Laura Labriola

Diagnosis, prevention and treatment of haemodialysis catheter-related bloodstream infections (CRBSI) : a position statement of European Renal Best Practice (ERBP)

Nephrology Section, Department of Internal Medicine, University Hospital, Gent, Belgium, Nephrology, Dialysis and Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France, Department of Renal Medicine, Royal Derby Hospital, Derby, UK, Nephrology, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, Brussels, Belgium, Nephrology Department, Consorcio Hospital General Universitario, Valencia, Spain and Vascular Surgery, Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands

Infectious complications following conversion to buttonhole cannulation of native arteriovenous fistulas: a quality improvement report.

BACKGROUND Constant-site or buttonhole cannulation of native arteriovenous fistulas (AVFs) has gained in popularity compared with rope-ladder cannulation. However, cannulating nonhealed skin might increase the risk of (AVF-related) infectious events, as suggested by small reports. STUDY DESIGN Quality improvement report. SETTING & PARTICIPANTS All patients on in-center hemodialysis therapy using a native AVF from January 1, 2001, to June 30, 2010. QUALITY IMPROVEMENT PLAN Shift to buttonhole cannulation between August 2004 and January 2005. Because the infectious event rate increased after the shift, educational workshops were held in May 2008 for all nurses, with review of every step of buttonhole protocol. OUTCOMES Infectious events (unexplained bacteremia caused by skin bacteria and/or local AVF infection) and complicated infectious events (resulting in metastatic infection, death, or AVF surgery) were ascertained during 4 periods: (1) rope-ladder technique in all, (2) switch to buttonhole, (3) buttonhole in all before workshops, and (4) buttonhole in all after workshops. RESULTS 177 patients (aged 70.4 ± 11.5 years) with 193 AVFs were analyzed, including 186,481 AVF-days. 57 infectious events occurred (0.31 events/1,000 AVF-days). The incidence of infectious events increased after the switch to the buttonhole method (0.17 [95% CI, 0.086-0.31], 0.11 [95% CI, 0.0014-0.63], and 0.43 [95% CI, 0.29-0.61] events/1,000 AVF-days in periods 1, 2, and 3, respectively; P = 0.003). This reached significance during only the second full year of buttonhole cannulation. During period 4, the incidence tended to decrease (0.34 events/1,000 AVF-days). Complicated infectious events (n = 12) were virtually restricted to period 3 (n = 11; 0.153 [95% CI, 0.076-0.273] events/1,000 AVF-days), with a significant decrease in period 4 (n = 1; 0.024 [95% CI, 0.001-0.118] events/1,000 AVF-days; RR for period 3 vs period 4, 6.37 [95% CI, 1.09-138.4]; P = 0.04). LIMITATIONS Observational partly retrospective design. CONCLUSION Intensive staff education regarding strict protocol for the buttonhole procedure was associated with a decrease in infectious events.

Catheter-related blood stream infections (CRBSI): a European view

Nephrology Section, Department of Internal Medicine, University Hospital, Gent, Belgium, Nephrology, Dialysis and Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France, Department of Renal Medicine, Royal Derby Hospital, Derby, UK, Nephrology, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, Brussels, Belgium, Nephrology Department, Consorcio Hospital General Universitario, Valencia, Spain and Vascular Surgery, Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands

Preparing renal replacement therapy in stage 4 CKD patients referred to nephrologists: a difficult balance between futility and insufficiency. A cohort study of 386 patients followed in Brussels

BACKGROUND KDOQI guidelines recommend preparation for renal replacement therapy (RRT) once stage 4 chronic kidney disease (CKD) is reached. Recent studies conducted in the general population and in patients referred to nephrologists have shown that CKD patients, especially the elderly, are much more likely to die than to reach RRT. We investigated whether futile preparation for RRT was performed in CKD patients referred to our nephrology department. METHODS We included all patients (n = 386) with stage 4 CKD and without prior RRT, seen at our outpatient clinic between 1 November 2004 and 30 April 2007. Demographics, clinical and laboratory data at inclusion were collected. Follow-up continued until 1 November 2007 or later (last appointment or study outcome). The primary outcome was death without requiring RRT, and secondary outcomes were RRT, going through our pre-dialysis education programme (PDEP) and undergoing the creation of an arterio-venous fistula (AVF). Factors predicting these outcomes were analysed. RESULTS During complete follow-up (average 23.4 months), 47 patients (12.1%) died without requiring RRT and 59 patients (15.3%) started RRT. The rate of death without requiring RRT in the overall cohort increased from 50 years onwards and exceeded that of RRT in incident patients aged ≥ 80 years. A structured PDEP was offered to 66.1% of patients starting RRT vs 14.9% of patients dying without requiring RRT and 13.9% of patients surviving without requiring RRT (P < 0.001). In addition, 53.3% of patients starting haemodialysis had a prior AVF creation vs 6.4% of patients dying without requiring RRT and 5.7% of patients surviving without requiring RRT (P < 0.001). CONCLUSIONS The risk of death exceeds that of RRT in stage 4 CKD incident patients aged ≥ 80 years referred to our clinic. Futile preparation for RRT was relatively uncommon (14.9%). We were able to largely avoid futility at the expense of incomplete exposure of patients who eventually started RRT, to the structured PDEP, and of a relatively low (53%) level of AVF created prior to start of HD. Whether and how these figures can be improved will require further investigation.

Tenofovir-related acute kidney injury and proximal tubule dysfunction precipitated by diclofenac : a case of drug-drug interaction

We describe an HIV1-positive patient under long-term tenofovir treatment who developed a severe, biopsy-proven, acute tubular necrosis with proximal tubule (PT) dysfunction, precipitated by the very recent start of diclofenac, a nonsteroidal antiinflammatory drug (NSAID). Recent studies show that NSAIDs not only alter glomerular filtration but also multidrug resistance protein (MRP) 4-mediated PT secretion of several substrates. Since the patient tolerated tenofovir well for several years prior to diclofenac use, our observation suggests that diclofenac interfered with tenofovir clearance, thereby favoring its nephrotoxicity. NSAIDs should be avoided in patients under tenofovir.

Immunogenicity of an adjuvanted 2009 pandemic influenza A (H1N1) vaccine in haemodialysed patients

Abstract Background. The 2009 pandemic of influenza A (H1N1) prompted an urgent worldwide vaccination campaign, especially of high-risk subjects, such as maintenance haemodialysis (HD) patients. Still the immunogenicity of the pandemic A (H1N1) vaccine in HD patients is unknown. Methods. We prospectively studied the immunogenicity of a monovalent adjuvanted influenza A/California/2009 (H1N1) vaccine (Pandemrix®, GSK Biologicals, Rixensart, Belgium) in HD patients and controls. Antibody level was measured using a seroneutralization assay before (D0) and 30 days after (D30) a single 3.75 μg vaccine dose. Specimens were tested in quadruplicates. Geometric mean (GM) antibody titers were determined in each subject at D0 and D30. Seroconversion was defined as an increase in GM titers by a factor 4 or more. Results. Fifty-three adult HD patients [aged 71 ± 10, 58.5% males, on HD for a median of 38 (3 − 146) months] and 32 control subjects (aged 47.3 ± 14, 31.3% males) were analyzed. Baseline GM titers were similar in HD patients and controls [7.9 (6.6 − 9.6) vs 10 (6 − 17); p = 0.69]. Seroconversion was observed in 30 (93.8%) controls and 34 (64.2%) HD patients (p = 0.002). In addition, GM titers at D30 were significantly higher in controls than in HD patients [373 (217 − 640) vs 75.5 (42.5 − 134); p = 0.001]. HD patients were significantly older than controls (p < 0.001) and more likely to be males (p = 0.02). However, by multivariate analysis, HD status [OR 0.13 (0.02-0.78), p = 0.03], but neither age [OR 0.99 (0.96 − 1.03); p = 0.7] nor male gender [OR 1.31 (0.45 − 3.85); p = 0.63] was independently associated with seroconversion. The vaccine was generally well tolerated by HD patients. Conclusions. Only 64% of chronic HD patients developed seroconversion after a single dose of adjuvanted influenza A (H1N1) vaccine, a much lower rate than in controls (94%). These results underscore the substantial immunodeficiency associated with End-Stage Renal Disease. The persistence of protective antibodies as well as the effect of a booster dose remain to be investigated in HD patients.

Massive amoxycillin crystalluria causing anuric acute renal failure.

The authors report the case of a 45-year-old woman admitted for pneumonia who presented anuric acute renal failure after 12 days of intravenous amoxycillin-clavulanate treatment. Acute renal failure resolved rapidly and completely after antibiotic withdrawal. Analysis of the first post-anuric urine specimen showed many crystals. Infrared spectrophotometry revealed that the crystals were composed of trihydrated amoxycillin. The possibility of intrarenal obstruction due to massive drug crystalluria should not be overlooked in the face of abrupt anuria.

Barriers to adopting a fistula-first policy in Europe: an international survey among national experts

Purpose The purpose of this study is to explore how vascular access care was reimbursed, promoted, and organised at the national level in European and neighbouring countries. Methods An electronic survey among national experts to collect country-level data. Results Forty-seven experts (response rate, 76%) from 37 countries participated. Experts from 23 countries reported that 50% or less of patients received routine pre-operative imaging of vessels. Nephrologists placed catheters and created fistulas in 26 and 8 countries, respectively. Twenty-one countries had a fee per created access; the reported fee for catheter placement was never higher than for fistula creation. As the number of haemodialysis patients in a centre increased, more countries had a dedicated coordinator or multidisciplinary team responsible for vascular access maintenance at the centre-level; in 11 countries, responsibility was always with individual nephrologists, independent of a centres size. In 23 countries, dialysis centres shared vascular access care resources, with facilitation from a service provider in 4. In most countries, national campaigns (n = 35) or educational programmes (n = 29) had addressed vascular access-related topics; 19 countries had some form of training for creating fistulas. Forty experts considered the current evidence base robust enough to justify a fistula-first policy, but only 13 believed that more than 80% of nephrologists in their country would attempt a fistula in a 75-year-old woman with comorbidities. Conclusions Suboptimal access to surgical resources, lack of dedicated training of clinicians, limited routine use of pre-operative diagnostic imaging and patient characteristics primarily emerged as potential barriers to adopting a fistula-first policy in Europe.

Chronic kidney disease and arrhythmias: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Patients with chronic kidney disease (CKD) are predisposed to heart rhythm disorders, including atrial fibrillation (AF)/atrial flutter, supraventricular tachycardias, ventricular arrhythmias, and sudden cardiac death (SCD). While treatment options, including drug, device, and procedural therapies, are available, their use in the setting of CKD is complex and limited. Patients with CKD and end-stage kidney disease (ESKD) have historically been under-represented or excluded from randomized trials of arrhythmia treatment strategies,1 although this situation is changing.2 Cardiovascular society consensus documents have recently identified evidence gaps for treating patients with CKD and heart rhythm disorders.3–7 To identify key issues relevant to the optimal prevention, management, and treatment of arrhythmias and their complications in patients with kidney disease, Kidney Disease: Improving Global Outcomes (KDIGO) convened an international, multidisciplinary Controversies Conference in Berlin, Germany, titled CKD and Arrhythmias in October 2016. The conference agenda and discussion questions are available on the KDIGO website (http://kdigo.org/conferences/ckd-arrhythmias/; 13 February 2018).

Paradoxical response to furosemide in uromodulin-associated kidney disease

Mutations in the UMOD gene coding for uromodulin cause autosomal dominant tubulointerstitial kidney disease. Uromodulin is known to regulate transport processes in the thick ascending limb, but it remains unknown whether UMOD mutations are associated with functional tubular alterations in the early phase of the disease. The responses to furosemide and to a water deprivation test were compared in a 32-year-old female patient carrying the pathogenic UMOD mutation p.C217G and her unaffected 31-year-old sister. A single dose of furosemide induced an intense headache with exaggerated decrease in blood pressure (Δsyst: 30 versus 20 mmHg; Δdiast: 18 versus 5 mmHg) and body weight (Δ2.6 kg versus Δ0.9 kg over 3 h) in the proband versus unaffected sib. The diuretic response and the fall in urine osmolality were also more important and detected earlier in the affected sib. Water deprivation led to increased plasma osmolality and urine concentration in both siblings; however, the response to desmopressin was attenuated in the affected sib. These data reveal that mutations of uromodulin cause specific transport alterations, including exaggerated response to furosemide and a failure to maximally concentrate urine, in the early phase of the disease.