KDOQI guidelines recommend preparation for renal replacement therapy (RRT) once stage 4 chronic kidney disease (CKD) is reached. Recent studies conducted in the general population and in patients ...referred to nephrologists have shown that CKD patients, especially the elderly, are much more likely to die than to reach RRT. We investigated whether futile preparation for RRT was performed in CKD patients referred to our nephrology department.
We included all patients (n = 386) with stage 4 CKD and without prior RRT, seen at our outpatient clinic between 1 November 2004 and 30 April 2007. Demographics, clinical and laboratory data at inclusion were collected. Follow-up continued until 1 November 2007 or later (last appointment or study outcome). The primary outcome was death without requiring RRT, and secondary outcomes were RRT, going through our pre-dialysis education programme (PDEP) and undergoing the creation of an arterio-venous fistula (AVF). Factors predicting these outcomes were analysed.
During complete follow-up (average 23.4 months), 47 patients (12.1%) died without requiring RRT and 59 patients (15.3%) started RRT. The rate of death without requiring RRT in the overall cohort increased from 50 years onwards and exceeded that of RRT in incident patients aged ≥ 80 years. A structured PDEP was offered to 66.1% of patients starting RRT vs 14.9% of patients dying without requiring RRT and 13.9% of patients surviving without requiring RRT (P < 0.001). In addition, 53.3% of patients starting haemodialysis had a prior AVF creation vs 6.4% of patients dying without requiring RRT and 5.7% of patients surviving without requiring RRT (P < 0.001).
The risk of death exceeds that of RRT in stage 4 CKD incident patients aged ≥ 80 years referred to our clinic. Futile preparation for RRT was relatively uncommon (14.9%). We were able to largely avoid futility at the expense of incomplete exposure of patients who eventually started RRT, to the structured PDEP, and of a relatively low (53%) level of AVF created prior to start of HD. Whether and how these figures can be improved will require further investigation.
Antibiotic lock therapy (ALT), in conjunction with systemic antibiotics, is recommended by scientific societies as a treatment of uncomplicated catheter‐related bloodstream infections (CRBSI) in ...hemodynamically stable hemodialysis patients for whom catheter salvage is the goal. The rationale for this strategy is the eradication of intraluminal biofilms by the highly concentrated antibiotic used in the lock. However, the available evidence supporting this recommendation is scanty, and only includes small, short‐term, observational studies (most of them single‐arm), with different definitions of CRBSI cure and variable follow‐up periods. Furthermore, the ability of an antibiotic to eradicate a biofilm is not predicted by its inherent spectrum of antibacterial activity, since sessile microorganisms in their biofilm display other mechanisms of resistance to antibiotics than their planktonic counter‐parts. Additionally, penetration of some antibiotics frequently used into biofilms produced by common microorganisms appears to be low. In this editorial we provide a critical view on the available evidence regarding the efficacy of ALT on the treatment of CRBSI in hemodialysis patients, as well as the microbiological issues and technical challenges of this strategy.
Potential effects of projected climate variability on base flow and groundwater storage in the North Fork Red River aquifer, Oklahoma (USA), were estimated using downscaled climate model data coupled ...with a numerical groundwater-flow model. The North Fork Red River aquifer discharges groundwater to the North Fork Red River, which provides inflow to Lake Altus. To approximate future conditions, Coupled Model Intercomparison Project Phase 5 climate data were downscaled to the watershed and a time-series of scaling factors were developed and interpolated for three climate scenarios (central tendency, warmer and drier, and less warm and wetter) representing future climate conditions for the period 2045–2074. These scaling factors were then applied to a soil-water-balance model to produce groundwater recharge and evapotranspiration estimates. A MODFLOW groundwater-flow model of the North Fork Red River aquifer used the scaled recharge and evapotranspiration data to estimate changes in base flow and water-surface elevation of Lake Altus. Compared to a baseline scenario, the mean percent change in annual base flow during 2045–2074 was −10.8 and −15.9% for the central tendency and warmer/drier scenarios, respectively; the mean percent change in annual base flow for the less-warm/wetter scenario was +15.7%. The mean annual percent change in groundwater storage for the central tendency, warmer/drier, and less-warm/wetter climate scenarios and the baseline are −2.7, −3.2, and +3.0%, respectively. The range of outcomes from the climate scenarios may be influenced by variability in the downscaled climate data for precipitation more than for temperature.
Background Constant-site or buttonhole cannulation of native arteriovenous fistulas (AVFs) has gained in popularity compared with rope-ladder cannulation. However, cannulating nonhealed skin might ...increase the risk of (AVF-related) infectious events, as suggested by small reports. Study Design Quality improvement report. Setting & Participants All patients on in-center hemodialysis therapy using a native AVF from January 1, 2001, to June 30, 2010. Quality Improvement Plan Shift to buttonhole cannulation between August 2004 and January 2005. Because the infectious event rate increased after the shift, educational workshops were held in May 2008 for all nurses, with review of every step of buttonhole protocol. Outcomes Infectious events (unexplained bacteremia caused by skin bacteria and/or local AVF infection) and complicated infectious events (resulting in metastatic infection, death, or AVF surgery) were ascertained during 4 periods: (1) rope-ladder technique in all, (2) switch to buttonhole, (3) buttonhole in all before workshops, and (4) buttonhole in all after workshops. Results 177 patients (aged 70.4 ± 11.5 years) with 193 AVFs were analyzed, including 186,481 AVF-days. 57 infectious events occurred (0.31 events/1,000 AVF-days). The incidence of infectious events increased after the switch to the buttonhole method (0.17 95% CI, 0.086-0.31, 0.11 95% CI, 0.0014-0.63, and 0.43 95% CI, 0.29-0.61 events / 1,000 AVF-days in periods 1, 2, and 3, respectively; P = 0.003). This reached significance during only the second full year of buttonhole cannulation. During period 4, the incidence tended to decrease (0.34 events/1,000 AVF-days). Complicated infectious events (n = 12) were virtually restricted to period 3 (n = 11; 0.153 95% CI, 0.076-0.273 events/1,000 AVF-days), with a significant decrease in period 4 (n = 1; 0.024 95% CI, 0.001-0.118 events/1,000 AVF-days; RR for period 3 vs period 4, 6.37 95% CI, 1.09-138.4; P = 0.04). Limitations Observational partly retrospective design. Conclusion Intensive staff education regarding strict protocol for the buttonhole procedure was associated with a decrease in infectious events.
Buttonhole cannulation (BHC) has been associated with a greater risk of arteriovenous fistula (AVF)-related infections and septicemia than the rope ladder cannulation (RLC) in in-center hemodialysis ...(HD). Such infections have never been studied in satellite HD units.
Retrospective single center study.
All patients in our satellite HD unit using a native AVF from 1 January, 1990, to 31 December, 2012.
Two different kinds of cannulation have been used during the study period: From 1 January, 1990 to 1, January, 1998 RLC was used in the unit (period 1). After 1 January, 1998 onwards, all the patients were switched within 3 months to BHC (period 2).
Three different infectious events were observed during the two periods: local AVF infection, bacteremia, and combined infection. The aim of this study was to evaluate the incidence of AVF-related infections in our low-care HD unit and to determine whether BHC is associated with an increased risk of infection in this population.
162 patients were analyzed; 68 patients participated to period 1 and 115 to period 2. Sixteen infectious events occurred. Incidences of AVF-related infectious events were 0.05 95% CI, 0.02-0.16 and 0.13/1000 AVF-days 95% CI, 0.0.8-0.23, for period 1 and 2 (p = 0.44) respectively. Recurrence of AVF-related infection was observed only during period 2. Unadjusted incidence rate ratio (IRR) of all infections was 0.39 (95%CI 0.12-1.37). Two complicated infections occurred during the study period: one in period 1 and one in period 2.
Observational retrospective single centre study.
BHC is not associated with an increased infectious incidence in our HD population from a satellite dialysis unit. In the rare patients with AVF-related infection it seems necessary to change cannulation sites as recurrence of infection might be an event more frequent with BHC.
Cardiovascular (CV) disease is the leading cause of mortality in patients with end-stage kidney disease (ESKD). The aim of the present study was to determine whether Proprotein Convertase ...Subtilisin/Kexin type 9 (PCSK9) could be an independent predictor of CV events and all-cause mortality in black African haemodialysis patients.
We carried out a prospective cohort study of all consecutive hemodialysis (HD) patients between August 2016 and July 2020, admitted in six hemodialysis centers of Kinshasa, Democratic Republic of Congo. Independent determinants of plasma PCSK-9 measured by ELISA were sought using multiple linear regression analysis. Kaplan-Meier's method described the incidence of CV events while competitive and proportional risk models looked for independent risk factors for death at the .05 significance level.
Out of 207 HD patients, 91 (43.9%) died; 116 (56.1%) have survived. PCSK9 level was significantly higher in deceased patients compared to survivors: 28.0 (24.0-31.0) ng/l vs 9.6 (8.6-11.6) ng/ml (p < 0.001). Patients with plasma PCSK9 levels in tertile 3 had a higher incidence of CV events and mortality compared to patients with plasma PCSK9 levels in tertile 2 or tertile 1 (p < 0.001). Tertile 3 negatively influence survival rates (26.6%) compared to tertile 2 (54.7%) and tertile 1 (85.3%). Patients in tertile 3 and tertile 2 had a 4-fold higher risk of death than patients in tertile 1. After adjustment for all parameters, competitive risk analysis showed that mortality was 2 times higher in patients with stroke. Similarly, serum albumin < 3.5 g/dL or PCSK9 in tertile 3 were respectively associated with 2 or 6 times higher rates of deaths.
Elevated plasma PCSK9 level is an independent major predictor of incident CV events and all-cause mortality in black African HD patients.
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