Jean-Philippe Rioux

Pentastarch 10% (250 kDa/0.45) is an independent risk factor of acute kidney injury following cardiac surgery.

Objective, Design and Patients: The risk of acute kidney injury (AKI) associated with hydroxyethyl starch may be limited to higher molecular weight agents. We retrospectively evaluated the risk of AKI using pentastarch 10% (250 kDa, 0.45) in a random cohort of 563 patients operated for a cardiac surgery at a university hospital. Measures: We assessed previously identified preoperative, perioperative, and postoperative risk factors, and the volume of pentastarch given until the end of the first postoperative day. We defined AKI by a 50% rise in serum creatinine within 4 days after surgery. Different propensity adjustment methods were used to further assess the selection bias. Results: Fifty-four (10%) patients developed AKI. Risk factors of AKI were age, female gender, preoperative creatinine clearance, hypertension, diuretic use, left ventricular ejection fraction, valvular surgery, duration of extracorporeal circulation, duration and dose of postoperative vasopressor support, and the number of red blood cells and fresh frozen plasma transfusions. Patients with AKI received 16 ± 9 mL/kg of pentastarch as opposed to 10 ± 7 mL/kg in controls (p < 0.001). Pentastarch remained independently predictive of AKI, with an adjusted odds ratio per mL/kg of 1.08 (95% confidence interval 1.04–1.12, p = 0.001). This risk was dose-dependent, and the optimal cutoff volume predicting AKI was 14 mL/kg. Different propensity adjustment methods were tested, and pentastarch as a risk factor of AKI was identified. Conclusions: This study identified a dose-dependent risk of AKI with pentastarch following cardiac surgery, given until the end of the first postoperative day.

FSGS permeability factor-associated nephrotic syndrome: remission after oral galactose therapy

Some cases of nephrotic syndrome in focal and segmental glomerulosclerosis (FSGS) are associated with a circulating factor, the FSGS permeability factor (FSPF). Galactose has a high affinity for FSPF, and experimental data suggest that it could reduce its activity. We describe the case of a 48-year-old male with a nephrotic syndrome found to be resistant to corticosteroids, immunosuppression and plasmaphaeresis. The patient was given oral galactose as a last resort treatment, which was followed by a remission of his nephrotic syndrome that correlated with a reduction of FSPF activity. This case is the first report of a long-standing remission of an FSPF-associated nephrotic syndrome on oral galactose therapy.

Canadian Society of Nephrology guidelines for the management of patients with ESRD treated with intensive hemodialysis.

Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research.

Effect of an In-Hospital Chronic Kidney Disease Education Program among Patients with Unplanned Urgent-Start Dialysis

BACKGROUND AND OBJECTIVES The effect of in-hospital education on the adoption of home dialysis (peritoneal dialysis [PD] and home hemodialysis [HHD]) after an unplanned dialysis start is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Clinical demographics of consecutive patients acutely initiating hemodialysis (HD) from January 2005 to December 2009 were abstracted using institutional electronic records. All patients received multimedia chronic kidney disease education by the same advanced care nurse practitioner before discharge from the hospital. Clinical characteristics of patients choosing home dialysis or staying on in-center HD were compared. RESULTS Between 2005 and 2009, 228 patients acutely started renal replacement therapy (RRT) at the center. Seventy-one patients chose home dialysis (49 patients adopted PD and 22 adopted HHD), 132 chose to remain on in-center HD, and 25 died before discharge from the hospital. Patients adopting home dialysis tended to be younger than in-center HD patients (55 ± 18 [home dialysis] versus 59 ± 16 [in center] years; P=0.09) and were similar in gender distribution (49% [home dialysis] versus 56% [in center] male; P=0.2). Patients adopting home dialysis were more likely to have a failed kidney transplant (24% [home dialysis] versus 12% [in center]; P=0.045) and less likely to have ischemic nephropathy (9% [home dialysis] versus 21% [in center]; P=0.03). The distribution of comorbid conditions was different between patients adopting home dialysis and in-center HD. CONCLUSIONS Home dialysis is feasible after urgent dialysis start. Education should be promoted among patient experiencing acute-start dialysis.

Albumin administration is associated with acute kidney injury in cardiac surgery: a propensity score analysis

IntroductionThe risk of acute kidney injury (AKI) with the use of albumin-containing fluids compared to starches in the surgical intensive care setting remains uncertain. We evaluated the adjusted risk of AKI associated with colloids following cardiac surgery.MethodsWe performed a retrospective cohort study of patients undergoing on-pump cardiac surgery in a tertiary care center from 2008 to 2010. We assessed crystalloid and colloid administration until 36 hours after surgery. AKI was defined by the RIFLE (risk, injury, failure, loss and end-stage kidney disease) risk and Acute Kidney Injury Network (AKIN) stage 1 serum creatinine criterion within 96 hours after surgery.ResultsOur cohort included 984 patients with a baseline glomerular filtration rate of 72 ± 19 ml/min/1.73 m2. Twenty-three percent had a reduced left ventricular ejection fraction (LVEF), thirty-one percent were diabetics and twenty-three percent underwent heart valve surgery. The incidence of AKI was 5.3% based on RIFLE risk and 12.0% based on the AKIN criterion. AKI was associated with a reduced LVEF, diuretic use, anemia, heart valve surgery, duration of extracorporeal circulation, hemodynamic instability and the use of albumin, pentastarch 10% and transfusions. There was an important dose-dependent AKI risk associated with the administration of albumin, which also paralleled a higher prevalence of concomitant risk factors for AKI. To address any indication bias, we derived a propensity score predicting the likelihood to receive albumin and matched 141 cases to 141 controls with a similar risk profile. In this analysis, albumin was associated with an increased AKI risk (RIFLE risk: 12% versus 5%, P = 0.03; AKIN stage 1: 28% versus 13%, P = 0.002). We repeated this methodology in patients without postoperative hemodynamic instability and still identified an association between the use of albumin and AKI.ConclusionsAlbumin administration was associated with a dose-dependent risk of AKI and remained significant using a propensity score methodology. Future studies should address the safety of albumin-containing fluids on kidney function in patients undergoing cardiac surgery.

Vascular Access for Intensive Maintenance Hemodialysis: A Systematic Review for a Canadian Society of Nephrology Clinical Practice Guideline

BACKGROUND Practices in vascular access management with intensive hemodialysis may differ from those used in conventional hemodialysis. STUDY DESIGN We conducted a systematic review to inform clinical practice guidelines for the provision of intensive hemodialysis. SETTING & POPULATION Adult patients receiving maintenance (>3 months) intensive hemodialysis (frequent [≥5 hemodialysis treatments per week] and/or long [>5.5 hours per hemodialysis treatment]). SELECTION CRITERIA FOR STUDIES We searched EMBASE and MEDLINE (1990-2011) for randomized and observational studies. We also searched conference proceedings (2007-2011). INTERVENTIONS (1) Central venous catheter (CVC) versus arteriovenous (AV) access, (2) buttonhole versus rope-ladder cannulation, (3) topical antimicrobial cream versus none in buttonhole cannulation, and (4) closed connector devices among CVC users. OUTCOMES Access-related infection, survival, hospitalization, patency, access survival, intervention rates, and quality of life. RESULTS We included 23, 7, and 5 reports describing effectiveness by access type, buttonhole cannulation, and closed connector device, respectively. No study directly compared CVC with AV access. On average, bacteremia and local infection rates were higher with CVC compared with AV access. Access intervention rates were higher with more frequent hemodialysis, but access survival did not differ. Buttonhole cannulation was associated with bacteremia rates similar to those seen with CVCs in some series. Topical mupirocin seemed to attenuate this effect. No direct comparisons of closed connector devices versus standard luer-locking devices were found. Low rates of actual or averted (near misses) air embolism and bleeding were reported with closed connector devices. LIMITATIONS Overall, evidence quality was very low. Limited direct comparisons addressing main review questions, small sample sizes, selective outcome reporting, publication bias, and residual confounding were major factors. CONCLUSIONS This review highlights several differences in the management of vascular access in conventional and intensive hemodialysis populations. We identify a need for standardization of vascular access outcome reporting and a number of priorities for future research.

Systematic differences among patients initiated on home haemodialysis and peritoneal dialysis: the fallacy of potential competition

BACKGROUND The adoption of home-based dialysis therapies is growing internationally. There is a possibility that competition for patients may exist between peritoneal dialysis (PD) and home haemodialysis (HHD) for their respective growth. METHODS Clinical demographics of patients initiating PD and HHD from 2004 to 2008 in our centre were abstracted using institutional electronic records. We compared clinical demographics, laboratory data and process of care to describe potential factors leading to patients choosing home-based dialysis therapies. RESULTS Between 2004 and 2008, 236 patients initiated home dialysis therapy in our centre: 153 patients to PD and 83 patients to HHD. PD and HHD patients differed in age (PD 62 +/- 16 vs HHD 46 +/- 13 years; P < 0.001) and gender distribution (PD 57 vs HHD 70% male; P = 0.05). A higher proportion of PD patients had diabetes and hypertension as the primary cause of their end-stage renal disease (ESRD). In contrast, there were more patients with glomerulonephritis among the HHD cohort. Cardiovascular and peripheral vascular diseases were more common among patients on PD. HHD patients had longer ESRD vintage (PD 0.34 +/- 0.69 and HHD 4.8 +/- 6.8 years on therapy; P = 0.002). The proportion of patients receiving chronic kidney disease care was higher among PD starters (PD 86 vs HHD 65%; P < 0.001). Sixteen percent of PD patients and 9% of HHD patients initiated their home-based renal replacement therapy after an acute hospitalization without prior modality education. CONCLUSION There is a systematic difference between patients initiated on PD and HHD. Our data reaffirm that modality selection is a complex process. Patients on the two home therapies differ demographically and arrive through different routes. This finding suggests that the two home-based modalities are not in competition.

Dialysate Calcium Concentration and Mineral Metabolism in Long and Long-Frequent Hemodialysis: A Systematic Review and Meta-analysis for a Canadian Society of Nephrology Clinical Practice Guideline

BACKGROUND Patients treated with conventional hemodialysis (HD) develop disorders of mineral metabolism that are associated with increased morbidity and mortality. More frequent and longer HD has been associated with improvement in hyperphosphatemia that may improve outcomes. STUDY DESIGN Systematic review and meta-analysis to inform the clinical practice guideline on intensive dialysis for the Canadian Society of Nephrology. SETTING & POPULATION Adult patients receiving outpatient long (≥5.5 hours/session; 3-4 times per week) or long-frequent (≥5.5 hours/session, ≥5 sessions per week) HD. SELECTION CRITERIA FOR STUDIES We included clinical trials, cohort studies, case series, case reports, and systematic reviews. INTERVENTIONS Dialysate calcium concentration ≥1.5 mmol/L and/or phosphate additive. OUTCOMES Fragility fracture, peripheral arterial and coronary artery disease, calcific uremic arteriolopathy, mortality, intradialytic hypotension, parathyroidectomy, extraosseous calcification, markers of mineral metabolism, diet liberalization, phosphate-binder use, and muscle mass. RESULTS 21 studies were identified: 2 randomized controlled trials, 2 reanalyses of data from the randomized controlled trials, and 17 observational studies. Dialysate calcium concentration ≥1.5 mmol/L for patients treated with long and long-frequent HD prevents an increase in parathyroid hormone levels and a decline in bone mineral density without causing harm. Both long and long-frequent HD were associated with a reduction in serum phosphate level of 0.42-0.45 mmol/L and a reduction in phosphate-binder use. There was no direct evidence to support the use of a dialysate phosphate additive. LIMITATIONS Almost all the available information is related to changes in laboratory values and surrogate outcomes. CONCLUSIONS Dialysate calcium concentration ≥1.5 mmol/L for most patients treated with long and long-frequent dialysis prevents an increase in parathyroid hormone levels and decline in bone mineral density without increased risk of calcification. It seems prudent to add phosphate to the dialysate for patients with a low predialysis phosphate level or very low postdialysis phosphate level until more evidence becomes available.

Caregiver burden among nocturnal home hemodialysis patients

Recent studies have suggested improvements in quality of life (QOL) in patients on quotidian dialysis compared with conventional hemodialysis. Few studies have focused on the burden and QOL in caregivers of patients with end‐stage renal disease (ESRD) on nocturnal home hemodialysis (NHD). We aim to assess the caregivers’ burden, QOL, and depressive symptoms and to compare these parameters with their patients’ counterparts. Cross‐sectional surveys were sent to 61 prevalent NHD patients and their caregivers. Surveys assessed demographics, general self‐perceived health using the 12‐Item Short Form Health Survey (SF‐12) and the presence of depression using the Beck Depression Inventory. Subjective burden on caregivers was assessed by the Caregiver Burden scale and was compared with perceived burden by the patients. Thirty‐six patients and 31 caregivers completed the survey. The majority of caregivers were female (66%), spouse (81%) with no comorbid illness (72%). Their mean age was 51 ± 11 years. Patients were mostly male (64%) with a median ESRD vintage of 60 months (interquartile range [IQR], 18–136 months) and a mean age of 52 ± 10 years. Compared to caregivers, patients had lower perceived physical health score but had similar mental health score. Depression criteria were present in 47% of patients and 25% of caregivers. Total global burden perceived by either caregivers or patients is relatively low. Although there is a relatively low global burden perceived by caregivers and patients undergoing NHD, a significant proportion of both groups fulfilled criteria for depression. Further innovative approaches are needed to support caregivers and patients performing NHD to reduce the intrusion of caring for a chronic illness and the risk of developing depression.

Patient selection and training for home hemodialysis.

Patient selection and training is arguably the most important step toward building a successful home hemodialysis (HD) program. We present a step‐by‐step account of home HD training to guide providers who are developing home HD programs. Although home HD training is an important step in allowing patients to undergo dialysis in the home, there is a surprising lack of systematic research in this field. Innovations and research in this area will be pivotal in further promoting a higher acceptance rate of home HD as the renal replacement therapy of choice.