Chronic renal failure, home dialysis and - Europe PMC

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specialist home haemodialysis training and support unit. ... Hemodialysis in the home; its integration ..... cured in 1962 and 1967 by ureteral li- thotomy were ...
fully selected and trained they can take considerable responsibility and so free the physician from much routine and administrative work. They can give the patients the entire training and deal with all equipment matters. The administrative load, shared by all, dwindled once the machinery was set up to order stores, maintain equipment and keep records, alter homes and deliver supplies. Technical problems occurring at home were dealt with in most cases by a telephone call. In others, the despatch of a spare part which the patient himself fitted, was usually were rarely enough. Only home visits needed by the staff. A nurse, technician and physician are on call at all times. Patients in remote areas consult their general practitioners for daily medical care, but those living nearer tend to rely on the Renal Unit staff. We like to see patients twice a year for assessment, but many living in distant parts are reluctant to come that often. There is not enough money to pay for all that medicine has to offer. There are many legitimate and pressing claims on limited funds. At first sight, home dialysis may seem an expensive luxury. This is not so. It costs less to keep a patient on home hemodialysis for a year than to treat a sufferer from any other chronic condition in an institution for the same time. It is often more expensive to keep a man in prison than to give another life at home with an artificial kidney. A significant part of the annual cost of home hemodialysis is readmission to hospital for complications related to the shunt. With the advent of the arteriovenous fistula we expect these costs to diminish markedly. If we exclude this expense from our average figure, the annual cost of maintaining a patient on home hemodialysis is less than $4000. It is difficult to express in terms of cash the benefit to the community of a patient learning home dialysis, vacating a hospital bed, returning to work and caring for his family. It is probable that once home, many dialysis patients give good value for the money society spends on them. Seen in this way, home hemodialysis is far from being a luxury. It is a very reasonable return for a modest investment and should be offered to all able to do it. The spiralling costs of medicine are causing great

concern. The chief culprits are wages and other hospital and laboratory expenses. These are greatly reduced by home hemodialysis. References 1. BLAGG CR, HICKMAN RO, ESCHBACH JW, et al: Home hemodialysis: six years experience. N Engl JMed 283: 1126-1131, 1970 2. SHALDON S, OAKLEY JJ: An independent

specialist home haemodialysis training and support unit. Proceedings of the European Dialysis and Transplant Association. IV: 24-27, 1967 3. IVANOVITCH P, MARR TA, GOTHBERG LA, et al: A compact hydraulic propor-

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tioning system for hemodialysis. Trans Am Soc Artif Intern Organs 12: 357-362, 1966 RAE AI, MARR TA, STEURY RE, et al: Hemodialysis in the home; its integration into general medical practice. JA MA 206: 92-96, 1968 MARR TA: Personal communication, 1971 BRESCIA MJ, CIMINO JE, APPEL K, et al: Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N EnglJ Med 275: 1089-1092, 1966 QUINTON WE, DILLARD D, SCRIBNER BH, Cannulation of blood vessels for prolonged hemodialysis. Trans Am Soc Artif Internal Organs 6: 104-113, 1960 Management Engineering and Nursing Study No. 00-01-70. A study of the renal programme in British Columbia, 1970

Chronic renal failure, home dialysis and the liaison psychiatrist Graeme J. Taylor, M.B., CH.B., D.PSYCH., C.R.C.P. [c], Toronto

In recent years much attention has been given to evaluating the emotional reactions of patients with chronic renal failure treated by maintenance hemodialysis or renal transplantation.'`7 In many centres psychiatric consultation is now routinely included in the assessment of uremic patients who are being considered for these modalities of therapy.8 The data obtained may influence selection criteria2 but may also be used to guide medical personnel who become intimately involved with the patient during his subsequent medical management.3 The introduction of home dialysis has considerably reduced the high cost of maintenance hemodialysis but has been accompanied by additional psychiatric This case report was prepared while the author was a Fellow on the Medical-Psychiatric Liaison Service, State University of New York, Downstate Medical Center College of Medicine, Brooklyn, New York. He is currently an Associate in the Department of Psychiatry, University of Toronto and Staff Psychiatrist at the New Mount Sinai Hospital in Toronto.

Reprint requests to: Dr. Graeme J. Taylor, Department of Psychiatry, New Mount Sinai Hospital, 550 University Avenue, Toronto, Ont.

1318 C.M.A. JOURNAL/JUNE 24, 1972/VOL. 106

complications. The contributions which a liaison psychiatrist can make are demonstrated in the report of a patient who became psychotic following nephrectomy and after being accepted into a home dialysis program. The spouse also developed major psychiatric symptomatology when faced with the responsibility of monitoring his wife's kidney machine. Case report The patient, a 37-year-oid woman, was admitted to the State University Hospital of the Downstate Medical Center with uremia in July 1970. A diagnosis of bilateral polycystic disease of the kidneys had been made nine years previously but it was only during the past two years that uremic symptoms had occurred, preventing her from working and resulting in three previous hospitalizations. She experienced considerable abdominal pain and was forced to wear maternity clothing as abdominal girth progressively increased. She felt her abdomen to be larger than when she was nine months pregnant with her only child. Although she had refrained from sexual intercourse for the past five years, allegedly because of her husband's illness, she at first fantasied a twin pregnancy but was reassured to the contrary by her family physician. While her fanta-

sy never assumed delusional proportions, there were frequent family jokes about her "pregnant belly". On the present hospital admission it was thought that improvement could not be expected without maintenance hemo¬ dialysis. She was recommended for the home dialysis program and a psychiatric consultation was requested. The liaison psychiatrist interviewed the patient, her husband and their daughter separately, and then interviewed the patient and husband together. On psychiatric examination the pa¬ tient showed a mild organic brain syn¬ drome compatible with the uremic syn¬ drome and which was therefore expected to improve following dialysis. There was evidence of anxiety, feelings of helplessness and a moderately depressed mood. Denial served as her major psychologi¬ cal defense. Her father died at age 52 in 1960 from polycystic disease, after four years of uremic symptomatology. Her mother had suffered three minor strokes in recent years and now lived with the patient's sister. The patient's husband, a 45-year-old aircraft mechanic, was of average intelli¬ gence but a passive, compliant man who had been born with hypospadias. Follow¬ ing surgery for urethral stricture at age 31, he had experienced recurrent epididymitis and painful erections which vir¬ tually terminated the marital sexual re¬ lationship. After undergoing right epididymectomy two and a half years ago he complained of almost constant pain in his left testis. He showed major conflicts over

unmet

dependency needs, having

cared throughout most of his childhood for his mother who was constantly incapacitated by chronic illness. He express¬ ed resentment over his wife's constant physical complaints but indicated he consciously refrained from expressing his anger. He wanted her to be accepted for home dialysis and was willing to be trained to assist with the machine. The patient's daughter, a 16-year-old Grade XI student, was moderately de¬ pressed but also stressed her wish to help with the machine and was seriously contemplating a future career as a nurse. Although radiological examination in the past had been negative, she harboured a lingering fear that she, too, might develop polycystic kidney disease. Psychodynamically she showed a strong identification with her mother but consi¬ derable guilt over unconscious rage re¬ sulting from her own unmet dependency needs. Although the patient expressed a strong preference for her daughter to be trained as co-technician, the daughter's conscious motivation to help appeared significantly related to unconscious guilt. Her involvement would effectively preserve distance in the marital relation¬ ship and likely hinder her need in the future to separate from the family. The liaison psychiatrist therefore recom¬

mended that the husband be trained as co-technician and the daughter be given only a minor role to play. While still in hospital the patient commenced hemodialysis and instruction in the use of the machine. Once her uremic state had sufficiently improved, bilateral

nephrectomy was performed to remove source of abdominal pain and enlargement. Postoperatively she was hy¬ potensive for several hours and for the first few days ventilated inadequately on account of abdominal discomfort. Electrolyte imbalance and rising blood urea necessitated dialysis on the third post¬ operative day (which was Labour Day). The patient appeared to be delirious and told a visiting relative that "she had de¬ livered a baby but the doctors would not tell her". Psychiatric consultation was requested on the sixth postoperative day at which time the patient was disoriented, confused and expressed the delusion that she had received a kidney transplant without her consent. She was terrified since she "knew rejection of the organ was inevitable". Pregnancy fantasies could no longer be detected but the pa¬ tient described a fear that her daughter had been in an accident. Despite reassurance, this fear persisted for several days until her daughter visited. In fact, the patient's husband suffered concussion when his car was hit in the rear on the day after his wife's operation. He was hospitalized for one day but the incident was not disclosed to the patient. However, she had been informed that the manufacturing company was now unwilling to rent a home dialysis machine, being prepared only to sell. The medical insurance company was only willing to subsidise a rental, thus creating an unsolvable problem in the patient's mind. Despite reassurance that this difficulty could eventually be resolved, the patient anxiously claimed she would die, now being without her kidneys and having no machine. Her mood was markedly de¬ pressed. The following day she remained dis¬ oriented and complained of pain "simi¬ lar to that after a cesarean section". With hemodialysis every second or third day and daily supportive psycho¬ therapy the patient's psychosis and confusion gradually cleared. By the 13th day she was fully oriented and stated that "she had been in a fog and confused by stupid thoughts". She was discharged from the hospital the next day to return as an outpatient three times weekly for home dialysis training. Meanwhile, since his accident, the pa¬ tient's husband began complaining of recurrent headaches, insomnia and diffi¬ culty with concentration. Neurological investigations were negative. Several weeks later when he began training at the dialysis centre, these symptoms were still present, together with complaints of severe testicular pain. Contrary to earlier predictions he showed consider¬ the

able

difficulty learning

to

operate the

machine, manifesting forgetfulness and

carelessness. On several occasions he was found obliviously performing pro¬ cedures which were potentially hazardous to his wife, for example clamping off incorrect tubing and injecting air into his wife's veins. After consulting his urologist he reported that he required orchiectomy. The dialysis team again requested help from the medical-psychiatric liaison service. The urologist indicated that he found no evidence of organic pathology, had reassured his patient of this, but threatened castration "in the hope that this might frighten him into giving up a func¬ tional symptom". He had not recog¬ nized his patient's intra-psychic conflicts which resulted in a distortion of this statement into a "need for orchiecto¬ my". The testicular pain and posttraumatic headaches were therefore consider¬ ed as conversion symptoms related to the current stress as well as to longstanding conflicts over sexual identity. Mental status examination and psycho¬ logical testing showed no evidence of cerebral damage but clinically the hus¬ band was now quite depressed. Projective tests indicated "gross confusion over sexual differentiation with little or no sense of a male sexual identity". The symptom of testicular pain appear¬ ed to defend against tremendous anxiety arising from a strong aggressive com¬ ponent to his sexual conflicts. It was felt that with his tendency to use primitive projection he might act out his uncon¬ scious resentment towards his wife. The liaison psychiatrist expressed concern that if given the power to control his wife's life or death via the machine, then he might eventually find the conflict which this responsibility aroused too much to tolerate. Psychological testing elicited again his own intense dependent needs which were being frustrated and repressed by his responsibility to care for his wife and daughter. He accepted a recommendation to re¬ ceive psychiatric treatment and the med¬ ical staff were advised that his involve¬ ment in the patient's care should be kept minimal. More time was then given to supporting her in becoming relatively independent in using the machine. This required a much longer time in training during which she also received suppor¬ tive psychotherapy.

By May 1971 the patient was coping well at home, with both her husband and daughter assisting in minor ways under her direction. She was cheerful, contented, showed an appropriate hopeful optimism and there was no evidence of residual cognitive impairment. Her husband was continuing psychiatric treatment although still consulting urologists, while their daughter was func¬ tioning well in school with a firmer deci¬ sion to later become a nurse.

C.M.A. JOURNAL/JUNE 24,

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Discussion Neurotic depressive reactions frequently occur in patients receiving maintenance hemodialysis. However, schizophrenic-like episodes, psychotic depressive reactions, hypomanic psychosis and paranoid psychosis which required termination of treatment in two cases have also been reported.9'12 Sexual and birth fantasies are also common in dialysis and renal transplant patients.6' 13 Muslin'4 studied the special relationship formed between female patients and their new kidneys and found a close resemblance to a mother-child postpartum symbiosis in which the women spoke of "my baby" and of the protective feelings they experienced toward their new organ. The converse of this relationship has been noted by some workers2' 7, 15 in the "umbilical fantasies" of dialysis patients, some of whom have spontaneously described their dependent relationship with the machine as a "fetal-placental" one. Cooper"0 reported a patient on maintenance hemodialysis who developed a hypomanic psychosis in which she believed herself to be a "chosen woman" who was pregnant with a "special baby". Similarly the patient described in this report became the mother of a fantasied child while simultaneously being placed in a helpless position, dependent on an "unreliable" but lifesustaining "machine-mother". Her psychosis appeared to be precipitated by a combination of metabolic and psychological factors. In this case the spouse developed psychiatric symptomatology when intrapsychic conflicts over sexual identity and frustrated dependency needs aroused excessive hostility with which he could no longer cope. This reaffirms other workers' findings that the spouses' greatest difficulty is in handling unconscious hostility towards their marital partner. Shambaugh et al16 have found the psychological stress for the spouse so great that on occasions he cannot continue. They describe intense feelings of deprivation and hostility which develop in response to the multiple losses and frustrations incurred by their partners' illnesses. Many of these feelings are unconsciously directed toward other people but they report some spouses becoming concerned with the possibility of killing the patient. In the spouses they studied, mild depres-

sion was the rule, but somatic reactions also occurred including episodes of diarrhea, headaches and minor conversion symptoms. Several spouses had even contemplated suicide during periods of intense depression. As a way of reducing these difficulties Shambaugh and Kanter17 have tried group meetings with the spouses, although Scribner18 finds "many of the problems are eliminated when the patient learns first, gains confidence, realises that it is her procedure and life and the spouse is merely an assistant when needed". A situation akin to this emerged in the case reported. I wish to thank Dr. F. Reichsman, Professor of Medicine, and Dr. N. Levy, Assistant Professor of Medicine, Downstate Medical Center College of Medicine, for their advice and helpful criticism in preparing this report.

References 1. ABRAM HS: The psychiatrist, the treatment of chronic renal failure, and the prolongation of life: I. Am J Psychiatry 124:1351,1968 2. Idem: The psychiatrist, the treatment of chronic renal failure and the prolongation of life: II. Am J Psychiatry 126: 157, 1969

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3. CRAMOND WA, KNIGHT PR, LAWRENCE JR: The psychiatric contribution to a renal unit undertaking chronic hemodialysis and renal transplantation. Br J Psychiatry 1 3: 1201, 1967 4. KAPLAN-DE-NOUR A, SHALTIEL J, CZACAKES J: Emotional reactions of patients on chronic hemodialysis. Psychosom Med 30: 521, 1968 5. KEMPH JP: Renal failure, artificial kidney and,kidney transplant. Am J Psychiatry 122: 1270, 1966 6. Idem: Observations of the effects of kidney transplant on donors and recipients. Dis Nerv Syst 31: 323, 1970 7. WRIGHT RG, SAND P, LIVINGSTON G: Psychological stress during hemodialysis for chronic renal failure. Ann Intern Med

64:611,1966 8. SAND P, LIVINGSTON G, WRIGHT RG: Psychological assessment of candidates for a hemodialysis programme. Ibid p. 602 9. SHEA EJ, BOGDAN DF, FREEMAN RB, et al: Hemodialysis for chronic renal failure IV. Psychological considerations. Ann Intern Med 62: 558, 1965 10. COOPER AJ: Hypomanic psychosis precipitated by hemodialysis. Compr Psychiatry8: 168, 1967 11. BROWN HW, MAHER JF, LAPIERRE L, et al: Clinical problems related to the prolonged artificial maintenance of life by hemodialysis in chronic renal failure. Trans Am Soc Artif Intern Organs 8: 281, 1962 12. GONZALEZ FM, PABILO RC, BROWN HW, et al: Further experience with the use of intermittent hemodialysis in chronic renal failure. Trans Am Soc ArtifIntern Organs

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13. KEMPH JP: Psychotherapy with patients receiving kidney transplant. Am J Psychiatry 124:5, 1967 14. MUsLIN H L: On Acquiring a Kidney. Paper presented at the 123rd Annual Meeting of the American Psychiatric Association, 1970 15. ABRAM HS: The prosthetic man. Compr Psychiatry 11: 475, 1970 16. SHAMBAUGH PW, HAMPERS CL, BAILEY

GL, et al: Hemodialysis in the homeemotional impact on the spouse. Trans Am Soc Artif Intern Organs 13: 41, 1967 17. SHAMBAUGH PW, KANTER SS: Spouses under stress: group meetings with spouses of patients on hemodialysis. Am J Psychiatry 125: 7, 1969 18. SCRIBNER BH: Discussion of Shambaugh PW et al: Trans Am Soc Artif Intern Organs 13: 49, 1967

Three kidney transplantations in a patient with primary hereditary hyperoxaluria B. Koch, M.D., F.R.C.P. [C], F.A.C.P., A. H. Irvine, M.D., F.R.C.S.[C], C.A.C.S., J. R. Barr, M.B., CH.B., F.C.A.P., and W. J. Poznanski, M.D., F.R.C.P. [c], Ottawa, Ont.

Primary hyperoxaluria is a rare inbotn error of oxalate metabolism that is transmitted by a recessive autosomal gene. Two enzyme deficiencies, one of a-keto-glutarate: glyoxylate carboligase (type I), the other of D-glyceric dehydrogenase (type II), have been identified but are clinically indistinguishable.' The first case was reported by Lapontre in 1925 and since then over 64 case reports have appeared in the world literature.2 The clinical features of this rare illness include hematuria, elevated urine oxalate excretion, renal colic due to oxalate stone formation, progressive renal failure and deposition of oxalate crystals in renal as well as in other body tissues. First symptoms usually develop in childhood and males and females are affected equally. The disorders of oxalate metabolism have recently been reviewed by Williams and Smith.2 Four renal transplantations have been reported in three patients who survived less than one to 18 months following operation.3`5 Almost invariably the transplanted kidney became the victim of the original disease. These authors concluded, therefore, that transplantation was not a justified treatment for this illness. This paper reports three cadaver kidney transplants in one patient with primary hyperoxaluria, who survived From the Department of Metabolism, Ottawa Civic Hospital. Reprint requests to: Dr. B. Koch, Ottawa Civic Hospital, Ottawa, Ontario, K IY 4E9

33 months after the first operation. If we undertook such treatment in spite of the discouraging reports quoted above, it was for the following reasons: (1) several drugs which block oxalate synthesis have recently become available; (2) while an inborn error of metabolism is considered a relative contraindication for transplantation if it is likely to affect the transplanted organ in a manner distinct from immunological rejection, in this patient clinical evidence of the error of metabolism had not manifested itself for 22 years after his birth. This is far longer than a transplanted cadaver kidney is expected to survive. In spite of these considerations all three transplanted kidneys developed oxalosis within a few months, while systemic oxalosis progressed concurrently and ultimately in itself became a life-limiting factor. Case report W.J.H. was born in 1940. From 1962 to 1967 he was treated for recurrent formation of renal stones composed of calcium oxalate. During that period his creatinine rose from a normal range to 4 mg. %. Retrograde pyelography showed multiple calculi in the renal medulla bilaterally. The urinary collecting system was unremarkable. According to the family history one grandfather had died with renal disease. The patient's only sister, born in 1942, was treated for recurrent attacks of renal colic from 1959 to 1967. Calculi procured in 1962 and 1967 by ureteral lithotomy were composed of calcium oxalate. Both parents and the sister were

asymptomatic and their plasma creatinine and urine analysis were normal. The sister's urinary oxalate excretion was elevated to 142 mg. per 24 hours (normal 10-55 mg.).2 Early in January 1968 the patient was admitted because the serum creatinine had risen to 6.9 mg. %. He was still free of symptoms. Following 16 hours of fasting the highest urine osmolality was 320 mOsm/kg. and after a water load the lowest urine osmolality was 188 mOsm/kg. Following a standard oral acid load of 0.1 g. ammonium chloride per kg. body weight the blood pH fell to 7.261, the urine pH fell to a minimum of 5.38, urinary excretion of ammonia was 6.35 mEq./min., of titratable acid 21.0 mEq./min., of bicarbonate 1.68 mEq./min. and of total acid 25.67 mEq./min.6 He was readmitted on January 31, 1968, acutely ill, complaining of weakness, anorexia, dyspnea and marked pain in the calves. On examination he was grossly uremic. The blood pressure was 160/105. Calves, hands and feet showed numerous areas of purple discolouration that were exquisitely tender (Fig. 1). He was oliguric and the serum creatinine was 33 mg. %. On February 1, peritoneal dialysis was performed. On February 9, an arteriovenous fistula was constructed in the right arm. On February 14 the patient underwent hemodialysis for the first time and twice weekly thereafter, using a Baxter twin coil dialyzer. On March 14, bilateral nephrectomy was performed and on the same occasion a cadaver kidney was transplanted to the right iliac fossa, from an ABO compatible donor. The regimen of immunosuppressive therapy used for this, and for subsequent transplants, consisted of azathioprine 300 mg. per day initially and later adjusted to keep the peripheral leukocyte count at about 5000 per mm.3 Prednisone 25 mg. was given daily for the first two to four weeks and then reduced to 10 to 20 mg. per day except during rejection. Actinomycin D 200,ug. was given intravenously on the second, fourth and sixth postoperative days. Local radiation was administered to the transplanted kidneys in thrice weekly doses of 50 rads each for a total of two weeks. Immediately following operation serum creatinine fell to 1 mg. %. On March 27 graft rejection was diagnosed on clinical grounds and responded to

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