The Association Between Serum Vancomycin Level and Clinical Outcome in Patients With Peritoneal Dialysis Associated Peritonitis.

Introduction: Intraperitoneal (IP) vancomycin is often first-line empiric therapy and then maintenance therapy for peritoneal dialysis (PD) peritonitis. However, how vancomycin serum levels correlate with clinical outcomes remains unclear. Methods: We conducted a retrospective single-center adult cohort study of 98 patients with PD peritonitis treated with IP vancomycin between January 2016 and May 2022. The association between nadir vancomycin level and cure was evaluated in a logistic regression model, first unadjusted and then adjusted for age, sex, weight, glomerular filtration rate (GFR), and total number of days on PD. Vancomycin was assessed both as a continuous exposure (per 1 mg/l increase) and as a categorical exposure (<15 mg/l vs. ≥15 mg/l). A receiver operating characteristic curve (ROC) was created to explore nadir vancomycin level thresholds in an attempt to identify an optimal target level during treatment. Results: Of the patients, 81% achieved cure, and patients with nadir vancomycin level ≥15 mg/l were 7.5 times more likely to experience cure compared to those with a nadir level <15 mg/l (odds ratio [OR] 7.58, 95% confidence interval [CI] 1.71-33.57, P = 0.008). Weight, GFR, days on PD, sex, and age were not independently associated with outcome. The vancomycin level with the greatest discriminatory capacity for cure on the ROC analysis was 14.4 mg/l. Conclusion: Increasing IP vancomycin serum levels are associated with increased odds of cure; and maintaining vancomycin serum levels above 14-15 mg/l throughout the course of PD peritonitis treatment is likely to improve clinical outcomes.

Early Experience with Modified Dose Nirmatrelvir/Ritonavir in Dialysis Patients with Coronavirus Disease 2019.

BACKGROUND: Nirmatrelvir/ritonavir was approved for use in high-risk outpatients with coronavirus disease 2019 (COVID-19). However, patients with severe CKD were excluded from the phase 3 trial, and the drug is not recommended for those with GFR <30 ml/min per 1.73 m 2 . On the basis of available pharmacological data, we developed a modified low-dose regimen of nirmatrelvir/ritonavir 300/100 mg on day 1, followed by 150/100 mg daily from day 2 to 5. In this study, we report our experience with this modified dose regimen in dialysis patients in the Canadian province of Ontario. METHODS: We included dialysis patients who developed COVID-19 and were treated with the modified dose nirmatrelvir/ritonavir regimen during a 60-day period between April 1 and May 31, 2022. Details of nirmatrelvir/ritonavir use and outcomes were captured manually, and demographic data were obtained from a provincial database. Data are presented with descriptive statistics. The principal outcomes we describe are 30-day hospitalization, 30-day mortality, and required medication changes with the modified dose regimen. RESULTS: A total of 134 dialysis patients with COVID-19 received nirmatrelvir/ritonavir during the period of study. Fifty-six percent were men, and the mean age was 64 years. Most common symptoms were cough and/or sore throat (60%). Medication interactions were common with calcium channel blockers, statins being the most frequent. Most patients (128, 96%) were able to complete the course of nirmatrelvir/ritonavir, and none of the patients who received nirmatrelvir/ritonavir died of COVID-19 in the 30 days of follow-up. CONCLUSIONS: A modified dose of nirmatrelvir/ritonavir use was found to be safe and well tolerated, with no serious adverse events being observed in a small sample of maintenance dialysis patients.

Magnesium and Fracture Risk in the General Population and Patients Receiving Dialysis: A Narrative Review.

Purpose of Review: Magnesium is an essential mineral for bone metabolism, but little is known about how magnesium intake alters fracture risk. We conducted a narrative review to better understand how magnesium intake, through supplementation, diet, or altering the concentration of dialysate magnesium, affects mineral bone disease and the risk of fracture in individuals across the spectrum of kidney disease. Sources of Information: Peer-reviewed clinical trials and observational studies. Methods: We searched for relevant articles in MEDLINE and EMBASE databases. The methodologic quality of clinical trials was assessed using a modified version of the Downs and Black criteria checklist. Key Findings: The role of magnesium intake in fracture prevention is unclear in both the general population and in patients receiving maintenance dialysis. In those with normal kidney function, 2 meta-analyses showed higher bone mineral density in those with higher dietary magnesium, whereas 1 systematic review showed no effect on fracture risk. In patients receiving maintenance hemodialysis or peritoneal dialysis, a higher concentration of dialysate magnesium is associated with a lower concentration of parathyroid hormone, but little is known about other bone-related outcomes. In 2 observational studies of patients receiving hemodialysis, a higher concentration of serum magnesium was associated with a lower risk of hip fracture. Limitations: This narrative review included only articles written in English. Observed effects of magnesium intake in the general population may not be applicable to those with chronic kidney disease particularly in those receiving dialysis.

Justification: Le magnésium est un minéral essentiel pour le métabolisme osseux, mais on en sait peu sur la façon dont un apport en magnésium modifie le risque de fracture. Nous avons procédé à un examen narratif afin de mieux comprendre comment les maladies liées à la densité minérale osseuse et le risque de fracture sont affectés par un apport en magnésium (supplémentation, régime alimentaire ou modification de la concentration de dialysat de magnésium) chez les personnes atteintes d'insuffisance rénale. Sources: Essais cliniques et études observationnelles examinés par des pairs. Méthodologie: Nous avons répertorié les articles pertinents dans les bases de données MEDLINE et EMBASE. Une version modifiée des critères de contrôle de la qualité des études de Downs et Black a servi à évaluer la qualité méthodologique des essais cliniques retenus. Principaux résultats: Le rôle d'un apport en magnésium dans la prévention des fractures n'est pas clair, tant dans la population générale que chez les patients sous dialyse d'entretien. Chez les personnes ayant une fonction rénale normale, deux méta-analyses ont montré que les personnes dont le régime alimentaire est riche en magnésium présentent une densité minérale osseuse plus élevée; alors qu'une revue systématique n'a montré aucun effet sur le risque de fracture. Chez les patients sous hémodialyse d'entretien ou dialyse péritonéale, une concentration plus élevée de dialysat de magnésium est associée à une plus faible concentration d'hormone parathyroïdienne, mais on en sait peu sur les autres effets liés aux os. Dans deux études observationnelles portant sur des patients sous hémodialyse, une concentration plus élevée de magnésium sérique a été associée à un risque plus faible de fracture de la hanche. Limites: Cet examen narratif ne comprend que des articles rédigés en anglais. Il est possible que les effets d'un apport en magnésium observés dans la population générale ne puissent s'appliquer aux personnes atteintes d'une néphropathie chronique, en particulier aux personnes sous dialyse.

Pre-Peritoneal Dialysis Peritonitis After Saline Infusion Sonohysterogram in a Patient With an Embedded Catheter: A Case Report.

Rationale: Clear guidelines currently exist regarding antibiotic prophylaxis for patients on peritoneal dialysis (PD) prior to common diagnostic procedures. However, these guidelines do not include patients with subcutaneously embedded PD catheters who are awaiting PD initiation although both these populations share a great deal of risk factors for infections. Issues regarding antibiotic prophylaxis and avoidable infections are bound to keep occurring if physicians are not conscious of the risks of infections shared by all patients suffering from renal failure. Presenting concerns: Two weeks after a saline infusion sonohysterography (SIS), a 48-year-old woman with chronic kidney disease (CKD) G5 ND, type 2 diabetes, a subcutaneously embedded PD catheter, and prior abnormal uterine bleeding presented to the emergency department complaining of nausea, vomiting, diarrhea, weakness, and abdominal pain. The patient received no antibiotic prophylaxis prior to her SIS. Diagnoses: The final diagnosis of peritonitis was established after acute kidney injury, gastroenteritis, and small bowel obstruction were considered and ruled out. A delay in the final diagnosis occurred because of the complex presentation, the fact that the patient had not yet initiated PD, and the presence of concomitant anion gap metabolic acidosis and an acute elevation of the patient's creatinine. Interventions: The patient was started on broad-spectrum intravenous antibiotics when the diagnosis of peritonitis was established. Insulin and intravenous bicarbonate infusions were used to correct the patient's anion gap metabolic acidosis. Surgical debridement of the necrotic subcutaneous tissue and removal of the embedded PD catheter were necessary. Outcomes: The patient's infection resolved completely as did her anion gap metabolic acidosis. The patient had to transfer permanently from PD to hemodialysis for her renal replacement therapy. Teaching points: This case report serves as a good reminder that physicians should keep in mind the possibility of peritonitis in patients with embedded PD catheters. As these patients are also at risk of infections, antibiotic prophylaxis should be used in patients with embedded catheters in the same way it is used for PD patients prior to obstetrical, gynecological, or gastrointestinal procedures.

Justification: Il existe des directives claires quant à la prophylaxie antibiotique à utiliser préalablement aux procédures de diagnostic courantes chez les patients sous dialyse péritonéale (DP). Les patients disposant d'un cathéter de DP implanté sous-cutané en attendant le début de la dialyse ne sont pas inclus dans ces recommandations, même si cette population partage plusieurs facteurs de risque d'infections avec les patients déjà sous DP. Des enjeux liés à la prophylaxie antibiotique et aux infections évitables continueront de se poser si les médecins ignorent les risques d'infections partagés par tous les patients souffrant d'insuffisance rénale. Présentation du cas: Une femme âgée de 48 ans atteinte d'insuffisance rénale chronique (IRC) G5 ND et de diabète de type 2 s'étant présentée aux urgences deux semaines après une sono-hystérographie (SHG) avec infusion intra-utérine de solution saline. La patiente portait un cathéter de PD implanté sous-cutané et avait déjà eu des saignements utérins anormaux dans le passé. Elle se plaignait de nausées, de vomissements, de diarrhées, de faiblesse générale et de douleurs abdominales. Elle n'avait reçu aucune prophylaxie antibiotique avant la SHG. Diagnostic: Le diagnostic final de péritonite a été établi après que l'insuffisance rénale aiguë, la gastro-entérite et une obstruction de l'intestin grêle aient été envisagées et écartées. Le diagnostic final a été retardé en raison de la présentation complexe, du fait que la patiente n'avait pas encore amorcé la DP et de la présence concomitante d'une acidose métabolique à trou anionique et d'une élévation subite de la créatinine. Interventions: La patiente a reçu des antibiotiques à large specter par voie intraveineuse lorsque le diagnostic de péritonite a été établi. Des infusions d'insuline et de bicarbonate par voie intraveineuse ont été utilisées pour corriger l'acidose métabolique à trou anionique. Un débridement chirurgical des tissus sous-cutanés nécrosés et l'ablation du cathéter PD se sont avérés nécessaires. Résultats: L'infection a guéri complètement, tout comme l'acidose métabolique à trou anionique. La patiente a dû passer définitivement de la DP à l'hémodialyse pour son traitement de suppléance rénale. Enseignements tirés: Ce cas illustre bien que les médecins devraient toujours garder les risques de péritonite à l'esprit lorsqu'ils traitent des patients portant un cathéter de PD implanté sous-cutané. Puisque ces patients présentent eux aussi un risque d'infection, la prophylaxie antibiotique devrait leur être administrée avant les procédures obstétricales, gynécologiques ou gastro-intestinales, comme c'est le cas pour les patients sous DP.

Canadian Association of Radiologists Guidance on Contrast-Associated Acute Kidney Injury.

Purpose: Iodinated contrast media is one of the most frequently administered pharmaceuticals. In Canada, over 5.4 million computed tomography (CT) examinations were performed in 2019, of which 50% were contrast enhanced. Acute kidney injury (AKI) occurring after iodinated contrast administration was historically considered a common iatrogenic complication which was managed by screening patients, prophylactic strategies, and follow-up evaluation of renal function. The Canadian Association of Radiologists (CAR) initially published guidelines on the prevention of contrast induced nephropathy in 2007, with an update in 2012. However, new developments in the field have led to the availability of safer contrast agents and changes in clinical practice, prompting a complete revision of the earlier recommendations. Information sources: Published literature, including clinical trials, retrospective cohort series, review articles, and case reports, along with expert opinions from radiologists and nephrologists across Canada. Methods: The leadership of the CAR formed a working group of radiologists and nephrologists with expertise in contrast administration and patient management related to contrast-associated AKI. We conducted a comprehensive review of the published literature to evaluate the evidence about contrast as a cause of AKI, and to inform evidence-based recommendations. Based on the available literature, the working group developed consensus recommendations. Key Findings: The working group developed 21 recommendations, on screening, choice of iodinated contrast media, prophylaxis, medication considerations, and post contrast administration management. The key changes from the 2012 guidelines were (1) Simplification of screening to a simple questionnaire, and not delaying emergent examinations due to a need for creatinine measurements (2) Prophylaxis considerations only for patients with estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 (3) Not recommending the routine discontinuation of any drugs to decrease risk of AKI, except metformin when eGFR is less than 30 mL/min/1.73 m2 and (4) Not requiring routine follow up serum creatinine measurements post iodinated contrast administration. Limitations: We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. Implications: Given the importance of iodinated contrast media use in diagnosis and management, and the low risk of AKI after contrast use, these guidelines aim to streamline the processes around iodinated contrast use in most clinical settings. As newer evidence arises that may change or add to the recommendations provided, the working group will revise these guidelines.

Justification: Les agents de contraste iodés (ACI) sont parmi les produits pharmaceutiques les plus fréquemment administrés. Au Canada, plus de 5,4 millions d'examens de tomodensitométrie (TDM) ont été réalisés en 2019, dont 50 % ont été faits avec un ACI. L'insuffisance rénale aiguë (IRA) survenant après l'administration d'un ACI était historiquement considérée comme une complication iatrogénique fréquente qui était prise en charge par le dépistage des patients, des stratégies prophylactiques et une évaluation de suivi de la fonction rénale. L'Association canadienne des radiologistes (CAR) a publié des lignes directrices pour la prévention de la néphropathie induite par les agents de contraste en 2007 et une mise à jour en 2012. De nouveaux développements sur le terrain ont toutefois mené à la disponibilité d'agents de contraste plus sécuritaires et à des changements dans la pratique clinique, ce qui a entraîné une révision complète des recommandations antérieures. Sources: La littérature publiée, y compris les essais cliniques, les séries de cohortes rétrospectives, les articles-synthèse et les rapports de cas, de même que les opinions d'experts de radiologistes et de néphrologues de partout au Canada. Méthodologie: La direction de la CAR a formé un groupe de travail composé de radiologues et de néphrologues ayant une expertise dans l'administration d'ACI et la gestion de patients atteints d'IRA survenant après l'administration d'un ACI. Le groupe a procédé à une revue complète de la littérature publiée afin d'évaluer les données probantes sur les ACI comme cause de l'IRA et de formuler des recommandations en fonction de celles-ci. Le groupe de travail a élaboré des recommandations consensuelles en se fondant sur la documentation disponible. Principaux résultats: Le groupe de travail a élaboré 21 recommandations sur le dépistage, le choix des agents de contraste iodés, la prophylaxie, les considérations relatives aux médicaments et la gestion post-administration de l'ACI. Les principaux changements par rapport aux lignes directrices de 2012 étaient : (1) de simplifier le dépistage à un simple questionnaire et de ne pas retarder les examens émergents en raison du besoin de mesurer la créatinine; (2) d'avoir des considérations prophylactiques uniquement pour les patients dont le débit de filtration glomérulaire estimé (DFGe) est inférieur à 30 mL/min/1,73 m2; (3) de ne pas recommander l'arrêt des médicaments visant à réduire le risque d'IRA, comme c'est normalement le cas, sauf la metformine lorsque le DFGe est inférieur à 30 mL/min/1,73 m2 et; (4) ne pas demander de mesures de suivi de routine de la créatinine sérique après administration d'un agent de contraste iodé. Limites: Le groupe n'a pas procédé à une revue formelle et systématique de la littérature sur le sujet ni à une méta-analyse. Les suggestions n'ont pas été évaluées dans un environnement clinique. Conclusion: Compte tenu de l'importance des agents de contraste iodés dans le diagnostic et la prise en charge des patients, et du faible risque d'IRA encouru après leur administration, ces recommandations ne visent qu'à simplifier les processus relatifs à l'utilisation des ACI dans la plupart des milieux cliniques. Le groupe de travail révisera ces lignes directrices au fur et à mesure que des éléments de preuve plus récents seront ajoutés aux recommandations fournies.

Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury.

Iodinated contrast media (ICM) is one of the most frequently administered pharmaceuticals. In Canada, over 5.4 million computed tomography (CT) examinations were performed in 2019, of which 50% were contrast enhanced. Acute kidney injury (AKI) occurring after ICM administration was historically considered a common iatrogenic complication which was managed by screening patients, prophylactic strategies, and follow up evaluation of renal function. The Canadian Association of Radiologists (CAR) initially published guidelines on the prevention of contrast induced nephropathy in 2007, with an update in 2012. However, new developments in the field have led to the availability of safer contrast agents and changes in clinical practice, prompting a complete revision of the earlier recommendations. This revised guidance document was developed by a multidisciplinary CAR Working Group of radiologists and nephrologists, and summarizes changes in practice related to contrast administration, screening, and risk stratification since the last guideline. It reviews the scientific evidence for contrast associated AKI and provides consensus-based recommendations for its prevention and management in the Canadian healthcare context. This article is a joint publication in the Canadian Association of Radiologists Journal and Canadian Journal of Kidney Health and Disease, intended to inform both communities of practice.

Neobladder creation is still a conduit to peritoneal dialysis - Successful use of peritoneal dialysis after invasive bladder cancer.

Peritoneal dialysis (PD) is as safe and more cost-effective than haemodialysis (HD). It also allows patients to undergo renal replacement therapy (RRT) from home. However, PD remains underutilised in many parts of the world. This is true in part because of many perceived relative contraindications to PD, including a history of prior major abdominal surgery. Prior major abdominal surgery is a concern for standard bedside or surgical catheter placement since these patients are at risk of having adhesions, which can complicate catheter placement. However, with laparoscopic advancements, prior major abdominal surgery is no longer even a relative contraindication to PD for skilled and experienced surgeons. We report the case of a male in his 70s with a history of cystoprostatectomy which was curative for a muscle invasive bladder carcinoma 5 years prior to his RRT. The patient had longstanding chronic kidney disease which worsened gradually. After receiving RRT education, the patient favoured PD. The catheter was placed despite the surgeon noting abdominal adhesions and the patient successfully underwent 12 months of PD which had a positive impact on his quality of life. He transferred to HD after contracting a complex PD-associated peritonitis. Thus, new research should be conducted to better understand the real impact of prior abdominal surgeries as a contraindication to PD, especially in centres where the surgeons have experience with advanced laparoscopy.

Intravenous albumin for the prevention of hemodynamic instability during sustained low-efficiency dialysis: a randomized controlled feasibility trial (The SAFER-SLED Study).

BACKGROUND: Hemodynamic instability is a frequent complication of sustained low-efficiency dialysis (SLED) treatments in the ICU. Intravenous hyperoncotic albumin may prevent hypotension and facilitate ultrafiltration. In this feasibility trial, we sought to determine if a future trial, powered to evaluate clinically relevant outcomes, is feasible. METHODS: This single-center, blinded, placebo-controlled, randomized feasibility trial included patients with acute kidney injury who started SLED in the ICU. Patients were randomized to receive 25% albumin versus 0.9% saline (control) as 100 mL boluses at the start and midway through SLED, for up to 10 sessions. The recruitment rate and other feasibility outcomes were determined. Secondary exploratory outcomes included ultrafiltration volumes and metrics of hemodynamic instability. RESULTS: Sixty patients (271 SLED sessions) were recruited over 10 months. Age and severity of illness were similar between study groups. Most had septic shock and required vasopressor support at baseline. Protocol adherence occurred for 244 sessions (90%); no patients were lost to follow-up; no study-related adverse events were observed; open label albumin use was 9% and 15% in the albumin and saline arms, respectively. Ultrafiltration volumes were not significantly different. Compared to the saline group, the albumin group experienced less hemodynamic instability across all definitions assessed including a smaller absolute decrease in systolic blood pressure (mean difference 10.0 mmHg, 95% confidence interval 5.2-14.8); however, there were significant baseline differences in the groups with respect to vasopressor use prior to SLED sessions (80% vs 61% for albumin and saline groups, respectively). CONCLUSIONS: The efficacy of using hyperoncotic albumin to prevent hemodynamic instability in critically ill patients receiving SLED remains unclear. A larger trial to evaluate its impact in this setting, including evaluating clinically relevant outcomes, is feasible. Trial registration ClinicalTrials.gov (NCT03665311); First Posted: Sept 11th, 2018. https://clinicaltrials.gov/ct2/show/NCT03665311?term=NCT03665311&draw=2&rank=1.

Accurate determination of glomerular filtration rate in adults for carboplatin dosing: Moving beyond Cockcroft and Gault.

OBJECTIVE: Carboplatin is a cytotoxic chemotherapy drug developed in the 1980s which is still widely used today across various tumour types. Despite its common application, there remains a significant controversy and practice variation on its unique method of dosing by area under the curve (AUC). One potential reason for this variability stems from the reliance of using an estimated glomerular filtration rate (eGFR) as an extrapolation of the measured GFR (mGFR) which the commonly used Calvert equation was originally validated for. This review takes a novel and collaborative nephro-oncology approach to highlight the historical evolution of carboplatin dosing, methods for estimating GFR and its relative performance in the application of carboplatin dosing for adult patients. DATA SOURCES: We reviewed all pertinent publications comparing carboplatin AUC-based dosing in adult patients based on the various methods of GFR measurements or estimations in order to provide a comprehensive description of each method's advantages and risks. DATA SUMMARY AND CONCLUSIONS: The Cockcroft-Gault equation has been widely studied but newer eGFR equations, such as the CKD-Epidemiology Collaboration (CKD-EPI) or Janowitz-Williams equation have outperformed the Cockcroft-Gault in recent studies.

Retrospective study of patients on hybrid dialysis: Single-center data from North America.

Hybrid dialysis involves combining peritoneal and hemodialysis (HD) in patients with end-stage renal disease. Its reported use is quite limited outside of Japan. We present a retrospective review of 18 patients at our center that received this therapy and describe their ultimate disposition. We observed that 39% of the population on hybrid dialysis ultimately transitioned to full in center HD, 28% continue until death, and 33% either transition to home HD or received a transplant. In our center, hybrid dialysis was successful as a bridging therapy or in balancing continuation of dialysis with quality of life among those with a limited prognosis.

A Survey of Training for Temporary Hemodialysis Catheter Insertion During Nephrology Fellowship in Canada: An Update.

BACKGROUND: Controversy exists as to whether the insertion of temporary hemodialysis catheters (THDCs) should remain a mandatory requirement of nephrology fellowship training in Canada. A survey conducted by our group in 2012 showed that many nephrology trainees reported inadequate training to achieve procedural competence. OBJECTIVE: To determine the current practices and training of the insertion of THDCs in nephrology fellowship programs in Canada and how this has evolved since 2012. DESIGN: A survey study was designed comprising the following sections: demographics, details regarding the number and types of THDCs inserted within the past 6 months of fellowship training, adherence to sterile techniques, the use of ultrasound guidance during THDC insertion, training for THDC insertion received before and during nephrology fellowship, and self-perceived adequacy of training and competence in THDC insertion. SETTING: The survey was distributed by e-mail in May 2018 either directly or through Canadian nephrology training programs. PARTICIPANTS: Current trainees of Canadian adult nephrology training programs. MEASUREMENTS: Descriptive statistics were used to analyze the summarized data. The means and interquartile ranges (IQRs) were used to summarize the number of THDC insertions performed, and the categorical data, including data on training and self-perceived competency, were reported using frequencies and percentages. A chi-squared test was used to evaluate the relationship between those who received simulation-based training and self-perceived confidence in either internal jugular or femoral catheter insertion. METHODS: An online survey, available in both English and French, was distributed to all adult nephrology trainees in Canada in May 2018 either directly or through their respective programs. RESULTS: Completed surveys were received from 46 of 136 nephrology trainees across Canada (34%). Of those who responded, the median (IQR) number of combined femoral and/or internal jugular THDCs inserted in the past 6 months of fellowship training was 3 (1-6). Eight respondents (17%) indicated that they had not inserted a THDC in the past 6 months. However, only 7 of 42 respondents (17%) indicated that they did not feel competent or adequately trained to perform either femoral or internal jugular THDC insertion. LIMITATIONS: Limitations of the study include participation of trainees at different stages of their training. Many trainees indicated that it was not a requirement to keep a formal log of their procedures performed and likely had recall bias when reporting their procedure details. CONCLUSIONS: Nephrology fellows in Canada are performing fewer THDC insertions compared to 2012 but report higher levels of self-perceived competence and better training. This may be as a result of significantly more simulation-based training. Our data suggest that training to procedural mastery using simulation-based techniques may be a path to ensuring adequate training for THDC insertion despite fewer procedures being performed during training.

CONTEXTE: Une controverse existe à savoir si l'insertion de cathéters d'hémodialyse temporaires (CHT) devrait demeurer une exigence de la formation des néphrologues au Canada. Une enquête menée par notre groupe en 2012 montrait que plusieurs stagiaires en néphrologie jugeaient leur formation insuffisante pour l'acquisition de compétences techniques. OBJECTIFS: Faire état des pratiques et de la formation actuelles en matière d'insertion de CHT dans les programs canadiens de stages en néphrologie, et témoigner de l'évolution de la situation depuis 2012. CONCEPTION DE L'ÉTUDE: L'étude, sous forme de sondage, a été conçue en incluant les éléments suivants: les données démographiques, les détails quant au nombre et au type de cathéters insérés au cours des six derniers mois de la formation, l'observance des techniques d'asepsie, le recours à l'échoguidage pendant la procédure, la formation reçue sur l'insertion de CHT avant et pendant le stage en néphrologie, et l'auto-évaluation de l'adéquation de la formation et des compétences individuelles en insertion de CHT. TYPE D'ÉTUDE: Un sondage distribué en mai 2018 par courrier électronique, directement ou par l'entremise des programs de formation en néphrologie. SUJETS: Les stagiaires actuels des programs canadiens de formation en néphrologie adulte. MESURES: Des statistiques descriptives ont été utilisées pour analyzer les données agrégées. Les moyennes et les écarts interquartiles (EIQ) ont été employés pour résumer le nombre d'insertions de CHT. Les données catégorielles, y compris les données sur la qualité de la formation et la compétence perçue, ont été rapportées en fréquences et en pourcentages. Enfin, un test x2 a évalué le lien entre la compétence individuelle perçue quant à l'insertion d'un cathéter dans la jugulaire interne ou dans la veine fémorale et le fait d'avoir ou non reçu une formation par simulation. MÉTHODOLOGIE: En mai 2018, un sondage électronique, disponible en anglais et en français, a été distribué à tous les stagiaires canadiens en néphrologie adulte, directement ou par l'intermédiaire de leurs programs respectifs. RÉSULTATS: Des 136 stagiaires ayant reçu le sondage, 46 (34%) l'ont retourné dument rempli. Le nombre médian combiné de CHT insérés dans la veine fémorale et/ou la jugulaire interne au cours des 6 derniers mois de formation était de 3 (EIQ: 1 à 6). Huit répondants (17%) n'avaient pas pratiqué cette procédure au cours des six derniers mois. Néanmoins, seulement 7 répondants sur un total de 42 (17%) ont indiqué ne pas se sentir à l'aise ou suffisamment formés pour pratiquer l'insertion d'un CHT dans la veine fémorale ou dans la jugulaire interne. LIMITES: L'étude porte sur des stagiaires à différentes étapes de leur formation. Aussi, plusieurs stagiaires ont indiqué qu'on ne les obligeait pas à tenir un registre officiel des procédures effectuées, leur déclaration pourrait donc présenter un biais de rappel. CONCLUSION: Les stagiaires en néphrologie canadiens pratiquent moins d'insertions de CHT, mais signalent une meilleure formation et des niveaux plus élevés de compétence perçue qu'en 2012, un constat qui pourrait s'expliquer par une formation axée sur la simulation de meilleure qualité. Ces résultats suggèrent que l'apprentissage de procédures par des techniques axées sur la simulation pourrait constituer un moyen d'assurer une formation adéquate en insertion de CHT, et ce, malgré le nombre réduit de procédures exécutées pendant la formation.

Death due to delirium: a case of a self-cut hemodialysis dialysis catheter - a case report.

BACKGROUND: Neuropsychiatric conditions such as depression, delirium and cognitive impairment are common in patients with end-stage kidney disease (ESKD) and individuals suffering from ESKD are more likely to commit suicide than members of the general population. Self-harm gestures are not infrequent for ESKD patients suffering from depression, but not well described in other conditions. CASE PRESENTATION: We present a case of self-harm in a patient with ESKD suffering from acute delirium. A man in his mid-seventies was admitted with fungal peritoneal dialysis (PD) associated peritonitis. On the first day post operatively, he was found with absent vital signs due to exsanguination from newly inserted central catheter which he which had self-severed. He died a few days later as a result of the self-harm gesture. CONCLUSION: This case highlights that delirium may lead to self-harm events in ESKD and identifies a few strategies to help reduce the risk of self-harm events.

Uremic leontiasis ossea due to secondary hyperparathyroidism complicated by vitamin C deficiency in a non-adherent chronic hemodialysis patient: A case report.

Non-adherence to medical therapy in patients with end-stage kidney disease (ESKD) can lead to severe metabolic derangements rarely seen in the current medical era. Such complications may take the form of secondary hyperparathyroidism (HPT) leading to rare manifestations of bone mineral disease, and profound vitamin C deficiency from poor nutrition combined with removal of water-soluble vitamins during dialysis. Secondary HPT causes renal osteodystrophy which can lead to diffuse enlargement of the facial skeleton and morphological changes suggestive of leontiasis ossea. We report a 36-year-old, non-adherent woman on chronic dialysis for over 10 years who developed progressive, diffuse facial bone enlargement in the context of years of extreme HPT and newly diagnosed severe vitamin C deficiency. Imaging revealed diffuse hypertrophy of the maxillary and mandibular bones. Histopathology showed extensive fibro-osseous proliferation without evidence of Brown tumor, suggestive of uremic leontiasis ossea. In this report, we discuss the orofacial manifestations of secondary HPT and the possible potentiating role of vitamin C deficiency on the development of renal osteodystrophy through altered vitamin D metabolism. Non-adherent patients on chronic dialysis should be evaluated for vitamin C deficiency, and the development of uremic leontiasis ossea should be considered when such patients present with distortion of facial features in the context of severe secondary HPT.

Safety and Efficacy of Tinzaparin Anticoagulation during Nocturnal Hemodialysis.

BACKGROUND: The safety and efficacy of low-molecular-weight heparin in the prevention of extracorporeal dialysis circuit clotting among in-center extended duration nocturnal hemodialysis (INHD) patients are unknown. The aim of this study was to determine the safety and efficacy of 2 doses of tinzaparin, among INHD patients receiving 6-8 h hemodialysis, 3 times per week. METHODS: We conducted a retrospective cohort study to examine antifactor Xa levels at time 0, 2 h, 4 h mid-hemodialysis (mid-HD), 6 h, and at end of each INHD session for 4 weeks and to determine extracorporeal dialysis circuit clotting and bleeding events after switching from unfractionated heparin to tinzaparin, using a standard protocol of tinzaparin delivery at the initiation and midpoint of HD. RESULTS: All 16 patients in The Ottawa Hospital INHD program were converted to tinzaparin and followed for 177 INHD sessions. Mean antifactor Xa level at 2 h of HD was 0.41 ± 0.21 (SD) IU/mL, at 4 h (mid-HD) 0.19 ± 0.17 IU/mL, at 6 h 0.44 ± 0.21 IU/mL, and at dialysis end 0.26 ± 0.14 IU/mL. Antifactor Xa levels were undetectable at the start of INHD, suggesting no tinzaparin accumulation. Five patients required an increase in tinzaparin due to extracorporeal dialysis circuit clotting. There were no bleeding events. One patient required a switch to fondaparinux due to an adverse reaction. CONCLUSION: Tinzaparin was safe and efficacious for most INHD patients without accumulation or bleeding. The conversion from unfractionated heparin to tinzaparin required an increased tinzaparin dose for 31% of INHD patients.

Accurate GFR in obesity-protocol for a systematic review.

BACKGROUND: Obesity is increasing globally. Chronic kidney disease (CKD) is strongly associated with obesity. Kidney function is commonly estimated with equations using creatinine (such as CKD-EPI equation) which is a product of muscle metabolism. Decisions about categorizing CKD, planning modality of renal replacement therapies, and adjusting dosages of medications excreted by the kidneys are done using these equations. However, it is not well appreciated that creatinine-based equations may not accurately estimate kidney function in obese individuals. We plan a systematic review of diagnostic studies which will compare estimating equations to actual measured kidney function. METHODS: We will systematically search electronic bibliographic databases including MEDLINE, EMBASE, and the Cochrane Library with no restrictions on language or specific dates. The search terms will be adapted for the different databases using a combination of Medical Subject Heading and relevant keywords contained in titles and abstracts. Our preliminary search strategy using Cochrane, MEDLINE, and EMBASE databases have identified 190, 1246, and 1660 citations, respectively. For all studies selected, we will extract information on general study characteristics, study participant (age, sex, ethnicity, weight, height, BMI, BSA), type and protocol of reference standard utilized, the index test studied, the methodology of measurement of index test, categories of GFR, the proportion of eGFR within 10, 20, 30, 40, and 50% of measured GFR, and bias between eGFR and measured GFR. If the quality of methods and risk of bias are adequate, we will perform a meta-analysis. We will assess the heterogeneity using the χ 2 and the I 2 statistics to examine whether the estimates from studies included could be pooled. Sensitivity and multivariate meta-regression analyses will be performed to assess the effects of clinical factors and socio-demographic characteristics reported in included studies on the meta-analytic estimates. All analysis will be performed using the Comprehensive Meta-analysis software. DISCUSSION: This systematic review might help to inform clinicians on the best equation to use in patients with obesity and CKD for staging of CKD and for medication dosing. If no equation is deemed suitable, this review will form a basis for future studies of GFR in obese individuals. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018104345.