Impact of Remote Monitoring on Standardized Outcomes in Nephrology-Peritoneal Dialysis.

Introduction: This study aimed to evaluate the association between the use of remote patient monitoring (RPM) in patients on automated peritoneal dialysis (APD) and the Standardized Outcomes in Nephrology in peritoneal dialysis (SONG-PD) clinical outcomes. Methods: A prospective and multicenter cohort study was conducted on patients with advanced chronic kidney disease on APD, recruited at 16 Spanish Hospitals, between June 1 and December 31, 2021. Patients were divided into 2 cohorts, namely patients on APD with RPM (APD-RPM) and patients on APD without RPM. The primary endpoints were the standardized outcomes of the SONG-PD clinical outcomes: PD-associated infection, cardiovascular disease (CVD), mortality rate, technique survival, and life participation (assessed as health-related quality of life [QoL]). Propensity score matching (PSM) was used to evaluate the association of RPM exposure with the clinical outcomes. Results: A total of 232 patients were included, 176 (75.9%) in the APD-RPM group and 56 (24.1%) in the APD-without-RPM group. The mean patient follow-up time was significantly longer in the APD-RPM group than in the APD-without-RPM group (10.4 ± 2.8 vs. 9.4 ± 3.1 months, respectively; P = 0.02). In the overall study sample, the APD-RPM group was associated with a lower mortality rate (hazard ratio [HR]: 0.08; 95% confidence interval [CI]: 0.01 to 0.69; P = 0.020) and greater technique survival rate (HR: 0.25; 95% CI: 0.11 to 0.59; P = 0.001). After PSM, APD-RPM continued to be associated with better technique survival (HR: 0.23; 95% CI: 0.06 to 0.83; P = 0.024). Conclusion: The use of RPM programs in patients on APD was associated with better survival of the technique and lower mortality rates. However, after PSM, only technique survival was significant.

Opportunities to improve the management of anemia in peritoneal dialysis patients: lessons from a national study in routine clinical practice.

Background: Current guidelines establish the same hemoglobin (Hb) and iron biomarkers targets for hemodialysis (HD) and peritoneal dialysis (PD) in patients receiving erythropoiesis-stimulating agents (ESAs) even though patients having PD are usually younger, more active and less comorbid. Unfortunately, specific renal anemia [anemia in chronic kidney disease (aCKD)] trials or observational studies on PD are scanty. The aims of this study were to describe current aCKD management, goals and adherence to clinical guidelines, identifying opportunities for healthcare improvement in PD patients. Methods: This was a retrospective, nationwide, multicentre study including patients from 19 PD units. The nephrologists collected baseline data, demographics, comorbidities and data related to anemia management (laboratory values, previously prescribed treatments and subsequent adjustments) from electronic medical records. The European adaptation of KDIGO guidelines was the reference for definitions, drug prescriptions and targets. Results: A total of 343 patients (mean age 62.9 years, 61.2% male) were included; 72.9% were receiving ESAs and 33.2% iron therapy [20.7% intravenously (IV)]. Eighty-two patients were receiving ESA without iron therapy, despite 53 of them having an indication according to the European Renal Best Practice guidelines. After laboratory results, iron therapy was only started in 15% of patients. Among ESA-treated patients, 51.9% had an optimal control [hemoglobin (Hb) 10-12 g/dL] and 28.3% between 12-12.9 g/dL. Seventeen patients achieved Hb >13 g/dL, and 12 of them remained on ESA after overshooting. Only three patients had Hb <10 g/dL without ESAs. Seven patients (2%) met criteria for ESA resistance (epoetin dose >300 IU/kg/week). The highest tertile of erythropoietin resistance index (>6.3 UI/kg/week/g/dL) was associated with iron deficiency and low albumin corrected by renal replacement therapy vintage and hospital admissions in the previous 3 months. Conclusion: Iron therapy continues to be underused (especially IV). Low albumin, iron deficiency and prior events explain most of the ESA hyporesponsiveness. Hb targets are titrated to/above the upper limits. Thus, several missed opportunities for adequate prescriptions and adherence to guidelines were identified.

Hemodialysis vascular access flow measurements by the novel DMed NephroFlow® device: A comparative study with Transonic®.

INTRODUCTION: The current Spanish Clinical Guidelines on Vascular Access for Hemodialysis support the need for surveillance and monitoring of vascular access (VA) to avoid complications. Ultrasound dilution (UD) methods are accepted for the evaluation of VA flow and Transonic® has established the gold standard method for the measurement. The DMed NephroFlow (NIPRO®) device, based on UD method has recently been incorporated. We report a comparative study between the classic Transonic® versus the new NephroFlow® device. MATERIAL AND METHODS: For two consecutive months, measurements of VA flow using both referred systems were performed in patients with a native arteriovenous fistula (AVF) or a graft (AVG) on hemodialysis (HD) in our unit. Both studies were undertaken according to the usual recommendations: VA flow of 250 ml/min, ultrafiltration rate without modifications, both needles in the same vein, and always in the first hour of the HD session. RESULTS: Forty-five patients were included: 17 women and 28 men, mean age of 67 ± 12 years. Thirty patients were diabetic. The baseline meantime on HD was 51 ± 39 months (range: 3-163). Type of VA was: 17 patients radio-cephalic AVF, 17 brachiocephalic AVF, 7 brachiobasilic AVF, and 3 with a graft. The mean flow estimated by the Transonic® was 1222 ± 805 ml/min and the estimated flow by the NephroFlow® device was 1252 ± 975 ml/min. Good reliability between Transonic® and NephroFlow® was observed, with a reliability index of Cronbach's Alpha of 0.927 and an Intraclass Correlation Index of 0.928. CONCLUSIONS: The NephroFlow® device seems comparable with the accepted gold standard UD method for estimating VA flow. More studies must be performed to verify these results. However, they should be considered for the surveillance and monitoring of VA flow, in agreement with the Spanish Guidelines.

Effectiveness and safety of ferric carboxymaltose therapy in peritoneal dialysis patients: an observational study.

BACKGROUND: The efficacy of intravenous (IV) ferric carboxymaltose (FCM) has been demonstrated in haemodialysis and non-dialysis studies, but evidence is lacking in patients undergoing peritoneal dialysis (PD). METHODS: This multicentre, retrospective study evaluated the effectiveness and safety of FCM in patients on PD over 12 months. We retrospectively reviewed the electronic medical records of PD patients who initiated FCM treatment between 2014 and 2017 across seven Spanish centres. RESULTS: Ninety-one patients were included in the safety population (mean ± SD age 57.7 ± 15.0 years) and 70 in the efficacy population (mean age 50.9 ± 14.5 years). No hypersensitivity reaction, FCM discontinuation or dose adjustment due to a serious adverse event (SAE) was registered in the safety population. The most common non-SAEs reported were headache (four events), mild hypotension (three events) and hypertension (two events), among others. In the efficacy population (n = 70), 68.6% of patients achieved ferritin levels of 200-800 ng/mL, 78.4% achieved transferrin saturation (TSAT) >20%, and 62.8% achieved TSAT >20% and ferritin >200 ng/mL after 12 months of FCM initiation (P < 0.01). Haemoglobin (Hb) levels were maintained at >11 g/dL with a lower dose of darbepoetin throughout the follow-up. The sub-analysis of patients naïve to IV iron and with absolute or relative iron deficiency (n = 51) showed that 76.5% reached ferritin >200 ng/mL, 80.4% TSAT >20% and Hb increased (1.2 g/dL) after 4 months of FCM treatment (P < 0.01). CONCLUSION: In this multicentre, retrospective, real-world study conducted in the PD population, FCM was effective, safe and easy to administer during routine clinical visits.

Aspectos clave en el mantenimiento de la diuresis residual en pauta de hemodiálisis incremental. Experiencia de diez años / Key aspects in maintaining residual diuresis in an incremental haemodialysis schedule. Experience of ten years

INTRODUCCIÓN: La hemodiálisis incremental o progresiva es una modalidad de inicio de hemodiálisis, basada en la diuresis residual y adaptada a las necesidades del paciente, poco extendida pese a sus potenciales beneficios. Para su correcto seguimiento es necesario establecer unas pautas específicas en cada sesión de hemodiálisis, que deben ser conocidas por el personal que atiende a estos pacientes de forma regular. OBJETIVO: analizar la evolución de los pacientes que han iniciado tratamiento renal sustitutivo con hemodiálisis incremental. MATERIAL Y MÉTODO: Estudio observacional retrospectivo de pacientes incidentes en tratamiento renal sustitutivo mediante hemodiálisis incremental en nuestro centro en los últimos 10 años. Comparación de resultados basales y a los 12 meses de seguimiento. RESULTADOS: En este periodo de tiempo se han incluido 49 pacientes en técnica de hemodiálisis incremental. Aunque la diuresis residual desciende en el primer año de 2030±600 ml/día a 1300±500 (p < 0,05), ésta se mantiene por encima de un litro en la mayoría de los casos. El aclaramiento de urea también desciende de 5,7±1,6 ml/min a 3,4±1,6 ml/min al año (p < 0,05). CONCLUSIONES: Iniciar tratamiento renal sustitutivo con hemodiálisis incremental puede mantener más tiempo la diuresis residual, para eso es clave el conocimiento de la técnica y su correcto manejo durante las sesiones de diálisis

INTRODUCTION: Incremental or progressive haemodialysis is a modality for starting haemodialysis, based on residual diuresis and adapted to the needs of the patient, and not very widespread despite the potential benefits. For correct follow-up, it is necessary to establish specific guidelines in each haemodialysis session, which must be known by the staff who treat these patients regularly. AIM: To analyse the evolution of patients who start renal replacement therapy with incremental haemodialysis. MATERIAL AND METHOD: Retrospective observational study of incident patients on renal replacement therapy using incremental haemodialysis in our centre in the last 10 years. Comparison of baseline and 12-month follow-up results was carried out. RESULTS: In the study period, 49 patients with incremental haemodialysis were included. Although the residual diuresis falls in the first year from 2030±600 ml/day to 1300±500 (p < 0.05), in most cases, it remains above one litre. Urea clearance also decreases from 5.7±1.6 ml/min to 3.4±1.6 ml/min per year (p < 0.05). CONCLUSIONS: Starting renal replacement therapy with incremental haemodialysis can keep residual diuresis longer. Knowledge of the technique and correct handling during dialysis sessions are key

Respuesta al artículo: «Brote de bacteriemia por Serratia marcescensen hemodiálisis». Comentarios al artículo: «Brote de bacteriemia por Serratia marcescens en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros» / Answer to the article: «Serratia marcescens bacteraemia outbreak in hemodialysis». Comment on «Serratia marcescens bacteraemia outbreak in haemodialysis patients with tunnelled catheters due to colonisation of antiseptic solution. Experience at 4 hospitals»

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Establishment of buttonhole technique as a puncture alternative for arteriovenous fístulas. experience of a centre over 3years. / Instauración de la técnica de buttonhole como alternativa de punción para las fístulas arteriovenosas. Experiencia de un centro en 3años.

INTRODUCTION: The buttonhole (BH) puncture technique for arteriovenous fistulas is an alternative to the classical staggered puncture. PURPOSE: We present 3years' results incorporating the BH puncture technique for arteriovenous fistulas in our dialysis unit. MATERIAL AND METHODS: Twenty-two patients were started on BH technique, 15 men and 7 women (mean age: 62 years; SD: 12), with time spent on dialysis when starting the BH technique of 34 months (SD: 34, median: 27, range: 3-136). Seven patients received acenocoumarol and 9 antiplatelet agents. The vascular access median time at the beginning of the technique was 27 months (range: 3-252). RESULTS: Between 5 and 8 consecutive dialysis sessions were necessary to achieve a proper tunnel puncture. No patient suffered major complications. The average time on BH technique until December 2015 was 12 months (SD: 10, median: 9, range: 1-45). By the end of the study, 5patients were performing self-puncture. Haemostasis times post-dialysis were reduced from 18.6min (SD: 8, prior to the BH technique), to 12.2minutes (SD: 3 after BH) (P=.0005). CONCLUSIONS: The BH technique is an alternative puncture technique for dialysis patients. Self-puncture and reduction in hemostasis time are potential beneficial aspects. A greater diffusion of this technique in the hemodialysis units would allow it to be better applied. A highly motivated nursing staff is key and a necessary condition for its implementation.

Instauración de la técnica de buttonhole como alternativa de punción para las fístulas arteriovenosas. Experiencia de un centro en 3 años / Establishment of buttonhole technique as a puncture alternative for arteriovenous fístulas. experience of a centre over 3 years

Introducción: La técnica de punción de buttonhole (BH) o de ojal para fístulas arteriovenosas es una alternativa a la punción escalonada clásica. Objetivo: Mostramos la experiencia en nuestra unidad de hemodiálisis tras la incorporación de esta técnica a la práctica clínica diaria. Material y métodos: Se ha aplicado la técnica de BH a 22 pacientes, 15 hombres y 7 mujeres, con una edad media de 62 años (DE: 12), con un tiempo en diálisis en el momento de iniciar la técnica de BH de 34 meses (DE: 34; mediana: 27; rango: 3-136). Siete pacientes recibían acenocumarol y 9 estaban antiagregados. La mediana de tiempo con el acceso vascular al inicio de la técnica de BH fue de 27 meses (rango: 3-252). Resultados: Fueron necesarias entre 5 y 8 sesiones consecutivas de diálisis para la consecución de un correcto túnel de canalización. Ningún paciente presentó complicaciones mayores. El tiempo medio en la técnica de BH fue de 12 meses (DE: 10; mediana: 9; rango: 1-45). Al final del periodo de estudio 5 pacientes realizaban autopunción. El tiempo de hemostasia posdiálisis se redujo de 18,6 min (DE: 8) previamente a la técnica de BH a 12,2 (DE: 3) posteriormente a su utilización (p=0,0005). Conclusiones: La técnica de BH es una alternativa de punción en hemodiálisis. Puede presentar aspectos beneficiosos como la autopunción o la reducción de los tiempos de hemostasia. Una mayor difusión en las unidades de hemodiálisis sería necesaria para mejorar en su aplicación adecuada. El personal de enfermería altamente motivado es clave y condición necesaria para su implantación (AU)

Introduction: The buttonhole (BH) puncture technique for arteriovenous fistulas is an alternative to the classical staggered puncture. Purpose: We present 3 years’ results incorporating the BH puncture technique for arteriovenous fistulas in our dialysis unit. Material and methods: Twenty-two patients were started on BH technique, 15 men and 7 women (mean age: 62 years; SD: 12), with time spent on dialysis when starting the BH technique of 34 months (SD: 34, median: 27, range: 3-136). Seven patients received acenocoumarol and 9 antiplatelet agents. The vascular access median time at the beginning of the technique was 27 months (range: 3-252). Results: Between 5 and 8 consecutive dialysis sessions were necessary to achieve a proper tunnel puncture. No patient suffered major complications. The average time on BH technique until December 2015 was 12 months (SD: 10, median: 9, range: 1-45). By the end of the study, 5 patients were performing self-puncture. Haemostasis times post-dialysis were reduced from 18.6min (SD: 8, prior to the BH technique), to 12.2 minutes (SD: 3 after BH) (P=.0005). Conclusions: The BH technique is an alternative puncture technique for dialysis patients. Self-puncture and reduction in hemostasis time are potential beneficial aspects. A greater diffusion of this technique in the hemodialysis units would allow it to be better applied. A highly motivated nursing staff is key and a necessary condition for its implementation (AU)

Application of a pattern of incremental haemodialysis, based on residual renal function, when starting renal replacement therapy. / Aplicación de una pauta de hemodiálisis incremental, basada en la función renal residual, al inicio del tratamiento renal sustitutivo.

INTRODUCTION: The interest in the preservation of residual kidney function on starting renal replacement therapy (RRT) is very common in techniques such as peritoneal dialysis but less so in haemodialysis (HD). In our centre the pattern of incremental dialysis (2 HD/week) has been an option for a group of patients. Here we share our experience with this regimen from March 2008. MATERIAL AND METHODS: We included incident patients with residual diuresis >1,000ml/24h, clinical stability, absence of oedema, absence of hyperkalaemia >6.5 mEq/l and phosphoremia >6mg/dl, with acceptable comprehension of dietetic care. Exclusion criteria were: Clinical instability, no dietary or medical compliance and the afore mentioned laboratory abnormalities. RESULTS: A total of 24patients were included in incremental technique. The mean age at start of RRT was 60 (15 years. The average time on incremental technique was 19 (18 months (range: 7-80), with a mean time on dialysis of 31 (23 months (range: 12-86). The reasons for transfer to thrice-weekly HD were: in 6patients due to laboratory tests, in 2patients for heart failure events, one for poor compliance and 3for receiving a kidney graft. The residual diuresis decreased in the first year from 2,106 (606ml/day to 1,545 (558 (P=.17) with the urea clearance and calculated residual renal function, basal 5.7 (1.5vs. 3.8 (1.9ml/min per year (P=.01) and basal 8.9 (2.4vs. 6.9 (4.3 per year (P=.28), respectively. CONCLUSIONS: Incremental HD treatment, with twice-weekly HD, may be an alternative in selected patients. This approach can largely preserve residual renal function at least for the first year. Although this pattern probably is not applicable to all patients starting RRT, it can and should be an initial alternative to consider.

Aplicación de una pauta de hemodiálisis incremental, basada en la función renal residual, al inicio del tratamiento renal sustitutivo / Application of a pattern of incremental haemodialysis, based on residual renal function, when starting renal replacement therapy

Introducción: El interés por preservar la función renal residual una vez iniciado un tratamiento renal sustitutivo (TRS) es notorio en técnicas como la diálisis peritoneal pero es menor en hemodiálisis (HD). En nuestro centro la pauta de diálisis incremental (2HD/semana) ha sido una opción posible para un grupo de pacientes. Mostramos nuestra experiencia con dicha pauta desde marzo de 2008. Material y métodos: Incluimos a pacientes incidentes con diuresis residual >1.000ml/24 h, estabilidad clínica, ausencia de edemas, ausencia de hiperpotasemia >6,5mEq/l y de fosforemia >6mg/dl, con aceptable comprensión de los cuidados dietéticos. Fueron criterios de exclusión: la inestabilidad clínica, el no cumplimiento dietético ni médico y las alteraciones analíticas referidas. Resultados: Veinticuatro pacientes han sido incluidos en la técnica incremental. La edad media al inicio de TRS fue de 60 (15 años. El tiempo medio en técnica incremental fue de 19 (18 meses (rango: 7-80), con una permanencia media en TRS de 31 (23 meses (rango: 12-86). Los motivos de cambio a 3HD/semana fueron: 6pacientes por parámetros analíticos, 2 por episodios de insuficiencia cardiaca, uno por mal cumplimiento terapéutico y 3 por recibir un injerto renal. La diuresis residual desciende en el primer año de 2.106 (606ml/día a 1.545 (558 (p=0,07) junto con el aclaramiento de urea y la función renal residual calculada, basal de 5,7 (1,5 vs. 3,8 (1,9ml/min al año (p=0,01) y basal de 8,9 (2,4vs. 6,9 (4,3 al año (p=0,28), respectivamente. Conclusiones: La HD incremental, con 2 sesiones de HD/semana, puede ser una alternativa en un grupo seleccionado de pacientes. Esta modalidad puede preservar la función renal residual en buena medida, al menos durante el primer año. Aunque probablemente no sea aplicable a todos los pacientes que inician TRS, puede y debe ser una alternativa inicial que considerar (AU)

Introduction: The interest in the preservation of residual kidney function on starting renal replacement therapy (RRT) is very common in techniques such as peritoneal dialysis but less so in haemodialysis (HD). In our centre the pattern of incremental dialysis (2 HD/week) has been an option for a group of patients. Here we share our experience with this regimen from March 2008. Material and methods: We included incident patients with residual diuresis >1,000ml/24h, clinical stability, absence of oedema, absence of hyperkalaemia >6.5 mEq/l and phosphoremia >6mg/dl, with acceptable comprehension of dietetic care. Exclusion criteria were: Clinical instability, no dietary or medical compliance and the afore mentioned laboratory abnormalities. Results: A total of 24patients were included in incremental technique. The mean age at start of RRT was 60 (15 years. The average time on incremental technique was 19 (18 months (range: 7-80), with a mean time on dialysis of 31 (23 months (range: 12-86). The reasons for transfer to thrice-weekly HD were: in 6patients due to laboratory tests, in 2 patients for heart failure events, one for poor compliance and 3 for receiving a kidney graft. The residual diuresis decreased in the first year from 2,106 (606ml/day to 1,545 (558 (P=.17) with the urea clearance and calculated residual renal function, basal 5.7 (1.5vs. 3.8 (1.9ml/min per year (P=.01) and basal 8.9 (2.4vs. 6.9 (4.3 per year (P=.28), respectively. Conclusions: Incremental HD treatment, with twice-weekly HD, may be an alternative in selected patients. This approach can largely preserve residual renal function at least for the first year. Although this pattern probably is not applicable to all patients starting RRT, it can and should be an initial alternative to consider (AU)

Brote de bacteriemia por Serratia marcescens en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros / Serratia marcescens bacteraemia outbreak in haemodialysis patients with tunnelled catheters due to colonisation of antiseptic solution. Experience at 4 hospitals

Introducción: La aplicación de una solución antiséptica previa al uso de los catéteres tunelizados es una práctica recomendada. Estas medidas habituales en la manipulación de los catéteres para hemodiálisis son cruciales para evitar complicaciones. Presentamos un brote de infección por Serratia marcescens (S. marcescens) en varias unidades de hemodiálisis de la Comunidad Autónoma de Madrid. Material y métodos: Los primeros casos de bacteriemia por S. marcescensfueron aislados en diciembre de 2014. La detección de un germen infrecuente en varios pacientes se puso en conocimiento de los Servicios de Medicina Preventiva por sospecha de probable brote nosocomial. Se recogieron datos de 4 centros donde se detectaron episodios de bacteriemias similares por S. marcescens. Resultados: Fueron detectados un total de 21 casos de bacteriemia por S. marcescens. La edad media de los pacientes era de 72±10 años. El tiempo medio en hemodiálisis de los pacientes afectados era de 33±13 meses (rango: 3-83), el tiempo medio del catéter tunelizado era de 22±13 meses. En 11 casos el cuadro clínico fue semejante, caracterizado por hipotensión y malestar general durante la sesión de hemodiálisis. En otros 7 pacientes se asoció fiebre. En 3 casos la forma de presentación fue asintomática y se detectó por hemocultivos. Todos eran portadores de catéteres tunelizados (12 pacientes con catéter en la vena yugular derecha, 5 en la yugular izquierda, 2 en la femoral derecha y 2 en la subclavia izquierda). El tratamiento que se aplicó en 6 casos fue gentamicina posdiálisis intravenosa (1mg/kg) más sellado del catéter con solución de ciprofloxacino durante 3 semanas. En 12 pacientes el tratamiento fue ceftazidima 2g IV más sellado de catéter con el mismo antibiótico durante 2 semanas. Cuatro pacientes recibieron dosis de ciprofloxacino oral, en un caso se asoció a vancomicina IV, durante 2 semanas. A las 48h de iniciar el tratamiento, los pacientes quedaron asintomáticos y no presentaron nuevos episodios. No se observó ninguna complicación mayor. Esta situación fue comunicada por los equipos a las autoridades sanitarias. Posteriormente, se notificó la presencia de lotes de antiséptico de clorhexidina acuosa al 0,05 y 2% colonizados por S. marcescens. Dada la aplicación de forma rutinaria del antiséptico en el manejo de los catéteres en estas unidades, este fue considerado el foco de contagio. Tras la retirada de los lotes no acontecieron nuevos casos. Conclusiones: Las bacteriemias por gérmenes no convencionales deben ponernos sobre aviso para investigar posibles brotes. La aplicación de una solución contaminada por S. marcescens en los catéteres en hemodiálisis fue la vía de bacteriemia. El tratamiento antibiótico intravenoso y el sellado de los catéteres permitió una excelente supervivencia tanto de los pacientes como de los catéteres (AU)

Introduction: The application of antiseptic solution for handling tunnelled catheters is recommended in patients undergoing haemodialysis. These routine antiseptic procedures in handling catheters are crucial to avoid complications. We report an outbreak of Serratia marcescens (S. marcescens)bacteraemia in numerous haemodialysis units of the Community of Madrid. Material and methods: The first cases of bacteraemia due to S. marcescens were isolated in December 2014. The Preventive Medicine Services were informed of the detection of an atypical pathogen in several patients, suspecting a probable nosocomial outbreak. Information from 4 centres with similar S. marcescens bacteraemia was analysed. Results: Twenty-one cases of bacteraemia related to S. marcescenswere identified. The mean age of affected patients was 72±10 years. The mean time on haemodialysis of affected patients was 33±13 months (range: 3-83 months), the median time of tunnelled catheter was 22±13 months. In 11 cases the clinical picture was similar, with hypotension and general malaise during the haemodialysis session. Fever was present in a further 7 cases. In 3 cases the presentation was asymptomatic and was detected by blood cultures. All patients had tunnelled catheters (12 patients with catheter in the right jugular vein, 5 in the left jugular, 2 in the right femoral artery and 2 in the left subclavian artery). Gentamicin intravenous doses (1mg/kg) with catheter lock solution with ciprofloxacin post-dialysis were administered for 3 weeks in 6 patients. In 12 patients the treatment was ceftazidime (2g IV) plus catheter lock solution with the same antibiotic, for 2 weeks. Four patients received oral ciprofloxacin for 2 weeks, in one case together with IV vancomycin. The patients were asymptomatic and without new episodes 48 hours after the treatment. No major complications were observed. The teams informed the health authorities of the situation, which then reported the presence of batches of antiseptic (chlorhexidine 0.05 and 2%) colonised by S. marcescens. Given the routine application of this antiseptic in handling catheters at these units, this was considered the source of contagion and new cases were not observed after the removal of the batches. Conclusions: The presence of bacteraemia due to unconventional germs should alert us to a potential outbreak. The application of a solution contaminated by S. marcescens in haemodialysis catheters was the source of bacteraemia. The intravenous antibiotic treatment and the catheter lock solution allowed an excellent survival of patients and catheters (AU)

Serratia marcescens bacteraemia outbreak in haemodialysis patients with tunnelled catheters due to colonisation of antiseptic solution. Experience at 4 hospitals. / Brote de bacteriemia por Serratia marcescens en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros.

INTRODUCTION: The application of antiseptic solution for handling tunnelled catheters is recommended in patients undergoing haemodialysis. These routine antiseptic procedures in handling catheters are crucial to avoid complications. We report an outbreak of Serratia marcescens (S. marcescens) bacteraemia in numerous haemodialysis units of the Community of Madrid. MATERIAL AND METHODS: The first cases of bacteraemia due to S. marcescens were isolated in December 2014. The Preventive Medicine Services were informed of the detection of an atypical pathogen in several patients, suspecting a probable nosocomial outbreak. Information from 4 centres with similar S. marcescens bacteraemia was analysed. RESULTS: Twenty-one cases of bacteraemia related to S. marcescens were identified. The mean age of affected patients was 72±10 years. The mean time on haemodialysis of affected patients was 33±13 months (range: 3-83 months), the median time of tunnelled catheter was 22±13 months. In 11 cases the clinical picture was similar, with hypotension and general malaise during the haemodialysis session. Fever was present in a further 7 cases. In 3 cases the presentation was asymptomatic and was detected by blood cultures. All patients had tunnelled catheters (12 patients with catheter in the right jugular vein, 5 in the left jugular, 2 in the right femoral artery and 2 in the left subclavian artery). Gentamicin intravenous doses (1mg/kg) with catheter lock solution with ciprofloxacin post-dialysis were administered for 3 weeks in 6 patients. In 12 patients the treatment was ceftazidime (2g IV) plus catheter lock solution with the same antibiotic, for 2 weeks. Four patients received oral ciprofloxacin for 2 weeks, in one case together with IV vancomycin. The patients were asymptomatic and without new episodes 48hours after the treatment. No major complications were observed. The teams informed the health authorities of the situation, which then reported the presence of batches of antiseptic (chlorhexidine 0.05 and 2%) colonised by S. marcescens. Given the routine application of this antiseptic in handling catheters at these units, this was considered the source of contagion and new cases were not observed after the removal of the batches. CONCLUSIONS: The presence of bacteraemia due to unconventional germs should alert us to a potential outbreak. The application of a solution contaminated by S. marcescens in haemodialysis catheters was the source of bacteraemia. The intravenous antibiotic treatment and the catheter lock solution allowed an excellent survival of patients and catheters.

Effects of a single, high oral dose of 25-hydroxycholecalciferol on the mineral metabolism markers in hemodialysis patients.

Vitamin D deficiency is common in dialysis patients with chronic kidney disease. Low levels have been associated with increased cardiovascular risk and mortality. We evaluated the administration of a high, single oral dose of 25-OH cholecalciferol (3 mg of Hidroferol, 180 000 IU) in patients on chronic hemodialysis. The 94 chronic hemodialysis patients with vitamin D deficiency 25 (OH)D <30 ng/mL included in the study were randomized into two groups. Follow-up time was 16 weeks. Neither the usual treatment for controlling Ca/P levels nor the dialysis bath (calcium of 2.5 mEq/L) were modified. Of the 86 patients who finished the study, 42 were in the treated group and 44 in the control group. An increase in 25(OH)D levels was observed in the treated group that persisted after 16 weeks and was associated with a significant decrease in parathyroid hormone (PTH) levels during the 8 weeks post-treatment. Baseline 1,25(OH)2 D levels of the treated group increased two weeks after treatment (5.9 vs. 21.9 pg/mL, P<0.001) but gradually reduced to 8.4 at week 16. The administration of a single 3 mg dose of 25-OH cholecalciferol seems safe in patients on hemodialysis and maintains sufficient levels of 25(OH)D with a decrease in PTH for 3 months.

Portosystemic encephalopathy in a patient treated with peritoneal dialysis.

We present a case of a 75-year-old man with end-stage renal disease caused by immunoglobulin A nephropathy who developed hepatic encephalopathy 15 months after starting continuous ambulatory peritoneal dialysis therapy. Liver test results were normal except for hyperammonemia (ammonia, 317 microg/dL [186 micromol/L]) and mildly increased alkaline phosphatase and gamma-glutamyl transpeptidase levels. Abdominal ultrasonography showed normal liver architecture, and color Doppler ultrasonography showed a normal splenic-portal axis with hepatopetal blood flow. Histological examination of a laparoscopic liver biopsy specimen showed moderate fibrosis limited to portal tracts without necrosis or inflammation. Magnetic resonance angiography and percutaneous transhepatic portal angiography showed a large shunt between the left gastric and azygous veins, with blood flowing from the portal vein to the superior vena cava. The patient was transferred to hemodialysis treatment, and although his condition improved slightly, episodes of encephalopathy did not disappear. Surgical ligation of the left gastric vein was performed. In the 8 months after surgery, he has experienced no further episodes of hepatic encephalopathy or hyperammonemia. We speculate that increased intra-abdominal pressure and vasodilation caused by peritoneal dialysis solutions in a patient with a spontaneous portosystemic shunt resulted in ammonia-rich blood flow from the portal vein to the superior vena cava and encephalopathy. In addition, it is possible that chronic hepatic hypoxia caused by hypoperfusion from portosystemic shunting contributed to the development of liver fibrosis. To our knowledge, this is the first report of spontaneous portosystemic shunt encephalopathy in a patient with a noncirrhotic liver undergoing peritoneal dialysis.