**8.1 Nausea and vomiting**

Nausea and vomiting is encountered in the hemodialysis patient group at rates up to 10% (Bregman H et al., 1994). While nausea and vomiting can be part of dialysis-related complications such as disequilibrium syndrome, hypotension, allergic reactions and electrolytic imbalance, they may also accompany acute coronary syndrome, cerebrovascular events and infections. Patients with nausea and vomiting should be examined for the causes of these events. One of the points to remember is that besides the factors enumerated above, prevalence of dyspeptic complaints and gastritis, duodenitis, peptic ulcer and colelithiasis has also increased in the dialysis patient group (Jain J & Thiele D, 2006). Therefore, hemodialysis-related complications should be set aside in the hemodialysis patients with nausea and vomiting, and the patients should be assessed in terms of any cerebrovascular and cardiovascular events, and infection. If these causes are absent, presence of other gastrointestinal symptoms should be assessed and a gastroscopy should be conducted. Nausea and vomiting not associated with hemodynamics may benefit from 5 to 10 mg of metoclopramide before dialysis (Bregman H et al., 1994).

### **8.2 Itching**

Itching is one of the most frequently encountered symptoms in chronic kidney disease. Complaints of itching was found in 50 to 60% of the patients with end-stage renal failure who are undergoing a dialysis therapy (Narita et al., 2008). Although the etiology of uremic itching is not fully clarified, the factors held responsible include xerosis (Morton et al., 1996), peripheral neuropathy (Johansson et al.,1989), increases in divalent ions such as calcium, magnesium and phosphorus (Blachley et al., 1985), high level of parathyroid hormones (Morachiello et al., 1991) increases in the level of, and sensitivity to, histamine (Stockenhuber et al., 1987) and dialysis-related factors (Schwartz&Iaina 1999).

In diagnosing uremic itching, first the other causes of itching should be ruled out. Various tropical and systemic therapies have been tried in treating it for many years, but there have been patients who did not benefit from any of such therapies. For this reason, both the pathogenesis and the treatment of itching continue to be researched today. The recommended tropical therapy at present involves moisturizing creams and creams containing capsaicin (Breneman et al., 1992). Other treatment methods include phototherapy, acupuncture, a lowprotein diet, long-chain fatty acids, lidocaine, orally activated charcoal, cholestramine, efficient dialysis, heparin, opioid antagonists, erythropoietin, parathyroidectomy, serotonin antagonists, thalidomide, antihistaminics and nicergoline (Schwartz&Iaina, 2000).

#### **8.3 Cramps**

Muscle cramps were being seen at a rate of 24 to 86% in the years when hemodialysis was first introduced (Kobrin&Berns,2007; Chou et al., 1985). Today, the intradialytic cramp rate

surface are held responsible in the pathogenesis of dialysis-induced neutropenia. In addition, several studies have shown a correlation between complement activation and leukopenia. (Hakim et al., 1984; Huang et al., 2009; Lee et al., 1984; Takemoto et al., 2011) Temporary neutropenia does not generally lead to significant clinical problems. However, it is regarded as maybe one of the factors causing a predisposition to infection observed in

Nausea and vomiting is encountered in the hemodialysis patient group at rates up to 10% (Bregman H et al., 1994). While nausea and vomiting can be part of dialysis-related complications such as disequilibrium syndrome, hypotension, allergic reactions and electrolytic imbalance, they may also accompany acute coronary syndrome, cerebrovascular events and infections. Patients with nausea and vomiting should be examined for the causes of these events. One of the points to remember is that besides the factors enumerated above, prevalence of dyspeptic complaints and gastritis, duodenitis, peptic ulcer and colelithiasis has also increased in the dialysis patient group (Jain J & Thiele D, 2006). Therefore, hemodialysis-related complications should be set aside in the hemodialysis patients with nausea and vomiting, and the patients should be assessed in terms of any cerebrovascular and cardiovascular events, and infection. If these causes are absent, presence of other gastrointestinal symptoms should be assessed and a gastroscopy should be conducted. Nausea and vomiting not associated with hemodynamics may benefit from 5 to 10 mg of

Itching is one of the most frequently encountered symptoms in chronic kidney disease. Complaints of itching was found in 50 to 60% of the patients with end-stage renal failure who are undergoing a dialysis therapy (Narita et al., 2008). Although the etiology of uremic itching is not fully clarified, the factors held responsible include xerosis (Morton et al., 1996), peripheral neuropathy (Johansson et al.,1989), increases in divalent ions such as calcium, magnesium and phosphorus (Blachley et al., 1985), high level of parathyroid hormones (Morachiello et al., 1991) increases in the level of, and sensitivity to, histamine

In diagnosing uremic itching, first the other causes of itching should be ruled out. Various tropical and systemic therapies have been tried in treating it for many years, but there have been patients who did not benefit from any of such therapies. For this reason, both the pathogenesis and the treatment of itching continue to be researched today. The recommended tropical therapy at present involves moisturizing creams and creams containing capsaicin (Breneman et al., 1992). Other treatment methods include phototherapy, acupuncture, a lowprotein diet, long-chain fatty acids, lidocaine, orally activated charcoal, cholestramine, efficient dialysis, heparin, opioid antagonists, erythropoietin, parathyroidectomy, serotonin

Muscle cramps were being seen at a rate of 24 to 86% in the years when hemodialysis was first introduced (Kobrin&Berns,2007; Chou et al., 1985). Today, the intradialytic cramp rate

(Stockenhuber et al., 1987) and dialysis-related factors (Schwartz&Iaina 1999).

antagonists, thalidomide, antihistaminics and nicergoline (Schwartz&Iaina, 2000).

hemodialysis patients.

**8.1 Nausea and vomiting** 

metoclopramide before dialysis (Bregman H et al., 1994).

**8. Others** 

**8.2 Itching** 

**8.3 Cramps** 

fell down to 2% in a week owing to the improvements in the dialysis technology (Ahsan et al., 2004). Although cramps are mostly seen in the lower extremities, they can also occur in the abdomen, arms and hands.

Pathogenesis of muscle cramps is not fully clarified, but electromyographic research indicates that they more likely to originate from the neurons rather than the muscle itself (McGee, 1990). Subnormal muscle metabolism is considered as the most important factor in cramp etiology (Chang et al., 2002). For this reason, hypotension, changes in plasma osmolarity, hyponatremia, carnitine deficiency, hypomagnesemia and tissue hypoxia are thought to cause development of cramps (Ahsan et al., 2004; Chou et al., 1985; Khajehdehi et al., 2001). In these aforesaid situations, the muscle metabolism is impaired and cramps develop. Muscle cramps may lead to early finishing of dialysis sessions, failure to carry out sufficient ultrafiltration and finally dialysis inefficiency.

Hypertonic glucose, saline and mannitol may be administered in the acute treatment of cramps (Canzanello et al., 1991). Non-medical measures that can be taken to prevent cramps include avoidance of intradialytic hypotension and osmolarity changes, and regular exercise. There are studies showing that administration of 320 mg quinine sulfate 1 or 2 hours before hemodialysis therapy decreased muscle cramps **(**Kaji et al**.,** 1976; Roca et al., 1992). However, use of quinine sulfate has side-effects such as cinchonism, optical atrophy, thrombocytopenia, arrhythmia, hemolytic uremic syndrome and interaction with drugs such as digoxin and warfarin (Wolf et al., 1992; Goldenberg&Wexler, 1988; Kojouri et al., 2001; Pedersen et al., 1985). There are also studies showing that muscle cramp development is reduced by administering 400 mg/day vitamin E, 250 mg/day vitamin C (Khajehdehi et al., 2001), 12 gm of creatinin monohydrate before dialysis (Chang et al.,2002), prozosin (0.25- 1 mg) (Sidhom et al., 1994) and L-carnitine (Bellinghieri et al., 1983). However, the safety of using vitamin C above 200 mg for a long time is not proven (Kobrin et al., 2007).

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**17** 

*1Japan 2Italy* 

**Review of the Effectiveness of** 

Masaharu Aritomi1 and Francesco Galli2 *1Asahi Kasei Kuraray Medical Co., Ltd. Tokyo 2Dept of Internal Medicine, University of Perugia* 

**Cellulose- and Polysulfone-Based** 

**Vitamin E-Bonded Dialysis Membranes** 

Reduction of the stressful effects of extracorporeal circulation is a major target in hemodialysis (HD) therapy. These effects can be attributed to the HD-associated uremic comorbidity and the oxidative and non-oxidative events that occur because of the extracorporeal treatment. Anemia, cardiovascular disease, chronic inflammation, immunosuppression and intradialytic hypotension are among the most common complications in patients receiving HD, which show a causal relationship with oxidative stress (Galli, 2002 and Del Vecchio et al., 2011). During HD, the patient's blood is repeatedly exposed to components of the extracorporeal circulation, a key component of which is the hollow-fiber dialyzer membrane. This phenomenon may lead to leukocyte and platelet activation, thereby causing oxidative stress. Moreover, bioactive contaminants, e.g., bacterial endotoxins in the dialysis fluids, to which the patient's blood is eventually exposed through the dialyzer membrane, may further sustain leukocyte activation. These variables, which are usually included under the definition of "bio-incompatibility," should be carefully monitored by dialysis centers because these variables are responsible for causing proinflammatory events, oxidative stress, and pro-thrombotic effects. Leukocyte activation and oxidative stress are also reported to cause erythrocyte damage that is further aggravated by shear stress and other mechanical injuries. Plasma proteins and lipids show signs of oxidative damage (Piroddi et al., 2007 and Galli, 2007), and this may influence the burden of uremic toxicity by inducing cell and tissue reactions, abnormal metabolism of these oxidation products, vascular and immune reactions, etc. To reduce the risk of oxidative stress and other adverse reactions that can be caused by poor biocompatibility of HD treatment, highly purified dialysis fluids and dialyzer membranes with greater biocompatibility have been developed, and are currently under investigation for further

The bio-incompatibility of prototypical dialyzer membranes made of regenerated cellulose has been associated with the contact of blood components with the hydroxyl groups of beta-D-glucose. These groups trigger intradialytic activation of the complement

**1. Introduction** 

improvement.

