Quality of life, self-care ability, and sense of coherence in hemodialysis patients: a comparative study

The number of patients treated for end-stage renal disease has increased in Sweden as in the rest of the world. During the last 6 years, more than 1000 people per year started renal replacement therapy in Sweden. Today hemodialysis (HD) patients have the opportunity to choose from different treatment modalities, home HD, self-care dialysis or conventional dialysis. The aim of the study was to investigate whether there are differences in the way HD patients view their quality of life, self-care ability and sense of coherence if they dialyze themselves at home, dialyze themselves in center (self-care), or if they are dialyzed by nurses in an outpatient dialysis unit. The instruments consisted of the Short Form 36 (SF-36) health survey, the Appraisal of Self-Care Agency questionnaire and the Sense of Coherence questionnaire. Nineteen patients participated in the study (5 patients on home HD, 6 self-care patients and 8 patients on conventional in center dialysis). There was a tendency for those who dialyzed at home to score higher on quality of life, self-care ability and sense of coherence than those who dialyzed themselves in center. Since the number of participants in this study was low, it is necessary for future studies to include more patients to verify the results.     

Severe hypercalcemia caused by Milk‐Alkali syndrome requiring urgent hemodialysis – Tums by the ton

An increased frequency of the Milk‐Alkali syndrome in the last several years has been noticed related to increasing use of calcium carbonate as a phosphate binder in CKD patients, as an antacid or as calcium supplementation. We present a case of severe hypercalcemia secondary to Milk‐Alkali syndrome that precipitated acute renal failure requiring urgent hemodialysis. A 59-year‐old male with history of hypertension, diabetes mellitus, and acid reflux presented to the ER with confusion, lethargy, nausea, vomiting, and diarrhea. His family relayed a history of recent indigestion and relief with Tums. He was taking several tablets at short intervals to self‐treat the indigestion. At the time of presentation, patient was confused and noted to be dehydrated. Lab findings were significant for elevated BUN/Cr‐ 121 mg/dl/11.1 mg/dl (baseline Cr 1.1 mg/dl few months ago), bicarbonate 38 mg/dl, calcium 16.7 mg/dl, ionized Ca of 1.76 mmol/L, iPTH 10 pg/ml, PTHrP 0.7 pg/ml. Medical management with intravenous fluids and furosemide showed no improvement in renal failure, or calcium level. Patient was then started on hemodialysis with 2.0 mmol/L calcium in the dialysate the next day. There was gradual improvement in patient's mental status, calcium values, and renal failure over the ensuing 2 weeks.
Discussion and Conclusions:  The diagnosis of Milk‐Alkali syndrome is made on the basis of history. Metabolic abnormalities involved in this syndrome are hypercalcemia with low to normal PTH and Vit. D levels, renal failure, and metabolic alkalosis. Failed medical management required acute dialysis in this patient. Acute hemodialysis in such a case could be life saving. Due to increasing use of calcium carbonate for dyspepsia and osteoporosis, patients should be made aware of these severe, potentially life-threatening adverse effects.     

Hypertension and left ventricular mass index (L.VMI) in patients on regular hemodialysis (RDT)

Background:  Because of high incidence of acquired renal cyst and renal malignancy, it is suggested that spontaneous renal rupture more frequently occurs in patients receiving long‐term hemodialysis than in the general population. This study was performed to evaluate the clinical characteristics of spontaneous renal rupture in hemodialysis patients. Methods:  This retrospective study enrolled 12 hemodialysis patients who developed spontaneous renal rupture. We investigated primary renal disease, duration of dialysis, clinical symptoms and signs, radiologic findings, treatment modalities, and histologic findings. Result:  The mean age of the patients was 54 ± 10 years old and the number of male was 9. Primary renal disease consisted of autosomal dominant polycystic kidney disease (PCKD)(n = 5), chronic glomerulonephritis (n = 2), diabetic nephropathy (n = 1), hypertensive nephropathy (n = 1), unknown cause (n = 3). Presenting symptoms and signs were sudden onset of flank pain in 9 patients and gross hematuria with mild flank pain in 3 patients. Mean duration from initiation of hemodialysis to development of spontaneous renal rupture was 53 ± 36 months. Abdominal computed tomography showed subcapsular or perinephric hematoma in all patients. Of the 7 non‐PCKD patients, 6 patients had multiple acquired renal cysts. Surgical exploration was undertaken in 9 patients. Pathologic examination demonstrated small sized renal cell carcinoma in 2 of 9 patients. Three patients were only treated with conservative management including blood transfusion. All 12 patients recovered without recurrence. Conclusion:  This study demonstrated that genetic or acquired renal cyst was an important cause of spontaneous renal rupture in hemodialysis patients and presenting manifestations were sudden onset of flank pain and gross hematuria.     

Choice Reaction Time and Adequacy of Dialysis: A New Application of an Old Method

Background:  Choice Reaction Time (CRT) is the time it takes for a subject to accurately respond to a flashing panel of lights. The CRT has been used to assess the quality of dialysis in hemodialysis patients and to assess the neurological impairments in patients with Parkinson's disease.
Methods:  Three groups of end‐stage renal disease (ESRD) patients on three different renal replacement therapies were tested using CRT: intermittent peritoneal dialysis (IPD, n = 11), thrice weekly hemodialysis (HD, n = 22), and well‐functioning kidney transplant (Tx, n = 6). A group of volunteers with normal renal function (NL, n = 12) was also tested.
Results:  The CRT was significantly longer in IPD patients (618 ± 89 ms) than observed in the other three groups (p < 0.0001). CRT in HD patients was 461 ± 50 ms, which was significantly longer than in Tx patients (396 ± 25 ms, p = 0.05). However, the CRT in the Tx patients was no different from the NL (382 ± 22, p = 0.32). There was a strong negative correlation between CRT and weekly creatinine clearance in the IPD group (r =− .96) and between the dialysis index and CRT in HD (r =− 0.79).
Conclusions:  CRT may be a useful tool in assessing the adequacy of dialysis.     

Patient experiences and preferences on short daily and nocturnal home hemodialysis

Quotidian/intensive hemodialysis (short daily and nocturnal) has variable effects on health‐related quality of life (HRQOL) as measured by standard HRQOL tools. We sought to understand the perceived benefits and limitations of quotidian dialysis by interviewing patients who had switched from conventional to home quotidian dialysis. We used a qualitative, phenomenological approach to explore the perceived benefits of quotidian dialysis from 10 patients using either short daily or nocturnal hemodialysis at a tertiary health care center in London, Canada. The patients varied in gender, age, employment status, home support, physical capacity, primary cause of kidney disease, previous forms of renal replacement therapy, and level of education. Four major themes emerged: (1) improvement in physical and mental well‐being including better blood pressure and concentration, (2) increased control over patient's own life including time availability, choosing when to dialyze, and dialyzing at home, (3) decreased perception of being sick including returning to regular employment and avoiding sicker patients who must have in‐center dialysis, and (4) identification of the competencies and supports required for quotidian dialysis including ability to provide self‐care, supportive family, and medical support. Our findings suggest when patients' willingness and physical ability to use quotidian dialysis are coupled with education and support systems to assist patients' and families' self‐directed care, patients qualitatively perceive benefits of both increased physical and mental health, both measures of health‐related quality of life.     

Marked functional improvement in a pediatric patient treated with hemodialysis for scleroderma related renal failure

Systemic sclerosis (SSc) is a rare autoimmune disease characterized by fibrosis and vasculopathy of the skin and visceral organs. Scleroderma renal crisis (SRC), the most acute and life threatening complication, occurs in 10–20% of adult patients with SSc and has not been reported in children. A 10‐year‐old girl was diagnosed with SSc when she presented with weakness and skin thickening. She had positive ANA and anti‐Scl 70. Renal function, urinalysis, and blood pressure were normal. She was treated with steroids, penicillamin and methotrexate as well as amlodipine for Raynaud's phenomenon, but her diffuse skin thickening and contractures progressed and she became wheelchair bound and had poor growth despite nutrition through a G‐tube. At age 15 (weight 28 kg), when evaluated for abdominal pain, she was found to have acute renal failure (BUN 54 mg/dl, creatinine 2.2 mg/dl) and hypertension. Despite therapy with enalapril, serum creatinine continued to rise and she became oligoanuric, requiring initiation of hemodialysis. BP was controlled with enalapril and dialysis but she remained dialysis dependent. Steroid therapy was discontinued and replaced by low dose cyclosporine. Enalapril was replaced by losartan because of leukopenia and BP remained normal. Over the next 2 years, she was treated with hemodialysis and did not experience any complications. She progressively had an outstanding overall clinical improvement, marked skin softening, and was able to walk independently. Renal function did not improve. 28 months after the SRC, she received LRD renal transplant. Immunosuppression included cyclosporine, mycophenolate and prednisone. Creatinine 2 months post‐transplant is 0.7 mg/dl. SRC in children may progress to end‐stage renal disease but can be treated successfully with dialysis and transplantation without significant complications.     

Predicting Acute Renal Failure after Cardiac Surgery: Validation and Re‐definition of a Risk‐Stratification Algorithm

Background:  Acute renal failure (ARF) after cardiac surgery is associated with significant morbidity and mortality, irrespective of the need for dialysis. Previous studies have attempted to identify predictors of ARF and develop risk stratification algorithms. This study aims to validate the algorithm in an independent cohort of patients that includes a significant proportion of female and black patients and compares two different definitions of renal outcome.
Methods:  A large single center cardiac surgery database was examined (n, 24,660; 1993–2000) which included 29.9% females and 3.7% black patients. Post‐operative ARF was defined as: a) ARF requiring dialysis, b) > 50% reduction in creatinine clearance relative to baseline or requiring dialysis. Clinical variables related to baseline renal function and cardiovascular disease were used in recursive partitioning analysis for both outcome definitions. Chi‐square goodness of fit analysis was performed to validate the algorithm.
Results:  The frequency of post‐operative ARF requiring dialysis ranged between 0.5 and 15.5% based on the risk categories with the area under the receiver operating characteristic (ROC) curve of 0.78. Using the more inclusive definition of ARF, the frequency was significantly higher ranging from 2.6 to 25%(P < 0.001) with an area under ROC curve of 0.65.
Conclusions:  The renal risk stratification algorithm is valid in predicting post‐operative ARF in an independent cohort of patients, well represented by differences in gender and race. Since the need for dialysis remains subjective, a more objective and inclusive definition of ARF may help in identifying a larger number of patients 'at‐risk'.     

A case of plasma component exchange using membrane plasma separator EVACURE™

Purpose:  Performed free coagulant hemodialysis to patients having hemorrhage with the hope to avoid aggravation of bleeding caused by anticoagulant agent from dialysis. Method:  Examined 19 cases of patients with bleeding tendency, whether it is possible to perform free coagulant hemodialysis by using PAES membrane, EVAL membrane, PS membrane, Cellulose triacetate membrane and Vitamin‐E modified‐dialysis membrane. Result:  With PAES membrane, the result showed a non‐ blockade rate of 91% after four hours and 100% after two hours. Therefore, blockade was prevented with a fairly high rate. In cases of blockade, most of them were possibly avoidable with a little contrivance as the reason were lack of establish blood flow rate, faulty position of a needle, etc. Conclusions:  By using PAES membrane, it was possible to perform free coagulant hemodialysis. In order to completely have no blockade of blood lines in the future, we must strive further on.     

The use of near infrared interactance in hemodialysis

Forty‐one consecutive admissions to a hemodialysis center were evaluated. Demographic information including age, gender, race, and diagnosis was collected. Patients, >18 years old, with end stage renal disease and on hemodialysis for at least one year were included. Those with edema or known ascites were excluded. Weight was measured before and after hemodialysis (HD) using a standard scale and by considering the amount of fluid loss by the hemodialysis machine. Body composition including total body water (TBW) was calculated before and after HD using near infrared interactance (NIR). All measurements were completed during half hour before and after HD. Forty‐one patients included: men (n = 26), women (n = 15); median age 58 (range 28–88 years). Twenty‐eight were African American and the rest Caucasians. The amount of intravascular fluid taken after HD (assessed by weight reduction) ranged 0–5 L with median 2.2 L. NIR analysis for the same patients at the same time showed different total body water measurements in 91% of cases (P > 0.05). Moreover, NIR analysis showed increase in total body water in 24% of patients even though the hemodialysis machine showed a loss of total body water; median of 1.3 (range: 0–3L). The error in measuring body composition with NIR was both large and varied (random and not systematic error). We conclude that NIR analysis cannot be considered as a reliable method to evaluate body composition, especially total body water, amongst patients with end stage renal disease undergoing hemodialysis.     

6 Month Experience with 1 Nurse Training 2 Patients Together for Nightly Home Hemodialysis

Purpose:  Nocturnal home hemodialysis (NHHD, 6–7 times weekly 6–9 h) results in better clinical outcome than conventional 3 times weekly hemodialysis. A good training program for patient and partner is a prequisite for success. We developed a training course for patients and partners.
Methods:  Since December 2001, we trained 20 patients and their partners to perform NHHD in 2 succeeding groups. The first group, consisting of 15 patients and their partners, started a NHHD pilot study. During this pilot study, we improved the training course. The second group of 5 were trained with this improved program. All 5 participants were home hemodialysis patients for over 1 month before starting the NHHD course. First, they learned how to handle the single needle system. Then, they performed single needle hemodialysis for 2 weeks at home. This was followed by an in-center NHHD training, consisting of 4 conventional day-time and 3 long (8 h) nocturnal dialysis treatments. Main targets during this training period are to learn to deal with safety precautions, online monitoring, and special machine features, and to check biochemistry and heparinization during long dialysis. 1 month after the training we evaluated the course with all participants.
Results:  For 9 of 15 couples in the first group, the training appeared to be exhausting. Stress factors were an overloaded program and too little experience with several new skills including needle technique before starting NHHD. The second group started the NHHD training 2 weeks after the single needle training. This second group was pleased with the training protocol.
Conclusion:  The training course for NHHD should not be overloaded. Patients need time to learn new skills before starting NHHD.     

Understanding barriers to home‐based and self‐care in‐center hemodialysis

Despite superior outcomes and lower associated costs, relatively few patients with end‐stage renal disease undergo self‐care or home hemodialysis. Few studies have examined patient‐ and physician‐specific barriers to self‐care and home hemodialysis in the modern era. The degree to which innovative technology might facilitate the adoption of these modalities is unknown. We surveyed 250 patients receiving in‐center hemodialysis and 51 board‐certified nephrologists to identify key barriers to adoption of self‐care and home hemodialysis. Overall, 172 (69%) patients reported that they were “likely” or “very likely” to consider self‐care hemodialysis if they were properly trained on a new hemodialysis system designed for self‐care or home use. Nephrologists believed that patients were capable of performing many dialysis‐relevant tasks, including: weighing themselves (98%), wiping down the chair and machine (84%), clearing alarms during treatment (53%), taking vital signs (46%), and cannulating vascular access (41%), but thought that patients would be willing to do the same in only 69%, 34%, 31%, 29%, and 16%, respectively. Reasons that nephrologists believe patients are hesitant to pursue self‐care or home hemodialysis do not correspond in parallel or by priority to reasons reported by patients. Self‐care and home hemodialysis offer several advantages to patients and dialysis providers. Overcoming real and perceived barriers with new technology, education and coordinated care will be required for these modalities to gain traction in the coming years.     

In‐center hemodialysis attendance: Patient perceptions of risks,barriers, and recommendations

Missed hemodialysis treatments lead to increased morbidity and mortality in the end‐stage renal disease population. Little is known about why patients have difficulty attending their scheduled in‐center dialysis treatments. Semistructured interviews with 15 adherent and 15 nonadherent hemodialysis patients were conducted to determine patients' attitudes about dialysis, health beliefs and risk perception regarding missed treatments, barriers and facilitators to hemodialysis attendance, and recommendations to improve the system to facilitate dialysis attendance. Average time on dialysis was 2.5 years for the nonadherent group and 7.3 years in the adherent group. In both groups, patients felt that dialysis is life‐saving and a necessity. A substantial number of patients in both groups understood that missing hemodialysis treatments is dangerous and several patients could clearly communicate the risk of skipping. The most common barriers to hemodialysis were inadequate or unreliable transportation (mentioned in both groups) and a lack of motivation to get to dialysis or that dialysis is not a priority (typically mentioned by the nonadherent group). Facilitators to hemodialysis attendance included explanations from the health care team regarding the risk of skipping and relationships with other dialysis patients. Patient recommendations to improve dialysis attendance included continued education about the risk of poor attendance and more accessible transportation. Patients did not feel that home dialysis would improve adherence. Hemodialysis patients must adhere to a complex and burdensome regimen. Through the elucidation of barriers and facilitators to hemodialysis attendance and through specific patient recommendations, at least three interventions may be further investigated to improve hemodialysis attendance: Improvement of the transportation system, education and supportive encouragement from the health care team, and peer support mentorship.     

Compliance, quality of life, and contributing factors in renal transplantation waiting list patients

Poor patient compliance is common during dialysis therapy. We aimed to study incidence of noncompliance, contributing factors, and effects on quality of life (QOL) among cadaveric renal transplantation waiting list patients. We included 86 renal transplantation waiting list patients (56M/30F). Dialysis duration, previous renal transplantation history, comorbid conditions, interdialytic weight gain, predialysis BUN, creatinine, potassium, and phosphate were recorded. Noncompliance criteria were skipping >1 dialysis session or shortening a dialysis session>10 min in 1 month, interdialytic weight gain>5.7% of body weight, predialysis serum potassium >6 mEq/L, and phosphate level >7.5 mg/dl. There were 49 noncompliant (age: 46.8 ± 21.8 years, HD duration: 83.9 ± 48.7 months) and 37 compliant (age: 42.8 ± 12.1 years, HD duration: 96.5 ± 45.2 months) patients. QOL was evaluated by short form 36 and depression levels by Beck Depression Inventory. Previous renal transplantation was present in 24.4% and comorbid diseases in 31.3% of all patients. In depressed patients, 77.8% had comorbid diseases. No difference was found between the groups considering age, gender, dialysis duration, previous transplantation history, and comorbid diseases (p > 0.05). Noncompliant patients had lower QOL (p < 0.04). Noncompliant patients had higher degree of depression (p = 0.01). QOL and Beck scores were negatively correlated (p = 0.001, r = −0.561). Noncompliance to diet and dialysis therapy is associated with depression, which further decreases QOL in renal transplantation waiting list patients. Early diagnosis of depression, is possible by monitoring noncompliance, and therapeutic intervention may benefit during the transplantation‐waiting period.     

Studies of phosphate dynamics during hemodialysis

Regulation of phosphate (PO₄) in hemodialysis patients is very difficult and ideal levels are rarely maintained. A high removal and a normal phosphate level is important, as high and low levels are both associated with morbidity and a very high mortality.
We studied phosphate dynamics and its relation to other small "uremic" molecules in 48 patients by measuring pre‐ and postdialysis levels and all removed phosphate, urea and creatinine (creat) in all dialysate during 455 dialyses done at different frequencies (freq): 3.7 ± 1.2, range 3–6 treatments per week and durations of dialysis (t): mean: 196 ± 95, range 80–560 min and with high (HF) and low flux membranes.
Kt/V‐PO₄, Kt/V‐urea and Kt/V‐creat, volumes (Vr) for all solutes and their relationships to frequency and duration of dialysis, urea clearance and predialysis phosphate were calculated.  

     

Heparin Use in Daily Hemodialysis

More frequent dialysis is thought to be associated with increased heparin requirements; however, limited data are available which compare heparin requirements of conventional to daily dialysis. Objectives: To determine differences in heparin dose during conventional thrice‐weekly dialysis (CHD) compared to daily hemodialysis (DHD). Methods: All patients within the daily home hemodialysis at the Northwest Kidney Centers were evaluated for heparin dose both pre‐ and post initiation of daily hemodialysis. Patients on DHD received an initial bolus of heparin, without a continuous heparin drip, and supplemental heparin midway through the dialysis run as needed to maintain adequate activated clotting times (ACTs). CHD patients received a heparin bolus, followed by initiation of heparin drip as needed to maintain adequate ACTs. Results: Of the 1117 patients who dialyze at the NKC, 55% were Caucasian, 21% African‐American, 20% Asian/Pacific Islander, and 35% were of other ethnicity. The majority of patients were greater than 60 years (56%), while 36% ranged from 40–60 years and 13% ranged from 20–40 years. Male patients constituted 54% of patients. Diabetes was the primary cause of renal disease (36%), followed by hypertension (21%) and glomerular disease (18%). Of those patients in the home hemodialysis program (n = 45), 10 patients started daily home hemodialysis using the Aksys daily home hemodialysis system. Of those, the majority was male (100%), Caucasian (78.8%) with an average age of 46.7 ± 18 years. Glomerulonephritis was the primary cause of end‐stage renal disease (40%), while the percentages of other diseases were similar [Alport's syndrome (20%), hypertension (20%) and diabetes (10%)]. Compared to initial DHD heparin requirements (10,111 ± 2219 units), CHD heparin dose requirements (6833 ± 2715 units) were significantly lower (p = 0.045); however, total heparin needs were similar between groups (10,166 ± 4380 units vs. 10,778 ± 2959 units) (p = 0.324). Conclusion: Although patients initiating DHD have greater initial heparin requirements than when on CHD, total heparin doses remain similar to those required on conventional thrice‐weekly hemodialysis. Greater initial heparin doses required during short daily dialysis appear safe compared to those of conventional dialysis.     

Quality of life and alternate nightly nocturnal home hemodialysis

Hemodialysis has been associated with reduced quality of life (QOL). Small cohort studies of quotidian hemodialysis regimens suggest general QOL and dialysis-related symptoms may improve compared with conventional regimens. An observational cohort study was conducted on 63 patients (age 51.7 ± 12.9 years; 79.4% male; 33.3% diabetes; duration of renal replacement therapy 1.9 [0.7–6.4] years) converted from conventional home hemodialysis (3–5 sessions weekly, 3–6 h/session) to home nocturnal home hemodialysis (NHD) (3–5 sessions weekly, 6–10 h/session). Kidney Disease Quality of Life (KDQOL) and Assessment of Quality of Life instruments and 6-minute–walk tests were applied at baseline and 6 months. Baseline and 6 month surveys were returned by 70% of patients. On KDQOL, significant improvements in general health (P=0.02) and overall health ratings (P=0.0008), physical function (P=0.003), physical role (P=0.018), and energy and fatigue (P=0.027) were documented. There was a trend toward improvement in burden of kidney disease (P=0.05) and emotional role (P=0.066). There was a significant improvement in distance covered in the 6-minute–walk test from 513 m (420.5–576.4) to 536.5 m (459–609), P=0.007. On Assessment of Quality of Life, there was a trend toward improvement in overall utility score from 0.65 (0.39–0.81) to 0.73 (0.46–0.86), P=0.096. After 86.2 patient-years of observation, 23 patients have discontinued NHD (12 transplanted, 5 deceased, 4 psychosocial problems, 1 dialysis access problem, 1 medically unsuitable). Nocturnal home hemodialysis is a sustainable therapy. In addition to improving general QOL, alternate nightly NHD can significantly improve physical functioning as measured by KDQOL and 6-minute–walk tests.     

Daily (quotidian) nocturnal home hemodialysis: Nine years later

Daily nocturnal home hemodialysis was developed to satisfy the need for a highly effective, smooth, and cost‐effective home dialysis therapy. It combines the benefits of the following dialysis methods: long, frequent, and home hemodialysis. It provides a high dialysis dose for small, as well as large, molecules including β₂‐microglobulin; improves quality if life; and leads to control of hyperphosphatemia without the need for phosphate binders, as well as dissolution for extraosseous calcifications. Furthermore, it controls blood pressure often without medications, is associated with regression of left ventricular hypertrophy, improves cardiac function, improves anemia as well as nutrition, allows an unrestricted diet, and corrects sleep apnea. Finally, it decreases the overall cost of patient care and improves cost utility when compared to conventional hemodialysis. The main obstacle to its wider utilization is the structure of the current reimbursement system. Along with short daily hemodialysis, long intermittent dialysis, and the convective dialysis techniques, daily nocturnal hemodialysis promises to improve dialysis outcomes.     

Is Dialysis Always Justified? Ethics and Economics

Introduction:  Terminally ill patients requiring dialysis present complex ethical and medical dilemma to the nephrologists. With the rising health care costs and futility of care in such cases, the financial burden is a lingering concern.
Methods:  We describe a 77-year-old male with lymphoma and prostate cancer admitted for abdominal pain and weight loss. He was found to have metastatic pancreatic adenocarcinoma on laparotomy. His malignancy was deemed inoperable and was offered palliative care. Subsequent hospital course was complicated by sepsis with multiple organ failure resulting in acute renal failure requiring dialysis support. Being aware of his poor prognosis, patient initially declined interventions including dialysis. He was later convinced by his family and agreed to aggressive therapeutic intervention. Anticipating a complicated course, hemodialysis was initiated through cuffed tunneled catheter (CTC). Subsequently, he had multiple episodes of sepsis resulting in removal of CTC, necessitating insertion of 9 temporary dialysis catheters and 3 CTC over a 9-month period; further complicated by thrombosis of both femoral veins. Eventually, patient's condition progressively deteriorated and dialysis was withdrawn with family's consent 9 months following surgery. Patient was put on comfort care and died 2 days later. He spent a total of 7½ months in ICU, 1 month in skilled care facility, and 2 weeks on regular hospital floor. Total VAMC expenditure was $373,964, which in a private setting would be approximately $1.0 million.
Conclusion:  This case highlights the futility of aggressive management of renal failure in terminally ill elderly patients. Besides its inability to improve quality of life, it adds as a financial burden to the society.     

Infections Controlling exit site infections: Does it decrease the incidence of catheter‐related bacteremia in children on hemodialysis?

The most common complication of tunneled‐cuffed hemodialysis catheters is catheter‐related bacteremia (CRB), which contributes to patient morbidity and loss of vascular access. Gram positive microorganisms are the most common etiologic agents; coagulase negative staphylococcus and corynebacterium species are the two most prevalent strains in our center. These are the common inhabitants of skin flora, suggesting that infection of catheters occur through the exit site. The Biopatch is a chlorhexidine impregnated dressing designed to keep the exit site from colonization with skin flora. This may decrease the incidence of CRB due to organisms from the skin. Objective:  To investigate whether the application of the biopatch at the exit site has any effect on the incidence and the etiology of CRB. Methods:  Chart review of 63 pediatric chronic hemodialysis patients who were dialysed between January 1999 and December 2003 was performed. The mean age at start of hemodialysis was 13.9 ± 4.6 years. The pre‐Biopatch era started in January 1999 till the end of June 2001, and the Biopatch era started in July 2001 to December 2003. Biopatch was applied at the beginning of every dialysis week after Betadine cleansing of the exit site, which was then covered with a transparent dressing. In the pre‐Biopatch era, the exit site was cleansed with Betadine at every dialysis session and then covered with a transparent dressing. Results:  The use of the Biopatch at the exit site caused a significant decrease in the exit site infections. However, contrary to what was expected, there was no decrease in the incidence of CRB.  

     

On‐line Haemodiafiltration in the Management of Acute Renal Failure

Dialysis adequacy targets are frequently difficult to achieve in large hemodialysis patients. Dual dialyzers can be used to improve clearance. It is unknown whether series or parallel configurations are superior. Objective: to improve urea clearance in large patients using parallel and series dual dialyzers. Patients and Methods: Eighteen large hemodialysis patients (mean 92.4 kg) were enrolled in a randomized, crossover trial to directly compare dual dialyzers in parallel and series configurations. Treatments times, blood flow rates, and dialysate flow rates were kept constant. Results: Compared to single dialyzers, parallel dual dialyzers increased the spKt/V from 1.25 +/− 0.22 to 1.43 +/− 0.29 (p < 0.003). Series dual dialyzers improved the spKt/V to 1.46 +/− 0.26 (p < 0.0003 compared to single dialyzer). The Kt/V and URR of dual dialyzers in parallel were not significantly different from dual dialyzers in series. Half of the subjects failed to meet the NKF‐K/DOQI recommended adequacy target of spKt/V urea >/= 1.2 using a single dialyzer. With the use of dual dialyzers 83% of subjects achieved this adequacy target. Serum levels of 'middle molecule,' beta‐2 microgobulin, were reduced 34% after two months of dual dialyzer therapy. Cost analysis estimates annual net savings of $1260 with dual dialyzer therapy, primarily from projected savings in inpatient expenses. Conclusions: In large hemodialysis patients, our study demonstrates that dual dialyzers in parallel and series are equally effective in improving urea clearance without prolonging dialysis treatment times.