Seminars in Dialysis最新文献

Background: Peritoneal dialysis (PD) and hemodialysis (HD) form the basis of renal replacement therapy (RRT) in patients with end-stage renal disease. Both methods have advantages, and in our study, we aimed to examine the effect of both methods on exhaled nitric oxide (FeNO) levels.

Methods: Our study included RRT patients between 18 and 65 who our hospital's nephrology clinic followed up for at least 2 years. A total of 100 patients, 35 patients from both RRT groups and 30 healthy control groups, were included in our study. Echocardiography (ECHO) and FeNO measurements were performed.

Results: In the comparison of the groups' mean pulmonary arterial pressure (PAP) and pre-RRT FeNO levels, it was observed that both levels were higher in HD patients compared to PD patients (p = 0.04, < 0.001, respectively). The control group observed that both predialysis and postdialysis FeNO levels in HD patients showed a statistically significant difference compared to the control group (p ≤ 0.001, 0.01, respectively). It was observed that mean arterial pressure (MAP) levels were higher in HD patients compared to PD patients before RRT (p = 0.01). FeNO positively correlated with age and gamma-glutamyl transferase (GGT) level (R = 0.542, p = 0.01, R = 0.629, p = 0.01, respectively).

Conclusion: FeNO is known as an essential indicator of oxidative stress and inflammation. The higher FeNO level in HD patients compared to PD and its positive correlation with oxidative stress markers such as GGT suggest that PD may be more suitable for the physiological structure.

Background: Tunneled dialysis catheters (TDCs) are preferred over temporary noncuffed catheters for access in patients on maintenance hemodialysis. The removal of TDC after catheter-related blood stream infections (CRBSIs) is often not practiced even when indicated, and the adverse outcomes after such salvage are presently unclear.

Aims and objectives: The study aimed to evaluate adverse outcomes after the first episode of definite or probable CRBSI. The composite adverse outcome was recorded as the presence of at least one of three adverse outcomes-death in the index hospital admission, occurrence of recurrent bacteremia, and death within 3 months.

Results: During the study period, the TDC CRBSI incidence rate was 6.9/1000 catheter days. Of the 110 study participants, majority were male (63%), with a median age of 35 years, belonging to rural (56%) and agrarian (39%) communities, and 66% were getting dialyzed at stand-alone dialysis units. Gram-negative infections predominated (64%), with 37% of isolates showing resistance to carbapenems. Catheter salvage was practiced in 80%, and immediate catheter removal was done only in the sickest of patients (in seven of eight with in-hospital mortality). Predictors of composite adverse outcomes included sites other than right internal jugular vein (OR 3.6) and resistance to β lactam-β lactamase inhibitors (OR 16.2). At a median follow-up of 7 months, all survivors at 3 months were alive and 46% had recurrent TDC CRBSIs.

Conclusion: Up to one-half of patients with end-stage kidney disease experienced composite adverse outcomes after the first episode of TDC CRBSI, with infection-related 3-month mortality of 15%.

Trial registration: Clinical trial number: CTRI/2023/10/058556.

Background: Potassium imbalance, particularly hypokalemia, is a critical risk factor for adverse outcomes in patients undergoing hemodialysis (HD). However, the association between hypokalemia and mortality is unclear.

Methods: For this systematic review and meta-analysis, we assessed the association between hypokalemia and mortality in patients undergoing HD. We performed a systematic search of electronic databases (PubMed, Embase, Cochrane Library, and Scopus) to identify relevant studies published up to April 2024. Eligible studies were prospective or retrospective cohort studies reporting hazard ratios (HRs) for mortality in association with the presence of hypokalemia among patients undergoing HD. We used the assessed study Newcastle-Ottawa Scale to assess quality of the selected studies.

Results: We carried out both qualitative and quantitative assessments. For the meta-analysis, we pooled the HRs for all-cause and cardiovascular mortalities. The overall pooled HR for all-cause mortality and cardiovascular mortality were 1.34 (95% CI, 1.15, 1.55) and 1.49 (95% CI, 1.12, 1.98), respectively, indicating significant associations between hypokalemia and all-cause mortality and cardiovascular mortality in patients undergoing HD. Additionally, we conducted subgroup analyses based on study design, geographical location, type of dialysis, and serum potassium levels.

Conclusion: Our findings provide robust evidence of a significant association between hypokalemia and mortality in patients undergoing HD. Early detection and proactive management of hypokalemia are crucial for improving outcomes and reducing mortality risk in these patients.

Extracorporeal therapies could be required for treatment of life-threatening severe acute intoxication. We present the case of an 82-year-old patient admitted to our Nephrology Unit because of metformin-associated lactic acidosis (MALA) and acute kidney injury (AKI stage III AKIN criteria). The patient also presented severe intoxication of digoxin and apixaban. The electrocardiogram presented a junctional escape rhythm with atrial fibrillation (AF) and lateral ST-segment depression that, despite fab-fragments' administration, has not regress. Due to patient's hemodynamic instability, an 8 h of sustained low-efficiency diafiltration (SLED) was prescribed. This treatment allowed to reduce serum concentration of apixaban and digoxin. Similarly, patient's hemodynamic and ECG trace improved with the resolution of junctional rhythm and persistence of AF. Even if continuous renal replacement therapy (CRRT) is the first choice in critical ill patients, SLED could represent a valid option for patients without indication to ICU.

Introduction: Distal forearm arteriovenous fistulas (AVFs) for hemodialysis (HD) include radiocephalic fistulas (RCFs) and ulnar-basilic fistulas (UBFs). However, due to the unique anatomical peculiarities of the latter approach, UBFs are only established in a limited subset of patients undergoing vascular access procedures. This study aimed to present a retrospective case series detailing the creation of UBFs, emphasizing both the technical challenges and clinical outcomes associated with this approach.

Methods: We conducted a retrospective review of UBFs created between 2008 and 2023. Data collected included patient demographics, comorbidities, patency, functionality, and outcomes. Adequate blood flow and personalized Kt/Vurea levels were prerequisites for defining UBF functionality for HD.

Results: Among 253 patients receiving HD, 82.2% had an AVF, with only 3.3% (n = 5) of the 150 distal AVFs functional for HD being UBFs. In this series, a total of 11 UBF fistulas were created, with nine patients experiencing an immediate thrill. Among those with UBF failure, three patients were aged > 85 years, and three had concurrent diabetes mellitus, peripheral vascular disease, and ischemic heart disease. The survival rate in the UBF group correlated with the duration of dialysis in the three patients for whom the UBF was the sole AVF, with one patient achieving a remarkably prolonged period of > 10 years. No incidences of ischemia, hand edema, or ulnar nerve lesions were noted.

Conclusion: While the difficulties experienced in achieving functional UBFs for HD are highlighted in this long-term perspective, its safety and durability make it a viable option in managing an increasingly comorbid patient population.

Background: Cuff extrusion of tunneled dialysis catheter (TDC) leads to catheter dysfunction, leading to loss of vascular access and the need for new catheter. Definitive management is to remove TDC and reinsert new catheter by new venous puncture and tunnel, which may not be possible in all cases. The study evaluated the surgical experience and early outcomes of a novel "Catheter Exchange with Elongation of Tunnel (CEET)" procedure for cuff extrusion.

Methods: The retrospective study included all cases of hemodialysis with TDC with partial or complete cuff extrusion and excluded complete catheter dislodgement, tunnel infection, or any catheter related infection. All patients also underwent the CEET procedure under fluoroscopy guidance, and the clinical details and outcomes were analyzed.

Results: Eleven cases of TDC cuff extrusion underwent the CEET procedure of which three (27.2%) had previous and four (36.4%) had partial cuff extrusion, and seven cases (63.6%) had short tunnel length, which likely predisposed to cuff extrusion. CEET procedure was successful in 10 cases (success rate 90.1%) with desired position of catheter tip and good blood flow. Study population was divided into early and late cuff extrusion (≥1 month). Short tunnel length was associated with late extrusion (p = 0.05), whereas premature removal of TDC anchor sutures was associated with early cuff extrusion (p = 0.04).

Conclusion: CEET procedure is a successful alternative technique for correction of cuff extrusion of TDC with good success rate. Premature removal of anchor sutures was associated with early cuff extrusion, whereas short tunnel length was associated with late cuff extrusion.

Background: The optimal time for the salvaging of thrombosed hemodialysis grafts is controversial. This study was aimed at determining the optimal time related to the outcome of percutaneous pharmacomechanical thrombolysis (PMT) for the treatment of thrombosed arteriovenous graft (AVG).

Methods: This was a retrospective study of 191 hemodialysis patients who underwent PMT for thrombosed AVG from April 2014 to December 2021. Demographic data and details of the procedure were recorded. The procedural success rate related to the onset time of PMT was analyzed. The postinterventional circuit primary assisted patency rate was presented by the Kaplan-Meier curve.

Results: A total of 191 hemodialysis patients, 101 females and 90 males, were enrolled. Their median age was 66 years (interquartile range of 58-75 years). The majority type of thrombosed AVG was brachiocephalic loop graft (60.2%). The procedural success rate of PMT that was performed ≤ 48 h was 86.2%. There was a statistically significant procedural success rate of PMT in the group with an onset of treatment ≤ 48 h compared to > 48 h (odds ratio = 2.77; 95% confidence interval = 1.06, 7.28; p = 0.037). The median postintervention circuit primary assisted patency in the group of treatment ≤ 48 and > 48 h was 7.3 and 3.9 months (p = 0.023), respectively.

Conclusion: From this study, the optimal time of PMT for treatment of thrombosed AVG should be within 48 h after onset of thrombosis for enhancing procedural success and patency rates.

We report the successful application of single pass albumin dialysis (SPAD) and hemoadsorption (HA) in two teenagers with amlodipine poisoning. A 16-year-old girl with amlodipine overdose developed refractory shock and lactic acidosis despite multiple inotropes, calcium, insulin, and glucagon infusion. SPAD was initiated 18 h after the incident for 21 h. She improved dramatically and was able to wean off all inotropes 54 h after admission. Another 16-year-old girl required extracorporeal membrane oxygenation (ECMO) support after deliberate consumption of 1100-mg amlodipine. SPAD was initiated 13 h after the incident for 38 h, followed by two more sessions of HA using the Cytosorb column. All inotropes were stopped 18 h after terminating the HA, and ECMO was weaned off 28 h later. There were no major complications during the therapy. Our cases demonstrated that early extracorporeal removal can be considered as an adjunctive therapy in children with life-threatening amlodipine overdose.

Background: The long-term efficacy and safety of desidustat in real world are unknown. We conducted a retrospective real-world experience of desidustat in 100 consecutive patients on hemodialysis.

Materials and methods: The first 100 consecutive stable patients on hemodialysis who were prescribed desidustat between May and December 2022, without history of infection, surgery, chronic hepatitis, or HIV infection, 1 month prior to initiation, were eligible for analysis from electronic records. Those who were lost to follow up, underwent transplantation, or discontinued medicine within 6 months were excluded. We looked at mean dose; efficacy at 1, 6, and 12 months; side effects; and adherence of desidustat over a period of 12 months.

Results: Out of 100, 59 patients completed 1 year of the drug and were analyzed. There was statistically significant increase in hemoglobin from baseline to 1 month (9 ± 1.2 vs. 9.4 ± 1.3 g/dL, p = 0.01) and from baseline to 12 months (9 ± 1.2 vs. 9.9 ± 1.5 g/dL, p = 0.02). The percentage of patients who achieved target hemoglobin of 10-12 g/dL was 17% at baseline, which increased to 19.1% at 1 month, 43% at 6 months, and 38.9% at 12 months. Side effects were noted in 20% of patients, with edema being the most common (6%) and infections in 5% of cases. Nonadherence was observed in 15% patients.

Conclusion: Desidustat is effective and safe in management of anemia in hemodialysis patients over a period of 1 year. It helps in achieving target hemoglobin in majority of patients within 6 months.