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31st annual conference on peritoneal dialysis, 17th international symposium on hemodialysis, and 22nd annual symposium on pediatric dialysisHemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts Hemodialysis Abstracts from the Annual Dialysis Conference 31st Annual Conference on Peritoneal Dialysis, 17th International Symposium on Hemodialysis, and 22nd Annual Symposium on Pediatric Dialysis February 20–22, 2011 r 2011 The AuthorsHemodialysis International r 2011 International Society for HemodialysisDOI:10.1111/j.1542-4758.2010.00516.x 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 Buttonhole Tunnel Preparation: 16 or 15 G SharpNeedles? Native Distal Cimino-Brescia Arteriovenous Lisa Di Giandomenico, Luisa Cardi, Mirella Lovo, Fernanda Fistula Survival in Diabetic and Nondiabetic Nasuti, Massimo Lodi, Rodolfo Stanziale. Nephrology and Dialy- sis Unit, Spirito Santo Hospital, Pescara, Italy Rodolfo Stanziale, Massimo Lodi, Fulvio Sammartino, Enrico Background: A well-functioning vascular access was crucial in clin- D'Andrea, Mario Campanella. Ospedale Civile Sprito Santo, ical management of patients on dialysis. The cannulation of arterio- venous fistula (AVF) by means of the buttonhole method offersseveral advantages: Low incidence of complications of AVF, easier Purpose: The goal of this stud was evaluate the survival of the cannulation by staff, less perception or absence of the pain by the distal native Brescia-Cimino arteriovenous fistula (AVF) at the patient at moment of cannulation. Purpose: We know that the suc- wrist in 2 groups consisting of diabetic patients in one, and cess of the buttonhole technique is related to the proper preparation nondiabetic patients in the other. Methods: In the period of the subcutaneous tunnel. This is done by means of sharp needles lasting from June 30, 2004 to June 30, 2010 we performed for a period lasting from 6 to 8 sessions of dialysis. The K-DOQI 245 native AVF at the wrist or distal forearm in patients guidelines do not specify the size of needles to use. In our experi- with end-stage renal failure (ESRF) before starting dialysis.
ence, we evaluated the success rate of the buttonhole technique with Forty-six patients were insulin dependent and 199 were not sharp needles 16 vs. 15 G. Methods: We have performed the prep- diabetic but they had come to ESRF for other nephropathies.
aration of the tunnel in 11 patients with primary AVF, 7 men and 4 The mean age in the diabetic group was 62.4 15.6 years and women on dialysis from 11.7 7.8 months whose chronological 14 of the 46 were female, whereas in the nondiabetic group, age was 57.6 24.3 years. The mean age of the AVF in these pa- the mean age was 63.8 17.3 years and 61 of 199 were tients was 12.3 9.7 months. The suitable sites selected should female. The end-to-side anastomosis was used in 52.2% have the following characteristics: elastic skin, straight stretch of the of diabetic and in 50.3% of no diabetic patients without vessel, not inflamed, scarred or already used areas. The statistical any significant difference. In other patients we performed study was performed with the Fisher exact test. Results: First stage: a end-to-end anastomosis. The preoperative evaluation was preparation of the tunnel in 2 females and 5 males with AVF age of done by the same nephrologists who took care to create an 12.1 10.6 months by means of sharp needles 16 G. Only in 1 AVF in the operating room located inside the dialysis center.
patient (male) the outcome was positive. In 6 patients the prepara- Patients with suitable vessel (diameter not less than 2–2.5 mm tion of the tunnel was not successful. Second phase: we repeated the for the artery and vein, respectively) were chosen. The tunnel preparation in these 6 patients using 15 G needles, adding 4 average time to first dialysis treatment after operation was new patients (2 females and 2 males). In this second phase, there- 2.38 1.83 months in diabetic and 2.19 1.79 months fore, were treated a total of 10 patients with AVF age of 12.8 9.7 months with 15 G needles. The preparation was successful in 9 pa- formed by comparing averages and between the Student tients, 1 patient had negative outcome. The difference was close to t-test and the chi-square test. Results: The median survival statistical significance with a P value of 0.059 at the Fisher exact test.
of distal AVF was 21.59 20.85 months in diabetic patients Conclusion: In our experience we have seen a high success rate of and 27.48 22.51 months in patients without diabetes.
the buttonhole technique, using 15 G compared with 16 G needles, This difference was significant to the Student t-test (P = 0.05).
regardless of age of the fistula. It should be noted, therefore, the Examining the AVF survival curves in both groups of patients, we importance of the gauge needle. For this we suggest the use of the found that the primary patency 1 year rate was 56.1% in 15 or larger size gauge sharpneedles. It is also important, in our diabetic patients and 73.1% in nondiabetics with P = 0.025 opinion, to consider the possibility of extending the preparation of to the chi-square test. Over time, the survival of AVF in the tunnel over the 2 weeks recommended by current procedures.
patients without diabetes was not statistically significant.
Conclusions: The study we have conducted on distal nativeAVF in patients who have to start dialysis treatment, leads Interventional Nephrology for the Preparation and us to conclude that diabetic patients could not be considered Revision of Vascular Access for Hemodialysis: for a distal native AVF because a primary patency 1 year rate Experience of a Single Center significantly reduced compared with nondiabetic patients.
But, the policy of vascular savings and the chance of reusing Rodolfo Stanziale1, Massimo Lodi1, Enrico D'Andrea1, Fulvio arterialized veins after failing of the primary AVF, may suggest Sammartino1, Roberto Summa1, Andrea Toppetti2, Nicola Limb- preparing a distal AVF also in diabetic patients. In any case, it ucci2. 1Nephrology and Dialysis Unit; 2Interventional Radiology is in the experience and wisdom of those who deal with these Unit, Spirito Santo Hospital, Pescara, Italy issues, to decide whether to prepare, for starting dialysis, a distalAVF in patients with compromised vessels such as those found Purpose: To develop an organizational model for making and re- in diabetics.
vising the permanent vascular access (VA) in dialysis or starting r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts dialysis patients so that they have a valid and suitable VA.
and position; dialysis blood pump speed; and preprotocol and Methods: Patients who had to start dialysis were divided into 3 postprotocol urea reduction (URR) and CR.The protocol, in place groups: group A with a glomerular filtration rate between 25 and for 9 months, was initiated by a URR o65% on routine labs and 20 mL/min which is monitored every 2 to 3 months to assess the CSR. The tPA given was 4 mg infusion and 1 mg lock and dwell for decline of the renal function and the time of surgery. Group B with 3 consecutive HD sessions. A second series was given if indicated, glomerular filtration rate between 19 and 10 mL/min where the followed by a line change if unsuccessful. A 50% reduction in operation is planned within 30 days after the visit. Lastly group C measured CR was targeted. Extrapolated from response of catheter (identified with the late referral) with glomerular filtration dysfunction to tPA, primary outcome was set at 80% of protocol rate below 9 mL/min where the intervention is planned within 7 initiations. Results: Of 134 patients on HD via catheter, 46 had to 15 days. The revisions of the arteriovenous fistula, in patients URR o65% across 93 labs. The mean SD CR with lines S and R on dialysis, were performed in 24 to 96 hours. In all cases, was 3.1 5.9% (n = 18) and 32.3 15.2% (n = 75), respectively.
the patients were evaluated by the same team of nephrologists There were no associations between line type (brand or length), who took care of the management of VA. A physical examination site (vein and side), or vintage, and CSR. Lines R were signifi- was done with the Allen test and an ultrasound mapping follow- cantly associated with CSR (P = 0.03).Thirty-five patients had CSR ing minimum criteria suggested by Robbin. If the patient had and met criteria for tPA. Two patients had lines S; 33 had lines R central venous catheter or cardiac devices such as pacemakers or with 37.9 12.2% CR (n = 58). Twenty-three complete protocols defibrillators, a further evaluation with angiographic examination were available for 19 patients. Catheter recirculation decreased will be required. Results: From January 1, 2006 to April 30, 5.5 56.3%. Six (26%) protocols achieved target, all to Tran- 2010, 560 interventions for VA in 316 patients with ESRD un- sonics o20%. A second series was given for 6 protocols, from dergoing hemodialysis were carried out. Of these 560 interven- which an additional 1 achieved target. Conclusion: Catheter re- tions, 414 were those for preparing or revisioning arteriovenous circulation is common when lines are R; rates at our institution fistula, 16 interventions for arteriovenous graft and 15 for super- echo those previously reported. Despite an unachieved primary ficialization or transposition of the deep veins in the arm. One outcome, tPA may be useful for CSR, as evidenced by a 26% suc- hundred fifteen interventions were performed for placement cess rate in this study.
or revision of tunneled central venous catheter and 9 percutane-ous angioplasty in the angiography room. The patients werefrom other hospitals for 46% of total. Conclusion: All this has Clinical Significance of Early Postoperative allowed us, together with a multidisciplinary approach with ra- Venography of Vascular Access diologists, to prepare the most suitable VA for each patient with Hyun Gyung Kim, Young Ok Kim. Uijeongbu St Mary's Hospital, substantial reductions in complications. The results of the last 5 The Catholic University of Korea, Gyeonggi-do, Korea years comfort and encourage us to continue the road, which hasbeen taken. We believe this is the best to solve, in a reasonably Introduction: Venography has been a standard method to detect short time and with less discomfort, the VA problems of the pa- vascular access dysfunction (VAD) under maintenance hemodial- tients who belong to our center hemodialysis and those who come ysis (HD). However, there has been few data about the veno- from other hospitals.
graphy to verify VAD before first needling. Methods: FromAugust 2004 to April 2010, 300 patients received vascular access Is Aggressive Protocolized Tissue Plasminogen Acti- operation. Venography was performed 4 to 6 weeks after the op- vator Effective in Reducing Catheter Recirculation? eration and before first needling for HD. Results: Mean age of thepatients was 56 13 years. Males and females were 148 and 152, Gordon Yeung1, Kara Thompson2, Paula Mossop1, David Hirsch1.
respectively. One hundred seventy-five out of 300 had diabetes 1Division of Nephrology; 2Department of Medicine, Queen Eliz- mellitus. Vascular access comprised 237 arteriovenous fistulas abeth II Health Sciences Centre, Halifax, Nova Scotia, Canada (192 radiocephalic, 25 bracihocephalic, and 20 brachiobasilic)and 63 arteriovenous grafts. Venography revealed 31.3% (n = 94) Background: Catheter recirculation (CR) in hemodialysis (HD) is of severe stenosis, which required further intervention such as the reversal of intravascular blood flow resulting in venous out- percutaneous transluminal angioplasty (PTA) or reoperation. Out flow directly entering arterial inflow without passage through the of 300 patients, 40.7% (n = 122) showed good patency and 28% circulation. Clinically significant recirculation (CSR) is defined as (n = 84) had mild stenosis. For 31.4% (n = 94) with severe stenosis, Transonics 410% and 420% with lines straight (S) and re- PTA and reoperation were performed in 70.2% (n = 66) and 17% versed (R), respectively. Rates reportedly reach 24% with lines S (n = 16), respectively. Out of 86 patients with mild stenosis, 65 and 86% with lines R. Thrombus and fibrin sheath may cause CR; patients were followed for 1 year and VAD occurred in 13 patients and thus respond to tPA, a treatment that has been successful in (20%) and 11 patients received successful PTA. Out of 122 pa- catheter dysfunction. Evidence to support tPA in CR is lacking. A tients with normal venography, 102 patients were followed for 1 protocolized approach was adopted at our institution, with con- year and VAD did not occur in any patients. Conclusion: Early comitant data collection. The rate and significance of CR were also postoperative venography before first needling is helpful to detect queried. Methods: Data collected included line type, site, vintage and treat early VAD in HD patients.
r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 Pull-Back Venographic and the Gross Findings Using Angiocaths to Create Buttonhole Tunnel Tracks Young Ok Kim, Hyun Gyung Kim. Uijeongbu St Mary's Hospital, Sandra Martyn. WellBound of Emeryville, Emeryville, The Catholic University of Korea, Gyeonggi-do, Korea Purpose: The number of tunneled cuffed catheter (TCC) in hemo- Establishing buttonhole access requires a series of cannulations dialysis (HD) patients is increasing, however, there are few data with sharp needles to create scar-tissue tunnel tracks before the about natural history of TCC removed in asymptomatic HD patients.
cannulation with blunt needles. This method poses challenges The purpose of this study is to evaluate pull-back venographic and including: fragility of blood vessel walls leading to repeated infil- gross findings of removed TCCs. Methods: One hundred two TCCs trations and development of blind tracks resulting from multiple were removed between March 2009 and June 2010. Pull-back ve- cannulations caused by different needle insertion angles, direc- nography was performed and we recognized the presence of fibrin tions, and depths. A successful method that leaves 2 angiocaths in sheath around the catheter, filling defects suspicious of thrombus situ for up to 14 days to establish scar tracks to facilitate subse- and stenotic lesions. Removed TCCs were cut at 1 and 2 cm from the quent cannulations with blunt needles has been reported in the tip and intracatheter fibrin and thrombi were grossly investigated.
literature.1 A pilot project was developed using this methodology.
Results: Mean age of the patients was 57.8 13.5 years and 60 Thirty-nine patients in 13 home dialysis centers participated in patients (58.8%) were men. Patients with diabetes mellitus ac- the project. A flexible angiocath (Clampcath), a telescopic needle counted 65.7% (n= 67). A total of 45 (44.1%) of 102 cases had ab- retraction system and introducer needle were used to establish normal venographic findings such as fibrin sheath (35.3%), buttonhole access. The angiocath was secured with tape and left thrombus (7.8%), and stenosis (2.9%). Intracatheter fibrin and in place from 4 to 17 days, with a transparent dressing over the thrombus was detected in 53 (51.9%) catheters by gross evaluation site. Frequent inspections by staff or patients were performed in- of cut lumen. Overall, 74 (72.5%) out of 102 patients had catheter cluding twice weekly dressing changes. Patients were taught to related complications on the inside or outside of the catheter. Con- keep the dressing dry and report signs of infection. No infections clusion: This study shows that a considerable number of asymp- were noted. Complications included bleeding around the site, tomatic HD patients have catheter-related problems. The reduction which was exacerbated by movement, especially in upper arm of the number of dwelling TCCs is thought to be more important access. In all but 1 case, bleeding was minimal. Accidental dis- than the adequate management to prevent complications.
lodgement of angiocath, especially during dressing changes oc-curred. Skin rash under the dressing was also seen. Buttonholesfailed to form after 14 days in 9 patients with risk factors that The Impact of Arterial Microcalcification on Aortic included older age, diabetes, and fistulas requiring revision. The Stiffness and Endothelial Dysfunction in Patients with remaining patients developed patent buttonhole access. The an- End-Stage Renal Disease giocath method resulted in a reduction of blind track develop-ment, decreased risk of infiltration and less painful cannulation.
Hyun Gyung Kim, Young Ok Kim. Uijeongbu St Mary's Hospital, When properly utilized, angiocath method provides clinicians The Catholic University of Korea, Gyeonggi-do, Korea another tool to establish buttonholes successfully with less traumafor the patient.
Purpose: Although vascular gross calcification by radiologic study Reference 1. Marticorena, et al. Hemodial Int. 2009;13(3):316–321.
is known as a risk factor for cardiovascular morbidity and mortalityin end-stage renal disease (ESRD) patients, the role of arterial mi-crocalcification (AMC) by histologic evaluation is not reported yet.
The Benefits of a Central Venous Catheter to Methods: Sixty-five ESRD patients awaiting vascular access opera- Peritoneal Dialysis Catheter Conversion Program tion were included. Aortic stiffness and flow mediated dilation wereevaluated with pulse wave velocity (baPWV) and flow-mediated di- John Moran, Janet Holland, Mary Isambert, Mahesh Krishnan.
latation (FMD) of the brachial artery, respectively. Diagnosis of AMC DaVita Inc., Denver, Colorado, USA was made by von kossa staining. Results: Mean age of the patientswas 60 12 years and patients with diabetes mellitus accounted Introduction: Central venous catheter (CVC) to peritoneal dialy- 70.8%. The AMC was detected in 36 patients (55.4%). The AoAC sis catheter (PDC) conversion is a collaborative effort between the score was higher in the positive AMC group compared with the in-center hemodialysis (ICHD) team and the peritoneal dialysis negative AMC group (P= 0.001). The baPWV was also higher in the (PD) team to transition appropriate patients from a CVC to a PDC.
positive AMC group, compared with the negative AMC group Patients with CVCs are at higher risk for increased infection, (26.5 9.4 vs. 19.8 6.6 m/s, P= 0.006). But there was no differ- morbidity, mortality, and hospitalizations. The opportunities to ence in FMD between the 2 groups (5.4 2.6% vs. 5.7 3.5%, convert patients from CVC to PDC include ICHD patients with P= 0.764). Conclusion: This data showed that AMC at vascular ac- exhausted accesses, new ICHD patients with a CVC, patients who cess site was related to baPWV but not to FMD in ESRD patients.
are needle phobic or have body image issues with having a fistula We suggest that AMC is associated with cardiovascular morbidity placed, ICHD patients with a clotted access who may not want and mortality via aortic stiffness in ESRD patients.
to have another vascular access placed, and patients who have r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts experienced chronic hemodialysis access infections. Meth- Material and Methods: Analysis of a 6-month cohort of AKI ods: The CVC to PDC initiative started in May 2009 and is con- patients treated with shift continuous venovenous hemodialysis ducted in partnership with DaVita Inc.'s CathAway program, (CVVHD) (Nxstage 8 hours 40 L dialysate per session), demograph- which supports reducing the number of patients with CVCs.
ics, lab data, and survival obtained from the EMR, technical and The CVC to PDC program begins with patient education outlining monitoring details from the dialysis run sheet pre-BUN/post-BUN the benefits of PD as an alternative dialysis therapy. The care team Kt/V urea reduction (URR), CVVHD dose (mL/kg/h) per standard identifies appropriate CVC patients who are potential PD candi- methods, data as mean and SD. Results: Thirty-nine patients with dates and partners the patient with a PD nurse to explain the AKI requiring dialysis (43.6% sepsis, 28.2% CV surgery, 28.2% benefits of the dialysis therapy. Once the patient, family, and phy- other), mortality 39% (52.9% sepsis, 62.6% CV surgery, 18% other), sician agree to begin PD therapy, the patient is scheduled for PD 8.1 days on dialysis, 19.2 days in the hospital, 196 treatments were catheter placement and PD therapy training. Results: From May analyzed; mean age 55.9 years (19), weight 106 kg (62), dialyzed for 2009 to May 2010, a total of 700 prevalent patients have con- 7.1 hours (1.6), QB 300 mL/min (45), dialysate K 2.75 mEq/L (0.5), verted from CVCs to PDCs (figure). Approximately 76% of the vasopressor 197 (46), heparin 1374U (1600), hypotension/h 0.15 patients are still actively using the PDC. Conclusion: Through (0.3), pre-MAP 82.3 mmHg (15), post-MAP 83.3 mmHg (14), ul- collaborative cross-discipline efforts, this program has proven trafiltration 3.4 L (1.7), ultrafiltration 483 mL/h (248), URR 44.5% effective in CVC removal for patients going from ICHD to PD.
(14.6), Kt/V per session 0.81 (0.32), CVVHD dose 55.8 mL/kg/h Dedicated support from the nurse, vascular access manage, social (21.2). Nonsurvivors had a higher albumin (2.2 vs. 1.9 g/dL), lower worker, and physician was provided for those patients requiring phosphorous (4.7 vs. 5.7 mg/dL), lower predialysis BUN (68 vs.
further education on the importance of PDC conversion. By hav- 78 mg/dL), Po0.05. Good correlation between Kt/V and dose ing their CVC removed patients are less likely to experience in- CVVHD (r= 0.75). Inverse correlation between weight and Kt/V fection and hospitalizations related to CVC use and thus have an and dose CVVHD. Heavier patients (495 kg) had a better survival improved quality of life.
rate despite receiving a lower dose of CVVHD. Conclusion: ShiftCVVHD is a method of RRT that can be used for AKI requiringdialysis. The survival is similar to other methods, the dose of dial-ysis, as measured (URR Kt/V mL/kg/min), did not differ betweensurvivors and nonsurvivors suggesting that other factors affect thesurvival outcome (weight).
Acute Kidney Injury: Shift Continuous Venovenous Inpatient Hemodialysis: How are we Doing? Hemodialysis Dose Hoang-Lan Nguyen, Dang-Quang Tran, Luis Concepcion. Scott & Luis Concepcion, Hoang-lan Nguyen. Scott & White Hospital, White Hospital, Texas A&M Health Science Center, Temple, Texas A&M Health Science Center, Temple, Texas, USA Introduction: The treatment of acute kidney injury (AKI) requir- Background: Inpatient hemodialysis is an important part of the ing dialysis is controversial regarding the modality and dose.
nephrology practice. There are not many descriptions of the r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 details and quality of the procedure. Methods: We analyze 3 Hemodialysis Dose (Kt/V): Comparison of Two consecutive months of all end-stage renal disease patients admit- Formulas and an Online Clearance Monitor ted to the hospital who had at least 1 treatment. Data frompatients obtained from EMR dialysis data from the dialysis run Guilherme Breitsameter, Ana Figueiredo, Daiana Saute. FAENFI sheets. Conventional hemodialysis (HD) (Fresenius) and contin- and Hospital Sa˜o Lucas da PUCRS Porto Alegre, Rio Grande do uous venovenous hemodialysis (CVVHD) (Nxstage). Pre-BUN/ post-BUN obtained by protocol. Data is shown as mean and SD.
Results: Four hundred thirty-six treatments were analyzed 86.4% Introduction: The hemodialysis (HD) dose should be measured conventional HD, 50.1% with AV access (AVF, AVG) 46.4% with IJ to estimate whether treatment is appropriate. It has been catheters, 3.5% femoral, 58.7% male, age 55.9 (13) weight 78.6 recommended, by NKF-DOQI guidelines, to keep a spKt/V (17) kg. Conventional Dialysis: Mean arterial pressure (MAP) 41.2. Currently there are dialysis machines that offer online predialysis 94.9 (22) mmHg, QB 388 (53) mL/min, QD613 monitoring (OCM) of dialysis efficiency and show the Kt/V in (87 mL/min) dialysate K 2.5 (0.6) mEq/L, HD time 228(43) min, real-time on screen. The aim of this study is to compare Kt/V ultrafiltration (UF) 3325 (1528) mL, UF/h 796 (426) mL/h, urea measured by the OCM and Kt/V obtained by blood samples, reduction (URR) 68.4 (13)%, Kt/V 1.4 (0.4). CVVHD: Mean ar- using the formulas of Lowrie (L) and Daugirdas (D) second terial pressure predialysis 86.1 (17) mmhg, QB 300 (15) mL/min, generation. Methods: Observational cross-sectional study. Fifty- dialysate K2.9 (0.4) HD time 452(70) min, UF 3143 (1375) UF/h three patients on HD at Sa˜o Lucas Hospital. Data were collected 313 (184) mL/h, URR 46 (16)% Kt/V 0.8 (0.5) dose of CVVHD 65 at the same dialysis session, with preurea and posturea, (7) mL/kg/min. Conventional vs. CVVHD (Po0.05): Kt/V and ultrafiltration volume and reading of Kt/V on OCM from Fresenius URR lower per treatment (more frequent CVVHD 5–6/wk), post- Results: Ninety-five BUN lower, precreatinine, higher, higher QB, lower dialysate K, majority of patients were male 52 years old (55%), with shorter HD time, higher MAP predialysis, higher UF/h, higher mean age of 57.1 14. Hypertension was the most prevalent hypotension per hour. No difference in the Kt/V obtained with etiology if chronic kidney disease with 39% (37) followed catheter vs. AV (arteriovenous fistula, arteriovenous graft). No by diabetes 20% and polycystic kidneys 9% (8). The mean hem- difference also in the CVVHD dose. The dose of dialysis as Kt/V atocrit level was 32.9 4.9. Dialysis doses calculated from was 1.37 (0.4) P25:1.01 P75:1.6. For CVVHD was 65.7 (9.7) mL/ L, D, and OCM were 1.31, 1.41, and 1.32, respectively. The kg/h P25:58.3 P75:72.8. Conclusion: Inpatient HD is effective comparison between the 3 formulas has shown that there is no and delivers adequate dose in the majority of patients in the hos- statistical difference among L and OCM (P = 0.795); however, a pital. No difference despite the different vascular access, com- difference was found between D and OCM P = 0.000. A Pearson pared with CVVHD it obtained a higher Kt/V UF and had more correlation of 0.950 was found between D and L, a weaker cor- episodes of hypotension/h. It is important to monitor the delivery relation with D and OCM 0.396 and 0.557 with OCM and L.
of dialysis in the hospital.
Conclusions: We can conclude that the Kt/V on line can be usedas an indicator of adequacy of dialysis.
Moderately High Hemodialysis Dose is Associatedwith Lower Platelet Count Elani Streja1, Miklos Z. Molnar1, John J. Sim2, Csaba P.
Kovesdy3, Kamyar Kalantar-Zadeh1. 1Harold Simmons Center atLABioMed/Harbor—UCLA, Torrance, California, USA; 2DaVitaInc., Lakewood, Colarado, USA; 3DaVita Inc., Salem, Virginia,USA Background: We have shown that moderately high dialysisdose (achieved single pool Kt/V of 1.6–2.0) is associated withgreater survival in maintenance hemodialysis (MHD) patients.
Because platelet reactivity plays a central role in the genesisof thromboembolic events, we hypothesized that low Kt/V isassociated with higher platelet count (relative thrombocytosis).
Methods: Using linear regression models, we examined asso-ciations between 3-month averaged Kt/V (achieved, single pool)and platelet counts during July to December 2001 in a cohortof 40,697 MHD patients from all DaVita clinics in the United r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts States. Models were adjusted for case-mix. Results: Patients 66.03 13.7 years, Po0.001), diabetic (35.6 vs. 25.7%, were 61 15 years old and included 47% women, 46% diabet- Po0.001), lower GFR (36.54 17.9 vs. 52.36 25.0, Po0.001).
ics, and 34% African Americans. The 13-week averagedplatelet count was 229 78 103/mL. In unadjusted, and case-mix adjusted models, incrementally higher Kt/V values Anemic (N = 201) Nonanemic N = 359 up to 2.2 were associated with lower platelet count whereasKt/V below 1.2 or above 2.2 exhibit highest thrombocytosis Serum albumin (g/dL) (see figure).
Prealbumin (mg/dL) Phophorous (mg/dL) Parathormone (pg/mL) 25 vitamin D (ng/mL) Urinary Alb/Cr index Conclusion: Vitamin D is significantly lower in anemic patients.
Further studies are required to explore the effects of 25D onerythropoiesis in CKD patients.
Effect of Intravenous and Oral Ascorbic Acid inHemodialysis Patients with Anemia andHyperferritinemia Ji-Min Jeon, Yong-Ki Park. Department of Nephrology, DongRae Conclusions: Lower hemodialysis dose in MHD patients is asso- Bong Seng Hospital, Busan, Korea ciated with relative thrombocytosis, which may explain the pooroutcomes observed with inadequate dialysis treatment. Additional Hemodialysis patients with anemia and hyperferritinemia often studies need to verify these findings.
develop resistance to recombinant human erythropoietin (EPO).
Ascorbic acid is believed to improve anemia in hemodialysis patients. We evaluated the efficacy of intravenous and oral ascor-bic acid on Epo-hyporesponsive anemia in hemodialysis patients Anemia and Vitamin D Deficit in Chronic Kidney Dis- with hyperferritinemia. Forty-seven of 156 hemodialysis patients ease Stages 2–5ND: a New Vitamin D Pathogenic Role? with Hbo11 g/dL and ferritin levels 4300 ng/mL were prospec-tively followed-up. Patients were randomly divided into 3 groups: Secundino Cigarran1, Emilio Gonzalez Parra2, Francisco Coronel3, 16 patients who received standard care (group 1), 17 patients Guillermina Barril4, Montserrat Pousa1. 1Hospital Da Costa, Lugo, who received standard care and daily oral ascorbic acid at a dose Spain; 2Fundacio´n Jimenez Dı´az, Madrid, Spain; 3Hospital Clı´nico of 500 mg/d (group 2), and 14 patients who received standard Universitario San Carlos, Madrid, Spain; 4Hospital Universitario de la care and 300 mg of intravenous vitamin C with each dialysis ses- Princesa, Madrid, Spain sion (group 3). Each group was similar in clinical characteristics.
Blood samples for measurement of hemoglobin, hematocrit, Patients with chronic kidney disease (CKD) are at high risk for serum iron, ferritin, transferrin saturation, and EPO dose were cardiovascular disease and mortality remains high. Vitamin D de- obtained at baseline and after 3 months of treatment. After 3 ficiency appears at early stages of CKD playing a biologic role as months, hemoglobin and hematocrit and transferrin saturation pleitropic hormone. Our aim in cross-sectional study is to assess levels significantly increased in groups 2 and 3 (Po0.05) but not the vitamin D influence on anemia in CKD 0.563 patients were changed in group 1. Erythropoietin dosage and ferritin levels enrolled, mean age 68–13 years, mean GFR 46.67 23.9 mL/ decreased in groups 2 and 3 (Po0.05). There was no difference in min/1.73 m2, 38% female and 30% DM, mean Hb level groups 2 and 3. In conclusion, our study has demonstrated 13.16 1.68 g/dL. Anemia-defined Hb level o12.5 g/dL was in that intravenous or oral ascorbic acid therapy can improve 201 patients (35.9%). Parameters analyzed were anemia, nutri- anemia, hyperferritinemia and EPO resistance in hemodialysis tional inflammation, cardiovascular, and mineral bone disease.
patients. The effects of intravenous and oral ascorbic acid are Data were analyzed with SPSS 15 (SPSS, Chicago, IL, USA). Ane- similar. Further studies are needed to determine ascorbic acid mic vs. nonanemic, anemic were older (71.17 11.79 vs.
r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 Once-Monthly Anemia Management with CERA ods: Data were analyzed for 184 patients observed from January Maintains Stable Hemoglobin Levels in Hemodialysis 2008 to December 2009. All patients were treated with intrave- Patients: Results from the HbDay Study nous administration of either recombinant human erythropoietin(750–9000 U/wk) or darbepoetin (DPO; 10–120 mg/wk) in order Piotr Seniuta, Thierry Baranger, Franck Berge, Valerie Drouillat, to maintain a target Hb level between 10.0 and 12.0 g/dL. The 184 Carlos Frangie, Emmanuelle Rosier. Polyclinique Bordeaux Nord cases were divided into 2 groups according to the ESA; Group A Aquitaine, Bordeaux, France (erythropoietin: n = 96, M:F = 69:27, age = 62.19 15.66 years,HD duration = 82.1 66.9 months) and Group B (DPO: 88, Objective: Methoxy polyethylene glycol-epoetin b is a continu- 58:30, 64.48 17.97, 85.1 49.9). The weekly average values ous erythropoietin receptor activator (CERA) and provides the of Hb were measured at 2-day intervals just before HD. The Hb maintenance of stable hemoglobin (Hb) levels in hemodialysis variability classified according to the following categories as re- patients with once-monthly administration. Chronic kidney dis- ported by Ebben, et al.1—consistently low (L), consistently within ease patients with renal anemia undergoing treatment with an the target range (T), consistently high (H), low amplitude low erythropoiesis-stimulating agent (ESA) can be given supplemen- (LAL), low amplitude high (LAH) and high amplitude (HA)—was tary iron to maintain the Hb target. The HbDay study evaluates the adopted and serial changes of Hb variability that occurred be- maintenance of stable Hb levels with an intravenous supplemen- tween 2008 and 2009 were analyzed in all 184 patients. The life tary iron (iron hydroxy/dextran), on the same day as the subcu- prognosis of each patient was also examined until September taneous administration of CERA every 4 weeks. Material and 2010. Results: (1) According to Hb variability in 2008, the num- Methods: This ‘‘real-life'' observational study is based on a 9- bers of patients classified into 6 categories were as follows: HA month period in a single center. The data on Hb level, iron status (Group A: 56 cases, 57.8% vs. B: 59, 67.0%), LAH (A: 16, 16.5% and ESA treatment was collected retrospectively for a 3-month vs. B: 21, 23.9%), LAL (A: 21, 21.6% vs. B: 8, 9.1%), H (A: 2, period before the once-monthly anemia management and during 0.02% vs. B: 0, 0.0%), and T (A: 1, 0.01% vs. B: 0, 0.0%). Sig- the next 6 months. Hundred twenty-five hemodialysis patients nificant differences (Po0.05) between 2 groups were found in were evaluated (48% female), the mean duration on dialysis is 5 HA, LAH, and LAL. (2) Maintenance of HA in both years could be years and the mean age is 73 years. Age distribution is o65 years, seen in 20 cases out of 48 (41.7%) in A, and 33 out of 52 (62.5%) 25%, 65 to 75 years, 21%, 75 to 85 years, 38%, 85 years, 16%.
in B. Marked differences were detected between 2 groups Results: The Hb level and iron status are stable during the study.
(Po0.05). In Group A, 5 out of 17 patients (29.4%) changed The mean Hb level is 11.1 1.33 g/dL in baseline (1 week before from LAL in 2008 to HA in 2009, in B, 6 out of 8 (75.0%) patients the start of CERA) and 10.9 1.21 g/dL, during the evaluation at changed (Po0.01). At the same time, 19 out of 48 (39.6%) cases W24 (P = 0.242) of the patients are between 10 and 12 g/dL in in A changed from HA to LAL, while 5 out of 49 (10.3%) cases in baseline and 66% during the evaluation. During the evaluation at B made a similar change (Po0.01). (3) The relationship between W24, the mean serum ferritine is 363 mg/L, the mean transferrine Hb variability in patients 1 year before death and the number of saturation is 26%, the median dose of iron hydroxyl/dextran is deaths in both groups could be seen as follows: in HA, 8 patients 200 mg/mo and the median dose of CERAis 150 mg/mo (45% pa- (50.0%) in Group A and 11 (91.7%) in B; in LAH, 5 (31.1%) tients with the same dose as the baseline, 33% decrease and 22% in A and 1 (8.3%) in B; in LAL, 2 (12.5%) in A and 0 (0.0%) in B; increase). Discussion: The Hb levels can be maintained in hemo- in L, 0 (0.0%) in A and 1 (1.3%) in B. Conclusions: These results dialysis patients with both administrations of iron supplementat- indicate that patients classified into HA show poor prognosis; ion and CERAon the same day every 4 weeks. Conclusions: This additionally, adjustment to an adequate Hb level is more difficult ‘‘real-life'' study in a intensive dialysis center shows that the once- in patients treated with DPO owing to a higher incidence of monthly anemia management can be effective. This is an op- HA and also because patients who turn from HA to LAL are fewer portunity to simplify the organization of dialysis centers and as a result make them more cost effective.
Reference 1. Ebben, et al. Clin J Am Soc Nephrol. 2006;1:1205–1210.
Serial Changes of Hemoglobin Variability in Patient-Centered Data-Based Physiologic Erythropoie- Maintenance Hemodialysis Patients Treated with tin (EPO) and IV Iron Dosing in Hemodialysis Patients Erythropoiesis-Stimulating Agents: Associations Boosts Hemoglobin and Reduces EPO Requirement with Life Prognosis Takashi Yokoyama. Department of Nephrology and Dialysis, Jonathan Lorch1, Victor Pollak2,3. 1Rogosin Institute, Weill- Sapporo Tokushukai Hospital, Sapporo, Japan Cornell Medical College, New York, New York, USA; 2MIQSInc., Denver, Colorado, USA; 3Department of Medicine, Univer- Objectives: Retrospective analyses were performed to clarify the sity of Colorado HSC, Denver, Colorado, USA relationship between serial changes of hemoglobin (Hb) variabil-ity and life prognosis in patients undergoing hemodialysis (HD) Background: Erythropoietin (EPO) dosing has been driven by treated with 2 different erythropoiesis-stimulating agents. Meth- guidelines and changing Medicare regulations rather than patient r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts physiologic responses. Recent US EPO dosing is high (17,996 U/ (4110%). Results: In the CH group, the serum level of i-PTH wk); Medicare changes now encourage reduced EPO doses. Long- was significantly reduced in each subgroup, whereas the dosage of term HD patient survival was shown to be best with hemoglobin DA was clearly decreased only in subgroup 1. The levels of Hb, (Hb)412 g/dL, TSAT425%, moderate IV iron, relatively low albumin did not change significantly in each subgroup (Table 1).
EPO (BMC Nephrology 2009, 10:6). Retrospective analysis of pro- In the Cont group, there were not significant changes in i-PTH, spectively collected individual patient data from 3 dialysis units Hb, and dosages of DA in each subgroup.Bone density, the iron (The Rogosin Institute, New York, NY) in a patient-centered EMR saturation level, and volume of parathyroid in the CH group did (MIQS Inc., Boulder, CO) showed that expected Hb change lagged not change (data not shown). Conclusions: The reduction of ESA EPO dose changes by many weeks. Over short (4–12 weeks) dosage in the relation to the improvement of inflammation was and long periods (8–12 years) EPO given to individual patients only observed in the CH group. It suggests that CH improves varied widely, sometimes within weeks, with no obvious reasons, responsiveness to ESA by improving the systemic inflammatory and with high Hb variance. 25% of patients were iron insufficient (TSAT 25%). In unit A (250 patients receiving EPO) a newdosing model was initiated in February 2010; using the traditional Table 1 Parameters in CH group dosing model, units B and C (202 and 169 patients receiving EPO,respectively) served as controls. Objectives: Hemoglobin and iron sufficiency (TSAT persistently 25% and serum ferritin 300 mg/L), low Hb variance, modest/low EPO dosing.
Method: Evaluate EPO and iron status not more frequently than 4 to 8 weeks using a reporting tool for each patient that aggregates hematologic data and hematinic medications monthly for theprior 18 months. Actions: Replete iron IV as needed; maintain, adjust downward, but do not stop EPO. Results: Unit A: by Sep- tember 30, 2010 (i.e., after 8 months), Hb increased 4.5% from 11.42 to 11.93 g/dL, Hb variance decreased from 1.21 to 0.68 g2/ dL2, IV iron given increased 38% from 184 to 253 mg/mo, and median patient TSAT increased from 27% to 33.5% while EPOdecreased from 15,100 to 9,730 U/wk. Units B and C: EPO doses decreased by 13% and 14% to 19,000 and 17,600 U, but Hb wasunchanged at 11.48 g/dL in unit B and decreased by 1.3% to11.16 g/dL in unit C. Conclusion: The new dosing model facil-itated orderly EPO reduction, and increased Hb and iron suffi- Calcium, Phosphorus, Bone ciency. The allowable payment for EPO administered decreased by37% to $37.50 per HD treatment for those receiving EPO. Whenall patients, including the 15 in Unit A not receiving EPO are Sagliker Syndrome in Long-Term Hemodialysis Patient considered, the allowable EPO cost per HD treatment for all pa- Alicja E. Grzegorzewska1, Vanessa Kaczmarek-Leki2. 1Department tients in the unit was $35.40.
of Nephrology, Transplantology and Internal Diseases, Universityof Medical Sciences, Poznan˜, Poland; 2International Dialysis Cen- Cinacalcet Hydrochloride Improved Chronic Inflam- ter, Ostro´w Wlkp, Poland mation, and Decrease the Dosage of ErythropoiesisStimulating Agent Background: Sagliker syndrome is one of the most severe mani-festations of secondary hyperparathyroidism (sHPT) complicating Megumi Sato, Yuzuru Sato. Satojunnkannkikanaika Matsuyama, chronic kidney disease. Case Report: A male patient, 49.6 years old, was treated with hemodialysis (HD) since November 1985 dueto end-stage renal disease in the course of chronic glomerulone- Methods: Nineteen out of 157 chronic dialysis patients in our phritis. In 1994 to 1995, total alkaline phosphatase activity was facility have been followed under the treatment of CH for 1 year 1235 IU/L, respectively. In 1995, he suffered fracture of the based on our therapeutic policy for 2 HPT (CH group). The rest left femoral neck. In 1996, bone scintigraphy showed typical image 138 patients have been also followed as a control (Cont group).
of sHPT, but (99 m) Tc-MIBI scintigraphy did not reveal enlarge- Serum levels of intact PTH (i-PTH), albumin, high-sensitive C- ment of parathyroid glands. First available serum parathyroid hor- reactive protein (hs-CRP), and the dosages of darbepoietin-a (DA; mone level of 1681 pg/mL is from January 2004; the last one of mg/wk) have been monitored before and 1 year after CH. The pa- 1189 pg/mL is from July 2010. Osteoporotic fractures of bone tients in each group were divided in to 3 subgroups by the pre- spine, scoliosis, and kyphosis resulted in a decrease of height from ratio/postratio in high-sensitive C-reactive protein; subgroup 1 176 to 151 cm. Sagliker syndrome developed over the last 20 years: 10%), subgroup 2 ( 10% to 110%), subgroup 3 characteristic face appearance, lower height than in the previous r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 years, peculiar appearance of the fingertips: upward curved devel- 116 mg and 135 mg with calcium carbonate and lanthanum car- opment of phalanges. Only pharmacological medication of sHPT bonate, respectively, and 177 mg with calcium acetate (all (aluminum hydroxide in the past, calcium carbonate, active vitamin 1000 mg doses). Based on urinary excretion studies, binding ca- D, recently cinacalcet) was used in the course of dialysis treatment.
pacities ranged from 31 mg and 36 mg with calcium carbonateand sevelamer hydrochloride, respectively, to 132 mg with cal-cium acetate and 79 to 156 mg with lanthanum carbonate (all1000 mg doses). Using available formulations of these PBs, bind-ing of typical excess daily dietary phosphate (B250 mg) wouldrequire 2 to 3 lanthanum carbonate 1000 mg tablets, 8 to 11 cal-cium acetate 667 mg tablets (containing 169 mg calcium), 9 to 12sevelamer 800 mg tablets, and 5 to 21 calcium carbonate 400 mgtablets. Conclusion: Compared with other PBs, fewer lanthanumcarbonate tablets are required to bind typical excess phosphate.
These data may be useful to allow patients and their health careproviders to provide a rationale for PB dosage.
Case Management of Calciphylaxis in ExtendedTherapy Hemodialysis Patient Lisa Koester, Laurel Bryant, Kathy Ehrhard, Cheryl Cress, JanetBardsley, Robyn Re, Michelle Bloom. Renal Division, WashingtonUniversity School of Medicine, St Louis, Missouri, USA Thirty-three-year-old white male with end-stage renal disease sec-ondary to obstructive uropathy, LRD transplant September 1985 Conclusion: In the XXI century, despite great advances in med- to January 1988, March 1988 cadaveric renal allograft until March icine it is still possible to meet patients with characteristic human 2000 until rejection secondary to membranoproliferative GN in face appearances and other disturbances of the skeletal system, which patient resumed traditional in-center hemodialysis. Patient which emerged in the course of untreated or inadequately treated has several comorbid conditions including HTN, DVT, plasma exchange s/p IVC filter, afib, CHF/restrictive cardiomyopathy,chronic hyperphosphatemia, and secondary hyperparathyriodism.
Estimating the Binding Capacity of Available Phos- The patient was transferred to extended nocturnal in-center dial- phate Binders: A Rational Basis for Prescribing ysis, 3 times/wk for 8-hour sessions in 2006. Eight 2009 patientsdeveloped painful ulceration to left breast, which was mammo- J. Brian Copley1, Raymond Pratt1, Michael Smyth2. 1Shire Phar- gram negative for cancer. Plan of care for this lesion was wound maceuticals, Wayne, Pennsylvania, USA; 2Shire Pharmaceuticals, management, discontinuation of coumadin and continuing of ex- Basingstoke, Hampshire, UK tended hemodialysis therapy. Left breast lesion resolved within1 year. In May 2010, 3 more painful lesions erupted to right Background: Adjusting phosphate binder (PB) dose based on di- shoulder, left leg and fingers, biopsy proved calchiphylaxis and etary phosphate intake can help to manage hyperphosphatemia in initiated the use of sodium thioslufate 12.5 g per dialysis session dialysis patients. To do this effectively, knowledge is needed of the along with aggressive wound management from wound clinic.
phosphate-binding capacity of each available PB. Methods: In Patient was actively tolerating IV sodium thiosulfate and lesions this analysis, dietary phosphate absorption was evaluated in di- were healing with active management. The increase of sodium alysis patients and healthy volunteers. Binding capacities of PBs thiosulfate from 18.75 to 25 g per dialysis session was tried.
were calculated using data from a metabolic study comparing Discussion: Calciphylaxis is a poorly understood and highly lanthanum carbonate and sevelamer carbonate in healthy volun- morbid syndrome of vascular calcification and skin necrosis. Le- teers, and published results of other trials in which phosphate sions can develop thick, dark crusts, and open very painful de- binding was measured directly in the gastrointestinal tract. These bilitating skin ulcers. Diagnosis includes skin biopsy. Management results were compared with estimates based on urinary phosphate includes IV sodium thiosulfate, lab monitoring, correction of excretion. Results: In hemodialysis patients, ingested phosphate hyperphosphatemia, discontinuation of calcium and vitamin D absorption ranged from 60% to 86%, depending on vitamin D supplementation, and anticoagulation therapy if warranted.
status. In studies in healthy volunteers, around 75% to 80% of Despite aggressive treatment regimens, calciphylaxis still has a phosphate was absorbed. Phosphate-binding capacity of PBs cal- high mortality rate. Research has demostrated the benefits of culated from metabolic balance studies in healthy volunteers extended dialysis therapy in the successful management of ranged from 63 mg with sevelamer carbonate (2400 mg dose) to r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts Aortic Calcification in Hepatitis C-Seropositive in different parts of the GIT, especially the esophagus and Prevalent Hemodialysis Patients stomach. In chronic renal failure (CRF), previous studies onNO and VIP showed different results whether decreased, Mohamed Ibrahim1, Walid Bichari1, Dawlat Sany1, Ahmed Awad- increased or even not altered, and the role of NO and VIP on alla2, Reham Awad3. 1Nephrology Department, Ain Shams Uni- gastrointestinal tract in CRF was not evaluated. Patients and versity, Cairo, Egypt; 2Clinical Pathology Department, Banha Methods: The study was carried out on 60 patients with chronic University, Cairo, Egypt; 3Radiology Department, Ain Shams Uni- renal disease divided into 3 groups. Group 1 included 20 patients versity, Cairo, Egypt with CRF with creatinine clearance between 20 and 40 mL/min.
Group 2 included 20 patients with ESRD (creatinine clearance Aortic calcification is very common in prevalent hemodialysis o10 mL/min) just before the start of hemodialysis therapy.
patients. The liver has an important role in synthesis or activation Group 3 included 20 patients on regular hemodialysis (HD).
of natural calcification inhibitors, e.g. fetuin A and matrix Control group (group 4) included 20 healthy subjects. For all gla-protein. The aim of this study is to assess frequency of groups, full history and clinical examination, routine laboratory aortic vascular calcification in hepatitis C-seropositive chronic investigations, creatinine clearance, serum nitrate levels an index prevalent hemodialysis patients. Twenty heptitis C-seropositive of in vivo NO generation, esophageal manometry, and elect- (by ELISA) prevalent hemodialysis patients, as well as another 20 rogastrogram were done. Results: There was a significant differ- hepatitis C-seronenegative (by both ELISA and PCR) prevalent ence with serum nitrate between diseased CRF and healthy hemodialysis patients were randomly selected from our hemodi- controls and in between patients groups. In the comparison alysis unit. The 2 groups of patients were similar in age, sex, BMI, between diseased CRF and healthy controls regarding dominant and duration of hemodialysis. All patients were studied by routine frequency, there is a highly significant difference, but no signi- biochemistry including serum calcium, PO4, albumin in addition ficant difference was found in between patients groups. In to PTH (Intact), Ultrasensitive C-reactive protein, and CT scan of the patients with CRF, regarding diagnosis based on esophageal abdominal aorta to aortic calcification index (ACI). We detected manometry and EGG: 16 patients was normal by esophageal significantly lower ACI in hepatitis C-seropositive patients in manometry (26.7%), 21 patients with NSMD (35%), 5 with GERD comparison with seronegative patients. On the other hand, we (8.3%), 8 with DOS (13.3%), and 10 with esophageal aperistalsis did not detect significant difference between seronegative and (16.7%), this showed a highly significant difference in compari- seropositive groups regarding serum Ca, PO4, albumin, Ca to son with the control group. Thirty-four patients was normogastric PO4 product, C-reactive protein, PTH level and calcium carbon- by EGG (56.7%), 19 was bradygastric (31.7%), and 7 was tachy- ate nor vitamin D intake. Although serum liver enzymes gastric (11.7%), and also a highly significant difference in com- and bilirubin and PT were significantly higher in seropositive parison to the control group. But in between the 3 CRF studied patients (all of Child A group), yet there was no significant groups, no significant difference was found with regard to diag- correlation between ACI and serum enzymes not PT level in nosis based on both esophageal manometry and EGG. A highly these patients.It may be concluded that, contrary to what may be significant, weak negative linear correlation between NO and DF.
expected of possible higher ACI in seropositive patients due to There is significant association between the manometric-based possible defect in natural calcification inhibitors, hepatitis C-sero- diagnosis, in CRF patients (3 groups), and NO. Conclusion: positive prevalent hemodialysis patients may be at lower risk of Serum NO is disturbed in ESRD whether those patients are on conservative medical management, or at the time of initiation ofhemodialysis therapy or after maintaining regular hemodialysistherapy. The disturbed serum level of nitric oxide is associated Clinical Experiences with upper gastrointestinal dysmotility, which in turn may affectnutritional status of CRF patients and hence affects morbidity.
Role of NO on GIT Motility in Chronic Kidney Diseaseand Dialysis Patients Are There Clinical Predictors of Nonobstructive Cor-onary Artery Disease Among Patients with End-Stage Magdy El-Sharkawy, Saeed Abdelwahab, Ahmed Aziz, Hayam Renal Disease on Dialysis Referred for Coronary Aref, Medhat Ali. Nephrology Department, Ain-Shams University, Walter Coats1, Youngju Pak2, Eric Chan1, Kul Aggarwal1. 1De- Introduction: Gastrointestinal motor abnormalities may account partment of Internal Medicine-Cardiology; 2Department of Bio- for dyspeptic symptoms of chronic uremia patients. The gastro- statistics, University of Missouri, Columbia, Missouri, USA intestinal disorders possibly affect function and structure ofthe gastrointestinal tract and negatively impact on the nutritional Background: Cardiovascular diseases including hypertension and status of the patients causing malnutrition, which is a major coronary artery disease (CAD) are extremely common and the problem with end-stage renal disease (ESRD). Nitric oxide (NO) is leading cause of mortality in patients on dialysis. These patients a proven gut neurotransmitters and their receptors were identified also frequently have multiple other risk factors for CAD, including r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 dyslipidemia and diabetes. The National Kidney foundation rec- Table 1 Modality choice by region and time period ommends that all patients with chronic kidney disease should bedeemed high risk for CAD. Despite this, some individuals appear to be relatively spared from severe obstructive CAD. We sought to examine whether there are clinical predictors of absence of ob-structive CAD. Methods: We analyzed all patients with chronic kidney disease on dialysis referred for coronary angiography at a single hospital center. Age, sex, indication for cardiac catheteriza- tion, anemia, diabetes, smoking, dyslipidemia, and presence or absence of obstructive CAD (450% stenosis in any of the ep-icardial coronary arteries) were evaluated. Results: Of 38 patients Syndrome of Rapid Onset End-Stage Renal Disease: A referred for coronary angiography, 15 had obstructive CAD and New Unrecognized Pattern of Progression of Chronic 23 did not. Patients without CAD were younger (53 vs. 65 years;P = 0.018), more likely to be female (65% vs. 20%; P = 0.0064), Kidney Disease to ESRD and less likely to have dyslipidemia (52% vs. 93%; P = 0.0116).
Macaulay Onuigbo1,2, Nnonyelum Onuigbo3. 1Mayo Clinic, Ro- There was no significant difference between the 2 groups on ane- chester, Minnesota, USA; 2Midelfort Clinic, Mayo Health System, mia, use of aspirin, statin, erythropoietin, blood pressure, diabetes Eau Claire, Wisconsin, USA; 3NTEC Solutions Llc, Eau Claire, or indication for coronary angiography. However, patients without CAD were more likely to be referred for renal transplant evalu-ation. Average dialysis duration was similar between the 2 groups.
Background: By most accounts, there is an increasing worldwide Interestingly, among patients with elevated cardiac troponins, end-stage renal disease (ESRD) epidemic. This ESRD epidemic 36% of patients were found to have nonobstructive coronary dis- persists despite over 2 decades of intensified reno-protection ease. Limitations: Retrospective analysis of a small number of strategies including attempts at optimal hypertension manage- patients. Conclusion: Patients with end-stage renal disease on di- ment, optimization of diabetic control, smoking cessation efforts alysis form a high-risk yet diverse population. Although it is diffi- and the extensive application of RAAS blockade in both diabetic cult to predict which patients have nonobstructive disease, some and nondiabetic chronic nephropathies. Current consensus clinical features such as age, gender, dyslipidemia, and indication and thoughts depend on a paradigm that chronic kidney disease for angiography may be helpful.
(CKD) progression to ESRD is a continuous, progressive andpredictable loss of eGFR in CKD patients, inexorably leading Influence of Satellite Hemodialysis On Modality to ESRD. Our recent experience in a Mayo Health System Choice Among Aboriginal Incident Dialysis Patients Hypertension Clinic, as well as new reports associating ESRDdevelopment in CKD patients with episodes of acute kidney Janet McComb1, Karen Yeates2, Ross Morton2, Eduard Iliescu2.
injury (AKI), led us to hypothesize that CKD to ESRD progres- 1Kingston General Hospital, Kingston, Ontario, Canada; 2Queen's sion is not predictable, after all. Methods: The details of the University, Kingston, Ontario, Canada 100-patient cohort have been recorded in our previous reports.
We have continued to follow kidney function as measured by Objective: To examine the influence that hemodialysis (HD) serum creatinine and MDRD eGFR, together with urine albumin availability has on the choice of dialysis modality among Aborig- creatinine ratio (mg/g), in our patients, at least every 3 months inal Canadian incident dialysis patients. Methods: This is a ret- since recruitment. In July 2009, an 82-month prospective rospective study of Aboriginal patients starting dialysis in and very detailed patient-level data analysis was completed.
southeastern Ontario (SEO) and the James Bay Coastal area Details are reported in the September 2010 issue of the journal (JBC) in Northern Ontario. Peritoneal dialysis (PD) was the only Renal Failure. Results: Hundred patients were recruited into the modality available in JBC until 2006 when a HD unit was estab- cohort over the 30-month enrollment period. Overall, as previ- lished in that region. Both modalities have been available in SEO ously noted in our past publications, eGFR had initially improved all along. We compared the modality choice in 5-year periods or otherwise remained stable, in most patients, following the before and after the opening of the JBC HD unit. Results: In both discontinuation of the ACE inhibitor and/or the ARB. Subse- time periods most SEO patients chose HD. In 2000 to 2005 most quently, at analysis in July 2009, 17 (17%) patients had developed JBC patients chose PD presumably to avoid relocation to SEO.
irreversible ESRD with need for maintenance dialysis. These Following the opening of the JBC HD unit about half of JBC pa- 17 patients at enrollment had CKD stage III (2), stage IV (11), tients still chose PD. For comparison, about 20% of nonaboriginal and stage V (4), respectively. In the last 24 months of follow-up, patients start PD at our center (Table 1). Conclusions: The results only 2 new patients had reached ESRD, both following cardio- of this study suggest that when HD is made available in northern thoracic procedures. Age did not predict ESRD. Most pertinently, Communities, Aboriginal patients still favor PD. Given that JBC is ESRD progression was unpredictable (by eGFR and/or CKD a large and sparsely populated region, it is possible that geo- staging), and was preceded by AKI in 15/17 (88%) patients graphic location still has a major influence on modality choice.
who progressed to ESRD. Acute kidney injury in the 15/17 r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts patients resulted from hypotension/cardiogenic shock (7), sepsis Interleukin-18 Promoter Polymorphism and Develop- (2), following cardiac surgery (2), malignant lymphoma (1), con- ment of Antibodies to Surface Antigen of Hepatitis B trast nephropathy (1), obstructive uropathy (1), and dementia/ failure to thrive (1). Conclusions: Among a 100 high-risk CKDpatient cohort followed prospectively since 2002, we have dem- Alicja E. Grzegorzewska1, Piotr Wobszal1,2, Pawez P. Jagodzin˜ski2.
onstrated that in 15 of 17 (88%) patients who progressed to 1Department of Nephrology, Transplantology and Internal Dis- ESRD, CKD to ESRD progression was unpredictable, nonlinear, eases; 2Department of Biochemistry and Molecular Biology, Uni- abrupt and rapid, and this followed AKI secondary to medical and versity of Medical Sciences, Poznan˜, Poland surgical events. We have coined a new term, the syndrome ofrapid onset end-stage renal disease to represent this previously Background: IL-18 is involved in hepatitis B virus (HBV) clear- unrecognized syndrome. Larger studies are warranted to confirm ance and augments anti-surface antigen of hepatitis B virus our single-center findings. If confirmed to represent a significant (HBsAG) production during DNA vaccination. The IL18 proportion of the ESRD population, at least here in the United 1297C4T (rs360719) polymorphism may modulate the States, this finding will demand major paradigm shifts in current IL18 expression. Aim: To determine the potential association concepts of reno-protection and A-V Fistula first programs.
1297C4T polymorphism with development of anti- HBsAg in HD patients. Methods: The frequency of IL18 1297C4T alleles and genotypes was identified by polymerase Pruritus in Hemodialysis Patients chain reaction-restriction fragment length polymorphism in 347hemodialysis patients. Group I (n = 219) developed an anti-HBsAg Bassam Alchi, Henry Yung, Afzal Chaudhry, Sanjay Ojha. Renal titer 410 IU/L as a result of vaccination (patients with negative Unit, Addenbrooke's Hospital, Cambridge, UK total antibodies to core antigen of HBV, anti-HBcAg, n = 125) or asa result of HBV transmission (patients with total anti-HBcAg pos- Background: Pruritus is one of the most annoying symptoms in itive, n = 94). Group II (n= 128) included patients who did not hemodialysis (HD) patients, which affects the quality of life and develop an anti-HBsAg titer 410 IU/L in response to at least 1 full overall prognosis. The aims of this study were to evaluate the series of vaccination (patients with total anti-HBcAg negative, prevalence of pruritus in our chronic HD patients, and to correlate n = 106) or HBV transmission (patients with total anti-HBcAg pos- its presence and intensity with relevant clinical and laboratory itive, n = 22). The Hardy-Weinberg equilibrium was determined parameters. Methods: One hundred thirty-one patients on main- by the chi-square test. The significance of genotypes frequency tenance HD in 2 out-patient HD units were enrolled in the study.
was tested using the Fisher exact test. Results: The IL-18 A questionnaire was given to each patient to assess the intensity 1297C allele frequency was detected in 27.1% and 24.2% of and frequency, as well as pruritus-related sleep disturbance. The patients of groups I and II, respectively. The frequencies of relationship between clinical and laboratory data and the severity 1297TT genotypes were 7.3%, of pruritus were analyzed. Results: Pruritus was found in 62.6% 39.7%, and 53.0% in group I, respectively, and in group II were of patients. In those with pruritus, the intensity of itching was 1.6%, 45.3%, and 53.1%, respectively. There was no statistical mild with a visual analogue scale (VAS) score of o4.0, moderate deviation from the Hardy-Weinberg equilibrium in the genotype (VAS 4.0–6.9) and severe (VAS 7.0), in 53.7%, 34.1% and frequencies of group I (w2 = 0.003), but it was for group II 12.2%, respectively. The intensity of itching strongly correlated (w2 = 7.036). The odds ratio (OR) for CC vs. CT1TT was 0.201 with the frequencies of skin scratching (Po0.0001) and of sleep (95% CI = 0.046–0.891, P = 0.022) and OR for CC vs. TT was disturbance (Po0.0001). There was no correlation between the 0.213 (95% CI = 0.048–0.956, P = 0.036). Conclusion: In hemo- occurrence of pruritus and demographic or clinical parameters dialysis patients, IL-18 1297CC genotype may play a role in (e.g., type of kidney disease, various comorbidities, and dialysis anti-HBsAg development in response to HBV surface antigen. Pa- efficacy as expressed by urea reduction ratio) of the patients. His- 1297CC genotype may exhibit on average 5.0- tory of parathyroidectomy tended to be more frequent in patients fold increased chance of development of anti-HBsAg in response with pruritus, but this did not reach statistical significance to vaccine HBV surface antigen or HBV infection.
(P= 0.091). Treatment with antidepressants was more commonin patients who had itch (Po0.05). There was a ‘‘U''-shaped re-lationship between the duration of HD and severity of itching. In-terestingly, higher serum urea and lower vitamin B12 levels were Seasonal Variation in Number of Deaths Among significantly correlated with the presence (Po0.01 and Po0.01, Patients on Hemodialysis and Peritoneal Dialysis respectively) and intensity (Po0.01 and Po0.05, respectively) ofpruritus. Conclusions: Pruritus is still a common problem in pa- Bhrigu Raj Sood, Inaam Mohammed, Pratik Solanki, James Marsh.
tients undergoing HD and has a negative impact on the quality of South West Thames Renal Unit, Epsom ans St Helier Hospital sleep and mood. Our study is the first to suggest that low vitamin NHS Trust, Carshalton, Surrey, UK B12 levels could be a cause of pruritus in HD patients. We recom-mend measuring vitamin B12 level in patients with uremic pruritus, Background: Cardiovascular disease accounts for 450% of even if they do not have clinical manifestations of B12 deficiency.
deaths in dialysis patients. The expected rate of attrition is ex- r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 pected to be uniform throughout the year. We had anecdotal re- clinical condition, causes severe lactic acidosis with significant ports of a rise in deaths among our hemodialysis patients during mortality. Hemodialysis is an efficient method to treat MTF in- winter months. Two years ago we analyzed mortality over 4 years toxication and correct the metabolic abnormalities.
among established hemodialysis patients and found increasedmortality in autumn/winter months. Objective: We aimed to ex-plore if the same variation is seen in mortality among patients on peritoneal dialysis as well, and compare seasonal mortality withpatients on hemodialysis. Methods: We analyzed data on our hemo and peritoneal dialysis population between January 1, 2004 and March 31, 2010. Date of death was collected for all patients.
Seasons were defined by months as follows: spring (March–May), summer (June–August), autumn (September–November), and winter (December–February). Results: Total number of deaths between April 4 2004 to March 31, 2010. Peritoneal dialysis pa- tients—67, hemodialysis patients—636. Conclusion: Although there is increased rate of mortality in hemodialysis patients in autumn and winter months, the same is not seen in patients on peritoneal dialysis. Knowing that cardiovascular disease is main culprit in mortality among dialysis population, this variation is difficult to explain. There are small studies that indicate higher cardiovascular mortality in nondialysis population, attributing that to low vitamin D levels and increased blood pressure, but Mtf removal per c even that fails to explain contrast among hemodialysis and peri-toneal dialysis patients. This study has stimulated investigation,which might help us to identify a vulnerable subpopulation of Is Warfarin More Harmful than Beneficial in Hemo- hemodialysis patients and to increase surveillance during these dialysis Patients? Ruma Das, Ramesh Naik. Royal Berkshire Hospital, Reading,Berkshire, UK Metformin Intoxication Requiring Dialysis Purpose: The aim of this study was to carry out a retrospective Hoang-Lan Nguyen, Luis Concepcion. Texas A&M Health Science analysis of the use of warfarin treatment in our hemodialysis (HD) Center, Scott & White Hospital, Temple, Texas, USA patients with atrial fibrillation (AF); AF is the commonest ar-rhythmia in this group, but there are only a few retrospective stud- Background: Metformin (MTF) is one the most common oral ies and no clinical trial. Method: Proton database was used to agents used to treat diabetes mellitus. Intoxication is associated identify all HD patients who developed AF between January 2005 with lactic acidosis and has significant clinical consequences. We and December 2009; patients were divided into those who received report 12 cases requiring dialytic intervention. Methods: Twelve warfarin or aspirin or declined either. Complications and outcomes patients from 2005 to 2010, 10 treated with dialysis. Conven- were compared in the first 2 groups. Results: Out of 445 patients tional HD and continuous venovenous hemodialysis treatments starting maintenance HD during study period, 48 (10.8%) devel- with bicarbonate dialysate results as mean and SD. Re- oped confirmed AF; 20 started treatment with warfarin with regular sults: Twenty-five percent mortality, 33% male patients, hospital INR monitoring (1.5–3) and 26 received aspirin 75 mg daily. Two stay 9.3(12) days, average MTF dose 1.7 g/d. Base glomerular fil- patients who refused either were excluded from analysis. Mean age, tration rate 51.5 mL/min, age 64 (11) years. On presentation all comorbidity scores (UK renal registry criteria) and outcome are had acute kidney injury with BUN/creatinine 75 (30)/8.1 shown in Table 1. Warfarin was stopped in 5 (25%) because of (3.7) mg/dL, Lactic acid 12.4 (8.1) mmol/L, pH 7.04 (0.19) bi- hemorrhagic complications and discontinued in 4 (20%) in whom carbonate 7.2 (4.5) mmol/L, MTF level 25 (17) mcg/mL, AGap 28 warfarin was later thought to be unsafe (frequent falls, age, etc.).
(9) serum K 5.4 (1.3) mEq/L. Seventy percent were treated with Nonfatal stroke and death was similar in both groups; 1 patient in conventional HD. Patients required 4 (5) dialysis treatments at each group died of bleeding complications. Conclusions: The ben- blood flow QB 330 (53), dialysate flow QD 571 (111) for 305 efits of oral anticoagulation in HD patients with AF must be carefully (122) minutes. Postdialysis treatment the acidosis corrected weighed against bleeding complications and possible increase in (Po0.05): bicarbonate 19.2(4.1) mmol/L lactic acid 6 (4) mmol/L vascular calcification from vitamin K deficiency. Lifelong anticoag- and MTF level decrease 8.9 (5.7) mcg/mL MTF percent removal of ulation is recommended in high-risk nonrenal patients with AF but 60 (24). No difference between HD and continuous venovenous extrapolation of these guidelines to dialysis patients may not be ap- hemodialysis. Only difference between survivors was age 53 (7)vs.
propriate. In our study only 55% of patients started on warfarin 78 (10) Po0.05. Conclusion: Metformin toxicity is a serious could continue it and 18% (2 out of 11) continuing warfarin still r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts had thrombotic stroke. Benefit of long-term warfarin treatment in sense of choice and control over the way they spend their time in HD patients with AF can only be evaluated in large controlled stud- the dialysis chair.
ies. Until then warfarin must be used with caution in this group.
Daily Hemofiltration, a Useful Therapy in the Treat-ment of Cardiac Complications with Digoxin Toxicity in a Patient with Anuric Acute Kidney Injury Thiruselvan Thirunavukarasu, Ian Reilly, Hannah Sammut, Mu- Comorbidity score hammad Shahed Ahmed. Royal Liverpool University Hospital, Continued treatment Liverpool, Merseyside, UK Stopped due to hemorrhage Stopped to avoid hemorrhage Introduction: Patients with severe renal failure are at increased Thrombotic stroke risk of life threatening digoxin toxicity, as it is excreted by thekidney. The major reservoir of digoxin is skeletal muscle and only15% to 20% is protein bound in serum. Various treatment hasbeen adopted including hemoperfusion (HP), Digoxin-specific Integrating the Art and Science of Patient Care: antibody fragments (Digibind) and plasma exchange (PE) with Assessing the Role of Creative Expression for limited success. We report a case of successful management ofDigitalis toxicity with anuric acute kidney injury (AKI) and car- Hemodialysis Patients diac complication treated with hemofiltration (HF). Case De- Mary Cooper, Michael Yonas, Filitsa Bender. University of Pitts- scription: A 77-year-old male was presented with anuric AKI due burgh, School of Medicine, Pittsburgh, Pennsylvania, USA to dehydration, nephrotoxic medications, and digoxin toxicity.
His biochemical profile showed Urea 36.8 mmol/L, serum creati- Objectives: This qualitative pilot study was designed to explore nine 654 mmol/L, potassium level of 4.7 mmol/L, and digoxin the perceived influence of creative activities on patients during level of 4.1 ug/L. ECG revealed junctional rhythm with variable long-term hemodialysis (HD) care. Methods: Nine individuals heart block due to digitalis effect. His renal function deteriorated consented to participate and completed the project: 2 men, 7 rapidly with uremic symptoms and marked bradycardia (HR women; ages 39 to 86; 5 African Americans, 4 European Amer- 35 bpm). Digibind was not given as his BP was stable and the icans. Participants were randomly assigned to the intervention possibility of potential rebound of free digoxin causing severe group (N = 5) and control (N = 4). The intervention group received toxicity. He had daily HF and his HR gradually improved with art-making materials and project ideas, developed in collaboration slow reduction of serum digoxin level (see Picture 1). His renal with the Carnegie Museum of Art in Pittsburgh, PA, over 3 HD function recovered and did not require further HF after day 4.
sessions. The control group received new magazines of their Discussion: The current treatment strategy for digoxin toxicity in choice. In-depth interviews were conducted with each participant renal failure includes HP with resin, charcoal and specific col- to assess the impact of the intervention upon the experience of umns of b2-microglobulin adsorption, activated charcoal intesti- dialysis. Qualitative data were transcribed verbatim, coded, and nal dialysis, digibind, PE and peritoneal dialysis. All the above thematic analysis conducted. Results: Participants in both groups treatments have variable limited success in digoxin toxicity. In reported the positive influence of power of choice, of material or situation where there is cardiac destabilization of a patient with topic, given to them. The majority of participants in both groups digoxin toxicity and anuric AKI, HF can be a useful treatment to enjoyed the project as an alternative way to occupy their time stabilize patient by clearing the free digoxin from the circulation during HD. Half of the control group reported a desire to partic- and allowing gradual reduction of serum digoxin from critical ipate in the art group. The intervention group participants shared high level. Conclusion: Daily HF is a useful therapy in the treat- more about their life outside of HD and about the arts intervention ment of digoxin toxicity with cardiac complications in a patient as a way to bridge their lives and their time-consuming, physically with anuric AKI. Our case may be beneficial to nephrologists constraining treatment regimen. The intervention group partici- faced with this clinical scenario in the future. Picture 1: Digoxin pants also shared about their artwork and its production as a level with successive HF treatment.
process of problem solving and reflection. For all these reasons, 8out of 9 participants were enthusiastic about participating in artmaking during future HD sessions. Conclusion: This pilot studysupports at least a larger study comparing multiple clinics thatemploys a more generalizable quantitative measure of quality oflife during HD. According to the results of this study, the HD pa-tient population could benefit from arts-based programs that pro-vide a chance to reflect in a structured manner and give them a r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 Improved Hemodialysis: A Necessity egories to identify common patterns and key themes about thepatients' experiences of dialysis. Results: Preliminary results dis- Jarl Ahlmen, Agneta Stahl. Department of Nephrology, Ryhovs tinguish 4 key themes. (1) Decisions about initiating and staying Hospital, Jonkoping, Sweden on dialysis are often difficult for elderly patients. There was a widerange of experiences. (2) Elderly patients who have better support Seventy-five percent of end-stage renal disease patients are de- either from family, friends (including other patients) and dialysis pending on chronic dialysis for their survival. 25% are alive after 5 staff were more likely to have a positive experience. (3) The at- years. Functional status is of interest among chronic hemodialysis mosphere of the dialysis facility and the quality of interactions (HD) patients.
between patients and patients and staff significantly affected the Methods: Out of 37 HD patients, 26 were suitable for investiga- elderly patients' positive or negative experience of dialysis. (4) The tion with the Dartmouth COOP charts. Mean age was 68 years.
role of the primary care physician was key in initial education and Mean time on HD was 37 months. Charts were also given to the guidance about dialysis. Conclusions: Both providers and aging nurses in charge. Results: Each of the 9 dimensions in the charts patients would benefit from improved descriptions and under- was graded from 0 to 5 points, the latter meant bad status. Phys- standing of the experiences and quality of life of very elderly di- ical performance was low among 73% of the patients. The overall alysis patients.
health dimension was low among 62% of the patients. Pain wasperceived to be severe in 35% of the patients. Only 4 patientsanswered that they had been bothered emotionally during the last Difference of Postdialysis Extracellular Water to Total 2 weeks. The nurses estimations coincided well with most of the Body Water Ratios Between Arms May be Useful for patients' 9 COOP dimensions. The nurses overestimated the emo- Early Detection of Central Vein Stenosis tional problems and the overall health status. They underesti- Noritomo Itami1, Kazushi Tsuneyama2, Susumu Uemura2, Jouji mated the patients' pain and social support. Discussion: Several Takada1, Hiromi Hamada1. 1Kidney Center; 2Department of Clin- factors influence the depressing results, e.g. high age, comorbid- ical Engineering, Nikko Memorial Hospital, Muroran, Hokkaido, ities, length of dialysis. To improve survival the dialysis treatment has to be longer and more frequent as well as increased physicalactivity and better education of the patient. Conclusion: The sim- Extracellular water (ECW) to total body water (TBW) ratio using ple COOP enquiry demonstrated clearly the deficiency of inade- bioelectrical impedance analysis (BIA) by InBody (Biospace, Ko- rea) is 0.380 in healthy persons. We use the postdialysis ECW/TBW ratio to assess dry weight in hemodialysis (HD) patients.
The Experience of Being on Dialysis Among the Elderly Central vein stenosis (CVS) is sometimes noted after swelling andedema have appeared. Duplex venous ultrasound is the only non- Sandra Tye1, James Campbell1,2, Lucas Lenci1. 1School of Medi- invasive detection method. We found BIA useful for CVS detec- cine; 2Department of Family Medicine, University of Missouri, tion. A 47-year-old woman with 22 years HD developed swelling Columbia, Missouri, USA on the left and visibly dilated vein in the shoulder. Scar below theleft subclavian was noted. Duplex venous ultrasound could not Background: People over 75 years of age are the fastest-growing locate the stenosis. Venogram of the left arteriovenous fistula population of patients with chronic kidney disease Stage 5 who (AVF) showed severe occlusion of the left subclavian vein with are currently initiating dialysis. Despite this rapid growth in the dilated collateral veins in neck and shoulder. Surgery was per- prevalence of chronic kidney disease in the elderly, little is known formed for AVF occlusion and formation of a new right-side AVF.
about how dialysis affects these patients. Age alone does not mea- A retrospective data check including BIA showed postdialysis sure a person's ability to survive and benefit from dialysis. Thus, ECW/TBW of the left upper limb to be 0.398 and 0.367 on the obtaining more information on how the elderly experience life right. After occlusion, ECF/TBW decreased to 0.378 on the left after initiating dialysis is important in order to guide physicians, and remained at 0.366 on the right. This case illustrated the patients, and families in their decisions regarding initiating and difference between arms as an early marker for CVS detection.
living with dialysis. Methods: This was a qualitative study that With a 0.027 difference in this case, we examined a difference of used a semistructured interview schedule centered on the follow- over 0.020 in the ECF/TBW ratio in maintenance HD patients.
ing categories: initiating dialysis, patient education, physical con- Hundred ten patients (male 68, female 42, mean age: 65.9 12.3 dition, social and psychological support, experience of dialysis, years old, dialysis vintage: 7.4 7.1 years) were surveyed post- and the coordination of care including the coordination between dialysis using a body composition analyzer. A 61-year-old woman the nephrologist and the primary care physician. A total of forty had an ECF/TBW ratio of 0.389 in the left arm with AVF and patients between the ages of 75 and 88 were interviewed in 5 0.368 in right arm. No swelling or edema was noted. Arteriove- chronic dialysis care facilities located in the Midwest. Twenty-one nous fistula venogram showed moderate-to-severe stenosis of left females and 19 males were interviewed with the range of time that innominate vein. Angioplasty was performed. Postdialysis ECF/ they had been on dialysis varying from 2 months to 13 years.
TBW ratio decreased to 0.384 after surgery. Postdialysis ECF/TBW Interviews were transcribed and then analyzed in each of the cat- ratio may be useful for CVS detection before clinical manifesta- r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts tions such as edema or swelling emerge. Further studies and re- Nurul Islam3. 1NIKDU, Dhaka, Bangladesh; 2BIRDEM, Dhaka, consideration of more sensitive postdialysis ECF/TBW ratio for Bangladesh; 3UHL, Dhaka, Bangladesh detection of early stage CVS are warranted.
Objective and Purpose: Control of blood pressure (BP) is a major Dialytic Therapy for Idiopathic Hyperammonemia issue in maintenance hemodialysis (MHD) patients. Different Following Lung Transplantation: A Case Report types of antihypertensives are being used but selections regard-ing optimum ones are still debated. In this study the efficacy of Jamie Green1, Chandraprakash Umapathy2, Kelly Liang1. 1Renal- ACE inhibitor Enalapril (E) in comparison to slow release Nifedi- Electrolyte Division; 2Department of Medicine, University of Pitts- pine (N) on reduction of BP in MHD patients was observed.
burgh, Pittsburgh, Pennsylvania, USA Method: This was a prospective, randomized, parallel group andopen label study. Patients of MHD having predialysis BP4140/ Idiopathic hyperammonemia (IHA) is a rare but often fatal con- 90 mmHg despite existing antihypertensive medications were in- dition characterized by abrupt alterations in mental status and cluded in 2 groups. Alternate patients were given either Enalapril markedly elevated ammonia levels in the absence of any identi- (group E) or sustained-release Nifedipine (group N). In E group fiable cause. It has been described following lung transplantation, Enalapril was started with 10 mg once daily and in N group bone marrow transplantation, and high-dose chemotherapy. Suc- Nifedipine sustained-release formulation 20 mg (phase 1). The cessful treatment depends on the early initiation of multimodality phase 1 dose was increased after 4 weeks to 10 mg twice in E treatment to rapidly reduce ammonia levels. Dialysis is an effective and 20 mg twice in N group if BP is not lowered to 140/ therapy to enhance ammonia clearance, which is dependent on 90 mmHg (phase 2). After another 4 wks if BP is still not in target the blood flow rate (BFR), dialysate flow rate (DFR), and dialyzer range (o140/90) additionally nifedipine, up to 20 mg, was surface area; however, the optimum dialysis modality in the set- added to both E/N groups as required (phase 3). Results: Finally ting of IHA is unknown. We report the case of a 69-year-old analyzed subjects of both the E (n = 17) and N (n = 20) groups woman who developed hyperammonemia a few days following were matched at recruitment for age (49 13 vs. 44 15 years); bilateral lung transplantation. Her postoperative course was com- duration of hypertension (9 6 vs. 6 5 years); duration of plicated by prolonged mechanical ventilation and vasopressor sup- dialysis (8 9 vs. 10 10 months) and residual urine volume port. On postop day 6, she developed altered mental status and was (0.4 0.3 vs. 0.5 0.4 L/d). They were mostly dialyzed twice/ found to have an ammonia level of 305 mmol/L in the absence of wk with a Kt/Vureea of 0.8 0.3 vs. 0.7 0.3 per session and liver dysfunction. Her ammonia level peaked at 413 mmol/L com- ultra filtration rate 2.6 0.6 vs. 2.7 0.7 L per session; (P = NS).
plicated by seizures and evidence of increased intracranial pressure.
Similar number of subjects in 2 groups were on erythropoietin As an adjunct to other measures to reduce her ammonia level, she (41% vs. 55%, P = NS). In both groups at the starting of the was started on continuous venovenous hemodiafiltration using a study, antihypertensive medication atenolol was taken by 65% vs.
BFR of 180 mL/min, DFR of 2500 mL/h, and replacement fluid at 55% (P = NS), amlodipine 76% vs. 47% (Po02); prazosin 56% vs.
2000 mL/h. The next day, her ammonia level remained elevated at 60% (P = NS), furosemide 58% vs. 51% (P = NS). Only 16% 301 mmol/L, and intermittent hemodialysis (IHD) was added with were on any ACEI drugs and 8% on ARBs. The base line pretri- maximal BFR and DFR with a reduction in her ammonia level to al systolic and diastolic BP in E and N group, respectively, was 90 mmol/L after 4 hours and 76 mmol/L after 6 hours. She was 158 16 vs.163 17 and 88 10 vs. 93 12, mmHg (P = NS).
continued on a combination of IHD and continuous venovenous At the end of phase 1 drug, 33% vs. 50% (P = NS) was non- hemodiafiltration with maintenance of her ammonia level below responder in E vs. N group having systolic and diastolic BP 200 mmol/L. Despite aggressive therapy, the patient died on post- 167 19 vs.165 18 & 98 7 vs. 91 16 (P = NS). After operative day 11 from complications of IHA. High-efficiency IHD is doubling the dose at phase 2 in both the groups, 29% vs. 35% the most effective dialysis modality to rapidly reduce ammonia lev- (P = NS) remained nonresponder with the BP of 168 16 els, but it must be instituted early in the course of IHA before sig- vs.161 16 and BP 89 6 vs. 88 12 mmHg (P = NS). When nificant neurologic complications occur. Repeated sessions are at phase 3 additional dose of Nifedipine (22 13 vs.
usually needed because of residual or rebound hyperammonemia.
15 10 mg) was added to all nonresponder subjects of phase 2 Continuous renal replacement therapy can be used to maintain (n = 20), the BP was still uncontrolled in 15% vs. 20% (n = 7).
ammonia levels between IHD sessions.
While in the responders of E group (n = 6) this came down to(systolic and diastolic BP, mmHg) 171 10 vs.132 8(Po0.001) and 93 5 vs. 77 8 (Po0.004); and similar of N Efficacy of Enalapril and Sustained-Release Nifedipine group (n = 7) to 162 11 vs.131 7 (Po0.001) and 92 11 vs.
in Controlling Blood Pressure of Patients on Mainte- 80 2 (Po0.03). As a whole target BP (o140/90) was achieved nance Hemodialysis: Observations from Ongoing in 17% at phase 1, 36% in phase 2, and 65% at phase 3.
Conclusion: It may be concluded that Enalapril and Nifedipine, separately with usual doses, are not adequate in reducing Masud M. Iqbal1, Nurun Nahar1, Ayub A. Chowdhury1, Shamim blood pressure as an additional antihypertensive for majority of Ahmed1, Kazi S. Alam1, M. Firoz Khan1, M. Abul Mansur2, M.
maintenance hemodialysis patients. By adding at a higher dose, r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 Nifedipine may reduce blood pressure more significantly in re- Development of Intermittent Infusion Hemodialysis sistant hypertensive subjects.
Using Ultrapure Dialysis Fluid by an AutomatedDialysis Machine Michio Mineshima1, Kei Eguchi1, Takashi Sato2, Kenji Tsuchida3,Jun Minakuchi3, Misaki Moriishi4, Hideki Kawanishi5, TetsuyaMatsushima6. 1Department of Clinical Engineering, Tokyo Wo- Dialysis Systems, Equipment men's Medical University, Tokyo, Japan; 2Meiko Kyoritsu Clinic,Nagoya, Japan; 3Kawashima Hospital, Tokushima, Japan; 4Naka-jima Tsuchiya Clinic, Hiroshima, Japan; 5Tsuchiya General Hos- Monitoring and Improving the Quality of Water in pital, Hiroshima, Japan; 6Nishijin Clinic, Fukuoka, Japan Portable Reverse Osmosis Machines In a typical hemodialysis (HD) treatment, excessive water removal Lori Coddington, Tiffany Lannan, Martha Tarley, Rebecca Sch- often induces hypotension and muscle spasm. Intermittent infu- midt. West Virginia University Hospitals Inc., Morgantown, West sion hemodialysis (IIHD) using ultrapure dialysis fluid produced by an automated dialysis machine, GC-110N (JMS Co. Ltd,Tokyo, Japan) was newly developed. The IIHD may therefore Background: It is important to monitor microbial contamination transiently improve the peripheral circulation by repeated inter- of water used in hemodialysis machines in order to provide mittent infusion. A multicenter clinical trial was carried out to safe and effective hemodialysis. Regulatory agencies, such as the evaluate the clinical effectiveness of the IIHD therapy in compar- Centers for Disease control and prevention and the Association for ison with standard HD (SHD). We enrolled 20 chronic renal dis- the Advancement of Medical Instrumentation, have established ease patients were participated in this crossover study of the IIHD allowable upper limits of microbial contamination of water.
and SHD. The IIHD includes the intermittent rapid infusion of During routine monitoring of water in the dialysis unit, we noted 200 to 300 mL of ultrapure dialysis fluid at a rate of 100 mL/min 7 bacterial counts above the allowable limits on the portable to 10 times per treatment. The values of removal rate, solute reverse osmosis machines. Objective: In order to identify clearance, and cleared space (CS) for urea, creatinine, uric acid, potential causes of the elevated microbial counts, a Root Cause inorganic phosphate, b Analysis was conducted by an interdisciplinary team consisting and a1-microglobulin were compared between the IIHD and the SHD therapies. Time of representatives from Dialysis, Infection control, Bio-medical course of blood volume (BV) and peripheral blood flow rate of engineering, and Facilities Management. Methods: A review of the patient were measured continuously by a hematocrit monitor water cultures for the past year revealed a consistent increase in and a laser flowmeter, respectively. As a result, increases of BV and the level of microbial counts from the portable reverse osmosis peripheral blood flow rate were observed for each infusion in all machines. There was no increase in the number of health care patients. Time-averaged BV reduction during a treatment was sig- associated infections in hemodialysis patients during this time nificantly lower in the IIHD than that in the SHD, in spite of period. The entire process for monitoring and maintaining the identical water removal amount. Although no significant differ- quality of water in the dialysis machines was flowcharted. An ag- ence between the IIHD and the SHD therapies was obtained for gressive staff education program was undertaken. In order to removal rate in all solutes, the averaged values of CS in the IIHD eliminate variance and improve accuracy, 1 person and an alter- was higher than those in SHD for all solutes. In particular, IIHD nate were trained and assigned the task for collecting the water had significantly higher CS values for inorganic phosphate and a cultures. The daily log for documenting results of water cultureswas revised to ensure appropriate follow-up. A database was cre- than the SHD. Improvement of peripheral circulation due to intermittent infusion might be increased in wa- ated for tracking water cultures. Those requiring actions were ter and solute transport from the extravascular to intravascular highlighted in yellow or red depending upon the microbial count.
The database also includes the dates of cleaning and disinfectionof the central water system and dialysis machines. The data werereviewed by the Hospital Dialysis Unit Governing body and theInfection Control Committee. Results: The efforts of this inter- disciplinary team resulted in significant reduction in microbialcontamination of water in the dialysis unit. Water cultures from John Agar. Barwon Health, Geelong, Victoria, Australia the portable reverse osmosis machines that exceeded the allow-able level were reduced from 48% to 2% after process changes.
Introduction: As 35 of our 114 hemodialysis (HD) patients cur- Conclusions: The process changes and ongoing feedback of in- rently self-dialyze on paired Fresenius 4008B1Aquauno reverse formation from infection control to the interdisciplinary team osmosis (R/O) systems at home (HHD), their power costs mount made positive impact on our water culture surveillance program despite a state of Victoria prorata reimbursement for utilities of and served as a basis for implementing a process structure that A$1450/patient/y. As a first step toward a patient1program ‘‘part- ensures adherence.
nership'' to install solar power for HD in the home as a further r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts incentive for HHD, we report a pilot project to fully solar power nine (MW113), vitamin B12 (MW1355), or chymotripsin our HHD training facility. This is the first known, reported solar (MW25400). Results and Discussion: Exactly the same sieving powered dialysis facility in the world. Method: Eighteen Conergy coefficients were found in 4 dialyzers over time in creatinine, P170 M solar panels (panel weight 306 kg: panel area = 23.409 m2: which implied there were no adsorption characteristics in these predicted power output [historical means] = 4.58 kW h/m2/d/y) membranes to creatinine. In the case of vitamin B12, however, and a Conergy inverter (total equipment1installation cost- higher clearances were found with a PEPA dialyzer (about 1.6 A$16,219) were installed at our 4 chair, 4 operating d/wk HHD times) for the first 10 minutes after starting the experiment training facility. All generated solar power feeds into and is reim- than those of other 3 dialyzers. Additionally, PMMA and PEPA bursed from the state grid. Our HD1R/O systems have been membrane dialyzers showed significantly high clearances for circuit isolated and group metered to record all grid-drawn dial- chymotripsin compared with other 2 membranes. The initial ysis-related power and all system operating time is metered. The clearance was about 2 times and 4 times higher in PMMA system ‘‘went live'' in July 2010. Results: In the first 49 opera- and in PEPA, respectively, than that in polysulfone (16.7 mL/ tional days (July–September = Australian winter), 13.35 kW h/d/ min) with no adsorption. Polyester polymer alloy may have the wk has been generated while all 4 HD systems have drawn same or even greater adsorption characteristics to PMMA that has 14.5 kW h/d/wk in 19.79 h/d. The historical expected annualized been known to have excellent performance in removing mediators solar exposure (SE) is 4.58 kW h/m2/d while the historical mean in CRRT. Conclusions: Adsorption characteristics are useful in SE (July–September) is 3.4 kW h/m2/d, 74% of the expected an- CRRT, especially for removing middle or large molecules, nualized SE. Despite a winter start, our system is already provid- and, PMMA and PEPA membrane have excellent adsorption ing 91.5% of all required power. Using both historical SE and actual draw data, full-cost repayment via grid reimbursement canbe predicted within the first 8 years. As estimated panel life is 25to 30 years, free power and a future income stream should Assessment of a Device to Detect Venous Needle accrue beyond the first decade. Conclusion: While a full 12- month assessment is clearly needed to confirm the sustain- Jan Cowperthwaite1, Ann Rivers2, Alison Lacey2, Maria Sun- ability of this encouraging start, we believe that solar powered dstro¨m3, Jo¨rgen Hegbrant1. 1Diaverum Renal Services Group, dialysis may prove to be practical, cost effective and environ- Lund, Sweden; 2Burnely Dialysis Clinic, Burnley, UK; 3Redsense mentally responsible for both facilities and HHD alike. The Medical, Halmstad, Sweden development of shared-cost patient1program installation agree-ments may add an extra incentive to our already successful HHD Background: Although venous pressure monitoring is currently standard practice to detect venous needle dislodgement (VND) itis not always effective. Additional protection is often required usingdevices intended to detect blood loss to the environment. Objec- Role of Adsorption in Dialyzers for Continuous Renal tive: In the first phase of the study we assessed the use of a device Replacement Therapy to detect VND (Redsense Medical, Halmstad, Sweden). During thesecond phase, following improvement work by the manufacturer Narumi Tomisawa1,2, Yoichi Jinbo1,3 Taku Obata1, Akihiro C.
the device was re-evaluated. Method: Training was provided by the Yamashita1. 1Department of Human & Environmental Science, manufacturer and equipment to enable 100 treatments was sup- Shonan Institute of Technology, Kanagawa, Japan; 2Nikkiso Co., plied. On completion of all treatments nurses were asked to com- Tokyo, Japan; 3Nikkiso Technical Research Institute, Tokyo, plete a questionnaire. This included some questions regarding the use of the device, followed by a set of statements where each re-spondent was asked to express their level of agreement using a Objectives: Continuous renal replacement therapy (CRRT) is Likert scale. During the second phase retraining was provided by usually performed under limited amount of dialysis fluid. Fur- the manufacturer and equipment to enable 100 treatments was thermore, better clinical outcomes in CRRT have been reported supplied. Staff and patients were asked to complete a questionnaire with dialyzers with high-adsorption characteristics than that with at the end of each treatment. On completion of all treatments nurses high solute permeabilities. The aim of this study is to evaluate were asked to give feedback using a modified version of the ques- solute removal performances of commercial dialyzers for CRRT in tionnaire used in phase 1. Results: Hundred percent of respon- vitro in terms of adsorption characteristics of the membrane. Ma- dents in both phases of the study agreed that the device was easy to terials and Methods: Materials of the membrane were polyester use. In phase 1, 9 nurses completed the questionnaire. There was a polymer alloy (PEPA) and that with hydrophilic agent (Nikkiso level of agreement of 3.5 that the device did not always work as Co., Tokyo, Japan), polymethylmethacrylate (PMMA), and expected. Some of the findings indicated false alarms and others no polysulfone (Toray Co., Tokyo, Japan). Ultrafiltration experiments alarm when oozing occurred. In phase 2, 70 end of treatment with aqueous test solution were performed at 310 k under questionnaires were completed; 13 patients and 13 nurses gave QB=100 mL/min, QF=1000 mL/h. One of the following sub- feedback. On completion of the study 8 nurses completed the stances was chosen as a test solute in each experiment, i.e., creati- modified (phase 1) questionnaire. No occurrences of VND were r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 recorded during the study period. There were no occurrences of particularly at the blood inlet when IF rate is raised. Conclu- false alarms. 62.5% of nurses reported that the alarm unit was im- sions: The time course of IF properties can be evaluated by the proved from the first evaluation, 25% were not sure and 1 nurse Doppler ultrasonography. Excessive IF enhancement may de- (12.5%) had not been involved in the initial evaluation. Ninety-four crease membrane permeability due to accelerated membrane foul- percent of nurses believed the use of the device improves monitor- ing particularly at the blood inlet. Hemodialysis treatments using ing during hemodialysis and 91% of patients responded that it im- high-flux dialyzers, therefore, have an advantage of increasing proved safety. Despite this 100% of nurses either disagreed or solute removal efficiency by enhanced convective transport and strongly disagreed that the device should absolutely be used for simultaneously a disadvantage of decreasing solute removal effi- all patients. However, 85% believed that the device should abso- ciency by membrane fouling.
lutely be used for certain patients. Conclusions: The nurses foundthe device easy to use. The results from phase 2 indicate that the Use of Sorbent Dialysis for the Removal of Contami- problems identified in phase 1 have been resolved. The nurses inthis study reported that the device improved monitoring during nants from Potable Tap Water to Produce ANSI/AAMI treatment. Although they did not feel the device would be necessary Quality Dialysate for all patients they did believe that it was necessary for certain pa- Steve Merchant, Fred Kemp, Preston Thompson. SORB Technol- tients. The clinic is simultaneously evaluating an assessment tool to ogy Division, Renal Solutions Inc., Oklahoma City, Oklahoma, identify patients at increased risk of VND.
Time Course of Internal Filtration Properties of a Resurging interest in sorbent dialysis is due largely to its capability High-Flux Dialyzer of reducing the water required for patient treatment from approx-imately 120 L of RO water to 6 L of potable tap water. This dra- Atsushi Kotoya1, Ken-ichiro Yamamoto2, Ryoichi Sakiyama2, matic reduction in both the volume of water and the expense Michio Mineshima2, Kiyotaka Sakai1. 1Department of Chemical associated with producing RO quality water is garnering world- Engineering, Waseda University, Tokyo, Japan; 2Department of wide attention as the leading alternative to the typical single-pass Clinical Engineering, Tokyo Women's Medical University, Tokyo, dialysis treatment. The purpose of this study was to determine whether the HISORB1TM sorbent cartridge could produce ANSI/AAMI quality water for dialysate from water that has been Objective: Performance of a high-flux dialyzer depends on inter- spiked to contain the US EPA indicated potable water maximum nal filtration (IF) in addition to diffusive transport. It is, however, allowable contaminant limit (MACL) for the specific chemicals hard to evaluate IF property exactly. The objective of the present listed in ANSI/AAMI RD62:2001. The results indicate that all of study is to evaluate the time course of IF properties of high-flux the metallic inorganic contaminants and fluoride are removed dialyzers and also to clarify the time-dependency of membrane from the system after 30 minutes of dialysate circulation to levels fouling caused by IF. Materials and Methods: In vitro dialysis below ANSI/AAMI MACL; this includes removal of contaminants experiments were performed using commercially available high- from any dilution water used to control conductivity up to that flux dialyzers; APS-15SA, APS-15E, and APS-15EX for 4 h. two point. The oxoanions sulfate and nitrate, however, did not show liters of bovine blood with 30% of HCT and 6.5 g/dL of TP were any appreciable reduction from initial levels. This result was circulated at 200 mL/min to the test dialyzers. On the other hand, expected as the cartridge is not designed to remove these a phosphate buffer solution was fed to the dialysis fluid side of the species from dialysate. It is inevitable with the use of tap water dialyzers at 500 mL/min. Net filtration rate QF was set to 0 mL/ that chemical species will be encountered, which may not be re- min. The time course of IF rate (QIF) was measured by observing a moved from the dialysate by the sorbent cartridge. These in- blood velocity profile along the dialyzer by the Doppler ultra- stances highlight the value of volume reduction: for example, a sonography. To evaluate time dependency of the membrane foul- typical single-pass dialysis treatment using 120 L of water with ing property, analytical solution of the newly introduced sulfate at the ANSI/AAMI MACL of 100 mg/L would expose theoretical model for flow and pressure profiles of the dialyzer the patient to a maximum mass of 12 g of sulfate. In comparison, was fitted to the data on the time course of local QB profiles along a typical sorbent dialysis treatment using 6 L of water at the EPA the dialyzer. Results: The IF rates gradually decreased with time, MACL of 250 mg/L would expose the patient to a maximum and these values at 15 and 240 minutes were 20 and 11 mL/min mass of 1.5 g of sulfate, or 8 times less of the contaminant.
for APS-15SA, 53 and 47 mL/min for APS-15E, and 59 and In conclusion, the HISORB1TM sorbent cartridge effectively 49 mL/min for APS-15EX, respectively. Discussion: These decline reduces the potential exposure of chemical contaminants found tendencies are due to membrane fouling greatly depending on in potable water to the patient by directly removing the species total filtration volume. Numerically analyzed QB profiles had a from the dialysate and by drastically reducing the volume of good agreement with experimental data at 15 min. However, at dialysate required for the treatment. Additional studies will in- the blood inlet of the dialyzer, a difference between theoretical clude an investigation of the sorbent cartridge performance with and experimental QB values was slightly greater than that at the source water from locations where the water quality is known to other parts in the dialyzer. Greater membrane fouling may occur r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts CROWNWeb Phase III and the 2011 National Release: naire to all participants and all studied subjects were asked to estimate their subjective QOL and psychiatric illness by answeringquestionnaires. Results: Quality of life of the renal transplant pa- Matthew McDonough. FMQAI—The Florida ESRD Network, tients is better than HD group. As regard psychiatric illness renal Tampa, Florida, USA transplant is better than HD patients in total scores of GeneralHealth Questionnaires. In HD group we found that females' gen- CMS recently announced plans to release the third phase of its der, low serum hemoglobin, and low urea reduction ratio are as- CROWNWeb data-collection system, to be used by end-stage re- sociated with psychiatric illness. Meanwhile, long duration after nal disease dialysis organizations, in January 2011, and expects to kidney transplantation and reduced glomerular filtration rate are roll out the full-national release in late Spring 2011. What users associated with prevalence of psychiatric illnesses in transplant can expect include:Phase III Overview group. The prevalence of psychiatric illness leads to worsening the 1. Begins Q1 2011 QOL among both groups. Meanwhile QOL is not related to any 2. Twenty facilities in each Network—Expands number of partic- sociodemographic, clinical, and laboratory variables. Conclu- ipating facilities from 180 to B360 sions: Hemodialysis patients have worse QOL and more suscep- 1. Split approximately 50/50 between large dialysis organiza- tible for psychiatric illnesses than posttransplant recipients.
tions (Batch Submitting Organizations) and smaller groupsand independents 1. Batch data submission still being refined Changing the Way We Work 1. BSOs will continue to submit 100% of patient population Colleen Wile, Doris Kane, Leslie Jackson. QE II Health Science into CROWNWeb via batch testing Centre, Halifax, Nova Scotia, Canada 1. User accounts will be managed through new QualityNet Iden- tity Management System (QIMS) Working in a busy clinic that provides acute and chronic hemo- 2. Phase III includes Multifactor Authentication (MFA) security dialysis treatments can be challenging for staff. Ensuring an adequate supply of health human resources now and in the fu- 3. Changes to Graphical User Interface in: ture is also challenging. Imperative to safe patient care is ensuring 1. Section 508 compliance the right person is providing the right care at the right time and that no resources are being wasted. Our hemodialysis unit em- 3. Clarification of fields/error messages.
barked on a new initiative ‘‘Changing the Way We Work,'' to createa practice environment in which RNs, LPNs, and NPs could op- 2011 National Release timize their respective scopes of practice within the hemodialysis Expected launch in late Spring 2011 with 100% of facilities unit to meet the needs of the patient population that we serve. An important component of the ‘‘Changing the Way We Work'' ini- Submission still accomplished via manual entry and EDI tiative was to effectively integrate the support personnel into the QIPS retired—only QIMS system available.
care team. A working group consisting of LPNs, RNs, NP, renalassistants, nurse educators, a professional practice leader and themanager embarked on this journey to engage nurses and renal Education, Quality Improvement assistants as active participants in creating change and decisionmaking at the point of care. This poster presentation will highlight Health-Related Quality of Life and Psychiatric Illness the many tools and work that was completed within our hemo- after Kidney Transplantation in Comparison to dialysis unit by the staff to create a patient/family-centered work Hemodialysis: Variables that Influence Them environment that supports nurses to work to their full scope ofpractice and provides an environment that supports effective uti- Kalid Abou Seif1, Dawlat Sany1, Yasser ElShahawy2, Doaa Rad- lization of the support staff.
wan2. 1Renal Division; 2Psychiatry Division, Ain Shams UniversityCairo, Egypt Improving Mortality and Morbidity Rates Among New Introduction: The relevance of quality-of-life (QOL) indications is Dialysis Patients During the First 90 Days of Dialysis derived not only because QOL is a basic aspect of health, but alsoa close relationship exists between QOL, morbidity, and mortality.
Demetriace Stingley. Fresenius Medical Care Mobile, Alabama, USA The purpose of this study to evaluate and compare the effect ofhemodialysis (HD) and transplantation on QOL, psychiatric ill- Background/Objectives: Several studies have highlighted multi- ness, and to explore the variables affecting it using WHOQOL- ple comorbidities and risk factors that are present in the majority 100 and General Health Questionnaires. Methods: In this cross- of patients starting dialysis therapies the first 90 days of treatment.
sectional study, QOL and psychiatric illness were analyzed in 80 After assessing the current education practice for new dialysis renal transplant recipients compared with 80 HD patients. Both patients, the Right Start Program was implemented to improve questionnaires were administered as a self-completed question- new patient quality outcomes. The patient's improvement in qual- r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 ity indicators such as albumin, hemoglobin, phosphorus, and Encouraging and Supporting Patients to Make Their urea clearance decreased the mortality and hospitalization rate in Own Healthcare Decisions comparison to patients receiving no Right Start education. Newpatients with a o2 weeks start date were identified. One-on-one Janet Baker, Vanessa Deck, Maria Doyle. Halton Healthcare education began on a test group of 10 patients. Objectives: (1) Services, Oakville, Ontario, Canada Patient will be able to verbalize understanding of dialysis regimenand schedule. (2) Patient will also demonstrate a clear under- There is a growing trend to encourage and support patients who standing of dietary restrictions and lab values and recommended want to be active in the decisions surrounding their healthcare.
goals. (3) Patients will also verbalize understanding of medica- This is most often referred to as Self-Management and the renal tions and their action. Methods: Ten new patients received early setting is the perfect environment to support patients in decision intervention education using the Right Start education modules making. Self-Management is a fundamental component of many and a control group of 7 patients new to dialysis received new models of care for chronic disease prevention and management in patient education currently being practiced in the dialysis micro- today's healthcare. The evidence points toward patients and their systems. Patients were assessed for learning style and ability to caregivers wanting to participate in their care decisions. In the comprehend reading material. The patients were given handouts chronic kidney disease setting these decisions can take place in regarding each variable discussed. Evaluation consisted of discus- many formats including predialysis clinics and in-center hemodi- sions followed by lab results review. Patients were given a short alysis units. It can range from patients on home therapies and cover multiple-choice test to assess retention of knowledge. Re- all facets of multidisciplinary care. The decisions that our patients sults: The 10 patients that received early education had no deaths make can be as simple as deciding to monitor their own blood in comparison to 2 deaths recorded in the patients who did not pressure or glucose at home or as large as starting or withdrawing participate in the Right Start education plan. There were no hos- from dialysis care. What is the role of the renal team in this climate pitalizations for participants in Right Start and 421 days reported of patient decision making? It can be confusing for patients as well for the control group. The decrease in hospitalizations and deaths as staff. How can members of the renal team educate patients in the results in more billable dialysis treatments. Ninety percent of the decision-making process and how do we support patients in mak- educated participants met their goal with no hospitalizations, ing these crucial decisions? The predialysis unit at our hospital generating a cost saving of $31,195. Conclusion: According to adopted the philosophy of self-management and supporting our evidence-based practice, early educational intervention positively patients as they make educated decisions regarding their care. How influences quality indicators for new dialysis patients who are at did the renal team change their patient approach? How did this risk for higher mortality and hospitalizations. There was a signifi- change in care philosophy modify the role of the team who work cant improvement in laboratory quality indicators and reduction with this group of patients? Are our patients happier and are our in mortality and hospitalizations for patients who received edu- measured outcomes different? Our multidisciplinary team had training in self-management strategies and then decided on the ar-eas that would be most appropriate for the introduction of self-management to our patients. Each discipline in the clinic developed Chronic Kidney Disease and Vein Preservation: A group classes for patients to attend as they desired. We are final- Provincial Approach izing a patient binder ‘‘Helping you to be an active participant in themanagement of your kidney disease'' and hope to roll this out in Richard Luscombe, Jocelyn Hill, Cathy Duerkson, Janet Willaims.
January 2011. This change in care philosophy has been a year long Vancouver Coastal Health Authority, Vancouver, British Colombia, process and not without challenges, however, we all believe that this is the best for our patients and our patients are responding wellto this change. They are voluntarily signing up for classes and we Preservation of veins in patients with chronic kidney disease who have seen a positive shift in the decision making done by our pa- may or may not be on hemodialysis is crucial for the successful tients. They seem more confident in their decisions as it pertains to future creation of arteriovenous fistulas and grafts. Frequent ve- the management of their renal disease and more satisfied in general.
nipunctures and the indiscriminate use of peripheral intravenouslines can damage veins, impair the circulatory system, and jeo-pardize future fistula and graft creation and/or function. This It Can Work: Daily Hemodialysis in a Rehabilitation presentation will demonstrate a multi-disciplinary, multicenter and cross-continuum approach to the development and imple-mentation of a provincial guideline on vein preservation in people Irma Funes1, Stuart Sprague2, Neenoo Khosla2. 1WellBound of with chronic kidney disease. The guideline makes 4 recommen- Evanston, Skokie, Illinois, USA; 2Northshore University Health dations, including an algorithm to assist health care providers in System, Evanston, Illinois, USA selecting the most appropriate vein for venous access sites. Edu-cational material was also developed to support the implementa- The increasing prevalence of end-stage renal disease in patients tion of the guideline and targets both health care professional and older than 75 years presents unique challenges in providing ap- propriate dialytic care. The associated comorbid issues in this r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts population frequently require admission to nursing homes (NH) missed and/or shortened training sessions, failure to complete re- or rehabilitation facilities (rehab). The most effective way to pro- quired documentation, and missed laboratory draws), and diffi- vide concomitant adequate hemodialysis (HD) and rehabilitation culty adjusting to stage 5 chronic kidney disease as potential root services is unknown. The current NH/rehab model provides con- causes. Our QAPI process, therefore, will focus on how we can ventional HD 3 times a week. Often, rehab services are foregone better assist candidates to adjust and adhere to the limits and on these days secondary to patient fatigue and scheduling con- rigors of home dialysis. We decided on an interdisciplinary ap- flicts. A novel paradigm utilizing daily home HD with the NxStage proach, meeting with the social worker, the dietitian, and the system was executed at 1 NH in August of 2009. Dialysis was nurses in the training center to discuss the best methods for deal- administered 5 days a week with no interruption of prescribed ing with patients who do not adhere to treatment requirements, rehab services. An additional goal of the program was to expose and to brainstorm approaches that might help those patients as patients to home dialysis therapies with eventual discharge to ei- well as those with complex family issues to be successful on home ther NxStage or peritoneal dialysis (PD). Training of home ther- dialysis. Our presentation will detail the solutions we are testing apies was coordinated while at the NH. Dialysis naı¨ve nurses from and present preliminary observations about our success.
the rehab facility were trained for 1 month in NxStage. Withgrowth of the program 2 technicians with HD experience were All-Hazards Emergency Preparedness and Planning in also trained. In 1 year the program provided dialysis to 30 patients 2009 to Prevent Dialysis Treatment Interruption aged 60 to 80 years. Nearly half of the 30 patients were newlydiagnosed with chronic kidney disease and recently initiated renal Myra Kleinpeter. Tulane University, New Orleans, Louisiana, USA replacement therapy. Treatment length was typically 2. 5 to 3hours 5 days a week. The average Kt/V was 42.1, and all subjects Locally and federally declared disasters and emergencies ranged received weekly SQ erythropoietin. Intravenous iron was admin- from severe weather events across to man-made chemical spills istered as needed at the local hospital infusion center. The average that disrupted dialysis services temporarily, throughout the year.
stay was for 1 to 2 months. Two deaths were reported that were Using an all-hazards disaster planning approach, the effects on dialysis not related to dialysis therapy. Two (6%) of the patients were suc- patients can be mitigated or prevented. A review of the federally de- cessfully trained and discharged on home therapies. A daily HD clared disasters and emergencies in 2009 was done and categorized program with NxStage is a feasible and effective way to provide with recommendations for dialysis patients to prevent morbidity and dialysis in a NH/rehab setting. In this center, patients were able to mortality from the emergency or disaster. Disasters in 2009 extended fully participate, progress in rehabilitation and eventually be across the nation, but were primarily related to severe storms through- transferred out of the rehab facility with improved independence.
out the year. Secondary effects from severe storms led to interruption Notably the program was successful in transitioning patients to of utilities, which resulted in disruption of dialysis services temporarily home dialysis. Further randomized studies are warranted to assess in most areas, occurred in some areas for extended periods. Alternate optimal regimen for HD in rehab setting.
dialysis services were arranged when services were interrupted. Bydeveloping and reviewing disaster plans periodically, dialysis providers Improving Home Dialysis Patient Retention: Quality and patients can recover early and minimize interruption of dialysisservices. Recommendations are made to mitigate the effects of the Assessment and Performance Improvement disaster on patients and assist dialysis providers in rapid recovery Eileen MacFarlane. WellBound of Mercer, Hamilton, New Jersey, USA from disaster. Using the all-hazards disaster planning approach,dialysis patients and providers are constantly prepared for inter- Patient retention is important in home dialysis training programs.
ruption in dialysis services by natural or man-made emergencies Training patients who do not succeed or who transfer to other and disasters. Dialysis providers are required to develop and im- facilities for their follow-up care is costly and demoralizing for plement disaster plans for patients and their services as a part of staff and disrupts patient care. Literature reports of dropout rates the current Medicare conditions for coverage. Information from from home dialysis are difficult to compare and there has been no this review of emergencies and disasters may be used to optimize average US rate reported in recent years. An analysis of our own emergency preparedness resource utilization to provide efficient data from January 1, 2009 to September 15, 2010 showed that use of dialysis services during declared emergencies and disasters.
28% of patients who began home dialysis training at our centertransferred to other facilities, mostly for in-center hemodialysis,which we do not offer. Most could be explained as ‘‘treatment failures'' due to difficulty learning or adhering to treatment re-quirements. Some had family dynamics that proved unsuitable for Adoption Barriers to Nocturnal Home Hemodialysis in home therapy, and some found other facilities closer to home/ Hong Kong (HK): A Three-year Review from Queen work for their follow-up care. We are concerned that our drop-out Elizabeth Hospital, HK rate is unacceptably high. We have started a QAPI project to an-alyze the situation and implement changes. An analysis of our Ho Sing Joseph Wong1, M. L. Bonnie Tam1, S. C. Agnes Cheung1, transfers-out pointed to nonadherence (as evidenced by repeated S. C. Janet Li1, K. F. Chau1, C. S. Li1, Andreas Pierratos3, r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 T. Christopher Chan2. 1Queen Elizabeth Hospital, Renal Unit, unit training period is 4 to 6 weeks, after which the patient trans- Hong Kong SAR; 2Toronto General Hospital; 3Humber River Re- fers to home to perform self-sufficient hemodialysis. During the gional Hospital, University of Toronto, Toronto, Ontario, Canada training period the patients go to the in-center unit 4 to 5 times/wk. The traditional hemodialysis machine gives patients the free- Background: Nocturnal home hemodialysis (NHHD) was started dom to plan their treatment within their own day-to-day sched- as a pioneer program in Queen Elizabeth Hospital (QEH) in May ules. Patients perform their dialysis treatment in various 2007 to serve the increasing HD demand in Hong Kong (HK).
individual ways, either during the day or night. Sometimes pa- Major barriers to NHHD in HK included (1) patients had to pay tients can also mix both night and day treatments together. Treat- for part of the program, (2) HK is adopting PD first policy, (3) ment time and day can be changed in a swift and individual basis.
limited household space in HK. A cross-sectional survey was cre- A short training time necessitates effective planning and swift ac- ated to assess the attitude of staff toward NHHD and to identify tion, what enables patients to quickly transfer to the hemodialysis the reasons for the low utilization rate of NHHD in HK. We hy- setting. Patient training commences straight away from the first pothesized that this survey can help the future development of treatment date in the in-center unit. Inserting dialysis needles is NHHD in HK. Methods: Nocturnal home hemodialysis is estab- begun when the trainer knows where the patient's good veins are lished as an alternate night HD (3.5 times/wk, 8 hours per treat- located. The patient commits to the training period by agreeing to ment) therapy. In QEH, we have 268 CAPD patients and 70 a withdrawal date to the home setting during the first training chronic center HD patients. Since May 2007, 19 patients (10 M:9 session. As well as learning the basics of their hemodialysis treat- F) with mean age of 44.9 10 years old were recruited. Eighteen ment, it is very important for the patients to learn to take respon- patients attained full vocational rehabilitation after conversion to sibility for their own treatment. At first the trainer strongly NHHD. The mean household size of patients was 690 242 sq ft.
supports the patient and creates a sense of security for the pa- All renal staff in QEH including 36 renal nurses and 8 renal phy- tient that this treatment will work. At the same time a relationship sicians had completed the survey. The survey will be distributed of trust is created between the patient and the trainer, that enables and extended to all renal staff in HK. Results: the patient to try to manage by themselves at home. The trainermust also allow the patient to fail, as this is an important part ofthe training. Home visits, technical modifications to be made in Perceived percentage of patients the home and various other issues to be considered are begun experiencing PD failure straight away from the start of the training session, so that patients Perceived percentage of existing center withdrawal date to the home hemodialysis setting does not get HD patients can be converted to NHHD delayed. On-call support is an indispensable service after the in- Percentage of staff perceiving NHHD is tensive training period. It helps to decrease patient anxiety when posing stress to family members transferring to the home hemodialysis setting as well as creating a Percentage of staff perceiving NHHD safety net for the patient.
as most ideal form of RRT Perceived major barriers to NHHD Financial barrier and Calcium and Phosphorous Flux During Long Perceived optimal frequency for NHHD Alternate night NHHD Hemodialysis Sessions and 5 times/wk NHHD Sadashiv Santosh, Janet Bardsley, Cheryl Cress, Brent Miller.
Department of Medicine, Renal Division, Washington University Conclusion: This survey identified the barriers and attitudes to- School of Medicine, St Louis, Missouri, USA ward NHHD in HK as perceived by renal staff and formed thebasis for the future planning and development of NHHD in HK.
Background: Long, overnight hemodialysis (HD) may have ben-efits over conventional HD due to increased removal of phosphate How is a Patient Trained for Home Hemodialysis in 4 (Pi) and other uremic toxins. Typically, calcium (Ca) baths of 3.0 to 3.5 mEq/L are used to prevent negative Ca balance and boneloss, Pi removal of 4800 mg per session is needed to eliminate Pi Sanna Laitinen, Riitta Muroma-Karttunen, Jyrki Hyttinen, Peter binders, and target urea reduction ratios are B50%. The System Tamminen, Ros-Marie Taponen, Virpi Rauta, Eero Honkanen.
One (NxStage Medical, Lawrence, MA, USA) system is primarily Helsinki Unit, Central Hospital, Helsinki, Finland utilized for short-daily HD with small dialysate volumes. Thepurpose of this pilot trial is to study removal of uremic toxins Helsinki University Central Hospital in Finland has from the be- using the NxStage system for extended-time HD. Methods: End- ginning of 1998 trained 232 patients to perform home hemodi- stage renal disease patients currently using the NxStage system alysis. The training program has been fine tuned, so that only the underwent 4 HD sessions with varying times and dialysate vol- essential information regarding patient care remains. This has also umes (see Table 1), using a dialysate Ca of 3.0 mEq/L. Timed impacted the training time required for patient education that has samples of blood and spent dialysate were collected throughout now been condensed to a very short time period. The in-centre the treatments. Spent dialysate was pooled and mixed samples r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts were used to calculate total removal of each substance. Re- scored similarly and were sustained at a consistently high level sults: Five patients completed all 4 treatments. Removal of var- throughout the 8-year study. However, our NHD patients did still ious substances per treatment is shown in Table 1. Mean removal feel that the total burden of their kidney disease and its treatment of protein and albumin were 4.0 and 0.8 g respectively. Discus- requirements remained significant, as was reflected by their lower sion: This is the first study to quantify Ca, Pi, and B2M removal though also stable scores for the ‘‘burden of kidney disease.'' Fur- during extend-time dialysis using the NxStage system. Pi removal ther analysis revealed statistically significant improvements may be sufficient to eliminate the need for oral binders. A Ca bath (Po0.05) in pre-NHD and 6 months scores in the domains, Bur- of 3.0 mEq/L resulted in essentially net-zero intradialysis Ca bal- den of Kidney Disease and Effect of Kidney Disease. Conclu- ance with ultrafiltration. A substantial fraction of B2M removal in sion: This study reveals that the symptom impact and lifestyle HD occurs by adsorption, so true removal was likely higher than limitations in the NHD group are broadly mild and do not dete- estimated by dialyzer-side measurements. Urea removal met the riorate throughout an 8-year follow-up period. However, there target for other extended dialysis studies. Conclusion: The System was a pervasive perception of frustration at the interference kid- One (NxStage) system used in long HD sessions results in sub- ney disease had on overall lifestyle. This impression persisted stantial removal of uremic toxins, and deserves further study in throughout the study period. This data suggests that despite the larger trials of extended dialysis.
lack of major lifestyle limitations, and despite physical and mentalstability, NHD patients are still dialysis-dependent—an unalter-able, permanent, additional encumbrance in their daily lives.
A Comparison of Quality of Life Across the ThreeDialysis Modalities All 1.13 5.9 1029 382 265 98 12380 3331 0.74 0.268 h, David Lau, Raelene Hungerford, Trish Kinrade, Robert MacGinley, Rosemary Simmonds, Christine Somerville, John Agar. Depart- ment of Renal Medicine, Barwon Health, Geelong, Victoria, Background: Numerous observational studies have shown the superiority of nocturnal hemodialysis (NHD) over conventional dialysis regiments, confirming improvements in left ventricular Values are mean SD.
mass, reduction in antihypertensives and phosphate binders, as B2M = B2-microglobulin; Cr =creatinine; est. from pre-HD BUN and well as better quality of life (QOL). To date, QOL comparison weight; TBUN = total body urea nitrogen; UN = urea nitrogen.
studies have been few, numbers small, and duration short. Our 6-year longitudinal prospective study compares QOL in NHD, sat-ellite (SHD), and peritoneal dialysis (PD) patients, using KDQOL-36TM, a validated QOL tool in dialysis subgroups. Methods: TheKDQOL-36TM questionnaire was collected at intervals of at least 6 A Longitudinal Follow-Up of Quality of Life Among to 12 months, from 2004 to 2009, results grouped into years since Patients on Nocturnal Hemodialysis commencing dialysis. Results: A total of 34, 19, and 29 surveyswere returned from patients who had been on dialysis for 0 to 1 David Lau, Raelene Hungerford, Trish Kinrade, Robert MacGinley, year; 78, 15, and 33 (1–3 years); 83, 11, and 19 (3–6 years); 92, Rosemary Simmonds, Christine Somerville, John Agar. Department 2, and 5 (46 years), in the SHD, PD, and NHD groups, respec- of Renal Medicine, Barwon Health, Geelong, Victoria, Australia tively. Quality of life in NHD did consistently better than bothSHD and PD, across all domains of the KDQOL. Nocturnal hemo- Background: Studies have shown that nocturnal hemodialysis dialysis also maintained superior QOL over time. Satellite hemo- (NHD) improves quality of life (QOL) when compared with con- dialysis also maintained similar QOL scores over time. There was ventional dialysis regimens. However, to our knowledge, there is a slow but consistent trend toward improvement in the burden currently no published QOL data of NHD patients followed over a and effect of kidney disease domains in patients who had been on prolonged period. We report the QOL outcomes for NHD over an 6 or more years of SHD. Peritoneal dialysis did poorly in our 8-year period. Method: Using the KDQOL-36, a validated tool in study, with QOL scores falling markedly with time, across all do- assessing QOL in dialysis subgroups, QOL data were collected mains, though numbers were small. We do acknowledge volun- annually from 2001 to 2009. Patients were categorized by their teer bias and an incomplete data set as potential confounders for NHD vintage. Results: A total of 111 surveys were returned in the this data. Conclusion: This comparative study, conducted over a 8 years, with a total of 314 patient-years on NHD. The 2 QOL significantly longer period of observation than previous studies domains reflecting the ‘‘prevalence of symptoms'' and the ‘‘indi- has confirmed that NHD sustains QOL over a 6-year period, in vidual restrictions placed on lifestyle by dialysis treatment'' both addition to its QOL superiority over both SHD and PD.
r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 Analysis of Blood Platelet Counts in Home Daily number of patients with low platelet counts. Overall platelet counts remain very consistent on a month-to-month basis.
Les Spry1, Sara Christianson1, Yoojin Lee2. 1Dialysis Center ofLincoln, Lincoln, Nebraska, USA; 2Tufts Medical Center, Boston,Massachusetts, USA Infection, Inflammation Study Design: We retrospectively analyzed blood platelet countsfrom 54 home daily hemodialysis (DHD) patients from the Dial- Klebsiella Pneumoniae Liver Abscess in a Hemodialy- ysis Center of Lincoln (DCL), NE, who initiated home DHD ther- apy on the NxStage System One between 2004 and 2009.
Yao-Min Hung1, Sen-Ting Huang2. 1Jiannren Hospital, Kaohsiung, Monthly blood platelet results were collected for each patient Taiwan; 2Long Cyuan Veterans Hospital, Pingtung County, Taiwan from the time they transferred from conventional in-center HD(CHD) up to and including their most recent count on DHD, as of Background: Pyogenic liver abscess is uncommon in patients July 2010. For patients that discontinued DHD before this time with end-stage renal disease undergoing maintenance dialysis point, data were collected up to the time of discontinuation.
therapy, but it is still a disease of significant mortality. We report Analysis consisted of a comparison between baseline (last count a 85-year-old man on hemodialysis with liver cirrhosis, who de- before transferring from CHD) and the last recorded count on veloped Klebsiella pneumoniae liver abscess and then pneumonia DHD (last count). A subanalysis was performed on the number of with neutropenia and fatal outcome. Case report: An 85-year-old patients with low platelet counts (o100,000, and o150,000). A man, who had history of liver cirrhosis and had been on hemo- separate analysis was performed to assess the month-to-month dialysis treatment for 3 months, was admitted with fever, weak- variation of platelet counts over a 6-month period between April ness, and general malaise. Physical examination on admission and September 2009. Patient Characteristics: Mean SD age revealed right upper quadrant tenderness Lab data showed le- was 60 14 years, 54% were female, 96% were white, ukocytosis and elevated alkaline phosphatase. Abdominal ultra- mean SD BMI was 31 8 kg/m2, and 63% used an arteriove- sound revealed a 7.2 cm hypoechoic mass with ill-defined margin nous fistula. Diabetes was the primary cause of end-stage renal at S5-6 junction, with cystic change and septums inside. Abdom- disease in 39%. The mean time on DHD was 2.7 1.8 years.
inal computed tomograpgy showed a ill-defined cystic lesion with Results: Baseline vs. last counts are presented in the table below.
septation and perifocal edema at S5-6 of liver noted, size about5 cm. Pyogenic liver abscess was impressed and managed with intravenous antibiotics and continuous catheter drainage. Fluid Mean count of all patients (1000s) culture was positive for Klebsiella pneumoniae. Severe leukopenia No. of patients with o150,000 with WBC low as 370/mL developed and then antibiotics adjust- No. of patients with o100,000 ment to piperacillin/tazobactam was done. However, spiking feverand shortness of breath developed 3 days later and CXR showed 1Baseline data were not available for 2 patients.
pneumonia. Antibiotics coverage including meropenem, lev- P value by signed-rank test.
3P value from MacNemar test.
ofloxacin, and vancomycin were used. However, disease progres-sion was noted and hypotension developed. The patient finally Average counts for all patients between the months of April to expired on day 22. Conclusion: We report a fatal case of Klebsi- September 2009 are presented below.
ella pneumoniae liver abscess and pneumonia with severe ne-utropenia in a patient with end-stage renal disease undergoing maintenance dialysis therapy.
Inflammation Markers, Chronic Kidney Disease and Count (1000s) 197 74 202 71 196 78 201 71 199 74 Renal Replacement Therapy Summary: Results show mean blood platelet counts did not Bernardo A. Lavin1, Rosa Palomar2, Marı´a Gago2, Estefanı´a change (210,000 vs. 205,000) over a mean follow-up time of Gomez1, Jose Antonio Quintanar1, Domingo Gonza´lez-Lamun˜o3, 2.7 years on DHD. There was no significant change in the number Manuel Arias2, Juan Antonio Go´mez-Gerique1. 1Clinical Bio- of patients that recorded low platelet counts (o100,000 and chemistry (Dyslipidemia and Vascular Risk Unit); 2Nephrology o150,000). Results over the 6-month timeframe between April Department; 3Pediatric Department, H.U.Marque´s de Valdecilla and September 2009 remained very consistent on a month-to- Santander, Cantabria, Spain month basis. Conclusion: Daily hemodialysis does not appear tohave any impact on blood platelet counts. Long-term follow-up of Introduction: Many studies show that the immune system partic- patients that transfer from CHD to DHD shows blood platelet ipates actively in the development of vascular disease. Early stages counts are maintained at similar levels, with no change in the of atherosclerosis are characterized by an infiltration of inflamma- r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts tory cells in the vascular wall, attracted by innate immunity. That is Pyuria In Hemodialysis Patients: Is It Significant? the reason why many researchers are interested in the study ofthese markers of inflammation (protein-standardized C-reactive Dawlat Sany, Yasser El Shahawy, Ahmed Aziz, Osama El Nabarawe.
protein [cCRP], pentraxin-3 (PTX3), the serum component of Department of Nephrology, Ain Shams University, Cairo, Egypt amyloid A (SAA), and procalcitonin (PCT). The aim of our studywas to describe the changes in emerging markers of innate im- Background: Dialysis patients are more susceptible to urinary tract mune and inflammatory response in populations with different infections (UTI). Delayed diagnosis is a relevant issue because the degrees of renal function. Material and Methods: We obtained urinary tract is often overlooked as a source of infection in dialysis serum-EDTA plasma of 139 individuals (69 people with normal patients. The diagnostic accuracy of pyuria in hemodialysis patients renal function (GP) Group 1, 25 chronic renal disease (stages IV has been incompletely evaluated and so the object of this study to and V) Group 2, 22 peritoneal dialysis (PD) Group 3, and 23 he- evaluate the value of pyuria in the diagnosis of asymptomatic uri- modilaysis (HD) patients Group 4. We analyzed the following se- nary tract infection among hemodialysis patients. Setting and Par- rum biomarkers: creatinine (sCre) (RXL2000 Dimension, Siemens ticipants: Fifty patients on regular hemodialysis with urine output Healthcare, Mannheim, Germany), cCRP, SAA, Cystatin-C (CysC) 4200 mL/d were dialyzed 3 times weekly with polysulfone dialyzer by immunonephelometry (BN-II, Siemens Healthcare), PCT by membrane, and bicarbonate dialysate. Microscopic examination of immunoassay (BRAHMS-PCT-sensitive, Kryptor, BRAHMS GmbH, urine for pyuria was done for all subjects as well as and urine cul- Hennigsdorf, Germany), and plasma PTX3 by ELISA (Human ture and sensitivity. Results: Thirty-two percent had pyuria 10 Pentraxin3/TSG-14 ELISA System, Perseus Proteomics, R&D pus cells/HPF together with significant bacteriuria. Among this Systems, Minneapolis, MN, USA). The statistical treatment of data group 87.5% had positive urine culture. Pyuria 10 cells/HPF (U-Mann-Whitney significance if Po0.050) was carried out with was shown to have high sensitivity, specificity and negative predic- the program Medcalc. Results: See Table 1. Conclusions: Protein- tive value (0.875, 0.94, 0.96), respectively, for diagnosis of urinary standardized C-reactive protein is increased in chronic kidney tract infection. In studied subjects with positive urine culture E. coli disease and does not increase with renal replacement therapy.
was the most prevalent organism. Conclusions: There is high prev- pentraxin-3 increases only when end-stage chronic kidney disease alence of pyuria and asymptomatic bacteriuria in the hemodialysis on HD. Serum component of amyloid A, acute phase reactant, has patients. Pyuria 10 cells/HPF is always associated with significant a similar behavior to C-reactive protein. Of particular relevance is bacteriuria and positive urine culture, so pyuria may be used in that PCT increased progressively as glomerular filtration rate de- detection and follow-up of asymptomatic bacteriuria.
clined, this increase was higher in PD and HD patients, which canconfuse the evaluation of septic states in these groups.
Humoral Immune System Dysfunction in ChronicKidney Disease: Role of Parathyroid Hormone Dawlat Sany1, Yasser El Shahawy1, Hany Refeat, Manal Mahran2, Mona Hosny1. 1Department of Nephrology, Nephrology andHypertension Division; 2Clinical Pathology Department, Ain Shams University, Cairo, Egypt 0.91 (0.88–0.95) 3.95 (3.48–4.41) Background: Chronic kidney disease (CKD) is a globally increasing 0.81 (0.75–0.86) 3.16 (2.89–3.44) condition associated with secondary hyperparathyroidism and im- 1.40 (1.19–2.11) 6.50 (3.57–8.32) a munological disorders. Methods: Sixty patients with CKD (predial- 0.55 (0.30–0.95) 7.11 (5.07–29.47) a ysis), and 20 healthy volunteers. Group I: 38 cases with high PTH 0.02 (0.02–0.03) 0.12 (0.09–0.16) acd levels. Group II: 11 cases with normal PTH levels. Group III: 11 cases 0.54 (0.30–0.95) 0.71 (0.32–1.50) d with low PTH levels. Group IV: Twenty healthy volunteers as control, blood study including S. Parathyroid hormone level by ELISA test, B-cell by flow cytometry, measurement of IgM and IgG concentration by 7.46 (6.40–8.52) 8.15 (7.33–8.96) radial immunodiffusion (RID). Study Design: Cross-sectional study to 5.34 (4.64–6.03) 5.56 (5.05–6.05) evaluate immunological state of CKD. Results: This study showed 7.60 (2.19–22.10) a 9.60 (6.62–16.38) a significant difference between cases and control group regarding WBC 9.69 (5.07–29.47) a 15.90 (6.80–37.48) a count, lymphocyte %, B cells %, IgM, IgG levels, and all the immu- 0.32 (0.20–0.46) abd 0.79 (0.45–0.99) abc nological parameters were lower in cases signifying marked humoral 1.52 (0.65–2.13) a 1.67 (1.05–2.27) ab immune suppression in CKD, but there was no significant difference between CKD patients with high (38 cases) and normal PTH (11 cases) level regarding the immunological parameters. Also there was a: Po0.05 when compared with (1); b: Po0.05 when compared with no significant correlation between PTH level and all the immunolog- (2); c: Po0.05 when compared with (3); d: Po0.05 when compared ical parameters although the mean value of all the immunological pa- with (4).
GP= general population.
rameters were lowest in CKD patients with high PTH level indicating r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 that PTH may not the only factor responsible for immune deficiency.
signs. The presence of 1 or more of these signs is awarded a score.
Conclusions: Chronic kidney disease patients have immune defect.
The total score then guides the management of a potential ESI. Wehave undertaken a validation exercise by getting various membersof the medical and nursing team to assess a panel of different exit- Development and Validation of a Hemodialysis site photographs to see what the interobserver variation in scoring Catheter Exit Site Evaluation Tool was. The sample size was small (n = 15), but the concordance withregard to discriminating between scores 4 or o4 was 480%. We David Makanjuola, Siddiq Anwar, Joseph Arthur, Maggi Steele, are in the process of carrying out a validation exercise on a larger Pauline Swift. St Helier Hospital, Surrey, UK group. Discussion: Since we introduced the scoring system aspart of a catheter care bundle in 2007, we have noticed a reduc- Introduction: Catheter related infection is an important cause tion in ESIs by about 60%.
of morbidity and mortality in dialysis patients. A systematic Conclusion: While we cannot completely attribute the reduction in approach to the evaluation and care of the catheter exit site for ESIs to the scoring system alone, we have found that it has led to a peritoneal dialysis has been established by Twardowski and Pro- significant reduction the number of inappropriate exit site swabs, want. Currently there is no similar tool available to evaluate exit thus preventing inappropriate administration of antibiotics. We be- sites of hemodialysis catheters. Methods: We have developed an lieve that this scoring system will help to standardize the practice of exit site scoring system, which aims to provide a systematic identifying ESIs and improve care of the exit site in the long term.
method of exit site evaluation and thus will hopefully help im-prove the identification of possible exit site infections (ESIs). Theintention is that any member of the dialysis team should be able tolook at the exit site at any hemodialysis session and make an as- Partnership within Network 13 to Improve the Dialy- sessment of the exit site using straightforward objective clinical sis Patient Immunization Rates for Influenza, Pneu-mococcal Pneumonia, and Hepatitis B Linda Duval, Cheryl George, Niloufar Hedrick, Sandra Woodruff,Myra Kleinpeter. ESRD Network 13, Oklahoma City, Oklahoma, USA Objectives: Immunizations are available for primary preventionof many infections for adults. Adult hemodialysis and peritonealdialysis patients despite having many opportunities for immuni-zation are often missed. A performance improvement project wasconducted to increase the rates of influenza during the recentH1N1 influenza outbreak. The project included an educationphase, baseline assessment of immunization rates, interventionand follow-up assessment of immunization rates. Methods: At thebeginning of the Network-wide project, overall across each state,influenza immunization rates were below the Centers for DiseaseControl and Prevention (CDC) reported average influenza immu-nization rate for adults and far below the Centers for Disease Controland Prevention target for adults. This project incorporated methodsfor educational interventions to improve patient acceptance of im-munizations, methods for educational interventions to improve staffparticipation in quality improvement activities, and improved tech-niques of quality improvement data collection and analysis by par-ticipants. Through this project, the immunization rates for hepatitisB and pneumococcal vaccine were also reviewed. The morbidity andmortality from invasive disease from Streptococcus pneumonae (pneu-mococcus) remains high and may be largely preventable throughpneumococcal immunization of high-risk adults, including dialysispatients. The current 23-valent vaccine is widely available and isefficacious with a low adverse event profile. Revaccination is rec-ommended in patients with immunocompromising conditions, in-cluding chronic kidney disease. Results: Improvement wasdemonstrated in all 3 focus areas at project's conclusion, with sta-tistically significant improvements noted in both influenza andpneumococcal vaccinations rates as seen here.
r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts do-single compartment model was used where the phosphorusmobilization rate was formulated as the difference between pre-dialysis and instantaneous plasma phosphorus levels multipliedby a proportionality constant KM. The model equations weresimplified to estimate KM from predialytic and postdialyticplasma phosphorus concentrations (Cpre and Cpost), ultrafiltrationrate (QUF), and measured KD: KM =Cpost(KD The results from this simplified approach were then compared withthose estimated from the full model using nonlinear regression.
Results: KM values estimated using simplified equation were106 54 mL/min compared with 99 47 mL/min obtainedfrom the full model. The Bland-Altman plot illustrates the 95%confidence interval ( 25, 39 mL/min) and mean (7 mL/min) of the difference between estimated KM using each method.
Conclusions: A simple method using only predialytic and postdi- alytic plasma phosphorus concentrations resulted in estimates ofphosphorus mobilization clearance similar to those when using thefull model; this approach may allow easy clinical evaluation ofphosphorus kinetics during HD.
Conclusion: The use of educational interventions to improve staff participation in QI, and collection and analysis of QI data can bereplicated in many practice settings to improve immunizationrates for dialysis patients and other patients with chronic illnesses.
A Simple Method to Estimate Phosphorus Mobiliza-tion in Hemodialysis Using Only Predialytic andPostdialytic Plasma Samples Modeling Phosphorus Kinetics During Short and Baris U. Agar1, Alp Akonur1, Alfred K. Cheung2,3, John K. Ley- Conventional Hemodialysis Treatment Sessions poldt1. 1Renal Division, Baxter Healthcare Corporation, McGawPark, Illinois, USA; 2VA Salt Lake City Healthcare System, Salt Lake Baris U. Agar1, Alp Akonur1, Ying-Cheng Lo2, Alfred K.
City, Utah, USA; 3Division of Nephrology & Hypertension, Uni- Cheung3,4, John K. Leypoldt1. 1Renal Division, Baxter Healthcare versity of Utah, Salt Lake City, Utah, USA Corporation, McGaw Park, Illinois, USA; 2Technology Resources,Baxter Healthcare Corporation, Round Lake, Illinois, USA; 3VA Background: We have recently developed a pseudo-single com- Salt Lake City Healthcare System, Salt Lake City, Utah, USA;4 partment kinetic model that includes phosphorus mobilization Division of Nephrology & Hypertension, University of Utah, Salt into plasma. This model was shown to describe intradialytic and Lake City, Utah, USA postdialytic phosphorus kinetics. In this study, we made furthersimplifications to permit estimation of phosphorus mobilization Background: The kinetics of plasma phosphorus during hemo- dialysis (HD) treatments cannot be described using conventional M) from predialytic and postdialytic blood samples.
Methods: The clinical data for the kinetic analysis were collected 2-compartment models. A pseudo-single compartment model in- from 22 chronic hemodialysis (HD) patients during a conven- cluding phosphorus mobilization from a large second compart- tional HD (CHD) session (241 27 min, dialyzer phosphorus ment was used in this study to estimate patient-specific parameters during short and conventional HD treatments. Meth- D): 146 30 mL/min). The previously reported pseu- r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 ods: The phosphorus mobilization rate was formulated as the Metabolism, Nutrition difference between predialysis and instantaneous plasma phos-phorus levels multiplied by a mobilization clearance (KM). Clin- The Effect of High-Protein Supplements on Serum ical data to evaluate the model were collected from 22 chronic HD Albumin Levels of Hemodialysis Patients patients (16 male, 6 female, 80 20 (SD) kg, 61 18 years ofage). Each patient was treated by a short HD (SHD) session Joan Andrews, Shauna Lee, Zvi Talor. DCI University of Florida, Gainesville, Florida, USA 152 25 mL/min) and a conventional HD (CHD) session(241 27 minutes, KD: 146 30 mL/min). Mobilization clear- Background: Analysis of monthly labs in our hemodialysis (HD) ance and the distribution volume of phosphorus (VD) were si- clinic showed only 20% to 30% of (HD) patients with an albumin multaneously estimated from several intradialytic and postdialytic of 4.0 g% or above. Objective: Since albumin is closely linked to (rebound) plasma phosphorus concentrations using nonlinear overall health outcomes, and low albumin is a major predictor of parameter estimation. Results: See figures below: estimates of mortality in HD patients—a plan was developed to improve KM (98 44 mL/min for SHD and 99 47 mL/min for CHD) for albumin levels to 4.0 g% and above in at least 40% of our HD each patient were correlated (concordance correlation coefficient patients. Methodology: The study lasted 5 months, April through [rc]= 0.85) and were not different (P= 0.74). The distribution vol- August 2010. Fifty patients participated. We offered VitalProtein ume of phosphorus estimates of 11.0 4.2 L for SHD and RX protein bars, Nepro supplemental dietary drink, and hard- 11.9 3.8 L for CHD (n˜c=0.45) were also not different boiled eggs to HD patients—each dialysis day on each shift. The (P = 0.34). Conclusion: The proposed pseudo-single compart- snacks contained an average of 16 g of protein. The snacks were ment model of phosphorus kinetics is relatively simple and distributed per individual patient preference. Documentation of describes phosphorus mobilization into plasma during HD treat- acceptance or refusal was maintained only on patients whose al- ments and postdialytic rebound.
bumin was below 4.0 each month. The dietician and nursing staffencouraged protein intake and educated the patients on the ben-efits of improved albumin Results: Sixty percent of patients in thestudy with an albumin below 4.0 g% accepted snacks at least 75%of the time. The other 40% of patients either accepted them oc-casionally or consistently refused. The average number of grams ofprotein per serving was 16 g. Those accepting snacks at least 75%of the time increased their protein intake by 36 to 48 g/wk. (Thegraph indicates the percentage of change in monthly albuminlevels, and the percentage of times protein snacks were offered.)By the end of the study our goal of albumin of 4.0 g% or above for40% or more patients was met. Summary: Even with good pro-tein intake, other factors such as infection, edema, surgery, orcertain disease conditions, can affect albumin levels. However, asa group, when protein intake increased, so did albumin. Conclu-sion: Increased protein intake with the provision of high-proteinsnacks at each dialysis treatment can help improve albumin valuesin HD patients. This correlates with better clinical outcomes forHD patients.
Carotid Atherosclerosis and Body CompositionAssessment by Bioelectrical Vectorial Impedancein Chronic Kidney Disease Patients Stage 2-5ND Secundino Cigarran1, Guillermina Barril2, Francisco Coronel3,Montserrat Pousa1, Montserrat Porteiro1, Marı´a Jesus Mendez1.
1Department of Nephrology, Hospital Da Costa Burela, Lugo,Spain; 2Department of Nephrology, Hospital Universitario de laPrincesa Madrid, Madrid, Spain; 3Department of Nephrology,Hospital Universitario San Carlos Madrid, Madrid, Spain Evidence suggests atherosclerotic vascular disease is a major causeof morbid-mortality in chronic kidney disease (CKD) patients.
r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts The prevalence of carotid atherosclerosis (CA) by ultra- in addition to assessment of serum 25 cholecalciferol and 1,25 sonoghraphy was significant higher in CKD than general popu- cholecalciferol (by ELISA), serum Ca, PO4, albumin, PTH (intact), lation. The aim of cross-sectional study is to assess the as well as HbA1C, HOMA(IR), and HOMA-b cell%. We detected relationship of CA with body composition markers. Two hundred significantly lower levels of both 25 and 1,25 cholecalciferol in both twenty-seven patients with CKD stages 2 to 5, were examined by diabetic and nondiabetic HD patients, compared with normal con- high-resolution B-mode ultrasonography (USBM) with a 7.5 MHz trol. Both 25 and 1,25 cholecalciferol levels did not correlate with linear array probe (LogiQ PRO7, GE Healthcare Medical System, all studied glucoparameters except a significant positive correlation Milwaukee, WI, USA). Body composition assessment was per- between serum level of 25 cholecalciferol and HOMA-B cell% in formed by whole tetrapolar bioelectrical vectorial impedance anal- diabetic HD group (A). It may be concluded that vitamin D level is ysis (BIVA) (EFG, Akern, Firenza, Italy). Data derived from BIVA commonly deficient in prevalent HD patients, and it may be an were Na-K exchange, Phase angle, body cell mass/ECW ratio, PA aggravating factor for defective insulin secretion in type 2 diabetic standardized (PA and PA SD derived from healthy population).
patients on prevalent hemodialysis treatment.
Data were analyzed by SPSS15.0. 168 (74.4%) had CA and com-pared with non-CA were older (68.66 10.1 vs. 54.34 10.5years, Po0.001), Diabetic (36.1% vs. 17.3%, Po0.001) (Table Determinants of Malnutrition Inflammation Complex 1).Carotid atherosclerosis is associated to older, lower glomerular Syndrome Severity in Patients on Maintenance filtration rate, diabetic and cellular damage expressed by increased Hemodialysis Patients Na-K exchange, lower PA, PA standard, and BCM/ECW ratio.
Further clinical trials are required to explain this biologic difference.
Christopher Agbo1, Frank Strutz2, Gerhard Mueller2. 1Depart-ment of Renal Medicine, Cambridge University Hospitals NHS, Table 1 T-paired test Cambridge, UK; 2Department of Nephrology & Rheumatology,Georg August University Hospital, Goettingen, Germany Objectives: Malnutrition Body cell mass (%) (MICS) is a common and universally identified condition among maintenance hemodialysis patients. Malnutrition inflammation score (MIS) is a comprehensive and quantitative system used to assess MICS. The aim of this study was to assess the determinants Expenditure (cal/d) of severity of MICS in maintenance hemodialysis patient. Meth- ods: We carried out descriptive cross-sectional study of patients undergoing hospital maintenance hemodialysis. Patients of age4 18 years and on hemodialysis 41 month were included in the study. The MIS of each patient was recorded and variables such as age, sex, duration on dialysis, total iron-binding capacity (TIBC)level, cholesterol were analyzed. Results: A total of 63 patientswere studied, the mean age was 68.4114.7, sex (male: 65.08%,female: 34.92%), mean duration on dialysis in months was 51 Study of the Relation Between Serum 25 and 1,25 (ranging 2–420), TIBC: 161132.4. The mean MIS was 5.112.5.
Cholecalciferol and Glucoparameters in Type 2 Duration on dialysis and TIBC were found to be strongly associ- Diabetic Prevalent Hemodialysis Patients ated with severity of MICS, P values of 0.012 and 0.025, respec-tively. Age, sex, cholesterol level had no significant association Mohamed Ibrahim, Walid Bichari, Iman El Gohary. Department of with the severity of MICS. Conclusion: Our study revealed in- Nephrology, Ain Shams University, Cairo, Egypt creased duration on dialysis and decrease in TIBC level as strongindependent factors that determine the severity of MICS in pa- Vitamin D is frequently given to hemodialysis (HD) patients for tients on maintenance hemodialysis.
management of mineral bone disease (MBD). However, extra skel-etal effects of vitamin D, and particularly on glucose homeostasisand insulin resistance in hemodialysis patients, are not well stud- Heparin-Induced Extracorporal LDL Precipitation ied. The aim of this study is to assess the possible relation between Apheresis in Hemodialysis Patients with Peripheral serum 25 and 1,25 vitamin D levels and parameters of glucose homeostasis in chronic prevalent hemodialysis diabetic patients.
Twenty patients suffering from type 2 diabetes mellitus on prevalent Roumen Penkov, Zorka Ramsheva, Konstantin Ramshev, Kalina HD (group A), another group (B) of 20 nondiabetic prevalent HD Penkova. Military Medical Academy, Sofia, Bulgaria patients, and a third group (C) of 12 normal subjects, were ran-domly selected. The 3 groups were similar in age, sex, and body Introduction: Peripheral arterial disease (PAD) is a major compli- mass index. All subjects were investigated by routine biochemistry cation in patients with end-stage of renal failure (ERF). The mech- r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 anism by which HELP apheresis affects PAD is still disputable. We suggest that HELP apheresis affects positively oxygen stress inPAD patients with diabetes. Methods: We have performed HELP Population Care Management Program in an apheresis procedure in 3 patients. All 3 patients have been on Integrated Healthcare System: How to Delay the dialysis treatment, however, for a different period of time. We Progression of Chronic Renal Failure through Patient have treated 2000 to 2500 mL of patient's plasma in every proce-dure, utilizing standard HELP system (HELP Futura). The proce- Education and Empowerment Activities dures have been performed at every 6 months. Results: We have Oscar Cairoli. Kaiser Permanente, Downey, California, USA observed improvement of ischemic symptoms in 2 patients (66%).
One procedure of HELP apheresis removes B70% of LDL from Kaiser Permanente is America's leading integrated health care or- patient's serum. Two of the patients have exhibited significant im- ganization. Founded in 1945, it is a nonprofit, group practice provement of severe symptoms of PAD, such as skin ulcers, after prepayment program with headquarters in Oakland, CA. Kaiser serial HELP treatment. The fibrinogen levels have been decreased Permanente serves the needs of 9.2 million members in 19 states by 35% in every single procedure and these decreases continued and the District of Columbia. Patients with chronic diseases are over the entire period of therapy. Conclusions: HELP apheresis the most complex, expensive and highest utilizers of our health- has improved ischemic symptoms in hemodialysis patients with care system. By moving from management of symptoms to a pro- PAD by reducing oxygen stress. We concluded that HELP aphere- active Population Management approach, we are able to identify sis is an effective treatment in hemodialysis patients complicated patients at risk and manage their disease before they are acutely ill by PAD, as well.
or at end of life. Our model can be applied to any population ordisease management program. We would like to share the busi- Study of Vitamin D (25 and 1,25 Cholecalciferol) ness case for population/care management and the progress we in Hepatitis C-Seropositive Prevalent Hemodialysis have made in Southern California Kaiser Permanente in our pre- end-stage renal disease (ESRD) and ESRD programs.Core compo-nents of our model include: Mohamed Ibrahim1, Walid Bichari1, Dawlat Sany1, Ahmed Awad-alla2. 1Nephrology Department, Ain Shams University, Cairo, 1. Early identification of patients at risk Egypt; 2Clinical Pathology Department, Banha University, Cairo, 2. Risk stratification 3. Clinical practice guidelines4. Proactive management Vitamin D deficiency is commonly recognized in prevalent hemo- 5. Care coordination dialysis (HD) patients who may have serious skeletal and extraskel- 6. Patient education etal complications in these patients. The liver is an important site for 7. Outcome measurement vitamin D synthesis (25 hydroxylation). The impact of hepatitis C 8. Continuous improvement.
virus seropositivity on serum levels of 25 and 1,25 vitamin D level inHD patients is not previously reported in the literature. The aim of Our program is customized to the individual member, assures a study is to assess serum level of 25 and 1,25 cholicalciferol in prev- comprehensive approach and continuity of care and results in alent hemodialysis patients. Twenty hepatitis C seropsitive (by high-quality outcomes in a cost-effective manner. The multidisci- ELISA) prevalent HD patients (Group A), another 20 hepatitis C plinary teams are led by the Renal Nursing Care Coordinator, who seronegative (by both ELISA and PCR) prevalent HD patients plays a critical role in the program's success. Her focus is on qual- (Group B), as well as a control group of 12 healthy subjects were ity of care, customer service, and overseeing costs of care.
randomly selected. All patients and control group were studied byroutine biochemistry including serum Ca, PO4, albumin, liver en-zymes, bilirubin, PT, as well as CRP, PTH (Intact), serum levels both The Expanding Role of the LPN of 25 and 1,25 cholecalciferol (by ELISA). We detected significantlylower levels of both 25 aand 1,2 cholecalciferol in HD patients Colleen Wile, Doris Kane. QE II Health Science Centre, Halifax, compared with control group. Moreover, though all our hepatitis C Nova Scotia, Canada seopositive patients were CHID A chronic liver disease, yet theirserum levels of both forms of vitamin D were significantly lower The LPN has been a member of the hemodialysis team in our unit than seronegative HD patients, whereas there was no significant for the past 18 years. With the increasing volume of dialysis pa- difference between the 2 groups of HD patients regarding Ca, PO4, tients, it became more evident that the knowledge/skill and com- CaxPO4 product nor PTH level. It may be concluded that hepatitis C petency of the LPN needed to be drawn upon in a more effective seropositivity in prevalent HD patients may be associated with more manner. Historically the role of the LPN was to act in the capacity severe deficiency of both 25 and 1,25 cholecalciferol serum levels of ‘‘ward aid.'' For example the LPN role included weighing pa- compared with seronegative HD patients, which may need more tients, assisting with blankets/snacks, and washing machines. The attention to vitamin D supplementation in this group of patients.
role of the LPN has evolved over the last 8 years to maximize their r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts scope of practice to help meet the needs of the patient population time to discuss about terminal care in patients on dialysis more they service. To meet the educational requirements to fulfill these new competencies, the LPN was provided with educational op-portunities to learn how to prime the dialysis machines, needle-established fistulas, and perform transonic measurements andeducation on how to work in a collaborative care model with RNs in the delivery of care for identified stable patients. Addi-tionally, an initiative in the hemodialysis unit began in 2007 with amandate to ensure that the right person was providing the right Use of Ionic Dialysance to Calculate Kt/V in Pediatric care at the right time for the right patient population. In accor- dance with this objective, the LPN scope of practice was further Olivera Marsenic, Kristi Booker, Kathleen Studnicka, Donna Wil- enhanced to include education on medication administration and son, Ann Beck, Tiffany Swanson, Dwayne Henry, Martin Turman.
care of stable tunneled CVC catheters. All of these efforts have Oklahoma University Health Sciences Center, Oklahoma City, enabled LPN to maximize their practice thus enabling the RN to be able to coordinate and develop the plan of care for our dialysispatients.
Objective: On-line clearance (OLC) monitor measures conduc-tivity difference between dialysate entering and leaving thedialyzer, with different electrolyte concentrations. The derived Recognition Level About ‘‘Living Will'' and ‘‘Right to ionic dialysance then represents effective urea clearance (KECN), Die'' in Maintenance Dialysis Patient in Japan from which Kt/V is calculated. This allows for Kt/V to be mon-itored at every treatment without blood sampling. Although Hitomi Unozawa1, Taku Mimura2, Hitomi Katori1, Mayumi Kat- widely used in adults, use of ionic dialysance has not been re- sube3, Hidetomo Nakamoto4. 1Tamura Memorial Hospital, Nurs- ported in pediatric hemodialysis (HD). Our objective was to ing Session, Choshi, Chiba, Japan; 2Department of Nephrology, test ionic dialysance accuracy in children on HD and provide Tamura Memorial Hospital, Choshi, Chiba, Japan; 3Shinyamate recommendations for its use in this population. Methods: Thirty- Hospital, Nursing Session, Musashi-murayama, Tokyo, Japan; eight HD sessions in 11 patients (13–19 years; 6 M, 5 F; 4Department of General Intetnal Medicine, Saitama Medical weight 33–55 kg) and 140 calculated Kt/V results were studied.
School, Iruma-gun, Saitama, Japan Fresenius machines 2008 K with built-in OLC monitors wereused. To calculate Kt/V from ionic dialysance, urea distribution Background: In Japan, recently concern about discontinuance of volume (V) is needed as an input. Three methods of V estimation maintenance dialysis or the nonintroduction of the dialysis in were used: Mellits and Cheek (MC), 27 4 L; total body water end-stage renal disease patients was increasing, especially in pa- nomograms (TBWN), as recommended by KDOQI, 24 3 L; V tients with aged, handicapped, bedridden, and impaired con- derived from OLC independent from tested HD sessions, sciousness. However, small number of dialysis centers explained 20 5 L. Reference Kt/V was calculated as sp Kt/V from predi- about death with dignity and advanced directives. In Japan, over alytic and post-HD BUN from blood samples, using urea kinetic time, discussion about death with dignity and terminal care had modeling. This sp Kt/V was then compared with Kt/V calculated been avoided. Aim: To clarify the recognition levels about ‘‘Right from KECN derived from OLC and representing K, duration of to Die'' and ‘‘Living Will'' in patients on dialysis. Method: We in- HD session t and 3 different Vs, providing 3 groups of Kt/V re- vestigated the recognition levels of ‘‘Living Will'' and ‘‘Right to Die'' sults: (1) Kt/V-MC, (2) Kt/V-TBWN and (3) Kt/V-OLC. Re- in patients on dialysis. The questionnaire survey about the rec- sults: spKt/V was 1.68 0.22, 1.24 to 2.26, n = 38; Kt/V-MC ognition of ‘‘Right to Die'' and ‘‘Living Will'' was performed to 149 was 1.23 0.15 (n = 38, %bias 25.88 10.64, r = 0.292, maintenance dialysis patients in the Tamura Memorial Hospital in Chiba Prefecture and 53 maintenance dialysis patients in To- korozawa Kidney Clinic in Saitama Prefecture. Results: As a re- 1.70 0.21 (n = 26, %bias 7.86 6.15, r = 0.642, P40.05).
sult, the patient over 70% had recognition concerning necessity of Conclusions: Ionic dialysance accurately calculates Kt/V in pedi- ‘‘Living Will'' and ‘‘Right to Die'' in each clinic. In addition, having atric HD patients when V is estimated by OLC. The TBWN the hope for ‘‘Right to Die'' in the state of the end became clear in method for V estimation results in more accurate Kt/V than if us- the patient of 70%. However, the recognition of the medical treat- ing MC formulas, but consistently underestimates Kt/V. The ment person side to it is a situation in which it is insufficient, and TBWN method can be used if average difference of 0.3 in Kt/V not performed a religious backup. In addition, the system of in- is accounted for. This is the first study of use of ionic dialysance in formed consent about ‘‘Right to Die'' and ‘‘Living Will'' is poor.
children and it provides recommendations for accurate use. On- Conclusions: The recognition of maintenance dialysis patients line clearance monitoring of each HD session allows timelier op- about ‘‘Living Will'' and ‘‘Right to Die'' is extremely high in timization of HD without blood samples. The ability to provide Japan. However, small number of dialysis centers explained about timely feedback is especially important in pediatrics where death with dignity and advanced directives. In Japan, it comes at monthly assessments may be insufficient.
r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 Preliminary Examination of Medical Traumatic Stress and helplessness. Two caregivers (11.8%) and 2 patients (8.7%) Symptoms in Pediatric Dialysis Patients and Their met criteria for a PTSD diagnosis based on endorsed symptom frequency and severity. Examination of PTSD symptom clustersreveal that significantly more caregivers (76.5%) than patients Shari K. Neul1, Stuart L. Goldstein2. 1Renal Section, Baylor Col- (40%) recalled dissociation (i.e., felt as if events were not real; lege of Medicine & Texas Children's Hospital, Houston, Texas, w2 = 4.98; P = 0.03) and intrusive symptoms (e.g., bad dreams, USA; 2Cincinnati Children's Hospital, Cincinnati, Ohio, USA upsetting memories; see Table 1), with both groups experiencingarousal symptoms (e.g., difficulties sleeping, hypervigilance) to Diagnosis of end-stage renal disease and initiation of dialysis (ID) less of a degree. Avoidance symptoms (e.g., avoiding thoughts, can be upsetting and life-altering for children and caregivers. Di- people associated with dialysis) were least recalled.These results alysis can be painful and life-threatening events may occur (e.g., suggest that diagnosis of end-stage renal disease and ID is asso- myocardial infarction, severe HTN) leading to distress and poten- ciated with MTS in some patients and caregivers. Screening for tial traumatic stress. Recent research in pediatric medical popu- MTS in pediatric patients ID and caregivers may be warranted lations has demonstrated that children and their caregivers may prompting early intervention efforts, which may improve at-risk experience significant traumatic stress, i.e., medical traumatic patient and caregiver adjustment and functioning.
stress (MTS), when faced with life-threatening and serious chronicillnesses and dealing with burdensome and invasive treatments.
Medical traumatic stress can include psychological and physio- Nurse-driven Initiative to Improve AV Fistula Rates in logical symptoms similar to PTSD of hyperarousal, re-experienc- Pediatric Patients ing/intrusiveness, and avoidance resulting in poor adjustment andcoping. To date, no one has investigated MTS in the pediatric di- Laurel More, Barbara Cometti. The Children's Hospital, Aurora, alysis population and its impact on patient and caregiver func- tioning. Now underway is a retrospective study of patient and Background: Arteriovenous (AV) fistulas are considered the ideal caregiver recall of MTS symptoms associated with ID utilizing a permanent vascular access in hemodialysis patients. Advantages modified version of a commonly used self-report PTSD symptom associated with AV fistulas are decreased incidence of infection checklist (UCLA-PTSD reaction index). Preliminary data are avail- and clotting, improved dialysis adequacy, decreased hospitaliza- able from 28 of our patients (mean age 16.5 years; 82.4% male; 9 tions, and improved patency rates. Permanent access in the pe- HD, 3 home HD, 6 PD, 10 TX) and 16 caregivers (10 patient- diatric population presents unique challenges due to the size of caregiver dyads). Time since ID ranged from 3 to 126 months with the patient and lower blood pressures can make the placement just over half of the patients (13–22 years) recalling ID as trau- and on-going patency of the AV fistula difficult. Purpose: The matic. A majority of caregivers recalled these events as traumatic purpose of this project was to increase the number of AV fistulas for themselves and for their children producing significant fear placed in pediatric patients receiving hemodialysis in 2010 at atertiary pediatric hospital. Methods: Nurse driven initiatives in-volved the following: Table 1 Summary of preliminary data on recall of PMTSassociated with initiating dialysis Multidisciplinary monthly Quality Assessment Performance Im- provement (QAPI) meeting to review AV fistula rates and de- velopment of strategies for improvement Early scheduling for AV fistula surgical evaluation Comprehensive patient/family education Utilization of a child life specialist for support of the patient Caregiver Self-report undergoing cannulation 3 times a week Extensive staff education and training related to assessment of Patient self-report AV fistulas and cannulation techniques Development of new AV fistula policy and procedure to address Symptoms most frequently development of the nurse's skill level in the cannulation of AV fistulas that are less mature Implementation of formal surveillance process to identify AV fistulas that are not functioning optimally.
Caregiver Self-report Results: Improvement in usable AV fistula rates from 25% in 2009 to 72% YTD 2010. Decrease in bacteremic events from 4.23 Patient self-report events/1000 HD (hemodialysis) days in 2009 to 0.94 events/1000 HD days YTD 2010. Discussion: Variation in RN skill mix re- Severity score cutoff 38 indicative of possible PTSD.
quired creating appropriate staffing patterns and increased nurs- r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts ing time. Participation of patients in education of fellow patients.
This project highlights the utility of rapid cycle PDSA in quickly Conclusion: Exceeded fistula first initiative of 66%. Reduction in impacting clinical outcomes.
bacteremic events per 1000 HD days.
Estimation of Pediatric Standard Kt/V from 30-SecondBUN: Concordance with a Gold Standard Implementation of a Blood Volume Monitoring Proto-col Using a Quality Improvement Model in a Pediatric Cherry Mammen1, Stuart Goldstein2, Poyyapakkam Srivaths3,White Colin1. 1Department of Pediatrics, Division of Nephro- logy, BC Children's Hospital, Vancouver, British Colombia, Can- Donald J. Weaver, Jr, Patti Spina. Levine Children's Hospital, ada; 2Department of Pediatrics, Division of Nephrology and Hy- Charlotte, North Carolina, USA pertension, Cincinnati Children's Hospital Medical Center,Cincinnati, Ohio, USA; 3Department of Pediatrics, Renal Section, Introduction: Pediatric hemodialysis (HD) patients are at risk for Baylor College of Medicine, Houston, Texas, USA development of severe left ventricular (LV) hypertrophy, which is aknown risk factor for cardiovascular mortality in adults. Hyper- Background: Previously we derived standard Kt/V (standard Kt/ tension and chronic volume overload are 22 of the most signifi- V) values for children on thrice-weekly hemodialysis (HD) using cant risk factors for development of LV hypertrophy. Estimating the gold standard of a 30-second and 15-minute post-HD BUN and achieving dry weight in pediatric HD patients is a difficult eKt/V equation (Goldstein). Despite its theoretical benefit, the process due to many reasons and is made more difficult due to need for obtaining a 15-minute sample may be onerous for pa- pediatric patients' growth on dialysis that is not seen in the adult tients and dialysis units. Purpose: Determine the accuracy and population. Through the use of noninvasive monitoring (NIVM) concordance of pediatric standard Kt/V values derived using only of the hematocrit, a more accurate method of estimating the dry 30-second BUN samples as compared with Goldstein's eKt/V.
weight has been established. Rationale: Our goal is to improve Methods: Four published adult eKt/V equations (Table 1), which the overall health of chronic hemodialysis patients in the pediatric use only 30-second BUN values, were compared with Goldstein's dialysis unit by implementing a change package of evidence-based eKt/V from 399 chronic HD runs. All standard Kt/V values were strategies to optimize dry weight and volume control. Goals of this calculated by Leypoldt's standard Kt/V formula & rounded to the project include decrease in intradialytic symptoms, accurate doc- nearest 0.1 U. Sensitivity, specificity, positive and negative predic- umentation of dry weight assessments each month, standardized tive values were calculated for standard Kt/V estimated by the 4 blood volume monitoring (BVM) protocol using the hematocrit adult-based formula in comparison with Goldstein derived stan- monitor, and documentation of ultrafiltration rate changes which dard Kt/V at the cut-off of 2.2 (equivalent to spKt/V 1.4).
will include rationale for these changes based on BVM. Meth- Results: See Table 1. Discussion: As individual or unit under- ods: To achieve this, the model for improvement and rapid cycle dosing of dialysis would generally be of most concern, we con- PDSA's before implementation of change ideas will be utilized. We sidered positive predictive values to be the most valuable metric.
will implement a standard BVM protocol, perform monthly (min- Based on criteria, all formula as applied performed well in com- imum) dry weight assessments of all pediatric HD patients, and parison to eKt/V (Goldstein) with PPV 85%. For most pediatric improve documentation of changes and patient response during HD units, we suggest that any of the 30-second post-BUN equa- ultrafiltration. Measurements will include percent decrease in int- tions provide an acceptable substitute for Goldstein's eKt/V in radialytic symptoms, percent of dry weight assessments per- monthly monitoring of standard Kt/V. However, given the current formed each month at a minimum, percent of time the values observed, we suggest Goldstein derived standard Kt/V still standardized BVM protocol is used with patients receiving ultra- be used for outcome studies. Future analysis is planned around filtration and percent of time documentation for ultrafiltration rate issues of access specificity as both the Tattersall and Daugirdas changes and description and rationale for changes. Results: This eKt/V formula also account for arteriovenous fistula/arteriovenous protocol was implemented in July 2010 and to date we have graft vs. catheter use.
shown that 100% of patients who are being ultrafiltrated areplaced on the BVM protocol. Ninety percent of medical recordsreviewed demonstrated documentation of BVM readings andchanges in ultrafiltration rate in accordance with the protocol.
Table 1 Concordance with standard Kt/V calculated based In terms of blood pressure control, we have seen that 50% of el- on Goldstein's eKt/V igible patients have documented improvement in predialysisblood pressure readings. Review of intradialytic symptoms has shown a decrease from 12% of patients with documented intra- dialytic symptoms (nausea, vomiting, hypotension, dizziness, muscle cramps, etc.) to 7.6%. Conclusions: Ongoing analysis will confirm these preliminary findings leading to our goal to improve the overall health of our chronic pediatric hemodialysis patients.
r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 Otoneurological Evaluation in Children and treatments (64/67), albumin diluted in Ringer lactate in the other Adolescents on Hemodialysis: Preliminary Data 3 sessions. An arterovenous fistula was used as vascular access in5 patients, whereas 2 children used either percutaneous or tun- Lucimary Sylvestre1, Karlin Klagenberg2, Paulo Liberalesso1,2, neled central venous catheters. We prescribed for HD the dial- Bianca Zeigelboim2, Ari Jurkiewicz2. 1Hospital Pequeno Principe, yzers that patients have been currently utilizing (surface area 0.3– Curitiba, Parana, Brazil; 2Universidade Tuiuti do Parana´, Curitiba, 1.8 m2). Peritoneal exchange was performed using the Gambro PF2000N Plasmafilter (0.3 m2). The HD circuit was first con-nected and the ultrafiltration started. Hemodialysis blood flow Background: Patients with chronic kidney disease can develop rates (HD QB) was maintained in the usual range of the patient.
several systemic side effects. Neurologic and hearing complications When cardiocirculatory parameters were stable, the PE circuit was can be frequently seen, however, they are not routinely accessed.
connected by means of a U-shaped connector positioned imme- The aim of our study was to investigate hearing and vestibular diately before the venous access of the patient. Blood pump functions in pediatric patients on hemodialysis. Methods: We velocity of the BM25 device was set at 30% to 70% of the HD evaluated patients from 5 to 16 years old on hemodialysis. All of QB. No supplemental heparin was added to the circuit, compared them were submitted to otologic inspection, audiological screen- with the usual dose of HD. The exchange volume was 100% to ing (audiometry and imitanciometry) and vectoelectronystagmo- 150% of the plasma volume. No calcium gluconate infusion was graphy (vestibular balance evaluation). Results: Ten patients were prescribed. In 66/67 treatments TPH was successfully completed.
eligible for the study, 5 male and 5 female, from 5 to 16 years old, Only one treatment was complicated by a hypotensive episode, in all of them on hemodialysis at the same pediatric center. Audio- a 31-year-old woman, whose past history was characterized by metric evaluation showed moderate neurossensorial unilateral recurrent intradialytic hypotensive episodes. We conclude that hearing loss in 1 patient (10%), all of them showed type A tym- TPH is a safe and well-tolerated procedure, even in children and panograms (normal), 40% of the patients had alterations in ves- adolescents with stable cardiocirculatory conditions.
tibular assessment—3 with peripheral vestibular syndrome and 1(10%) with irritative type peripheral vestibular syndrome. Discus-sion: Even though hearing impairment is frequent in chronic kid- Dialysis Headache Due to Dialysis Disequilibrium ney disease patients, there are few large studies looking at this Syndrome Related to a Medulloblastoma subject. Dizziness is not an unusual complaint, but is more asso-ciated to hypotension. Conclusion: Our study suggests that we Robertino Dilena1, Fabio Paglialonga2, Sergio Barbieri1, Alberto should take more careful look to the otoneurological evaluation.
Edefonti2. 1Department of Neurological Sciences; 2Pediatric Ne- Vestibular assessment by vectoelectronystagmography appeared as phrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospe- a sensible method in pediatric patients and should be used rou- dale Maggiore Policlinico, Milan, Italy tinely in order to help improving their quality of life.
A 5-year-old boy with end-stage renal disease due to congenitalanomalies of the kidney and urinary tract was shifted from peri- Tandem Plasmapheresis and Hemodialysis in a Pedi- toneal dialysis, performed since the age of 6 months, to hemo- atric Dialysis Unit dialysis (HD) because of recurrent peritonitis. Since his first treat-ment he complained of headache during the HD sessions: the Fabio Paglialonga, Gianluigi Ardissino, Antonietta Biasuzzi, Sara headache had frontal location and throbbing quality, had its onset Testa, Alberto Edefonti. Pediatric Nephrology and Dialysis Unit, 1 hour after the beginning of HD and ended with the end of HD Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, treatment. Nausea and vomiting were sometimes associated. Di- alysis prescription was adequate and predialysis azotemia was140 mg/dL. Intradialytic mannitol infusion, sodium profiling and The simultaneous application of plasmapheresis (PE) and hemo- reduction of blood flow rate proved unsuccessful in improving the dialysis (HD), known as tandem PE and HD (TPH), is useful in symptoms. Dialysis headache, supported by familiar susceptibility patients who necessitate both techniques: however, little experi- to migraine and normal neurological examination, was initially ence exists about its use in pediatric dialysis units. We retrospec- hypothesized. One month after the first HD-related headache, tively reviewed the TPH sessions performed in the last 5 years in short episodes of mild headache began to appear occasionally out our institution. There were 67 TPH treatments in 7 patients, me- of the HD sessions. Brain computer tomography and magnetic dian age 16.2 years (range 5–34), median weight 37 kg resonance imaging showed a triventricular hydrocephalus and a (17.0–59.0). Indications for TPH were atypical hemolytic uremic median large cerebellar mass. A radical surgical resection of the mass was performed, leading to the diagnosis of medulloblastoma.
glomerulosclerosis (immediately before kidney transplantation) After surgery, no more headaches occurred. To our knowledge, and hyperimmunization in patients waiting for a kidney trans- this is the first report of a medulloblastoma presenting with di- plant in the remaining 3 sessions. In all of the cases Gambro AK alysis disequilibrium syndrome (DDS). Disequilibrium syndrome 200 ultra machine was used for HD and Baxter BM 25 device for is the clinical manifestation of an acute neurological dysfunction, PE. Fresh frozen plasma was used as substitution fluid in most attributed to cerebral edema occurring during HD treatment. An r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts intradialytic increase of intracranial pressure was shown in these culties in pediatric dialysis patients should be part of HRQOL as- patients, due to the so-called ‘‘reverse osmotic gradient'': during sessment. Screenings can identify need for sleep study referrals and HD, the clearance of organic osmolytes is slower across blood- inform dialysis unit initiatives to offer education and strategies for brain barrier than across HD membrane, generating an osmotic improving sleep quality in our patients.
gradient that produces water movement into brain cells. In ourpatient the compensatory reserve had to be low, because of the Pica: An Important and Unrecognized Problem in cerebral mass. In conclusion, when evaluating patients who de- Pediatric Dialysis Patients velop neurological symptoms during HD treatment, disequilib-rium syndrome must be differentiated from simple dialysis Chryso Katsoufis, Myerly Kertis, Judith McCullough, Tanya Pere- headache, the former presenting with symptoms of intracranial ira, Wacharee Seeherunvong, Jayanthi Chandar, Gaston Zilleruelo, hypertension. Disequilibrium syndrome can hide causes of re- Carolyn Abitbol. Division of Pediatric Nephrology, Holtz Chil- duced compliance of intracranial compartment, like intracranial dren's Hospital, University of Miami, Miami, Florida, USA tumors: in such cases, paradoxically, HD allows for an earlier di-agnosis of intracranial lesions.
Background: Pica, defined as the compulsive consumption ofnonnutritive substances, is thought to be increased in the dialysis Sleep Disturbances in Pediatric Patients on In-Center population. Little is known regarding the incidence or the met-abolic complications resulting from pica, particularly in children.
Objective: The purpose of our study was to determine the prev- Annabelle N. Chua, Shari K. Neul. Baylor College of Medicine, alence of pica among patients in our pediatric dialysis center. De- Texas Children's Hospital, Houston, Texas, USA sign/Methods: Eighty-seven patients followed on chronic dialysistherapy were surveyed for consumption of nonnutritive sub- Sleep disturbances, such as sleep-related breathing problems stances. Those with pica were assessed for demographic, nutri- (SRB), restless leg syndrome (RLS), and periodic limb movements tional, and metabolic characteristics. Dialysis efficiency was during sleep (PLMS), are commonly reported in adult dialysis pa- estimated by calculating urea clearance per patient volume (Kt/ tients, with a prevalence of 60% to 80%. One study in pediatric V). Sixty-seven (76%) patients were receiving hemodialysis (HD) dialysis patients revealed that 86% of children undergoing dialysis- 3 to 4 times weekly on hollow fiber dialyzers. Twenty (23%) pa- endorsed sleep disturbance symptoms. In our dialysis population tients were maintained on peritoneal dialysis using nightly cycling at Texas Children's Hospital, fatigue was a common complaint (CCPD). Results: The patients' mean age was 17.2 7.2 years.
noted on Health-Related Quality-of-Life (HRQOL) assessments. As The race/ethnicity of the population was predominantly nonwhite a result, the Pediatric Sleep Questionnaire (PSQ) is currently being (93%). Dialysis efficiency reflected by Kt/V averaged 1.5 0.5.
administered as part of an ongoing Quality Assessment and Per- The survey indicated that 46% of patients experienced some form formance Improvement Initiative (QAPI) to screen for sleep-related of pica, divided into simple ‘‘ice'' pica (34.5%) vs. ‘‘hard'' pica difficulties in our in-center hemodialysis population. Caregiver (12.6%). Hard pica included the compulsive consumption of and/or patients were individually interviewed using the PSQ to chalk, starch, soap, sand, clay, Ajax cleanser, sponge, and potting determine risk of SRB, excessive daytime sleepiness (EDS), PLMS, soil. Those on HD were 8.3 times more likely to have hard pica and insomnia (INS). Behavioral and environmental factors associ- compared with those on CCPD. Greater than 5 years on dialysis ated with disturbed sleep patterns were also assessed. Patients was associated with a 3.2 odds ratio (OR) of having pica were excluded if on dialysis for o2 months. Preliminary data on (P = 0.02). Anemia was the most significant morbid association 16 patients (62.5% male) with an average age of 16.31 years (mean with pica, occurring at an OR of 4.4 (P = 0.001) for all pica and 6.5 7–22 years) are currently available. Two patients were identified as (P = 0.02) for hard pica. Once pica initiated, an ‘‘addictive'' nature meeting criteria for a suspected sleep disorder (i.e., criteria met on to the consumption became apparent. Intervention consisted of 1 of 4 domains screened) with 4 patients (25%) identified as being behavioral modification employing substitution strategies by child at-risk for PLMS. None were identified as being at-risk for SRB psychology. Conclusion: Our data indicate that pica is a prevalent disorder. Of note, a subthreshold level of PLMS symptoms were and potentially harmful affliction that needs further attention in endorsed by 4 patients with 2 of these (plus 1 additional) patients the nutritional management of dialysis patients.
also endorsing a subthreshold level of SRB symptoms. Daytimesleepiness, complaints of daytime sleepiness, and commonly tak- Effect of Varied Dialysate Bicarbonate Levels on ing a daytime nap were endorsed by 25%, 44%, and 63% of pa- Phosphate and Potassium Removal: A Pilot Study tients, respectively. Five patients rated 2 or more ADHD symptomsas notably problematic with nearly 38% (6) falling sleep with the Konggrapun Srisuwan, Turki Al-Shareef, Michelle Frieling, Nemec TV on, 31% (5) falling asleep with music on, and 19% (3) having Rose, Mukesh Gajaria, Elizabeth Harvey, Denis Geary. The Hos- background noise interfering with sleep. These preliminary results, pital for Sick Children, Toronto, Ontario, Canada on nearly 50% of our in-center HD patients, support findings fromprevious research on sleep problems in pediatric end-stage renal Background: Elevation of serum phosphate (P) and potassium disease and provide initial evidence that screening for sleep diffi- (K) is common in dialysis patients. Alkalosis shifts P and K into r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 erythrocytes, and may reduce removal during dialysis. Therefore, forcement and allowed the staff to play a more active role in ed- lower bicarbonate dialysate might increase their removal with ucating and rewarding the patients for their accomplishments.
hemodialysis (HD). Objectives: Compare P and K removal in se- Methods: Before introducing the project to the patients, our child rum and dialysate during HD with low (28 mmol/L) and high life specialist provided education to our interdisciplinary team to (38 mmol/L) dialysate bicarbonate concentrations. Methods: Sta- discuss developmentally appropriate ways to communicate with ble children on maintenance HD with an elevated predialysis se- and to teach patients. Next, the patients painted self-portraits to rum P were studied. Each patient was evaluated as follows; 1 week be displayed in the dialysis unit to create a team feeling and to with low dialysate bicarbonate, 1 week with high dialysate bicar- reinforce the ‘‘we can do it'' concept. Nursing, dietary, and child bonate, 1 week washout between the cross-over. Each dialysis life staff introduced the goals to each patient. Goals included rec- session was standardized and consistent except for dialysate bi- ognizing target potassium and phosphorus levels, minimizing in- carbonate. All patients continued their prescribed P binder. Mean terdialytic weight gains, and adhering to their assigned dialysis serum P, K, and bicarbonate levels of each predialysis, postdial- schedule. Potassium levels were checked before dialysis and pre- ysis-, and 1 hour postdialysis treatment values are presented. Di- dialysis weights were checked to determine interdialytic weight alysate P and K levels are mean of q30-minute aliquot samples gains. Phosphorus levels were checked intermittently and patients during each dialysis. Results: Six patients, aged 16.0 2.5 were were rewarded if the level was decreased from previous labs or studied (4/6, male).
remained within goal range. Patients were also rewarded if theycame to dialysis treatments on time. Rewards for each goal achieved were colored poker chips that each patient wrote his Serum predialysis name and achieved goal on and placed into a clear bucket. The chips provided a reward that was visible as the team watched the chips build up in the bucket, tactile as patients touched and wrote on the chips, immediate personal reinforcement, and team effort Serum Postdialysis to motivate. Once the bucket was full, the entire dialysis unit re- ceived a cotton candy party for reaching their goals as a team.
Results: Child life was very helpful to the team in facilitating communication and educating patients. This project helped us Serum 1 hour Postdialysis recognize that many patients did not know their potassium, phos- phorus, or fluid intake goals. The project helped improve staff, patient, and family communication. Families and patients were more engaged with their interdisciplinary team. This project Dialysate Excretion helped individuals identify problems they had with their medical regimen and work toward improving compliance in a fun and positive manner.
Conclusion: This study failed to demonstrate that lower bicar- Plasma Exchange for Patients with Steroid-Resistant bonate dialysate content increases P and K removal.
Nephrotic Syndrome Gianluigi Ardissino, Fabio Paglialonga, Sara Testa, Antonietta You Can Do It: Educational Incentive Project for Biasuzzi, Maria Elena Albion, Giovanna Bagnaschi, Alessandro Children on Hemodialysis Biasibetti. Pediatric Nephrology and Dialysis Unit, FondazioneIRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy Kirsten Cotten-Sheldon1, Sabrina Martinelli1, Kathy Cagan1,Brandy Begin1, Kari Salsbery1, Cynthia Wong2. 1Lucile Packard Plasma exchange is one of the possible treatment strategies for Children's Hospital, Palo Alto, California, USA; 2Department of steroid-resistant nephrotic syndrome (SRNS), in particular when Pediatric Nephrology, Stanford University, Stanford, CA, USA associated to focal segmental glomerulosclerosis. Most of the pa-tients with SRNS become resistant to diuretics and the manage- Background and Purpose: We identified a need for a quality im- ment of their fluid overload sometimes becomes a major clinical provement project to help improve patient's knowledge of their challenge. We describe here our experience with combining medical regimen focusing on assigned dialysis on-time, avoidance ultrafiltration together with plasma exchange (PEX) aimed at of extra dialysis treatment time due to excess fluid weight gain, removing part of the fluid overload in 1 child with SRNS. A 10- and knowing goal potassium and phosphorus levels. We routinely year-old boy with a working weight of 36 kg, currently weighing had been using ‘‘report cards'' to discuss patient's progress with 39 kg, with SRNS underwent PEX treatment (using a Baxter their medical regimen each month in clinic. However, this was not BM11—14 device) with a substitution of 150% of plasma vol- motivating our patients to improve their compliance with their ume (3000 mL of 4.5% albumin solution in Ringer Lactate) in medical regimen. This incentive project focused on positive rein- 3 hours. Heparinization schedule was 2000 U at the beginning r 2011 International Society for Hemodialysis Hemodialysis International Vol. 15 No. 1, 2011 31st Annual Dialysis Conference: Abstracts followed by 1000 U/h. On the arterial line, just before the plasma Quotidian Long and Short Home Hemodialysis: Fac- filter (Gambro PF2000N), a hemofilter (Edwards Lifesciences HF tors Associated with Patient and Technique Survival 0.3) was placed, with a single line out for collecting and measur-ing ultrafiltrate. Relevant biochemistry at beginning of the proce- Robert Lockridge1, George Ting2, Carl Kjellstrand3. 1Lynchburg dure was hematocrit 25.6%, sAlbumin 1.9 g/dL, and sCreatinine Nephrology Physicians, Lynchburg, Virginia, USA; 2El Camino 0.9 mg/dL. The session was well tolerated, no unexpected com- Hospital, Mountain View, California, USA; 3Department Medi- plications were recorded, patient's hemodynamics was stable and cine, Loyola University, Chicago, Illinois, USA the procedure provided 650 mL of ultrafiltrate (4 mL/min). Hem-atocrit (monitored by CritLine2000) remained stable throughout Background: We studied 9 patient and 11 dialysis factors and the entire session. Based on this very limited experience, the their association with patient and technique (uncensoring for re- combination of ultrafiltration and PEX is feasible, safe and effica- turn to 3/wk HD) survival in 81 patients on long night (45 cious and it can represent an additional tool whenever fluid re- hours) and 110 on short day (o5 hours) surviving 43 months moval is necessary in patients unresponsive to diuretics and on QHHD followed for 452 patient-years. Patients: The mean age requiring PEX.
was 54 14 years, 39% were black, 66% males, 50% had sec-ondary renal disease (23% had diabetes). They had been on end-stage renal disease treatment for 4.7 4.9 (range 0–25) yearsbefore HHD. Patients on long QHHD were older (57 vs. 53 years,P = 0.024) and more often Afro-American (49% vs. 27%, P = 0.013). Methods: Cox proportional hazards analyses, Kaplan-Meier analyses. Po0.05 significant, Po0.1 borderline. Confi- Nocturnal In-Center Hemodialysis: A Pilot Program dence intervals (CI) 95%. Results: Of the patients, 99 (52%) Becomes an Alternative Therapy Option—Logistic remained on daily HHD, 34 (18%) were transplanted, 31 (16%) Issues and Improved Clinical Outcomes returned to 3/wk HD and 27 (14%) died. Five-year patient sur-vival was 71 6% (long 79 7%, short 69 9%, P = 0.024).
Sheila Doss, Brigitte Schiller. Satellite Healthcare Inc., San Jose, Five-year technique survival was 80 4% (long 93 3%, short 46 17%. P = 0.001). In univariate Cox proportional hazards an-alyses; dialysis hours, weekly dialysis hours, Kt/V, and standard A pilot in-center nocturnal hemodialysis (NHD) program to eval- Kt/V were significantly associated with better survival and young uate the logistics and feasibility for alternative extended hour age and primary renal disease borderline associated. Older age, therapy was started in January 2009. A total of 21 patients were secondary renal disease, late era of start of HHD, dialysis hours, enrolled, providing 247 patient months of experience. Two pa- weekly dialysis hours, Kt/V and standard Kt/V were associated tients died (1 withdrawal, 1 cardiac) and 1 transferred to home with better technique survival. In backward stepwise Cox pro- HD. Thrice weekly 8-hour HD was offered to patients on con- portional hazards analyses: patient survival was independently ventional HD. Recruitment was easily achieved via meetings ex- associated only with age (HR = 1.03, CI = 1.00–1.06, P = 0.023) plaining to interested patients and families the purpose of the and hours of each dialysis (HR = 0.64, CI = 0.50–0.82, P = 0.003) pilot. Reasons to switch to nocturnal were not doing well on cur- and technique survival with secondary renal disease (HR = 0.37, rent therapy (12/21), physician initiated (2/21), excess fluid gains CI = 0.17–0.80, P = 0.011) and weekly standard Kt/V (HR = 0.37, (1/21), benefits of longer dialysis (4/21), employment (1/21), and CI = 0.28–0.68, P = 0.0002). Conclusions: In quotidian HHD, 1 transfer from another nocturnal program. The major operational longer hours of dialysis is associated with better patient survival issue was recruiting and retaining the RN staff for nocturnal and higher dose of dialysis with better technique survival. Long schedule. Clinical outcome measures improved during 12 months night hemodialysis appear superior to short-daily hemodialysis.
of NHD 97% albumin 3.5 g/dL compared with 86% in the pre-vious 12 months; 62% of phosphate values o5.5 mg/dL com-pared with 46% prior; mean standard Kt/V before starting NHD A Successful Term Pregnancy Using In-Center, Inten- was 2.5 0.4 and increased to 2.8 0.3 on NHD. While main- sive Quotidian Hemodialysis taining Hb levels (prenocturnal 11.8 1.2; NHD 12.3 1.5 g/dL) ESA utilization decreased over time reaching a 62% lower Catherine Marnoch1, Stephanie Thompson2, Syed Habib2, Robert epogen dose per treatment by month 12 (P = 0.0002). Quality-of- Pauly2. 1Division of General Internal Medicine; 2Division of life assessment by KDQOL-SF36 at 6 months compared with Immunology and Nephrology, University of Alberta, Canada Ed- monton, Alberta, Canada (P = 0.04), effect of kidney disease (P = 0.05) and patient satisfac-tion with delivery of end-stage renal disease care (n = 0.009). Pa- Background: Conventional hemodialysis (CHD) in pregnancy is tients on center NHD experience significant improvement in associated with poor fetal survival, lower birth weights, and high QOL. Challenges in implementation of nocturnal programs as preterm delivery rates. Even in women who conceive before com- part of routine end-stage renal disease care are outweighed by mencing dialysis, fetal loss is up to 26% and preterm delivery rate improved outcomes including decreased drug utilization.
74%. Current guidelines recommend more intensive dialysis, at r 2011 International Society for Hemodialysis 31st Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 15 No. 1, 2011 least 20 h/wk. Improved pregnancy outcomes have been reported started an At-Home program to offer patients home choices be- with nocturnal hemodialysis (NHD); this effect has been attributed yond peritoneal dialysis. At-Home broadened the access to pa- to the superior blood pressure control and uremic clearance with tients who may quality of this innovative dialytic therapy and this modality compared with CHD. Following from the principles created modality option educational tools to ensure successful of the nocturnal dialysis experience in pregnancy, we report on a matching. At-Home is now the largest HHD program in the world.
case of a successful pregnancy from an in-center hemodialysis set- Methods: Comparison of the composition of DaVita HHD patients ting. Case: A 30-year-old primagravida with chronic kidney dis- to the national HHD sample using retrospective data and the 2010 ease secondary to reflux nephropathy became pregnant. Losartan United States Renal Data System (2008 USRDS) Annual Report.
was discontinued at 5 weeks gestation with no recurrence of hy- DaVita Inc. patients were included if they had an HHD treatment pertension during pregnancy. At 9 weeks gestation, eGFR of 14 mL/ recorded in the month specified. Results: The HHD program has min/1.73 m2, she commenced a NHD-type prescription, performed consistently grown over the past 3 years (Table 1) and made up in-center for logistical reasons. She received 36 hours of dialysis/ 48.6% of the prevalent HHD population in the United States in wk. Biochemical parameters were maintained within a physiolog- 2008. Conclusions: By expanding the acceptable characteristics of ical range. Anemia was treated with increased darbepoetin and patients who may be suitable for HHD the program has grown to iron. Supplementation of phosphate was required. Fetal develop- allow this important option to benefit more patients. As in other ment was normal. At 39 weeks, she had a spontaneous labor and areas of medicine, the advantage of a personalized approach to vaginal delivery of a healthy 3000 g infant. She required on-going modality selection is demonstrated by the success of our program.
HD after pregnancy. Discussion: Our case provides an example ofhow an in-center intensive quotidian hemodialysis prescription can result in a successful pregnancy. If this outcome is reproduced,women with advanced chronic kidney disease or end-stage renal DaVita HHD patients disease may be provided better guidance during pregnancy espe- cially when nocturnal hemodialysis is not available or feasible. Ourexperience is consistent with more recent literature suggesting 35 to 45 h/wk of hemodialysis is associated with the best maternal and 52.4 14.3 53.0 14.3 53.3 14.4 fetal outcomes.
% African American Composition of Home Hemodialysis Patients in a Large Dialysis Organization in the United States % Native American John Moran, Joe Weldon, Mahesh Krishnan. DaVita Inc., Denver, Background: Home hemodialysis (HHD) provides improved quality of life and potential survival benefit. But, in the United States, o2% of end-stage renal disease patients received HHD in Note for USRDS, only age range available with 46.6% being 45–64 2008. Given its strong commitment to this modality, DaVita Inc.
r 2011 International Society for Hemodialysis
Journal of the American College of Cardiology Vol. 44, No. 5, 2004 © 2004 by the American College of Cardiology Foundation ISSN 0735-1097/04/$30.00 Published by Elsevier Inc. Impact of Physical Deconditioningon Ventricular Tachyarrhythmias in Trained AthletesAlessandro Biffi, MD,* Barry J. Maron, MD, FACC,‡ Luisa Verdile, MD,* Fredrick Fernando, MD,*Antonio Spataro, MD,* Giuseppe Marcello, MD,* Roberto Ciardo, MD,* Fabrizio Ammirati, MD,†Furio Colivicchi, MD,† Antonio Pelliccia, MD*Rome, Italy; and Minneapolis, Minnesota