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"Beat Those Bugs!" was the call to action for the Providence Health Care Renal and Infection Prevention and Control programs to provide closer-to-home care in community dialysis units, for hemodialysis patients positive for the antibiotic-resistant organisms, Methicillin- Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus. The initiative assessed barriers and facilitators to: implementing Contact Precautions; developing practice standards for nurses and renal technicians to enact Contact Precautions care; providing staff and patient education essential to implementing these standards; and, securing environmental and equipment supports required for Contact Precautions care. Through the "Beat Those Bugs!" initiative, all six Providence Health Care Community Dialysis Units have the capacity to provide Standard/ Routine as well as Contact Precautions care enabling patients to receive closerto- home care in their home communities regardless of their antibiotic-resistant microorganism status. Program evaluation (based on annual screening) demonstrates that the "Beat Those Bugs!" program is an effective model for safe, evidence-based and ethical care in the hemodialysis setting. [ABSTRACT FROM AUTHOR]

Secondary hyperparathyroidism is common among dialysis patients and leads to numerous complications including cardiovascular disease and renal osteodystrophy. Cinacalcet, an oral daily calcimimetic agent that sensitizes the calcium receptor to serum calcium, is approved for treatment of secondary hyperparathyroidism in dialysis patients. We identified 101 patients who received their first cinacalcet prescription between November 2004 and April 2005. All patients were participating in a Missouri state-funded pharmacy program providing free or low cost medications. We tracked the cinacalcet refill rate and refills for another control medication prescribed to each patient. The average cinacalcet refill rate over the first 12 months was 56% vs. 64% for the control medication (P=0.02). Good adherence, defined as >80% medication possession ratio over the 12 months, was 29% for cinacalcet and 33% for the control medication (P=0.68). Additionally, the refill rate for cinacalcet fell significantly over five quarterly periods from 53% in the first quarter to 37% in the 5th quarter. We conclude that dialysis patients' adherence to medications, including cinacalcet, is poor even when medications are provided at a nominal cost. Poor cinacalcet adherence would be expected to impair long-term control of SHPT. In a reimbursement system where injectable, but not oral medications, are bundled with dialysis payments there may be pressure to move patients to oral medications. The poor compliance found in this study highlights the potential adverse effects of movement toward self-administered oral therapy. [ABSTRACT FROM AUTHOR]

Acquired perforating dermatoses (APD) is an uncommon skin disorder seen in patients with diabetes mellitus, chronic kidney disease, or both together. We present the clinicopathological features of APD in patients with diabetic kidney disease and discuss the recent advances in management. We retrospectively analyzed the data of 8 patients with APD presenting to our center. All patients were known cases of Type 2 diabetes and chronic kidney disease requiring maintenance dialysis. Acquired perforating dermatoses was diagnosed based on clinical presentation of itchy, keratotic papulonodular lesions, and characteristic histopathological features of transepithelial elimination on skin biopsy. The patients were subdivided into 4 types of APD based on the biopsy features. All our patients had Type 2 diabetes over 5 years duration and were on maintenance dialysis for more than 6 months before presentation. Acquired perforating dermatoses symptoms appeared 2 to 6 months before presentation. The majority of patients (6/8) had a subtype of reactive perforating collagenosis. All the patients showed significant resolution with topical glucocorticoid therapy. Acquired perforating dermatoses is a skin complication seen in Type 2 diabetes, chronic kidney disease, or when both are present together. Early identification and therapy prevents the associated morbidity. [ABSTRACT FROM AUTHOR]

Intradialytic hypertension is not a rare complication of dialysis, with a prevalence of 5-15% among hemodialysis patients, and it seems to be associated with adverse outcomes. This complex phenomenon is not well understood, and many uncertainties exist regarding its pathophysiologic mechanisms and appropriate treatment strategies. Mechanisms that might be involved in the pathogenesis of intradialytic hypertension include extracellular volume overload, increased cardiac output, changes in electrolyte levels (particularly sodium), activation of the renin-angiotensin-aldosterone system, overactivity of the sympathetic nervous system, and endothelial cell dysfunction. Most current treatment strategies are based only on expert opinion and not on the results of randomized clinical trials, as very little data on the therapy of intradialytic hypertension are available. The most important treatment is adequate sodium and water removal, but reducing sympathetic hyperactivity and reducing endothelin-1 levels should also be considered. Well-designed, randomized clinical trials are urgently needed to better understand the pathophysiologic mechanisms of this complex phenomenon and to improve its diagnosis, prognosis and treatment. [ABSTRACT FROM AUTHOR]

More than 1 in 1,000 patients in the U.S. has end-stage renal disease, and most patients who require renal-replacement therapy undergo hemodialysis. By the year 2020, more than 750,000 patients are expected to have end-stage renal disease, and over 500,000 will require hemodialysis. The greatest limitation of hemodialysis is the finite durability of hemodialysis accesses, which on average remain patent for <3 years but are the lifeline for hemodialysis patients. Catheter-based interventions are successful in restoring flow in more than 80% of hemodialysis accesses that undergo thrombosis and have replaced surgical revision as the treatment of choice for failing or thrombosed accesses. Catheter-based interventions have improved the quality of life for hemodialysis patients by reducing the need for temporary hemodialysis catheters and have prolonged total survival time by preserving existing access sites and by saving venous segments for future access creation. This review discusses the pathophysiology of dialysis access failure, presents the success rates of catheter-based treatments, and illustrates the interventional approaches for treating failing and thrombosed fistulas and grafts. [Copyright &y& Elsevier]

Background: Left ventricular (LV) hypertrophy is common among patients on hemodialysis. While a relationship between blood pressure (BP) and LV hypertrophy has been established, it is unclear which BP measurement method is the strongest correlate of LV hypertrophy. We sought to determine agreement between various blood pressure measurement methods, as well as identify which method was the strongest correlate of LV hypertrophy among patients on hemodialysis. Methods: This was a post-hoc analysis of data from a randomized controlled trial. We evaluated the agreement between seven BP measurement methods: standardized measurement at baseline; single pre- and post-dialysis, as well as mean intra-dialytic measurement at baseline; and cumulative pre-, intra- and post-dialysis readings (an average of 12 monthly readings based on a single day per month). Agreement was assessed using Lin's concordance correlation coefficient (CCC) and the Bland Altman method. Association between BP measurement method and LV hypertrophy on baseline cardiac MRI was determined using receiver operating characteristic curves and area under the curve (AUC). Results: Agreement between BP measurement methods in the 39 patients on hemodialysis varied considerably, from a CCC of 0.35 to 0.94, with overlapping 95% confidence intervals. Pre-dialysis measurements were the weakest predictors of LV hypertrophy while standardized, post- and inter-dialytic measurements had similar and strong (AUC 0.79 to 0.80) predictive power for LV hypertrophy. Conclusions: A single standardized BP has strong predictive power for LV hypertrophy and performs just as well as more resource intensive cumulative measurements, whereas pre-dialysis blood pressure measurements have the weakest predictive power for LV hypertrophy. Current guidelines, which recommend using pre-dialysis measurements, should be revisited to confirm these results. [ABSTRACT FROM AUTHOR]

The author discusses a study on clinical characteristics and in-hospital mortality of patients experiencing septic shock with and without chronic dialysis conducted by Manish Sood and colleagues. He states that the study inferred higher mortality of patients with chronic dialysis in comparison to those without dialysis, and mentions that dialysis patients reported higher Acute Physiology and Health Evaluation (APACHE) II scores. He emphasizes on the need of detecting infection in dialysis.

Background. Peripheral arterial disease (PAD) is a major complication of haemodialysis (HD), especially in patients with diabetes mellitus. Although previous reports have indicated that low-density lipoprotein apheresis (LDL-A) improves arteriosclerosis in PAD patients, the mechanism by which LDL-A affects PAD is still unclear. In this study, we tested the hypothesis that LDL-A attenuates reactive oxygen species (ROS) production in HD patients with PAD. [ABSTRACT FROM PUBLISHER]

Homocysteine is considered as independent predictor of cardiovascular risk. Patients treated with haemodialysis (HD) exhibit elevated homocysteine levels, even four times higher than the general population does. This study focuses on the determination of the vascular risk in patients treated with conventional HD and haemodiafiltration on-line (HDF). It was also considered important to determine whether there was a relationship between homocysteine and the variables given to the patient such as dialysis dose, obesity and treatment with folic acid, vitamin B6 and vitamin B12. A one-year cross-sectional observational study was conducted on patients initially treated with renal replacement therapy such as HDF on-line and conventional HD. Data collected included patient's age, sex, aetiology, duration of dialysis treatment and association with dialysis session, including data on body mass index, waist circumference, treatment with vitamin B6, B12 and folic acid. The results obtained conclusively indicate that patients treated with renal replacement therapy such as HDF on-line exhibit lower homocysteine levels than those treated with conventional HD. Therefore we can conclude that: homocysteine markers indicate that patients treated with HDF on-line are exposed to lower average vascular risk. [ABSTRACT FROM AUTHOR]

Native arteriovenous fistulae (AVF) remain the vascular access of choice for hemodialysis (HD). Despite being associated with superior long-term outcomes (cf. catheter use), little is known about the systemic hemodynamic consequences of AVFs. Repetitive myocardial injury (myocardial stunning) is an under-recognized common consequence of HD. The aim of this study was to examine the impact of AVF flow (Qa) on dialysis-induced cardiac injury. We studied 50 chronic HD patients. All patients underwent echocardiography (and subsequent quantitative offline analysis) at baseline, during and post dialysis, to assess left ventricular function and the development of regional wall motion abnormalities. Qa was measured using ionic dialysance. Patients were divided into Qa tertiles (<500, mean 291±101 mL/min, 500–1000, mean 739±130 mL/min and >1000, mean 1265±221 mL/min). There were no significant differences between the groups in terms of age, sex, diabetes, or resting ejection fraction. Patients with Qa>1000 mL/min had a lower prevalence of left ventricular hypertrophy (55% vs. 76%, P=0.01). Dialysis-induced myocardial stunning (seen in 65% of the patients studied) was significantly and sequentially reduced in those patients with higher Qas. This was seen in a lower number of segments and ventricular regions developing regional wall motion abnormalities, as well as a significantly reduced mean and cumulative percentage reduction in fractional shortening of those ventricular segments affected (−187±37%, −161±26%, and −101±25%, respectively, P=0.04). Relatively higher AVF flows appear to be associated with a lower level of observed HD-induced cardiac injury. [ABSTRACT FROM AUTHOR]

Blood damage is an unavoidable side effect of extracorporeal circulation. The effects of blood damage on patients’ hematocrit and erythropoietin requirement as well as other potential side effects have not been studied for uneventful treatments. Comparing long nocturnal dialysis with regular 4-hour, three times per week dialysis allows for the conclusion that the influence of blood damage caused by extracorporeal circulation is small compared with biochemical effects. Acute hemolysis is one of the few remaining mechanical problems of dialysis. Acute hemolysis is caused by obstructions within the extracorporeal circuit caused by manufacturing errors, kinking of blood tubing or user errors, or by a combination of excessive flow and improper cannula or catheter dimensions. The risk of acute hemolysis can be further reduced by industrial quality control, better design of dialysis equipment, and hemodialysis machine control. Adverse effects caused by chronic mechanical hemolysis need to be studied. [ABSTRACT FROM AUTHOR]

Calciphylaxis is a life-threatening complication of hemodialysis involving calcium deposition in media of hypodermic arteries and skin necrosis. With current unsatisfactory treatment, the calcium chelator and antioxidant sodium th iosulphate emerges as a possible new therapy. We report the case of a dialysis patient with parathyroidectomy for secondary hyperparathyroidism complicated by severe hypoparathyroidism and hypocalcemia, requiring sustained Ca and vitamin D treatment. With in a year, typical calciphylaxis developed on the breasts, associated with extensive calcification of medium-sized arteries on mammography. Cessation of calcium load and aggressive wound care led to no improvement. Sodium th iosulphate 25g th rice weekly for 2 month s resulted in dramatic healing. Besides unusual location on the breasts, onset of lesions in the setting of an adynamic bone is noteworthy and probably favored by calcium load. This is, to our knowledge, the first use of sodium th iosulphate in calciphylaxis associated to low bone turnover, a valuable therapeutic asset since unlike in hyperparathyroidism, other treatment options lack. Also th is is the first use of sodium th iosulphate for treatment of calciphylaxis in Romania, the drug being prepared in our University. [ABSTRACT FROM AUTHOR]

Background. Induction of heat shock proteins (HSP), i.e. of the major family member HSP70, is an important cytoprotective-resistance mechanism for monocytes/ macrophages (Mphi). Patients on haemodialysis present with a high infectious morbidity and enhanced carcinoma incidence. Renal insufficiency-related alteration of microbicidal and tumoricidal functions of Mphi, major effectors of the immune system, might promote these diseases. [ABSTRACT FROM PUBLISHER]

Pulmonary artery hypertension is common in patients undergoing hemodialysis. Its main causes are hypervolemia and high cardiac output that may occur in end-stage renal disease. This study has been made in order to assess the influence of haemodialysis on pulmonary haemodinamics, as well as the correlation between these effects, myocardial function before dialysis and some associated conditions. The 40 studied patients had chronic renal insufficiency and they were on maintenance haemodialysis. High blood pressure was noted in all cases (100%). In varied percentage, other conditions associated to end-stage renal disease were coronary artery disease, mitral and/or aortic valvulopathies, exudative pericarditis, chronic pulmonary diseases and clinically manifest heart failure. 10% of patients were smokers. Subjects were assessed by transthoracic echocardiography before and after haemodialysis session, in order to estimate pulmonary artery systolic pressure, as well as systolic and diastolic ventricles function. Authors found an important reduction in frequency of pulmonary hypertension (32,5% postdialytic vs 80% predialytic; p < 0,01) and in its severity, after dialysis. Moreover, haemodialysis led to a normalized pulmonary artery pressure in 40% of cases, statistically significant (p < 0,001). The improvement of pulmonary hypertension was noted especially in patients that, before dialysis, had left ventricle both systolic and diastolic impairment (29,5% postdialytic vs 82,4% predialytic; p < 0,005) and in those with normal right ventricle diastolic function (18,2% postdialytic vs 72,7% predialytic; p < 0,05). Smoking, as well as respiratory and heart diseases, were associated with a high rate of predialytic pulmonary hypertension, up to 100%. Prevalence droped after dialysis, no mather of coexistent diseases; variation had statistic significance in patients with coronary artery disease (34,7% postdialytic vs 82,5% predialytic; p < 0,005), mitral and/or aortic valvulopathies (32,4% postdialytic vs 83,8% predialytic; p < 0,001) and clinically manifest heart failure (40,6% postdialytic vs 87,5% predialytic; p < 0,001). Conclusions: pulmonary hypertension is common in dialysed patients and its main pathogenetic mechanism is hypervolemia; haemodialysis is an efficient way to treat pulmonary hypertension in patients with chronic terminal renal insufficiency, no mather of predialytic myocardial function or associated cardio-respiratory diseases. [ABSTRACT FROM AUTHOR]

Abstract: Background: Patients in haemodialysis units are at an increased risk of blood borne virus infections. Birmingham city (West Midlands, UK) has a large number of its population from an ethnic origin other than white (30%). Recently due to the increase in number of haemodialysis centres abroad and particularly in the Indian Subcontinent, a large number of haemodialysis patients from these ethnic minorities are encouraged to take holidays in their countries of origin. Objectives: To present the data on a series of cases of holiday haemodialysis acquired hepatitis C virus (HCV) infections from two large dialysis units in Birmingham. Study design: In this retrospective study we have reviewed the case records of all patients in two large dialysis units who had holiday dialysis abroad and developed HCV infection after returning to the UK. Results: A total of 16 patients from two large dialysis units in Birmingham who developed HCV infection after haemodialysing abroad mainly in the Indian Subcontinent are being described. This constituted 44% of the total HCV positive patients in the two haemodialysis units (16/36). The cases occurred over a period of 9 years between 2000 and 2008. The last twelve of these fifteen cases had been diagnosed in the past 17 months. There were 10 male patients with a mean age 62.8 years (range 26–84 years) and 6 female patients with a mean age of 57 years (range 44–68 years). HCV genotypes 1, 3 and 4 were found in 9, 4 and 3 patients, respectively. Conclusion: These cases underline the importance of enhanced surveillance and infection control procedures in haemodialysis units for patients who return after dialysing in resource poor countries. To the best of our knowledge this represents the largest series of imported HCV infection after holiday haemodialysis, and demonstrates clearly the significance of the perceived risk with increasing number of incident infections. [Copyright &y& Elsevier]

It is essential for nephrology nurses to understand the basics of iron function and the importance of maintaining iron balance in their patients. Iron forms the cornerstone of oxygen delivery in the body and is the most essential nutrient for the building of healthy erythrocytes. Given the vital importance of iron, the body has devised elaborate and tightly controlled mechanisms to transport iron to the bone marrow for hemoglobin production, recycle iron from dying erythrocytes, and prevent iron loss. In the healthy individual, daily iron intake needs are very small, and sufficient iron is easily absorbed from the duodenum. In patients on hemodialysis, this iron balance is dramatically altered due to blood loss, inflammation, and the use of erythropoiesis-stimulating agents. This article discusses the basics of iron physiology and the mechanisms by which iron is moved throughout the body and made available for developing erythrocytes. The ways in which iron balance is altered in the patient on hemodialysis and the most effective strategies to replete iron stores and maintain iron balance through the use of intravenous iron are also reviewed. [ABSTRACT FROM AUTHOR]

Background. It is difficult to diagnose tuberculosis (TB) in dialysis patients because of the high rate of extrapulmonary TB in these patients compared with the general population. Recently, a new diagnostic test called QuantiFERON (QFT) has been developed and shown promise as a diagnostic tool for active TB diseases and latent TB infection. [ABSTRACT FROM PUBLISHER]

Background and Aims: Hemodialysis (HD) patients seem to be at considerable risk of acquiring HBV infection. This study was carried out to determine the seroprevalence of hepatitis B virus (HBV) infection in hemodialysis patients living in the province of Tehran and to investigate the association between viral hepatitis B and the probable risk factors for HD patients. Methods: From June to August 2005, this study was done on the entire HD population of the province of Tehran (2630 patients; 1505 males and 1125 females, mean age: 53.4 years). Social and demographic data, date of onset of HD, length of time receiving HD services, history of a kidney transplant, multiple sex partners, and other probable risk factors were evaluated. Blood samples were tested for liver enzyme levels as well as human immunodeficiency virus (HIV) 1, HIV 2, hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and hepatitis C antibody (anti-HCV). Results: A total of 64 patients were HBsAg positive (2.4%). The male-to-female ratio was 45/19 for HBsAg-positive patients and 1462/1104 for the remaining patients (P = 0.03), respectively. Except for nationality (P < 0.001), previous kidney transplants (P < 0.001), age (P < 0.001), and transient HD (P < 0.001), no association was found between HBV infection and probable risk factors. Conclusions: Common erythropoietin administration, blood testing for transfusion purposes, implementation of universal precaution in dialysis units as well as the use of dedicated machines for HBV-infected patients has led to a decreasing trend of HBV infection. Periodic surveillance of HBV infection among patients undergoing hemodialysis is strongly recommended. [ABSTRACT FROM AUTHOR]

Objective: Both diabetes and hemodialysis (HD) are associated with increased oxidative stress. The aim of this study was to clarify the effect of maintenance HD on oxidative stress parameters in diabetic patients and to explore any relation between carotid artery intima-media thickness (CIMT) and oxidative stress markers. Methods: Twenty Type 2 diabetic patients undergoing chronic maintenance HD, 20 type 2 diabetic patients with normal renal function, and 20 age- and sex-matched healthy subjects were included. Serum thiobarbituric acid reactive substances (TBARS), protein carbonyl content (PCO), and nitrite/nitrate levels were determined as oxidative stress markers. Serum vitamin E, plasma sulfhydryl (P-SH), erythrocyte glutathione (GSH) levels, and superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) activities were measured as antioxidants. CIMT was assessed by carotid artery ultrasonography. Results: Both diabetic patient groups had enhanced oxidative stress indicated by higher levels of TBARS, PCO, and nitrate/nitrite and lower activities of SOD, CAT, and GPx compared to controls. Diabetic patients undergoing HD had significantly higher CIMT (P=.001) and higher levels of nitrite/nitrate (P=.05), PCO (P=.03), and GSH (P=.04) but significantly lower levels of P-SH (P<.001), serum vitamin E (P=.04), SOD (P=.02), CAT (P=.001), and GPx (P=.006) compared to diabetic patients with normal renal functions. There were significant negative correlations between CIMT and SOD (r=-0.50, P<.001), CAT (r=-0.41, P=.003), and P-SH levels (r=-0.51, P<.001) and significant positive correlation between CIMT and nitrite/nitrate levels (r=0.41, P=.003) and TBARS (r=0.35, P=.02). Linear regression analysis showed TBARS was significantly and positively correlated with CIMT (P=.04), while SOD and P-SH were significantly and negatively correlated with CIMT (P=.05 and P=.02, respectively). Conclusions: Hemodialysis exacerbates oxidative stress and disturbances in antioxidant enzymes in diabetic patients. Serum nitrite/nitrate and TBARS can be used as positive determinants, while erythrocyte SOD, CAT activities, and P-SH level can be used as negative determinants of atherosclerosis assessed by CIMT in diabetic patients. [ABSTRACT FROM AUTHOR]

Background Tumor lysis syndrome (TLS) is rare in the treatment of solid tumors, but it may occur in myelolymphoproliferative diseases. Methods A 58-year-old man with bulky metastatic melanoma of the liver was treated with transcatheter arterial infusion of cisplatin and embolization therapy. The patient developed classic signs of TLS within 24 h of chemotherapy, including acute renal failure. Results The patient was treated with aggressive hydration, allopurinol, and repeated hemodialysis. He gradually improved and his biochemical markers returned to normal. Conclusion TLS is an uncommon, but potentially life-threatening, complication in melanoma and other solid tumors. It is important for oncologists to recognize this complication and prevent its development if bulky metastatic disease and several pre-existing risk factors, such as multiple and bulky liver metastases, elevated lactate dehydrogenase, and hyperuricemia, are present. [ABSTRACT FROM AUTHOR]

Abstract: Peritonitis, exit site and tunnel infections are serious complications of peritoneal dialysis (CAPD), which may lead to catheter loss, despite measures taken to reduce the infection rate. Catheters coated with antimicrobials have shown only short-term activity. We have developed a process for conferring broad-spectrum, long-duration antimicrobial activity on CAPD catheters while reducing the risk of resistance. Catheters were processed using an impregnation method. Three agents were used: rifampicin, triclosan and trimethoprim. Tests included establishing the duration of activity before test bacteria became resistant, the ability to kill 100% of attached bacteria in a predetermined time (tK100), and ability to withstand multiple high-count challenges until failure in a flow model. Antimicrobial activity continued until it was stopped at 280 days and the agents prevented the emergence of resistant strains. tK100 results showed a >99.9% reduction of attached bacteria. The flow model showed no colonization when repeatedly challenged with high loads of meticillin-resistant Staphylococcus aureus or Escherichia coli for ∼90 days. The antimicrobial catheter material showed prolonged activity against common CAPD pathogens and promises to reduce clinical CAPD infection. [Copyright &y& Elsevier]

Background. Hepatitis C virus infection is common among patients undergoing hemodialysis, and HD patients are at high risk for infection with such virus. Recently, some studies and case reports indicated attenuated anemia in HD patients with HCV infection, and they previously considered this to be related to increased erythropoietin production after hepatic stimulation by chronic infection with hepatitis virus. Aim. The aim of our study is to investigate whether HCV-positive HD patients have higher hemoglobin (Hb) and hematocrit (HCT) values compared to HCV-negative patients. Methods. We retrospectively studied 83 chronic HD patients from Prince Salman Center for Kidney Disease, and monthly samples were collected between July 2007 and July 2008. The HCV status was determined by anti-HCV antibodies and confirmed with RNA polymerase chain reaction (PCR). Those with a history of blood transfusion or massive blood loss during the last six months were excluded from the study. Results. Thirty-three percent of our patients tested positive for anti-HCV antibody (51.8% were male). The mean age for HCV-positive group was 54.92 ± 15.61 years, while it was 51.01 ± 14.81 years for the HCV-negative group (p = 0.27). Mean Hb in the HCV-positive group was 11.18 ± 1.41gm/dL compared to 10.87 ± 1.29 gm/dL for the HCV-negative group (p = 0.05). Mean HTC values for the HCV-positive group was 34.4 ± 3.9, compared to 32.41 ± 3.41 for the HCV-negative group 12 months after starting hemodialysis. Eighty-one patients (27 HCV-positive and 54 HCV-negative) received erythropoietin (EPO) therapy. Seventy-two patients (25 HCV-positive and 47 HCV-negative) received IV iron (p = 0.28). Mean erythropoietin dose was (114.83 ± 84.92 IU/kg/week) for HCV-positive compared to (122.2 ± 91.46 IU/kg/week) for HCV-negative group (p = 0.74). Liver function tests were normal except for higher bilirubin level in the HCV-positive group, 7.74 ± 4.03 Umol/L compared to 5.47 ± 3.71 Umol/L in the HCV-negative group (p = 0.01). Conclusion. Our study showed that ESRD patients on HD with HCV infection have higher Hb and HCT levels compared with HCV-negative patients. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) diastolic function has been causally deteriorated on hypotensive episodes during hemodialysis (HD). The influence of intravascular volume deterioration and arterial pressure reduction on LV function in patients without hypotensive episodes during HD has not been adequately studied. 23 patients on HD were studied for 48±35 months, whose mean age was 50±12 years, their mean body mass index was 24±4kg/m² and their mean fluid retention between HD sessions 2.2±1.1 kgr. We used 2D and Doppler echocardiography before and after the same HD session. The following parameters were measured: a) end-diastolic (LVED) and end-systolic LV diameters, left atrial diameter (LA) and fraction shortening (FS) b) isovolumic relaxation (IVRT) and contraction (ICT) time, deceleration time (DT), E and A waves of the mitral inflow and ejection time (ET) of the LV outflow velocity. The following indices were calculated: E/A ratio, myocardial performance index (MPI) using the (IVRT+ICT)/ET formula, mean arterial pressure (MAP), the % reduction in MAP and the reduction in intravascular volume after HD. Stroke volume (SV) and corresponding cardiac output (CO), were calculated from the LV outflow velocity waveform. All patients demonstrated systolic arterial pressure at the level of ≥90mmHg and normal FS before HD, while they had demonstrated restrictive LV diastolic filling before HD. MAP, SV, CO, LVED, LA, E wave and E/A decreased while IVRT increased after HD (p<0.01). After HD, low MPI values (normal range <0.44) were related to greater ultrafiltration volume loss (UFV) (r=0.53, p<0.01) and greater % reduction in MAP (r=0.62, p<0.01). Conversely, abnormal MPI values were related to high MAP after HD (r=0,44, p<0.01). Increased UFV was related to greater % increase in IVRT (r=0.43, p<0.01) and % decrease in E/A (r=0.40, p<0.01) after HD. Patients with UFV >3kg (7/23) had lower MPI (0.47±0.2 vs. 0.84±0.3, p<0.01) and greater % increase in IVRT and % reduction in E/A (p<0.01 ) than those with <3kgr. Fluid retention between HD sessions leads to restrictive LV diastolic filling as shown by an E/A>1 and a short IVRT in patients before HD. Reduction in the excess intravascular volume after HD normalises MAP and thus, improves LV performance. [ABSTRACT FROM AUTHOR]

The article reports on the results of an investigation which was launched by the New York State Department of Health in 2008 after it received reports of three hemodialysis patients who had seroconverted from anti-hepatitis C virus (HCV) negative to anti-hepatitis C virus positive while being treated in a New York City hemodialysis unit. The investigation found that six additional patients had also tested positive for hepatitis C, and that the hemodialysis unit in question had numerous deficiencies in infection control policies, procedures and training.

Uremic neuropathy (UN) is a typical complication of long-term dialysis therapy and may manifest as distal, symmetric, and both senso-motoric and autonomic nerve dysfunction. Its clinical picture is highly variable and it is not known how the symptoms of UN reported by chronic dialysis patients correspond to positive results of clinical tests for autonomic dysfunction. The objective of this study was to compare the prevalence of self-reported symptoms of autonomic neuropathy (AN) revealed in patient questionnaires with the prevalence of findings from objective clinical tests. The study group included 45 patients (26 males, 19 females), mean age 60 ± 15.5 years, on chronic hemodialysis for 7.8 ± 2.6 years. In all subjects, blood pressure (BPci) and heart rate (HRci) variability indexes (calculated as BP and HR during Ewing and Clarke’ tests divided by HR and BP at rest) were measured using the Finapres which records beat-to-beat blood pressure and heart rate. Additionally, patients completed seven-question questionnaires which assessed the presence of most typical AN symptoms. The control group comprised 12 healthy subjects (age 52 ± 19.5 years). The results from the questionnaires showed that falls of BP occurred in 73% of patients, itching of skin in 42%, constipation or diarrhea in 33%, filling of stomach in 25%, and decreased sweating in 17%. Altogether 85.9% of patients reported one or more subjective symptoms of neuropathy. In contrast, modified Ewing and Clarke’s test revealed that only 17.7% of participants demonstrated overt pathologies. Neither blood pressure nor heart rate changeability indexes in patients and healthy subjects showed significant differences with the exception of intense inhalation and static effort. Our results show much higher frequency of subjective symptoms of AN in chronic dialysis patients than objective symptoms detected with clinical tests. [ABSTRACT FROM AUTHOR]

Guidelines for treatment of hypertension are not available for chronic hemodialysis (HD) population, despite the high mortality rate due to cardiovascular disease (CVD). Survival is much better among hypertensive patients than normal to hypotensive patients. Target levels of blood pressure and the class of antihypertensive drugs have not been examined in prospective studies. We designed a prospective randomized controlled study among hypertensive HD patients in Okinawa (Okinawa Dialysis Study, OKIDS). The outcomes will be compared between two treatment regimens, such as (1) renin–angiotensin system (RAS) inhibitor Olmesartan and others, and (2) antihypertensive drugs without RAS inhibitors, in a parallel fashion. The title of the study is Olmesartan Clinical Trial in Okinawan Patients under OKIDS (OCTOPUS). Outcomes are any cause of death and CVD in 3 years in a total of 462 patients. Subjects are age 20–79 years and ambulatory on thrice weekly HD treatment. Eligible patients have resistant hypertension: pre-HD session blood pressure 140/90 mmHg and over for more than 1 month regardless with the use of antihypertensive drugs. Patients treated with RAS drugs are eligible if they continue to be hypertensive for more than 1 month after switching to non-RAS antihypertensive drugs. This study provides evidence for the target levels of blood pressure at a pre-HD session and the impact of RAS inhibitors. We also evaluate the usefulness of home blood pressure monitoring in HD patients. [ABSTRACT FROM AUTHOR]

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The article focuses on the case of a 58 year old woman who reported a 6 month history of migraine headaches which occurred during the last 35-45 minutes of her weekly hemodialysis treatments. A discussion of the diagnostic criteria related to headache attributed to hemodialysis, and of the treatments which can be used for it, is presented.

Background: It is unclear whether the prevalence of gallbladder stones (GBS) is higher in patients with chronic kidney disease (CKD). Methods: A total of 398 patients with CKD of each of the 5 disease stages [CKD1: 26; CKD2: 52; CKD3: 58; CKD4: 48; CKD5: 214, of whom 61 were predialysis and 153 were on dialysis (CKD5D)] were included in this study. Those in whom GBS were detected by ultrasonographic examination or who had a history of cholecystectomy owing to GBS were considered GBS patients. Results: In comparison to the GBS prevalence of 5.9% in the control group, that in CKD patients increased with the advancement of the disease stage (CKD1: 7.7%; CKD2: 15.4%; CKD3: 19.0%; CKD4: 20.8%; CKD5 predialysis: 21.3%; CKD5D: 22.9%). The prevalence was significantly greater in CKD5 patients than in the control group. CKD5 is a risk factor for GBS independent of age or sex. However, no significant relationship was found between the prevalence of GBS and the duration of hemodialysis therapy in CKD5D patients. Age was the only factor that was associated with GBS in predialysis CKD patients. Conclusion: The risk of GBS formation was high in predialysis CKD patients. Although the risk disappeared in CKD5D patients, the prevalence of GBS was still significantly higher than in the control population. Factors that promote GBS formation in predialysis CKD patients and/or that inhibit GBS formation in CKD5D patients remain unknown. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical topics which include the use of trans-arterial approach in treating radial artery lesions in dysfunctional wrist fistulas, the use of imaging system in estimating the length of insertion and selecting optimal size on chest roentography and the analyzes on the success and complication rates of hemodialysis access procedures performed by interventional nephrologist working in multiple rural medical centers.

Patients with end-stage renal disease (ESRD) continue to have a higher morbidity and mortality despite the advances in renal replacement therapy. Cardiovascular events are the main causes of increased morbidity and mortality. Recent reports have demonstrated a high incidence of unexplained pulmonary hypertension in patients with ESRD on replacement therapy and at the predialysis stage. This serious cardiovascular complication is associated with increased mortality in this group of patients. Highlighting this problem is important for prevention, enabling early detection, and proper management. Understanding the pathophysiology of the disease is important for its management. In this review, we tried to collect most of the available data about this category of pulmonary hypertension in patients with ESRD. [ABSTRACT FROM AUTHOR]

Background: The radiocephalic arteriovenous fistula (RC-AVF) at the wrist is the recommended first choice for hemodialysis access. Several authors have reported early thrombosis or failure of RC-AVFs to mature in up to 20% to 57% of patients. We report a consecutive series of individuals in whom physical and ultrasonography (US) examinations predicted success with RC-AVFs. Study Design: Records of all patients who underwent vascular access operations by the communicating author from June 2003 through June 2008 were reviewed to identify those individuals with RC-AVF procedures. Physical examination and US screening criteria for creating a RC-AVF included a continuous and uninterrupted outflow vein diameter ≥ 2.5 mm and a normal radial artery inflow examination with vessel diameter ≥ 2.0 mm. A venous branching point at the wrist was identified to create a broad patch for the RC-AVF anastomosis. Results: We reviewed 796 consecutive vascular access operations, identifying 75 RC-AVFs created in 74 patients. Patient ages were 20 to 82 years (mean 57 years). Eighteen were women and 42 were diabetic. Mean followup was 14.5 months. Primary, primary-assisted, and cumulative (secondary) patency were 58.3%, 96.2%, and 100%, respectively, at 12 months and 48.1%, 91.5%, and 95.7%, respectively, at 24 months. Conclusions: RC-AVF at the wrist remains our first choice for vascular access in the subset of patients meeting specific preoperative criteria by physical and United States examinations. Cumulative patency was 100% at 12 months and 95.7% at 24 months. Although RC-AVF construction technique is important, careful patient selection is believed to be the critical element in creating functional and durable RC-AVFs. [Copyright &y& Elsevier]

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AbstractThe fluid used for hemodialysis may contain DNA fragments from bacteria, which could be harmful for patient outcomes. DNA fragments from bacteria, containing the nonmethylated CpG motif, can trigger inflammation through the monocyte and lymphocyte Toll-like receptor 9, and these DNA fragments have been observed in dialysate. The fragments may transfer across the dialyzer into the patient’s bloodstream during hemodialysis treatment. During hemodiafiltration, the fragments would be introduced directly into the bloodstream. The DNA fragments may arise from biofilm in the pipes of the water system, from growth of bacteria in the water, or as contaminants in the bicarbonate and salt mixture used for preparation of dialysate. Current filtration methods, such as Diasafe filters, are not able to remove these fragments. It would be prudent to seek to reduce or eliminate these contaminants. However, the cost and effort of decreasing bacterial DNA content may ultimately require substantial facility improvements; we therefore need to fund research studies to determine if modifications to reduce bacterial DNA content are clinically warranted. This research will require methods to accurately determine the species of bacteria that contribute the DNA, since this information will allow the source to be established as biofilm, bicarbonate mixtures, or other problems in the dialysis system such as bacterial growth or leakage during water preparation. In this review, the evidence for bacterial DNA fragments will be examined and suggestions for further studies will be described.Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

AbstractDialysis relies upon the transfer of waste products and electrolytes across a semi-permeable membrane contained in the dialyser facilitated by the dialysis fluid, a fast-flowing electrolyte solution prepared continuously by the mixing of treated water with a concentrated electrolyte solution. Both the water, the buffer and electrolyte composition play important roles in modulating complications associated with treatment. With respect to water, historically the focus was on chemical contaminant content, but more recently has shifted to microbiological quality due to the role that such quality plays in the pro-inflammatory state. The composition of the dialysis fluid is crucial in normalization of electrolyte composition of plasma water, homeostasis and acid-base balance, and should be individualized to the patients’ requirements in the same way as blood and dialysate flow rates are individualized to ensure optimal comfort and minimal complications associated with the procedure.Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The duration and frequency of hemodialysis was determined empirically when this therapy first came into use, and treatment was commonly three 8 h sessions per week by the end of the 1960s. Subsequently, however, the growing number of patients who required this therapy had to be reconciled with the shortage of equipment; therefore, dialysis time was decreased to three 4 h sessions per week. At the same time, on the basis of data from the first randomized controlled trial of dialysis--the National Cooperative Dialysis Study--Kt/Vurea was devised as the optimum measure of dialysis adequacy. Nowadays, although Kt/Vurea targets are fulfilled in an increasing number of patients, observational studies show that individuals on hemodialysis continue to experience a high rate of complications, including hypertension, left ventricular hypertrophy, cardiac failure, hyperphosphatemia, malnutrition and death. Although no randomized controlled trial has yet been published, observational data indicate that increasing hemodialysis time and/or frequency improves a number of these complications, especially the death rate. This Review outlines the advantages of longer and/or more frequent dialysis sessions and highlights the barriers to adoption of such regimens, which largely relate to economics, patient willingness, and organization of dialysis units. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To evaluate failing hemodialysis fistula complications using 16-detector MDCTA, and to assess the accuracies of different 3D planes. Materials and methods: Thirty patients (16 men, 14 women, aged 27–79 years) were referred for hemodialysis access dysfunction. Thirty-one MDCTA exams were done prior to fistulography. For MDCTA, contrast was administered (2mL/kg at 5mL/s) via a peripheral vein in the contralateral arm. Axial MIP, coronal MIP, and VRT images were constructed. Venous complications were evaluated on axial source images, on each 3D plane, and on all-planes together. Results were analyzed using McNemar test. Results: Axial MIP, VRT and all-planes evaluations were most sensitive for fistula site detection (93%). Coronal MIP had the highest sensitivity, specificity and accuracy (35%, 96%, and 85%, respectively) for detecting venous stenosis. VRT and all-planes had the highest sensitivity and accuracy for detecting aneurysms (100%). All-planes and axial MIP were most sensitive for detecting venous occlusion (61% and 54%). Comparisons of detection frequencies for each venous pathology between the five categories of MDCTA revealed no significant differences (P >0.05). MDCTA additionally showed 3 partially thrombosed aneurysms, 4 anastomosis site stenosis and 12 arterial complications. Conclusion: MDCTA overall gives low sensitivity for detection of central vein stenosis and moderate sensitivity for occlusion. For most pathology, all-planes evaluation of MDCTA gives highest sensitivity and accuracy rates when compared to other planes. For venous stenosis and occlusion, MDCTA should be considered when ultrasonography and fistulography are inconclusive. MDCTA is helpful in identifying aneurysms, collaterals, partial venous thromboses and additional arterial, anastomosis site pathologies. [Copyright &y& Elsevier]

Background: Exercise training in hemodialysis patients improves fitness, physical function, quality of life and markers of cardiovascular disease such as arterial stiffness. The majority of trials investigating this area have used supervised exercise training during dialysis (intradialytic), which may not be feasible for some renal units. The aim of this trial is to compare the effects of supervised intradialytic with unsupervised home-based exercise training on physical function and arterial stiffness. Methods and design: This is a randomised, controlled clinical trial. A total of 72 hemodialysis patients will be randomised to receive either six months of intradialytic exercise training, home-based exercise training or usual care. Intradialytic patients will undergo three training sessions per week on a cycle ergometer and home-based patients will be provided with a walking program to achieve the same weekly physical activity. Primary outcome measures are six-minute walk distance (6 MWD) and aortic pulse wave velocity (PWV). Secondary outcome measures include augmentation index, peripheral and central blood pressures, physical activity and self-reported health. Measures will be made at baseline, three and six months. Discussion: The results of this study will help determine the efficacy of home-based exercise training in hemodialysis patients. This may assist in developing exercise guidelines specific for these patients. [ABSTRACT FROM AUTHOR]

Abstract: A 67-year-old male with dilated cardiomyopathy and chronic renal failure who received chronic hemodialysis for 9 years admitted with pulmonary edema. Three days after admission, electrocardiogram showed transient prolongation of QT interval which was followed by macroscopic T wave alternans (TWA) and ventricular fibrillation (VF). Temporary pacing from right ventricular apex suppressed TWA and VF effectively. Combined cardiac resynchronization therapy and implantable cardioverter defibrillator device was implanted for the secondary prevention of VF. Both prolongation of QT interval and TWA disappeared for 10 days after therapy and no arrhythmic event occurred since then. [Copyright &y& Elsevier]

Large public health interventions to control infectious disease outbreaks are common, but rigorous evaluation to improve the quality and effectiveness of these is rarely undertaken. This project aimed to prevent blood borne virus (BBV) cross-transmission in dialysis units. Following an incident concerning the diagnosis of acute Hepatitis B in a haemodialysis patient, possibly from healthcare associated acquisition, a multifaceted and multidisciplinary investigation was conducted involving consumers, health professionals and administrations. The results of this investigation were then used to produce practical operational guidelines for planning and future interventions. To date, there has been no incidence reported of any cross-transmission of BBV amongst our dialysis population. The actions implemented can be utilised by other departments in preventing other bacterial or viral outbreaks. [ABSTRACT FROM AUTHOR]

A prospective analysis was conducted comparing dysfunction attributable to catheter thrombosis in subjects who received a heparin catheter lock three times a week (n = 15) to those who received a heparin lock six times a week (n = 15) immediately after the insertion of a temporary haemodialysis catheter. Thrombus related catheter removal occurred in two patients in control but no patients in the experiment group. Heparin locking six times a week was found to be effective in prolonging the mean of the first day where difficulty was experienced in aspiration. It also prevented any possible difficulty in catheter flushing. Increased locking frequency prevents any thrombus accumulation within the temporary catheter, while it has limited but significant preventive effect on thrombus accumulated around the catheter. [ABSTRACT FROM AUTHOR]

Although haemodialysis (HD) has become a routine treatment, adverse side effects, and occasionally life threatening clinical complications, still happen. Venous needle dislodgment (VND) is one of the most serious accidents that can occur during HD. If the blood pump is not stopped, either by activation of the protective system of the dialysis machine or manually, the patient can bleed to death within minutes. Fatal and near-fatal blood loss due to VND have been described in the literature ( ECRI 1998 ; Sandroni 2005 ; Mactier & Worth 2007 ), but published reports represent only the tip of the ice berg, as such incidents are normally handled at a local or national level. The European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) has produced 12 practice recommendations to help reduce the risk of VND and detect blood leakage as early as possible. A poster summarising these recommendations has been created ( Van Waeleghem et al. 2008 ). [ABSTRACT FROM AUTHOR]

Patients who receive a preemptive kidney transplant before starting dialysis avoid the medical complications related to dialysis and have the highest graft success and lowest mortality rates. Because only 2.5% of incident patients receive kidney transplants preemptively, improved psychosocial education may assist more patients in accessing preemptive transplant. This article outlines (1) unique psychosocial issues affecting patients with chronic kidney disease stage 4 (glomerular filtration rates >20 mL/min per 1.73 m²) and (2) how an educational program about preemptive living donor transplant should be designed and administered to increase access to this treatment option. Early referral patients may be overwhelmed in coping with and learning about their disease and, therefore, not ready to make a treatment decision, or they may be highly motivated to obtain a transplant to avoid dialysis and return to a normal life. An education program that defines the quality-of-life and health benefits possible with early transplant is outlined. The program is focused on minimizing the disruption of starting 2 treatment techniques and maximizing early transplant health, graft survival, employability, and retention of insurance coverage. Once the benefits of preemptive living donor transplant are outlined, educators can focus on demystifying the living donor evaluation process and assisting interested patients in planning how to find a living donor. To reach all patients, especially racial minorities, education about preemptive transplant should be available in primary-care physicians' and community nephrologists' offices, at dialysis centers, and through other kidney organizations. [ABSTRACT FROM AUTHOR]

Background/Aims: Pulmonary hypertension (PHT) has been reported to be high among end-stage renal disease (ESRD) patients. This study evaluated PHT in ESRD patients and the role of arteriovenous fistula (AVF), thromboxane B2 (TXB2) and pro-BNP in this complication. Methods: 45 ESRD patients on regular hemodialysis (HD) (group 1) and 31 ESRD patients on conservative treatment (group 2) underwent clinical and biochemical testing. Pulmonary artery pressure (PAP) was evaluated using Doppler echocardiography. Cardiac assessment by echocardiography and AVF flow measurement by Doppler ultrasound were done. Levels of TXB2 and N-terminal pro-brain natriuretic peptide (NT-proBNP) in plasma were determined. Results: PHT was found in 44.4% in group 1 and in 32.3% in group 2. Comparing the two groups shows a significant difference with regard to PAP, proBNP, and TXB2. Patients with PHT have a significantly higher AVF blood flow, proBNP, and TXB2. In patients with PHT, 76.7% have left ventricular diastolic dysfunction (LVDD). PAP correlates with AVF flow, proBNP, and TXB2. Conclusions: Results show a high prevalence of PHT among patients with ESRD on chronic HD or on conservative treatment. PHT in such patients is related to AVF flow, TXB2 and NT-proBNP level and LVDD. AVF flow is an important correctable cause of PHT. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Infective spondylodiscitis (ISD) is a rare but potentially devastating condition in hemodialysis (HD) patients. Reports are limited especially in patients receiving high-flux HD and hemodiafiltration (HDF). In a retrospective analysis, 13 patients on our maintenance high-flux HD/HDF program were identified as having has infective spondylodiscitis over a 10-year period (1997–2006), an incidence of approximately 1 episode every 215 patient-years. The incidence was around 3 times higher in patients dialyzing with tunnelled central venous catheters (TCVC) than in those with arteriovenous fistulae. Affected patients were elderly (mean age 70 years) and had multiple comorbidities. Access problems, particularly TCVC infection, were common in the months preceding it's onset. Tunnelled central venous catheter removal during these episodes did not necessarily prevent it. Diagnosis was based on a history of back pain, raised C-reactive protein, positive blood cultures, and characteristic magnetic resonance findings. Many patients were apyrexial and had normal white cell counts. In our patients on high-flux HD/hemodiafiltration, its incidence appears comparable to that in conventional HD settings. No patients had infection with waterborne organisms. Blood cultures were positive in 77%. Gram-positive organisms predominated, particularly Staphylococcus aureus. The major route of infection was hematogenous, with the most likely source the venous access. All received antibiotics for 6 to 12 weeks or until death. Only 2 patients underwent surgical drainage. Mortality was high (46%) and predicted by the development of complications, and by pre-existing cardiovascular comorbidity. Prevention, using strategies to reduce the prevalence of bacteremia, including limiting the use of TCVC, should be an overriding aim. [ABSTRACT FROM AUTHOR]

This paper describes the design and implementation of a decision support system for risk management in hemodialysis (HD) departments. The proposed system exploits a domain ontology to formalize the problem as a Bayesian network. It also relies on a software tool, able to automatically collect HD data, to learn the network conditional probabilities. By merging prior knowledge and the available data, the system allows to estimate risk profiles both for patients and HD departments. The risk management process is completed by an influence diagram that enables scenario analysis to choose the optimal decisions that mitigate a patient's risk. The methods and design of the decision support tool are described in detail, and the derived decision model is presented. Examples and case studies are also shown. The tool is one of the few examples of normative system explicitly conceived to manage operational and clinical risks in health care environments. [ABSTRACT FROM AUTHOR]

Background: The prognostic factors of intracerebral haemorrhage (ICH) in haemodialysis (HD) patients are not fully clear and there is no standard clinical grading scale to predict 30-day mortality. Our aim was to develop such a scale. Methods: Records of all HD patients with spontaneous ICH presenting to Chang Gung Memorial Hospital in Taiwan during 1994–2004 were reviewed. The study design was a retrospective analysis of data collected from one hospital. Prognostic factors were identified by Student’s t-test and χ2-test. Independent predictors of 30-day mortality were determined by the logistic regression method. An outcome score based on a combination of these predictors was developed with weighting of independent predictors based on strength of association. Results: The overall 30-day mortality rate was 67.3%. Prognostic factors independently associated with mortality were the Glasgow Coma Scale score ( P < 0.001), age ≥70 years ( P = 0.032), systolic blood pressure <130 mmHg or ≥200 mmHg ( P = 0.016), ICH volume ≥30 mL ( P = 0.012), presence of intraventricular haemorrhage ( P = 0.004) and serum glucose ≥8.8 mmol/L ( P = 0.023). The score was the sum of individual points assigned as follows: Glasgow Coma Scale score 12–15 (0 points), 9–11 (1), 3–8 (4); age <70 years, yes (0), no (2); and systolic blood pressure 130–199 mmHg, yes (0), no (1). The 30-day mortality rate increased steadily with score ( P < 0.001). Conclusion: The outcome score is a simple clinical grading scale that allows risk stratification of HD patients presenting with ICH. This scale could be used to design treatment protocols and clinical research studies of ICH in HD patients. [ABSTRACT FROM AUTHOR]

Background. Prevention of catheter-related bloodstream infections in patients undergoing hemodialysis by use of antimicrobial catheter lock solutions has been examined in several trials, but no consensus is available for clinical practice. Methods. A systematic review and meta-analysis were performed of randomized controlled trials that compared single or combination antimicrobial catheter lock solutions with heparin or another antimicrobial for the prevention of infections in patients undergoing hemodialysis. The primary outcomes assessed were bloodstream infections, catheter-related bloodstream infections, and the need for catheter removal. Relative risks with 95% confidence intervals (CIs) for individual trials were pooled. Results. Eleven trials (924 patients) that assessed antibiotic catheter lock solutions and 5 trials (661 patients) that assessed nonantibiotic antimicrobial catheter lock solutions met inclusion criteria. None of the trials assessed all bloodstream infections. Antibiotic catheter lock solutions significantly reduced catheter-related bloodstream infections (relative risk, 0.44; 95% CI, 0.38-0.50). Significant heterogeneity for this outcome could be explained by smaller effect estimates in larger trials that reported adequate randomization methods (relative risk, 0.60; 95% CI, 0.54-0.67). Efficacy was higher when additional preventive measures were used and to prevent the first episode of catheter-related bloodstream infection. Catheter removal rates were significantly reduced (relative risk, 0.35; 95% CI, 0.23-0.55). Resistance development was documented in a single patient. Data concerning nonantibiotic antimicrobial lock solutions were limited and heterogenous. High-quality trials that used additional preventive measures showed a significant reduction in catheter-related bloodstream infections (relative risk, 0.25; 95% CI, 0.13-0.50). Conclusions. Antibiotic catheter lock solutions reduce catheter-related bloodstream infections, with a number needed to treat of 4 patients (95% CI, 4-5), and catheter removal rates in patients undergoing hemodialysis. The use of antibiotic catheter lock solutions should be considered in routine clinical practice in conjunction with other prevention modalities. [ABSTRACT FROM AUTHOR]

Introduction Hemodialysis access-related pseudoaneurysm is a known complication in patients requiring hemodialysis via prosthetic arteriovenous grafts (AVGs). The traditional treatment strategy of AVG-related pseudoaneurysms is either AVG ligation or interposition replacement with another prosthetic graft segment or autogenous veins. Patients and methods From June 2002 to August 2007, 32 self-expanding stent grafts were implanted in 26 patients with AVG pseudoaneurysms. Indications for treatment consisted of large AVG pseudoaneurysm size, localized pain at pseudoaneurysm site, enlarging pseudoaneurysm, and skin site breakdown. AVG pseudoaneurysm exclusion was accomplished with Wallgrafts, Viabahn endoprosthesis, and Fluency endograft. Technical success was achieved in all patients. Nineteen patients experienced a marked decrease in the size of their pseudoaneurysm following endograft exclusion. Successful hemodialysis was resumed through endograft-excluded AVG in all patients within 48 hours. Conclusions Endoluminal exclusion of AVG pseudoaneurysms using endografts is a safe and effective treatment strategy in patients with hemodialysis-related pseudoaneurysm. [ABSTRACT FROM AUTHOR]

The article presents a study seeking to determine whether the drug clopidogrel reduces early failure of hemodialysis fistulas among patients treated with hemodialysis. The design, setting, and participants of the double-blind, placebo controlled trial involving 877 patients with end-stage renal disease or advanced chronic kidney disease are detailed. The main outcomes measured were fistula thrombosis and failure of the fistula to become suitable for dialysis. Researchers conclude that clopidogrel was capable of reducing the frequency of early thrombosis of arteriovenous fistulas, but it failed to increase the proportion of fistulas that became suitable for dialysis.