Survival, cumulative hospital days and infectious complications in urgent-start PD compared with urgent-start HD.

BACKGROUND: Urgent-start peritoneal dialysis (PD) carries a similar efficacy and safety profile compared to urgent-start haemodialysis (HD) but is only sparsely applied due to resource issues and concerns of complication risks. Furthermore, few data exist on adverse outcomes associated with central venous catheter (CVC) insertions in urgent-start HD patients. Thus, we sought to compare patient and dialysis-related outcomes in patients undergoing urgent-start PD or HD. METHODS: All patients initiating urgent-start PD in a tertiary research hospital in 2005-2018 were included in this retrospective, single-centre, comparative study and matched with urgent-start HD patients of similar age and chronic kidney disease aetiology. All urgent-start PDs were initiated within 72 h after catheter insertion, and urgent-start HDs were performed via a CVC. All analyses were performed at 3 months and at 1 year of follow-up, respectively. RESULTS: Thirty-three patients who commenced urgent-start PD and 58 matched urgent-start HD control patients were included. Altogether, 26 patients (29%; PD: 36%, HD 24%) died within the 1-year follow-up, and patient survival was similar at 3 months (hazard ratio (HR): 1.15, 95% confidence interval (CI): 0.35-3.81, p = 0.82) and at 1 year of follow-up (HR: 0.64, 95% CI: 0.30-1.39, p = 0.26) between the study groups. There were no differences in the total kidney replacement therapy (KRT)-related infection rate (p = 0.66) or cumulative first-year hospital care days (p = 0.43) between the treatment groups. Altogether, 139 CVCs were inserted during the 1-year follow-up. The number of CVCs per patient was associated with the emergence of blood culture-positive bacteraemia and increased cumulative first-year hospital care days. CONCLUSIONS: Patient survival, cumulative first-year hospital care days and total KRT-related infection rate at 3 months and 1-year follow-up are similar between urgent-start PD and urgent-start HD patients. Furthermore, CVC insertion rate is associated with incident blood culture-positive bacteraemia and increased cumulative first-year hospital care days.

First-year mortality in incident dialysis patients: results of the Peridialysis study.

BACKGROUND: Controversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI. METHODS: Among 1580 patients participating in the Peridialysis study, a study of causes and timing of DI, we registered features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice. Patients were followed for 12 months or until transplantation. A flexible parametric model was used to identify independent factors associated with all-cause mortality. RESULTS: First-year mortality was 19.33%. Independent factors predicting death were high age, comorbidity, clinical contraindications to PD or HD, suboptimal DI, high eGFR, low serum albumin, hyperphosphatemia, high C-reactive protein, signs of overhydration and cerebral symptoms at DI. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD. CONCLUSIONS: First-year mortality in incident dialysis patients was in addition to high age and comorbidity, associated with clinical contraindications to PD or HD, clinical symptoms, hyperphosphatemia, inflammation, and suboptimal DI. In patients with a "free" choice of dialysis modality based on their personal preferences, PD and in-center HD led to broadly similar short-term outcomes.

Choice of dialysis modality among patients initiating dialysis: results of the Peridialysis study.

BACKGROUND: In patients with end-stage kidney disease (ESKD), home dialysis offers socio-economic and health benefits compared with in-centre dialysis but is generally underutilized. We hypothesized that the pre-dialysis course and institutional factors affect the choice of dialysis modality after dialysis initiation (DI). METHODS: The Peridialysis study is a multinational, multicentre prospective observational study assessing the causes and timing of DI and consequences of suboptimal DI. Clinical and biochemical data, details of the pre-dialytic course, reasons for DI and causes of the choice of dialysis modality were registered. RESULTS: Among 1587 included patients, 516 (32.5%) were judged unsuitable for home dialysis due to contraindications [384 ( 24.2%)] or no assessment [106 (6.7%); mainly due to late referral and/or suboptimal DI] or death [26 (1.6%)]. Older age, comorbidity, late referral, suboptimal DI, acute illness and rapid loss of renal function associated with unsuitability. Of the remaining 1071 patients, 700 (65.4%) chose peritoneal dialysis (61.7%) or home haemodialysis (HD; 3.6%), while 371 (34.6%) chose in-centre HD. Somatic differences between patients choosing home dialysis and in-centre dialysis were minor; factors linked to the choice of in-centre dialysis were late referral, suboptimal DI, acute illness and absence of a 'home dialysis first' institutional policy. CONCLUSIONS: Given a personal choice with shared decision making, 65.4% of ESKD patients choose home dialysis. Our data indicate that the incidence of home dialysis potentially could be further increased to reduce the incidence of late referral and unplanned DI and, in acutely ill patients, by implementing an educational programme after improvement of their clinical condition.

Suboptimal dialysis initiation is associated with comorbidities and uraemia progression rate but not with estimated glomerular filtration rate.

BACKGROUND: Despite early referral of uraemic patients to nephrological care, suboptimal dialysis initiation (SDI) remains a common problem associated with increased morbimortality. We hypothesized that SDI is related to pre-dialysis care. METHODS: In the 'Peridialysis' study, time and reasons for dialysis initiation (DI), clinical and biochemical data and centre characteristics were registered during the pre- and peri-dialytic period for 1583 end-stage kidney disease patients starting dialysis over a 3-year period at 15 nephrology departments in the Nordic and Baltic countries to identify factors associated with SDI. RESULTS: SDI occurred in 42%. Risk factors for SDI were late referral, cachexia, comorbidity (particularly cardiovascular), hypoalbuminaemia and rapid uraemia progression. Patients with polycystic renal disease had a lower incidence of SDI. High urea and C-reactive protein levels, acidosis and other electrolyte disorders were markers of SDI, independently of estimated glomerular filtration rate (eGFR). SDI patients had higher eGFR than non-SDI patients during the pre-dialysis period, but lower eGFR at DI. eGFR as such did not predict SDI. Patients with comorbidities had higher eGFR at DI. Centre practice and policy did not associate with the incidence of SDI. CONCLUSIONS: SDI occurred in 42% of all DIs. SDI was associated with hypoalbuminaemia, comorbidity and rate of eGFR loss, but not with the degree of renal failure as assessed by eGFR.

Abdominal Aortic Calcifications Predict Survival in Peritoneal Dialysis Patients.

BACKGROUND: Peripheral arterial disease and vascular calcifications contribute significantly to the outcome of dialysis patients. The aim of this study was to evaluate the prognostic role of severity of abdominal aortic calcifications and peripheral arterial disease on outcome of peritoneal dialysis (PD) patients using methods easily available in everyday clinical practice. METHODS: We enrolled 249 PD patients (mean age 61 years, 67% male) in this prospective, observational, multicenter study from 2009 to 2013. The abdominal aortic calcification score (AACS) was assessed using lateral lumbar X ray, and the ankle-brachial index (ABI) using a Doppler device. RESULTS: The median AACS was 11 (range 0 - 24). In 58% of the patients, all 4 segments of the abdominal aorta showed deposits, while 19% of patients had no visible deposits (AACS 0). Ankle-brachial index was normal in 49%, low (< 0.9) in 17%, and high (> 1.3) in 34% of patients. Altogether 91 patients (37%) died during the median follow-up of 46 months. Only 2 patients (5%) with AACS 0 died compared with 50% of the patients with AACS ≥ 7 (p < 0.001). The adjusted hazard ratio for all-cause mortality was 4.85 (95% confidence interval [CI] 1.94 - 24.46) for aortic calcification (AACS ≥ 7), 2.14 for diabetes (yes/no), 0.93 for albumin (per 1 g/L), and 1.04 for age (per year). A low or high ABI were not independently associated with mortality. CONCLUSIONS: Severe aortic calcification was a strong predictor of all-cause mortality in PD patients. The evaluation of aortic calcifications by lateral X ray is a simple method that allows the identification of high-risk patients.

Why do physicians prescribe dialysis? A prospective questionnaire study.

INTRODUCTION: The incidence of unplanned dialysis initiation (DI) with consequent increased comorbidity, mortality and reduced modality choice remains high, but the optimal timing of dialysis initiation (DI) remains controversial, and there is a lack of studies of specific reasons for DI. We investigated why and when physicians prescribe dialysis and hypothesized that physician motivation for DI is an independent factor which may have clinical consequences. METHODS: In the Peridialysis study, an ongoing multicenter prospective study assessing the causes and timing of DI and consequences of unplanned dialysis, physicians in 11 hospitals were asked to describe their primary, secondary and further reasons for prescribing DI. The stated reasons for DI were analyzed in relation to clinical and biochemical data at DI, and characteristics of physicians. RESULTS: In 446 patients (median age 67 years; 38% females; diabetes 25.6%), DI was prescribed by 84 doctors who stated 23 different primary reasons for DI. The primary indication was clinical in 63% and biochemical in 37%; 23% started for life-threatening conditions. Reduced renal function accounted for only 19% of primary reasons for DI but was a primary or contributing reason in 69%. The eGFR at DI was 7.2 ±3.4 ml/min/1.73 m2, but varied according to comorbidity and cause of DI. Patients with cachexia, anorexia and pulmonary stasis (34% with heart failure) had the highest eGFR (8.2-9.8 ml/min/1.73 m2), and those with edema, "low GFR", and acidosis, the lowest (4.6-6.1 ml/min/1.73 m2). Patients with multiple comorbidity including diabetes started at a high eGFR (8.7 ml/min/1.73 m2). Physician experience played a role in dialysis prescription. Non-specialists were more likely to prescribe dialysis for life-threatening conditions, while older and more experienced physicians were more likely to start dialysis for clinical reasons, and at a lower eGFR. Female doctors started dialysis at a higher eGFR than males (8.0 vs. 7.1 ml/min/1.73 m2). CONCLUSIONS: DI was prescribed mainly based on clinical reasons in accordance with current recommendations while low renal function accounted for only 19% of primary reasons for DI. There are considerable differences in physicians´ stated motivations for DI, related to their age, clinical experience and interpretation of biochemical variables. These differences may be an independent factor in the clinical treatment of patients, with consequences for the risk of unplanned DI.

Thromboembolism as a cause of renal artery occlusion and acute kidney injury: the recovery of kidney function after two weeks.

Thromboembolic occlusion is a rare cause of acute kidney injury (AKI). It may lead to permanent loss of renal function. Our patient, who had dilated cardiomyopathy and prosthetic aortic valve, presented with AKI due to thromboembolic arterial occlusion of a solitary functioning kidney. After 2 weeks delay, local intra-arterial thrombolytic treatment with recombinant tissue plasminogen activator was performed without sufficient effect. However, a subsequent percutaneous transluminal angioplasty with stenting was successful. Diuresis began immediately, and renal function was fully recovered after 2 weeks. Although there had been no evident arterial circulation in the kidney, we think that minor flow through subtotal occlusion of the main renal artery made the hibernation of kidney tissue possible and contributed to the recovery. Thus, even after prolonged ischemia, revascularization can be useful.

[Sodium thiosulfate--new hope for the treatment of calciphylaxis]. / Natriumtiosulfaatti --toivoa kalsifylaksian hoitoon.

Calciphylaxis is a rare disease primarily affecting patients dependent on dialysis. It is characterised by small vessel media calcification leading to cutaneous ischemia and necrosis. The mortality rate is high with infection and sepsis being the most common causes of death. Calcium salts, vitamin D and high levels of serum calcium and phosphorus increase the risk of calciphylaxis. Current therapies including restoration of mineral homeostasis, wound care and pain control, are not entirely effective. Sodium thiosulfate, by dissolving calcium deposits, is a novel therapeutic choice for calciphylaxis. It has proved successful also in cases refractory to conventional treatment.

[Blue toe syndrome--a rare but possible complication of anticoagulant therapy]. / Sinisten varpaiden oireyhtymä-- antikoagulanttihoidon harvinainen komplikaatio.

Cholesterol microembolization syndrome (CMS) is a multiorgan ischemic disorder resulting from occlusion of small vessels by cholesterol crystals that are derived from atherosclerotic plaques of major arteries. Flow distribution of cholesterol crystals determines the clinical picture of CMS. Cholesterol crystals distributed to the lower extremities cause a typical "blue toe" appearance. The predisposing factors of CMS include various vascular procedures that scratch the luminal surface of the vascular wall and make the release of cholesterol crystals from the atherosclerotic plaques possible. However, CMS can also occur as a consequence of continuous anticoagulant use. Therefore, patients on anticoagulant therapy complaining even minor toe symptoms should be examined for possible CMS.

Long-term outcome of infective endocarditis: a study on patients surviving over one year after the initial episode treated in a Finnish teaching hospital during 25 years.

BACKGROUND: Only a few previous studies have focused on the long-term prognosis of the patients with infective endocarditis (IE). Our purpose was to delineate factors potentially associated with the long-term outcome of IE, recurrences of IE and requirement for late valve surgery. METHODS: A total of 326 episodes of IE in 303 patients were treated during 1980-2004 in the Turku University Hospital. We evaluated the long-term outcome and requirement for late valve surgery for 243 of these episodes in 226 patients who survived longer than 1 year after the initial admission. Factors associated with recurrences were analysed both for the 1-year survivors and for all 303 patients. RESULTS: The mean (SD) follow-up time for the 1-year survivors was 11.5 (7.3) years (range 25 days to 25.5 years). The overall survival was 95%, 82%, 66%, 51% and 45% at 2, 5, 10, 15 and 20 years. In age and sex adjusted multivariate analyses, significant predictors for long-term overall mortality were heart failure within 3 months of admission (HR 1.97, 95% CI 1.27 to 3.06; p = 0.003) and collagen disease (HR 2.54, 95% CI 1.25 to 5.19; p = 0.010) or alcohol abuse (HR 2.39, 95% CI 1.30 to 4.40; p = 0.005) as underlying conditions, while early surgery was significantly associated with lower overall mortality rates (HR 0.31, 95% CI 0.17 to 0.58; p < 0.001). Heart failure was also significantly associated with the long-term cardiac mortality (p = 0.032). Of all 303 patients, 20 had more than 1 disease episode. Chronic dialysis (p = 0.002), intravenous drug use (p = 0.002) and diabetes (p = 0.015) were significant risk factors for recurrent episodes of IE, but when analysed separately for the 1-year survivors, only chronic dialysis remained significant (p = 0.017). Recurrences and late valve surgery did not confer a poor prognosis. CONCLUSION: Heart failure during the index episode of IE was the complication, which significantly predicted a poor long-term outcome. Patients who underwent surgery during the initial hospitalisation for IE faired significantly better than those who did not.

Short-term and one-year outcome of infective endocarditis in adult patients treated in a Finnish teaching hospital during 1980-2004.

BACKGROUND: Previous studies on factors predicting the prognosis of infective endocarditis have given somewhat conflicting results. Our aim was to define the factors predicting the outcome of patients treated in a Finnish teaching hospital. METHODS: A total of 326 episodes of infective endocarditis in 303 patients treated during 1980-2004 were evaluated for short-term and 1-year outcome and complications. RESULTS: Infection of 2 native valves and the occurrence of neurological complications, peripheral emboli, or heart failure significantly predicted both in-hospital and 1-year mortality, while age > or =65 years or the presence of a major criterion or vegetation on echocardiography predicted death within 1 year. A significant trend was observed between the level of serum C-reactive protein (CRP) on admission and both the short-term and 1-year outcome. In the patients who had CRP values > or =100 mg/l on admission, the hazard ratio for in-hospital death was 2.9-fold and the hazard ratio for 1-year death was 3.9-fold as compared to those with lower CRP values. Male sex and age < 64 years significantly predicted a need for both in-hospital and 1-year surgery, as did the development of heart failure or the presence of a major criterion or vegetation on echocardiography. Peripheral emboli were associated with a need for in-hospital surgery, while Streptococcus pneumoniae as the causative agent or infection of 2 native valves predicted a need for surgery within 1 year from admission. CONCLUSION: Some of the factors (e.g. heart failure, neurological complications, peripheral emboli) predicting a poor prognosis and/or need for surgery were the same observed in previous studies. A new finding was that high CRP values (> or =100 mg/l) on admission significantly predicted both short-term and 1-year mortality.

Aetiological diagnosis of infective endocarditis by direct amplification of rRNA genes from surgically removed valve tissue. An 11-year experience in a Finnish teaching hospital.

BACKGROUND/AIMS: The aetiology of infective endocarditis (IE) can be determined directly from surgically removed valve tissue using broad-range bacterial rDNA polymerase chain reaction (PCR) followed by sequencing. We sought to assess the value of this methodology in a routine clinical setting. METHODS: Broad-range PCR with primers targeting conserved bacterial rDNA sequences was applied to directly analyse valve samples from 56 patients operated on for diagnosed or suspected IE. Identification of the aetiological agent was performed by partial DNA sequencing of the 16S and 23S rDNA genes. RESULTS: The final diagnosis was definite IE in 36 patients and possible IE in 2 patients, while the diagnosis of IE was rejected in 18 patients. PCR analysis from removed valve tissue was positive in 25 patients with IE. Molecular identification was consistent with the blood culture finding in 20 of these patients. The PCR approach was the only method to yield the aetiological diagnosis in additional 4 patients (2 Staphylococcus species, 1 Streptococcus bovis, 1 Bartonella quintana), all of whom had received antimicrobials before blood cultures were taken. The mean duration of preoperative antimicrobial treatment for the patients with PCR-positive valves was 19.6 (range 1-58) days. CONCLUSIONS: Bacterial DNA may persist during treatment in infected valves for long periods. The PCR method is especially useful when the causative agent of IE is fastidious or when the specimen is taken during antimicrobial treatment.

Utility of serum C-reactive protein in assessing the outcome of infective endocarditis.

AIMS: To evaluate the diagnostic usefulness of serial serum C-reactive protein determinations in monitoring the outcome of infective endocarditis (IE). METHODS AND RESULTS: C-reactive protein, erythrocyte sedimentation rate (ESR), and white blood cell count (WBC) were measured from admission until week 10 in 129 patients with 134 episodes of IE. Need for cardiac surgery and final outcome were assessed until 3 months from admission. Data were evaluated using extensive statistical analyses. The fall in serum C-reactive protein or WBC was significantly faster when a patient had an uncomplicated recovery than when complications developed or death ensued, but no such behaviour was observed in ESR. None of the 80 patients who had normal C-reactive protein by week 10 died of IE. Moreover, none of the 22 patients who had normal C-reactive protein by week 4 needed cardiac surgery and only two of the 33 patients who had normal C-reactive protein by week 6 needed cardiac surgery, both after successful medical treatment of IE. Of the 87 patients whose WBC normalized within 4 weeks, six died and 15 needed valve surgery. CONCLUSION: The normalization of C-reactive protein proved to be a good predictor of a favourable late outcome (surgery, death) of IE. Also WBC count proved useful in the assessment of patients with IE, but the value of ESR was negligible.

Lymphomas diagnosed by percutaneous kidney biopsy.

BACKGROUND: Occult renal lymphoma clinically mimicking renal medical disease constitutes a diagnostic challenge to nephrologists, radiologists, and renal pathologists. The clinical and radiological findings, mostly nonspecific or inconclusive, seldom obviate the need for a kidney biopsy. METHODS AND RESULTS: We report 5 new cases of diffuse bilateral renal lymphoma diagnosed by percutaneous kidney biopsy, all presenting with acute renal failure (ARF) of unknown cause. Three cases showed an interstitial and 2 an intraglomerular/intravascular type of lymphomatous infiltration. All tumors were of B-cell lineage. Our cases add to 50 similar cases reported since 1980. Considering all 55 cases together, 39 (87%) of the 44 cases with interstitial and 5 of 11 (45%) of those with intraglomerular lymphoma presented with ARF. In contrast, 5 of 10 cases with intraglomerular but none with interstitial infiltration presented with nephrotic range proteinuria. All but 2 cases (95%) with ARF and interstitial lymphoma but none with ARF and intraglomerular lymphoma showed bilaterally enlarged kidneys. Signs of extrarenal lymphomatous involvement were detected in 24 cases (44%) at the time of kidney biopsy or shortly thereafter. However, in only 10 cases (18%), all with interstitial lymphoma, was a tumor suspected prior to biopsy, mainly based on radiographical evidence of enlarged kidneys. CONCLUSION: Both types of diffuse bilateral renal lymphoma may clinically mimic renal medical disease. ARF in interstitial and in intraglomerular lymphoma may be due to increased intrarenal pressure and intraglomerular obstruction, respectively. Percutaneous kidney biopsy provides the most expedient means of establishing the diagnosis. Differential diagnosis includes interstitial nephritis and proliferative glomerulonephritis.