Feasibility of long-term intradialytic exercise for older patients receiving hemodialysis: a retrospective single-center study

International Urology and Nephrology - Decreased physical function and physical activity are associated with adverse outcomes among patients undergoing hemodialysis (HD). Although intradialytic...     

Effects of diuretics on intradialytic hypotension in maintenance dialysis patients: a systematic review and meta-analysis

Purpose

Intradialytic hypotension (IDH) is a serious complication in dialysis patients. Diuretics might reduce the incidence of IDH by decreasing ultrafiltration. However, the effect of diuretics on IDH in maintenance dialysis patients is still unclear.

Methods

We searched Medline, Embase, the Cochrane Library, China National Knowledge Infrastructure and clinical trials registries from 1945 to May 2019. Randomized controlled trials (RCTs) or observational studies about IDH in maintenance dialysis with diuretics were included.

Results

Seven studies including 28,226 patients were included, of which 4 were RCTs involving mineralocorticoid receptor antagonists (MRAs) and 3 were observational studies involving loop diuretics. There was a trend that a lower incidence rate of IDH in maintenance dialysis patients who used loop diuretics than control, although the result was not statistically significant (OR 0.65, 95% CI 0.34–1.22, P?=?0.18). Similarly, lower incidence rate of all-cause mortality (OR 0.92, 95% CI 0.87–0.99; P?=?0.02) and cardiovascular (CV) mortality (OR 0.86, 95% CI 0.75–0.99, P?=?0.03) in dialysis patients who used loop diuretics than control. On the contrary, there were no significant difference in the incidence of IDH (OR 1.35, 95% CI 0.78–2.34, P?=?0.29) and all-cause mortality (OR 0.73, 95% CI 0.26–2.01; P?=?0.54) and CV mortality (OR 0.57, 95% CI 0.14–2.25; P?=?0.42) in maintenance dialysis patients who used MRAs compared with control.

Conclusion

Loop diuretics, but not MRAs, might have a potential benefit to reduce the incidence rate of IDH, all-cause mortality and CV mortality. More high-quality studies are needed to strengthen the arguments.

     

Evaluation of a fluidised positioner to reduce occipital pressure injuries in intensive care patients: A pilot study

This pilot study aimed to evaluate the clinical efficacy and feasibility of a fluidised positioning device to reduce occipital pressure injuries (PIs). A post‐test design with a historical control group was used in a 54‐bed intensive care unit between September 2017 and August 2018. Patients who were receiving either extracorporeal membrane oxygenation, were mechanically ventilated, or had raised intracranial pressure (≥20) were recruited. The intervention consisted of a fluidised positioning device under the patient's head, and a skin assessment every 8 h. Outcome measures included the occurrence of occipital PIs and registered nurses (RNs)' perspectives of the intervention. Data collected from patients in the intervention group were compared with data obtained from the historical control group between May 2016 and April 2017. Sixty‐four patients were recruited in the intervention phase and 63 were in the historical control group. Results showed a statistically significant reduction in occipital PIs by 87.7% (16/63; 25.4% historical control vs 2/64; 3.13% interventional group). Bedside RNs provided positive evaluation of the fluidised positioning device. The findings demonstrate that the fluidised positioning device is a feasible and effective intervention in reducing the risk of occipital PIs in intensive care patients, which merits the continuation of use and further evaluation through a larger‐scale study.     

Association of intradialytic hypotension and 5-year mortality in maintaining hemodialysis patients

Objective To assess the risk factors of intradialytic-hypotension (IDH) and the prognosis of IDH among maintenance hemodialysis (MHD) patients for the prevention and treatment of IDH. Methods 276 MHD patients were enrolled during Jan. 2009 to Mar. 2009. Intradialytic blood pressure was monitored during a 3-month period. IDH was defined as an event characterized by a sudden drop in systolic BP more than 20 mmHg or in mean artery pressure (MAP) more than 10 mmHg associated with clinical events and need for interventions. Dialysis-related information was collected. Kaplan-Meier method, log-rank test, logistic regression and Cox regression analyses were performed to examine the association between IDH and survival, using a follow-up through 31 May 2014. Results A total of 276 patients were recruited. The incidence rate of IDH was 40.9%. 163 patients with no-IDH (＜1/10 hypotensive events/3 months) served as controls. 113 patients with IDH (≥1/10 hypotensive events/3 months) were identified among all 276 patients. Multivariate logistic regression analysis showed that age, ultrafiltration rate, gender, serum NT-proBNP, serum albumin and aortic rool inside dimension (AoRD) were associated with IDH among MHD patients. During the 5-year follow-up, 74 patients died, with a mortality rate 5.2 per 100 person-year. Kaplan-Meier survival curve showed significant difference of overall and CV mortality rates between 2 groups. The multivariate Cox regression model indicated that IDH increased the risk of death (HR=1.572, 95%CI 1.077-2.293, P=0.019). So did the rise of LVMI (HR=1.010, 95%CI 1.009-1.085, P=0.020). Conclusion Elderly, female, high ultrafiltration rate, high level of serum NT-proBNP, hypoalbuminemia and shorter AoRD are independent risk factors for IDH among MHD patients. LVMI can predict the outcome of MHD patients. Intradialytic hypotension is an independent risk factor for long-term mortality in MHD patients.     

Effects of intradialytic cycling exercise on daily physical activity,physical fitness,body composition,and clinical parameters in high-volume online hemodiafiltration patients: a pilot randomized-controlled trial

Purpose

The mortality of dialysis patients treated with high-volume online hemodiafiltration (OL-HDF) is better than hemodialysis, but is still higher than healthy population. Low daily physical activity increases cardiovascular mortality. Addition of intradialytic exercise (IDX) program might improve physical activity and health status in OL-HDF patients. This pilot open-labeled randomized-controlled trial was conducted to evaluate the effects of IDX on physical activity and other clinical parameters in OL-HDF patients.

Methods

Twelve OL-HDF patients were randomized into control (n?=?6) or IDX (n?=?6) groups. The subjects in IDX group were trained to exercise using a cycle ergometer for 60 min during each OL-HDF session. Physical activity measured as daily step count using a wrist-worn triaxial accelerometer, physical fitness, or cardiorespiratory fitness assessed by VO₂max and other physical performance tests, lean body mass determined by the Dual-energy X-ray absorptiometry (DXA), quality of life (QOL), and various parameters were compared between baseline and 6 months.

Results

The baseline physical activity status was comparable. Following 6-month IDX, the physical activity was significantly improved in IDX group [+?1048.79 (+?741.50,?+?2792.54) vs. ? 362.06 (? 1626.82, ? 167.47) steps/day, p?=?0.01], while physical fitness and QOL were unchanged. The lean body mass parameters were preserved in the IDX group while seemed to decrease in the control group. Serum albumin was significantly increased in the IDX group (p?=?0.01). The hemoglobin changes were significantly better (p?=?0.01) and the erythropoietin resistance index was significantly lower in the IDX group (p?=?0.03). Phosphate reduction was significantly greater in the IDX group (p?=?0.04).

Conclusions

IDX could improve physical activity and other metabolic parameters in OL-HDF patients and these might contribute to further improvement in clinical and survival outcomes.

Trial registration

ClinicalTrials.gov Registration: NCT03353844.

     

参附注射液持续静滴治疗透析相关性低血压的疗效

目的探讨参附注射液对透析相关性低血压患者低血压的治疗作用。方法选择30例维持性血液透析反复发生IDH的患者,给予0．9％o生理盐水100ml加参附注射液20m1静滴,观察患者临床症状的变化,监测透析中血压变化。结果治疗后显效率63．3％,有效率26．7％,无效率10％,总有效率为90％;治疗前后的差异具有统计学意义。结论参附注射液能有效治疗透析相关性低血压。     

High ultrafiltration rate induced intradialytic hypotension is a predictor for cardiac remodeling: a 5-year cohort study

BackgroundIntradialytic-hypotension (IDH) is a common complication of hemodialysis. High ultrafiltration rate (UFR) might lead to IDH. However, the relationships between UFR, IDH, and cardiac remodeling among hemodialysis patients in the long-term have not been deeply explored.MethodsThis retrospective cohort study collected clinical and echocardiographic data. Patients were enrolled from 1 January 2014 to 31 March 2014 and were followed-up for 5-year. Those who suffered from more than four hypotensive events during three months (10% of dialysis treatments) were defined as the IDH group. Subgroup analysis was done according to the UFR of 10 ml/h/kg. Associations between UFR, IDH, and alterations of cardiac structure/function were analyzed.ResultsAmong 209 patients, 96 were identified with IDH (45.9%). The survival rate of IDH patients was lower than that of no-IDH patients (65.5% vs. 81.4%, p = .005). In IDH group, decreased ejection fraction (EF), larger left atrium diameter index (LADI), and left ventricular mass index (LVMI) (p < .05) were observed at the end of the follow-up. In multivariate logistic model, the interaction between UFR and IDH was notably associated with LVMI variation (OR = 1.37). After adjusting covariates, UFR was still an independent risk factor of LVMI variation (OR = 1.52) in IDH group. In subsequent analysis, we divided patients according to UFR 10 ml/h/kg. For IDH-prone patients, decreased EF, larger LADI, and LVMI (p < .05) were observed at the end of the study only in high-UFR group.ConclusionsUFR and IDH have interactions on cardiac remodeling. High ultrafiltration rate induced IDH is a predictor for cardiac remodeling in long-term follow-up.     

Do higher hospital-wide nurse staffing levels reduce in-hospital mortality in elderly patients with hip fractures: a pilot study

Background  

There is increasing recognition that lower nurse staffing levels are associated with higher morbidity and mortality among medical and surgical patients. The degree to which this applies to elderly patients with hip fractures is unclear.     

Low-dose continuous infusion of landiolol can reduce adrenergic response during tracheal intubation in elderly patients with cardiovascular disease

The objective of this study was to examine the effects of low-dose infusion of landiolol on hemodynamics during tracheal intubation in elderly patients with cardiovascular disease. The study population consisted of 30 patients with American Society of Anesthesiologists physical status II and III, aged 65–77 years, who were scheduled to undergo elective surgery under general anesthesia. Patients were randomly divided into two groups (n = 15 each): a control group, receiving normal saline, and a landiolol group, receiving landiolol at 30 μg/kg/min. After oxygenation, 1 μg/kg of fentanyl was injected intravenously, followed by continuous infusion of normal saline or landiolol for 5 min. General anesthesia was induced and maintained with target-controlled infusion of propofol at a blood concentration of 4 μg/ml and tracheal intubation was performed 3 min after vecuronium injection. Heart rate, blood pressure, and bispectral index were measured before and after tracheal intubation. Results showed that low-dose continuous infusion of landiolol is an effective and relatively safe method of preventing an intubation-induced adrenergic response in elderly patients with cardiovascular disease.     

品管圈活动在降低血液透析相关性低血压发生率中的作用

目的探讨应用品管圈（quality control circle,QCC）方法降低血液透析相关性低血压发生率的效果。方法选择2011年10月在航空总医院血液透析中心发生透析相关性低血压患者21例为研究对象,成立品管圈活动小组、确立活动课题,进行现状调查、分析发生血液透析相关性低血压的原因、设定目标值、制订对策并实施,比较实施品管圈活动前后低血压的发生率。结果开展品管圈活动后血液透析相关性低血压发生率从15．00％下降到5．38％,活动前后比较,差异具有统计学意义（P〈0．05）。结论品管圈活动可降低血液透析相关性低血压发生率。     

Anti-inflammatory effect of an insulin infusion in patients on maintenance haemodialysis: a randomized controlled pilot study

Aim: A pilot study to investigate the anti‐inflammatory effect of insulin in patients on maintenance haemodialysis. Background: Elevated concentrations of pro‐inflammatory and oxidative mediators are thought to contribute to the increased cardiovascular risk in haemodialysis. Insulin has been demonstrated to have anti‐inflammatory properties and a continuous low‐dose insulin infusion in critically ill patients is associated with improved outcomes. The anti‐inflammatory effects of insulin in haemodialysis have not been investigated. Methods: In a single‐blind cross‐over study, 11 stable, non‐diabetic, haemodialysis patients received a continuous insulin infusion (Actrapid 2 IU/h) during a dialysis of 4 h or a conventional dialysis in random order. Normoglycaemia was maintained by a modified glucose dialysate and glucose infusion. Blood samples were collected at baseline, 1, 4, 6 and 24 h. C‐reactive protein (CRP), tumour necrosis factor‐α, interleukin‐6, neopterin, vascular cell adhesion molecule 1, protein thiols, dityrosine and peroxides were measured. Results: Insulin produced a significant reduction in median CRP over the immediate dialysis phase (confidence interval) by 6% (2–9% (95% CI), P = 0.006) and an even greater decline at 24 h (19% (8–28%, 95% CI), P = 0.001) compared with values of the conventional dialysis. No significant changes were observed in the other markers. Median glucose levels were comparable during both dialysis sessions. Conclusions: During haemodialysis, insulin may have a modest anti‐inflammatory effect as evident by a reduction in CRP that appears to have a persistent effect over the next 24 h post dialysis. More studies are required to examine longer‐term benefits as well as the potential role in more high‐risk individuals.     

联机血液透析滤过治疗尿毒症的临床应用研究

目的：探讨联机血液透析滤过（On-line hemodiafiltration,On-line HDF)对尿毒症患不同分子量物质的清除率、患耐受性及临床疗效。方法：回顾性分析18例伴有血透并发症及不适症状的尿毒症患行后稀释法On-line HDF 231例次，并与23例仍行常规血液透析（HD）治疗的患（887例次）进行比较，观察Kt/V，血清肌酐（Scr)、尿素氮（BUN）、血磷（SP）、β2－微球蛋白（β2－M）下降率及治疗中患血透常见并发症和不良反应发生率。结果：患对联机HDF治疗效果和耐受性显优于HD，透析并发症和不适症状发生率显低于HD（P＜0．01），联机HDF治疗后血清Scr、BUN、SP、β2－M水平显降低，KT／V明显增高。结论：后稀释法联机HDF能有效清除尿毒症患血中大、中、小分子物质，透析效果显提高，患对该法治疗的耐受性明显提高，适用于易出现血透并发症及不适症状的尿毒症患。     

MASTERPLAN: study of the role of nurse practitioners in a multifactorial intervention to reduce cardiovascular risk in chronic kidney disease patients

Moderate to severe chronic kidney disease (CKD) is associated with increased cardiovascular risk. Usually nephrologists are primarily responsible for the care of CKD patients. However, in many cases treatment goals, as formulated in guidelines, are not met. The addition of a nurse practitioner might improve the quality of care. The Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of Nurse Practitioners (MASTERPLAN) study is a randomized controlled multicenter trial, aimed at investigating whether a multifactorial approach in patients with moderate to severe CKD (stage 3 and 4) to achieving treatment goals using both a polydrug strategy and lifestyle treatment either with or without the addition of a nurse practitioner will reduce cardiovascular risk and slow the decline of kidney function. Patients (n=793) have been randomized to nurse care or physician care. In the nurse-care arm of the study, nurse practitioners use flowcharts to address risk factors requiring drug and/or lifestyle modification. They have been trained to coach patients by motivational interviewing with the aim of improving patient self-management. At baseline, both treatment groups show equal distributions with regard to key variables in the study. Moreover, in only 1 patient were all risk factors within the limits as defined in various guidelines, which underscores the relevance of our initiative.     

Feasibility of PTSD risk identification in pediatric trauma patients using PsySTART: A pilot study

BackgroundTrauma patients undergo a standardized history and physical, however identification of mental health risk factors is not typically included. We aimed to assess the feasibility of using a modified version of Psychological Simple Triage and Rapid Treatment (PsySTART) to identify post-traumatic stress disorder (PTSD) risk factors in pediatric trauma patients. We hypothesized that PsySTART could identify risk factors and be integrated into the electronic medical record (EMR).MethodsTrauma patients 10–17 years old at a level II pediatric trauma center from 2014 to 2015 were screened. PsySTART was used on a pilot cohort to determine if risk factors were present. PsySTART was then integrated into an automated EMR workflow and completion rates were evaluated.ResultsPsySTART was completed in a pilot cohort of 63 patients with the following findings: 33.3% (n = 21) with 1 risk factor, 22.2% (n = 14) with 2 risk factors, and 19.1% (n = 12) with ≥3 risk factors. The most commonly identified risk factor was, “felt or expressed extreme fear or panic” (n = 27, 43.0%). After EMR integration, PsySTART was successfully completed with automatic consults in 156 of 198 patients (78.8%).ConclusionsPsySTART identified risk factors in pediatric trauma patients. EMR integration was feasible and led to proactive psychological management and intervention.Level of EvidenceIV