Management of Acute Kidney Injury in Coronavirus Disease 2019.

Acute kidney injury is a common complication in hospitalized patients with coronavirus disease 2019. Similar to acute kidney injury associated with other conditions such as sepsis and cardiac surgery, morbidity and mortality are much higher in patients with coronavirus disease 2019 who develop acute kidney injury, especially in the intensive care unit. Management of coronavirus disease 2019-associated acute kidney injury with kidney replacement therapy should follow existing recommendations regarding modality, dose, and timing of initiation. However, patients with coronavirus disease 2019 are very hypercoagulable, and close vigilance to anticoagulation strategies is necessary to prevent circuit clotting. During situations of acute surge, where demand for kidney replacement therapy outweighs supplies, conservative measures have to be implemented to safely delay kidney replacement therapy. A collaborative effort and careful planning is needed to conserve dialysis supplies, to ensure that treatment can be safely delivered to every patient who will benefit for kidney replacement therapy.

Policy and Pandemic: The Changing Practice of Nephrology During the Coronavirus Disease-2019 Outbreak.

The coronavirus (coronavirus disease-2019) pandemic has changed care delivery for patients with end-stage kidney disease. We explore the US healthcare system as it pertains to dialysis care, including existing policies, modifications implemented in response to the coronavirus disease-2019 crisis, and possible next steps for policy makers and nephrologists. This includes policies related to resource management, use of telemedicine, prioritization of dialysis access procedures, expansion of home dialysis modalities, administrative duties, and quality assessment. The government has already established policies that have instated some flexibilities to help providers focus their response to the crisis. However, future policy during and after the coronavirus disease-2019 pandemic can bolster our ability to optimize care for patients with end-stage kidney disease. Key themes in this perspective are the importance of policy flexibility, clear strategies for emergency preparedness, and robust health systems that maximize accessibility and patient autonomy.

Home Dialysis in the Coronavirus Disease 2019 Era.

The coronavirus disease 2019 pandemic has had a significant impact on patients with end-stage kidney disease and their care, especially given the potential for severe coronavirus disease 2019 in those with a depressed immune status. Patients receiving in-center hemodialysis have been particularly affected by this pandemic because of their need to travel multiple times a week to receive treatment. Although patients on home dialysis are able to avoid such exposure, they face their own unique challenges. In this review, we will discuss the challenges posed by the coronavirus disease 2019 pandemic for patients on home dialysis, the impact of coronavirus disease 2019 on various aspects of their care, and the resultant rapid adaptations in policy/health-care delivery mechanisms with implications for the future care of patients on home dialysis.

Utilidad de las tiras reactivas multistix 10 SG(R) en el diagnóstico de peritonitis en diálisis peritoneal / Utility of the Multistix 10 SG (R) reagent strips in the diagnosis of peritonitis in peritoneal dialysis

Introducción: La infección peritoneal es una complicación frecuente en diálisis peritoneal, que condiciona una importante morbimortalidad. Habitualmente el diagnóstico se establece mediante signos y síntomas clínicos, efluente turbio y cultivo positivo. En ocasiones los síntomas son poco evidentes, el recuento leucocitario puede no estar disponible y el cultivo se demora varios días. Por otro lado se sabe que el inicio precoz del tratamiento antibiótico aumenta la eficacia y favorece la resolución de los episodios de infección peritoneal. Objetivo: Estudiar la capacidad diagnóstica de las tiras reactivas Multistix 10 SG Siemens® en la determinación de peritonitis en pacientes en diálisis peritoneal. Material y métodos: Estudio observacional prospectivo donde se analizaron muestras de líquido peritoneal efluente de pacientes prevalentes en diálisis peritoneal, durante seis meses. Se tomó como criterio de peritonitis la presencia de más de 100 Leucocitos (L)/ μl y más de 50% de ellos polimorfonucleares. Las muestras de líquido peritoneal efluente fueron obtenidas después de permanencias mínimas de dos horas y volumen mínimo de 1500 cc. Todas las muestras se analizaron usando tiras reactivas de Multistix ® 10 SG Siemens durante 2 minutos, anotando el observador el resultado de acuerdo a la escala cromática (valor 0= 0-15 L/μl, valor 1= 16-70 L/μl, valor 2=71-125 L/μl y valor 3=126-500 L/μl) y se compararon con las enviadas al laboratorio de nuestro hospital para el recuento manual de leucocitos. Se recogieron otras variables clínicas y epidemiológicas. Resultados: Se analizaron 111 muestras de efluente peritoneal. Detectándose infección peritoneal en 28 muestras (25.2%). No se observaron diferencias significativas entre infectados y no infectados por razón de edad, sexo, diabetes ni número de peritonitis anteriores. El 68 % de los pacientes infectados declararon sufrir dolor. El 73% de las muestras con infección presentaron líquido turbio. En relación al resultado del Multistix, y considerando infección un valor por encima de 1, encontramos una sensibilidad del 100% y una especificidad del 95.2%. Si el punto de corte se toma en el valor 2 encontramos una sensibilidad del 96,4% y una especificidad del 100%. Conclusiones: La utilización de las tiras Multistix® 10 SG Siemens como prueba diagnóstica para la detección de infección peritoneal, tiene una validez excelente, pudiendo sustituir al recuento manual de leucocitos (AU)

Introduction: Peritoneal infection is a common com- plication in peritoneal dialysis, which determined a significant morbidity and mortality. Usually the diagnosis is established by clinical signs and symptoms, cloudy effluent and positive culture. Sometimes the symptoms are not evident, the leukocyte count may not be available and culture takes several days. On the other hand it is known that early antibiotic therapy increases effectiveness and promotes the resolution of the episodes of peritoneal infection. Objective: Study the diagnostic capacity of Siemens Multistix 10 SG® reagent strips in determining peritonitis in patients on peritoneal dialysis. Methods: A prospective observational study was carried out. Samples of peritoneal fluid effluent from prevalent patients on peritoneal dialysis were analyzed for six months. It was taken as the criterion of peritonitis, the presence of more than 100 leukocytes (L)/ μl and over 50% of these polymorphs. Samples of peritoneal fluid effluent were obtained after two-hours minimum stays and minimum volume of 1500 cc. All samples were analyzed using Siemens Multistix 10 SG® reagent strips for 2 minutes, scoring the observer the result according to the chromatic scale (value 0 = 0-15 L / μl; value 1 = 16-70 L / μl; value 2 = 71-125 L / μl; and value 3 = 126-500 L / μl) and compared to those sent to the hospital laboratory for manual leukocyte count. Other clinical and epidemiological variables were collected. Results: 111 samples of peritoneal dialysis were analyzed. Peritoneal infection were detected in 28 samples (25.2%). No significant differences between infected and uninfected by reason of age, sex, diabetes or number of previous peritonitis were observed. 68% of infected patients reported suffering from pain. In those infected samples, 73% presented cloudy fluid. In relation to the result of Multistix and considering infection a value greater than 1, we found a sensitivity of 100% and a specificity of 95.2%. If the cut point is taken in the value 2 we found a sensitivity of 96.4% and a specificity of 100%. Conclusions: The use Siemens Multistix 10 SG® reagent strips as a diagnostic test for the detection of peritoneal infection has excellent validity and could replace the manual leukocyte count (AU)

Childhood renal disorders in Ilorin, north central Nigeria.

AIMS AND OBJECTIVES: To determine the pattern of renal disorders seen at the University of Ilorin Teaching Hospital located in the North Central region of Nigeria. MATERIALS AND METHODS: The renal register of the Paediatric Nephrology Unit of the Hospital was analysed for children seen in the last thirteen years (January 1995-December 2008). RESULTS: A total number of 164 children were seen during the study period. Nephrotic syndrome was the leading renal disorder accounting for 69 (42.1%) cases. This was followed by acute glomerulonephritis (AGN) which occurred in 47 (28.7%) children. There were also 19 cases of acute renal failure (ARF). Sepsis was the leading cause 7(36.8%) followed by diarrhea related illness 5 (26.3%). Eleven deaths were recorded among the ARF cases giving a case fatality of 57.9%. CONCLUSION: Nephrotic syndrome and acute glomerulonephritis are the leading renal disorders in children in our center. The few cases of ARF seen, recorded attendant high mortality because of inadequate access to dialysis.

The use of alternative anti-coagulation strategies for a nocturnal home hemodialysis patient with heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is a potentially catastrophic hyercoagulable state. The prevalence of HIT in individuals doing nocturnal home hemodialysis (NHD) is unknown and the appropriate treatment protocol has yet to be determined. The objective is to describe the clinical course and treatment plan ofa patient who developed HIT while undergoing NHD. A 49-year-old man with a past history of end stage renal disease (ESRD) of unknown etiology was initiated on NHD in February 2005. His clinical and biochemical parameters improved after conversion to NHD. However, excessive bleeding at the vascular access sites complicated his treatments. Clinical investigations revealed development of HIT Alternative therapeutic strategies were attempted to enable our patient to continue NHD: unfractionated heparin, citrated regional anticoagulation, Danaparoid, and Argatroban. In conclusion, NHD patients with HIT pose a specific clinical challenge. We speculate that the augmented exposure of heparin coupled with a primed autoimmune response may be responsible for the development of HIT in our patient. Further research is required to elucidate the appropriate clinical monitoring and treatment strategy for this patient.

On-line technique for producing substitution fluid in haemodiafiltration and haemofiltration.

When the kidneys are not able to fulfil their task anymore the individual reaches a situation known as End-Stage Renal Disease (ESRD). Haemodialysis may be carried out. In order to have a more efficient dialysis the treatment modes haemodiafiltration and haemofiltration are also in use. In these modes a substitution fluid is added to the bloodstream and continuously removed by the dialyser. However, these modes require large volumes of sterile fluids, 10 to 30 litres for haemodiafiltration and 70 - 100 litres for haemofiltration. This fact has made these treatment modes expensive. The fluids have traditionally been produced by the pharmaceutical industry in five litre bags, but in bags not all solutions are stable or possible to produce, for instance when sodium bicarbonate is used as a buffer. Today sodium bicarbonate is the absolute predominant buffer. An alternative way of producing the fluids has to be found. In 1978 LW Henderson (1) described a technique using filtration to produce substitution fluid on-line i.e. preparing the fluid directly on site and giving it to the patient. Since then work has taken place in order to construct a system that is able to both mix, sterilise and administrate the substitution fluid in haemodiafiltration and haemofiltration. This work has resulted in dialysis machines with the feature to fulfil the task of producing sterile substitution fluid. On-line haemodiafiltration is carried out in dialysis clinics. There are approximately 65 in Sweden, 1000 in Germany, 900 in Italy, 600 in France and 2500 in the US. The number of dialysis patients is around 1.000.000 worldwide and the increase is around 7 - 9% annually.