Reducing complications during hemodialysis using gradient ultrafiltration with gradient sodium dialysate

The objective of this study was to determine if patient complications and nursing interventions during hemodialysis could be reduced using gradient ultrafiltration and gradient sodium dialysate. Twenty outpatients who had been on hemodialysis for at least 3 months, and using gradient sodium dialysate for at least 1 month, participated. Patients received either ultrafiltration at a constant hourly rate or gradient ultrafiltration, in which the ultrafiltration rate was set higher initially, then decreased step-wise mid-dialysis. Patients received each protocol for 3 months, using a randomized cross-over design. Both protocols used gradient sodium dialysate (150 mEq/L x 3 hrs, 140 mEq/L x 1 hr). There were significantly fewer complications and interventions using gradient ultrafiltration, as compared to constant ultrafiltration. No differences were found in interdialytic weight gain, intradialytic weight loss, or orthostatic blood pressure. These results indicate that gradient ultrafiltration combined with gradient sodium dialysate enhances patient well-being and reduces nursing interventions during hemodialysis.

Injuries among children in home and out-of-home care

As the number of children receiving care in out-of-home settings increases in the United States, the risk of injury in such settings has become the subject of intense research.

OBJECTIVES

This study examined the relative safety of out-of-home care compared with care in a child's own home.

METHODS

This community based prospective cohort study of 656 families in three adjacent counties in the Piedmont region of North Carolina characterizes the patterns and rates of injuries among children less than 5 years of age in three child care settings, home care (HC), center based care (CBC), and other out-of-home care (OOHC). Information about minor and severe injuries was obtained from parents using monthly telephone interviews over a one year period. Statistical modeling designed to handle unbalanced data with correlated observations was used as the primary tool for analysis.

RESULTS

Rate of minor injuries was highest in CBC, followed by HC, and then OOHC. However, these differences for OOHC may have been due to reporting biases and errors in rate estimates. There were no significant differences in severe injury rates among the three settings.

CONCLUSIONS

The risk of serious injury among children under 5 in CBC is not different from that of children in HC or OOHC despite the fact that the risk of minor injury is higher.

Molecular recognition in the HIV-1 capsid/cyclophilin A complex

The HIV-1 capsid protein (CA) makes an essential interaction with the human peptidyl prolyl isomerase, cyclophilin A (CypA), that results in packaging of CypA into the virion at a CA to CypA stoichiometry of approximately 10:1. The 231 amino acid residue capsid protein is composed of an amino-terminal CypA binding domain (1 to approximately 151; CA151) and a carboxyl-terminal dimerization domain (approximately 151 to 231). We find that CypA binds dimeric CA and monomeric CA151 with identical intrinsic affinities (K[d] = 16(+/-4) microM). This result demonstrates that capsid dimerization and cyclophilin A binding are not thermodynamically coupled and suggests that the substoichiometric ratio of CypA in the HIV-1 virion results from the intrinsic stability of the CA/CypA complex. In the known co-crystal structure of the CA151/CypA complex, CypA binding is mediated exclusively by an exposed capsid loop that spans residues Pro85 to Pro93. The energetic contributions to CypA binding were quantified for each residue in this loop, and the results demonstrate that the Gly89-Pro90 dipeptide is the primary cyclophilin A recognition motif, with Pro85, Val86, His87, Ala88, and Pro93 also making energetically favorable contacts. These studies reveal that the active site of CypA, which can catalyze the isomerization of proline residues in vitro, also functions as a sequence-specific, protein-binding motif in HIV-1 replication.

Self-delivery of hemodialysis care: a therapy in itself

Patient autonomy, sense of control, and well-being are thought to be enhanced by self-care hemodialysis as a therapy for end-stage renal disease. Dialysis in a satellite setting reduces travel time and can diminish therapy intrusiveness. Health-related quality of life (HRQOL), in terms of functional status and well-being, was measured in a group of patients trained for self-care, and then measured again after these patients were transferred to a satellite unit. Comparison was made with an age- and comorbidity-matched cohort of full-care patients. Patients trained for self-care tended to score higher than the full-care patients in the psychosocial domains of HRQOL, such as role function, social function, and emotional well-being, before and after transfer to the satellite unit. Physiological measurements did not differ significantly between groups at any time during the study, indicating that differences in HRQOL were not attributable to differences in metabolic stability. We conclude that patients trained for self-care hemodialysis experience better subjective quality of life than their full-care counterparts. This study highlights both the usefulness of measuring HRQOL as an outcome of hemodialysis therapy and the potential benefits of therapies such as self-care and satellite dialysis.

Assessment of health status in peritoneal dialysis patients: a potential outcome measure

OBJECTIVES

To determine the feasibility and practicality of measuring general health status (GHS) in an outpatient peritoneal dialysis population. To determine whether GSH correlated intuitively with biochemical, socio-demographic and co-morbidity measurements.

DESIGN

The Medical Outcomes Study 20-item short form was administered on a voluntary basis in the outpatient setting. Demographic and current biochemical data were extracted from the medical record. The effects of the socio-demographic, biochemical and physiologic variables on the six subscales of GHS generated by the questionnaire were estimated using multivariate linear regression analysis resulting in the development of six separate models.

SETTING

Peritoneal dialysis program of a University Hospital.

PATIENTS

Sixty stable patients on home peritoneal dialysis completed the GHS questionnaire during regularly scheduled outpatient visits. Ages ranged from 13 to 81 years. The study group included 14 diabetics (23%).

RESULTS

Administering the questionnaire caused no logistical difficulties in the outpatient setting. Regression models for predicting GHS were both significant and intuitively correct. The presence of co-morbidities such as diabetes mellitus (p = 0.002; Social Subscale) and peripheral vascular disease (p = 0.016: General Health Subscale) had the most significant negative impact on GHS. An increased length of time on dialysis was associated with a higher GHS (p = 0.002; Physical Subscale).

CONCLUSION

General Health Status questionnaires can be readily administered to peritoneal dialysis patients in the outpatient setting. They have face validity as a measurement of wellness and functioning. The longitudinal use of such instruments in conjunction with clinical and laboratory findings may identify both medical and non-medical factors impacting on our peritoneal dialysis population.

Measuring and predicting outcomes in ESRD patients

To test the feasibility of using general health status as a practical dialysis outcome measure, in a longitudinal pilot study, two well-validated instruments were administered to patients from our dialysis unit or clinic. The instruments were administered three times, at eight-week intervals for seven months to 41 hemodialysis (HD) patients. Forty-five transplant (Tx) patients were surveyed once as a validating control. Sociodemographic, imaging and biochemical data were tested as outcome predictors. Unexpected hospitalizations and adverse intercurrent events were used as additional outcome measures. Preliminary analysis shows HD patients scoring low, while Tx patients scored higher (healthier). These preliminary results suggest that assessment of general health status is a valid and practical outcome measure.