Inadequate dietary energy intake associates with higher prevalence of metabolic syndrome in different groups of hemodialysis patients: a clinical observational study in multiple dialysis centers.

BACKGROUND: Metabolic syndrome (MetS) has been established as a risk for cardiovascular diseases and mortality in hemodialysis patients. Energy intake (EI) is an important nutritional therapy for preventing MetS. We examined the association of self-reported dietary EI with metabolic abnormalities and MetS among hemodialysis patients. METHODS: A cross-sectional study design was carried out from September 2013 to April 2017 in seven hemodialysis centers. Data were collected from 228 hemodialysis patients with acceptable EI report, 20 years old and above, underwent three hemodialysis sessions a week for at least past 3 months. Dietary EI was evaluated by a three-day dietary record, and confirmed by 24-h dietary recall. Body compositions were measured by bioelectrical impedance analysis. Biochemical data were analyzed using standard laboratory tests. The cut-off values of daily EI were 30 kcal/kg, and 35 kcal/kg for age ≥ 60 years and < 60 years, respectively. MetS was defined by the American Association of Clinical Endocrinologists (AACE-MetS), and Harmonizing Metabolic Syndrome (HMetS). Logistic regression models were utilized for examining the association between EI and MetS. Age, gender, physical activity, hemodialysis vintage, Charlson comorbidity index, high sensitive C-reactive protein, and interdialytic weight gains were adjusted in the multivariate analysis. RESULTS: The prevalence of inadequate EI, AACE-MetS, and HMetS were 60.5%, 63.2%, and 53.9%, respectively. Inadequate EI was related to higher proportion of metabolic abnormalities and MetS (p <  0.05). Results of the multivariate analysis shows that inadequate EI was significantly linked with higher prevalence of impaired fasting glucose (OR = 2.42, p <  0.01), overweight/obese (OR = 6.70, p <  0.001), elevated waist circumference (OR = 8.17, p <  0.001), AACE-MetS (OR = 2.26, p <  0.01), and HMetS (OR = 3.52, p <  0.01). In subgroup anslysis, inadequate EI strongly associated with AACE-MetS in groups of non-hypertension (OR = 4.09, p = 0.004), and non-cardiovascular diseases (OR = 2.59, p = 0.012), and with HMetS in all sub-groups of hypertension (OR = 2.59~ 5.33, p <  0.05), diabetic group (OR = 8.33, p = 0.003), and non-cardiovascular diseases (OR = 3.79, p <  0.001). CONCLUSIONS: Inadequate EI and MetS prevalence was high. Energy intake strongly determined MetS in different groups of hemodialysis patients.

Why are hospitalisations too long? A simple checklist for identifying the main social barriers to hospital discharge from a nephrology ward.

The present increase in life span has been accompanied by an even higher increase in the burden of comorbidity. The challenges to healthcare systems are enormous and performance measures have been introduced to make the provision of healthcare more cost-efficient. Performance of hospitalisation is basically defined by the relationship between hospital stay, use of hospital resources, and main diagnosis/diagnoses and complication(s), adjusted for case mix. These factors, combined in different indexes, are compared with the performance of similar hospitals in the same and other countries. The reasons why an approach like this is being employed are clear.Cutting costs cannot be the only criteria, in particular in elderly, high-comorbidity patients: in this population, although social issues are important determinants of hospital stay, they are rarely taken into account or quantified in evaluations. Quantifying the impact of the "social barriers" to care can serve as a marker of the overall quality of treatment a network provides, and point to specific out-of-hospital needs, necessary to improve in-hospital performance. We therefore propose a simple, empiric medico-social checklist that can be used in nephrology wards to assess the presence of social barriers to hospital discharge and quantify their weight.Using the checklist should allow: identifying patients with social frailty that could complicate hospitalisation and/or discharge; evaluating the social needs of patient and entourage at the beginning of hospitalisation, adopting timely procedures, within the partnership with out-of-hospital teams; facilitating prioritization of interventions by social workers.The following ten items were empirically identified: reason for hospitalisation; hospitalisation in relation to the caregiver's problems; recurrent unplanned hospitalisations or early re-hospitalisation; social/family isolation; presence of a dependent relative in the patient's household; lack of housing or unsuitable housing/accommodation; loss of autonomy; lack of economic resources; lack of a safe environment; evidence of physical or psychological abuse.The simple tool here described needs validation; the present proposal is aimed at raising attention on the importance of non-medical issues in medical organisation in our specialty, and is open to discussion, to allow its refinement.

Post-hospitalization dialysis facility processes of care and hospital readmissions among hemodialysis patients: a retrospective cohort study.

BACKGROUND: Both dialysis facilities and hospitals are accountable for 30-day hospital readmissions among U.S. hemodialysis patients. We examined the association of post-hospitalization processes of care at hemodialysis facilities with pulmonary edema-related and other readmissions. METHODS: In a retrospective cohort comprised of electronic medical record (EMR) data linked with national registry data, we identified unique patient index admissions (n = 1056; 2/1/10-7/31/15) that were followed by ≥3 in-center hemodialysis sessions within 10 days, among patients treated at 19 Southeastern dialysis facilities. Indicators of processes of care were defined as present vs. absent in the dialysis facility EMR. Readmissions were defined as admissions within 30 days of the index discharge; pulmonary edema-related vs. other readmissions defined by discharge codes for pulmonary edema, fluid overload, and/or congestive heart failure. Multinomial logistic regression to estimate odds ratios (ORs) for pulmonary edema-related and other vs. no readmissions. RESULTS: Overall, 17.7% of patients were readmitted, and 8.0% had pulmonary edema-related readmissions (44.9% of all readmissions). Documentation of the index admission (OR = 2.03, 95% CI 1.07-3.85), congestive heart failure (OR = 1.87, 95% CI 1.07-3.27), and home medications stopped (OR = 1.81, 95% CI 1.08-3.05) or changed (OR = 1.69, 95% CI 1.06-2.70) in the EMR post-hospitalization were all associated with higher risk of pulmonary edema-related vs. no readmission; lower post-dialysis weight (by ≥0.5 kg) after vs. before hospitalization was associated with 40% lower risk (OR = 0.60, 95% CI 0.37-0.96). CONCLUSIONS: Our results suggest that some interventions performed at the dialysis facility in the post-hospitalization period may be associated with reduced readmission risk, while others may provide a potential existing means of identifying patients at higher risk for readmissions, to whom such interventions could be efficiently targeted.

Center Effects and Peritoneal Dialysis Peritonitis Outcomes: Analysis of a National Registry.

BACKGROUND: Peritonitis is a common cause of technique failure in peritoneal dialysis (PD). Dialysis center-level characteristics may influence PD peritonitis outcomes independent of patient-level characteristics. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Using Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data, all incident Australian PD patients who had peritonitis from 2004 through 2014 were included. PREDICTORS: Patient- (including demographic data, causal organisms, and comorbid conditions) and center- (including center size, proportion of patients treated with PD, and summary measures related to type, cause, and outcome of peritonitis episodes) level predictors. OUTCOMES & MEASUREMENT: The primary outcome was cure of peritonitis with antibiotics. Secondary outcomes were peritonitis-related catheter removal, hemodialysis therapy transfer, peritonitis relapse/recurrence, hospitalization, and mortality. Outcomes were analyzed using multilevel mixed logistic regression. RESULTS: The study included 9,100 episodes of peritonitis among 4,428 patients across 51 centers. Cure with antibiotics was achieved in 6,285 (69%) peritonitis episodes and varied between 38% and 86% across centers. Centers with higher proportions of dialysis patients treated with PD (>29%) had significantly higher odds of peritonitis cure (adjusted OR, 1.21; 95% CI, 1.04-1.40) and lower odds of catheter removal (OR, 0.78; 95% CI, 0.62-0.97), hemodialysis therapy transfer (OR, 0.78; 95% CI, 0.62-0.97), and peritonitis relapse/recurrence (OR, 0.68; 95% CI, 0.48-0.98). Centers with higher proportions of peritonitis episodes receiving empirical antibiotics covering both Gram-positive and Gram-negative organisms had higher odds of cure with antibiotics (OR, 1.22; 95% CI, 1.06-1.42). Patient-level characteristics associated with higher odds of cure were younger age and less virulent causative organisms (coagulase-negative staphylococci, streptococci, and culture negative). The variation in odds of cure across centers was 9% higher after adjustment for patient-level characteristics, but 66% lower after adjustment for center-level characteristics. LIMITATIONS: Retrospective study design using registry data. CONCLUSIONS: These results suggest that center effects contribute substantially to the appreciable variation in PD peritonitis outcomes that exist across PD centers within Australia.

Prevalencia de bacteriemias relacionadas con el catéter de hemodiálisis en una unidad hospitalaria / Prevalence of catheter-related bacteraemia in a hospital haemodialysis unit

En la actualidad ha aumentado el uso de catéteres tunelizados como acceso vascular permanente para los pacientes en hemodiálisis a pesar de las complicaciones que tiene asociadas, como puede ser la bacteriemia relacionada con el catéter. El objetivo de este trabajo es mostrar la tasa de prevalencia de bacteriemia relacionada con el catéter para hemodiálisis, obtenida con la aplicación estricta de un protocolo de cuidados del catéter tunelizado por un personal bien entrenado en la unidad de hemodiálisis del Hospital Universitario Infanta Leonor entre abril de 2008 y abril de 2013, así como describir las posibles causas de bacteriemia relacionada con el catéter, la relación con alguna de las variables y su evolución en los últimos años. Durante los 5 años de estudio tuvimos 9 episodios de bacteriemia relacionada con el catéter, lo que supone una tasa global de prevalencia de 0,25/1000 días de catéter. La tasa por cada uno de los años fue menor de 1/1000 días de catéter. Los pacientes que tuvieron una bacteriemia relacionada con el catéter tuvieron implantados mayor número de catéteres que los que no la tuvieron, siendo esta diferencia significativa (p=0,027). No se encontraron diferencias con respecto a la edad, el sexo, la diabetes mellitus, el índice de comorbilidad de Charlson y la localización de los catéteres entre los pacientes que padecieron una bacteriemia relacionada con el catéter de los que no (AU)

Currently has increased the use of tunneled catheters as permanent vascular access for hemodialysis patients despite having associated complications, such as bacteremia. The aim of this work is to show the incidence of catheter-related bacteremia for hemodialysis obtained with the strict implementation of a protocol tunneled catheter care by well-trained personnel in the Hemodialysis Unit of University Hospital Infanta Leonor between April 2008 and April 2013, and to describe possible causes of bacteremia, the relationship with any of the variables and their evolution in recent years. During 5 years of study there had been 9 episodes of catheter-related bacteremia which is an overall incidence rate of 0.25 / 1000 catheter days. The fee for each of the years was less than 1/1000 catheter days. Patients who had bacteremia had catheters implanted more than those who had not, and this difference was significant (p = 0.027). No differences were found with respect to age, sex, diabetes mellitus, the Charlson comorbidity index and location of catheters among patients who developed bacteremia from those without (AU)

Análisis enfermero de la presencia de la técnica del ojal en las unidades de hemodiálisis Españolas / Nursing analysis of the presence of the buttonhole technique in Spanish haemodialysis units

El uso de la Técnica Buttonhole o Técnica del Ojal como abordaje para la punción del acceso vascular en Unidades de Hemodiálisis en Espańa, está siendo lento e inferior a su implantación en otros países europeos. Nuestra experiencia con la técnica del ojal tanto en la potenciación del auto-cuidado en pacientes en hemodiálisis domiciliaria y en centro, como en el rescate de fístulas arterio-venosas difíciles, ha sido altamente positiva, tanto en pacientes como en profesionales. Los objetivos de nuestro estudio se basan en: • Conocer el grado de presencia de la técnica del ojal para punción del acceso vascular en las unidades de hemodiálisis espańolas. • Identificar los elementos relacionados con su escasa presencia. • Proponer estrategias enfermeras para aumentar su presencia. Se trata de un estudio descriptivo transversal. La población estudiada son las unidades de hemodiálisis espańolas. Para desarrollar el estudio se creó un cuestionario semi-cerrado (se enviaron a 436 unidades de hemodiálisis, y se obtuvo 135 respuestas: tasa de respuesta > 31 % de las enviadas, lo que valida las mismas). El análisis de los datos se realizó con el programa estadístico SPSS 17.0. Se analizaron las frecuencias relativas de las variables cualitativas estudiadas, así como las frecuencias absolutas, de las variables con una población inferior a 10 casos. Tras los resultados obtenidos podemos concluir, que existe una gran diferencia entre las unidades de hemodiálisis espańolas que dicen conocer la técnica y las que la utilizan, esto nos hace pensar que el conocimiento podría etiquetarse como "por referencias" pero no en profundidad; que el conocimiento de la técnica es teórico pero no lo suficiente para su implementación; que a pesar de ser una técnica de enfermería, su utilización está parcialmente condicionada por la opinión y/o conocimiento que de la misma tienen los nefrólogos; por último afirmar, que para aumentar la utilización de la técnica del ojal, sería necesario programar talleres prácticos sobre la misma y abordar los problemas logísticos

The use of the Buttonhole Technique for vascular access puncture in haemodialysis units in Spain is lower and its implementation is slower than in other European countries. Our experience with the buttonhole technique both in promoting self-care of home haemodialysis patients and patients who receive haemodialysis at the unit, and in the rescue of difficult arteriovenous fistulae, has been very positive, both for patients and professionals. The objectives of our study are based on: • Determining the degree of presence of the buttonhole technique for vascular access puncture in Spanish haemodialysis units. • Identifying the elements related to its limited presence. • Proposing nursing strategies to increase its presence. This is a transversal descriptive study. The population studied was comprised of the Spanish haemodialysis units. To carry out the study a semi-closed questionnaire was drawn up (which was sent to 436 haemodialysis units, obtaining 135 responses: response rate > 31 % of the questionnaires sent, which validates them). Data analysis was carried out using the SPSS 17.0 statistical programme. The relative frequencies of the qualitative variables studied were analysed, as well as the absolute frequencies of the variables with a population of less than 10 cases. Following the results obtained, we can conclude that there is a great difference between the Spanish haemodialysis units that claim to be familiar with the technique and those that use it. This suggests to us that the knowledge could be labelled as "by reference" and not in-depth knowledge; that the knowledge of the technique is theoretical but not sufficient for implementation; that although it is a nursing technique, its use is partially conditioned by nephrologists' opinion and/or knowledge of it; finally, in order to increase the use of the buttonhole technique, practical workshops on the technique would have to be planned, and the logistical problems would have to be addressed

Influencia de factores epidemiológicos en la elección de la modalidad de tratamiento renal sustitutivo en la consulta de enfermería de enfermedad renal crónica avanzada / Influence of epidemiological factors in the choice of type of renal replacement therapy in advanced chronic renal disease nursing consultation

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¿Qué indicadores son considerados por enfermería para conseguir una diálisis perfecta en el paciente en hemodiafiltración en línea? / What indicators are considered by nursing staff to achieve perfect dialysis in patients under on-line haemodiafiltration?

Tanto las guías, como las indicaciones del Grupo de Gestión de Calidad de la Sociedad Española de Nefrología nos proponen una serie de indicadores para medir la calidad de la prestación de la hemodiálisis. El objetivo del presente estudio fué, tras conocer cuales son los principales indicadores de una diálisis óptima para el personal de enfermería, evaluar objetivamente cada sesión de diálisis, en el convencimiento de que del conocimiento de los aciertos/fallos de cada sesión, obtendríamos propuestas de mejora de una forma más precoz que con los indicadores comúnmente utilizados. Para ello, se realizó una encuesta entre el personal de enfermería (n=26) solicitándole que enumerara los 10 parámetros que le parecían fundamentales para una sesión de diálisis óptima. Los 10 ítems más nombrados se utilizaron para elaborar la hoja de recogida de datos, con respuestas si/no. En cada paciente (n=160) se analizaron 3 sesiones consecutivas (n=480 sesiones), con la misma pauta de tratamiento. El enfermero que realiza las sesiones desconoce que sesiones se van a evaluar, así como la identidad de un segundo enfermero evaluador, que será el encargado de marcar si/no en cada uno de los ítems. Por cada objetivo conseguido se otorga 1 punto. La puntuación máxima por cada paciente es de 30 puntos (10 porsesión), excepto en los portadores de catéter tunelizado, en los que es de 27 puntos (9 por sesión), al no ser procedente valorar la hemostasia. Hemos obtenido como resultado que el 41,3% de las sesiones realizadas obtuvieron la máxima puntuación (42,1% con Fístula arteriovenosa y 35,1% con catéter tunelizado, p=0,043). La puntuación porcentual obtenida fue 88,7 ± 11,9%, porcentaje significativamente mayor con FAV que con catéter (89,9 ± 9,9 versus 79,7 ± 19,4, p<0,001). No se aprecian diferencias por sexo, edad, etiología o permanencia. 30 pacientes (18,8%) obtienen la puntuación máxima en las tres sesiones. El 77,7% de los pacientes (124) obtiene una puntuación superior al 85%, y el 87,1% de los pacientes mayor del 80%. Apenas en el 42,5% de los pacientes en las 3 sesiones se produce una completa recuperación del circuito limpia (60,5% de las sesiones). Presentan síntomas durante la diálisis en al menos una sesión 50 pacientes (31,2%), aunque solo el 15,2% de las sesiones son sintomáticas, lo que implica que existe una agrupación de síntomas en los mismos pacientes. Todos los demás ítems se encuentran por encima del 90% de las sesiones, destacando el cumplimiento del Kt en un 96,3% y del volumen de reinfusión en el 92,7%, probablemente porque en el 92% de los casos se alcanza un flujo de sangre óptimo, y el tiempo prescrito se cumple en el 95% de las sesiones. Por tanto, podemos concluir que la valoración objetiva en cada sesión de diálisis, en la intención de optimizarla, nos proporciona una valiosa información en tiempo real, y por tanto nos ofrece reafirmación en aquello que realizamos correctamente, y oportunidades de mejora en los aspectos que ejecutamos de forma más deficiente...(AU)

Both the guides and the instructions of the Spanish nephrology society’s quality management group offer a series of indicators for measuring quality in the provision of haemodialysis. The aim of this study was, after identifying the main indicators of optimal dialysis in the view of nurses, to assess each dialysis session objectively, in the conviction that knowing what went right and wrong in each session would give us proposals for improvement, earlier than with the indicators in common use. To this end, a survey was conducted among nursing staff (n=26) asking them to list the 10 parameters they considered fundamental to a successful dialysis session. The 10 most-cited items were used to draw up the data gathering sheet, with yes/no responses. For each patient (n=160) 3 consecutive sessions were assessed (n=480 sessions), involving the same treatment pattern. The nurse conducting the sessions was unaware which sessions were to be assessed, nor did they know the identity of a second assessing nurse, whose job would be to mark each of the items yes or no. 1 point was given for each objective achieved. The maximum score for each patient was 30 points (10 per session), except in those with tunnelled catheters, for whom it was 27 points (10 per session), as haemostasis is not assessed. The result was that 41.3% of the sessions conducted got the top score (42.1% with arteriovenous fistula and 35.1% with tunnelled catheter, p=0.043). The percentage score was 88.7 ± 11.9%, the percentage being significantly higher with AVF than with a catheter (89.9 ± 9.9 versus 79.7 ± 19.4, p<0.001). No differences by sex, age, aetiology or length of admission were detected. 30 patients (18.8%) got the maximum score in all three sessions. El 77.7% of patients (124) scored over 85%, and 87.1% of patients over 80%. In barely 42.5% was there a full recovery of the clean circuit in all three sessions (60.5% of the sessions). 50 patients (31.2%) displayed symptoms during dialysis in at least one session, though only 15.2% of the sessions were symptomatic, implying that the symptoms were clustered in the same patients. All the other items were checked over 90% of the sessions, with KT compliance particularly high at 96.3% and reinfusion volume at 92.7%, probably because in 92% of cases optimum blood flow was achieved and the prescribed time was achieved in 95% of sessions. We can therefore conclude that objective assessment of each dialysis session, with the intention of optimising them, provides us with valuable real-time information, and therefore serves to confirm what we were doing right and highlight opportunities for improvement in aspects in which our performance is weaker. The involvement of nephrological nurses in this cycle of improvement will have a positive impact on the classic quality indicators which are regularly measured, anticipating the solution before the problem is reported (AU)

Estudio comparativo de flujos y resistencias de catéteres para hemodiálisis usando bioconectores luer-lock / Comparative study of flows and resistances of haemodialysis catheters using luer lock bioconnectors

El objetivo de este trabajo es evaluar los flujos y resistencias al usar dos tipos de bioconectores luer-lock para catéteres de hemodiálisis. Como objetivos secundarios se pretende evaluar los cambios en la coagulación del sistema, el tiempo empleado en la conexión/desconexión y la opinión de enfermería respecto a su utilización. Material y métodos: estudio experimental aleatorizado en 10 pacientes en hemodiálisis, 5con bioconector Tego® (grupo A) y 5 con BD QSyte® (grupo B), a lo largo de 12 sesiones consecutivas(6 con bioconectores y 6 con conexión directa al monitor). Se estudian las siguientes variables: sociodemográficas, tipo de técnica de hemodiálisis, flujos de sangre, presión venosa, Kt, KtV, coagulación del sistema, tiempo empleado en la conexión/desconexión y la opinión del personal de enfermería. Resultados: La muestra se compuso de 6 mujeres y 4 hombres, con una edad media 62 años y un tiempo medio en hemodiálisis de 4,2 años. En el grupo A, no existieron diferencias estadísticamente significativas entre los flujos de sangre, las presiones venosas y las dosis de diálisis. El grupo B presentó diferencias estadísticamente significativas en los flujos de sangre y en las presiones venosas. No hubo diferencias entre el uso de bioconectores y la conexión directa al catéter en la coagulación del sistema. Los tiempos de conexión y desconexión disminuyeron en ambos grupos. El personal de enfermería opinó quela comodidad en el uso de bioconectores era: mucha (82%), bastante (9%) e igual que sin ellos (9%).Conclusiones: Las tiempos de conexión y desconexión disminuyen con la utilización de bioconectores. El bioconector Tego®, ofrece mejores flujos sanguíneos y menores resistencias venosas (AU)

The aim of this study is to evaluate flows and resistances when using two types of luer lock bioconnectors for haemodialysis catheters. As secondary objectives, the study seeks to evaluate the changes in the coagulation of the system, connection/disconnection time and the opinion of nursing staff on their use. Material and methods: randomized experimental study of 10 patients undergoing haemodialysis, 5with Tego® bioconnectors (group A) and 5 with BD Q-Syte® (group B), over 12 consecutive sessions(6 with bioconnectors and 6 directly connected to the monitor). The following variables were studied: sociodemographic, type of haemodialysis technique, blood flows, venous blood pressure, Kt, KtV, coagulation of the system, time used in connecting/disconnecting and the opinion of nursing staff. Results: The sample comprised 6 women and 4men, with an average age of 62 and an average time on haemodialysis of 4.2 years. In group A, there were no statistically significant differences between blood flows, venous blood pressure and dialysis dose. Group B showed statistically significant differences in blood flows and venous blood pressure. There were no differences between the use of bioconnectors and direct connection to the catheter in the coagulation of the system. Connection and disconnection times were reduced in both groups. Nursing staff considered that the convenience of the use of bioconnectors was: very convenient(82%), quite convenient (9%) the same as without them (9%).Conclusions: Connection and disconnection times fall with the use of bioconnector. The Tego® bioconnector offers better blood flows and lower venous resistance (AU)

Centros de diálisis extrahospitalaria: ¿de dónde venimos, a dónde vamos? / No disponible

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Necesidad de una información responsable sobre las modalidades de tratamiento renal sustitutivo / Need of responsible information on modalities of renal replacement therapy

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As atividades lúdicas em unidade de hemodiálise / Playful activities in haemodialisis units

Este trabalho objetivou conhecer a influência de atividades lúdicas no tratamento de pacientes com Insuficiência Renal Crônica Terminal, durante a hemodiálise. Foi utilizada uma abordagem qualitativa a partir de entrevistas semiestruturadas. O estudo foi realizado com 16 pacientes de uma clínica de hemodiálise. Foi percebida uma categoria definida como a capacidade de as pessoas entenderem, de maneira positiva ou negativa, suas experiências. As subcategorias são: percepção positiva, considerada como todo sentimento desvelado pelo paciente por meio das atividades lúdicas como bemestar; percepção negativa é todo sentimento de indiferença por tais atividades. Os resultados revelaram que as atividades lúdicas influenciam positivamente a vida da maioria dos pacientes, proporcionando bemestar. Mesmo os que se mostraram indiferentes, admitiram ter gostado da experiência. Acreditamos que os resultados reforçam a necessidade de a enfermagem buscar ações mais humanizadas nas unidades de diálise