REPLACEMENT OF RENAL FUNCTION BY DIALYSIS

Fourth edition

DRUKKER, PARSONS and MAHER

REPLACEMENT OF RENAL FUNCTION

BY DIALYSIS Fourth edition

Edited by

C. JACOBS

C. M. KJELLSTRAND

K. M. KOCH

J. F. WINCHESTER (editor-in-chief)

KLUWER ACADEMIC PUBLISHERS

DORDRECHT I BOSTON I LONDON

Library of Congress Cataloging in Publication Data 4 e p i a c e m e n t a f r e n a l f u n c : ? o n b y d l a l y s ' s ' e d l t e a b y C ' a d d e J a c 3 b s

. . . [ $ * a l . 1 . -- 4 t h e d . 3 . ;In.

I n c l ~ d e s b l b l l ~ ~ r a p h l c a l r e f e r e n c e s a n 2 i n d e x . ISBN 0 - 7 9 2 3 - 3 6 ' 0 - 0 ( b b a l k . p a p e r ) 1 . H e m o d l a l y s l s . I. J a c a o b s . C l a u c e . [DNLM 1 . H e m o d i a l d s l s . dJ 3 7 8 4 4 2 5 1 9 9 5 1

R C 9 0 1 . 7 . H 4 5 R 4 6 ' 9 9 5 6 1 7 . 4 ' 6 1 0 5 9 - - d c 2 0 DNLM f DLC f o r L i b r a r y o f C o n g r e s s 9 5 - 3 1 0 8 1

ISBN 0-7923-3610-0

First edition 1978 Second, revised and enlarged edition 1983 Third edition, updated and enlarged 1989

Reprinted 1992 Fourth edition, 1996 (completely revised)

Published by Kluwer Academic Publishers, P.O. Box 17, 3300 AA Dordrecht, The Netherlands

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Printed in the Netherlands

Cover illustration: The illustration on the cover is meant to visualize a blood contacting biomaterial by an artistic concept of molecular modelling. The colours indicate the hydrophilicity of the functional groups ranging from deep blue (hydrophilic) to reddish (hydrophobic).

It shows a ~ e m o ~ h a n @ hernodialysis membrane, with its hydrophobic DEAE substituents evolving from the hydrophilic cellulose backbone.

Copyright by C. Hahn and M. Diarnantoglou, Akzo Nobel Central Research

FOREWORD TO THE FOURTH EDITION

BELDING H. SCRIBNER

Within these pages the reader will find detailed descrip- tions of dialysis techniques and equipment whose excel- lence is to this old timer almost unbelievable. The question that has bothered me more and more these past few years is whether or not we nephrologists are making the best use of all this largess. On the basis of disappointing sur- vival data, especially in the United States, the answer is 'No.' Of course there are outstanding exceptions and I will discuss some of these below.

Why have survival results, especially among patients on dialysis in the United States, been so disappointingly poor? Some of the answers will be found in the pages of this long overdue 4th edition. However, 2 factors seem to stand out above all others The first cause of shortened sur- vival is gross underdialysis of large numbers of patients. Gotch was among the first to identify this serious problem in a classic paper in which he studied visitors to his unit in San Francisco (1). Since then this fact of widespread underdialysis has been repeatedly documented.

I believe that underdialysis is caused mainly by the widespread misuse of the technique of high efficiency shortened time hemodialysis. This misuse results from the fact that it is very easy to shorten dialysis time because everybody is in favor of it - especially the patients and the 'bottom liners.' In sharp contrast it is extremely dif- ficult to increase hemodialysis efficiency, unless special equipment is used and special precautions are taken. Most hemodialysis units simply do not have the equipment andlor the know-how to increase dialysis efficiency. In this connection it is important to remember that whenev- er a dialysis technique is pushed toward the upper limit of performance, as it must be in high efficiency dialysis, the chances of error and malfunction increase exponen- tially. Therefore those readers who do get involved with high efficiencylshortened time dialysis should study very carefully the chapters in this volume that deal with this subject.

Even when properly carried out, I believe that high effi- ciencylshortened time dialysis has very limited applica- tion. It should be used only on the minority of patients who can maintain normal blood pressure despite the marked reduction in dialysis time. Two to three hours of dialy- sis simply does not allow sufficient time to remove the salt water accumulated since the last dialysis. This fact

brings me to a brief discussion of the second major fac- tor responsible for the low survival among hemodialysis patients, namely failure to control blood pressure.

Despite the fact that the classic paper by Haire and Sher- rard on the adverse effect of hypertension (and smoking) on survival of patients on dialysis was published back in 1978 (2), surprisingly few papers and presentations at meetings have dealt with this all important subject. Important exceptions are the publications of Charra and his colleagues from Tassin in France (3, 4). Indeed their 1992 paper (4) sets the gold standard for survival on dial- ysis. Because they were using a very long low efficiency dialysis technique, they were able to deliver a very large dose of dialysis and provide a large protein intake to the 445 patients in their series thereby eliminating these two important factors that could adversely affect survival. That made it possible to pinpoint excellent control of blood pressure as the major factor that accounted for their out- standing survival data. Readers of this volume should pay particular attention to the chapters that deal with control of blood pressure both during the years before starting dialysis as well as control while on dialysis and after transplantation if survival figures among patients on renal replacement therapy are to improve significantly in the future.

As this is being written in the spring of 1994, studies are in progress on Charra's patients to try and determine whether or not the long 8 hour dialysis also lowers blood pressure by removing a uremic toxin that increases blood pressure, as suggested in a recent publication by Ritz (5). If Ritz's postulate is correct, this toxin must behave during dialysis like a middle molecule, whose removal, unlike urea, is mainly a function of time on dialysis (6). For a more general discussion of this topic of uremic toxins, see Chapter 1 by Vanholder.

Of emerging importance is the observation that nutri- tional parameters may also affect survival. Several ana- lytic studies in hemodialysis (7), and in CAPD (8) and confirmed by the US Renal Data System (9), show that a serum albumin lower than normal increases the relative risk of death on dialysis. This deserves further study, and attention to detail in nutritional management of dialysis patients.

vi Belding H. Scribner

The experience we have had over the years with some of our original patients sheds additional light on matters under discussion here. Patient #2 in our series, who began dialysis on March 20, 1960, survived 28 years and died suddenly of an acute myocardial infarction while playing golf at Palm Springs, California in the winter of 1989. This death probably was due to the accelerated atherosclerosis (10) that he may have developed during his early years on dialysis when we did not understand the importance of blood pressure control. Patient #5, who began dialysis in the summer of 1960, currently is in his 34th year of hemodialysis and as such is the longest survivor in the world. He has had a very successful career in academia as a Professor of Physics. In January of 1963 we accept- ed for temporary treatment a young medical student from Guy's Hospital in London. Now 30 years later this patient is a world renowned dermatologist on the faculty of the University of London. His health is good, having received a cadaveric transplant, which was performed by Mr Peter Morris at Oxford in 1991. This patient has provided a fascinating account of what it was like to be a chronic hemodialysis patient during the early years (1 1). Even though they are anecdotal, these early successful out- comes stand in sharp contrast to what is being reported today in terms of survival and quality of life among dialy- sis patients. These outcomes are all the more remarkable when one takes into account the fact that by today's stan- dards, all 3 of these early patients received very poor care during their first decade on renal replacement thera- py because we simply did not know what constituted good dialysis care.

Finally, a word about quality of life among dialysis patients. The recent literature reports that quality of life on dialysis is good in only a minority of patients. These poor results are encountered despite the fact that the improve- ment in anemia with erythropoietin promised a consid- erable improvement in quality of life. The reasons for the disappointing quality of life are multifactorial. There is no question that the modern dialysis patient not only is older, but has more intercurrent conditions (diabetes, cardiac disease, drug addiction, aids, etc) and compli- cations of those conditions (blindness, amputations, etc) than hislher early dialysis predecessor. The disabilities entailed by aging or non-renal complications cannot be overcome by dialysis itself, and demand much from the practicing nephrologist. Such patients present a medical challenge to the modern dialysis practitioner, and conse- quently place more demands on the medical community for adequate training. It is my observation that there may be a serious deficiency in the training that we nephrol- ogists have received over the years. During fellowships,

most nephrologists learn about dialysis by taking care of patients with acute potentially reversible renal failure and with rare exceptions get very little exposure to the day to day care of chronic dialysis patients. Recently there are indications that this neglected area of training may be corrected. If and when this task is undertaken, I believe it is important to keep in mind the often overlooked fact that patients with chronic renal failure suffer from a chronic disease. This fact in turn means that nephrologists must be taught the same skills used in the care of chronic illness that are taught routinely to fellows in rehabilitation medicine and rheumatology. Perhaps if that is done, then the quality of life of dialysis patients will improve and thereby indicate that the best use is being made of the marvelous knowledge and technology presented in this volume.

References

1. Gotch FA, Yarian S, Keen M: A kinetic survey of US hemodialysis prescriptions. Am J Kidney Dis 5: 5 1 1, 1990

2. Haire HM, Sherrard DJ, Scarpadane 0, Curtis FK, Bmn- zell JD: Smoking, hypertension and mortality in a mainte- nance dialysis population. Cardiovasc Med 3: 1163, 1978

3. Charra B, Calemard E, Laurent G: Control of hyperten- sion and prolonged survival on maintenance hemodialysis. Nephron 33: 96, 1983

4. Charra B, Calemard E, Ruffet M, Chazot C, Terrat JC, Vane1 T, Laurent G: Survival as an index of adequacy of dialysis. Kidney Int 41: 286, 1992

5. Ritz E: Hypertension and cardiac death in dialysis patients - should target blood pressure be lowered? Semin Dial 6: 227, 1993

6. Babb AL, Farrell P, Uvelli D, Scribner BH: Hemodialyz- er evaluation by examination of solute molecular spectra. Trans Am Soc ArtifIntern Organs 18: 98, 1972

7. Lowrie EG, Lew NL: Death risk in hemodialysis patients: The predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 15: 458, 1990

8. Teehan BT, Schleifer C, Brown J, et al: Urea kinetic analy- sis and in CAPD. A five year longitudinal study. Adv Peri- toneal Dial 6: 18 l , 1990

9. US Renal Data System, USRDS 1992 Annual Data Report, The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, August 1992.

10. Lindner A, Charra B, Sherrard DJ, Scribner BH: Accelerat- ed atherosclerosis in prolonged maintenance hemodialysis. N Engl J Med 290: 697, 1974

11. Eady RAJ: A patient's experience of over one thousand haemodialyses. Proc Eur Dial Transplant Assoc 8: 50, 1971

INTRODUCTION AND TRIBUTE TO DRUKKER, PARSONS AND MAHER

CLAUDE JACOBS, CARL M. KJELLSTRAND, KARL M. KOCH and JAMES F. WINCHESTER

The years 1978, 1983, and 1989 were the publication dates for the three previous editions of this book, the first two editions having all three editors in place, while the last was edited by Jack Maher alone. This book has been a global resource and considered as the prime textbook for information on dialysis for many years. As Maher wrote in his introduction in 1989, they were all 'first generation nephrologists', and in our opinion at the leading edge of clinical and research nephrology of the times. Sadly, we cannot call on them for advice, as all have passed away. However, we have gieaned knowledge from them in the past in person, and by their written word. We have also been aided in having the same publisher, Boudewijn Commandeur, for this edition as in all previous. He has served as a lynchpin for the project. Therefore, during the construction of this book we have as much as possible tried to keep the same flavor, of first outlining the principles of a subject, and then its clinical application.

First, we asked is there a need for this book? Despite our cumulative nephrology experience of at least a century, we were unanimous in our affirmative answer. There, of course, are other books related to dialysis available, but what made the previous editions unique, were the careful eye to detail, in theory and in application, the introduction of topics never previously discussed in a single text (e.g. in this text, dialysis in developing countries), and finally the comprehensive nature of all previous editions, and hopefully this edition as well. We strived to make this book a repository of information, as a reference text, as well as a practical clinical tool. We want this book to become familiar to seasoned nephrologists, nephrology trainees, dialysis nurses and technicians, and perhaps to students as well - it is our wish to see this book used - even torn and tattered. We have, therefore, gathered together, those whom we consider leaders in this subject, be it theoretical, or be it practical.

In acute renal failure, we have become more cognizant of the fact that multi-organ involvement is associated with a poor outcome. This has led to continuous thera- pies, such as arterio-venous and veno-venous hemodialy- sis and hemofiltration, to automated machines to accom- plish these tasks, to the use of biocompatible membranes, to citrate anticoagulation, and to intensive nutritional sup- port. All of these subjects are covered in detail. Similarly,

the infrastructure necessary to perform acute or chronic hemodialysis and peritoneal dialysis is covered - namely, water preparation, dialysate composition, bacterial conta- mination, and machine design. Today's dialysis machines are largely automated and have built in safety controls, blood pressure monitors, continuous anticoagulation, pro- grammable sodium delivery, in-line solute measurement. The fledgling nephrologist might easily by-pass the theory and the nuances of dialysis understanding. We hope that this text will be used to overcome and give understanding of the complexities of modern dialysis apparatus, whose starting point was the simple physical process discovered by Thomas Graham in 1861, that solutes travel down a concentration gradient.

We have tried to address the current problems in dial- ysis practice today. Over half a million patients receive dialysis world-wide. There appears to be no shortage of patients, nor trends towards a global decrease in patients reaching end-stage renal disease from the most com- mon diseases, such as diabetes, hypertension, glomeru- lonephritis, or inherited renal disorders. Despite demon- strations that control of hypertension, and control of dia- betes may slow the progress of, or prevent, end-stage kidney disease, and the identification of genetic abnor- malities, any effect on prevalence of patients requiring dialysis has yet to filter down to the nephrology commu- nity at large. We must not forget that, while life span has increased in the modern world this brings with it reduc- tion in renal function, and intercurrent conditions which make the application of dialysis that much more difficult (mostly related to vascular disease), as well as diabetes and severe hypertension. For these reasons we have added sections specifically to address these issues. How do we as specialists assess the effect of dialysis? After all it is a substitute only for the solute excretory component of renal function. Yes, we can now replace the renalfiormones ery- thropoietin and 1,25 dihydroxycholecalciferol, but what of the other hormonal derangements, the lipid disorders, the impaired immunological function, etc. Most impor- tantly, perhaps, how do we know if we are prescribing enough, or if the patient is receiving enough, dialysis - these issues are at the forefront of investigation and clin- ical application. Each of these topics and more are dealt with in detail.

viii Introduction and Tribute to Drukker, Parsons and Maher

Continuous ambulatory peritoneal dialysis is now the preferred home dialysis therapy throughout the world, and we have concentrated on discussion of its applica- tion, its amplification by machine delivered peritoneal fluid, its limitations and its complications. Like the prob- lems facing the hemodialysis patient with angioaccess, also described in this book, the peritoneal dialysis patient also faces problems with access to the peritoneal cavity. These topics are addressed in a special section. Because of renewed interest in home hemodialysis, we have added a section to cover that topic.

How does the patient feel about dialysis? Can helshe work? Can helshe play? Is dialysis long-term survival or outcome the same all over the world? When should we let our patients tell us that it is time to stop, and let them die? These issues are real ones, and we may have been remiss in the past by not addressing them in detail. For that reason we have added sections on quality of life, and a new section on outcome analysis, lacking in the previous editions.

What other 'new' problems face the dialysis patient, and perhaps dialysis staff in the late 1990s. We are all familiar with the hepatitis B outbreaks and deaths of the 1970s, and the often observed bacteremia in hemodial- ysis patients. But what of the diseases of the 1990s - human immunodeficiency virus, hepatitis C, and tubercu- losis. Each has unique characteristics, management prob- lems, complications and affects to a great extent staffing and organization of dialysis units. Currently, the Centers for Disease Control, in Atlanta, Georgia, does not rec- ommend isolation of patients with HIV nor hepatitis C, yet for the latter the debate may not be definitively closed.

Tuberculosis has its own 1990s uniqueness, drug resis- tance and association with recent immigration or HIV. All these topics can be found in this text.

We have also striven to make sure that all the topics covered are correct in detail, but we wish the reader to make judgements as to validity of concept, a prescription, a formula, a diagram, and to use such judgement to adjust therapy in clinical application. Due to the ever changing nature of medicine, and technology, differences of opinion are to be found in this book, and the publisher and editors assume no responsibility for these differences of opinion, rather publishing them as written to improve the academic impact of our text.

Finally, what have we left and what have we taken away. We felt that the previous chapter on the history of dialysis as written by Dmkker could not be bettered, and in deference to him we omitted it. We have changed many of the authors in this text, not for changes sake, but to bring in new and younger, and perhaps the fourth or fifth generation nephrologists. This is a changing field, steeped in tradition, and to honor that tradition it was our decision to retain the name of the text as Drukker, Parsons and Maher, our first generation nephrology col- leagues and friends. In keeping with the changing nature of investigation, to molecular biology, we have replaced the familiar cover diagram of middle molecule peak 7c, with a schematic of molecular modeling of a well known cellulosic dialysis membrane.

Claude Jacobs, Paris Carl M. Kjellstrand, Edmonton Karl M. Koch, Hannover James F. Winchester, Washington

Figure 1. William Drukker, Jack Maher, Frank Parsons. Figure2. Jim Winchester, Boudewijn Commandeur (Publisher), Karl Koch, Claude Jacobs, Carl Kjellstrand.

CONTRIBUTING AUTHORS

i? Agfshi, M.D. Kidney Center Tokyo Women's Medical College Department of Surgery 8- 1 Kawada-Cho, Shinjuku-ku Tokyo 162, Japan Chapter 58C

J. Ahlme'n, M.D., Ph.D. Department of Nephrology Central Hospital S-541 85 Skovde, Sweden Chapter 62B

Alfred C. Alfrey, M.D. Veterans Affairs Medical Center 1055 Clermont Street Denver, CO 80220, USA Chapter 51

G.S. Arbus, M.D. Department of Nephrology Hospital for Sick Children 555 University Avenue Toronto, ON, Canada M5G 1x8 Chapter 58F

R.S. Barsoum, M.D. The Cairo Kidney Center P.O. Box 91 Bab-el-Louk Cairo 1 1 5 1 3, Egypt Chapter 60

Robert H. Barth, M.D. Hernodialysis Unit VA Medical Center 800 Poly Place Brooklyn, NY 1 1209, USA Chapter 16

William M. Bennett, M.D., Ph.D. Division of Nephrology and Hypertension Oregon Health Sciences University 3 18 1 SW Sam Jackson Park Road L 455 Portland, OR 97201, USA Chapter 29

Christopher Blagg, M.D. Northwest Kidney Centers 700 Broadway Seattle, WA 98 122, USA Chapter 56

Peter Blake, M.D. University of Western Ontario Victoria Hospital Corp. P.O. Box 5375,375 South Street London, Ontario N6A 4G5, Canada Chapter 24

Marcel Broyer, M.D. Department of Pediatric Nephrology Hospital for Sick Children Paris, France Chapter 31

C.E. Butler, M.D. Brigham & Women's Hospital Department of Surgery Boston, MA 021 15, USA Chapter 10

Bernard J.M. Canaud, M.D. Division of Nephrology Lapeyronie University Hospital F-34295 Montpellier, France Chapter 8

x Contributing Authors

Cyril Chantler, M.D. Evelina Children's Department Guy's and St. Thomas' Hospital Guy's Hospital L,onaan, England Chapter 31

D.N. Churchill, M.D. Division of Nephrology McMaster University Hamilton, Ontario, Canada L8N 4A6 Chapter 23

Allan J. Collins, M.D. Regional Kidney Disease Program 914 S. 8th Street Minneapolis, MN 55404, USA Chapters 46,61

C.K. Colton, Ph.D. Department of Chemical Engineering Massachusetts Inst. of Technology 25 Amnes St., Room 66-452 Cambridge, MA 02139, USA Chapter 3

Pi? Copleston, M.D. Canadian Organ Replacement Register Canadian Institute for Health Information Box 3900 Don Mills, Ontario, Canada M3C 2T9 Chapter 58F

Ronald Cranford, M.D. Hennepin County Medical Centre 701 Park Ave S Minneapolis Minnesota 55415, USA Chapter 63

John Daugirdas, M.D., Ph.D. University of Illinois at Chicago Department of Research (1 5 1) Westside VA Medical Center 820 South Damen Avenue Chicago, Illinois 60612, USA Chapter 24

Alex M. Davison, M.D., Ph.D. Department of Renal Medicine St. James's University Hospital Beckett Street Leeds LS9 7TF, England Chapter 54

R. De Smet, M.D. Nephrology Department University Hospital De Pintelaan 185 B-9000 Ghent, Belgium Chapter 1

Wilfried A. De Backer, M.D. Department of Pulmonary Medicine University Hospital Antwerp Wilrijkstraat 10 B-2650 Edegem-Antwerpen, Belgium Chapter 41

Marc E. De Broe, M.D., Ph.D. Department of Nephrology-Hypertension University Hospital Antwerp Wilrijkstrzat 10 B-2650 Edegem-Antwerpen, Belgium Chapter 41

Fran~oise Degos, M.D. Service d'HCpato-Gastro-EntCrologie 2 Hapita1 Beaujon 100 Boulevard du Gen. Leclerc 921 10 Clichy, France Chapter 47B

Barbara G. Delano, M.D. Department of Medicine State University of New York Health Science Center Brooklyn 450 Clarkson Ave, Box 52 Brooklyn, NY 1 1203, USA Chapter 55A

B. Descamps-Latscha, M.D., Ph.D. INSERM U.25 GH Necker-Enfants Malades 161 rue de S k r e s 75015 Paris, France Chapter 45

Marie Desmeules, M.D. Laboratory Centre for Disease Control LCDC Building, Rm22-c Tunney's Pasture Ottawa, ON, Canada KIA OL2 Chapter 58F

J.A. Diaz-Buxo, M.D. Metrolina Nephrology Associates P.A. 928 Baxter Street Charlotte, NC 28204-2879, USA Chapter 21

Contributing Authors xi

A.P.S. Disney, M.D. The Queen Elizabeth Hospital 28 Woodville Road Woodville South Adelaide, South Australia 501 1 Chapter 58E

Raymond Donckenvolcke, M.D. Department of Nephrology Alberta Children's Hospital 1820 Richmond Road S W Calgary, Alberta Canada T2T 5C7 Chapter 31

Jochen H.H. Ehrich M.D. CharitC University Hospital Humboldt University Berlin, Germany Chapter 33

Joseph W. Eschbach, M.D. Department of Medicine University of Washington 5 15 Minor Ave. Seattle, WA 98 104, USA Chapter 43

Aldo Fabris, M.D. Department of Nephrology St. Bortolo Hospital Via Rodolfi 1-36100 Vicenza, Italy Chapters 9 ,40

S.A. Fenton, M.D. Toronto Hospital-General Division 200 Elizabeth Street, EN13-232 Toronto, Ontario, Canada M5G 2C4 Chapter 58F

Mariano Feriani, M.D. Department of Nephrology St. Bortolo Hospital Via Rodolfi 1-361 00 Vicenza, Italy Chapters 9 ,20,40

M.J. Flanigan, M.D. Department of Internal Medicine, W336- 16 University of Iowa Hospitals and Clinics 200 Hawkins Drive Iowa City, IA 52246, USA Chapter 49

R.N. Foley, M.D. Division of Nephrology The Health Sciences Center Memorial University St. Johns, Newfoundland, Canada A1B 3V6 Chapter 38

Denis Fouque, M.D. Department of Nephrology Hapita1 Edouard Herriot University Claude Bernard 69437 Lyon CCdex 03, France Chapter 52

Ulrich Frei, M.D. Virchow-Klinikum of Humboldt-University Medical Clinic and Policlinic Department of Internal Medicine and Nephrology Augustenburger Platz 1 13353 Berlin, Germany Chapter 34

Eli A. Friedman, M.D. SUNY Health Science Center 450 Clarkson Ave, Box 52 Brooklyn, NY 1 1203, USA Chapters 17,35

Daniel H. Froment, M.D. Service de NCphrologie Hapita1 Notre Dame UniversitC du MontrCal MontrCal, QuCbec, Canada Chapter 58F

Ram Gokal, M.D. Manchester Royal Infirmary Department of Renal Medicine Oxford Road Manchester M13 9WL, England Chapter 25

Thomas A. Golper, M.D. University of Arkansas College of Medicine, Mail Slot 501 Department of Internal Med./Div. of Nephrology 4301 West Markham Street Little Rock, AR 72205, USA Chapter 29

Frank A. Gotch, M.D. University of California 45 Castro Street # 227 San Francisco, CA 941 14, USA Chapter 2

xii Contributing Authors

E. Grapsa, M.D. Division of Nephrology Toronto Hospital - Western Division 399 Bathurst Street Toronto, Ontario, Canada M5T 2S8 Chapter 32

A. Grassmann, Ph.D. AKZO Nobel Faser AG Business Unit Membrana 0hder Strasse 28 D-42289 Wuppertal, Germany Chapter 28

A.P. Gue'rin, M.D. Nephrology and Hemodialysis Department Center Hospitalier Manh2s 8 Grande Rue 9 1700 Fleury MCrogis, France Chapter 37

Rolf W. Giinther, M.D. Department of Diagnostic Radiology University of Technology Pauwelsstrasse D-52057 Aachen, Germany Chapter I I

Hans Gurland, M.D. Nephrology Division Medical Department I Klinikum Grosshadern Marchioninistrasse 15 D-8000 Munich 70, Germany Chapter 18

Raymond M. Hakim, M.D., Ph.D. Renal Division S-3307 MCN, VUMC 1 16 1 2 1 st Avenue S. and Garland Nashville, TN 37232-2372, USA Chapter 6

J.D. Harnett, M.D. Division of Nephrology The Health Sciences Center Memorial University St. Johns, Newfoundland, Canada A1B 3V6 Chapter 38

Philip J. Held, Ph.D. Department of Health Services Management and Policy University of Michigan Ann Arbor, MI 48 103, USA Chapter 58B

Lee W. Henderson, M.D. Baxter Healthcare Corp. 1620 Waukegan Rd MeGaw Park, IL 60085-6730, USA Chapter 4

J. Himmelfarb, M.D. Maine Nephrology Associates P.A. 1600 B Congress Street Portland, ME 04102, USA Chapter 6

Nicholas A. Hoenich, Ph.D. Department of Medicine, Medical School University of Newcastle upon 'Qne Newcastle-upon-Tyne NE2 4HH, England Chapter 7

C. Hsu,M.D.,Ph.D. Nephrology Division Department of Medicine University of Michigan Medical School Ann Arbor, MI 48 103, USA Chapter I

Todd Ing, M.D. Loyola University, Chicago Stritch School of Medicine Maywood, IL 60153, USA Chapter 26

I. Ishikawa, M.D. Department of Internal Medicine Kanazawa Medical University 1 - 1 Daigaku, Uchinada-Machi Kahoku-gun, Ishikawa-ken, 920-02 Japan Chapter 58C

Katsumi Ito, M.D. Department of Surgery Kidney Center Tokyo Women's Medical College 8-1 Kawada-Cho-Shinjuku-Ku Tokyo 162, Japan Chapter 58F

Claude Jacobs, M.D. Service de Nephrologie HBpital de La Pitie 83, Blvd. de 1'HBpital 7501 3 Paris, France Chapter 57

. . . Contributing Authors xtii

John J. JefSery, M.D. Section of Nephrology Health Sciences Center 820 Sherbrook Street Room GE-441 Winnipeg, MB, Canada Chapter 58F

Paul Jungers, M.D. Department of Nephrology GH Necker-Enfants Malades 161 rue de Sitvres 750 15 Paris, France Chapters 45,47B

A.A. Kaplan, M.D. University of CT Health Center Division of Nephrology, MC 1405 Farmington, CT 06030, USA Chapter 15

B.L. Kasiske, M.D. Hennepin County Medical Center Div. of Nephrology 701 Park Ave. S. Minneapolis, MN 55415, USA Chapter 36

Michael Kaye, M.D. Montreal General Hospital 2650 Cedar Ave Montreal Quebec H3G 1 A4, Canada Chapter 63

William F. Keane, M.D. University of Minnesota Division of Nephrology Department of Medicine Hemepin County Medical Center 701 Park Avenue Minneapolis, MN 55415, USA Chapter 46

Carl M. Kjellstrand, M.D., Ph.D. Department of Medicine 2E3-31 W. McKenzie University of Alberta Hospital Edmonton, Alberta, Canada T6G 2B7 Chapters 26,30,58F, 63

Saul Klahr, M.D. Department of Medicine The Jewish Hospital of St. Louis 21 6 South Kingshighway St. Louis, Missouri 631 10, USA Chapter 59

Karl M. Koch, M.D. Department of Nephrology Medizinische Hochschule Hannover Postfach 61 01 80 D-3000 Hannover 61, Germany Chapters 27,53

Joe D. Kopple, M.D. Harbor-UCLA Medical Center 1000 W. Carson Street Torrance, CA 90509, USA Chapter 52

S. Koshikawa, M.D. Department of Internal Medicine Showa University Fujigaoka Hospital 1-30 Fujigaoka, Midori-ku Yokohama-Shi, 227 Japan Chapter 58C

Raymond 7: Krediet, M.D., Ph.D. Renal Unit, F4-215 Academic Medical Center Meibergdreef 9 1 105 AZ Amsterdam, The Netherlands Chapter 5

Giuseppe La Greca, M.D. Department of Nephrology St. Bortolo Hospital Via Rodolfi 1-36 100 Vicenza, Italy Chapters 20,40

J.M. Lazarus, M.D. Brigham and Women's Hospital Nephrology Department 75 Francis Street Boston, MA 02215, USA Chapter 42

H. Lemke, M.D. AKZO Nobel D-63785 Obernburg, Germany Chapter 28

N. W. Levin, M.D. Division of Nephrology Beth Israel Medical Center 1 st Avenue at 16th Street New York, NY 10003, USA Chapter 13

xiv Contributing Authors

VS. Lim, M.D. Department of Internal Medicine W336-16 University of Iowa Hospitals and Clinics 200 Hawkins Drive Iowa City, IA 52246, USA Chapter 49

Robert MacGregor Lindsay, M.D. University of Western Ontario 375 South Street London, Ontario N6A 4G5, Canada Chapter 44

Robert R. Lins, M.D., Ph.D. Department of Nephrology A.Z. Stuivenberg Lange Beeldekensstraat 267 B-2060 Antwerpen, Belgium Chapter 41

Francisco Llach, M.D. Beth Israel Medical Center 201 Lyons Avenue Newark, NJ 07 1 12, USA Chapter 48

Gkrard London, M.D., Ph.D. Nephrology and Hemodialysis Department Center Hospitalier Manhks 8 Grande Rue 91 700 Fleury MCrogis, France Chapter 37

G. Lonnemann, M.D. Department of Nephrology Medizinische Hochschule Hannover Postfach 6101 80 D-3000 Hannover 6 1, Germany Chapter 2 7

Michael J. Lysaght, Ph.D. Division of Biology and Medicine Brown University Providence, RI, USA Chapters 3 ,18

Netar P. Mallick, M.D. Manchester Royal Infirmary Department of Renal Medicine Oxford Road Manchester M13 9WL, England Chapters 58A, 5 8 0

D.A. Mandelbrot, M.D. 250 Longwood Ave. Seeley Mudd Bldg, Rm 504 Boston, MA 021 15, USA Chapter 42

S. Marchais, M.D. Nephrology and Hemodialysis Department Center Hospitalier Manhks 8 Grande Rue 91700 Fleury MCrogis, France Chapter 37

M.A. Marx, Ph.D. Asst. Professor of Pharmacy Practice College of Pharmacy University of Arkansas for Med. Sciences Little Rock, AR 72205, USA Chapter 29

Anne Marie V Miles, M.D. SUNY-Health Science Center at Brooklyn 450 Clarkson Avenue-Box 52 Brooklyn, NY 1 1203, USA Chapters 17,35

Charles M. Mion, M.D. Division of Nephrology Lapeyronie University Hospital F-34259 Montpellier CCdex, France Chapters 8,22

Salim K. Mujais, M.D. Northwestern University School of Medicine Section of Nephrology Chicago, IL 60153, USA Chapter 26

Iraj Nadjaji, M.D. Nephrology-Dialysis-Transplant Unit Dr Shariaty Hospital University of Tehran Kargar Avenue Tehran, Iran Chapter 61

H. Nihei, M.D. Kidney Center Tokyo Women's Medical College Department of Surgery 8- 1 Kawada-Cho, Shinjuku-ku Tokyo 162, Japan Chapter 58C

Contributing Author.> xv

M. Nowicki, M.D. Department Nephrology Silesian School of Medicine Katowice, Poland Chapter 39

Dimitrios G. Oreopoulos, M.D. Division of Nephrology Toronto Hospital - Western Division 399 Bathurst Street Toronto, Ontario, Canada M5T 2S8 Chapter 32

K. Ota, M.D. Kidney Center Tokyo Women's Medical College Department of Surgery 8-1 Kawada-Cho, Shinjuku-ku Tokyo 162, Japan Chapter 58C

Patrick S. P a r - , M.D., Ph.D. Division of Nephrology The Health Sciences Center Memorial University St. Johns, Newfoundland, Canada A1B 3V6 Chapter 38

Beth Piraino, M.D., Ph.D. Medical Center F1159 Presbyterian University Hospital 200 Lothrop Street Pittsburgh, PA 1521 3, USA Chapter 19

Hans D. Polaschegg, Ph.D. Griinswiesenweg 9 D-61440 Oberursel, Germany Chapter 13

Frederick K. Port, M.D. University of Michigan Kidney Epidemiology and Cost Center 315 W. Huron St., Suite 240 Ann Arbor, MI 48 103. USA Chapter 58B

Eduard A. Quellhorst, M.D. Nephrology Center Niedersachsen Vogelsang 105 D-34346 Hannover-Miinden, Germany Chapter 14

KE. Quijada, M.D. Department of Nephrology Georgetown University Medical Center 3800 Reservoir Road Washington, DC 20007, USA Chapter 44

TK. Sreepada Rao, M.D. SUNY Health Science Center at Brooklyn 450 Clarkson Ave., Box 52 Brooklyn, NY 11203-2098, USA Chapter 47A

Giuseppe Remuui, M.D. Division of Nephrology and Dialysis Ospedali Riuniti di Bergamo 1-24100 Bergamo, Italy Chapter 12

Ann Rinehart, M.D. Hennepin County Medical Center Department of MedicineIDiv. of Neprohology 701 Park Avenue Minneapolis, MN 55415, USA Chapter 46

Severin Ringoir, M.D., Ph.D. Nephrology Department University Hospital De PinteIaan 185 B-9000 Ghent, Belgium Chapter I

E. Ritz, M.D., Ph.D. Ruperto Carola University Department of Internal Medicine Bergheimerstr. 58 D-69 1 15 Heidelberg, Germany Chapter 39

Gianfranco Riuoni, M.D. Division of Nephrology and Dialysis Department of Pediatric Research and Teaching Ospedale Bambino Jesu Rome, Italy Chapter 31

Claudio Ronco, M.D. Department of Nephrology St. Bortolo Hospital Via Rodolfi 1-36 100 Vicenza, Italy Chapters 7,9,20,40

xvi Contributing Authors

G. Said, M.D. Service de Neurologie Center Hospitalier Universitaire BicCtre 78, Ave. de GCnCral Leclerc 94275 Le Kremlin BicCtre CCdex, France Chapter 50

Walter Samtleben, M.D. Nephrology Division Medical Department I. Klinikum Grosshadern University of Munich Miinchen, Germany Chapter 18

John A. Sargent, Ph.D. 5901 Christie Avenue Suite 201 Emeryville, CA 94608, USA Chapter 2

J. Schaeffer, M.D. Division of Nephrology - 6840 Hannover Medical School D-30623 Hannover, Germany Chapter 53

A. Schieppati, M.D. Mario Negri Inst. for Pharmacol. Res. Clinical Res.Cntr. for Rare Diseases 'Aldo e Cele Dacco' Villa Camozzi 1-24020 Ranica, Italy Chapter 12

Belding H. Scribner, M.D. Division of Nephrology University of Washington Mailstop Rm 11 Seattle, WA 98 195, USA Foreword

Neville H. Selwood, Ph.D. UK Transplant Service Southmead Hospital Bristol, England Chapter 57

Stanley Shaldon, M.D. 86, Rue de Grezac F-34100 Montpellier, France Chapter 28

A. Shinoda, M.D. Department of Internal Medicine Kanazawa Medical University 1-1 Daigaku, Uchinada-Machi Kahoku-gun, Ishikawa-ken, 920-02 Japan Chapter 58C

C. Shuler, M.D. Division of Nephrology and Hypertension Oregon Health Sciences University 3 18 1 SW Sam Jackson Park Road L 455 Portland, OR 97201, USA Chapter 29

Heinz-Gunther Sieberth, M.D. Department Internal Medicine I1 University of Technology Pauwelsstrasse D-52057 Aachen, Germany Chapter I I

Kim Solez, M.D. Department of Laboratory Medicine 5B4.02 W. MacKenzie Center University of Alberta Hospitals Edmonton, Alberta, Canada T6G 2R7 Chapter 61

B.P. Teehan, M.D. Lankenau Medical Center # 135 100 Lancaster Avenue Wynnewood, PA 19096, USA Chapter 30

S. Teraoka, M.D., Ph.D. Kidney Center Tokyo Women's Medical College 8-1 Kawada-Cho, Shinjuku-ku 162 Tokyo, Japan Chapter 58C

Nicholas L. Tzlney, M.D. Division of Transplant Surgery Brigharn and Women's Hospital 75 Francis Street Boston, MA 021 15, USA Chapter 10B

H. Toma, M.D. Kidney Center Tokyo Women's Medical College Department of Surgery 8- 1 Kawada-Cho, Shinjuku-ku Tokyo 162, Japan Chapter 58C

Contributing Authors xvii

Sato Tsuyoshi, M.D. Tokai University School of Medicine Department of Transplantation I, Boseidai, Isehara-shi Kanagawa-ken, 269- 1 1 Japan Chapter 58F

M.N. Turenne, M.D. Department of Medicine and Epidemiology University of Michigan Ann Arbor, MI 48 103, USA Chapter 58B

R. Uldall, M.D. (deceased) Wellesley Hospital Room 372 160 Wellesley Str., Bruce Wing 3-372 Toronto, Ontario M4Y 1 J3, Canada Chapter I OA

Raymond Vanholder, M.D., Ph.D. Nephrology Department University Hospital De Pintelaan 185 B-9000 Ghent, Belgium Chapter 1

Claude Verger, M.D. HGpital RenC Dubos Unit6 de Dialyse Avenue de 1'Ile de France F-95301 Pontoise, France Chapter 55B

Jorg Vienken, M.D. Fresenius AG Medical Department Borkenberg 14 D-61440 Oberursel, Germany Chapter 28

G. Vigano, M.D. Mario Negri Inst. for Pharmacol. Res. Clinical Res.Cntr. for Rare Diseases 'Aldo e Cele Daccb' Villa Camozzi 1-24020 Ranica, Italy Chapter 12

P. Vogeleere Nephrology Department University Hospital De Pintelaan 185 B-9000 Ghent, Belgium Chapter I

Dierk Vorwerk, M.D. Department of Diagnostic Radiology University of Technology Pauwelsstrasse D-52057 Aachen, Germany Chapter I I

A. Wiecek, M.D. Department of Nephrology Silesian School of Medicine Francuska 20 40-027 Katowice, Poland Chapter 39

P.G. Wilson, M.D. Department of Psychiatry Cornell University Medical Center 525 68th Street New York, NY 1002 1, USA Chapter 62A

James F: Winchester, M.D. Department of Nephrology Georgetown University Medical Center 3800 Reservoir Road Washington, DC 20007, USA Chapters 1 8,44

Antony J. Wing, M.D. Department of Renal Medicine St. George's Hospital Blackshaw Road, Tooting London S W 17 OQT, England Chapter 33

C . Wofindin, M.D. Renal Unit Royal Victoria Infirmary Queen Victoria Road Newcastle upon v n e , NEl 4LP, England Chapter 7

Ali-Reze Atef Zafarmand, M.D. Nephrology-Dialysis-Transplant Unit Dr Shariaty Hospital University of Tehran Kargar Avenue Tehran, Iran Chapter 61

TABLE OF CONTENTS

Foreword to the fourth edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BELDING H. SCRIBNER v

Introduction and tribute to Drukker, Parsons and Maher C. JACOBS, C. M. KJELLSTRAND, K. M. KOCH and J. F. WINCHESTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contributing authors ix

SECTION I Pathophysiology of the uremic syndrome.

Principles and biophysics of dialysis

1. The uraemic syndrome R. VANHOLDER, R. DE SMET, P. VOGELEERE, C. HSU and S. RINGOIR . . . . . . . . . . . . . . . . . . . . . . . . 1

2. Principles and biophysics of dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J. A. SARGENT and F. A. GOTCH 34

3. Membranes for hemodialysis ............................................................ C. K. COLTON and M. J. LYSAGHT 103

4. Biophysics of ultrafiltration and hemofiltration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L. W. HENDERSON 1 14

5 . Peritoneal anatomy and physiology during peritoneal dialysis R. T. KREDIET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

6. Biocompatibility - principles R. M. HAKIM and J. HIMMELFARB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

SECTION I1 Technology of dialysis and associated methods

7. Haemodialysers and associated devices N. A. HOENICH, C. WOFFINDIN and C. RONCO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

8. Water treatment for contemporary hemodialysis B. J. M. CANAUD and C. M. MION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Table of Contents xxi

Acute complications of hemodialysis and their prevention and treatment S. K. MUJAIS, T. ING and C. M. KJELLSTRAND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 688

Replacement of renal function by dialysis G. LONNEMANN and K. M. KOCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726

Biocompatibility - Clinical aspects H.-D. LEMKE, A. GRASSMANN, J. VIENKEN and S. SHALDON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734

SECTION V Pharmacological considerations

Drug dosage in dialysis patients T. A. GOLPER, M. A. MARX, C. SHULER and W. M. BENNETT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 750

SECTION VI Special clinical situations

Acute renal failure C. M. KJELLSTRAND and B. P. TEEHAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 821

Renal replacement therapy in children R. DONCKERWOLCKE, M. BROYER, C. CHANTLER and G. RIZZONI . . . . . . . . . . . . . . . . . . . . . . . . . . 863 Dialysis in the elderly E. GRAPSA and D. G. OREOPOULOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 896

Pregnancies in women on renal replacement therapy A.J.WINGandJ.H.H.EHRICH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911

The dialysis patient and transplantation U.FREI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 924 Dialytic management of diabetic uremic patients

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E. A. FRIEDMAN and A. M. V. MILES 935 Dialysis in special clinical situations: Anesthesia B. L. KASISKE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 954

SECTION VII Organ system and metabolic complications in chronic dialysis

Blood pressure control in chronic hemodialysis patients G. LONDON, S. MARCHAIS and A. P. GUERIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 966 Organ and metabolic complications: cardiac P. S. PARFREY, R. N. FOLEY and J. D. HARNETT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 990 Organ and metabolic complications: Lipids / atherosclerosis E. RITZ, M. NOWICKI and A. WIECEK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1003 Organ and metabolic complications: Acid-base M. FERIANI, C. RONCO, A. FABRIS and G. LA GRECA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014 Pulmonary aspects of dialysis patients M. E. DE BROE, R. L. LINS and W. A. DE BACKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1034

xxii Table of Contents

Gastrointestinal complications in dialysis patients D. A. MANDELBROT and J. M. LAZARUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1049 Hematological problems of renal failure J. W. ESCHBACH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1059

Organ and metabolic complications: bleeding disorders in renal failure V. E. QUIJADA, R. M. LINDSAY and J. F. WINCHESTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1077

Immunological and chronic inflammatory abnormalities in end stage renal disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. DESCAMPS-LATSCHA and P. JUNGERS 1083

Host defenses and infectious complications in maintenance hemodialysis patients A. RINEHART, A. J. COLLINS and W. F. KEANE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103

Viral infections in dialysis patients Part A: Human immunodeficiency virus infection in dialysis patients

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . T. K. SREEPADA RAO 1 123

Part B: Dialysis associated hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F. DEGOS and P. JUNGERS 1 133

Renal osteodystrophy F. LLACH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 59 Organ and metabolic complications - abnormal endocrine function in chronic renal failure

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V. S. LIM and M. J. FLANIGAN 1236

Neurological aspects of dialysis patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. SAID 1243

Organ and metabolic complications. Trace elements A. C. ALFREY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1260

Malnutrition and dialysis D. FOUQUE and J. D. KOPPLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 27 1

Organ and metabolic complications: P2-microglobulin amyloidosis J. SCHAEFFER and K. M. KOCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1290

SECTION VIII Organization and results of chronic dialysis

Options in renal replacement therapy A. M. DAVISON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1304

Part A: Hemodialysis-clinical management and follow up B. G. DELANO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 16

Part B: Clinical management and follow up of PD patients C. VERGER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1331

Home hemodialysis and satellite hemodialysis C. BLAGG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1346 Long-term survival in dialysis patients: A demographic overview C. JACOBS and N. H. SELWOOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1358 Part A: The work of the registries for renal disease and renal failure: A critical review N. P. MALLICK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1366

Part B: Outcomes with ESRD therapy: A critical overview from the United States F. K. PORT, M. N. TURENNE and P. J. HELD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 1

Table of Contents xxiii

Part C: Registry report of dialysis therapy in Japan S. TERAOKA, H. TOMA, H. NIHEI, T. AGISHI, K. OTA, I. ISHIKAWA, A. SHINODA and S. KOSHIKAWA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1376

Part D: Structure and outcome measurements - EDTA-ERA registry N.P.MALLICK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1388

Part E: Outcomes - critical overview: Australian registry A.P.S.DISNEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1398

Part F: Renal replacement therapy in Canada 198 1-1992 S. S. A. FENTON, P. F. COPLESTON, M. DESMEULES, G. S. ARBUS, D. H. FROMENT, C. M. KJELLSTRAND and J. J. JEFFERY ........................................................ 1406

Prevention of chronic renal failure S. KLAHR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1423

Dialysis in developing countries R. S. BARSOUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1433

Planning of dialysis for disasters K. SOLEZ, I. NADJAFI, A-R. A. ZAFARMAND and A. J. COLLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1443

Part A: Psychiatric aspects of the dialysis patients P. G. WILSON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1455

Part B: Quality of life of the dialysis patient J. AHLMEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1466

Stopping dialysis. Practice and cultural, religious and legal aspects C. M. KJELLSTRAND, R. CRANFORD and M. KAYE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1480

Combined Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1503