The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as coronavirus disease (COVID-19), is a major pandemic challenging health care systems around the world. The optimal ...management of patients infected with COVID-19 is still unclear, although the consensus is moving toward the need of a biphasic approach. During the first phase of the disease (from onset of the symptoms up to 7–10 days) viral-induced effects are prominent, with the opportunity to institute antiviral therapy. In the second inflammatory phase of the disease, immunosuppressive strategies (for example with glucocorticoids or anticytokine drugs) may be considered. This latter stage is characterized by the development of progressive lung involvement with increasing oxygen requirements and occasionally signs of the hemophagocytic syndrome. The management of the disease in patients with kidney disease is even more challenging, especially in those who are immunosuppressed or with severe comorbidities. Here we present the therapeutic approach used in Brescia (Italy) for managing patients infected with COVID-19 who underwent kidney transplantation and are receiving hemodialysis. Furthermore, we provide some clinical and physiopathological background, as well as preliminary outcome data of our cohort, to better clarify the pathogenesis of the disease and clinical management.
Background The arteriovenous fistula (AVF) provides an effective vascular access for hemodialysis; however, the associated hemodynamic effects may alter cardiac structure and function. The objective ...of this study is to evaluate the effect of AVF closure on functional and structural echocardiographic findings. Study Design Prospective observational study. Setting & Participants In a single center between 2003 and 2006, we enrolled 25 consecutive hemodialysis patients with AVF malfunction who underwent AVF closure and conversion to a tunneled central venous catheter because of exhaustion of alternative vascular sites and 36 matched controls with a well-functioning AVF. Predictor AVF closure. Outcomes & Measurements Outcomes were changes in findings on echocardiograms obtained before and 6 months after AVF closure for patients in the AVF-closure group and at baseline and 6 months later for controls. Echocardiographic measurements included left ventricular (LV) internal diastolic diameter, interventricular septum thickness, diastolic posterior wall thickness, LV mass (LVM), LVM index (LVMi), and LV ejection fraction (LVEF). Dialysis modality and scheme were unchanged. Results In the AVF-closure group, LVM decreased from 225 ± 55 to 206 ± 51 g ( P < 0.001) and LVMi decreased from 135 ± 40 to 123 ± 35 g/m2 ( P < 0.001). LV internal diastolic diameter, interventricular septum thickness, and diastolic posterior wall thickness decreased significantly, whereas LVEF increased from 56% ± 7% to 59% ± 6% ( P < 0.001). No significant changes were observed in controls. In patients with AVF closure, LV morphologic characteristics showed a decrease in both eccentric and concentric hypertrophy in favor of normalization or a pattern of concentric remodeling. No significant changes were observed in controls. Limitations Use of matched rather than randomized controls. Conclusions Closure of an AVF determines a significant decrease in LV internal diastolic diameter, interventricular septum thickness, and diastolic posterior wall thickness. This is associated with significant improvement in LVEF, a significant decrease in LVM and LVMi, and a more favorable shift of cardiac geometry toward normality.
The SARS-CoV-2 epidemic is pressuring healthcare systems worldwide. Disease outcomes in certain subgroups of patients are still scarce, and data are needed. Therefore, we describe here the experience ...of four dialysis centers of the Brescia Renal COVID Task Force. During March 2020, within an overall population of 643 hemodialysis patients, SARS-CoV-2 RNA positivity was detected in 94 (15%). At disease diagnosis, 37 of the 94 (39%) patients (group 1) were managed on an outpatient basis, whereas the remaining 57 (61%) (group 2) required hospitalization. Choices regarding management strategy were made based on disease severity. In group 1, 41% received antivirals and 76% hydroxychloroquine. Eight percent died and 5% developed acute respiratory distress syndrome (ARDS). In group 2, 79% received antivirals and 77% hydroxychloroquine. Forty two percent died and 79% developed ARDS. Overall mortality rate for the entire cohort was 29%. History of ischemic cardiac disease, fever, older age (over age 70), and dyspnea at presentation were associated with the risk of developing ARDS, whereas fever, cough and a C-reactive protein higher than 50 mg/l at disease presentation were associated with the risk of death. Thus, in our population of hemodialysis patients with SARS-CoV-2 infection, we documented a wide range of disease severity. The risk of ARDS and death is significant for patients requiring hospital admission at disease diagnosis.
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Abstract
Background and Aims
Etelcalcetide (ETC) is an intravenous calcimimetic approved for the management of secondary hyperparathyroidism (sHPT) in hemodialysis (HD) patients, with benefits in ...terms of reduction of FGF23 levels and prevention of progression of left ventricular hypertrophy. The label recommendation is a starting dose of 5 mg after HD, to be titrated every 4 weeks according to parathyroid hormone (PTH) and calcium levels. However, it remains unclear what dosage is best to start with and, thus, how this treatment can be implemented in a real-life setting. The aim of this study was to assess the efficacy and cost-effectiveness of ETC started at lower doses than those suggested by the manufacturer in patients with moderate sHPT.
Methods
This is a retrospective observational study comparing two different initial ETC dosing strategies, a “Low-dose approach” (LD, ETC starting dose<10 mg/week) and a “Classic approach” (CL, ETC starting dose≥10 mg/week), in terms of effects on CKD-MBD related biomarkers and costs during the first year of prescription. The study was conducted on HD patients with basal PTH between 500 and 1500 ng/l, treated with ETC for at least 3 months between 2018 and 2022 at ASST Spedali Civili di Brescia. Monthly monitoring of serum calcium, phosphorus and PTH was performed in both groups for dose adjustment.
Results
Overall, 53 patients were identified, 24 in the LD and 29 in the CL group. Both groups showed similar baseline characteristics (Table 1). Median follow-up was 52 weeks, during which 4 patients (one in the LD and three in the CL group) discontinued ETC (Table 1). At the end of follow-up, 92% of patients in the LD and 90% in the CL group achieved a decrease in PTH ≥30% compared to baseline, with median PTH levels of 282 (207 - 332) and 294 (151 – 382) ng/l, respectively (p = 0.825). Other CKD-MBD biochemical parameters were comparable between the two groups at all timepoints (Figure 1). The median of average ETC weekly doses per patient was 7.6 (6.2 – 10.2) mg in the LD and 10.6 (9.7 – 15) mg in the CL group (p<0.001). During follow-up, the median ETC dose remained stable in the LD group, while partially decreasing in the CL group (Figure 1). Use of paricalcitol was comparable in both groups. At cost analysis, the median of average ETC weekly costs per patient was €36.6 (29.6 – 50.0) in the LD and €50.5 (46.4 – 71.7) in the CL group (p<0.001). This translates into an average yearly cost per patient of €1909 and €2635 using the LD and CL approach, respectively, with a saving of €726 per patient-year in favour of the LD strategy.
Conclusion
In this retrospective study in HD patients with moderate sHPT, we showed that starting ETC at a lower dose than the one suggested by the manufacturer is as effective as the classic approach in terms of control of CKD-MBD parameters, with a significant reduction in treatment costs. Future prospective studies will be needed to validate the results in bigger cohorts, test whether these benefits can extend beyond the first year of treatment and assess the effects on FGF23 levels and other relevant clinical outcomes.
Abstract
Background and Aims
The aim of this work is to explain the training to create a multidisciplinary team that in the future will activate the psychoeducational groups in nephrology. These ...groups will be support to patients and caregivers already in the waiting period from the intervention of the fistula at the beginning hemodialysis.
Method
The training of five meetings was realized from March 2019 to May 2019. The training for a team composed by 3 nephrologist, 4 nurses, 1 dietician, 1 nursing coordinator was conducted of a psychologist to established modalities and aims of a psychoeducational pathway for patients that will begin hemodialysis and their caregivers. In the first meeting, through a focus group, the participants discussed the word “to cure”. In the second meeting participants defined patient and caregiver’s needs after the diagnosis of Chronic Kidney Disease. In the third meeting the team work defined the objectives and methods of conducting future groups psychoeducational. In the fourth meeting participants decided the duration and modalities of the psychoeducational pathway for patient and caregiver. Finally, in the fifth meeting, the team reviewed the objectives, recipients and thematic areas of the meetings for patients and caregivers. In addition, an evaluation questionnaire was administered to verify the benefit and satisfaction of the training. All the contents of the training were transcribed in a diary and analyzed with a pencil and paper mode.
Results
In the first meeting the team discussed the need to accompany and educate patients even before the onset of haemodialysis. In the second meeting team decided that the therapeutic education is not only for patients waiting to start haemodialysis but also on their caregivers often uninformed and not involved by doctors and nurses. In this focus the caregiver appears an important figure that support the patient at home and if not properly informed it can become an obstacle in patient care. In the fourth and fifth meetings have been defined a possible psychoeducational training in three total meetings so named:
Knowing each other differently: to get to know both the patient and the caregiver in an active listening setting.
Knowing dialysis concretely: to know better the treatment and pay attention to the care of your psychological well-being too.
Knowing the diet actively: to inform and support the patient and caregiver of future and current changes in eating habits.
The participants in the satisfaction questionnaire to the question “how much did this training respond to the needs of your job?” on nine answers collected, the outcome it was M = 4.7 on Likert scale 1(few)-5 (much).
Conclusion
The training has managed to build a multidisciplinary team ready to care patients and caregivers that will begin haemodialysis in a more informed and aware way. Currently, two psychoeducational groups have been created for patient and caregiver. As shared in the multidisciplinary team’s training these psychoeducational groups are activated to help the patient to accept dialysis at the same time help the family member to take on the role of caregiver. This project has made it possible to improve not only teamwork but overall patient and caregiver care.
Abstract
Background and Aims
Four RCTs have been published that compared on-line HDF (Ol-HDF) with HD. However, to date, an indisputable answer in determining whether patients treated with Ol-HDF had ...a better survival than those treated with high-flux HD (Hf-HD) has not been reached. The aim of our study was to retrospectively evaluate the impact of the dialysis modality (Hf-HD, Ol-HDF or acetate-free biofiltration AFB) on patient survival and dialysis adequacy.
Methods
We retrospectively evaluated all the incident patients that started dialysis due to uremia from 01-01-2008 to 31-12-2018 at the U.O. Nephrology ASST Spedali Civili of Brescia. Exclusion criteria were: duration of dialysis treatment less than 3 months, and previous dialytic treatment or kidney transplantation. The dialysis modality performed (Hf-HD vs Ol-HDF), the modality of infusion (pre-dilution or post-dilution) and mean total convective volume (replacement fluid volume + ultrafiltration) during last year’s dialysis session in Ol-HDF were analyzed for each patient.
Results
During observation 677 patients started HD treatment. 70 patients were excluded due to less than 3 months HD treatment. 607 patients (male 390, 64%) were analyzed. 467 pts (77%) were treated with Hf-HD, 103 pts (17%) with Ol-HDF, 36 pts (6%) with AFB. Median duration of HD treatment was 2.6 years (IQR 1.3; 4.7). Ol-HDF was performed in post-dilution mode in 60% of cases (total convective volume 25±4 L); pre-dilution mode was used in 40% of the cases (total convective volume 51±18 L). Patients in the Ol-HDF group were significantly younger than those in Hf-HD and AFB groups (respectively 59±15 years vs 71±15 vs 78±9, p <0.05), and had less diabetes, hypertension and ischemic heart disease (p<0.05) while presenting similar prevalence of cirrhosis (p=0.93) and peripheral vascular disease (p=0.09). Adequacy indices were similar between groups (eKt/V 1.39±0.02 vs 1.41±0.01 vs 1.44±0.04, p=0.47) as well as the protein intake (PCRn 0.92±0.01 vs 0.93±0.01 vs 0.90±0.03 g/Kg/d, p=0.69) and residual renal function (1.5±0.3 vs 1.6±0.1 vs 0.8±0.4 ml/min, p=0.20). Patients on Ol-HDF more frequently had an AV fistula (71% vs 58% vs 59%, p<0.05). At the end of follow-up, 12% of patients had undergone kidney transplantation, 42% continued dialytic treatment while 43% died. Univariate analysis showed a better survival for Ol-HDF patients (Figure 1) (p <0.05). This benefit was confirmed in multivariate analysis (Figure 2) showing that older age, cirrhosis and ischemic heart disease negatively affect survival, while a high protein intake, use of an AV fistula and Ol-HDF (HR 0.430.30-0.61) are protective.
Conclusions
The use of Ol-HDF is associated with better survival compared to Hf-HD. This is confirmed after adjustment for demographic and comorbidities of the patients, characterizing Ol-HDF as an independent predictor of better survival.
Figure:
Abstract
Background and Aims
AKI (Acute Kidney Injury) is a condition associated with elevated morbility and mortality. It determines prolonged hospitalization and severe long-term complications. AKI ...often complicates the course of patients’ stay in ICU (Intensive Care Units) sometimes requiring CRRT (Continuous Renal Replacement Therapy). Our aim was to prospectively analyze and report our experience on CRRT carried out in our hospital’s ICUs, and to compare it with guideline recommendations and with other international experiences.
Method
This is a single-center prospective observational study. We collected epidemiologic, clinical and technical data regarding all CRRT treatments performed in the four ICUs (two general ICUs and two cardiological ICUs) at the ASST Spedali Civili of Brescia Italy, between 02/01/2018 and 05/31/2019. AKI was defined according to KDIGO guidelines. Exclusion criteria were: age less than 16 years, chronic dialysis treatment, functioning kidney transplantation. All CRRT were provided in the CVVH (Continuous Veno-Venous Hemofiltration) mode.
Results
We included 146 incident patients (M: 103; 70%), mean age 71 ± 15 years. Most treatments were performed in the cardiological ICUs (58%) as opposed to the general ICUs (42%). AKI was present at the moment of admission to the ICU in 67% of patients. 53% of patients had previous CKD. The most frequent comorbidities were: hypertension (73%), diabetes (45%), ischemic heart disease (38%). The most frequent reasons for starting CVVH were: severe oliguria (88%) and fluid overload (68%). 57% of patients had stage 3 AKI. At the time of treatment initiation 55% of patients also had congestive heart failure, 52% metabolic acidosis, and 51% sepsis. 23% were recovering from heart surgery and 10% from general surgery. Mechanic ventilation was performed in 40% of patients, non-invasive ventilation in 28%. 82% of patients required vasoactive treatment. The average SOFA score was 10 ± 2,9. Technical details of CVVH prescription are reported in Fig 1. The most common vascular access was a dual lumen femoral vein catheter in 96% of cases. Citrate anticoagulation was used in 32% of treatments, heparin in 27%. Circuit coagulation was the most frequent cause for set substitution (45%). Treatments using citrate had fewer set coagulations compared to heparin (18% vs 32%). The average dialysis dose was 31,2 ml/kg/h. Median treatment duration was 7,6 days, median stay in the ICU was 14,3 days, median global hospitalization lasted 30,9 days. Mortality rate was 47% in the ICU and 64% 90 days after discharge. The most frequent causes of death were MOF (33%), septic shock (20%) and cardiogenic shock (14%). As illustrated in figure 2, multivariate analysis showed that mortality was negatively influenced by the presence of liver cirrhosis, septic shock, cardiogenic shock and rhabdomyolysis. After hospital discharge, 14 patients continued to require chronic dialysis.
Conclusion
Our experience shows that in patients with AKI requiring CVVH, mortality rate is negatively influenced by the presence of septic and cardiogenic shock, liver cirrhosis and rhabdomyolysis. Treatment prescription respected clinical and technical guideline recommendations, and is mostly comparable to the related international literature.
Table 1
Technical details of CVVH prescriptions.
Mean
Qb (ml/min)
143 (SD ± 19)
Reinfusion (ml/h)
1863 (SD ± 502)
Fluid removal (ml/h)
114 (SD ± 58)
Predilution (%)
75 (SD ± 11)
Patient weight (kg)
78 (SD ± 18)
Dialysis dose (ml/kg/h)
31,2 (SD ± 4,7)
Table 2
Technical details of CVVH prescriptions.
Liver cirrhosis
Septic shock
Cardiogenic shock
Rhabdomyolysis
RR
4,4
2,2
2,3
2,9
CI 95%
2,02 – 9,46
1,38 – 3,67
1,38 – 3,85
1,13 – 7,39
P
<0,001
0,001
0,001
0,027
Abstract
Background and Aims
Survival comparison between peritoneal dialysis (PD) and hemodialysis (HD) is still controversial. While some retrospective studies have shown better survival in PD, ...particularly in the first year, others have not identified this difference. The only RCT published so far showed a 3-year mortality rate similar between two groups. However, the number of patients was too small to provide sufficient statistical power to identify any survival differences between the two dialysis techniques. Aim of this study was to compare HD and PD in term of survival rate and factors possibly involved in a ten-years observational study.
Method
We retrospectively evaluated all the incident patients that started a dialytic treatment, either HD or PD, due to uremia from 01-01-2008 to 31-12-2018 at the U.O. Nephrology ASST Spedali Civili of Brescia. Exclusion criteria were: duration of dialysis treatment less than 3 months, and previous dialytic treatment or kidney transplantation. For each patient anthropometric, clinical-anamnestic data and comorbidities at dialysis start were recorded.
Results
One thousand and six patients were identified. 130 patients were excluded due to dialysis treatment less than 3 months. A total 876 patients were analyzed. 77% of patients started dialysis on HD while 23% chose PD. Age was significantly higher in HD patients (69±15 vs 65±16 years; p<0.05). No differences were found in the incidence of: ischemic heart disease (HD 24%, PD 25%, p=0.90), diabetes (32% vs 32%, p=0.83), cancer (20% vs 17%, p=0.37), cardiac arrhythmia (20% vs 25%, p=0.08) and peripheral vascular disease (25% vs 25%, p=0.89). An increased incidence of COPD (HD 17% vs PD 8%, p<0.05) and hypertension (73% vs 87%, p<0.05) was present in PD patients. During follow-up, 17% of patients treated with PD shifted to HD due to catheter malfunction, recurrent infections, insufficient dialytic adequacy or ultrafiltration failure. Kidney transplants were performed more frequently in PD patients (HD 12%; PD 24%, p<0.05). At an intention to treat analysis of the data, univariate analysis showed better survival in PD patients (p<0.05, Figure 1). This difference was not confirmed at multivariate analysis (Figure 2), where age, cardiac arrhythmia, cirrhosis, diabetes and peripheral vascular disease were independently associated with an increased risk of mortality. No independent influence on mortality of the dialysis treatment modality was found.
Conclusion
This ten years observational study shows that HD and PD are similar in term of patient survival. Age and comorbidities seem to play the most important role in patient survival.
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