Minimized weight gain between hemodialysis contributes to a reduced risk of death

The risk of death is higher in dialysis patients compared to age matched healthy subjects, the main reason being cardiovascular. This prospective study investigated if the extent of ultrafiltration was of importance for the outcome. MATERIAL AND METHODS: 88 hemodialysis patients were included and followed prospectively. The outcome was registered in regard to death, acute myocardial infarction or coronary vascular intervention. The extent of ultrafiltration needed at dialysis was calculated as a mean during the observation period as were other variables. The mean extent of ultrafiltration was compared for patients who had survived without end-points (group 1, n=53) versus those who reached any end-point during the period (group 2, n=35). RESULTS: In total, 40% of the patients reached end-point during the observation period. There was no difference at baseline between the groups in regard to age, prevalence of diabetes mellitus or history of previous cardiovascular disease, KT/V, residual renal function ultrafiltration need, C-reactive protein, s-albumin, cholesterol, LDL-cholesterol, HDL-cholesterol, appetite or wellbeing, while triglyceride was lower in group 2 (p=0.035). The observation period for group 1 was at a mean 24.7 months (SD13.1) and for those in group 2 at a mean 13.8 (+/-11.7 months, p<0.001). Patients representing group 1 at 24 and 30 months had less need of ultrafiltration than those in group 2. Thus, the need of ultrafiltration was about 27% lower at 24 months (for 29 persons in group 1: 3.63+/-1.93 weight% versus 4.97+/-1.70 weight% for 9 patients from group 2, p=0.046) and 46% at 30 months (for 18 from group 1: 3.48+/-1.95 versus 6.45+/-1.55 for 3 from group 2, p=0.030). C-reactive protein did not differ significantly between the groups during the period. CONCLUSION: After a prolonged period of 24 months the extent of ultrafiltration need seems to be important for the outcome of the patients. Thereby those with higher need of ultrafiltration had worse prognosis. It seems important to motivate patients to reduce the extent of fluid intake between dialysis to prolong survival.     

Reduced risk for peritonitis in CAPD with the use of a UV connector box.

A common route for peritoneal infection is the bag transfer connecting site. To investigate possible reduction of such transfer infections with the use of a bag transfer set (UV-XD, Travenol, Baxter, Minneapolis), this study sampled patients using a transfer set with or without UV light sterilization. Calculations excluded peritonitis due to penetrating tunnel infection or defective peritoneal dialysis bag (4 episodes in 2 patients). The study included 51 patients with a median age of 62 years (range 25-81). Five were switched from manual connection (Travenol, Type II) to UV-XD, and each suffered from at least 2 peritonitis episodes during 9-24.5 months prior to the change to UV-XD. In this patient group, the incidence of peritonitis fell significantly from 1 peritonitis/4 to 1/21 months. The bag transfer set was used without UV light in 35 patients for a total of 178 months, producing an incidence of 1 episode/7.7 treatment months. These patients had significantly more peritonitis than 35 patients who used the UV light for a total of 416 months (1 episode/21 months). In 19 patients who used both techniques, there was less risk for peritonitis when UV light was used (p = 0.001). We conclude that the UV-XD device is simple to handle and may reduce the incidence of peritonitis, especially if the box is used in tandem with UV light sterilization.     

One-dose cefuroxime i.v. and i.p. reduces microbial growth in PD patients after catheter insertion

Background. When a peritoneal dialysis catheter is inserted intra-abdominally in a patient starting peritoneal dialysis (PD) there is always a risk for postoperative wound infection and peritonitis. At our centre, PD is started immediately after the dialysis catheter is inserted. This may increase the postoperative risk for peritonitis and wound infection. The aim of this prospective, randomized, study was to evaluate whether the incidence of microbial growth postoperatively (within 10 days) after catheter insertion could be reduced by prophylactic antibiotic therapy. Subjects and methods. During a period of 27 months, 38 patients, who consecutively entered the PD programme, (11 women and 27 men, mean age 57 years) were included in the study. Eighteen patients were given cefuroxime 1.5 g i.v. preoperatively and 350 mg i.p. in the first dialysis bag (containing 1 litre fluid) as prophylaxis. Twenty patients were not given prophylactic antibiotics (control group). All catheter insertions were performed in an operating theatre by the same surgeons using the same technique. Results. In the test group, none of the patients showed microbial growth in the dialysis fluid during the post-operative period, while in the control group six of 20 patients (30%) suffered from such growth (P=0.021) Conclusions. Prophylactic treatment by cefuroxime i.v. pre- an i.p. perioperatively may reduce the risk for microbial growth and peritonitis after insertion of a Tenckhoff catheter.     

Low-dose atorvastatin in severe chronic kidney disease patients: a randomized, controlled endpoint study

OBJECTIVE: There have been no endpoint studies with statins for patients with severe renal failure. The purpose of this prospective, open, randomized, controlled study was to investigate whether atorvastatin (10 mg/day) would alter cardiovascular endpoints and the overall mortality rate of patients with chronic kidney disease stage 4 or 5 (creatinine clearance < 30 ml/min). MATERIAL AND METHODS: The study subjects comprised 143 patients who were randomized either to placebo (controls; n=73; mean age 69.5 years) or to treatment with atorvastatin (n=70; mean age 67.9 years). The patients included were either non-dialysis (n=33), haemodialysis (n=97) or peritoneal dialysis (n=13) patients. Analysis focused on the primary endpoints of all-cause mortality, non-lethal acute myocardial infarction, coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. Statistical analysis for endpoint data was mainly by intention-to-treat. RESULTS: Primary endpoints occurred in 74% of the subjects. There was no difference in outcome between the control and atorvastatin groups. The 5-year endpoint-free survival rate from study entry was 20%. Atorvastatin was withdrawn in 20% of patients due to unacceptable side-effects. In the atorvastatin group, low-density lipoprotein (LDL) cholesterol was reduced by 35% at 1 month and then sustained. The controls showed a progressive reduction in LDL cholesterol until 36 months. CONCLUSIONS: Although atorvastatin reduced total and LDL cholesterol effectively it was not beneficial regarding the long-term outcomes of cardiovascular endpoints or survival. In contrast to other patient groups, patients with severe chronic kidney disease, especially those on dialysis, seem to derive limited benefit from this lower dose of atorvastatin.     

Access in therapeutic apheresis

Various modes may be used to perform apheresis, such as plasma exchange, plasmapheresis, immunoadsorption, and blood perfusion. The vascular access used for acute procedures may be sufficiently supplied by two peripheral veins or catheters placed in the femoral vein or the right internal jugular vein. For chronic treatment it might be necessary to place an arteriovenous fistula or graft. The risks involved when using the various accesses is discussed, as is the insertion technique of the femoral vein catheter. The insertion of catheters into larger vessels is preferably controlled by ultrasound guidance. The incidence of adverse events due to access problems is about 0.4%. Once in every 1000 planned procedures, a problem with the access will cause an interruption of apheresis. Other complications that may occur are infections and thrombosis. Long-term use of particularly subclavian vein catheters more frequently results in stenosis than the use of other accesses. The placement of a femoral vein catheter is facilitated by outward rotation of the leg. In addition, other practical suggestions are given.     

Safety and efficacy of atorvastatin in patients with severe renal dysfunction

OBJECTIVE: To investigate the efficacy and safety of a daily dose of 10 mg of atorvastatin in patients with chronic kidney disease (CKD) stages 4 and 5 and a glomerular filtration rate of <30 ml/min. MATERIAL AND METHODS: This was an open, prospective, randomized study. A total of 143 patients were included: 73 were controls and 70 were prescribed 10 mg/day of atorvastatin. As efficacy variables, total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and triglyceride levels were determined at the start of the study and at 1, 3, 6, 12, 18, 24, 30 and 36 months. RESULTS: The follow-up period was a mean of 20+/-14.4 months (range 1-36 months) for those on atorvastatin versus 22+/-12.7 months (range 0.5-36 months) for the controls. Compared with baseline values, patients treated with atorvastatin had significantly lower concentrations of total cholesterol at Month 36 (5.8 vs 4.4 mmol/l; -23%; p<0.001), of LDL cholesterol at Month 36 (3.6 vs 2.2 mmol/l; -35%; p<0.001) and of triglycerides at Months 24 (2.5 vs 1.9 mmol/l) and 36 (2.5 vs 1.8 mmol/l). The controls had significantly reduced levels of total cholesterol at Month 36 (p<0.21) and of LDL cholesterol at Months 30 and 36. Compared with the controls, the atorvastatin group had lower levels of total cholesterol and LDL cholesterol at Months 1-30. Fifteen patients (21%) stopped taking their medication as they could not tolerate the side-effects, the most frequent complaints being gastrointestinal discomfort and headache. CONCLUSION: Although the medication caused no severe adverse events, we recommend caution when using atorvastatin for severe CKD patients until further evidence of its safety and efficacy is verified.     

Absence of leakage by insertion of peritoneal dialysis catheter through the rectus muscle

To reduce leakage of peritoneal dialysis fluid, insertion of a 2-cuff Tenckhoff catheter (TeC) was performed under local anaesthesia by a lateral approach on 30 occasions in 26 patients. Incision was 3 cm laterally of the linea alba. The inner cuff of the TeC was fixed by a purse-string suture of the peritoneal membrane on the abdominal side of the cuff and another purse-string suture, of the inner fascial blade, around the distal end of the cuff. A third purse-string suture was placed around the TeC at the exit through the outer fascial blade. A subcutaneous tunnel completed the insertion. In all patients, dialysis was started immediately after TeC insertion. The median treatment time was 6.5 months (range 3 days-15 months). No leakage developed in any patient and no hernia was created from this approach. Peritonitis was treated on 8 occasions over a period of 163 months. We conclude that the technique is simple, enables immediate start of dialysis with low risk for leakage.