Associations between echocardiographic findings and prospective changes in residual renal function in patients new to peritoneal dialysis.

Although echocardiograms are often performed when peritoneal dialysis is started, associations between commonly reported findings and prospective changes in renal function remain understudied. Ninety-nine of 101 patients in the Trio Trial had transthoracic echocardiograms within 6 months of dialysis initiation, and measurements of residual renal function every six weeks for up to two years. Generalized mixed modelling linear regression in STATA was used to examine associations between left atrial size, left ventricular hypertrophy, left ventricular ejection fraction, right ventricular systolic pressure, and left valvular calcification with subsequent slopes in renal function. After echocardiography (performed a median of 16 days following peritoneal dialysis initiation) right ventricular systolic pressure was associated with faster, while declining left ventricular ejection fraction and valvular calcification were associated with slower declines in residual renal function. Future studies could be conducted to confirm these findings, and identify pathophysiological mechanisms.

Variability in CKD stage in outpatients followed in two large renal clinics.

OBJECTIVE: Chronic kidney disease (CKD) is staged by glomerular filtration rate (GFR). CKD stages sometimes vary between routine office visits, and it is unknown if this impacts renal and patient survival separately from a cross-sectional CKD stage value. We quantified and categorized CKD stage variability in a large group of outpatients and correlated this with clinical and demographic features and with renal and patient survival. METHODS: All estimated GFRs were staged in the first observation period. CKD stages were then categorized as static, improving, worsening, or fluctuating. Logistic regression analysis was performed to identify clinical variables associated with CKD stage variability. Death and dialysis progression rates were then collected and analyzed using Cox proportional regression. RESULTS: During a 1.1-year observation period, 1,262 patients (mean age 71.25 years) had a mean 5 eGFR's. CKD stages were static in 60.4%, worsened in 14.4%, improved in 7.4%, and fluctuated in 17.2% of patients. Secondary analysis revealed heavy proteinuria and East Asian ethnicity to be negatively, and diabetes mellitus and previous acute kidney injury to be positively associated with improving CKD stages. Cox proportional regression of 902 patients analyzed 2.3 years later revealed a negative association with improving CKD stage and subsequent need for dialysis. CONCLUSIONS: CKD stage changed in 40% of 1,262 elderly patients when determined 5 times in just over 1 year. Improving CKD stage was the only variability pattern significantly associated with any of the clinical outcomes when assessed 2.3 years later, being unlikely to be linked with subsequent need for dialysis.

Use of PTFE stent grafts for hemodialysis-related central venous occlusions: intermediate-term results.

PURPOSE: To assess the safety and effectiveness of a polytetrafluoroethylene (PTFE) encapsulated nitinol stents (Bard Peripheral Vascular, Tempe, AZ) for treatment of hemodialysis-related central venous occlusions. MATERIALS AND METHODS: Study design was a single-center nonrandomized retrospective cohort of patients from May 2004 to August 2009 for a total of 64 months. There were 14 patients (mean age 60 years, range 50-83 years; 13 male, 1 female). All patients had autogenous fistulas. All 14 patients had central venous occlusions and presented with clinical symptoms of the following: extremity swelling (14%, 2 of 14), extremity and face swelling (72%, 10 of 14), and face swelling/edema (14%, 2 of 14). There was evidence of access dysfunction with decreased access flow in 36% (5 of 14) patients. There were prior interventions or previous line placement at the site of the central venous lesion in all 14 patients. Results were assessed by recurrence of clinical symptoms and function of the access circuit (National Kidney Foundation recommended criteria). RESULTS: Sixteen consecutive straight stent grafts were implanted in 14 patients. Average treated lesion length was 5.0 cm (range, 0.9-7 cm). All 14 patients had complete central venous occlusion (100% stenosis). The central venous occlusions were located as follows: right subclavian and brachiocephalic vein (21%, 3 of 14), right brachiocephalic vein (36%, 5 of 14), left brachiocephalic vein (36%, 5 of 14), and bilateral brachiocephalic vein (7%, 1 of 14). A total of 16 PTFE stent grafts were placed. Ten- or 12-mm-diameter PTFE stent grafts were placed. The average stent length was 6.1 cm (range, 4-8 cm). Technical (deployment), anatomic (<30% residual stenosis), clinical (resolution of symptoms), and hemodynamic (resolution of access dysfunction) success were 100%. At 3, 6, and 9 months, primary patency of the treated area and access circuit were 100% (14 of 14). CONCLUSIONS: This PTFE encapsulated stent graft demonstrates encouraging intermediate-term patency results for central vein occlusions. Further prospective studies with long-term assessment and larger patient populations will be required.

Ultrahigh-pressure angioplasty versus the Peripheral Cutting Balloon™ for treatment of stenoses in autogenous fistulas: comparison of immediate results.

PURPOSE: To compare the immediate results of ultrahigh-pressure (UHP) balloons vs. peripheral cutting balloons (PCB) for the treatment of stenoses associated with autogenous fistulas using intra-access blood flow measurements. MATERIALS AND METHODS: This prospective randomized study consisted of 22 hemodialysis (HD) patients with autogenous fistulas who had decreased intra-access blood flow (<500 mL/min). All patients underwent a fistulogram and intraprocedural blood flow measurements. Patients were randomized once into two groups; one group undergoing UHP angioplasty and the second group undergoing PCB angioplasty. Randomization occurred once after the diagnostic fistulogram and each patient in each arm only underwent percutaneous transluminal angioplasty with either UHP or PCB. The study cohort consisted of 12 patients in the UHP group and 10 patients in the PCB group. Data collected included fistula anatomy, degree of stenosis, length of stenosis, balloon specifications and residual stenosis. RESULTS: The 22 study patients underwent 35 angioplasty procedures; 23 in the UHP group (12 patients) and 12 in the PCB group (10 patients). The technical success rate was 91%. The pre-intervention mean blood flow was 288 mL/min in the UHP group and 391 mL/min in the PCB group. The post-intervention mean blood flow was 613 mL/min in the UHP group and 606 mL/min in the PCB group. The mean increase in blood flow was 325.8 mL/min in the UHP group and 213 mL/min in the PCB group. This represents a relative mean increase in blood flow of 253% in the UHP group and 85% in the PCB group. An unpaired t-test showed there was no significant difference between the groups with respect to pre-flow, post-flow, and mean and relative mean increase in flow. There were two failures; one in the UHP group and one in the PCB group. There was one minor complication (2.8%) but no major complications. CONCLUSIONS: In this small group of HD patients with autogenous fistulas our comparison of UHP to the PCB demonstrated that the immediate results, as determined by measurement of intra-access blood flow, were equivalent. Further long-term follow-up will be required to determine the longevity of these results.

Peritoneal dialysis in the nursing home.

UNLABELLED: The mean age of patients with end-stage renal disease increases steadily. The elderly on dialysis have significant comorbidity and require extra attention to meet their dialysis, dietary, and social needs, and some may need to be treated at a long-term care facility such as a nursing home (NH). Providing dialysis and caring for elderly patients in a nursing home (NH) presents a number of challenges. Few data are available in the literature about elderly patients on peritoneal dialysis (PD) in an NH. This paper describes our experience of starting and maintaining a peritoneal dialysis program in three community-based nursing homes. RESULTS: During the period 2004-2008, after the nursing home personnel had received appropriate training, we established a PD program in three community-based nursing homes and admitted 38 patients on peritoneal dialysis. We educated 112 NH staff over the three-year period. Mean age of the patients at entry was 77.3 + or - 8.5(18.4%) were male. The main causes of end-stage renal disease were diabetes mellitus (DM) 21 (55.8%) and hypertension 13 (34.2%). Comorbid conditions included DM (27, 71.1%), hypertension (26, 68.4%), coronary artery disease (18.5%), chronic heart failure (11, 28.9%), cerebrovascular event (12, 31.6%), and cancer(3, 7.9%). The average total time on chronic peritoneal dialysis was 36.5 + or - 29.8 months, (median 31, range: 1-110 months) of which the average time in the NH program, as of the time of this report, was 18.4 + or - 13.1 months (median 15.5, range: 1-45 months). During the study period, 16 (42.1%) of the patients died, 2 (5.3%) transferred to HD, 2 (5.3%) stopped treatment, and 18 (47.4%) are still in the program. Actuarial patient survival from entry into the NH program was 89.5% at six months, 60.5% at 12 months, 39.5% at 24 months and 13.2% at 36 months. Patient survival from initiation of chronic dialysis was 89.5% at six months, 76.3% at 12 months, 63.1% at 24 months, and 39.5% at 36 months. We observed 28 episodes of peritonitis with a rate of one episode every 40.3 treatment-months. Two PD catheters had to be replaced, giving a rate of one in every 362.5 patient months. CONCLUSION: Our results with elderly patients in a nursing home show an excellent patient and technique survival and a low peritonitis rate. With appropriate training of the NH nursing staff, peritoneal dialysis could be performed successfully in these nursing homes. Successful peritoneal dialysis in a nursing home requires a close collaboration between the nursing home staff and PD dialysis unit.

Improvement in eGFR in patients with chronic kidney disease attending a nephrology clinic.

BACKGROUND: The adverse effects arising from late referral to a nephrologist of patients with chronic kidney disease (CKD) are well known. Retrospectively we examined the initial characteristics of patients referred in various stages of CKD to our nephrology division and tried to identify potential baseline factors associated with subsequent changes in estimated glomerular filtration rate (eGFR). PATIENTS AND METHODS: Between September 1997 and June 2006 1,443 patients (909 male, 534 female) with CKD, with eGFRs ranging from 15 to 89 ml/min, were referred to our nephrology division and categorized using the National Kidney Foundation classification for CKD based on eGFR. The slope of eGFR change (ml/min-1/1.73/m2-1/year-1) was determined by linear regression analysis and the patients were divided into five groups: (1) significantly progressive slope (deterioration) (more negative than -5 ml/min/year); (2) mildly progressive slope (>-5 to -1 to +1 to or=+5). RESULTS: At the first nephrology referral, 5.8% of the patients were on CKD stage 2 (eGFR: 90-60 ml/m), 46.7% on CKD stage 3 (eGFR: 59-30 ml/m), and 47.5% on CKD stage 4 (eGFR: 29-15 ml/m) CKD. Significantly improved slope was detected in 48.2% of CKD stage 2 patients, 29.3% of CKD stage 3 patients, and only 14.7% of CKD stage 4 patients (P<0.05). Being in stage 4 or stage 3 versus being in stage 2 significantly reduced the likelihood of an improved slope in logistic regression analysis whereas age, gender, presence of hypertension, and diabetes mellitus did not reach the level of significance. CONCLUSION: Referral to a nephrology clinic can lead not only to arrest of progression of CKD but also to regression/improvement. Early referral is a positive predictive factor for improvement in eGFR, which emphasizes the importance of such referral. The previously held idea that, once established, CKD progresses invariably is not valid anymore.