Advances in Human-Centered Care to Address Contemporary Unmet Needs in Chronic Dialysis

Advances in the treatment of kidney failure with chronic dialysis have stagnated over the past three decades, with over 50% of patients still managed by conventional in-hospital haemodialysis. In parallel, the demands of chronic dialysis medical care have changed and evolved due to a growing population that has higher frailty and multimorbidity. Thus, the gap between the needs of kidney failure patients and the healthcare capability to provide effective overall management has widened. To address this problem, healthcare policy has increasingly aligned towards a human-centred approach. The paradigm shift of human-centred approach places patients at the forefront of decision-making processes, ensuring that specific needs are understood and prioritised. Integration of human-centred approaches with patient care has been shown to improve satisfaction and quality of life. The aim of this narrative is to evaluate the current clinical challenges for managing kidney failure for dialysis providers; summarise current experiences and unmet needs of chronic dialysis patients; and finally emphasise how human-centred care has advanced chronic dialysis care. Specific incremental advances include implementation of renal supportive care; home-assisted dialysis; hybrid dialysis; refinements to dialysis methods; whereas emerging advances include portable and wearable dialysis devices and the potential for the integration of artificial intelligence in clinical practice.

The CKD bowel health study: understanding the bowel health and gastrointestinal symptom management in patients with chronic kidney disease: a mixed-methods observational longitudinal study (protocol)

BACKGROUND

Gastro-intestinal (GI) intolerance is a frequently reported outcome in patients with kidney failure receiving maintenance dialysis and those who have received kidney transplants. Symptoms of GI intolerance (diarrhoea, constipation, bloating, abdominal pain, heart burn, and reflux) are associated with significant reduction in quality of life, morbidity, and increased used of healthcare resources. Having chronic kidney disease (CKD), together with related changes in diet and medication, may alter the gut microbiota and the microbial-derived uraemic metabolites that accumulate in kidney failure, and contribute to various complications including chronic diarrhoea, opportunistic infections, and drug-related colitis. Despite the high disease burden among patients with kidney replacement therapies, GI symptoms are often under-recognised and, consequently limited resources and strategies are devoted to the management of gastrointestinal complications in patients with CKD.

METHODS

The CKD Bowel Health Study is a multi-centre mixed-methods observational longitudinal study to better understand the bowel health and GI symptom management in patients with CKD. The program comprises of a longitudinal study that will assess the burden and risk factors of GI intolerance in patients treated with maintenance dialysis; a semi-structured interview study that will describe experiences of GI intolerance (including symptoms, treatment, self-management) in transplant candidates and recipients; and a discrete choice experience to elicit patient preferences regarding their experiences and perspectives of various intervention strategies for the management of GI symptoms after kidney transplantation.

DISCUSSION

This proposed program of work aims to define the burden the GI intolerance in patients with kidney failure and generate evidence on the patients' experiences of GI intolerance and their perspectives on their clinical and own management strategies of these symptoms, ensuring a patient-centred approach to guide clinical decision making and to inform the best study design for intervention trials.

TRIAL REGISTRATION

This study is registered on the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000548831 . This study has been approved by the Western Sydney Local Health District Human Research Ethics Committee of New South Wales Health (HREC ETH03007). This study is supported by a National Health and Medical Research Council (NHMRC) Australia Investigator Grant (APP1195414), and an NHMRC Australia Postgraduate Scholarship (APP2005244).

Incidence and Outcomes of COVID-19 in People With CKD: A Systematic Review and Meta-analysis

Rationale & Objective

Coronavirus disease 2019 (COVID-19) disproportionately affects people with chronic diseases such as chronic kidney disease (CKD). We assessed the incidence and outcomes of COVID-19 in people with CKD.

Study Design

Systematic review and meta-analysis by searching MEDLINE, EMBASE, and PubMed through February 2021.

Setting & Study Populations

People with CKD with or without COVID-19.

Selection Criteria for Studies

Cohort and case-control studies.

Data Extraction

Incidences of COVID-19, death, respiratory failure, dyspnea, recovery, intensive care admission, hospital admission, need for supplemental oxygen, hospital discharge, sepsis, short-term dialysis, acute kidney injury, and fatigue.

Analytical Approach

Random-effects meta-analysis and evidence certainty adjudicated using an adapted version of GRADE (Grading of Recommendations Assessment, Development and Evaluation).

Results

348 studies (382,407 participants with COVID-19 and CKD; 1,139,979 total participants with CKD) were included. Based on low-certainty evidence, the incidence of COVID-19 was higher in people with CKD treated with dialysis (105 per 10,000 person-weeks; 95% CI, 91-120; 95% prediction interval [PrI], 25-235; 59 studies; 468,233 participants) than in those with CKD not requiring kidney replacement therapy (16 per 10,000 person-weeks; 95% CI, 4-33; 95% PrI, 0-92; 5 studies; 70,683 participants) or in kidney or pancreas/kidney transplant recipients (23 per 10,000 person-weeks; 95% CI, 18-30; 95% PrI, 2-67; 29 studies; 120,281 participants). Based on low-certainty evidence, the incidence of death in people with CKD and COVID-19 was 32 per 1,000 person-weeks (95% CI, 30-35; 95% PrI, 4-81; 229 studies; 70,922 participants), which may be higher than in people with CKD without COVID-19 (incidence rate ratio, 10.26; 95% CI, 6.78-15.53; 95% PrI, 2.62-40.15; 4 studies; 18,347 participants).

Limitations

Analyses were generally based on low-certainty evidence. Few studies reported outcomes in people with CKD without COVID-19 to calculate the excess risk attributable to COVID-19, and potential confounders were not adjusted for in most studies.

Conclusions

The incidence of COVID-19 may be higher in people receiving maintenance dialysis than in those with CKD not requiring kidney replacement therapy or those who are kidney or pancreas/kidney transplant recipients. People with CKD and COVID-19 may have a higher incidence of death than people with CKD without COVID-19.

The Learning Curves for Transradial and Ultrasound-Guided Arterial Access: An Analysis of the SURF Trial

INTRODUCTION

Historically, coronary angiography and percutaneous coronary intervention involved accessing the femoral artery via palpation. However, recently there has been a trend towards using a transradial approach and ultrasound guidance for arterial access. Studies have shown that these techniques respectively improve major bleeding rates and access outcomes. There have been no studies conducted that assess the time it takes to train operators to attain proficiency. This sub-analysis of the Standard versus Ultrasound-guided Radial and Femoral access in coronary angiography and intervention (SURF) trial aims to assess the number of procedures required to attain proficiency in ultrasound-guided transradial and transfemoral access.

METHODS

The SURF trial randomised 1,388 patients undergoing coronary angiography and/or percutaneous coronary intervention into standard or ultrasound-guidance and radial or femoral access in a 2×2 factorial design. Operators who participated in this trial were required to have performed at least 50 standard and 10 ultrasound-guided punctures for each of transradial and transfemoral access. Cases were then chronologically ordered and stratified into groups of five, from which the primary endpoint measured was a progression in mean access time and first-pass success rates.

RESULTS

Across all operators, there was a reduction in mean access time between procedures one to five and six to 10 with ultrasound-guided femoral punctures (60.5 secs-51.5 secs, p=0.029) and between procedures 11 to 15 and 16 to 20 ultrasound-guided radial punctures (74s to 62.5 secs, p=0.082). This trend was more obvious in trainees, with significant reductions in mean access time between procedures one to five and six to 10 from 73.5 to 53.5 seconds (p<0.001) for ultrasound-guided femoral access and from 99.5 seconds to 60 seconds (p=0.024) for ultrasound-guided radial access. There were no trends with standard transradial access.

CONCLUSION

The numbers required to attain competency in ultrasound-guided femoral and radial access are 15 and 25 punctures, respectively. Fifty (50) punctures appear adequate for proficiency in a standard transradial approach. These numbers are useful in incorporating into training program for advanced trainees and interventionalists.

Comparison of standard versus ultrasound guidance in radial and femoral access: a subanalysis of the randomised SURF trial

Background

Ultrasound (US) guidance in facilitating arterial access may reduce vascular complications and possible bleeding. There are still limited trials assessing real-time US guidance for coronary angiography. The SURF (Standard versus ultrasound-guided radial and femoral access in coronary angiography and intervention) trial showed no difference in primary outcome when the combined radial and femoral ultrasound analysis compared with standard (SD) technique, but significantly improved access efficiency and success rate.

Purpose

This subanalysis compared clinical and procedural outcomes of the individual radial and femoral access with US guidance versus standard technique.

Methods

Patients (n=1388) undergoing coronary angiography and percutaneous coronary intervention were randomised (1:1) into radial or femoral access, and (1:1) to SD or US guidance. The primary outcome was a composite of ACUITY (Acute Catheterisation and Urgent Intervention Triage strategY) major bleeding, MACE (death, stroke, myocardial infarction or urgent target lesion revascularisation) and vascular complications at 30 days. Secondary outcomes were access time, number of attempts, venepuncture, difficult accesses and first-pass success.

Results

Compared to standard, US guidance produced no difference in composite endpoint for both radial (1.4% vs 1.2%, p=0.78) and femoral (3.1% vs 3.8%, p=0.65) accesses. ACUITY major bleeding (radial: 0.9% US vs 0.6% SD, p=0.69; femoral: 1.9% US vs 2.3% SD, p=0.69), vascular complications (radial: 0.3% US vs 0.3% SD, p=0.98; femoral: 1.3% US vs 0.9% SD, p=0.63) and MACE (radial: 0.6% US vs 0.3% SD, p=0.59; femoral: 0.9% US vs 1.2% SD, p=0.78) were similar in the US and SD approaches, respectively. However, US guidance resulted in improved procedural outcomes for both accesses. Femoral access derived the most benefit from US, with reduced mean access time (73 sec vs 97 sec, p=0.006), attempts (1.35 vs 1.84, p≤0.0001), difficult accesses (1.8% vs 6.2%, p=0.004), venepuncture (5.8% vs 12.6%, p=0.002) and improved first-pass success (77.2% vs 58.8%, p≤0.0001). For radial, US reduced attempts (1.59 vs 1.97, p=0.0007), difficult accesses (6.9% vs 12.3%, p=0.02), venepuncture (2.5% vs 5.6%, p=0.04) and improved first-pass success (69.2% vs 60.7%, p=0.02). There was no difference in radial mean access time (111 sec vs 126 sec, p=0.18).

Conclusions

US guidance in radial and femoral access did not reduce primary outcome compared to standard technique. The use of US significantly improved the efficiency and success rate of arterial cannulation, with femoral access derived the most benefit.

Funding Acknowledgement

Type of funding source: None

Standard versus ultrasound-guided radial and femoral access in coronary angiography and intervention (SURF): a randomised controlled trial

AIMS

This study aimed to compare outcomes in unselected patients undergoing cardiac catheterisation via transradial versus transfemoral access and standard versus ultrasound-guided arterial access.

METHODS AND RESULTS

This was a prospective, randomised (radial vs. femoral and standard vs. ultrasound), 2x2 factorial trial of 1,388 patients undergoing coronary angiography and percutaneous coronary intervention. The primary outcome was a composite of ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) major bleeding, MACE (death, stroke, myocardial infarction or urgent target lesion revascularisation) and vascular complications at 30 days. Transradial access reduced the primary outcome (RR 0.37, 95% CI: 0.17-0.81; p=0.013), mostly driven by ACUITY major bleeding (RR 0.343, 95% CI: 0.123-0.959; p=0.041) when compared with the transfemoral approach. There was no difference in the primary outcome between standard and ultrasound guidance (p=0.76). Ultrasound guidance, however, reduced mean access time (93 sec vs. 111 sec; p=0.009), attempts (1.47 vs. 1.9; p<0.0001), difficult accesses (4.5% vs. 9.2%; p=0.0007), venepuncture (4.1% vs. 9.2%; p<0.0001) and improved first-pass success (73% vs. 59.7%; p<0.0001).

CONCLUSIONS

Transradial access significantly reduced the composite outcome compared to transfemoral access. Ultrasound guidance did not reduce the primary outcome compared to the standard technique, but significantly improved the efficiency and overall success rate of arterial access.

Synergetic and inhibition effects in carbon dioxide gasification of blends of coals and biomass fuels of Indian origin

The present study investigates the enhancement of CO2 gasification reactivity of coals due to the presence of catalytic elements in biomass such as K2O, CaO, Na2O and MgO. Co-gasification of three Indian coal chars with two biomass chars has been studied using isothermal thermogravimetric analysis (TGA) in CO2 environment at 900, 1000 and 1100°C. The conversion profiles have been used to establish synergetic or inhibitory effect on coal char reactivity by the presence of catalytic elements in biomass char by comparing the 90% conversion time with and without biomass. It is concluded that both biomasses exhibit synergistic behavior when blended with the three coals with casuarina being more synergetic than empty fruit bunch. Some inhibitory effect has been noted for the high ash coal at the highest temperature with higher 90% conversion time for the blend over pure coal, presumably due to diffusional control of the conversion rate.

Shape Optimisation of Curved Interconnecting Ducts

<p class="AbstractText">Practical ducting layout in process plants needs to satisfy a number of on-site constraints. The search for an optimal flow path around the obstructions is a multi-parameter problem and is computationally prohibitively expensive. In this study, authors proposed a rapid and efficient methodology for the optimal linkage of arbitrarily oriented fluid flow ducts using a single-parameter quadratic/cubic Bézier curves in two/three dimensions to describe the centreline of the curved duct. A smooth interconnecting duct can then be generated by extruding the duct face along the curve. By varying the parameter either along the angular bisector or along the axes of the ducts, a family of Bézier curves is generated. Computational fluid dynamics simulations show that the relationship between pressure drop and the adjustable parameter is a unimodal curve and the optimal connecting duct is the one which has the least pressure drop while satisfying on-site constraints can be used for linking the ducts. The efficacy of the method is demonstrated by applying it to some cases of practical interest.</p><p class="AbstractText"><strong>Defence Science Journal, Vol. 65, No. 4, July 2015, pp. 300-306, DOI: http://dx.doi.org/10.14429/dsj.65.8353</strong></p><p class="AbstractText"> </p>

CFD analysis of dense gas dispersion in indoor environment for risk assessment and risk mitigation

Environmental risks are inherent in the operation of any complex chemical process industry. The indoor release of hazardous chemicals that are denser than air is a topic of special concern, since dense clouds tend to persist at ground level or human breath level which leads to a magnification of their harmful potential. In the present work, we propose a computational fluid dynamics (CFD) based model for indoor risk assessment considering accidental release of a sustained, small, undetected leak of a dense toxic gas (chlorine) in an industrial indoor environment. Results from simulations show that the denser chlorine gas spreads like a liquid and flows all along the floor. At the same time, its concentration at a point away from the ground level increases slowly, thus showing that both stratification and dilution effects are present as the dense gas spreads. The implications of this spreading pattern from a risk assessment and risk mitigation point of view are discussed.

Ultrasonic coal-wash for de-sulfurization

Coal is the one of the world's most abundant fossil fuel resources. It is not a clean fuel, as it contains ash and sulfur. SOx as a pollutant are a real threat to both the ecosystem and to human health. There are numerous de-sulfurization methods to control SO(2) emissions. Nowadays, online flue gas de-sulfurization is being used as one such method to remove sulfur from coal during combustion. The biggest disadvantage associated with this method is formation of by-products (FGD gypsum). A way for effective usage of FGD gypsum has not yet been found. This will lead to acute and chronic effects to humans as well as plants. Power ultrasound can be used for the beneficiation of coal by the removal of sulfur from coal prior to coal combustion. The main effects of ultrasound in liquid medium are acoustic cavitation and acoustic streaming. The process of formation, growth and implosion of bubbles is called cavitation. Bulk fluid motion due to sound energy absorption is known as acoustic streaming. In addition, coupling of an acoustic field to water produces OH radicals, H(2)O(2), O(2), ozone and HO(2) that are strong oxidizing agents. Oxidation that occurs due to ultrasound is called Advanced Oxidation Process (AOP). It converts sulfur from coal to water-soluble sulphates. Conventional chemical-based soaking and stirring methods are compared here to ultrasonic methods of de-sulfurization. The main advantages of ultrasonic de-sulfurization over conventional methods, the mechanism involved in ultrasonic de-sulfurization and the difference between aqueous-based and solvent-based (2N HNO(3), 3-volume percentage H(2)O(2)) de-sulfurization are investigated experimentally.

Leucocytoclastic vasculitis in infant

Acute hemorrhagic edema of infancy is a laucocytoclastic vasculitis characterized by a triad of fever, large purpuric skin lesions and edema. The presentation is often dramatic. The manifestations are often misinterpreted as a septicemic illness. We report the occurrence of this syndrome in a 1 1/2-year-old-child, highlighting some of the diagnostic and therapeutic problems encountered.