RESUMO
BACKGROUND: Patients undergoing haemodialysis (HD) are at higher risk of developing worse outcomes if they contract COVID-19. In our renal service we reduced HD frequency from thrice to twice-weekly in selected patients with the primary aim of reducing COVID 19 exposure and transmission between HD patients. METHODS: Dialysis unit nephrologists identified 166 suitable patients (38.4% of our HD population) to temporarily convert to twice-weekly haemodialysis immediately prior to the peak of the COVID-19 pandemic in our area. Changes in pre-dialysis weight, systolic blood pressure (SBP) and biochemistry were recorded weekly throughout the 4-week project. Hyperkalaemic patients (serum potassium > 6.0 mmol/L) were treated with a potassium binder, sodium bicarbonate and received responsive dietary advice. RESULTS: There were 12 deaths (5 due to COVID-19) in the HD population, 6 of which were in the twice weekly HD group; no deaths were definitively associated with change of dialysis protocol. A further 19 patients were either hospitalised and/or developed COVID-19 and thus transferred back to thrice weekly dialysis as per protocol. 113 (68.1%) were still receiving twice-weekly HD by the end of the 4-week project. Indications for transfer back to thrice weekly were; fluid overload (19), persistent hyperkalaemia (4), patient request (4) and compliance (1). There were statistically significant increases in SBP and pre-dialysis potassium during the project. CONCLUSIONS: Short term conversion of a large but selected HD population to twice-weekly dialysis sessions was possible and safe. This approach could help mitigate COVID-19 transmission amongst dialysis patients in centres with similar organisational pressures.
Assuntos
Agendamento de Consultas , COVID-19/prevenção & controle , Pandemias , Diálise Renal/estatística & dados numéricos , SARS-CoV-2 , Idoso , Instituições de Assistência Ambulatorial/organização & administração , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Pressão Sanguínea , Peso Corporal , COVID-19/epidemiologia , Comorbidade , Inglaterra/epidemiologia , Feminino , Humanos , Hiperpotassemia/etiologia , Falência Renal Crônica/sangue , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/fisiopatologia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Potássio/sangue , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Diálise Renal/efeitos adversosRESUMO
BACKGROUND: Patient portals are considered valuable instruments for self-management of long term conditions, however, there are concerns over how patients might interpret and act on the clinical information they access. We hypothesized that visual cues improve patients' abilities to correctly interpret laboratory test results presented through patient portals. We also assessed, by applying eye-tracking methods, the relationship between risk interpretation and visual search behaviour. METHODS: We conducted a controlled study with 20 kidney transplant patients. Participants viewed three different graphical presentations in each of low, medium, and high risk clinical scenarios composed of results for 28 laboratory tests. After viewing each clinical scenario, patients were asked how they would have acted in real life if the results were their own, as a proxy of their risk interpretation. They could choose between: 1) Calling their doctor immediately (high interpreted risk); 2) Trying to arrange an appointment within the next 4 weeks (medium interpreted risk); 3) Waiting for the next appointment in 3 months (low interpreted risk). For each presentation, we assessed accuracy of patients' risk interpretation, and employed eye tracking to assess and compare visual search behaviour. RESULTS: Misinterpretation of risk was common, with 65% of participants underestimating the need for action across all presentations at least once. Participants found it particularly difficult to interpret medium risk clinical scenarios. Participants who consistently understood when action was needed showed a higher visual search efficiency, suggesting a better strategy to cope with information overload that helped them to focus on the laboratory tests most relevant to their condition. CONCLUSIONS: This study confirms patients' difficulties in interpreting laboratories test results, with many patients underestimating the need for action, even when abnormal values were highlighted or grouped together. Our findings raise patient safety concerns and may limit the potential of patient portals to actively involve patients in their own healthcare.
Assuntos
Técnicas de Laboratório Clínico , Conhecimentos, Atitudes e Prática em Saúde , Portais do Paciente , Interface Usuário-Computador , Percepção Visual , Adulto , Medições dos Movimentos Oculares , Feminino , Humanos , Transplante de Rim , Masculino , Pessoa de Meia-Idade , Medição de RiscoRESUMO
BACKGROUND: Following a pneumocystis pneumonia (PCP) outbreak in our nephrology unit, all transplant patients were offered chemoprophylaxis with trimethoprim-sulphamethoxazole (TMP-SMX) as the first line agent. A high rate of complications was noted. We aimed to quantify TMP-SMX associated adverse events and evaluate its prophylactic benefit in their light. Potential risk factors for complications' development were also investigated. METHOD: This was an observational study of outcomes in transplant recipients commenced on TMP-SMX prophylaxis for 1year period. End-points were adverse events due to TMP-SMX, the additional medical burden resulting from these events, and PCP diagnosis. RESULTS: 290 patients commenced on TMP-SMX. 110 (38%) developed complications with most common being rise in serum creatinine (Cr) (n = 63, 22%) followed by gastrointestinal symptoms (n = 15, 5%), and leucopenia (n = 5, 2%). PCP incidence fell from 19 cases in 19 months to 2 cases in 12 months. Baseline renal function (P = 0.019) was an independent predictors for developing rise in Cr with TMP-SMX. CONCLUSION: Use of chemoprophylaxis is an effective strategy in dealing with a PCP outbreak but can lead to a high number of complications. Rises in serum Cr can cause significant concern and increase in the number of investigations.
Assuntos
Anti-Infecciosos/efeitos adversos , Transplante de Rim/efeitos adversos , Pneumonia por Pneumocystis/prevenção & controle , Combinação Trimetoprima e Sulfametoxazol/efeitos adversos , Adulto , Idoso , Quimioprevenção , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos ProporcionaisRESUMO
Antineutrophil cytoplasmic autoantibody (ANCA)-associated systemic vasculitides (AASV) consists of small-vessel systemic inflammatory disorders which commonly affect the kidneys and without treatment have a poor prognosis. Rituximab is a novel biological agent which is being used experimentally in the management of AASV. This report presents the case of a young woman with rapidly progressive life-threatening AASV. Despite prompt diagnosis and initial treatment with steroids and alkylating agents her condition became life threatening. With addition of rituximab therapy she showed an excellent sustained response. Rituximab appears an effective and safe treatment choice for the induction of remission in severe AASV that is not responding to standard agents, at the initial presentation and for maintenance therapy, without the development of common serious side-effects associated with immunosuppression.
Assuntos
Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/tratamento farmacológico , Anticorpos Monoclonais Murinos/uso terapêutico , Anticorpos Monoclonais/uso terapêutico , Fatores Imunológicos/uso terapêutico , Adolescente , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/diagnóstico , Anticorpos Monoclonais/administração & dosagem , Anticorpos Monoclonais Murinos/administração & dosagem , Estado Terminal/terapia , Feminino , Humanos , Fatores Imunológicos/administração & dosagem , Indução de Remissão , RituximabRESUMO
BACKGROUND AND AIMS: Patients with atheromatous renovascular disease (ARVD) have high cardiovascular morbidity and mortality. The cardiac markers N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin (cTnT) are easily measured, yet not widely used in renal patients as they are thought to be inaccurate in renal disease. We aimed to see if these markers could be used as prognostic indicators of cardiovascular events (CVEs) and death in ARVD. METHODS: Subjects with ARVD treated in 1 renal center in 2003 were prospectively followed up. NT-proBNP and cTnT at baseline were correlated with CVEs and death, echocardiographic findings and degree of renal artery stenosis. Cutoff levels of 0.03 ng/ml (cTnT) and 43 pmol/l (NT-proBNP) were used. RESULTS: Eighty-two patients (mean +/- SD age 69 +/- 8 years, mean follow-up 40.2 +/- 16.6 months) were suitable for analysis. Twenty-nine percent of patients suffered new CVEs, and 37.8% died. Renal function was a significant predictor of CVEs and death. Patients with a raised NT-proBNP were more likely to die than those in the same chronic kidney disease (CKD) category with normal levels (p < 0.0001) even after adjusting for multivariate factors (hazard ratio 8.3 for high proBNP vs. 3.6 for low proBNP in CKD stage 4-5). CONCLUSION: No study to our knowledge has looked at both NT-proBNP and cTnT as outcome markers in ARVD. Our study shows that renal function is more important as a marker of suffering a CVE. However, raised NT-proBNP is associated with a greater likelihood of death when subdivided by CKD stage. Early risk stratification by simple measurement of these biomarkers may aid in intensifying management in high-risk patients, although further studies to assess the value of this approach are warranted.
Assuntos
Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/mortalidade , Rim/fisiopatologia , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Obstrução da Artéria Renal/diagnóstico , Obstrução da Artéria Renal/mortalidade , Troponina/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Doenças Cardiovasculares/epidemiologia , Feminino , Seguimentos , Taxa de Filtração Glomerular/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Estudos Prospectivos , Fatores de Risco , Taxa de SobrevidaRESUMO
Development of malignancy after solid-organ trans?lant is a well-known long-term complication of immunosuppressive therapy. Thus far, there are no specific oncologic recommendations regarding management of de novo tumors in transplanted kidneys. Here, we present the case of a 63-year-old male patient who developed a de novo renal cell carcinoma 6 years after the transplant procedure. The patient underwent nephron-sparing surgery with transperitoneal enucleation of the tumor. We discuss the decision-making process and the operative challenges that we faced. We conclude that this technique should be considered as a therapeutic strategy for selected patients so that transplant nephrectomy can be avoided.
Assuntos
Carcinoma de Células Renais/cirurgia , Falência Renal Crônica/cirurgia , Neoplasias Renais/cirurgia , Transplante de Rim/efeitos adversos , Tratamentos com Preservação do Órgão , Aloenxertos , Carcinoma de Células Renais/induzido quimicamente , Carcinoma de Células Renais/imunologia , Carcinoma de Células Renais/patologia , Tomada de Decisão Clínica , Humanos , Imunossupressores/efeitos adversos , Falência Renal Crônica/diagnóstico , Neoplasias Renais/induzido quimicamente , Neoplasias Renais/imunologia , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Tomografia Computadorizada por Raios X , Resultado do TratamentoAssuntos
Surtos de Doenças , Transplante de Rim/efeitos adversos , Pneumocystis carinii/classificação , Pneumocystis carinii/isolamento & purificação , Pneumonia por Pneumocystis/epidemiologia , Transplante , Análise por Conglomerados , DNA Fúngico/química , DNA Fúngico/genética , DNA Intergênico/química , DNA Intergênico/genética , DNA Mitocondrial/química , DNA Mitocondrial/genética , Genótipo , Humanos , Hospedeiro Imunocomprometido , Incidência , Técnicas de Tipagem Micológica , Pneumocystis carinii/genética , Análise de Sequência de DNA , Homologia de Sequência do Ácido Nucleico , Reino Unido/epidemiologiaRESUMO
BACKGROUND: The aim of the study is to describe serious adverse events in patients with renal insufficiency administered low molecular weight heparins (LMWHs). METHODS: Systematic case note review from July 2002 to March 2003, Hope Hospital, Salford, UK, was used. RESULTS: Ten patients experienced an adverse incident on LMWH therapy. Five patients were on maintenance hemodialysis therapy, and 1 patient was on continuous ambulatory peritoneal dialysis therapy. Three patients had calculated creatinine clearances of 5, 11, and 33 mL/min (0.08, 0.18, and 0.55 mL/s), and 1 patient had an estimated glomerular filtration rate of 12 mL/min. Age range was 45 to 89 years. Indications for anticoagulation were suspected pulmonary embolism (1 patient), acute coronary syndrome (7 patients), severe nephrotic syndrome (1 patient), and postoperative venous thromboembolic prophylaxis (1 patient). Three patients also were administered aspirin; 1 patient, clopidogrel; and 3 patients, aspirin and clopidogrel. LMWHs used were enoxaparin (6 patients), tinzaparin (3 patients), and dalteparin sodium (1 patient). Bleeding sources were retroperitoneal (1 patient), spontaneous soft tissue (3 patients), gastrointestinal (2 patients), dialysis catheter and cannula sites (2 patients), hemorrhagic pericardial effusion (1 patient), and intracranial (1 patient). Activated partial thromboplastin time was prolonged in 7 of 10 patients, with no other identifiable cause found. Three patients died despite aggressive resuscitation, including packed red blood cell infusions and protamine sulfate administration. Eight of the 10 prescriptions for LMWHs were either started or continued within our directorate, giving an approximate incidence of major hemorrhagic events in patients with chronic kidney disease of 7.8%. CONCLUSION: LMWHs administered at fixed-weight doses and without monitoring show unpredictable anticoagulant effects in patients with chronic kidney disease stages 4 and 5, leading to serious and even fatal adverse incidents.
Assuntos
Anticoagulantes/efeitos adversos , Heparina de Baixo Peso Molecular/efeitos adversos , Falência Renal Crônica/terapia , Diálise Renal , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/epidemiologia , Comorbidade , Feminino , Hemorragia/epidemiologia , Hemorragia/etiologia , Humanos , Falência Renal Crônica/epidemiologia , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Lupus nephritis (LN) is a rare disease but is the strongest predictor of poor outcome in patients with Systemic Lupus Erythematosis (SLE). It is associated with significant morbidity, with 10-20% of patients developing end stage renal failure. As there is a paucity of randomized clinical trial data in LN, and no consistent literature regarding baseline factors that predict renal outcome, we were prompted to analyse our centre's complete experience of managing LN. METHODS: A retrospective analysis was undertaken of all patients presenting to our renal centre with biopsy proven LN from 1979-2003. Patients were divided into two categories, those with stable or deteriorating renal function over time. Baseline parameters were correlated with renal outcome. RESULTS: Complete clinical records were available for 45 (40 female) patients. Mean (SD) age of onset of SLE was 32 +/- 14 years, and mean age onset of LN was 36 +/- 13 years. Patients were followed up for an average of 74 +/- 56 months. Four patients (9%) had WHO Class II LN, 11 (24%) WHO Class III and there were 15 (33%) each in Class IV and V, respectively on renal biopsy. Five (11%) patients presented with acute renal failure and all had proliferative changes on biopsy. The chief arbiters of renal functional deterioration over follow up were longer time to development of LN (P = 0.04), a high platelet count and worse baseline renal function (both P = 0.05). There was a trend relating low haemoglobin or membranous histology to poor renal outcome, and Class IV histology to better outcome. CONCLUSION: The study has identified that longer time to development of LN, high platelet count and poorer renal function at baseline suggest a worse renal outcome in LN. The study was small but LN is a rare condition. A combination of factors is likely to influence renal outcome in LN and larger prospective trials are required to ascertain consistent baseline prognostic markers.
Assuntos
Falência Renal Crônica/patologia , Nefrite Lúpica/patologia , Adolescente , Adulto , Biópsia/métodos , Progressão da Doença , Feminino , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/metabolismo , Nefrite Lúpica/epidemiologia , Nefrite Lúpica/metabolismo , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Resultado do TratamentoAssuntos
Apolipoproteínas A/genética , Dislipidemias/diagnóstico , Dislipidemias/genética , Proteinúria/diagnóstico , Adulto , Apolipoproteína A-V , Heterozigoto , Humanos , Hiperlipoproteinemia Tipo III/diagnóstico , Rim/patologia , Masculino , Mutação , Obesidade/diagnóstico , Proteinúria/genética , Splicing de RNA , Triglicerídeos/sangueRESUMO
BACKGROUND: Cardiovascular mortality in end-stage renal failure patients is high and early risk stratification in these patients may aid clinical management improving outcomes. Cardiac troponin T (cTnT) is a component of the cardiac myocyte which is released into the circulation following myocardial necrosis. It has been shown to be of prognostic significance in patients with unstable angina. The role of cTnT in patients with renal disease remains unclear. The aim of this investigation, therefore, was to assess the prognostic significance of cTnT in chronic renal impairment patients, pre-dialysis. METHODS: Ninety-six patients with chronic renal impairment were followed prospectively after cTnT determination by a quantitative laboratory method. The clinical outcomes after 2 years were determined. The measured cTnT values were correlated with biochemical parameters and clinical end-points. RESULTS: A cut-off of 0.1 ng/ml was used in assessing the prognostic significance of cTnT. Twenty-five patients had a cTnT >0.1 ng/ml, whilst 71 had a cTnT