Hypotension at Hospital Presentation and Post-contrast Acute Kidney Injury Following Computed Tomography with Contrast Media

Background: Post-contrast acute kidney injury (PC-AKI) is a major complication of contrast media usage, and risks for PC-AKI are generally evaluated before performing computed tomography (CT) with contrast at the emergency department (ED). Although persistent hypotension (systolic blood pressure [sBP] <80 mmHg for 1 h) is associated with increased PC-AKI incidence, it remains unclear whether tentative hypotension that is hemodynamically stabilised before CT is a risk for PC-AKI. We hypothesised that hypotension on ED arrival would be associated with higher PC-AKI incidence; even if CT with contrast was performed after patients are appropriately resuscitated. Methods: This multicenter retrospective observational study was conducted at three tertiary care centres during 2013–2014. We identified 280 patients who underwent CT with contrast at ED and whose kidney function was subsequently evaluated. Patients were divided into two groups based on sBP on arrival (<80 vs ≥80 mmHg); hypotension was considered as tentative because CT with contrast has always been performed after patients were stabilised at participating hospitals. PC-AKI incidence was compared between the groups, and inverse probability weighting (IPW) was conducted to adjust background characteristics, including age, sex, comorbidities, anaemia, and acute physiology and chronic health evaluation II score. Results: Eighteen patients were excluded due to chronic haemodialysis, cardiac arrest on arrival, or died within 72 h, and 262 were eligible for this study. PC-AKI incidence was higher in the tentative hypotension group than in the normotension group (7/27 [28.6%] vs 24/235 [10.2%], odds ratio [OR] 3.08 [95% confidence interval (CI) 1.18–8.03], p = 0.026), which was confirmed by IPW (OR 3.25 [95% CI 1.99–5.29], p < 0.001). Similar results were obtained in subgroups with an estimated glomerular filtration rate of <60 mL/min/1.73 m2. Conclusion: Tentative hypotension at ED was associated with PC-AKI development.

Comparison between Paricalcitol versus cinacalcet therapy in the management of secondary hyperparathyroidism among prevalent hemodialysis patients

Background Secondary hyperparathyroidism (SHPT) is one of the components of chronic kidney disease–mineral bone disorder (CKD-MBD) with significant contribution to the morbidity and mortality among prevalent hemodialysis (HD) patients. Objectives Multicentric experience study to compare the effectiveness of Intravenous (IV) paricalcitol versus oral cinacalcet and oral cinacalcet plus oral alfacalcidol as treatment regimens of secondary hyperparathyroidism (SHPT) among chronic haemodialysis (HD) patients. Methods Retrospective observational cohort study, 1year time horizon, 130 prevalent HD patients with SHPT were recruited from three main HD centres in Aljouf region in Saudi Arabia. Patients were divided into 3 groups: Group I (50) HD patients were treated by intravenous paricalcitol, group II (50) HD patients who received oral cinacalcet plus oral alfacalcidol, Group III (30) HD patients were on oral cinacalcet. Serum Intact parathyroid hormone, Calcium, Phosphorus and alkaline Phosphatase tests were assessed every 3 months. Results 130 (61 (47%) females, (53%) 69 males) HD patients, mean age 56.30 ± 19.1 years, mean HD duration 4.86±4.15 year. The mean of PTH is significantly reduced in all studied groups (P &lt; 0.001). Mean Δchanges in iPTH concentration in group I, II, III was (-242.11±148.75,225.54±153.91,-254.83±275.17)(P &gt; 0.05) respectively with statistical non-significant differences. Increase of CaxPo4 with paricalcitol group as mean ΔChange in (CaxPO4) was in the group I, II, III(15.39±9.46,1.97±11.74,-2.89 ±9.37) respectively (P &lt; 0.001). Significant increase in serum phosphorus from the baseline in patients in group II. Conclusions Intravenous Paricalcitol based regimen assumed to be equally effective in suppressing SHPT in prevalent hemodialysis patients when compared to the combination of oral Cinacalcet with oral alfacalcidol or treatment with oral cinacalcet alone, with less incidence of hyperphosphatemia with paricalcitol or cinacalcet in comparison to alfacalcidol regimen.

Quality Management System in a Haemodialysis Unit and Patient Satisfaction

Haemodialysis Units adopt a Quality Management System to provide quality healthcare services, to promote reliability and to increase the patients’ contentment and faith they receive the best possible care. The purpose of this study was to ascertain whether the ELOT EN ISO 9001:2015 Quality Management System, “Provision of Dialysis Services in Patients with Renal Failure”, in a Haemodialysis Unit affected the patients’ satisfaction level. The Quality Management System stipulated the use of a questionnaire containing 11 questions to measure the patients’ satisfaction. The data were collected in July 2018 during the annual audit for the continuous compliance of the Haemodialysis Unit with the quality requirements. 35 patients undergoing Chronic Haemodialysis for at least the last 6 months participated. The Quality Management System enabled the identification of the patients’ individual needs and the areas that required more attention. More specifically, 97.1% of the patients stated that the services provided had been improved and that requests such as the installation of TVs and the collaboration with a dietologist have been met. 77.1% of the patients were satisfied by the healthcare provided and 88.6% were satisfied by the staff in general. Regarding the care provided by the medical staff 74.3% of the patients were satisfied, while 54.2% found the information given for their health to be adequate. All of the patients (100%) were satisfied by the care provided by the nursing staff and almost all (97.1%) felt that the nursing staff was easy to communicate with. Only 6.1% of the patients stated that specific areas required further improvement. A Quality Management System in a Haemodialysis Unit leads to a better understanding of the patients’ individual needs, allowing for higher satisfaction. Moreover, the evidence based documentation of the quality of the services provided and the emphasis put on continuous improvement further enhances the patients’ trust. Doi: 10.28991/SciMedJ-2021-0303-2 Full Text: PDF

Blood Volume Monitoring: A Clinical Tool to Guide Ultrafiltration in Volume Control and Optimisation of Intradialytic Blood Pressure

The importance of extracellular volume control and avoidance of volume overload has been well documented in relation to the management of patients with chronic haemodialysis. Chronic volume overload results in poorly controlled hypertension, increased cardiovascular events, and increased all-cause mortality. Traditional methods of dry weight assessment have relied on clinical assessment to guide volume status. The challenge of achieving the balance between dry weights and preventing intradialytic complications is a formidable one. In order to achieve this, reproducible and sensitive methods are desirable to aid objective quantification of volume status. One such method is by the use of blood volume monitoring, which is achieved by real-time calculation of changes in relative blood volume via a cuvette placed in the arterial blood-line, which can be used to guide ultrafiltration targets during the haemodialysis session. This review article examines the use of blood volume monitoring as a tool to guide ultrafiltration during dialysis and to examine the current evidence to supports its use in assessing dry weight and in preventing intradialytic hypotension events.

Case of eustachian valve endocarditis and the importance of synergistic antibiotic therapy

A 46-year-old woman with a history of end-stage renal disease on chronic haemodialysis presented with 1 week of fever, chills, altered mental status and hand pain. She was febrile and ill-appearing on presentation with a pulse rate of 102 beats per minute. She had a tunnelled dialysis catheter in her right neck. Hand examination demonstrated a swollen, erythematous and tender wrist. Cardiovascular examination demonstrated no murmurs. CT of the hand showed abscesses involving the left forearm. Blood and abscess cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Transesophageal echocardiography (TEE) showed a 1.0×1.0 cm mobile vegetation involving the eustachian valve (EV), confirming EV endocarditis. She remained bacteraemic for 18 days despite being on vancomycin with appropriate blood levels. Vancomycin was switched to daptomycin and ceftaroline, which cleared her cultures. Repeat TEE showed improved vegetation size. Our case highlights the rarity and management of EV endocarditis and the importance of synergy for treatment of persistent MRSA bacteraemia.

MO214EVALUATION OF THE EFFECT OF A POTASSIUM BINDER ON ARRHYTHMIA-RELATED CARDIOVASCULAR OUTCOMES IN PATIENTS ON CHRONIC HAEMODIALYSIS WITH RECURRENT HYPERKALAEMIA: DESIGN AND RATIONALE FOR THE SODIUM ZIRCONIUM CYCLOSILICATE DIALIZE-OUTCOMES STUDY

Background and Aims Patients with end-stage renal disease (ESRD) on chronic haemodialysis are at an elevated risk of arrhythmias that can increase the risk of sudden cardiac death (SCD) and stroke, along with the need for hospitalisation and interventions. These arrhythmias may be exacerbated by pre-dialysis hyperkalaemia and rapid serum potassium (sK+) shifts that occur during and after haemodialysis sessions. The DIALIZE study (NCT03303521) demonstrated that sodium zirconium cyclosilicate (SZC) was an effective and well-tolerated treatment for pre-dialysis hyperkalaemia, when administered once-daily on non-dialysis days for 8 weeks in patients with ESRD undergoing chronic haemodialysis. The DIALIZE-Outcomes study (EudraCT 2020-005561-14) will evaluate the effect of SZC treatment on arrhythmia-related cardiovascular (CV) outcomes in patients with ESRD on chronic haemodialysis with recurrent hyperkalaemia. Method The DIALIZE-Outcomes study is an international, multicentre, randomised, double-blind, parallel-group, placebo-controlled study, to be conducted at ∼300 study sites across ∼20 countries. Adults (≥18 years of age) with ESRD on haemodialysis three times weekly and with recurrent pre-dialysis sK+ ≥5.5 mmol/L after the long interdialytic interval (LIDI) will be eligible for enrolment. Approximately 2300 patients will be randomised 1:1 to SZC or placebo (Figure), starting at 5 g orally once daily on non-dialysis days (4 days/week) and uptitrated weekly in 5 g increments (maximum 15 g) to achieve pre-dialysis sK+ 4.0–5.0 mmol/L after the LIDI. Dose adjustments after the uptitration phase will be guided by sK+ monitoring, as per clinical practice. The primary objective is to evaluate the efficacy of SZC versus placebo in reducing the incidence of the primary composite endpoint of time to first occurrence of SCD, stroke or hospitalisation/intervention/emergency department visit due to arrhythmias (atrial fibrillation, bradycardia, asystole, ventricular tachyarrhythmia). Secondary endpoints include the efficacy of SZC versus placebo in maintaining normokalaemia (sK+ 4.0–5.5 mmol/L after the LIDI) and preventing severe hyperkalaemia (sK+ ≥6.5 mmol/L after the LIDI) at 1 year (assessed through measurement of sK+ at the 12-month study visit), and time to occurrence of CV outcomes. Safety and tolerability of SZC versus placebo will also be evaluated. The study is event-driven, with patients remaining on study treatment until a pre-specified number of primary endpoint events (770) has occurred. The anticipated average treatment period is ∼25 months. Conclusion The DIALIZE-Outcomes study is the first evaluation of a K+ binder in improving CV outcomes in patients with ESRD on chronic haemodialysis and with recurrent hyperkalaemia. The study findings will provide valuable information that may help to further our understanding of the relationship between hyperkalaemia and CV morbidity and mortality in patients on chronic haemodialysis, and to optimise treatment regimens in this high CV and SCD risk population.

MO152CORRELATION OF PERCEIVED FRAILTY WITH MEASURED FRAILTY IN AN ADULT HAEMODIALYSIS POPULATION

Background and Aims Frailty is a measure of physiological reserve and the ability to respond to physiological stress. Increasing frailty predicts adverse health outcomes in patients with end stage renal disease (ESRD) Despite this, frailty is not routinely measured in clinical practice where clinician perception of frailty is used to inform decision making. The Clinical Frailty Scale (CFS) is a clinical judgement-based score that is a useful screening tool for frailty. Increasing frailty measured by CFS is predictive of adverse outcomes in patients with advanced chronic kidney disease (CKD) including falls, worsening disability, care home admissions, hospitalizations and ultimately mortality. It has been widely used in the assessment of patients with COVID-19 to help inform decisions regarding ceiling of care. This study aimed to assess the correlation between clinician perception of frailty and frailty as measured using the CFS. Method Frailty was assessed for all patients undergoing in centre hospital haemodialysis (n=53) in a single dialysis unit in Northern Ireland. A CFS score was calculated for all patients by a clinician who routinely uses the CFS in clinical practice. Patients with a score of 1-3 were classified as not frail, 4-5 as intermediately frail and 6-9 as frail. Nephrologists received basic education about frailty. They were then asked to categorize their patients as non-frail, intermediately frail or frail. The relationship between measured and perceived frailty was assessed using percent agreement. Participant characteristics of frail patients who were misclassified as intermediately frail or non-frail by clinicians were compared to those patients correctly classified as non-frail by clinicians. Fisher’s exact test was employed for categorical variables and t-tests were employed for pseudo normally distributed continuous variables. Results Of the 53 participants, the median age was 59 years (26-89). 41.5% were women. The median time on dialysis was 1.6 years. According to the CFS, 6 patients were categorised as non-frail, 30 patients as intermediately frail and 17 as frail. Among frail participants, 41% were correctly perceived as frail by their nephrologist. Among non-frail participants, 100% were correctly perceived as non-frail by their nephrologist. Among those who were frail according to the CFS, those misclassified as intermediately frail or non-frail, were younger (median age of those misclassified 49 years vs 62 years of those not mis-classified, P=0.03) but did not differ by sex (P=1), time on dialysis (P=0.39), presence of diabetes (P=0.30) or presence of vascular disease (P=1). Conclusion In this study of adult patients undergoing chronic haemodialysis, perceived frailty correlated with measured frailty using the CFS less than 50% of the time. This suggests that clinical perception is not an accurate surrogate for frailty status in this population group. Additionally, this study suggests that younger patients with ESRD are less likely to be correctly perceived as frail. Such misclassification could influence clinical decisions for treatment, including candidacy for kidney transplantation.

MO784ABDOMINAL AORTIC CALCIFICATIONS AND ARTERIOVENOUS FISTULA CLINICAL OUTCOMES ON HAEMODIALYSIS PATIENTS

Background and Aims Vascular calcification has now been recognized as a major problem in dialysis patients because of its strong influence on the prognosis of this population. Several reports have shown the strong relationship between vascular calcification and clinical outcomes including cardiovascular events and arteriovenous fistula (AVF)survival. The aim of this study is to evaluate the severity of vascular calcifications in our hemodialysis patients and to determine its impact on the AVF survival. Method It is a transversal descriptive and analytical study including chronic haemodialysis patients in our unit of the nephrology department. A lateral lumbar spine radiograph was taken: the aortic arch calcification(ACC) score (VCS) was calculated according to the score validated by Kauppila and Schousboe. The overall VCS ranged from 0 to 24. Results Our study included 55 patients divided into 31 men and 24 women with a sex ratio of 1.29. The mean age was 49.54 ± 12.66 years. The mean duration in HD was 96.16± 73 months. 76.8% of the patients have hypertension, 26.8% are diabetic and 14.3% are smokers. AVF failure was noted in 34 patients (60.7%). We divided our population in 3 groups: G1:23 patients with a low VCS (41.1%), G2: 15 patients with a moderate VCS (26.8%) and G3: 17 patients with a severe VCS (30.4%). Patients in G2 and G3 were more frequently diabetics (p=0.05): over 50% of patients in G3 were diabetic and the mean duration in HD was longer: 133 months in G3, 102 months in G2 and 74 months in G1 with a significant difference p=0.03. We noted that AVF failure was more frequent in patients in G2 and G3 (65.7%) patients) versus patients in G1 (39.13%) with a significant difference (p=0.01) Conclusion vascular access dysfunction is one of the leading causes of morbidity and mortality in haemodialysis patients We have demonstrated throw this study the relation between the presence of higher AAC grade and the poor survival of AVF in our patients. So, an identification of these ACC by a simple lateral lumbar spine radiograph would allow the clinician to implement more rigorous and planned monitoring for such AVFs.