Nikolas B. Harbord

The 2006 K/DOQI Guidelines for Peritoneal Dialysis Adequacy Are Not Adequate

The 2006 National Kidney Foundation K/DOQI guidelines have lowered the peritoneal dialysis adequacy standard of Kt/Vurea from 2.1 to 1.7 in anuric patients, largely based on the patient survival results of 2 clinical trials in Mexico and Hong Kong. It is our contention that the guidelines may be misleading since they have chosen to ignore the bias in these trials and have ignored the adverse outcomes in control groups in the trials on which the guidelines are based, as well as the body size of the subjects in these trials. Body size has changed in the US and Canada over the last few decades and there are similar changes worldwide. We suggest that the minimum targets for peritoneal dialysis be reinstituted at the previous standard Kt/Vurea of 2.0.

Disaster Preparedness and Awareness of Patients on Hemodialysis after Hurricane Sandy

BACKGROUND AND OBJECTIVES Patients with ESRD on dialysis live in a complex sociomedical situation and are dependent on technology and infrastructure, such as transportation, electricity, and water, to sustain their lives. Interruptions of this infrastructure by natural disasters can result in devastating outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Between November of 2013 and April of 2014, a cross-sectional survey was conducted of patients who received maintenance hemodialysis before and after the landfall of Hurricane Sandy on October 29, 2012 in lower Manhattan, New York. The primary outcome was the number of missed dialysis sessions after the storm. Dialysis-specific and general disaster preparedness were assessed using checklists prepared by the National Kidney Foundation and US Homeland Security, respectively. RESULTS In total, 598 patients were approached, and 357 (59.7%) patients completed the survey. Participants were 60.2% men and 30.0% black, with a median age of 60 years old; 94 (26.3%) participants missed dialysis (median of two sessions [quartile 1 to quartile 3 =1-3]), and 236 (66.1%) participants received dialysis at nonregular dialysis unit(s): 209 (58.5%) at affiliated dialysis unit(s) and 27 (7.6%) at emergency rooms. The percentages of participants who carried their insurance information and detailed medication list were 75.9% and 44.3%, respectively. Enhancement of the dialysis emergency packet after the hurricane was associated with a significantly higher cache of medical records at home at follow-up survey (P<0.001, Fishers exact test). Multivariate Poisson regression analysis showed that dialysis-specific preparedness (incidence rate ratio, 0.91; 95% confidence interval, 0.87 to 0.98), other racial ethnicity (incidence rate ratio, 0.34; 95% confidence interval, 0.20 to 0.57), dialysis treatment in affiliated units (incidence rate ratio, 0.69; 95% confidence interval, 0.51 to 0.94), and older age (incidence rate ratio, 0.98; 95% confidence interval, 0.97 to 0.99) were associated with a significantly lower incidence rate ratio of missed dialysis. CONCLUSIONS There is still room to improve the preparedness for natural disasters of patients with ESRD. Provider- or facility-oriented enhancement of awareness of the disease and preparedness should be a priority.

Extracorporeal Removal of Drugs and Toxins

Indications for extracorporeal removal of drugs and toxins are mostly clinical and include hemodynamic instability; clinical deterioration despite supportive treatment; mental status alteration; and midbrain/brainstem dysfunction resulting in respiratory depression, hypothermia, hypotension, or bradycardia. Further indications are evidence of failure of organ systems; impaired endogenous drug clearance due to cardiac, renal, or hepatic failure; and when a drug or poison can be removed more rapidly compared with endogenous elimination. Hemodialysis and hemofiltration techniques are most effective for the elimination of small molecular size, high water soluble compounds with a low degree of protein-binding, a small volume of distribution, and rapid equilibration of drug between plasma and tissues. Peritoneal dialysis can also be employed as an acute treatment modality for intoxication with water-soluble, small-molecular-weight solutes but should probably be limited to infants, children, and hemodynamically unstable adults intolerant of a blood circuit or anticoagulation. Therapeutic plasma exchange is of clinical utility when blood purification is required for substances with very high molecular weight and/or high degree of protein binding. Hemoperfusion is an absorptive modality which effectively can clear substances that are lipid-soluble or as much as 95% protein-bound. It provides superior drug clearance and is the preferred modality for extraction of theophylline, barbiturates, organophosphates, and many hypnotics/sedatives/tranquilizers.

Intoxications amenable to extracorporeal removal.

Extracorporeal removal of drugs was first attempted in 1913, by John Jacob Abel. Previously known to be a rarity, dialysis and to a lesser extent hemoperfusion have now become obvious tools for nephrologists in treating life-threatening cases of poisoning. Moreover, for dialysis patients, dialysis along with chelation therapy for removal of aluminum, once known to be common in the United States, is resurging in some countries. This article will discuss the principles of drug removal, the indications for dialysis, and give a brief outline of poisons amenable to dialysis.

Extracorporeal Therapies in Acute Intoxication and Poisoning

Abstract The chapter provides an overview of the management of the poisoned patient and introduces extracorporeal therapies to aid in detoxification. Indications for the use of hemodialysis, hemofiltration, and hemoperfusion are reviewed, and the principles underlying drug removal with each modality are described. Additional consideration is given to addition of chelating agents to augment clearance of metals, such as aluminum and iron. Clinical presentation, diagnosis, and therapeutic approach including extracorporeal treatment are described in detail for specific intoxicants: lithium, methanol, ethylene glycol, and salicylates. Comprehensive tables are included, containing drugs and intoxicants removed with extracorporeal therapy.

Antineutrophil cytoplasmic antibody-positive pauci-immune glomerulonephritis associated with mantle cell lymphoma

Renal involvement in non-Hodgkin lymphoma, especially mantle cell lymphoma (MCL) is rare. A 77-year-old man presented with acute kidney injury (AKI), which rapidly progressed to dialysis dependence. Kidney biopsy revealed patchy B-cell lymphocytic aggregates in the interstitium, which were positive for cyclin D1, consistent with atypical CD5-negative MCL as confirmed by the detection of translocation t(11;14) by FISH. Crescents were noted in 3 of 26 glomeruli; while PR-3 antineutrophil cytoplasmic antibody (ANCA) positivity and negative immunofluorescence suggested an additional pauci-immune (rapidly progressive) glomerulonephritis pattern of injury. Patient received chemotherapy (cyclophosphamide, vincristine, and prednisone), which improved his renal function and allowed for discontinuation of hemodialysis. However, he died from pulmonary hemorrhage 8 months after initial presentation. This is the first reported case of a patient with coexistence of renal MCL infiltration and ANCA-positive pauci-immune glomerulonephritis.