Search

Aim: This cross‐sectional survey aimed to determine the prevalence of Interventional Nephrology (IN) practice amongst nephrologists in the Asia‐Pacific Region (APR), specifically related to dialysis access (DA). Methods: The Association of VA and intervenTionAl Renal physicians (AVATAR) Foundation from India conducted a multinational online survey amongst nephrologists from the Asia‐Pacific to determine the practice of IN in the planning, creation, and management of dialysis access. The treatment modalities, manpower and equipment availability, monthly cost of treatment, specifics of dialysis access interventions, and challenges in the training and practice of IN by nephrologists were included in the survey. Results: Twenty‐one countries from the APR participated in the survey. Nephrologists from 18 (85.7%) countries reported performing at least one of the basic dialysis access‐related IN procedures, primarily the placement of non‐tunnelled central catheters (n‐TCC; 71.5%). Only 10 countries (47.6%) reported having an average of <4% of nephrologists performing any of the advanced IN access procedures, the most common being the placement of a peritoneal dialysis (PD) catheter (20%). Lack of formal training (57.14%), time (42.8%), incentive (38%), institutional support (38%), medico‐legal protection (28.6%), and prohibitive cost (23.8%) were the main challenges to practice IN. The primary obstacles to implementing the IN training were a lack of funding and skilled personnel. Conclusion: The practice of dialysis access‐related IN in APR is inadequate, mostly due to a lack of training, backup support, and economic constraints, whereas training in access‐related IN is constrained by a lack of a skilled workforce and finances. [ABSTRACT FROM AUTHOR]

Background. The association between economic status and kidney disease is incompletely explored even in countries with higher economy (HE); the situation is complex in lower economies (LE) of South Asia and Southeast Asia (SA and SEA). Methods. Fifteen countries of SA and SEA categorized as HE and LE, represented by the representatives of the national nephrology societies, participated in this questionnaire and interview-based assessment of the impact of economic status on renal care. Results. Average incidence and prevalence of end-stage kidney disease (ESKD) per million population (pmp) are 1.8 times and 3.3 times higher in HE. Hemodialysis is the main renal replacement therapy (RRT) (HE-68%, LE-63%). Funding of dialysis in HE is mainly by state (65%) or insurance bodies (30%); out of pocket expenses (OOPE) are high in LE (41%). Highest cost for hemodialysis is in Brunei and Singapore, and lowest in Myanmar and Nepal. Median number of dialysis machines/1000 ESKD population is 110 in HE and 53 in LE. Average number of machines/dialysis units in HE is 2.7 times higher than LE. The HE countries have 9 times more dialysis centers pmp (median HE-17, LE-02) and 16 times more nephrologist density (median HE-14.8 ppm, LE-0.94 ppm). Dialysis sessions >2/week is frequently followed in HE (84%) and <2/week in LE (64%). "On-demand" hemodialysis (<2 sessions/week) is prevalent in LE. Hemodialysis dropout rates at one year are lower in HE (12.3%; LE 53.4%), death being the major cause (HE-93.6%; LE-43.8%); renal transplants constitute 4% (Brunei) to 39% (Hong Kong) of the RRT in HE. ESKD burden is expected to increase >10% in all the HE countries except Taiwan, 10%–20% in the majority of LE countries. Conclusion. Economic disparity in SA and SEA is reflected by poor dialysis infrastructure and penetration, inadequate manpower, higher OOPE, higher dialysis dropout rates, and lesser renal transplantations in LE countries. Utility of RRT can be improved by state funding and better insurance coverage. [ABSTRACT FROM AUTHOR]

Background & Aims: There is emerging data on the use of Sofosbuvir‐based directly acting antiviral (DAA) drug regimens in chronic hepatitis C (CHC) patients with end‐stage renal disease (ESRD) on maintenance haemodialysis (MHD). We evaluated the safety and efficacy of Sofosbuvir plus Velpatasvir fixed‐dose combination in CHC patients with ESRD on MHD. Methods: Fifty‐one CHC patients with ESRD on MHD were included in a real‐life prospective study. All patients irrespective of genotype; presence of cirrhosis; treatment naive or experienced status were treated with full‐dose Sofosbuvir (400 mg) plus Velpatasvir (100 mg) fixed‐dosed combination given daily for 12 weeks. The efficacy was assessed by the sustained virological response (SVR12) with negative HCV RNA 12 weeks after the end of treatment (ETR). Side effects if any were recorded in all patients. Results: The median HCV RNA level in 51 CHC patients [Males 41 (80.4%), mean age 42.8 ± 14.6 years] was 2.0 × 106 IU/mL. HCV genotype was available in 19 patients with predominant genotype 1 in 15 (79%) patients. Ten (19.6%) patients had evidence of cirrhosis (defined as LSM ≥ 12.5 kPa on Transient Elastography), and 8 (15.6%) patients were treatment experienced. Testing for ETR was done in 36 patients and all 36 (100%) patients achieved ETR, and 49 patients (96%) achieved SVR 12. All 51 patients tolerated the Sofosbuvir + Velpatasvir combination, with none of the patients reporting any serious adverse event. Conclusion: Sofosbuvir plus Velpatasvir fixed‐dose combination is safe and effective in treating CHC in patients with ESRD on MHD. [ABSTRACT FROM AUTHOR]

Infection of the internal jugular vein (IJV) catheter continues to be a common cause of death in patients with end-stage renal disease undergoing hemodialysis (HD). The present study aimed to evaluate the effectiveness of personal hygiene on the incidence of IJV catheter-related bloodstream infection (CRBSI). A randomized, controlled, parallel, and non-inferiority trial was conducted on patients initiated on maintenance HD via right IJV catheter. Patients were randomly allocated to control and intervention group via computer-generated random table. Intervention package for the intervention group included hand washing (2–4 hourly and whenever visibly dirty), feet washing (12 hourly), and axillary shave (at any point during the study, no hair growth in axilla). Patients were provided with a pamphlet and reinforced to continue package till IJV catheter was in situ. Patients were followed up twice a week for one month from the date of catheter insertion for the incidence of CRBSI. The primary outcome of the study was percentage of patients free from CRBSI. On intention-to-treat analysis, the percentage of patients without CRBSI was 53.7% and 29.3% in the intervention and control arm, respectively [P = 0.04; 25.12% (1.43–45.28%)]. Positive blood cultures were higher in control (73.3%) as compared to the intervention group (28.6%) (P = 0.19). Personal hygiene interventions are an effective method to reduce the incidence of CRBSIs among population undergoing maintenance HD via non-cuffed IJV catheter. [ABSTRACT FROM AUTHOR]

Introduction Nearly 220000 patients are diagnosed with end-stage renal disease (ESRD) every year, which calls for an additional demand of 34 million dialysis sessions in India. The government of India has announced a National Dialysis Programme to provide for free dialysis in public hospitals. In this article we estimate the overall cost of performing hemodialysis (HD) in a tertiary care hospital. Second, we assess the catastrophic impact of out-of-pocket expenditures (OOPEs) for HD on households and its determinants. Methods The economic health system cost of HD was estimated using bottom-up costing methods. All resources, capital and recurrent, utilized for service delivery from April 2015 to March 2016 were identified, measured and valued. Capital costs were annualized after accounting for their useful life and discounting at 3% for future years. Sensitivity analyses were undertaken to determine the effect of variation in the input prices and other assumptions on the annual health system cost. OOPEs were assessed by interviewing 108 patients undergoing HD in the study hospital to account for costs from the patient's perspective. The prevalence of catastrophic health expenditures (CHEs) was computed per threshold of 40% of non-food expenditures. Results The overall average cost incurred by the health system per HD session was INR 4148 (US$64). Adjusting for capacity utilization, the health system incurred INR 3025 (US$47) per HD at 100% bed occupancy. The mean OOPE per patient per session was INR 2838 (US$44; 95% confidence interval US$34–55). The major components of this OOPE were medicines and consumables (64.1%). The prevalence of a CHE per HD session was 11.1%. Conclusion Our study findings would be useful in the context of planning for dialysis services, setting provider payment rates for dialysis under various publicly sponsored health insurance schemes and undertaking future cost-effectiveness analysis to guide resource allocation decisions. [ABSTRACT FROM AUTHOR]

Guidewire embolism during venous access for haemodialysis is not uncommon yet potentially avoidable iatrogenic complication. Unrecognised, long-standing in-situ guidewire may predispose to thrombosis and become a nidus for infection. This entity should always be borne in mind and considered as one of the differentials of unexplained pyrexia in patient on maintenance haemodialysis. In this context, we report a patient on maintenance dialysis who presented with fever of 6 weeks duration with no localising history and failed response to empirical antibiotics. On imaging, he was detected to have in-situ guidewire with fracture embolism into inferior vena cava and right external iliac vein and soon patient became afebrile following guidewire retrieval using gooseneck snare device, thereby retrospectively confirming causality. [ABSTRACT FROM AUTHOR]

Patients with end stage renal disease (ESRD) and severe hyponatremia always pose a challenge to manage. It is necessary to correct biochemical parameters, advanced azotemia, and fluid overload with conventional haemodialysis (HD) but it may correct serum sodium (Na) rapidly resulting in neurological complications like seizures and osmotic demyelination syndrome. Continuous renal replacement therapy (CRRT) is an ideal modality to manage such patients. However, most of the centers in the developing or underdeveloped nations do not have CRRT facility. We present two cases of ESRD, who had advanced azotemia requiring dialysis, also had persistent vomiting and severe hyponatremia (one with Na 107, another with Na 109 mEq/L), both cases were managed with conventional HD using dialysate Na concentration of 128 mEq/L (lowest permissible level of Na in a traditional HD machine) and keeping the blood flow of 50 mL/min. The serum Na increased by 1 mEq/L/h during first HD session, during the next session blood flow increased to 100 mL/min, and serum Na increased by two mEq/L/h. At the end of 48 hours, we were able to successfully correct serum Na by 18 mEq/L, with complete resolution of uremic manifestations and no neurological deficits. The current reports highlight management of hyponatremia in newly diagnosed ESRD in a cost limited setting. [ABSTRACT FROM AUTHOR]

Background: Femoral vein catheterization is the easiest and safest method for obtaining temporary vascular access in hemodialysis patients. We studied the structure and anatomical variation of femoral veins in uremic patients using ultrasound imaging. Methods: Ultrasonography of femoral vessels was carried out bilaterally in patients with acute renal failure (ARF) and chronic renal failure (CRF). The relationship between ultrasonographic measurements of femoral vessels and anthropometric data were evaluated using Pearson''s method. Results: A total of 157 patients (67 ARF, 90 CRF) were included in the study. The majority of the patients were male (68.8%), and mean age was 43.29 ± 16.74 years. Mean height, weight, and body mass index were 163.94 ± 8.53 cm, 61.96 ± 12.37 kg, and 22.99 ± 3.68 kg/m2, respectively. Mean depth of the femoral artery was 10.74 ± 4.74 mm on the left side and 9.92 ± 3.98 mm on the right side. Mean diameter of the femoral artery was 7.77 ± 1.57 mm on the left side and 7.64 ± 1.45 mm on the right side. Mean distance of the femoral vein from the skin surface was 13.68 ± 4.98 mm on the left side and 12.76 ± 4.85 mm on the right side. Mean diameter of the femoral vein was 9.47 ± 2.15 mm on the left side and 9.37 ± 2.25 mm on the right side. The femoral vein had adequate diameter (≥ 5 mm) on both sides in all patients. Abnormal location of the femoral vein was not observed in our study. The depth of femoral vasculature was deeper in overweight and obese patients compared to normal weight patients. Femoral artery puncture, multiple attempts before successful catheterization, and hematoma formation were observed in 11.0%, 13.5%, and 5.4% of patients, respectively. Conclusion: Anatomical variation and location anomalies of the femoral vein were not observed in Indian uremic patients. Femoral vein diameter was adequate (≥ 5 mm) in all patients bilaterally. However, there was a slight variation in depth (> 1 mm) and diameter (0.1 mm) of femoral vasculature between the left and right sides (left > right). [Copyright &y& Elsevier]