Bruce Cleland

Hypersensitivity reactions to the polysorbate contained in recombinant erythropoietin and darbepoietin (Case Report)

SUMMARY:  The following case reports are of two patients who have developed hypersensitivity reactions to the red cell growth hormones, darbepoietin and erythropoietin. The subsequent skin testing and clinical course suggested that the cause of these reactions was due to the excipient polysorbate 80. This finding might have implications in the recent increase in the incidence of pure red cell aplasia.

High-Sensitivity Troponin as a Predictor of Cardiac Events and Mortality in the Stable Dialysis Population

BACKGROUND High-sensitivity cardiac troponin T (hs-cTnT) is a biomarker used in diagnosing myocardial injury. The clinical utility and the variation of this biomarker over time remain unclear in hemodialysis (HD) and peritoneal dialysis (PD) patients. We sought to determine whether hs-cTnT concentrations were predictive of myocardial infarction (MI) and death and to examine hs-cTnT variability over a 1-year period. METHODS A total of 393 nonacute HD and PD patients (70% HD and 30% PD) were followed in a prospective observational study for new MI and death. RESULTS Median hs-cTnT was 57 ng/L (interquartile range, 36-101 ng/L) with no observed difference between HD and PD patients (P = 0.11). Incremental increases in mortality (P = 0.024) and MI (P = 0.001) were observed with increasing hs-cTnT quartiles. MI incidence increased significantly across quartiles in both HD and PD patients (P = 0.012 and P = 0.025, respectively), whereas mortality increased only in HD patients (P = 0.015). For every increase of 25 ng/L in hs-cTnT, the unadjusted hazard ratio (HR) was 1.10 for mortality in the whole group (95% CI, 1.04-1.16, P = 0.001) and 1.16 for MI (95% CI, 1.08-1.23, P < 0.001). Adjusted HR for mortality was 1.07 (95% CI, 1.01-1.15, P = 0.04) and 1.14 for MI (95% CI, 1.06-1.22, P < 0.001). Changes in hs-cTnT from baseline concentrations after 1 year were minimal (55 ng/L vs 53 ng/L, P = 0.22) even in patients who had an MI (P = 0.53). CONCLUSIONS hs-cTnT appears to have a useful role in predicting MI and death in the dialysis population. Over a 1-year period concentrations remained stable even in patients who sustained a new cardiac event.

Peritoneal dialysis in pregnancy: A case series

SUMMARY:  Patients with significant renal impairment have difficulties maintaining a viable pregnancy due to maternal and fetal complications. Both peritoneal dialysis and hemodialysis support throughout pregnancy has been reported to assist in these pregnancies. We report our experience with the use of peritoneal dialysis in five cases leading to successful deliveries with minimal complications.

CHANGE PROCESS DURING SYNCHRONISED CONVERSION TO A ONCE-MONTHLY ERYTHROPOIESIS-STIMULATING AGENT (ESA) ADMINISTRATION AT A SINGLE SATELLITE HAEMODIALYSIS UNIT

BACKGROUND There are currently no published data on the impact of changes to practice caused by introducing coordinated once-monthly erythropoiesis-stimulating agent (ESA) administration. OBJECTIVE This study aimed to measure staff satisfaction during and after ESA synchronisation within a single satellite haemodialysis unit. DESIGN A quantitative survey using a Likert scale was distributed to dialysis nurses pre-synchronisation and during follow-up at three and nine months post-synchronisation. Secondary outcomes included monitoring of haemoglobin (Hb) levels. RESULTS A total of 19 respondents completed the surveys. By nine months post-synchronisation, most nurses responded that ESA synchronisation was not a time-consuming task, did not increase their workload, had saved them time and was simpler for the unit. Additionally, most nurses reported that they had coped well with the change and that they wanted ESA synchronisation to be permanently introduced. At 8 months post-synchronisation, 53.3% of patients had an Hb level > 11 g/dl and < 12 g/dl. CONCLUSION Changes to practice resulting from ESA synchronisation did not appear to negatively impact nurse workplace satisfaction.

Administration of erythropoiesis-stimulating agents in patients undergoing haemodialysis: a time and motion study

BACKGROUND International guidelines recommend treatment of anaemia due to chronic kidney disease (CKD) with erythropoiesis-stimulating agents (ESAs). OBJECTIVE To document the time required and the cost in terms of nursing time to prepare and administer ESAs to patients on facility based haemodialysis (HD) with anaemia due to CKD before and after the introduction of long-acting ESAs. DESIGN A time and motion study was implemented at four HD units in Australia to determine the time and costs associated with preparing and administering ESAs before and after the introduction of long-acting ESAs. PARTICIPANTS This was a prospective, observational study of workplace practices at four HD units in Australia. MEASUREMENTS Outcome data included the time taken to prepare, and administer ESAs. RESULTS The time costs of preparation and administration per patient per year had a wide variability within each unit and ranged from Australian AUD

A case of recurrent severe pre-eclampsia associated with essential cryofibrinogenaemia

55.75 (38 euros) to AUD

A deadly thorn prick.

90.49 (62 euros) before the introduction of long-acting ESAs. This dropped by 73-80% following the introduction of long-acting ESAs, representing an annual cost savings of between AUD

An allergic reaction to erythropoietin secondary to polysorbate hypersensitivity

2,591 and AUD

HomeChoice automated peritoneal dialysis machines: the impact of reuse of tubing and cassettes.

5,914 if all patients on HD were switched to a long acting ESA. CONCLUSION Switching from a short-acting to a long-acting ESA in HD units leads to a significant reduction in time costs of health professionals in preparation and administration of ESAs by up to 80%. Practical application: This time and motion study has added further evidence on reduction of human effort by taking advantages of new research development, such as the long acting ESAs.

Pyrexia of unknown origin (PUO) in a hemodialysis patient

Essential cryofibrinogenaemia is a rare disorder characterized by cryofibrinogens without cryoglobulins. Connective tissue disorders and thrombophilia are known to increase risk of pre-eclampsia, but pre-eclampsia has not previously been reported in association with cryofibrinogenaemia. We report the case of a 32-year-old woman with recurrent severe pre-eclampsia diagnosed with essential cryofibrinogenaemia.