Search Results (11)

Acute kidney injury (AKI) and sudden exacerbation of chronic kidney disease (CKD) frequently necessitate urgent kidney replacement therapy (UKRT). Peritoneal dialysis (PD) is recognized as a viable modality for managing such patients. Urgent-start peritoneal dialysis (USPD) may be associated with an increased number of complications and is rarely utilized. This review examines recent literature investigating the clinical outcomes of USPD in CKD and AKI. Relevant research was identified through searches of the MEDLINE (PubMed), Scopus, Web of Science, and Google Scholar databases using MeSH terms and relevant keywords. Included studies focused on the emergency use of peritoneal dialysis in CKD or AKI and reported treatment outcomes. While no official recommendations exist for catheter implantation in USPD, the impact of the technique itself on outcomes was found to be less significant compared with the post-implantation factors. USPD represents a safe and effective treatment modality for AKI, although complications such as catheter malfunctions, leakage, and peritonitis were observed. Furthermore, USPD demonstrated efficacy in managing CKD, although it was associated with a higher incidence of complications compared to conventional-start peritoneal dialysis. Despite its cost-effectiveness, PD requires greater technical expertise from medical professionals. Close supervision and pre-planning for catheter insertion are essential for CKD patients. Whenever feasible, an urgent start should be avoided. Nevertheless, in emergency scenarios, USPD does remain a safe and efficient approach. Full article

Introduction: Rates of peritoneal dialysis (PD) have been traditionally low in Northern Ireland. With rising numbers of patients reaching end-stage kidney disease, PD is a more cost-effective treatment than haemodialysis and aligns with international goals to increase home-based dialysis options. The aim of our study was to highlight how a service reconfiguration bundle expanded access to PD in Northern Ireland. Methods: The service reconfiguration bundle consisted of the appointment of a surgical lead, a dedicated interventional radiologist for fluoroscopically guided PD catheter insertion, and a nephrology-led ultrasound-guided PD catheter insertion service in an area of particular need. All patients in Northern Ireland who had a PD catheter inserted in the year following service reconfigurations were included and prospectively followed up for one-year. Patient demographics, PD catheter insertion technique, setting of procedure, and outcome data were summarised. Results: The number of patients receiving PD catheter insertion doubled to 66 in the year following service reconfigurations. The range of approaches to PD catheter insertion (laparoscopic n = 41, percutaneous n = 24 and open n = 1) allowed a wide range of patients to benefit from PD. Six patients had emergency PD catheter insertion, with four receiving urgent or early start PD. Nearly half (48%, 29/60) of the PD catheters inserted electively were in smaller elective hubs rather than the regional unit. A total of 97% of patients successfully started PD. Patients who experienced percutaneous PD catheter insertion were older [median age 76 (range 37–88) vs. 56 (range 18–84), p < 0.0001] and had less previous abdominal surgery than patients who experienced laparoscopic PD catheter insertion (25%, 6/24 vs. 54%, 22/41, p = 0.05). Discussion: Through a service reconfiguration bundle, we were able to double our annual incident PD population. This study highlights how flexible models of service delivery introduced as a bundle can quickly deliver expanded access to PD and home therapy. Full article

Hungry bone syndrome (HBS), severe hypocalcemia following parathyroidectomy (PTX) due to rapid drop of PTH (parathormone) after a previous long term elevated concentration in primary (PHPT) or renal hyperparathyroidism (RHPT), impairs the outcome of underlying parathyroid disease. Objective: overview HBS following PTx according to a dual perspective: pre- and post-operative outcome in PHPT and RHPT. This is a case- and study-based narrative review. Inclusion criteria: key research words “hungry bone syndrome” and “parathyroidectomy”; PubMed access; in extenso articles; publication timeline from Inception to April 2023. Exclusion criteria: non-PTx-related HBS; hypoparathyroidism following PTx. We identified 120 original studies covering different levels of statistical evidence. We are not aware of a larger analysis on published cases concerning HBS (N = 14,349). PHPT: 14 studies (N = 1545 patients, maximum 425 participants per study), and 36 case reports (N = 37), a total of 1582 adults, aged between 20 and 72. Pediatric PHPT: 3 studies (N = 232, maximum of 182 participants per study), and 15 case reports (N = 19), a total of 251 patients, aged between 6 and 18. RHPT: 27 studies (N = 12,468 individuals, the largest cohort of 7171) and 25 case reports/series (N = 48), a total of 12,516 persons, aged between 23 and 74. HBS involves an early post-operatory (emergency) phase (EP) followed by a recovery phase (RP). EP is due to severe hypocalcemia with various clinical elements (<8.4 mg/dL) with non-low PTH (to be differentiated from hypoparathyroidism), starting with day 3 (1 to 7) with a 3-day duration (up to 30) requiring prompt intravenous calcium (Ca) intervention and vitamin D (VD) (mostly calcitriol) replacement. Hypophosphatemia and hypomagnesiemia may be found. RP: mildly/asymptomatic hypocalcemia controlled under oral Ca+VD for maximum 12 months (protracted HBS is up to 42 months). RHPT associates a higher risk of developing HBS as compared to PHPT. HBS prevalence varied from 15% to 25% up to 75–92% in RHPT, while in PHPT, mostly one out of five adults, respectively, one out of three children and teenagers might be affected (if any, depending on study). In PHPT, there were four clusters of HBS indicators. The first (mostly important) is represented by pre-operatory biochemistry and hormonal panel, especially, increased PTH and alkaline phosphatase (additional indicators were elevated blood urea nitrogen, and a high serum calcium). The second category is the clinical presentation: an older age for adults (yet, not all authors agree); particular skeleton involvement (level of case reports) such as brown tumors and osteitis fibrosa cystica; insufficient evidence for the patients with osteoporosis or those admitted for a parathyroid crisis. The third category involves parathyroid tumor features (increased weight and diameter; giant, atypical, carcinomas, some ectopic adenomas). The fourth category relates to the intra-operatory and early post-surgery management, meaning an associated thyroid surgery and, maybe, a prolonged PTx time (but this is still an open issue) increases the risk, as opposite to prompt recognition of HBS based on calcium (and PTH) assays and rapid intervention (specific interventional protocols are rather used in RHPT than in PHPT). Two important aspects are not clarified yet: the use of pre-operatory bisphosphonates and the role of 25-hydroxyitamin D assay as pointer of HBS. In RHPT, we mentioned three types of evidence. Firstly, risk factors for HBS with a solid level of statistical evidence: younger age at PTx, pre-operatory elevated bone alkaline phosphatase, and PTH, respectively, normal/low serum calcium. The second group includes active interventional (hospital-based) protocols that either reduce the rate or improve the severity of HBS, in addition to an adequate use of dialysis following PTx. The third category involves data with inconsistent evidence that might be the objective of future studies to a better understanding; for instance, longer pre-surgery dialysis duration, obesity, an elevated pre-operatory calcitonin, prior use of cinalcet, the co-presence of brown tumors, and osteitis fibrosa cystica as seen in PHPT. HBS remains a rare complication following PTx, yet extremely severe and with a certain level of predictability; thus, the importance of being adequately identified and managed. The pre-operatory spectrum of assessments is based on biochemistry and hormonal panel in addition to a specific (mostly severe) clinical presentation while the parathyroid tumor itself might provide useful insights as potential risk factors. Particularly in RHPT, prompt interventional protocols of electrolytes surveillance and replacement, despite not being yet a matter of a unified, HBS-specific guideline, prevent symptomatic hypocalcemia, reduce the hospitalization stay, and the re-admission rates. Full article

Atypical Hemolytic Uremic Syndrome is a very rare condition that can be triggered in predisposed patients. It can remain undiagnosed and can result in a life-threatening event or permanent renal failure. We report a case of a 36-year-old pregnant woman who developed atypical hemolytic uremic syndrome postpartum. She underwent an emergency caesarean section due to abruptio placenta, and she developed biochemical alterations suggestive of a thrombotic microangiopathy. Due to worsening of renal function after plasma exchange therapy, we decided to start therapy with eculizumab. Therapy was carried out with a weekly dose of 900 mg IV for five weeks. An improvement of clinical and biochemical parameters was rapidly observed, and her renal function completely recovered. The therapy was continued for six months, with a dose of 1200 mg of eculizumab every two weeks. One year after discontinuation of the therapy, her blood pressure and renal function were still normal. Our case confirms that it is important to promptly identify a pregnancy-related thrombotic microangiopathy and that early therapy can be life-saving for the patient and can preserve renal function, avoiding dialysis. Full article

As we move into the third year with COVID-19, many countries have attempted to manage the disease as an endemic. However, this is limited by the disease’s morbidity and mortality, the emergence of new strains, and the effectiveness of the vaccine. This brief report describes, evaluates, and discusses the implementation of regular antigen rapid tests (ARTs) for COVID-19 in hemodialysis units. We introduced ARTs during the surge in our hemodialysis units. As compliance with the test was mandatory by regulatory requirements, we surveyed patients and caregivers to measure their acceptability, appropriateness, and feasibility of the ART’s implementation. Acceptability measured confidence and level of comfort when performing ART tests, while appropriateness measured the perception of the necessity of ARTs, safety in the dialysis unit with the implementation of ARTs, and understanding using a Likert scale. Feasibility measured the perception of the timely start of dialysis treatment and the convenience of the test. Our survey found that ARTs were acceptable to 98% of patients and caregivers, with the majority reporting no discomfort. The majority of the patients agreed that ARTs were appropriate and feasible. We reported successful ART implementation in a healthcare setting with no false-positive or transmission within the unit during this period. Nevertheless, the long-term implementation outcome will require further evaluation. Full article

Patients with chronic kidney disease require intervention planning because their physical function declines with worsening disease. Providers can work closely with patients during the induction phase of dialysis. This single-center, retrospective observational study aimed to investigate the rate of decline in walking independence during the induction phase of dialysis and the factors that influence this decline, and to provide information on prevention and treatment during this period. Of the 354 patients who were newly initiated on hemodialysis between April 2018 and January 2022, 285 were included in the analysis. The functional independence measure-walking score was used to sort patients into decreased walking independence (DWI; n = 46) and maintained walking independence (no DWI; n = 239) groups, and patient characteristics were compared. After adjusting for various factors by logistic regression analysis, we observed that age, high Charlson comorbidity index (CCI), C-reactive protein, and emergency dialysis start (EDS) were significant predictors of DWI. Even during the very short period of dialysis induction, as many as 16.1% of patients had DWI, which was associated with older age, higher CCI, higher inflammation, and EDS. Therefore, we recommend the early identification of patients with these characteristics and early rehabilitation. Full article

Existing studies display a huge disparity in terms of the number of patients who regret having engaged in dialysis. Modifiable care processes such as providing sufficient information and education prior to decision-making have been shown to have a greater impact on patient satisfaction. Despite the importance of regret as a measure of the quality of the dialysis decision-making process, few studies have examined regret following dialysis initiation. Aim: To explore the expectations and experiences of patients who have recently started centre-based dialysis treatment. Methods: A qualitative explorative study of centre-based dialysis patients was performed. Data were collected using focus group discussions of 2–4 patients. The study was guided by interpretive description and thematic analysis was used to analyse data. Results: Three focus group discussions were performed. Participants (n = 8) consisted of six men and two women aged 54 to 80 years of age with a median age of 72. Three themes emerged from the data: 1. transition from being a non-dialysis patient to becoming a dialysis patient, 2. physical condition following initiation of dialysis treatment, and 3. limitations and social disruptions. Conclusion: The initiation of dialysis disrupted daily life in terms of fluctuating fatigue, strict schedules, and time lost. There was a loss of independence, and participants did not view dialysis as an active choice. Nurses may have a significant impact on the perception of dialysis. This study highlights the need for further research to develop interventions to support newly initiated centre-based dialysis patients to transition from non-dialysis to dialysis patients. Full article

Nephropathic subjects with impaired immune responses show dramatically high infection rates of coronavirus disease 2019 (COVID-19). This work evaluated the ability to acquire and maintain protective antibodies over time in 26 hemodialysis patients and 21 kidney transplant recipients. The subjects were followed-up through quantitative determination of circulating SARS-CoV-2 S1/S2 IgG and neutralizing antibodies in the 6-month period after clinical and laboratory recovery. A group of 143 healthcare workers with no underlying chronic pathologies or renal diseases recovered from COVID was also evaluated. In both dialysis and transplanted patients, antibody titers reached a zenith around the 3rd month, and then a decline occurred on average between the 270th and 300th day. Immunocompromised patients who lost antibodies around the 6th month were more common than non-renal subjects, although the difference was not significant (38.5% vs. 26.6%). Considering the decay of antibody levels below the positivity threshold (15 AU/mL) as “failure”, a progressive loss of immunisation was found in the overall population starting 6 months after recovery. A longer overall antibody persistence was observed in severe forms of COVID-19 (p = 0.0183), but within each group, given the small number of patients, the difference was not significant (dialysis: p = 0.0702; transplant: p = 0.1899). These data suggest that immunocompromised renal patients recovered from COVID-19 have weakened and heterogeneous humoral responses that tend to decay over time. Despite interindividual variability, an association emerged between antibody persistence and clinical severity, similar to the subjects with preserved immune function. Full article

Although baseline hemoglobin and renal function are both important predictors of adverse outcomes after percutaneous coronary intervention (PCI), scarce data exist regarding the combined impact of these factors on outcomes. We sought to investigate the impact and threshold value of the hemoglobin to creatinine (Hgb/Cr) ratio, on in-hospital adverse outcomes among non-dialysis patients in a Japanese nationwide registry. We analyzed 157,978 non-dialysis patients who underwent PCI in 884 Japanese medical institutions in 2017. We studied differences in baseline characteristics and in-hospital clinical outcomes among four groups according to their quartiles of the Hgb/Cr ratios. Compared with patients with higher Hgb/Cr ratios, patients with lower ratios were older and had more comorbidities and complex coronary artery disease. Patients with lower hemoglobin and higher creatinine levels had a higher rate of in-hospital adverse outcomes including in-hospital mortality and procedural complications (defined as occurrence of cardiac tamponade, cardiogenic shock after PCI, emergency operation, or bleeding complications that required blood transfusion). On multivariate analyses, Hgb/Cr ratio was inversely associated with in-hospital mortality (odds ratio: 0.91, 95% confidence interval: 0.89–0.92; p < 0.001) and bleeding complications (odds ratio: 0.92, 95% confidence interval: 0.90–0.94; p < 0.001). Spline curve analysis demonstrated that these risks started to increase when the Hgb/Cr ratio was <15, and elevated exponentially when the ratio was <10. Hgb/Cr ratio is a simple index among non-dialysis patients and is inversely associated with in-hospital mortality and bleeding complications after PCI. Full article

Chronic Kidney Disease (CKD) is an important public health issue that requires early and close medical monitoring to start Renal Replacement Therapy (RRT) in the best conditions. However, in France, about 1/3 of patients start dialysis in emergency, despite the existence of CKD management guidelines. Using both quantitative and qualitative methods, we wanted to analyze the pre-dialysis care trajectory of patients with CKD and document the causes of Emergency dialysis Start (ES). To this aim, we designed a convergent mixed-method study. The quantitative component will analyze individual healthcare consumption and clinical data to identify the risk factors of ES by comparing the trajectories of patients who started dialysis in emergency in 2015 in France with those of patients who started in a planned manner and with the national recommendations. The qualitative component will explore the patients’ trajectories and identify barriers to a planned start using semi-structured interviews with patients who started dialysis in emergency and with their general practitioners and nephrologists. Using the strengths of a mixed methodology, this study will bring robust and valuable findings to improve the care of CKD patients. Full article

Emergency first dialysis start considerably increases the risk of morbidity and mortality. Our objective was to identify the geographic variations of emergency first dialysis risk in patients with end-stage renal disease in the Bretagne region, France. The spatial scan statistic approach was used to determine the clusters of municipalities with significantly higher or lower risk of emergency first dialysis. Patient data extracted from the REIN registry (sociodemographic, clinical, and biological characteristics) and indicators constructed at the municipality level, were compared between clusters. This analysis identified a cluster of municipalities in western Bretagne with a significantly higher risk (RR = 1.80, p = 0.044) and one cluster in the eastern part of the region with a significantly lower risk (RR = 0.59, p < 0.01) of emergency first dialysis. The degree of urbanization (the proportion of rural municipalities: 76% versus 66%, p < 0.001) and socio-demographic characteristics (the unemployment rate: 11% versus 8%, p < 0.001, the percentage of managers in the labor force was lower: 9% versus 13% p < 0.001) of the municipalities located in the higher-risk cluster compared with the lower-risk cluster. Our analysis indicates that the patients’ clinical status cannot explain the geographic variations of emergency first dialysis incidence in Bretagne. Conversely, where patients live seems to play an important role. Full article