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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Blood pressure (BP) and volume control are critical components of dialysis care and have substantial impacts on patient symptoms, quality of life, and cardiovascular complications. Yet, developing ...consensus best practices for BP and volume control have been challenging, given the absence of objective measures of extracellular volume status and the lack of high-quality evidence for many therapeutic interventions. In February of 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference titled Blood Pressure and Volume Management in Dialysis to assess the current state of knowledge related to BP and volume management and identify opportunities to improve clinical and patient-reported outcomes among individuals receiving maintenance dialysis. Four major topics were addressed: BP measurement, BP targets, and pharmacologic management of suboptimal BP; dialysis prescriptions as they relate to BP and volume; extracellular volume assessment and management with a focus on technology-based solutions; and volume-related patient symptoms and experiences. The overarching theme resulting from presentations and discussions was that managing BP and volume in dialysis involves weighing multiple clinical factors and risk considerations as well as patient lifestyle and preferences, all within a narrow therapeutic window for avoiding acute or chronic volume-related complications. Striking this challenging balance requires individualizing the dialysis prescription by incorporating comorbid health conditions, treatment hemodynamic patterns, clinical judgment, and patient preferences into decision-making, all within local resource constraints.
The oxido-redox status of plasma albumin in patients treated with hemodialysis was characterized with LC–ESI-MS/MS and was compared with models of oxidative stress. Oxidised albumin was characterized ...by sulfonation (SO
3
−) of the SH at Cys 34, unfolding and acidification of the molecule. Albumin in hemodialysis patients presented, instead, only intermediate oxidation products such as sulfenic (SO
2), sulfonic (SO) and methionine sulfoxide (C
5H
9NO
2S) involving Cys 165–269 and Met 329–548 but did not present SO
3
− at Cys 34. Absence of charge and structural alterations compared to the oxidised templates was also confirmed with electrophoretic titration and calorimetry. In conclusion, the oxido-redox status of plasma albumin in hemodialysis patients lacks the hallmarks of the advanced oxidation products. LC–ESI-MS/MS was crucial to characterize albumin in conditions of oxidation stress; surrogate techniques can mirror conformational changes induced by oxidation.
Background. The effect of the adequacy of dialysis on the response to recombinant human erythropoietin (rHuEpo) therapy is still incompletely understood because of many confounding factors such as ...iron deficiency, biocompatibility of dialysis membranes, and dialysis modality that can interfere. Methods. We investigated the relationship between Kt/V and the weekly dose of rHuEpo in 68 stable haemodialysis (HD) patients (age 65±15 years) treated with bicarbonate HD and unsubstituted cellulose membranes for 6–343 months (median 67 months). Inclusion criteria were HD for at least 6 months, subcutaneous rHuEpo for at least 4 months, transferrin saturation (TSAT) ≥20%, serum ferritin ≥100 ng/ml, and haematocrit (Hct) level targeted to 35% for at least 3 months. Exclusion criteria included HBsAg and HIV positivity, need for blood transfusions or evidence of blood loss in the 3 months before the study, and acute or chronic infections. Hct and haemoglobin (Hb) levels were evaluated weekly for 4 weeks; TSAT, serum ferritin, Kt/V, PCRn, serum albumin (sAlb), and weekly dose of rHuEpo were evaluated at the end of observation. No change in dialysis or therapy prescription was made during the study. Results. The results for the whole group of patients were: Hct 35±1.2%, Hb 12.1±0.6 g/dl, TSAT 29± 10%, serum ferritin 204±98 ng/ml, sAlb 4.1±0.3 g/dl, Kt/V 1.33±0.19, PCRn 1.11±0.28 g/kg/day, weekly dose of rHuEpo 123±76 U/kg. Hct did not correlate with Kt/V, whereas rHuEpo dose and Kt/V were inversely correlated (r=−0.49; P<0.0001). Multiple regression analysis with rHuEpo as dependent variable confirmed Kt/V as the only significant variable (P<0.002). Division of the patients into two groups according to Kt/V (group A, Kt/V ≤1.2; group B, Kt/V≥1.4), showed no differences in Hct levels between the two groups, while weekly rHuEpo dose was significantly lower in group B than in group A (group B, 86±33 U/kg; group A, 183±95 U/kg, P<0.0001). Conclusions. In iron‐replete HD patients treated with rHuEpo in the maintenance phase, Kt/V exerts a significant sparing effect on rHuEpo requirement independent of the use of biocompatible synthetic membranes. By optimizing rHuEpo responsiveness, an adequate dialysis treatment can contribute to the reduction of the costs of rHuEpo therapy.
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.
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