A Systematic Literature Review of Relational Autonomy in Dialysis Decision Making.

Nephrology interdisciplinary guidelines, professional codes of ethics, principle-based ethical standards, and literature promote patient autonomy and self-determination through shared decision making as ethical practice. Healthcare professionals are accountable for practice that is mindful of the impact of cultural diversity and community on the values and beliefs of the patient, an important part of shared decision making (SDM). Despite previous research regarding dialysis decision making, relational autonomy in chronic kidney disease (CKD) and end-stage kidney disease SDM conversations is not well understood. This systematic literature review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework for identifying peer-reviewed literature on SDM for CKD. The findings were summarized into four broad themes: (1) promoting autonomy is a foundation of medical caring; (2) providers have a responsibility to respond to their asymmetrical social power; (3) autonomy is situated within the context of the patient; and (4) dialogue is a tool that negotiates clinical recommendations and patient goals. The caring practices of promoting autonomy with a dialogical resolution of a conflict acknowledging the interdependence of the parties and the patient's social-relational situatedness support a perspective of relational autonomy in dialysis decision-making practice and research.

Targeting Zero Infections in the Outpatient Dialysis Unit: Core Curriculum 2020.

Although overall mortality rates in dialysis patients have improved during the last decade or so, infections remain a leading cause of death, second only to cardiovascular disease. In addition, infections account for a major share of hospitalizations in this patient population. Receiving hemodialysis treatments in an outpatient dialysis facility significantly contributes to patients' risks for infection. In dialysis units, patient-to-patient transmission of viral pathogens such as hepatitis B virus, hepatitis C virus, and human immunodeficiency virus can occur; proper screening and vaccination of patients can decrease the risk for transmission. Strict adherence to hand hygiene, use of appropriate personal protective equipment, transmission-based precautions, and maintaining aseptic technique while connecting the access to the hemodialysis machine can substantially decrease the likelihood of bacterial infections. With an effective infection control program in place, infection prevention becomes part of the dialysis facility's culture and results in improved patient safety. In this installment of the Core Curriculum series, we highlight best practices that should be followed by health care workers in the dialysis unit and discuss the role of the medical director in promoting initiatives to reduce infection rates.

Changes in pulmonary artery systolic pressure and right ventricular function in patients with end-stage renal disease on maintenance dialysis.

AIM: Pulmonary hypertension is common in patients with end-stage renal disease, and portends a poor prognosis. There are little data in this population, and previous studies have not evaluated quantitative changes in haemodynamics over time while on maintenance dialysis. This study sought to estimate changes in pulmonary artery systolic pressure (PASP) and right ventricular function over time, and to predict PASP change using clinical variables routinely available at time of initial measurement, in patients on maintenance dialysis. METHODS: We retrospectively studied patients with end-stage renal disease at a university-affiliated dialysis centre who had two separate echocardiograms 1-4 years apart. RESULTS: Seventy-six patients (65 haemodialysis, 11 peritoneal dialysis) were included. PASP was estimated by echocardiography. Baseline PASP was predicted by left-sided valvular disease, anaemia, COPD, left-ventricular mass index, and haemodialysis modality (P = 0.07 for modality). Average increase in PASP was 2.41 mmHg per year. Higher rates of PASP change were predicted by E/e' ratio by tissue doppler on echocardiogram, diabetes mellitus, low LV mass, and left-sided valvular heart disease (P = 0.07 for valvular disease). Patients with higher PASP had higher incidence of new-onset right ventricular dysfunction. CONCLUSION: In patients with end-stage renal disease, PASP increases over time. Changes are moderately predictable. Higher PASP predicted development of right ventricular dysfunction.

Show Me CKDintercept Initiative: A Collective Impact Approach to Improve Population Health in Missouri.

Ninety percent of people with chronic kidney disease (CKD) remain undiagnosed, most people at risk do not receive guideline-concordant testing, and disparities of care and outcomes exist across all stages of the disease. To improve CKD diagnosis and management across primary care, the National Kidney Foundation launched a collective impact (CI) initiative known as Show Me CKDintercept. The initiative was implemented in Missouri, USA from January 2021 to June 2022, using a data strategy, stakeholder engagement and relationship mapping, learning in action working groups (LAWG), and a virtual leadership summit. The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used to evaluate success. The initiative united 159 stakeholders from 81 organizations (Reach) to create an urgency for change and engage new CKD champions (Effectiveness). The adoption resulted in 53% of participants committed to advancing the roadmap (Adoption). Short-term results reported success in laying a foundation for CI across Missouri. The long-term success of the CI initiative in addressing the public health burden of kidney disease remains to be determined. The project reported the potential use of a CI initiative to build leadership consensus to drive measurable public health improvements nationwide.

Dyadic shared decision-making in dialysis: An interpretive phenomenological inquiry.

INTRODUCTION: Caregiver and family engagement in dialysis decisions varies over the end-stage kidney disease treatment trajectory, with family preferences as primary consideration factors for patients starting dialysis. This interpretive phenomenological study explores how dialysis patients and their partners experience dialysis decisions. METHODS: Thirteen patient-decision partner dyads (26 participants) were interviewed together about their experience with dialysis decision-making. A 5-step iterative process of data analysis occurred concurrently with data collection. RESULTS: The patients received in-center hemodialysis (n = 6) and home dialysis (peritoneal dialysis or home hemodialysis (n = 7). Decision partner relationships included romantic partners (n = 9) and either parent, sibling, or friend (n = 4). Fifty-7 percent of participants were White; 46% of patients were women, and 76% of decision partners were women. Three interrelated themes were identified: Their body, but not their life; Seeking semiliberation, and Decision-making is caring. DISCUSSION: Dyads were attuned to patient autonomy while managing the collateral effects of dialysis. Shifting the paradigm of dialysis treatment decisions from promoting patient autonomy to dialogues exploring relational autonomy helps providers balance the competing demands of incentivized standards to promote home dialysis with patients and their decision partners realities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Arrhythmia in chronic hemodialysis as a function of predialysis electrolytes and interdialytic interval.

INTRODUCTION: People with end-stage renal disease on hemodialysis are at increased risk for death due to arrhythmia associated with the prolonged interdialytic interval that typically spans the weekend, with bradycardia being the arrhythmia most closely associated with sudden death. In this prospective observational study we assessed whether predialysis fluid and electrolytes values including hyperkalemia are risk factors for the arrhythmias associated with the prolonged interdialytic interval. METHODS: Sixty patients on hemodialysis with a history of hyperkalemia underwent cardiac monitoring for 1 week. Arrhythmia frequency, average QTc interval, and average root mean square of successive differences (rMSSD) per 4-h period were reported. Predialysis electrolytes and electrocardiograms were collected prior to pre- and post-weekend dialysis sessions. Clinical variables were assessed for correlation with arrhythmias. FINDINGS: Predialysis hyperkalemia occurred in 29 subjects and was more common at the post-weekend dialysis session. Bradycardia occurred in 11 subjects and increased before and during the post-weekend dialysis session, but was not correlated with any electrolyte or clinical parameter. Ventricular ectopy occurred in 50 subjects with diurnal variation unrelated to dialysis. Pre-dialysis prolonged QTc was common and not affected by interdialytic interval. Average QTc increased and rMSSD decreased during dialysis sessions and were not correlated with clinical parameters. DISCUSSION: The results confirm that arrhythmias are prevalent in dialysis subjects with bradycardia particularly associated with the longer interdialytic interval; EKG markers of arrhythmia risk are increased during dialysis independent of interdialytic interval. Larger sample size and/or longer recording may be necessary to identify the clinical parameters responsible.

COVID-19 among Hospitalized Patients with Kidney Disease: Experience at a U.S. Midwestern Academic Medical Center.

We sought to characterize the clinical profiles and outcomes of patients with coronavirus disease 2019 and comorbid kidney disease hospitalized at urban, Midwestern tertiary care hospital. Material and Methods: In this single-center observational study, we describe 205 patients with acute kidney injury (n=98), dialysis-dependent chronic kidney disease stage 5 (n=54), or kidney transplant (n=53), admitted during the first surge of the local pandemic from March 19 2020, to July 31 2021. Results: Most patients in the cohort were African American (acute kidney injury, 51%; dialysis-dependent chronic kidney disease stage 5, 82%; kidney transplant, 62%), and obesity was common (acute kidney injury, 53%; dialysis-dependent chronic kidney disease stage 5, 44%; kidney transplant 56%). Mechanical ventilation was required in 50% of the acute kidney injury, 22% of the dialysis-dependent chronic kidney disease stage 5, and 13% of the kidney transplant recipients. Nearly half of the acute kidney injury patients (46%) died and 49% required replacement therapy, while in-hospital mortality was 24% in the dialysis-dependent chronic kidney disease stage 5 patients and 9% in the kidney transplant recipients. Logistic regression analysis identified older age and patient group as leading correlates of mortality, with lower death risk in the kidney transplant (24%; odds ratio (OR), 0.17; 95% CI 0.06-0.47) and dialysis dependent chronic kidney disease stage 5 (9%; OR, 0.36; 95% CI 0.16-0.78) patients compared to acute kidney injury patients (46%). Obesity was associated with 5-fold increased mortality risk in the coronavirus disease 2019 patients with acute kidney injury (OR, 5.32; 95% CI 1.41-20.03) but not in dependent dialysis chronic kidney disease stage 5 and kidney transplant patients. Conclusion: During the first surge of the pandemic, kidney patients hospitalized COVID-19 experienced high mortality, especially those with acute kidney injury, older age and obesity. Identifying those at highest risk for adverse outcomes may direct preventative strategies including counseling on vaccination.

A case of immune complex mediated tubulointerstitial disease and nephrotic syndrome: anti LRP-2 Nephropathy with diffuse podocyte effacement.

Anti-LDL Receptor-Related Protein 2 (Anti-LRP2) nephropathy is a rare form of kidney disease that affects the older patients and is characterized with acute kidney injury (AKI) and progressive renal tubular injury associated with IgG immune complex deposits along the basement membrane of proximal tubules, and circulating autoantibodies to the proximal tubule brush border protein LRP2 (megalin). We present the case of a 79-year-old man who was hospitalized for worsening malaise, abdominal distention and bilateral lower extremity edema, diagnosed with AKI and had nephrotic range proteinuria. Percutaneous kidney biopsy revealed tubulointerstitial nephritis with IgG immune complex deposits along the basement membrane of proximal tubules and brush borders. Immunofluorescence staining for LRP2 (megalin) showed similar granular tubular basement membrane deposits along the proximal tubules and proximal tubule brush borders. Electron microscopy revealed global podocyte foot process effacement. The patient was started on oral prednisolone 1 mg/kg and rituximab at a dose of 375 mg/m2 once weekly for 4 weeks with gradual tapering of prednisone. This case with AKI and nephrotic syndrome highlights the significant morphologic overlap with minimal change disease and anti-LRP2 nephropathy, which is associated with autoantibodies to the tubular brush border protein LRP2/megalin.

Purpura Fulminans in the Setting of Klebsiella Pneumoniae Bacteremia and Acetaminophen Overdose.

Purpura fulminans (PF) is a rare, life-threatening disorder characterized by disseminated intravascular coagulation (DIC), circulatory collapse, and hemorrhagic cutaneous purpura. It typically occurs secondary to acute infections, usually meningococcal septicemia, although there are also congenital and acquired causes. We report a case of a 56-year old female who presented to our institution with clinical signs of PF in the setting of acetaminophen overdose and Klebsiella pneumoniae sepsis. Given the rarity of the disease, we also review cases of PF in similar clinical scenarios that have been described in the literature.

Hypercalcemia complicating Marjolin's ulcer.

A 54-year-old male with chronic osteomyelitis presented with new-onset hypercalcemia. Extensive initial evaluation did not reveal the underlying cause of his hypercalcemia. Subsequent biopsies revealed squamous cell carcinoma transformation consistent with Marjolin's ulcer. Timely surgery had been shown to be effective in achieving remission in patients with Marjolin's ulcers, even in the presence of hypercalcemia. Therefore, we recommend that patients with chronic wounds and new-onset or otherwise unexplained hypercalcemia should be evaluated for development of Marjolin's ulcers.

A report on four new cases of nephrogenic fibrosing dermopathy in chronic hemodialysis patients.

Nephrogenic fibrosing dermopathy (NFD) is a rare clinical entity affecting patients with renal failure, often on chronic dialysis or after transplantation. The patient profile at risk for this debilitating condition is undefined. Lack of awareness of the condition has hampered epidemiologic work in identifying the etiology. We present four chronic hemodialysis (HD) patients who developed this disease. The patients' ages ranged from 26 to 75 years, and they had received HD from between 20 months and 10 years before the diagnosis of NFD. Two patients had a history of renal transplantation. All patients had progressive thickening and woody induration of the skin associated with contractures, leading to difficult ambulation, and permanent disability within weeks of the diagnosis. In one case, the diaphragm, psoas muscle, and pericardium were involved. The latter is likely the first report of pericardial involvement of NFD. In all four patients, the skin findings were restricted to the extremities, sparing the trunk and face. Skin biopsy findings included thickened dermis with particularly thickened collagen bundles, fibroblast proliferation, minimal mucin deposition, and nearly absent inflammation. The pathologic findings were distinct from scleromyxedema and scleroderma. We found no laboratory evidence of autoimmune disease or thyroid dysfunction to account for alternate etiologies. CD34-positive cells were documented in the skin biopsies as well as in the diaphragm, psoas muscle, and pericardial tissue of the concerned case. NFD is a novel fibrosing disorder of progressively debilitating nature which needs further clinical characterization and recognition to guide investigation of its pathogenesis.

Lupus-like glomerulonephritis: an autoimmune complication of hepatitis C infection.

Lupus-like glomerulnephritis in patients with negative lupus serologies and no extra-renal manifestations of lupus can create a diagnostic dilemma. We describe a 53-year-old gentleman with chronic hepatitis C virus (HCV) infection who presented with dialysis-requiring renal failure, renal histologic findings of "full-house" immunofluorescence label and tubuloreticular inclusions on electronic microscopy, but no extra-renal or laboratory signs of systemic lupus erythematosis. Attempted treatment with cyclophosphamide and corticosteroids was limited by cyclophosphamide hypersensitivity. The patient remained dialysis-dependent over 18 months of observation and did not develop extra-renal clinical or biological manifestations of lupus. Mimics of seronegative lupus with isolated renal involvement can include HCV-related autoimmunity. Treatment of acute glomerulonephritis may be similar initially, but other concerns in patients with HCV infection include excluding cryoglobulinemia, the potential impact of immunosuppression therapy on liver disease and consideration of subsequent use of antiviral therapy. Given the increasing prevalence of HCV globally, the recognition of extra-hepatic autoimmune manifestations of HCV infection will likely increase.

Immune-complex deposits in "pauci-immune" glomerulonephritis: a case report and brief review of recent literature.

Anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis is considered a "pauci-immune" disease, characterized by absent or mild glomerular tuft staining for immunoglobulin and/or complement. We describe a 72-year-old man with progressive renal failure over five months who was found to have P-ANCA associated crescentic glomerulonephritis. Renal biopsy also revealed immunofluorescence staining for Immunoglobulin G and C3. Treatment comprised corticosteroids, cyclophosphamide, and plasmapheresis but unfortunately kidney function did not recover, likely due to substantial interstitial fibrosis at diagnosis. This case illustrates that serologic evaluation for ANCAs should not be discounted when immune deposits are present. Prompt diagnosis is warranted.

Delivery patterns of recommended chronic kidney disease care in clinical practice: administrative claims-based analysis and systematic literature review.

BACKGROUND: Clinical practice guidelines for management of chronic kidney disease (CKD) have been developed within the Kidney Disease Outcomes Quality Initiative (K/DOQI). Adherence patterns may identify focus areas for quality improvement. METHODS: We retrospectively studied contemporary CKD care patterns within a private health system in the United States, and systematically reviewed literature of reported practices internationally. Five hundred and nineteen patients with moderate CKD (estimated GFR 30-59 ml/min) using healthcare benefits in 2002-2005 were identified from administrative insurance records. Thirty-three relevant publications in 2000-2006 describing care in 77,588 CKD patients were reviewed. Baseline demographic traits and provider specialty were considered as correlates of delivered care. Testing consistent with K/DOQI guidelines and prevalence of angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) medication prescriptions were ascertained from billing claims. Care descriptions in the literature sample were based on medical charts, electronic records and/or claims. RESULTS: KDOQI-consistent measurements of parathyroid hormone (7.1 vs. 0.6%, P = 0.0002), phosphorus (38.2 vs. 1.9%, P < 0.0001) and quantified urinary protein (23.8 vs. 9.4%, P = 0.008) were more common among CKD patients with versus without nephrology referral in the administrative data. Nephrology referral correlated with increased likelihood of testing for parathyroid hormone and phosphorus after adjustment for baseline patient factors. Use of ACEi/ARB medications was more common among patients with nephrology contact (50.0 vs. 30.0%; P = 0.008) but appeared largely driven by higher comorbidity burden. The literature review demonstrated similar practice patterns. CONCLUSIONS: Delivery of CKD care may be monitored by administrative data. There is opportunity for improvement in CKD guideline adherence in practice.

Thrombotic thrombocytopenic purpura without schistocytes on the peripheral blood smear.

A hallmark of the clinical syndrome of thrombotic thrombocytopenic purpura (TTP) is evidence of microangiopathic hemolytic anemia. The presence of schistocytes on the peripheral blood smear, elevated plasma lactic dehydrogenase, and decreased haptoglobin concentration are used as evidence of microangiopathic hemolytic anemia to make a diagnosis of TTP. This report describes a case of recurrence of TTP in the absence of schistocytes in the peripheral blood smear during the recurrent episode. Although careful attention should be paid to microscopic examination of a blood smear in any patient presenting with acute renal failure and thrombocytopenia, this case emphasizes the need to consider TTP-hemolytic uremic syndrome in the differential diagnosis, even in the absence of peripheral schistocytosis.

Routine replacement of tunneled, cuffed, hemodialysis catheters eliminates paraspinal/vertebral infections in patients with catheter-associated bacteremia.

BACKGROUND: Management of tunneled, cuffed, central venous catheters in hemodialysis (HD) patients with bacteremia remains a challenge. Attempts to salvage the catheter with systemic antibiotics alone have been associated with increased risk of metastatic infectious complications. METHODS: Retrospective case series of patients with infectious complications in a chronic dialysis unit, affiliated with a tertiary care university hospital. RESULTS: Between 1996 and 1999, when we treated HD catheter-associated bacteremia with systemic antibiotics alone, we encountered a clustering of 8 cases of paraspinal/vertebral infections in a population of 162 patients. After changing our protocol, i.e., routine catheter exchange over a guide wire at approximately 48 h, while on systemic antibiotic therapy, we did not encounter any new cases of paraspinal/vertebral infections over a 15-month period. CONCLUSION: Our experience suggests that routine exchange of tunneled, cuffed catheters over a guide wire in HD patients presenting with bacteremia may significantly reduce serious infectious complications, e.g., epidural abscess/vertebral osteomyelitis.