Evidence supporting the use of a subjective staff evaluation to assess the benefit of rehabilitation in hemodialysis patients undergoing inpatient rehabilitation.

BACKGROUND: We questioned whether the introduction of a subjective evaluation of patient-specific goals, could be used as a valid method to assess the effectiveness of inpatient rehabilitation. METHODS: In this prospective cohort study, all admissions to the UHN hemodialysis rehabilitation service between April 2013 and August 2016 were included. We introduced a system of subjective assessment, performed by the team at the time of admission and discharge. We evaluated Functional Independence Measure (FIM®) score and KDQoL for objective measures of physical function and patient-reported quality of life. RESULTS: A total of 201 patients were included. The median FIM score at discharge correlated well with the subjective staff evaluation. FIM score changes for those with evaluations for Success, Partial success, and Not Successful were 28 [interquartile range (IQR) 20-34], 24 [IQR18-31], 16 [IQR 11-34] respectively. The median PCS at discharge for those deemed to have Success was 37.4 [IQR31.0, 44.7], and for those with Partial success & Not Successful 28.8 [IQR 22.4, 39.2]. There was no correlation with MCS scores (55.2 [IQR 51.2, 60.2], 58.4 [IQR 50.1, 63.1] respectively). CONCLUSIONS: These results suggest the subjective staff evaluation is a brief but valid assessment of patient outcome for dialysis patients undergoing inpatient rehabilitation.

Activities of daily living at different levels of renal function in elderly hospitalized heart failure patients.

BACKGROUND: Renal function (RF) and activities of daily living (ADL) are risk factors for heart failure (HF) patients. AIMS: We evaluated differences in motor and cognitive ADL in relation to RF in elderly hospitalized HF patients. METHODS: Participants were selected from 414 consecutive hospitalized HF patients based on certain criteria. We investigated patient characteristics including Functional Independence Measure (FIM) and estimated glomerular filtration rate (eGFR). Subjects were divided into three groups by RF level and analyzed with one-way ANOVA and Chi-square tests and two-way ANCOVA and multiple comparison tests. RESULTS: Of the 414 patients, 165 met the inclusion criteria (high RF: 41, moderate RF: 84, low RF: 40). There were significant differences between the three groups in age, eGFR, hemoglobin level, mobility, cognitive function, and length of hospital stay (p < 0.05). Motor FIM showed an interaction between term and group, and cognitive FIM showed a main effect on the group (p < 0.05). In the multiple comparisons, motor FIM of all groups indicated significant recovery, but it was significantly lower after 1 week in the low RF versus moderate/high RF groups (p < 0.05). Cognitive FIM showed no significant recovery in the low RF group; the FIM score after 2 weeks was significantly lower than that in the moderate/high RF groups (p < 0.05). CONCLUSIONS: In elderly hospitalized HF patients, the motor ADL recovery process in the low RF group was delayed compared to the high RF group. Cognitive ADL in hospitalized HF patients is difficult to recover, especially in those with low RF.

Lesión en el lóbulo inferior derecho pulmonar por catéter Shaldon / Right lower pulmonary lobe injury due to a Shaldon catheter

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[Allogeneic kidney transplantation. Preoperative, perioperative and postoperative management]. / Allogene Nierentransplantation. Prä-, peri- und postoperatives Management.

Allogeneic renal transplantation is the best treatment for many patients with chronic renal failure and end-stage kidney disease. Especially the health-related quality of life markedly improves after renal transplantation and the side effects of dialysis treatment as well as the progression of organ and tissue deterioration related to renal failure which are not treated effectively by dialysis are greatly reduced. To achieve good results of renal transplantation, however, the best possible preoperative as well as perioperative and postoperative conditions have to be established and patients on waiting lists need to be well prepared. Interdisciplinary patient care is needed before and after renal transplantation in order to achieve durable and long-term success of renal transplantation.

Is serum phosphorus control related to parathyroid hormone control in dialysis patients with secondary hyperparathyroidism?

BACKGROUND: Elevated serum phosphorus (P) levels have been linked to increased morbidity and mortality in dialysis patients with secondary hyperparathyroidism (SHPT) but may be difficult to control if parathyroid hormone (PTH) is persistently elevated. We conducted a post hoc analysis of data from an earlier interventional study (OPTIMA) to explore the relationship between PTH control and serum P. METHODS: The OPTIMA study randomized dialysis patients with intact PTH (iPTH) 300-799 pg/mL to receive conventional care alone (vitamin D and/or phosphate binders [PB]; n=184) or a cinacalcet-based regimen (n=368). For patients randomized to conventional care, investigators were allowed flexibility in using a non-cinacalcet regimen (with no specific criteria for vitamin D analogue dosage) to attain KDOQI™ targets for iPTH, P, Ca and Ca x P. For those assigned to the cinacalcet-based regimen, dosages of cinacalcet, vitamin D sterols, and PB were optimized over the first 16 weeks of the study, using a predefined treatment algorithm. The present analysis examined achievement of serum P targets (≤ 4.5 and ≤ 5.5 mg/dL) in relation to achievement of iPTH ≤ 300 pg/mL during the efficacy assessment phase (EAP; weeks 17-23). RESULTS: Patients who achieved iPTH ≤ 300 pg/mL (or a reduction of ≥ 30% from baseline) were more likely to achieve serum P targets than those who did not, regardless of treatment group. Of those who did achieve iPTH ≤ 300 pg/mL, 43% achieved P ≤ 4.5 mg/dL and 70% achieved P ≤ 5.5 mg/dL, versus 21% and 46% of those who did not achieve iPTH ≤ 300 pg/mL. Doses of PB tended to be higher in patients not achieving serum P targets. Patients receiving cinacalcet were more likely to achieve iPTH ≤ 300 pg/mL than those receiving conventional care (73% vs 23% of patients). Logistic regression analysis identified lower baseline P, no PB use at baseline and cinacalcet treatment to be predictors of achieving P ≤ 4.5 mg/dL during EAP in patients above this threshold at baseline. CONCLUSIONS: This post hoc analysis found that control of serum P in dialysis patients was better when serum PTH levels were lowered effectively, regardless of treatment received. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT00110890.

[Corneal opacity in a contact lens wearer on hemodialysis for renal failure]. / Hornhauttrübungen bei einer Kontaktlinsenträgerin mit hämodialysepflichtiger Niereninsuffizienz.

A 53-year-old contact lens wearer on renal dialysis developed visual impairment due to corneal opacity. The opacity was of a crystalline type and diffusely scattered in the anterior cornea. As oxalosis was suspected ascorbic acid was immediately omitted from the dialysis treatment schedule. Within a few weeks the visual acuity recovered and the corneas became nearly clear. The cornea is an uncommon manifestation site for oxalosis. Nevertheless, one should be aware of this possible sign for oxalosis, which can be a life-threatening complication of treatment with high dose ascorbic acid.

Linear parameter varying system based modeling of hemodynamic response to profiled hemodialysis.

This paper proposes a novel linear parameter varying (LPV) system to model the hemodynamic response of end-stage renal failure patients to profiled hemodialysis (PHD). Ultrafiltration rate (UFR) and dialysate sodium concentration (Na) are imposed as the control inputs and the model computes the relative blood volume (RBV), percentage change in heart rate (ΔDHR(%)) and percentage change in systolic blood pressure (ΔDSBP(%)) during the course of hemodialysis. Model parameters are estimated using least squares approach based on data collected from 12 patients where each patient underwent 4 profile hemodialysis sessions. Parameter identification based on four profiled sessions of the same patient revealed an average mean square error of 0.11 for RBV, 0.24 for ΔDHR and 0.43 for ΔDSBP. The results provided a good model to estimate the individual patient's hemodynamic behavior during hemodialysis. The developed model can play a vital role in designing a robust control system to automatically regulate the UFR and Na while maintaining the hemodynamic variables within stable range.

Transpondo limites com doadores falecidos: transplantes bem-sucedidos com rins de doador com creatinina sérica igual a 13,1 mg/dL / Overcoming limits with deceased donors: successful renal transplantations from a donor with serum creatinine of 13.1 mg/dL

Doadores falecidos não limítrofes com insuficiência renal aguda podem ser uma opção segura para aumentar a oferta de rins para transplante. a avaliação histológica é fundamental para o estabelecimento do prognóstico funcional desses enxertos. Dois transplantes renais foram realizados com rins provenientes de um doador falecido jovem com insuficiência renal aguda severa sem comprometimento estrutural do parêquima renal. Ambos os enxertos apresentaram atraso de funcionamento no período pós-operatório, embora um deles com boa diurese inicial não tenha necessitado diálise. Função renal adequada foi observada a partir do 30º dia após o transplante. A insuficiência renal aguda severa no doador falecido não é fator de risco independente para a evolução em curto prazo do enxerto renal e não deve ser considerada contra-indicação absoluta para a realização do transplante.

Deceased donors not bordering with acute renal failure can be a safe option to increase the supply of kidneys for transplantation. histological evaluation is essential to establish the functional prognosis of these grafts. Two kidney transplants were performed with kidneys from a deceased donor couple with acute renal failure without severe structural impairment of parenchymal kidney. Both grafts were functioning in the late postoperative period, although one with good initial diuresis has not required dialysis. Adequate renal function was observed from day 30 after transplantation. Acute renal failure in severe deceased donor is not an independent risk factor for the development in short-term renal graft and should not be considered an absolute contraindication for transplantation was performed.

[Kidney and liver support therapies: state-of-the-art methods]. / Stand der Technik bei der Nieren- und Leberersatztherapie.

Today, worldwide approximately 1.5 million uremic patients owe their lives to hemodialysis. This figure will increase further by a growth rate of 6% annually reflecting a necessary increasing high interest in innovative technologies as well as in individualized therapies in this area. The main focus of developmental efforts, today and in the future, is to adapt the therapy to the specific physiological conditions of kidney patients, e.g., by means of a precise control of body water and its removal. This can be precisely monitored by bioimpedance analyses. Liver patients also benefit from the experiences with extracorporeal blood circuits. In contrast to hemodialysis, protein-permeable membranes are applied which allow for the removal of albumin-bound toxins. Albumin is then cleansed in the secondary circuit by adsorber cartridges and then readministered to the patient leading to improved recovery. This short review summarizes the state-of-the-art of blood purification methods in hemodialysis and liver support therapies.

Renal artery stent placement for restoration of renal function in hemodialysis recipients with renal artery stenosis.

PURPOSE: Renal artery stent placement to treat renal artery stenosis (RAS) in patients undergoing hemodialysis is not performed commonly. We present our outcomes of discontinuation of hemodialysis after treating patients with RAS by stent placement on acute (< or =30 days of hemodialysis) and chronic hemodialysis (>30 days). MATERIALS AND METHODS: A retrospective study was conducted in 16 patients (nine men) with an average age of 74.6 years +/- 10.6 (range, 49-86 y) who underwent treatment of 22 RAS for acute renal failure (n = 8) or uncontrolled hypertension with chronic hemodialysis (n = 8). The average follow-up was 448 days +/- 450 (median, 363.5 d; range, 6-1,583 d). The primary outcome consisted of discontinuation of hemodialysis, death, and transplantation. Secondary endpoints included restenosis, changes in blood pressure (and use of medications), and estimated glomerular filtration rate (eGFR). RESULTS: After the stent procedure, eight patients were able to discontinue hemodialysis and remained free from dialysis over a mean period of 564 days +/- 533. The predictors of discontinuation of hemodialysis were 24-hour proteinuria, eGFR before renal artery stent placement, and size of the kidney on ultrasound studies (P < .05 for all three). There was no difference in patients who were undergoing acute versus chronic hemodialysis. There were three minor complications, and one patient died 6 days after the procedure because of multiple cardiovascular problems. CONCLUSIONS: Renal artery stent placement for the treatment of RAS in patients receiving hemodialysis can result in discontinuation of hemodialysis in patients with low proteinuria level and adequate kidney size and eGFR.

Clinical outcome of the Tal Palindrome chronic hemodialysis catheter: single institution experience.

PURPOSE: To report the authors' clinical experience with the Tal Palindrome chronic dialysis catheter with a symmetric tip. MATERIALS AND METHODS: During a 39-month period, 126 Palindrome catheters were placed consecutively in 85 patients. Follow-up was available for 115 catheters. Insertion complications, patency, catheter-related bacteremia, exit site infections, and reasons for catheter removal were recorded. The patient's initial cause of end-stage renal disease, underlying diseases, and site of access were recorded as well. RESULTS: Patient ranged in age from 35 to 91 years (median, 69 years). Fifty percent of patients had diabetes. One hundred twenty-six Palindrome catheters were placed for a total of 12,046 catheter-days. The technical success rate of catheter placement was 100%. The average catheter indwell time was 105 days (range, 1-673 days). Catheters were inserted via the right (n = 107) or left (n = 19) jugular vein in all patients without insertional complication. Catheter-related infections occurred in 16 of the 115 catheters (13.9%) during the study period and culture-proved bacteremia occurred in four (3.5%). Seven exit site infections were recorded, and 10 catheters (8.7%) developed fibrin sheaths that necessitated catheter exchanges. CONCLUSIONS: Clinical experience with the Tal Palindrome hemodialysis catheter demonstrated safe and reliable use with low infection rates.

Acute exercise may exacerbate oxidative stress response in hemodialysis patients.

BACKGROUND/AIMS: Hemodialyzed patients (HD) demonstrate elevated oxidative stress (OXS) levels. Exercise effects on OXS response and antioxidant status of HD was investigated in the present study. METHODS: Twelve HD and 12 healthy controls (HC) performed a graded exercise protocol. Blood samples, collected prior to and following exercise, were analyzed for lactate, thiobarbituric acid-reactive substances (TBARS), protein carbonyls (PC), reduced (GSH) and oxidized glutathione (GSSG), total antioxidant capacity (TAC), catalase, and glutathione peroxidase (GPX) activity. RESULTS: HC demonstrated higher time-to-exhaustion (41%), lactate (41%) and VO2 peak (55%) levels. At rest, HD exhibited higher TBARS, PC, and catalase activity values and lower GSH, GSH/GSSG, TAC, and GPX levels. Although exercise elicited a marked change of OXS markers in both groups, these changes were more pronounced (p < 0.05) in HD patients. After adjusting for VO2 peak, differences between groups disappeared. VO2 peak was highly correlated with GSH/GSSG, TBARS, TAC and PC at rest and after exercise. CONCLUSIONS: These results imply that HD demonstrate higher OXS levels and a lower antioxidant status than HC at rest and following exercise. Acute exercise appears to exacerbate OXS response in hemodialyzed patients probably due to diminished antioxidant defense. However, aerobic capacity level seems to be related to OXS responses in this population.

On line mesurement of urea by aplication in paired filtration dialysis (PFD) experience in military hospital center.

The present paper shows the design and development the on-line measure of urea in blood during paired filtration dialysis (PFD), using non-invasive technical by employ the optical sensing in the visible range. We design and used a simple prototype for measurement the Nitrogen Ureic in Blood (BUN) by employ the optical sensor. In addition we compared the Urea measured in blood Pre and Post treatment, as well beta2 Microglobulin, Paratahormone (PTHi), Tiroglobulin and Phosphorus, register by laboratory. Previous results obtained in Military Hospital Centre in Mexico displayed good correlation between BUN contents and optical absorbance in the red region obtained through the arterial line in hemodialysis machine. Our hypothesis considers that the cause of this dependence is the volume change of the red cells with the urea concentration due to the osmotic pressure and to the mechanisms regulation cell. The reduction of the volume cells to a decrease respect to optical absorbance measurement. The most relevant parameter is water extraction along the dialysis treatment, given that changes in the blood fluid and arterial pressure (Hypotension or Hypertension), thus affecting the measurement principle.

[Renal failure and neurogenic bladder]. / Insuffisance rénale et vessie neurologique.

Historically, impaired renal function was the leading cause of death in spinal cord injury patients. Although the management of these patients has considerably improved due to progress in functional rehabilitation and neurourology, renal failure remains a significant cause of morbidity in this population. In this article, the authors review and classify the diagnostic tools able to detect urological changes likely to induce irreversible impairment of renal function. Based on a review of the recent literature, they define the incidence of renal impairment (morphological or function) in spinal cord injury patients and describe the main risk factors for deterioration of renal function in these patients.

Implications of levels of serum mineral metabolism markers, albumin and C-reactive protein for treatment costs of patients on maintenance dialysis.

BACKGROUND: Secondary hyperparathyroidism, malnutrition and inflammation have been reported to associate with adverse outcomes in dialysis patients. However, little is known about the implications of these conditions for treatment costs. METHODS: The cost data of all adult patients who had entered dialysis therapy at Tampere University Hospital between 1991 and 1996 and had remained on dialysis for at least 1 year were collected. results of measurements of parathyroid hormone (PTH), calcium, phosphorus, albumin and C-reactive protein (CRP) were obtained from the database of the hospital. RESULTS: Patients (n = 109), aged 57.0 +/- 14.9 years, included 57% men and 37% diabetics; 62% started on hemodialysis and 38% on peritoneal dialysis. Average daily costs were USD 161 (range 95-360). After controlling for patients' age, body mass index, gender, dialysis modality and primary renal disease, there was a positive correlation between average CRP and average costs and a negative correlation between albumin and costs. Correlations between mineral metabolism markers and costs were not found, but there was a trend towards lower cost among patients who achieved the Kidney Disease Outcomes Quality Initiative targets of calcium, phosphorus and PTH (USD 145 +/- 31) compared with those with nonoptimal levels (USD 165 +/- 48; p = 0.095). Costs of patients with at least one in-target PTH measurement were lower than costs of patients with constantly low PTH (USD 148 +/- 31 vs. 170 +/- 48; p = 0.01). CONCLUSION: Serum levels of albumin and CRP correlated with dialysis patients' treatment costs. Achieving the Kidney Disease Outcomes Quality Initiative targets may be associated with lower costs.

Reduction in platelet activation by citrate anticoagulation does not prevent intradialytic hemodynamic instability.

BACKGROUND: The etiology of intradialytic hemodynamic instability is multifactorial. Of the various factors involved, a rise in core temperature seems to be crucial. In this respect, the bioincompatibility of hemodialysis (HD) treatment might play an important role. The application of cool dialysate reduces the number of periods of intradialytic hypotension (IDH) considerably. In rats, roller pump perfusion caused hypotension by shear stress induced platelet aggregation and subsequent serotonin release. During clinical HD, citrate anticoagulation abolished platelet activation almost completely. Hence, citrate anticoagulation might reduce IDH, whereas the beneficial effect of cool dialysate might be partly explained by reduced platelet activation. METHODS: In the present study, blood pressure, IDH episodes, platelet activation, platelet aggregation, and serotonin release were studied crossover in 10 patients during HD with dalteparin anticoagulation at normal and low dialysate temperatures and during HD with citrate. RESULTS: Citrate strongly reduced platelet activation, but did not improve IDH. The blood pressure was best preserved during cool-temperature HD, despite manifest platelet activation. Platelet activation was not accompanied by a rise in the plasma serotonin concentration. CONCLUSIONS: Three major conclusions can be drawn: (1) it is unlikely that platelet activation and subsequent serotonin release underlie IDH in the clinical situation; (2) the protective effects of cool dialysate on IDH appear to be independent of HD-induced platelet activation, and (3) extrapolating results from rat experiments to the human situation requires uppermost prudence.