Adequacy of haemodialysis and associated factors among patients with end-stage kidney disease in Tanzania

Objectives

Adequate haemodialysis helps maintain normal renal function by removing toxins and other waste products in patients with end-stage kidney disease. This study was aimed at determining the prevalence and predictors of adequacy of haemodialysis and outcomes in patients with end-stage kidney disease.

Methods

This longitudinal analytical hospital-based study was conducted at two dialysis centres in Dodoma city, Tanzania, between February and July of 2020. Adequacy of haemodialysis was measured with single-pool (sp) Kt/V and urea reduction rate (URR) formulae. Binary logistic regression and multivariable analysis were used to assess the independent predictors of adequacy of haemodialysis.

Results

The analysis included 100 patients with a mean age of 50.6 ± 15.0 years. The prevalence of adequacy of haemodialysis according to URR and sp-Kt/V was 72 % and 75 %, respectively. Having <12 months since dialysis initiation (AOR = 7.3, 95 % CI = 0.11-0.90, p = 0.032), fewer than three dialysis sessions per week (AOR = 6.9, 95 % CI = 1.52-31.49, p = 0.013) and severe anaemia (AOR = 2.2, 95 % CI = 0.26-0.93, p = 0.033) were predictors of inadequate haemodialysis, according to the URR formula. Having fewer than three dialysis sessions per week was significantly associated with inadequate haemodialysis (AOR = 5.6, 95 % CI = 1.47-19.66, p = 0.011), according to the sp-Kt/V formula. The mortality rate was 11.2 %, and cardiovascular disease and uremic syndrome were responsible for most deaths.

Conclusion

This study indicated a high percentage of adequacy of haemodialysis among patients with end-stage kidney disease. Having fewer than three dialysis sessions per week, late initiation of dialysis after diagnosis of end-stage kidney disease and severe anaemia were predictors of inadequate haemodialysis among patients.

Assessing Adequacy: A Meta-Analysis of Rapid Onsite Evaluation of Thyroid Nodules

INTRODUCTION

Fine-needle aspiration (FNA) is the standard form of preoperative evaluation of thyroid nodule cytological status. A significant number FNAs are classified as inadequate for interpretation, requiring a repeat FNA which is potentially avoidable, costly, and delays treatment. To address these concerns and maximize first-time FNA adequacy, rapid onsite evaluation (ROSE) of FNA specimens was introduced. Our study aims to determine the impact of ROSE on FNA adequacy.

METHODS

PubMed, Embase, and Web of Science were searched for primary articles assessing the adequacy of ROSE in thyroid nodules.

RESULTS

A total of 17 studies were included for a total of 24,649 thyroid nodes. Thirteen thousand two hundred fifteen (53.6%) thyroid nodules were assessed utilizing ROSE and 11,434 (46.4%) were not. Pooled adequacy increased significantly from 76% without ROSE to 92% with rose (P = 0.001). Use of ROSE increased the odds of adequate FNA by 22% (risk ratio (RR) = 1.22, 95% confidence interval (CI) = 1.12-1.32). At institutions with less than 85% effective diagnostic adequacy without ROSE, the risk for diagnostic adequacy increased by 28% with ROSE implementation (RR = 1.28, 95% CI = 1.20-1.37). In contrast, in studies reported from institutions with an effective diagnostic rate greater than 85% without the use of ROSE, the diagnostic adequacy only increased by 5% with ROSE implementation (RR = 1.05, 95% CI = 1.03-1.06).

CONCLUSIONS

The use of ROSE during first-time FNA of thyroid nodules can significantly improve adequacy, especially at institutions with baseline high inadequacy rates. Implementation of ROSE can reduce repeat FNAs and its associated consequences.

Optimal growth and development: are teenagers getting enough micronutrients from their diet?

The teenage years represent a crucial period of physical and cognitive growth and development with sufficient micronutrient intakes necessary to meet high nutritional requirements. This review examines current micronutrient intakes in teenagers in the Western world in the context of public health implications including the prevalence of inadequate intakes and risk of excessive intakes. Intakes of vitamins A, D, E and C, folate, calcium, iron, magnesium, zinc and potassium in teenagers are low when compared to generally accepted recommendations, while there is little risk of excessive micronutrient intakes based on current dietary patterns. Therefore, strategies should focus on increasing micronutrient intakes in order to decrease the risk of negative impacts resulting from these low intakes. These strategies should be mindful of guidance towards an environmentally sustainable diet whilst ensuring that nutrient intakes in teenagers are not further negatively impacted. In order to identify, implement and monitor the effectiveness of such strategies, intakes of micronutrients should be continually monitored in nationally representative samples of the population for all age groups including this vulnerable cohort of teenagers.

Health care management adequacy among French persons with severe profound intellectual and multiple disabilities: a longitudinal study

BACKGROUND

The care organization of persons with profound intellectual and multiple disabilities (PIMD) varies by country according to the health care system. This study used a large sample of French individuals with severe PIMD/polyhandicap to assess: 1) the adequacy of care setting over a 5-year period and 2) health care consumption.

METHODS

The longitudinal study used data from the French EVALuation PoLyHandicap (EVAL-PLH) cohort of persons with severe PIMD/polyhandicap who were receiving managed in specialized care centres and residential facilities. Two assessments were performed: wave 1 (T1) in 2015-2016 and wave 2 (T2) in 2020-2021. The inclusion criteria were as follows: age > 3 years at the time of inclusion; age at onset of cerebral lesion younger than 3 years old; and severe PIMD. The adequacy of the care setting was based on the following: i) objective indicators, i.e., adequacy for age and adequacy for health status severity; ii) subjective indicators, i.e., self-perception of the referring physician about medical care adequacy and educational care adequacy. Health care consumption was assessed based on medical and paramedical care.

RESULTS

Among the 492 persons assessed at the 2 times, 50% of individuals at T1 and 46% of individuals at T2 were in an inadequate care setting based on age and severity. Regarding global subjective inadequacy, the combination of medical adequacy and educational adequacy, 7% of individuals at T1 and 13% of individuals at T2 were in an inadequate care setting. At T2, a majority of individuals were undermonitored by medical care providers (general practitioners, physical medicine rehabilitation physicians, neurologists, orthopaedists, etc.). Important gaps were found between performed and prescribed sessions of various paramedical care (physiotherapy, occupational therapy, psychomotor therapy, etc.).

CONCLUSIONS

This study revealed key elements of inadequate care management for persons with severe PIMD/polyhandicap in France. Based on these important findings, healthcare workers, familial caregivers, patients experts, and health decision-makers should develop appropriate care organizations to optimize the global care management of these individuals.

TRIAL REGISTRATION

NCT02400528, registered 27/03/2015.

Gross Appearance of Fine Needle Aspiration Smears: Can Adequacy of the Sample be Assessed and Correlated with their Microscopic Cytological Yield

Background

Fine needle aspiration cytology (FNAC) is a simple procedure that is widely accepted as a first-line investigation. It should ideally be performed near the patient with microscopic assessment for evaluation of adequacy of aspirate. Since this is not always possible, a worthwhile substitute is to assess the gross appearance of the material obtained. This study was aimed to determine the value of this alternative rapid, bed-side approach.

Method

This study was carried out in a tertiary care hospital for a duration of 1 year, where 50 cases undergoing FNAC in the out-patient department (OPD) were included. Unstained smears of commonly encountered lesions were photographed and assessed by three independent observers, who graded them into four grades, viz. Grade 1: unlikely to contain diagnostic material. Grade 2: possibly contains diagnostic material. Grade 3: probably contains diagnostic material. Grade 4: material suggesting a specific diagnosis. Results were subsequently compared with the microscopic findings of stained smears.

Results

Distribution of the 50 cases between grades 1, 2, 3, and 4 were 5, 6, 17, and 22, respectively.

Conclusion

Gross appearances of FNA smears are helpful in predicting the adequacy of the sample and sometimes the final microscopic diagnosis. The cellularity of a sample can be gauged by inspection and sometimes a likely diagnosis can be made. Some lesions show typical gross appearance easily detected by the experienced eye so a likely diagnosis can be predicted prior to microscopic examination. However, near-patient microscopic assessment of FNA specimens for rapid onsite evaluation, if available, should be the preferred mode.

[Adequacy of histopathology request forms and pathological reports of breast cancer surgical specimens in Benin]

Introduction

Breast cancer requires multidisciplinary management. Pathologists and physicians communicate using the histopathology request form and the pathology report. There are some minimal criteria that both should respect.

Objective

We assessed the adequacy of histopathology request forms and pathology reports in the management of female breast cancer specimens in Southern Benin.

Method

This was a cross-sectional, descriptive and analytical study, with retrospective data collection over 57 months (4 years and 9 months). The adequacy of the histopathology request forms and pathology reports was assessed on the basis of the recommendations of the Haute Autorité de Santé (HAS) of France. Data processing was done using SPSS software. We checked frequencies with the Chi2 test, with a significance level set at 5%.

Results

31.3% of histopathology request forms complied with HAS recommendations. Pathology reports were presented in a narrative way in 92.7% of cases and 68.8% met the minimal criteria. The presence of vascular embolus, of hormone receptors and the HER2 status were all reported in only 29.2% of the reports.

Discussion

The draft of histopathology request forms and pathology reports did not comply to the required minimal criteria. This situation could mainly be explained by the inexistence of consensus between physicians and pathologists and by the lack of immunohistochemistry. Editing national referentials and using synoptic reports would give better results.

Effectiveness and safety of Shankhaprakshalana-a yogic technique-in bowel preparation for colonoscopy: A retrospective study

INTRODUCTION

Shankhaprakshalana (SP) is a yogic method aiming to cleanse the bowel. It involves the use of warm saline water and a combination of five asanas. This study was designed to assess the effectiveness and safety of bowel preparation by SP.

METHODS

This is a retrospective observational study of prospectively collected data. Patients planned for colonoscopy were screened and enrolled to undergo bowel preparation by SP on the day of the colonoscopy. Patients having comorbid conditions, poor performance status, suspected or previously diagnosed intestinal stricture and past history of major abdominal surgery and those unable to perform asanas of SP were excluded. A low-fiber diet was advised for one day before the colonoscopy. Patients were advised to drink 400 mL of lukewarm saline water followed by five asanas (exercises) of SP, each done eight times dynamically and sequentially. After completing six such cycles, patients underwent colonoscopy. Boston Bowel Preparation Scale (BBPS) score was used to assess the quality of bowel preparation.

RESULTS

Total 238 patients were included. The major indications for colonoscopy were abdominal pain (35.3%), hematochezia (23.9%), diarrhea (20.2%), constipation (10.9%) and anemia (9.7%). The mean age was 37.7 (± 12) years. The mean BBPS was 8 (± 1.2). Bowel preparation was inadequate (BBPS < 6) in only two patients. Mean segmental BBPS for the three segments of the colon (right, transverse and left) was 2.6 (± 0.5), 2.7 (± 0.4) and 2.6 (± 0.7), respectively. Minor adverse events (nausea, abdominal pain, vomiting, giddiness and bloating) were noted in 10 participants (4.2%), which did not require hospitalization. Bowel preparation was completed in 133 (± 35) minutes.

CONCLUSION

Shankhaprakshalana is an effective and safe method to achieve adequate bowel preparation before colonoscopy. Since this is a single-center and retrospective study, future multi-centric, prospective studies comparing it with the standard bowel preparation regimens are warranted.

Intake of ultra-processed food, dietary diversity and the risk of nutritional inadequacy among adults in India

OBJECTIVE

This study assessed diet diversity and consumption of ultra-processed foods and explored its impact on macronutrient intake and risk of micronutrient inadequacy.

DESIGN

Cross-sectional, non-probability snowball sampling.

SETTING

Nutrient intake was assessed using 24-h dietary recall method and diet diversity through FAO-diet diversity score (DDS). Mann-Whitney U test was used to assess differences in risk of inadequacy across gender. Spearman's rank correlation assessed associations between energy contributed by ultra-processed food and risk of nutrient inadequacy.

PARTICIPANTS

A total of 589 adults (20-40 years) belonging to upper-middle and high-income groups.

RESULTS

The average individual DDS was 4·4 ± 0·6. Most of the participants (>80 %) had intakes less than national recommendations of pulses/eggs/flesh foods, milk/milk products, fruits, vegetables and nuts. Ultra-processed foods contributed to 17 % of total energy intake, 12 % of protein, 17 % of carbohydrate, 29 % of added sugar, 20 % of total fat and 33 % of Na intake. The average risk of nutrient inadequacies for Zn (98 % v. 75 %), folate (67 % v. 22 %) and niacin (83 % v. 44 %) was higher among males than females (P < 0·001). The average risk of nutrient inadequacies for Fe (58 % v. 7 %), vitamin B6 (95 % v. 90 %) and vitamin A (68 % v. 44 %) was higher among females than males (P < 0·001). There was a positive correlation between energy contributed by ultra-processed food and risk of niacin (ρ = 0·136, P = 0·001) and folate (ρ = 0·089, P = 0·049) inadequacy.

CONCLUSION

Reformulating ultra-processed food to reduce fat, sugar and salt and increase micronutrients and behaviour change communication strategies that promote dietary diversity will improve micronutrient adequacy and diet quality.

Sampling from Extracorporeal Circuit: A Step Forward for Dose Monitoring in Continuous Renal Replacement Therapy

INTRODUCTION

Continuous renal replacement therapies (CRRTs) require constant monitoring and periodic treatment readjustments, being applied to highly complex patients, with rapidly changing clinical needs. To promote precision medicine in the field of renal replacement therapy and encourage dynamic prescription, the Acute Dialysis Quality Initiative (ADQI) recommends periodically measuring the solutes extracorporeal clearance with the aim of assessing the current treatment delivery and the gap from the therapeutic prescription (often intended as effluent dose). To perform this procedure, it is therefore necessary to obtain blood and effluent samples from the extracorporeal circuit to measure the concentrations of a target solute (usually represented by urea) in prefilter, postfilter, and effluent lines. However, samples must be collected simultaneously from the extracorporeal circuit ports, with the same suction flow at an unknown rate.

METHODS

The proposed study takes the first step toward identifying the technical factors that should be considered in determining the optimal suction rate to collect samples from the extracorporeal circuit to measure the extracorporeal clearance for a specific solute.

RESULTS

The results obtained identify the low suction rate (i.e., 1 mL/min) as an ideal parameter for an adequate sampling method. Low velocities do not perturb the external circulation system and ensure stability prevailing pressures in the circuit. Higher velocities can be performed only with blood flows above 120 mL/min preferably in conditions of appropriate filtration fraction.

DISCUSSION/CONCLUSIONS

The specific value of aspiration flow rate must be proportioned to the prescription of CRRT treatments set by the clinician.

Peritoneal Dialysis Prescription and Adequacy in Clinical Practice: Core Curriculum 2023

As the global prevalence of peritoneal dialysis (PD) continues to grow, practitioners must be equipped with prescribing strategies that focus on the needs and preferences of patients. PD is an effective form of kidney replacement therapy that offers numerous benefits to patients, including more flexibility in schedules compared with in-center hemodialysis (HD). Additional benefits of PD include salt and water removal without significant changes in patient hemodynamics. This continuous yet gentle removal of solutes and fluid is associated with better-preserved residual kidney function. Unfortunately, sometimes these advantages are overlooked at the expense of an emphasis on achieving small solute clearance targets. A more patient-centered approach emphasizes the importance of individualized treatment, particularly when considering incremental PD and other prescriptions that align with lifestyle preferences. In shifting the focus from small solute clearance targets to patient needs and clinical goals, PD remains an attractive, patient-centered form of kidney replacement therapy.

Role of Prescription Practice in Ensuring Patient Safety in the Primary Health-Care Settings in India

"Completeness (a measure of adequacy)" and the "appropriateness (a measure of the quality of care)" are two dimensions of good prescription practice. The study assessed the prescription practices at the primary health centers (PHCs); to demonstrate the effect of individual and system-level factors, on adequacy and appropriateness of prescription practices, with special reference to e-prescription over manual prescription given the rising acceptance of teleconsultation in health care. A total of 600 manual and 1000 e-prescriptions were randomized using a probability-proportional-to-size sampling method to distribute/allocate samples across manual and e-prescriptions. Findings revealed that while adequacy and appropriateness of prescriptions depend on individual training and clinical practice; adequacy of prescription, especially the manual was compromised by systemic factors, such as nonavailability of space in a prescription, forcing doctors to prioritize documentation of diagnosis, advising tests, and prescribing medicines, over other details (chief complaints and examination findings).

The optimal approach of EBUS-FNA rapid on-site evaluation (ROSE): a five-year experience from a large academic medical center

INTRODUCTION

Rapid on-site evaluation (ROSE) performed during endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) has shown significant value. However, ROSE may not be available for some pulmonary centers. Performing ROSE can be challenging and stressful due to time constrains for preparing, staining and reviewing the cytology slides between passes.

MATERIALS AND METHODS

A retrospective cytology report review of EBUS-FNA procedures performed between October 2014 and May 2019 revealed 516 cases that were included in the study. The number of passes for each procedure was documented. The adequacy rates were assessed at 4 different study points; ≤3 passes, ≤5 passes, at odd passes only, and the even passes only. The study groups results were compared to the overall ROSE and the final cytology adequacy.

RESULTS

The overall ROSE interpretation was adequate in 370 (71.7%) and inadequate in 146 (28.3%). After reviewing the Papanicolaou stained slides and cell blocks, the final cytology results were adequate in 473 (91.7%) and inadequate in 43 (8.3%) of the cases. The number of passes per procedure ranged from 1 to 17. Our results showed that ROSE evaluation of the first 5 passes during the EBUS-FNA procedure could achieve the similar adequacy rate compared to the overall ROSE evaluation of all the passes.

CONCLUSIONS

To achieve the most benefits of ROSE and to reduce the procedure time for EBUS-FNA, we recommend performing ROSE for ≤5 passes depending on the adequacy, and save all additional passes for cell blocks preparation if more than 5 passes are attempted.

Efficacy and safety of percutaneous renal biopsy performed using 18G needle versus 16G needle: a single-center retrospective study

Background

At present, both 16G and 18G needles are used for percutaneous renal biopsy in China. This study aimed to compare the efficacy and safety of biopsy performed with the 18G needle vs. the 16G needle.

Methods

The data of patients who underwent percutaneous renal biopsy at our hospital between January 2015 and December 2019 were retrospectively analyzed. The number of glomeruli obtained by puncture and postoperative complications were compared between patients undergoing biopsy with the 16G and 18G needles. Continuous variables were compared by the t test or the Mann–Whitney U test, and categorical variables by the chi-square test. Correlation analysis was used to examine the relationship of different variables with hematoma size.

Results

Of the total 3138 kidney biopsies, 2526 were performed with the18G needle and 612 with the 16G needle. The number of glomeruli obtained was not significantly different between the two groups (P = 0.078). Large hematomas were significantly more common the 16G group than in the 18G group (9.31% vs. 5.98%, P = 0.003). Arteriovenous fistula was also more common in the 16G group (1.14% vs. 0.23%, P = 0.005). Other complications were rare, with similar incidence in the two groups.

Conclusion

The 18G needle is as effective as the 16G needle for percutaneous renal biopsy. The risk of large hematoma and arteriovenous fistula appear to be lower with the 18G needle.

Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors

Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.

[Adequacy of pre-surgical hand hygiene in an university teaching hospital in Madrid (Spain).]

OBJECTIVE

We know the importance of hand hygiene in the prevention of healthcare-associated infections. However, its compliance is still a challenge. Moreover, when it is complied with, as in the case of preoperative hygiene, there are few studies on the proper performance of the technique. The aim of this paper is to assess adequacy of pre-surgical hand hygiene in operating room staff of different surgical specialities at a university teaching hospital in Madrid.

METHODS

A cross-sectional study was made. Adequacy of pre-surgical hand hygiene was assessed in operating room staff of the different specialities and professional categories by direct covert observation. It was evaluated in 852 opportunities during the months of October, November and December 2020. A specific form was designed for data collection, following the recommendations of the World Health Organisation (WHO). Adequacy was described with frequency distributions of the different groups observed. Whether Chi-square or Fisher's exact tests were used to compare the different categories.

RESULTS

Pre-surgical hand hygiene opportunities were evaluated, 75.5% in surgeons and 24.5% in nurses. Overall compliance with pre-surgical hand hygiene technique was 80.5 % (686). The most frequent surgical service evaluated was General Surgery with 240 observations. The professional category with the best adequacy was nursing (86.1%) and the surgical service one was Traumatology (90.2%). An stopwatch was used by some 25.8% of the evaluated professionals, with an adequate hygiene time of 96,8% (p<0,05) for that group.

CONCLUSIONS

The overall adequacy of pre-surgical hand hygiene in the operating room professionals is high. Significant statistically differences in adequacy are found between professional categories and surgical specialities, with better compliance in nursing staff and in Traumatology. Better results are achieved by the use of an stopwatch.

Contrast-enhanced ultrasound improves the potency of fine-needle aspiration in thyroid nodules with high inadequate risk

Background

This study aims to determine the clinical value of contrast enhanced ultrasound (CEUS) for fine-needle aspiration (FNA) of high inadequate risky thyroid nodules.

Methods

During April 2018 and April 2021, consecutive 3748 thyroid nodules underwent FNA were retrospectively analyzed. CEUS guided FNA (CEUS-FNA) was applied in 115 nodules with high inadequate risk in Lingnan Campus. Ten nodules underwent CEUS-FNA presented non-enhancing, and would be further analyzed independently. Other 105 partial or total enhancing nodules were included as CEUS-FNA group, and 210 nodules with high inadequate risk in Tianhe Campus were match as the US-FNA control group. FNA specimens were collected for liquid-based preparation. Cytological results were classified following the Bethesda System for Reporting Thyroid Cytopathology.

Results

The overall FNA specimen inadequate rate in our center was 6.6%. All of the ten non-enhancing nodules under CEUS have an inadequate result in cytopathological analyzes. The subsequent postoperative pathology and follow-up ultrasonography showed the non-enhancing nodules were benign or stable without further malignant features. Total specimen inadequate rate of high inadequate risk thyroid nodules in CEUS-FNA group was significantly lower than US-FNA group (6.7% vs. 16.7%, P = 0.014). Further stratified analyzed shown that FNA under US guidance, the inadequate rates in cystic, predominantly cystic, predominantly solid and solid sub-groups were 28.1%, 17.1%, 10.0% and 9.2% (P = 0.019). In contrast, the inadequate rates in cystic, predominantly cystic, predominantly solid and solid sub-groups were 7.4%, 6.7%, 5.6% and 6.7% (P = 0.996) in CEUS-FNA group.

Conclusions

CEUS can improve the specimen adequacy of FNA in high inadequate risk thyroid nodules by avoiding unnecessary FNAs of the non-enhancing nodules, and accurately locating the viable tissue and precise guidance in real-time. CEUS is a recommend modality for FNA guidance of high inadequate risk thyroid nodules.

Peritoneal dialysis adequacy: a paradigm shift

For the past 30 years, nephrologists have focused on a single minimal threshold of Kt/V_urea to determine the adequacy of peritoneal dialysis (PD). To date, there is no evidence that shows Kt/V_urea to be a good surrogate measure of uremic symptom control or nutritional state in patients on PD. Volume of distribution (V_urea) generally is considered equivalent to total body water (TBW). Yet, accurate determination of TBW is difficult. The most recent International Society for Peritoneal Dialysis practice recommendations on prescribing high-quality PD emphasized incorporation of multiple measures rather than the single value of Kt/V_urea. These measures include shared decision-making between the patient and the care team and assessment of health-related quality of life, burden of uremic symptoms, presence of residual kidney function, volume status, and biochemical measures including serum potassium and bicarbonate levels. In some cases, PD prescriptions can be tailored to the patient priorities and goals of care, such as in frail and pediatric patients. Overall, there has been a paradigm shift in providing high-quality care to PD patients. Instead of focusing on small solute clearance in the form of Kt/V_urea, nephrologists are encouraged to use a more comprehensive assessment of the patient as a whole.

Inflammation and hemodialysis adequacy: are C-reactive protein levels influenced by the dose of dialysis?

INTRODUCTION

Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the "dialysis dose" (Kt / V) using ionic dialysance.

METHODS

Multicenter cross-sectional study. 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into two groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence.

RESULTS

Median CRP was 4.10 mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48 ± 0.308. Kt/V was lower in the patients included in the high inflammation group (p = 0.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log INL (p < 0.001) and inversely proportional with serum albumin values (p = 0.014), Kt/V (p = 0.037) and serum iron (p < 0.001).

CONCLUSION

The poorer adequacy in terms of dialysis doses, lower Kt / V values, may contribute to a higher degree of inflammation in chronic hemodialysis patients.

Kidney biopsy adequacy and complications in children - does technique matter?

Kidney biopsy is part of the diagnostic workup of many children with renal disease. Traditionally, a perpendicular approach to the biopsy has been used, but more recently, some proceduralists have favoured a tangential approach. It is not clear if one technique is superior with regards to tissue adequacy or complication rates. In our centre, interventional radiologists (IR) use general anaesthetic and a tangential approach, whereas paediatric nephrologists (PN) use sedation and a perpendicular approach. We examined consecutive native kidney biopsies performed between January 2008 and December 2017 for adequacy (sufficient tissue for light and electron microscopy and immunofluorescence) and examined the electronic medical records for data regarding technique and complications. IR performed 72 (29%) of the 245 native kidney biopsies, obtaining more total glomeruli (median 39 vs 16, p < 0.001) and more glomeruli per tissue core (median 13 vs 8, p < 0.001) than PN. No differences in specimen adequacy were observed between the two groups (79% IR vs 81% PN, p = 0.75) and a diagnosis could be made in 99% and 94% respectively (p = 0.1). A statistically lower rate of peri-nephric haematoma (28% vs 42%, p = 0.04) was detected in the IR group, but there were no significant differences in other complications. One patient required a blood transfusion (PN) and another required surgical intervention for a perinephric haematoma (IR).

CONCLUSION

IR obtained larger samples and number of glomeruli, but the overall adequacy for native kidney biopsies was good using both perpendicular and tangential techniques, with low rates of significant complications.

WHAT IS KNOWN

• Kidney biopsy is integral to the diagnostic work-up of many children with kidney disease. • Kidney biopsy is a safe procedure with well-established complications in a minority of children.

WHAT IS NEW

• Interventional radiologists had higher biopsy yield than paediatric nephrologists, possibly due to the tangential approach. • Biopsy adequacy rates are high using both techniques and provided a diagnosis in over 95% of cases.

Adequacy of probabilistic prehospital antibiotic therapy for septic shock

BACKGROUND

Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown.

METHODS

From May 2016 to March 2021, all consecutive patients with SS cared for by a prehospital mICU intervention were retrospectively analyzed.

RESULTS

Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) were deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p = 4.10^-3). After propensity score matching, a significant association between adequate prehospital ABT administration and day-30 mortality was observed (aOR = 0.09 [0.01-0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR = 0.70 [0.53-0.93].

CONCLUSIONS

Among SS cared for by a mICU, probabilistic prehospital ABT is adequate most of the time and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.

Comparative study on the adequacy of cervical smears using wooden Ayre's spatula, VS Papcone® sampling device

•

This study was conducted in two tertiary health institutions in Anambra state of southeastern Nigeria.

•

It compared the adequacy of Pap smears obtained with two sampling devices- the wooden Ayre’s spatula and the Papcone®.

•

The adequacy of smears obtained with Papcone® was significantly better than those of wooden Ayre’s spatula.

•

Papcone® should always be preferred, especially in developing countries where liquid-based cytology is not yet routine.

This is a comparative study on the adequacy of cervical smears obtained using the Papcone® sampling device or wooden Ayre’s spatula conducted from two tertiary health facilities –– Nnamdi Azikiwe University Teaching Hospital Nnewi and Chukwuemeka Odumegwu Ojukwu University Teaching Hospital Awka, in Anambra State, Nigeria. Slides from smears obtained using both devices were read by a cytopathologist blinded for the study. The primary outcome was the proportion of smears with an adequate endocervical component. Significantly higher adequate cervical smears were obtained in 177/192 (92.2%) women using the Papcone® sampling device, compared to 152/192 (79.2%) using wooden Ayre’s spatula (p < 0.001). Kappa analysis showed moderate inter-rater agreement between the two devices. We recommend the use of the Papcone device when it is available, as the adequacy of cervical smears obtained with the Papcone® was better than that obtained using wooden Ayre’s spatula.

Tailoring nutrition therapy amid the COVID-19 pandemic: Does it work?

Background

The COVID-19 pandemic has been a challenge for nutrition monitoring and delivery. This study evaluates clinical and nutritional characteristics of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and investigates the relationship between nutrition delivery and clinical outcomes.

Methods

Prospective observational study of adults admitted for >24 hrs to a tertiary-care hospital during a period of 2months. Data was collected on disease severity, energy, protein delivery and adequacy, use of mechanical ventilation (MV), hospital length of stay (LOS). Multivariate logistic regression models were used to determine the associations with mortality as the primary outcome.

Results

1083 patients: 69% male (n = 747), 31% females (n = 336), mean age 58.2 ± 12.8 with 26.6 ± 4.32 BMI were analysed. 1021 patients survived and 62 deaths occurred, with 183 and 900 patients in the ICU and ward, respectively. Inadequate calorie and protein delivery had significantly higher mortality than those with adequate provision (p < 0.001) among the ICU patients. In bivariate logistic regression analysis, inadequacy of energy and protein, disease severity, comorbidities ≥3, NRS score ≥3 and prone ventilation correlates with mortality (p < 0.001). In multivariate logistic regression analysis of the ICU patients, energy inadequacy (OR:3.6, 95%CI:1.25–10.2) and prone ventilation (OR:11.0, 95%CI:3.8–31.9) were significantly (p < 0.05) associated with mortality after adjusting for disease severity, comorbidities and MV days.

Conclusion

Most patients infected with SARS-CoV-2 are at nutrition risk that can impact outcome. Our data suggest that addressing nutritional adequacy can be one of the measures to reduce hospital LOS, and mortality among nutritionally risk patients.

Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors

Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.

Monitoring dialysis adequacy: history and current practice

Dialysis adequacy for pediatric patients has largely followed the trends in adult dialysis by judging the success or adequacy of peritoneal or hemodialysis with urea kinetic modeling. While this provides a starting point to establish a dose of dialysis, it is clear that urea is only part of the picture. Many clinical parameters and interventions now have been identified that are just as impactful on mortality and morbidly as urea clearance. As such, our concept of adequacy is evolving to include non-urea parameters and assessing the impact that following an "adequate therapy" has on patient lives. As we move to a new era, we consider the impact these therapies have on patients and how it affects the quality of their lives; we must take these factors into consideration to achieve a therapy that is not just adequate, but livable.

Hemodialysis (HD) dose and ultrafiltration rate are associated with survival in pediatric and adolescent patients on chronic HD-a large observational study with follow-up to young adult age

BACKGROUND

Hemodialysis (HD) dose targets and ultrafiltration rate (UFR) limits for pediatric patients on chronic HD are not known and are derived from adults (spKt/V>1.4 and <13 ml/kg/h). We aimed to characterize how delivered HD dose and UFR are associated with survival in a large cohort of patients who started HD in childhood.

METHODS

Retrospective analysis on a cohort of patients <30 years, on chronic HD since childhood (<19 years), having received thrice-weekly HD 2004-2016 in outpatient DaVita centers.

OUTCOME

Survival while remaining on HD.

PREDICTORS

(I) primary analysis: mean delivered dialysis dose stratified as spKt/V ≤1.4/1.4-1.6/>1.6 (Kaplan-Meier analysis), (II) secondary analyses: UFR and alternative dialysis adequacy measures [eKt/V, body-surface normalized Kt/BSA] on continuous scale (Weibull regression model).

RESULTS

A total of 1780 patients were included (age at the start of HD: 0-12y: n=321, >12-18y: n=1459; median spKt/V=1.55, eKt/V=1.31, Kt/BSA=31.2 L/m², UFR=10.6 mL/kg/h). (I) spKt/V<1.4 was associated with lower survival compared to spKt/V>1.4-1.6 (P<0.001, log-rank test), and spKt/V>1.6 (P<0.001), with 10-year survival of 69.3% (59.4-80.9%) versus 83.0% (76.8-89.8%) and 84.0% (79.6-88.5%), respectively. (II) Kt/BSA was a better predictor of survival than spKt/V or eKt/V. UFR was additionally associated with survival (P<0.001), with increased mortality <10/>18 mL/kg/h. Associations did not alter significantly following adjustment for demographic characteristics (age, etiology of kidney disease, and ethnicity).

CONCLUSIONS

Our results suggest usefulness of targeting Kt/BSA>30 L/m² for best long-term outcomes, corresponding to spKt/V>1.4 (>12 years) and >1.6 (<12 years). In contrast to adults, higher UFR of 10-18 ml/kg/h was not associated with greater mortality in this population.

Potential role of mobile rapid on-site evaluation® in thyroid fine-needle aspiration cytology to reduce delayed repeated aspiration

Rapid on-site evaluation of fine-needle aspiration cytology is time-consuming and requires specialized cytopathology staff. Mobile Rose^® is a newly developed device for rapid on-site evaluation of fine-needle aspiration cytology. This study aimed to investigate the potential role of Mobile Rose^® in reducing delayed repeated aspiration of the thyroid. A total of 120 cytological samples were collected and observed using Mobile Rose^® after fine-needle aspiration cytology between September and October 2020, with immediate assessment of minimal or no cell clusters after conventional smear preparation. After qualifying and scoring, needle washout materials were prepared using the BD CytoRich^TM method and correlated with cytology results. The average turn-around time of Mobile Rose^® was found to be 1.5 minutes. Sensitivity, specificity, positive predictive value, and negative predictive value were 94.4%, 100%, 100%, and 57.1%, respectively. False-negative results were attributed to small aggregates of cells that were difficult to distinguish from the background and artifacts. Mobile Rose^® may represent an important innovation for rapid on-site evaluation that is fast, has high diagnostic performance, does not require the presence of specialized cytology staff, and can reduce delayed repeated aspiration of the thyroid gland. However, further minor improvements and confirmation are required.

Inflammation and hemodialysis adequacy: Are C-reactive protein levels influenced by dialysis dose?

INTRODUCTION

Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" (Kt/V) with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the Kt/V using ionic dialysance.

METHODS

Multicenter cross-sectional study. A total of 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into 2 groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence.

RESULTS

Median CRP was 4.10mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48±0.308. Kt/V was lower in the patients included in the high inflammation group (P=.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log neutrophil-lymphocyte ratio (P<.001) and inversely proportional with serum albumin values (P=.014), Kt/V (P=.037) and serum iron (P<.001).

CONCLUSION

The poorer adequacy in terms of dialysis doses (lower Kt/V values) may contribute to a higher degree of inflammation in chronic hemodialysis patients.

Efficacy and Safety of Plastic Cannulae Compared with Metal Needles in the Initial Use of an Arteriovenous Fistulae in Incident Hemodialysis Patients: A Randomized Controlled Study

INTRODUCTION

Successful cannulation of an arteriovenous fistula (AVF) is important in patients starting hemodialysis (HD). Metal needles have been used for decades, but the usefulness of plastic cannulae has recently been demonstrated as a new technique.

METHODS

This was a prospective, randomized, open-label study of incident HD patients. Eligible patients were randomized into 2 groups in a 1:1 ratio (n = 45/group). Maturation of the AVF was confirmed using Doppler ultrasound prior to first needling, and 2 well-trained nurses implemented the AVF cannulation. The primary endpoint was the initial cannulation failure rate, defined as the failure of successful completion of 3 consecutive dialysis sessions. The secondary endpoints were time for hemostasis at the end of HD, degree of patients' pain, degree of cannulation difficulty felt by the nursing staffs, and achieving optimal HD adequacy.

RESULTS

The mean elapsed time from AVF creation to the first cannulation was 48.1 ± 16.7 days. A total of 17 cases of cannulation failure occurred, and the failure risk tended to be higher in the metal needle group than the plastic cannula group (hazard ratio 2.6, 95% confidence interval 0.95-7.41) after adjusting for age, gender, comorbidities, and AVF location. The overall incidence of vessel injury was higher and time for hemostasis was significantly longer in the metal group than the plastic group. The use of plastic cannula was associated with a better HD adequacy compared to a metal needle. However, the patients' pain score (p = 0.004) and nursing staff's cannulation difficulty score (p = 0.084) were higher in the plastic group, emphasizing the great importance of practice using plastic cannulae.

CONCLUSION

The vascular outcomes of plastic cannulae were much favorable compared to metal needles in incident HD patients. The use of plastic cannulae could be a new and innovative way to improve the quality of dialysis.

Adequacy of prenatal care services and associated factors in Southern Ethiopia

BACKGROUND

Prenatal care is an important component for the continuum of care in maternal and child health services. Despite increased attention on prenatal care service coverage, the adequacy of service provision has not been well addressed in Ethiopia. Therefore, this study aimed to describe the status of the adequacy of prenatal care and its associated factors in Southern Ethiopia.

METHOD

A longitudinal study done by the Performance care Monitoring and Accountability (PMA2020) project was used. The study was conducted from August 2016 to January 2017 in Southern Ethiopia. A multistage stratified cluster design in which all enumeration areas were randomly selected using probability proportional to size and all households were screened to identify 324 pregnant women of six or more months. Questions regarding early attendance of prenatal care, enough visits, and sufficient services were asked to measure the adequacy of prenatal care. Finally, an ordered logistic regression analysis was employed to assess factors associated with the adequacy of prenatal care services.

RESULTS

Of the total pregnant women 44.21 % attended enough visits, 84.10 % had early visits, and 42.03 % received sufficient services. The women residing in urban areas had 2.35 odds of having adequate prenatal care in reference to rural areas (adjusted odds ratio (aOR) 2.35 [95 % CI 1.05-5.31]). Women who attended primary and secondary education had 2.42(aOR 2.42 [95 % C.I. 1.04, 5.65]), and 4.18 (aOR 4.18 [95 % CI 1.32, 13.29]) odds of adequate prenatal care in reference with those who never attended education respectively. The women participating in one to five networks have 2.18 odds of adequate prenatal care in reference to their counterparts (aOR 2.78 [95 % CI 1.01, 7.71]).

CONCLUSIONS

The adequacy of prenatal care services in Southern Ethiopia is very low. The Ethiopian health care system should strengthen one to five networks to discuss on family health issues. Further research, should validate the tools and measure the adequacy of the services in different contexts of Ethiopia using a mixed method study for an in-depth understanding of the problem.

Improvement of Pediatric Liver Core Biopsy Adequacy by Reducing Laboratory-Related Tissue Fragmentation and Increasing Portal Tract Yield

OBJECTIVES

We aimed to identify potential laboratory causes of suboptimal liver biopsy quality and sought to implement corresponding measures to improve biopsy adequacy.

METHODS

We prospectively measured the number and size of tissue fragments and the amount of portal tracts in 200 consecutive pediatric medical liver biopsies before and after quality improvement processes were initiated.

RESULTS

We identified laboratory-related tissue fragmentation as a significant cause of low biopsy adequacy. The principal approaches to reduce fragmentation included establishment of multistep monitoring of tissue integrity, adjustment of specimen-processing conditions, and laboratory staff education and awareness. These adjustments collectively led to lower overall tissue fragmentation (decreasing from 59% to 24%, P < .01) and higher biopsy adequacy rates (increasing from 32% to 56%, P < .01). The number of evaluable portal tracts increased from 4.4 to 5.7 portal tracts per centimeter of core biopsy tissue (P < .01).

CONCLUSIONS

We demonstrated a sustainable improvement in the overall quality of pediatric needle core liver biopsies by reducing tissue fragmentation. Effective laboratory adjustments included monitoring of tissue integrity, modifications of processing conditions, and laboratory staff education.

Predialytic versus Intradialytic Nutrition: A Study to Assess Effects on Intradialytic Blood Pressure, Dialysis Adequacy, and Urea Removal

BACKGROUND

Provision of oral protein in hemodialysis (HD) is desirable due to improved compliance to protein requirements and better nutritional status, but the risks of hypotension and underdialysis need to be considered. This study compared 2 different timings for administering oral nutritional supplements (ONS), predialysis and mid-dialysis, with respect to hemodynamics, dialysis adequacy, urea removal, and tolerability.

METHODS

This single-center, prospective crossover study analyzed 72 stable patients with ESRD on twice a week maintenance HD with a mean age of 38.7 (±11.2) years and a dialysis vintage of 28.2 (±13.1) months. In the first week, all the patients received ONS (450 kcal energy, 20 g protein) 1 h prior to start of dialysis (group 1) and in the next week, the supplement was administered after 2 h of start of dialysis (group 2), with a predialysis fasting period of at least 3 h in both groups. Blood pressures, serum, and spent dialysate samples were collected and nausea occurrence was noted by severity.

RESULTS

Predialytic intake (group 1) was associated with higher predialysis and 1st hour blood urea, dialysis adequacy, and urea removal than group 2. Both groups achieved mean Kt/V > 1.2, and the occurrence of symptomatic hypotensive episodes and nausea was not significantly different between the groups. On repeated measures ANOVA, changes in blood urea over time showed significant group effect.

CONCLUSIONS

Predialytic supplementation was associated with better dialysis adequacy and urea removal than intradialytic supplementation. However, both timings were equally tolerated and not associated with underdialysis.

Percutaneous Renal Biopsy Using an 18-Gauge Automated Needle Is Not Optimal

BACKGROUND

As percutaneous renal biopsies (PRBs) are increasingly performed by radiologists, an increase in the use of 18-gauge automated needle stands to compromise adequacy. We compare the adequacy and safety of PRB with 14-, 16-, and 18-gauge automated needles.

METHODS

PRB of native (N-592) and transplant (T-1,023) kidneys was performed from January 2002 to December 2019 using real-time ultrasound. Baseline clinical and laboratory data, biopsy data (number of cores, total glomeruli, and total glomeruli per core), and outcome (hematoma on renal US at 1-h, complications, and transfusion) were collected prospectively. PRB with N14g (337) versus N16g (255) and T16g (892) versus T18g (131) needles were compared. A p value of <0.05 was significant.

RESULTS

PRB with an 18-g needle yielded the lowest number of total glomeruli per biopsy (N14g vs. N16g: 33 ± 13 vs. 29 ± 12, p < 0.01 and T16g vs. T18g: 34 ± 16 vs. 21 ± 11, p < 0.0001), significantly fewer total glomeruli per core (T16g vs. T18g: 12.7 ± 6.4 vs. 9.6 ± 5.0, p < 0.001 and N16g vs. T18g: 14.2 ± 6.3 vs. 9.6 ± 5.0, p < 0.001). A hematoma by renal US 1-h post-PRB was similar for native (14g-35% vs. 16g-29%, p = 0.2), and transplant biopsies (16g-10% vs. 18g-9%, p = 0.9) and the complication rate for native (14g-8.9% vs. 16g-7.1%, p = 0.5), transplant biopsies (16g-4.6% vs. 18g-1.5%, p = 0.2) and transfusion rate for native (14g-7.7% vs. 16g-5.8%, p = 0.4), and transplant biopsies (16g-3.8% vs. 18g-0.8%, p = 0.1) were similar irrespective of needle size.

CONCLUSIONS

PRB of native and transplant kidneys with the use of a 16-gauge needle provides an optimal sample. However, our experience in transplant biopsies suggests the use of an 18-gauge needle stands to jeopardize the diagnostic accuracy of the PRB while not improving safety.

A Comparative Study of 22G versus 19G Needles for EUS-Guided Biopsies for Parenchymal Liver Disease: Are Thinner Needles Better?

BACKGROUND AND AIMS

Data on comparative efficacy of various available endoscopic ultrasound-guided liver biopsy (EUS-LB) needles are limited. We sought to compare the performance of a novel Franseen-tip 22G fine-needle biopsy (FNB) device to that of 19G needle platforms for liver parenchyma.

METHODS

Consecutive patients referred for EUS and suspected to have hepatic parenchymal disease underwent EUS-LB using different EUS needles and were included in this retrospective study. Two blinded expert liver pathologists independently reviewed and reported on: total number of tissue fragments, length of longest fragment, number of complete and incomplete portal tracts (CPT and IPT), and specimen adequacy.

RESULTS

A 22G Franseen-tip needle (A) was used in 30 patients; 19G Tru-Cut needle (B) in 50 patients; 19G reverse beveled non-Tru-Cut needle (C) in 27 patients; and a 19G flexible non-Tru-Cut needle (D) in 28 patients. In the order of needles, A, B, C and D,  > 10 tissue fragments were obtained in 100%, 6%, 82%, and 96% samples, the mean number of CPTs was 6.9; 3.0; 7.3; and 16.9, length of longest fragment was 3.8, 4. 7, 3.9, and 8.4 mm, and specimen adequacy was 66.7%, 46%, 82.1%, and 81.5%, respectively. A positive correlation was obtained between number of CPTs and length of longest fragment in samples accrued by 19G needles.

CONCLUSION

EUS-LB specimens using 22G Franseen-tip needle appear highly fragmented, leading to inferior specimen adequacy compared to 19G non-Tru-Cut needles. We also report on using length of longest fragment as an additional criterion for specimen adequacy as it positively correlates with number of CPTs standard.

Impacts of dialysis adequacy and intradialytic hypotension on changes in dialysis recovery time

Background

Dialysis recovery time (DRT) surveys capture the perceived time after HD to return to performing regular activities. Prior studies suggest the majority of HD patients report a DRT > 2 h. However, the profiles of and modifiable dialysis practices associated with changes in DRT relative to the start of dialysis are unknown. We hypothesized hemodialysis (HD) dose and rates of intradialytic hypotension (IDH) would associate with changes in DRT in the first years after initiating dialysis.

Methods

We analyzed data from adult HD patients who responded to a DRT survey ≤180 days from first date of dialysis (FDD) during 2014 to 2017. DRT survey was administered with annual KDQOL survey. DRT survey asks: “How long does it take you to be able to return to your normal activities after your dialysis treatment?” Answers are: < 0.5, 0.5-to-1, 1-to-2, 2-to-4, or > 4 h. An adjusted logistic regression model computed odds ratio for a change to a longer DRT (increase above DRT > 2 h) in reference to a change to a shorter DRT (decrease below DRT < 2 h, or from DRT > 4 h). Changes in DRT were calculated from incident (≤180 days FDD) to first prevalent (> 365-to- ≤ 545 days FDD) and second prevalent (> 730-to- ≤ 910 days FDD) years.

Results

Among 98,616 incident HD patients (age 62.6 ± 14.4 years, 57.8% male) who responded to DRT survey, a higher spKt/V in the incident period was associated with 13.5% (OR = 0.865; 95%CI 0.801-to-0.935) lower risk of a change to a longer DRT in the first-prevalent year. A higher number of HD treatments with IDH episodes per month in the incident period was associated with a 0.8% (OR = 1.008; 95%CI 1.001-to-1.015) and 1.6% (OR = 1.016; 95%CI 1.006-to-1.027) higher probability of a change to a longer DRT in the first- and second-prevalent years, respectively. Consistently, an increased in incidence of IDH episodes/months was associated to a change to a longer DRT over time.

Conclusions

Incident patients who had higher spKt/V and less sessions with IDH episodes had a lower likelihood of changing to a longer DRT in first year of HD. Dose optimization strategies with cardiac stability in fluid removal should be tested.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-020-02187-9.

16-gauge needles in native kidneys in Chinese individuals

BACKGROUND

Percutaneous renal biopsy (PRB) is the primary biopsy technique and it was used by 16G needles or 18G needles in China, but there is controversy about the effect and safety of the two different diameters. The study aims to compare the adequacy, complication rate and pathological classification when using 18G vs. 16G needles to perform renal biopsy with ultrasound-guidedance on native kidneys in Chinese individuals.

METHODS

We retrospectively analyzed the number of glomeruli, adequate sample rates, complication rates and pathological classification in 270 patients with the use of 18G or 16G needles from January 2011 to May 2017 and verified whether the needle gauge affected the disease diagnosis.

RESULTS

A total of 270 kidney biopsies were performed. Among them,72 were performed with 18G needles, and 198 were performed with 16G needles. There was no difference in the number of glomeruli under light microscope using 18G relative to 16G needles (24 ± 11 vs. 25 ± 11, p = 0.265), whereas more glomeruli were found in the 16G group than in the 16G group using immunofluorescence microscopy (3 ± 2 vs. 5 ± 3, p < 0.05). There was no significant difference in the adequate sample rates between the 18G group and the 16G group (90.28% vs. 93.94%, p = 0.298). Minor complications including the incidence of lumbar or abdominal pain (4.17% vs. 7.07%, p = 0.57), gross hematuria (4.17% vs. 3.54%, p = 0.729), and perinephric hematoma without symptoms (4.17% vs. 1.52%, p = 0.195), were not significantly different between the 18G and 16G groups. In the 16G group, 2 cases of serious complications occurred: severe gross hematuria requiring blood transfusion and retroperitoneal hematoma requiring surgery. No serious complications were observed in the 18G group, although there was no significant difference in serious complications rates between the 18G and 16G groups (0% vs. 1.02%, p = 1).

CONCLUSION

There was no significant difference in the number of glomeruli, adequate sample rates, or complication rates when using 18G or 16G needles to perform renal biopsy, and the use of an 18G needle with a smaller diameter did not affect the pathological diagnosis or classification of IgA nephropathy and lupus nephritis.

Importance of non-medical reasons for dropout in patients on peritoneal dialysis

BACKGROUND

To describe the associated factors for non-medical reasons for dropout in peritoneal dialysis (PD) patients.

METHODS

A retrospective cohort study was performed using registry data of adult patients commencing PD as their initial renal replacement therapy in one hospital-facilitated PD center in Taiwan between 2014 and 2018. The collected data included socio-demographics and relevant medical and PD-related parameters. Kaplan-Meier analysis was used to determine the impact of non-medical reasons and medical reasons on PD dropout.

RESULTS

The analysis included 224 PD patients, of whom 37 dropped out for non-medical reasons and 187 for medical reasons during the study period. There was significant difference between the two cohorts in age (62.3 years vs. 56.1 years, P = 0.010) and PD vintage (median 3.4 years vs. 4.8 years, P = 0.001). Diabetes was more predominant in the cohort for non-medical reasons than in the one for medical reasons (54.1% vs. 27.3% respectively, P = 0.001). In non-medical reason cohort, two leading reasons given for dropping out were lacking of caregivers (n = 12) and losing confidence (n = 10), whereas PD-related peritonitis (n = 101) was the main medical reason for PD dropout. Using Kaplan-Meier curve analysis, patients in the non-medical reason cohort demonstrated higher cumulative dropout rate compared to patients in the medical reason cohort during a 10-year period (P < 0.001).

CONCLUSIONS

The main characteristics of PD dropout patients for non-medical reasons are age, diabetes, patients' perception and caregiver support.

2005 Guidelines on targets for solute and fluid removal in adults being treated with chronic peritoneal dialysis: 2019 Update of the literature and revision of recommendations

BACKGROUND

The International Society for Peritoneal Dialysis guidelines for small solute clearance and fluid removal in peritoneal dialysis (PD) were published in 2005. The aim of this article is to update those guidelines by reviewing the literature that supported those guidelines and examining publications since then.

METHODS

An extensive search of publications was performed through electronic databases and a hand search through reference lists from the existing guideline and selected articles.

RESULTS

There have been no prospective intervention trials to inform the area of small solute clearance in PD since the publication of the original guideline in 2005. The trials to date are largely limited to a few prospective cohort studies and retrospective studies. These have, however, consistently demonstrated that residual renal function (RRF) is more often associated with patient outcome than peritoneal clearance. One of the few randomised controlled trials performed in this area does suggest that a weekly Kt/V of 2.27 ± 0.02 provides no statistically significant survival advantage over a weekly Kt/V of 1.80 ± 0.02. The lower limit of Kt/V is unknown but there is weak evidence to suggest that anuric people doing PD should have a weekly Kt/V of at least 1.7.

CONCLUSIONS

There continues to be very poor evidence in the area of small solute clearance and fluid removal in PD. The evidence that exists suggests that RRF is more important than peritoneal clearance and that there appears to be no survival advantage in aiming for a weekly Kt/V >1.70.

Plasma pseudouridine levels reflect body size in children on hemodialysis

BACKGROUND

Dialysis in children as well as adults is prescribed to achieve a target spKt/V_urea, where V_urea is the volume of distribution of urea. Waste solute production may however be more closely correlated with body surface area (BSA) than V_urea which rises in proportion with body weight. Plasma levels of waste solutes may thus be higher in smaller patients when targeting spKt/V_urea since they have higher BSA relative to body weight. This study measured levels of pseudouridine (PU), a novel marker solute whose production is closely proportional to BSA, to test whether prescription of dialysis to a target spKt/V_urea results in higher plasma levels of PU in smaller children.

METHODS

PU and urea nitrogen (ureaN) were measured in plasma and dialysate at the midweek hemodialysis session in 20 pediatric patients, with BSA ranging from 0.65-1.87m². Mathematical modeling was employed to estimate solute production rates and average plasma solute levels.

RESULTS

The dialytic clearance (K_d) of PU was proportional to that of ureaN (average K_dPU/K_dUreaN 0.69 ± 0.13, r² 0.84, p < 0.001). Production of PU rose in proportion with BSA (r² 0.57, p < 0.001). The pretreatment plasma level of PU was significantly higher in smaller children (r² 0.20, p = 0.051) while the pretreatment level of ureaN did not vary with size.

CONCLUSIONS

Prescribing dialysis based on urea kinetics may leave uremic solutes at higher levels in small children. Measurement of a solute produced proportional to BSA may provide a better index of dialysis adequacy than measurement of urea.

Oxidative Stress in Peritoneal Dialysis Patients: Association with the Dialysis Adequacy and Technique Survival

Introduction:

Increased oxidative stress is suggested as one of the possible mechanisms of structural and functional damage to the peritoneal membrane in peritoneal dialysis patients. But there are few available data on the association of oxidative stress with peritoneal dialysis adequacy and technique survival. The present study was undertaken to investigate the association of oxidative stress biomarkers with the peritoneal dialysis adequacy and technique survival.

Methods:

This prospective single-center observational study was conducted between January 2010 and May 2015. Adequacy of dialysis, malondialdehyde levels in the serum and erythrocytes (as an indicator of lipid peroxidation), the concentration of ceruloplasmin, transferrin, and sulfhydryl groups in the blood, and total peroxidase activity in erythrocyte (as indicators of antioxidant system) were determined in 44 stable ambulatory non-diabetic peritoneal dialysis patients.

Results:

The follow-up period was 3 years. We identified a negative correlation between the serum level of malondialdehyde in the patients and total weekly Kt/V. Peritoneal weekly CrCl was positively correlated with the levels of transferrin, total peroxidase activity, and SH– groups. Daily peritoneal ultrafiltration had a positive correlation with the total peroxidase activity and the serum transferrin levels. The results of the Kaplan–Meier analysis and the log-rank test also demonstrated a significant difference in the cumulative technique survival rate between the patients with ceruloplasmin level ≤0.19 g/l and ≥0.2 g/l.

Conclusions:

The results mentioned above could be considered as one of the ways to explain better technique survival in PD patients.

This 'Rose' Has no Thorns-Diagnostic Utility of 'Rapid On-Site Evaluation' (ROSE) in Fine Needle Aspiration Cytology

Fine needle aspiration (FNA) cytology is a basic diagnostic technique used to investigate superficial and deep swellings. Rapid on-site evaluation (ROSE) using toluidine blue (TB) is easily available, cheap, cost-effective, can be used both for testing adequacy and giving provisional diagnosis. To evaluate the role of ROSE using toluidine blue staining in arriving at a diagnosis in comparison to routine stains. A total of 1500 cases of FNA of palpable swellings from sites like salivary gland, breast, thyroid, lymph node, and soft tissue lesions [non-image guided] during a 9-month period were studied. All the cases were evaluated by ROSE using toluidine blue stain and routine Giemsa/PAP staining. The results were compared in each case. Only 2% cases proved inadequate on TB, Giemsa and PAP combination, commonest site of inadequacy being lymph node. Adequate sample was obtained within two passes in 92.5% cases. The turn-around time (TAT) was 1 day in 96.4% of cases. The average time for making a provisional diagnosis on TB was 3 minutes. There was 99.2% concordance between TB and final cyto-diagnosis. Validity parameters: sensitivity 98%, specificity 100%, positive predictive value 100%, negative predictive value 99.8%, efficacy 99.2% and false negative 1.94%. ROSE using toluidine blue is a reliable means of demonstrating sample adequacy, for making a provisional diagnosis and guiding collection of diagnostic material for microbiology, immunocytochemistry (ICC), cell block and molecular testing etc. The technique is easy enough for general laboratories to incorporate into their routine practice. ROSE can be called as the "frozen section of cytology".

Fluoroscopy Guided Percutaneous Transpedicular Biopsy of Vertebral Body Lesion

BACKGROUND

The common causes of vertebral body lesion are metastasis, infection, primary malignancies or osteoporotic fractures. Histopathological examination is necessary to confirm the diagnosis. There are different approaches to collect the biopsy samples and they have different adequacy and accuracy rates and also possible complications. This study aims to determine adequacy, accuracy and safety of the fluoroscopy guided percutaneous transpedicular biopsy of the vertebral body lesion.

METHODS

This is retrospective review of all the patients who underwent fluoroscopy guided percutaneous transpedicular biopsy from January 2013 to October 2016. We reviewed medical records and biopsy reports, plain radiographs, Computed Tomography Scan and Magnetic Resonance Imaging and additional necessary investigations required to confirm the diagnosis.

RESULTS

Fifty two patients underwent fluoroscopy guided percutaneous transpedicular biopsy of vertebral body lesion in 55 different levels. Thirty six patients were male and 16 were female with mean age of 54.17 years (range 2-87 years). This procedure was performed in 55 levels from D3 to S1. The adequate sample was retrieved from 50 samples in 47 cases (90.9%). The diagnosis was confirmed by histopathological examination from41 samples in 38 cases (82%). In three cases the histopathology was inconclusive but microbiological investigation of tissue sample confirmed the diagnosis. So in total 44 samples from 41 cases (80%), the diagnosis was confirmed by the procedure. We did not encounter any complications during the procedure.

CONCLUSIONS

Fluoroscopy guided percutaneous transpedicular biopsy is a safe minimally invasive procedure with high adequacy and accuracy rate.

Ultrasound-Guided Transthoracic Fine-Needle Aspiration: A Reliable Tool in Diagnosis and Molecular Profiling of Lung Masses

INTRODUCTION

Pulmonary adenocarcinoma is a major cause of mortality worldwide. The majority of patients present with advanced stage disease, and minimally invasive procedures are desirable for diagnosis and treatment plans. Herein, we report our experience with percutaneous/transthoracic needle aspiration (TT-NA) in the cytologic diagnosis of pulmonary adenocarcinoma.

MATERIAL AND METHODS

After institutional review board approval, the cytopathology electronic data system was searched for all consecutive TT-NA of the lung masses from January 2011 to November 2015. Patients' medical records were reviewed and cytologic materials were evaluated.

RESULTS

A total of 151 specimens were identified, with a mean age of 62.8 years; 62.9% of the patients had a prior history of malignancy. Carcinoma/adenocarcinoma was the most common (80%) diagnosis. The targeted lesions were predominantly located in the lung (56.3%, 81/151) and pleural based (27.8%, 42/151). The mean size of the lesions was 3.6 cm. Cytology specimens were adequate in 70.9% of the cases, while 72.8% (110/151) of the cases also had concurrent core biopsy. A malignant diagnosis was rendered in the majority of the cases (64.9%). In 71% of the cases, immunohistochemistry/histochemistry studies were successfully performed. Molecular/genetic studies were requested in 80% of the cases and had adequate material. Complications of the procedure were seen in 9.9% of the patients including pneumothorax (7.9%) and hemoptysis (1.9%).

CONCLUSION

TT-NA is a relatively safe and reliable technique in the assessment of pulmonary lesions.

Adequacy of Lymph Node Yield for Papillary Thyroid Cancer: An Analysis of 23,131 Patients

BACKGROUND

Threshold numbers for defining adequacy of lymph node (LN) yield have been determined for evaluation of occult nodal disease during papillary thyroid cancer (PTC) surgery. This study assesses the prevalence of adequate LN yield and estimates its association with patient clinicopathologic characteristics.

MATERIALS AND METHODS

Adult patients with cN1 pT1b or pT2 and cN0 or cN1 pT3 M0 PTC ≥1 cm who received surgery with ≥1 LN resected were identified from the National Cancer Database, 2004-2015. Adequate yield was defined as removing ≥6, 9, and 18 LNs for pT1b, pT2, and pT3 stages, respectively, based on recently published literature. Univariable and multivariable logistic regression were used to determine factors associated with adequate yield.

RESULTS

A total of 23,131 patients were included; 7544 (32.6%) had adequate LN yield. Rate of adequate yield increased from 19.9% to 36.6% over time. After adjustment, patients at academic facilities were more likely to have adequate yield than those at community centers [OR 1.94 (95% CI 1.55-2.41), P < 0.001]. Patients with more advanced tumors were less likely to have adequate yield (pT1b: 75.9% versus pT2: 64.5% versus pT3: 24.6% adequate LN yield, P < 0.001). Patients with adequate LN yield were 0.89 times likely to receive radioactive iodine compared with those with inadequate yield [OR 0.98 (95% CI 0.81-0.98), P = 0.02].

CONCLUSIONS

The rate of adequate LN yield has increased over time, but only a minority of lymphadenectomies performed for PTC can be defined as adequate. Disparities still exist based on patient and facility characteristics; patients with more advanced tumors appear less likely to have adequate LN yield.

Periendoscopic management of antiplatelet therapy: Prospective evaluation of adherence to guidelines

INTRODUCCIóN: Adherence to guidelines on the periendoscopic management of antiplatelet therapy (APT) has not been analyzed in detail. Our aim was to assess adherence to guidelines in patients referred to our Endoscopy Unit on a case-by-case basis, describing in detail the detected deviations and identifying areas of improvement.

PATIENTS AND METHODS

Cross-sectional study of outpatients consecutively scheduled for an unsedated upper or lower gastrointestinal endoscopy between January and June 2015. Patients on anticoagulant therapy were excluded.

RESULTS

675 patients were evaluated, including 91 (13.5%) patients on APT [upper GI endoscopy 25 (27.5%), lower GI endoscopy 66 (72.5%)]. Contrary to the clinical guidelines, aspirin was discontinued in 25 of the 77 patients previously prescribed the drug (32.5%) but this modification was patient's own decision in 11 cases. Most of the apparent deviations in the management of clopidogrel and dual antiplatelet therapy (DAPT) were not true non-adherence cases. The Primary Care physician modified an APT prescribed by another physician in 8 of 9 cases (88.9%), always in cases with aspirin. No relationship was found between the endoscopic procedure's predicted risk of bleeding or the patient's thrombotic risk and modification of therapy.

DISCUSSION

In many patients, the peri-procedural management of APT goes against current guidelines, but some of these inconsistencies cannot be considered true deviations from practice. Identified areas for improvement are increasing patient awareness about APT, disseminating the guidelines in Primary Care, and underscoring the significance of thrombotic risk related to APT withdrawal.

Urea reduction ratio may be a simpler approach for measurement of adequacy of intermittent hemodialysis in acute kidney injury

BACKGROUND

Assessment of adequacy of intermittent hemodialysis (IHD) is conventionally based upon urea kinetic models for calculation of single pool Kt/V_urea (Kt/V), with 1.2 accepted as minimum adequate clearance for thrice weekly IHD. In the Acute Renal Failure Trial Network (ATN) Study, adequacy of IHD in patients with acute kidney injury (AKI) was assessed using Kt/V. However, equations for Kt/V require volume of distribution of urea, which is highly variable in AKI. Therefore, simpler methods are needed to assess adequacy of IHD in AKI. We assessed correlation of urea reduction ratio (URR) with Kt/V and determined URR thresholds corresponding to Kt/V values to determine if URR could be a simpler means to assess the delivered dose of IHD.

METHODS

Using patients who received IHD for 2.5-6 h and with pre-dialysis BUN ≥20 mg/dL, we plotted URR against Kt/V. We determined URR thresholds (0.60 to 0.75) corresponding to Kt/V ≥ 1.2, 1.3, and 1.4. We generated receiver operating characteristic (ROC) curves for increasing URR values for each level of Kt/V to identify the corresponding thresholds of URR.

RESULTS

There was strong correlation between URR and Kt/V. ROC curves comparing URR with Kt/V ≥ 1.2, 1.3, and 1.4 had area under the curves (AUC) of 0.99. Sensitivity and specificity of URR ≥0.67 for corresponding values of Kt/V ≥ 1.2 were 0.769 (95% CI: 0.745 to 0.793) and 0.999 (95% CI: 0.997 to 1.000), respectively and the sensitivity and specificity of URR ≥0.67 for corresponding values of Kt/V ≥ 1.4 were 0.998 (95% CI: 0.995 to 1.000) and 0.791 (95% CI: 0.771 to 0.811), respectively.

CONCLUSIONS

Targeting a URR ≥0.67 provides a simplified means of assessing adequacy of IHD in patients with AKI. Use of URR will enhance ability to assess delivery of small solute clearance and improve adherence with clinical practice guidelines in AKI.

Determination of appropriate urine volume cutoff values for voided urine specimens to assess adequacy

INTRODUCTION

Incorporating urine volume into adequacy assessment was recommended by The Paris System for Reporting Urinary Cytology. The concept was relatively new, however, and supportive studies were sparse. We accordingly aimed to determine the role of urine volume in adequacy assessment and cutoff values for urine samples using ThinPrep (Hologic, Inc, MA) processing.

MATERIAL AND METHODS

Archived consecutive urine cytology cases (n = 2117) were analyzed. Patient age, sex, collection method, urine volume and fixative (CytoLyt, Hologic, Inc) added, adequacy and diagnoses were documented. Adequate samples were defined as samples with >50 well-preserved, well-visualized urothelial cells. Diagnoses of suspicious and positive for high-grade urothelial carcinoma were combined for analysis. Statistical analysis was performed using IBM SPSS Statistics for Windows.

RESULTS

There was a correlation between urine volume and the unsatisfactory/less than optimal cellularity versus satisfactory samples (P ≤ 0.001) in voided urine specimens. A minimum of 10 mL of fresh voided urine was found to be a reasonable cutoff to achieve sufficient cellularity. Cutoff values of 30 mL for voided urine for the high-risk diagnosis were associated with the highest χ² statistic, although this was not statistically significant.

CONCLUSIONS

Urine volume was justified as an adequacy criterion in voided urine. Although 10 mL of fresh voided urine might achieve sufficient cellularity, higher volume (≥30 mL) is recommended in order to maximize the chance of detecting a high-risk diagnosis. Nevertheless, the presence of high-grade urothelial carcinoma can still be detected in low-volume (<20 mL) specimens. Hence, correlation of clinical information with voided urine volume cutoff values for individual cases might also be beneficial.

A new technique for low-volume continuous sampling of spent dialysate: a validation study

The measure of hemodialysis (HD) adequacy recommended nowadays by most guidelines, Kt/V-urea, presents significant drawbacks. Direct dialysis quantification (DDQ) through total dialysate collection (TDC), considered the gold standard measure of HD adequacy, is cumbersome, which precludes its widespread use in clinical practice. The present study aims to validate a low-volume continuous sampling of spent dialysate (CSSD). Cross-sectional study carried out at a university hospital. Throughout 4-h hemodialysis sessions, urea removal was measured by three DDQ methods: TDC, CSSD, and fractional sampling of dialysate (FSD). The primary outcome was the comparison between the total mass of urea removed measured by TDC and the dialysate sampling techniques. The comparison between urea distribution volume (UDV) estimated by anthropometric method and through DDQ was a secondary outcome. The analysis was done through linear regression and Bland-Altman concordance method. Twenty HD sessions were studied. The mean amount of urea collected in TDC and calculated from the 40-mL sample of CSSD were 33.70 ± 11.70 g and 33.90 ± 11.70 g, respectively [r 0.96, p < 0.0001; bias - 0.2 (95% CI - 1.8 to 1.4); limits of agreement - 6.8 to 6.4]. The anthropometric measure, when compared with DDQ method, underestimated UDV in patients with smaller body size. This new simple, inexpensive, and small volume CSSD technique can provide accurate information about the total amount of solutes removed by hemodialysis.

Assessment of dialysis adequacy: beyond urea kinetic measurements

Adequacy of dialysis is a term that has been used for many years based on measurement of small solute clearance using urea and creatinine. This has been shown in some but not all studies in adults to correlate with survival. However, small solute clearance is just one minor part of the effectiveness of dialysis and in fact 'optimum' dialysis, rather than 'adequate' dialysis is what most paediatric nephrologists would want for their patients. Additional ways to assess the success of dialysis in children would include dialysis access complications and longevity, preservation of residual kidney function, body composition, biochemical and haematological control, nutrition and growth, discomfort during the dialysis process and psychosocial adjustment including hospitalisation and school attendance. These criteria need to be balanced against a dialysis programme that has the least possible adverse effects on quality of life.

A need for a paradigm shift in focus: From Kt/Vurea to appropriate removal of sodium (the ignored uremic toxin)

Hemodialysis for chronic renal failure was introduced and developed in Seattle, WA, in the 1960s. Using Kiil dialyzers, weekly dialysis time and frequency were established to be about 30 hours on 3 time weekly dialysis. This dialysis time and frequency was associated with 10% yearly mortality in the United States in 1970s. Later in 1970s, newer and more efficient dialyzers were developed and it was felt that dialysis time could be shortened. An additional incentive to shorten dialysis was felt to be lower cost and higher convenience. Additional support for shortening dialysis time was provided by a randomized prospective trial performed by National Cooperative Dialysis Study (NCDS). This study committed a Type II statistical error rejecting the time of dialysis as an important factor in determining the quality of dialysis. This study also provided the basis for the establishment of the Kt/V_urea index as a measure of dialysis adequacy. This index having been established in a sacrosanct randomized controlled trial (RCT), was readily accepted by the HD community, and led to shorter dialysis, and higher mortality in the United States. Kt/V_urea is a poor measure of dialysis quality because it combines three unrelated variables into a single formula. These variables influence the clinical status of the patient independent of each other. It is impossible to compensate short dialysis duration (t) with the increased clearance of urea (K), because the tolerance of ultrafiltration depends on the plasma-refilling rate, which has nothing in common with urea clearance. Later, another RCT (the HEMO study) committed a Type III statistical error by asking the wrong research question, thus not yielding any valuable results. Fortunately, it did not lead to deterioration of dialysis outcomes in the United States. The third RCT in this field ("in-center hemodialysis 6 times per week versus 3 times per week") did not bring forth any valuable results, but at least confirmed what was already known. The fourth such trial ("The effects of frequent nocturnal home hemodialysis") too did not show any positive results primarily due to significant subject recruitment issues leading to inappropriate selection of patients. Comparison of the value of peritoneal dialysis and HD in RCTs could not be completed because of recruitment problems. Randomized controlled trials have therefore failed to yield any meaningful information in the area of dose and or frequency of hemodialysis.

Home hemodialysis treatment and outcomes: retrospective analysis of the Knowledge to Improve Home Dialysis Network in Europe (KIHDNEy) cohort

Background

Utilization of home hemodialysis (HHD) is low in Europe. The Knowledge to Improve Home Dialysis Network in Europe (KIHDNEy) is a multi-center study of HHD patients who have used a transportable hemodialysis machine that employs a low volume of lactate-buffered, ultrapure dialysate per session. In this retrospective cohort analysis, we describe patient factors, HHD prescription factors, and biochemistry and medication use during the first 6 months of HHD and rates of clinical outcomes thereafter.

Methods

Using a standardized digital form, we recorded data from 7 centers in 4 Western European countries. We retained patients who completed ≥6 months of HHD. We summarized patient and HHD prescription factors with descriptive statistics and used mixed modeling to assess trends in biochemistry and medication use. We also estimated long-term rates of kidney transplant and death.

Results

We identified 129 HHD patients; 104 (81%) were followed for ≥6 months. Mean age was 49 years and 66% were male. Over 70% of patients were prescribed 6 sessions per week, and the mean treatment duration was 15.0 h per week. Median HHD training duration was 2.5 weeks. Mean standard Kt/V_urea was nearly 2.7 at months 3 and 6. Pre-dialysis biochemistry was generally stable. Between baseline and month 6, mean serum bicarbonate increased from 23.1 to 24.1 mmol/L (P = 0.01), mean serum albumin increased from 36.8 to 37.8 g/L (P = 0.03), mean serum C-reactive protein increased from 7.3 to 12.4 mg/L (P = 0.05), and mean serum potassium decreased from 4.80 to 4.59 mmol/L (P = 0.01). Regarding medication use, the mean number of antihypertensive medications fell from 1.46 agents per day at HHD initiation to 1.01 agents per day at 6 months (P < 0.001), but phosphate binder use and erythropoiesis-stimulating agent dose were stable. Long-term rates of kidney transplant and death were 15.3 and 5.4 events per 100 patient-years, respectively.

Conclusions

Intensive HHD with low-flow dialysate delivers adequate urea clearance and good biochemical outcomes in Western European patients. Intensive HHD coincided with a large decrease in antihypertensive medication use. With relatively rapid training, HHD should be considered in more patients.