107 research outputs found
Chronic kidney disease and neurological disorders: are uraemic toxins the missing piece of the puzzle?
Full text linkChronic kidney disease (CKD) perturbs the crosstalk with others organs, with the interaction between the kidneys and the heart having been studied most intensively. However, a growing body of data indicates that there is an association between kidney dysfunction and disorders of the central nervous system. In epidemiological studies, CKD is associated with a high prevalence of neurological complications, such as cerebrovascular disorders, movement disorders, cognitive impairment and depression. Along with traditional cardiovascular risk factors (such as diabetes, inflammation, hypertension and dyslipidaemia), non-traditional risk factors related to kidney damage (such as uraemic toxins) may predispose patients with CKD to neurological disorders. There is increasing evidence to show that uraemic toxins, for example indoxyl sulphate, have a neurotoxic effect. A better understanding of factors responsible for the elevated prevalence of neurological disorders among patients with CKD might facilitate the development of novel treatments. Here, we review (i) the potential clinical impact of CKD on cerebrovascular and neurological complications, (ii) the mechanisms underlying the uraemic toxins' putative action (based on pre-clinical and clinical research) and (iii) the potential impact of these findings on patient care
Autonomic Imaging: The Cardiorenal Axis
No full textIn this chapter, we discuss the pathophysiology of the various chronic cardiorenal interactions and their consequences on the sympathetic nervous system (SNS). Increased activity of SNS is observed in all stages of chronic renal disease. The chronic elevation of SNS activity is a major contributor of the complex pathophysiology of hypertension, heart failure, insulin resistance, sleep disorders, diuretic resistance, and progressive kidney disease. Overactivity of SNS contributes to the high incidence of cardiovascular events and cardiac mortality, especially in patients with end-stage renal failure. The dysfunction of sympathetic innervation can be visualized directly by use of [123 I]-metaiodobenzylguanidine ([123 I]-MIBG) scintigraphy.</p
Clinical Applications of Biofeedback Systems in Hemodialysis
No full textDespite the tremendous progress in hemodialysis technology over the past decades, hemodynamic instability during hemodialysis is still a frequent complication. This is caused by the fact that in most patients large amounts of fluid are being removed over a short period of time, in combination with an increasingly higher proportion of (elderly) patients with significant cardiovascular co-morbidity. In recent years various closed-loop techniques have been developed to prevent hemodynamic instability during hemodialysis. These techniques differ with respect to the input and output parameters but have in common that they are based on current concepts of the pathophysiology of dialysis hypotension. In this chapter we will outline the pathophysiology of dialysis hypotension and discuss the various closed-loop techniques for hemodialysis that are currently available.</p
Strategies to prevent SARS-CoV-2 transmission in hemodialysis centres across Europe-lessons for the future
Full text linkBACKGROUND: Early reports on the pandemic nature of coronavirus disease 2019 (COVID-19) directed the nephrology community to develop infection prevention and control (IPC) 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 1 March 2020 and 31 July 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 severe acute respiratory syndrome coronavirus 2 (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.sponsorship: Dutch Kidney Foundationstatus: Publishe
Relative blood volume measurements during hemodialysis: Comparisons between three noninvasive devices
Full text linkThe monitoring of relative blood volume changes (ΔRBV) has been advocated for the prevention of hemodialysis (HD) hypotension. Stand-alone devices (Crit-Line) or devices incorporated into the HD apparatus (blood volume monitor [BVM], Hemoscan) are widely used for this purpose. Comparisons between devices are scarce. The aim of this study was, first, to compare ΔRBV results from these 3 devices with ΔRBV calculated from changes in laboratory-derived hemoglobin (ΔRBV-lab-Hb) and, second, to compare ΔRBV results between the different devices. Fourteen patients received 2 HD treatments in a randomized order: one with the Hemoscan and Crit-Line combination and one with the BVM and Crit-Line combination. ΔRBV-lab-Hb was measured at 2 and 4 hr into the HD session. Bland-Altman analyses showed that ΔRBV results from the 3 devices differed systematically from ΔRBV-lab-Hb, i.e., the difference between the 3 devices and ΔRBV-lab-Hb varied significantly (p < 0.05) with the magnitude of the measurement. The interdevice comparison showed considerable differences in ΔRBV results. At the end of the treatment, a significant difference (p < 0.05) between ΔRBV measured by the Hemoscan and Crit-Line device (-9.8 ± 2.7% and -11.5 ± 4%, respectively) was found. In most patients, a systematic difference between Crit-Line and Hemoscan and between Crit-Line and BVM was observed. Relative blood volume change measurements by Crit-Line, Hemoscan, and BVM yield results that differ systematically from the results obtained from laboratory-derived Hb changes. Furthermore, there are substantial differences in ΔRBV results between the 3 ΔRBV devices.</p
Clinical, Functional, and Mental Health Outcomes in Kidney Transplant Recipients 3 Months After a Diagnosis of COVID-19
Full text linkBACKGROUND: Kidney transplant patients are at high risk for coronavirus disease 2019 (COVID-19)-related mortality. However, limited data are available on longer-term clinical, functional, and mental health outcomes in patients who survive COVID-19.METHODS: We analyzed data from adult kidney transplant patients in the European Renal Association COVID-19 Database who presented with COVID-19 between February 1, 2020, and January 31, 2021.RESULTS: We included 912 patients with a mean age of 56.7 (±13.7) y. 26.4% were not hospitalized, 57.5% were hospitalized without need for intensive care unit (ICU) admission, and 16.1% were hospitalized and admitted to the ICU. At 3 mo follow-up survival was 82.3% overall, and 98.8%, 84.2%, and 49.0%, respectively, in each group. At 3 mo follow-up biopsy-proven acute rejection, need for renal replacement therapy, and graft failure occurred in the overall group in 0.8%, 2.6%, and 1.8% respectively, and in 2.1%, 10.6%, and 10.6% of ICU-admitted patients, respectively. Of the surviving patients, 83.3% and 94.4% reached their pre-COVID-19 physician-reported functional and mental health status, respectively, within 3 mo. Of patients who had not yet reached their prior functional and mental health status, their treating physicians expected that 79.6% and 80.0%, respectively, still would do so within the coming year. ICU admission was independently associated with a low likelihood to reach prior functional and mental health status.CONCLUSIONS: In kidney transplant recipients alive at 3-mo follow-up, clinical, physician-reported functional, and mental health recovery was good for both nonhospitalized and hospitalized patients. Recovery was, however, less favorable for patients who had been admitted to the ICU.</p
Renal survival and prognostic factors in patients with PR3-ANCA associated vasculitis with renal involvement
No full textRenal survival and prognostic factors in patients with PR3-ANCA associated vasculitis with renal involvement.BackgroundSevere renal disease is a feature of anti-neutrophil cytoplasmic antibodies (ANCA)-associated small-vessel vasculitis. We evaluated patient and renal survival and prognostic factors in patients with PR3-ANCA associated vasculitis with renal involvement at diagnosis during long-term follow-up.MethodsEighty-five patients were diagnosed between 1982 and 1996 and followed until 2001 allowing ≥5 years of follow-up. All patients were treated with prednisolone and cyclophosphamide. Univariate and multivariate analyses with patient and renal survival as dependent variables were performed.ResultsOf the 85 patients in this study, 17 (20%) died within one year after diagnosis. Of the 25 patients (29%) who were dialysis dependent at diagnosis, two remained dependent and two again became dialysis dependent after less than one year; nine died early without renal recovery. Risk factors for death occurring within one year in univariate analysis (RR, 95% CI) were age>65 years (6.5, 1.6–13.7) and dialysis dependency at diagnosis (3.6, 1.0–13). Twenty patients died beyond one year during the long-term follow-up. Male gender (4.7, 1.6–10) and developing dialysis dependency during follow-up (4.1, 1.4–12) were associated with poor outcome. Risk factor for renal failure within one year was dialysis dependency at diagnosis (29, 3.6–229). Of 64 patients dialysis independent one year after diagnosis, 12 patients became dialysis dependent during follow-up. A renal relapse was strongly associated with development of renal failure in long-term follow-up (17, 3.5–81).ConclusionsEarly death and failure to recover renal function in PR3-ANCA associated vasculitis is associated with age> 65 years and dialysis dependency at diagnosis. Long-term renal survival is determined by renal relapses during follow-up only. Slow, progressive renal failure without relapses is rarely observed in this group
Recovery of dialysis patients with COVID-19:Health outcomes 3 months after diagnosis in ERACODA
Full text linkBackground. Coronavirus disease 2019 (COVID-19)-related short-term mortality is high in dialysis patients, but longer-term outcomes are largely unknown. We therefore assessed patient recovery in a large cohort of dialysis patients 3 months after their COVID-19 diagnosis. Methods. We analyzed data on dialysis patients diagnosed with COVID-19 from 1 February 2020 to 31 March 2021 from the European Renal Association COVID-19 Database (ERACODA). The outcomes studied were patient survival, residence and functional and mental health status (estimated by their treating physician) 3 months after COVID-19 diagnosis. Complete follow-up data were available for 854 surviving patients. Patient characteristics associated with recovery were analyzed using logistic regression. Results. In 2449 hemodialysis patients (mean ± SD age 67.5 ± 14.4 years, 62% male), survival probabilities at 3 months after COVID-19 diagnosis were 90% for nonhospitalized patients (n = 1087), 73% for patients admitted to the hospital but not to an intensive care unit (ICU) (n = 1165) and 40% for those admitted to an ICU (n = 197). Patient survival hardly decreased between 28 days and 3 months after COVID-19 diagnosis. At 3 months, 87% functioned at their pre-existent functional and 94% at their pre-existent mental level. Only few of the surviving patients were still admitted to the hospital (0.8–6.3%) or a nursing home (∼5%). A higher age and frailty score at presentation and ICU admission were associated with worse functional outcome. Conclusions. Mortality between 28 days and 3 months after COVID-19 diagnosis was low and the majority of patients who survived COVID-19 recovered to their pre-existent functional and mental health level at 3 months after diagnosis.</p
Association between quality of life and various aspects of intradialytic hypotension including patient-reported intradialytic symptom score
Full text linkThere is increasing awareness that, besides patient survival, Quality of Life (QOL) is a relevant outcome factor for patients who have a chronic disease. In haemodialysis (HD) patients, intradialytic hypotension (IDH) is considered one of the most frequent complications, and this is often accompanied by symptoms. Several studies have investigated QOL in dialysis patients, however, research on the association between intradialytic symptoms and QOL is minimal. The goal of this study was to determine whether the occurrence of IDH has an influence on the perception of QOL.MethodsDuring 3 months, haemodynamic data, clinical events, and interventions of 2623 HD-sessions from 82 patients were prospectively collected. The patients filled out a patient-reported intradialytic symptom score (PRISS) after each HD session. IDH was defined according to the EBPG as a decrease in SBP ≥20 mmHg or in MAP ≥10 mmHg associated with a clinical event and need for nursing interventions. Patient’s self-assessment of QOL was evaluated by the 36-Item Short-Form Health Survey.ResultsThere were no significant associations between the mental summary score or the physical summary score and the proportion of dialysis sessions that fulfilled the full EBPG definition. A lower PRISS was significantly associated with the proportion of dialysis sessions that fulfilled the full EBPG definition (R = − 0.35, P = 0.0011), the proportion of dialysis sessions with a clinical event (R = − 0.64, P = 0.001), and the proportion of dialysis sessions with nursing interventions (R = − 0.41, P = 0.0001). The physical component summary and mental component summary were significantly negatively associated with the variable diabetes and positively with PRISS (P = 0.003 and P = 0.005, respectively). UF volume was significantly negatively associated with mental health (P = 0.02) and general health (P = 0.01).ConclusionsOur findings suggest that the EBPG definition of IDH does not capture aspects of intradialytic symptomatology that are relevant for the patient’s QOL. In contrast, we found a significant association between QOL and a simple patient-reported intra-dialytic symptom score, implying that how patients experience HD treatment influences their QOL.<br/
Clinical triage of patients on kidney replacement therapy presenting with COVID-19: an ERACODA registry analysis
Full text linkRationale & Objective. Patients on kidney replacement therapy (KRT) are at a very high risk of COVID-19. Triage pathway for KRT patients presenting with varying severity of COVID-19 illness remains ill-defined. We studied clinical characteristics of patients at initial and subsequent hospital presentations and its impact on patient outcomes.
Study Design, Setting, Participants. European Renal Association COVID-19 Database (ERACODA) was analysed for clinical and laboratory features of 1423 KRT patients with COVID-19 either hospitalized or non-hospitalized during first presentation and those representing after non-admission at initial triage. Predictors of outcomes (Hospitalisation, 28-day mortality) were determined for those not hospitalized at first presentation.
Results. Amongst 1423 KRT patients with COVID-19 (Hemodialysis=1017/Transplant=406), 25% (n=355) were not hospitalized at first presentation (30% Hemodialysis/13% Transplant). Of these non-hospitalized patients, 10% (n=36) re-presented second time, with a 5-day median interval between two presentations (Interquartile interval 2-7 days). Patients who re-presented had worsening respiratory symptoms, a fall in oxygen saturation (97% vs. 90%) and rise in C-reactive protein between attendances (26 vs. 73 mg/L). Patients on second presentation were older (72 vs. 63 years), had early respiratory symptoms and lung imaging abnormalities compared with those who did not return second time. The 28-day mortality for those admitted at first or second presentations was not significantly different (25% vs. 29%, p=0.6). Higher age, prior smoking history, higher clinical frailty score and self-reported shortness of breath at first presentation, were identified as predictors of mortality in those discharged at initial triage.
Conclusions. The study provides evidence that KRT patients with COVID-19 and mild pulmonary abnormalities with lack of pulmonary insufficiency can be safely discharged, with vigilance of respiratory symptoms, especially in those with risk factors for poor outcomes. Our findings support a risk-stratified clinical approach to admissions and discharges of KRT patients presenting with COVID-19, to aid clinical triage and optimise resource utilisation during the ongoing pandemic
- …
