Context: Patients with end-stage renal disease (ESRD) have a life-limiting illness associated with significant morbidity. The 'tipping point' where increased medical and supportive care is needed ...urgently can be missed. It cannot be assumed that specialist palliative care (SPC) services which evolved to care for patients with cancer will also be right for patients with different diagnoses.
Objectives: To review retrospectively the end-of-life care of patients receiving renal replacement therapy (RRT) from our institution.
Methods: We conducted a single-centre retrospective cohort study. We reviewed medical charts and electronic records to record patient characteristics, mode of dialysis, place of death and the time spent in hospital.
Results: One hundred and sixty-one patients were included in our study. The mean age at death was 63 years and 68% were male. In their last year of life, patients spent a median of 53 days as inpatients with a median of three admissions. The haemodialysis cohort spent a median of 59 inpatient days in their last year of life, excluding day case attendances. One hundred and twenty-two (76%) patients died in hospital, 103 of those in our institution. Twenty-seven (17%) patients died at home while four (2%) died in an inpatient hospice unit. Preference for place of care was documented for 33 (20%) patients. Overall, 56 (35%) patients were referred to SPC.
Conclusion: End-of-life planning should be a more regular goal in all patients on RRT. Given the frequency of hospital attendance, opportunities should be grasped to make advance plans to facilitate patients' wishes.
National and international guidelines recommend the use of effective vascular access (VA) and infection prevention and control practices within the haemodialysis environment. Establishing an ...arterio-venous fistula (AVF) and preventing central venous catheter (CVC)-related infections are ongoing challenges for all dialysis settings. We surveyed VA and routine infection prevention and control practices in dialysis units, to provide national data on these practices in Ireland.
A descriptive survey was emailed to nurse managers at all adult (n = 19) and children (n = 1) outpatient haemodialysis units in the Republic of Ireland. Data collected included AVF formation, CVC insertion and maintenance practices, VA use and surveillance of infection and screening protocols. Nineteen of the 20 units responded to the survey.
The AVF prevalence was 49% for 1370 patients in 17 units who provided these data mean prevalence per unit: 45.7% (SD 16.2); the CVC mean prevalence per unit was 52.5% (SD 16.0). Fourteen dialysis units experienced inadequate access to vascular surgical procedures either due to a lack of dedicated theatre time or hospital beds. Six units administered intravenous prophylactic antimicrobials prior to CVC insertion with only two units using a CVC insertion checklist at the time of catheter insertion.
In general, dialysis units in Ireland show a strong adherence to national guidelines. Compared with the 12 countries participating in the Dialysis Outcomes Practice Patterns Study (DOPPS 4), in 2010, AVF prevalence in Irish dialysis units is the second lowest. Recommendations include establishing an AVF national prevalence target rate, discontinuing the administration of intravenous prophylactic antimicrobials prior to CVC insertion and promoting the use of CVC insertion checklists.
NMR spectroscopy as a novel approach to the monitoring of renal transplant function. High field 1H NMR spectroscopy was used for the rapid multicomponent analysis of low molecular wt compounds in ...urine in order to investigate the patterns of metabolic changes associated with early renal allograft dysfunction. Urine samples were collected daily for 14 days from 33 patients who underwent primary renal allograft transplantation, and analyzed by 500 and/or 600MHz 1H NMR spectroscopy. All patients received 20mg prednisolone and 5 mg/kg b.d. oral cyclosporin A (CsA) solution. In this study no patient showed clinical or histopathological evidence of CsA nephrotoxicity. For each patient the NMR-generated metabolite data were correlated with the clinical observations, graft biopsy pathology, and data from conventional laboratory techniques for assessing renal function. The NMR spectra of urine from patients with immediate functioning grafts were similar with respect to their patterns of amino acids, organic acids and organic amines, whereas the patients with delayed or non-functioning grafts showed significantly different metabolite excretion patterns. In longitudinal studies on individual patients there were increased urinary levels of trimethylamine-N-oxide (TMAO), dimethylamine (DMA), lactate, acetate, succinate, glycine and alanine during episodes of graft dysfunction. However, only the urinary concentration of TMAO was statistically significantly higher (P < 0.025) in the urine collected from patients during episodes of graft dysfunction (410 ± 102 µM TMAO/mm creatinine) than in patients with good graft function (91 ± 18 µM TMAO/mm creatinine) or healthy control subjects (100 ± 50 µM TMAO/mm creatinine). These findings suggest that graft dysfunction is associated with damage to the renal medulla which causes the release of TMAO into the urine from the damaged renal medullary cells. This provides a possible novel urinary marker for post-transplant graft dysfunction. This study shows that NMR spectroscopy of biofluids, when used in combination with conventional laboratory techniques, is a valuable aid to renal transplant monitoring.
Urinary proteins have been found to be a sensitive marker of renal damage caused by nephrotoxic agents. An electrophoretic method was used to investigate the potential value of the pattern of urinary ...protein excretion in 14 cyclosporin-treated renal transplant patients, to differentiate between graft rejection episodes and other causes of renal dysfunction. Urinary protein excretion consistent with renal damage was observed in all of the patients studied, with no marked differences between those with signs of graft rejection, those with renal dysfunction, or those with stable renal function.
Conventional continuous ambulatory peritoneal dialysis (CAPD) in patients without residual renal function and with high solute transport is associated with worse clinical outcomes. Automated ...peritoneal dialysis (APD) has the potential to improve both solute clearance and ultrafiltration in these circumstances, but its efficacy as a treatment modality is unknown. The European Automated Peritoneal Dialysis Outcomes Study (EAPOS) is a 2-year, prospective, European multicenter study designed to determine APD feasibility and clinical outcomes in anuric patients. The present article describes the baseline data for patients recruited into the study.
All PD patients treated in the participating centers were screened for inclusion criteria urinary output < 100 mL/24 h, or residual renal function (RRF) < 1 mL/min, or both. After enrollment, changes were made to the dialysis prescription to achieve a weekly creatinine clearance above 60 L per 1.73 m2 and an ultrafiltration rate above 750 mL in 24 hours.
The study is being conducted in 26 dialysis centers in 13 European countries. BASELINE DATA COLLECTION: The information collected includes patient demographics, dialysis prescription, achieved weekly creatinine clearance, and 24-hour ultrafiltration (UF).
The study enrolled 177 anuric patients. Median dialysis duration before enrollment was 22.5 months (range: 0-285 months). Mean solute transport measured as the dialysate-to-plasma ratio of creatinine (D/P(Cr)) was 0.74 +/- 0.12. Patients received APD for a median of 9.0 hours overnight (range: 7-12 hours) using a median of 11.0 L of fluid (range: 6-28.75 L). Median daytime volume was 4.0 L (range: 0.0-9.0 L). Tidal dialysis was used in 26 patients, and icodextrin in 86 patients. At baseline, before treatment optimization, the weekly mean total creatinine clearance was 65.2 +/- 14.4 L/1.73 m2, with 105 patients (60%) achieving the target of more than 60 L/1.73 m2. At baseline, 81% of patients with high transport, 69% with high-average transport, and 40% with low-average transport met the target. At baseline, 70% of patients with a body surface area (BSA) below 1.7 m2, 60% with a BSA of 1.7-2.0 m2, and 56% with a BSA above 2.0 m2 achieved 60 L/1.73 m2 weekly. Median UF was 1090 mL/24 h, and 75% of patients achieved the UF target of more than 750 mL/24 h.
This baseline analysis of anuric patients recruited into the EAPOS study demonstrates that a high proportion of anuric patients on APD can achieve dialysis and ultrafiltration targets using a variety of regimes. This 2-year follow-up study aims to optimize APD prescription to reach predefined clearance and ultrafiltration targets, and to observe the resulting clinical outcomes.
Europe's organ donation crisis Mellotte, George J
Irish Medical Times,
11/2007, Letnik:
41, Številka:
45
Trade Publication Article
* There is a need to develop strategies to increase the number of donors and this needs to be at a government level. Such strategies could include: promoting living donor transplantation; increasing ...cadaveric donor rates and looking at ICU practice and supporting hospitals in encouraging organ donation; and searching for alternate sources of donors such as non-heart beating donors.
We examined the hypothesis that administering epoetin to maintain a lower target haemoglobin (Hb) results in a reduced side effect profile and a lower maintenance epoetin dose. We report a ...prospective study of 14 haemodialysis patients assessing epoetin dose efficiency and side effect profile of partially correcting dialysis-associated anaemia. Initial Hb was 6.2 +/- 0.6 g/dl (mean +/- 1 SD). Intravenous epoetin was commenced at 120 IU/kg/week in 3 divided doses and titrated to achieve a target Hb of 8 g/dl. Follow-up was 24 weeks. The final Hb was 8.7 +/- 0.8 g/dl. The peak epoetin dose was 196 +/- 86 IU/kg/week with a maintenance dose of 141 +/- 71 IU/kg/week. Therapy was associated with hypertension--5 patients (32%); seizures--1 patient (6%) (withdrawn from therapy), and temporary iron deficiency--4 patients (35%). Iron deficiency was corrected with oral therapy. There was 1 treatment failure. Comparable conventional regimens use 100-200 IU/kg to maintain the Hb at 10-13 g/dl and have a similar incidence of side effects. We concluded that reducing the target Hb in order to decrease epoetin requirements is not justified as it offers no benefit over conventional Hb targets in terms of dose requirements or side effects.
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