Search

Background:Microwave ablation (MWA) can be used to treat severe secondary hyperparathyroidism; however, its efficacy and the predictor of its efficacy are unclear. In this retrospective study we determined the predictor of efficacy of MWA and compared the efficacy of MWA and parathyroidectomy. Materials and methods:Patients with severe secondary hyperparathyroidism who had received MWA or parathyroidectomy were enrolled in the study. Participants with MWA were divided into response and no response groups based on efficacy. Possible predictors were analysed using logistic regression to determine efficacy predictors. The participants were divided into MWA and parathyroidectomy groups, and the efficacy (including rates of achieving recommended goals for intact parathyroid hormone (iPTH), calcium, and phosphorus levels) were compared between the two groups. Results:Thirty-one participants were enrolled for predictor analysis. Only baseline iPTH level predicted efficacy (OR 0.997,P = 0.018). The optimal threshold value of iPTH for predicting efficacy was 1493.5 pg/mL. To compare efficacy, 30 patients were enrolled in MWA (18/30) and parathyroidectomy (12/30) groups. The rates of achieving recommended goals for iPTH levels varied between 0 and 60%; a significant difference was found between the groups at 5 months (P = 0.01). However, in the parathyroidectomy group, the iPTH level and rate of iPTH <124 pg/mL (lower limit of target range) were significantly lower than in the MWA group after treatment (40–75% versus 0–16.7%). Conclusion:Baseline iPTH level is a good predictor of MWA efficacy for severe secondary hyperparathyroidism; parathyroidectomy is more effective for severe secondary hyperparathyroidism than MWA. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aims of this study were to assess the incidence, risk factors and complications of falls in the hemodialysis (HD) population. MATERIAL and METHODS: Using a prospective study design, chronic HD patients aged ≥50 years were recruited. The baseline characteristics and laboratory markers of all study participants were recorded. Participants were followed prospectively for 12 weeks. Patients were questioned thrice weekly about fall incidents. RESULTS: A total of 34 patients (mean age 69.1 year) participated in this study. 16 falls occurred in nine (26.5%) patients over 12 weeks of follow-up with an incidence rate of 1.30 falls/patient-year. By applying univariate logistic regression analysis, previous fall history (odds ratio 10.5, P-value= 0.008), high parathyroid hormone level (odds ratio 1.032, P-value= 0.016) and impaired balance (odds ratio 9.00, P-value=0.017) were identified as significant risk factors for falls. CONCLUSION: We concluded that high parathyroid hormone levels might be an important predictor of falls in HD patients in addition to impaired balance and previous fall history. As such, parathyroid hormone is a crucial factor to target for future intervention strategies aimed at reducing the fall incidence in the HD population. [ABSTRACT FROM AUTHOR]

Aortic valve stenosis (AS) is a frequent complication contributing to poor prognosis in chronic hemodialysis (CHD) patients. High blood pressure (BP) is known to be associated with AS progression in the general population. In CHD patients, however, BP varies during and between hemodialysis sessions with ultrafiltration volume or inter-dialytic weight gain; therefore it is difficult to characterize the BP status with a conventional single measurement. Our purpose was to clarify the BP variables affecting AS progression in CHD patients. We retrospectively enrolled 32 consecutive CHD patients with AS [aortic valve area (AVA), 1.3 ± 0.3 cm; mean age 69 ± 8 years] who had serial transthoracic echocardiographic studies at least 6 months apart (mean 23 ± 9 months). AS progression was evaluated using absolute reduction in AVA per year. Pre-dialytic and intra-dialytic (every hour during sessions) BPs throughout the 3 consecutive visits were used to determine each patient's BP status. We calculated the mean values of pre-dialytic and intra-dialytic BPs and their variability. In univariate analysis, mean visit-to-visit pre-dialytic and intra-dialytic BP were associated with AS progression, whereas all variables of BP variability were not. Multiple regression analysis indicated that only mean visit-to-visit intra-dialytic systolic and diastolic BP remained independently associated with AS progression after adjustment for age, sex, hypertension, hypercholesterolemia, diabetes mellitus, and serum parathyroid hormone ( p < 0.05). Although BP regulation in CHD patients is complex and multifactorial, mean visit-to-visit intra-dialytic BP was independently associated with AS progression. Prospective studies are necessary before considering intra-dialytic BP as a potential target for therapy. [ABSTRACT FROM AUTHOR]

Background. Evaluation of mortality trends in dialysis patients is important for improving their prognoses. The present study aimed to examine temporal trends in deaths (all-cause, cardiovascular, noncardiovascular and the five leading causes) among Japanese dialysis patients. Methods. Mortality data were extracted from the Japanese Society of Dialysis Therapy registry. Age-standardizedmortality rates were calculated by direct standardization against the 2013 dialysis population. The average annual percentage of change (APC) and the corresponding 95% confidence interval (CI) were computed for trends using joinpoint regression analysis. Results. A total of 469 324 deaths occurred, of which 25.9% were from cardiac failure, 17.5% from infectious disease, 10.2% from cerebrovascular disorders, 8.6% from malignant tumors and 5.6% from cardiac infarction. The joinpoint trend for all-cause mortality decreased significantly, by -3.7% (95% CI -4.2 to -3.2) per year from 1988 through 2000, then decreased more gradually, by -1.4% (95% CI -1.7 to -1.2) per year during 2000-13. The improved mortality rates were mainly due to decreased deaths from cardiovascular disease, with mortality rates due to noncardiovascular disease outnumbering those of cardiovascular disease in the last decade. Among the top five causes of death, cardiac failure has shown a marked decrease in mortality rate. However, the rates due to infectious disease have remained stable during the study period [APC 0.1 (95% CI -0.2-0.3)]. Conclusions. Significant progress has been made, particularly with regard to the decrease in age-standardized mortality rates. The risk of cardiovascular death has decreased, while the risk of death from infection has remained unchanged for 25 years. [ABSTRACT FROM AUTHOR]

Cerebral air embolism (CAE) is an infrequently reported complication of routine medical procedures. We present two cases of CAE. The first patient was a 55-year-old male presenting with vomiting and loss of consciousness one day after his hemodialysis session. Physical exam was significant for hypotension and hypoxia with no focal neurologic deficits. Computed tomography (CT) scan of head showed gas in cerebral venous circulation. The patient did not undergo any procedures prior to presentation, and his last hemodialysis session was uneventful. Retrograde rise of venous air to the cerebral circulation was the likely mechanism for venous CAE. The second patient was a 46-year-old female presenting with fever, shortness of breath, and hematemesis. She was febrile, tachypneic, and tachycardic and required intubation and mechanical ventilation. An orogastric tube inserted drained 2500 mL of bright red blood. Flexible laryngoscopy and esophagogastroduodenoscopy were performed. She also underwent central venous catheter placement. CT scan of head performed the next day due to absent brain stem reflexes revealed intravascular air within cerebral arteries. A transthoracic echocardiogram with bubble study ruled out patent foramen ovale. The patient had a paradoxical CAE in the absence of a patent foramen ovale. [ABSTRACT FROM AUTHOR]

Background: After the concept of healthcare associated pneumonia (HCAP) was introduced in 2005 by the American Thoracic Society/Infectious Disease Society of America (ATS/IDSA), pneumonia in hemodialysis patients has been classified as HCAP. Even though there are several risk factors and scoring systems of drug-resistant pathogens (DRPs) in HCAP, the risk factors for DRPs in hemodialysis-associated pneumonia are unclear.Methods: Patients who were admitted to our tertiary care hospital from January 2005 to December 2010 were screened by a discharge diagnosis of pneumonia. Patients were enrolled if they fulfilled the definition of HCAP according to the 2005 ATS/IDSA guidelines.Results: A total of 530 subjects were diagnosed with HCAP, of whom 48 (9.1 %) received regular hemodialysis (HD group) and the other 482 did not (non-HD group). The most common pathogens in HD group were Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus (MRSA). There was a similar distribution of Gram-negative bacilli infections between the two groups except for Haemophilus influenzae and Citrobacter species. The incidence of DRPs was not significantly different between the two groups (HD vs. non-HD, 35.4 vs. 39.2 %, p = 0.607). Wound care, severe pneumonia and an age of more than 70 years were significant risk factors for DRPs. The area under the operating cure of predicting DRPs was 0.727 (0.575-0.879, p = 0.01).Conclusion: P. aeruginosa and MRSA were the most important pathogens in hemodialysis-associated pneumonia. Wound care, severe pneumonia and old age were significant risk factors for DRPs. [ABSTRACT FROM AUTHOR]

Background. Inflammation is a common feature in dialysis patients and is associated with cardiovascular complications and poor outcome. Measuring the variability of inflammatory markers may help in understanding underlying factors triggering inflammation. Whether the inflammatory pattern in hemodialysis (HD) and peritoneal dialysis (PD) patients differs has scarcely been studied. Here we explored factors associated with the magnitude and variability of inflammation markers in HD and PD patients. Methods. In two 3-month, prospective cohort studies comprising 228 prevalent HD and 80 prevalent PD patients, interleukin- 6 (IL-6) and high-sensitivity C-reactive protein (CRP) were measured in blood samples drawn each month and every week, respectively. Information on comorbidity, protein-energy wasting (PEW) and medications was gathered at baseline, and information on symptoms potentially related to inflammation was gathered weekly. A mixed-effect model was used for multivariate analysis of factors linked to CRP and IL-6 variation. Results. IL-6 and CRP levels were higher and showed higher variability in HD versus PD patients [median IL-6 8.3 (interquartile range, IQR, 5.3-14.5) versus 6.7 (IQR 4.2-10.0) pg/ mL, P < 0.001 and median CRP 6.1 (IQR 2.5-14.0) versus 5.4 (IQR 1.6-9.0) mg/L, P < 0.001). PEW predicted increased inflammation variability after correcting for age, sex, dialysis vintage, modality and comorbidity. Increased comorbidity predicted IL-6, but not CRP, variability. Conclusions. Circulating concentrations as well as variability of IL-6 and CRP levels were higher in HD as compared with PD patients. In HD and PD patients, short-term variability of IL-6 and CRP levels associated strongly with PEW, while comorbidity was related to IL-6 but not to CRP variability. [ABSTRACT FROM AUTHOR]

Background. Although citrate dialysate (CiDi) is regarded to be safe, dialysis modalities using higher dialysate volumes, like haemodiafiltration (HDF), may expose patients to higher citrate load and thus increase the risk of complications. We investigated the residual risk of CiDi compared with standard dialysate (StDi) in patients on different dialysis modalities and its effect on dialysis dose. Methods. In a multicentre randomized crossover study, 92 dialysis patients (HDF post-dilution: n = 44, HDF pre-dilution: n = 26, haemodialysis: n = 25) were treated for 4 weeks with each dialysate (StDi and CiDi). Hypocalcaemia (ionized calcium =0.9 mmol/L), alkalosis (pH ≥7.55), post-treatment bicarbonate ≥32 mmol/L, pre-treatment bicarbonate ≥27 mmol/L, intra-dialytic events (IEs) and adverse events (AEs) between dialysis sessions were investigated as primary end points. The secondary objective was dialysis efficacy, i.e. dose and removal ratios of urea, creatinine, phosphate and β-2-microglobulin. Results. Post-dialysisovercorrection of bicarbonate (>32 mmol/L) was less frequent with CiDi (P = 0.008).Other predefined calcium and acid-base disturbances did not vary. There was no significant difference in IE. However, more patients developed AEs such as fatigue, muscle spasms or pain using CiDi (StDi: 41 versus CiDi: 55 patients, P = 0.02), particularly in the first 2 weeks of exposure. Dialysis efficacy was comparable with both dialysates. Conclusions. It can be confirmed that CiDi is not associated with the development of severe calcium and acid-base disorders, even when dialysis modalities with higher citrate loads are used. However, a refinement of the CiDi composition to minimize AEs is necessary. [ABSTRACT FROM AUTHOR]

Several observational studies have reported an association between higher serum bicarbonate level and high mortality risk in dialysis patients. However, in such studies mere discovery of associations does not allow one to infer causal relationships. This association may be related to inadequate dietary protein intake that may lead to less acid generation and hence a higher serum bicarbonate level. Since undernutrition is a strong predictor of death in hemodialysis patients, the observed associationmay be an epiphenomenon and not a biologically plausible relationship. Higher protein and fluid intake between two subsequent hemodialysis treatments may lead to lower serum bicarbonate level. This low bicarbonate level may appear protective, as patients with higher food intake and better appetite generally exhibit greater survival. In the contemporary three-stream proportioning system of hemodialysis treatment, the bicarbonate concentrate is separate fromthe acid concentrate, and the contribution of the acid concentrate organic acid (acetate, citrate or diacetate) to the delivered bicarbonate pool of the patient is negligible. The concept of 'total buffer' that assumes that the combination of bicarbonate and acetate concentrations in the dialysate are added equally as bicarbonate equivalents is likely wrong and based on the misleading notion that the acetate of the acid concentrate is fully metabolized to bicarbonate in the dialysate. Given these uncertainties it is prudent to avoid excessively high or low bicarbonate levels in dialysis patients. [ABSTRACT FROM AUTHOR]

Infectious complications are a major cause of morbidity and mortality among pediatric patients undergoing dialysis. Hemodialysis is the most common modality for initiation of dialysis. Risk of infections in the hemodialysis population is related to increased exposure to health care environment, lapses in infectious control practices, requirement of central venous access, and an immunocompromised state. Here, we review risk factors toward infection, strategies for prevention, and approach to therapy in the pediatric hemodialysis population. [ABSTRACT FROM AUTHOR]

Summary Background The adverse effects of yellow fever (YF) vaccine in dialysis patients are not well known. There is concern about the risks and benefits of the vaccine in immunocompromised patients living in endemic areas, particularly given the risk of resurgence of urban YF with the spread of Aedes aegypti mosquitoes. The purpose of this study was to assess the coverage and safety of YF vaccine in chronic dialysis patients. Methods A cross-sectional study of 130 chronic dialysis patients was performed. Data were collected on clinical characteristics and YF vaccine status. Patients not vaccinated against YF or without a booster vaccination within the last 10 years were referred to receive the vaccine, and adverse effects were monitored. Results Previous vaccination was verified in 44 patients within the last 10 years and in 26 patients at more than 10 years ago, with no mention of adverse effects. Thirty-six patients had never been vaccinated and 24 had an unknown vaccination status. Of the total 86 patients referred for immunization, 45 actually received the YF vaccine, with 24.4% experiencing mild local adverse effects and 4.4% experiencing fever. No serious adverse effects attributable to YF vaccine were observed (anaphylaxis, neurological or viscerotropic disease). Conclusions YF vaccine coverage among hemodialysis patients is low, and the vaccine appeared to be safe in this population with a small sample size. [ABSTRACT FROM AUTHOR]

Infections are major complications in peritoneal dialysis (PD) with a multifactorial etiology that comprises patient, microbial and dialytic factors. This study aimed at investigating the contribution of microbial biofilms on PD catheters to recalcitrant infections and their interplay with PD related-factors. A prospective observational study was performed on 47 patients attending Centro Hospitalar of Porto and Vila Nova de Gaia/Espinho to whom the catheter was removed due to infectious (n = 16) and non-infectious causes (n = 31). Microbial density on the catheter was assessed by culture methods and the isolated microorganisms identified by matrix-assisted laser desorption/ionization time-of-flight intact cell mass spectrometry. The effect of conventional and three biocompatible PD solutions on 16 Coagulase Negative Staphylococci (CNS) and 10 Pseudomonas aeruginosa strains planktonic growth and biofilm formation was evaluated. Cultures were positive in 87.5% of the catheters removed due infectious and 90.3% removed due to non-infectious causes. However, microbial yields were higher on the cuffs of catheters removed due to infection vs. non-infection. Staphylococci (CNS and Staphylococcus aureus) and P. aeruginosa were the predominant species: 32% and 20% in the infection and 43.3% and 22.7% in the non-infection group, respectively. In general, PD solutions had a detrimental effect on planktonic CNS and P. aeruginosa strains growth. All strains formed biofilms in the presence of PD solutions. The solutions had a more detrimental effect on P. aeruginosa than CNS strains. No major differences were observed between conventional and biocompatible solutions, although in icodextrin solution biofilm biomass was lower than in bicarbonate/lactate solution. Overall, we show that microbial biofilm is universal in PD catheters with the subclinical menace of Staphylococci and P. aeruginosa. Cuffs colonization may significantly contribute to infection. PD solutions differentially impact microbial species. This knowledge is important for the development of infection diagnosis, treatment and preventive strategies. [ABSTRACT FROM AUTHOR]

Background: Patients on long-term hemodialysis frequently suffer from complications, such as secondary hyperparathyroidism, bone fractures, and arteriosclerosis. The process of regulating Ca/P metabolism depends on factors, such as FGF23 and Klotho. This study aimed to answer the question of whether the Klotho polymorphism rs9536314 is associated with FGF23 plasma concentration.Methods: In 118 patients undergoing hemodialysis, blood was collected before and after hemodialysis. The following parameters were measured in plasma: FGF23, serum: Ca, P, PTH, HGB, and iron concentrations. TheKLgene polymorphism rs9536314 was identified by PCR-RFLP.Results: TheKLpolymorphism rs9536314 was not associated with Ca, P, PTH, or FGF23. There was a negative correlation between FGF23 and blood HGB levels and positive correlation between FGF23 and ESA dose.Conclusions: The results obtained may indicate that there is no association between theKLpolymorphism and FGF23 concentration in patients undergoing long-term. [ABSTRACT FROM PUBLISHER]

Background. The risk of hydrocephalus in end-stage renal disease (ESRD) patients on dialysis has not been studied in depth. Methods. Using Taiwan National Health Insurance claims data, we identified 29 684 incident ESRD patients from 2000 to 2010, including 10 030 peritoneal dialysis (PD) patients and 19 654 hemodialysis (HD) patients. The control cohort consisted of 118 736 people randomly selected from those without kidney disease, frequency matched with ESRD patients by age, sex and index year. We also established propensity score- matched cohorts with 10 014 PD and 10 014 HD patients. The incidence rates and hazard ratios (HRs) of hydrocephalus were calculated until the end of 2011. Results. Incidence rates of hydrocephalus were greater in HD and PD patients than in controls (8.44 and 11.0 versus 4.11 per 10 000 person-years, respectively), with an adjusted HR of 1.86 [95% confidence interval (CI) 1.43-2.41] for all ESRD patients compared with controls. A higher proportion of hydrocephalus patients underwent surgical bypass to relieve hydrocephalus in ESRD patients than controls, 40.7% (46/113) versus 24.5% (67/273), with an adjusted odds ratio of 2.11 (95% CI 1.33-3.36). Compared with controls, the adjusted HRs of communicating hydrocephalus for HD and PD patients were 1.77 (95% CI 1.22-2.55) and 2.51 (95% CI 1.61-3.89), respectively. The propensity score-matched analysis showed an HR of 0.72 (95% CI 0.42-1.23) for hydrocephalus in HD patients compared with PD patients. Conclusions. Patients with ESRD are at an increased risk of hydrocephalus. The risk difference between HD and PD patients is not significant. [ABSTRACT FROM AUTHOR]

Background. Liver disease is a common comorbid condition in maintenance hemodialysis (MHD) patients and may be associated with poor survival. The relationship between aspartate aminotransferase (AST) and survival has not yet been addressed in these patients. We hypothesized that higher AST level is associated with higher death risk in MHD patients. Methods. A 5-year (January 2007-December 2011) cohort of 109 718MHDpatients was studied in the USA in dialysis clinics where ASTwas measured in at least 50% of all outpatients in the baseline calendar quarter. Survival models were adjusted for demographic variables, and available clinical and laboratory surrogates of malnutrition-inflammation complex, and cubic survival splines were plotted. Results. A linear association existed between baseline serum AST levels and mortality. Increasing AST of >20 IU/L was incrementally and almost linearly associated with higher death risk at all levels of adjustment. In fully adjusted models, AST levels of =40 IU/L were associated with the highest risk of mortality (hazard ratio: 1.46, 95% CI: 1.38-1.54). Low AST levels (<15 IU/L) were associated with increased death risk only in fully adjusted models examining hepatitis C virus-positive patients. Conclusions. Higher AST level of >20 IU/L is incrementally associated with higher mortality in MHD patients whereas AST in the 15-20 IU/L range is associated with the greatest survival. These findings suggest that the assessment of liver function and improving liver disease may confer survival benefit to MHD patients. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to evaluate the safety and effectiveness of a novel catheter-based mechanical thrombectomy device, XCOILTM, as a first line therapy to restore patency of thrombosed dialysis grafts and fistulae.Methods: In 2010, 18 consecutive/sequential patients (11 male, 7 female; median age, 52 years; age range, 32-69 years) with occluded arteriovenous grafts (n=15) or fistulae (n=3) were treated with XCOILTM (NexGen Medical Systems Inc.) without adjunctive thrombolytic drugs. XCOILTM was advanced distal to the thrombus within the outflow vein as well as distal to the arterial inflow platelet thrombin plug, using a 4F angiographic catheter. The percentage of thrombus cleared, primary patency, procedure time, and XCOILTM performance were documented.Results: Thrombosis occurred 1-30 days prior to the procedure. Thrombosed segments of graft/fistula measured 10-50 cm. Pre- and postprocedure angiography demonstrated that in 15 of 18 cases (83%) XCOILTM removed 80%-100% of the venous outflow thrombus. In 11 of 14 cases (79%), the platelet thrombin plug was also removed. Thrombectomy procedure time averaged 8 min, with one to three passes with the XCOILTM required. No evidence of distal embolization or graft/vessel injury was found on angiography following clot removal. In four cases in whom patency was not restored with XCOILTM, subsequent use of other clot removal devices also failed to restore patency. In one case with severe venous stenosis, the device failed to deploy and the thrombus was not captured. No intraprocedural complications related to XCOILTM use occurred.Conclusion: XCOILTM is an effective and safe first-line therapy option for the treatment of thrombosed hemodialysis grafts/fistulae. Rapid removal of intact thrombus and platelet thrombin plug can be achieved without adjunctive thrombolytics. [ABSTRACT FROM AUTHOR]

Background: New highly sensitive (hs) assays have challenged the interpretation of cardiac troponins (cTn). The present study was designed to evaluate simultaneously conventional cTnT and cTnI together with their corresponding highly sensitive determinations in stable hemodialysis (HD) patients. Ability of cTn to stratify HD patient risk was assessed. Methods: A total of 224 stable HD patients was included in this observational study. cTnT and hs-cTnT were measured using Roche cTnT/hs-cTnT assays based on a Cobas e601® analyzer. cTnI and hs-cTnI were measured using Beckman AccuTnI/hs-TnI IUO assays on Access II system. Patients were followed up prospectively during 9 years. Relationship between cTn level and mortality was assessed through Cox survival analysis. Results: The median cTnT and cTnI concentrations were 38.5 ng/L (IQR, 18.8-76) and 10 ng/L (IQR, 10-20), respectively. The median hs-cTnT and hs-cTnI concentrations were 62.5 ng/L (IQR, 38.8-96.3) and 13.9 ng/L (IQR, 8.4-23.6), respectively. The prevalence of values above the 99th percentile was significantly more marked with cTnT (85.3 and 97.8% for conventional and hs cTnT, respectively) than with cTnI (7.6 and 67.4% for conventional and hs cTnI, respectively). During the follow-up, 167 patients died, mainly from cardiac cause (n = 77). The optimized cut-off values, determined by bootstrap method, predicting mortality were 38, 69, 20 and 11 ng/L for cTnT, hs-cTnT, cTnI and hs-cTnI, respectively. After full adjustment, elevated plasma concentrations of all troponin were significant predictors of mortality. Conclusions: A large proportion of patients free of acute coronary syndrome (ACS) has hs-cTn I or T higher than the 99th percentile which could be seen as a limiting factor for ACS screening. However, all generation and type of troponin assays could be reliable indicators of prognosis risk in HD patients. [ABSTRACT FROM AUTHOR]

Catheter-related blood stream infection (CRBSI) is a major complication in hemodialysis patients. We assessed the efficacy of systemic daptomycin (DPT) plus DPT antibiotic lock therapy (DPT-ALT) for catheter salvage in patients with Gram-positive CRBSIs. This is a retrospective study of hemodialysis patients with tunneled and cuffed hemodialysis catheters. All patients were from a single institution in Taipei and received systemic DPT plus DPT-ALT for the treatment of Gram-positive CRBSI. Successful resolution of CRBSI was implemented. Resolution of fever within 48 hours, negative result of repeated blood cultures after resolution of fever, no clinical evidence of CRBSI relapse and no need for catheter removal were measured. Fifteen hemodialysis patients received DPT-ALT for CRBSI, nine with coagulase-negative Staphylococcus (CONS), two with methicillin-resistant Staphylococcus aureus (MRSA), three with methicillin-sensitive Staphylococcus aureus (MSSA) and one with polymicrobial infections. Systemic DPT plus DPT-ALT cured 11 patients (73.3%). Treatment failed in all three MRSA cases (two with MRSA and one with MRSA + Enterococcus faecalis). Retrospective design and small sample size were the limitations of this study. Systemic DPT plus DPT-ALT appears to be a promising treatment for CRBSI from CONS and MSSA, but not for MRSA CRBSI. Systemic DPT plus DPT-ALT should be considered for patients with CRBSIs caused by certain species. [ABSTRACT FROM AUTHOR]

Intradialytic hypotension is the most common complication associated with hemodialysis. We describe a case of severe intradialytic hypotension during routine chronic dialysis, the presenting symptom of hypocalcemia due to a procedural error involving a zero calcium liquid acid dialysate concentrate. Although human factors were the root cause of this event, we discuss physical and procedural controls that may help to minimize the risk of human error. Citrate anticoagulation for renal replacement therapy is increasingly used, particularly in acute kidney injury. Thus, zero calcium liquid acid dialysate is more likely to be stocked by dialysis units that serve both inpatients and outpatients. Providers in such units must maintain the utmost vigilance for human error involving these concentrates, as it is likely that the reported literature does not accurately reflect the frequency of such adverse events occurring during dialysis. Structured and universal reporting of errors to allow systematic analysis of hemodialysis device related hazards would allow identification of engineering controls that could prevent such potentially catastrophic clinical errors. [ABSTRACT FROM AUTHOR]

Vascular access-related infection is an important adverse event in home hemodialysis (HHD). We hypothesize that errors in self-cannulation or manipulation of dialysis vascular access are associated with increased incidence of access-related infection. We conducted a retrospective cohort study of all prevalent HHD patients at the University Health Network. All vascular access-related infections were recorded from 2006 to 2013. Errors in dialysis access were ascertained by nurseadministered vascular access checklist. Ninety-two patients had completed at least one vascular access audit. Median HHD vintage was 2.3 (0.9-5.0) years in patients with appropriate vascular access technique and 5.8 (1.5-9.4) years in patients with erroneous vascular access technique. The overall rate of infection between patients with and without appropriate vascular access technique was similar (0.27 and 0.28 infections per year, P = 0.166). Among patients who were identified with errors in dialysis access manipulation, patients with five or more errors were associated with higher rate of access-related infection (mean of 0.47 vs. 0.16 infection per patient-year, P < 0.001). The use of vascular access audit is a feasible strategy, which can identify errors in vascular access technique. Patients with a longer median HHD vintage are associated with higher risk of inappropriate vascular access technique. Patients with multiple errors in vascular access technique are associated with a higher risk of dialysis access-related infection. Prospective evaluation of the impact of vascular access audit on adverse vascular access events is warranted. [ABSTRACT FROM AUTHOR]

Aim The evidence about prevalence, associated factors of pulmonary hypertension (PH) and its impact on patient's outcomes is limited. Methods We included 211 haemodialysis patients, we estimated the systolic pulmonary artery pressure (SPAP) by 2D Doppler echocardiography defining PH as a SPAP above 35 mmHg, the median follow-up was 39 (19-56) moths, and the primary endpoints were all cause mortality and cardiovascular events. Results We found PH in 91 patients (43.9%). Independent determinants of PH were age, previous cardiovascular disease, the Nt-pro-BNP level hs-TnT, the systolic dysfunction, diastolic dysfunction and left ventricular hypertrophy. Over the follow-up 94 cardiovascular events occurred, variables associated were: PH, age, history cardiovascular disease, dyslipidaemia, elevated concentration of Nt-pro-BNP and hs-TnT, systolic and diastolic dysfunction, in a multivariate model, the PH maintained its independent association. Mortality data: 88 patients died (41.7%); 35 (29.5%) in the no PH group and 53 (58.5%) in the PH group ( P < 0.001). In the Cox survival analysis, we found an association between mortality and age, previous cardiovascular disease, history of peripheral vascular disease, Nt-pro-BNP levels. In a multivariate model the PH remains as independent predictor of mortality. Conclusions Pulmonary hypertension is a common finding in HD patients and a valuable predictor of mortality and cardiovascular events. Prospective studies are needed to assess the effect of intervention on risk factors in improving patient's outcomes. [ABSTRACT FROM AUTHOR]

In previous reports of the Frequent Hemodialysis Network trials, frequent hemodialysis (HD) reduced extracellular fluid (ECF) and left ventricular mass (LVM), with more pronounced effects observed among patients with low urine volume (UVol). We analyzed the effect of frequent HD on interdialytic weight gain (IDWG) and a time-integrated estimate of ECF load (TIFL). We also explored whether volume and sodium loading contributed to the change in LVM over the study period. Treatment effects on volume parameters were analyzed for modification by UVol and the dialysate-to-serum sodium gradient. Predictors of change in LVM were determined using linear regression. Frequent HD reduced IDWG and TIFL in the Daily Trial. Among patients with UVol <100 ml/day, reduction in TIFL was associated with LVM reduction. This suggests that achievement of better volume control could attenuate changes in LVM associated with mortality and cardiovascular morbidity. TIFL may prove more useful than IDWG alone in guiding HD practice. [ABSTRACT FROM AUTHOR]

The article offers information on the intradialytic and interdialytic hypertension. The topics addressed include information on an evaluation of chronobiology of blood pressure (BP) variation on dialysis and details on the dryweight probing in the ultrafiltration group steepened the intradialytic systolic blood pressure (SBP) slopes.

Thrombocytopenia is a potential dialysis-related treatment complication. Developments in bio-compatible dialyser membranes have decreased the occurrence of thrombocytopenia. We investigated whether thrombopoiesis is impaired in haemodialysis patients by measuring the thrombopoietin level and absolute immature platelet number ( AIPN) in the blood of patients undergoing haemodialysis. Samples were collected from the dialysis tubing pre- and post- haemodialysis in a cohort of 45 well-characterized haemodialysis patients. Thrombopoietin levels and AIPN increased following haemodialysis, despite no change in platelet count. Observed increase in release of immature platelets from the bone marrow following haemodialysis indicates possible complement activation secondary to interaction between blood constituents and the dialysis membrane. [ABSTRACT FROM AUTHOR]

Potassium-binding resins are widely used in the treatment of hyperkalemia, mostly in the acute setting. Gastrointestinal adverse events, although reported, are not frequently seen due to its short course of use. This report describes a case involving an end-stage renal disease patient on hemodialysis who developed a colonic mass after being on sodium polystyrene sulfonate chronically for persistent hyperkalemia. Gastrointestinal symptoms developed late during the treatment rather than early as reported previously in the literature. This mass was mistaken for a carcinomatous lesion, which initiated an extensive work-up as well as hospitalization that nearly resulted in a subtotal colectomy. [ABSTRACT FROM AUTHOR]

Background: Sudden cardiac death (SCD) is the most common etiology of death in hemodialysis patients but not much is known about its risk factors. The goal of our study was to determine the association and risk prediction of SCD by serum N-terminal prohormone of brain natriuretic peptide (NTproBNP) troponin I (cTnI) in hemodialysis patients.Methods: We measured NTproBNP and cTnI in 503 hemodialysis patients of a national prospective cohort study. We determined their association with SCD using Cox regression, adjusting for demographics, co-morbidities, and clinical factors and risk prediction using C-statistic and Net Reclassification Improvement (NRI).Results: Patients' mean age was 58 years and 54 % were male. During follow-up (median 3.5 years), there were 75 outpatient SCD events. In unadjusted and fully-adjusted models, NTproBNP had a significant association with the risk of SCD. Analyzed as a continuous variable, the risk of SCD increased 27 % with each 2-fold increase in NTproBNP (HR, 1.27 per doubling; 95 % CI, 1.13-1.43; p < 0.001). In categorical models, the risk of SCD was 3-fold higher in the highest tertile of NTproBNP (>7,350 pg/mL) compared with the lowest tertile (<1,710 pg/mL; HR for the highest tertile, 3.03; 95 % CI, 1.56-5.89; p = 0.001). Higher cTnI showed a trend towards increased risk of SCD in fully adjusted models, but was not statistically significant (HR, 1.17 per doubling; 95 % CI, 0.98-1.40; p = 0.08). Sensitivity analyses using competing risk models showed similar results. Improvement in risk prediction by adding cardiac biomarkers to conventional risk factors was greater with NTproBNP (C-statistic for 3-year risk: 0.810; 95 % CI, 0.757 to 0.864; and continuous NRI: 0.270; 95 % CI, 0.046 to 0.495) than with cTnI.Conclusions: NTproBNP is associated with the risk of SCD in hemodialysis patients. Further research is needed to determine if biomarkers measurement can guide SCD risk prevention strategies in dialysis patients. [ABSTRACT FROM AUTHOR]

Introduction: Haemodialysis is one of the most conventional treatments of chronic renal failure. The risk of clot formation is high during haemodialysis due to regular contact of blood with the surfaces of foreign objects such as catheters, dialyzers' membrane, and other materials used for dialysis. Therefore, to prevent clot formation during haemodialysis, the dialysis system requires anticoagulation; this is usually done by heparin. Aim: The present study aimed to compare two heparinization methods and determine the proper impacts of these methods. Materials and Methods: In this quasi-experimental study, 80 haemodialysis patients covered by the dialysis center of Amir-al-momenin Hospital of Zabol were studied in two 40-member groups of heparin therapy methods of bolus injection and continuous infusion. PT and PTT were measured in blood samples collected from all patients before starting haemodialysis. The first group received 3000 units of heparin once the haemodialysis machine started to work and 2000 units of heparin two hours later as bolus injection. In the second group, 1500 units of heparin was injected at the start of dialysis after then, 5000 units of heparin (one mL) were mixed with 11 mL of distilled water and infused using a heparin injection pump up to half an hour before the end of dialysis. At 30 minutes after starting dialysis and at the end of 4 hours of haemodialysis, PT and PTT were measured and compared between the two groups. Results: According to the results, the mean partial thromboplastin time in the bolus and continuous heparin-receiving group was 41.75±6.29 and 37.90±4.77, respectively, which was statistically significant (p=0.036). But PT was 14.45±1.82 in the bolus heparin group and 13.95±1.39 in the continuous heparin group, which was not significant according to the results of independent t-test (p=0.336). Conclusion: The results indicated a statistically significant difference between the bolus heparin injection and the continuous heparin infusion groups in terms of coagulation tests in haemodialysis patients (p=0.036). Therefore, given the effects of heparin on coagulation, it was more effective in the bolus heparin group than the continuous infusion group. It is recommended to use the bolus method for heparin therapy during haemodialysis. [ABSTRACT FROM AUTHOR]

Background: Whether oral anticoagulant use should be considered in patients undergoing hemodialysis with atrial fibrillation (AF) remains controversial because of the uncertainty regarding risk-benefit assessments. The purpose of this study was to investigate the risk of ischemic stroke in patients undergoing hemodialysis with new-onset AF, in comparison with those without arrhythmia.Methods and Results: This nationwide, population-based, propensity score-matched cohort study used data from Taiwan's National Health Insurance Research Database during 1998 to 2011 for patients on hemodialysis with new-onset nonvalvular AF and matched subjects without arrhythmia. The clinical end points were ischemic stroke (fatal or nonfatal), all-cause death, and other serious adverse cardiovascular events. In comparison with the matched cohort, patients with AF (n=6772) had higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.13-1.43), all-cause death (aHR, 1.59; 95% CI, 1.52-1.67), in-hospital cardiovascular death (aHR, 1.83; 95% CI, 1.71-1.94), myocardial infarction (aHR, 1.33; 95% CI, 1.17-1.51), and hospitalization for heart failure (aHR, 1.90; 95% CI, 1.76-2.05). After considering in-hospital death as a competing risk, AF significantly increased the risk of heart failure (HR, 1.56; 95% CI, 1.45-1.68), but not those of ischemic stroke and myocardial infarction. Additionally, the predictive value of the CHA2DS2-VASc score for ischemic stroke was diminished in the competing-risk model.Conclusions: The risk of stroke was only modestly higher in patients undergoing hemodialysis with new-onset AF than in those without AF, and it became insignificant when accounting for the competing risk of in-hospital death. [ABSTRACT FROM AUTHOR]

Background: Intradialytic hypertension is a condition where there is an increase in blood pressure (BP) from pre- to posthemodialysis; this condition has been recently identified as an independent mortality risk factor in hypertensive hemodialysis patients. The mechanisms and management of intradialytic hypertension have been explored in numerous research studies over the past few years. Summary: Patients with intradialytic hypertension have been found to be more chronically volume overloaded compared to other hemodialysis patients, although no causal role has been established. Patients with intradialytic hypertension have intradialytic vascular resistance surges that likely explain the BP increase during dialysis. Acute intradialytic changes in endothelial cell function have been proposed as etiologies for the increase in vascular resistance, although it is unclear if endothelin- 1 or some other vasoconstrictive peptide is responsible. There is an association between dialysate to serum sodium gradients and BP increase during dialysis in patients with intradialytic hypertension, although it is unclear if this is related to endothelial cell activity or acute osmolar changes. In addition to probing the dry weight of patients with intradialytic hypertension, other management strategies include lowering dialysate sodium and changing antihypertensives to include carvedilol or other poorly dialyzed antihypertensives. Key Messages: Hemodialysis patients with intradialytic hypertension have an increased mortality risk compared to patients with modest decreases in BP during dialysis. Intradialytic hypertension is associated with extracellular volume overload in addition to acute increases in vascular resistance during dialysis. Management strategies should include reevaluation of dry weight and modification of both the dialysate prescription and medication prescription. [ABSTRACT FROM AUTHOR]

Chronic renal impairment causes profound physiologic and metabolic changes. Its impact on surgical outcome after pancreatectomy is not well established. We sought to quantify complication rates of pancreatectomy in patients with chronic renal impairment. Database from the American College of Surgeons National Surgical Quality Improvement Project (2005-2011) was queried to identify patients with chronic renal impairment who underwent pancreatectomy. The study population consisted of 16,708 patients of whom 16,649 patients were not on dialysis and 59 patients were on dialysis. Overall mortality for those on dialysis was 5.1 per cent, whereas it was 2.3 per cent for those not on dialysis (P = 0.114). Patients on dialysis were more likely to have failure to wean ventilation (P < 0.001), reintubation (P = 0.004), myocardial infarction (P = 0.007), and sepsis (P = 0.046). Patients not on dialysis were then divided into three groups: serum creatinine levels <1.2 mg/dL, between 1.2 mg/dL and 2.0 mg/dL, and >2.0 mg/dL. We found the mortality rates for these three groups were 2.0 per cent, 4.6 per cent, and 7.5 per cent, respectively (P < 0.001). In conclusion, need for dialysis is associated with increased postoperative complications. Increased serum creatinine levels were associated with increased mortality rates. These findings should facilitate informative risk/benefit calculation for patients with renal impairment who are considering pancreatectomy. [ABSTRACT FROM AUTHOR]

Peritonitis is the leading complication of peritoneal dialysis, which is primarily caused by bacteria rather than fungi. Peritonitis is responsible for approximately 18% of the infection-related mortality in peritoneal dialysis patients. In this paper, we report the isolation of a rare fungus, Quambalaria cyanescens, from the peritoneal fluid of a man after he switched from continuous ambulatory peritoneal dialysis to nocturnal intermittent peritoneal dialysis. Based on the morphological examination and multigene phylogeny, the clinical isolate was confirmed as Q. cyanescens. This pathogen exhibited low sensitivity to all tested echinocandins and 5-flucytosine. Interestingly, morphological characterization revealed that Q. cyanescens UM 1095 produced different pigments at low temperatures (25°C and 30°C) on various culture media. It is important to monitor the emergence of this rare fungus as a potential human pathogen in the tropics. This study provides insight into Q. cyanescens UM 1095 phenotype profiles using a Biolog phenotypic microarray (PM). Of the 760 nutrient sources tested, Q. cyanescens UM 1095 utilized 42 compounds, and the fungus can adapt to a broad range of osmotic and acidic environments. To our knowledge, this is the first report of the isolation of Q. cyanescens from peritoneal fluid, revealing this rare fungus as a potential human pathogen that may be misidentified using conventional methods. The detailed morphological, molecular and phenotypic characterization of Q. cyanescens UM 1095 provides the basis for future studies on its biology, lifestyle, and potential pathogenicity. [ABSTRACT FROM AUTHOR]

Intradialytic hypotension (IDH) is a major complication during hemodialysis treatment, and therefore it is highly desirable to identify, at an early stage during treatment, whether the patient is prone to IDH. Heart rate variability (HRV), blood pressure variability (BPV) and baroreflex sensitivity (BRS) were analyzed during the first 30 min of treatment to assess information on the autonomic nervous system. Using the sequential floating forward selection method and linear classification, the set of features with the best discriminative power was selected, resulting in an accuracy of 92.1%. Using a classifier based on the HRV features only, thereby avoiding that continuous blood pressure has to be recorded, accuracy decreased to 90.2%. The results suggest that an HRV-based classifier is useful for determining whether a patient is prone to IDH at the beginning of the treatment. [ABSTRACT FROM AUTHOR]

Aim Haemodialysis ( HD) patients have an increased risk of cardiovascular death. In addition to the standard cardiovascular disease ( CVD) risk factors, HD patients have additional risk factors including bone mineral disorders, anaemia and uraemic toxins, including advance glycosylation end product ( AGEs). AGEs increase in HD patients due to reduced renal clearance and increased production. Tissue AGEs measured by skin autofluorescence ( SAF) have been shown to be more reliable and reproducible to asses AGE accumulation in HD patients compared with serum levels. We wished to determine whether increasing SAF due to AGEs was associated with reduced survival in HD patients. Methods We measured SAF in the non-fistula arm in a cross-sectional study of 332 thrice weekly HD outpatients who were then followed prospectively for 30 months. Results Mean patient age was 65.7 ± 15.1 years, 64.2% male, 41.9% diabetic, mean dialysis vintage 65.1 (range 1-413) months, with an average sessional Kt/Vurea of 1.43 ± 0.34. A percentage of 61.1 had a history of hypertension, 32.2% had CVD, 16% had peripheral vascular disease ( PVD) and 37% was current smokers. The mean SAF was 3.27 ± 0.96 IU, and patients with SAF above the mean (>3.27 IU) had a higher risk of death, and higher SAF was independently associated with increased mortality: hazard ratio 12.95 (1.60-104.8), P = 0.016. Conclusion Accumulation of AGEs, measured by SAF, was independently associated with higher risk of death in HD patients. Additional studies are required to determine whether a reduction in tissue AGEs in dialysis patients may reduce mortality in this high-risk population. [ABSTRACT FROM AUTHOR]

In this cross-sectional study, we hypothesized that hemodialysis patients consuming greater processed meat is associated with hypertension risk, which can be partly explained by the high sodium content in processed meat. From September 2013 to May 2014, one hundred and four patients requiring chronic hemodialysis treatment were recruited from hemodialysis centers. Data on systolic blood pressure and diastolic blood pressure before receiving dialysis, and 3-day dietary records of the recruited patients were collected. HD patients with systolic and diastolic blood pressures greater than140 mmHg and higher than 90 mmHg, respectively, were considered hypertension risk. Protein foods were divided into 4 categories: red meat, white meat, soybeans, and processed meat (e.g., sausage and ham). In a model adjusted for energy intake and hypertension history, additional servings of processed meats was positively associated to systolic blood pressure >140 mmHg (odds ratio [95% confidence interval]: 2.1 [1.0–4.3]), and diastolic blood pressure > 90 mmHg (odds ratio: 2.5 [1.2–5.5]). After adjustment for dietary sodium contents or body mass index (BMI), most associations were substantially attenuated and were no longer significant. In systolic blood pressure greater than140 mmHg, one serving per day of red meats (β = -1.22, P < .05) and white meats (β = -0. 75, P = .05) was associated with a reduced risk compared with one serving per day of processed meats. Similarly, compared with one serving per day of processed meat, a reduced risk of diastolic blood pressure higher than 90 mmHg was associated with one serving per day of red meat (β = -1. 59, P < .05), white meat (β = -0. 62, P < .05). Thus, in these hemodialysis patients, intake of processed meat is significantly positively associated with higher blood pressure risk, and both sodium contents in processed meat and BMI significantly contributes to this association. [ABSTRACT FROM AUTHOR]

Background: Anemia is an important risk factor for mortality in hemodialysis (HD) patients. However, higher hemoglobin (Hb) is not necessarily better, as seen in several studies. This study aimed to validate the clinical use of an Hb target of 10–11 g/dL in Korean HD patients. Methods: A total of 1,276 HD patients from the Clinical Research Center (CRC) for End-Stage Renal Disease (ESRD) were investigated in a prospective observational study. Cox proportional hazard analysis was conducted for each category of time-dependent Hb level and erythropoiesis-stimulating agent (ESA) dose, with subgroup analysis stratified by age and diabetes status. Results: Using a reference Hb level of 10–11 g/dL, the hazard ratios (HRs) of death were 5.12 (95% confidence interval [CI], 2.62–10.02, P <0.05) for Hb level <9.0 g/dL, and 2.03 (CI, 1.16–3.69, P <0.05) for Hb level 9.0–10.0 g/dL, after adjustment for multiple clinical variables. However, an Hb level ≥11 g/dL was not associated with decreased mortality risk. In an adjusted model categorized by Hb and ESA dose, the risk of death at an Hb level <10 g/dL and a higher dose of ESA (≥126 U/kg/week) had an HR of 2.25 (CI, 1.03–4.92, P <0.05), as compared to Hb level 10–11 g/dL and a lower dose of ESA. In subgroup analysis, those older than 65 years or who were diabetic had greater risk for mortality only in Hb category <9.0 g/dL. However, there was no significant interaction between age or diabetes status and Hb. Conclusion: Using CRC-ESRD data, we validated the association between Hb and ESA dose and mortality in Korean HD patients. The clinical practice target of an Hb of 10–11 g/dL before the new KDIGO guideline era seems reasonable considering its survival benefit in HD patients. [ABSTRACT FROM AUTHOR]

Introduction: The global prevalence of chronic kidney disease (CKD) is estimated to be 8-16%. Studies have shown that the increased mortality in patients with CKD is due to anemia that leads to cardiovascular disease (CVD), also known as "Cardio renal anemia syndrome". The present study was undertaken to look into the laboratory profiles of end stage renal disease (ESRD) patients. Aim: To study the laboratory profiles of End stage renal disease (ESRD) patients coming for hemodialysis. Materials and Methods: The study was a retrospective, crosssectional study done by collecting data from the medical case records of all patients during a period of one year from January 1st 2014 to December 31st 2014. Records of a total of 140 patients who underwent hemodialysis during this period were taken. The laboratory profiles that was recorded included haemoglobin, serum sodium, potassium, chloride, fasting glucose, calcium and phosphorus. Results: The mean age of the subjects was 53.5±14.5 yrs. All the patients had moderate anaemia. There was a significant difference in the mean systolic and diastolic blood pressure, serum creatinine and serum urea values between males and females. The mean serum calcium levels were low. Conclusion: The present study is the first such study in this rural area and shows evidence of a relatively young population with ESRD having moderate anaemia and hypertension. There is evidence of hypocalcaemia and serum phosphorus is on the higher end of the normal range. These findings are usually associated with a higher risk of mortality. With the explosion of diabetes and hypertension in India, chronic kidney disease should be diagnosed and managed as early as possible if not prevented. [ABSTRACT FROM AUTHOR]

INTRODUCTION: This study aims to determine the rate of catheter related bloodstream infection using intraluminal 70% ethanol lock 20 min prior to initiation of hemodialysis in comparison with heparin lock and also to study adverse events with the use of locks. MATERIAL AND METHODS: Out of 196 patients, eligible 128 patients who under went hemodialysis in Tribhuwan University Teaching Hospital, were randomly allocated to 68 jugular catheterization with ethanol lock or heparin lock and 60 femoral catheterization with ethanol lock or heparin lock. 5 patients with jugular catheter with ethanol lock and 3 patients with heparin lock changed center. The major outcomes were catheter-related blood stream infection (CRBSI) or thrombosis or other adverse effects. RESULTS: According to KDIGO definition of CRBSI, definite CRBSI occurred in 22 (18.33%) patients in Heparin group, probable CRBSI occurred in 31 (25.83%) patients in Heparin whereas definite CRBSI occurred in 1 (1.38%) patient in Ethanol group, and possible CRBSI occurred in 18 (15.00%) patients in Ethanol group. Most common organisms isolated were Staphylococcus aureus and Enterococcus faecalis in heparin group. No adverse events occurred in ethanol group. CONCLUSION: Our study has suggested Ethanol lock therapy is effective in preventing CRBSI as there were fewer CRBSI in ethanol lock in comparision to heparin lock which needs to studied in large population. [ABSTRACT FROM AUTHOR]

Few studies evaluated the effects of pentoxifylline on hard endpoints in patients with predialysis stage 5 chronic kidney disease (CKD). Thus, we tried to explore the effects of pentoxifylline and its interaction with renin-angiotensin-aldosterone system (RAAS) blockade on the development of endstage renal disease (ESRD) and mortality. This nationwide cohort study retrospectively included patients who had a serum creatinine level of >6 mg/dL and received erythropoiesis-stimulating agents (ESAs) between 2000 and 2010. We analyzed 7,366 pentoxifylline users and 7,366 propensity score-matched nonusers. Using Cox proportional hazard models, pentoxifylline reduced the risks of ESRD and the composite renal outcome but not that of mortality. In terms of the risks of developing ESRD, pentoxifylline alone exerted a comparable beneficial effect to combined therapy with an RAAS inhibitor and greater renoprotection than RAAS inhibitor monotherapy. This study suggests pentoxifylline is efficacious in slowing progression to ESRD in patients with predialysis stage 5 CKD. [ABSTRACT FROM AUTHOR]

OBJECT IVE: Chronic kidney disease - mineral and bone disorder (CKD -BMD) is a worldwide challenge in hemodialysis patients (HD). Widespread use and improved methods of HD may have changed the spectrum of locomotor system disorders in this population. Locomotor system disorders have an impact on health-related quality of life (QOL). The objective of this study was to assess the effect of CKD-BMD on the locomotor system (bone, joint, muscle, tendon and bursa) and document the prevalence of locomotor system disorders in HD populations and its impact in QOL. MATER IAL and MET HODS : 550 HD patients were enrolled in this study. Each HD patient received complete locomotor system examination and specific diagnostic investigation. iPTH level classified study population into three groups. Group 1. (149 patients) iPTH level < 100 pg/ml, low- turnover renal osteopathy, Group 2. (126 patients) iPTH from 150-300 pg/mL, Group 3. (275 patients) iPTH > 300 pg/ mL, high turnover bone disease. Patients were offered a self-administered QOL questionnaire, which assessed various QOL variables. RESU LTS : 75% of hemodialysis patients suffered from one or more locomotor system disorders and the commonest was bone pain 60%, followed by muscle cramps 36%, proximal muscle weakness 30%, osteoarthritis 25%, osteoporosis 16%, rotator cuff syndrome15%, gout pre-HD 12.5%, carpal tunnel syndrome 12%, bone fracture 7%, fibromyalgia 7%, tenosynovitis 6%, periarticular calcification 5%, Dupuytren's contracture 2%, septic arthritis 0.9% and osteomyelitis 0.9%. The three studied groups were represented by 27%, 23% and 50% respectively. The prevalence of osteoarthritis, muscle cramps, bone pain, spontaneous bone fracture and osteoporosis were higher in the third group. 30% of our HD patients completed the QOL questionnaire without assistance and their mean functional status, psychological status, pain scale, fatigue scale, global assessment and joint count were 3.24±2.24, 3.13 ±1.67, 4.07 ±1.7, 4.95 ±1. 8, 3.97 ±1.55 and 9.65±9.95 respectively. QOL variables pronouncedly worsen in HD patients, however the second group patients have a better quality of life than other groups (P<0.001). CONCLUS ION: Locomotor system involvement is still very common in our HD patients, especially in high turnover bone disease group and can compromise the QOL. [ABSTRACT FROM AUTHOR]

Destructive spondyloarthropathy (DSA) has been reported in patients undergoing long-term hemodialysis. Cervical spinal lesions, including those of the upper cervical spine, are reported to be some of the most common. To our knowledge, we report for the first time, a case of atlanto-occipital subluxation requiring surgical treatment due to severe myelopathy and nuchal pain in a patient undergoing long-term hemodialysis. The patient was a 66-year-old woman who had undergone hemodialysis for 40 years. She visited our hospital due to an acute progression of gait disturbance and severe nuchal pain. Computed tomography showed posterior subluxation of the atlanto-occipital joints. DSA was also observed in the lower cervical spine. Magnetic resonance imaging showed spinal canal stenosis at both the upper and lower cervical levels. We performed Oc-C7 fixation, C1 laminectomy, and C3-C7 laminoplasty. We first recognized that the atlanto-occipital subluxation was caused by the extremely long-term, in this case, 40 years, hemodialysis. [ABSTRACT FROM AUTHOR]

Background: Unfractionated heparin is the most common anticoagulant used in haemodialysis (HD), although it has many potential adverse effects. Citrate dialysate (CD) has an anticoagulant effect which may allow reduction in cumulative heparin dose (CHD) compared to standard acetate dialysate (AD). Methods: This double-blinded, randomised, cross-over trial of chronic haemodialysis patients determines if CD allows reduction in CHD during HD compared with AD. After enrolment, intradialytic heparin is minimised during a two-week run-in period using a standardised protocol based on a visual clotting score. Patients still requiring intradialytic heparin after the run-in period are randomised to two weeks of HD with AD followed by two weeks of CD (Sequence 1) or two weeks of HD with CD followed by two weeks of AD (Sequence 2). The primary outcome is the change in CHD with CD compared with AD. Secondary outcomes include metabolic and haemodynamic parameters, and dialysis adequacy. Discussion: This randomised controlled trial will determine the impact of CD compared with AD on CHD during HD. Trial registration: ClinicalTrials.gov NCT01466959 [ABSTRACT FROM AUTHOR]

Background: Higher left ventricular mass (LV) strongly predicts cardiovascular mortality in hemodialysis patients. Although several parameters of preload and afterload have been associated with higher LV mass, whether these parameters independently predict LV mass, remains unclear. Methods: This study examined a cohort of 391 adults with incident hemodialysis enrolled in the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease (PACE) study. The main exposures were systolic and diastolic blood pressure (BP), pulse pressure, arterial stiffness by pulse wave velocity (PWV), volume status estimated by pulmonary pressures using echocardiogram and intradialytic weight gain. The primary outcome was baseline left ventricular mass index (LVMI). Results: Each systolic, diastolic blood, and pulse pressure measurement was significantly associated with LVMI by linear regression regardless of dialysis unit BP or non-dialysis day BP measurements. Adjusting for cardiovascular confounders, every 10 mmHg increase in systolic or diastolic BP was significantly associated with higher LVMI (SBP β = 7.26, 95 % CI: 4.30, 10.23; DBP β = 10.05, 95 % CI: 5.06, 15.04), and increased pulse pressure was also associated with higher LVMI (β = 0.71, 95 % CI: 0.29, 1.13). Intradialytic weight gain was also associated with higher LVMI but attenuated effects after adjustment (β = 3.25, 95 % CI: 0.67, 5.83). PWV and pulmonary pressures were not associated with LVMI after multivariable adjustment (β = 0.19, 95 % CI: -1.14, 1.79; and β = 0.10, 95 % CI: -0.51, 0.70, respectively). Simultaneously adjusting for all main exposures demonstrated that higher BP was independently associated with higher LVMI (SBP β = 5.64, 95 % CI: 2.78, 8.49; DBP β = 7.29, 95 % CI: 2.26, 12.31, for every 10 mmHg increase in BP). Conclusions: Among a younger and incident hemodialysis population, higher systolic, diastolic, or pulse pressure, regardless of timing with dialysis, is most associated with higher LV mass. Future studies should consider the use of various BP measures in examining the impact of BP on LVM and cardiovascular disease. Findings from such studies could suggest that high BP should be more aggressively treated to promote LVH regression in incident hemodialysis patients. [ABSTRACT FROM AUTHOR]

Translumbar tunneled dialysis catheter ( TLDC) is a temporary dialysis access for patients exhausted traditional access for dialysis. While few small studies reported successes with TLDC, additional studies are warranted to understand the short- and long-term patency and safety of TLDC. We conducted a retrospective analysis of adult patients who received TLDC for hemodialysis access from June 2006 to June 2013. Patient demographics, comorbid conditions, dialysis details, catheter insertion procedures and associated complications, catheter patency, and patient survival data were collected. Catheter patency was studied using Kaplan-Meier curve; catheter functionality was assessed with catheter intervals and catheter-related complications were used to estimate catheter safety. There were 84 TLDCs inserted in 28 patients with 28 primary insertions and 56 exchanges. All TLDC insertions were technically successful with good blood flow during dialysis (>300 ml/minute) and no immediate complications (major bleeding or clotting) were noted. The median number of days in place for initial catheter, secondary catheter, and total catheter were 65, 84, and 244 respectively. The catheter patency rate at 3, 6, and 12 months were 43%, 25%, and 7% respectively. The main complications were poor blood flow (40%) and catheter-related infection (36%), which led to 30.8% and 35.9% catheter removal, respectively. After translumbar catheter, 42.8% of the patients were successfully converted to another vascular access or peritoneal dialysis. This study data suggest that TLDC might serve as a safe, alternate access for dialysis patients in short-term who have exhausted conventional vascular access. [ABSTRACT FROM AUTHOR]

The usually applied conversion technique from temporary to tunneled central venous catheters ( CVCs) using the same venous insertion site requires a peel-away sheath. We propose a conversion technique without peel-away sheath: a guide wire is advanced through the existing temporary CVC; then, a subcutaneous tunnel is created from the exit to the venotomy site. After removing the temporary CVC, the tunneled one is advanced along the guide wire. The study group included all patients requiring a catheter conversion from January 2012 to June 2014; the control group included incident patients who had received de novo placement of tunneled CVCs from January 2010 to December 2011. The main outcome measures were technical success and immediate complications. Seventy-two tunneled catheters (40 with our conversion technique and 32 with the traditional one) were placed in 72 patients. The technical success was 95% in the study group and 75% in the controls ( p = 0.019). The immediate complications were one bleeding in the study group (2.5%) and one air embolism, one pneumothorax, and four bleedings (18.7%) in the controls ( p = 0.039). Conversion from temporary to tunneled CVC using a guide wire and without a peel-away sheath is an effective and safe procedure. [ABSTRACT FROM AUTHOR]

Background: The optimal prevention measures against hemodialysis (HD)-associated complications, including all-cause thrombotic events and death, are unclear. Methods: This prospective study was designed to assess the effect of aspirin on prevention of HD-associated complications. Patients were divided into four groups according to platelet factor-4/heparin-complex (PF4/H) antibody detection and aspirin prescription: Group 1, antibody(-)/aspirin(+); Group 2, antibody(-)/aspirin(-); Group 3, antibody(+)/aspirin(+); and Group 4, antibody(+)/aspirin(-). Adverse events were compared among all four groups. Cox hazard regression was performed to analyze the effects of anti-PF4/H antibody and aspirin on thrombosis and death. Results: This study included 648 patients undergoing HD; 142 were positive for anti-PF4/H antibodies, and 229 had received aspirin before enrollment. During the 4-year follow-up period, 138 patients developed thrombosis, and 63 of these events were anti-PF4/H antibody-associated. A total of 112 patients died; 75 died of coronary heart disease (CHD). Group 4 had a significantly higher incidence of total and anti-PF4/H antibody-associated thrombosis events as well as total and CHD-associated death than did the other three groups. Aspirin had a preventive effect against all adverse events in anti-PF4/H antibody-positive patients, but not in antibody-negative patients. Group 1 patients with baseline D-dimer levels of <0.6μg/mL developed more hemorrhagic events than did patients in the other groups. Conclusions: Aspirin prevention of thrombosis and death in patients undergoing HD might require consideration of the anti-PF4/H antibody status. In antibody-positive individuals, taking aspirin could improve the prognosis and therefore might be recommended. In antibody-negative individuals, prevention was minimal and the bleeding risk was obviously increased; thus, aspirin should be avoided or at least require careful evaluation prior to aspirin treatment. [ABSTRACT FROM AUTHOR]

Background: Vascular access-related infections and septicemia are the main causes of infections among hemodialysis patients, the majority of them caused by Staphylococcus species. Acetylsalicylic acid (ASA) has recently been reported with a probable antistaphylococcal activity. This study aimed to evaluate the effect of ASA on the risk of dialysis-related infection and septicemia among incident chronic hemodialysis patients. Methods: In a nested case-control study, we identified 449 cases of vascular access-related infections and septicemia, and 4156 controls between 2001 and 2007 from our incident chronic hemodialysis patients' cohort. Cases were defined as patients hospitalized with a main diagnosis of vascular access-related infection or septicemia on the discharge sheet (ICD-9 codes). Up to ten controls per case were selected by incidence density sampling and matched to cases on age, sex and follow-up time. ASA exposure was measured at the admission and categorized as: no use, low dose (80-324 mg/d), high dose (=325 mg/d). Odds ratios (OR) for infections were estimated using multivariable conditional logistic regression analysis, adjusting for potential confounders. Results: Compared to no use, neither dose of ASA was associated with a decreased risk of infection: low dose (OR 1.03, 95 % CI 0.82-1.28) and high dose (OR 1.30, 95 % CI 0.96-1.75). However, diabetes (OR = 1.32, 95 % CI = 1.07-1.62) and anticoagulant use (OR = 1.62, 95 % CI = 1.30-2.02) were associated with a higher risk. Conclusion: Among hemodialysis patients, ASA use was not associated with a reduced risk of hospitalizations for dialysis-related infections or septicemia. However, ASA may remain beneficial for its cardiovascular indications. [ABSTRACT FROM AUTHOR]

Background: Greater interdialytic weight gain (IDWG) is associated with risk of all-cause mortality and hospitalization. Dialysis patients are also at greater risk of cardiovascular (CV) events than patients without kidney disease. This retrospective study examined the potential association between IDWG and specific types of CV events. Methods: Data were obtained from United States Renal Data System claims and the electronic health records of Medicare patients who initiated hemodialysis between 01 January 2007 and 31 December 2008 at a large dialysis organization. Absolute IDWG was defined as predialysis weight minus postdialysis weight from the prior treatment, and relative IDWG was calculated as percentage of postdialysis weight with mean values for each, calculated over dialysis days 91 to 180. Patient outcomes were considered beginning on day 181, continuing until death, discontinuation of care, censoring, or study end (31 December 2009). Outcomes included all-cause mortality, CV mortality, hospitalization for nonfatal heart failure/volume overload, hospitalization for nonfatal myocardial infarction, MACE (a composite measure of nonfatal myocardial infarction, nonfatal ischemic stroke, or CV death), and MACE+ (events comprising MACE as well as arrhythmia, nonfatal hemorrhagic stroke, or hospitalization for heart failure). Associations between IDWG and outcomes over the exposure period were estimated using proportional hazards regression and adjusted for baseline characteristics. Results: 39,256 patients qualified for analysis. In general, associations of relative IDWG with outcomes were more potent, consistent, and monotonic than those for absolute IDWG. Relative IDWG > 3.5 % body weight was independently associated with all outcomes studied: point estimates ranged from 1.18 (myocardial infarction) to 1.26 (CV mortality) and were consistent among patients with and without diabetes, and with and without baseline heart failure. Absolute IDWG > 3 kg was associated with outcomes other than myocardial infarction: point estimates ranged from 1.11 (MACE) to 1.20 (heart failure). Conclusions: Greater IDWG is associated with an increased risk of CV morbid events. Strategies that mitigate IDWG may improve CV health and survival among hemodialysis patients. [ABSTRACT FROM AUTHOR]

Background: Osteoporotic hip fractures cause high mortality and morbidity in elderly adults. Compared to the general population, subjects with end-stage renal disease and hemodialysis often develop mineral bone disorders and have a higher risk for hip fractures. Methods: We conducted a matched cohort study design and used competing risk analysis to estimate the cumulative incidence of the complication rate. Subjects aged greater than 60 years with hip fracture were selected from Taiwan's National Health Insurance Research Database covering a period from 1997 to 2007, and these subjects were followed up until 2009. We used the Kaplan-Meier method to estimate the overall survival and used the log-rank test and multiple Cox proportional hazards model to explore the risk factors for survival. The cumulative incidence of the first complication was estimated using competing risk analysis. Results: Among hemodialysis subjects, the three-month, one-year, two-year and five-year mortality rates were 17.3 %, 37.2 %, 51.5 %, and 80.5 %, respectively; the one-year and five-year cumulative incidences of the first surgical complication were 14.2 % and 20.6 %, respectively; and the three-month cumulative incidence of the first medical complication was 24.1 %. Hemodialysis subjects presented a 2.32 times (95 % CI: 2.16-2.49) higher hazard ratio of overall death, 1.15 times (95 % CI: 1.01-1.30) higher sub-hazard ratio (sub-HR) of surgical complications, and 1.35 times (95 % CI: 1.21-1.52) higher sub-HR of the first medical complication than non-hemodialysis controls. Conclusions: The overall mortality and complication rates of hemodialysis subjects after surgery for hip fracture were significantly higher than those of non-hemodialysis subjects. Further prospective studies which include important risk factors are necessary to more precisely quantify the adjusted effect of hemodialysis. [ABSTRACT FROM AUTHOR]

Background/Aims: The incidence of adverse events (AEs) in adults who receive continuous renal replacement therapy (CRRT) is unknown. We report the incidence of mechanical, metabolic, and hemodynamic CRRT AEs. Methods: This is a retrospective study of all consecutive adult patients (≥18 years) who underwent CRRT from January 1, 2007 to December 31, 2009. Results: Out of 595 patients who underwent CRRT, 366 (62%) were male and 500 (84%) were Caucasian. Regional citrate anticoagulation was used in 98.6% of all patients. The most common clinically significant electrolyte derangements were ionized hypocalcemia (22%), ionized hypercalcemia (23%), and hyperphosphatemia (44%). Almost all (97%) patients had at least one additional AE including new onset hypotension (within the first hour after CRRT initiation) (43%), hypothermia (44%), new onset arrhythmias (29%), new onset anemia (31%) and thrombocytopenia (40%). Conclusions: ICU patients who require CRRT have a high incidence of AEs. Although the extent to which these complications are attributable to CRRT is not known, clinicians need to be cautious and aware of their high prevalence in this patient population. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Renal replacement therapy is needed for end-stage chronic renal failure patients to sustain their lives. Renal replacement therapy could be either hemodialysis or peritoneal dialysis. Peritoneal dialysis provides several advantages to the patient compared to hemodialysis. It requires fewer hospital visits, has greater patient autonomy and could be adjusted to daily personal activities. However, complications such as peritonitis, line blockage, leakage and hernia, may occur. Objective: To evaluate the trends of Peritoneal Dialysis, its outcome and associated complications. Design: A Retrospective, Descriptive Study. Setting: Peritoneal Dialysis Centers, Ministry of Health, Bahrain. Method: One hundred eight patients who underwent peritoneal dialysis line insertion from January 2007 to January 2015 were included in this study. Result: One hundred eight patients had peritoneal dialysis line insertion from January 2007 to January 2015. Forty-eight (44.44%) patients are currently on regular peritoneal dialysis. Sixty (55.55%) stopped peritoneal dialysis due to several reasons: 23 (38.3%) blockage, 11 (18.3%) death, 5 (8.3%) inadequate dialysis, 4 (6.6%) transplant, 4 (6.6%) social and 8 (13.3%) unknown. Complications occurred in 52 (48.1%) patients: peritonitis in 29 (26.8%), and blockage in 23 (21.3%) patients. No other complications were reported. Conclusion: Peritoneal Dialysis remains an effective method of renal replacement therapy and it offers several advantages in comparison to hemodialysis. Our results are consistent with most reported regional and international findings. However, we look forward to improve our practice, particularly reducing the infection and blockage rates. [ABSTRACT FROM AUTHOR]