Current Issue : April - June Volume : 2015 Issue Number : 2 Articles : 7 Articles
Background: The purpose of this study was to evaluate the feasibility of utilizing an in-vitro, closed loop\nhemodialysis system as a method to assess drug clearance. Secondarily, this study tested the influence of variables\n(blood flow rate, dialysate flow rate, and type of filter) in the hemodialysis procedure on the clearance of\nvancomycin and gentamicin.\nMethods: An in-vitro, closed loop hemodialysis system was constructed. The vancomycin (30 mg/L) and gentamicin\n(25 mg/L) were added to a simulated blood system (SBS). Four conditions (C1-C4) were tested by defining the filter\n(Polyflux 170H or F180) and the blood and dialysate flow rates (BFR and DFR). All hemodialysis sessions were\n3 hours in length and each condition was completed in duplicate. Dialysate effluent was collected in a 50 gallon\npolyethylene drum. Samples were collected (in duplicate) from the SBS and the dialysate effluent at baseline and at\nthe end of the hemodialysis session. Samples were analyzed for vancomycin and gentamicin with an ultrahigh\nperformance liquid chromatography/tandem mass spectrometry method.\nResults: A total of eight 3-hour hemodialysis sessions were conducted. For all tested conditions (C1-C4), vancomycin\nwas undetectable in the SBS at the end of dialysis. However, total vancomycin recovery in the dialysis effluent was\n85�±18%, suggesting that up to 15% may have adsorbed to the dialysis filter or tubing. Gentamicin clearance from\nSBS was >98% in all tested conditions. Average gentamicin recovery in the dialysate effluent was 99�±15%.\nConclusion: Both vancomycin and gentamicin were readily removed by high-flux hemodialysis under all conditions\nstudied. No significant differences in drug clearance were observed between conditions used in this in vitro study.\nThe clinical implications of changing these hemodialysis parameters are unknown....
Background: Hepatocyte growth factor (HGF) counteracts peritoneal fibrosis in animal models and in-vitro studies, but\nno study explored effluent HGF in peritoneal dialysis (PD) patients with ultrafiltration failure (UFF). Our aim was to assess\nthe relationship between effluent HGF with UF profile, free water transport (FWT) and small-solute transport.\nMethods: We performed 4-hour, 3.86% PET with additional UF measurement at 60 minutes in 68 PD patients.\nMTACcreatinine, FWT, small-pore ultrafiltration, and effluent HGF were quantified.\nResults: Effluent HGF negatively correlated with UF (r = ?0.80, p = 0.009) and FWT (r = ?0.69, p = 0.04). Patients with UFF\nhad higher dialysate HGF (103 pg/mL vs 77 pg/mL, p = 0.018) and, although not statistically significant, those with FWT\ncompromise had also higher dialysate HGF compared with subgroup of UFF without FWT compromise (104 pg/mL vs\n88 pg/mL, p = 0.08). FWT ? 45% without clinical UFF was documented in some patients who also had increased effluent\nHGF.\nConclusions: Dialysate HGF concentration is significantly higher among patients with UFF, specially, if FWT is impaired,\nbeing a sign of peritoneal membrane deterioration....
Background: Impairments of health related quality of life (HRQoL) are frequently observed in Fabry disease (FD)\nand are known to be related to neuropathic pain and cardiovascular events. This study aimed to explore the role of\nchronic kidney disease (CKD) in a large cohort of patients with FD.\nMethods: In 96 patients (53% female; age 40 �± 12 yrs) with genetically proven FD, HRQoL was assessed by the\nMedical Outcomes Study (SF-36) questionnaire. All patients were na�¯ve to enzyme replacement therapy. Three\ncategories for kidney dysfunction were chosen, eGFR ?/<60 ml/min/1.73 m2 or need of renal replacement therapy\n(RRT). Minor (e.g. arrhythmia, angina pectoris, etc.) and major (e.g. myocardial infarction, coronary artery bypass,\nstroke or implantable cardioverter-defibrillator) vascular events as well as pain and pain therapy were considered in\nlinear regression analyses with the dimensions of HRQoL.\nResults: Ten patients (10%) had impaired kidney function and a further nine were on RRT (9.4%). Kidney function\nand pain emerged as the main factors associated with lower scores on the SF 36, in particular on physical\ncomponents (PCS beta-coefficients for CKD ?6.2, for RRT ?11.8, for pain ?9.1, p < 0.05, respectively), while\ncontrolling for gender, vascular event and pain-therapy. Relationships were found for mental aspects of HRQoL.\nAge and history of vascular events were not related to HRQoL.\nConclusion: Cardiovascular events and pain are important factors related to HRQoL, social functioning and\ndepression. Our study highlights impaired chronic kidney disease, in particular after initiation of RRT, as a strong\ndeterminant of reduced HRQoL in FD....
Background: The risk of end stage renal disease (ESRD) is increased among individuals with low income and in\nlow income communities. However, few studies have examined the relation of both individual and community\nsocioeconomic status (SES) with incident ESRD.\nMethods: Among 23,314 U.S. adults in the population-based Reasons for Geographic and Racial Differences in\nStroke study, we assessed participant differences across geospatially-linked categories of county poverty [outlier\npoverty, extremely high poverty, very high poverty, high poverty, neither (reference), high affluence and outlier\naffluence]. Multivariable Cox proportional hazards models were used to examine associations of annual household\nincome and geospatially-linked county poverty measures with incident ESRD, while accounting for death as a\ncompeting event using the Fine and Gray method.\nResults: There were 158 ESRD cases during follow-up. Incident ESRD rates were 178.8 per 100,000 person-years (105 py)\nin high poverty outlier counties and were 76.3 /105 py in affluent outlier counties, p trend = 0.06. In unadjusted\ncompeting risk models, persons residing in high poverty outlier counties had higher incidence of ESRD (which was\nnot statistically significant) when compared to those persons residing in counties with neither high poverty nor\naffluence [hazard ratio (HR) 1.54, 95% Confidence Interval (CI) 0.75-3.20]. This association was markedly attenuated\nfollowing adjustment for socio-demographic factors (age, sex, race, education, and income); HR 0.96, 95% CI 0.46-\n2.00. However, in the same adjusted model, income was independently associated with risk of ESRD [HR 3.75, 95%\nCI 1.62-8.64, comparing the < $20,000 income group to the > $75,000 group]. There were no statistically significant\nassociations of county measures of poverty with incident ESRD, and no evidence of effect modification.\nConclusions: In contrast to annual family income, geospatially-linked measures of county poverty have little relation\nwith risk of ESRD. Efforts to mitigate socioeconomic disparities in kidney disease may be best appropriated at the\nindividual level....
Background: Little is known about patients� and carers� experiences of interacting with home haemodialysis (HHD)\ntechnology, in terms of user experience, how the design of the technology supports safety and fits with home use,\nand how the broader context of service provision impacts on patients� use of the technology.\nMethods: Data were gathered through ethnographic observations and interviews with 19 patients and their carers\nassociated with four different hospitals in the UK, using five different HHD machines. All patients were managing\ntheir condition successfully on HHD. Data were analysed qualitatively, focusing on themes of how individuals used\nthe machines and how they managed their own safety.\nResults: Findings are organised by three themes: learning to use the technology, usability of the technology, and\nmanaging safety during dialysis. Home patients want to live their lives fully, and value the freedom and autonomy\nthat HHD gives them; they adapt use of the technology to their lives and their home context. They also consider\nthe machines to be safe; nevertheless, most participants reported feeling scared and having to learn through\nmistakes in the early months of dialysing at home. Home care nurses and technicians provide invaluable support.\nAlthough participants reported on strategies for anticipating problems and keeping safe, perceived limitations of\nthe technology and of the broader system of care led some to trade off safety against immediate quality of life.\nConclusions: Enhancing the quality and safety of the patient experience in HHD involves designing technology\nand the broader system of care to take account of how individuals manage their dialysis in the home. Possible\ndesign improvements to enhance the quality and safety of the patient experience include features to help patients\nmanage their dialysis (e.g. providing timely reminders of next steps) and features to support communication\nbetween families and professionals (e.g. through remote monitoring)....
Background: This study was performed to evaluate the effectiveness of surveillance for screening and treatment of\npatients with chronic kidney disease undergoing hemodialysis and colonized by Staphylococcus aureus.\nMethods: A systematic review and meta-analysis were performed. The literature search involved the following\ndatabases: the Cochrane Controlled Trials Register, Embase, LILACS, CINAHL, SciELO, and PubMed/Medline. The\ndescriptors were ââ?¬Å?Staphylococcus aureusââ?¬Â, ââ?¬Å?MRSAââ?¬Â, ââ?¬Å?MSSAââ?¬Â, ââ?¬Å?treatmentââ?¬Â, ââ?¬Å?decolonizationââ?¬Â, ââ?¬Å?nasal carrierââ?¬Â, ââ?¬Å?colonizationââ?¬Â,\nââ?¬Å?chronic kidney diseaseââ?¬Â, ââ?¬Å?dialysisââ?¬Â, and ââ?¬Å?haemodialysisââ?¬Â or ââ?¬Å?hemodialysisââ?¬Â. Five randomized controlled trials that\nexhibited agreement among reviewers as shown by a kappa value of >0.80 were included in the study; methodological\nquality was evaluated using the STROBE statement. Patients who received various treatments (various treatments\ngroup) or topical mupirocin (mupirocin group) were compared with those who received either no treatment or\nplacebo (control group). The outcomes were skin infection at the central venous catheter insertion site and bacteremia.\nResults: In total, 2374 patients were included in the analysis, 626 (26.4%) of whom were nasal carriers of S. aureus. The\nprobability of S. aureus infection at the catheter site for hemodialysis was 87% lower in the mupirocin group than in\nthe control group (odds ratio [OR], 0.13; 95% confidence interval [CI], 0.05ââ?¬â??0.34; p < 0.001). The risk of bacteremia was\n82% lower in the mupirocin group than in the control group (OR, 0.18; 95% CI, 0.08ââ?¬â??0.42; p < 0.001). No statistically\nsignificant difference in bacteremia was observed between the various treatments group (excluding mupirocin) and\nthe control group (OR, 0.77; 95% CI, 0.51ââ?¬â??1.15; p = 0.20).\nConclusions: Twenty-six percent of patients undergoing hemodialysis were nasal carriers of S. aureus. Of all treatments\nevaluated, topical mupirocin was the most effective therapy for the reduction of S. aureus catheter site infection and\nbacteremia in patients undergoing chronic hemodialysis....
Background: Although most outpatients are relatively healthy, many have chronic renal insufficiency, and high\noverride rates for suggestions on renal dosing have been observed. To better understand the override of renal\ndosing alerts in an outpatient setting, we conducted a study to evaluate which patients were more frequently\nprescribed contraindicated medications, to assess providers� responses to suggestions, and to examine the drugs\ninvolved and the reasons for overrides.\nMethods: We obtained data on renal alert overrides and the coded reasons for overrides cited by providers at the\ntime of prescription from outpatient clinics and ambulatory hospital-based practices at a large academic health care\ncenter over a period of 3 years, from January 2009 to December 2011. For detailed chart review, a group of 6\ntrained clinicians developed the appropriateness criteria with excellent inter-rater reliability (? = 0.93). We stratified\nproviders by override frequency and then drew samples from the high- and low-frequency groups. We measured\nthe rate of total overrides, rate of appropriate overrides, medications overridden, and the reason(s) for override.\nResults: A total of 4120 renal alerts were triggered by 584 prescribers in the study period, among which 78.2%\n(3,221) were overridden. Almost half of the alerts were triggered by 40 providers and one-third was triggered by\nhigh-frequency overriders. The appropriateness rates were fairly similar, at 28.4% and 31.6% for high- and lowfrequency\noverriders, respectively. Metformin, glyburide, hydrochlorothiazide, and nitrofurantoin were the most\ncommon drugs overridden. Physicians� appropriateness rates were higher than the rates for nurse practitioners\n(32.9% vs. 22.1%). Physicians with low frequency override rates had higher levels of appropriateness for metformin\nthan the high frequency overriders (P = 0.005).\nConclusion: A small number of providers accounted for a large fraction of overrides, as was the case with a small\nnumber of drugs. These data suggest that a focused intervention targeting primarily these providers and\nmedications has the potential to improve medication safety....
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