No benefit of systematic hemodialysis catheter blood cultures for the early detection of catheter-related bloodstream infection
.

BACKGROUND: The use of a catheter for hemodialysis is associated with a 5-fold increased risk of septicemia. Early detection of catheter-related bloodstrean infection (CRBSI) may decrease morbidity and mortality, but the benefits of systematic blood cultures have not been demonstrated. MATERIALS AND METHODS: We retrospectively studied the blood culture results of patients who had been dialyzed with a tunneled jugular catheter for more than 1 month in a dialysis unit from January to December 2015. Systematic monthly catheter blood cultures were taken from the heparin lock solutions in the arterial and venous branches, at the beginning or end of the session. CRBSI was assessed using patient symptoms (fever, chills, hemodynamic instability) and positive catheter blood cultures. RESULTS: 75 patients were included. We analyzed the results of 577 systematic catheter blood cultures. 27 (5%) were positive, including 23 from patients who did not develop CRBSI in the following month. For the latter, there was a predominance of coagulase-negative staphylococci. Only four patients with positive catheter blood cultures went on to develop CRBSI in the following month. The sensitivity and specificity of these monthly blood cultures to detect CRBSI in the following month were 0.44 and 0.95, respectively. The positive and negative predictive values of the test were 0.14 and 0.99, respectively. CONCLUSION: In this study, systematic catheter blood cultures did not predict the occurrence of CRBSI. The sensitivity of these tests could be improved by increasing the sampling frequency. A cost-benefit analysis of such measures should be performed.

[Community pharmacists' interventions to prevent and screen chronic kidney disease patients]. / Implication du pharmacien d'officine dans le parcours de soins de la maladie rénale chronique.

Chronic kidney disease (CKD) is a major concern of public health. The pharmacist is known as a health practitioner involved in prevention and therapeutic education. Our study aimed at defining the impact of community pharmacists' interventions for preventing and screening CKD. In our observational prospective study of 5 months conducted in 109 community pharmacy, we included 2 groups of patients: A (therapeutic optimization): CKD patients and B (CKD screening): population at risk. In group A, we included 354 patients, mainly women (51.2%), in stage 3 of CKD, mean age 73 years old, with hypertension alone (40.6%) or associated with diabetes (44%). About 70% of the patients had a follow up by a nephrologist and 45% of them were good adherent according to the Morisky-Green self-report. However, approximately 20% of patients did not have nephroprotective treatments in their regimen although they were on stage 3 or 4 CKD patients, and about half of them were not aware of medical situations at risk. Concerning group B, 532 patients were included. The pharmaceutical interventions screened 10% of patients with a GFR<60mL/min/1.73m2. The community pharmacists' interventions helped to optimize the therapeutic management of CKD patients and in the early screening of patients at risk. More studies are needed to extrapolate our observations to a larger population.

[Patterns of nephrology referral and predialysis management of patients with chronic kidney disease]. / Suivi néphrologique et niveau de prise en charge des patients en insuffisance rénale terminale.

INTRODUCTION: Numerous studies showed that late referral (LR) to a nephrologist of patients with chronic kidney disease stated by a simple quantitative criterium (initiation of renal replacement therapy (RRT) within 3 or 4 months of referral to a nephrologist, independantly from the quality of care) is associated with worse survival rate, limited to the first 3 months following the initiation of RRT. We wanted to test a criterium of LR definition supposing a more important "dose of nephrological care", to try to understand the reasons of this early death. METHODS: One hundred and thirty-eight patients receiving their first RRT in 1999 and 2000 in Valenciennes (France) were enrolled in this study. Two LR definitions were used: a qualitative criterium C1 (whether the patient was under an uninterrumpted nephrological pre-dialysis care - independantly from the date of the nephrological referral - or not) and a more simple quantitative criterium C2 (initiation of RRT within 3 months of referral to a nephrologist). Comorbidity was assessed by Charlson's score. The analysis concerned the respective influence of C1 and C2 on the clinical and biological effects of chronical azotemia, on the circumstances at first RRT (emergency first dialysis, pulmonary edema, type of vascular access), and on survival rates (Kaplan-Meier's analysis). RESULTS: LR rates are 23% according to C1 and 20% according to C2. Comorbidity is similar in the different groups. Whatever the definition criterium, LR is associated to a lower hemoglobin and albumin, a more severe acidosis, a longer duration of first hospitalization, and higher rate of emergency first dialysis and use of central temporary catheter. The survival rates at 2 years following the first RRT of lately referred patients are 53% according to C1 (vs 86% for early referred patients, P<0,001) and 56% according to C2 (vs 84%, P<0,05). For both, early death (within the first 3 months) explained the observed differences of survival rates. CONCLUSION: In this study, early death of lately referred patients seems to be independant from the criterium of definition of LR. Elements of explanation are suggested, and can lead to further prospective studies.

Effect of the correction of metabolic acidosis on nutritional status in elderly patients with chronic renal failure.

BACKGROUND: Metabolic acidosis (MA) is a frequent complication in advanced chronic renal failure (CRF). Currently, there is good evidence that MA contributes to malnutrition in CRF patients. METHODS: We evaluated the effect of correcting MA on nutritional status after 6 months of oral sodium bicarbonate supplementation in 18 patients aged 73 +/- 6 years with CRF to maintain serum bicarbonate levels at 24 +/- 2 mmol/L. The following parameters were measured: dietary record, energy intake, dietary protein intake (DPI), mini-nutritional assessment (MNA), serum albumin level, prealbumin level, prognosis inflammatory and nutritional index (PINI), and protein catabolic rate (nPCR). RESULTS: No significant changes in body weight or systolic and diastolic blood pressure were observed. Serum albumin and prealbumin levels showed a significant increase. nPCR decreased significantly. DPI, energy intake, PINI, and MNA score did not change significantly. No patient reported side effects or fluid retention during the study. CONCLUSION: Correction of MA improves serum albumin and prealbumin concentration, and it is not associated with any significant change in DPI, but induces a decrease in nPCR values. Whereas nPCR may provide an index of protein catabolism, it does not differentiate between dietary sources of protein or net catabolism of endogenous proteins. In the absence of dietary changes, the decrease in nPCR values may be attributed to a decrease in whole body protein degradation.