Bendamustine-induced nephrogenic diabetes insipidus - A case report.

INTRODUCTION: In patients with relapsed or refractory lymphoma, high-dose chemoimmunotherapy with subsequent autologous hematopoietic cell transplantation (HCT) is a standard of care. Bendamustine, an alkylating agent, is used in the BeEAM (bendamustine, etoposide, cytarabine, melphalan) protocol for conditioning therapy before autologous HCT in patients with relapsed or refractory lymphoma who are eligible for transplant. There is no consensus regarding an optimal salvage regimen and the approach varies according to toxicity. CASE REPORT: We present a case of partial nephrogenic diabetes insipidus after receiving bendamustine, as part of the BeEAM protocol.Management and outcome: The patient was managed with parenteral fluid administration and intranasal desmopressin before the condition resolved on its own. DISCUSSION: We summarize published reports of bendamustine-induced diabetes insipidus.

Clinical Use of Complement, Inflammation, and Fibrosis Biomarkers in Autoimmune Glomerulonephritis.

INTRODUCTION: Complement activation, inflammation, and fibrosis play central roles in the mechanisms of injury in autoimmune glomerulonephritis (GN) but they are seldom assessed in epidemiologic studies. The measurement of urinary biomarkers of these pathways of injury could parallel disease activity and add clinical value beyond proteinuria. METHODS: We performed a prospective cohort study of 100 patients with focal and segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), IgA nephropathy (IgAN), lupus nephritis (LN), anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV), and membranoproliferative GN (MPGN) followed for 33 (18-54) months. Repeated urinary samples were collected throughout their follow-up to determine proteinuria, urinary sC5b-9, monocyte chemoattractant protein-1 (MCP-1), and transforming growth factor-beta 1 (TGF-ß1), expressed as creatinine ratios. We identified 177 periods of active and inactive disease based on current remission definitions for each disease. RESULTS: Urinary sC5b-9, MCP-1, and TGF-ß1 were present in each disease. In periods leading to a remission, the reduction of urinary sC5b-9 was 91%, greater than for proteinuria with 76%. During inactive periods, those who did not experience a relapse maintained lower levels of biomarkers compared with those who relapsed. At that time, the increase in urinary sC5b-9 was significantly greater than the rise in proteinuria (8.5-fold increase compared with 3.2-fold) and urinary MCP-1 and TGF-ß1. Using current remission definitions for each disease, thresholds for each biomarker were determined using receiver operating characteristic curves. Individuals who averaged levels below these cutoffs during their follow-up had better renal outcomes. CONCLUSION: In autoimmune glomerular diseases, urinary sC5b-9, MCP-1, and TGF-ß1 are present and parallel disease activity and outcomes. Urinary sC5b-9 appears to be a more discerning marker of immunologic remissions and relapses.

Patient selection and training for home hemodialysis.

Patient selection and training is arguably the most important step toward building a successful home hemodialysis (HD) program. We present a step-by-step account of home HD training to guide providers who are developing home HD programs. Although home HD training is an important step in allowing patients to undergo dialysis in the home, there is a surprising lack of systematic research in this field. Innovations and research in this area will be pivotal in further promoting a higher acceptance rate of home HD as the renal replacement therapy of choice.

Albumin administration is associated with acute kidney injury in cardiac surgery: a propensity score analysis.

INTRODUCTION: The risk of acute kidney injury (AKI) with the use of albumin-containing fluids compared to starches in the surgical intensive care setting remains uncertain. We evaluated the adjusted risk of AKI associated with colloids following cardiac surgery. METHODS: We performed a retrospective cohort study of patients undergoing on-pump cardiac surgery in a tertiary care center from 2008 to 2010. We assessed crystalloid and colloid administration until 36 hours after surgery. AKI was defined by the RIFLE (risk, injury, failure, loss and end-stage kidney disease) risk and Acute Kidney Injury Network (AKIN) stage 1 serum creatinine criterion within 96 hours after surgery. RESULTS: Our cohort included 984 patients with a baseline glomerular filtration rate of 72 ± 19 ml/min/1.73 m(2). Twenty-three percent had a reduced left ventricular ejection fraction (LVEF), thirty-one percent were diabetics and twenty-three percent underwent heart valve surgery. The incidence of AKI was 5.3% based on RIFLE risk and 12.0% based on the AKIN criterion. AKI was associated with a reduced LVEF, diuretic use, anemia, heart valve surgery, duration of extracorporeal circulation, hemodynamic instability and the use of albumin, pentastarch 10% and transfusions. There was an important dose-dependent AKI risk associated with the administration of albumin, which also paralleled a higher prevalence of concomitant risk factors for AKI. To address any indication bias, we derived a propensity score predicting the likelihood to receive albumin and matched 141 cases to 141 controls with a similar risk profile. In this analysis, albumin was associated with an increased AKI risk (RIFLE risk: 12% versus 5%, P = 0.03; AKIN stage 1: 28% versus 13%, P = 0.002). We repeated this methodology in patients without postoperative hemodynamic instability and still identified an association between the use of albumin and AKI. CONCLUSIONS: Albumin administration was associated with a dose-dependent risk of AKI and remained significant using a propensity score methodology. Future studies should address the safety of albumin-containing fluids on kidney function in patients undergoing cardiac surgery.

The Canadian Society of Nephrology methods in developing and adapting clinical practice guidelines: a review.

INTRODUCTION: The Canadian Society of Nephrology (CSN) was established to promote the highest quality of care for patients with renal diseases and to encourage research related to the kidney and its disorders. The CSN Clinical Practice Guideline (CPG) Committee develops guidelines with clear recommendations to influence physicians' practice and improve the health of patients with kidney disease in Canada. REVIEW: In this review we describe the CSN process in prioritizing CPGs topics. We document the CSN experience using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We then detail the CSN process in developing de novo CPGs and in adapting existing CPGs and developing accompanying commentaries. We also discuss challenges faced during this process and suggest solutions. Furthermore, we summarize the CSN effort in disseminating and implementing their guidelines. Additionally, we describe recent development and partnerships that allow evaluation of the effect of the CSN guidelines and commentaries. CONCLUSION: The CSN follows a comprehensive process in identifying priority areas to be addressed in CPGs. In 2010, the CSN adopted GRADE, which enhanced the rigor and transparency of guideline development. This process focuses on systematically identifying best available evidence and carefully assessing its quality, balancing benefits and harms, considering patients' and societies' values and preferences, and when possible considering resource implications. Recent partnership allows wider dissemination and implementation among end users and evaluation of the effects of CPG and commentaries on the health of Canadians.

INTRODUCTION: La mission de la Société canadienne de néphrologie (SCN) est de promouvoir des soins de grande qualité aux patients atteints de maladies rénales et d'encourager la recherche en néphrologie. Le comité des guides de pratique clinique (GPC) de la SCN a pour objectif le développement de lignes directrices comportant des recommandations claires de façon à influencer la pratique médicale et d'améliorer le bien-être des patients atteints de maladies rénales au Canada. REVUE: Dans cette publication, nous décrivons l'approche utilisée par la SCN dans la priorisation des différents sujets abordés dans les GPC. Nous abordons l'expérience de la SCN avec l'utilisation de l'approche GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Nous détaillons également le processus utilisé par la SCN dans le développement de nouveaux GPC et dans la modification des GPC existants. Nous discutons des difficultés rencontrées lors de ce processus tout en suggérant des solutions. Nous résumons les efforts encourus par la SCN pour la diffusion et l'application des lignes directrices. Finalement, nous décrivons les récentes collaborations de la SCN permettant l'évaluation de l'impact des lignes directrices de la SCN. CONCLUSION: La SCN suit un processus rigoureux dans l'identification des priorités à aborder dans les GPC. Depuis 2010, la SCN a décidé d'adopter l'approche GRADE pour faire preuve de plus de rigueur et de transparence dans l'élaboration de lignes directrices. Cette approche consiste à identifier toutes les évidences en étudiant leur qualité, en mesurant les risques et les bénéfices, en considérant les valeurs et les préférences pour les patients ainsi que la société et en tenant compte des ressources disponibles. Le partenariat permet une plus grande diffusion des guides de pratique et une évaluation des effets des GPC sur la santé des canadiens.

Programmatic variation in home hemodialysis in Canada: results from a nationwide survey of practice patterns.

BACKGROUND: Over 40% of patients with end stage renal disease in the United States were treated with home hemodialysis (HHD) in the early 1970's. However, this number declined rapidly over the ensuing decades so that the overwhelming majority of patients were treated in-centre 3 times per week on a 3-4 hour schedule. Poor outcomes for patients treated in this fashion led to a renewed interest in home hemodialysis, with more intensive dialysis schedules including short daily (SDHD) and nocturnal (NHD). The relative infancy of these treatment schedules means that there is a paucity of data on 'how to do it'. OBJECTIVE: We undertook a systematic survey of home hemodialysis programs in Canada to describe current practice patterns. DESIGN: Development and deployment of a qualitative survey instrument. SETTING: Community and academic HHD programs in Canada. PARTICIPANTS: Physicians, nurses and technologists. MEASUREMENTS: Programmatic approaches to patient selection, delivery of dialysis, human resources available, and follow up. METHODS: We developed the survey instrument in three phases. A focus group of Canadian nephrologists with expertise in NHD or SDHD discussed the scope the study and wrote questions on 11 domains. Three nephrologists familiar with all aspects of HHD delivery reviewed this for content validity, followed by further feedback from the whole group. Multidisciplinary teams at three sites pretested the survey and further suggestions were incorporated. In July 2010 we distributed the survey electronically to all renal programs known to offer HHD according to the Canadian Organ Replacement Registry. We compiled the survey results using qualitative and quantitative methods, as appropriate. RESULTS: Of the academic and community programs that were invited to participate, 80% and 63%, respectively, completed the survey. We observed wide variation in programmatic approaches to patient recruitment, human resources, equipment, water, vascular access, patient training, dialysis prescription, home requirements, patient follow up, medications, and the approach to non-adherent patients. LIMITATIONS: Cross-sectional survey, unable to link variation to outcomes. Competition for patients between HHD and home peritoneal dialysis means that case mix for HHD may also vary between centres. CONCLUSIONS: There is wide variation between programs in all domains of HHD delivery in Canada. We plan further study of the extent to which differences in approach are related to outcomes.

PROBLÉMATIQUE: Au début des années 70, plus de 40% des patients en insuffisance rénale terminale aux États-Unis étaient traités par hémodialyse à domicile (HDD). Cette proportion a décliné rapidement au cours des décennies suivantes, de sorte que le mode de suppléance pour la majorité des patients est maintenant l'hémodialyse 3 fois par semaine à raison de 3 à 4 heures par séance. Les mauvais résultats obtenus avec cette méthode ont renouvelé l'intérêt pour l'HDD, notamment pour les dialyses intensives incluant la dialyse quotidienne courte (DQC) et l'hémodialyse nocturne (HDN). Étant donné leur nouveauté, il y a peu de données sur les façons de faire avec ces modes de suppléance. OBJECTIF: Afin de décrire les pratiques actuelles, nous avons réalisé un questionnaire systématique auprès des programmes d'HDD au Canada. DESIGN: Développement et déploiement d'un outil qualitatif. CADRE: Programmes d'HDD académiques et communautaires au Canada. PARTICIPANTS: Médecins, infirmières et technologues. VARIABLES MESURÉES: Approches pour la sélection des patients, le mode de suppléance, les ressources humaines disponibles et le mode de suivi pour chaque programme. MÉTHODOLOGIE: Nous avons développé un outil en trois phases. Un groupe de discussion composé de néphrologues canadiens ayant une expertise en DQC ou HDN ont échangé sur le contenu de l'étude et ont rédigé des questions sur 11 domaines. Trois néphrologues familiers avec tous les aspects de l'HDD ont révisé la validité des questions, puis ont demandé un nouvel avis à tout le groupe de discussion. Des équipes multidisciplinaires provenant de trois sites ont ensuite évalué le questionnaire et ont apporté des suggestions. En juillet 2010, le questionnaire a été distribué électroniquement à tous les programmes qui offrent l'HDD d'après le Registre canadien des insuffisances et des transplantations d'organes. Les résultats ont été compilés au moyen de méthodes qualitatives ou quantitatives, le cas échéant. RÉSULTATS: 80% des centres académiques et 63% des centres communautaires invités ont répondu au questionnaire. Nous avons observé des variations importantes entre les programmes quant au recrutement des patients, aux ressources humaines, à l'équipement, à l'eau, aux accès vasculaires, à l'entraînement des patients, à la prescription de dialyse, aux exigences du domicile, au suivi des patients, à la médication et à l'approche face aux patients non-adhérents. LIMITATIONS: Étude transversale, incapacité d'associer les variations aux issues cliniques. La compétition entre l'HDD et la dialyse péritonéale pour le recrutement des patients entraîne peut-être une variabilité entre les centres dans la composition des groupes de patients en HDD. CONCLUSIONS: Il y a de grandes variations entre les programmes dans tous les domaines concernant l'HDD au Canada. Nous planifions d'étudier dans le futur jusqu'à quel point ces différences sont reliées aux issues cliniques.

Vascular access for intensive maintenance hemodialysis: a systematic review for a Canadian Society of Nephrology clinical practice guideline.

BACKGROUND: Practices in vascular access management with intensive hemodialysis may differ from those used in conventional hemodialysis. STUDY DESIGN: We conducted a systematic review to inform clinical practice guidelines for the provision of intensive hemodialysis. SETTING & POPULATION: Adult patients receiving maintenance (>3 months) intensive hemodialysis (frequent [≥5 hemodialysis treatments per week] and/or long [>5.5 hours per hemodialysis treatment]). SELECTION CRITERIA FOR STUDIES: We searched EMBASE and MEDLINE (1990-2011) for randomized and observational studies. We also searched conference proceedings (2007-2011). INTERVENTIONS: (1) Central venous catheter (CVC) versus arteriovenous (AV) access, (2) buttonhole versus rope-ladder cannulation, (3) topical antimicrobial cream versus none in buttonhole cannulation, and (4) closed connector devices among CVC users. OUTCOMES: Access-related infection, survival, hospitalization, patency, access survival, intervention rates, and quality of life. RESULTS: We included 23, 7, and 5 reports describing effectiveness by access type, buttonhole cannulation, and closed connector device, respectively. No study directly compared CVC with AV access. On average, bacteremia and local infection rates were higher with CVC compared with AV access. Access intervention rates were higher with more frequent hemodialysis, but access survival did not differ. Buttonhole cannulation was associated with bacteremia rates similar to those seen with CVCs in some series. Topical mupirocin seemed to attenuate this effect. No direct comparisons of closed connector devices versus standard luer-locking devices were found. Low rates of actual or averted (near misses) air embolism and bleeding were reported with closed connector devices. LIMITATIONS: Overall, evidence quality was very low. Limited direct comparisons addressing main review questions, small sample sizes, selective outcome reporting, publication bias, and residual confounding were major factors. CONCLUSIONS: This review highlights several differences in the management of vascular access in conventional and intensive hemodialysis populations. We identify a need for standardization of vascular access outcome reporting and a number of priorities for future research.

Canadian Society of Nephrology guidelines for the management of patients with ESRD treated with intensive hemodialysis.

Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research.

Dialysate calcium concentration and mineral metabolism in long and long-frequent hemodialysis: a systematic review and meta-analysis for a Canadian Society of Nephrology clinical practice guideline.

BACKGROUND: Patients treated with conventional hemodialysis (HD) develop disorders of mineral metabolism that are associated with increased morbidity and mortality. More frequent and longer HD has been associated with improvement in hyperphosphatemia that may improve outcomes. STUDY DESIGN: Systematic review and meta-analysis to inform the clinical practice guideline on intensive dialysis for the Canadian Society of Nephrology. SETTING & POPULATION: Adult patients receiving outpatient long (≥5.5 hours/session; 3-4 times per week) or long-frequent (≥5.5 hours/session, ≥5 sessions per week) HD. SELECTION CRITERIA FOR STUDIES: We included clinical trials, cohort studies, case series, case reports, and systematic reviews. INTERVENTIONS: Dialysate calcium concentration ≥1.5 mmol/L and/or phosphate additive. OUTCOMES: Fragility fracture, peripheral arterial and coronary artery disease, calcific uremic arteriolopathy, mortality, intradialytic hypotension, parathyroidectomy, extraosseous calcification, markers of mineral metabolism, diet liberalization, phosphate-binder use, and muscle mass. RESULTS: 21 studies were identified: 2 randomized controlled trials, 2 reanalyses of data from the randomized controlled trials, and 17 observational studies. Dialysate calcium concentration ≥1.5 mmol/L for patients treated with long and long-frequent HD prevents an increase in parathyroid hormone levels and a decline in bone mineral density without causing harm. Both long and long-frequent HD were associated with a reduction in serum phosphate level of 0.42-0.45 mmol/L and a reduction in phosphate-binder use. There was no direct evidence to support the use of a dialysate phosphate additive. LIMITATIONS: Almost all the available information is related to changes in laboratory values and surrogate outcomes. CONCLUSIONS: Dialysate calcium concentration ≥1.5 mmol/L for most patients treated with long and long-frequent dialysis prevents an increase in parathyroid hormone levels and decline in bone mineral density without increased risk of calcification. It seems prudent to add phosphate to the dialysate for patients with a low predialysis phosphate level or very low postdialysis phosphate level until more evidence becomes available.

Caregiver burden among nocturnal home hemodialysis patients.

Recent studies have suggested improvements in quality of life (QOL) in patients on quotidian dialysis compared with conventional hemodialysis. Few studies have focused on the burden and QOL in caregivers of patients with end-stage renal disease (ESRD) on nocturnal home hemodialysis (NHD). We aim to assess the caregivers' burden, QOL, and depressive symptoms and to compare these parameters with their patients' counterparts. Cross-sectional surveys were sent to 61 prevalent NHD patients and their caregivers. Surveys assessed demographics, general self-perceived health using the 12-Item Short Form Health Survey (SF-12) and the presence of depression using the Beck Depression Inventory. Subjective burden on caregivers was assessed by the Caregiver Burden scale and was compared with perceived burden by the patients. Thirty-six patients and 31 caregivers completed the survey. The majority of caregivers were female (66%), spouse (81%) with no comorbid illness (72%). Their mean age was 51 ± 11 years. Patients were mostly male (64%) with a median ESRD vintage of 60 months (interquartile range [IQR], 18-136 months) and a mean age of 52 ± 10 years. Compared to caregivers, patients had lower perceived physical health score but had similar mental health score. Depression criteria were present in 47% of patients and 25% of caregivers. Total global burden perceived by either caregivers or patients is relatively low. Although there is a relatively low global burden perceived by caregivers and patients undergoing NHD, a significant proportion of both groups fulfilled criteria for depression. Further innovative approaches are needed to support caregivers and patients performing NHD to reduce the intrusion of caring for a chronic illness and the risk of developing depression.

Gene polymorphisms as clinical tools in chronic glomerulopathies: a prospective study.

BACKGROUND/AIMS: Studies have proposed various polymorphisms of genes implicated in the physiopathology of chronic kidney disease as risk factors of progression and potential clinical tools. We sought to validate and simultaneously compare their predictive value in a prospective cohort of chronic glomerulopathies receiving recommended antihypertensive and antiproteinuric therapies. METHODS: Using PubMed, we identified 9 polymorphisms previously associated with progression. These were mostly of the renin-angiotensin-aldosterone and inflammation pathways: MCP-1 A2518G, TGF-ß1 T869C and C-509T, ACE I/D, AGT M235T, AT1R A1166C, TSC-22 A-396G, eNOS 4b/a and CYP11ß2 C-344T. We hypothesized that their determination would identify individuals at higher risk of progression. RESULTS: We recruited 93 predominantly male and Caucasian patients with a mean age of 63 and baseline eGFR of 33 ml/min/1.73 m(2) followed prospectively over a median of 36 months. 61% of patients had diabetic nephropathy, almost all received RAA blockade (90%) and none immunosuppressive therapy. The average blood pressure during follow-up was 140/72 mm Hg, the urinary protein to creatinine ratio 0.15 g/mmol and the rate of renal function decline -3.2 ± 4.1 ml/min/1.73 m(2)/year. Proteinuria and blood pressure strongly predicted progression. However, under recommended therapy, none of the proposed polymorphisms predicted renal function decline. In addition, none showed simple or partial correlations with the severity of proteinuria or blood pressure. Finally, summation variable of risk polymorphisms did not predict progression. CONCLUSION: This study does not validate the use of these 9 polymorphisms as individual clinical tools in patients with chronic glomerulopathies on recommended antihypertensive and antiproteinuric therapies.

Effect of an in-hospital chronic kidney disease education program among patients with unplanned urgent-start dialysis.

BACKGROUND AND OBJECTIVES: The effect of in-hospital education on the adoption of home dialysis (peritoneal dialysis [PD] and home hemodialysis [HHD]) after an unplanned dialysis start is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Clinical demographics of consecutive patients acutely initiating hemodialysis (HD) from January 2005 to December 2009 were abstracted using institutional electronic records. All patients received multimedia chronic kidney disease education by the same advanced care nurse practitioner before discharge from the hospital. Clinical characteristics of patients choosing home dialysis or staying on in-center HD were compared. RESULTS: Between 2005 and 2009, 228 patients acutely started renal replacement therapy (RRT) at the center. Seventy-one patients chose home dialysis (49 patients adopted PD and 22 adopted HHD), 132 chose to remain on in-center HD, and 25 died before discharge from the hospital. Patients adopting home dialysis tended to be younger than in-center HD patients (55 ± 18 [home dialysis] versus 59 ± 16 [in center] years; P=0.09) and were similar in gender distribution (49% [home dialysis] versus 56% [in center] male; P=0.2). Patients adopting home dialysis were more likely to have a failed kidney transplant (24% [home dialysis] versus 12% [in center]; P=0.045) and less likely to have ischemic nephropathy (9% [home dialysis] versus 21% [in center]; P=0.03). The distribution of comorbid conditions was different between patients adopting home dialysis and in-center HD. CONCLUSIONS: Home dialysis is feasible after urgent dialysis start. Education should be promoted among patient experiencing acute-start dialysis.

Home dialysis is a successful strategy in nonrenal solid organ transplant recipients with end-stage renal disease.

BACKGROUND: Chronic kidney disease (CKD) is a common complication of solid organ transplantation with a substantial risk of progression to end-stage renal disease (ESRD). The impact of dialysis modality on morbidity and mortality is unknown in these patients. The aim of the present analysis was to describe our experience with home dialysis [peritoneal dialysis (PD) and home haemodialysis (HHD)] to assess the feasibility of this modality in patients who developed ESRD after nonrenal solid organ transplant (NRSOT). METHODS: A retrospective observational cohort study with consecutive patients initiated on home dialysis after NRSOT from 2000 to 2009 was conducted. We collected data on patient demographics, laboratory parameters and blood pressure as well as clinical adverse events using our electronic clinical database. RESULTS: Between 2000 and 2009, 25 patients [median age, 56 years; interquartile range (IQR), 43-65 years] initiated home dialysis. Ten patients started HHD and 15 patients initiated PD. The types of NRSOT were liver (n = 11), heart (n = 8), lung (n = 5) and heart-lung (n = 1). The median vintage of NRSOT at the time of dialysis initiation was 8.7 years (IQR, 6.3-11.4 years). The median home dialysis follow-up was 24 months (IQR, 15-53 months). The median values of blood pressure, phosphate, calcium, parathyroid hormone and haemoglobin were within the K/DOQI targets. The hospitalization and infection rates were 1 episode every 22 and 29 patient-months, respectively. Three patients switched to in-centre conventional HD during follow-up and eight patients died. CONCLUSIONS: . Home dialysis (PD and HHD) is a feasible and sustainable modality for patients with ESRD after NRSOT. Home dialysis offers several potential benefits, such as improved haemodynamic and metabolic control, which may be important in the NRSOT population. Home dialysis in patients who develop ESRD after NRSOT should be actively considered for this cohort.

Systematic differences among patients initiated on home haemodialysis and peritoneal dialysis: the fallacy of potential competition.

BACKGROUND: The adoption of home-based dialysis therapies is growing internationally. There is a possibility that competition for patients may exist between peritoneal dialysis (PD) and home haemodialysis (HHD) for their respective growth. METHODS: Clinical demographics of patients initiating PD and HHD from 2004 to 2008 in our centre were abstracted using institutional electronic records. We compared clinical demographics, laboratory data and process of care to describe potential factors leading to patients choosing home-based dialysis therapies. RESULTS: Between 2004 and 2008, 236 patients initiated home dialysis therapy in our centre: 153 patients to PD and 83 patients to HHD. PD and HHD patients differed in age (PD 62 +/- 16 vs HHD 46 +/- 13 years; P < 0.001) and gender distribution (PD 57 vs HHD 70% male; P = 0.05). A higher proportion of PD patients had diabetes and hypertension as the primary cause of their end-stage renal disease (ESRD). In contrast, there were more patients with glomerulonephritis among the HHD cohort. Cardiovascular and peripheral vascular diseases were more common among patients on PD. HHD patients had longer ESRD vintage (PD 0.34 +/- 0.69 and HHD 4.8 +/- 6.8 years on therapy; P = 0.002). The proportion of patients receiving chronic kidney disease care was higher among PD starters (PD 86 vs HHD 65%; P < 0.001). Sixteen percent of PD patients and 9% of HHD patients initiated their home-based renal replacement therapy after an acute hospitalization without prior modality education. CONCLUSION: There is a systematic difference between patients initiated on PD and HHD. Our data reaffirm that modality selection is a complex process. Patients on the two home therapies differ demographically and arrive through different routes. This finding suggests that the two home-based modalities are not in competition.

Measurement of the international normalized ratio (INR) in hemodialysis patients with heparin-locked central venous catheters: evaluation of a novel blood sampling method.

BACKGROUND: Accurate measurement of the international normalized ratio (INR) may be difficult in hemodialysis (HD) patients with heparin-locked central catheters. Blood contamination with locking solutions may interfere with INR measurement when samples are collected directly from the catheter. METHODS: The aim of our study was to evaluate a novel sampling method for the measurement of INR in HD patients with heparin-locked central catheters. This novel method consists of measuring the INR directly from the dialysis circuit (arterial bloodline sample port) after 1 hr of treatment regardless of heparin administration during dialysis. We compared this method to the gold standard (peripheral venipuncture prior to dialysis) using the paired t-test. We included 30 patients (23 with warfarin therapy and 7 without). RESULTS: INRs obtained using the novel sampling method were only minimally overestimated compared to venipuncture values (mean INR overestimation: 0.2 +/- 0.2). This overestimation was not clinically significant and did not lead to changes in warfarin prescription for any of the patients. Correlation tests confirmed the influence of heparin administration on INR overestimation (R=0.4; p=0.05). This influence was present mostly among patients receiving more than 100 Units/kg of heparin during their treatment. CONCLUSION: This novel sampling technique provides a convenient and simple method of monitoring INR among HD patients.

FSGS permeability factor-associated nephrotic syndrome: remission after oral galactose therapy.

Some cases of nephrotic syndrome in focal and segmental glomerulosclerosis (FSGS) are associated with a circulating factor, the FSGS permeability factor (FSPF). Galactose has a high affinity for FSPF, and experimental data suggest that it could reduce its activity. We describe the case of a 48-year-old male with a nephrotic syndrome found to be resistant to corticosteroids, immunosuppression and plasmaphaeresis. The patient was given oral galactose as a last resort treatment, which was followed by a remission of his nephrotic syndrome that correlated with a reduction of FSPF activity. This case is the first report of a long-standing remission of an FSPF-associated nephrotic syndrome on oral galactose therapy.

Pentastarch 10% (250 kDa/0.45) is an independent risk factor of acute kidney injury following cardiac surgery.

UNLABELLED: OBJECTIVE, DESIGN AND PATIENTS: The risk of acute kidney injury (AKI) associated with hydroxyethyl starch may be limited to higher molecular weight agents. We retrospectively evaluated the risk of AKI using pentastarch 10% (250 kDa, 0.45) in a random cohort of 563 patients operated for a cardiac surgery at a university hospital. MEASURES: We assessed previously identified preoperative, perioperative, and postoperative risk factors, and the volume of pentastarch given until the end of the first postoperative day. We defined AKI by a 50% rise in serum creatinine within 4 days after surgery. Different propensity adjustment methods were used to further assess the selection bias. RESULTS: Fifty-four (10%) patients developed AKI. Risk factors of AKI were age, female gender, preoperative creatinine clearance, hypertension, diuretic use, left ventricular ejection fraction, valvular surgery, duration of extracorporeal circulation, duration and dose of postoperative vasopressor support, and the number of red blood cells and fresh frozen plasma transfusions. Patients with AKI received 16 +/- 9 mL/kg of pentastarch as opposed to 10 +/- 7 mL/kg in controls (p < 0.001). Pentastarch remained independently predictive of AKI, with an adjusted odds ratio per mL/kg of 1.08 (95% confidence interval 1.04-1.12, p = 0.001). This risk was dose-dependent, and the optimal cutoff volume predicting AKI was 14 mL/kg. Different propensity adjustment methods were tested, and pentastarch as a risk factor of AKI was identified. CONCLUSIONS: This study identified a dose-dependent risk of AKI with pentastarch following cardiac surgery, given until the end of the first postoperative day.