There are more than 1.7 million sufferers of end stage kidney disease (ESKD) worldwide and for many a donated kidney provides the only chance of regaining independence from dialysis. Unfortunately, the demand for kidneys for transplantation far exceeds the available supply. It is important, therefore, that we understand the factors that may influence kidney donation rates. While certain socio-demographic factors have been linked to kidney donation rates, few studies have examined the influence of multiple socio-demographic factors on rates of both living and deceased kidney transplantation (KT) and none have examined their comparative effect in large numbers of culturally and socio-politically diverse countries. In this study, we performed univariate and multivariate analyses of the influence of 15 socio-economic factors on both the living donor (LD) and the deceased donor (DD) kidney transplantation rates (KTR) in 53 countries. Our analyses demonstrated that factors such as UN HDI (United Nations Human Development Index), religion, GDP, education, age, healthcare expenditure, presumed consent legislation and existence of a nationally managed organ donation program were associated with higher deceased KTR. In contrast, the only factors associated with living KTR were a highly significant negative association with presumed consent and variable associations with different religions. We suggest that by identifying factors that affect kidney transplantation rates these can be used to develop programs for enhancing donor rates in individual countries where those rates are below the leading countries.
The Framingham Risk Score (FRS), calculated by considering conventional risk factors of cardiovascular diseases, was developed to predict coronary heart disease in various populations. However, reverse epidemiology has been raised concerning these risk factors in predicting high cardiovascular mortality in hemodialysis patients. Our objectives are to determine whether FRS is associated with overall and cardiovascular mortality and the role of new risk markers when they were added to a FRS model in hemodialysis patients.
This study enrolled 201 hemodialysis patients aged 20-80 years old. The FRS is used to identify individuals categorized as low (< 6% 10-year risk), intermediate (6-20% risk) or high risk (> 20% risk). Medical records were reviewed to collect clinical information. Data of ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) were obtained by an ABI-form device.
The mean follow-up period was 4.4 ± 1.5 years. Intermediate risk predicted overall hazard ratio (HR) (2.157, P = 0.039) and cardiovascular mortality (HR= 5.023; P = 0.004) versus low risk, but “high” risk did not. High risk (versus low risk) predicted cardiovascular events (HR = 2.458, P = 0.05). Besides, addition of ABI < 0.9 (P = 0.021) and baPWV (P = 0.014) to a FRS model significantly improved the predictive value for overall mortality.
In hemodialysis patients, intermediate risk but not high risk categorization by FRS predicted overall and cardiovascular mortality, and high risk predicted cardiovascular events. ABI < 0.9 and baPWV provided additional predictive values for overall mortality. Future study is needed to develop hemodialysis-specific equations and assess whether risk refinement using ABI < 0.9 and baPWV leads to a meaningful change in clinical outcomes.
Percutaneous renal biopsy (PRB) remains the gold standard for the diagnosis of renal disease however the tissue yield which relates to the optimal needle size used for native-kidney biopsies has not been clearly established. Our study compares the sample adequacy and complication rates using 16 gauge (G) and 18 gauge (G) automatic needles on native kidney PRB.
A retrospective analysis was performed of native-kidney biopsies at two centres, one exclusively utilizing 16G and the other exclusively utilizing 18G needles. All samples were assessed by a single centralised pathology service. We compared patient characteristics, indications, diagnoses, adequacy of tissue samples, and complications.
A total of 934 native-kidney biopsies were performed with real time ultrasound guidance: 753 with Bard Max Core 16G x 16cm needles, and 181 with Bard Magnum 18G x 20cm needles. The median (range) of total glomeruli count per biopsy was higher in the 16G group compared with the 18G group [19 (0-66) vs. 12 (0-35), p<0.001], despite having fewer cores per biopsy [2 (0-4) vs. 3 (1-4), p<0.001]. The 16G group provided a greater proportion of adequate biopsy samples [94.7% vs. 89.4%, p=0.001]. There was no significant difference in the frequency of total complications between the 16G and 18G groups (3.7% vs. 2.2%, p = 0.49).
This retrospective study demonstrates 16G needles provide more glomeruli, more diagnostically adequate renal tissue, with fewer cores without a significant increase in complications compared with 18G needles. Based on these observations, 16G needles should be considered as the first line option in native-kidney PRB.
Acute kidney injury (AKI) is a common complication among patients hospitalized for acute heart failure (AHF), and is associated with increased mortality. The goal of this study was to derive and validate a prediction score for AKI in AHF patients.
The hospital medical records of 1709 patients with AHF were reviewed. AKI was defined as an increase in serum creatinine (SCr) of ≥ 26.4 μmol/L or ≥ 50% within 48 hours. A multivariate logistic regression analysis was undertaken to develop a new prediction score. The area under the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow goodness-of-fit statistic test were calculated to assess the discrimination and calibration of the prediction score, respectively.
AKI developed in 32.2% of patients with AHF. Factors independently associated with the risk of AKI included: ≥70 years of age, ≥3 previous hospital admissions for AHF, systolic blood pressure <90 mmHg, serum sodium <130 mmol/L, heart functional class IV, proteinuria, SCr ≥104 μmol/L, and intravenous furosemide dose ≥80 mg/d. A prediction score for AKI was derived based on the β coefficients of each risk factor. Patients with ≥8 points would be considered at high risk for development of AKI (55.1% incidence vs 18% in those with <8 points, P<0.001). Both the derived and validated datasets showed adequate discrimination (area under ROC curve was 0.76 in both datasets) and calibration (Hosmer-Lemeshow statistic test, P=0.98 and 0.13, respectively).
The newly derived and validated clinical prediction score may effectively predict AKI in the patients hospitalized with AHF.
Performing haemodialysis therapy at home has been associated with improved survival for end stage kidney disease patients and can generally be delivered at a lower cost to the health care system when compared to centre and satellite unit dialysis. However, only a minority of dialysis dependent ESKD patients successfully sustain haemodialysis at home. Current practice for determining dialysis treatment modality and location takes into account medical suitability and social situation, but infrequently formally examines the contribution of psychological factors. This study explores demographic, health, and psychological factors that may predict patients’ ability to sustain home haemodialysis.
One hundred and thirteen successful and unsuccessful home haemodialysis users were recruited to the study, and 55 responded to self-report measures. Demographic (age, gender, education level, carer support), health (co-morbidities, diabetes, psychiatric condition) and psychological (locus of control beliefs, coping styles) information was used as predictor variables for the participants’ time maintaining home therapy (Home Time).
In a 3-step regression, the model explained 32% of variance in Home Time. Coping styles significantly contributed 16% of the variance in Home Time after accounting for other variables. Adaptive Coping was significantly correlated with the length of time sustaining home therapy.
Adaptive coping strategies are associated with improved ability to sustain home haemodialysis therapy. Evidence-based psychological approaches can help patients develop more adaptive coping strategies. More research is needed to assess whether instituting these psychological interventions will assist patients to adopt and sustain dialysis therapies which require increased patient self management.
Peritoneal dialysis (PD) is an alternative treatment for elderly patients with end-stage renal disease (ESRD. In Taiwan, non-professional personnel are employed to provide assisted care for elderly patients. Whether assisted care is appropriate for elderly patients is unknown. The aim of this paper is to evaluate the outcomes of assisted care in a single center.
This is a retrospective cohort study in a single medical center. The outcomes were derived from the assessment of patient survival, technique survival and peritonitis incidence between self-care patients and assisted-care patients.
From 1984 to 2010, there were 138 elderly PD patients at Taichung Veterans General Hospital, of which 70% were assisted-care patients and 30% self-care patients. The mean duration of PD survival was 49.2 months in self-care patients, which was significantly longer than the 17.0 months of assisted-care patients (P<0.05). Using the multivariate Cox proportion regression model to adjust for risk factors, it was found that self-care patients had a lower risk in both patient survival (Hazard Ratio 0.15; 95 % CI 0.2-0.94, P <0.05) and technique survival (Hazard ratio; 0.11 , 95% CI 0.1-0.9, P <0.05). Fluid overloading was the major cause of technique failure in assisted-care patients. Type of assistance was not a risk factor for PD-related peritonitis.
Our elderly assisted care had patients had a poorer survival and technique survival rates than those of the self-care patients. We argue that this is because early recognition of medical deterioration and early medical intervention are necessary for a better outcome for elderly PD patients.
Case 1. The Distressed Health Care Provider
Mr MF was a 72 yo married father living independently with his wife.
Mr MF was admitted electively for non-operative correction of a known left renal artery stenosis. Previous investigations reported two small kidneys with total obstruction of the right renal artery and > 60% obstruction of the left. Recent health was compromised by multiple admissions to Coronary Care (CCU) with chest pain and acute pulmonary edema (APO) despite recent plasty of a blocked coronary graft, placed in 2002. An Interventional Radiologist accessed the left renal artery. Unfortunately the tip of the catheter guide wire snapped off in the proximal part of the vessel, totally occluding it. An Interventional Cardiologist was unable to retrieve the remnant wire via a brachial approach. The entry site at the right brachial artery puncture developed a hematoma. The Vascular Surgeons opined that open revascularisation of the blocked renal artery was not an option.
With variable availability of RSC programmes available throughout Australia and New Zealand, there is a need for provision of training in this area to be available to all medical and paramedical staff
On-line resources may be a potential source of training material for staff and information for patients and families.
The possibility of exchange programmes between renal medicine and palliative care should be explored as a way of enhancing education in both fields.
The ANZSN and the ANZ Society of Palliative Care both have special interest groups in RSC. The potential for bringing these two groups together to facilitate cross-specialty training should be explored.
A doctor incurs no civil or criminal liability if, on the basis of a refusal to commence or continue dialysis, the doctor does not give that treatment. To go ahead and give treatment to a patient who has refused consent, constitutes a battery.
If the actions of a Nephrologist are reasonable in withholding dialysis or withdrawing from dialysis then it is highly unlikely that a successful action in negligence would occur.
The law does not obligate a Nephrologist to provide treatment that they believe is of no benefit to the patient or that any benefit is outweighed by the burdens of the treatment, but best practice requires that the Nephrologist communicate with the substitute decision-makers regarding the patient's best interests.
The withholding of or withdrawing from dialysis is not euthanasia. Equally it does not constitute Physician Assisted Suicide.
If a patient is competent the decision whether or not to consent to dialysis is that of the person. The family cannot insist on dialysis.
If the patient is incompetent and the surrogate decision makers or families have reached an impasse with the clinician then some simple preliminary steps may be taken, including seeking a second opinion but it may require seeking clarification with the Supreme Court of the jurisdiction.
Available guidelines fall into 2 categories – medication guides and service provision guides
Few guidelines exist for the management of patients choosing to not have dialysis apart from those covering end of life (EOL) management and general ones for the management of chronic kidney disease.
Most guidelines are only based on low level evidence, relying on expert opinion or current practice. This limits their usage when advising on matters such as trials of dialysis and caution should be applied when discussing these matters. More data is needed before firmer recommendations can be made.
Units in Australia and New Zealand should consider maintaining registers of ‘at risk’ patients to allow greater input into symptom management and end-of-life support
Concentration of research is recommended in the following areas:
Prospective studies of the appropriateness, relevance, timing and sustainability of dialysis in elderly patients
Health related quality of life (HRQoL) in older patients choosing not to dialyse and in those choosing to dialyse with comparison to a matched population without renal disease
Methods of communication of prognosis and factors affecting decision making
Models of care – comparative studies to delineate how best to deliver renal supportive care
Treatment preferences amongst indigenous patients
Symptom control, focussing on those areas specific to the needs of renal patients
General Practitioner are important and should be involved in decision making and Advanced Care Planning for patients with advanced kidney disease
Advanced kidney disease has a biphasic nature of life trajectory
No treatment does not mean no dialysis for the patient with CKD – CKD care and terminal phase care.
Patients in rural areas are both economically and medically disadvantaged
Access to specialist services in rural areas is limited. More care is likely to be out-sourced to local physicians, GPs and palliative care nurses who will need ‘on the ground’ outreach support from renal/palliative care services
Referral to these services may low due to knowledge of availability and previous exposure of the referring physician to the use of these services.
Developments in Information Technology are likely to play a significant role in management (telemedicine), education and advice in these specialist areas.
There is significant variation between cultural groups in the way the end of life is discussed and handled (1). This guide does not seek to be an exhaustive resource on Māori cultural practices as they apply to healthcare or the end of life. Dr Stallworthy is a New Zealander of European descent and a renal physician with an interest in renal supportive care and Advance Care Planning. Ms Glavish is from the Ngati Whatua iwi (Māori tribe) and is Chief Advisor-Tikanga (Māori protocol) for Auckland and Waitemata District Health Boards in New Zealand. Where statements in this section are based on Ms Glavish's expert opinion this is noted by ‘(NG)’ following the statement.
]]>Highest rates of chronic and end stage kidney diseases occur within remote, regional and indigenous communities in Australia.
Advance care planning is not common practice for most ATSI people.
There are many barriers to providing effective supportive care to ATSI people.
Choice of place of death: being able to “finish up” in the place of their choice is very important to many indigenous Australians.
Family meetings, preferably in the presence of a cultural broker to explain treatment pathways and care issues will lead to informed choices being made in an environment where all stakeholders are able to participate freely. Each indigenous person is different and should not be stereotyped.
Resuscitation status and Advance Care Plans need to be discussed and clearly documented
The Liverpool Care Pathway is a recognized model of EOL care in, and has been adapted for patients with end stage renal disease
Recognition of a dying patient allows initiation of a multidisciplinary EOL pathway such as the Liverpool Care Pathway for hospital inpatients, and for support for families if a home death is planned. A fall in performance status is an indicator of decline.
To date no consistent model of care has been available for supporting patients and their families on a conservative non-dialysis pathway. Broadly speaking the United Kingdom appears to have embraced this pathway more than most other countries but even there, there are divergent views on what models of care should be implemented. One model, developed at St. George hospital in Sydney, is as follows: The RSC team oversees a program deliberately titled ‘HOPE: Helping Older Patients with End-stage kidney disease’. The multidisciplinary team (MDT) is essentially an integration of Renal and Palliative Medicine, utilising the skills of both disciplines to ensure optimum nephrology care whilst adding a focus on symptom control, holistic physical and spiritual care and, when appropriate, the facilitation of a ‘good death’.
]]>A core competency of Nephrology should be the capacity to diagnose dying. Withdrawal of dialysis is ethically and legally valid
]]>The palliative approach to patients with ESKD includes all aspects of the physical, emotional and spiritual dimensions of the illness and care of the family. Health professionals dealing with patients with ESKD need to acquire skills in these areas Continuing collaboration between renal medicine and palliative medicine is essential The cultural and religious beliefs of patients may inform or determine their view on medical decision-making including in relation to the withholding or withdrawing of dialysis and the care of the dying.
]]>Patients with ESKD, with or without RRT, are heavily burdened with symptoms which may interact and compound each other. The burden of symptoms experienced by patients on dialysis is rarely mentioned in patient information sheets despite being well documented in research data. There are significant barriers to medication use in ESKD including a lack of knowledge of pharmacokinetics in dialysis and conflicting information about drug dose and safety. There is a growing body of literature on the symptom management of patients with ESKD Patients need clear information about the potential effects dialysis and non-dialysis pathways on symptom burden and how this can change with time Standardisation of tools used to collate information about symptoms can assist in the provision of information to patients. We recommend the POS-S (Renal) tool (accessible via the kcl.ac.uk website) for assessing symptom burden.
]]>Advance care planning should be available to all patients with chronic kidney disease, including end-stage kidney disease on renal replacement therapy. Advance care planning is a process of patient-centred discussion, ideally involving family/significant others, to assist the patient to understand how their illness might affect them, identify their goals and establish how medical treatment might help them to achieve these. An Advance Care Plan is only one useful outcome from the Advance Care Planning process, the education of patient and family around prognosis and treatment options is likely to be beneficial whether or not a plan is written or the individual loses decision making capacity at the end of life. Facilitating Advance Care Planning discussions requires an understanding of their purpose and communication skills which need to be taught. Advance Care Planning needs to be supported by effective systems to enable the discussions and any resulting Plans to be used to aid subsequent decision making.
]]>An approach based on Ethics can lead to better and more nuanced decision-making. Several guidelines on the initiation of and withdrawal from dialysis provide assistance in these deliberations. Each of the bioethical principles are important. Autonomy does not override the other principles. In difficult cases Nephrologists should seek the advice of colleagues and, where available, a Bioethicist.
]]>Patients with ESKD are known to have a worse QOL than age-matched general population What constitutes a poor QOL of life varies from person to person and the potential impact of dialysis on an individual will be unique for each person Patients need good information in order to allow them to assess the potential impact of RRT on their lives The SF-36 QOL questionnaire is a suitable tool to be used in dialysis and non-dialysis patients to assess QOL changes
]]>This guideline will review the current prediction models and survival/mortality scores available for decision making in patients with advanced kidney disease who are being considered for a non-dialysis treatment pathway. Risk prediction is gaining increasing attention with emerging literature suggesting improved patient outcomes through individualised risk prediction (1). Predictive models help inform the nephrologist and the renal palliative care specialists in their discussions with patients and families about suitability or otherwise of dialysis. Clinical decision making in the care of end stage kidney disease (ESKD) patients on a non-dialysis treatment pathway is currently governed by several observational trials (3). Despite the paucity of evidence based medicine in this field, it is becoming evident that the survival advantages associated with renal replacement therapy in these often elderly patients with multiple co-morbidities and limited functional status may be negated by loss of quality of life (7) (6), further functional decline (5, 8), increased complications and hospitalisations.
]]>There is a disproportionate increase in the number of elderly patients, many with multiple co-morbidities, commencing dialysis. Predictors of survival for elderly patients on dialysis include age, comorbidity score, malnutrition, poor functional status and late referral. Patients with high co morbidity scores may not gain a survival advantage with dialysis vs a non dialysis pathway. Late referral and lack of dialysis access are independent predictors of mortality in elderly patients commencing dialysis. Hospital free survival may be similar in dialysis and non-dialysis treated groups We have little data on those choosing not to start dialysis in terms of numbers, clinical course and survival. Most available data is not from an Australian or New Zealand source. The effects on quality of life of different management pathways on patients, carers and staff still need to be addressed.
]]>Nephrologists seek to provide dialysis to those who will benefit most while being honest and direct with those who are unlikely to benefit or even be harmed by dialysis; these can be difficult decisions A ‘conservative’ or ‘not for dialysis’ pathway is an important option for the management of ESKD patients who are elderly, have significant co-morbidity, poor functional status, malnutrition or who reside in a nursing home. Such a pathway is best underpinned by a specific Renal supportive Care program in each Unit. Nephrologists need to lead realistic discussions about likely survival with patients and their families before dialysis is instituted. Key ethics principles are a good aid in this decision making process A ‘non-dialysis’ renal supportive care program is a very positive way of offering holistic care for patients and their families; many of these patients live much longer without dialysis than might have been expected.
]]>The usefulness of the absolute NT-proBNP concentration and its digit number for screening for cardiac disease was explored in new hemodialysis patients.
A cross-sectional study involving 71 (68±14 years, 83% male) new dialysis patients was conducted. Receiver operator characteristic curve analysis was performed to identify the cutoff level of NT-proBNP for identifying cardiac disease at the start of dialysis.
The median NT-proBNP concentration was 6576 pg/mL just before the first dialysis session, and its mean digit number was 4.3±0.6. Overall, 67%, 52%, 9%, and 35% of patients had left ventricular (LV) hypertrophy, LV dilatation, systolic dysfunction, and significant coronary artery disease, respectively. NT-proBNP levels of about 6000, 10000, and 14000 pg/mL were the best cutoff levels for the diagnosis of coronary artery disease (AUC, 0.754; p<0.001), LV systolic dysfunction (AUC, 0.765, p=0.001), and LV dilatation (AUC, 0.685, p=0.008), respectively. Interestingly, 4.5 was the best digit number cutoff for all cardiac abnormalities. These findings suggest that a digit number of 5 or more means a potentially high risk for cardiovascular disease, and a digit number of 3 or less means a relatively low risk.
The NT-proBNP concentration just before the first dialysis session is a useful tool for screening for cardiac abnormalities. Considering the wide variation of the NT-proBNP cutoff levels depending on each cardiac abnormality, the digit number could be potentially easier to use for initial risk stratification for cardiac disease in new dialysis patients.
Infections of the lower urinary tract and Acute Pyelonephritis are commonly encountered in clinical practice. Widespread usage of antibiotics and changing susceptibility profiles of uropathogens requires regular review of treatment guidelines to meet these challenges. We aimed to better understand the prevalence of uropathogens and emerging antibiotic resistance in patients with pyelonephritis requiring hospital admission.
In this single centre, 12 year retrospective observational study, we reviewed case notes and urine culture results of 249 patients admitted with Acute Pyelonephritis under the care of the Nephrology Department, along with 46,660 urine samples with positive isolates from the Emergency Department (ED) during the same period. The prevalence of uropathogens, their antibiotic susceptibilities and emerging resistance patterns to commonly used antibiotics were studied. Antibiotic susceptibilities were also reviewed in line with the currently recommended national guidelines for empiric therapy.
We found the most prevalent uropathogen to be E. coli. Approximately 50% of E. coli infections were resistant to ampicillin. First and third generation cephalosporin resistance was <5%, however, the latter has increased over the last decade and is more prevalent in the elderly. Enterococcus faecalis was associated with less than 10% of cases of lower urinary tract infections and no case of pyelonephritis.
Antibiotic resistance of uropathogens to commonly used antibiotics is increasing with time and there is a need for hospitals to review their recommended guidelines for empiric therapy in line with local patterns of uropathogens and antibiotic susceptibilities.
Since the introduction of hemodialysis in the management of acute kidney injury in the 1940s and for chronic kidney disease in the 1960s dialysis has become one of the most successful advances in medical technology, with almost 11,000 patients currently receiving dialysis in Australia and almost 2500 in New Zealand. Like all medical technologies, its place continues to evolve. For a time, dialysis was seen as a treatment best delivered only to younger patients without diabetes; today the greatest uptake of dialysis is in patients over age 65 and the most common cause of needing dialysis is diabetes. Along with these extended criteria for dialysis, that have evolved over many years, has come the recognition that the older dialysis patient often has considerable co-morbidity and frailty, that time spent on dialysis is not always beneficial to these patients and that their overall prognosis is considerably worse than their younger counterparts. CARI guidelines recommend that “an expectation of survival with an acceptable quality of life” is a useful starting point for recommending dialysis.
]]>Diabetes is a significant problem worldwide, with the number of people with diabetes expected to increase to 380 million by 2025 [1]. Diabetic kidney disease is a major cause of chronic and end-stage kidney disease[2], accounting for approximately 20% - 40% of people on dialysis [1] . In type 2 diabetic patients, proteinuria is an indicator of the severity of kidney disease [2], as is reduced estimated glomerular filtration rate, eGFR [3]. Epidemiological studies suggest that the burden of patients requiring dialysis can be reduced by early identification and treatment of their renal disease [4] . An important treatment option is the use of angiotensin-II-receptor blockers (ARB) which provides protection against the progression of nephropathy due to type 2 diabetes[5-7], although the response varies in patients. . The well described paradoxical early fall in eGFR with the initiation of ARB therapy, is usually non-progressive, predicting better long term prognosis when non-diabetics were studied [8] and should not be regarded as reflecting irreversible structural change [8]. However, in predicting long term renal outcomes, the introduction of a new standard of clinical care (in this case maximum ARB) necessitates, after therapy has been established, assessment of risk factors for disease progression.
]]>Background. Ankle-brachial index (ABI) is a marker for peripheral artery disease and can predict mortality in advanced chronic kidney disease (CKD) and hemodialysis patients, respectively. However, it is seldom studied in Taiwan, an area with high prevalence of CKD and end-stage renal disease. The aim of this study was to investigate the predictors for mortality via using ABI value in patients with CKD and hemodialysis in Taiwan.
Methods. We enrolled 169 patients with CKD stage 3–5 and 231 hemodialysis patients in one regional hospital. The mean follow-up period was 23.3 ± 3.3 months. Patients were stratified into three groups according to ABI value (< 0.9, ≥ 0.9 to < 1.3, and ≥ 1.3). The relative mortality risk was analyzed by Cox-regression methods.
Results. In multivariate analysis, ABI ≥ 1.3 (hazard ratio, 3.846; P= 0.043), and coronary artery disease (P= 0.012) were positively associated with overall mortality, and serum low-density lipoprotein cholesterol level (P= 0.042) was negatively associated with overall mortality. In addition, ABI < 0.9 (P= 0.049), ABI ≥ 1.3 (P= 0.033), coronary artery disease (P= 0.024) and hemodialysis treatment (P= 0.043) were strong predictors for cardiovascular mortality.
Conclusions. Our findings show that ABI ≥ 1.3 predicts for both overall and cardiovascular mortality, and ABI < 0.9 predicts for cardiovascular mortality in CKD and hemodialysis patients. Screening patients with chronic renal failure by means of ABI may help to identify a high risk group for increased mortality.
Interstitial infiltrates, consisting of macrophages and other inflammatory cells, have been consistently reported in human and animal models of polycystic kidney diseases (PKD). However, the mechanisms underlying this inflammation are not well defined. Evidence suggests that interstitial inflammation in PKD is driven by pro-inflammatory chemoattractants such as monocyte chemoattractant protein-1 (MCP-1), and cytokines such as tumour necrosis factor (TNF)-α. Putative upregulated inflammatory pathways include JAK-STAT and nuclear factor (NF)-κB signalling. In addition, the genetic mutations of PKD may further complicate the relationship between inflammation and cystic disease, by increasing the susceptibility to inflammatory injury, and facilitating interactions between the genetically determined cystoproteins and biological mediators of inflammation. Moreover, the roles of interstitial inflammation in promoting cyst growth and progression to kidney failure in PKD are not clearly understood. Although anti-inflammatory therapies have attenuated cystogenesis in animal models, inflammatory cells may also have reparative actions. Thus, in developing therapies for PKD, it is prudent to consider the potential negative outcomes of ablating inflammation, and whether it is more viable to target certain inflammatory pathways over others.
Incidence and prevalence of atrial fibrillation (AF) is higher in haemodialysis (HD) population than general population. AF is associated with higher morbidity and mortality than sinus rhythm in this population. The purpose of this review is to summarize all available evidence regarding use of warfarin in HD patients with AF for stroke prevention. The enormous heterogeneity of available studies does not allow pooling of the data in the form of meta-analysis or systematic review. Current evidence regarding use of warfarin for AF in terms of risk benefit ratio in this population is limited and conflicting. Randomized control trials evaluating the safety and efficacy of anticoagulation in this population by means of risk/benefit assessment tools are urgently needed. However, suitable HD patients with AF should be counselled on their likelihood of reduction of stroke risk and experiencing side-effects before initiating anticoagulant therapy. It is particularly important to incorporate the patient's preferences and willingness to trade off benefit and risk in stroke prevention. An individualized holistic approach optimizing all potential risk factors of bleeding and ischemic stroke in HD patients with AF is recommended.
CD39 (NTPDase1), a critical immune and vascular ecto-nucleotidase, hydrolyses pro-inflammatory and pro-thrombotic nucleotides (adenosine-5′-triphosphate (ATP) and adenosine diphosphate) to adenosine. In humans, CD39 is the dominant ecto-nucleotidase in placental trophoblastic tissues and modulates ATP-dependent trophoblastic functions. CD39 is an integral component of regulatory T cells (Treg), which are central to immunological tolerance and maintenance of normal pregnancy. We examined the impact of CD39 overexpression in a mouse model of preeclampsia. Matings were performed between virginal BALB/c female (wild-type (WT) or CD39 transgenic (CD39TG)) and C57BL/6 male mice. On days 10 and 12 of pregnancy BALB/c Th1-polarized cells were injected. Systolic blood pressure (SBP) was measured throughout pregnancy. Mice were sacrificed at day 15 of pregnancy. Following transfer of Th1-polarized cells, SBP of pregnant WT mice increased (118 ± 3 mmHg to 142 ± 5 mmHg). Although ultrastructural changes were evident in the kidney this was not accompanied by significant proteinuria. SBP remained unchanged (115 ± 2 mmHg to 114 ± 3 mmHg) in pregnant CD39TG mice without evidence of renal lesions. We conclude that gestational hypertension can be induced in mice following transfer of maternally derived Th1-polarized cells and that overexpression of CD39 is protective in this model.
To compare the clinical outcome between continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) in specific subgroups of patients.
We reviewed the clinical outcome of 90 consecutive incident APD patients and 180 CAPD patients in our centre.
The median follow up was 21.9 months (inter-quartile range, 9.5 to 46.5 months). The APD group was younger and had a lower Charlson's score than the CAPD group. Furthermore, the APD group had a highly skewed distribution of the Charlson's score, indicating the possibility of two different groups of patients. Multivariate analysis showed that in addition to the treatment mode (APD vs CAPD) and Charlson's score, there was a significant interaction between the two (P = 0.043) on patient survival. For patients with Charlson's score ≤6, the APD group had a significantly better patient survival than the CAPD group (78.3% vs 65.4% at 5 years, P = 0.039), while for patients with Charlson's score ≥7, the APD group had a worse patient survival than the CAPD group (16.3% vs 48.4% at 5 years, P = 0.028). Similarly, Charlson's score and its interaction with treatment mode, but not the APD group per se, were independent predictors of technique survival (P = 0.013). For patients with Charlson's score ≥7, the APD group had a significantly lower technique survival than the CAPD group (8.8% vs 34.3%, P = 0.001), while for patients with Charlson's score ≤6, the technique survival was similar (44.4% vs 42.5%, P = 0.15). Peritonitis-free survival was 35.2% and 32.2% for APD and CAPD groups, respectively (P = 0.021), and the difference was not affected by Charlson's score.
Comorbid diseases had a significant interaction with the mode of PD on patient and technique survival of incident PD patients. Our result suggests that APD may offer benefit in, and only in, young patients with minimal comorbid diseases.
Published literature on fracture in dialysis patients seldom addressed the effect of co-morbidity and malnutrition. In this study, we reported the incidence and risk factors for fracture in peritoneal dialysis patients. Peritoneal dialysis patients who had fractures between 2006 and 2011 were recruited. Demographic data, details of fracture, Charlson Co-morbidity Index (CCI) and biochemical parameters were also collected. Non-fracture controls, matched for age, gender and duration of dialysis, were also recruited at ratio 1:1 for fracture risk analysis. The incidence of fracture was 1 in 37 patient-years. The commonest site of fracture was neck of femur (n = 16, 55.2%). Twenty-four patients (82.8%) developed fracture after slip and fall injury. Eight out of 17 self-ambulatory patients (47.1%) became non-ambulatory after fracture. Infection was the commonest complication during hospitalization. Univariant analysis demonstrated high CCI (P = 0.001), hypoalbuminaemia (P < 0.001), loss of self autonomy (P = 0.006) and non-ambulatory state (P = 0.011) significantly associated with increased fracture risk. However, only CCI (odds ratio (OR) 1.373, P = 0.028) and albumin (OR 0.893, P = 0.025) increased fracture risk significantly on multivariant analysis. Bone profile and parathyroid hormone were not significant risk factors. To conclude, fracture associated with adverse outcome in peritoneal dialysis patients. High CCI score and hypoalbuminaemia significantly increase risk of fracture.
To assess the first year outcomes in terms of patient survival rate, graft survival rate and secondary outcomes after starting the first live related renal transplant in Tribhuvan University Teaching Hospital, Nepal.
A retrospective analysis was done of the first 70 renal transplants, who have completed a minimum of 1 year of follow up. All recipients were on Tacrolimus, Mycophenolate Mofetil, and corticosteroids.
Patient and graft survival rate at the end of one year was 94.3% (95% confidence interval (CI) 86.2–97.8). Mean serum creatinine and estimated glomerular filtration rate at 1 year was 115 ± 25 μmol/L (range 63–192) and 66 ± 15 mL/min per 1.73 m2 (range 37–102) respectively. Twenty-two episodes of biopsy proven acute rejection occurred in 18 recipients (25.7%). Three patients (4.2%) had acute tubular necrosis; however, only one (1.4%) had delayed graft function. One patient, with focal segmental glomerulosclerosis had recurrence of native kidney disease. Thirty-two episodes of urinary tract infection were observed in 22 recipients (31.4%), and Escherichia coli was the most commonly isolated organism, 17 (53.1%) out of 32 episodes. New onset diabetes mellitus after transplant occurred in 16 recipients (22.8%).
One-year patient survival, graft survival and secondary outcomes of our kidney transplant recipients, with our limited facilities, were within acceptable limits.
Myocardial perfusion imaging (MPI) with SPECT (single photon emission computerized tomography) is commonly used for preoperative renal transplant assessment. We performed an audit to evaluate the prognostic value of MPI in this cohort.
Between 1999 and 2009, 838 transplants were performed in South Australia. A total of 387 patients had 393 preoperative MPI in three hospitals. Using a statewide electronic clinical information system (OACIS) cardiac events, MPI results (positive: any reversible defect; negative: fixed defects and normal), clinical follow up and comorbidities (diabetes and hypertension) were determined. End-point events were ‘soft’: admission with angina, percutaneous intervention or bypass; or ‘hard’: myocardial infarction or cardiac death. The end-point event rates were determined using Kaplan–Meier curves. Multivariate analyses were performed for age (60 years), gender, diabetes and hypertension. For negative MPI the event rates in dipyridamole stress were compared with tachycardic stress.
Soft events: There was a statistically significant lower event rate for MPI negative versus positive, 3.9% versus 20.8% (hazard ratio 4.4 confidence interval: 2.1–9.6, P < 0.001) at 5 years of follow up – no effect from age, gender, diabetes and hypertension. Hard events: There was a lower event rate for MPI negative versus positive (also unaffected by age, gender, hypertension and diabetes) but the result was not statistically significant, P = 0.153. For negative MPI the soft and hard event rates were similar for dipyridamole and tachycardic stress.
MPI is a good modality of prognosticating cardiac events in renal failure patients being considered for transplantation. The value of a negative MPI is similar for dipyridamole and tachycardic stress.
Renal transplant recipients are at risk of developing Pneumocystis pneumonia (PcP), especially in the first 2 years after transplantation, with a mortality rate of up to 50%. No data are available on pulmonary colonization with Pneumocystis jirovecii in renal transplant recipients. The aim of this study was to determine the prevalence of pulmonary colonization with Pneumocystis jirovecii in renal transplant recipients and to find related risk factors.
We investigated the induced sputa of 70 renal transplant recipients for the presence of Pneumocystis jirovecii using nested polymerase chain reaction.
Thirteen of 70 patients (18.6%) were colonized with Pneumocystis jirovecii. There was no significant correlation between colonization and immunosuppressive medication or regimens. However, colonized subjects had undergone transplantation longer ago than non-colonized subjects. 30.8% of those whose transplantation had taken place more than 8 years previously were colonized, in contrast to 11.4% of those whose transplantation had taken place less than 8 years ago (P = 0.059; odds ratio = 3.467, 95% confidence interval = 0.99–12.09).
Most cases of Pneumocystis colonization were detected in those patients where renal transplantion had taken place more than 2 years previously. As most PcP cases occur within the first 2 years of transplantation, colonization does not seem to play a role in the development of acute PcP in this period. Though Pneumocystis pneumonia is likely to be a newly acquired infection in the first 2 years after transplantation, colonized patients remain a potential source of transmission of Pneumocystis jirovecii.