Alex Disney

Atrial fibrillation in hemodialysis patients: clinical features and associations with anticoagulant therapy

Using data from the international Dialysis Outcomes and Practice Patterns Study (DOPPS), we determined incidence, prevalence, and outcomes among hemodialysis patients with atrial fibrillation. Cox proportional hazards models, to identify associations with newly diagnosed atrial fibrillation and clinical outcomes, were stratified by country and study phase and adjusted for descriptive characteristics and comorbidities. Of 17,513 randomly sampled patients, 2188 had preexisting atrial fibrillation, with wide variation in prevalence across countries. Advanced age, non-black race, higher facility mean dialysate calcium, prosthetic heart valves, and valvular heart disease were associated with higher risk of new atrial fibrillation. Atrial fibrillation at study enrollment was positively associated with all-cause mortality and stroke. The CHADS2 score identified approximately equal-size groups of hemodialysis patients with atrial fibrillation with low (less than 2) and higher risk (more than 4) for subsequent strokes on a per 100 patient-year basis. Among patients with atrial fibrillation, warfarin use was associated with a significantly higher stroke risk, particularly in those over 75 years of age. Our study shows that atrial fibrillation is common and associated with elevated risk of adverse clinical outcomes, and this risk is even higher among elderly patients prescribed warfarin. The effectiveness and safety of warfarin in hemodialysis patients require additional investigation.

Bilateral basal ganglia lesions in patients with end-stage diabetic nephropathy.

Summary:  Acute movement disorder associated with reversible bilateral basal ganglia lesions is an increasingly recognized syndrome in patients with end‐stage renal disease, especially in the setting of concurrent diabetes mellitus. We report an elderly man with end‐stage diabetic nephropathy treated by daily automated peritoneal dialysis who developed subacute symptoms of gait disturbance, dysarthria, dysphagia and lethargy. Computed tomography and magnetic resonance imaging of the head revealed bilateral symmetrical basal ganglia lesions. Repeat imaging 3 weeks later showed that these lesions had regressed spontaneously. However, his neurological symptoms improved slowly. These findings were similar to 23 other cases in the literature. Review of these cases shows that clinical features were predominantly bradykinesia, gait disturbance and concurrent metabolic acidosis (observed in 90% of cases). The pathogenesis of this condition has not been clearly defined, but uraemia may be an aggravating factor in predisposed patients, particularly in the presence of diabetic microvascular disease. There is no specific treatment for this condition; supportive measures are the mainstay of management. In the majority of patients, neurological improvement lags behind regression of basal ganglia lesions seen with neuroimaging, and the long‐term outcome is variable.

Recommendations for the use of icodextrin in peritoneal dialysis patients.

SUMMARY: Icodextrin is a starch‐derived, high molecular weight glucose polymer, which has been shown to promote sustained ultrafiltration equivalent to that achieved with hypertonic (3.86%/4.25%) glucose exchanges during prolonged intraperitoneal dwells (up to 16 h). Patients with impaired ultrafiltration, particularly in the settings of acute peritonitis, high transporter status and diabetes mellitus, appear to derive the greatest benefit from icodextrin with respect to augmentation of dialytic fluid removal, amelioration of symptomatic fluid retention and possible prolongation of technique survival. Glycaemic control is also improved by substituting icodextrin for hypertonic glucose exchanges in diabetic patients. Preliminary in vitro and ex vivo studies suggest that icodextrin demonstrates greater peritoneal membrane biocompatibility than glucose‐based dialysates, but these findings need to be confirmed by long‐term clinical studies. This paper reviews the available clinical evidence pertaining to the safety and efficacy of icodextrin and makes recommendations for its use in peritonal dialysis.

Randomized cross-over comparison of intravenous and subcutaneous darbepoetin dosing efficiency in haemodialysis patients.

Background:  Studies have consistently shown the superior dosing efficiency of subcutaneous (s.c.) compared to intravenous (i.v.) erythropoietin (r‐HuEPO). Unlike r‐HuEPO, data from pivotal darbepoetin trials support s.c. and i.v. dosing equivalence, however, no blinded cross‐over randomized studies of s.c. and i.v. dose efficiency or intra‐patient variability in response have been published.

Darbepoetin alfa administered monthly maintains haemoglobin concentrations in patients with chronic kidney disease not receiving dialysis: a multicentre, open-label, Australian study.

Aim:  Darbepoetin alfa, an erythropoiesis‐stimulating protein, has a longer serum half‐life than recombinant human erythropoietin, allowing less‐frequent administration. This study aimed to demonstrate that once‐monthly (QM) darbepoetin alfa administration would maintain haemoglobin (Hb) concentrations in subjects with chronic kidney disease (CKD) not receiving dialysis who had previously been administered darbepoetin alfa every 2 weeks (Q2W).

Psychosocial variables are associated with being wait-listed, but not with receiving a kidney transplant in the Dialysis Outcomes and Practice Patterns Study (DOPPS)

BACKGROUND Psychosocial factors are associated with clinical outcomes in patients with end-stage renal disease. It is not known if self-reported depression and quality of life influence the likelihood of being wait-listed and receiving a transplant. METHODS Prevalent cross section of 18- to 65-year-old hemodialysis (HD) patients in the USA (N = 2033) and seven European countries (N = 4350) from the Dialysis Outcomes and Practice Patterns Study phase II and III was analyzed. Wait-listed patients (N = 1838) were followed until kidney transplantation. Self-reported depressive symptoms were assessed by the Center for Epidemiologic Studies-Depression scale, 10-item version (CES-D) and health-related quality of life (HR-QoL) by the Kidney Disease Quality of Life Short Form 12 scale Physical Component Score (PCS). RESULTS At study entry, 27% (USA) to 53% (UK) of patients were wait-listed in participating countries. Variables associated with lower odds of being on the waiting list included worse HR-QoL, more severe depressive symptoms, older age, fewer years of education, lower serum albumin, lower hemoglobin, shorter time on dialysis and presence of multiple comorbid conditions. Among wait-listed patients, significantly lower transplantation rates were seen for females, blacks, patients having prior transplantation and multiple comorbid conditions but not PCS or CES-D. CONCLUSIONS Fewer depressive symptoms and better HR-QoL are associated with being on the waiting list in prevalent HD patients but not with receiving a kidney transplant among wait-listed dialysis patients. Regular assessment of subjective well-being may help identify patients with reduced access to wait-listing and kidney transplantation.

Bilateral basal ganglia lesions in patients with end-stage diabetic nephropathy (Brief Communication)

Summary:  Acute movement disorder associated with reversible bilateral basal ganglia lesions is an increasingly recognized syndrome in patients with end‐stage renal disease, especially in the setting of concurrent diabetes mellitus. We report an elderly man with end‐stage diabetic nephropathy treated by daily automated peritoneal dialysis who developed subacute symptoms of gait disturbance, dysarthria, dysphagia and lethargy. Computed tomography and magnetic resonance imaging of the head revealed bilateral symmetrical basal ganglia lesions. Repeat imaging 3 weeks later showed that these lesions had regressed spontaneously. However, his neurological symptoms improved slowly. These findings were similar to 23 other cases in the literature. Review of these cases shows that clinical features were predominantly bradykinesia, gait disturbance and concurrent metabolic acidosis (observed in 90% of cases). The pathogenesis of this condition has not been clearly defined, but uraemia may be an aggravating factor in predisposed patients, particularly in the presence of diabetic microvascular disease. There is no specific treatment for this condition; supportive measures are the mainstay of management. In the majority of patients, neurological improvement lags behind regression of basal ganglia lesions seen with neuroimaging, and the long‐term outcome is variable.

Amyloid, advanced glycation end products, and dialysis related arthropathy

Dialysis associated arthropathy (DRA) is a syndrome peculiar to long term dialysis patients. It includes large and small joint symptoms, pathological fractures through bony cysts and an axial spondyloarthropathy, and is closely associated with carpal tunnel syndrome. It is characterised by deposition of β2 microglobulin (β2M) as an amyloid protein. This was first linked to the osteoarticular syndrome 12 years ago.1 Several other forms of bone and joint pathology also occur more frequently in dialysis patients, including secondary hyperparathyroidism, osteoporosis, gout, pseudogout, and aluminium induced bone disease.2 Prevalence of DRA is closely related to age and years of dialysis treatment. Symptoms develop in some patients within four to five years of treatment and are almost universally present in those who have been treated by haemodialysis for 15 years.2-4 The number of patients in this at risk group is steadily increasing; in Australia the proportion of patients with over 10 years exposure to dialysis treatment has remained constant around 6% over the past decade but the total number of patients needing dialysis treatment has doubled and the proportion over 65 years rose from 18% to 35%.5 Other Western countries face a similar problem. Several active areas of investigation and debate remain. The nature of the β2M deposition has been intensively studied, with recent demonstration of non-enzymatic modification of β2M to form advanced glycation end products (AGEs). The roles of different dialysis membranes and techniques in the production and clearance of β2M and the genesis of DRA continues to be actively investigated, although there have been few major technological advances in this area over the past five years. β2M is a 11.8 kDa polypeptide. The light chain of the HLA class I complex, it is expressed on the cell membrane of all nucleated cells. Freely filtered across the …

The CARI guidelines. Dialysis adequacy (HD) guidelines.

(Suggestions are based on Level III and IV evidence) • Adequacy of dialysis should be assessed on all patients at least 3-monthly, as clinically based assessment has proven unreliable. • Adequate dialysis should always include careful blood pressure control and ECF volume management with regular re-evaluation of ideal dry weight, salt intake and a review of the ultrafiltration rate. • Adequacy of dialysis can be assessed in several ways. The most common acceptable methods are: formal ureakinetic Kt/V, URR, natural log Kt/V and the Daugirdas second generation formula. A renal unit should be consistent in the method it uses. (Opinion) • The minimum achieved spKt/V should be 1.2 (URR = 65%). To consistently achieve this in at least 80% of patients, it is recommended that the target spKt/V should be 1.4 (URR = 70%).

Successful Treatment of Pulmonary Mucormycosis in a Renal Transplant Recipient with Limited Pulmonary Reserve by Combined Medical and Surgical Therapy

Mucormycosis is a rare opportunistic fungal infection in renal transplant recipients which is associated with exceedingly high mortality when inadequately treated. Risk factors for this infection include diabetes, neutropaenia and immunosuppression. We report a case of pulmonary mucormycosis in a renal allograft recipient with type 2 diabetes and limited pulmonary reserve. The patient was successfully treated with lobectomy and liposomal amphotericin B with preservation of pulmonary and allograft functions. Early recognition of this infection is warranted before dissemination, which carries a poor prognosis.