LEFT VENTRICULARDILATATION AND SYSTOLIC DYSFUNCTION.E. Cecchin, S. De Marchi, R. Ciani, F. Curcio, M. Adorati, G.Sepiacci, F. Zanello, L. Sechi, E. Bartoli.Department of Internal Medicine, University of Udine.

Adrenomedullin is a novel endogenous vasodilator peptide. Toevaluate the pathophysiological significance of adrenomedullinin patients with end-stage renal disease on hemodialysis weinvestigated the relationship between plasma adrenomedullinlevel and some echocardiographic measurements of left ven-tricular (LV) hypertrophy and dilation and systolic dysfunction.Thirty hemodialysis patients and 30 healthy subjects (age andsex matched) were enrolled in a cross-sectional study.Echocardiogragrams were performed with M-mode andtwodimensional echocardiography. Plasma adrenomedullin levelwas measured before dialysis using a radioimmunoassaymethod.The mean value (±SD) of plasma adrenomedullin in hemodialysispatients (36.1 ± 16.1 pg/ml) was higher than that in the controlgroup (27.9 ± 7.0 pg/ml; P<0.05). In these patients plasmaadrenomedullin concentration correlated inversely with LVend-diastolic diameter (r=-0.71, P<0.01) and LV end-diastolicdiameter (r=-0.78, P<0.005). Conversely, plasma adrenomedullinlevels showed no correlation with posterior LV wall thickness,interventricular sept thickness and LV mass index. In addition,there was a strong positive relationship between LV end-systolicdiameter and ejection fraction (r=-0.79, P < 0.005).In conclusion, hemodialysis patients have increased plasmaadrenomedullin levels that are closely related with left ventricu-lar dilatation. Considering its potent vasodilator effect, such anincrease in plasma adrenomedullin concentration may be in-volved in the defence mechanism regulating blood pressure andpreserving the functional integrity of the cardiovascular system.

LOW FLUX VERSUS HIGH FLUX MEMBRANES IN CHRONICHEMODIALYSIS PATIENTSC Gil, M Possante, MC Catarino, A Cruz, R Andrade, R Teixeira, N Santos, AFerreiraHEMODIAL-Centro de Hemodialise de Vila Franca de Xira, Portugal

Objective: Evaluate the chronic effects of shifting the dialysis membrane fromlow to high flux polyssulphone in a group of stable hemodialysis patients (pts.).Material and Methods: A retrospective study was performed on 21 pts. (11men), mean age 44±9,26 years, on HD for over one year. In each patient wecompared two consecutive periods of 6 months, the first under a low fluxpolyssulphone (F7HPS or F8HPS-chosen according to body surface, with an invitro UF coefficient of 9,8 or 11,1 ml/h/mmHg, respectively) and in the secondperiod a high flux polyssulphone (F60S or F80S with an in vitro UF coefficientof 40 or 55 ml/h/mmHg, respectively) was used. The dose of dialysis, evaluatedby the Kt/v was similar in both periods. During the 12 months of the study, wemonthly evaluated several biochemical, haematological and clinical param-eters such as serum (s) calcium, s phosphorous, plasma (p) iPTH, p bone alkalineisophosphatase, blood haemoglobin (Hb), albuminemia, s aluminum (sAl), sβ2microglobulin (β2-m) and dose of eritropoietin (EPO) administered.Al concentration in the HD water was persistently lower than 2 µg/l.Results: The mean results for each period of 6 months, were:

Low Flux HD High Flux HD p*β2-m (mg/l) 36,95 28,92 0,004Hb (g/dl) 11,36 11,98 0,04sAl (µg/l) 16,01 11,26 0,002*paired t Student

All the other parameters evaluated were not significantly different betweenboth periods.The p iPTH levels decreased from 442,3 pg/ml to 386,6 pg/ml (p=0,59) and thedose of EPO was reduced from 6523 U/pt./week to 6285 U/pt./week (p=0,67).Conclusion: The change from low flux to high flux polyssulphone seems veryuseful in the prevention of some of the most relevant adverse effects of chronicHD, namely dialysis associated amyloidosis and aluminum intoxication. Theuse of these high flux membranes was associated with an increase in Hb levelsunder a lower dose of EPO.

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LP (A) LEVELS AND OTHER RISK FACTORS FOR ATHEROSCLEROSIS INDIALYSIS PATIENTS.Del Corso C., Giovannetti R., Giacomelli A., Capitanini A., Rossi A., Straniti M.,Baldi R.*, Saba P.Dept of Medicine - Hospital of Pescia (Pistoia), Italy. Dept of Nephrology- Hos-pital of Pistoia, Italy.

The aim of this study was to quantify immunologically plasma Lp(a) levels andtheir relations to other lipid and non lipid risk factors for vascular events in 132patients. They were divided in two groups according to Lp(a) levels until 30mg/dl (group 1) or greater (group 2) in blood drawn at 8 a.m., after overnightfasting, before dialysis. In the patients total cholesterol, tryglicerides, fibrino-gen were evaluated; variables as age, gender, dialytic age, ABO blood group,presence of hypertension, diabetes, vascular ischemic disease were also inves-tigated. The results were statistically evaluated by anova and values expressedas percentage by the X2 method.The correlation between Lp(a) levels and other parameters studied was alsoassessed.

Group 1 Group 2 pPatients 70(53%) 62(47%) nsDialysis age yrs 4.3±4 2.1±2.5 nsBlood group A 21(30%) 36(60%) < 0.005Blood group 0 38(54%) 18(30%) <0.005Fibrinogen (mg/dl) 432± 104 449± 117 nsCholesterol (mg/dl) 194+-44 183±42 nsHypertension 48(68%) 51(82%) < 0.005Diabetes 8 (11%) 5(8%) nsIschemic disease 21(30%) 42(68%) < 0.001

As shown in the table the group 2 patients were 47% of the entire sample whilein the general population Lp(a) levels higher than 30 mg/dl are found in 17-20% subjects; the A and O blood group were more represented respectively ingroup 2 and 1; the prevalence of hypertension and ischemic vascular diseasewas more elevated in group 2. The study indicates that: 1) renal failure is asso-ciated with elevated Lp(a) levels with different blood group pattern; 2) Lp(a)high levels are associated with ischemic vascular disease and hypertension; 3)Lp(a) may be an indipendent risk factor for vascular events, particulary fre-quent in uremic patients.

EFFECTIVENESS FOR ROTATIONAL ATHERECTOMY INCALCIFIED CORONARY LESIONS ON HEMODIALYSEDPATIENTST Saijyo, M Nakamura, N Joki, M Fukazawa, H Fukuda, HIshikawa, K Mitsuo, H Hase, H Hirai, T YamaguchiThird Department of Internal Medicine, TOHO UniversityOhashi Hospital, Tokyo, Japan

The coronary lesions on hemodialysed (HD) patients docu-ment the presence of the heavy calcification. Calcification isa widely accepted as a risk factor for poor success withrelatively complications during balloon angioplasty (PTCA).Rotational atherectomy (RA) may provide an effective strat-egy for the treatment of calcified lesions in HD patients.To define the efficacy of RA for the treatment of the calcifiedlesion in HD patients, a total of 22 lesions treated by RAwere evaluated (mean age 61, 14 male, mean duration ofHD 48 months, 14 had DM). Stents following RA were com-pleted in 19 lesions, adjunctive PTCA were performed in 3lesions. Procedural success was 100%, there were no majorcomplications (death, CABG, Q wave myocardial infarc-tion), however creatin phosphokinase level elevations wereoccurred in 3 cases (> 2 x noted range), and acute heartfailure due to stunned myocardium was in 1 patient. Threemonth’s follow-up angiography was performed in 10 le-sions, and the 3 lesions of them needed revascularization.In conclusion, these results suggest that RA appear morepromising than PTCA in treating the heavy calcified lesionson HD patients.

EFFECTS OF THE THOROMBIN INHIBITOR AS A ANTICO-AGULANT FOR HEMODIALYSIS (HD) THERAPY.M Jyuni1, T Hirose1, Y Arai1, K Matsuno1, T Shimazu1, NSuzuki1, M Ominato2, S Owada21Tachibana-dai Hospital, Yokohama and 2St. Marianna Univ.School of Medicine, Kawasaki, Japan

Argatoroban (Arg; Mitubishi Kasei Pharm. CO., Japan), whichis a highly selective thrombin inhibitor, has been used to preventthrombogenic diseases. And Arg was also used as a anticoagu-lant in HD therapy for patients with ATIII deficiency or heparininduced thrombocytopenia. In this study, we evaluate antico-agulant effects of Arg and usefulness of activity clotting time(ACT) as a bed side monitor for anticoagulation during HDtherapy.Nine regular HD patients were selected for this study (M:F ; 5:4,mean age; 68 yr, mean duration of HD; 28 month). All patientswere dialyzed with a cellulose acetate hollow-fiber dialyzer us-ing heparin as a anticoagulant. And blood ATIII levels of themwere low or bottom of normal range. Arg was given 10mg as apriming dose and 5-20mg/h as a continuous infusion. ACT andAPTT were measured before and 30, 60, 120, 180, 240 min afterthe start of HD. During the study, same dialyzer was used.During HD therapy using Arg, blood ATIII levels (%) were in-creased to normal range (after 30 min: 97,7±20.6, after 240 min:117±25.6,VS before HD: 65.6±16.0, P<0.01).And ACT were increased 1.3 to 1.4-fold after 30min of the startof HD when compared with the level of before HD. The appear-ance of clot formation in the extracorporeal circuit was affectedby the change of ACT, rather than APTT. And mean dose of Argas a continuous infusion to maintain the circulation was11.7±6.5mg/h.In conclusion, Arg was useful drug as a anticoagulant for ATIIIdeficiency patients and ACT is a good marker of monitor foranticoagulation during HD.

RENAL CELL CARCINOMA (RCC) WITH ACQUIREDCYSTIC DISEASES OF KIDNEY (ACDK) IN CHRONICDIALYSIS PATIENTSA Katayama, Y Hibi, T Satoh, K Yamada, T Haba, YTominaga, K UchidaDept. of Transplant Surgery, Kidney Center, Nagoya DainiRed Cross Hospital, Nagoya, Japan

Renal cell carcinoma (RCC) with acquired renal cystic dis-ease (ACDK) is one of the most important complication inpatients on long-term hemodialysis or peritoneal dialysisin Japan. To assess treatment for RCC with ACDK andevaluate the clinical outcomes and complications, we en-rolled 20 patients who detected RCC with ACDK betweenMarch 1993 and February 1999 at Nagoya Daini Red CrossHospital. The follow-up periods were 1 to 72 months (mean:34.7 months). The duration of dialysis was 5 to 23 years(mean: 15.5 years).Clinical diagnosis was based on sonographic examinationor CT scan (12 cases) and only 8 cases were symptomatic.Seventeen patients underwent curative operations, 1 un-derwent non curative operation and 2 were inoperable ofcause distant metastasis. Six patients were in clinical stage I,9 in stage II, 2 in stage III and 3 in stage IV. Seventeenpatients survived; 16 were tumor-free and 1 had cancer.Three patients had died of causes related to RCC.Our results demonstrate that the prognosis of patients onchronic dialysis who underwent radical nephrectomy forRCC with ACDK is almost good, and careful observationbased on sonographic examination and CT scan is neces-sary for patients on long-term dialysis.

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HIGH POSTDIALYSIS UREA REBOUND PREDISPOSE TOINTRADIALYTIC INCREASE IN INTRAOCULAR PRESSURED. Tovbin1, M Friger2 S. Shapira3 and C Chimovitz1

Departments of Nephrology1, Epidemiology2 and Ophtalmology3,Soroka Medical Center, Ben-Gurion University, Beer-sheva, Is-rael.

Increase in intraocular pressure (IOP) has been observed duringhemodialysis (HD) sessions. Urea administration was consid-ered as effective therapy for increased IOP. Our hypothesis wasthat IOP might be influenced by entry of water to intraoculartissues or fluid, resulting from delayed clearance of urea fromaqueous or intraocular tissues as compared to rapid clearancefrom plasma.We assumed that post dialysis urea rebound (PDUR) inducedby urea exit from cells due to ID urea gap, can predict IDchanges in IOP.To evaluate ID changes in IOP and their correlation with PDUR,we studied 28 chronic HD patients (56 eyes) without history ofglaucoma or high IOP on examination. Serum urea levels andIOP were measured at start, end and 1 hour after dialysis.ID increase in mean IOP of 2 eyes (IDMIOP) was observed in 7of 28 studied patients (25%); all had PDUR ≥9 mg % and %PDUR ≥ 16%. PDUR was positively correlated with IDMIOP(r=0.52, p=0.05) and % IDMIOP (r=0.58, p=0.01). When 8 pa-tients with extreme serum urea levels (<100 or >300 mg %) wereexcluded, also % PDUR was positively correlated with IDMIOP(r=0.342, p=0.037) and % IDMIOP (r=0.406, p=0.012).In conclusion, PDUR may predict susceptibility to ID increasein IOP. Slower urea removal which has been shown by previousstudies to be associated with decreased % PDUR and PDUR, isprobably preferred in patients with high IOP.

EFFECT OF HEMODIALYSIS AND PARATHYROID HORMONE ON SERUMAMYLOID-A LEVELSS. Ulusoy, B. Altun, I. Haznedaroglu, C. Usalan, Y. Erdem, S. Kirazli, Ü. Yasavul,Ç. Turgan, S. ÇaglarHacettepe University School of Medicine, Ankara, Turkey

Serum amyloid A (SAA) is an acute -phase protein produced by the liver as aresult of tissue injury, infection or inflammation. Hemodialysis (HD) may in-duce acute inflamatory phenomena which are reflected by rises in the serumconcentrations of acute-phase proteins. Furthermore administration of parathy-roid hormone-related protein to mice increased hepatic serum amyloid A mRNAlevels as well as circulating levels of SAA. In this study, we aimed to determineSAA levels in hemodialysis and to investigate influence of PTH levels in chronicrenal failure.We studied thirty-five patient (20 M and 15 F) aged mean 41±13 years;all pa-tients were usually dialysed three times of weekly or more than one year (meandialysis time was 7,6±5,4 years).In sixteen patients (group A) PTH plasma con-centrations were in normal range (12-72 pg/ml), in nineteen patients (group B)were above the 72 pg/ml. Control group consisted of ten healthy volunteers (6M, 4 F, mean age 38±19). Hepatic function test results were in normal range inboth groups. Blood samples were collected both before and after dialysis forevaluating SAA concentrations with ELISA method.

SAA(ng/ml) Before HD After HD

Group A (n:16) 242,8±126,5 210,9±127,9 Group B (n;19) 134,5±127,0 160,1±146,0 Total (n:35) 172,8±137,5 185,5±138,3 Control group (n:10) 39,8±24,3

The SAA level in hemodialysis patient was significantly higher than controlgroup (p<0,005).Furthermore it was seen that SAA levels increased afterhemodialysis (p<0,05). SAA levels of group B was significantly lower thangroup A before hemodialysis (p<0,05). PTHrP is member of the cascade ofproinflammatory cytokines produced within the liver that can stimulate theacute phase response. Downregulation of PTH/PTHrP receptors might be re-sponsible for low SAA levels in high-PTH hemodialysis patients

EARLY DETECTION AND PERCUTANEOUS TREATMENTOF HEMODIALYSIS VASCULAR ACCESS DYSFUNCTION.JJ Gallego, JA Herrero, M. Marques, A H. Lezana, F Coronel, RMoreno, A Barrientos.Dept. of Radiology and Nephrology. Hospital Clínico San Carlos,Madrid, Spain.

The purpose of the study was to assess the usefulness of a pro-gram for the early detection of hemodialysis vascular access (VA)dysfunction and the impact of pecutaneous transluminalangioplasty (PTA) and stent implantation to correct venous ste-nosis. Detection was based on physical examination, blood flowrate, venous pressure, dialysis efficiency and recirculation meas-urements. Percutaneous procedures consisting of angioplasty(PTA) or PTA plus stent deployment when the PTA were insuffi-cient.We performed 246 fistulography procedures in 110 patients stud-ied over a period of 80 months. Brescia-Cimino (B-C) were 67 %of VA, polytetrafluoroethylene (PTFE) grafts 27 %, and externalThomas shunts 6 %. The most important indicators of dysfunc-tion were increased venous pressure and difficulty in cannula-tion. Significant stenosis were revealed by 227 (92.2 %) of the 246fistulography procedures performed, and 174 (76.6 %) were se-lected for percutaneous treatment. PTA results were satisfactoryin 100 % of Thomas, 74 % of B-C, and 53 % of PTFE. Technicalsuccess rates for stent deployment were 92 % for B-C and 100 %for PTFE. The primary patency of B-C was 86 % at 3 months, 76% at six months, 71 % at 12 months; for the PTFE 92 % at 3months, 66 % at 6 months and 36 % at 12 months; for the Thomas71 % at 3 months, 54 % at six months and 8 % at 12 months.Reintervention was required in 32 % of cases. Assisted patencyfor the B-C was 89 % at six months and 82 % at 24 months; for thePTFE 92 % at six months and 46 % at 18 months; for the Thomas100 % at 24 months.We conclude that a surveillance program of VA dysfunction pro-vide an early diagnosis of the stenosis. The pecutaneous interven-tion as required, achieved excellent primary and assisted patencyrates.

CONCORDANCE BETWEEN SUBJECTIVE GLOBALASSESMENT (SGA) AND OTHER NUTRITIONAL PARAM-ETERS IN DIALYSIS PATIENTS (pts).R. Carreras, C. Najun Zarazaga, J. Lobo.Instituto de Diálisis, Mansilla 3141, Buenos Aires, Argentina.

Protein-calorie malnutrition is common in dialysis population.Nutritional status (NS) can be evaluated by SGA, a non invasivetechnique based on anamnesis and physical examination. Theaim of this cross sectional study was to assess NS in our dialysispts by SGA, establishing it usefulness and comparing the re-sults with other commonly used nutritional parameters.We performed SGA in 65 pts, 36 M and 29 F, 46 in HD and 19 inPD. We also determine albumin (Alb) g/dl, cholesterol (Chol)mg/dl and PCRn g/k/d. The NS prevalence by SGA was nor-mal (A) 67.7%, mild (B) 24.6%,and severely malnourished (C)7.7%. ANOVA was applied to compare Alb, PCR and Chol,among the different groups according to SGA. (TableI).

Table I SGA(A) SGA(B) SGA(C) pAlb (X±SD) 4.04±0.22 3.43±0.17 2.99±0.28 <0.001

(CI95%) 3.97-4.13 3.27-3.59 2.79-3.23PCR (X±SD) 1.12±0.22 0.94±0.17 0.57±0.17 <0.001

(CI95%) 1.05-1.19 0.86-1.02 0.42-0.72Chol(X±SD) 178±49 151±23 137±11 0.003

(CI95%) 163-192 139-162 127-146

Using Alb as a reference parameter of NS, SGA sensibility was0.91(CI95%:0.83-0.99), specificity: 0.89 (CI 95%:0.75-1), posi-tive predictive value: 0.95, and negative predictive value:0.80.Our results showed a 32.3% of malnutrition. We found a highsensibility and specificity for SGA, and that Alb, PCRn and Cholwere significantly different among each SGA group.This resultsupport the hypothesis that SGA is a reliable and useful tool toevaluate NS.

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IDENTIFICATION OF DEHP METABOLITES IN PLASMA,URINE AND BREATH AND IN VITRO SCREENING FORTHEIR ANTIPROLIFERATIVE EFFECTSH G Wahl1, P C Dartsch2, D Luft1, T Risler3, H M Liebich1

Medizinische Universitätsklinik Tübingen, Germany,1ClinicalChemistry, 3Nephrology, 2Department of Occupational and So-cial Medicine

There is great concern about the toxicity of the plasticizer DEHPand its metabolites especially for risk groups such as patientson hemodialysis or criticall ill patients, where DEHP was de-tected in plasma. Some of the proposed and shown effects inanimals are carcinogenity, peroxisome proliferation, mutagenicactivity, infertility and changes in lipid metabolism. Differentmetabolites have been blamed for the toxicity: phthalic acid,mono- and di-reesterified phtalate. We found elevated levels of2-ethylhexanol, 4-heptanone and 2-heptanone in breath, urineand serum from patients on hemodialysis and from patients inan intensive care unit. In a pilot study with five control persons,infusions of 500 ml NaCl through regular -DEHP containing-infusion systems lead to an increase of urinary 4-heptanonefrom 202 ± 58 to 643 ± 31 µg/24h. Breath analysis was per-formed by Thermodesorption Gas Chromatography MassSpectrometry (TDS-GC-MS), urine and plasma samples wereanalyzed by headspace GC-MS. Toxicity of 2-ethylhexanol and4-heptanone was checked using adherent human cell lines ofkidney and liver. Cells were seeded into 12-well plates and al-lowed to attach and spread for 24 hours. Thereafter, cells wereincubated for another 24 h with a mixture of 2-ethylhexanol and4-heptanone (1:1, v/v) at concentrations ranging from 0 to 500ng/ml for each compound. Cell viability was checked by count-ing the number of viable cells and examination of mitochondrialenzymatic activity by hydrolysis of 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT). The results fromboth tests using adherent human cell lines of kidney and liverclearly demonstrate a dose-dependent reduction of viable cellsfor 2-ethylhexanol and 4-heptanone at concentrations found inpatients on hemodialysis and others exposed to DEHP.

ROLE CHLAMYDIA INFECTION IN ATHEROSCLEROTIC PROCESS INHEMODIALYSIS PATIENTS: IS INFLAMMATION ENHANCES ATHERO-SCLEROSIS?C. Usalan, A Oto, B. Altun, S. Ulusoy, A.A. Kiykim, Y. Erdem, Ü. Yasavul, Ç.Turgan, S. Çaglar.Hacettepe University School of Medicine, Ankara-Turkey

Measurement of intima media thickness of carotid artery by high resolution B-mode ultrasonography is increasingly used to evaluate the atherosclerotic vas-cular changes. Several lines of of evidence suggests that inflammation and acutephase proteins such as C-reactive protein (CRP) and serum amyloid A (SAA) areassociated with atherosclerotic process in general population.Seroepidemiological studies revealed Chlamydial infections might have a rolein the pathogenesis and progression of atherosclerosis. The aim of this study isto evaluate the role of inflammatory process and Chlamdyia infection in theatherosclerotic disease in hemodialysis patients.Forty-seven patients (25M, 22F, aged 40±12) were involved in this study. Fifty-two age and sex matched healthy subjects served as control group. PredialysisSAA levels (ELISA) and CRP levels and both right carotid intima media thick-ness (RCIMT) and left carotid intima media thickness (LCIMT) were measuredin patients and control group. Chlamydial infection was evaluated with sero-logical examination and patients were stratified into 2 groups according totitraton of antibody: 28 patients (Group A) have a titration value <1/100 and 19patients (Group B) have a titration value above1/100. Both RCIMT and LCIMTof hemodialysis patients were greater than control group (0.73±0.24 mm vs.0.54±0.15 mm, p< 0.001 and 0.76 ± 0.24 mm vs. 0.56±0.15 mm, p<0.001). Age ofthe patients were correlated with IMT of carotid arteries (p<0.001). RCIMT andLCIMT of the Group B is greater than Group A patients (0.63±0.14 mm vs.0.88±0.28 mm, p< 0.05 and 0.66±0.15 mm vs. 0.91±0.28 mm, p< 0.05). SAAlevels (p< 0.001) and CRP levels (p<0.05) were correlated with RCIMT and LCIMT.The relationship of chlamydia serology of patients and IMT of carotid arteriesshowed a positive correlation (p< 0.001).In conclusion these findings suggest that chlamydia infections inflammationtogether with might play a role in the pathogenesis and progression of athero-sclerosis in hemodialysis patients.

ROLE OF RENIN ANGIOTENSIN SYSTEM IN ATHEROSCLE-ROSIS AND LEFT VENTRICULAR HYPERTROPHY OF NOR-MOTENSIVE AND HYPERTENSIVE HEMODIALYSIS PA-TIENTSB. Altun, K. Aytemir, A Oto, A.A. Kiykim, C. Usalan, Y. Erdem,S. Aksöyek, S. Kes, Ü. Yasavul, Ç. Turgan, S. Çaglar.Hacettepe University School of Medicine, Ankara-Turkey

Atherosclerosis and left ventricular hypertrophy play a determi-nant role in the cardiovascular complications of end stage renaldisease patients. Renin angiotensin system (RAS) has been knownto contribute to development of left ventricular hypertrophyand atherosclerosis in adults. The aim of this study is to evalu-ate the role of RAS in the process of atherosclerosis and leftventricular hypertrophy in normotensive and hypertensivehemodialysis patients.Thirty hemodialysis patients ( ) were involved in this study.Sixteen patients (Group A ) were hypertensive whereas 14 pa-tients (Group B) have a blood pressure within normal limits.End diastolic measurements of interventricular septal (ISV)thickness, posterior wall (PW) thickness, left ventricular enddistolic diameter (LVEDD) were measured and left ventricularmass index (LVMI) was calculated. Intima media thickness ofright (RCIMT) and left (LCIMT) carotid arteries were measuredby B-mode ultrasonography to determine the degree of athero-sclerosis. Predialysis and post of dialysis plasma renin activitywere measured. ACE gene polymorphism (II, ID, DD) of thepatients were determined. Percent increase in PRA and volumedepletion were similar in group A and group B patients Percentincrease in PRA activity was positively correlated with ISV thick-ness (p=0,004), and LVMI (p=0,01) in normotensive group butnot in hypertensive group. When the patients were stratifiedaccording to DD (n: 22) and II/ID (n: 8) groups, no significantdifference was observed in echocardiographic andultrasonographic findings.In conclusion, activation of renin angiotensin system inhemodialysis might be an independent factor for left ventricularhypertrophy in normotensive hemodialysis patients.

BLOOD DECANTATION IN A CLOSED SYRINGE ALLOWS PRE DIALYSIS PLASMA SAMPLINGWITHOUT ERYTHROCYTE LOSSESCristol JP., Bosc JY., Bonardet A., Piva MT., Descomps B., Canaud B.Nephrology and Biochemistry A and B Depts, Lapeyronie University Hospital, 34059 Montpellier,France.

Quality control of treatment and dialysis adequacy require repeated blood sampling. To overcome redblood cell losses in anemic patients, Bergström et al purposed a sedimentation technique used forpredialysis determination of parameters such as urea, creatinine and electrolytes. To expand thissampling modality for both hydrophylic and hydrophobic (lipid and protein parameters) substances,20 chronic hemodialysis patients were included in this study. At the start of dialysis session a 50 mlheparinized syringe connected to arterial blood line via a 3-way stop-cock allowed blood samplingand decantation in a closed appendix circuit. Plasma was sampled after 30 minutes via the 3-way stop-cock to solute analyses and then sediment was returned to arterial line. Hydrophilic and hydrophobicsolutes (urea, creatinine, electrolytes, ß2Microglobulin, albumin, prealbumin, cholesterol, triglycer-ides, apolipoproteins, Immunoglobulins, Lp(a), CRP) were measured in plasma after sampling bydecantation and by conventionnal predialysis blood sampling. Results obtained by both modalitieswere compaired using t test and Spearman correlation (R). For all parameters no significant differencewas observed, moreover R was greather than 0.93. Figures show correlation obtained for albuminand cholesterol.

y = 1.01x - 0.13

R = 0.99

1

3

5

7

9

1 3 5 7 9Blood sampling

De

ca

nta

tion

Cholesterol

R = 0 . 9 6

2 0

3 0

4 0

2 0 3 0 4 0Blood sampling

Albumin

De

ca

nta

tion

y = 1.04 x - 2.15

In conclusion decantation provides a safe and effective procedure to determine routinely both hydophillicand hydrophobic predialysis substances sparing erythrocyte losses.In conclusion decantation appears as a suitable procedure to determine routinely both hydophillic andhydrophobic pre dialysis solutes without red blood losses.Solute Decantation Conventionnal t Rurea 19.9±5.4 22.4±5.4 ns 0.93creatinine 767±178 819±180 ns 0.97calcium 2.2±0.2 2.2±0.2 ns 0.94phosphates 1.6±0.6 1.8±0.6 ns 0.98potassium 4.5±0.7 4.7±0.8 ns 0.93ß2 microglobuline 33.9±6.5 34.6±6.7 ns 0.96albumine 31.6±4.2 32.6±3.9 ns 0.96prealbumine 0.33±0.09 0.34±0.09 ns 1.00IgA 2.17±1.79 2.24±1.82 ns 1.00IgM 1.04±0.79 1.08±0.78 ns 1.00IgG 8.85±5.18 9.26±5.30 ns 1.00C 3 0.88±0.15 0.90±0.15 ns 0.96CRP 8.28±9.00 7.49±8.91 ns 0.98cholesterol 5.29±1.79 5.36±1.75 ns 0.99triglicerides 1.83±1.42 1.94±1.39 ns 0.97Apo A 1.40±0.38 1.46±0.36 ns 0.98Apo B 1.06±0.36 1.07±0.35 ns 0.99

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DO HIGH DIALYSIS DOSE AND SYNTHETIC MEMBRANE IMPROVEANEMIA IN DIALYSIS PATIENTS?David S, Barbisoni F, Palmerio G, Leonardi S, Maggiore U, Cambi V, for theMulticenter Dialysis Adequacy Study GroupChair of Nephrology- University of Parma – Italy

While inadequate dialysis is a well known cause of EPO resistance, the advan-tages of higher dialysis dose and synthetic membrane on the correction of anemiain ESRD are still debated.The aim of this study is to investigate whether synthetic membrane alone, orcombined to higher Kt/V is able to increase Hct level or reduce EPO require-ments in a dialysis population with low comorbidity.We performed a post hoc analysis on data from 110 non diabetic patients on HDfrom 6-24 months (GFR<2 ml/min), selected from a population of 121 on thebasis of an observation period of at least 9 month. After a 4-month run-in period(A), they were randomly assigned to one of the following groups: 1) Kt/V=1 andCuprophan membrane, as control group; 2) Kt/V=1 and synthetic membrane; 3)Kt/V =1.3 and synthetic membrane. Measurement of actual Kt/V, includingpost-dialysis (+30 min) urea rebound was performed monthly during the studyperiod. Hct, ferritin (F), transferrin saturation index (TSI), albumin and PTHwere also measured at the same time. Experimental phase was divided in two4-month periods (B,C) and results are expressed as mean ±SD of each consideredperiod.Results:

Period A Period B Period CGroup Hct Kt/V Hct Kt/V Hct Kt/V1 (n=40) 29.1±3.4 1.11±0.17 29.5±3.8 1.10±0.14 29.9±3.2 1.06±0.132 (n=37) 29.3±5.0 1.08±0.13 30.9±4.0 1.05±0.14 30.5±3.5 1.03±0.133 (n=33) 29.4±4.5 1.11±0.11 29.7±3.9 1.30±0.15 30.3±3.8 1.33±0.14The whole population showed a slight and significant increase in Hct levels(p=0.014), but the increase was not statistically different in the three groups(p=0.48). Either EPO cumulative dose or the proportion of patients no treatedwith EPO (32.5%, 43.2% and 30.3% in groups 1,2 and 3, respectively) were notdifferent (p=0.47 and 0.40, respectively). Plasma F, TSI, PTH and Albumin werealso comparable in all groups during the study. The incidence of morbid eventswas low (1.65,2.04,and 1.57 hospitalizations in the three groups, respectively,per 100 person-months). In conclusion, this study suggests that in patients with-out relevant comorbidities, an administered dialysis dose of 1.1 (measured asKt/V at equilibrium) is adequate to maintain stable Hct levels and no furtherrelevant advantages are offered by higher Kt/V levels and synthetic membraneinstead of Cuprophan.

ANTIBIOTIC LOCK, AN EFFECTIVE MANNER FOR PREVENTING PERMA-NENT CATHETER RELATED INFECTIONS.Leray-Moragues H., Bosc JY., Canaud B.Nephrology Department, Lapeyronie University Hospital, 34059 Montpellier,France.

Implantable atrial catheters (KT) are increasingly used as long termhaemodialysis access. Infections (exit site infections, tunnellitis, bacteriemiaand /or septicemia) still represent the major complication.The aim of this preliminary study was to evaluate the efficacy of antibiotic lockbased on a sodium citrate and gentamicin mixture.The method proposed by Sodemann and al (ASN 1997) combines anticoagulant(sodium citrate 3,8%), antibiotic (gentamicin 40mg/ml) and sodium chloride.The mixture is instilled in each catheter at the end of dialysis session, left in situuntil the next session and withdrawn before catheter use.This prospective non randomized study consisted in two consecutive phaseslasting 6 months each:- Phase A (1/1/98-1/7/98) used conventional pure standard heparin lock.- Phase B (2/7/98-1/1/99) used citrate/gentamicin lock.13 end-stage renal failure patients (5 men, 8 women) harboring permanent di-alysis KT (Dual cath, Hemotech) were involved in both phases of the study.Handling and desinfection procedures applied did not change over time.During phase A (heparin lock), incidence of bacteriemia was 3,5 episodes /1000patients/days. A total of 8 bacteriemia were observed in 5 patients with threecases of tunnellitis and exit site infection. Three catheters were removed due touncontrolled infection.During phase B (citrate/gentamicin lock), incidence of bacteriemia was nil forthe same duration of exposure.No side effect related to gentamicin use was noted. Blood dosages were unableto confirm any gentamicin spilling out from KT.We conclude from this preliminary study that the sodium citrate and gentamicinlock appears very effective, safe and costless in preventing long term dialysiscatheter related sepsis.

IS LARGE SURFACE AREA (SA) HEMODIAFILTRATION (HDF) BETTERTHAN. LARGE SA HEMODIALYSIS (HD)?V Barlee, GJ Mishkin, JP Bosch.The George Washington University, Washington, DC, USA

Convective therapies such as HDF have been shown to improve the treatmentdelivered when compared to conventional HD. These comparisons, however,are limited by low blood flows (Qb) and standard hemodialyzer SA. Differ-ences in the quantity of treatment delivered with Qb greater than 500 ml/minand extremely large dialyzer SA (3.6 m2) have not been reported.HDF was performed using two polysulfone (F80A or F8, Fresenius Medical Co,CA) hemodialyzers (total SA of 3.6 m2) with both the blood and dialysate com-partments in series. A dialysate flow restrictor was placed between the dialyzers(Mid) in order to enhance Uf in the first dialyzer with compensatory backfiltrationin the second dialyzer. HD was performed using the same dialyzer configura-tion without a dialysate flow restrictor. 8 pts participated in the study, aftergiving consent. Each pt underwent each of the four modalities (HDF or HD withF80A or F8) and a ten min clearance (K) period was evaluated for each modalityby drawing blood samples from the arterial, venous and Mid positions. K val-ues account for red blood cell volume. Uf rates were calculated by changes inhematocrit.K values correspond to K in the first dialyzer (K1), K in the second dialyzer (K2)and total K (K

T), which is calculated by the arterial and venous values and is not

equal to the sum of K1 + K2.

Mode Dialyzer Urea K (ml/min) UfT

QbK1 K2 K

Tml/min ml/min

HDF F80A 335 a 264 a 467 a 136 a 532 aHD F80A 329 a 277 a 458 ab 95 b 532 aHDF F8 274 b 320 b 443 bc 38 c 533 aHD F8 289 b 320 b 442 c 30 d 533 a• a, b, c, d signify differences between groups at p < 0.01.

In all four modalities, extracorporeal K of urea (KT) was greater than 83% of

delivered Qb. As expected, high flux dialyzers permitted better Uf, however,HDF with high flux dialyzers yielded an Uf rate 43% greater than high flux HD.In conclusion, treatment efficiency will be enhanced by using 3.6 m2 SA and a Qb> 500 ml/min. Use of the dialysate flow restrictor will improve Uf rates andmiddle molecule removal. These treatments should be used to treat pts greaterthan 80 kg in less than 240 minutes.

EVIDENCE OF HCV-RNA DETECTION IN HEMODIALYSISULTRAFILTRATES. Spaia, Ch. Katsinas, N. Askepidis, K.Baltatzi, M. Pazarloglou,G. Antoniadi, V. Liakopoulos, G. Papathomas, G. VayonasRenal Department,2nd Hospital of IKA,Thessaloniki, Greece

Detection of HCVRNA has been reported in various body fluids,as in bile,while HCV antibodies have been reported in saliva andurine. Decreased HCVRNA has also been re-ported in the bloodof hemodialysis patient at the exit port of a certain dialyser,while ultrafiltrate contained no dete-ctable RNA.The purpose ofthis study is to clarify the dete-ction of HCVRNA in theultrafiltrate of HD pts and its potential infectivity. Methods:Nine patients who were hemodialysed with different dialyzerswith positive anti-HCV anti-bodies were tested for HCVRNA bya qualitative and quan-titative Amplicor HCV Monitor Assayboth in serum and in the ultrafiltrate, ten minutes after initiationof isolated ultra-filtration. Three samples were drawn each timefor each collection. An overall of 54 samples were determined.Results: Qualitative assay (sensitivity of > 100 copies/ml) waspositive in the serum of all the patients and in 4 samples ofultrafiltrate (45%). Quantitative assay (sensitivity of>2000c/ml) was positive in the blood samples of 5 pts (m.v. 133000±154000c/ml) and in none of the ultrafiltrate. Type of dialyzerhad no impact on the results. Six patients were dialysed withlow flux dialyzers and 3 with high flux. Three of them hadfinished a 6-month course with interferon A. Only one had elevatedALT at the time. Conclusions: Unlike previous reportsultrafiltrate of HCV antibody-positive patients could beinfectious since we have demonstrated detectable HCV-RNA init. HCVRNA could pass even through low flux dialyzers.Adsorption of HCV RNA by different membranes has not beendemonstrated by this study. Conditions that influence themagnitude of trasmission to ultrafiltrate should be furtherclarified by repeated determinations in larger samples. Detectionthreshold of the assay employed seems to be of criticalimportance for the outcome.

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FIBRONECTIN (FN) AS AN IMPORTANT PARAMETER OFHYPERCOAGULABILITY IN PATIENTS ON REGULARHAEMODIALYSIS TREATMENT (RDT)M. G. Saadi, F. Fadel*, T. Eyada**, A. Roushdy, U. Sharaf El-Din,and M. H. Hafez.The departments of nephrology, pediatrics* and clinical pathol-ogy**, Faculty of medicine, Cairo University, Egypt.

FN is a glycoprotein present in body fluids and tissues and isknown to have a binding property involved in the haemostaticmechanism among other functions. FN is known to be low inchronic renal failure (CRF) patients undergoing RDT. Whether itplays any role in the hypercoagulability of some such patients;particularly clotting in the hollow fibre; is not known.FN was studied in 12 CRF patients on RDT havinghypercoagulability and requiring higher heparin doses on dialy-sis, 12 similar patients with no coagulation problems and re-ceiving usual heparin doses, and in 10 normal controls.In all the patients the examined coagulation tests were withinthe normal ranges and showed no significant differences amongthe patients groups. Anti thrombin III was significantly higherin the hypercoagulability group than the healthy control andinsignificantly higher than the normal RDT group. Plasma FN inthe normal heparin group (240.8 ± 89.5 mg/L) was significantlylower than in the control cases (365 ± 39.4 mg/L) p< 0.001. Thelevel in the hypercoagulability group (555.8 ± 202.14 mg/L)was significantly higher than the level in the healthy controls p<0.005, and consequently more significantly higher than the levelin the normal heparin group p< 0.001. FN was above the normalrange in 8/12 cases with hypercoagulability suggesting an im-portant role in inducing coagulation and/or antagonising theanticoagulant.The coagulation profile study for RDT patients should includeplasma FN as one of its parameters, which could predict higherheparin requirements on dialysis.

EARLY NEPHROLOGICAL REFERRAL IMPROVES SURVIVALON HEMODIALYSIS (HD) IN PATIENTS WITH VASCULARRENAL DISEASES (VRD).R Boulahrouz, C Stanescu, C Charasse, KS Ang, Ph Le Cacheuxand P Simon.Dept of Nephrology, La Beauchée H St-Brieuc 22000, France.

Previous studies demonstrated that late nephrological referralbefore end stage renal failure (ESRF) had detrimental conse-quences to maintenance HD.We retrospectively studied clinical data and survival on HD in412 uremic patients who started HD treatment at our unit be-tween January 1983 and December 1997. Causes of ESRD wereprimary glomerular disease (n=109 patients), hereditary neph-ropathy (n=71 pts), systemic diseases (n=106 pts, whose 51had diabetes), chronic tubulo-interstitial nephropathy (n= 43pts), and VRD (n=75 pts), indetermined (n= 8 pts). We com-pared pts who benefited regular nephrological follow-up for atleast 6, 12 or 18 months before ESRF and those who were re-ferred less than 6, 12 or 18 months before ESRF. The most signifi-cant results were found in pts with VRD who benefited earlynephrological referral (ER) at least 18 months before ESRF (n=41, males/females=28/13, average creatinine clearance at thefirst referral : 29+-13 ml/mn)) in comparison with late referred(LR) pts (n= 34, M/F 22/12, average CrCl: 11+-10 ml/mn and< 18 months of follow-up). Whereas mean age at ESRF wassimilar in both groups (ER vs LR): 68 +- 12 years (M : 67+-14, F:73+-5) vs 66+-11 yrs (M: 65+-11, F: 66+-12) (ns), the number ofdeaths after HD initiation was significantly lower at 3 months :1 (2.4%) vs 8 (23.5%), p< 0.02, at 6 months : 4 (9.8%) vs 10(29.4%), p< 0.03 and at 12 months : 7 (17.1%) vs, 14 (41.2%) p<0.02. No difference was found at 24 months and more : 27(65.8%) vs 20 (58.8%).This study shows that better survival is obtained for the first 12months of HD treatment in patients with VRD when they areearly referred to a nephrologist

abstracts haemodialysis nephrology dialysis transplantation vol

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