Do echocardiographic parameters predict mortality in patients with end-stage renal disease?

BACKGROUND: Left ventricular function predicts cardiovascular mortality both in the general population and those with end-stage renal disease. Echocardiography is commonly undertaken as a screening test before kidney transplantation; however, there are little data on its predictive power. METHODS: This was a retrospective review of patients assessed for renal transplantation from 2000 to 2009. A survival analysis using demographic and echocardiographic variables was undertaken using the Cox proportional hazards regression model. RESULTS: Of 862 patients assessed for transplantation, 739 had an echocardiogram and 217 of 739 (29%) died during a mean follow-up of 4.2 years. In a multivariate survival analysis, increased age (P<0.0001), diabetes (P<0.0001), transplant listing status (P<0.0001), severely impaired left ventricular function (P<0.01), pulmonary hypertension and/or right ventricular dysfunction (P=0.01), and regional wall motion abnormalities (P<0.01) were associated with all-cause mortality. Combined in a score where one point was given for the presence of each of the parameters above, these factors were strongly predictive of increased mortality with a hazard ratio of 3.57, 6.80, and 44.47 for the presence of one, two, or more factors, respectively, compared with the absence of any of these factors. CONCLUSIONS: In patients with end-stage renal disease, multiple easily determined echocardiographic parameters, including regional wall motion abnormalities and pulmonary hypertension and/or right ventricular dysfunction, were independently associated with all-cause and cardiovascular mortality. Combining these factors in a simple score may further assist in risk stratifying patients being considered for renal transplantation.

Effect of antimicrobial locks for tunneled hemodialysis catheters on bloodstream infection and bacterial resistance: a quality improvement report.

BACKGROUND: Catheter-restricted antimicrobial lock (AML) use reduces catheter-associated bloodstream infection (CA-BSI) in clinical trial settings, but may not be as effective in clinical settings and may increase bacterial resistance. DESIGN: Quality improvement report analyzed using a cross-sectional time series (unbalanced panel) design. SETTING & PARTICIPANTS: The study cohort comprised all prevalent adults treated with hemodialysis through a tunneled catheter for any, but not necessarily all, of the time from January 1, 2003, to June 30, 2006, in Manukau City, New Zealand (135,346 catheter-days, 404 tunneled catheters, 320 patients). QUALITY IMPROVEMENT PLAN: Catheter-restricted AMLs (heparin plus gentamicin) for all tunneled catheters from July 1, 2004. MEASURES: Repeated observations of CA-BSI, hospitalization, tunneled catheter removal, and death from CA-BSI analyzed by using generalized estimating equations with a single level of clustering for each tunneled catheter and patterns of bacterial resistance analyzed by using simple descriptive statistics. RESULTS: AML use was associated with reductions in rates of CA-BSI and hospitalization for CA-BSI by 52% and 69% for patients with tunneled catheters locked continuously with AMLs since their insertion compared with those with tunneled catheters that were not, respectively. AML exposure also was associated with a trend to increased gentamicin resistance amongst coagulase-negative staphylococci isolates, a pattern similar to that observed for BSIs in our general hemodialysis population in which tunneled catheters were not the source of BSI, but different from that in the general non-end-stage renal disease population in the region. LIMITATIONS: This is an uncontrolled observational study and cannot prove causality. The follow-up period of 18 months is longer than for other studies, but still too short to definitely answer whether AML use drives bacterial resistance. CONCLUSIONS: A change to use of AMLs may improve clinical outcomes; however, additional study of associated bacterial resistance is needed before AML use becomes standard care.