Impact of hernias on peritoneal dialysis technique survival and residual renal function

OBJECTIVE

We evaluated the effect of hernias and their surgical or conservative management on peritoneal dialysis (PD) technique survival and residual renal function.

METHODS

This 10-year single-center retrospective case-control study (January 2001 - January 2011) compared patient survival, PD technique survival, and residual renal function in patients with a history of abdominal hernias and in a control cohort matched for age and PD vintage.

RESULTS

Of 73 hernias identified in 63 patients (mean age: 55 years; 63% men), umbilical hernias were the most frequent (40%), followed by inguinal (33%), incisional, and epigastric hernias. Some hernias were surgically repaired before (n = 10) or at the time of PD catheter insertion (n = 11), but most (71%) were diagnosed and managed after initiation of PD. Overall, 49 of 73 (67%) hernias were treated surgically. In 53% of subjects, early postoperative dialysis was not needed; only 7 patients required temporary hemodialysis. The occurrence of a hernia and its treatment did not significantly affect residual renal function. After a hernia diagnosis or repair, 86% of patients were able to continue with PD. ♢

CONCLUSIONS

The incidence of abdominal hernia and hernia management in patients on PD do not significantly influence residual renal function or PD technique survival. Timely management of hernias is advisable and does not preclude continuation with PD as a dialysis modality.

Outcomes weighting for comprehensive haemodialysis centre assessment

BACKGROUND

At present, there is no adequate system available for evaluating dialysis centres.

OBJECTIVES

To construct an overall haemodialysis results weighting system, acceptable to the different stakeholders involved which allows the comparison of centres using a compound marker.

METHOD

The Quality Management Work Group of the Spanish Society of Nephrology (WG) established a set of preselected indicators. A Focus Group, independent of the WG, was established. It was made up of nine individuals: three patients, three clinicians and three clinical managers, who assessed these indicators using an approved methodology and established the selected indicators. Finally, the indicators were weighted through three weighting stages, each separated by two debate periods, which involved the distribution of 100 points between each variable, according to the personal assessment and the debate sustained.

RESULTS

The clinical results included: haemodialysis doses, anaemia, plasma calcium and phosphorus, type of vascular access, and hospitalisation days. The weighting given to each variable following the third weighting process, expressed as an average of all the factors, was as follows: clinical results 38.9; annual mortality 25.0; satisfaction with the centre 12.2; health-related quality of life 15.6; and cost 8.3 (total 100).

CONCLUSIONS

The weighting structure covers relevant and overall results and includes the opinion of all stakeholders involved; all of which will increase its acceptability and widespread use and contribute to the analysis of the value produced by the centres and the improvement of the results.

Exploring the opinion of CKD patients on dialysis regarding end-of-life and Advance Care Planning

Advance care planning (ACP) and the subsequent advance directive document (ADD), previously known as "living wills", have not been widely used in Spain. The Ethics Group from the Spanish Society of Nephrology has developed a survey in order to investigate the opinion of dialysis patients regarding the ADD and end-of-life care. Patients received documentation explaining ACP and filled out a survey about their familiarity with and approval of the ADD. Seven hospital dialysis centres participated in the study for a total of 416 active dialysis patients. Questionnaires were distributed to 263 patients, 154 of which answered (69.2% completed them without assistance). The rates for ADD implementation (7.9%) and designation of a representative person (6.6%) were very low. Most of the patients clearly expressed their wishes about irreversible coma, vegetative state, dementia and untreatable disease. More than 65% did not want mechanical ventilation, chronic dialysis, tube feeding or resuscitation if cardiorespiratory arrest occurred. They reported that an ADD could be done before starting dialysis but most thought that it should be offered only to those who requested it (65% vs 34%). In conclusion, patients have clear wishes about end-of-life care, although these desires had not been documented due to the very low implementation of the ADD.

Conversion to everolimus in kidney transplant recipients with decreased renal function

Whenever graft function is good and proteinuria is under control, many reports describe the efficacy and safety of the conversion to Everolimus (EVL) among stable kidney recepients, simultaneously withdrawing the calcineurin inhibitor (CNI). However, there are few publications that evaluate the role of EVL in patients with decreased renal function. We describe our experience with 22 stable renal transplant recipients whose serum creatinine concentrations were >2 mg/dL and proteinuria <1000 mg/24 h who underwent an abrupt switch from a CNI to EVL. Conversion was simple, well-tolerated, and safe using an initial dose of 1-3 mg/d that was sufficient to achieve the recommended levels of 3-8 ng/dL. The adverse events were expected; most of them were of medium intensity. Globally, over the 24 months follow-up, there was improved renal function despite the initial creatinine. The improvement was greater when the switch was performed during the first year after transplantation. Two patients lost their grafts after a dramatic evolution with development of nephrotic syndrome and increasing creatinine. In our experience, conversion to EVL is a safe alternative among patients with chronic allograft nephropathy or nephrotoxicity due to CNI, even in patients with significantly decreased renal function at the time of the switch.

Combination of everolimus and tacrolimus in kidney transplant patients with intolerance to mycophenolate mofetil/mycophenolic acid

OBJECTIVE

Most immunosuppressive protocols in de novo renal transplantation include tacrolimus in combination with mycophenolate mofetil/mycophenolic acid (MMF/MPA) and prednisone. A variable percentage of patients show intolerance to MMF/MPA needing a reduction, interruption, or suspension of the drug, thereby exposing the patient to a greater risk of a rejection episode. The association of everolimus and tacrolimus may prove to be an alternative option in such cases. The aim of this study was to present our clinical experience, evaluating the incidence of graft rejection.

PATIENTS AND METHODS

We performed a descriptive study of 19 kidney transplant patients from 2001-2008 who were treated with tacrolimus, MMF/MPA, and prednisone and displayed gastrointestinal or hematological adverse events to MMF/MPA, which were addressed with everolimus. We analyzed parameters up to 2 years after the change.

RESULTS

The doses and levels of everolimus were increased progressively. At the same time, we decreased the doses and levels of tacrolimus. Renal function remained stable during the period and there was no case of a rejection episode during the 2 years. Only 5 patients (26%) showed side effects which were attributable to everolimus; 36% of patients required starting and/or increasing the erythropoietin dose, 15% required iron supplements, 15% required diuretics, and 31% began or increased treatment with statins.

CONCLUSION

Our experience suggested that a combination of tacrolimus and everolimus may be a safe, effective alternative for kidney transplant patients who show intolerance to MMF/MPA.