Initiation of maintenance hemodialysis through central venous catheters: study of patients' perceptions based on a structured questionnaire.

BACKGROUND: Despite well-publicized suggestions to utilize arteriovenous fistulae and grafts to initiate hemodialysis, too many patients in the United States start dialysis via central venous catheters despite their well-known association with increased morbidity, mortality, and cost. METHODS: To determine the reasons for this high rate of catheter use, and, ultimately, ways to reduce it, we developed a questionnaire designed to determine where in the process of patient care the process to fistula or graft placement was not completed, thus requiring the use of central venous catheters. The questionnaire was reviewed by several nephrologists not involved with the study. We administered the questionnaire to 52 consecutive hospitalized patients who started maintenance dialysis with catheters at a University-affiliated Hospital and referral center. The questionnaire asked each patient to provide details pertaining to pre-dialysis care, referrals, and follow-through on recommended referrals. If the patient did not see the physician to whom he/she was referred, we asked the reason(s) for such failure. RESULTS: Patient responses showed that there were two major lapses in the transition from diagnosis of advanced kidney disease to construction of appropriate dialysis access: failure by the patients to see a nephrologist and/or an access surgeon, and failure by physicians to refer patients to an access surgeon. Twenty percent of the patients failed to follow up with either a nephrologist or a surgeon. Only 38% (15/40) of those seen by a nephrologist had been referred to a surgeon. CONCLUSIONS: The quality of care was impaired by lack of referral to surgeons by nephrologists and by lack of follow-through by patients. Areas for improvement include improved communications between physicians and patients and more careful follow-up by both physicians and patients. Several methods of providing better patient care and communication between patients and nephrologists are recommended.

The Unpredictability of Idiopathic Membranous Nephropathy: An Illustrative Case Report.

The case of a female patient with primary membranous nephropathy is presented. She was treated with corticosteroids and chlorambucil after conservative therapy had failed and went into remission for 5 years. Her nephrotic syndrome recurred but did not respond to the same regimen. She had another complete remission after treatment with corticosteroids and cyclosporine, but the nephrosis recurred after 7 years. Again, she failed to respond with retreatment of steroids plus cyclosporine. She was treated with alternate-day steroid plus mycophenolate and, once again, had a complete remission. She was maintained on low-dose mycophenolate for 7 more years. The mycophenolate had to be discontinued because of cytomegalovirus colitis. Treatment with ganciclovir abolished the colitis. She is still in remission 10 years later. The case is discussed with regard to current knowledge of the immune pathogenesis of membranous nephropathy as well as the unknowns of the immunogenesis of the disease.

Physician Prevention of Acute Kidney Injury.

BACKGROUND: The frequency of acute kidney injury has become substantially greater over the recent past. Acute kidney injury, moreover, is associated with increased mortality and morbidity over both the short and long term. Despite these facts, its therapy has not changed significantly for many decades. Currently, therefore, prevention is the only action that can reduce the frequency and consequences of acute kidney injury. METHODS: Charts of 492 patients were reviewed retrospectively for the presence of acute kidney injury based on creatinine elevation. One hundred seventy patients were found to have acute kidney injury defined as a sustained elevation of serum creatinine ≥ 0.3 mg/dL for 48 hours or more. An agent or event was determined to be responsible for renal injury if there was the defined increase in serum creatinine within 48 hours of exposure. Charts were reviewed to determine if the renal injury was preventable. RESULTS: Fifty-one cases were considered to be preventable. Of these, 16 had not received saline prophylaxis for intravenous contrast when appropriate, 15 were not treated appropriately for hemodynamic instability or for hypertension, 9 had inappropriate use of medications, and 11 received multiple nephrotoxic agents. CONCLUSIONS: In a retrospective analysis of 170 hospitalized patients who developed acute kidney injury during admission, 30% of episodes could have been avoided if physicians had taken appropriate preventive actions.

Plasma protein biomarkers enhance the clinical prediction of kidney injury recovery in patients undergoing liver transplantation.

UNLABELLED: Biomarkers predictive of recovery from acute kidney injury (AKI) after liver transplantation (LT) could enhance decision algorithms regarding the need for liver-kidney transplantation or renal sparing regimens. Multianalyte plasma/urine kidney injury protein panels were performed immediately before and 1 month post-LT in an initial test group divided by reversible pre-LT AKI (rAKI = post-LT renal recovery) versus no AKI (nAKI). This was followed by a larger validation set that included an additional group: irreversible pre-LT AKI (iAKI = no post-LT renal recovery). In the test group (n = 16), six pre-LT plasma (not urine) kidney injury proteins (osteopontin [OPN], neutrophil gelatinase-associated lipocalin, cystatin C, trefoil factor 3, tissue inhibitor of metalloproteinase [TIMP]-1, and ß-2-microglobulin) were higher in rAKI versus nAKI (P < 0.05) and returned to normal values with renal recovery post-LT. In the validation set (n = 46), a number of proteins were significantly higher in both rAKI and iAKI versus nAKI. However, only pre-LT plasma OPN (P = 0.009) and TIMP-1 (P = 0.019) levels were significantly higher in rAKI versus iAKI. Logistic regression modeling was used to correlate the probability of post-LT rAKI, factoring in both pre-LT protein markers and clinical variables. A combined model including elevated OPN and TIMP-1 levels, age <57, and absence of diabetes had the highest area under the curve of 0.82, compared to protein-only and clinical variable-only models. CONCLUSION: These data suggest that plasma protein profiles might improve the prediction of pre-LT kidney injury recovery after LT. However, multicenter, prospective studies are needed to validate these findings and ultimately test the value of such protein panels in perioperative management and decision making.

Effect of predialysis eating on measurement of urea reduction ratio and Kt/V.

Physicians utilize the measurement of the urea reduction ratio (URR) and Kt/V as surrogates for the adequacy of hemodialysis, as well as to follow the course of patients longitudinally. These measurements are affected by the duration of a dialysis treatment, the type and size of the dialyzer membrane used during the treatment, the blood flow rate during the treatment, and the adequacy of vascular access. We, and others, have noted that eating during dialysis can be associated with decreases in URR and Kt/V. However, there have been no previous studies that have examined the effects of eating before dialysis on these variables. This study examined the effects of eating one-third of a daily diet 2 hours before dialysis as opposed to fasting for a minimum of 3 hours before dialysis on the measured URR and Kt/V as obtained routinely in our dialysis unit. Sixty seven patients gave informed consent for the study, and 42 completed the protocol. No differences were found in URR or Kt/V when dialysis was performed 2 hours after eating compared with performing dialysis after at least a 3-hour fast in the group as a whole or in subgroup analyses of men, women, patients with diabetes, patients in different age groups, or patients who dialyzed on different shifts. Unlike intradialytic food ingestion, moderate predialysis food intake does not affect the measurement of dialysis adequacy as determined by URR and Kt/V.