Incremental Hemodialysis: What We Know so Far.

Traditionally, patients that develop progressive chronic kidney disease in need of kidney replacement therapy are prescribed thrice weekly in-center hemodialysis sessions at the beginning of therapy. This empiric prescription is based on historic trials that were comprised of mostly prevalent patients. Incremental hemodialysis is the process of performing <3 sessions of dialysis per week or limiting dialysis dose by duration at the initial onset of treatment to provide a more gradual transition, mimicking the progressive nature of kidney disease. Adding clearance contributions from residual kidney function is the standard of care with peritoneal dialysis but has not routinely been employed with hemodialysis. Accounting for residual kidney function accompanied by improvement in adjuvant pharmacotherapy, such as newer potassium binding agents and dietary modification, can augment dialytic clearances and allow for an incremental approach. Utilizing incremental dialysis has been associated with both preserving residual kidney function as well as improving patient quality of life. Barriers to this approach include concerns regarding patient acceptance of dialysis prescription changes, adherence to therapy, and provider factors that would require a restructuring of the current thrice weekly hemodialysis rubric. Candidacy for incremental therapy has shown the best outcomes when urea clearances exceed 3 mL/min and urine volumes are >500 mL/day, although these measures have been deemed conservative. A significant amount of retrospective and registry data has been supportive of initiating incremental hemodialysis and several pilot studies have shown the feasibility of implementing such an approach. Larger, randomized control trials are needed to fully evaluate safety and efficacy to allow for more widespread acceptance of this patient-centered approach to chronic kidney disease.

Preventing Hepatitis B in the Dialysis Unit.

Patients with end-stage renal disease are at risk for contracting hepatitis B virus (HBV) because of their exposure to blood products and compromised immune status. Despite a decrease in the incidence of HBV infection, continued vigilance in the form of surveillance is imperative in preventing the spread of this robust DNA virus. Regular review of serologic markers with isolation and decontamination practices as appropriate are paramount to maintaining a safe environment for dialysis to occur. Vaccination response rates are known to be suboptimal in the hemodialysis population. This has been attributed to altered cellular and humoral immunity. Vaccine response rates are improved with modification of the vaccine schedule. Explicit care must be taken to ensure patients are screened on entry to the dialysis unit especially after hospitalization, and periodically thereafter. This review discusses HBV in terms of epidemiology, prevention strategies, vaccination options, and identifying serologic markers. Finally, our experience with incorporation of an alert system incorporated within the electronic medical record that highlights markers of infection and immunity is described.

Pathophysiology and Treatment of Hepatitis B and C Infections in Patients With End-Stage Renal Disease.

An in-depth understanding of viral hepatitis is important to the care of patients with end-stage renal disease undergoing hemodialysis. Both hepatitis B and C viruses are acquired through hematogenous spread and can lead to horizontal transmission. Concurrent hepatic and renal injuries have ominous outcomes with significant morbidity. Hepatitis B incidence has decreased through practices including vaccination of nonimmune individuals and isolation of patients with the disease. The pathogenesis of hepatitis B leads to various symptoms and serologic changes with unique temporal associations dictating an acute or chronic presentation. Chronic hepatitis B develops when there is persistence of surface antigen for more than 6 months. Occult hepatitis B is an enigmatic form of the chronic disease where viral DNA is present despite the patient remaining seronegative. Nucleoside analogs are used as a treatment for individuals with hepatitis B who have comorbid CKD; however, the mainstay of infection control relies on immunization. Hepatitis C, an RNA virus, has increased in prevalence. Strict universal precautions with sound infection-control practices are important to prevent seroconversion. Recent therapeutic advances involving the development of direct-acting antiviral agents have broadened treatment options for patients with renal impairment and hepatitis C, offering the potential for a definitive cure. Controversy on the timeliness of treatment for transplant options has also risen with the advent of these newer therapies. We review the epidemiology, pathophysiology, and updates in treatment of these viral entities as they relate to the hemodialysis population.

Coronal mode ultrasound guided hemodialysis cannulation: A pilot randomized comparison with standard cannulation technique.

BACKGROUND: Infiltrations from cannulation result in significant morbidity including loss of hemodialysis (HD) vascular access (VA). Cannulation is dependent on personnel skill and VA characteristics. Surface marking of VA lacks real-time information and traditional ultrasound (US) devices are large, expensive, requiring skilled operators. Sonic Window© (Analogic Ultrasound, Peabody, MA, USA) is a coronal mode ultrasound device (CMUD) approved for VA cannulation. METHODS: Single center randomized, prospective pilot study comparing handheld US-guided cannulation of new arteriovenous fistula (AVF) to standard cannulation practices. Patients with end stage renal disease (ESRD) on in-center HD who had a new AVF cleared for cannulation and dialysis were enrolled. Patients with new AVF received either standard cannulation (control group) or image guidance using CMUD (study group) for 3 weeks. Ultrasound characteristics of VA, cannulation practices and complications end points were obtained. RESULTS: An infiltration rate of 9.7% was noted during the study. Slightly lower odds ratio (OR) of infiltration was observed in the study group (OR 0.94, 95% CI: 0.26-3.41, P value = 0.93). Study group yielded longer time for assessment (101.8 ± 80.2 vs. 22.3 ± 22.5 seconds, P = < 0.001), increased cannulation time (41.1 ± 70.6 vs. 25.0 ± 27.9 seconds, P = 0.04), and increased patient satisfaction (94.6% vs. 82%, P = 0.04) compared to control group. Number of cannulation attempts, needle size, arterial or venous needle insertion, and tourniquet usage between groups were not statistically different. CONCLUSION: Handheld ultrasound is a safe and useful aid in cannulation of dialysis access.

Change in Lactate Levels After Hemodialysis in Patients With End-Stage Renal Disease.

STUDY OBJECTIVE: Patients with end-stage renal disease commonly visit the emergency department (ED). The purpose of this investigation is to examine the prevalence of baseline abnormal lactate levels and to evaluate the effects of hemodialysis on serum lactate levels. METHODS: This was a prospective observational cohort study performed at an outpatient dialysis facility at an urban tertiary care hospital. The study consisted of 226 patients with end-stage renal disease who were receiving long-term hemodialysis and were enrolled during a 2-day period at the beginning of December 2015. Blood drawn for lactate levels was immediately analyzed before and after hemodialysis sessions. All patients completed their hemodialysis sessions. RESULTS: The prevalence of an abnormal lactate level (greater than 1.8 mmol/L) before hemodialysis was 17.7% (n=40). Overall, lactate levels decreased by 27% (SD 35%) after hemodialysis, with a decrease of 37% (SD 31%) for subgroups with a lactate level of 1.9 to 2.4 mmol/L, and 62% (SD 14%) with a lactate of 2.5 to 3.9 mmol/L. CONCLUSION: The data presented help providers understand the prevalence of abnormal lactate values in an outpatient end-stage renal disease population. After hemodialysis, lactate levels decreased significantly. This information may help medical providers interpret lactate values when patients with end-stage renal disease present to the ED.

Sodium Homeostasis in Chronic Kidney Disease.

The pathologic consequences of sodium retention in the CKD population can lead to hypertension, edema, and progressive disease. Sodium excess is responsible for increases in oxidative stress, which alters kidney vasculature. As progression of CKD occurs, hyperfiltration by remaining nephrons compensates for an overall decrease in the filtered load of sodium. In the later stages of CKD, compensatory mechanisms are overcome and volume overload ensues. Nephrotic syndrome as it relates to sodium handling involves a different pathophysiology despite a common phenotype. Extrarenal sodium buffering is also examined as it has significant implications in the setting of advanced CKD.

Prevention of catheter-related bloodstream infections in patients on hemodialysis: challenges and management strategies.

Catheter-related bloodstream infections are a significant source of morbidity and mortality in the end-stage renal disease population. Although alternative accesses to undergoing renal replacement therapy exist, many patients begin hemodialysis with a dialysis catheter due to logistic and physiologic factors involved in arteriovenous fistula creation and maturation. Colonization of catheters via skin flora leads to the production of biofilm, which acts as a reservoir for virulent bacteria. Preventative therapies center on appropriate catheter maintenance, infection control measures, and early removal of devices as patients transition to other access. Despite best efforts, when conservative measures fail to prevent infections in a high-risk population, antimicrobial lock therapy should be considered as an option to combat catheter-related bloodstream infections.

Comparative effectiveness of two catheter locking solutions to reduce catheter-related bloodstream infection in hemodialysis patients.

BACKGROUND AND OBJECTIVES: Infection is the second leading cause of death in hemodialysis patients. Catheter-related bloodstream infection and infection-related mortality have not improved in this population over the past two decades. This study evaluated the impact of a prophylactic antibiotic lock solution on the incidence of catheter-related bloodstream infection and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This prospective, multicenter, observational cohort study compared the effectiveness of two catheter locking solutions (gentamicin/citrate versus heparin) in 555 hemodialysis patients dialyzing with a tunneled cuffed catheter between 2008 and 2011. The groups were not mutually exclusive. Rates of catheter-related bloodstream infection and mortality hazards were compared between groups. RESULTS: The study population (n=555 and 1350 catheters) had a median age of 62 years (interquartile range=41-83 years), with 50% men and 71% black. There were 427 patients evaluable in the heparin period (84,326 days) and 322 patients evaluable in the antibiotic lock period (71,192 days). Catheter-related bloodstream infection in the antibiotic lock period (0.45/1000 catheter days) was 73% lower than the heparin period (1.68/1000 catheter days; P=0.001). Antibiotic lock use was associated with a decreased risk of catheter-related bloodstream infection compared with heparin (risk ratio, 0.23; 95% confidence interval, 0.13 to 0.38 after multivariate adjustment). Cox proportional hazards modeling found that antibiotic lock was associated with a reduction in mortality (hazard ratio, 0.36; 95% confidence interval, 0.22 to 0.58 in unadjusted analyses; hazard ratio, 0.32; 95% confidence interval, 0.14 to 0.75 after multivariate adjustment). The rate of gentamicin-resistant organisms decreased (0.40/1000 person-years to 0.22/1000 person-years) in the antibiotic lock period (P=0.01). CONCLUSIONS: The results of this study show that the use of a prophylactic, gentamicin/citrate lock was associated with a substantial reduction in catheter-related bloodstream infection and is the first to report a survival advantage of antibiotic lock in a population at high risk of infection-related morbidity and mortality.