Charles J. Foulks

Use of a Silicone Dual-Lumen Catheter With a Dacron Cuff as a Long-Term Vascular Access for Hemodialysis Patients

We evaluated our experience over a 4-year period with a silicone dual-lumen catheter with a Dacron cuff (SDLCDC) to determine if the catheter represents an alternative to the polytetrafluoroethylene graft for long-term vascular access for hemodialysis patients. Records of 131 patients who used 168 catheters were reviewed for catheter function, duration of use, and occurrence and response to treatment of complications. Eighty-five percent of catheters functioned adequately until their use was no longer required or the end of the study. One-year catheter survival estimate was 65% and median survival estimate was 18.5 months. Mean blood flow rate achieved was 243 mL/min and recirculation was 7.5%. Exit-site infection occurred in 21% of patients and bacteremia in 12%. There were significantly more exit-site infections in diabetics than nondiabetics (33% v 11%, P less than 0.02). Exit-site infections resolved with parenteral antibiotic therapy in 90% and bacteremia in 25% of cases without catheter removal. Unresolved bacteremia was the most common cause of catheter removal and led to the loss of 7% of catheters. Thrombotic complications occurred in 46% of catheters. Urokinase instillation successfully treated catheter occlusion in 81% of cases. When urokinase instillation failed, streptokinase infusion restored catheter patency 97% of the time. The literature on the polytetrafluoroethylene (PTFE) graft was reviewed, and the SDLCDC was found to be similar to the graft in function, duration of use, and frequency of infectious and thrombotic complications. We conclude that the catheter represents an alternative to the graft for long-term vascular access in hemodialysis patients. Because of the frequent complications with both accesses, neither should be considered optimal. Further research is required to improve vascular access for patients in whom placement of an arteriovenous fistula is not possible.

The Effect of Oral Sodium Phosphate Drug Products on Renal Function in Adults Undergoing Bowel Endoscopy

BACKGROUND Oral sodium phosphate solution (OSPS) preparations are preferred cleansing agents for colonoscopy because of ease of use and excellent preparation quality. Besides causing acute renal failure in some patients, the high phosphorus content can potentially cause chronic kidney damage to patients undergoing colonoscopy. METHODS We carried out a retrospective study on patients with creatinine levels in the normal range who had undergone colonoscopy or flexible sigmoidoscopy using OSPS preparation from January 1998 to February 2005 and followed them for 1 year to determine its effects on their renal function. A control group of patients with similar comorbidities during this period were chosen to assess age-related decline in renal function in this population. RESULTS A total of 286 patients were selected in the study group, and 125 patients were selected in the control group. Both groups had similar baseline characteristics. The baseline glomerular filtration rate (GFR) in the study group was 79 mL/min/1.73 m(2), which declined to 73 mL/min/1.73 m(2) at 6 months after exposure to OSPS preparation. This finding was significantly different from the control group, in whom the baseline GFR was 76 mL/min/1.73 m(2) and remained stable at 6 months. Linear regression analysis showed that use of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers and the presence of diabetes were significant determinants of the fall in GFR after use of OSPS preparation. CONCLUSIONS Oral sodium phosphate solution preparation is associated with decline in GFR in elderly patients with creatinine levels in the normal range. Its routine use for elective and screening procedures should be discouraged in the elderly population.

An evidence-based evaluation of intradialytic parenteral nutrition

Malnutrition is a well-recognized comorbid condition in dialysis patients that contributes to the increased mortality seen in these patients. Multiple interventions have been tried in an effort to decrease mortality. The most controversial of these is intradialytic parenteral nutrition. In an era of high costs and shrinking budgets, it is important to critically examine published data to determine the quality of the data and to determine whether the reported results are valid and clinically applicable. Using an evidence-based approach, all published literature concerning intradialytic parenteral nutrition was reviewed, quality of the data determined, number needed to treat (NNT) calculated, and potential costs of treatment determined. Twenty-four studies that met the search criteria were identified. Only three studies were randomized; one of these was a feasibility study, and the other two were only of level B quality. The remaining studies were either case reports or observational studies of level C quality. The absolute risk reduction in mortality with intradialytic parenteral nutrition (IDPN) usage ranged from 0.12 to 0.65; relative risk reduction ranged from 0.48 to 0.74; NNT ranged from 2 to 17; cost ranged from

The Effect of Intradialytic Parenteral Nutrition on Hospitalization Rate and Mortality in Malnourished Hemodialysis Patients

150,000,000 to

Comparison of Four Bedside Indicators Used to Predict Duodenal Feeding Tube Placement With Radiography

877,500,000; and 588 to 9,750 patients might be expected to experience a decrease in mortality. The results of this review indicate that the data supporting the use of IDPN are weak and a clear recommendation cannot be made. IDPN use in hemodialysis patients seems to be associated with decreased mortality. IDPN should be available for use in patients who meet previously published guidelines and who are not normoalbuminemic.

Indications for the Use of Intradialytic Parenteral Nutrition in the Malnourished Hemodialysis Patient

■ Objective: To determine if intradialytic parenteral nutrition (IDPN) therapy of malnourished hemodialysis patients results in a decrease in hospitalization rate and mortality. ■ Data sources: Outpatient hemodialysis records, patient interviews, registered dietitian evaluations, and hospitalization discharge summaries. ■ Study selection: All hemodialysis patients treated with IDPN from July 1, 1989, until March 15, 1991, death, or cessation of IDPN. All patients had to meet criteria defining malnutrition and to have failed 2 weeks of intensive dietary counseling with (64%) or without (36%) dietary supplements. ■ Data extraction: Data base abstracted by two registered nurses skilled in data collection and familiar with hemodialysis. Data were collected, and patients were evaluated on a monthly basis. ■ Data synthesis: Responders (Rs) were those with a greater than 5-g/L (0.5-g/dL) increase in albumin or total protein or a greater than 10% nonfluid weight gain. Rs differed from nonresponders (NRs) in baseline values for albumin (22 ± 7 g/L [2.2 ± 0.7 g/dL]; 30 ± 9 g/L [3.0 ± 0.9 g/dL]; P ■ Conclusion: IDPN may be related to increased serum albumin and total protein concentrations in subsets of malnourished hemodialysis patients. There may also be a link between decreased hospitalizations and mortality in patients who respond to IDPN. Differences in Rs and NRs could not be found to explain these findings.

Sexual Dysfunction in the Male Dialysis Patient: Pathogenesis, Evaluation, and Therapy

The validity of four indicators to predict successful duodenal feeding tube placement was evaluated in a prospective trial. Data were collected on each indicator at prepyloric (< or = 65 cm) and postpyloric (> or = 75 cm) feeding tube lengths. Feeding tubes were placed in 106 patients. Eighteen feeding tubes were located in the stomach, and 88 were in the duodenum. Auscultation (progression of loudest sound locations from the left to the right abdomen) had a positive predictive value of 85% (negative predictive value, 31%). The vacuum effect (a change from 40 mL of aspirated air to < or = 10 mL after 60 mL of air instillation) had a positive predictive value of 86% (negative predictive value, 45%) and was significantly correlated with duodenal placement (p = .02). Aspirate was present at prepyloric and postpyloric lengths in 35 cases. Ten of these 35 cases had the defined change in pH from < or = 4.0 to > or = 6.0 (positive predictive value, 100%; negative predictive value, 28%). The positive predictive value of color (a change to yellow) was also 100% (n = 11); the negative predictive value was 29%. The low negative predictive values of the indicators suggest that the absence of defined changes is of no assistance in discriminating between stomach and duodenal placement. A positive auscultation or vacuum effect test is not conclusive for duodenal placement. A positive pH or color change test may obviate the need for a confirmatory radiograph.(ABSTRACT TRUNCATED AT 250 WORDS)

Improving house staff ordering of three common laboratory tests. Reductions in test ordering need not result in underutilization.

Intradialytic parenteral nutrition (IDPN) has developed as a therapy for the outpatient treatment of malnutrition. Multiple studies have evaluated the effects of providing either parenteral or oral nutritional supplements over the dialysis period as a treatment of malnutrition. Most studies have been of short duration and have involved few patients. Randomization, blinding, and crossover techniques have not been used to control for non-nutrition-related variables. A few studies suggest that IDPN may reverse biochemical abnormalities and possibly cause increased appetite and weight gain. Because of the tremendous expense and the lack of data to show efficacy of this therapy in decreasing morbidity and mortality in hemodialysis patients, IDPN should be reserved for those patients who fail conventional measures to reverse weight loss, hypoalbuminemia, and progressive malnutrition.

The admission urinalysis - Impact on patient care

Impotence is a common problem in male dialysis patients. Although dialysis patients may appear to have more reasons to be depressed than nondialysis patients, depression has not been found to be correlated with erectile dysfunction in this group. Primary testicular failure is common in male dialysis patients as is hyperprolactinemia. These disorders may be the cause of impotence in some of these patients. An algorithm for the evaluation and treatment of impotence in the male dialysis patient is presented. Successful renal transplantation is associated with improvement in the testicular failure, in the hyperprolactinemia, and in the erectile dysfunction of the male patient with end-stage renal disease.

Invited Review: Intradialytic Parenteral Nutrition: A Useful Therapy?

Most studies of modifying test ordering have focused on costs. Questions not addressed are whether programs to reduce testing lead to a higher proportion of clinically indicated tests and is underutilization an adverse outcome of such programs? To investigate this, we studied the house staffs ordering of three common laboratory tests at baseline and after educational and administrative interventions. Over a 2-year period, 3,603 urine cultures, sputum cultures, and admission urinalyses were reviewed. A lecture emphasizing the indications for these tests followed by chart audit and weekly feedback increased the proportion of clinically indicated tests. Subsequently, an administrative intervention requiring the intern to list the reason for ordering the test on the laboratory request form further improved test ordering. Underutilization, defined as a failure to order a potentially indicated test, was assessed during two representative periods. The “underutilization rate” (omitted tests per 100 patients) was no worse during maximal intervention than it was 9 months after the last intervention (7.7 vs. 11.1, NS). No immediate adverse consequences resulted from tests not ordered. Our findings indicate that it may be possible to selectively reduce the ordering of unnecessary tests without sacrificing quality of care.