Post-transplant outcomes in recipients of living donor kidneys and intended recipients of living donor kidneys.

BACKGROUND: Long-term kidney transplant survival at the population level is consistently favorable, but this survival varies widely at an individual level due to both recipient and donor factors. The distinct contribution of recipient and donor factors to individual post kidney transplant outcome remains unclear. Comparing outcomes in deceased donor (DD) recipients with potential but non-actualized living donors (DD1) to those recipients with actualized living donors (LD), and to DD recipients without potential living donors (DD0) may provide transplant candidates with more information about their own post-transplant prognosis. METHODS: We conducted an observational retrospective cohort study of kidney transplant candidates presenting to our centre for evaluation between 01/01/06 and 31/12/18, and who also received a transplant during that time. Patients were followed to 31/08/2019. Candidates were classified as DD0, DD1, or LD based on whether they had an identified living donor at the time of initial pre-transplant assessment, and if the donor actualized or not. Primary outcome was 5-year death-censored graft survival, adjusted for common pre- and post-transplant donor and recipient risk factors. Secondary outcomes analyzed included patient survival and graft function. RESULTS: There were 453 kidney transplant recipients (LD = 136, DD1 = 83, DD0 = 234) who received a transplant during the study period. DD0 and DD1 did not differ in key donor organ characteristics. The 5-year death censored graft survival of DD1 was similar to LD (p = 0.19). DD0 graft survival was inferior to LD (p = 0.005), but also trended inferior to DD1 (p = 0.052). By multivariate Cox regression analysis, LD demonstrated similar 5-year graft survival to DD1 (HR for graft loss 0.8 [95% CI 0.25-2.6], p = 0.72) but LD graft survival was superior to DD0 (HR 0.34 [0.16-0.72], p = 0.005). The 5-year patient survival in DD1 was similar to LD (p = 0.26) but was superior to DD0 (p = 0.01). CONCLUSIONS: DD recipients with potential but non-actualized living donors exhibit similar mid-term graft and patient survival compared to LD recipients. Having an identified living donor at the time of pre-transplant assessment portends a favorable prognosis for the recipient.

Retrospective Analysis of Tacrolimus Intrapatient Variability as a Measure of Medication Adherence.

BACKGROUND: Increased intrapatient variability (IPV) in tacrolimus levels is associated with graft rejection, de novo donor-specific antibodies, and graft loss. Medication nonadherence may be a significant contributor to high IPV. OBJECTIVE: The objective of this study is to determine the utility of tacrolimus IPV in detecting nonadherence by examining the relationship between self-reported adherence and tacrolimus coefficient of variability (COV), a measure of IPV. DESIGN: Retrospective cohort study. SETTING: St. Michael's Hospital, Toronto, Ontario. PATIENTS: All patients who were at least 1-year post-kidney transplant as of March 31, 2019, prescribed tacrolimus as an immunosuppressant and had a self-reported adherence status. Patients were excluded from the primary analysis of examining the correlation between COV and self-reported adherence if they lacked a calculatable COV. MEASUREMENTS: Self-reported adherence, COV, demographic data, transplant, and medication history. METHODS: A modified Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) administered by healthcare professionals to assess self-reported adherence was used. The COV of tacrolimus trough levels was calculated and its correlation to BAASIS response was noted. The median COV was used as a cutoff to examine the characteristics of patients deemed "high COV" and "low COV." RESULTS: A total of 591 patients fit the initial criteria; however, only 525 had a recent calculatable COV. Overall, 92.38% of the population were adherent by self-report. Primary analysis identified a COV of 25.2% and 29.6% in self-reported adherent and nonadherent patients, respectively, though the result was not significant (P = .2). Secondary analyses showed a significant correlation between younger age at transplant and at the time of adherence self-reporting with nonadherence (P = .01). In addition, there was a strong correlation between those nonadherent with routine post-transplant blood work and younger age (P < .01). LIMITATIONS: The limitations included modified nonvalidated BAASIS questionnaire, social desirability bias, BAASIS only administered in English, and patients with graft failure not active in clinic not being captured. CONCLUSIONS: The COV should not be used as the sole method for determining medication adherence. However, COV may have some utility in capturing individuals who are not adherent to their blood work or patients who are having a poor response to tacrolimus and should be switched to another medication.

CONTEXTE: Une plus grande variabilité intra-individuelle des taux de tacrolimus est associée au rejet de la greffe, aux anticorps spécifiques au donneur de novo et à la perte du greffon. La non-observance du traitement médicamenteux pourrait être un facteur important de cette variabilité élevée. OBJECTIF: L'objectif de cette étude était d'évaluer la pertinence de la variabilité intra-individuelle des taux de tacrolimus pour la détection de la non-observance en examinant la relation entre l'observance autodéclarée et le coefficient de variabilité (CoV) du tacrolimus, une mesure de la variabilité intra-individuelle. TYPE D'ÉTUDE: Étude de cohorte rétrospective. CADRE: L'hôpital St Michael's de Toronto (Ontario). SUJETS: Tous les patients qui, au 31 mars 2019, avaient subi une transplantation depuis au moins un an, à qui on avait prescrit du tacrolimus comme immunosuppresseur et qui déclaraient adhérer à leur traitement. Les patients qui ne disposaient pas d'un CoV calculable ont été exclus de l'analyse principale examinant la corrélation entre le CoV et l'observance autodéclarée. MESURES: L'observance autodéclarée, le CoV, les données démographiques, ainsi que les antécédents de transplantation et pharmaceutiques des patients. MÉTHODOLOGIE: Une version modifiée du questionnaire BAASIS (Basel Assessment of Adherence to Immunosuppressive Medications Scale) administrée par les professionnels de la santé a été employée pour évaluer l'observance autodéclarée. Le CoV des concentrations minimales de tacrolimus a été calculé et sa corrélation avec les réponses au questionnaire BAASIS a été notée. Le CoV médian a été employé comme mesure limite pour examiner les caractéristiques des patients réputés avoir un « CoV élevé ¼ ou un « CoV faible ¼. RÉSULTATS: Au total, 591 patients satisfaisaient aux critères initiaux, mais seulement 525 disposaient d'une mesure récente et calculable du CoV. Dans l'ensemble, 92,38 % de la population étudiée déclarait adhérer au traitement. L'analyse primaire a permis d'établir le CoV à 25,2 % chez les patients adhérents et à 29,6 % chez les patients non-adhérents; bien que les résultats n'aient pas été jugés significatifs (p = 0,2). Les analyses secondaires ont montré une corrélation significative entre la non-observance autodéclarée au traitement et le fait d'être plus jeune au moment de la transplantation (p = 0,01). On a en outre observé une forte corrélation entre la non-observance des bilans sanguins habituels post-transplantation et un plus jeune âge (p < 0,01). LIMITES: La version modifiée du questionnaire BAASIS n'a pas été validée, l'étude comporte de possibles biais de désirabilité sociale, le questionnaire BAASIS n'a été passé qu'en anglais et les patients avec échec de la greffe qui étaient inactifs en clinique n'ont pu être saisis. CONCLUSION: Le coefficient de variabilité ne devrait pas être le seul élément à considérer pour déterminer l'adhérence au traitement. Ce coefficient peut cependant avoir une certaine utilité pour repérer les patients qui ne font pas leurs bilans sanguins ou les patients qui répondent peu au tacrolimus et qui devraient passer à un autre médicament.

A Peritoneal Dialysis Access Quality Improvement Initiative: A Single-Center Experience.

Background:Little evidence exists regarding optimal peritoneal dialysis (PD) access insertion pathways, benchmarking for patency targets, and definitions of access dysfunction.Methods:This quality improvement (QI) project evaluated patients with PD catheters inserted at a single center in Toronto, Canada, following: establishment of PD catheter insertion protocols, a PD access coordinator, PD access operator training, and outcomes reporting. We define primary vs secondary PD catheter dysfunction by presentation before/after initial home PD treatment. We report catheter dysfunction rates, interventions restoring PD catheter patency (interventional radiology [IR] vs advanced laparoscopic [AL]) (embedded vs non-embedded) between 2012 and 2017.Results:A total of 297 first PD catheters were inserted between January 2012 and December 2017. Interventional radiology PD catheters (n = 94) were placed in older patients with greater comorbidities and less prior abdominal surgery than AL-placed catheters. Indications for IR insertion included need for urgent dialysis given resource availability (36.2% [n = 34]) and prohibitive surgical risk (26.6% [n = 25]). Interventional radiology-inserted catheters had overall (primary and secondary) dysfunction rates of 17%. Non-embedded AL catheters had 16.1% overall dysfunction. Embedded AL-inserted PD catheters had a 24.6% overall dysfunction rate. Among all dysfunctional catheters, IR manipulation was successful in 31% (n = 11), and surgical revision was necessary in all unsuccessful cases with either lysis of adhesions or omentopexy to establish patency.Conclusion:Our PD catheter QI initiative involved tracking, outcome reporting, defining PD catheter dysfunction and PD access insertion pathway development, yielding important insights into opportunities for program improvement. Multicenter research initiatives are needed to further improve PD access dysfunction definitions and to establish the best benchmarks for these metrics.

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.

The Association Between Conversion to In-centre Nocturnal Hemodialysis and Left Ventricular Mass Regression in Patients With End-Stage Renal Disease.

BACKGROUND: In-centre nocturnal hemodialysis (INHD, 7-8 hours/session, 3 times/week) is an increasingly utilized form of dialysis intensification, though data on the cardiovascular benefits of this modality are limited. METHODS: In this prospective cohort study, we enrolled 67 prevalent conventional hemodialysis (CHD, 4 hours/session, 3 times/week) recipients at 2 medical centres in Canada, of whom 37 converted to INHD and 30 remained on CHD. The primary outcome was the change in left ventricular mass (LVM) after 1 year as assessed by cardiac magnetic resonance imaging. Secondary outcomes included changes in serum phosphate concentration, phosphate binder burden, haemoglobin, erythropoiesis stimulating agent usage, and blood pressure. RESULTS: Conversion to INHD was associated with a 14.2 (95% confidence interval [CI] 1.2-27.2) g reduction in LVM as compared with continuation on CHD. This result was maintained after adjustment for baseline imbalances between the groups and in ancillary analyses. There was a trend toward a larger drop in systolic blood pressure (9.8 [95% CI, -1.4-20.9] mm Hg) among INHD recipients with a significant reduction in the number of prescribed antihypertensive agents (0.7 [95% CI, 0.3-1.1] agents). Serum phosphate declined by 0.40 (95% CI, 0.16-0.63) mmol/L among INHD recipients without any difference in calcium-based phosphate binder requirements, as compared with those who remained on CHD. CONCLUSIONS: Compared with continuation of CHD, conversion to INHD was associated with significant LVM regression and reduction in serum phosphate concentration at 1 year.

Early outgrowth pro-angiogenic cell number and function do not correlate with left ventricular structure and function in conventional hemodialysis patients: a cross-sectional study.

BACKGROUND: Left ventricular hypertrophy (LVH) is commonly found in chronic dialysis (CD) recipients, and is associated with impaired microvascular cardiac perfusion and heart failure. In response to LVH and cardiac ischemia, early outgrowth pro-angiogenic cellS(EPCs) mobilize from the bone marrow to facilitate angiogenesis and endothelial repair. In the general population, EPC number and function correlate inversely with cardiovascular risk. In end-stage renal disease (ESRD), EPC number and function are generally reduced. OBJECTIVES: To test whether left ventricular abnormalities retain their potent ability to promote EPC reparative responses in the setting of ESRD. DESIGN: Cross-sectional study. SETTING: St. Michael's Hospital, Toronto, Ontario, Canada. PATIENTS: 47 prevalent chronic dialysis recipients. MEASUREMENTS: (1) circulating CD34(+) and CD133(+) EPC number, (2) cultured EPC migratory ability, in vitro differentiation potential, and apoptosis rate, and (3) cardiac magnetic resonance-measured LV mass, volume and ejection fraction. METHODS: Bivariate correlation analysis was performed with Spearman's rho test. RESULTS: Of the 47 patients (mean age: 54 ± 13 years), the mean delivered urea reduction was 74 ± 10 %. Mean LV mass was 123 ± 38 g. Circulating CD34(+) and CD133(+) EPCs represented 0.14 % (IQR: 0.05 - 0.29 %) and 0.05 % (IQR: 0.01 - 0.10 %) of peripheral blood mononuclear cells. There were no significant correlations between any EPC parameter and measures of LV mass or ejection fraction. LIMITATIONS: Lack of a non-ESRD control population, and the inability to measure all parameters of EPC function due to limitations in blood sampling. Our inability to measure cardiac VEGF expression prevented an assessment of changes in cardiac EPC mobilization signals. CONCLUSIONS: These data suggest that in ESRD, the reparative EPC response to cardiac hypertrophy may be blunted. Further investigation of the effects of uremia on EPC physiology and its relationship to cardiac injury are required.

CONTEXTE: L'hypertrophie ventriculaire gauche (HVG), qui est associée à la perfusion cardiaque microvasculaire alterée et à l'insuffisance cardiaque, n'est pas rare chez les patients qui reçoivent une dialyse chronique. En réponse à l'HVG et à l'ischémie cardiaque, les cellules proangiogéniques à croissance précoce (CPCP) se mobilisent au sein de la moelle osseuse afin de faciliter l'angiogenèse et la réparation endothéliale. Dans l'ensemble de la population, le nombre et l'activité des CPCP sont inversement proportionnels au risque cardiovasculaire. Dans le cas d'insuffisance rénale chronique terminale (IRT), le nombre et l'activité des CPCP sont généralement réduits. OBJECTIFS: Vérifier si les anomalies du ventricule gauche demeurent aussi efficaces à promouvoir les actions réparatrices des CPCP dans le contexte de l'IRT. CONTEXTE: St. Michael's Hospital, à Toronto, en Ontario, au Canada. PARTICIPANTS: 47 cas prévalents de patients qui reçoivent une dialyse chronique. MESURES: (1) le nombre de CPCP CD34+ et CD133+ en circulation, (2) l'habileté migratoire des CPCP, le potentiel de différentiation in vitro, le taux d'apoptose, et (3) la mesure de la masse ventriculaire gauche par imagerie cardiaque à résonnance magnétique. MÉTHODES: L'analyse de la corrélation simple a été effectuée au moyen du coefficient de corrélation des rangs de Spearman. RÉSULTATS: On a observé une réduction de 74 ± 10 % en moyenne parmi les 47 participants (moyenne d'âge : 54 ± 13 ans). La masse ventriculaire gauche était de 123 ± 38 g en moyenne. Les CPCP CD34+ et CD133+ en circulation représentaient 0,14 % (IQR : 0,05­0,29 %) et 0,05 % (IQR : 0,01­0,10 %) des cellules mononuclées de sang périphérique. On n'a observé aucune corrélation substantielle entre les paramètres relatifs aux CPCP et les mesures de la masse ventriculaire gauche, ou la fraction d'éjection. LIMITES DE L'ÉTUDE: L'absence d'une population témoin non atteinte d'IRT, de même que l'inhabilité de mesurer tous les paramètres de l'activité des CPCP, en raison des limites de l'échantillon sanguin. Notre incapacité à mesurer l'expression du facteur de croissance endothéliale vasculaire nous a empêchés d'effectuer l'analyse des modifications dans les signaux cardiaques de mobilisation des CPCP. CONCLUSIONS: Ces données suggèrent que dans le cas d'une IRT, la réponse réparatrice des CPCP à l'hypertrophie cardiaque peut être atténuée. Des observations plus poussées sur les effets de l'urémie sur la physiologie des CPCP et sur le lien avec les lésions cardiaques seraient nécessaires.

Relationship between different blood pressure measurements and left ventricular mass by cardiac magnetic resonance imaging in end-stage renal disease.

Hypertension is prevalent in patients with end-stage renal disease and is strongly associated with left ventricular hypertrophy (LVH), an independent predictor of cardiovascular mortality. Blood pressure (BP) monitoring in hemodialysis patients may be unreliable because of its lability and variability. We compared different methods of BP measurement and their relationship with LVH on cardiac magnetic resonance imaging. Sixty patients undergoing chronic hemodialysis at a single dialysis center had BP recorded at each dialysis session over 12 weeks: pre-dialysis, initial dialysis, nadir during dialysis, and post-dialysis. Forty-five of these patients also underwent 44-hour inter-dialytic ambulatory BP monitoring. Left ventricular mass index (LVMI) was measured using cardiac magnetic resonance imaging and the presence of LVH was ascertained. Receiver operator characteristic curves were generated for each BP measurement for predicting LVH. The mean LVMI was 68 g/m(2) (SD = 15 g/m(2)); 13/60 patients (22%) had LVH. Mean arterial pressure measured shortly after initiation of dialysis session was most strongly correlated with LVMI (Pearson correlation coefficient r = 0.59, P < .0001). LVH was best predicted by post-dialysis systolic BP (area under the curve, 0.83; 95% confidence interval, 0.72-0.94) and initial dialysis systolic BP (area under the curve, 0.81; 95% confidence interval, 0.70-0.92). Forty-four-hour ambulatory BP and BP variability did not significantly predict LVH. Initial dialysis mean arterial pressure and systolic BP and post-dialysis systolic BP are the strongest predictors of LVH, and may represent the potentially best treatment targets in hemodialysis patients to prevent end-organ damage. Further studies are needed to confirm whether treatment targeting these BP measurements can optimize cardiovascular outcomes.

Comparative assessment of 2-dimensional echocardiography vs cardiac magnetic resonance imaging in measuring left ventricular mass in patients with and without end-stage renal disease.

BACKGROUND: While echocardiography (ECHO)-measured left ventricular mass (LVM) predicts adverse cardiovascular events that are common in hemodialysis (HD) recipients, cardiac magnetic resonance imaging (CMR) is now considered the reference standard for determination of LVM. This study aimed to evaluate concordance between LVM measurements across ECHO and CMR among chronic HD recipients and matched controls. METHODS: A single-centre, cross-sectional study of 41 chronic HD patients and 41 matched controls with normal kidney function was performed to compare LVM measurements and left ventricular hypertrophy (LVH) designation by ECHO and CMR. RESULTS: In both groups, ECHO, compared with CMR, overestimated LVM. Bland-Altman analysis demonstrated wider agreement limits in LVM measurements by ECHO and CMR in the chronic HD group (mean difference, 60.8 g; limits -23 g to 144.6 g) than in the group with normal renal function (mean difference, 51.4 g; limits -10.5 g to 113.3 g). LVH prevalence by ECHO and CMR in the chronic HD group was 37.5% and 22.5%, respectively, while 17.5% and 12.5% had LVH by ECHO and CMR, respectively, in the normal kidney function group. Intermodality agreement in the designation of LVH was modest in the chronic HD patients (κ = 0.42, P = 0.005) but strong (κ = 0.81, P < 0.001) in the patients with preserved kidney function. Agreement was strong in assessing LVH by ECHO and CMR only in those with normal kidney function. CONCLUSIONS: Our results suggest that the limitations of LVM measurement by ECHO may be more pronounced in patients receiving HD, and provide additional support for the use of CMR in research and clinical practice when rigourous assessment of LVM is essential.

Arteriovenous fistulas for hemodialysis: application of high-frequency US to assess vein wall morphology for cannulation readiness.

PURPOSE: To determine whether venous wall thickness and hoop (circumferential) stress, as determined with high-frequency ultrasonography (US), can predict cannulation readiness in arteriovenous fistulas (AVFs). MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this prospective study. To determine the US appearance of the venous wall, an AVF specimen was excised and scanned in a bath of degassed lactated Ringer solution with a 55-MHz probe. The appearance of the wall at high-frequency US was correlated with histologic findings. High-frequency (40-55-MHz) US was used to image the near-field AVF venous wall of 14 men (mean age, 59 years ± 11 [standard deviation]) and six women (mean age, 55 years ± 14) with newly created AVFs within 1 week of cannulation between January 2008 and December 2009. Measurements of the intima-media thickness (IMT) were generated by three independent observers who were blinded to outcomes. Intraclass correlation analysis was performed. Cannulation readiness was defined as no extravasation during the first dialysis treatment. RESULTS: By using high-frequency US, the IMT was defined as the sum of a thin echogenic blood-intima interface and a uniform hypoechoic media. The mean IMT of the no extravasation group (0.16 mm ± 0.03) was greater than that of the extravasation group (0.10 mm ± 0.02) (P < .001). A minimum threshold IMT of 0.13 mm (P < .001) was associated with successful cannulation. The mean hoop stress of the no extravasation group (246 kPa ± 57) was lower than that of the extravasation group (530 kPa ± 199) (P < .001). A maximum hoop stress threshold of 248 kPa was associated with successful cannulation (P = .009). CONCLUSION: Venous IMT and hoop stress assessed with high-frequency US can predict cannulation readiness in AVFs that are clinically deemed mature.

A simple method to create buttonhole cannulation tracks in a busy hemodialysis unit.

The preference for fistulae as the hemodialysis access of choice has led to a significant number of accesses that are less than ideal for cannulation. Buttonhole cannulation is ideal for such accesses, but the technique for creation provides major challenges. In 12 patients, buttonhole tunnel tracks were created by leaving the polyurethane catheter of a Clampcath hemodialysis needle indwelling for 10 days after the initial cannulation. After each dialysis the catheter was flushed, and dressed with an antibacterial ointment and gauze. Dialysis was carried out via the catheter during that time. After day 10, the catheter was removed, the tunnel track covered with an antibacterial dressing and the tunnel track was cannulated with a dull buttonhole needle at the next dialysis. Successful buttonhole accesses were created in 11 patients after 10 days, the 12th patient required a single sharp needle cannulation before using dull needles. During the first 2 weeks of dull needle cannulation both pain experienced on cannulation and the difficulty cannulating the access were significantly less than in the classical buttonhole technique (P<0.01). Complications during the follow-up period (6 months-1.5 years) included difficulty cannulating with a dull needle (22) and antibacterial agent induced contact dermatitis (4). There was no episode of sepsis or tunnel track infection. Initial cannulation of the fistula using a Clampcath hemodialysis needle, leaving the polyurethane catheter indwelling for 10 days, is a simple, safe, and effective technique for the creation of buttonhole tunnel tracks.

In-center nocturnal hemodialysis: another option in the management of chronic kidney disease.

BACKGROUND AND OBJECTIVES: Some patients are not optimally treated by conventional in-center hemodialysis (HD) and are unable to perform home HD. We examined the effect of in-center thrice-weekly nocturnal HD (INHD) on patient outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patients who were not optimally treated on conventional HD were offered INHD. Thirty-nine patients' laboratory data and medication use were analyzed for the 12 mo before and after conversion to INHD until September 1, 2007. Quality of life on conventional HD and INHD was compared. RESULTS: After conversion to INHD, median values for phosphorus decreased from 5.9 to 3.7 mg/dl (P < 0.01), alkaline phosphatase level increased from 84 to 161 U/L (P < 0.01), and percentage reduction in urea increased from 74 to 89% (P < 0.01). The mean number of antihypertensive drugs prescribed declined from 2.0 to 1.5 (P < 0.05) during the course of INHD, and the mean daily dosage of phosphate binders declined from 6.2 to 4.9 at study end (P < 0.05). There was a significant reduction in erythropoietin-stimulating agent use of 1992 U/wk (P < 0.01). There was no significant change in median hemoglobin, iron saturation, corrected calcium, or parathyroid hormone levels. Overall, quality of life, sleep, intradialytic cramps, appetite, and energy level all improved significantly on INHD. CONCLUSIONS: INHD offers an effective form of HD for long-term dialysis patients who are unable to perform home HD.

A change from subcutaneous to intravenous erythropoietin increases the cost of anemia therapy.

BACKGROUND: It seems that more erythropoietin (EPO) is required when given intravenously (IV) than when given subcutaneously (SC). Estimates of the magnitude of this difference vary widely, impeding development of economic models in this area. Concerns about pure red cell aplasia led our program to switch from SC to IV EPO, so we studied the impact of this change on the cost of anemia therapy. METHODS: All in-center hemodialysis patients who had received EPO for at least 3 months prior to and following conversion to IV EPO were studied. Data was obtained retrospectively for 1 year prior to and prospectively for 1 year following conversion. The costs of anemia therapy (EPO, transfusions and iron) were calculated from the hospital's perspective. RESULTS: 158 patients were studied. One month after switching, the hemoglobin fell significantly, reaching a nadir at 3 months. This triggered more use of EPO, iron and transfusions. By month 7 hemoglobin levels had returned to initial levels, with a median rise in EPO dose of 1,250 units/week (p < 0.001). After the switch, the median rise in total anemia therapy costs was 13.1% (CAD 665/patient-year, p < 0.01). CONCLUSIONS: Conversion of EPO from SC to IV dosing increased the costs of anemia therapy at our center.

Role of oral iron in the management of long-term hemodialysis patients.

BACKGROUND: The literature contends that oral iron supplementation is relatively ineffective in patients who are on long-term hemodialysis (HD), and intravenous iron is the superior form of supplementation. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Data were prospectively abstracted from a cross-sectional cohort of all patients in the long-term in-center HD program at St. Michael's Hospital (SMH) from April 1, 2003, to April 1, 2004. Laboratory data were measured monthly. SMH data were compared with those in eight other centers in the Toronto Region Dialysis Registry. RESULTS: A total of 93% of the 151 patients tolerated oral iron. Eighty-eight (58%) patients received oral iron exclusively, and 60 (40%) patients received intravenous iron with or without oral iron. Of the patients who received oral iron exclusively, 73% maintained a hemoglobin of > or =110 g/L and 93% maintained a hemoglobin of > or =100 g/L. A total of 74% had an iron saturation > or =20%, and 36% had a ferritin level >100 g/L. Among the patients who were on oral iron alone and had hemoglobin of > or =110 g/L, the same amount of erythropoietin was used regardless of ferritin levels (P = 0.17), but less erythropoietin was used when they reached the target for either iron saturation or both iron indices (P = 0.02 and 0.03, respectively). Among the centers in the Toronto Region Dialysis Registry, hemoglobin levels and erythropoietin dosages did not differ among the three centers that predominantly used oral iron versus the six centers that predominantly use intravenous iron (P = 0.46 and 0.95, respectively). CONCLUSIONS: Oral iron is a well-tolerated and effective form of iron supplementation in long-term HD patients.

The salvage of aneurysmal fistulae utilizing a modified buttonhole cannulation technique and multiple cannulators.

We describe the St Michael's Hospital (SMH) modified buttonhole (BH) cannulation technique as a method that offers a solution for fistulae with aneurysmal dilatation due to repetitive cannulation in a restricted area. This is a prospective cohort study of 14 chronic hemodialysis (HD) patients with problematic fistulae (marked aneurysmal formation and thinning of the overlying skin, bleeding during treatment, and prolonged hemostasis post-HD) because of repetitive, localized cannulation. Each patient was followed for 12 months. The protocol was as follows: creation of tunnel tracks by 1 to 3 experienced cannulators per patient, using sharp needles. After the tunnel tracks were established and cannulation was easily achieved with dull needles, additional cannulators were incorporated with the guidance of a mentor. Bleeding from cannulation sites during dialysis ceased within 2 weeks and skin damage resolved within 6 months in all patients. Hemostasis time postdialysis decreased from 24 to 15 min. Cannulation pain scores decreased significantly. Access flows and dynamic venous pressure measurements remained unchanged. No interventions were required to maintain access patency. In 2 cases, the aneurysms became much less evident. Complications included one episode of septic arthritis and one contact dermatitis. A third patient developed acute bacterial endocarditis 9 months following completion of her follow-up. The SMH modified BH cannulation technique can salvage problematic fistulae, prevent further damage, and induce healing of the skin in the areas of repetitive cannulation. This technique can be successfully achieved by multiple cannulators in a busy full-care HD unit.

Multidisciplinary predialysis care and morbidity and mortality of patients on dialysis.

BACKGROUND: Multidisciplinary predialysis care results in fewer hospitalizations and more patients starting hemodialysis therapy with vascular access. Rigorous comparisons of the effect of different types of predialysis care on outcomes after the initiation of dialysis therapy are in their infancy. We hypothesized that outcomes after the initiation of dialysis therapy would be superior in patients receiving multidisciplinary predialysis care than in those receiving conventional care. METHODS: All incident dialysis patients at our center who had received at least 3 months of specialist predialysis care were categorized according to whether they had attended the multidisciplinary Progressive Renal Disease Clinic (PRDC). Patients with a failed transplant, acute renal failure, or previous renal replacement therapy were excluded. We compared these groups at initiation and during 3 years of dialysis therapy. RESULTS: At the start of dialysis therapy, patient demographics and residual renal function were similar. PRDC patients were more likely to have a functioning access and be administered angiotensin-converting enzyme inhibitors, iron supplements, and bicarbonate therapy and had greater serum albumin and serum calcium levels. PRDC patients had fewer hospitalizations at 1 year (7.0 versus 69.7 d/patient/y; P < 0.01) and during the study duration (10.8 versus 57.4 d/patient/y; P < 0.05). There were fewer deaths in the PRDC group at 1 year (2% versus 23%; P < 0.01) and during the study duration (21% versus 42%; P < 0.05). A history of cardiovascular disease, older age, and non-PRDC predialysis care independently predicted death on dialysis therapy. CONCLUSION: Multidisciplinary predialysis care is associated with superior clinical outcomes after the start of dialysis therapy.