Effect of insertion site on tunnelled haemodialysis catheter outcomes: an observational study of 967 catheters.

BACKGROUND: The right internal jugular vein is the preferred approach to tunnelled haemodialysis catheter placement. However, the effect of the insertion site on long-term catheter outcomes remains uncertain. AIMS: We aimed to analyse a large cohort of tunnelled haemodialysis catheter placements to compare short-term and long-term results according to central venous catheter location. METHODS: A retrospective cohort study was performed on consecutive tunnelled catheter insertions at two centres over 7 years. The primary outcome was catheter survival, compared according to the central vein site. We used the Kaplan-Meier curve method and Cox proportional hazards modelling to determine the effect of the catheterisation route on primary patency, adjusted for clinical risk factors for catheter failure. RESULTS: There were 967 tunnelled dialysis catheter placements in 620 patients. The median survival for right internal jugular vein catheters was 569 days. There were no differences in rates of catheter failure between right internal jugular, left internal jugular (adjusted hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.52-1.21), external jugular (HR, 0.79; CI, 0.33-3.13), subclavian (HR, 0.67; CI, 0.58-2.44) and femoral vein (HR, 1.20; CI, 0.36-1.33) catheters following multivariable analysis. There were no major differences in functionality or complications between the groups. CONCLUSIONS: This study identified no statistically significant relationship between tunnelled haemodialysis catheter insertion site and catheter survival. The contemporary approach to dialysis vascular access should be tailored to specific patient circumstances.

Survey study of trends in adult nephrology advanced training in Australia and New Zealand.

BACKGROUND: There has been considerable growth in nephrology advanced trainee numbers in Australia and New Zealand, with uncertain effects on clinical experience, competence and employment outcomes. AIMS: To review the perceived adequacy and temporal trends of advanced training in nephrology in Australia and New Zealand by evaluating training experiences, personal views on important aspects of training and nephrology, career paths and early employment outcomes. METHODS: An online survey was distributed to members of the Australian and New Zealand Society of Nephrology through email in December 2020. Responses were sought from current trainees and from nephrologists qualifying since 2014. Likert scale proportions were calculated and group comparisons made using the Chi-squared test. RESULTS: A total of 88 participants returned the survey yielding a response rate of 32%, with a representative sample of trainees and consultants from across Australia and New Zealand. Training was reported as adequate in most aspects of clinical nephrology, although 88% of respondents felt poorly prepared for entering private practice and 61% reported inadequate training in kidney histopathology. Exposure to clinical procedures was variable, with adequate training in percutaneous kidney biopsy, but mostly inadequate training in dialysis access insertion. Sixty-nine percent of nephrologists completed their advanced training entirely in large urban centres and 85% worked in an urban area after training. Only 23% of consultants were engaged in full-time clinical employment in their first-year post-training and 78% were undertaking at least one of dual specialty training or a higher degree by research. Demand for subspecialty fellowships was high. CONCLUSION: Trainees and nephrologists in Australia and New Zealand are currently satisfied with their training in most aspects of nephrology; however, some clinical experiences are perceived as inadequate and early career paths after advanced training are increasingly diverse.

Long-term outcomes of high-dose-rate brachytherapy for intermediate- and high-risk prostate cancer with a median follow-up of 10 years.

OBJECTIVE: To evaluate the long-term outcomes of high-dose-rate (HDR) brachytherapy for patients with intermediate- and high-risk prostate cancer. SUBJECTS AND METHODS: We retrospectively analysed a prospective longitudinal cohort database including a single-surgeon series of 507 consecutive men treated with external beam radiotherapy and an HDR prostate brachytherapy boost between August 2000 and December 2009. The risk factors used were based on the D'Amico classification. We measured the incidence of no biochemical evidence of disease (bNED) based on the Phoenix definition of failure (nadir PSA + 2 ng/mL). We also reviewed the incidence of urethral stricture in this cohort. RESULTS: With minimum and median follow-ups of 6 and 10.3 years, respectively, the bNED rates for men with intermediate- and high risk disease were 93.3% and 74.2%, respectively, at 5 years and 86.9% and 56.1%, respectively, at 10 years. The 10-year bNED rate for men with only one intermediate-risk factor was 94%, whereas for patients with all three high-risk factors it was 39.5%. The overall urethral stricture rate was 13.6%. Before 2005, the urethral stricture rate was 28.9% and after January 2005 it was 4.2%. For the 271 men with a minimum follow-up of 10 years the actuarial 10-year prostate cancer-specific survival rate was 90.8% and the actuarial overall survival rate was 86.7%. CONCLUSIONS: For men with intermediate- or high-risk prostate cancer features, who are considered not suitable for, or wish to avoid a radical prostatectomy, HDR prostate brachytherapy remains an appropriate treatment option. From December 2004, prevention strategies decreased the risk of post-brachytherapy urethral strictures.

A Rare Case of Adult Rhabdomyosarcoma.

BACKGROUND: Rhabdomyosarcoma is a rare, soft tissue malignancy, diagnosed particularly in adults. It commonly metastasizes to the bone marrow. We present a rare case of an adult rhabdomyosarcoma which illustrates the importance of magnetic resonance imaging in identifying early changes in the internal bone structure. CASE REPORT: A 50-year-old male presented with acute urinary retention. The patient initially had a CT scan of the lumbar spine which only revealed a protrusion of the L5-S1 intervertebral disc and no apparent cause for the patient's symptoms. One week later, an MRI was performed which showed extensive bone marrow metastases throughout the lumbar spine and a soft tissue mass in the lower sacral region. The bony metastases were not evident on the CT scan and the soft tissue mass was out of the coverage area of the CT. Subsequent biopsy of the soft tissue mass was performed and histopathology concluded the tissue to be a rhabdomyosarcoma. Unfortunately, the patient died one week after diagnosis. CONCLUSIONS: Although adult rhabdomyosarcomas are very rare, this case highlights the advantage of MRI over CT in identifying early changes in the internal bone structure. Therefore, CT should not be relied upon to exclude bony metastases, particularly in the setting of primary cancer with a known tendency to metastasize to the bone marrow.

Non-steroidal anti-inflammatories and the development of analgesic nephropathy: a systematic review.

BACKGROUND: Analgesic nephropathy (AN) is chronic renal impairment as a direct consequence of chronic heavy analgesia ingestion. An association between non-steroidal anti-inflammatory agents and chronic kidney disease (CKD) has long been suspected. Despite ample observational data obtained in recent decades the relationship remains uncertain. This systematic review intends to summarize the available literature and to define the role of non-steroidal anti-inflammatories in the natural history of AN. METHODS: We conducted a systematic literature search for articles describing the association between non-steroidal anti-inflammatory abuse and renal insufficiency. No restriction was placed on publication date, but papers were limited to English language, observational design, and human studies. RESULTS: Nine articles met our inclusion criteria and were discussed in this review. This includes 5 cohort studies and 4 case-control trials, with a combined population of 12,418 study subjects and 23,877 controls. Eight of the nine reports failed to identify any increased risk of chronic renal impairment with heavy non-steroidal anti-inflammatory consumption. Study methods were heterogeneous and the overall quality of data was relatively poor. CONCLUSION: A relationship between non-steroidal anti-inflammatory medicines and the development of CKD has never been proven. Based on the available scientific evidence non-steroidal anti-inflammatory agents do not appear to be implicated in the pathogenesis of AN.

Eosinophilic oesophagitis--a guide for primary care.

BACKGROUND: Eosinophilic oesophagitis (EoE) is an increasingly recognised inflammatory disorder of the oesophagus. The incidence of this chronic, food-triggered disease is rising in Australia and diagnosis should be considered in patients who complain of dysphagia. OBJECTIVE: This article provides an overview of the pathogenesis, evaluation and management of EoE. It is intended as a useful tool for general practitioners (GPs) in the primary care setting and to raise awareness of EoE. DISCUSSION: EoE is an increasingly prevalent allergic disorder of the oesophagus. It is characterised clinically by symptoms of oesophageal dysfunction and microscopically by eosinophilic inflammation of the oesophagus. Treatment involves avoiding trigger foods and corticosteroid therapy, which may be necessary intermittently or long term, given the relapsing nature of the condition. EoE can significantly impair quality of life and GPs are key to recognising the disease and directing patients' long-term care.

Helicobacter pylori eradication - an update on the latest therapies.

BACKGROUND: The eradication of Helicobacter pylori (H. pylori) can be challenging in certain circumstances. There is no current first-line therapy that is curative in all patients. OBJECTIVE: This article summaries the role of emerging novel therapies in the treatment of H. pylori. Known as sequential therapy and salvage therapy, these new therapeutic strategies are thought to produce eradication rates superior to currently recommended first-line therapies. This article outlines the growing body of evidence supporting their efficacy. DISCUSSION: Sequential therapy and salvage therapy have emerged recently as alternative regimens for the eradication of H. pylori. Although current guidelines continue to recommend established therapies for first-line management of H. pylori, general practitioners should be aware of these new strategies such that these options could be applied when traditional therapy fails.

Peritoneal dialysis catheter design and function and implications for the clinical setting.

INTRODUCTION: Peritoneal catheters are a fundamental form of dialysis access. An appreciation of the principles of catheter design is important for practitioners involved in the insertion and maintenance of peritoneal dialysis access. Although silicone dual-cuffed catheters are standard, the optimal catheter design remains uncertain. AREAS COVERED: This narrative review outlines common peritoneal dialysis catheter characteristics and summarizes their practical relevance. Catheter material, cuffs, tips, and tunneled segment shape are discussed. EXPERT OPINION: Peritoneal dialysis catheter selection is informed by theoretic design principles and limited clinical evidence, but operator experience and patient and center factors are probably stronger predictors of outcomes.

Low Posterior Internal Jugular Vein Approach for Tunnelled Haemodialysis Catheter Insertion: A Report on Outcomes at a Single Centre.

AIM: The impact of technical differences in cannulation technique for tunnelled haemodialysis catheter insertion is undetermined. We aimed to assess clinical outcomes of the low posterior approach for internal jugular vein tunnelled catheter placement. METHODS: A retrospective audit was undertaken on consecutive tunnelled catheter procedures performed at a single centre between January 2016 and June 2022. Only catheters specifically placed with a low posterior internal jugular approach were included. The study's primary outcome was 12-month catheter survival, evaluated using the Kaplan-Meier survival curve and log-rank test. Secondary outcomes included catheter performance and procedure-related complications. RESULTS: During the study period, 391 tunnelled internal jugular haemodialysis catheters were inserted in 272 patients using the low posterior technique. The 12-month primary patency rate was 68%. Catheter insertion was successful in 96% of cases. Peri-procedural complications occurred in 4% of cases, most frequently bleeding. The most common reasons for catheter loss were dysfunction (10%) and bacteraemia (6%). The best predictors of catheter failure were advanced age (HR 1.02, 95% CI 1.00-1.04) and in-centre dialysis treatment locality (HR 2.04, 95% CI 1.19-3.45). CONCLUSION: The low posterior approach for internal jugular vein tunnelled catheter insertion is effective and safe. We demonstrated a 12-month catheter survival rate of 68%. Further research comparing the low posterior approach with other internal jugular vein cannulation techniques is warranted.

Peritoneal dialysis catheterization with an upward tunnel and exit site: An observational study.

BACKGROUND: The preferred techniques for peritoneal dialysis catheterization are uncertain. Catheter implantation with formation of an inferiorly-directed tunnel and exit site is widely recommended to reduce the risk of infective complications. We aimed to compare percutaneous peritoneal dialysis catheter insertion using an upwardly-directed tract to catheter insertion using a downwardly-directed tract. METHODS: A retrospective cohort study was performed on consecutive peritoneal dialysis catheterizations over a 10-year period at a single centre. Participants were classified into two groups: catheter insertion with an upward tunnel and exit site versus insertion with a downward tunnel and exit site. The primary outcome was peritoneal dialysis catheter survival. RESULTS: There were 247 peritoneal dialysis catheters inserted during the study period. The median catheter survival was 18 months, with no difference between the two groups (p = 0.23). The 12-month catheter patency rates were 76% for catheters with an upward tract and 79% for catheters with a downward tract (p = 0.15). Multivariate analysis identified no clinical factors predictive of catheter survival. A downward catheter tunnel and exit site was associated with an increased incidence of peritonitis (0.23 vs 0.11 episodes per year; p ⩽ 0.01). CONCLUSION: In this study, percutaneous peritoneal dialysis catheter insertion with an upward tunnel and exit site demonstrated similar catheter survival to insertion with a downward tunnel and exit site and was not associated with increased infections.

Prostate cancer - active surveillance as a management option.

BACKGROUND: Active surveillance, followed by delayed definitive treatment for those who develop evidence of significant cancer progression, is now a recognised management strategy for selected men with low risk prostate cancer. OBJECTIVE: This article summarises the role of active surveillance in the management of prostate cancer. It outlines the benefits of active surveillance and the indications for proceeding with curative treatments if required. DISCUSSION: A considerable proportion of men with low grade prostate cancer on biopsy may never progress to higher stage disease or develop symptoms from their cancers. These patients are suitable for active surveillance under the care of a urologist. Active surveillance involves initial stringent observation of the prostate cancer, with inclusion of monitoring biopsies rather than immediate active treatment in the form of surgery or radiotherapy. With careful selection, about 70% of men will not require any intervention for at least 5 years. Men with low grade disease should be offered active surveillance as a treatment option and provided with information about the risks and benefits of this approach.

Tunneled Hemodialysis Catheter Insertion: Technical and Clinical Considerations.

Tunneled hemodialysis catheter insertion is a common and important procedure. Clinicians involved in the placement or maintenance of tunneled catheters require an appreciation of their best clinical application. Although comprehensive guidelines are available, many aspects of the published literature on this subject remain uncertain. This primer offers a concise, evidence-based discussion of 10 fundamental, everyday questions with respect to tunneled hemodialysis catheter insertion.

Obstructive uropathy - acute and chronic medical management.

Obstructive uropathy is an important cause of acute and chronic kidney disease. Decompression of the urinary tract is an essential aspect of treatment. The cause and aetiology of obstruction typically determine the surgical approach. Acute relief of obstruction is frequently complicated by fluid and electrolyte imbalance. Standard therapeutic interventions for acute or chronic renal failure also apply for cases of obstructive uropathy. This narrative review summarises the early and long-term medical management of obstructive uropathy.

Urgent-start peritoneal dialysis.

Peritoneal dialysis is an important form of kidney replacement therapy. Most patients presenting with an unplanned, urgent need for dialysis are prescribed haemodialysis, leading to peritoneal dialysis underutilisation. Urgent-start peritoneal dialysis refers to treatment that is commenced within 2 weeks of catheter placement. Urgent-start peritoneal dialysis represents an efficacious, cost-effective alternative to the conventional approach of commencing dialysis. There is a paucity of evidence to guide management, however experience with the technique is increasing. This article overviews the rationale and practical application of urgent-start peritoneal dialysis.

Haemodialysis catheters - a review of design and function.

INTRODUCTION: Hemodialysis (HD) catheters are a fundamental form of dialysis access. An appreciation of the principles of catheter design is important for practitioners involved in the insertion and maintenance of hemodialysis access. Although a wide range of styles and brands are available on the market, comparative clinical trials are lacking. AREAS COVERED: This concise review outlines common dialysis catheter characteristics and summarizes their practical relevance. Materials and surface coatings, tip geometry, side holes, and lumen cross-sectional shape are discussed. EXPERT OPINION: HD catheter choice should be at the operator's discretion based on their best clinical judgment and experience. While device selection should be informed theoretic design principles, more important is a concentration on thoughtful catheter insertion and maintenance practices.

Dialysis and extracorporeal therapies for enhanced elimination of toxic ingestions and poisoning.

Poisoning and toxic ingestions cause significant morbidity and mortality worldwide. Extracorporeal therapies such as dialysis, hemoperfusion, and plasma exchange are selectively applied to patients with severe intoxications unresponsive to standard interventions and can be lifesaving. Extracorporeal therapies are a complex but fundamental aspect of the practice of nephrology. Without high-quality evidence to guide implementation, an understanding of toxicokinetics and the physiochemical principles of the enhanced elimination techniques is especially important. This review provides a comphrensive, user-friendly outline of the application of extracorporeal therapy in the poisoned patient.

Clavicular hook: Cuffed haemodialysis catheter insertion using a paramedian tunnel in patients with recurrent tip migration.

Tunnelled, cuffed central venous catheters are commonly used for the provision of haemodialysis. Internal jugular vein catheters are generally tunnelled subcutaneously to the anterolateral chest wall. However, the lateral subcutaneous tract may increase the risk of catheter migration, particularly in the setting of obesity or large breast tissue. Catheter tip migration is an important cause of catheter failure. We describe two cases in which a paramedian tunnel was fashioned in patients experiencing recurrent catheter migration.

Ewing sarcoma: A pictorial review of typical and atypical locations with reference to the updated 2020 WHO classification system.

Ewing sarcoma (ES) is a small round cell sarcoma which usually occurs in the paediatric and young adult age groups. This pictorial review briefly discusses and presents the typical skeletal and extraskeletal locations which ES is encountered, including the metadiaphysis of long bones, pelvis, chest wall and paravertebral regions. Five cases of ES in atypical locations are then presented along with an observation of demographic differences between skeletal and extraskeletal ES. These cases include ES arising from the metatarsal, scapula, breast, intracranial soft tissue and the paranasal sinuses. Presenting symptoms, treatment approach and prognosis are highly variable depending on the location; and multimodal imaging is centrepiece in the management process. Management usually includes any combination of chemotherapy, radiotherapy and surgery. The WHO classification system was updated in 2020 to include some of the rare genetic subtypes of ES. One such case of the BCOR subtype is demonstrated in this review and occurs in an atypical location. Whether these subtypes have distinct radiological features or a propensity to occur in atypical locations is an area for further research.

Respiratory Failure: A Rare Complication of Chronic Kidney Disease Mineral and Bone Disorder.

Background: Disordered metabolism of bone and minerals is a problem frequently encountered in patients with chronic kidney disease. Early biochemical changes include altered calcium and phosphate balance, while advanced disease produces reduced bone strength and extraskeletal calcification. The syndrome describing this constellation of findings is termed chronic kidney disease mineral and bone disorder. Case Report: This report details a rare and extreme manifestation of chronic kidney disease mineral and bone disorder in a patient on long-term hemodialysis for end-stage renal failure. Progressive abnormalities of the thoracic skeleton were ultimately severe enough to produce restrictive lung physiology and symptomatic respiratory failure. Conclusion: Cases of chronic kidney disease mineral and bone disorder with pronounced clinical sequelae occur uncommonly in contemporary practice because of early detection and effective therapies. To our knowledge, this report is the first case in the literature of severe thoracic involvement manifesting as respiratory failure.