Josephine Chow

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.

Review: anticoagulation for haemodialysis.

The coagulation cascade is complex but well studied. Dialysis membranes and lines are inherently pro‐coagulant and activate both the intrinsic and extrinsic pathways of coagulation, as well as platelets and other circulating cellular elements. To provide safe and effective dialysis, appropriate anticoagulant measures must be applied. Haemodialysis, including anticoagulation, is prescribed by dialysis doctors but delivered by dialysis nurses. The main agents used in clinical practice for anticoagulation during haemodialysis are unfractionated heparin (UF heparin) and low‐molecular‐weight heparin (LMWH). LMWH has a number of potential advantages, apart from cost. One of the most serious complications of the use of any form of heparin is heparin‐induced thrombocytopaenia (HIT) Type II, which occurs more commonly with UF heparin than LMWH. HIT Type II risks severe morbidity and mortality and is challenging to treat successfully in both the acute and chronic phase. In HIT Type II anticoagulation must be delivered without heparin. A wide array of newer anticoagulants are becoming progressively available, each with unique advantages and disadvantages. In maintenance haemodialysis patients with an increased risk of bleeding, a ‘no heparin’ dialysis may be undertaken, or regional anticoagulation considered. Because this aspect of dialysis is so important to the safe and effective delivery of haemodialysis therapy, dialysis clinicians need to review and update their knowledge of dialysis anticoagulation on a regular basis.

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.

Acute vascular access catheters for haemodialysis: complications limiting technique survival.

SUMMARY: The use of acute vascular access catheters (AVACs) has facilitated the delivery of haemodialysis to patients lacking functioning access. A review of the experience of a tertiary Australian renal treatment centre, consisting of 205 sequential AVACs in 93 patients, was undertaken over 1 year, to identify issues limiting technique survival. Acute vascular access catheters were inserted as acute dialysis access for patients with chronic renal failure (CRF; 21%), failed grafts or fistulae (18%), acute renal failure (12%), failed chronic ambulatory peritoneal dialysis (CAPD; 8%) or failed prior AVACs (37%). The majority of AVACs were on the right (74%), and the placement site was simple jugular (69%), tunnelled jugular (15%), femoral (12%), or subclavian (4%). During follow up, 198 of 205 AVACs were removed. The mean AVAC survival was superior (P < 0.0001, Fishers protected least significant difference (PLSD) for tunnelled jugular AVACS (62 ± 46 (SD) days) compared with simple jugular (20 ± 19), subclavian (18 ± 13) and femoral (7 ± 6). Causes for AVAC removal were: elective (47%), blockage (31%), infection (20%) or cracked catheter (1%). Routine postremoval tip cultures grew coagulase negative Staphylococcus (CNS, 46%), negative culture (33%), methicillin‐resistant Staphylococcus aureus (MRSA; 9%), Staphylococcus aureus (9%), Gram‐negative rods (1%), Pseudomonas (0.5%) or other uncommon organisms (2%). Blood cultures were drawn through the AVAC in the setting of suspected bacteraemia in 42 of 198 AVACs. Blood cultures were negative in 40%. Positive cultures included Staphylococcus species in 55%: including MRSA (19%), Staphylococcus aureus (29%) and CNS (34%). Rare cultures identified Escherichia coli (2%) or Serratia (2%). Infection and blockage significantly reduced AVAC survival, affecting more than 50% of cases. Approaches to minimize these complications are likely to lead to improved clinical outcomes with AVAC use.

Evaluation of the implementation of Assistant in Nursing workforce in haemodialysis units

Chow J, Miguel SS. International Journal of Nursing Practice 2010; 16: 484–491 Evaluation of the implementation of Assistant in Nursing workforce in haemodialysis units The aim of this project was to evaluate the introduction of Assistant in Nursing (AINs) in the haemodialysis units at a major tertiary Area Health Service in Sydney, Australia. All nursing staff were asked to complete a baseline and follow-up survey to determine changes to their attitudes to the new skill mix model and their satisfaction with the new organization of care delivery in their dialysis units. Comparison of the baseline and follow-up surveys in the paired data was favourable with nurses acknowledging that they would cope well with the introduction of AINs, and they were more likely to disagree with the statement that their workload would increase after the introduction of AINs in the follow-up survey. There was little difference in (i) the workload of the dialysis units before and during the intervention; and (ii) the incidence of patient and nursed related adverse outcome events.The aim of this project was to evaluate the introduction of Assistant in Nursing (AINs) in the haemodialysis units at a major tertiary Area Health Service in Sydney, Australia. All nursing staff were asked to complete a baseline and follow-up survey to determine changes to their attitudes to the new skill mix model and their satisfaction with the new organization of care delivery in their dialysis units. Comparison of the baseline and follow-up surveys in the paired data was favourable with nurses acknowledging that they would cope well with the introduction of AINs, and they were more likely to disagree with the statement that their workload would increase after the introduction of AINs in the follow-up survey. There was little difference in (i) the workload of the dialysis units before and during the intervention; and (ii) the incidence of patient and nursed related adverse outcome events.

NEEDLE-STICK INJURY: A NOVEL INTERVENTION TO REDUCE THE OCCUPATIONAL HEALTH AND SAFETY RISK IN THE HAEMODIALYSIS SETTING

Needle-stick injury (NSI) is a major occupational health and safety issue facing healthcare professionals. The administration of erythropoiesis-stimulating agents (ESA) in haemodialysis patients represents a major cause for injections. The purpose of this initiative was to familiarise nursing staff with needle-free administration of an ESA in haemodialysis patients to reduce the risk of NSI. Epoetin beta comes in a commercial presentation with a detached needle. Epoetin beta was administered to 10 haemodialysis patients via the venous bubble trap short line of the haemodialysis circuit. An audit was conducted that included a retrospective assessment of NSI for the previous six months; and a prospective assessment for eight weeks to assess whether there is a nursing staff preference for needle-free administration of ESA. There were no reports of NSI in the needle-free group. Haemoglobin levels were maintained. Ninety-one percent of the nursing staff preferred needle-free administration of ESA. In conclusion, the commercial presentation of epoetin beta with the detached needle presents an opportunity to reduce the potential risk of NSI in haemodialysis units.

VASCULAR DIALYSIS ACCESS FLOW MEASUREMENT: EARLY INTERVENTION THROUGH EARLY DETECTION

AIM The aim of the project is to determine the effectiveness of using online access flow measurement, thermodilution method (Fresenius BTM), in detecting and predicting thrombosis or stenosis of the haemodialysis fistula, so that early intervention could be instituted. METHODOLOGY All haemodialysis patients with permanent vascular dialysis access, either arteriovenous fistula (AVF) or arteriovenous fistula graft (AVG), in a large tertiary referral Dialysis Service in Australia were included in this prospective observational quality project, conducted over 12 months. RESULTS Out of 165 patients studied, 36 patients were found to have poor dialysis access flow, defined as AVF--flow of <200 ml/min or a decrease of 25% from last measurement or AVG--flow of <600 ml/min or a decrease of 25% from last measurement. Doppler ultrasounds were performed, and confirmed findings of significant stenosis, either on the arterial or venous sites, as indicated by poor dialysis access flow results. CONCLUSION Thermodilution technique is a reliable and effective method of detecting poor dialysis access flow for patients with permanent vascular access, comparable with other techniques.

THE EFFICACY OF SHORT DAILY DIALYSIS—A SINGLE‐CENTRE EXPERIENCE

Studies have shown that patients converted to short daily haemodialysis (SDHD) have reported many clinical benefits, decreased complications during dialysis and a better quality of life.A six-month prospective cohort study was conducted to examine the efficacy of SDHD to patients previously receiving three times per week haemodialysis therapy. Following informed consent, participants received haemodialysis daily, Monday-Saturday, between 2 and 2.5 hours for each treatment and followed-up for a six-month period. The participants continued to experience hypotension, cramping and headache and were noncompliant with fluid intake. There was a gradual reduction in blood pressure, cessation of antihypertensives and reduction of erythropoietin therapy (ERT). There were no hospital admissions or reports of access complications. The nursing staff reported an increase in activity levels and nursing interventions with the participants following conversion to SDHD. However, the participants reported a better quality of life.SUMMARY Studies have shown that patients converted to short daily haemodialysis (SDHD) have reported many clinical benefits, decreased complications during dialysis and a better quality of life.A six-month prospective cohort study was conducted to examine the efficacy of SDHD to patients previously receiving three times per week haemodialysis therapy. Following informed consent, participants received haemodialysis daily, Monday–Saturday, between 2 and 2.5 hours for each treatment and followed-up for a six-month period. The participants continued to experience hypotension, cramping and headache and were noncompliant with fluid intake. There was a gradual reduction in blood pressure, cessation of antihypertensives and reduction of erythropoietin therapy (ERT). There were no hospital admissions or reports of access complications. The nursing staff reported an increase in activity levels and nursing interventions with the participants following conversion to SDHD. However, the participants reported a better quality of life.

Uptake of home dialysis in younger adults: case studies that illustrate the multifaceted influence of home circumstances on dialysis decisions

Younger adults considering home dialysis need support to ensure home circumstances are suitable and affordable. Home circumstances relate closely to the financial burden reported by younger home dialysis users. Attention to home circumstances of younger patients with chronic kidney disease by policymakers, funders, and healthcare practitioners is needed.

Randomized Controlled Trial Protocol on Buttonhole Cannulation: A Technique to Reduce Arteriovenous Fistula Access Complications

Objectives This multicenter, prospective, open-label randomized controlled trial will be undertaken to determine whether or not the buttonhole cannulation technique in new and established hemodialysis fistula reduces complications and prolongs access life compared to usual practice. Methods A total of 70 subjects will be recruited for this study. Subjects randomized to the buttonhole group will have their fistula cannulated by the same staff member for 2-4 weeks at the same angle and direction with sharp needles. Once the tunnel is developed, blunt needles will be used. The control group will continue with usual practice (rope ladder rotation technique). Measurement of treatment effects will include: (1) quality of life; (2) pain assessment of cannulation; (3) lignocaine use; (4) intradialytic blood flow rate and venous and arterial pressures; (5) dialysis adequacy; (6) cannulation proficiency; and (7) hemostasis time. Conclusion This study has been designed to provide evidence to help renal clinicians and their hemodialysis patients determine the optimal cannulation technique for prevention of fistula access complications.