Residual kidney function in nocturnal vs conventional haemodialysis patients: a prospective observational study.

BACKGROUND: Residual kidney function (RKF) provides substantial volume and solute clearance even after dialysis initiation. Preservation of RKF is associated with improved outcomes including mortality in patients on both peritoneal and haemodialysis (HD). Factors predicting RKF loss are unclear, including HD modality. Nocturnal haemodialysis (NHD) may result in less aggressive fluid and solute shifts, however, retrospective data suggests frequent NHD may accelerate RKF decline. The aim of the study was to determine if decline in RKF differs between patients undergoing conventional haemodialysis (CHD) versus NHD. METHODS: A prospective observational study of incident HD patients was undertaken comparing patients undertaking CHD (4-5 h, 3 days/week) and NHD (8 h, 3-5 nights/week). Change in RKF was measured by urea and creatinine clearance (48-h interdialytic urine collection) and glomerular filtration rate (GFR) (Cr51-EDTA nuclear scan) at initiation of dialysis (baseline) and 12 months. RESULTS: A total of 18 incident HD patients were recruited (8 CHD, 10 NHD). Three patients withdrew after baseline (n = 15). Baseline RKF was similar between groups with mean nuclear GFR of 13.3 ± 4.1 mL/min in the CHD cohort vs 13.5 ± 4.6 mL/min in the NHD group (p = 0.89). Baseline urine volume was 2399 ± 950 mLs and 2794 ± 1662 mLs in the CHD and NHD, respectively (p = 0.57). Nuclear GFR declined from time 0 to 12 months to 9.3 ± 2.5 mL/min and 10.4 ± 4.3 mL/min in the CHD and NHD, respectively (p = 0.52). There was a significant decline in 48-h urine volume over 12 months with a mean volume of 1943 ± 1087.0 mLs in the CHD compared to 601.7 ± 315.3 mLs in the NHD (p = 0.01). No significant difference was found in other measures of RKF between groups over 12 months. CONCLUSION: This small prospective cohort study found that the loss of residual urine volume was greater in the NHD vs the CHD cohort but there was no difference in other measures of RKF.

The use of electron microscopy in the diagnosis of focal segmental glomerulosclerosis: are current pathological techniques missing important abnormalities in the glomerular basement membrane?

Background: There is an increasing appreciation that variants of the collagen IV genes may be associated with the development of focal segmental glomerulosclerosis (FSGS). On electron microscopy, such variants may produce characteristic changes within the glomerular basement membrane (GBM). These changes may be missed if glomerular lesions histologically diagnosed as FSGS on light microscopy are not subjected to electron microscopy. Methods: We conducted a retrospective cohort analysis of all patients presenting to two hospitals who received a primary histological diagnosis of FSGS to see if these samples underwent subsequent electron microscopy. Each such sample was also scrutinised for the presence of characteristic changes of an underlying collagen IV disorder Results: A total of 43 patients were identified. Of these, only 30 underwent electron microscopy. In two samples there were histological changes detected that might have suggested the underlying presence of a collagen IV disorder. Around one in three biopsy samples that had a histological diagnosis of FSGS were not subjected to electron microscopy. Conclusion: Renal biopsy samples that have a histological diagnosis of primary FSGS not subjected to subsequent electron microscopy may potentially miss ultrastructural changes in the GBM that could signify an underlying collagen IV disorder as the patient's underlying disease process. This could potentially affect both them and their families' investigative and management decisions given potential for implications for transplant, heritability and different disease pathogenesis. This represents a gap in care which should be reflected upon and rectified via iterative standard care and unit-level quality assurance initiatives.

Alcohol use among young adults presenting to the emergency department.

OBJECTIVES: To determine the prevalence of young ED patients at risk from hazardous alcohol consumption, to identify high-risk patient subgroups and evaluate the feasibility of use of the Alcohol Use Disorders Identification Test (AUDIT) in this setting. METHODS: We undertook a cross-sectional survey of 336 ED patients aged 18-30 years, inclusive. All were breathalysed prior to self-administering the AUDIT. A 'positive' AUDIT score (> or = 8) defined hazardous alcohol consumption. AUDIT scores were correlated with sex and trauma diagnosis. RESULTS: One hundred and thirty-one (39.0%, 95% confidence interval [CI] 33.8-44.5) patients were classified as AUDIT-positive. Men were significantly more likely to be AUDIT-positive (49% vs 23%, P < 0.001) and had significantly higher total AUDIT scores (P < 0.001) than women. Trauma patients were significantly more likely to be AUDIT-positive (P < 0.001) and had significantly higher AUDIT scores than non-trauma patients (P < 0.001). Of the six patients who recorded a positive breath alcohol reading, all were AUDIT-positive. One hundred (76.3%, 95% CI 68.0-83.1) AUDIT-positive patients did not report others being concerned about their drinking or had not been given advice to cut down. CONCLUSION: It is feasible to use the AUDIT screening tool in the ED to identify those at risk from hazardous drinking. In our ED there is a high prevalence of hazardous alcohol consumption in young adult patients, many of whom have not previously received advice to cut down on their drinking.

Investigation of the variables that impact upon the knowledge of cardiac risk factors.

OBJECTIVE: Awareness of cardiac disease risk factors is required before they can be modified. The present study aimed to investigate risk factor knowledge and the variables that impact upon this knowledge. METHODS: We undertook an analytical, cross-sectional survey of 226 patients attending an ED. Patients were asked to recall as many cardiac risk factors as possible and to rate the risk of nine given risk factors. Data relating to sources of risk factor information were collected. Uni- and multivariate (multiple linear regression) analyses determined variables that impacted upon the risk factor knowledge score. RESULTS: Mean patient age was 60.2 +/- 15 years, 55.3% (95% confidence interval 48.6-61.9) were male and 19.9% (95% confidence interval 15.0-25.8) had known cardiac disease. The mean risk factor knowledge score of 2.5 +/- 1.5 out of a possible 12 (median 3) was indicative of poor knowledge. Smoking, poor diet and stress/worry/tension were the most common factors reported. Variables impacting significantly on the knowledge score were English as a first language (P < 0.001), age (negative correlation, P < 0.001) and the receipt of information relating to cardiac health (P < 0.001). The patients' general practitioner and the media were the most important sources of information. CONCLUSIONS: Patients' knowledge of cardiac risk factors is generally poor and education strategies are indicated. At the individual level, the general practitioner is likely to remain as an important influence on knowledge. However, complementary media education programs are indicated at the community level. Patient subgroups at 'high risk' through poor knowledge should be specifically targeted.

Solar-assisted hemodialysis.

BACKGROUND AND OBJECTIVES: Hemodialysis resource use-especially water and power, smarter processing and reuse of postdialysis waste, and improved ecosensitive building design, insulation, and space use-all need much closer attention. Regarding power, as supply diminishes and costs rise, alternative power augmentation for dialysis services becomes attractive. The first 12 months of a solar-assisted dialysis program in southeastern Australia is reported. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A 24-m(2), 3-kWh rated solar array and inverter-total cost of A$16,219-has solar-assisted the dialysis-related power needs of a four-chair home hemodialysis training service. All array-created, grid-donated power and all grid-drawn power to the four hemodialysis machines and minireverse osmosis plant pairings are separately metered. After the grid-drawn and array-generated kilowatt hours have been billed and reimbursed at their respective commercial rates, financial viability, including capital repayment, can be assessed. RESULTS: From July of 2010 to July of 2011, the four combined equipment pairings used 4166.5 kWh, 9% more than the array-generated 3811.0 kWh. Power consumption at 26.7 c/kWh cost A$1145.79. Array-generated power reimbursements at 23.5 c/kWh were A$895.59. Power costs were, thus, reduced by 76.5%. As new reimbursement rates (60 c/kWh) take effect, system reimbursements will more than double, allowing both free power and potential capital pay down over 7.7 years. With expected array life of ∼30 years, free power and an income stream should accrue in the second and third operative decades. CONCLUSIONS: Solar-assisted power is feasible and cost-effective. Dialysis services should assess their local solar conditions and determine whether this ecosensitive power option might suit their circumstance.