Delayed nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure

We sought to determine whether late referral to a nephrologist in patients with chronic renal failure influences the adequacy of vascular access for hemodialysis. We analyzed data describing all health care encounters for all Medicare and Medicaid patients with end-stage renal failure in New Jersey between January 1991 and June 1996. Patients were required to have been diagnosed with renal disease at least 1 year prior to onset of hemodialysis. In the resulting cohort of 2,398 incident hemodialysis patients, 35% had their first nephrologist consultation < or =90 days prior to initiation of dialysis. After controlling for demographic characteristics, socio-economic status and underlying renal disease, we found that patients who were referred to a nephrologist >90 days prior to onset of hemodialysis were 38% more likely to have undergone predialysis vascular access surgery than those who were referred to a nephrologist < or =90 days before dialysis [OR: 1.38; 95% CI (1.15; 1.64)]. Similarly, patients referred late were 42% more likely to require central venous access for hemodialysis compared to those seen by a nephrologist early [OR: 1.42; 95% CI (1.17; 1.71)]. Inadequate development of vascular access for renal replacement therapy in patients with late nephrologist referral unnecessarily contributes to the burden of disease experienced by this vulnerable patient population.     

腹膜透析技术相关性并发症的研究

目的探讨腹膜透析技术规范化的必要性及临床意义。方法选取2007年2月至2011年8月采用腹膜透析技术治疗慢性肾功能衰竭患者69例,研究与腹膜透析技术相关的并发症情况。结果与腹膜透析技术相关的并发症主要包括：感染（发生率由2007年的42．85％逐年下降至2011年的5．26％,总发生率为14．49％）;外科技术相关性并发症如管周渗漏（4．35％）、渗血（15．94％）、疼痛（39．13％）;导管技术相关性并发症如导管脱落（1．45％）、导管堵塞（5．80％）、导管移位（18．84％）。结论重视腹膜透析技术的规范化有助于推广腹膜透析治疗慢性肾功能衰竭．明显减少腹膜透析的退出率。     

The work results in a recently created pediatric dialysis unit

Results of the first period of two working years in a dialysis unit, at a provincial pediatric hospital, are exposed. A total of 26 patients, 20 children and 6 adults, was submitted to hemodialysis and peritoneal dialysis. Within the first, male sex prevailed and age groups more often submitted to dialysis were those under one year old and school children aged 5-14 years. A total of 370 peritoneal dialysis and 264 hemodialysis was performed to children. In the case of peritoneal dialysis, 11.1% was performed by puncture catheter, for acute patients, and the remainder 88.9% by fixed Tenckhoff's catheter, for patients with chronic renal insufficiency. Diseases that more often require the use of dialytic methods were, in first place, acute renal insufficiency, followed by chronic renal insufficiency and, in second place, obstructive uropathies. At the end of the research, 56.0% of the patients assisted in the dialysis unit was cured, with renal transplantations presenting a good evolution or under periodical dialysis waiting for transplantation. Emphasis is made on the most frequent complications occurred during the performance of the fore-mentioned procedures.     

Acute kidney failure caused by rhabdomyolysis

Rhabdomyolysis developed in the muscles of the left lower extremity of a 43 year old man leading to myoglobinuria and acute renal failure. The diagnosis of rhabdomyolysis was strengthened by muscle and renal biopsy. The renal functions were restituted after peritoneal dialysis performed four times (12 hours each) within two weeks. The possible role of alcohol or Dalgol intoxication as well the disturbed circulation in the development of rhabdomyolysis is discussed. Authors point out the benefit of peritoneal dialysis in acute renal failure caused by rhabdomyolysis.     

A case of multiple myeloma treated with long-term peritoneal dialysis

A 54-year-old female was admitted to our hospital in November 1979 with a history of lumbago and proteinuria. She was diagnosed as suffering from chronic renal failure (CRF) due to multiple myeloma (Bence-Jones kappa type). Intermittent COP therapy (a combination of cyclophosphamide, vincristine and prednisolone) and peritoneal dialysis were started. Her clinical condition was improved and well controlled by peritoneal dialysis over a period of 26 months until she died of pneumonia. Renal failure due to multiple myeloma has been a very poor prognosis. Hemodialysis has been used for renal failure much more frequently than peritoneal dialysis. In this case, control of chronic renal failure due to multiple myeloma with peritoneal dialysis was successfully performed over a long period of time. Peritoneal dialysis, therefore, may be an effective therapy for CRF due to multiple myeloma.     

Cost-effectiveness analysis of timely dialysis referral after renal transplant failure in Spain

ABSTRACT: BACKGROUND: A cost-effectiveness analysis of timely dialysis referral after renal transplant failure was undertaken from the perspective of the Public Administration. The current Spanish situation, where all the patients undergoing graft function loss are referred back to dialysis in a late manner, was compared to an ideal scenario where all the patients are timely referred. METHODS: A Markov model was developed in which six health states were defined: hemodialysis, peritoneal dialysis, kidney transplantation, late referral hemodialysis, late referral peritoneal dialysis and death. The model carried out a simulation of the progression of renal disease for a hypothetical cohort of 1,000 patients aged 40, who were observed in a lifetime temporal horizon of 45 years. In depth sensitivity analyses were performed in order to ensure the robustness of the results obtained. RESULTS: Considering a discount rate of 3 %, timely referral showed an incremental cost of 211 [EURO SIGN], compared to late referral. This cost increase was however a consequence of the incremental survival observed. The incremental effectiveness was 0.0087 quality-adjusted life years (QALY). When comparing both scenarios, an incremental cost-effectiveness ratio of 24,390 [EURO SIGN]/QALY was obtained, meaning that timely dialysis referral might be an efficient alternative if a willingness-to-pay threshold of 45,000 [EURO SIGN]/QALY is considered. This result proved to be independent of the proportion of late referral patients observed. The acceptance probability of timely referral was 61.90 %, while late referral was acceptable in 38.10 % of the simulations. If we however restrict the analysis to those situations not involving any loss of effectiveness, the acceptance probability of timely referral was 70.10 %, increasing twofold that of late referral (29.90 %). CONCLUSIONS: Timely dialysis referral after graft function loss might be an efficient alternative in Spain, improving both patients' survival rates and health-related quality of life at an affordable cost. Spanish Public Health authorities might therefore promote the inclusion of specific recommendations for this group of patients within the existing clinical guidelines.     

Increased resting energy expenditure in patients with end-stage renal disease

BACKGROUND: Protein-calorie malnutrition is a significant problem for patients with end-stage renal disease. Increased resting energy expenditure may be an important contributing factor. We postulate that resting energy expen diture in the different stages of renal disease and treatments may be different. METHODS: Resting energy expenditure was measured using a whole-room indirect calorimeter (metabolic chamber) along with nutritional parameters and body composition after 12-hour fasting in 15 patients with advanced chronic renal failure patients, 15 patients on chronic hemodialysis, and 10 patients on peritoneal dialysis. Patients on hemodialysis were assessed on a non-dialysis day. A 2-day dietary recall was used to assess energy intake. RESULTS: Resting energy expenditure, adjusted for fat-free mass, was similar in patients on hemodialysis and peritoneal dialysis but significantly higher than in patients with chronic renal failure (p < .05). Resting energy expenditure in all patients were generally higher (10% to 20%) than predicted values using standard equations derived in normal and obese populations, whereas daily energy intake was less (26% to 34%) than energy expenditure for all groups, adjusted for light daily activity. CONCLUSIONS: End-stage renal disease patients displayed increases in resting energy expenditure over the predicted values derived using normal populations. Resting energy expenditure was significantly higher in patients receiving dialysis, regardless of the modality, than patients with chronic renal failure. Daily energy intake was substantially less than required in all patient groups studied, suggesting that patients with renal failure could develop protein-calorie malnutrition because of increased resting energy expenditure, which is exacerbated by dialysis.     

Serum levels of vitamin A and retinol binding protein in chronic renal patients treated by continuous ambulatorial peritoneal dialysis.

The possible causes and consequences of hypervitaminosis A and retinol binding protein (RBP) levels were investigated in patients with chronic renal disease submitted or not to dialysis treatment. The study was conducted on 20 patients divided into two groups: 10 patients with chronic renal failure (CRF) treated by continuous ambulatorial peritoneal dialysis (CAPD), and 10 CRF patients with no dialysis treatment. Ten normal subjects formed the control group. Retinol levels were determined by HPLC, and RBP levels by immunoassay in plasma and in post-dialysis fluid at different periods of time. Laboratory tests were carried out on all subjects, and dietary history was taken. Patients on dialysis had higher retinol levels than untreated patients. Retinol levels were found to be correlated with RBP levels. Serum retinol and RBP levels did not vary with diet, age or time of disease, dialysis group or time of dialysis, nor were they correlated with the levels measured in the dialysis fluid (CAPD). There was no significant correlation in retinol levels between chronic patients and controls. It is suggested that vitamin A and RBP clearances during dialysis do not accompany urea or creatinine clearance. Hypervitaminosis A did not show any toxic effect.     

Nutritional management in a child on chronic peritoneal dialysis: a team approach

The nutritional management of a child on chronic peritoneal dialysis (CPD) requires considerable dietetic input as frequent adjustments are necessary to account for growth and changes in biochemical parameters. The progress is described of a 6-year-old boy with chronic renal failure (CRF) from birth due to renal dysplasia. In contrast to the relative ease of overnight dialysis, feeding problems have been the major source of stress for the family. Management involves constant support using a multidisciplinary team approach. A recent renal transplant has resolved many of the problems.     

Microbes and Morals

Successful application of peritoneal dialysis has awaited key technologic improvements. The advanced state of the art now makes it a useful modality for certain subsets of patients with acute or chronic renal failure.     

腹膜透析置管手术方式改进后对患者早期预后效果分析

目的探讨腹膜透析置管方法改进后对长期肾脏替代治疗患者早期预后的影响。方法将我科2009年4-12月腹膜透析置管方法改进后的手术患者44例作为观察组,另选择1992年1月-1994年3月腹膜透析置管手术患者131例作为对照组,术后观察腹透置管成功后一月内并发症情况。结果观察组与对照组相比,观察组术后早期并发症的发生率明显降低（P〈0.05）。结论腹膜透析置管方法改进后可改善长期肾脏替代治疗患者早期预后。     

End-Stage Renal Disease in Nursing Homes: A Systematic Review

Objectives/IntroductionDemand for nursing home (NH) care by patients with end-stage renal disease (ESRD) is likely to increase with growing numbers of older adults initiating chronic dialysis. We completed a systematic review to summarize the literature on NH residents with ESRD.MethodsMEDLINE, CINAHL, EMBASE, and relevant conference proceedings were searched to identify articles using the following MESH terms or related key words in the title or abstract: “residential facilities”, “renal dialysis”, “renal replacement therapy”, and “chronic kidney failure”. We selected case control, cohort studies, and clinical trials that included older adults with ESRD (defined as those receiving chronic dialysis or those with stage 5 chronic kidney disease) living in residential care facilities. We abstracted information on study design, quality, and results.ResultsOf 198 unique citations identified by the search strategy, 14 articles met eligibility criteria. Most articles were multicenter studies that were conducted in the 1990s. One study focused on patients with stage 5 chronic kidney disease, and the remaining 13 studies focused on patients receiving chronic dialysis, of which eight studies included only those receiving peritoneal dialysis, four studies included patients receiving both peritoneal dialysis and hemodialysis, and one study included only patients receiving hemodialysis. All studies were observational, no clinical trials were identified, and study design limitations and heterogeneity within study populations were common. Summarizing results across these studies suggests that NH residents with ESRD have limited survival, particularly early after dialysis initiation. Functional impairment is highly prevalent in this population and independently associated with poor outcomes.ConclusionsNH residents with ESRD appear to be a particularly vulnerable population, but current information on their prevalence, characteristics, and outcomes is limited. Further research is needed to provide a better understanding of modifiable predictors of survival and functional decline in this population.     

Long-term outcome and cost-effectiveness of parenteral nutrition for acute gastrointestinal failure

Although there are several published audits of long-term home parenteral nutrition for chronic gastrointestinal failure, there is little data concerning the long-term outcome following prolonged in-patient parenteral nutrition for an episode of acute gastrointestinal failure. Between 1983 and 1 July 1993, 162 patients received total parenteral nutrition (TPN) in our unit for acute gastrointestinal failure for a total of 4997 patient days and using 192 central venous catheters. Over the 10 years there were 11 mechanical complications resulting in one death. Although the overall catheter infection rate was 5.7%, in the last 4 years it was 0%, associated with a reduction in the frequency of site dressing and change of giving set from three times to once weekly. All patients had lost more than 10% of their body weight before TPN. In the non-malignant group, fed for more than 21 days (mean 50 days), the 10-year survival was 74% at a cost of 4723 pounds sterling per year of life saved. In the malignant group, the 5-year survival was 27% at a cost of 8351 pounds sterling per year of life saved. These costs compare favourably with other technologies, such as dialysis for acute renal failure. Better patient selection, fewer complications and lower costs are obtained when this treatment is carried out by an expert team.     

Retarded motor and cognitive development of young children with severe kidney disorders]

OBJECTIVE. Medical and technical advances make it possible to treat young children with end-stage renal disease with far-reaching methods such as continuous ambulatory peritoneal dialysis (CAPD) and haemodialysis (HD). We investigated whether chronic renal failure has deleterious effects on motor function and cognitive development. SETTING. The pediatric dialysis centres of the university hospitals of Nijmegen, Utrecht and Rotterdam. DESIGN. Prospective study. METHODS. 18 patients (mean age 37 months) with chronic renal failure since infancy and 18 healthy children (mean age 35 months) as controls were assessed on cognitive and behavioural parameters. Nine patients and 17 control subjects were tested on their motor function. RESULTS. A significant delay (more than one SD) was found in the motor as well as in the cognitive development of the patient group. Within this group a large difference was noticed between patients under conservative treatment (n = 8; mean dev. index 92.0) and those under CAPD or HD treatment (n = 10; mean dev. index 72.4). CONCLUSION. Young dialysis patients are evidently at risk for developmental retardation. Monitoring this vulnerable group by developmental screening and intensive counselling of the parents is strongly recommended.     

持续质量改进改善腹膜透析患者的容量超负荷

目的：通过持续质量改进（CQI）的PDCA方法,改善腹膜透析患者的容量超负荷状态,减少心血管并发症,提高患者生存质量。方法对135例透析龄超过3个月的腹膜透析患者,要求每月随访时提供透析日志,在CQI实施前后监测心脏超声指标LVEF及LVEDD,运用PDCA循环法,设计并实施纠正患者容量超负荷的流程。结果高血压发生率由69.63%降至27.40%,高血压伴水肿的发生率由23.70%降至10.37%,充血性心衰的发生率由4.50%降至0.74%,1年内新增患者76例无1例发生心衰。结论通过持续质量改进措施对尿毒症腹膜透析患者的容量负荷状态进行管理,减少了心血管并发症的发生率,提高了患者的生存质量。     

Altérations métaboliques au cours de l’insuffisance rénale chronique

Chronic renal failure results in metabolic derangements, nutritional and hormonal dysfunction which in turn may lead to several complications such as anemia, bone disease, insulin resistance, dyslipidemia and malnutrition. Furthermore, the increased oxidative stress and the accumulation of pro-inflammatory cytokines in addition to repeated infections lead to a persistent inflammatory state. There is a close association between malnutrition and inflammation, and both of which are strong predictors of poor outcome among predialysis and dialysis patients. It is essential to assess early these metabolic disturbances and treat them before the initiation of dialysis in order to prevent the increased cardio-vascular morbi-mortality and malnutrition in chronic renal failure patients.     

25 years of kidney replacement treatment at a general hospital

Between February 1963 and January 1988, 174 patients were treated for acute and 307 for chronic renal failure by dialysis in the St. Joseph Hospital Eindhoven, a general hospital. Sixty-two per cent of the patients treated for acute renal failure had tubular necrosis as a cause. In the patients treated for end-stage renal disease the median age of the dialysis population increased from 37 to 62 years. Vascular renal disease and diabetes mellitus were more frequent during the last ten years. Because of the inflow of older people, the outflow by death increased strongly, while the outflow by transplantation remained stable during the last 15 years. Due to an active transplantation policy together with haemodialysis at home and CAPD, 66% of the total now living patient population could be discharged from the dialysis department. Infection and cardiovascular accidents were the major causes of morbidity and mortality among the dialysis and transplant patients. Overall survival curves of all treated patients showed a 5-year survival of 60% and a 10-year survival of 42%.     

A preventable illness? Purulent pericarditis due to Streptococcus pneumoniae complicated by haemolytic uraemic syndrome in an infant.

A previously healthy eight-month-old infant presented with shortness of breath and pyrexia. He was found to have purulent pericarditis due to Streptococcus pneumoniae, complicated by acute renal failure due to haemolytic uraemic syndrome. He received peritoneal dialysis and recovered with normalisation of renal function. This case highlights two important complications of pneumococcal infection in one individual and illustrates the need for rapid diagnosis and treatment of invasive pneumococcal disease. It is anticipated that introduction of the conjugate pneumococcal vaccination to the Australian Standard Vaccination Schedule from 2005 will reduce the incidence of pneumococcal infection and its associated morbidity and mortality.     

腹膜透析植管术中两种缝合方法的临床应用比较

目的 比较腹膜透析植管术中的两种缝合方法术后的早期并发症.方法 2005年3月～2011年3月在某科行腹膜透析置管术的患者67例,其中35例做双荷包缝合为A组,32例做单荷包缝合为B组,比较两组术后早期发生的出血、渗漏、感染情况.结果 腹膜透析植管术后早期可能出现的腹透液渗漏、出血、外口感染等并发症,两组间差异无统计学意义(P＞0.05).结论 腹膜透析植管术中单层荷包缝合并没有增加术后发生早期并发症的风险.     

Opinions of Unmarried Patients Receiving Peritoneal Dialysis Treatment About Sexuality

Unmarried patients exposed to peritoneal dialysis treatment often encounter sexual concerns during the treatment. However, the sexual concerns of these patients are often overlooked. Unmarried patients exposed to peritoneal dialysis treatment are no exception to this oversight. This qualitative study was performed to identify changes in the sexual lives of unmarried patients receiving peritoneal dialysis treatment. The study was conducted with 15 unmarried patients whose peritoneal dialysis treatments were ongoing in the peritoneal dialysis unit. The data was collected through semistructured and in-depth individual interviews. All interviews were tape-recorded. The raw results were obtained by analyzing the content of the recorded data. In this study, seven content analysis themes were found. Sexuality is mutual love and respect and sharing, the disease is an obstacle for marriage, the disease is an obstacle for finding a lover/partner, pre-marital sex is not possible, marriage is to serve the man and being ill is an obstacle for this service, there should be masturbation, body image distortion from peritoneal dialysis. In the light of these findings, it could be argued that nurses should be aware of the patient’s sexual lifestyle and functioning. These patients should be referred to comprehensive sexual health programs for treatment, if available.