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Technology-assisted cognitive-behavioral therapy (CBT) interventions have been conducted for symptoms including depression, pain, and fatigue in patients with chronic illnesses but not in end-stage renal disease (ESRD). The purpose of this study was to pilot the feasibility and acceptability of a technology-assisted CBT intervention in ESRD patients on hemodialysis (HD), share design and implementation lessons learned, and provide preliminary results on changes in select patient-reported symptoms. This was a single-center pilot feasibility study of adult ESRD patients on HD. Study eligibility required clinically elevated levels of at least one symptom (depression, pain, or fatigue). Patients met weekly with a CBT therapist for eight sessions, each 45-60 min, during HD sessions via a video-conferencing platform. Symptom questionnaires were completed at baseline and 3 months follow-up. Of 10 patients screened, 100% screened positive for at least one symptom, 100% of eligible patients consented, and eight (of 10) completed the intervention (mean age 59 years, 50% male, 50% African American). Patient adherence and satisfaction was high, and seven of the eight patients completed all eight prescribed sessions. Minimal interference with HD was reported. Preliminary results indicate no statistically significant changes in depression, fatigue, or pain at follow-up. However, there was small improvement in SF-36 Physical Component score [t(7) = -2.60, p = .035], and four of the six patients (67%) with clinically elevated pain at baseline reported improvement at follow-up. A technology-assisted CBT intervention for ESRD patients was feasible, well-accepted, and required minimal additional resources in the HD setting. Larger, adequately powered clinical trials are needed to evaluate the effect on ESRD patient-reported outcomes., (© Society of Behavioral Medicine 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Disseminated candidiasis caused by the fungus Candida albicans is a major clinical problem in individuals with kidney disease and accompanying uremia; disseminated candidiasis fatality is twice as common in patients with uremia as those with normal kidney function. Many antifungal drugs are nephrotoxic, making treatment of these patients particularly challenging. The underlying basis for this impaired capacity to control infections in uremic individuals is poorly understood. Here, we show in multiple models that uremic mice exhibit an increased susceptibility to systemic fungal infection. Uremia inhibits Glut1-mediated uptake of glucose in neutrophils by causing aberrant activation of GSK3β, resulting in reduced ROS generation and hence impaired killing of C. albicans in mice. Consequently, pharmacological inhibition of GSK3β restored glucose uptake and rescued ROS production and candidacidal function of neutrophils in uremic mice. Similarly, neutrophils isolated from patients with kidney disease and undergoing hemodialysis showed similar defect in the fungal killing activity, a phenotype rescued in the presence of a GSK3β inhibitor. These findings reveal a mechanism of neutrophil dysfunction during uremia and suggest a potentially translatable therapeutic avenue for treatment of disseminated candidiasis., (Copyright © 2020 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Background and Objectives: Current therapies for hyponatremia have variable effectiveness and tolerability, and in certain instances, they are very expensive. We examined the effectiveness, safety, and tolerability of urea for the treatment of inpatient hyponatremia., Design, Setting, Participants, & Measurements: We identified all patients hospitalized at the University of Pittsburgh Medical Center between July 2016 and August 2017 with hyponatremia (plasma sodium <135 mEq/L) who received urea, including a subgroup of patients who received urea as the sole drug therapy for hyponatremia (urea-only treated). We matched urea only-treated patients to a group of patients with hyponatremia who did not receive urea (urea untreated) and compared changes in plasma sodium at 24 hours and the end of therapy as well as the proportion of patients who achieved plasma sodium ≥135 mEq/L. We abstracted data on adverse events and reported side effects of urea., Results: Fifty-eight patients received urea (7.5-90 g/d) over a median of 4.5 (interquartile range, 3-8) days and showed an increase in plasma sodium from 124 mEq/L (interquartile range, 122-126) to 131 mEq/L (interquartile range, 127-134; P <0.001). Among 12 urea only-treated patients, plasma sodium increased from 125 mEq/L (interquartile range, 122-127) to 131 mEq/L (interquartile range, 129-136; P =0.001) by the end of urea therapy. There was a larger increase in plasma sodium at 24 hours in urea only-treated patients compared with urea-untreated patients (2.5 mEq/L; interquartile range, 0-4.5 versus -0.5 mEq/L; interquartile range, -2.5 to 1.5; P =0.04), with no difference in change in plasma sodium by the end of therapy (6 mEq/L; interquartile range, 3.5-10 versus 5.5 mEq/L; interquartile range, 3-7.5; P =0.51). A greater proportion of urea only-treated patients achieved normonatremia, but this difference was not statistically significant (33% versus 8%; P =0.08). No patients experienced overly rapid correction of plasma sodium, and no serious adverse events were reported., Conclusions: Urea seems effective and safe for the treatment of inpatient hyponatremia, and it is well tolerated., (Copyright © 2018 by the American Society of Nephrology.)

Background: Automated peritoneal dialysis (APD) is one of the fastest growing dialysis modalities. It is unknown whether sleep and mood are disturbed while performing repeated overnight exchanges., Objectives: In this report, we aim to describe and compare the prevalence of sleep-disordered breathing (SDB), periodic limb movements (PLMS), poor sleep quality (SQ), and depression among APD patients compared with stages 3b-5 (estimated glomerular filtration rate ≤44 ml/min/1.73 m2) chronic kidney disease (CKD) and hemodialysis (HD) patients., Design: This is a cross-sectional, descriptive study., Setting: Study participants were recruited from outpatient nephrology clinics, local dialysis centers, and the Thomas E. Starzl Transplant Institute in Western Pennsylvania between April 2004 and July 2009., Patients: There were 186 participants in this study including 22 APD patients, 89 CKD patients, and 75 HD patients., Measurements: In-home polysomnography was performed and two questionnaires were completed, the Pittsburgh Sleep Quality Index (PSQI) and the Patient Health Questionnaire-9 (PHQ-9)., Methods: SDB and PLMS were quantified by in-home unattended polysomnography; poor SQ was defined by a score >5 on the PSQI, and the presence of moderate to severe depression was defined by a score >5 on the PHQ-9., Results: The APD patients had a median age of 37.5 years, were predominantly female (72.7 %), and had a median body mass index (BMI) of 23.8 kg/m2. In univariate analyses, APD patients had significantly lower apnea-hypopnea index compared to HD patients by 12.2 points (likelihood ratio test p = 0.008) and revealed the least percent of TST with nocturnal hypoxemia compared to CKD patients by 2.7 points, respectively (likelihood ratio test p = 0.01). The APD group had also significantly greater stages 3 to 4 sleep compared to the CKD patients by 8.6 points (likelihood ratio test p = 0.009). In multivariate analyses and after adjustment for age, gender, race, and BMI, both APD and HD patients had higher average PSQI scores than CKD patients by 2.54 and 2.22 points, respectively (likelihood ratio test p = 0.005). No other comparisons of sleep parameters among groups reached statistical significance., Limitations: The limitations of this study are the small sample size of the APD population and the demographic and clinical differences among the three study groups., Conclusions: Despite differences in univariate analyses, after multivariate adjustment, APD patients had similar sleep parameters and sleep architecture and as poor SQ and symptoms of depression as HD patients. Future studies with larger APD cohorts are needed.

Studies have shown that a single-item question might be useful in identifying patients with limited health literacy. However, the utility of the approach has not been studied in patients receiving maintenance peritoneal dialysis (PD). We assessed health literacy in a cohort of 31 PD patients by administering the Rapid Estimate of Adult Literacy in Medicine (REALM) and a single-item health literacy (SHL) screening question "How confident are you filling out medical forms by yourself?" (Extremely, Quite a bit, Somewhat, A little bit, or Not at all). To determine the accuracy of the single-item question for detecting limited health literacy, we performed sensitivity and specificity analyses of the SHL and plotted the area under the receiver operating characteristic (AUROC) curve using the REALM as a reference standard. Using a cut-off of "Somewhat" or less confident, the sensitivity of the SHL for detecting limited health literacy was 80%, and the specificity was 88%. The positive likelihood ratio was 6.9. The SHL had an AUROC of 0.79 (95% confidence interval: 0.52 to 1.00). Our results show that the SHL could be effective in detecting limited health literacy in PD patients.

This review is focused on minimizing complications and avoiding harm in peritoneal dialysis (PD) patients. Issues related to planning for PD are covered first, with emphasis on PD versus hemodialysis outcomes. Catheter types and insertion techniques are described next, including relevant recommendations by the International Society for Peritoneal Dialysis. A brief review of both noninfectious and infectious complications follows, with emphasis on cardiovascular and metabolic complications. Finally, recommendations for preventing PD-related infections are provided. In conclusion, with proper catheter insertion technique, good training, and attention to detail during the tenure in PD, excellent outcomes can be obtained in a well-informed motivated patient., (Copyright © 2012 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Encapsulating peritoneal sclerosis (EPS) is a life-threatening complication of peritoneal dialysis. Few data are available from the United States about the incidence of EPS over time. To examine that question, we retrospectively examined our PD registry, in existence for 30 years, to identify patients with EPS. All other data were collected prospectively. We asked a radiologist to review all computed tomography (CT) scans taken at the time of EPS diagnosis. Incidence of EPS in our 676 patients was 1.2%, but rose to 15% after 6 years, and 38% after 9 years on PD. Peritonitis rates were not high in patients that developed EPS. Scoring of CT scans confirmed the diagnosis of EPS in all patients. Treatment was variable, but in recent years, steroids and tamoxifen were generally used when EPS was recognized. Mortality related to EPS was 38%. Several years after diagnosis, 3 patients are still alive; none is on total parenteral nutrition. In summary, the risk of EPS is low early in the course of PD, but increases progressively at 6 years and beyond. Imaging by CT is useful for diagnosing EPS. Our preliminary results suggest that steroids and tamoxifen are beneficial. Multicenter studies on this serious problem are needed.

The Kidney Disease Outcomes Quality Initiative guidelines for peritoneal dialysis (PD) emphasize the need for quality improvement interventions to improve outcomes in PD. Here, we report 17 years experience of initiatives focused on lowering peritonitis rates in a single PD program. This institutional review board-approved retrospective analysis used a PD registry containing prospectively collected data on patient demographics, initial Charlson comorbidity index (CCI), peritonitis, and clinical outcomes, including reasons for transfer to hemodialysis. Periods were analyzed based on quality initiatives: 1990 - 1991, baseline; 1992 - 1995, randomized controlled trial of exit-site infection prophylaxis comparing mupirocin cream applied daily to the exit site with oral cyclical (every 12 weeks) rifampin; 1996 - 1999, compact assist device introduced for spiking on the cycler; 2000 - 2004, randomized controlled trial comparing daily gentamicin cream with mupirocin as exit-site prophylaxis; and 2005 - 2007, gentamicin prophylaxis implemented as routine care (2005) and retraining of all patients (2006). Infection rates and technique failure rates in each period were compared with baseline rates using incident rate ratio analysis. A total of 382 PD patients were evaluated [median age: 50 years (range: 18 - 90 years); 54% women; 19% African American; 36% with diabetes; median CCI: 5 (range: 2 - 14)]. The peritonitis rate declined from 0.5 episodes per year at risk in 1990 - 1991 to 0.25 episodes per year at risk in 2005 - 2007 (p < 0.004). The exit-site infection rate declined from 0.72 episodes per year at risk to 0.1 episodes per year at risk over the same period (p < 0.0001). The percentage of patients transferring to hemodialysis did not change significantly over time (overall 14%, varying from 12% to 17% annually), nor did the mortality rate, which varied from 115 per 1000 years to 171 per 1000 years. We conclude that quality improvement initiatives can reduce infection rates in PD patients.

The Kidney Disease Outcomes Quality Initiative (K/ DOQI) 2006 recommended a minimum weekly Kt/V of 1.7 for peritoneal dialysis (PD) patients while emphasizing the importance of keeping the patient free of uremic symptoms. We examined a symptom score index [Pittsburgh Symptom Score (PSS)] designed to evaluate uremic symptoms to determine if the score improved in the first year of PD. The PSS is a 10-symptom (fatigue, trouble sleeping, difficulty concentrating, restless legs, change in taste, loss of appetite, nausea or vomiting, pruritus, bone pain, muscle pain or weakness) questionnaire that uses a Likert scale of 0 (none) to 5 (severe). From January 1, 2003, to December 31, 2006, incident PD patients completed the PSS at 0, 3, 6, 9, and 12 months. Patients were excluded from analysis if they had been on PD for less than 6 months or on hemodialysis 6 months or more before starting PD. Prevalences of individual symptoms at 1 year and at baseline were compared using the chi-square test. Differences in PSS at the various time intervals were compared using the sign test. The study included 45 patients [51% women; 31% African Americans; 33% with diabetes; mean age: 58.0 years (range: 30 - 89 years); mean initial Charlson Comorbidity Index: 5 (range: 2 - 11)]. Initial median total score improved to 8 from 12 (p = 0.005) by 3 months, with no further improvement. Improvements occurred in change in taste (p = 0.029 at 3 months), difficulty concentrating (p = 0.04 at 6 months), itching (p = 0.007 at 3 months), loss of appetite (p = 0.009 at 3 months), muscle pain or weakness (p = 0.002 at 3 months), sleep disturbance (p = 0.04 at 9 months), and restless legs (p = 0.026 at 9 months). Fatigue, bone pain, and nausea or vomiting scores were low at the start and did not significantly change over the first year. Significant decreases in symptom prevalence were seen in difficulty concentrating (p = 0.03), change in taste (p = 0.005), loss of appetite (p = 0.04), and muscle pain or weakness (p = 0.02) at 1 year. Initiation of PD results in improvement in the prevalence and severity of most uremic symptoms by 3 to 9 months and is maintained at 12 months. We recommend routine checklist evaluation of symptoms at regular clinical intervals.

This is the case of a 41-year-old renal transplant recipient taking tacrolimus immunosuppressive therapy, who had a large pleural effusion, found on a chest radiograph during the work-up of digital clubbing. The patient had undergone a renal transplant 17 months earlier for end-stage renal disease secondary to immunoglobulin A nephropathy. Analysis of the effusion fluid demonstrated a lymphocytic exudate. Biopsy specimens of pleural and lung tissues showed noncaseating granulomas. Fluid and tissue cultures were negative for viral, fungal, and bacterial pathogens. Diagnosis of sarcoidosis was established by identification of noncaseating granulomas in pleural and lung tissue, the exclusion of other conditions, and rapid resolution of the effusion after the institution of corticosteroid therapy. The patient has remained free of pulmonary symptoms and had normal chest radiographs during the 20-month follow-up period.

Most women on dialysis are amenorrheic and do not ovulate, but little information about menstrual patterns in women on dialysis exists, especially since the introduction and use of recombinant human erythropoietin, a therapy that may improve sexual interest and function. In this study, women who were < or = 55 years of age at the start of dialysis (n = 76) completed questionnaires and form the study group. Women older than 55 years at the start of dialysis did not complete the entire questionnaire (n = 115), but their medication records were reviewed for estrogen replacement therapy. The questionnaire asked about pregnancies, menstrual periods (regularity, frequency, duration, character of flow, menopause), and menopause before beginning dialysis and currently. Women also responded to questions about sexual activity, use of birth control, contraception counseling by physicians, yearly Papanicolaou smears, and mammograms. Demographic data (age, race, age at the time dialysis started, mode of dialysis, use of recombinant human erythropoietin, and history of renal transplant) were also obtained through the questionnaires. Fifty-nine percent of the 76 women who completed the study were white and had been on dialysis a median of 3 years (range, 0.1 to 18 years). The median age was 43 years, 68% were on hemodialysis, 90% were receiving recombinant human erythropoietin, and 70% had been pregnant (a total of 179 pregnancies; four pregnancies in four women occurred after the start of dialysis). Significantly more women were menstruating before dialysis started than currently (63% v 42%; P < 0.025), but the difference could be explained by patient age: currently menstruating women were younger (37 +/- 9 v 46 +/- 11 years; P = 0.0002). More women reported menstrual regularity before beginning dialysis (75% v 42% currently; P < 0.005), but there were no differences in number of days between or number of days of menstruation before beginning dialysis and currently. Menstrual flow was reported as heavier currently by more women (64% heavy flow with clots v 38% before dialysis started; P < 0.05). The median age at menopause was 47 years; 28% of the women were postmenopausal. Fifty percent of the women were sexually active, but only 36% used birth control. Discussions between the women and their nephrologist about possible pregnancy and contraception were reported by only 13% of women. Sixty-three percent of the women reported having yearly Papanicolaou smears and 73% had had a mammogram. Only 5% of the 113 women who were older than 55 years when they began dialysis were receiving estrogen replacement therapy. Amenorrhea was reported in this study by a smaller proportion of women than in studies conducted before the introduction of recombinant human erythropoietin. The possibility that erythropoietin may restore normal hormonal cyclic function in women with end-stage renal disease requires further study. Nephrologists as well as primary care physicians and gynecologists need to focus more on the gynecologic concerns of women on dialysis, including the potential for pregnancy. The effects of estrogen replacement on atherosclerosis and osteoporosis, and consideration of such therapy in women on dialysis warrants attention.

The medical care of end-stage renal disease (ESRD) patients includes not only dialysis-related medical care but preventive and general medical care as well as the care of minor acute illnesses. There is little information about nephrologists' interpretation of their potential role as a primary health care provider for the general medical needs of chronic dialysis patients. To characterize nephrologists' primary care practice patterns related to the care of chronic dialysis patients, we surveyed a randomly selected group of practicing nephrologists and asked questions about preventive medicine guidelines followed, treatment of minor acute illnesses, and management of chronic medical problems in ESRD patients. The results of 233 questionnaires (46% response rate) were analyzed. Most of the responding nephrologists were men (91%), were board certified in internal medicine (96%) and nephrology (83%), were out of nephrology practice for a mean of 16 years, had a mean age of 48 +/- 7 years, and were in private practice (65%). The average percentage of time spent with chronic dialysis patients was reported as 30%; 38% of that time was devoted to the general medical care of those patients. Ninety percent of nephrologists reported that they provided primary care to their dialysis patients, and only 21% said a nurse practitioner or physician assistant worked with them. Age and number of years in practice were the only demographic factors increasing the likelihood of nephrologist-provided primary care, with older, more experienced practitioners more likely to be providing primary care to dialysis patients. Most nephrologists reported that they managed minor acute illnesses and comorbid conditions (diabetes mellitus, cardiac disease, and gastrointestinal disease) in their dialysis patients. Nephrology fellowship training programs and recertification programs may need to address issues of primary general health care of ESRD patients. Plans under development for health care programs and reimbursement criteria also need to recognize and consider the primary medical care role practiced by nephrologists caring for ESRD patients.

Studies with 1.75 mmol/L calcium dialysate have shown that patients gain calcium from dialysate. Thus, hypercalcemia, especially when calcium compounds are used for phosphate control, is a commonly seen complication. Dialysate with 1.25 mmol/L calcium has been available since 1989. Little is known about calcium mass transfer (CMT) with dialysate of this calcium concentration. CMT was measured in 20 stable adult peritoneal dialysis patients. Each CMT study consisted of a 2-L continuous ambulatory peritoneal dialysis (CAPD) exchange with a dwell time of 4 hours. CMT studies were performed using 1.25 and 1.75 mmol/L calcium dialysate with 1.5, 2.5, and 4.25 g/dL dextrose concentrations. CMT with 1.25 mmol/L calcium dialysate was compared to that with 1.75 mmol/L for each dextrose concentration. With a dextrose concentration of 1.5 g/dL, the mean CMT for 1.25 mmol/L calcium dialysate was -0.1 +/- 0.3 mmol versus 0.6 +/- 0.3 mmol for 1.75 mmol/L calcium dialysate (P < 0.0001). A dextrose concentration of 2.5 g/dL resulted in a mean CMT of -0.4 +/- 0.2 mmol for 1.25 mmol/L calcium versus 0.45 +/- 0.25 mmol for 1.75 mmol/L calcium (P < 0.0001). Using a dextrose concentration of 4.25 g/dL, the mean CMT was -0.7 +/- 0.25 mmol for 1.25 mmol/L calcium versus -0.05 +/- 0.35 mmol for 1.75 mmol/L calcium (P < 0.0001). Mean serum ionized calcium (SiCa) was between 1.15 and 1.20 mmol/L for all study groups. CMT inversely correlated with SiCa for each type of dialysate used. CMT was dependent on the concentrations of calcium and dextrose in the dialysate and the SiCa level at the time of the exchange.(ABSTRACT TRUNCATED AT 250 WORDS)

Polycythemia in CAPD patients has been rarely described. Over an eight year period, 4 out of 123 CAPD patients (3%) were identified as having Hct values exceeding 50% for 1 month or longer. All of the 4 patients were insulin dependent diabetics (4/47 diabetic patients, 8.5%). Charts were reviewed on 3 of these 4 patients. Polycythemia developed after a mean of 21 +/- 7 months on peritoneal dialysis. Prior to the development of polycythemia, ferritin levels were low and ferrous sulfate therapy was begun at a time the Hct values were 36 to 40%. Erythropoietin levels were obtained in 2 patients, and were 22 U/L (Hct 51%) and less than 5 U/L (Hct 55%). Renal ultrasound failed to show renal masses or cysts. One patient had a plasma volume of 2.1 L (normal 2.4-3.2 L); another patient was clinically volume depleted. Complications during the period of polycythemia included gangrenous feet requiring amputation in 2 patients, CVA in 2 patients, and splenic infarct in 1 patient. One patient died of cerebral thrombosis. We conclude that polycythemia is uncommon in CAPD patients and occurs most often in diabetic patients. Volume depletion and iron therapy may play a role in its etiology. In this high risk group of patients polycythemia may contribute to vascular complications and should be avoided.

Provoked by changes that are occurring in health care, hospitals are currently formulating and implementing strategies to identify and control costs while maintaining the highest quality of care. Because drug costs account for a significant proportion of the hospital supply budget (5 to 10%), there is an increased need for the P & T Committee to become involved in the cost containment effort. This article will demonstrate how an existing program of drug utilization review (DUR) has reduced drug expenses without sacrificing the quality of care or imposing unnecessary restrictions on formulary items. Furthermore, implementation of the DUR program has not resulted in conflict between pharmacy, medical, nursing or administrative staffs within the institution.

The Pharmacy and Therapeutics (P & T) Committee is an important medical staff advisory group. As the primary, formal communication link between the pharmacy and medical staff, the P & T Committee is of particular importance to the department of pharmacy services. All matters pertaining to the use of medications within the institution, including pharmacy programs, must be reviewed and approved through the committee. In addition, medication formulary data is reviewed through the committee and recommendations are offered to the medical staff. Such a wide diversification of involvement and activity necessitates the effective communication between all committee members. An active involvement in the committee by the department of pharmacy services is vital in order to develop a contemporary and progressive institutional pharmacy program. This series of four articles will address several important aspects of the committee's operation, including committee formation, mechanics, operation, and problem solving.

Abuse of the oral combination of glutethimide (DORIDEN) and codeine, commonly referred to as "sets", in the northwest Pennsylvania area is reviewed. Nine fatalities have been reported in the Erie area from 1985-87 due to acute toxicity with this combination. The glutethimide/codeine combination reportedly produces a euphoric effect comparable to intravenous heroin but is longer lasting. Age of the victims ranged from 18 to 37 years. In all cases there was a history of chronic intentional "sets" abuse by the victims prior to death. The 9 fatalities due to this combination of prescription drugs is unusually high for this area considering the population and rural nature of the Erie community. Although the use of "sets" has been reported occasionally in other localized areas of the country, no other significant use has been reported in Pennsylvania.

An active and enthusiastic participation by all members of the P & T Committee greatly improves committee effectiveness and productivity. Specific responsibilities for the physician, pharmacist, and nursing members of the committee are presented and discussed. In addition, the importance of open communication among committee members is reviewed. Examples of problems that may develop and suggested solutions are also presented.