Patient knowledge and adherence to maintenance hemodialysis: an International comparison study.

BACKGROUND: Non-adherence to hemodialysis (HD) is associated with increased morbidity and mortality. In this cross-sectional study, we compared correlates and rates of non-adherence between the US and Japan to determine if differences in patient knowledge about HD might account for international variation in adherence. METHODS: We evaluated 100 US and 116 Japanese patients on maintenance HD. Patient knowledge was scored based on the identification of their vascular access, dry weight, cause of kidney disease, and ≥ 3 phosphorus- and potassium-rich foods. Patients were considered non-adherent if they missed > 3% of HD sessions in 3 months. RESULTS: 23% of the US and none of the Japanese patients were non-adherent. Using logistic regression, we found that in the US non-adherence was more common in black patients [Odds ratio (OR) 3.98; 95% confidence interval (CI) 1.42-11.22], while high school graduates (OR 0.20; 95% CI 0.05-0.81) and those on the transplant waiting list (OR 0.25; 95% CI 0.083-0.72) were less likely to miss their treatments. There was no significant association between knowledge and non-adherence in the US. However, Japanese patients had significantly higher levels of HD knowledge than US patients after adjusting for age (p < 0.001). CONCLUSION: Age-adjusted HD knowledge was higher and non-adherence rates were lower in Japan vs. the US. However, because of the unexpected finding of 100% adherence in Japan, we were unable to formally test whether knowledge was significantly associated with adherence across both countries. Further research is needed to understand the reasons behind the higher non-adherence rates in the US.

Bisphosphonate use in chronic kidney disease: association with adynamic bone disease in a bone histology series.

Dual X-ray absorptiometry is the standard diagnostic modality for identification of low bone mineral density, a finding which is in the general population usually indicative of osteopenia or osteoporosis. However, chronic kidney disease (CKD) patients diagnosed with osteopenia or osteoporosis may in actual fact have renal osteodystrophy with high or low bone turnover. While bisphosphonates are currently prescribed for the prevention of fractures in osteoporosis and high-risk osteopenic patients, the clinical utility of bisphosphonate therapy in CKD has not been established. Furthermore, bisphosphonates accumulate in bone, inhibit osteoclasts, and may cause or exacerbate low-turnover (adynamic) bone disease - particularly in patients presenting with low parathyroid hormone (PTH) levels or receiving treatment for secondary hyperparathyroidism. Bone biopsy with non-decalcified histopathology remains the gold standard for the identification and evaluation of bone disorders, including osteoporosis and renal osteodystrophy. Thirteen CKD patients (stage II-IV), referred to our clinic over a 12-month period, were identified as having taken bisphosphonates from 4 to >60 months after a diagnosis of osteopenia or osteoporosis. All patients underwent biopsies of trabecular bone from the iliac crest following oral administration of time-separated doses of doxycycline and tetracycline. Bone pathology was assessed after processing for mineralized histology. For all patients, clinical data collection included assessment of likely causes of kidney disease, MDRD glomerular filtration rate, calcium-phosphate product, intact PTH level, alkaline phosphatase, and bisphosphonate exposure. All 13 patients were diagnosed with adynamic bone on biopsy evaluation. Eleven biopsies revealed decreased cancellous bone mass; 8 showed decreased osteoid surface; 8 disclosed decreased osteoid thickness, and all 13 demonstrated low or low-normal osteoclast/osteoblast interface. Assessment of dynamic bone formation demonstrated decreased or absent single- or double-labeled osteoid in all 13 bone specimens. Based on these observations, the use of bisphosphonates in CKD cannot be recommended.

Antineutrophil cytoplasmic antibody-positive pauci-immune glomerulonephritis associated with mantle cell lymphoma.

Renal involvement in non-Hodgkin lymphoma, especially mantle cell lymphoma (MCL) is rare. A 77-year-old man presented with acute kidney injury (AKI), which rapidly progressed to dialysis dependence. Kidney biopsy revealed patchy B-cell lymphocytic aggregates in the interstitium, which were positive for cyclin D1, consistent with atypical CD5-negative MCL as confirmed by the detection of translocation t(11;14) by FISH. Crescents were noted in 3 of 26 glomeruli; while PR-3 antineutrophil cytoplasmic antibody (ANCA) positivity and negative immunofluorescence suggested an additional pauci-immune (rapidly progressive) glomerulonephritis pattern of injury. Patient received chemotherapy (cyclophosphamide, vincristine, and prednisone), which improved his renal function and allowed for discontinuation of hemodialysis. However, he died from pulmonary hemorrhage 8 months after initial presentation. This is the first reported case of a patient with coexistence of renal MCL infiltration and ANCA-positive pauci-immune glomerulonephritis.

Disaster Preparedness and Awareness of Patients on Hemodialysis after Hurricane Sandy.

BACKGROUND AND OBJECTIVES: Patients with ESRD on dialysis live in a complex sociomedical situation and are dependent on technology and infrastructure, such as transportation, electricity, and water, to sustain their lives. Interruptions of this infrastructure by natural disasters can result in devastating outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Between November of 2013 and April of 2014, a cross-sectional survey was conducted of patients who received maintenance hemodialysis before and after the landfall of Hurricane Sandy on October 29, 2012 in lower Manhattan, New York. The primary outcome was the number of missed dialysis sessions after the storm. Dialysis-specific and general disaster preparedness were assessed using checklists prepared by the National Kidney Foundation and US Homeland Security, respectively. RESULTS: In total, 598 patients were approached, and 357 (59.7%) patients completed the survey. Participants were 60.2% men and 30.0% black, with a median age of 60 years old; 94 (26.3%) participants missed dialysis (median of two sessions [quartile 1 to quartile 3 =1-3]), and 236 (66.1%) participants received dialysis at nonregular dialysis unit(s): 209 (58.5%) at affiliated dialysis unit(s) and 27 (7.6%) at emergency rooms. The percentages of participants who carried their insurance information and detailed medication list were 75.9% and 44.3%, respectively. Enhancement of the dialysis emergency packet after the hurricane was associated with a significantly higher cache of medical records at home at follow-up survey (P<0.001, Fisher's exact test). Multivariate Poisson regression analysis showed that dialysis-specific preparedness (incidence rate ratio, 0.91; 95% confidence interval, 0.87 to 0.98), other racial ethnicity (incidence rate ratio, 0.34; 95% confidence interval, 0.20 to 0.57), dialysis treatment in affiliated units (incidence rate ratio, 0.69; 95% confidence interval, 0.51 to 0.94), and older age (incidence rate ratio, 0.98; 95% confidence interval, 0.97 to 0.99) were associated with a significantly lower incidence rate ratio of missed dialysis. CONCLUSIONS: There is still room to improve the preparedness for natural disasters of patients with ESRD. Provider- or facility-oriented enhancement of awareness of the disease and preparedness should be a priority.

Intoxications amenable to extracorporeal removal.

Extracorporeal removal of drugs was first attempted in 1913, by John Jacob Abel. Previously known to be a rarity, dialysis and to a lesser extent hemoperfusion have now become obvious tools for nephrologists in treating life-threatening cases of poisoning. Moreover, for dialysis patients, dialysis along with chelation therapy for removal of aluminum, once known to be common in the United States, is resurging in some countries. This article will discuss the principles of drug removal, the indications for dialysis, and give a brief outline of poisons amenable to dialysis.