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BACKGROUND: Individuals with end-stage renal disease have a higher risk of hepatitis C virus (HCV) acquisition during long-term hemodialysis (HD). Our report was designed to investigate HCV prevalence and genotype, in addition to the clinical use of HCV core antigen (HCVcAg), within multiple HD facilities in Thailand. METHODS: This cross-sectional report was investigated between January and June 2019. HCV infection was assessed by anti-HCV and confirmed active infection by measuring HCV RNA and HCVcAg. HCV genotype was determined by phylogenetic analysis using nucleotide sequences of NS5B region. RESULTS: Overall, 140 of 3,305 (4.2%) patients in 15 dialysis centers had anti-HCV positive. Among them, HCV RNA was further assessed in 93 patients and was detectable in 59 (63.4%) persons. Considering HCV viremia, HCVcAg measurement exhibited high accuracy (96.8%), sensitivity (94.9%) and specificity (100%) in comparison with HCV RNA testing. Moreover, individuals infected with HCV received a longer duration of dialysis vintage when compared to anti-HCV negative controls. The major sub-genotypes were 1a, 1b, 3a, 3b, 6f and 6n. Regarding phylogenetic analysis, there were 7 clusters of isolates with high sequence homology affecting 17 individuals, indicating possible HCV transmission within the same HD centers. CONCLUSIONS: HCV frequency and common sub-genotypes in HD centers were different from those found in the Thai general population. HCVcAg might be an alternate testing for viremia within resource-limited countries. Enhanced preventive practices, dialyzer reuse policy and better access to antiviral therapy are crucial for HCV micro-elimination within HD facilities.
Assuntos
Hepacivirus , Hepatite C , Estudos Transversais , Genótipo , Hepacivirus/genética , Hepatite C/epidemiologia , Humanos , Filogenia , Prevalência , RNA Viral/genética , Diálise Renal , Tailândia , Viremia/epidemiologiaRESUMO
BACKGROUND: Citrate anticoagulation is increasingly favored for preventing extracorporeal circuit clotting during renal replacement therapy. This study tested the effect of citrate compared with acetate on heparin avoidance and other parameters. METHODS: Sixty-one chronic hemodialysis (HD) patients were switched from conventional dialysis fluid (acetate) to citrate dialysis fluid and were treated in 3 phases, each lasting 4 weeks: 50%, 25%, and no heparin. Visual clotting score, erythropoiesis stimulating agent (ESA) dose, and laboratory parameters were measured. RESULTS: Except for 2 episodes of clotting, the same dialyzers were used throughout each citrate phase. The mean visual clotting scores were comparable across study periods. Hemoglobin decreased slightly in phase 2 despite the constant ESA dose. The ionized calcium levels rose after HD in most sessions. No adverse events occurred during citrate dialysis. CONCLUSION: During citrate dialysis in chronic HD patients, heparin can be completely avoided. The electrolyte levels, the adequacy of dialysis, and hemoglobin can be maintained without significant adverse events.
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Anemia/etiologia , Anticoagulantes/farmacologia , Coagulação Sanguínea/efeitos dos fármacos , Ácido Cítrico/farmacologia , Soluções para Diálise/efeitos adversos , Diálise Renal/efeitos adversos , Adulto , Anemia/diagnóstico , Anticoagulantes/administração & dosagem , Análise Química do Sangue , Testes de Coagulação Sanguínea , Ácido Cítrico/administração & dosagem , Soluções para Diálise/química , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Clusters of bloodstream infections caused by Burkholderia cepacia and Stenotrophomonas maltophilia are uncommon, but have been previously identified in hemodialysis centers that reprocessed dialyzers for reuse on patients. We investigated an outbreak of bloodstream infections caused by B cepacia and S maltophilia among hemodialysis patients in clinics of a dialysis organization. STUDY DESIGN: Outbreak investigation, including matched case-control study. SETTING & PARTICIPANTS: Hemodialysis patients treated in multiple outpatient clinics owned by a dialysis organization. PREDICTORS: Main predictors were dialyzer reuse, dialyzer model, and dialyzer reprocessing practice. OUTCOMES: Case patients had a bloodstream infection caused by B cepacia or S maltophilia; controls were patients without infection dialyzed at the same clinic on the same day as a case; results of environmental cultures and organism typing. RESULTS: 17 cases (9 B cepacia and 8 S maltophilia bloodstream infections) occurred in 5 clinics owned by the same dialysis organization. Case patients were more likely to have received hemodialysis with a dialyzer that had been used more than 6 times (matched OR, 7.03; 95% CI, 1.38-69.76) and to have been dialyzed with a specific reusable dialyzer (Model R) with sealed ends (OR, 22.87; 95% CI, 4.49-∞). No major lapses during dialyzer reprocessing were identified that could explain the outbreak. B cepacia was isolated from samples collected from a dialyzer header-cleaning machine from a clinic with cases and was indistinguishable from a patient isolate collected from the same clinic, by pulsed-field gel electrophoresis. Gram-negative bacteria were isolated from 2 reused Model R dialyzers that had undergone the facility's reprocessing procedure. LIMITATIONS: Limited statistical power and overmatching; few patient isolates and dialyzers available for testing. CONCLUSIONS: This outbreak was likely caused by contamination during reprocessing of reused dialyzers. Results of this and previous investigations demonstrate that exposing patients to reused dialyzers increases the risk for bloodstream infections. To reduce infection risk, providers should consider implementing single dialyzer use whenever possible.
Assuntos
Bacteriemia/epidemiologia , Infecções por Burkholderia/epidemiologia , Surtos de Doenças , Desinfecção/estatística & dados numéricos , Infecções por Bactérias Gram-Negativas/epidemiologia , Falência Renal Crônica/terapia , Rins Artificiais/estatística & dados numéricos , Stenotrophomonas maltophilia/imunologia , Idoso , Idoso de 80 Anos ou mais , Burkholderia cepacia , Estudos de Casos e Controles , Descontaminação , Contaminação de Equipamentos , Feminino , Humanos , Controle de Infecções , Rins Artificiais/microbiologia , Masculino , Pessoa de Meia-Idade , Diálise Renal , Estados Unidos/epidemiologiaRESUMO
Despite almost universal practice of dialyzer reuse from the earliest days of haemodialysis, reusing dialyzer always remains a controversial issue and several ethical concerns have been raised. Some of the important are safety of reuse over single use, informed consent of the patient, conflict of interest on the part of physician or manufacturer, fiscal responsibility and environmental stewardship. Indeed, at the beginning of this century, there was a drastic shift of practice in favour of single use in developed countries due to availability of biocompatible haemodialyzers, at favourable price. Despite this mega shift, dialyzer reuse is still widely practised in low-income countries. Considering cost inflation and limited medical resources in such countries, dialyzer reuse may be justified as a cost-saving strategy for this part of world. However, it poses the same ethical questions to us which were a matter of debate for the western world in the 1980s and 1990s. This review of literature was planned to revisit and highlight these concerns.
Assuntos
Países em Desenvolvimento , Reutilização de Equipamento/economia , Ética Médica , Rins Artificiais/economia , Conflito de Interesses , Redução de Custos/ética , Humanos , Consentimento Livre e Esclarecido/ética , Qualidade da Assistência à SaúdeRESUMO
Global warming and climate change represent the most significant threats to humanity in the 21st century, both of which are manmade catastrophes. Addressing climate change requires corrective action across all aspects of modern human life and work, including the medical field. Among healthcare sectors, dialysis units stand out as major contributors to plastic waste and excessive water consumption. It is imperative for hemodialysis units to lead by example in the judicious use of natural resources. This systemic review is aimed to establish a bare minimum of recommendations for environmental sustainability across Indian dialysis units, and to guide future initiatives to reduce the environmental impact of dialysis process. A literature search was conducted on PubMed, and Google to retrieve articles or studies related to green dialysis. The predefined keyword search yielded a total of 291 studies. A total of 54 studies and articles which were relevant to study question, and fulfilled inclusion criteria, were retrieved and analyzed to form opinions on the implementation of green dialysis initiatives from an Indian perspective. Green dialysis initiatives are much-needed reforms to be adopted by the Indian dialysis community. Through careful planning and minimal efforts, substantial amounts of water used in hemodialysis can be conserved and repurposed for other hospital activities. Similarly, the vast majority of discarded plastic waste can be recycled or reused. Despite controversy, reconsidering the risk-benefit aspects of dialyzer reuse is essential, particularly in the context of resource-limited developing nations like India.
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We conducted a randomized crossover trial to identify whether the use of citrate dialysate (CD) for bicarbonate hemodialysis is beneficial compared to regular acetate dialysate (AD) in terms of adequacy, reuse, and quality of life. Thirty-two stable end-stage renal disease patients on twice-weekly maintenance hemodialysis were randomly assigned to CD or AD fluid in a single-blinded randomized prospective crossover trial of 1-year duration. The primary outcomes studied were the impact of CD in comparison with AD on hemodialysis adequacy, reuse of dialyzer, and quality of life. Secondary outcomes studied were the effect on intradialytic hypotension, acidosis correction, and episodes of symptomatic hypocalcemia. A total number of 28 patients underwent a total of 1456 sessions of hemodialysis with CD over 6 months and 1456 sessions with AD over 6 months. There was a significant increase in dialyzer reuse with the use of CD (P = 0.02). There was no difference in dialyzer adequacy as measured by Single pool Kt/V (spKt/V) (P = 0.840) and urea reduction ratio (%) (P = 0.90). Quality of life did not differ between the two groups. No statistically significant difference was observed in predialysis arterial pH (P = 0.23) serum bicarbonate (0.17) and calcium change (P = 0.16). CD is safe and equally effective as compared to AD. It significantly improves the reuse of dialyzer but it does not offer any added advantage in terms of improvement in hemodialysis adequacy and quality of care.
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Although dialyzer reuse for home hemodialysis (done by patients at home) has been in practice since the 1960s, it is now almost completely abandoned. The need for dialyzer reuse resurfaced with the renewed interest in daily/nightly forms of home hemodialysis and the associated increase in operating costs. We describe a method of dialyzer reuse based on reprocessing of dialyzers at the center, after they had been stored in a refrigerator at home for 1 week by the patient. Transportation of the dialyzers by either the patient or a transportation service was acceptable to the patients. Despite the lower number of reuses, possibly related to the delayed processing, dialyzer reuse in this setting provided significant financial benefits. Experience with this process for 3 years has not disclosed any negative effects after the initial logistical issues related to dialyzer transportation were resolved. In summary, weekly dialyzer reprocessing at the center provides a solution to the need for dialyzer reuse for the home hemodialysis patient.
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The first objective of this study was to validate the use of water at 85°C ± 5°C to achieve high-level disinfection of a clean-in-place extracorporeal dialysis circuit. The second objective was to demonstrate that applying this hot water method to the entire fluid pathways of a newly designed dialysis instrument, including an integral reverse-osmosis membrane, routinely allowed the production of back-filtered dialysate meeting the U.S. Pharmacopeia (USP) standard for the water for injection (WFI). In a first study, six dialyzers were inoculated with P. aeruginosa, incubated, and subjected to 75°C water for 30 minutes. No organisms could be recovered from the experimental dialyzers nor from three negative controls, but they were recovered from three positive controls. In a second study, the carbon tanks in the water inlet line and the dialysate tank were both inoculated with massive amounts of dialysis water-adapted Gram-negative organisms, followed by seven dialysis treatments using bovine blood, where the fifth and sixth procedures were separated by 2 idle days and the sixth and seventh procedures were separated by 3 idle days. In addition, the bovine blood used in each treatment was highly contaminated. In every case, the back-filtered dialysate met the WFI standard. From the above results we conclude that a hot water disinfection process is efficacious in reducing even grossly exaggerated contamination in the Aksys personal hemodialysis system to the point where it can produce water and dialysate that greatly exceed the Association for the Advancement of Medical Instrumentation (AAMI) standards and priming and rinse-back solution (back-filtered dialysate) that meets the USP standard for WFI.