Can Dialysis Patients Identify and Diagnose Pulmonary Congestion Using Self-Lung Ultrasound?

BACKGROUND: With the recent developments in automated tools, smaller and cheaper machines for lung ultrasound (LUS) are leading us toward the potential to conduct POCUS tele-guidance for the early detection of pulmonary congestion. This study aims to evaluate the feasibility and accuracy of a self-lung ultrasound study conducted by hemodialysis (HD) patients to detect pulmonary congestion, with and without artificial intelligence (AI)-based automatic tools. METHODS: This prospective pilot study was conducted between November 2020 and September 2021. Nineteen chronic HD patients were enrolled in the Soroka University Medical Center (SUMC) Dialysis Clinic. First, we examined the patient's ability to obtain a self-lung US. Then, we used interrater reliability (IRR) to compare the self-detection results reported by the patients to the observation of POCUS experts and an ultrasound (US) machine with an AI-based automatic B-line counting tool. All the videos were reviewed by a specialist blinded to the performer. We examined their agreement degree using the weighted Cohen's kappa (Kw) index. RESULTS: A total of 19 patients were included in our analysis. We found moderate to substantial agreement between the POCUS expert review and the automatic counting both when the patient performed the LUS (Kw = 0.49 [95% CI: 0.05-0.93]) and when the researcher performed it (Kw = 0.67 [95% CI: 0.67-0.67]). Patients were able to place the probe in the correct position and present a lung image well even weeks from the teaching session, but did not show good abilities in correctly saving or counting B-lines compared to an expert or an automatic counting tool. CONCLUSIONS: Our results suggest that LUS self-monitoring for pulmonary congestion can be a reliable option if the patient's count is combined with an AI application for the B-line count. This study provides insight into the possibility of utilizing home US devices to detect pulmonary congestion, enabling patients to have a more active role in their health care.

Admission of kidney patients to a closed staff nephrology department results in a better short-term survival.

BACKGROUND: The outcome of patients with chronic kidney disease (CKD) and acute kidney injury (AKI) is often dismal and measures to ameliorate their course are scarce. When admitted to the hospital, kidney patients are often hospitalized in general Medicine wards rather than in a specialized Nephrology department. In the current study, we compared the outcome of two cohorts of kidney patients (CKD and AKI) admitted either to general open-staff (with rotating physicians) Medicine wards or to a closed-staff (non-rotating Nephrologists) Nephrology ward. METHODS: In this population-based retrospective cohort study, we enrolled 352 CKD patients and 382 AKI patients admitted to either Nephrology or General Medicine wards. Short-term (< = 90 days) and long-term (>90 days) outcomes were recorded for survival, renal outcomes, cardiovascular outcomes, and dialysis complications. Multivariate analysis was performed using logistic regression and negative binomial regression adjusting to potential sociodemographic confounders as well as to a propensity score based on the association of all medical background variables to the admitted ward, to mitigate the potential admittance bias to each ward. RESULTS: One hundred and seventy-one CKD patients (48.6%) were admitted to the Nephrology ward and 181 (51.4%) were admitted to general Medicine wards. For AKI, 180 (47.1%) and 202 (52.9%) were admitted to Nephrology and general Medicine wards, respectively. Baseline age, comorbidities and the degree of renal dysfunction differed between the groups. Using propensity score analysis, a significantly reduced mortality rate was observed for kidney patients admitted to the Nephrology ward vs. general Medicine in short term mortality (but not long-term mortality) among both CKD patients admitted (OR = 0.28, CI = 0.14-0.58, p = 0.001), and AKI patients (or = 0.25, CI = 0.12-0.48, p< 0.001). Nephrology ward admission resulted in higher rates of renal replacement therapy (RRT), both during the first hospitalization and thereafter. CONCLUSIONS: Thus, a simple measure of admission to a specialized Nephrology department may improve kidney patient outcome, thereby potentially affecting future health care planning.

Community-based serum chloride abnormalities predict mortality risk.

INTRODUCTION: This population-based study aimed to investigate the prognostic value of ambulatory serum chloride abnormalities, often ignored by physicians. METHODS: The study population included all non-hospitalized adult patients, insured by "Clalit" Health Services in Israel's southern district, who underwent at least 3 serum chloride tests in community-based clinics during 2005-2016. For each patient, each period with low (≤97 mmol/l), high (≥107 mmol/l) or normal chloride levels were recorded. A Cox proportional hazards model was used to estimate the mortality risk of hypochloremia and hyperchloremia periods. RESULTS: 664,253 serum chloride tests from 105,655 subjects were analyzed. During a median follow up of 10.8 years, 11,694 patients died. Hypochloremia (≤ 97 mmol/l) was independently associated with elevated all-cause mortality risk after adjusting for age, co-morbidities, hyponatremia and eGFR (HR 2.41, 95%CI 2.16-2.69, p<0.001). Crude hyperchloremia (≥107 mmol/L) was not associated with all-cause mortality (HR 1.03, 95%CI 0.98-1.09 p = 0.231); as opposed to hyperchloremia ≥108 mmol/l (HR 1.14, 95%CI 1.06-1.21 p<0.001). Secondary analysis revealed a dose-dependent elevated mortality risk for chloride levels of 105 mmol/l and below, well within the "normal" range. CONCLUSION: In the outpatient setting, hypochloremia is independently associated with an increased mortality risk. This risk is dose-dependent where the lower the chloride level, the higher is the risk.

Renal Tubular Acidosis Type I with Prominent Hypokalemia and Nephrolithiasis as a Presentation of Sjögren's/Systemic Lupus Erythematosus Disease.

Female patient, suffering from nephrolithiasis, at the age of 32 was admitted for renal colic caused by a stone obstructing UP junction with left hydronephrosis. Nephrostomy was placed, resulting in brisk diuresis. Severe metabolic acidosis with normal anion gap and urine pH of 6.5 was noted. Potassium level dropped to extremely low level (1.6 mEq/L), causing muscle paralysis and respiratory failure, necessitating mechanical ventilation. The patient was treated by potassium chloride infusion, followed by correction of severe metabolic acidosis by sodium bicarbonate. Diagnosis of distal type renal tubular acidosis type I (dRTA) was made based on normal anion gap metabolic acidosis, alkaline urine, hypokalemia, and nephrolithiasis. Five years later, the patient presented with severe hypoxia, lung opacities, and bronchiolitis obliterans organizing pneumonia which was confirmed by bronchoscopy with lung tissue biopsy. Concurrently, the patient presented with dry mouth, pruritus, skin rash with hypocomplementemia, elevated anti-DNA, anti-Ro, and anti-SmAb. Diagnosis of overlap Sjögren's/systemic lupus erythematosus disease was done and treatment by hydroxychloroquine, prednisone, and azathioprine was started. Possible presence of Sjögren's syndrome should be considered in adult patients with unexplained dRTA.

A1 and A2A adenosine receptors play a protective role to reduce prevalence of autoimmunity following tissue damage.

Adenosine is a potent modulator that has a tremendous effect on the immune system. Adenosine affects T cell activity, and is necessary in maintaining the T helper/regulatory T cell (Treg ) ratio. Adenosine signalling is also involved in activating neutrophils and the formation of neutrophil extracellular traps (NETs), which has been linked to autoimmune disorders. Therefore, adenosine, through its receptors, is extremely important in maintaining homeostasis and involved in the development of autoimmune diseases. In this study, we aim to evaluate the role of adenosine A1 and A2A receptors in involvement of autoimmune diseases. We studied adenosine regulation by NETosis in vitro, and used two murine models of autoimmune diseases: type I diabetes mellitus (T1DM) induced by low-dose streptozotocin and pristane-induced systemic lupus erythematosus (SLE). We have found that A1 R enhances and A2A R suppresses NETosis. In addition, in both models, A1 R-knock-out (KO) mice were predisposed to the development of autoimmunity. In the SLE model in wild-type (WT) mice we observed a decline of A1 R mRNA levels 6 h after pristane injection that was parallel to lymphocyte reduction. Following pristane, 43% of A1 R-KO mice suffered from lupus-like disease while WT mice remained without any sign of disease at 36 weeks. In WT mice, at 10 days A2A R mRNA levels were significantly higher compared to A1R-KO mice. Similar to SLE, in the T1DM model the presence of A1 R and A2A R was protective. Our data suggest that, in autoimmune diseases, the acute elimination of lymphocytes and reduction of DNA release due to NETosis depends upon A1 R desensitization and long-term suppression of A2A R.

The impact of gender on early scientific publication and long-term career advancement in Israeli medical school graduates.

BACKGROUND: Many medical schools and residency programs incorporate research projects into their curriculum, however most remain unpublished. Little is known on the long-term effect of early-career publication, especially in female graduates. METHODS: We collected data on physicians 15-20 years after graduation (representing a mid-career point), and analysed data on early publication, publication volume and impact according to graduates' gender and professional characteristics. Physicians were divided into those who never published, early-publishers (EP) who published within 2 years of graduation and late-publishers (LP). We analysed and compared the demographics, publication volume, publication quality as well as current mid-career position. RESULTS: Of 532 physicians, 185 were EP (34.8%), 220 were LP (41.3%), 127 (23.9%) never published, 491 (92.2%) became specialists and 122 (22.3%) achieved managerial position. Of the 405 who published, the average number of publications was 20.3 ± 33.0, and median (IQR) 9(19). H-index was significantly higher in EP, males, surgical specialists, and those holding a managerial position. Male gender was associated with higher publication rate (OR = 1.742; 95% CI 1.193-2.544; P = 0.004). Using quantile regression, female gender was negatively associated with the number of publications in Q50-Q95. Surgical specialty and managerial position were positively associated with publications in Q25 to Q75 and early publication in Q25 and Q75. CONCLUSIONS: We found a strong association between EP and the number, impact, and quality of publications throughout their academic career. This study illuminates the need for further investigations into the causes of gender discrepancies. We should invest in support programs encouraging early high quality research projects for young physicians and female graduates.

Cannabis is associated with blood pressure reduction in older adults - A 24-hours ambulatory blood pressure monitoring study.

BACKGROUND: Medical cannabis use is increasing rapidly in the past several years, with older adults being the fastest growing group. Nevertheless, the evidence for cardiovascular safety of cannabis use is scarce. The aim of this study was to assess the effect of cannabis on blood pressure, heart rate, and metabolic parameters in older adults with hypertension. METHODS: We conducted a prospective study of patients aged 60 years or more with hypertension and a new prescription of cannabis. We have performed the following assessments: 24-hours ambulatory blood pressure monitoring, ECG, blood tests, and anthropometric measurements prior to the initiation of cannabis therapy and 3 months afterward. The primary outcome was change in mean 24-h blood pressure at 3 months. RESULTS: Twenty-six patients with a mean age of 70.42 ± 5.37 years, 53.8% females completed the study. At 3 months follow-up, the mean 24-hours systolic and diastolic blood pressures were reduced by 5.0 mmHg and 4.5 mmHg, respectively (p<0.001 for both). The nadir for the blood pressure and heart rate was achieved at 3 hours post-administration. The proportion of normal dippers changed from 27.3% before treatment to 45.5% afterward. No significant changes were seen in the different metabolic parameters assessed by blood tests, anthropometric measurements, or ECG exam. CONCLUSION: amongst older adults with hypertension, cannabis treatment for 3 months was associated with a reduction in 24-hours systolic and diastolic blood pressure values with a nadir at 3 hours after cannabis administration.

Chronic drug treatment among hemodialysis patients: a qualitative study of patients, nursing and medical staff attitudes and approaches.

BACKGROUND: Dialysis patients have a high pill burden, increasing their care complexity. A previous study in our institution's dialysis unit found notable discrepancies between medication prescriptions, purchases and patient reports of medication use: overall adherence to medication was 57%, on average; staff reported patients took 3.1 more medication types than actual purchases; concordance of patient purchases and nurse reports was found in 5.7 out of 23.6 months of patient follow-up. We sought to investigate patients and staff concepts and attitudes regarding medication care and to understand better the previously identified inconsistencies. METHODS: We performed a qualitative research based on the grounded theory approach, using semi-structured, in-depth, interviews with patients and staff from the same dialysis unit studied previously, at the Hadassah Medical Center, Jerusalem, Israel. RESULTS: Though all respondents described a seemingly synchronized system of care, repeated questioning revealed that staff distrust patient medication reports. Patients, on their part, felt that their monitoring and supervision were bothersome and belittling. Along with patients, nurses and physicians, we identified a "fourth" factor, which influences medication care - the laboratory tests. They serve both as biological parameters of health, but also as parameters of patient adherence to the prescribed medication regimens. CONCLUSIONS: Participant responses did not clearly resonate with previous findings from the quantitative study. The central role of laboratory tests should be carefully considered by the staff when interacting with patients. An interaction process, less adversarial, centering on the patient attitudes to medication care, might establish better communication, better cooperation and better patient outcomes.

Risk Factors Before Dialysis Predominate as Mortality Predictors in Diabetic Maintenance Dialysis patients.

Diabetic patients undergoing maintenance dialysis (MD) have a particularly high mortality rate. Many of the risk factors for mortality have been identified in diabetics who die before reaching end stage renal disease (ESRD), i.e. before dialysis (BD). In addition, many risk factors for mortality have been identified in diabetics after dialysis onset (AD). However, whether in the BD period there are long-term risk factors for AD mortality in diabetics is unknown. We therefore investigated a new concept, i.e. that clinical and biochemical risk factors during the BD stage affect long-term AD mortality. We performed a population based retrospective cohort study, in diabetic CKD patients in a single center in south Israel who initiated MD between the years 2003 and 2015. Clinical and biochemical data 12 months BD and 6 months AD were collected and evaluated for association with mortality AD using Cox's proportional-hazards model. BD parameters that were found to be significant were adjusted for significant parameters AD, thus generating a "combined" regression model in order to isolate the contribution of BD factors on long term mortality. Six hundred and fifty two diabetic MD patients were included in the final analysis. Four independent BD parameters were found in the multivariate model to significantly predict AD mortality: age, BMI (inversely), pulse pressure (U-shaped) and cardiovascular comorbidity. AD independent risk factors for mortality were age, BMI (inversely) and albumin (inversely). Of note, BD factors remained dominantly significant even after additionally adjusting for AD factors. No association was found between either BD HbA1C levels or BD proteinuria and AD mortality. In diabetics who reach ESRD, BD parameters can predict long term AD mortality. Thus, some of the factors affecting the poor survival of diabetic MD patients appear to begin already in the BD period.

Dabigatran-induced nephropathy and its successful treatment with Idarucizumab - case report and literature review.

BACKGROUND: Anticoagulant induced renal injury has been previously described with Warfarin treatment. In the last decade direct oral anticoagulants (DOAC) were introduced. They include direct inhibitors of factor Xa (Rivaroxaban, Apixaban, Edoxaban) and a thrombin inhibitor (Dabigatran). There are isolated reports describing acute kidney injury (AKI) due to the use of DOACs. CASE REPORT: We report a clinical case of an 80-year-old patient recently started on Dabigatran for new onset atrial fibrillation. She presented with AKI and hematuria, urine specimen showed RBC casts, and a working diagnosis of anticoagulant nephropathy due to Dabigatran was made. During hospitalization she was treated with Idarucizumab with a full recovery of renal function. To the best of our knowledge, there are 4 published case reports describing kidney injury produced by Dabigatran. CONCLUSION: The use of DOACs is increasing rapidly, with increasing concern about its safety profile and, in particular, its potential harmful effect on renal function. As described in our case, treatment with Praxbind for Dabigatran induced kidney injury may be an acceptable management strategy that may obviate the need for urgent dialysis in selected cases by complete reversal of the AKI.

Atrial Fibrillation Characteristics in Patients on Haemodialysis vs. Peritoneal Dialysis.

Atrial fibrillation (AF) is highly prevalent in dialysis patients, however whether its impact differs between patients on haemodialysis (HD) vs. peritoneal dialysis (PD) is unknown. We aimed to compare the association of AF and clinical outcomes in different dialysis modalities. We performed a population based retrospective cohort study, including adult patients who initiated dialysis between the years 2002 and 2015. Clinical, echocardiographic and laboratory data were reviewed and correlated with outcomes in HD vs. PD. During the study period, 1,130 patients began dialysis. Of the 997 patients without AF before dialysis initiation, 17% developed new-onset AF after the initiation of dialysis (17.3% of HD vs. 13.7% of PD patients, p = 0.27). Using multivariate analysis, only enlarged left atrium at dialysis initiation (hazard ratio (HR) 2.82, CI95% 2.00-3.99) and age (HR 1.04, CI95% 1.03-1.06) were significantly associated with AF. Dialysis modality was not a significant predictor of AF in either univariate or multivariate analysis. In conclusion, our study demonstrated that AF is common in dialysis patients irrespective of modality. In our cohort, the risk factors associated with AF were older age and enlarged left atrium. AF was associated with increased rates of heart failure and mortality, but not stroke.

Changes of renal sinus fat and renal parenchymal fat during an 18-month randomized weight loss trial.

BACKGROUND & AIMS: Data regarding the role of kidney adiposity, its clinical implications, and its dynamics during weight-loss are sparse. We investigated the effect of long-term weight-loss induced intervention diets on dynamics of renal-sinus-fat, an ectopic fat depot, and %renal-parenchymal-fat, lipid accumulation within the renal parenchyma. METHODS: We randomized 278 participants with abdominal obesity/dyslipidemia to low-fat or Mediterranean/low-carbohydrate diets, with or without exercise. We quantified renal-sinus-fat and %renal-parenchymal-fat by whole body magnetic-resonance-imaging. RESULTS: Participants (age = 48 years; 89% men; body-mass-index = 31 kg/m2) had 86% retention to the trial after 18 months. Both increased renal-sinus-fat and %renal-parenchymal-fat were directly associated with hypertension, and with higher abdominal deep-subcutaneous-adipose-tissue and visceral-adipose-tissue (p of trend < 0.05 for all) after adjustment for body weight. Higher renal-sinus-fat was associated with lower estimated-glomerular-filtration-rate and with higher microalbuminuria and %HbA1C beyond body weight. After 18 months of intervention, overall renal-sinus-fat (-9%; p < 0.05 vs. baseline) but not %renal-parenchymal-fat (-1.7%; p = 0.13 vs. baseline) significantly decreased, and similarly across the intervention groups. Renal-sinus-fat and %renal-parenchymal-fat changes were correlated with weight-loss per-se (p < 0.05). In a model adjusted for age, sex, and visceral-adipose-tissue changes, 18 months reduction in renal-sinus-fat associated with decreased pancreatic, hepatic and cardiac fats (p < 0.05 for all) and with decreased cholesterol/high-density lipoprotein-cholesterol (HDL-c) (ß = 0.13; p = 0.05), triglycerides/HDL-c (ß = 0.13; p = 0.05), insulin (ß = 0.12; p = 0.05) and gamma glutamyl transpeptidase (ß = 0.24; p = 0.001), but not with improved renal function parameters or blood pressure. Decreased intake of sodium was associated with a reduction in %renal-parenchymal-fat, after adjustment for 18 months weight-loss (ß = 0.15; p = 0.026) and hypertension (ß = 0.14; p = 0.04). CONCLUSIONS: Renal-sinus-fat and renal-parenchymal-fat are fairly related to weight-loss. Decreased renal-sinus-fat is associated with improved hepatic parameters, independent of changes in weight or hepatic fat, rather than with improved renal function or blood pressure parameters. CLINICALTRIALS. GOVIDENTIFIER: NCT01530724.

Systemic inflammatory response syndrome-related lymphopenia is associated with adenosine A1 receptor dysfunction.

SIRS is associated with lymphopenia, and prolonged lymphopenia of septic patients has been associated with increased mortality risk. We hypothesize that elevated adenosine during SIRS down-regulates Gi-coupled A1R, which signals an effect that sensitizes a cAMP-dependent lymphotoxic response. In this study, we evaluate the role of adenosine in SIRS-mediated lymphopenia and impaired IL-15 production. Cecal ligation and puncture was used to induce sepsis-associated SIRS in mice. BMDCs were cultured and used to measure the effect of adenosine on IL-15. We found that A1R mRNA levels were significantly down-regulated and A1R-dependent Gi activity was abolished in T cells of septic mice. In accordance, cAMP was elevated in isolated T cells from cecal ligation and puncture compared with sham-treated mice. Similar to septic mice, leukopenia was evident in sham A1R-KO mice, after treatment with the A1R antagonist (8-cyclopentyl-1,3-dipropylxanthine), or after A1R desensitization. In contrast, A2AR-KO mice were protected from leukopenia. In addition, we observed that septic A1R-KO mice exhibited low IL-15 levels. Cultured BMDC agonists of A2AR and A2BR inhibited IL-15 production and adenosine blocked IL-15-dependent proliferation of cytotoxic T cells that were cocultured with stimulated BMDCs. To conclude, we suggest that SIRS-associated lymphopenia is initiated by A1R desensitization and adenosine-mediated inhibition of IL-15 production is part of the mechanism that accounts for the delay in leukopenia recovery in patients with severe sepsis. Interference with adenosine signaling may thus be potentially beneficial for septic patients with leukopenia.

The Combined Effect of High Ambient Temperature and Antihypertensive Treatment on Renal Function in Hospitalized Elderly Patients.

BACKGROUND: The aging kidney manifests structural, functional as well as pharmacological changes, rendering elderly patients more susceptible to adverse environmental influences on their health, dehydration in particular. HYPOTHESIS: Higher temperature is associated with renal function impairment in patients 65 years and older who routinely take thiazide and/or ACE-inhibitors/ARBs. METHODS: We obtained health data of patients older than 65 who were admitted to a large tertiary center during the years 2006-2011, with a previous diagnosis of hypertension, and treated with thiazide, ACE-inhibitors/ARBs or both. We collected environmental data of daily temperature, available from collaborative public and governmental institutions. In order to estimate the effect of daily temperature on renal function we performed linear mixed models, separately for each treatment group and creatinine change during hospital admission. RESULTS: We identified 26,286 admissions for 14, 268 patients with a mean age of 75.6 (±6.9) years, of whom 53.6% were men. Increment in daily temperature on admission of 5°C had significant effect on creatinine increase in the no treatment (baseline creatinine adjusted 0.824 mg/dL, % change 1.212, % change 95% C.I 0.082-2.354) and dual treatment groups (baseline creatinine adjusted 1.032mg/dL, % change 3.440, % change 95% C.I 1.227-5.700). Sub-analysis stratified by advanced age, chronic kidney disease and primary diagnosis on hospital admission, revealed a significant association within patients admitted due to acute infection and treated with dual therapy. CONCLUSION: Whereas previous studies analyzed sporadic climate effects during heat waves and/or excluded older population taking anti-hypertensive medications, the present study is novel by showing a durable association of temperature and decreased renal function specifically in elderly patients taking anti-hypertensive medications.

Vitamin D levels, vitamin D supplementation, and prognosis in patients with chronic kidney disease
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BACKGROUND: Vitamin D (Vit D) deficiency plays a central role in the pathogenesis of chronic kidney disease (CKD) complications, both skeletal and nonskeletal. The purpose of this study was to examine whether 25(OH)D levels and supplementation with oral cholecalciferol (Vitamin D3 (Vit D3)) are associated with morbidity and mortality among patients with significant CKD. METHODS: CKD patients attending the nephrology clinic at Shaare Zedek Medical Center between July 1, 2008 and January 31, 2012, tested at least twice for 25(OH)D levels, were enrolled. Primary endpoints included death, end-stage renal disease (ESRD) requiring start of dialysis, a rise of at least 50% in serum creatinine, or composite endpoints of the above. RESULTS: A total of 516 patients were studied, of whom 178, 257, and 81 patients had baseline vitamin D levels < 5 ng/mL, 15 - 30 ng/mL, and > 30 ng/mL, respectively. We found an association between baseline 25(OH)D level below 15 ng/mL and renal outcomes (start of dialysis or a rise of at least 50% in serum creatinine) in both crude and multivariate analyses (hazard ratio (HR) 3.17, 95% CI 1.12 - 8.94). Vit D3 supplementation demonstrated beneficial effects on combined renal outcomes and death in univariate analyses (p = 0.02). Moreover, an increment of 10 ng/mL in 25(OH)D levels was associated with a 25% reduction in mortality (HR 0.755 (95% CI 0.54 - 1.00), in crude but not adjusted analyses. CONCLUSIONS: Significant Vit D deficiency in CKD can serve as a biological marker indicating patients in whom adverse renal outcomes can be anticipated. Moreover, Vit D3 supplementation and rise of serum 25(OH)D levels may have beneficial influence on hard renal outcomes.
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Summary adherence estimates do not portray the true incongruity between drug intake, nurse documentation and physicians' orders.

BACKGROUND: Hemodialysis patients (HD) need to adhere to a complex medication regimen. Because their daily pill burden is one of the highest reported, poor compliance is a major cause of therapeutic failure. The primary aim of this study was to define patterns of medication prescription, intake and documentation among HD patients. METHODS: HD patients treated between 2007 and 2009 and assigned to the largest health service provider in Israel were randomly selected. Drug practices were abstracted from their records and compared to electronic pharmacy data. The discrepancy between drug intake reports and the actual purchase was measured to estimate adherence. Drug purchase, intake report and physician order were plotted in complementing diagrams to appreciate consistency and discrepancy patterns. RESULTS: The study included full analysis of 75 patients. The mean overall drug adherence was 56.7% (95% CI 53.6-59.9%), varying among drug families and over time. Often, there was a systematic disengagement between the nurses' documentation and the actual patient purchase. Specifically, we observed either different quantities of medication use, improper documentation of a non-purchased drug, drug purchase without nurse documentation and futile physician attempts to modify prescriptions of unpurchased medication. We found a high rate of physician order turbulence for active vitamin D and calcium. CONCLUSIONS: Drug prescription, documentation and adherence are incongruent and their mismatches are diverse. Summary estimates do not divulge the extent of these disparities. These system-wide communication failures compromise patient care. Strategies to promote system reconciliation and reasonable medication prescription are in need.

The incidence and prognosis of renal dysfunction following cardioversion of atrial fibrillation.

OBJECTIVE: Limited data are available regarding the incidence and clinical impact of renal dysfunction following cardioversion of atrial fibrillation. The objective of this study was to assess the incidence and implications of renal dysfunction following cardioversion of atrial fibrillation. METHODS: We conducted a nested case-control study to determine the incidence, timing, risk factors and outcome of atrial fibrillation cardioversion associated with renal dysfunction (AFCARD) in a tertiary medical center. Consecutive patients undergoing direct current cardioversion (DCCV) for atrial fibrillation in our institution during 2008-2009 with measurements of creatinine before and following cardioversion were included. AFCARD was defined as a rise in serum creatinine greater than 25% from baseline within a week following DCCV. RESULTS: One hundred and twelve patients were included in the study, of whom 19 (17%) developed AFCARD. One patient required hemodialysis. Patients with AFCARD had a higher incidence of advanced heart failure, diabetes mellitus and were more frequently treated with digoxin and enoxaparin. Patients with AFCARD had a significantly decreased survival rate at 1 year (63 vs. 92%; p < 0.001). CONCLUSIONS: AFCARD is relatively common and is associated with increased mortality. These findings suggest a role for close surveillance of renal function following DCCV.

The MONitoring Dialysis Outcomes (MONDO) initiative.

BACKGROUND: Systematic collection and analysis of global hemodialysis patient data may help to improve patient outcomes. METHODS: The MONitoring Dialysis Outcomes (MONDO) initiative comprises data from eight dialysis providers worldwide. Data are combined into one repository. Extensive procedures are employed to merge data across countries and providers. RESULTS: The MONDO database comprises longitudinal data of currently 128,000 hemodialysis patients from 26 countries on five continents. Here we report data from 62,345 incident hemodialysis patients. We found lower catheter rates in South-East Asia and Australia, lower hemoglobin levels in South-East Asia, and a higher prevalence of diabetes in North America. Longitudinal analyses suggest that there is a decline in interdialytic weight gain and serum phosphorus and an increasing neutrophil-to-lymphocyte ratio before death in all regions studied. CONCLUSIONS: While organizationally lean and low-cost, MONDO is the largest global dialysis database initiative to date, with a particular focus on high longitudinal data density and geographical diversity.