Richard S. Goldman

Nasal and Cutaneous Flora Among Hemodialysis Patients and Personnel: Quantitative and Qualitative Characterization and Patterns of Staphylococcal Carriage

Staphylococcal sepsis is a leading cause of morbidity and mortality among chronic hemodialysis (HD) patients. We studied nasal and cutaneous flora of HD patients and personnel and their patterns of staphylococcal carriage. HD patients had significantly increased cutaneous total bacterial colony counts (p less than 0.01) as well as both nasal (p less than 0.0001) and cutaneous (p less than 0.0001) carriage of Staphylococcus aureus compared to personnel. Cutaneous staphylococcal carriage could be significantly correlated with nasal carriage (p less than 0.01). Cutaneous streptococcal species and gram-negative bacilli were not different between patients and personnel. Staphylococcal phage typing of nasal isolates from staphylococcal carriers revealed a mean of 90% of isolates from each subject belonging to a predominant phage type. Predominant nasal staphylococcal phage types corresponded with respective predominant cutaneous phage types in 93% of HD patients carriers. These studies substantiate autoinoculation of S. aureus from the nasal vestibule to the skin overlying the vascular access site.

Comparison of 4% Chlorhexidine Gluconate in a Detergent Base (Hibiclens) and Povidone-Iodine (Betadine) for the Skin Preparation of Hemodialysis Patients and Personnel

The abnormal cutaneous flora of hemodialysis (HD) patients might contribute to their frequent septic complications. We compared the effects of 13 wk of Betadine and 13 wk of Hibiclens on the skin flora of HD patients and personnel. Skin cultures were obtained weekly immediately prior to the disinfection, preceding each triweekly HD treatment, and monthly, at 2 and 4 hr postdisinfection. Total bacterial counts from predisinfection cultures were not significantly altered over either 13-wk treatment period. Hibiclens reduced total bacterial counts (p less than 0.01) and eradicated cutaneous staphylococci (p = 0.032) at both 2 and 4 hr postdisinfection significantly more than did Betadine. No reduction of staphylococcal sensitivity to either germicidal agent could be demonstrated. Neither agent was associated with severe adverse reactions and Hibiclens could not be detected in the blood. Hibiclens appears to offer short-term advantages over Betadine in the HD setting because of significantly longer duration of antibacterial activity.

Continuous quality improvement in ESRD: The role of networks, the United States Renal Data System, and facility-specific reports

End-stage renal disease (ESRD) outcome improvement involves many different private and governmental entities. Networks have fulfilled a pivotal role in ESRD quality improvement by facilitating the change from quality assurance (QA) to continuous quality improvement (CQI) methodology, providing the collection and dissemination of outcome measures to facilities and developing quality improvement projects (QIPs) that interface directly with facilities. Improving outcomes in hemodialysis is generally limited to adequacy of hemodialysis and anemia management. Opportunities in peritoneal dialysis, nutrition, vascular access, and quality-of-life outcomes persist. Interaction between facilities and Medical Review Boards (MRBs) using workshops, site visits, and facility report cards can provide continuing ESRD outcome improvement. Every facility has unique people, procedures, and equipment producing their processes of care. Therefore, a certain amount of autonomy is required to encompass individual variation. Quality improvement methodology, although less rigorous than traditional outcome research, provides efficient and effective intervention when a rapid response is required to improve clinical outcomes. The two methods are not mutually exclusive but require distinct methodology to accomplish.

Pursuing permanent hemodialysis vascular access in patients with a poor prognosis: juxtaposing potential benefit and harm.

For patients with end-stage renal disease requiring hemodialysis, the native arteriovenous fistula remains the gold standard of vascular access, with tunneled cuffed central venous catheters reserved for temporary use or as a last resort in patients for whom a permanent vascular access is not possible. It is expected that most patients receiving hemodialysis will be suitable for arteriovenous fistula placement, with suitable patients defined as those: (1) for whom long-term dialysis is expected to confer benefit, (2) with vascular anatomy amenable to arteriovenous fistula placement, and (3) with progressive irreversible kidney failure who are more likely to require dialysis than to die before reaching dialysis dependence. The present article reviews considerations for vascular access decision making, focusing on older patients and those with a poor prognosis, weighing the risks and benefits of arteriovenous fistulas, arteriovenous grafts, and central venous catheters and emphasizing that in the process of vascular access decision making for such patients, medical and ethical obligations to avoid central venous catheters must be balanced by the obligation to do no harm.

Commentary: quality improvement projects: how do we protect patients' rights?

A recent ruling by the Office of Human Research Protection (OHRP) has renewed an ongoing debate over whether Institutional Review Boards (IRBs) should have oversight not only over clinical research but also over quality improvement projects (QIPs). The authors discussed the similarities and differences among clinical practice, QIPs, and clinical research, pointing out issues to consider when identifying the most appropriate method for QIP oversight and accountability. They note that potential solutions must address ethical issues (eg, patient safety, privacy, and self-determination) and weigh the effect of the underlying QIP goal (administrative versus clinical improvement) on an individual patient and patient populations. They conclude that because QIPs are an extension of clinical practice and have elements of clinical research, it too should have an oversight system. Institutional or regional quality improvement boards, operating parallel to current IRBs, are suggested as 1 means of ensuring that QIP participants are offered the same protections as those who take part in clinical research.

Mild Unilateral Proteinuria and Renal Vein Thrombosis Associated with Oral Contraceptive Usage

A previously healthy 15-yr-old female taking oral contraceptives presented with acute, isolated, unilateral renal vein thrombosis as documented by arteriography and venography. Mild proteinuria (760 mg/24 hr) was localized solely to the thrombosed kidney by selective ureteral collections. The case illustrates an oral contraceptive associated renal vein thrombosis in the absence of either inferior vena cava thrombosis, bilateral proteinuria, or the nephrotic syndrome. This patients proteinuria and clinical course suggest that nephrotic syndrome is a cause of renal vein thrombosis rather than an effect of renal vein thrombosis. The finding of localized, unilateral proteinuria is discussed.

Protein catabolic rate in patients on continuous peritoneal dialysis. A multivariate predictive model.

Protein catabolic rate (PCR) and PCR normalized to standard weight (PCRN) are important indices of nutrition in patients on continuous peritoneal dialysis. The purpose of this study was to test whether urea clearance is among the predictors of PCR and PCRN in a multivariate analysis. Stepwise logistic regression was used to develop separate models for low PCR and low PCRN on a set of 143 urea kinetic studies in 92 patients on continuous peritoneal dialysis. The regression models were tested on an independent sample of 189 urea kinetic studies in 102 patients on continuous peritoneal dialysis by deriving the area under a receiver operating characteristic curve. In the derivation set, low serum urea, high serum creatinine, low urine and dialysate drain volumes, and low body surface area were identified as predictors of PCR ≤ 50 g daily. The area under the receiver operating characteristic curve in the validation set was 0.930 (95% confidence interval: 0.915-0.945). Low serum urea, male gender, high body mass index and low urea fractional clearance (KT/V) were predictors of PCRN ≤ 0.80 g/kg daily. The receiver operating characteristic area for this model was 0.948 (95% confidence interval: 0.926-0.970). Logistic regression analysis was repeated twice after adding urea nitrogen excretion normalized to standard weight (UNEN) as a candidate variable. This process identified low UNEN, male gender, and obesity as the predictors of low PCRN, and low UNEN, male gender, low urine volume, low drain volume normalized by body water, and high serum albumin as predictors of low KT/V urea. The authors conclude that PCR and PCRN can be predicted by models that incorporate serum azotemic indices, body size and composition, and direct or indirect measurements of urea clearance. Small body size and lean body composition predict low PCR but high PCRN values. Both PCRN and KT/V urea are predicted by UNEN. Multivariate analysis cannot, therefore, rule out the hypothesis that PCRN and KT/V are linked mathematically.