Upward-directed exit-site of the swan-neck catheter and "Easy-to-disinfect the backside area of exit-site" may prevent PD complications.

BACKGROUND: Upward-directed exit-site has been believed to be the worst for frequent ESI by an old retrospective study using straight catheters. No comparison study of 3 exit-site directions using swan-neck catheter has been performed regarding which direction is the best for our endpoints, Easy-to-see the backside area of exit-site: ESBE, Easy-to-disinfect the backside area of exit-site: EDBE, reduction of both exit-site infection (ESI), symptomatic catheter dislocation and peritonitis. METHODS: We assessed the relationship of exit-site direction with our endpoints in a quantitative cross-sectional, multicentered questionnaire survey. Patients who received either non-surgical catheter implantation or exit-site surgery were excluded. RESULTS: The numbers (percentage) of exit-site directions in included 291 patients were upward 79 (26.0), lateralward 108 (37.5) and downward 105 (36.5). Cochran-Armitage analysis showed a significant step-ladder increase in the prevalence of ESI as the direction changed from upward to lateralward to downward (0.15 ± 0.41, 0.25 ± 0.54, 0.38 ± 0.69 episodes/patient-year, p = 0.03). Multivariable regression analysis revealed the upward exit-site independently associates with both higher frequency of ESBE (OR 5.55, 95% CI 2.23-16.45, p < 0.01) and reduction of prevalence of ESI (OR 0.55, 95%CI 0.27-0.98, p = 0.04). Positive association between the prevalence of symptomatic catheter dislocation and ESI (OR 2.84, 95% CI 1.27-7.82, p = 0.01), and inverse association between EDBE and either prevalence of symptomatic catheter dislocation (OR 0.27, 95% CI 0.11-0.72) or peritonitis (OR 0.48, 95% CI 0.23-0.99) observed. CONCLUSION: Upward-directed swan-neck catheter exit-site may be the best for both ESBE and prevention of ESI. EDBE may reduce catheter dislocation and peritonitis. Symptomatic catheter dislocation may predict ESI.

Use of the Superficialized Brachial Artery as Vascular Access for a Patient with Myasthenia Gravis with a Frequent Need for Plasmapheresis: A Case Report.

A 41-year-old woman diagnosed with seronegative myasthenia gravis struggled to maintain remission for a decade, facing crises every 3 months for several years. After repeated apheresis using a non-tunneled non-cuffed central venous dialysis catheter (NTNCC), complications such as catheter-related thrombus in the internal jugular veins and morbid obesity from steroids made the insertion of NTNCC increasingly difficult, leading to consideration of an alternative permanent vascular access (VA) approach. Thus, we created a subcutaneously superficialized brachial artery as the VA, which allowed the patient to undergo safe and uninterrupted apheresis therapy.

Resuming peritoneal dialysis after secondary embedding of the peritoneal dialysis catheter in the end-of-life period: A case report.

Secondary embedding of a peritoneal dialysis (PD) catheter has been performed for patients whose kidney function has improved enough to stop dialysis but recovery is not expected to be long term. In addition, we have also performed the procedure for patients who have poor general condition due to severe cerebrovascular and/or cardiac disease or who wish to have PD again at the end of life. Here, we report the case of the first terminal haemodialysis (HD) patient who resumed PD using a secondarily embedded catheter as an end-of-life choice. The patient had undergone secondary embedding of a PD catheter and had been transferred to HD, during which time multiple pulmonary metastases of thyroid cancer were observed. She hoped to resume PD in the end-of-life period, and the catheter was subsequently externalised. The catheter was used immediately, and the patient has continued on PD over the past 1 month without infectious or mechanical complications. For elderly end-stage kidney disease patients with progressive disease and cancer, secondary embedding of the PD catheter may be an option to permit them to live the remainder of their lives at home.

Twenty-four-hour Urinary Salt Excretion on Admission Predicts Significant Weight Loss with Seven-day Dietary Salt Restriction in Hospitalized Patients with Chronic Kidney Disease: A Single-center Study.

In patients with chronic kidney disease (CKD), restricting dietary salt is recommended to prevent fluid retention. Rapid weight loss is often observed when CKD patients with a high salt intake are hospitalized and started on a low-salt diet. We investigated the effects of 7-day dietary salt restriction on weight loss in hospitalized patients with CKD. During the 7-day hospitalization, a low-salt (6 g/day) and low-protein (0.6-0.8 g/kg/day ideal body weight) diet was served to all patients. Urine samples were collected for the first 24 h after admission, and patients were divided into quartiles (Q1-Q4) by urinary salt excretion. Body weight was measured on days 1 and 7. Weight loss after admission was compared among the groups. Factors associated with weight loss were evaluated by multivariate logistic regression. The mean age of the patients was 70.3 ± 11.7 years, and 73% were male. Mean weight loss was 1.6 ± 1.7 kg on day 7. Weight loss was significantly greater in Q3 and Q4 than in Q1 (P = 0.009 and P <0.001, respectively). In the univariate analysis, weight loss correlated positively with 24-h urinary salt excretion on admission (γ2 = 0.146) and body mass index (γ2 = 0.223). The 24-h urinary salt excretion on admission and BMI were independently associated with weight loss of >2 kg. The adjusted odds ratios (95% confidence interval) were 1.24 (1.13-1.36) and 1.15 (1.07-1.22), respectively. Twenty-four-hour urinary salt excretion on admission is useful for predicting significant weight loss with short-term dietary salt restriction.

Examine the optimal multidisciplinary care teams for patients with chronic kidney disease from a nationwide cohort study.

Background: Multidisciplinary team-based integrated care (MDC) has been recommended for patients with chronic kidney disease (CKD). However, team-based specific structured care systems are not yet established. Therefore, we investigated the efficacy of MDC system and the optimal number of professionals that make up the team for maintaining kidney function and improving prognosis. Methods: This nationwide, multicenter, observational study included 2,957 Japanese patients with CKD who received MDC from 2015 to 2019. The patients were divided into four groups according to the number of professionals in the MDC team. Groups A, B, C, and D included nephrologists and one, two, three, and four or more other professionals, respectively. Changes in the annual decline in estimated glomerular filtration rate before and after MDC were evaluated. Cox regression was utilized to estimate the correlation between each group and all-cause mortality and the start of renal replacement therapy (RRT) for 7 years. Results: The change in eGFR significantly improved between before and at 6, 12, and 24 months after MDC in all groups (all p < 0.0001). Comparing group D to group A (reference), the hazard ratio (HR) for all-cause mortality and the start of the RRT was 0.60 (95% confidence interval, 0.48-0.73; p < 0.0001) after adjustment for multiple confounders. Lower HR in group D was confirmed in both diabetes and nondiabetes subgroups. Conclusion: An MDC team comprised of five or more professionals might be associated with improvements in mortality and kidney prognosis. Furthermore, MDC might be effective for treating CKD other than diabetes.

Association between inpatient education program for patients with pre-dialysis chronic kidney disease and new-onset cardiovascular disease after initiating dialysis.

BACKGROUND: The association between inpatient education programs (IEPs) for patients with pre-dialysis chronic kidney disease (CKD) and new-onset cardiovascular disease (CVD) after initiating dialysis is unclear. METHODS: We conducted a retrospective cohort study between January 1, 2011 and December 31, 2018, evaluating CKD patients who were divided into two groups based on whether or not they participated in IEPs. The primary outcome was a new-onset CVD event after initiating dialysis. Cumulative incidence function was used to describe new-onset CVD considering the competing outcome of death. Additionally, Cox proportional hazards models were used to estimate the hazard ratio of new-onset CVD between IEP and non-IEP groups. RESULTS: Of the 493 patients, 131 (26.6%) patients had participated in IEPs. The IEP group had a significantly longer duration of CKD management by nephrologists (median 142 vs. 115 days, P = 0.007), lower rate of emergency hospital admissions (9.9% vs. 27.1%, P < 0.001), better ability to perform activities of daily living (Grade J; 81.6% vs. 69.1%, P = 0.046), higher rate of pre-placement of permanent vascular access or peritoneal dialysis catheters (82.4% vs. 59.4%, P < 0.001), and a higher serum albumin level at the beginning of dialysis (3.5 ± 0.5 vs. 3.3 ± 0.6 g/dL, P < 0.001). The cumulative incidence of new-onset CVD at three years after initiating dialysis in the IEP and non-IEP groups was 16.9% and 22.5%, respectively. The hazard ratio for new-onset CVD after initiating dialysis in the IEP group was 0.63 (95% CI: 0.41-0.97, P = 0.036). CONCLUSION: IEPs were associated with a lower rate of new-onset CVD after initiating dialysis.

A multi-institutional, observational study of outcomes after catheter placement for peritoneal dialysis in Japan.

BACKGROUND: This multi-institutional, observational study examined whether the outcomes after peritoneal dialysis (PD) catheter placement in Japan meet the audit criteria of the International Society for Peritoneal Dialysis (ISPD) guideline and identified factors affecting technique survival and perioperative complications. METHODS: Adult patients who underwent first PD catheter placement for end-stage kidney disease between April 2019 and March 2021 were followed until PD withdrawal, kidney transplantation, transfer to other facilities, death, 1 year after PD start or March 2022, whichever came first. Primary outcomes were time to catheter patency failure and technique failure, and perioperative infectious complications within 30 days of catheter placement. Secondary outcomes were perioperative complications. Appropriate statistical analyses were performed to identify factors associated with the outcomes of interest. RESULTS: Of the total 409 patients, 8 who underwent the embedded catheter technique did not have externalised catheters. Of the 401 remaining patients, catheter patency failure occurred in 25 (6.2%). Technical failure at 12 months after PD catheter placement calculated from cumulative incidence function was 15.3%. On Cox proportional hazards model analysis, serum albumin (hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.27-0.70) and straight type catheter (HR 2.14; 95% CI 1.24-3.69) were the independent risk factors for technique failure. On logistic regression analysis, diabetes mellitus was the only independent risk factor for perioperative infectious complications (odds ratio 2.70, 95% CI 1.30-5.58). The occurrence rate of perioperative complications generally met the audit criteria of the ISPD guidelines. CONCLUSION: PD catheter placement in Japan was proven to be safe and appropriate.

Inpatient multidisciplinary care can prevent deterioration of renal function in patients with chronic kidney disease: a nationwide cohort study.

Background: Multidisciplinary care is necessary to prevent worsening renal function and all-cause mortality in patients with chronic kidney disease (CKD) but has mostly been investigated in the outpatient setting. In this study, we evaluated the outcome of multidisciplinary care for CKD according to whether it was provided in an outpatient or inpatient setting. Methods: This nationwide, multicenter, retrospective, observational study included 2954 Japanese patients with CKD stage 3-5 who received multidisciplinary care in 2015-2019. Patients were divided into two groups: an inpatient group and an outpatient group, according to the delivery of multidisciplinary care. The primary composite endpoint was the initiation of renal replacement therapy (RRT) and all-cause mortality, and the secondary endpoints were the annual decline in the estimated glomerular filtration rate (ΔeGFR) and the changes in proteinuria between the two groups. Results: Multidisciplinary care was provided on an inpatient basis in 59.7% and on an outpatient basis in 40.3%. The mean number of health care professionals involved in multidisciplinary care was 4.5 in the inpatient group and 2.6 in the outpatient group (P < 0.0001). After adjustment for confounders, the hazard ratio of the primary composite endpoint was significantly lower in the inpatient group than in the outpatient group (0.71, 95% confidence interval 0.60-0.85, P = 0.0001). In both groups, the mean annual ΔeGFR was significantly improved, and proteinuria significantly decreased 24 months after the initiation of multidisciplinary care. Conclusion: Multidisciplinary care may significantly slow deterioration of eGFR and reduce proteinuria in patients with CKD and be more effective in terms of reducing initiation of RRT and all-cause mortality when provided on an inpatient basis.

Changes in erythropoiesis-stimulating agent responsiveness after transfer to combined therapy with peritoneal dialysis and hemodialysis for patients on peritoneal dialysis: A prospective multicenter study in Japan.

INTRODUCTION: Inadequate dialysis and fluid overload are corrected after starting combined therapy with peritoneal dialysis (PD) and hemodialysis (HD). However, the effects on anemia management has not been elucidated. METHODS: We conducted a prospective, multicenter, observational cohort study of 40 PD patients (age, 60 ± 10 years; male, 88%; median PD duration, 28 months) starting combined therapy and investigated changes in several clinical parameters, including erythropoiesis-stimulating agent (ESA) resistance index (ERI). RESULTS: ERI decreased significantly during 6 months after switching to combined therapy (from 11.8 [IQR 8.0-20.4] units/week/kg/(g/dL) to 7.8 [IQR 3.9-18.6] units/week/kg/(g/dL), p = 0.047). Body weight, urinary volume, serum creatinine and the dialysate-to-plasma creatinine ratio (D/P Cr) decreased, whereas hemoglobin and serum albumin increased. In subgroup analysis, the changes in ERI were not affected by cause for starting combined therapy, PD holiday and D/P Cr. CONCLUSION: Although detailed mechanism was unclear, ESA responsiveness improved after switching from PD alone to combined therapy.

Effectiveness and current status of multidisciplinary care for patients with chronic kidney disease in Japan: a nationwide multicenter cohort study.

BACKGROUND: Multidisciplinary care is well established in clinical practice, but its effectiveness in patients with chronic kidney disease (CKD) remains unclear. The aim of this study was to determine whether multidisciplinary care could help to avoid worsening kidney function in patients with CKD. METHODS: This nationwide study had a multicenter retrospective observational design and included 3015 Japanese patients with CKD stage 3-5 who received multidisciplinary care. We assessed the annual decrease in estimated glomerular filtration rate (ΔeGFR) and urinary protein in the 12 months before and 24 months after the start of multidisciplinary care. All-cause mortality and initiation of renal replacement therapy were investigated according to baseline characteristics. RESULTS: Most of the patients had CKD stage 3b or higher and a median eGFR of 23.5 mL/min/1.73 m2. The multidisciplinary care teams consisted of health care professionals from an average of four disciplines. ΔeGFR was significantly smaller at 6, 12, and 24 months after initiation of multidisciplinary care (all P < 0.0001), regardless of the primary cause of CKD and its stage when multidisciplinary intervention was started. Urinary protein level also decreased after initiation of multidisciplinary care. After a median follow-up of 2.9 years, 149 patients had died and 727 had started renal replacement therapy. CONCLUSION: Multidisciplinary care may significantly slow the decline in eGFR in patients with CKD and might be effective regardless of the primary disease, including in its earlier stages. Multidisciplinary care is recommended for patients with CKD stage 3-5. TRIAL REGISTRATION: UMIN00004999.

Effects of one-hour discussion on the choice of dialysis modality at the outpatient clinic: A retrospective cohort study using propensity score matching.

BACKGROUND: The aim of present study was to evaluate the effects of one-hour discussion on the choice of dialysis modality at the outpatient clinic. METHODS: Charts of consecutive patients who had started maintenance dialysis from May 2013 to April 2021 were retrospectively reviewed. Characteristics at the start of dialysis were compared between patients participated and not participated in the discussion. RESULTS: Of the 620 incident dialysis patients, 128 patients had participated in the discussion. After propensity score matching (1:1), 127 patients who participated in the discussion tended to have fewer urgent hospitalizations (13.4% vs. 21.3%, p = 0.068). In addition, more patients who initiated peritoneal dialysis (PD) (30.7% vs. 9.4%, p < 0.001). On multivariate analysis, participation in the discussion (OR 4.81, 95% CI 2.807-8.24; p < 0.001) was related to PD initiation. CONCLUSION: One-hour discussion on the choice of dialysis modality may increase PD initiations and decrease the number of urgent hospitalizations.

Accidental removal of dialysis central venous catheter inserted for blood purification therapy: a single-center study.

BACKGROUND: Dialysis central venous catheters (DCs) are used for various blood purification therapies. Accidental removal of a DC is a potentially life-threatening event. However, the risk factors associated with accidental removal have rarely been discussed in the literature. METHODS: We performed a 5 year retrospective, single-center, cohort study of patients who were admitted to the ward other than intensive care units and were inserted DCs. We compared patient characteristics between patients who used DCs with and without a history of accidental removal. RESULTS: There were 17 cases of accidental removal (3.5%) out of 489 DC insertions during the observation period. There was no significant difference between patients with and without accidental removal in terms of age, sex, reason for DC insertion, catheter type, or insertion site. The presence of dementia was 35 and 11% (p = 0.006), and that of delirium was 88 and 13% (p < 0.0001) in those with and without accidental removal, respectively. The median days from insertion to accidental removal were 5 (range 0-21) days, and removal occurred mainly at night (71%). One patient with accidental removal developed hemorrhagic shock, but there no deaths occurred due to accidental removal. CONCLUSIONS: The present findings suggest that to prevent accidental removal, sufficient attention should be paid to delirium that occurs after admission as well to pre-existing dementia at the time of admission. As accidental removal occurs most commonly early after insertion and at night, special attention should be paid during these periods.

Impact of inpatient educational programs on mortality after the start of dialysis therapy.

BACKGROUND: Although inpatient educational programs (IEPs) for non-dialysis-dependent chronic kidney disease (CKD) have been reported to slow disease progression, their legacy effect on prognosis after the start of dialysis therapy is unclear. METHODS: Consecutive patients who started dialysis therapy between January 1, 2011 and December 31, 2018 were included in a single-center, retrospective, observational study. The patients were divided into two groups according to whether or not they participated in IEPs before dialysis introduction, and their background characteristics were compared. The survival rate for each group was calculated using the Kaplan-Meier method and compared by the log-rank test. Furthermore, the hazard ratio (HR) of IEP participation adjusted for confounding factors associated with mortality was calculated using Cox regression analysis. RESULTS: Of the 490 subjects (median age 69 years, 71.0% male), 129 patients (26.3%) participated in the IEP. At the start of dialysis, the IEP group had higher serum albumin (3.5 vs. 3.3 g/dL, p < 0.001) and lower serum total cholesterol levels (151 vs. 166 mg/dL, p = 0.0076) and the proportion of patients with independence in their daily living activities was high (p = 0.034). The median observation period was 3.4 years, during which 153 patients (31.2%) died. The 5-year survival rates were 81.0 and 61.5% in the IEP and non-IEP groups, respectively (p = 0.0038). Cox regression analysis revealed a HR for IEP of 0.57 (95% Confidence interval 0.37-0.88, p = 0.011). CONCLUSION: IEPs for CKD patients are associated with a more favorable prognosis after the start of dialysis.

Clinical feasibility of transfer to combined therapy with peritoneal dialysis and hemodialysis for patients on peritoneal dialysis: A prospective multicenter study in Japan.

INTRODUCTION: Although combined therapy with peritoneal dialysis (PD) and hemodialysis (HD) is widespread in Japan, its clinical utility has been reported only in retrospective or before-and-after test lacking a control group. METHODS: We conducted a prospective, multicenter, observational cohort study of 176 incident PD patients and compared patient survival and changes in clinical parameters between patients on different dialysis modalities. RESULTS: During a median follow-up of 41 months, 47 patients transferred to combined therapy and 35 patients transferred directly to HD. Patients transferred to combined therapy had a significantly better survival than those transferred directly to HD. However, we could not establish this difference in a multivariate analysis because only six patients died among these groups. The decreases in urea nitrogen and serum creatinine were more prominent among patients directly transferred to HD. CONCLUSION: This is the first report revealing clinical feasibility of transfer to combined therapy for PD patients.

COVID-19 and adult-onset Still's disease as part of hyperferritinemic syndromes.

The coronavirus disease (COVID-19) is known to cause hyperferritinemia and haemophagocytic lymphohistiocytosis. Including this laboratory parameter, symptoms similar to COVID-19 have been observed in adult-onset Still's disease (AOSD), catastrophic antiphospholipid syndrome, macrophage activation syndrome, and septic shock, which has led to the proposal of a concept called 'hyperferritinemic syndromes'. High levels of some clinical markers in both COVID-19 and AOSD make them difficult to differentiate. While the efficacy of ciclesonide had been expected for mild pneumonia with COVID-19, the efficacy of tocilizumab (TCZ), which is a known treatment for AOSD, was not established. We report the first known occurrence of COVID-19 diagnosed in March 2020, preceded by the diagnosis of AOSD in April 2019. The patient was given prednisolone and TCZ, which led to remission. With the dyspnea and ground-glass appearance on chest computed tomography, PCR test revealed COVID-19 infection. Ciclesonide was started on Day 7 of the disease onset, which led to improved inflammatory markers. We infer that while TCZ is theoretically useful for COVID-19 due to its inhibition of interleukin 6. AOSD and COVID-19 may be differentiated by levels of ferritin, and appropriate treatment must be allocated.

Seasonal variation in emergent hemodialysis initiation in the late elderly: A single-center study.

BACKGROUND: The number of new dialysis patients, particularly among the elderly population, has been globally increasing. In Japan, patients aged ≥65 years and ≥75 years comprised 72% and 45% of patients on dialysis in 2018, respectively. Few studies have reported seasonal variations in the initiation of dialysis. We investigated the seasonal prevalence of the emergent hemodialysis initiation in the elderly. METHODS: We reviewed 479 elderly patients who initiated hemodialysis between January 2006 and December 2018. Early elderly patients were defined as patients aged between 65 and 74 years, and late elderly patients were defined as those aged ≥75 years. Emergent hemodialysis initiation was defined as initiation with a temporary vascular catheter without elective permanent vascular access or unplanned hemodialysis initiation due to patients requiring critical care regardless of elective permanent vascular access. The information collected included age, sex, and details of the initiation of hemodialysis. RESULTS: The early elderly group consisted of 199 patients, and the late elderly group consisted of 279 patients. In the late elderly group, hemodialysis initiation was most frequent in winter, followed by spring, autumn, and summer (p = 0.018). Moreover, emergent hemodialysis initiation was most frequent in winter, followed by spring, autumn, and summer (p = 0.009). Emergent hemodialysis initiation due to fluid overload was most frequent in winter, followed by autumn, spring, and summer (p < 0.001). Among late elderly patients who initiated hemodialysis, 78% did not have permanent hemodialysis access at the time of the initiation of hemodialysis. CONCLUSION: In the late elderly group, hemodialysis initiation and emergent hemodialysis initiation were significantly more frequent in the winter than in the remaining seasons. In addition, emergent hemodialysis initiation due to fluid overload was most frequent in winter in the late elderly group.