An Improvised Cost-Effective Repair Technique for Management of Broken Luer Connections of Tunneled Dialysis Catheter and Salvage Existing Catheter.

Mechanical problems like break or crack in Luer connectors or hubs, clamps, and tubings are common non-infectious complications of tunneled dialysis catheters (TDC), which may lead to other TDC complications and the need to insert a new catheter. These can be tackled using TDC repair kits or spare parts, which are often not available, resulting in the insertion of a new TDC that increases morbidity, TDC-related procedures, and healthcare costs. We discuss two cases of broken Luer connections of TDC, which were managed by exchanging the broken Luer connector of TDC with the similar Luer connector of a temporary dialysis catheter. Both the repaired TDCs are thereafter functioning well. This improvised technique provides an easy, effective, long-lasting option that salvages the existing TDC and reduces the cost factor.

Association of Medicaid Expansion with Tunneled Dialysis Catheter Use at the Time of First Arteriovenous Access Creation.

BACKGROUND: In the United States, many low-income patients initiating hemodialysis are uninsured before qualifying for Medicare. Inadequate access to predialysis care may delay their arteriovenous (AV) access creation and increase tunneled dialysis catheter (TDC) use. The 2014 Affordable Care Act expanded eligibility for Medicaid among low-income adults, but not every state adopted this measure. We evaluated whether Medicaid expansion was associated with decreased TDC use for hemodialysis initiation. METHODS: We queried the United States Vascular Quality Initiative state-level database for non-Medicare patients undergoing initial AV access creation from 2011 to 2018. We evaluated associations of receiving initial AV access in states that expanded Medicaid with concurrent TDC use, survival, and insurance coverage. RESULTS: Data were available for patients in 31 states: 19 states expanded Medicaid from January 2014 to February 2015. Among 8462 patients in the postexpansion period from March 2015 to December 2018, 58% were in Medicaid expansion states. Patients in Medicaid expansion states less often had concurrent TDCs (40% vs. 48%, P < 0.001). In multivariable analysis, Medicaid expansion was independently associated with fewer TDCs (OR 0.7, 95% CI 0.6-0.8, P < 0.001). Three-year survival was similar between patients in Medicaid expansion and nonexpansion states (84.7% vs. 85.2%, P = 0.053). Multivariable cox-regression confirmed the finding (HR 0.95, 95% CI 0.82-1.1, P = 0.482). In difference-in-differences analysis, Medicaid expansion was associated with a 9.2-percentage point increase in Medicaid coverage (95% CI 2.7-15.8, P = 0.009). Hispanic patients exhibited a 30.1-percentage point increase in any insurance coverage (95% CI 0.3-59.9, P = 0.048). CONCLUSIONS: Patients in Medicaid expansion states were less likely to have TDCs during initial AV access creation, suggesting earlier predialysis care. Hispanic patients benefited from increased insurance coverage. Expanding insurance options for the underserved may improve quality metrics and cost-savings for hemodialysis patients.

Changes in hemodialysis catheter management after introduction of the end-stage renal disease prospective payment system.

BACKGROUND: We investigated whether implementation of the end-stage renal disease prospective payment system (ESRD PPS) was associated with changes in thrombolytic therapy use and other aspects of catheter management in hemodialysis (HD) patients. METHODS: Using quarterly, period prevalent cohorts of patients undergoing maintenance HD with a catheter in the US Renal Data System (2008-2015), we studied rates of claims for within- and outside-HD-unit thrombolytic use, and thrombus/fibrin sheath removal, and rates of delayed HD treatment after ESRD PPS implementation, January 1, 2011. Associations between PPS implementation and change in trend of rates of each outcome were assessed using covariate-adjusted Poisson regression, using a piecewise linear function for quarter-time (with breakpoint at PPS implementation). RESULTS: Among an average of 69,428 quarterly catheter users, rates of claims for within-HD-unit thrombolytic use declined from 236.6 (Q1-2008) to 81.4 (Q4-2012) per 100 person-years (P < 0.0001, PPS association with change in trend); rates of claims for thrombus/fibrin sheath removal procedures increased from 3.9 (Q1-2008) to 8.8 (Q3-2015) per 100 person-years (P = 0.0001, PPS association with change in trend). Rates of delayed HD treatment increased from 1.6 (Q2-2008) to 2.3 (Q3-2015) per patient-quarter, although PPS implementation was associated with a decrease in this rising trend (1.6% increase per quarter pre-PPS, 1.2% post-PPS; P < 0.0001, change in trend). CONCLUSIONS: After PPS implementation, thrombolytic use decreased and thrombus/fibrin sheath removal increased. The increasing trend in delayed HD treatment appeared to slow after PPS implementation, but delayed sessions continued to increase year over year for unclear reasons.

Policy and Pandemic: The Changing Practice of Nephrology During the Coronavirus Disease-2019 Outbreak.

The coronavirus (coronavirus disease-2019) pandemic has changed care delivery for patients with end-stage kidney disease. We explore the US healthcare system as it pertains to dialysis care, including existing policies, modifications implemented in response to the coronavirus disease-2019 crisis, and possible next steps for policy makers and nephrologists. This includes policies related to resource management, use of telemedicine, prioritization of dialysis access procedures, expansion of home dialysis modalities, administrative duties, and quality assessment. The government has already established policies that have instated some flexibilities to help providers focus their response to the crisis. However, future policy during and after the coronavirus disease-2019 pandemic can bolster our ability to optimize care for patients with end-stage kidney disease. Key themes in this perspective are the importance of policy flexibility, clear strategies for emergency preparedness, and robust health systems that maximize accessibility and patient autonomy.

Assessment of removal and adsorption enhancement of high-flux hemodialyzers in convective therapies by a novel in vitro uremic matrix.

Adsorption properties of hemodialyzers are traditionally retrieved from diffusive treatments and mainly focused on inflammatory markers and plasma proteins. The possible depurative enhancement of middle and high molecular weight solutes, as well as protein-bound uremic toxins by adsorption in convective treatments, is not yet reported. We used discarded plasma exchanges from uremic patients and out-of-date erythrocytes as a novel in vitro uremic precursor matrix to assess removal and adsorption patterns of distinct material and structure but similar surface hemodialyzers in hemodialysis and on-line hemodiafiltration treatments. We further related the obtained results to the possible underlying membrane pore blocking mechanisms. Convection improved removal but slightly enhanced adsorption in the cellulosic and synthetic dialyzers tested. The polymethylmethacrylate hemodialyzer obtained the highest extracted ([Formula: see text]) and adsorbed ([Formula: see text]) mass values when submitted to hemodiafiltration for all molecules analyzed including albumin ([Formula: see text] g, [Formula: see text] mg), whereas the polyamide membrane obtained substantial lower results even for this molecule ([Formula: see text] g, [Formula: see text] mg) under the same treatment parameters. Hemodiafiltration in symmetric and enlarged pore hemodialyzers enhances removal and adsorption by internal pore deposition (intermediate pore-blocking) for middle and high molecular weight toxins but leads to substantial and deleterious albumin depuration.

Toxicological risk assessment of bisphenol a released from dialyzers under simulated-use and exaggerated extraction conditions.

Bisphenol A (BPA) belongs to a group of chemicals used in the production of polycarbonate, polysulfone, and polyethersulfone which are used, among other applications, in the manufacture of dialyzers. While exposure to BPA is widespread in the general population, dialysis patients represent a population with potentially chronic parenteral BPA exposures. To assess the potential risk of BPA exposure to dialysis patients through dialyzer use, exposure estimates were calculated based on BPA levels measured by ultra-high performance liquid chromatography-quadrupole time-of-flight mass spectrometry following extractions from dialyzers manufactured by Fresenius Medical Care. Extraction conditions included both simulated-use leaching and exaggerated extractions to evaluate possible leachable and extractable BPA, respectively, from the devices. The mean BPA concentrations were 3.6 and 108.9 ppb from simulated-use and exaggerated extractions, respectively, from polycarbonate-containing dialyzers. No BPA was detected from polypropylene-containing dialyzers. Margins of Safety (MOS) were calculated to evaluate the level of risk to patients from estimated BPA exposure from the dialyzers, and the resulting MOS were 229 and 45 for simulated-use and exaggerated extractions, respectively. The findings suggest that there is an acceptable level of toxicological risk to dialysis patients exposed to BPA from use of the dialyzers tested in the current study.

Dialysis Access: At the Intersection of Policy, Innovation, and Clinical Care.

The Advancing American Kidney Health executive order aims to reduce the incidence of end-stage kidney disease, promote home dialysis therapies, increase the number of kidney transplants, and encourage innovation in new technologies, evidence-based practice, and early detection of kidney disease. Improvements in dialysis access care are essential to the success and expansion of this program, and to being able to provide high-quality, cost-efficient care to this patient population. Specifically, the need for expanded access to home dialysis will require surgeons and interventionalists to become proficient and trained in peritoneal dialysis catheter placement and for the referral process to be streamlined to accommodate the increased interest in this modality. In addition, new technologies, namely percutaneous fistula creation, bioengineered vessels, and a variety of interventions to reduce arteriovenous stenosis, will hopefully allow for timely and durable vascular access options that will support implementation of the executive order.

The current and future landscape of dialysis.

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis - particularly haemodialysis and most notably in high-income countries (HICs) - the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization.

Impact of side-hole geometry on the performance of hemodialysis catheter tips: A computational fluid dynamics assessment.

Hemodialysis catheters are used to support blood filtration, yet there are multiple fundamentally different approaches to catheter tip design with no clear optimal solution. Side-holes have been shown to increase flow rates and decrease recirculation but have been associated with clotting/increased infection rates. This study investigates the impact of changing the shape, size and number of side-holes on a simple symmetric tip catheter by evaluating the velocity, shear stress and shear rate of inflowing blood. A platelet model is used to examine the residence time and shear history of inflowing platelets. The results show that side-holes improve the theoretical performance of the catheters, reducing the maximum velocity and shear stress occurring at the tip compared to non-side-hole catheters. Increasing the side-hole area improved performance up to a point, past which not all inflow through the hole was captured, and instead a small fraction slowly 'washed-out' through the remainder of the tip resulting in greater residence times and increasing the likelihood of platelet adhesion. An oval shaped hole presents a lower chance of external fibrin formation compared to a circular hole, although this would also be influenced by the catheter material surface topology which is dependent on the manufacturing process. Overall, whilst side-holes may be associated with increased clotting and infection, this can be reduced when side-hole geometry is correctly implemented though; a sufficient area for body diameter (minimising residence time) and utilising angle-cut, oval shaped holes (reducing shear stress and chances of fibrin formation partially occluding holes).

Challenges and novel therapies for vascular access in haemodialysis.

Advances in standards of care have extended the life expectancy of patients with kidney failure. However, options for chronic vascular access for haemodialysis - an essential part of kidney replacement therapy - have remained unchanged for decades. The high morbidity and mortality associated with current vascular access complications highlights an unmet clinical need for novel techniques in vascular access and is driving innovation in vascular access care. The development of devices, biological approaches and novel access techniques has led to new approaches to controlling fistula geometry and manipulating the underlying cellular and molecular pathways of the vascular endothelium, and influencing fistula maturation and formation through the use of external mechanical methods. Innovations in arteriovenous graft materials range from small modifications to the graft lumen to the creation of completely novel bioengineered grafts. Steps have even been taken to create new devices for the treatment of patients with central vein stenosis. However, these emerging therapies face difficult hurdles, and truly creative approaches to vascular access need resources that include well-designed clinical trials, frequent interaction with regulators, interventionalist education and sufficient funding. In addition, the heterogeneity of patients with kidney failure suggests it is unlikely that a 'one-size-fits-all' approach for effective vascular access will be feasible in the current environment.

Medical waste management - how industry can help us to protect environment and money?

Background: The global climate change and its consequences force us to remodel our processes and rethink the current model of providing the HD treatments. Waste management have a massive impact on the environment and the economy. Every HD session produces above 1 kg of medical waste, which should be properly stored and destroyed. In particular in the pandemia time we should improve the dialysis unit budget as well as decrease CO2 emission produced during the waste elimination.Materials and Methods: The checked the weight of different dialyzers used regularly in dialysis centers in Poland. The Kern CM 320-IN scale was used for the measurement. The measurement accuracy was 0.1 g. Also the filling volume of each dialyzer has been taken into consideration.Results: The dialyzers were divided into four groups depending on the surface. 1,4m2 in group one, 1.5-1.6 m2 in group two, 1.7-1.8 m2 in group three and finally 2.0-2.2 m2 in group four. FX class dialyzers were lightest in every group. The heaviest ones were Polyflux dialyzers. The difference between the lightest and heaviest dialyzers was about 95 g. The filling volume was lowest in FX dialyzers and the highest in Elisio dialyzers. The difference was 20 mL.Conclusions: The weight of different dialyzers available on the market differs. The decision-makers should take into account this fact as the additional quality feature. In extreme cases the weight difference reaches 95 g. In yearly perspective, the usage of the lighter dialysis set can cause the 17 million kg decrease of medical waste and significant savings.

Systematic Fluid Assessment in Haemodialysis: Development and Validation of A Decision Aid.

BACKGROUND: About a third of patients undergoing haemodialysis have poorly controlled fluid status, which may affect survival. Clinical assessment is subjective and imprecise, which has led to the increasing use of devices based on bioimpedance spectroscopy (BIS). However, BIS cannot provide a simple target applicable to all patients. Our aim was to develop and validate a decision aid combining clinical assessment of fluid status with information from BIS in target weight determination. METHODS: The decision aid was based on empirical experience and a literature review identifying physiological parameters already used in the clinical assessment of fluid status. Content validity was established by patient representatives, interdisciplinary stakeholders and external experts, who assessed item relevance and comprehensiveness. Reliability was assessed by inter-rater agreement analysis between nurses assessing typical patient cases. RESULTS: The decision aid for Recognition and Correction of Volume Alterations (RECOVA) consists of three parts (1) a scoring system; (2) thresholds and triggers; (3) a decision aid algorithm. Agreement between raters in the assessment of symptoms was almost perfect, with Intraclass Correlation Coefficient > 0.90. Agreement in clinical response was only fair, but increased to moderate, with training and self-reported confidence. CONCLUSION: RECOVA may enable systematic clinical assessment of fluid status, facilitating early recognition of fluid alterations, and incorporation of bioimpedance into target weight management. However, implementation into clinical practice will require training of staff. Clinical intervention studies are required to evaluate if RECOVA facilitates response to and correction of recognised fluid alterations.

Evaluation of the influence of the surface membrane and blood flow in medium «cut-off¼ (MCO) dialyzers. / Valoración de la influencia de la superficie de la membrana y el flujo sanguíneo en dializadores de medio cut-off.

INTRODUCTION: Recently, a new class of dialyzers, medium cut-off membranes (MCO), designed to improve the permeability, which could provide an efficacy similar to hemodiafiltration, have been incorporated into our therapeutic possibilities. To increase the knowledge about its use, the objective of the study was to evaluate the effect of the surface and blood flow (Qb) on the depurative efficacy in the MCO membranes. MATERIAL AND METHODS: We included 19 patients in the hemodialysis. Each patient received 6 sessions, in which the membrane surface was varied, from 1.7 to 2.0 m2, and/or the Qb (300, 350, 400 or 450mL/min). In each session, different solutes were determined at the beginning and end of dialysis. RESULTS: The surface change of the dialyzer did not show significant differences in the removal of small or large molecules, without changes in albumin loss. The increase in Qb was accompanied by an increase in clearance of small molecules, without showing differences in the percentage reduction of ß2-microglobulin, myoglobin, prolactin, α1-microglobulin and α1-acid glycoprotein, except for some comparison with Qb 450mL/min. There were also no differences in the loss of albumin in the dialysis fluid, less than 2.5 g in all situations. CONCLUSION: The increase of the surface area from 1.7 to 2.0 m2 in the MCO dialyzer has not meant a greater depurative effectiveness. In these dialyzers the increase of Qb does not seem to be as determinant as in hemodiafiltration except for the clearance of small molecules.

Placement of tunneled cuffed catheter for hemodialysis: Micropuncture kit versus Angiocath IV catheter.

INTRODUCTION: Tunneled cuffed catheters provide stable, instantaneous, long-term intravenous access for hemodialysis. Because catheterization is often performed in emergency situations, speed and accuracy are emphasized. METHODS: We retrospectively compared the Micropuncture kit with the standard 18-gauge Angiocath IV catheter for tunneled cuffed catheter insertion in the right jugular vein. From June 2016 to May 2017, 31 tunneled cuffed catheters were successfully inserted via the Micropuncture kit and another 31 via the Angiocath IV catheter. All patients underwent the same ultrasound-guided procedure performed by a single experienced interventionalist. Procedure time was the time from draping of the patient to the completion of povidone dressing after the catheterization. In our center, the Angio Lab nurse maintains records, including procedure time and method for every procedure. All patient records were retrospectively tracked through electronic medical record review. The primary outcome was procedure time and the secondary outcomes were complications and cost-effectiveness. RESULTS: There were no significant differences in the patients' demographic data between the two groups. However, procedure time was significantly shorter in the Angiocath group than in the Micropuncture group (12.4 ± 3.5 vs 17.6 ± 6.9 min, p = 0.001); there were no serious complications, such as hemorrhage, pneumothorax, or hematoma, in both groups. Moreover, cost-effectiveness was better in the Angiocath group than in the Micropuncture group (0.34 vs 52 US$, p < 0.01). CONCLUSIONS: Using the Angiocath IV catheter can reduce procedure time and cost with no severe complications. Moreover, experienced practitioners can reduce the risk of complications when using Angiocath. There are several limitations to this study. First, it was retrospective; second, it was not randomized; and finally, it was conducted by only one experienced interventionalist.

Direct costs of integrated procedures of conventional hemodialysis performed by nursing professionals.

OBJECTIVE: to analyze the mean direct cost of the constituent procedures of conventional hemodialysis, performed in three public teaching and research hospitals. METHOD: quantitative, exploratory-descriptive study, of the multiple case study type. The mean direct cost was calculated by multiplying the time (timed) spent by nursing professionals, on the execution of procedures, by the unit cost of direct labor, added to the cost of materials and solutions/medications. RESULTS: the total mean direct cost, in patients with an arteriovenous fistula corresponded to US$25.10 in hospital A, US$37.34 in hospital B and US$25.01 in hospital C, and in patients with a dual lumen catheter, US$32.07 in hospital A, US$40.58 in hospital B and US$30.35 in hospital C. The weighted mean values obtained were US$26.59 for hospital A, US$38.96 for hospital B and US$27.68 for hospital C. It was noted that the "installation and removal of hemodialysis fistula access" caused a significantly lower economic impact compared to "installation and removal of hemodialysis catheter access". CONCLUSION: with the knowledge developed it will be possible to support hospital managers, technical managers and nursing professionals in the decision making process, with a view to the rational allocation of the necessary inputs for the performance of conventional hemodialysis.

Randomized pilot study to compare metal needles versus plastic cannulae in the development of complications in hemodialysis access.

BACKGROUND: Hemodialysis requires needle insertions every treatment. Needle injury (mechanical or hemodynamic) may cause complications (aneurysms/stenosis) that compromise dialysis delivery requiring interventions. Metal needles have a sharp slanted "V"-shaped cutting tip; plastic cannulae have a dull round tip and four side holes. Preliminary observations demonstrated a difference in intradialytic blood flow images and mean Doppler velocities at cannulation sites between the two devices. Complications from mechanical and hemodynamic trauma requiring interventions were compared in each group. MATERIALS AND METHODS: In all, 33 patients (13 females and 17 new accesses) were randomized to metal group (n = 17) and plastic group (n = 16). Mechanical trauma was minimized by having five nurses performing ultrasound-guided cannulations. Complications were identified by the clinician and addressed by the interventionalists, both blinded to study participation. Patients were followed for up to 12 months. RESULTS: Baseline characteristics were not significant. Procedures to treat complications along cannulation segments increased from 0.41 to 1.29 per patient (metal group) and decreased from 1.25 to 0.69 per patient (plastic group; p = 0.004). The relative risks of having an intervention (relative risk = 1.5, 95% confidence interval = 0.88-2.67) and having an infiltration during hemodialysis (relative risk = 2.26, 95% confidence interval = 1.03-4.97) were higher for metal needles. Time to first intervention trended in favor of plastic cannula (p = 0.069). Cost of supplies for these interventions was approximately CAD$20,000 lower for the plastic group. CONCLUSION: Decreased burden of illness related to cannulation (less infiltrations during hemodialysis) and Qb were associated with plastic cannulae. Decreased procedure costs were suggested during the study period in the plastic group.