Multidisciplinary CKD care enhances outcomes at dialysis initiation.

In 2003, the Nephrology Section at Dartmouth-Hitchcock Medical Center embraced a new concept for providing care that included a continuing care manager and a nephrologist working together with the patient to introduce stage-based education and clinical interventions. This study compares the outcomes of patients initiating hemodialysis or peritoneal dialysis who received CKD care using a multidisciplinary care model (n = 89) with those who received traditional nephrology care (n = 82). Overall, the findings in this study support the use of the multidisciplinary clinic as a method for improving care of the patient with CKD initiating dialysis, and reducing hospital admissions and costs. The care coordination provided in the multidisciplinary setting improved the number of fistulas placed (60.7% vs. 21%, p < 0.001), the number of fistulas used for dialysis initiation (40.4% vs. 12.3, p < 0.001), and the management of anemia with higher hemoglobin levels prior to dialysis initiation (10.9 g/dL vs. 10.0 g/dL, p = 0.003). Patients receiving multidisciplinary care were 42% less likely to be admitted to the hospital for dialysis initiation, had significantly fewer days hospitalized (p = 0.001), fewer admissions (p = 0.005), and reduced charges for a 90-day period (p = 0.003) after dialysis initiation.

Tunneled hemodialysis catheter outcomes in elderly patients.

PURPOSE: This retrospective study evaluated tunneled catheter outcomes in patients aged 75 years and older undergoing hemodialysis. MATERIALS AND METHODS: Patients aged 75 years or older receiving hemodialysis comprised the study group. A control group of patients 40-60 years of age was randomly selected from the same dialysis quality assurance database. Demographic data, medical comorbidities, and catheter-specific data regarding indwelling time, function, interventions, and complications were recorded. RESULTS: Sixty-nine tunneled catheters were identified in 23 patients who comprised the study group (13 men and 10 women; mean age, 81.3 years; range, 75-88 y). The mean number of catheters per patient was three (range, 1-8). The mean indwelling time was 137.4 days (range, 2-622 d). Seventy-eight catheters were identified in the control group (n = 29; 14 men and 15 women; mean age, 50.6 years; range, 41-59 y). The mean number of catheters per patient was 2.7 (range, 1-9). The mean indwelling time was 139.7 days (range, 1-994 d). There was no statistically significant difference in the mean number of catheters per patient (P = .83) or the mean indwelling time (P = .93) between the two groups. There was no significant difference between the two groups in the indications for catheter removal or exchange: infection (P = 1.0), catheter no longer needed (P = 1.0), and physical catheter malfunction (P = .48). The calculated infection rates in the elderly patient and younger control groups were 0.30 per 100 catheter-days and 0.26 per 100 catheter-days, respectively. CONCLUSIONS: Tunneled catheter outcomes in patients aged 75 years and older undergoing hemodialysis do not vary significantly compared with those in a younger cohort.

Mucormycosis peritonitis: more than 2 years of disease-free follow-up after posaconazole salvage therapy after failure of liposomal amphotericin B.

A 57-year-old woman with end-stage kidney disease secondary to autosomal dominant polycystic kidney disease developed peritoneal dialysis-related Mucor peritonitis after her pet cockatoo bit through her transfer set. The infection persisted despite more than 8 weeks of treatment with liposomal amphotericin B. On a compassionate basis, she then received oral posaconazole, 800 mg/d, in divided doses for 6 months. She experienced complete remission and has remained disease free since then, for more than 2 years. We review the medical literature about mucormycosis peritonitis which, albeit rare, carries very high mortality. The treatment of choice is liposomal amphotericin B, which failed in our patient. Our case report suggests that posaconazole is an attractive treatment option in patients with peritoneal dialysis-related Mucor peritonitis.

Clinical epidemiology of long-bone fractures in patients receiving hemodialysis.

Although prevention of metabolic bone disease is a principal component of management of end-stage renal disease, the clinical epidemiology of long-bone fractures is not completely understood. Hospital discharge claims from 1994 through 1999 for 7159 subjects in the Dialysis Morbidity and Mortality Study were used to quantify incidence and risk factors of long-bone fractures and to test the hypothesis that long-bone fractures are associated with cardiovascular and infectious events and death in patients receiving hemodialysis. The incidence of long-bone fractures was 16.93 per 1000 patient-years, with the femoral neck being the most common site (59.8%); multivariate analysis revealed greater risk with older age, female gender, diabetes, more years receiving dialysis, and cardiovascular disease, and lower risk with African American race, increasing body mass index, parathyroid hormone values in the fourth quintile (227.1-538.0 pg/mL), and renal transplantation during followup. Postfracture mortality rates were 522.57 per 1000 patient years (versus 215.35 in the overall population). Time-dependent analysis suggested the adverse prognosis of long-bone fractures was related to subsequent congestive heart failure, stroke, pulmonary embolism, pneumonia, and septicemia. Long-bone fractures are common in patients receiving dialysis; their adverse prognostic implications may be linked to major cardiovascular and infectious events.

Acid-base disturbances in the intensive care unit: metabolic acidosis.

This article will discuss metabolic acidosis and, to a lesser extent, metabolic alkalosis in the ICU setting. A classification and clinical approach will be the focus.