Strategies to prevent SARS-CoV-2 transmission in hemodialysis centres across Europe - Lessons for the future

Background

Early reports on the pandemic nature of COVID-19 directed the nephrology community to develop infection prevention and control guidance. We aimed to make an inventory of strategies that dialysis centres followed to prevent infection with COVID-19 in the first pandemic wave.

Methods

We analyzed IPC measures taken by hemodialysis centres treating patients presenting with COVID-19 between March 1, 2020 and July 31, 2020 and that completed the European Renal Association COVID-19 Database centre questionnaire. Additionally, we made an inventory of guidelines published in European countries to prevent spread of SARS-CoV-2 in dialysis centres.

Results

Data from 73 dialysis units located in and bordering Europe were analyzed. All participating centres implemented IPC measures to mitigate the impact of SARS-CoV-2 during the first pandemic wave. Measures mentioned most often included triage with questions before entering the dialysis ward, measuring body temperature, hand disinfection, masking for all patients and staff, and personal protective equipment for staff members. These measures were also recommended in most of the 14 guidelines that were identified in the inventory of national guidelines and were also scored as being among the most important measures by the authors of this paper. Heterogeneity existed between centres and national guidelines regarding the minimal distance between dialysis chairs and recommendations regarding isolation and cohorting.

Conclusions

Although variation existed, measures to prevent transmission of SARS-CoV-2 were relatively similar across centres and national guidelines. Further research is needed to assess causal relationships between measures taken and spread of SARS-CoV-2.

Dupilumab for the treatment of atopic dermatitis: Real-world data from the Czech Republic BIOREP registry

BACKGROUND

Dupilumab has been approved to treat moderate-to-severe atopic dermatitis; however, the data in a real-world setting are still limited.

OBJECTIVE

To analyze the effectiveness and safety of dupilumab.

METHODS

This was a real-life Czech multicenter retrospective study from patients treated with dupilumab for severe AD.

RESULTS

A total of 360 patients were included. At 16 weeks, 66.6%, 34.1%, and 5.5% of patients achieved EASI75/90 and EASI100, respectively. Improvement continued with the time, and the proportion of patients with EASI75/90 and EASI100 increased to 89.5%, 55.6%, and 12.9% after one year of treatment and reached 95.8%, 60.4%, and 27.1% in the second year of therapy, respectively. A significant reduction was observed in the DLQI scores. The most common adverse events were infections in 5.8% of patients, followed by ocular complications in 2.5% of patients. Persistence rates were 98.2% at four months to 93.1% at month 24, and lack of effectiveness was the most common reason for discontinuation.

CONCLUSION

This real-life study confirmed the effectiveness and safety of dupilumab in a real-life setting during the COVID-19 pandemic. Our study revealed a higher frequency of infections and a lower conjunctivitis frequency than other real-life studies and clinical trials.

Ureteral Stenosis of Transplanted Kidney

Introduction: Ureteral stenosis is one of the most commonly reported urological complications after kidney transplantation. Material and methods: This is a retrospective analysis of the risk factors for ureteral stenosis (type of donor, age of donor, presence of interior polar arteria, unilateral dual transplantation, diabetes mellitus of the recipient and the donor, BK positivity, child recipient, cold ischaemia time, and delayed graft function), as well as the causes and types of treating ureteral stenoses. Results: In the group of 278 patients, the occurrence was 7.2 %. The medial of occurrence of ureteral stenoses was 24.6 months. The independent risk factor for ureteral stenosis in our group was the age of the donor ≥ 70 years [HR 6.5833; 95 % CI 2.2448-19,3070 (P = 0.0006)], BK positivity [HR 13.6667; 95 % CI 6.9127-27.0196 (P<0.0001)], cold ischaemia time > 1080 min [HR 4.0368; 95 % CI 1.7250-9,4465 (P = 0.0013)], and diabetes mellitus in the donor’s history [HR 16.2667; 95 % CI 7.8629-33.6525 (P <0.0001)]. The most frequent type of treating the ureteral stenosis in our group was retroureteroneocystostomy. After surgical treatment, we recorded no recurrence of stenosis. Conclusion: In our analysis, the confirmed independent risk factor was diabetes mellitus of the donor. However, further monitoring and analyses of large groups of patients are necessary. Surgical treatment of ureteral stenosis is safe. However, the most important momentum in surgical treatment of ureteral stenosis still remains the surgeon´s experience in the given type of treatment.

Arteriovenous graft for hemodialysis, graft venous anastomosis closure - current state of knowledge. Minireview

Backround. The use of artificial vascular grafts (arteriovenous graft, AVG) is indicated in patients in hemodialysis programs if the subcutaneous venous bed is exhausted or unsuitable for arteriovenous fistula (AVF) creation. The native fistula should be the hemodialysis access of first choice: AVF has better results in terms of function and potential complications. However, the use of AVG is necessary in some patients. In these patients, extensive clinical examination, color duplex sonography and angiography should be performed prior to indication. The technique of graft implantation requires respect for geometric relations for the graft anastomoses to minimize the formation of intimal hyperplasia mainly on the venous anastomosis. The main complications of AVG are stenosis on the venous anastomosis (VAG), causing closure of graft and graft infection. The cumulative function of AVG is 59-90% in the first year and 50-82% in the second year. Arteriovenous graft stenosis leading to thrombosis is a major cause of complications in patients undergoing hemodialysis. The purpose of this review is to summarise current knowledge of the diagnostics and treatment of graft thrombosis and discuss the issue in combination with relevant publications via Pubmed database.

CONCLUSION

The most frequent cause of failure of AVG for hemodialysis is stenosis and closure by VAG. AVG closure can be addressed surgically, endovascularly (amenable to thrombectomy by radiological or surgical means) and by hybrid performance.

Current treatment methods for long occlusions of the femoropopliteal segment in patients with intermittent claudication: Minireview

Backround. Intermittent claudication is a classic symptom of peripheral arterial disease. It is mainly treated conservatively but if this fails, a form of revascularization is indicated. The revascularization in chronic occlusion of femoropopliteal region is currently performed by two basic methods: the standard method of surgical bypass and the newer miniinvasive alternative represented by the endovascular method. The treatment of patients with solely claudication and long occlusion of femoropopliteal region remains controversial. The aim of this minireview was to determine whether surgical bypass is still the best method of choice in a time of endovascular techniques.

METHODS

A MEDLINE search for original and review articles using key terms, intermittent claudication and long femoropopliteal oclusion.

RESULTS AND CONCLUSION

No ideal treatment for long occlusions of the femoropopliteal segment has been established to date. It is clear that the role of endovascular techniques in the treatment of SFA occlusions is increasing. It remains that, lower risk patients with claudication should be examined to assess the quality of veins suitable for revascularization and bypass should be selected as the first method of choice.

Categorization of the hemodynamic response to hemodialysis: the importance of baroreflex sensitivity

Intradialytic hypotension (IDH) remains an important cause of morbidity and mortality in hemodialysis (HD) patients. The baroreflex arc is under autonomic control and regulates blood pressure. This study aimed to investigate the contribution of impaired baroreflex sensitivity (BRS) to the pathophysiology of IDH. Thirty-four chronic HD (12 IDH-prone, 22 IDH-resistant) patients underwent BRS measurement during HD with relative blood volume monitoring. During analysis, patients were separated into four age-matched groups according to resting BRS>or=4.5 ms/mmHg and hemodynamic stability. Resting BRS was extremely heterogenous (geometric mean BRS 5.78+/-1.41 [range 1.76-41.41] ms/mmHg). Relative blood volume reduction was well matched in all groups (mean reduction in relative blood volume for all patients -6.74%+/-0.86%, P>0.05). Thirty-seven episodes of IDH occurred in the IDH prone, reduced BRS group. Patients with impaired resting BRS and prone to IDH had markedly different responses to HD as compared to the preserved BRS group, but the total peripheral resistance response was significantly lower than in the IDH-resistant patients (15.9%+/-2.1% vs. 42.4%+/-3.0%, respectively, P<0.001). In those patients prone to IDH and with impaired resting BRS, percentage reduction in cardiac output at the end of HD highly correlated with reduction in relative blood volume (r=0.94, P=0.006). Hypotension during dialysis may be an important source of recurrent cardiac injury and early recognition of those patients prone to relative symptomatic and asymptomatic hypotension remains important. Impaired resting BRS and recognition of a suboptimal peripheral pressor response, appear to predict those patients most likely to undergo hemodynamic instability and may assist in the pursuit of this elusive goal.

The haemodynamic and metabolic effects of hypertonic-glucose and amino-acid-based peritoneal dialysis fluids

BACKGROUND

Continuous ambulatory peritoneal dialysis (CAPD) may exert significant effects on systemic haemodynamics. We have previously demonstrated that hypertonic glucose solutions are associated with higher blood pressure (BP) due to a rise in stroke volume (SV) and cardiac output (CO). However, the mechanisms underlying these changes have not been established.

METHODS

Ten non-diabetic CAPD patients entered a randomized crossover study (eight completed) to compare conventional glucose-based fluid, biocompatible pH-neutral glucose-based fluid and 1.1% amino acid solution (lactate-buffered but completely free of glucose degradation products). BP and haemodynamic variables were measured using continuous arterial pulse wave analysis, and serial plasma glucose and insulin concentrations were collected. Left ventricular (LV) diameters were measured at the start and end of each dwell period using M-mode echocardiography.

RESULTS

BP was similar during 1.36% glucose and 1.1% amino acid dwells, but was significantly higher during 3.86% glucose dwells with both conventional and biocompatible fluids (P < 0.001). This was associated with a significantly higher SV and CO (P < 0.001), although the haemodynamic response differed between conventional and biocompatible 3.86% solutions. Plasma glucose and insulin levels did not differ from baseline during 1.36% and amino acid dwells, but increased significantly during 3.86% glucose dwells. Despite a significantly higher ultrafiltration volume with 3.86% glucose, LV diameters were similar throughout.

CONCLUSIONS

In conclusion, we have confirmed our previous findings demonstrating higher BP and adverse haemodynamics during 3.86% glucose dwells. These changes are associated with hyperglycaemia and hyperinsulinaemia, but are not related to differences in cardiac filling.

Possible restorations of the upper extremity motion in tetraplegic patients - 5-year clinical experience

AIM

The aim of the work is to objectify the functional effectiveness of these operations and their influence on the quality of life of handicapped patients.

METHOD

The authors evaluate the results of reconstructive surgery restoring hand grip in a group of 15 tetraplegic patients (3 women and 12 men) with complete spinal cord lesion of C5-C7 segments. The average age of patients in the group is 33 (22-50) years old. The reconstructions were performed using tendon transfer and tenodesis in the forearm and hand area. The effectiveness of the transfer was assessed objectively with regard to muscle strength by measuring the restored "thumb-index finger" grip and "into fist" grip. The range of motion achieved was also evaluated. Transfer effectiveness was evaluated on the basis of subjective patients' evaluation. An ADL (activities of daily living) questionnaire by Mohammed's (1992) took into account the effect of the surgery in a whole range of common daily activities.

RESULTS

An extended range of daily activities was evident mainly in the fields of: communication, eating and drinking and operations associated with increase in general selfcare of the patient. There was no deterioration of condition in any of the activities.

CONCLUSIONS

Up to 80 % of tetraplegic patients are suitable candidates for transfers and, to a certain extent, it is possible to improve the upper limb function. In a partial function restoration of the upper limbs there is immense potential for improvement in the quality of life of these patients.