The outcome of nephrectomy in peritoneal dialysis patients.

Data regarding the outcomes of peritoneal dialysis (PD) patients undergoing nephrectomy are limited. In the 20-year retrospective study reported here, we included patients who underwent nephrectomy and then subsequently started PD within 1 year (group A) and those who underwent nephrectomy while already on PD (group B). We examined mechanical complications including incisional hernia, peritoneal leak, and wound infection or dehiscence. Among biochemical outcomes (group B only), we analyzed serum creatinine, albumin, potassium, and phosphate for 1 year pre- and post-nephrectomy. Among the 8 patients identified (4 in group A, 4 in group B), 7 underwent unilateral nephrectomy, and 1, bilateral nephrectomy. Surgery was laparoscopic in 1 patient and open in 7 patients. The approach was transperitoneal in 5 patients, and retroperitoneal in 3 patients. Incisional hernia occurred in 4 patients (2 in each group), and retroperitoneal leak was seen in 1 patient in group B after 2 months. No wound dehiscence or other complications occurred. In group B, 2 patients required hybrid therapy in the form of once-weekly hemodialysis with continuous ambulatory PD. Among the biochemical complications, we noted that serum creatinine increased (as expected), and serum albumin significantly declined and remained lower post-nephrectomy. Our data show that, post-nephrectomy, PD patients have a high incidence of incisional hernia. They also experience a significant decline in serum albumin and a substantial loss in residual kidney function potentially requiring intensified dialysis. The retroperitoneal approach may on occasion predispose to retroperitoneal leak of dialysate.

Tunneled dialysis line-associated hemorrhagic shock following self-inflicted trauma in a hemodialysis patient: A case report.

Complications of tunneled central venous catheters (CVCs) for hemodialysis are frequent, and most commonly include bacteremia, thrombosis, and stenosis. While bleeding is a relatively rare complication of dialysis lines overall, tunneled CVCs may present a unique bleeding risk given their ability to be displaced or damaged as patients have direct access to the equipment in place. Here, we describe the case of a 68-year-old man with end-stage renal disease and neurocognitive disorder, who developed hemorrhagic shock following self-inflicted laceration of his tunneled dialysis catheter proximal to the Y. Examination of the catheter tunnel revealed that the cuff was palpable proximal to the exit site, but the opening was well retracted. In such cases, hemorrhage is particularly difficult to control because the cuff is rigid and poorly amenable to compression, in addition to being difficult to access. This case demonstrates the risk of significant hemorrhage when a tunneled CVC is damaged at this location and the potential need for the urgent removal of the retained component to prevent recurrence of bleeding. It also highlights important patient safety considerations given the risk of self-inflicted trauma in patients with a neurocognitive disorder and a language barrier affecting communication.

Nocturnal Hemodialysis: Why Aren't More People Doing It?

Nocturnal hemodialysis is a form of intensive hemodialysis, which may be done in center or at home. Despite the documented clinical and economic benefits of ncturnal hemodialysis, uptake of this modality has been relatively low. In this review, we aim to address the potential barriers and possible mitigation strategies. Among the patient-related barriers, lack of knowledge and awareness remains the most common barrier, while administrative inertia to change from conventional in-center hemodialysis continues to be a challenge. Current global effort to grow home dialysis will re-focus the need for better patient education, innovate home dialysis technology, and evolve new models of care. New patient-focused policy will allow changes in reimbursement and develop appropriate momentum toward an integrated "home first model" to kidney replacement therapy.

Rate of Decline of Residual Kidney Function Before and After the Start of Peritoneal Dialysis.

UNLABELLED: ♦ BACKGROUND: There is a paucity of information on whether peritoneal dialysis (PD) slows the decline of residual kidney function (RKF) compared to the natural slope of RKF decline prior to dialysis start. Our aim was to analyze the RKF decline before and after initiating PD, and to determine the principal factors affecting this decline during the PD period. ♦ METHODS: We determined individual glomerular filtration rates (GFR) for approximately 12 months before and after PD in 77 new PD patients in a large academic medical center (2008 - 2012). The GFR was estimated by the Modification of Diet in Renal Disease (MDRD) equation in the predialysis period and by averaging 24-hour urine creatinine and urea clearances in the PD period. The rate of RKF decline was calculated using unadjusted linear regression analysis. Wilcoxon signed rank test was used to compare RKF decline before and after PD initiation. Multivariate linear regression was used to identify independent risk factors for RKF decline in the PD phase. ♦ RESULTS: A significantly slower mean rate of RKF decline was observed in the PD period compared with the predialysis period (-0.21 ± 0.30 vs -0.59 ± 0.55 mL/min/1.73 m(2)/month, p < 0.01). Higher baseline RKF, higher serum phosphate, and older age were independently associated with faster decline of RKF (all p < 0.01). ♦ CONCLUSIONS: In patients with advanced chronic kidney disease, initiating PD was associated with a slower rate of RKF decline compared to the rate in the predialysis period.

A prospective cohort conversion study of twice-daily to once-daily extended-release tacrolimus: role of ethnicity.

BACKGROUND: Tacrolimus is a widely used calcineurin inhibitor in kidney transplantation. It is available as twice-daily Prograf® (Tac-BID) and once-daily Advagraf® (Tac-OD). Although therapeutically equivalent, some patients require dose adjustments to achieve similar trough concentrations [C0] after conversion. Tacrolimus exposure is affected by ethnicity in the de novo setting but the role of ethnicity in determining dose requirements and adjustments after conversion is unknown. METHODS: In this study, 496 renal transplant recipients (RTRs) were prospectively converted from Tac-BID to Tac-OD, with dose adjustments targeted to achieve similar [C0] at 12 months post-conversion. Renal function, acute rejection and Tac dose adjustments by ethnicity were analyzed. RESULTS: There were similar numbers of recipients from living and deceased donors. The mean transplant duration was 7 years. Of the RTRs, 60% were Caucasian and 40% were identified as belonging to an ethnic minority. There was no change in estimated renal function (eGFR) post-conversion to Tac-OD. At 12 months, 35/488 (7%) RTRs were receiving a reduced dose, 101/488 (21%) required a dose increase of which 77 (16%) were receiving at least a 30% increase in dose over baseline. The percentage of those in ethnic groups requiring a dose increase of >30% varied from 8.0% for South Asians to 27.5% for East Asians (P = 0.03), despite East Asians having a similar baseline dose of Tac-BID (3.59 mg/day) compared to the entire cohort (3.53 mg/day). CONCLUSIONS: Ethnicity may play an important role in dosing requirements when converting from Tac-BID to Tac-OD, unrelated to baseline dose. Further investigation is required to determine the reasons for ethnic variability when patients are converted between tacrolimus preparations.

Sleep apnea is not associated with worse outcomes in kidney transplant recipients.

Obstructive sleep apnea(OSA) is one of the most common sleep disorders in kidney transplant recipients, however its long-term consequences have only rarely been investigated. Here, we hypothesized that the presence of OSA would be associated with higher risk of mortality and faster decline of graft function in kidney transplant recipients. In a prospective cohort study 100 prevalent kidney transplant recipients who underwent one-night polysomnography at baseline and were followed for a median 75 months. Generalized linear mixed-effects models and Cox regression models were used to assess the association between OSA and the rate of progression of chronic kidney disease(CKD) and mortality. The estimated slopes of estimated glomerular filtration rate(eGFR) in patients with and without OSA were compared using a two-stage model of eGFR change including only OSA as a variable. In this model patients with OSA (eGFR versus time was -0.93 ml/min/1.73 m(2)/yr(95%CI:-1.75 to-0.11) had a similar slope as compared to patients without OSA(eGFR versus time was -1.24 ml/min/1.73 m(2)/yr(95%CI: -1.67 to -0.81). In unadjusted Cox proportional regression analyses OSA was not associated with higher all-cause mortality risk (Hazard Ratio(HR) = 1.20; 95% Confidence Interval(CI): 0.50-2.85). No association was found between the presence of OSA and the rate of progression of CKD or all-cause mortality in prevalent kidney transplant recipients.