Self-cannulation of the vascular access in home hemodialysis: Overcoming patient-level barriers.

Patients with end-stage kidney disease who are considering home hemodialysis (HHD) face the challenge of learning to self-cannulate their arteriovenous access. Current practice discourages the use of tunneled central venous catheters, with recent indications that self-cannulating patients have superior outcomes. Patient-level barriers do not appear to preclude a successful HHD program and should not be viewed as insurmountable by healthcare staff or patients. The healthcare team must address patient fears while instructing the patient to perform self-cannulation safely. Identification and understanding of the barriers perceived by the patient will allow the patient and healthcare team work collaboratively, toward the goal of independence with self-cannulation both during initial training and follow-up care. The aim of this review was to provide a practical resource to aid in the identification and resolution of these patient-level barriers, with the overall goal of improving the patient experience and medical outcomes in home hemodialysis programs.

The Role of Desmopressin in the Management of Severe, Hypovolemic Hyponatremia: A Single-Center, Comparative Analysis.

BACKGROUND: The role of desmopressin (DDAVP) to prevent or treat rapid serum sodium concentration ([Na]s) correction during hyponatremia management remains unclear. OBJECTIVE: To assess DDAVP use during the first 48 hours of severe, hypovolemic hyponatremia management. The primary study hypothesis was that the use of DDAVP would slow the rate of [Na]s correction compared with those not receiving DDAVP. DESIGN: A retrospective, observational, comparison study. SETTING: A single, Canadian, tertiary center. PATIENTS: All admitted patients referred to the nephrology service for severe, hypovolemic hyponatremia ([Na]s < 125 mmol/L) over a 12-month period from November 2015. MEASUREMENTS: The primary outcomes measure was the [Na]s after medical management for 48 hours. The length of hospital stay was also measured. METHODS: Patients were grouped based on whether they received DDAVP during the first 48 hours of treatment, and [Na]s correction was compared between groups using linear regression. An exploratory, multivariable, linear regression model was used to adjust for diabetes status, active malignancy, intensive care unit (ICU) admission, and hypertonic saline administration. RESULTS: Twenty-eight patients were identified, with baseline mean [Na]s of 112.7 ± 6.6 mmol/L versus 117 ± 4.3mmol/L (P = .06) in those receiving (n = 16) and not receiving DDAVP (n = 12), respectively. The DDAVP group had a more rapid [Na]s correction on the first day compared with those not receiving DDAVP, 7.7 ± 3.8 mmol/L/d versus 5.1 ± 2.0 mmol/L/d (P = .04). On the second day, there was a similar rate of [Na]s correction between groups: 1.3 ± 4.3 mmol/L/d versus 2.6 ± 3.2 mmol/L/d (P = .39), respectively. Overall, there was no difference in [Na]s correction after 48 hours between those who received DDAVP and those who did not: 121.7 ± 7.5 mmol/L versus 124.8 ± 5.7 mmol/L (P = .24). Patients who had experienced an overcorrection were successfully treated with DDAVP (n = 5), so that no patient had an ongoing overcorrection by 48 hours. LIMITATIONS: The limited sample size and lack of randomization preclude definitive conclusion on the additional benefit of DDAVP to standard care. CONCLUSION: DDAVP appears to be safe and effective in the management of severe, hypovolemic hyponatremia, associated with similar [Na]s correction to those who did not receive DDAVP after 48 hours, despite an initial more rapid correction. A randomized trial should examine what benefit DDAVP confers in addition to standard care in the management of severe, hypovolemic hyponatremia.

CONTEXTE: Dans le contexte du traitement de l'hyponatrémie, le rôle de la desmopressine (DDAVP) pour prévenir et contrer la correction rapide de la concentration de sodium sérique ([Na] s) demeure nébuleux. OBJECTIF DE L'ÉTUDE: Notre objectif était d'étudier l'effet de l'administration de DDAVP au cours des 48 premières heures du traitement de l'hyponatrémie hypovolémique grave. L'hypothèse principale de l'étude était que l'administration de DDAVP ralentit le rythme de correction de la [Na] s chez les patients traités en comparaison des parents non traités. CADRE ET TYPE D'ÉTUDE: Il s'agit d'une étude comparative observationnelle, menée de façon rétrospective dans un centre de soins tertiaires canadien. PATIENTS: Ont été inclus tous les patients admis et ayant été dirigés vers l'unité de néphrologie en raison d'une hyponatrémie hypovolémique grave ([Na] s inférieure à 125 mmol/l) sur une période de douze mois à partir de novembre 2015. MESURES: La [Na] s après les 48 premières heures de traitement constituait la mesure principale. On a également noté la durée de l'hospitalisation des patients. MÉTHODOLOGIE: Les patients ont été regroupés selon qu'ils avaient reçu ou non de la DDAVP dans les 48 premières heures de traitement, et la comparaison de la correction de la [Na] s entre les groupes a été analysée par régression linéaire. Un modèle de régression linéaire multivariée et exploratoire a été utilisé pour ajuster les résultats en tenant compte de la présence de diabète, d'une affection maligne active, d'une admission à l'unité des soins intensifs et d'une administration de solution saline hypertonique. RÉSULTATS: Un total de 28 patients a été retenu pour l'étude. La [Na] s initiale moyenne était de 112,7 ± 6,6 mmol/l pour les patients ayant reçu de la DDAVP (n = 16) contre 117 ± 4,3 mmol/l pour les douze patients du groupe non traité (P = 0,06). Dans le groupe traité, la correction de la [Na] s a été plus rapide au cours de la première journée comparativement à celle mesurée chez les patients non traités (7,7 ± 3,8 mmol/l/jour contre 5,1 ± 2,0 mmol/l/jour; P = 0,04). Le taux de correction de la [Na] s s'est avéré similaire dans les deux groupes au cours de la deuxième journée de suivi, avec des valeurs de 1,3 ± 4,3 mmol/l/jour pour le groupe ayant reçu de la DDAVP, et de 2,6 ± 3,2 mmol/l/jour pour le groupe non traité. Dans l'ensemble, aucune différence de correction de la [Na] s n'a été observée entre les deux groupes après 48 heures de suivi. Les valeurs se situaient alors à 121,7 ± 7,5 mmol/l pour les patients ayant reçu de la DDAVP et à 124,8 ± 5,7 mmol/l pour les patients non traités (P = 0,24). Cinq patients ont expérimenté une surcorrection et ont dû être traités à la DDAVP; le traitement a bien fonctionné, de sorte qu'aucun patient ne présentait de surcorrection après 48 heures. LIMITES DE L'ÉTUDE: La taille restreinte de l'échantillon et l'absence de répartition aléatoire des cas nous empêchent de tirer une conclusion définitive quant à l'avantage supplémentaire apporté par l'ajout de la DDAVP aux procédures de soins courantes. CONCLUSION: La DDAVP semble efficace et sécuritaire pour traiter l'hyponatrémie hypovolémique grave. Elle est associée à une correction similaire à celle mesurée après 48 heures chez les patients non traités, quoiqu'elle entraîne une correction initiale de la [Na] s plus rapide. Nous sommes d'avis qu'un essai clinique à répartition aléatoire devrait être mené pour étudier les bienfaits offerts par l'ajout de la DDAVP aux procédures de soins courantes contre l'hyponatrémie hypovolémique grave.

Can we manage lupus nephritis without chronic corticosteroids administration?

The outcome of lupus nephritis (LN) has changed since the introduction of glucocorticoids (GCs), which dramatically reduced the mortality related to one of the most severe complications of systemic lupus erythematosus (SLE). Since the 1950's, other immunosuppressants, including biologic drugs (i.e. rituximab) have aided in maintaining remission, preserving kidney function, but not preventing treatment-related toxicity. GCs still remain the cornerstone in the treatment of SLE, including LN, and they are widely used in clinical practice. However, GC administration represents a double-edged sword. Indeed, from one side they allow a fast and effective control of disease activity by dampening inflammation; from the other side, they have many and severe side effects leading to organ damage. In this paper, we will discuss pros and cons of the chronic use of GCs, especially focusing on LN.

Renal Tubular Toxicity Associated With Rosuvastatin Therapy.

Preapproval clinical trials examining the safety and efficacy of rosuvastatin demonstrated an increased incidence of proteinuria, hematuria, rhabdomyolysis, and other acute kidney injury of unknown cause at high doses. The latter cases manifested with urine sediment findings and in some cases, renal histology, indicating renal tubular injury in the absence of rhabdomyolysis. Despite these provocative findings, there have been very few reports in the literature regarding non-rhabdomyolysis-mediated acute kidney injury associated with high-dose rosuvastatin since its widespread introduction more than a decade ago, suggesting that it is either a rare entity or systematically underdiagnosed and under-reported. We present a case of renal tubular toxicity attributable to the initiation of rosuvastatin treatment at a dose of 40mg in a patient with no prior evidence of kidney disease. Tubular toxicity should be considered in cases of unexplained kidney injury in the setting of exposure to a potent statin such as rosuvastatin, particularly at high dose. The limited evidence suggests a good kidney prognosis following withdrawal of the agent in these cases.

The influence of socioeconomic status on patient survival on chronic dialysis.

Socioeconomic status (SES) has been linked to worse end-stage kidney disease survival. The effect of SES on survival on chronic dialysis, including the impact of transplantation, was examined. A retrospective, observational study investigated the association of SES with dialysis patient survival, with censoring at time of transplantation. Adult patients commencing dialysis from 1990 to 2009 in an Irish tertiary center received a spatial SES score using the 2011 Pobal Haase-Pratschke Deprivation Index and were compared by quartile. Cox proportional hazard models and Kaplan-Meier survival analysis examined any association of SES with survival. The 1794 patients included had a median follow-up of 3.8 years. Patients in the lowest SES area quartile were significantly younger than the highest, mean age 56.7 vs. 59 years, P = 0.006, respectively. There was no association between SES area score and survival in an unadjusted model (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.99-1.01). Survival in the highest SES area quartile was superior to the lowest SES in a multivariable adjusted model including age, gender, and dialysis modality (HR 0.83, 95% CI 0.70-0.99, P = 0.04). These results were only mildly attenuated by censoring at time of transplantation (highest SES area quartile deprived vs. lowest SES area quartile, HR 0.85, 95% CI 0.70-1.03, P = 0.09). Superior patient survival was identified in the highest SES areas compared with the lowest following age-adjusted analyses, despite the older population in the most affluent areas. Further research should focus on identifying modifiable targets for intervention that account for this socioeconomic-related survival advantage.

Influence of socioeconomic status on allograft and patient survival following kidney transplantation.

AIM: Whether socioeconomic status confers worse outcomes after kidney transplantation is unknown. Its influence on allograft and patient survival following kidney transplantation in Ireland was examined. METHODS: A retrospective, observational cohort study of adult deceased-donor first kidney transplant recipients from 1990 to 2009 was performed. Those with a valid Irish postal address were assigned a socioeconomic status score based on the Pobal Hasse-Pratschke deprivation index and compared in quartiles. Cox proportional hazards models and Kaplan-Meier survival analysis were used to investigate any significant association of socioeconomic status with patient and allograft outcomes. RESULTS: A total of 1944 eligible kidney transplant recipients were identified. The median follow-up time was 8.2 years (interquartile range 4.4-13.3 years). Socioeconomic status was not associated with uncensored or death-censored allograft survival (hazard ratio (HR) 1.0, 95% confidence interval (CI) 0.99-1.00, P = 0.33 and HR 1.0, 95% CI 0.99-1.00, P = 0.37, respectively). Patient survival was not associated with socioeconomic status quartile (HR 1.0, 95% CI 0.93-1.08, P = 0.88). There was no significant difference among quartiles for uncensored or death-censored allograft survival at 5 and 10 years. CONCLUSION: There was no socioeconomic disparity in allograft or patient outcomes following kidney transplantation, which may be partly attributable to the Irish healthcare model. This may give further impetus to calls in other jurisdictions for universal healthcare and medication coverage for kidney transplant recipients.