Emaad M. Abdel-Rahman

Falls in elderly hemodialysis patients

The elderly, (age ≥ 65 years) hemodialysis (HD) patient population is growing rapidly across the world. The risk of accidental falls is very high in this patient population due to multiple factors which include aging, underlying renal disease and adverse events associated with HD treatments. Falls, the most common cause of fatal injury among elderly, not only increase morbidity and mortality, but also increase costs to the health system. Prediction of falls and interventions to prevent or minimize fall risk and associated complications will be a major step in helping these patients as well as decreasing financial and social burdens. Thus, it is vital to learn how to approach this important problem. In this review, we will summarize the epidemiology, risk factors, pathophysiology and complications of falls in elderly HD patients. We will also focus on available methods to assess and predict the patients at higher risk of falling and will provide recommendations for interventions to reduce the occurrence of falls in this population.

Clinical applications of therapeutic apheresis

The vast majority of the renal indications for plasmaexchange are related to immunoglobulin removal.Immunoglobulins, especially IgG, have a relativelylong half-life. Thus in antibody-mediated disease, therecould be persistence of significant amounts of antibodyin the circulation despite cessation of antibody produc-tion. The aim of plasma exchange is to significantlyreduce circulating antibodies. Removal of the circulat-ing antibodies constitutes the rationale for using plas-mapheresis to treat antibody-associated glomeruloneph-ritis (GN). Although small molecular weight substancesare removed by plasma exchange, their large volumeof distribution and short half-lives make plasmaexchange an inefficient means of extracorporeal re-moval of these substances. For instance, some comple-ment proteins have a half-life of 2 days. If the goalwere to be to deplete plasma complement levels, virtu-ally daily plasma exchanges would be needed. Discon-tinuation of daily plasma exchange would be followedby rapid resurgence to normal complement titers.Hence the shorter the half-life of the molecule beingremoved, the more aggressive has to be the apheresisschedule.Plasma volume can be estimated using the followingformula:EPV ¼ 0:065 3 TBW 3 ½1 Hctwhere EPV is the estimated plasma volume, TBW isthe total body water, and Hct is hematocrit.The removal of large molecular weight substancesfrom the plasma compartment follows first-orderkinetics. Repetitive treatments should be spaced every24–48 h to allow for extravascular to intravascularequilibration.Apheresis has been used to treat several renal condi-tions including primary renal diseases as well as renalmanifestations of systemic conditions (Table I).

Septic shock with multiorgan failure: from conventional apheresis to adsorption therapies.

Septic shock is often associated with multiorgan failure, a life threatening clinical condition during which there is an imbalance in the proinflammatory and anti‐inflammatory cytokines, chemokines, antigens, endotoxins, procoagulant, and anticoagulant factors and also resultant effects of therapeutic intervention like volume overload. Various extracorporeal therapies have shown some positive results as adjunctive therapeutic intervention to traditional antimicrobials in an effort to bring the inflammatory mediators to a homeostatic balance and to improve poor organ perfusion caused by hypotension and thrombosis in the microcirculation. This review focuses on current information on the use of therapeutic apheresis procedures as adjunctive therapy in such clinical situations as well as the exciting prospects for the near future. The sometimes disappointing results of early phase clinical studies may, in some cases, be related to the well known barriers to successful clinical trials in critically ill patients rather than to failure of the novel concept of adjunctive extracorporeal treatment of septic shock. It should be noted that some of the specialized apheresis technologies reviewed in this article are not yet available for clinical use in the United States as they are not yet approved for use by the US Food and Drug Administration.

Beck Depression Inventory and survival in elderly hemodialysis patients

sensitivity of peritoneal dialysis (PD) patients for posttransplant diabetes mellitus (PTDM) development. Courivaud et al. noticed that the strongest risk factors for PTDM appearance were older recipient age and higher body mass index (BMI) at transplantation, acknowledging simultaneously that PD patients were significantly younger (P = 0.004) and had a lower BMI (P = 0.07) than haemodialysis (HD) treated counterparts. Considering this fact, a lack of difference in PTDM occurrence between PD and HD patients can be interpreted as the argument for the metabolic disorder making PD patients more vulnerable for PTDM. It is noteworthy that, in our observation, the risk of PTDM in PD patients below the age of 50 years was similar to that in the HD group >50 years. The important distinctive element between Courivaud et al. and our study was the use of different criteria for diabetes diagnosis. We used the more sensitive current American Diabetic Association criteria, whereas they identified diabetes by the prescription of insulin or oral antidiabetics. This is probably the reason of the low diabetes rate (6.8%) in their study compared to our 22.1% revealed after 6 months. This last figure seems to reflect the real scale of glucose intolerance after renal transplantation [3]. We have also noted that two papers quoted in the letter are in fact not in favour of PD treatment. The main findings of Rodriguez Ayala et al. [4] were the observations that plasma ghrelin drops during the 12-month period of PD and this was significantly linked to increased fat mass and inversely correlated with plasma insulin. Rodriguez Ayala et al. commented in the discussion ‘we find it likely that hyperglycaemia and hyperinsulinaemia, two common findings in PD patients, may also be related to the observed decrease in plasma ghrelin levels during PD’. In turn, Wong et al. [5] did not state that inflammation was less activated in the PD group versus HD. They even noticed significantly higher serum TNF and IL-18 concentrations in PD patients. In conclusion, the data presented by Courivaud et al. [2] does not undermine the assumption that PD treatment may increase the risk of PTDM development. We obviously agree that further studies are needed to finally solve the issue.

Quality of Life, Perceptions, and Health Satisfaction of Older Adults with End‐Stage Renal Disease: A Systematic Review

To explore the quality of life (QOL), perceptions, and health satisfaction of older adults with end‐stage renal disease (ESRD) undergoing renal replacement therapy (RRT).

The 15-item geriatric depression scale as a predictor of mortality in older adults undergoing hemodialysis.

come. A previous study comparing patients admitted from long-term care and the community concluded that most long-term care residents did not regain prefracture function, but nursing home residents in this study were older and had more comorbidities including dementia that were likely to affect their rehabilitation potential. All patients in the current study participated in a coordinated multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their prefracture living arrangements. Despite this, a large proportion of individuals did not regain premorbid functional status, and not all returned to their premorbid residence; 38% were discharged to a long-term care facility, a figure that compares with other studies. These higher levels of care are costly and contribute to the hidden health economic burden of hip fracture. Furthermore, the reduction in social independence and function in these patients discharged to the community can significantly affect their quality of life. Although the current study had short follow-up, function at hospital discharge is a strong predictor of functional status at 1 year. The rising incidence of hip fractures reinforces the importance of preventing falls and fractures in older people. In 2008, the World Health Organization introduced the FRAX tool, which can be used to better identify people at high risk of fracture, and there is currently good evidence to support the use of many antiresorptive and anabolic drugs for fracture risk reduction. FRAX incorporates several known risk factors for fracture, along with bone mineral density T-score, if available, and calculates fracture probabilities from which treatment thresholds can be determined in individual countries. To encourage primary prevention of fracture at a national level, the use of FRAX should be encouraged among health professionals. To meet the challenges of increasing numbers of hip fracture in the future, strategies for management should encompass guidelines on prevention. Ongoing close liaison with orthopedic colleagues should continue to enhance the quality of care and recovery of older adults with hip fracture.

Perspectives on symptom experiences and symptom reporting among individuals on hemodialysis

BackgroundnIndividuals on hemodialysis bear substantial symptom burdens, but providers often underappreciate patient symptoms. In general, standardized, patient-reported symptom data are not captured during routine dialysis care. We undertook this study to better understand patient experiences with symptoms and symptom reporting. In exploratory interviews, we sought to describe hemodialysis nurse and patient care technician perspectives on symptoms and symptom reporting.nnnMethodsnWe conducted semi-structured interviews with 42 US hemodialysis patients and 13 hemodialysis clinic personnel. Interviews were conducted between February and October 2017 and were analyzed using thematic analysis.nnnResultsnSeven themes were identified in patient interviews: (i) symptoms engendering symptoms, (ii) resignation that life is dependent on a machine, (iii) experiencing the life intrusiveness of dialysis, (iv) developing adaptive coping strategies, (v) creating a personal symptom narrative, (vi) negotiating loss of control and (vii) encountering the limits of the dialysis delivery system. Overall, patient symptom experiences and perceptions appeared to influence symptom-reporting tendencies, leading some patients to communicate proactively about symptoms, but others to endure silently all but the most severe symptoms. Three themes were identified in exploratory clinic personnel interviews: (i) searching for symptom explanations, (ii) facing the limits of their roles and (iii) encountering the limits of the dialysis delivery system. In contrast to patients, clinic personnel generally believed that most patients were inclined to spontaneously report their symptoms to providers.nnnConclusionsnInterviews with patients and dialysis clinic personnel suggest that symptom reporting is highly variable and likely influenced by many personal, treatment and environmental factors.

Cardiovascular outcomes in dialysis patients: one size does not fit all

Cardiovascular disease (CVD) is the largest contributor to mortality in patients with the most severe form of kidney disease, end-stage kidney disease (ESKD). While this fact is widely understood, the mortality risk of the nearly half million US dialysis patients is truly hard to fathom: 166 per 1000 patient-years, a rate surpassing most metastatic cancers. Nearly half of this stunning mortality rate is attributed to CVD (Figure 1). Despite significant advances in our understanding of the pathology and treatment of CVD in the general population, little has been shown to improve the cardiovascular risk profile of the dialysis patient, aside from transplantation. Complicating matters, in ESKD patients, the leading cause of CVDrelated death is lethal arrhythmias/sudden cardiac death, not coronary artery disease/myocardial infarction. Recent studies of implantable loop recorders in ESKD have shown that most fatal arrhythmias appear to be bradycardic arrhythmias or pulseless electrical activity in nature, explaining the difficulty in demonstrating a mortality benefit of implantable cardiac defibrillators. Multiple factors account for the poor state of knowledge regarding cardiac complications in ESKD. Patients requiring dialysis are some of the most medically complex patients cared for in any health system. As such, they are typically excluded from the large prospective trials from which the cardiology field has rightfully earned acclaim. In the rare instances where a sizeable randomized controlled trial has been undertaken, results have generally been mixed. One example, the Deutsche Diabetes Dialyse (4 D) trial, randomized 1255 patients with < 2 years of dialysis, diabetes, and abnormal lipid profiles to atorvastatin vs. placebo and followed the patients for 3 years of therapy. Despite marked lipid profile improvement, no significant difference was seen in the composite cardiovascular outcome. If traditional risk factors are, at minimum, less predictive of cardiovascular outcomes in ESKD, are there non-traditional risk factors that have been identified? Over the years, many have been suggested. Chronic anaemia, hormonal derangements such as elevated levels of fibroblast growth factor 23, and, more recently, recurrent myocardial stunning during dialysis, to name just a few, have all been posited as non-traditional CVD risk factors in dialysis patients. However, there are no large randomized controlled trials of a successful intervention to reduce CVD in dialysis to date. This leaves the nephrologist and cardiologist with an evidence base of retrospective analyses subject to confounding, observational trial data, and small underpowered prospective trials. The limited interventional trials in CVD and ESKD proceed from the assumption that patients share a homogenous disease where interventions will be generalizable to the cohort as a whole. This belief persists despite a growing body of literature suggesting that ESKD is a heterogeneous mix with differing implications for health. Komatsu et al., showed that patients with ESKD due to immunoglobulin A (IgA) nephropathy had favourable outcomes. In contrast, Chen et al. compared clinical data of patients with diabetic nephropathy (DN) on haemodialysis (HD) vs. non-DN on HD. They showed that the incidence of hypertension, coronary heart disease, and cerebral thrombus in DN patients was higher than those in non-DN patients (P < 0.001). More recently, Al-Thani et al. confirmed that patients with diabetes mellitus and lupus nephritis (LN) undergoing HD had a significantly higher vascular disease burden and mortality compared with non-diabetic patients on HD. Levy et al. demonstrated higher mortality of patients with LN on HD when compared to controls with polycystic kidney disease, further suggesting that outcomes of dialysis patients may vary based on the initial cause of the kidney disease. Narrowing focus to glomerular disease, a recent New Zealand study examined patients with biopsy-proven primary glomerulonephritis (GN) with the goal of estimating the long-term risk of ESKD

Selected questions and answers given by apheresis medicine experts at TAA 2010

Q: We are seeing more 5and 6-L plasma-volume exchanges in chronic inflammatory demyelinating polyneuropathy (CIDP) patients. What are your thoughts on that? DR. WARD: The principles in CIDP are hard to elucidate; it may not be an IgG-based disease in all cases. If you exchange 5 or 6 L, you deplete less as you go down the curve. A lot of chronic-plasma exchange CIDP patients can be maintained on once a week or once every 2 weeks, so the temptation is to do more on the day that you see them. But I do not think that the last part of the procedure does very much, once you have exchanged more than 1.5 plasma volumes.