Incidence and risk factors for acute kidney injury in head and neck cancer patients treated with concurrent chemoradiation with high-dose cisplatin.

BACKGROUND: Three-weekly high-dose cisplatin (100 mg/m2) is considered the standard systemic regimen given concurrently with postoperative or definitive radiotherapy in locally advanced squamous cell carcinoma of the head and neck (LA-SCCHN). Concurrent chemoradiation (CRT) with high-dose cisplatin is associated with significant acute and late toxicities, including acute kidney injury (AKI). The aims of this study were to investigate the incidence of AKI in patients with LA-SCCHN during and after treatment with high-dose cisplatin-based CRT, to identify risk factors for cisplatin-induced AKI, and to describe the impact of AKI on long-term renal function and treatment outcomes. METHODS: This is a retrospective cohort study with measurements of renal function before CRT, weekly during CRT, every 1 or 2 days during hospitalizations, and 3 and 12 months after CRT in patients with LA-SCCHN. AKI was defined as increase in serum creatinine (sCr) of ≥1.5 times baseline or by ≥0.3 mg/dL (≥26.5 µmol/L) using the Kidney Disease Improving Global Outcomes (KDIGO) classification. Logistic regression models were estimated to analyze renal function over time and to identify predictors for AKI. RESULTS: One hundred twenty-four patients completed all measurements. AKI was reported in 85 patients (69%) with 112 episodes of AKI. Sixty of 85 patients experienced 1 AKI episode; 20 patients experienced ≥2 AKI episodes. Ninety-three (83%) AKI episodes were stage 1, 13 (12%) were stage 2, and 6 (5%) AKI episodes were stage 3. Median follow-up time was 29 months (Interquartile Range, IQR 22-33). Hypertension (Odds Ratio, OR 2.7, 95% Confidence Interval, CI 1.1-6.6; p = 0.03), and chemotherapy-induced nausea and vomiting (CINV; OR 4.3, 95% CI 1.6-11.3; p = 0.003) were associated with AKI. In patients with AKI, renal function was significantly more impaired at 3 and 12 months post-treatment compared to patients without AKI. AKI did not have a negative impact on treatment outcomes. CONCLUSION: AKI occurred in 69% of patients with LA-SCCHN undergoing CRT with high-dose cisplatin. Long-term renal function was significantly more impaired in patients with AKI. Hypertension and CINV are significant risk factors. Optimizing prevention strategies for CINV are urgently needed.

Improved nutrition after conversion to nocturnal home hemodialysis.

BACKGROUND: Protein-energy malnutrition is a frequently observed problem in hemodialysis patients. Nocturnal home hemodialysis (NHHD; 6 x 8hours during the night) seems to improve patient outcomes, including nutritional state. METHODS: In a single-center, prospective, nonrandomized study, the effects of NHHD on various aspects of nutrition in 14 hemodialysis patients during 1 to 2 years were investigated, using dietary records, appetite questionnaires, laboratory tests, and patient data. RESULTS: Appetite, body weight, and energy and protein intakes improved. Patients could drink more. Serum phosphate, calcium, and potassium intake increased. Laboratory results remained excellent, without phosphate-binding agents or potassium-binding resins. However, fat intake also increased, with a risk for overweight status. CONCLUSIONS: Nocturnal home hemodialysis has a positive effect on nutritional state.

Severe Acquired Coagulopathy During Fulminant Staphylococcus aureus Sepsis Most Likely Caused by S. aureus Exotoxins (SSLs).

Haemostatic abnormalities frequently occur during sepsis and are most often attributed to disseminated intravascular coagulation (DIC). We report the case of a patient with severe coagulopathy acquired during fulminant S. aureus sepsis. DIC was not present. This coagulopathy was most likely caused by S. aureus exotoxins forming inhibitory complexes with coagulation factor Xa. LEARNING POINTS: To our knowledge, this is the first report describing inhibition of coagulation by Staphylococcus aureus in vivo and so will hopefully broaden our knowledge of S. aureus sepsis, S. aureus exotoxins and coagulation disorders during sepsis.While disseminated intravascular coagulation (DIC) is the most frequent severe coagulopathy diagnosed during sepsis, inhibition of coagulation by SSL10 may be an underdiagnosed cause during S. aureus sepsis.As DIC and inhibition of coagulation by SSL10 should be treated differently, we emphasize the importance of considering inhibition of blood coagulation by S. aureus when an acquired coagulopathy is found during severe sepsis.

Cannulating in haemodialysis: rope-ladder or buttonhole technique?

BACKGROUND: The standard technique for fistula cannulation, the rope-ladder technique, is problematic for patients with short fistula lengths and for patients in whom the fistula is difficult to cannulate. The buttonhole technique, cannulation of exactly the same site, offers the advantage of an easy cannulation procedure. However, it can be used only in native fistulas and cannulation is preferably executed by a 'single-sticker'. This study was conducted to compare these cannulation techniques using objective parameters. METHODS: We introduced the buttonhole technique for self-cannulating home haemodialysis patients and compared it with baseline data obtained with the rope-ladder technique. Thirty-three patients with a native arteriovenous fistula were observed prospectively during 18 months on the following parameters: cannulating ease, number of bad sticks, pain, time of compression after cannula removal, bleeding, infectious complications and aneurysm formation. RESULTS: With the buttonhole method, cannulating ease improved distinctly, which was especially favourable in patients with a short fistula vein. Reported cannulation pain did not change significantly. The incidence of bad sticks decreased significantly, as well as time of compression after cannula removal, without increased incidence of bleeding. Three patients developed a local skin infection of their buttonhole during the study, after which the disinfection routine prior to cannulation was changed. CONCLUSIONS: Compared with the rope-ladder technique, the buttonhole method offers the advantage of an easier cannulation procedure with less bad sticks, which has a special benefit for patients with limited access cannulation sites or with a fistula which is difficult to cannulate. Prolonged compression times or re-bleeding episodes did not occur, but precautions have to be taken in order to prevent infectious complications. The buttonhole method can contribute considerably to the cannulating ease of self-cannulating patients, thus providing a better quality of life.