Hypothermic Perfusion Modifies the Association Between Anti-LG3 Antibodies and Delayed Graft Function in Kidney Recipients.

We previously reported associations between autoantibodies to the LG3 fragment of perlecan, anti-LG3, and a higher risk of delayed graft function (DGF) in kidney transplant recipients. Here, we aimed to determine whether some factors that modulate ischemia-reperfusion injury (IRI) can modify this association. We performed a retrospective cohort study in kidney transplant recipients in 2 university-affiliated centers. In 687 patients, we show that high pre-transplant anti-LG3 are associated with DGF when the kidney is transported on ice (odds ratio (OR): 1.75, 95% confidence interval 1.02-3.00), but not when placed on hypothermic perfusion pump (OR: 0.78, 95% CI 0.43-1.37). In patients with DGF, high pre-transplant anti-LG3 are associated with a higher risk of graft failure (subdistribution hazard ratio (SHR): 4.07, 95% CI: 1.80, 9.22), while this was not the case in patients with immediate graft function (SHR: 0.50, 95% CI 0.19, 1.29). High anti-LG3 levels are associated with a higher risk of DGF in kidneys exposed to cold storage, but not when hypothermic pump perfusion is used. High anti-LG3 are also associated with a higher risk of graft failure in patients who experience DGF, a clinical manifestation of severe IRI.

Immunosuppressant Medication Use in Patients with Kidney Allograft Failure: A Prospective Multicenter Canadian Cohort Study.

BACKGROUND: Patients with kidney transplant failure have a high risk of hospitalization and death due to infection. The optimal use of immunosuppressants after transplant failure remains uncertain and clinical practice varies widely. METHODS: This prospective cohort study enrolled patients within 21 days of starting dialysis after transplant failure in 16 Canadian centers. Immunosuppressant medication use, death, hospitalized infection, rejection of the failed allograft, and anti-HLA panel reactive antibodies were determined at 1, 3, 6, and 12 months and and then twice yearly until death, repeat transplantation, or loss to follow-up. RESULTS: The 269 study patients were followed for a median of 558 days. There were 33 deaths, 143 patients hospitalized for infection, and 21 rejections. Most patients (65%) continued immunosuppressants, 20% continued prednisone only, and 15% discontinued all immunosuppressants. In multivariable models, patients who continued immunosuppressants had a lower risk of death (hazard ratio [HR], 0.40; 95% confidence interval [CI], 0.17 to 0.93) and were not at increased risk of hospitalized infection (HR, 1.81; 95% CI, 0.82 to 4.0) compared with patients who discontinued all immunosuppressants or continued prednisone only. The mean class I and class II panel reactive antibodies increased from 11% to 27% and from 25% to 47%, respectively, but did not differ by immunosuppressant use. Continuation of immunosuppressants was not protective of rejection of the failed allograft (HR, 0.81; 95% CI, 0.22 to 2.94). CONCLUSIONS: Prolonged use of immunosuppressants >1 year after transplant failure was not associated with a higher risk of death or hospitalized infection but was insufficient to prevent higher anti-HLA antibodies or rejection of the failed allograft.

Comparison of the effects of standard vs low-dose prolonged-release tacrolimus with or without ACEi/ARB on the histology and function of renal allografts.

Targeting the renin-angiotensin system and optimizing tacrolimus exposure are both postulated to improve outcomes in renal transplant recipients (RTRs) by preventing interstitial fibrosis/tubular atrophy (IF/TA). In this multicenter, prospective, open-label controlled trial, adult de novo RTRs were randomized in a 2 × 2 design to low- vs standard-dose (LOW vs STD) prolonged-release tacrolimus and to angiotensin-converting enzyme inhibitors/angiotensin II receptor 1 blockers (ACEi/ARBs) vs other antihypertensive therapy (OAHT). There were 2 coprimary endpoints: the prevalence of IF/TA at month 6 and at month 24. IF/TA prevalence was similar for LOW vs STD tacrolimus at month 6 (36.8% vs 39.5%; P = .80) and ACEi/ARBs vs OAHT at month 24 (54.8% vs 58.2%; P = .33). IF/TA progression decreased significantly with LOW vs STD tacrolimus at month 24 (mean [SD] change, +0.42 [1.477] vs +1.10 [1.577]; P = .0039). Across the 4 treatment groups, LOW + ACEi/ARB patients exhibited the lowest mean IF/TA change and, compared with LOW + OAHT patients, experienced significantly delayed time to first T cell-mediated rejection. Renal function was stable from month 1 to month 24 in all treatment groups. No unexpected safety findings were detected. Coupled with LOW tacrolimus dosing, ACEi/ARBs appear to reduce IF/TA progression and delay rejection relative to reduced tacrolimus exposure without renin-angiotensin system blockade. ClinicalTrials.gov identifier: NCT00933231.

The incidence, management, and evolution of rapamycin-related side effects in kidney transplant recipients.

Conversion from a calcineurin-inhibitor-based immunosuppression to a rapamycin-based immunosuppression may preserve kidney graft function. The side effects of rapamycin can limit its usefulness, but their management and evolution are rarely reported in clinical trials. We performed a retrospective cohort study in patients transplanted before December 31, 2008 and who received rapamycin to replace calcineurin inhibitors. In 219 patients studied, 98% presented ≥1 side effects after starting rapamycin. Side effects occurring in ≥10% of patients were dyslipidemia (52%, 95% confidence interval (CI): 45-59%), peripheral edema (37%, 95%CI: 31-43%), cytopenia (36%, 95% CI: 30-42%), acne (29%, 95% CI: 23-35%), proteinuria (23%, 95% CI: 17-29%), and oral ulcers 14% (95% CI: 10-18%). Proteinuria, ulcers, and edema were difficult to manage and were more likely to cause cessation of rapamycin. Rapamycin was discontinued in 46% of patients (95% CI: 40-52%). Age (odds ratio [OR] per 10-yr increase: 1.29, 95% CI: 1.05-1.59) and obesity (OR: 2.57, 95% CI: 1.10-6.01) were independently associated with cessation of rapamycin. We conclude that successful control of dyslipidemia and cytopenia can be achieved without discontinuing rapamycin. Most other side effects are harder to manage. Leaner and younger patients are less likely to discontinue rapamycin due to side effects.

Practice Patterns in the Treatment and Monitoring of Acute T Cell-Mediated Kidney Graft Rejection in Canada.

BACKGROUND: One of the goals of the Canadian National Transplant Research Program (CNTRP) is to develop novel therapies for acute rejection that could positively affect graft outcomes with greater efficacy or less toxicity. To develop innovative management strategies for kidney graft rejection, new modalities need to be compared with current clinical practices. However, there are no standardized practices concerning the management of acute T cell-mediated rejection (TCMR). OBJECTIVES: To describe clinicians' practice patterns in the diagnosis, treatment, and monitoring of acute TCMR in Canada. DESIGN: Survey. SETTING PATIENTS/PARTICIPANTS: Canadian transplant nephrologists and transplant surgeons involved in the management of acute TCMR. METHODS AND MEASUREMENTS: We developed an anonymous, web-based survey consisting of questions related to the diagnosis, treatment, and monitoring of TCMR. The survey was disseminated on 3 occasions between June and October 2016 through the Canadian Society of Transplantation (CST) kidney group electronic mailing list. RESULTS: Forty-seven respondents, mostly transplant nephrologists (97%), originating from at least 18 of the 25 Canadian centers offering adult or pediatric kidney transplantation, participated in the study. Surveillance biopsies were used by 28% of respondents to screen for kidney graft rejection. High-dose steroids were used by most of the respondents to treat clinical and subclinical Banff grade 1A and 1B rejections. Nine percent (95% confidence interval [CI]: 1-17) of practitioners used lymphocyte-depleting agents as the first-line approach for the treatment of Banff grade 1B acute rejection. Eighteen percent (95% CI: 7-29) and 36% (95% CI: 8-65) of respondents reported that they would not use high-dose steroids for treating clinical and subclinical borderline rejections, respectively. Seventy percent (95% CI: 54-83) of respondents answered that there was no indication to assess histological response to treatment independent of the change in kidney function. LIMITATIONS: The limitations of this study are its limited sample size and the low representation of pediatric specialists. CONCLUSIONS: There is heterogeneity regarding the use of surveillance biopsies, treatment of borderline rejection, and modalities to monitor treatment response among transplant physicians. Our results illustrate the current state of practice patterns across Canada and can be used to inform the design of future trials.

CONTEXTE: Un des objectifs du Programme national de recherche en transplantation rénale du Canada (PNRTC) est de développer des traitements plus efficaces et moins toxiques en vue d'améliorer l'issue des greffes. Il est impératif de comparer ces nouvelles modalités aux pratiques cliniques existantes si l'on veut élaborer des stratégies de prise en charge thérapeutiques innovantes. Cependant, en contexte de greffe rénale, il n'existe aucune pratique standardisée pour la prise en charge thérapeutique du rejet aigu à médiation cellulaire (RAMC) provoqué par la cytotoxicité des lymphocytes T. OBJECTIF: Décrire le schéma de pratique des médecins canadiens en matière de diagnostic, de traitement et de monitorage du RAMC. TYPE D'ÉTUDE: Il s'agit d'une étude menée sous forme de sondage. PARTICIPANTS: Les chirurgiens et néphrologues en transplantologie impliqués dans la prise en charge du RAMC au Canada. MÉTHODOLOGIE: Nous avons préparé un sondage Web anonyme constitué de questions relatives au diagnostic et au monitorage du RAMC. Les répondants visés étaient les abonnés à la liste d'envoi du groupe de transplantation rénale de la Société canadienne de transplantation (SCT). Ils ont reçu le sondage à trois reprises entre juin et octobre 2016. RÉSULTATS: Les répondants, au nombre de 47, étaient en grande majorité des néphrologues transplantologues (97 %). Ils provenaient d'au moins 18 des 25 centres hospitaliers canadiens dans lesquels on pratique des greffes rénales (adultes ou pédiatriques). Vingt-huit pour cent (28 %) des répondants ont recours aux biopsies de surveillance pour évaluer le risque de rejet du greffon. Les stéroïdes administrés à fortes doses sont employés par la plupart des répondants pour traiter les rejets cliniques et infracliniques de stade 1A et 1B (classification de Banff). Les agents de déplétion des lymphocytes sont utilisés par 9 % (IC 95 % : 1-17) des praticiens comme approche thérapeutique de première ligne pour les rejets aigus de stade 1B de Banff. En matière de traitement des cas rejets limites cliniques et infracliniques, 18% (IC 95 % : 7-29) et 36 % (IC 95 % : 8-65) des répondants ont indiqués qu'ils n'emploieraient pas de stéroïdes à forte dose. Enfin, 70 % (IC 95 % : 54-83) des spécialistes sondés jugeaient qu'il n'y avait pas d'indication d'évaluer la réponse histologique au traitement indépendamment de la réponse au traitement en terme de fonction rénale. LIMITES DE L'ÉTUDE: Les résultats du sondage sont limités par le faible nombre de répondants et par la sous-représentation des spécialistes en pédiatrie. CONCLUSION: Chez les médecins sondés, on a constaté des différences dans trois aspects de la prise en charge de la greffe rénale : la fréquence du recours aux biopsies de surveillance, le traitement des cas limites de rejet et les modalités employées pour mesurer la réponse au traitement. Nos résultats témoignent de l'hétérogénéité actuelle des schémas de pratique au Canada et pourraient servir à orienter la conception d'études ultérieures.

Retrospective Study Looking at Cinacalcet in the Management of Hyperparathyroidism after Kidney Transplantation.

Objectives. The primary objective of this study is to evaluate the use of cinacalcet in the management of hyperparathyroidism in kidney transplant recipients. The secondary objective is to identify baseline factors that predict cinacalcet use after transplantation. Methods. In this single-center retrospective study, we conducted a chart review of all patients having been transplanted from 2003 to 2012 and having received cinacalcet up to kidney transplantation and/or thereafter. Results. Twenty-seven patients were included with a mean follow-up of 2.9 ± 2.4 years. Twenty-one were already taking cinacalcet at the time of transplantation. Cinacalcet was stopped within the first month in 12 of these patients of which 7 had to restart therapy. The main reason for restarting cinacalcet was hypercalcemia. Length of treatment was 23 ± 26 months. There were only 3 cases of mild hypocalcemia. There was no statistically significant association between baseline factors and cinacalcet status a year later. Conclusions. Discontinuing cinacalcet within the first month of kidney transplantation often leads to hypercalcemia. Cinacalcet appears to be an effective treatment of hypercalcemic hyperparathyroidism in kidney transplant recipients. Further studies are needed to evaluate safety and long-term benefits.

Efficacy of Acute Cellular Rejection Treatment According to Banff Score in Kidney Transplant Recipients: A Systematic Review.

BACKGROUND: The poor prognosis classically associated with Banff grade 2 acute cell-mediated rejection (CMR) may be due to unrecognized antibody-mediated damage. We thus performed a systematic review of the literature to determine the rate of response to treatment in kidney transplant recipients with pure CMR, stratified by Banff class. METHODS: In addition to a manual search, databases interrogated included Excerpta Medica Database (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), Evidence-Based Medicine (EBM) databases, Central, PubMed and CINAHL. Studies providing functional and/or histological response rates to the treatment of CMR rejection by Banff class (1997 or more recent) were included. RESULTS: Among the 746 articles identified, 5 articles were included in the final review. Two studies excluded some, and 2 excluded all features of antibody-mediated rejection, while providing data on functional recovery. The absence of functional recovery was reported in 4% of borderline, 15% for Banff grade 1A and IB pooled, 0% to 25% of Banff grade 1B alone, 11% to 20% of Banff grade 2A, and 38% of Banff grade 2B rejections. CONCLUSIONS: The rate of functional recovery of pure Banff IIA CMR overlapped with that of Banff grade 1 CMR, whereas Banff grade 2B showed worse prognosis. There was important heterogeneity in the definition of response to treatment and paucity of data describing the histological response to treatment stratified by Banff class. There is a pressing need to standardize outcome metrics for the reversibility of rejection in kidney transplant recipients in order to design high-quality trials for novel therapeutic alternatives.

Eculizumab for the Treatment of Severe Antibody-Mediated Rejection: A Case Report and Review of the Literature.

In renal transplantation, treatment options for antibody-mediated rejection are limited. Here, we report a case of severe AMR treated with eculizumab. A 50-year-old woman known for end stage kidney disease secondary to IgA nephropathy received a kidney transplant from a 50-year-old deceased donor. At 5 months after transplantation, she presented with acute graft dysfunction and biopsy showed a severe antibody-mediated rejection associated with thrombotic microangiopathy. Despite an aggressive conventional immunosuppressive regimen, signs of rejection persisted and the patient was treated with 3 doses of eculizumab. Following the therapy, markers of TMA improved and graft function stabilized. However, ongoing signs of rejection remained in the repeated biopsy. In kidney transplantation, eculizumab is an expensive treatment and its role in the treatment of antibody-mediated rejection remains to be determined.

BK Polyomavirus and the Transplanted Kidney: Immunopathology and Therapeutic Approaches.

BK polyomavirus is ubiquitous, with a seropositivity rate of over 75% in the adult population. Primary infection is thought to occur in the respiratory tract, but asymptomatic BK virus latency is established in the urothelium. In immunocompromised host, the virus can reactivate but rarely compromises kidney function except in renal grafts, where it causes a tubulointerstitial inflammatory response similar to acute rejection. Restoring host immunity against the virus is the cornerstone of treatment. This review covers the virus-intrinsic features, the posttransplant microenvironment as well as the host immune factors that underlie the pathophysiology of polyomavirus-associated nephropathy. Current and promising therapeutic approaches to treat or prevent this complication are discussed in relation to the complex immunopathology of this condition.

Association between novel indices of malnutrition-inflammation complex syndrome and cardiovascular disease in hemodialysis patients.

BACKGROUND: Inflammation and malnutrition are recognized as important risk factors for cardiovascular disease (CVD) in hemodialysis (HD) patients. Owing to substantial short-term variability of serum C-reactive protein (CRP), more reliable markers of malnutrition-inflammation complex syndrome should be sought with stronger associations with the risk of CVD in HD patients. We therefore explored the clinical relevance of a composite inflammatory index (prognostic inflammatory and nutritional index [PINI]) and of muscle protein mass indicators, derived from creatinine kinetics. METHODS: This cross-sectional study included 177 HD patients (89 women and 88 men; median age, 67.73 years). CVD and risk factors were assessed using medical charts, clinical examination, and biochemical measurements performed at inclusion. Lean body mass (LBM) was derived from creatinine kinetic modeling, whereas PINI was calculated as the ratio (CRP xalpha1-acid-glycoprotein)/(albumin x transthyretin). Patients were divided according to the presence or absence of established CVD. RESULTS: The traditional risk factors diabetes (odds ratio [OR], 5.83; p = 0.0045) and smoking (OR, 3.50; p < 0.02) were associated with an increase in prevalent CVD. Low transthyretin (OR, 3.79; p < 0.02) and high levels of CRP (OR, 2.70; p < 0.05), PINI (OR, 3.44; p < 0.02), observed LBM (OR, 3.01; p < 0.05), and the ratio of observed/expected LBM (OR, 4.24; p < 0.01) were associated with CVD after adjustment for age, sex, dialysis center, and dialysis vintage. After additional adjustment for diabetes and smoking, only PINI (OR, 2.85; p = 0.0446) and observed/expected LBM (OR, 2.96; p = 0.0361) were still significant. CONCLUSION: PINI and LBM are associated with increased relative risk for having CVD and could be used routinely to examine the degree of severity of malnutrition inflammation complex syndrome.

Oxidative stress in hemodialysis patients: is NADPH oxidase complex the culprit?

Oxidative stress results from an imbalance between oxidant production, including reactive oxygen species (ROS), reactive nitrogen species (RNS), chlorinated compounds, and antioxidant defense mechanisms. Most reports prove that oxidative stress is present in ESRD patients. Several studies tend to accreditate the hypothesis by which oxidative stress is a strong co-factor for the development of complications related to long-term HD such as atherosclerosis, amyloidosis, malnutrition, anemia, and infection. In order to evaluate the rationale for curative action against oxidative damage in chronic renal failure patients, we reviewed the putative factors involved in this process. Antioxidant systems are severely impaired in uremic patients and gradually altered with the degree of renal failure. Moreover, the inflammatory state caused by the hemoincompatibility of the dialysis system plays a critical role in the activation of NADPH oxidase, aggravating the pro-oxidant status of uremic patients. Prevention of ROS overproduction by improvement of dialysis biocompatibility, an important component of adequate dialysis, might be completed by antioxidant supplementation.

Blood flow and recirculation rates in tunneled hemodialysis catheters.

Long-term catheters are widely used in some dialysis units. Because of higher dialysis dose targets, high flow catheters have been made available. We measured blood flow (Qb in ml/min) and recirculation rate (R%) in two types of tunneled dialysis catheters using ultrasound-dilution technology (Transonic). Thirty-seven catheters were evaluated (27 Opti-Flow, 10 High-Flow), as inserted in jugular or subclavian veins. Real Qb and R were measured at increasing pump blood flows (250, 300, 350, 400, and 450 ml/min) in absence of ultrafiltration. For all, real Qb was similar to pump Qb (261 vs. 250, 304 vs. 300, 349 vs. 350, 389 vs. 400, and 431 vs. 450 ml/min, respectively). Catheters with reversed lines were all recirculating (R between 18% and 24%). Sixteen nonreversed catheters had no R at all Qb, whereas four nonreversed catheters had minimal R (between 7% and 11%); R did not increase significantly with the rise in pump Qb. The two types of tunneled catheters deliver high Qb without high R if ports are not reversed. The relative decrease in treatment efficiency should be accounted for in dialysis prescription if such tunneled catheters are used as long-term access, especially if lines have to be reversed.

Conversion from twice-daily to once-daily extended-release tacrolimus in renal transplant recipients: 2-year results and review of the literature.

OBJECTIVES: Tacrolimus extended-release formulation has been approved for use in Canada since October 2008. In initial studies, efficacy and safety profile were demonstrated as similar for both formulations (twice-daily tacrolimus and extended-release formula tacrolimus). To validate the safety and efficacy of extended-release formula tacrolimus, we conducted a prospective observational study. MATERIALS AND METHODS: At our institution, between January 2009 and January 2010, the switch from tacrolimus to extended-release formula tacrolimus was done in 130 stable kidney recipients. Clinical data were accessed at baseline (data before conversion), 1 to 2 weeks, 1 month, 3 months, 6 months, 12 months, and 24 months after conversion. RESULTS: One hundred thirty renal transplant recipients were included in the current study. During the observation period, we saw no acute rejection and no change in graft function (mean serum creatinine levels remained stable). However, compared with baseline, mean tacrolimus trough levels were significantly reduced at 1 to 2 weeks, at 1 month, 6 months, 12 months, and at 24 months after conversion. Regarding the safety profile, no significant changes were noted in blood glucose, potassium, and magnesium. Approximately 35% of recipients preferred the extended-release formula tacrolimus to twice-daily tacrolimus. CONCLUSIONS: Conversion from twice-daily tacrolimus to extended-release once-daily tacrolimus appears to be safe and convenient up to 2 years after conversion in some recipients.

Difficulty of patient selection in a combined heart-kidney transplant: a case report.

Combined heart-kidney transplant has become an alternative for heart transplant candidates with significant chronic kidney disease. However, it is not clear which patients will benefit most from such intervention, and in whom cardiac transplant alone will be sufficient to restore adequate renal function. We report the case of a man with ischemic cardiomyopathy and chronic kidney disease who was wait-listed for heart-kidney transplant after acute decompensated heart failure and renal failure requiring hemodialysis. Because of unexpected circumstances, the kidney transplant was cancelled, and only a heart transplant was performed. Nonetheless, the kidney function rapidly improved beyond the levels before hospitalization and remains stable months after transplant. This case illustrates the difficulties in assessing the reversibility of kidney damage in the context of heart failure requiring transplant. This issue is primordial to improve selection of patients who will benefit most from combined heart-kidney transplant in a context of scarce organ allocation resources.

Tinzaparin reduces health care resource use for anticoagulation in hemodialysis.

Anticoagulation is required during hemodialysis to prevent thrombus formation within the extracorporeal circuit. The low-molecular-weight heparin tinzaparin is more expensive than unfractionated heparin (UFH) in Canada but more convenient to administer. We conducted a time-and-motion study to test the hypothesis that tinzaparin may reduce nursing time and total health care costs compared with UFH. Data on health care resource use associated with anticoagulation during hemodialysis for chronic renal failure were collected at an academic hospital in Quebec. Nursing time was recorded for 8 nurses performing 16 dialysis sessions for 4 patients receiving tinzaparin and 4 receiving UFH (2 dialysis sessions per patient). Nurses had ≥ 1 year of experience supervising hemodialysis. We estimated total annual costs of nursing time and health care resources (anticoagulants, medical supplies, and laboratory testing) associated with anticoagulation. In sensitivity analyses, drug costs were varied ± 30% of their base-case values. Estimated annual nursing times per patient were 0.8 vs. 11.5 hours in the first year and 0.6 vs. 10.2 hours in subsequent years for tinzaparin vs. UFH, respectively. Annual drug costs per patient were CAD 898.56 for tinzaparin and 546.75 for UFH. Estimated total annual costs were CAD 1061.03 vs. 1012.71 in the first year and CAD 917.75 vs. 895.23 in subsequent years for tinzaparin vs. UFH, respectively. Use of tinzaparin was cost saving relative to UFH if tinzaparin price was reduced 30%. Most of the price differential between tinzaparin and UFH is offset by substantial time savings to nephrology nurses.

Comparison between standard heparin and tinzaparin for haemodialysis catheter lock.

Tinzaparin offers some advantages over unfractionated heparin (UFH) for hemodialysis circuit anticoagulation. No study has compared these two molecules as hemodialysis catheter locks. This study aimed to compare the efficacy of tinzaparin and UFH as locks for hemodialysis tunnelled central venous catheter in patients with end-stage renal disease (ESRD). A randomized, prospective, single-blinded, controlled study was undertaken. Patients were randomly assigned to receive UFH and tinzaparin for two 7-week periods in a crossover fashion. The doses used were 5,000 U of UFH and 2,000 U of tinzaparin per catheter line. The primary outcome was the need for thrombolytic catheter lock use defined with the Hemodialysis Unit alteplase protocol. Forty-two patients with ESRD were enrolled, totalling 815 UFH lock sessions and 729 tinzaparin lock sessions. A 47.4% reduction in the incidence of alteplase lock use was observed with tinzaparin lock (3.16% vs. 6.01%, chi-square, p = 0.0078). There was no significant difference in the time to first alteplase use between the two locks by Kaplan-Meier survival analysis (logrank, p = 0.0900). Our results suggest that tinzaparin could be an appropriate alternative for a hemodialysis tunnelled central venous catheter lock, but these results should be confirmed with a larger trial.

Predictors and outcome of cardiopulmonary resuscitation (CPR) calls in a large haemodialysis unit over a seven-year period.

BACKGROUND: Cardiac mortality is the leading cause of death in dialysis patients, with cardiac arrests being most frequent. Our purpose was to determine the epidemiology, predictors and outcomes of calls for cardiopulmonary resuscitation (CPR) occurring in our haemodialysis unit. METHODS: We reviewed retrospectively all calls for CPR occurring in our unit between August 1997 and December 2004 and compared data to a cohort of chronic haemodialysis patients from our unit. Dialysis sessions performed in the ICUs were not included. RESULTS: A total of 38 calls occurred over 307,553 sessions, corresponding to an incidence of 0.012%. In a multivariate logistic regression model, statistically significant predictors to have a call for CPR were ischaemic heart disease (OR: 3.93; 95% CI: 1.70-9.07), heart failure (OR: 2.74; 95% CI: 1.12-6.74) and female gender (OR: 2.96; 95% CI: 1.37-6.43). Patients who had a call for CPR had a lower dialysis vintage than control patients (OR: 0.98; 95% CI: 0.965-0.996). Twenty of the 38 events presented on Mondays or Tuesdays (P = 0.012); 78% occurred during haemodialysis, vs 14 and 8% immediately after and immediately before dialysis but still on the unit, respectively. Of the 38 events, 24 were true cardiopulmonary arrests. Cardiac etiology was the most frequent (34%) and only 4 events were attributed to potassium disorders. One quarter of patients were dialyzed against a dialysate potassium concentration of 1 mmol/l or below. An arrhythmia was identified in 19 patients; a malignant ventricular fibrillation or ventricular tachycardia was most frequently found (32%), followed by severe bradycardia (26%). For the whole group, there were 6 deaths (16%) within 48 h; 30 patients (79%) were alive at 30 days and discharged from the hospital. Among the 24 cardiopulmonary arrests, there were 4 deaths (17%) within 48 h; 18 patients (75%) were alive at 30 days and discharged from the hospital. There was a trend for worse prognosis at 60 days when related to cardiopulmonary etiology (P = 0.054) and when a true cardiopulmonary arrest occurred (P = 0.134). CONCLUSIONS: This study confirms that arrest codes occur more frequently on Mondays and Tuesdays in a haemodialysis unit. Survival after an arrest code appears to be better than in certain other circumstances, probably in part because of the presence of witness, physician and equipment, and vascular access being readily available.