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BACKGROUND: The national hospital-acquired complication programme captures complications arising from patient-related and hospital-related factors, but the proportion of the two is unclear. AIM: Health services are encouraged to evaluate data from the national hospital-acquired complications (HAC) programme and identify strategies to mitigate them. METHODS: A retrospective chart review compared HAC extracted from administrative data. The setting was a 430-bed university-affiliated metropolitan hospital. Records from 260 participants with, and 462 without, reported HAC from 2619 multi-day stay adults were reviewed. The main outcome measures were prevalence and positive predictive value (PPV) of HAC methodology. RESULTS: No errors of HAC coding or classification were identified. Four hundred and twenty-three HAC events were reported in 260 records; most commonly delirium (n = 57; 13.4%), pneumonia (n = 46; 10.9%), blood stream infection (n = 39; 9.2%), hypoglycaemia (n = 33; 7.8%) and cardiac arrhythmias (n = 33; 7.8%). One hundred and eight (25.5%) 'HAC' events in 69 separations (95% confidence interval (CI) = 2.05-3.33 per 100 separations) were false positive, and 43 of 462 (95% CI = 6.72-12.22 per 100 separations) were false negative. Prevalence of total (reported plus missing) HAC was 16.06 (95% CI = 14.02-19.52), reported HAC was 9.93 (95% CI = 8.76-11.21), potentially preventable HAC was 1.68 (95% CI = 1.22-2.26) and healthcare errors was 0.31 (95% CI = 0.13-1.30) per 100 separations. PPV of HAC for true clinical events was 0.74 (0.68-0.79), preventable events 0.18 (0.13-0.23) and healthcare error 0.03 (0.01-0.06). CONCLUSIONS: Prevalence of HAC events was higher than expected, but PPV for healthcare errors was low, suggesting provision of care is a less common cause of HAC events than patient factors. HAC may be an indicator of hospital admission complexity rather than HAC.
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Hospitalización , Evaluación de Resultado en la Atención de Salud , Adulto , Humanos , Estudios Retrospectivos , Prevalencia , Hospitales UniversitariosRESUMEN
BACKGROUND: Incremental peritoneal dialysis (PD) is recommended as a component of high-quality care by the international society for PD; however, its feasibility and clinical outcomes have not been widely reported. The aim of this study is to describe our experience with incremental PD. METHODS: This was a retrospective cohort study of incident PD patients at Eastern Health between 2015 and 2019. Patients who stopped PD within 30 days were excluded. Incremental PD was defined in CAPD as using <8 L/day of exchange volume and in automated PD as dialysing without a last fill. Dialysis modality accorded with patient and physician preferences. RESULTS: The 96 patients were included in this study; 54 with incremental PD. Compared to full-dose PD, incremental PD patients were more likely to be female, had less comorbid diabetes (28% vs. 52%) and higher residual kidney function (RKF) (Kt/V 2.0 ± 0.7 vs. 1.4 ± 0.7). Age, BMI and starting eGFR did not differ between groups. Incremental PD exposed patients to lower exchange volumes (4.4 ± 2.1 vs. 8.5 ± 1.1 L/day), glucose load (46 ± 41 g/day vs. 119 ± 46) and was associated with a longer peritonitis-free survival. PD technique survival, rates of peritonitis or hospitalization were comparable between groups. Predictors for longer incremental PD use included older age and higher starting eGFR. CONCLUSIONS: Incremental PD is a feasible, goal-directed initial prescription in patients with RKF with comparable peritonitis rates and technique survival. Validation of this prescription in prospective studies is warranted.
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Fallo Renal Crónico , Diálisis Peritoneal , Peritonitis , Factores de Edad , Anciano , Australia/epidemiología , Progresión de la Enfermedad , Femenino , Tasa de Filtración Glomerular , Hospitalización/estadística & datos numéricos , Humanos , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/epidemiología , Fallo Renal Crónico/fisiopatología , Fallo Renal Crónico/terapia , Pruebas de Función Renal/métodos , Pruebas de Función Renal/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Planificación de Atención al Paciente , Diálisis Peritoneal/efectos adversos , Diálisis Peritoneal/métodos , Diálisis Peritoneal/estadística & datos numéricos , Peritonitis/diagnóstico , Peritonitis/epidemiología , Peritonitis/etiología , Peritonitis/prevención & control , Estudios RetrospectivosRESUMEN
INTRODUCTION: The endothelial glycocalyx on the vascular luminal surface contributes to endothelial health and function. Damage to this layer is indicative of vascular injury, reflected by increased levels of its shed constituents in serum and an increase in the perfused boundary region (PBR) when measured in sublingual capillaries using the GlycoCheck™ device. We aimed to examine the longitudinal effects of kidney transplantation on the glycocalyx by measuring biochemical markers of the glycocalyx and endothelial dysfunction and the PBR. METHODS: We recruited healthy controls and stage 5 CKD patients scheduled to undergo a kidney transplant. Investigations were performed before transplant and then 1 and 3 months after transplantation. At each point, blood was collected for hyaluronan, syndecan-1, vascular cell adhesion molecule (VCAM-1), and von Willebrand factor (vWF), and a PBR measurement was performed. RESULTS: Thirty healthy controls and 17 patients undergoing a kidney transplant were recruited (9 cadaveric and 8 live donation; 12 on dialysis and 5 pre-emptive). Before transplant, transplant recipients had greater evidence of glycocalyx damage than controls. After transplant, PBR improved from median 2.22 (range 1.29-2.73) to 1.98 (1.65-2.25) µm, p = 0.024, and syndecan-1 levels decreased from 98 (40-529) to 36 (20-328) ng/mL, p < 0.001. Similarly, VCAM-1 fell from 1,479 (751-2,428) at baseline to 823 (516-1,674) ng/mL, p < 0.001, and vWF reduced from 3,114 (1,549-5,197) to 2,007 (1,503-3,542) mIU/mL, p = 0.002. Serum levels of hyaluronan remained unchanged. CONCLUSION: The combination of reduced PBR and syndecan-1 following transplant suggests that transplantation may improve glycocalyx stability at 3 months after transplant.
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Endotelio Vascular/patología , Glicocálix/patología , Fallo Renal Crónico/patología , Trasplante de Riñón , Adulto , Anciano , Biomarcadores/análisis , Femenino , Humanos , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Adulto JovenRESUMEN
Renal anaemia is a common and important complication in patients with chronic kidney disease (CKD). The current standard-of-care treatment for renal anaemia in CKD patients involves ensuring adequate iron stores and administration of erythropoietin stimulating agents (ESA). Hypoxia inducible factor (HIF) is a key transcription factor primarily involved in the cellular regulation and efficiency of oxygen delivery. Manipulation of the HIF pathway by the use of HIF-prolyl hydroxylase inhibitors (HIF-PHI) has emerged as a novel approach for renal anaemia management. Despite it being approved for clinical use in various Asia-Pacific countries, its novelty mandates the need for nephrologists and clinicians generally in the region to well understand potential benefits and harms when prescribing this class of drug. The Asian Pacific society of nephrology HIF-PHI Recommendation Committee, formed by a panel of 11 nephrologists from the Asia-Pacific region who have clinical experience or have been investigators in HIF-PHI studies, reviewed and deliberated on the clinical and preclinical data concerning HIF-PHI. This recommendation summarizes the consensus views of the committee regarding the use of HIF-PHI, taking into account both available data and expert opinion in areas where evidence remains scarce.
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Anemia/tratamiento farmacológico , Prolina Dioxigenasas del Factor Inducible por Hipoxia/antagonistas & inhibidores , Nefrología/normas , Inhibidores de Prolil-Hidroxilasa/uso terapéutico , Insuficiencia Renal Crónica/terapia , Anemia/diagnóstico , Anemia/etiología , Consenso , Humanos , Prolina Dioxigenasas del Factor Inducible por Hipoxia/metabolismo , Seguridad del Paciente , Inhibidores de Prolil-Hidroxilasa/efectos adversos , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/diagnóstico , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Damage to the endothelial glycocalyx is an early indicator of vascular damage and a potential marker of endothelial dysfunction. This study aimed to assess the relationship between markers of glycocalyx damage, endothelial dysfunction, and uraemic toxins in patients with chronic kidney disease. METHODS: Healthy controls, CKD patients, dialysis patients, and kidney transplant recipients had biochemical markers of glycocalyx damage (syndecan-1 and hyaluronan), endothelial dysfunction (von Willebrand factor; vWF and vascular cell adhesion molecule; VCAM-1), and uraemic toxins (indoxyl sulphate and p-cresyl sulphate) measured. In addition, Sidestream Darkfield imaging was performed using the novel GlycoCheck™ device to measure glycocalyx width by the perfused boundary region (PBR) in the sublingual microcirculation. RESULTS: Serum markers of glycocalyx damage were highest in the dialysis group (n = 33), followed by CKD patients (n = 32) and kidney transplant recipients (n = 30) compared to controls (n = 30): hyaluronan: 137 (16-1414), 79 (11-257), 57 (14-218) and 23 (8-116) ng/mL, respectively, p < 0.0001; syndecan-1: 81 (40-529), 46 (21-134), 39 (23-72), and 30 (12-138) ng/mL, respectively, p < 0.0001. Markers of endothelial dysfunction followed a similar pattern. No difference in the width of the PBR was detected between these groups (2.01 ± 0.35, 2.07 ± 0.27, 2.06 ± 0.28, and 2.05 ± 0.3 µm, respectively, p = 0.89). Glycocalyx damage correlated with markers of endothelial dysfunction (log-hyaluronan and log-VCAM-1: r = 0.64, p < 0.001) and levels of uraemic toxins (log-hyaluronan and log-indoxyl sulphate: r = 0.48, p < 0.001). CONCLUSIONS: Levels of biochemical markers of glycocalyx and endothelial cell damage are highest in patients receiving dialysis. Glycocalyx and endothelial damage markers correlated with each other, and with uraemic toxins. Although we could not demonstrate a change in PBR, the biochemical markers suggest that glycocalyx damage is most marked in patients with higher levels of uraemic toxins.
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Endotelio Vascular/ultraestructura , Glicocálix , Ácido Hialurónico/sangre , Insuficiencia Renal Crónica/sangre , Insuficiencia Renal Crónica/patología , Sindecano-1/sangre , Toxinas Biológicas/sangre , Uremia/sangre , Uremia/patología , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Correlación de Datos , Endotelio Vascular/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Insuficiencia Renal Crónica/complicaciones , Uremia/complicaciones , Adulto JovenRESUMEN
End-stage kidney disease is associated with reduced exercise capacity, muscle atrophy, and impaired muscle function. While these may be improved with exercise, single modalities of exercise do not traditionally elicit improvements across all required physiological domains. Blood flow-restricted exercise may improve all of these physiological domains with low intensities traditionally considered insufficient for these adaptions. Investigation of this technique appeals, but is yet to be evaluated, in patients undergoing dialysis. With the use of a progressive crossover design, 10 satellite patients undergoing hemodialysis underwent three exercise conditions over 2 wk: two bouts (10 min) of unrestricted cycling during two consecutive hemodialysis sessions (condition 1), two bouts of cycling with blood flow restriction while off hemodialysis on 2 separate days (condition 2), and two bouts of cycling with blood flow restriction during two hemodialysis sessions (condition 3). Outcomes included hemodynamic responses (heart rate and blood pressure) throughout all sessions, participant-perceived exertion and discomfort on a Borg scale, and evaluation of ultrafiltration rates and dialysis adequacy (Kt/V) obtained post hoc. Hemodynamic responses were consistent regardless of condition. Significant increases in heart rate, systolic blood pressure, and mean arterial blood pressure (P < 0.05) were observed postexercise followed by a reduction in blood pressures during the 60-min recovery (12, 5, and 11 mmHg for systolic, diastolic, and mean arterial pressures, respectively). Blood pressures returned to predialysis ranges following the recovery period. Blood flow restriction did not affect ultrafiltration achieved or Kt/V. Hemodynamic safety and tolerability of blood flow restriction during aerobic exercise on hemodialysis is comparable to standard aerobic exercise.
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Presión Sanguínea/fisiología , Ejercicio Físico/fisiología , Frecuencia Cardíaca/fisiología , Fallo Renal Crónico/terapia , Percepción/fisiología , Anciano , Estudios Cruzados , Femenino , Humanos , Masculino , Persona de Mediana Edad , Flujo Sanguíneo Regional/fisiologíaRESUMEN
BACKGROUND: Intravenous iron replacement is recommended for iron-deficient patients with inflammatory bowel disease (IBD), but may be associated with hypophosphataemia, predisposing to osteomalacia and fractures. This study aimed to evaluate the incidence and risk factors for hypophosphataemia following intravenous ferric carboxymaltose (FCM) in patients with IBD. METHODS: This prospective observational study of patients with and without IBD evaluated serum phosphate for 28 days following intravenous FCM, and assessed associations with symptoms, markers of inflammation and vitamin D status. RESULTS: Twenty-four patients with IBD (11 with Crohn's disease [CD], 13 with ulcerative colitis [UC], mean age 45 years [range 19-90], 7 female), and 20 patients without IBD (mean age 56 [22-88] y, 11 female), were included. Overall, serum phosphate declined by a mean of 36% at Day 7, with a mean fall of 42% (SD 19%) at some time point over 28 days (p < 0.001). Twenty-four of 44 (55%) patients developed moderate to severe hypophosphataemia (serum phosphate < 0.6 mmol/L). No differences between patients with and without IBD were seen, but patients with CD had greater decline in phosphate than those with UC. There was no association between hypophosphataemia and symptomatic adverse events, faecal calprotectin, C-reactive protein, albumin, platelet count, 25(OH) vitamin D, or 1,25(di-OH) vitamin D. Serum phosphate < 1.05 mmol/L on Day 2 predicted susceptibility to moderate-severe hypophosphataemia (OR 7.0). CONCLUSIONS: Hypophosphataemia following FCM is common, unrelated to symptomatic adverse events, baseline intestinal or systemic inflammation, or vitamin D status.
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Anemia Ferropénica/tratamiento farmacológico , Colitis Ulcerosa/complicaciones , Enfermedad de Crohn/complicaciones , Compuestos Férricos/efectos adversos , Hipofosfatemia/epidemiología , Maltosa/análogos & derivados , Administración Intravenosa , Adulto , Anciano , Anciano de 80 o más Años , Anemia Ferropénica/etiología , Colitis Ulcerosa/sangre , Enfermedad de Crohn/sangre , Femenino , Compuestos Férricos/administración & dosificación , Humanos , Hipofosfatemia/inducido químicamente , Incidencia , Masculino , Maltosa/administración & dosificación , Maltosa/efectos adversos , Persona de Mediana Edad , Estado Nutricional , Fosfatos/sangre , Estudios Prospectivos , Factores de Riesgo , Resultado del Tratamiento , Vitamina D/sangre , Adulto JovenRESUMEN
BACKGROUND: Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein-based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein-based nutritional supplements in this population is limited. OBJECTIVES: The aims of this review were to determine the benefits and harms of using oral protein-based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein-based nutritional supplements to no oral protein-based nutritional supplements or placebo. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes. MAIN RESULTS: Twenty-two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow-up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self-reported outcomes. Oral protein-based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I2 = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein-based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I2 = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein-based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid-arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein-based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI -0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD -0.04 kg/m2, 95% CI -0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI -1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein-based nutritional supplements affect triceps skinfold thickness, mid-arm circumference, C-reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein-based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies. AUTHORS' CONCLUSIONS: Overall, it is likely that oral protein-based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid-arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well-designed RCTs in this population are required.
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Proteínas en la Dieta/administración & dosificación , Desnutrición/terapia , Diálisis Renal , Insuficiencia Renal Crónica/terapia , Albúmina Sérica/metabolismo , Administración Oral , Brazo/anatomía & histología , Sesgo , Biomarcadores/sangre , Proteínas en la Dieta/efectos adversos , Humanos , Desnutrición/sangre , Desnutrición/etiología , Diálisis Peritoneal/estadística & datos numéricos , Placebos/administración & dosificación , Prealbúmina/metabolismo , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Diálisis Renal/estadística & datos numéricos , Insuficiencia Renal Crónica/sangre , Insuficiencia Renal Crónica/complicaciones , Grosor de los Pliegues CutáneosRESUMEN
BACKGROUND: Dialysis patients experience high rates of foot ulceration. Although risk factors for ulceration have been extensively studied in patients with diabetes, there is limited high-quality, longitudinal evidence in the dialysis population. Therefore, this study investigated risk factors for foot ulceration in a stable dialysis cohort. METHODS: We prospectively collected clinical, demographic, health status, and foot examination information on 450 adults with end-stage renal disease from satellite and home-therapy dialysis units in Melbourne, Australia over 12 months. The primary outcome was foot ulceration. Cox proportional hazard modelling and multinomial regression were used to investigate risk factors. RESULTS: Among 450 dialysis patients (mean age, 67.5 years; 64.7% male; 94% hemodialysis; 50.2% diabetes), new cases of foot ulceration were identified in 81 (18%) participants. Overall, risk factors for foot ulceration were neuropathy (HR 3.02; 95% CI 1.48 to 6.15) and previous ulceration (HR 2.86; CI 1.53 to 5.34). In those without history of ulceration, nail pathology (RR 3.85; CI 1.08 to 13.75) and neuropathy (RR 2.66; CI 1.04 to 6.82) were risk factors. In those with history of ulceration, neuropathy (RR 11.23; CI 3.16 to 39.87), peripheral arterial disease (RR 7.15; CI 2.24 to 22.82) and cerebrovascular disease (RR 2.08; CI 1.04 to 4.16) were risk factors. There were 12 (2.7%) new amputations, 96 (21.3%) infections, 24 (5.3%) revascularizations, 42 (9.3%) foot-related hospitalizations, and 52 (11.6%) deaths. CONCLUSIONS: Neuropathy and previous ulceration are major risk factors for foot ulceration in dialysis patients. Risk factors differ between those with and without prior ulceration. The risk factors identified will help to reduce the incidence of ulceration and its associated complications.
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Úlcera del Pie/etiología , Fallo Renal Crónico/terapia , Diálisis Renal/efectos adversos , Anciano , Amputación Quirúrgica/estadística & datos numéricos , Trastornos Cerebrovasculares/complicaciones , Femenino , Úlcera del Pie/mortalidad , Úlcera del Pie/cirugía , Humanos , Masculino , Enfermedades de la Uña/complicaciones , Enfermedades del Sistema Nervioso Periférico/complicaciones , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Recurrencia , Análisis de Regresión , Factores de Riesgo , Victoria/epidemiologíaRESUMEN
Background: Intravenous (IV) iron can modulate fibroblast growth factor 23 (FGF23) concentrations and cause transient but significant hypophosphataemia. However, it is unknown what other markers might be involved, especially in different patient groups. This study aimed to determine changes in bone and haematinic biomarkers following IV ferric carboxymaltose (FCM) and to identify risk factors for hypophosphataemia in pregnant subjects and those with chronic kidney disease (CKD). Methods: Changes in bone [serum FGF23, fractional excretion of phosphate urinary fractional excretion of phosphate (FEPi), serum phosphate and serum vitamin D derivatives] and haematinic [plasma hepcidin, serum ferritin and transferrin saturation (TSAT)] biomarkers after 1 g of IV FCM were followed in iron-deficient pregnant and CKD patients and compared with controls (estimated glomerular filtration rate > 60 mL/min/1.73 m2). Data were collected at baseline and up to 42 days after infusion. Risk factors for post-FCM hypophosphataemia were also assessed. Results: Sixty-five subjects completed the study (control, n = 20; pregnant, n = 20; CKD, n = 25). A uniform but variable increase across groups was seen in intact FGF23 (peak Day 2), whereas c-terminal FGF23 varied markedly. Trough serum phosphate timed with the peak FEPi at Day 7, recovering by Day 21 in the pregnant group and Day 42 in other groups. Independent predictors of a low phosphate nadir included baseline phosphate, FEPi and weight-adjusted FCM dose. All groups showed an early and marked increase in plasma hepcidin (peak Day 2), serum ferritin and TSAT (peak Day 7 for both). Conclusions: Changes in bone and haematinic biomarkers differ between patient groups following IV FCM. For patients with lower serum phosphate concentrations, limiting the dose and measuring levels 7 days after administration may mitigate clinically significant hypophosphataemia.
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Biomarcadores/sangre , Huesos/metabolismo , Compuestos Férricos/administración & dosificación , Factores de Crecimiento de Fibroblastos/sangre , Hematínicos/sangre , Hipofosfatasia/diagnóstico , Maltosa/análogos & derivados , Insuficiencia Renal Crónica/tratamiento farmacológico , Administración Intravenosa , Australia/epidemiología , Huesos/efectos de los fármacos , Estudios de Casos y Controles , Femenino , Factor-23 de Crecimiento de Fibroblastos , Tasa de Filtración Glomerular , Humanos , Hipofosfatasia/sangre , Hipofosfatasia/epidemiología , Masculino , Maltosa/administración & dosificación , Persona de Mediana Edad , Fosfatos/sangre , Embarazo , Estudios Prospectivos , Resultado del TratamientoRESUMEN
AIM: The Kidney Disease Improving Global Outcomes (KDIGO) guideline recommends the incorporation of a new risk calculator that quantifies the end-stage kidney disease (ESKD) risk based on a composite profile of risk factors in living kidney donor candidates (LKDC). We compared the ESKD risk estimates in previously declined versus accepted LKDC to evaluate the predictive capacity and potential impact of this tool. METHODS: Baseline 15 year and lifetime ESKD risk estimates without donation were calculated using the risk calculator for LKDC assessed from two centres between 2007 and 2015. LKDC suitability based on the proposed KDIGO and the existing Caring for Australasians with Renal Impairment national guidelines was compared. RESULTS: Median 15 year ESKD risk was 0.14% (IQR 0.09-0.31%) in declined LKDC (n=59) versus 0.10% (0.07-0.14%) in accepted LKDC (n=89) (P<0.001). Lifetime risk was similar: 0.39% (0.23-0.80%) versus 0.35% (0.22-0.56%), respectively; however, declined LKDC had a higher 98% risk percentile value (8.19% vs 1.02%) and were more likely to exceed a 1% ESKD risk threshold (15% vs 1%; P<0.01). The calculator captured reasons for declining donation in only 39% of LKDC; 46.9% of LKDC with Caring for Australasians with Renal Impairment contraindications were reclassified as having an acceptable (≤1%) lifetime risk and no KDIGO contraindications, primarily related to a lower pre-donation glomerular filtration rate or controlled hypertension with obesity. CONCLUSION: Declined LKDC had a higher 15 year but similar lifetime ESKD risk. However, the calculator successfully differentiated declined LKDC with a lifetime risk >1%. This risk calculator appears to complement but not replace clinical evaluation.
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Técnicas de Apoyo para la Decisión , Selección de Donante/normas , Fallo Renal Crónico/cirugía , Trasplante de Riñón/normas , Donadores Vivos , Guías de Práctica Clínica como Asunto , Adulto , Toma de Decisiones Clínicas , Selección de Donante/métodos , Femenino , Estado de Salud , Humanos , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/fisiopatología , Trasplante de Riñón/efectos adversos , Trasplante de Riñón/métodos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Medición de Riesgo , Factores de Riesgo , VictoriaRESUMEN
BACKGROUND: Leigh syndrome (LS) is a rare neurodegenerative mitochondrial disorder which typically presents in childhood but has a varied clinical course. Renal involvement such as proximal tubulopathy in patients with mitochondrial disorders has been described. However, end stage renal disease (ESRD) is uncommon and literature regarding patients undergoing kidney transplantation is limited. Successful deceased donor renal transplant has not been previously described in a patient with Leigh Syndrome. CASE PRESENTATION: We report a 21-year-old Han Chinese man who presented with limb weakness and unsteady gait, which progressed rapidly over a period of months until he was wheelchair-bound. He subsequently developed ESRD and was commenced on hemodialysis. Investigations revealed a m.13513G > A mutation with clinical and radiological features consistent with LS. His mitochondrial disease stabilised and he underwent a multidisciplinary assessment for deceased donor kidney transplantation to identify and minimise the LS-associated perioperative risks and potential negative effects of immunosuppressants on his LS. Successful kidney transplantation followed with excellent graft function three and a half years post-transplant and improvement in the patient's physical function. CONCLUSION: This case highlights the importance of careful pre-transplant perioperative risk assessment and post-transplant care in a rare and heterogeneous neurological disease to achieve an ultimately excellent clinical outcome. To our knowledge, this is the first report of successful deceased donor kidney transplant in a patient with known LS.
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Fallo Renal Crónico/sangre , Fallo Renal Crónico/diagnóstico por imagen , Trasplante de Riñón , Enfermedad de Leigh/sangre , Enfermedad de Leigh/diagnóstico por imagen , Atención Perioperativa/métodos , Humanos , Fallo Renal Crónico/etiología , Enfermedad de Leigh/complicaciones , Masculino , Medición de Riesgo/métodos , Adulto JovenRESUMEN
The endothelial glycocalyx is a layer comprised of proteins and carbohydrates on the luminal surface of vascular endothelial cells, thought to have an important role in the health and function of the endothelium. Disrupted by various pathophysiological conditions and linked with clinical outcomes, it is increasingly recognized as an early indicator of endothelial injury and a potential marker of vascular injury. In this review, we discuss current methods of assessment (including novel optical approaches), evidence for its use as a marker of vascular disease and its potential role in relation to microalbuminuria and glomerular endothelial dysfunction. Therapeutic strategies for restoration of the glycocalyx following injury are also explored.
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Células Endoteliales/química , Glicocálix/fisiología , Insuficiencia Renal Crónica/diagnóstico , Albuminuria/complicaciones , Biomarcadores , Glicocálix/química , Humanos , Insuficiencia Renal Crónica/fisiopatología , Enfermedades Vasculares/diagnósticoRESUMEN
BACKGROUND: Exercise during haemodialysis improves strength and physical function. However, both patients and clinicians are time poor, and current exercise recommendations add an excessive time burden making exercise a rare addition to standard care. Hypothetically, blood flow restriction exercise performed during haemodialysis can provide greater value for time spent exercising, reducing this time burden while producing similar or greater outcomes. This study will explore the efficacy of blood flow restriction exercise for enhancing strength and physical function among haemodialysis patients. METHODS: This is a randomised controlled trial design. A total of 75 participants will be recruited from haemodialysis clinics. Participants will be allocated to a blood flow restriction cycling group, traditional cycling group or usual care control group. Both exercising groups will complete 3 months of cycling exercise, performed intradialytically, three times per week. The blood flow restriction cycling group will complete two 10-min cycling bouts separated by a 20-min rest at a subjective effort of 15 on a 6 to 20 rating scale. This will be done with pressurised cuffs fitted proximally on the active limbs during exercise at 50% of a pre-determined limb occlusion pressure. The traditional cycling group will perform a continuous 20-min bout of exercise at a subjective effort of 12 on the same subjective effort scale. These workloads and volumes are equivalent and allow for comparison of a common blood flow restriction aerobic exercise prescription and a traditional aerobic exercise prescription. The primary outcome measures are lower limb strength, assessed by a three repetition maximum leg extension test, as well as objective measures of physical function: six-minute walk test, 30-s sit to stand, and timed up and go. Secondary outcome measures include thigh muscle cross sectional area, body composition, routine pathology, quality of life, and physical activity engagement. DISCUSSION: This study will determine the efficacy of blood flow restriction exercise among dialysis patients for improving key physiological outcomes that impact independence and quality of life, with reduced burden on patients. This may have broader implications for other clinical populations with similarly declining muscle health and physical function, and those contraindicated to higher intensities of exercise. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Register: ACTRN12616000121460.
Asunto(s)
Velocidad del Flujo Sanguíneo/fisiología , Terapia por Ejercicio/métodos , Ejercicio Físico/fisiología , Fallo Renal Crónico/terapia , Flujo Sanguíneo Regional/fisiología , Diálisis Renal/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Fallo Renal Crónico/fisiopatología , Masculino , Persona de Mediana Edad , Aptitud Física/fisiología , Diálisis Renal/efectos adversos , Adulto JovenRESUMEN
BACKGROUND: Adults on dialysis are at increased risk of foot ulceration, which commonly precedes more serious lower limb complications, including amputation. Limited data exist regarding the prevalence and factors associated with foot disease in this population. Hence, this study set out to investigate factors associated with foot ulceration and amputation in a dialysis cohort. METHODS: This study presents a cross-sectional analysis of baseline data from a multi-center prospective cohort study. We recruited 450 adults with end-stage renal disease on dialysis from multiple satellite and home-therapy dialysis units in Melbourne, Australia from January to December 2014. Data collection consisted of a participant interview, medical record review, health-status questionnaire and non-invasive foot examination. Logistic regression analyses were conducted to evaluate associations between screened variables and study outcomes. RESULTS: Mean age was 67.5 (SD, 13.2) years, 64.7% were male, 94% were on hemodialysis, median dialysis duration was 36.9 (IQR, 16.6 to 70.1) months, and 50.2% had diabetes. There was a high prevalence of previous ulceration (21.6%) and amputation (10.2%), 10% had current foot ulceration, and 50% had neuropathy and/or peripheral arterial disease. Factors associated with foot ulceration were previous amputation (OR, 10.19), peripheral arterial disease (OR, 6.16) and serum albumin (OR, 0.87); whereas previous and/or current ulceration (OR, 167.24 and 7.49, respectively) and foot deformity (OR, 15.28) were associated with amputation. CONCLUSIONS: Dialysis patients have a high burden of lower limb complications. There are markedly higher risks of foot ulceration and/or amputation in those with previous and/or current ulceration, previous amputation, peripheral arterial disease, lower serum albumin, and foot deformity. Although not a major risk factor, diabetes in men was an important effect modifier for risk of ulceration.
Asunto(s)
Amputación Quirúrgica , Úlcera del Pie/epidemiología , Úlcera del Pie/cirugía , Diálisis Renal/efectos adversos , Insuficiencia Renal Crónica/epidemiología , Insuficiencia Renal Crónica/terapia , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica/tendencias , Estudios de Cohortes , Estudios Transversales , Femenino , Úlcera del Pie/etiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Diálisis Renal/tendencias , Insuficiencia Renal Crónica/complicaciones , Factores de RiesgoRESUMEN
BACKGROUND: Intravenous iron affects serum levels of intact fibroblast growth factor-23 (iFGF23) and its cleavage product c-terminal FGF23 (cFGF23) in iron-deficient people with normal renal function. We hypothesized that intravenous iron modulates iFGF23 and cFGF23 in haemodialysis patients differently according to the type of iron used. METHODS: Prevalent, stable haemodialysis patients requiring protocol-based intravenous iron therapy were randomized to a single 200 mg dose of either ferric carboxymaltose (FCM) or iron sucrose (IS). The primary outcome was change in iFGF23 and cFGF23 from pre-infusion to Day 2 post-infusion. Serum hepcidin, ferritin and phosphate were also measured. Pair-wise comparisons utilised the Wilcoxon rank sum test; linear mixed models with an interaction term for treatment and time evaluated between-group effects. RESULTS: Forty-two participants completed the study. In those randomized to FCM (n = 22), median (interquartile range) values pre-infusion and Day 2, respectively, were 843 pg/mL (313-1922) and 576 pg/mL (356-1296, p = 0.05) for iFGF23, 704RU/mL (475-1204) and 813RU/mL (267-1156, p = 0.04) for cFGF23, and 1.53 mmol/L (1.14-1.71) and 1.37 (1.05-1.67, p = 0.03) for phosphate. These parameters did not change following IS. Both serum ferritin (p < 0.001) and hepcidin (p < 0.001) increased in both groups, and the increase in hepcidin was greater in the FCM group (p = 0.03 for between-group difference). CONCLUSIONS: Contrary to iron-deficient people with normal renal function, haemodialysis patients given protocol-driven intravenous FCM demonstrated a fall in iFGF23 and a rise in cFGF23, changes not evident with IS. This suggests a differential effect of intravenous iron treatment according to both formulation and renal function. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Register ACTRN12614000548639 . Registered 22 May 2014 (retrospectively registered).
Asunto(s)
Compuestos Férricos/administración & dosificación , Factores de Crecimiento de Fibroblastos/sangre , Ácido Glucárico/administración & dosificación , Hematínicos/administración & dosificación , Maltosa/análogos & derivados , Insuficiencia Renal Crónica/sangre , Insuficiencia Renal Crónica/terapia , Administración Intravenosa , Anciano , Femenino , Sacarato de Óxido Férrico , Factor-23 de Crecimiento de Fibroblastos , Factores de Crecimiento de Fibroblastos/efectos de los fármacos , Humanos , Masculino , Maltosa/administración & dosificación , Persona de Mediana Edad , Diálisis RenalRESUMEN
Health literacy (HL) refers to a person's ability to engage effectively with health information and services. We aimed to describe the HL of people receiving dialysis and the factors associated with it. A cross-sectional design was used, with demographic and clinical data as predictors. Participants were people receiving dialysis at a metropolitan health service in Melbourne, Australia. Health consumers with conditions not requiring dialysis were included for comparison. The Health Literacy Questionnaire, Kidney Disease Quality of Life-36, and Depression Anxiety Stress Scales-21 were administered. Participants (M age = 68.2 ± 13.7 years; n = 57 males) were 76 people receiving hemodialysis within a dialysis unit, 16 people receiving home peritoneal dialysis, and 8 people receiving home hemodialysis. Participants scored higher on the HL domains social support for health and engagement with health care providers but lower on active management of health than the comparison group (n = 813). Hierarchical cluster analysis revealed 2 clusters within the dialysis sample representing higher (n = 43) and lower (n = 57) profiles of HL. The higher HL cluster reported better quality of life across 4 of 5 domains of the Kidney Disease Quality of Life-36, fewer symptoms of depression and anxiety, and higher serum albumin (mean difference = 2.06 g/L, p = .04) than the lower HL cluster. These results show that people receiving dialysis feel better supported and informed about their health than other health consumers but are less active in managing it. Higher HL is associated with better mental health and quality of life. Identifying HL characteristics may help direct specific interventions to improve patient education and support.
Asunto(s)
Alfabetización en Salud/estadística & datos numéricos , Calidad de Vida , Diálisis Renal , Estrés Psicológico/etiología , Anciano , Anciano de 80 o más Años , Análisis por Conglomerados , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diálisis Renal/psicología , Encuestas y CuestionariosRESUMEN
BACKGROUND: Adults with end-stage renal disease are at increased risk of foot ulceration and lower extremity amputation. However, the central determinants of lower limb injury and loss are incompletely understood. METHODS: We conducted a systematic review of non-randomized studies that quantified the major risk factors for foot ulceration and amputation in adults treated with dialysis and analysed patient populations in which risks were greatest. Random-effects meta-analysis was used to generate summary estimates. RESULTS: Thirty studies (48 566 participants) were identified. Risk factors for foot ulceration and amputation included previous foot ulceration (odds ratios, OR, 17.56 and 70.13), peripheral arterial disease (OR, 7.52 and 9.12), diabetes (OR, 3.76 and 7.48), peripheral neuropathy (OR, 3.24 and 3.36) and coronary artery disease (OR, 3.92 and 2.49). Participants with foot ulceration or amputation had experienced a longer duration of diabetes (mean difference, MD, 4.04 and 6.07 years) and had lower serum albumin levels (MD, -0.23 and -0.13 g/dL). Risk factors for foot ulceration also included retinopathy (OR, 3.03), previous amputation (OR, 15.50) and higher serum phosphorus levels (MD, 0.40 mg/dL), while risk factors for amputation also included male sex (OR, 1.50), current smoking (OR, 2.26) and higher glycated haemoglobin levels (MD, 0.75%). CONCLUSIONS: Dialysis patients who have markedly higher risks of ulceration or amputation include those with previous foot ulceration or amputation, peripheral neuropathy, diabetes or macrovascular disease. The temporal relationship between these risk factors and the development of foot ulceration and/or limb loss is uncertain and requires further study. Stable estimates of the key risk factors for ulceration and amputation can inform the design of future trials investigating clinical interventions to reduce the burden of lower limb disease in the dialysis population.
Asunto(s)
Amputación Quirúrgica/estadística & datos numéricos , Pie Diabético/etiología , Extremidades/cirugía , Úlcera del Pie/etiología , Fallo Renal Crónico/complicaciones , Diálisis Renal/efectos adversos , Adulto , Pie Diabético/cirugía , Femenino , Úlcera del Pie/cirugía , Humanos , Fallo Renal Crónico/terapia , Masculino , Factores de RiesgoRESUMEN
AIM: In patients with renal failure or chronic inflammation, the accumulation of fetuin-A-containing calciprotein particles (CPP) in the extracellular fluid has been implicated in driving inflammatory pathways and extraosseous mineral deposition. We aimed to discover whether CPP are present in the peritoneal dialysis fluid effluent (PDF) of stable peritoneal dialysis (PD) patients, and if so, how these particles might be formed. METHODS: Serum and PDF were sampled from 20 stable PD patients. CPP were quantified by the reduction in fetuin-A concentration after high speed centrifugation. 8-iso-PGF2α in PDF was measured as a marker of oxidative stress. Fetuin-A and phosphate were added to commercially available dialysis fluids to assess their ability to support CPP formation ex vivo. RESULTS: We report that the major protein component of these mineral-containing nanoparticles, fetuin-A, is relatively abundant in PDF and that CPP were present in the PDF of 17/20 PD patients. PDF CPP levels were strongly correlated with 8-iso-PGF2α concentrations. In vitro experiments suggested that commonly used peritoneal dialysate fluids, irrespective of composition, could not sustain appreciable de novoâ CPP formation ex vivo. CONCLUSION: Fetuin-A is either actively transported or locally produced by the peritoneal membrane in PD patients. The association between fetuin-A-containing CPP and markers of oxidative stress warrants further mechanistic studies.
Asunto(s)
Nanopartículas Calcificantes/biosíntesis , Soluciones para Diálisis/química , Dinoprost/análogos & derivados , Diálisis Peritoneal , alfa-2-Glicoproteína-HS/análisis , Biomarcadores/análisis , Dinoprost/análisis , Humanos , Proyectos PilotoRESUMEN
AIM: In the Australian state of Victoria, the Renal Health Clinical Network (RHCN) of the Department of Health Victoria established a Renal Key Performance Indicator (KPI) Working Group in 2011. The group developed four KPIs related to chronic kidney disease and dialysis. A transplant working group of the RHCN developed two additional KPIs. The aim was to develop clinical indicators to measure performance of renal services to drive service improvement. METHODS: A data collection and benchmarking programme was established, with data provided monthly to the Department using a purpose-designed website portal. The KPI Working Group is responsible for analysing data each quarter and ensuring indicators remain accurate and relevant. Each indicator has clear definitions and targets, and assess (i) patient education, (ii) timely creation of vascular access for haemodialysis, (iii) proportion of patients dialysing at home, (iv) incidence of dialysis-related peritonitis, (v) incidence of pre-emptive renal transplantation, and (vi) timely listing of patients for deceased donor transplantation. RESULTS: Most KPIs have demonstrated improved performance over time with limited gains notably in two: the proportion of patients dialysing at home (KPI 3) and timely listing patients for transplantation (KPI 6). CONCLUSION: KPI implementation has been established in Victoria for 2 years, providing performance data without additional funding. The six Victorian KPIs are measurable, relevant and modifiable, and implementation relies on enthusiasm and goodwill of physicians and nurses involved in collecting data. The KPIs require further evaluation, but adoption of a similar programme by other jurisdictions could lead to improved national outcomes.