Native arteriovenous fistula placement in three patients after implantation of a left ventricular assist device with non‐pulsatile blood flow

Patients with left ventricular assist device have an increased risk for postoperative acute kidney injury and long‐term requirement of dialysis. As a chronic access for dialysis, native arteriovenous fistulae are uncommon options due to suspected maturation failure. We present three patients who received successful arteriovenous fistulae placement after left ventricular assist device implantation with assisted long term patency.     

Implantable cardioverter defibrillator in maintenance hemodialysis patients with ventricular tachyarrhythmias: A single-center experience

Patients with hemodialysis (HD) are at risk of death due to cardiac arrhythmias, worsening congestive heart failure (CHF), and noncardiac causes. This study reviews our experience with the use of implantable cardioverter defibrillators (ICDs) in patients with ventricular tachycardia who are under maintenance HD. We retrospectively reviewed 71 consecutive patients who underwent an ICD implantation in our hospital. There were 11 patients under maintenance HD and 60 patients without HD. The group of patients with HD (HD group) was compared with the patients without HD (control group). The mean follow-up period was 30±9 vs. 39±4 months in the HD group vs. the control group, respectively. Among these patients, 6 in the HD group and 26 in the control group received appropriate ICD therapies. There was no difference in appropriate ICD therapy, time to the first therapy, and electrical storm between the 2 groups. In the HD group, 1 patient underwent surgical removal of the ICD system due to infective endocarditis. There were 5 deaths in the HD group (4 from CHF) and 8 deaths in the control group (4 from CHF). There were no sudden cardiac deaths or arrhythmic deaths in both groups of patients during the follow-up period. However, the overall death rate was significantly higher in the HD group (P<0.01). In HD patients, ICD therapy prevented arrhythmic death, but their rate of nonarrhythmic adverse outcomes was high. This risk-benefit association should be considered before implantation of the device.     

Quality of water in hemodialysis centers in Baghdad,Iraq

Dialysis water quality is one of the important parameters all over the world because of its direct influence on the health of kidney patients. In Iraq, there are more than 20 dialysis centers; most of them contain identical units for the production of dialysis water. In this work, the quality of water used for dialysis in six dialysis centers located within Baghdad hospitals was evaluated. Samples of product water from each of the six dialysis centers were examined for total heterotrophic bacteria, endotoxin, and chemical contaminants. Endotoxin was measured on‐site using a portable instrument. Bacteriological and chemical examinations were done in the laboratory after collecting samples from each dialysis center. The results showed a fluctuation in the produced water quality that makes the produced water unaccepted when compared with international standards. Bacterial counts for 60% of the analyzed samples were above the action level (50 colony‐forming units[CFU]/mL), while five out of the six dialysis centers showed values higher than the maximum value (100 CFU/mL). Chemical analysis showed that the dialysis water quality suffers from elevated aluminum concentration for all dialysis centers. All hemodialysis centers need thorough monitoring and preventive maintenance to ensure good water quality. In addition, it is important to revise the design of the water treatment units according to the feed and product water quality.     

Cardiac response to hemodialysis with different cardiovascular tolerance: heart rate variability and QT interval analysis

A therapy-specific worsening of cardiovascular stability during bicarbonate dialysis (BD) with respect to acetate-free biofiltration (AFB) have been previously reported. We further investigated the impact of the 2 therapies on electrocardiographic parameters in order to gain novel insight into the cardiac responses. Holter ECG acquired during hypotension-free sessions (12 BD + 12 AFB) were retrospectively analyzed. R-R intervals were extracted from ECG recordings. An autoregressive spectral technique was used to compute low- and high-frequency (LF and HF) components of heart rate variability (HRV). QT interval duration was measured with a computer-assisted technique and corrected for HR. In BD the LF component of HRV after an initial increase was slowly depressed with respect to AFB (p < 0.05). QT duration showed a significant (p < 0.01) hemodialysis-induced reduction. QT shortening was more pronounced (p < 0.05) in BD than in AFB (-31 vs. -10 ms), even after correction for HR (p < 0.05). Cardiac electrical activity is significantly affected by the hemodialysis technique. The decrease in the LF component of HRV and the QT shortening are coherent with the worse cardiovascular tolerance observed in BD and with the hypothesis of an enhanced production of endogenous nitric oxide.     

Effect of mineralocorticoids on interdialytic weight gain in hemodialysis patients with perdialytic hypotension

Fludrocortisone is recommended in patients with orthostatic hypotension and a benefit has been suggested in hemodialysis patients with severe hypokaliemia. We report 2 patients who suffered from chronic severe perdialytic hypotension resistant to midodrine and who were treated in a long-term period with fludrocortisone. A rise of post-dialytic BP was observed with a decrease of the interdialytic weight gain (IWG). We suggest that the IWG decrease is induced by a lessening of the renin angiotensin aldosterone system that could be less stimulated at the end of the dialysis session because of a better-preserved arterial pressure. The decrease of angiotensin could lessen the feeling of thirst.     

Predictors of anemia in patients on hemodialysis

Even though the use of erythropoietin and intravenous iron has improved the treatment of anemia in hemodialysis patients, a considerable proportion of these patients still have anemia. The aim of this study was to identify predictors of anemia in a hemodialysis population. In a single-center hemodialysis unit, all patients were studied with blood tests and their medication recorded during a period of 22 months. Correlations with hemoglobin (Hb) were performed with a simple regression or a t test. Variables that reached 5% significance were entered in a multiple regression analysis. Selected variables were presented in quartiles with levels of Hb. Mean Hb was 11.3 g/dL, and 53 patients (40%) had Hb<11.0 g/dL. In the simple regression analysis Hb correlated positively with s-iron, CHr, s-albumin, and doses of sevelamer, and negatively with sedimentation rate (SR), ferritin, base excess, and doses of erythropoietin. In the multiple regression analysis erythrocytes SR was the only variable that remained significant. Elevated SR is the strongest predictor of anemia in hemodialysis patients receiving adequate treatment with erythropoietin and intravenous iron. Patients using high doses of sevelamer had higher Hb levels than patients using low doses.     

Left ventricular mechanical dyssynchrony in patients with different stages of chronic kidney disease and the effects of hemodialysis

Left ventricular (LV) dyssynchrony is a known cause of mortality in patients with heart failure and may possibly play a similar role in patients with chronic kidney disease (CKD) in whom sudden death is one of the most common and as yet not fully explained cause of death. LV synchronicity and its relationship with increased volume load and various biomarkers was analyzed in 145 patients including 53 patients with CKD stages 3 and 4 and in 92 CKD stage 5 patients undergoing hemodialysis (HD) or peritoneal dialysis (PD) using color tissue Doppler imaging and tissue synchronization imaging. The HD patients were evaluated both before and after a single HD session. LV dyssynchrony was defined as a regional difference in time to peak systolic myocardial velocity, between 12 LV segments > 105 milliseconds. LV dyssynchrony was present in 54% of the patients with no difference between CKD 3 and 4 (58%), HD (48%), and PD (51%). LV dyssynchrony was independently associated with LV mass index and increased estimation of LV end‐diastolic pressure. A single HD session resulted in significant changes in LV synchronicity variables—with improvement in 50% of the patients—especially in patients with higher myocardial systolic velocities and lower LV mass index. Abnormalities in LV synchronicity are highly prevalent in CKD patients already prior to dialysis treatment and are associated with LV hypertrophy, LV dysfunction and load conditions, underlining the importance of volume status for LV synchronicity in CKD patients.     

Survival pattern of hemodialysis patients in Kumasi, Ghana: A summary of forty patients initiated on hemodialysis at a new hemodialysis unit

To evaluate the survival pattern of hemodialysis patients at a dialysis unit in Kumasi, Ghana, through a retrospective (observational) study. Patients who were placed on hemodialysis at the dialysis unit at Komfo Anokye teaching hospital from October 25, 2006 to December 2007. The patients were followed from initiation of dialysis until December 31, 2007. The overall mortality was 14 (35.9%) on the incident population for the period and that for the first 90 days was 12 (32.4%) patients. Chronic glomerulonephritis was the underlying kidney disease in 35.9%. This was followed by hypertension (19.1%) and diabetes mellitus (15.4%), respectively. Cardiovascular diseases accounted for 42% of mortality. This was followed by septicemia (25%) from the access site and anemia (25%). Fifty percent of the patients were able to afford 20 sessions of hemodialysis before stopping. The most powerful predictors of survival were the duration of hemodialysis (P=0.05) and the number of hemodialysis sessions (P=0.02). Age at initiation of hemodialysis was not significant. First 90-day mortality of patients on hemodialysis is high in poor African countries. This is due partially to the late referral of patients and also the cost of the dialysis treatment. Efforts will have to be made to reduce the cost of the dialysis treatment. Reuse technology (of dialyzer, etc.) should be introduced to cut down the cost of hemodialysis. Peritoneal dialysis should also be introduced for highly motivated patients. Efforts should also be made to reduce the increasing incidence of kidney disease, and finally third-world countries should consider establishing kidney transplantation, that is cost effective.     

Right intra-atrial catheter placement for hemodialysis in patients with multiple venous failure

The purpose of this study is to evaluate the efficacy and safety of direct right atrial catheter insertion for hemodialysis in patients with multiple venous access failure. We retrospectively evaluated the charts of 27 patients with multiple venous access failure who had intra-atrial dialysis catheter placement between October 2005 and October 2010 in our clinic. Permanent right atrial dialysis catheters were placed through a right anterior mini-thoracotomy under intratracheal general anesthesia in all patients. Demographics of the cases, the patency rates of hemodialysis via atrial catheterization, existence of any catheter thrombosis, and catheter-related infections were documented and used in statistical analysis. Seventeen women (63%) and 10 men (37%) with the mean age of 59.0 ± 7.1 years (47-71) were enrolled in this study. Chronic renal failure was diagnosed for the mean of 78.9 ± 24.3 months (33-130). Five patients (18.5%) died. Ventricular fibrillation and myocardial infarction were the causes of death in the early postoperative period in two patients. Two of the remaining three patients died because of cerebrovascular events, and one patient died because of an unknown cause. Ten patients (37%) had been using anticoagulate agents (warfarin) because of concomitant disorders such as deep vein thrombosis, operated valve disease, and arrhythmias. Catheter thrombosis and malfunction was determined in three cases (11.1%). Intra-atrial hemodialysis catheterization is a safe and effective life-saving measure for the patients with multiple venous failure and without any possibility of peritoneal dialysis or renal transplantation.     

Factors associated with serum magnesium and vascular stiffness in maintenance hemodialysis patients

Introduction : We evaluated the associated factors of serum magnesium in patients on maintenance hemodialysis (MHD). Furthermore, we evaluated the relationship between low serum magnesium and arteriosclerosis in these patients. Methods : In 129 patients on MHD, we evaluated the blood levels of magnesium, brachial‐ankle pulse wave velocity (ba‐PWV), ankle‐brachial index (ABI), and intima‐media thickness of the common carotid artery (IMT). Findings : In MHD patients, the serum level of magnesium was significantly correlated with age, calcium, TNF‐α, albumin, and ba‐PWV but not with ABI or IMT. In the multiple regression analysis, albumin (P = 0.0001, β = 0.31) and calcium (P = 0.029, β = 0.18) were selected as significant predictors of the magnesium level in MHD patients. Furthermore, the serum level of magnesium, as well as systolic blood pressure (P = 0.0001, β = 0.32) and age (P = 0.005, β = 0.25), were selected as significant (P = 0.012, β = ?0.22) predictors of ba‐PWV in MHD patients. Discussion : In MHD patients, the serum magnesium level was associated with the serum levels of calcium and albumin. Furthermore, a low serum magnesium level in MHD patients was associated with the index of vascular stiffness.     

Association of low vitamin D levels with metabolic syndrome in hemodialysis patients

Low vitamin D levels have been linked to metabolic syndrome in the general population. In the present study, the relationship between inadequate serum concentrations of vitamin D and metabolic syndrome in patients with end‐stage renal disease undergoing hemodialysis was explored. In a cross‐sectional setting, 145 patients undergoing maintenance hemodialysis were enrolled. Metabolic syndrome was defined using the International Diabetes Federation criteria. Serum concentration of 25(OH) vitamin D was determined by a commercially available enzyme immunosorbent assay method. The prevalence of metabolic syndrome was 53.1%. The prevalence rate of severe vitamin D deficiency (<5 ng/mL) was 3.4%, mild vitamin D deficiency (5–15 ng/mL) 31.0%, vitamin D insufficiency (16–30 ng/mL) 36.6%, and vitamin D sufficiency (>30 ng/mL) 29.0%. With the increasing number of metabolic abnormalities, vitamin D levels significantly decreased (P for trend = 0.028). Among the components of metabolic syndrome, vitamin D deficiency was significantly associated with central obesity (odds ratio [OR], 95% confident interval [CI] = 2.80, 1.11–7.04, P = 0.028). A positive, but nonsignificant association between vitamin D deficiency and raised fasting plasma glucose was noted (OR, 95% CI = 2.40, 0.94–6.11, P = 0.067). Both vitamin D deficiency and insufficiency were significantly associated with an increased likelihood of having metabolic syndrome (P < 0.05). In a final model controlling for age, sex, and parathyroid hormone levels, vitamin D deficiency increased the odds of having metabolic syndrome by more than threefold (OR, 95% CI = 3.26, 1.30–8.20, P = 0.012). Low levels of vitamin D are frequent among hemodialysis patients and are associated with the metabolic syndrome.     

Functional iron deficiency in hemodialysis patients with high ferritin

Although functional iron deficiency (FID) may be present in hemodialysis (HD) patients with high serum ferritin levels (>800 ng/mL), current protocols often preclude the use of intravenous (IV) iron in these patients. However, it has not been demonstrated that iron supplementation during erythropoietin therapy is ineffective or unsafe in increasing hemoglobin (Hb) levels in patients with high serum ferritin. This report describes the hematologic efficacy and safety of ferric gluconate (FG) therapy in patients with serum ferritin >800 ng/mL. A retrospective analysis was performed on HD patients at a single California dialysis center from January 1 to December 31, 2003. Patients classified as having high ferritin levels (serum ferritin >800 ng/mL on at least 66% of routine monthly measurements and transferrin saturation [TSAT] <25% on at least 1 occasion) were stratified as follows: patients in Group I were suspected of having FID and received FG > or =250 mg IV over a 3-month period when Hb was <11 g/dL, and patients in Group II were thought not to have FID and received <250 mg FG over a 3-month period. Both groups received standard recombinant human erythropoietin therapy as per the unit's protocol. Of 496 patients, 95 exhibited high ferritin and of these, 39 patients had sufficient data for analysis. Group I patients (n=14) showed a significant increase in Hb levels compared with Group II (n=25). There was no increase in ferritin levels in response to iron administration. No significant differences in hospitalizations or infections were observed between groups. Hemodialysis patients with high ferritin levels may have FID, and IV iron therapy safely improves FID in some patients. A larger randomized trial examining the optimal management of iron administration in HD patients with high ferritin levels is warranted.     

Acquired perforating dermatoses in patients with diabetic kidney disease on hemodialysis

Acquired perforating dermatoses (APD) is an uncommon skin disorder seen in patients with diabetes mellitus, chronic kidney disease, or both together. We present the clinicopathological features of APD in patients with diabetic kidney disease and discuss the recent advances in management. We retrospectively analyzed the data of 8 patients with APD presenting to our center. All patients were known cases of Type 2 diabetes and chronic kidney disease requiring maintenance dialysis. Acquired perforating dermatoses was diagnosed based on clinical presentation of itchy, keratotic papulonodular lesions, and characteristic histopathological features of transepithelial elimination on skin biopsy. The patients were subdivided into 4 types of APD based on the biopsy features. All our patients had Type 2 diabetes over 5 years duration and were on maintenance dialysis for more than 6 months before presentation. Acquired perforating dermatoses symptoms appeared 2 to 6 months before presentation. The majority of patients (6/8) had a subtype of reactive perforating collagenosis. All the patients showed significant resolution with topical glucocorticoid therapy. Acquired perforating dermatoses is a skin complication seen in Type 2 diabetes, chronic kidney disease, or when both are present together. Early identification and therapy prevents the associated morbidity.     

Variability of pulse wave velocity and mortality in chronic hemodialysis patients

We have already demonstrated that in chronic hemodialysis (HD) patients, the cyclic variations in both hydration status and blood pressure are responsible for changes in pulse wave velocity (PWV). The aim of this study is to verify whether the cyclic variation of PWV influences mortality in dialysis patients. We studied 167 oligoanuric (urinary output <500 mL/day) patients on chronic standard bicarbonate HD for at least 6 months. They performed 3 HD sessions of 4 hours per week. Patients were classified into 3 groups: normal PWV before and after dialysis (LL); high PWV before and normal PWV after dialysis (HL); and high PWV before and after dialysis (HH). The carotid-femoral PWV was measured with an automated system using the foot-to-foot method. Analysis of variance was used to compare the different groups. The outcome event studied was all-cause mortality and cardiovascular mortality. The PWV values observed were LL in 44 patients (26.3%); HL in 53 patients (31.8%); and HH in 70 patients (41.9%). The 3 groups of patients are homogenous for sex, age, and blood pressure. The HH group had a higher prevalence of (P<0.001) ASCVD. It is interesting that the distribution of patients in the 3 groups is correlated with the basal value of PWV. In fact, when the basal measure of PWV is elevated, there is a higher probability that an HD session cannot reduce PWV (<12 ms). A total of 53 patients (31.7%) died during the follow-up of 2 years: 5 patients in the LL group (11.4%); 16 in the HL group (30.2%); and 32 in the HH group (50.7%) (LL vs. HL, P=0.047; LL vs. HH, P<0.00001; HL vs. HH, P=0.034). We evidence for the first time that different behaviors of PWV in dialysis subjects determine differences in mortality.     

Intermittent hemodialysis treatment in cefepime‐induced neurotoxicity: Case report,pharmacokinetic modeling,and review of the literature

Cefepime is a broad‐spectrum cephalosporin indicated for in‐hospital treatment of severe infections. Acute neurotoxicity, an increasingly recognized adverse effect of this drug in an overdose, predominantly affects patients with reduced renal function. Although dialytic approaches have been advocated to treat this condition, their role in this indication remains unclear. We report the case of an 88‐year‐old female patient with impaired renal function who developed life‐threatening neurologic symptoms during cefepime therapy. She was treated with two intermittent 3‐hour high‐flux, high‐efficiency hemodialysis sessions. Serial pre‐, post‐, and peridialytic (pre‐ and postfilter) serum cefepime concentrations were measured. Pharmacokinetic modeling showed that this dialytic strategy allowed for serum cefepime concentrations to return to the estimated nontoxic range 15 hours earlier than would have been the case without an intervention. The patient made a full clinical recovery over the next 48 hours. We conclude that at least 1 session of intermittent hemodialysis may shorten the time to return to the nontoxic range in severe clinically patent intoxication. It should be considered early in its clinical course pending chemical confirmation, even in frail elderly patients. Careful dosage adjustment and a high index of suspicion are essential in this population.     

Intestinal parasites in hemodialysis patients from developing countries: A systematic review and meta‐analysis

Intestinal parasitic infection (IPI) is the main cause of gastrointestinal complications in hemodialysis patients due to their impaired immune systems. We conducted a systematic review and meta‐analysis to evaluate the prevalence and odds ratio (OR) of IPIs in this population. Relevant eligible studies were identified by searching the PubMed, Science Direct, Scopus, Web of Science, and Google scholar databases up to January 30, 2019. A random‐effects meta‐analysis model was used to estimate the pooled prevalence, OR, and 95% confidence intervals (CI). Twenty‐two studies, from Turkey, Iran, Brazil, Egypt, Saudi Arabia, Pakistan, and Malaysia met eligibility criteria for analysis, and included 11 using a case–control design (980 patients and 893 controls) and 11 studies using a cross‐sectional design (a total of 1455 participants). Cross‐sectional studies suggested that the pooled prevalence of IPIs in hemodialysis patients was 24% (95% CI, 14–36%; 307/1455). In studies using a case–control design, the pooled prevalence of IPIs in hemodialysis patients (30%, 330/980) was found to be significantly higher than controls (10%, 115/893) (OR, 3.40; 95%CI, 2.37–4.87). With respect to the parasites, Cryptosporidium spp. (OR, 4.49; 95%CI, 2.64–7.64) and Blastocystis sp. (OR, 4.03; 95%CI, 1.20–13.51) were significantly higher in hemodialysis patients compared to the controls. The current study revealed a high prevalence of IPIs in hemodialysis patients from countries in which the baseline prevalence of parasitic infection is high. We recommend that periodic screenings for IPIs in such countries should be incorporated into the routine clinical care of hemodialysis patients.     

The deterioration in physical function of hemodialysis patients

Introduction: Physical function in people on hemodialysis deteriorates significantly, however quantification of the rate of deterioration has not been well established. The aim of this study was to examine the rate of deterioration in objective physical function among end‐stage kidney disease patients receiving hemodialysis. Methods: One hundred and ninety‐three participants (mean age 67.5 ±13.2 years, 60.6% males) receiving hemodialysis in Australia. Objective physical function was assessed via the 30‐second sit‐to‐stand and eight‐foot timed up‐and‐go at baseline, 12 and 24 weeks. Findings: We found a decrease in the mean number 30‐second sit‐to‐stands performed from 10.0 (IQR, 4.0 to 13.0); 95% CI (8.0, 11.0) to 8.0 (IQR, 0.0 to 11.0); 95% CI (5.5, 9.0) at 12 weeks to 7.0 (IQR, 0.0 to 11.0); 95% CI (5.5, 9.0) at 24 weeks and a significant overall decreased rate (RR = 0.82; 95% CI, 0.80 to 0.85; P < 0.001). There was a decreased performance in the eight‐foot timed up‐and‐go time from 8.9 seconds (95% CI: 8.1 to 9.7) to 9.0 (95% CI: 8.1 to 9.7) after 12 weeks and further increasing to 9.7 (95% CI: 8.7 to 9.6) seconds after 24 weeks, and overall decreased rate (HR = 0.56; 95% CI, 0.39 to 0.80; P = 0.001) between baseline and week 24. Discussion: Physical function significantly decreases on hemodialysis. Exercise programs to address this physical function decline should be included in hemodialysis treatment regimens.