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Background We explored the potential impact of staff opinions and service provision upon patient's willingness to recruit to a clinical trial studying the effects of extended treatment time (TT) on haemodialysis (HD), six hours versus four hours for a period of twenty-four weeks. Methods We conducted a local survey of dialysis nurses and a national survey of multidisciplinary HD staff opinions to extended TT including clinical benefits, tolerance to, prescription and ability to accommodate extended TT on in-centre HD programmes. Results The survey was completed by 56/134 (42%) local nurses and the national survey by 15/72 (21%) of dialysis providers across the UK (35% nurses and 75% other healthcare professionals). The majority of respondents felt extended TT was clinically beneficial but only 42% of nurses would recommend extended TT compared to 95% of non-nursing healthcare professionals (p < 0.0001). Although 45% of nurses felt that it was well tolerated, non-nursing healthcare professionals suggested this was significantly higher at 75% (p

Purpose Central venous catheters for maintenance hemodialysis (HD) are designed to attain the required dialysis dose through sustained high blood flow rates (BFR). The authors studied the immediate and long-term performance and complications of two twin-catheter systems, the Tesio catheter (TC) and the LifeCath Twin (LC), to inform clinical practice. Methods This single-center randomized controlled parallel-group trial allocated 80 incident patients (1:1) to receive either a TC (MedComp) or LC (Vygon). Patients were dialyzed to target BFR 450 mL/min and followed up for 12 months. The primary outcome was achievement of target BFR during the first HD session. Secondary outcomes included thrombotic dysfunction, displacement and catheter-related infection. Catheter dysfunction was defined by a BFR ≤ 250 mL/min. Results More LCs reached the primary endpoint (44% vs. 10%, p=0.001) delivering a higher BFR (mean 383±82 vs. 277±79 mL/min, pConclusions The LC can deliver greater BFRs in the first three HD sessions following insertion although this did not translate into differences in performance, dialysis adequacy or complication rates with long-term use. Both catheter types can consistently deliver high BFRs over an extended period of time.

Hypo-responsiveness to erythropoiesis-stimulating agents (ESAs) has been associated with increased mortality. We examined the effect of water treatment component replacement on declining ESA responsiveness in the absence of chemical or microbiological standards failure. Pre-emptive renewal of the water treatment system supplying 802 standard-flux haemodialysis patients resulted in a significant rise in haemoglobin from (mean ± SD) 12.1 ± 1.2 to 12.3 ± 1.0 g/dl (p < 0.0001), accompanied by a significant decrease in prescribed dose of darbepoetin alfa from 47.9 ± 27.3 to 44.7 ± 27.6 μg/week (p < 0.0001). ESA responsiveness improved significantly from 0.060 ± 0.041 to 0.055 ± 0.040 μg/kg/g·dl-1 (p < 0.0001) and the number of patients no longer requiring ESA therapy increased threefold. These benefits were derived in the absence of haemolysis or significant changes in water quality. Renewal of water system components should be conducted even in the absence of proven microbiological and chemical failure.

Analyses of national registry-based datasets have demonstrated the association of longer haemodialysis treatment times with lowered mortality risk.We performed a prospective cohort study of 451 incident haemodialysis patients and examined the effect of targeting higher dialysis dose with extended treatment time, on 10-year patient outcomes.Mean treatment time (TT) was 233 ± 22.8 minutes (median 235, range 180-296). Overall patient survival was 95% at 1 year, 75% at 3 years, 56% at 5 years and 25% at 10 years. Increasing TT was associated with incremental 10-year patient survival (TT/=241 minutes 39.7%, TT 226-240 minutes 19.6% and TT/=225 minutes 14.7%; p0.001). Single pool Kt/V and TT were strong independent predictors of patient survival in Cox multivariate analysis (p0.0001). At 10 years, each 0.1-unit increase in spKt/V and 20-minute increase in TT were associated with a 20% and 32% decrease in the relative risk of death, respectively. Survival benefits of higher dialysis dose and longer TT were cumulative, with highest survival exhibited by patients achieving both Kt/V1.6 and TT/=241 minutes, and lowest survival exhibited by patients receiving Kt/V1.2 and TT/=225 minutes.Extended treatment times are associated with higher patient survival irrespective of dialysis dose. Further study of extended treatment time and effect on patient outcomes is needed.

Stroke incidence in hemodialysis patients is up to 10 times greater than in the general population and is associated with a worse prognosis. Factors influencing stroke risk by subtype and subsequent prognosis are poorly described in the literature.Retrospective single-center cohort study.2,384 established maintenance hemodialysis patients at a single center from January 1, 2002, to June 1, 2009.Patient demographics, comorbid conditions.Incidence of acute stroke (International Classification of Diseases, 9th Revision codes 430, 431, 432.9, 433.1, and 434.1 with evidence of compatible neuroimaging), patient survival.Cumulative patient survival, incidence of acute fatal and nonfatal stroke.127 strokes occurred during 9,541 total patient-years of follow-up. First (incident) stroke occurred at a rate of 14.9/1,000 patient years (95% CI, 12.2-17.9) with a predominance of ischemic compared with hemorrhagic subtypes (11.2 vs 3.7/1,000 patient-years). 54% of hemorrhagic strokes occurred in patients of South Asian ethnicity compared with ischemic strokes, which occurred predominantly in white patients (45% of events). Diabetes mellitus (HR, 1.92; 95% CI, 1.29-2.85; P = 0.001) and prior cerebrovascular disease (HR, 4.54; 95% CI, 3.07-6.72; P0.001) were independently associated with incident cerebrovascular accident on multivariate analysis. Acute stroke was associated with worse patient survival (HR, 3.26; 95% CI, 2.47-4.30; P0.001) and overall 1-year mortality of 24%, which was significantly worse in patients with hemorrhagic events (39% vs 19% mortality for ischemic subtypes). Serum albumin level3.5 g/L (HR, 0.38; 95% CI, 0.19-0.76; P = 0.007) and C-reactive protein level3.0 mg/l (HR, 1.36; 95% CI, 1.12-1.64; P = 0.002) influenced survival after stroke on multivariate analysis.Retrospective analysis of data cannot prove causality.The high incidence of stroke in hemodialysis patients is associated with high mortality, especially hemorrhagic subtypes. Strict management of hypertension, better appreciation of hemodialysis anticoagulation, and large-scale interventional studies are urgently required to direct prevention and treatment of this significant disease.

The use of central venous catheters for long-term hemodialysis has been associated with increased mortality and high prevalence of infection and venous stenosis. However, because central venous catheters still constitute a significant proportion of vascular access in prevalent populations, even in the Fistula-First era, the authors examined the long-term patient outcomes and performance of this vascular access type to inform current clinical practice.The authors conducted a retrospective cohort study of 433 patients on maintenance hemodialysis in a dialysis program from January 1999 through April 2008 all using twin-catheter Tesio Caths (TCs) (MedCOMP, Harleysville, Pennsylvania). Written and electronic records were examined with respect to laboratory indices as well as mortality, access-related infection, need for thrombolytic infusion, access revision and dialysis adequacy.A total of 759 TCs were inserted with 552,035 catheter days follow-up. Thirty-six percent of insertions were in patients incident to dialysis (90 days). Mean single-pool Kt/V was 1.6 ± 0.3. Cumulative cohort survival rates were 85%, 72%, and 48% at 1, 2, and 5 years, respectively. No patients died as a result of lack of vascular access. Cumulative assisted primary access site patencies were 76%, 62%, and 42% at 1, 2, and 5 years, respectively. The prevalence of symptomatic central venous stenosis was 5%. Catheter-related bacteremia occurred at a rate of 0.34 per 1,000 catheter days.Appropriate use of TCs with protocolized care can deliver effective long-term hemodialysis with good adequacy and rates of access-related infection approaching those seen with arteriovenous grafts.

Background. The incidence of subdural haematoma (SDH) is high in haemodialysis (HD), with data suggesting an increasing incidence over time. The prognosis remains poor with 40% mortality at 30 days. The extent of this problem in non-US populations has not been described in the literature. Methods. We conducted a retrospective, single-centre UK study of non-traumatic SDH in patients established on maintenance HD between 1 January 2002 and 1 June 2009. Results. The prevalence of SDH was 0.4% at our centre with an overall annual incidence of 189 per 100 000 patients. SDH was associated with increased patient age (mean 71.3 ± 8.5 years) but not associated with a higher prevalence of major comorbid conditions and antiplatelet or anticoagulant use. Mortality was high (46% at 30 days, 58% at 1 year). We did not observe a trend to increasing prevalence of this condition over time. Conclusions. SDH has a higher (>20 times) incidence in HD patients than in the general population and is associated with high mortality. Although the prevalence in this study was lower than in published US studies, the incidence rate is similar. Further studies to validate prognostic criteria that guide decisions regarding surgery are required.

Background and objectives: Preemptive transplantation is ideal for patients with advanced chronic kidney disease (CKD). The practice has been to perform coronary angiography (CA) on all patients aged >50, all diabetics, and all patients with cardiac symptoms or disease with a view to revascularization before transplantation. Historically patients have delayed CA until established on renal replacement therapy due to concerns of precipitating the need for chronic dialysis. The objectives of this study were to establish the risk of contrast nephropathy in patients with advanced CKD who undergo screening CA, and to determine whether or not preemptive transplantation is achievable. Design and setting: This retrospective analysis included 482 patients with stage IV/V CKD seen in West London predialysis clinics from 2004 to 2007. Seventy-six of 482 (15.8%) patients considered as potential transplant recipients met the authors9 criteria for coronary angiography. Modification of Diet in Renal Disease (MDRD) GFR measurements were recorded for the 12 mo preceding and 12 mo following CA unless a defined endpoint was reached (transplantation, dialysis, or death). Results: Mean MDRD GFR at CA was 12.51 ± 3.51 ml/min. The trend was not significantly different 6 mo pre- and postangiography. Cumulative dialysis-free survival was 89.1% 6 mo postangiography. Twenty-three of 76 (30.3%) patients had flow-limiting coronary artery disease. Twenty-five of 76 (32.9%) patients underwent transplantation with 22 of 25 (88.0%) transplants being performed preemptively. Conclusions: The data suggest CA screening does not accelerate the decline in renal function for patients with advanced CKD, facilitating a safe preemptive transplant program.

Sodium citrate has antibacterial and anticoagulant properties that are confined to the catheter when used as a catheter lock. Studies of its use as a catheter lock have suggested its efficacy in preventing infection and bleeding complications compared with sodium heparin.Open-label randomized controlled trial of 2 catheter locks to examine the hypothesis that sodium citrate catheter locks will reduce catheter-related bacteremia and exit-site infection.232 consenting long-term hemodialysis patients in 4 satellite dialysis units to a large dialysis program with protocolized treatment and targets. All patients were using twin-catheter single-lumen Tesio-Caths (MedComp, Harleysville, PA).6 months' use of 46.7% sodium citrate (citrate) or 5% heparin (heparin) locked postdialysis in the dead space of the central venous catheter.Primary end point of catheter-related bacteremia and exit-site infection. Secondary end points of catheter thrombosis defined by the use of urokinase lock and infusion, new catheter insertion, catheter-related admission, blood transfusions, parenteral iron, and erythropoietin requirements.Catheter-related bacteremia did not differ in the 2 groups, with an incidence of 0.7 events/1,000 catheter-days. There was no significant difference in rates of exit-site infection (0.7 versus 0.5 events/1,000 catheter-days; P = 0.5). The secondary end point of catheter thrombosis defined by the use of a urokinase lock was significantly more common in the citrate group, with an incidence of 8 versus 4.3/1,000 catheter-days (P0.001). Other secondary end points did not differ. Citrate treatment was curtailed compared with heparin because of a greater incidence of adverse events, with a mean treatment duration before withdrawal of 4.8 +/- 2.0 versus 5.7 +/- 1.2 months, respectively (P0.001).Low baseline catheter-related bacteremia and exit-site infection event rates may have underpowered this study. High adverse-event rates may have been related to high-concentration citrate that led to increased overspill and reduction in lock volume. This may also explain the increased rates of thrombosis in this group.Widespread and long-term use of 46.7% citrate catheter locks with Tesio-Cath access is not justified by this study.

Ethnicity and survival on dialysis in west London.BackgroundIndo-Asian and Afro-Caribbean patients have higher rates of renal failure and requirement for renal replacement therapy than the general population in the UK. Despite this, information regarding survival on dialysis is limited.MethodsThe incident hemodialysis population of a large west London renal service was reviewed from 1996 to 2001 (N = 465).ResultsThe cohort's ethnic background was Indo-Asian (30.8%), Caucasian (49%), Afro-Caribbean (18.3%), and other (1.9%). Indo-Asians and Afro-Caribbeans were younger than Caucasian patients, with a higher rate of diabetes mellitus. Survival on hemodialysis for Indo-Asians was 97.5% and 81.6% at 1 and 3 years, respectively, compared with 92.7% and 75.2% for Caucasians, and 97.5% and 85.3% for Afro-Caribbeans (P = nonsignificant). Dialysis adequacy was observed to be associated with survival. Patients with mean single pool Kt/V of over 1.4 had survival of 90.6% and 74.8% at 2 and 5 years, respectively, compared with 74.0% and 42.9% for those with Kt/V less than 1.4 (P < 0.001). There were significantly more patients in the Indo-Asian cohort with a mean Kt/V of 1.4 or over (87.4%) compared with Caucasians (57.6%) and Afro-Caribbeans (52.4%), and the benefit of higher Kt/V was seen in all ethnic groups. In a multivariate analysis of factors including Kt/V over 1.4, age, diabetic status, gender, and ethnicity, Indo-Asian or Afro-Caribbean ethnicity did not confer a survival disadvantage. The strongest predictors of survival were age and dialysis adequacy.ConclusionIndo-Asian and Afro-Caribbean hemodialysis patients have survival comparable to Caucasians despite a higher burden of diabetes.

BACKGROUND Vascular access for haemodialysis is achieved by tunnelled central venous catheter (CVC) in at least 23% of prevalent patients in the UK, Canada and the USA. Use of CVCs is associated with an increased incidence of venous stenosis that can progressively limit future vascular access routes. Lack of conventional venous access routes mandates the use of alternative strategies such as the translumbar approach. METHODS We retrospectively analysed patients at our centre requiring translumbar inferior vena caval CVCs (TesioCath) for haemodialysis in the period 1999-2008. Written and electronic records capturing dialysis adequacy and complications, hospital admissions and laboratory data were examined. RESULTS Thirty-nine pairs of translumbar CVCs were inserted in 26 patients with 15 864 catheter days follow-up, mean patient age 61.9 +/- 12.1 years, 31% diabetic, 15% with ischaemic heart disease. All insertions were successful. Insertion of one CVC was associated with a self-limiting retroperitoneal haematoma. No patients died of a catheter-related cause or through lack of vascular access. Cumulative assisted primary catheter site patency was 81% at 6 months and 73% at 1 year (median 18.5 months). Good dialysis adequacy was achieved throughout (mean single-pool Kt/V 1.5 +/- 0.4). The incidence of access-related infection was 2.84/1000 catheter days (exit site infection rate 2.02/1000 catheter days; catheter-related bacteraemia rate 0.82/1000 catheter days). Catheter dysfunction (need for thrombolytic infusion or catheter change) led to 0.88 admissions per 1000 catheter days. CONCLUSION Translumbar inferior vena caval CVCs can offer relatively safe and effective long-term haemodialysis access in patients with no other options.

Background and objectives: Treatment without catheter replacement (catheter salvage) has been described for bacteremia associated with tunneled venous catheters in hemodialysis patients, but few data are available on which to base an estimation of the likelihood of treatment success. Design, setting, participants, & measurements: In a prospective cohort study, all cases of catheter-associated bacteremia that occurred in a large dialysis center were identified during a 12-mo period. Catheter salvage was attempted according to a standard protocol in all cases in which a favorable early response to antibiotic therapy was seen, and patients were followed for at least 6 mo. Bacteremias, catheter changes, and all major clinical events were recorded. Results: During a period covering 252,986 catheter days, 208 episodes were identified involving 133 patients, 74% of which were selected for attempted salvage. Salvage was successful in 66.1% of incident bacteremias with a very low complication risk (0.9%). Some bacteremias, however, recurred as late as 6 mo after the initial infection; salvage was less likely to be successful in treating recurrences. Conclusions: Appropriately used catheter salvage can be successful in approximately two thirds of cases; however, recurrences continue to occur up to 6 mo later and are unlikely to be cured without catheter replacement.

The experiences of sutureless levator plication by conjunctival route surgery are described in 80 primary operations performed for all grades of congenital ptosis in the past 2 years. The surgical steps, postoperative care and postoperative complications are reviewed.

Background. Vascular access is judged on its ability to provide good dialysis adequacy, its durability and complication rates. Formation of a functional arteriovenous fistula is desirable but difficult to achieve in a significant proportion of patients. We report the large-scale use of Tesio-Caths, a twin-line single-lumen central venous catheter, to maximize dialysis adequacy where formation of an arteriovenous fistula was not possible. Methods. All patients who had Tesio-Caths inserted between 1 January 1999 and 1 October 2002 were studied. Results. Six hundred and twenty-three Tesio-Caths were inserted from 1 January 1999 to 1 October 2002 in 435 patients, generating 7464 patient months of follow-up. Five hundred and ninety-four out of 623 (95.3%) Tesio-Caths were immediately functional. Mean dialysis adequacy measured by single-pool Kt/V was 1.5±0.3 for all Tesio-Caths for the entire period of study, with 68% of Tesio-Caths delivering a Kt/V >1.4. Cumulative functional Tesio-Cath survival to final failure was 77.8 and 44% at 1 and 3 years, respectively. Cumulative patient survival was 84.7, 71.4 and 63% at 1, 2 and 3 years, respectively. Access-related infection accounted for 0.28 admissions/1000 catheter days, and the death rate from access-related sepsis was 9.6 deaths/1000 patient years at risk. The admission rate for access dysfunction was 0.33/1000 patient years at risk. Conclusion. Tesio-Caths provide good dialysis adequacy for patients in whom an arteriovenous fistula cannot be formed. Patient and functional access survival for this group was comparable with current European data irrespective of vascular access type. Complication rates were acceptably low.

As Morelle et al.1 point out, one might expect to see a reduction in plasma hepcidin levels post dialysis—on size considerations alone, perhaps a 20–30% reduction would be anticipated, but in the six patients studied in our report,2 no reduction was observed. These patients were dialyzed for 4 h using 2.1 m2 low-flux acetate membranes with a minimum ultrafiltrate volume of 2 l, delivering a dialysis dose (spKt/V) of over 1.5 in all patients.