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BMC Nephrol ; 19(1): 16, 2018 01 19.
Artigo em Inglês | MEDLINE | ID: mdl-29351783


BACKGROUND: For patients unable to receive heparin anticoagulation during haemodialysis, saline flushes to reduce circuit clotting are often the norm. Regional citrate anticoagulation (RCA) although effective is not used by many centres including in Singapore. We wanted to demonstrate the superiority and safety of a simple regional citrate anticoagulation regime, compared to saline flushes, for heparin-free low flux haemodialysis. METHODS: This is a prospective, open label, cross over study on 25 sequential haemodialysis sessions for inpatients receiving heparin-free haemodialysis. Patients were allocated either to regional citrate anticoagulation or standard heparin free haemodialysis and subsequently cross over to the alternate method. RCA was carried out using a protocol derived from previous studies. Assessment of anticoagulation was performed using visual inspection of clot formation in dialysis circuits and post-filter ionized calcium (iCa2+) using point-of-care Ionized calcium device at stipulated intervals. Intravenous Calcium gluconate replacement was given to patients receiving citrate adjusting the rate according to pre-filter iCa2+. Laboratory analyses of electrolytes were also assessed at the start and end of the RCA sessions. RESULTS: There were no clots in the RCA arm, with 79% (n = 19) in the saline flush arm having some clot, including 1 clotted circuit. Post-filter iCa2+ at various time points were within acceptable range. Electrolyte readings in the RCA group were all within normal limits except for 4 cases of total Calcium:iCa2+ ratio > 2.5. CONCLUSION: RCA is confirmed to be superior to saline flushes for circuit patency. We have a simple and safe protocol that can be followed for low flux haemodialysis. The study was approved by Singapore National Health Group domain-specific ethnical committee. NHG DSRB reference number 2014/01037. TRIAL REGISTRATION: Trial registration number: ISRCTN69952745 (registration date 8/11/17).

Anticoagulantes/farmacologia , Coagulação Sanguínea/efeitos dos fármacos , Ácido Cítrico/farmacologia , Diálise Renal/métodos , Adulto , Idoso , Coagulação Sanguínea/fisiologia , Protocolos Clínicos , Estudos Cross-Over , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos
J Diabetes ; 10(7): 572-580, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29154443


BACKGROUND: The best model of care to retard diabetic kidney disease (DKD) in the clinic is underexplored. In this study we investigated the long-term renal outcomes of a joint endocrinologist-nephrologist clinic. METHODS: The present study was a nested case-control study derived from a cohort of patients with type 2 diabetes mellitus (T2DM) seen prospectively at a secondary care diabetes center (DC). Cases ("DKD clinic group") were patients seen at the CKD clinic after being referred by physicians in DCs for management of DKD. Controls ("non-DKD clinic group") were patients from the same DC (i.e. same source population) with the same inclusion criteria of Stages 3-4 chronic kidney disease (CKD) at baseline but not seen at the DKD clinic. The outcome was Stage 5 CKD, defined as an estimated glomerular filtration rate <15 mL/min per 1.73 m2 . RESULTS: During the median follow-up period of 3.0 years (interquartile range 1.2-5.1 years), 240 patients (28.7%) reached Stage 5 CKD, with 45.8% and 54.2% of those reaching Stage 5 CKD in the DKD and non-DKD clinic groups, respectively. Multivariable Cox regression revealed that the DKD clinic group had a lower risk of progressing to Stage 5 CKD (hazard ratio 0.55; 95% confidence interval 0.36-0.83; P = 0.004) compared with the non-DKD clinic group. CONCLUSIONS: Multidisciplinary endocrinology and nephrology care in the DKD clinic is associated with a lower risk of end-stage renal disease. These findings may inform future management strategies targeted at patients with T2DM and CKD, especially with regard to joint specialist management involving endocrinologists and nephrologists.

Diabetes Mellitus Tipo 2/complicações , Nefropatias Diabéticas/terapia , Falência Renal Crônica/prevenção & controle , Guias de Prática Clínica como Assunto/normas , Estudos de Casos e Controles , Nefropatias Diabéticas/etiologia , Progressão da Doença , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Fatores de Risco
J Vasc Access ; 18(4): 279-283, 2017 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-28665465


INTRODUCTION: Tunnelled dialysis catheters (TDCs) are being increasingly inserted by nephrologists globally but there is limited experience and paucity of published outcomes data from South-East Asia (SEA). This study was conducted to analyse the outcomes of TDC insertion by nephrologists from a single centre in SEA. METHODS: All patients who underwent TDC insertion by nephrologists from October 2013 to June 2016 were included. TDC survival was calculated using Kaplan-Meier survival method. Impact of variables was assessed using Cox proportional hazards model. RESULTS: A total of 344 TDCs were inserted in 274 patients. The most common indication was haemodialysis initiation (60.2%) followed by existing catheter dysfunction (CD) (12.2%), failed vascular access (10.2%) and catheter-related bacteraemia (CRB) (9.9%). Insertion was successful in 97% patients. The most common location was the right internal jugular vein (87%). The cumulative survival for all TDCs inserted, as defined by the time to non-elective removal of a TDC, at 3, 6 and 9 months was 83%, 61%, and 44%, respectively. Median catheter survival was 231 days. Common indications for removal were CD (13.4%) and CRB or suspected infection (12.5%). Common complications were bleeding (8.72%), infection (13.7%) and CD (16.5%). Median time to infection was 103 days. In multivariate analysis, male gender was associated with poor catheter survival, for primary insertions (p = 0.015, HR 0.62) and diabetes was associated with TDC infection (p = 0.024, OR 1.1). CONCLUSIONS: This is one of the first reports of TDC insertion by nephrologists from SEA. Our outcomes compare favourably with those reported in the literature.

Cateterismo Venoso Central/instrumentação , Cateteres de Demora , Cateteres Venosos Centrais , Nefrologistas , Diálise Renal/instrumentação , Idoso , Bacteriemia/diagnóstico , Bacteriemia/microbiologia , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/microbiologia , Cateterismo Venoso Central/efeitos adversos , Cateteres de Demora/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Remoção de Dispositivo , Falha de Equipamento , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Diálise Renal/efeitos adversos , Fatores de Risco , Fatores Sexuais , Singapura , Fatores de Tempo , Resultado do Tratamento
Nephrology (Carlton) ; 20(2): 85-90, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25346031


AIM: Initial heparin locks instilled after tunnelled dialysis catheter (TDC) insertion can leak causing systemic anticoagulation and also promote staphyloccocal biofilm formation, predisposing to catheter-related infection (CRI). The 1000 U/mL concentration is thus advocated as the optimal dose for preventing catheter bleeding and malfunction. The effect of lower heparin concentrations on further lowering these complications is not known. We compared early TDC outcomes between a non-standard ultra-low (500 U/mL) and standard initial heparin locks (1000 and 5000 U/mL). METHODS: This was a retrospective study on prospectively collected data on 238 de novo internal jugular TDCs placed by nephrologists. Cases were categorized into groups 1, 2 and 3, according to initial heparin lock: 500 [n = 30], 1000 [n = 180] and 5000 U/mL [n = 28] respectively. Bleeding and malfunction within 24 h of TDC insertion, 30 days CRI-free catheter survival and the effects of clinical and laboratory factors on bleeding were evaluated. RESULTS: Bleeding events were similar in groups 1, 2 and 3 (7 vs 14 vs 13%, respectively, P = 0.61). Malfunction was only seen in group 2 (3.3%). Thirty-day CRI-free catheter survival was comparable (96 vs 98 vs 97%, respectively, P = 0.22), giving a cumulative CRI rate of 0.76/1000 catheter days. All CRIs were staphylococcal. Univariate analysis did not reveal any significant predictors of catheter bleeding. CONCLUSION: Immediate TDC bleeding, malfunction and CRI rate are not influenced by heparin lock concentrations ≤5000 U/mL in this low-risk cohort. However this needs to be corroborated in higher risk patients.

Anticoagulantes/administração & dosagem , Obstrução do Cateter , Cateterismo Venoso Central/instrumentação , Cateteres de Demora , Heparina/administração & dosagem , Diálise Renal/instrumentação , Trombose/prevenção & controle , Adulto , Idoso , Anticoagulantes/efeitos adversos , Obstrução do Cateter/etiologia , Infecções Relacionadas a Cateter/microbiologia , Cateterismo Venoso Central/efeitos adversos , Intervalo Livre de Doença , Desenho de Equipamento , Feminino , Hemorragia/induzido quimicamente , Heparina/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Singapura , Staphylococcus/isolamento & purificação , Trombose/etiologia , Fatores de Tempo , Resultado do Tratamento