[Surveillance of infections in chronic hemodialysis patients]. / Surveillance des infections chez les hémodialysés chroniques en centre.

OBJECTIVE: To confirm rates of infections from a previous survey in chronic hemodialysis patients; to get information about incidents and manipulations of vascular access-site, number and reasons of hospitalisation; to asses a relationship between the frequency of vascular access-site infections (VASI) and quality of care during the procedures of vascular access-site use. DESIGN: Prospective, multicenter survey performed from February 2000 to January 2001, including all patients underwent chronic hemodialysis in 5 participating centers. Standardized definitions used and different clinical and biological risk factors recorded. RESULTS: 429 patients for a total of 4273 dialysis months (DM) were enrolled. 245 infections in 164 infected patients were reported. The overall rate was 5.73 infections per 100 DM (18 VASI, 25 bacteraemia, 84 respiratory, 29 urinary tract, 1 endocarditis and 88 other infections). 50% of infections were microbiologically documented. 19 of 21 antibiotics resistant microorganisms were meticillin resistant Staphylococcus aureus. Compared to the incidence rate of fistula (0.05 per 1000 days of follow-up) or prosthesis related VASI (0.11), the incidence rate of catheter related VASI (0.65) was significantly higher. Poor hygiene and duration of catheter use were the significant risk factors for VASI showed by logistic analysis regression. VASI and bacteraemia occurred more frequently after incident or manipulation of the vascular access-site. The decrease of VASI between the 2 periods of survey was significantly higher in centers having reduced the catheter use and implemented written protocols. CONCLUSIONS: This second period of surveillance has confirmed the frequency of infections rate in chronic hemodialysis patients and particularly bacteraemia and VASI. This study has allowed to establish risk factors for infections and showed that VASI in hemodialysis are related to factors in part preventable.

[Evaluation of the needs of a population of hemodialysis patients in Rhône-Alpes]. / Evaluation des besoins en soins d'une population de patients hémodialysés en Rhône-Alpes.

The evaluation of the needs of patients with terminal renal insufficiency is necessary to determine the appropriate care programme. An evaluation of the medical and nursing needs, as well as those related to handicap (a total of 47 items) was undertaken on all hemodialysis patients in the Rhône-Alpes region. Only 34.4% were free of co-morbidity and 35.7% of significant handicap, 63.7% needed no other nursing care than that related to supervision of the dialysis and 16.9% were free of all the conditions studied. The patients treated in the centre required care needs than those treated in all other structures. The autodialysis population differs from that treated at home by a greater need for care due to handicaps, and from that treated in a dialysis centre by a lesser degree of handicap and less need for medical treatment. A level of theoretical unsuitability (needs incompatible with the statutory provisions for each type of treatment) was defined: it concerns 5% of the population in a dialysis centre and to 33% of the population on home dialysis. The needs evaluation grid could be used to quantify the requirements of a dialysis population and to arrange for the necessary resources.

[A tool to predict the resources necessary for the whole hemodialysis population]. / Un outil de prédiction des moyens requis pour l'hémodialyse à l'échelon d'une population.

Predicting the resources necessary for the treatment of terminal renal insufficiency requires an understanding of the needs of the whole dialysis population. This study evaluates the advantages of a complete evaluation grid for care needs (CG, 47 items) compared with a simplified version (SG) and with the data obtained from REIN (R) as a tool for predicting the required resources. Compared to CG, the two other classifications under-estimate the level of care needed and the prevalence of patients who have at least one condition resulting in an 'excess' of needs. In a system with three types of structures, the theoretical distribution of patients according to the CG is: in structure A (permanent medical presence): 43.4% (vs 39 for SG and 21% for R); in structure B (intermediate): 34% (vs 31.5 and 24.7% respectively); and in structure C (independent): 22.3% (vs 29.5 and 53.5%) of patients. The care needs scores of populations assigned by R to home dialysis are incompatible with the resources allocated to it. With a certain number of adjustments and qualifications, a population study using a simplified needs grid could enable a prediction of the resources which need to be provided. The patients' records which take precedence in the future REIN should be modified in order to make possible a regular evaluation of the appropriateness of the resources allocated.

The physiological surveillance of hemodialysis sessions by the continuous measurement of L.F. impedance of the circulating blood (Thomasset's method).

Everybody grants as a fact that hemodialysis disturbances are produced by volemia variations. During H-D the vascular sector is the necessary transit medium to withdraw excessive interstitial water. If this withdrawing is greater than the coming back of the interstitial water into the vascular sector, the plasmatic volume will be decreasing. Thus, to measure the variations of the plasmatic volume in circulating blood it is sufficient to effect a continuous measurement of these ones in a transducer having a definite volume. So, by the mean of an impedancemeter, 5 kHz impedance is continuously measured between the two electrodes of the transducer, because it is known (Thomasset's method) that at 5 kHz current uses only the plasma in order to pass from one electrode to another.

Renal hemodynamic response to l-dopa during acute renal failure in man.

Twelve patients with acute renal failure underwent L.dopa infusion into a renal artery and 133Xenon wash-out recordings before and during the infusion. Urine volume and sodium output were also compared during two 24 hours periods, before and after the procedure. Hemodynamic data were compared with data obtained from a matched group of patients receiving Furosemide (8 patients) in place of L.dopa. Only L.dopa infusion significantly increased outer cortical distribution (p less than 0.005 using paired t-test). No blood flow change could be demonstrated in any component nor did the drug improve urinary excretion or the general course of the disease. Control data shows that reduced cortical distribution is the most consistent feature of acute renal failure, so that L.dopa does partially improve intrarenal hemodynamics in this condition. The failure of the drug to restore kidney function may be explained by the following reasons: a) Inability of the agent to restore a normal wash-out pattern; b) Involvement of non-hemodynamic factors, as suggested by comparing similar wash-out improvements after L.dopa in acute glomerulonephritis and in reversible acute renal failure.

[Auricular adynamia due to hyperkalemia]. / Adynamie auriculaire par hyperkaliémie

Auricular asystoly (A.A.) was the electrocardiographic pattern of 6 patients admitted for electrolytic disorders secondary to either renal failure or inadequate treatment. A rapid increase of blood potassium was the unique commun abnormality found to explain the dysrhytmia. Bradycardia (between 25 and 55 beats/mn) was present in each case with or without clinical symptoms. Temporary prophylactic pace maker insertion was performed in 4/7 patients. Recovery appeared after dialysis treatment in 6 cases, medical treatment in one, sinus rhythm being present in 6 and chronic atrial fibrillation in one. Prognosis of A.A. due to hyperkaliemia is good when hydroelectrolytic disorders are rapidly corrected. Follow up of blood electrolytes and electrocardiogram must be regular to prevent reccurencies.