Assisted peritoneal dialysis: strategies and outcomes

Assisted peritoneal dialysis (asPD) is a modality intended for not self-sufficient patients, mainly elderly, who are not able to perform peritoneal dialysis (PD) alone and require some help to manage the treatment. In the last decades, many countries developed strategies of asPD to face with aging of dialysis population and give an answer to the increasing demand of health service for elderly. Model of asPD varies according to the type of assistants employed and intensity of assistance provided. Both health care and non-health care assistants have been used with good clinical results. A mixed model of help, using different professional figures for short time or for longer according to patients’ need, has been proved successful and cost-effective. Outcomes of asPD are reported in different ways, and the comparative effect of asPD is unclear. Quality of life has rarely been evaluated; however, patients seem to be satisfied with the assistance provided, since it allows them to both retain independence and to be relieved from the burden of self-care. Assisted PD should not be intended as a PD-favoring strategy, but as a model that allows home dialysis also in patients who would not be eligible for PD because of social, cognitive or physical barriers.

An increase in circulating levels of branched-chain amino acids during hemodialysis with regard to protein breakdown: three case reports

Background Hemodialysis (HD) is a protein catabolic event. However, the amino acid (AA) kinetics during HD sessions involved in protein breakdown have not been well investigated in patients with and without diabetes mellitus (DM). Case presentation Three patients (two patients with DM and one patient without DM) underwent fasting HD. Plasma levels of branched-chain AAs (BCAA; leucine, isoleucine, and valine), major non-essential AAs (alanine and glutamine, including glutamate), insulin, and ketone bodies were measured every hour during each HD session. After the start of the HD session, the plasma levels of insulin and all BCAAs dropped simultaneously. There was a significant subsequent increase in the plasma level of leucine and isoleucine levels, while valine levels remained constant. However, the recovery in levels of BCAAs during HD indicated a profound amount of BCAAs entering the blood from body tissues such as muscles. BCAAs may have surpassed their removal by HD. Ketone body levels increased continuously from the start of the sessions and reached high values in patients with DM. Synchronous changes in insulin depletion and an increase in the levels of ketone bodies may indicate disruption of energy metabolism. Conclusions This is the first report to demonstrate the time course of the changes in circulating levels of BCAAs and related metabolites in energy homeostasis during HD. An increase in BCAA levels during HD was found to be due to their transfer from the body tissue which suggested protein breakdown.

Perimortem changes in clinical parameters in patients undergoing maintenance hemodialysis

Background End-of-life medical care for patients receiving maintenance hemodialysis (HD) therapy has become an increasingly important issue worldwide. Thus far, no clear indicators and/or biomarkers exist regarding the timing of HD therapy withdrawal. Methods To clarify the perimortem circumstances, we examined temporal changes in multiple clinical parameters during the last 10 serial HD sessions of 65 terminal patients with end-stage renal disease who had undergone maintenance HD and died in our hospital. Results The results showed that, while most of the laboratory data were unaltered, the physical parameters, such as systolic blood pressure and consciousness levels, gradually and significantly deteriorated toward the last HD session prior to death. The frequency of the use of vasopressors and O2 inhalation tended to increase. The accumulation of such severe conditions was observed at the last HD session. Of interest, the accumulation of severe conditions at the last HD session in patients with malignancies was significantly less than those with cardiovascular diseases or infectious diseases. The accumulation of severe conditions at the last HD session did not differ between patients who withdrew HD versus those who continued HD. Conclusion The results of the present study suggest that predicting the timing of maintenance HD therapy withdrawal is likely to be difficult and that the timing of maintenance HD therapy termination may differ among patient groups with distinct comorbid conditions.

Effects of Japanese-style online hemodiafiltration on survival and cardiovascular events

Background All-cause mortality can be reduced in patients receiving European-style high-volume post-dilution online hemodiafiltration (post-OHDF) compared with hemodialysis (HD). Japanese-style high-volume pre-dilution online hemodiafiltration (pre-OHDF) can also decrease all-cause mortality. No studies have investigated survival in patients receiving Japanese-style post-OHDF, and directly compared survival between pre-OHDF and post-OHDF. This study sought to clarify these issues. Methods We conducted this retrospective observational study at multiple facilities of our medical corporation, which have similar quality of healthcare management, from July 1, 2017 to July 1, 2020. Japanese-style OHDF included pre-OHDF and post-OHDF. Pre-OHDF and post-OHDF were each divided into high-volume and low-volume subgroups. We compared 3-year all-cause mortality and cardiovascular events between OHDF and high-flux HD using propensity score matching. In addition, we examined the effects of different modalities through comparisons between high-volume and low-volume pre-OHDF and between pre-OHDF and post-OHDF. Results Post-OHDF was associated with significantly lower all-cause mortality (P = 0.004, log-rank test; hazard ratio [HR] 0.257, 95% confidence interval [CI] 0.094–0.701) and cardiovascular events during all 3 years (P < 0.05) compared with HD. High-volume post-OHDF was associated with lower all-cause mortality compared with hemodialysis (log-rank test P = 0.022) but low-volume post-OHDF was not. Pre-OHDF was also associated with lower all-cause mortality (P < 0.001, log-rank test; HR 0.316; 95% CI 0.212–0.472) compared with HD but was not associated with cardiovascular events. All-cause mortality did not significantly differ between post-OHDF and pre-OHDF. Conclusions These findings suggest that Japanese-style post-OHDF may improve all-cause mortality to a level similar to that of pre-OHDF and that post-OHDF, particularly high-volume post-OHDF may reduce cardiovascular events.

Efficacy and safety of edoxaban tosylate hydrate 15 mg in the prevention of venous thromboembolism in patients with impaired renal function after orthopedic surgery of the lower extremities

Background Although not indicated in the USA, edoxaban tosylate hydrate 15 mg is used for venous thromboembolism (VTE) prophylaxis after orthopedic surgery of the lower extremities in Japan. However, its efficacy and safety in patients with impaired renal function have not been fully evaluated. We aimed to investigate the intervention’s effectiveness in these patients. Methods From 2018 to 2020, patients who underwent total hip arthroplasty, total knee arthroplasty, hip fracture surgery, or knee arthroplasty single granule replacement and with renal dysfunction were evaluated. Safety was evaluated according to bleeding occurrence during edoxaban treatment and liver function endpoints. Patients were divided into the 15- and 30-mg oral groups, including 23 patients with impaired renal function and 209 with normal renal function, respectively. Results VTE incidence in the 15- and 30-mg groups was 8.7% and 8.6%, respectively; the intergroup difference was insignificant (odds ratio [OR] 0.99; 95% confidence interval [CI] 0.22–4.56; p = 1.00). Bleeding did not occur in the 15-mg group and was noted in 9 patients in the 30-mg group during treatment with edoxaban; the intergroup difference was insignificant (p = 1.00). The increase in aspartate aminotransferase and alanine aminotransferase levels was 30% in the 15-mg group and 19% in the 30-mg group, with no difference between the groups (p = 0.27). Multivariate analysis showed that the dose of edoxaban was not a significant factor associated with the incidence of VTE (adjusted OR 2.31; 95% CI 0.39–13.8; p = 0.36). Conclusions Edoxaban 15 mg in patients with impaired renal function may be as effective as edoxaban 30 mg in patients with normal renal function. However, the number of cases included in this study was small and the power was insufficient; therefore, a study with a larger sample size is desirable.

Significance of nutrition in hemodialysis patients with peripheral arterial disease evaluated by skin perfusion pressure

Background Peripheral artery disease (PAD) is a serious complication in hemodialysis (HD) patients. Low skin perfusion pressure (SPP) is a useful marker for detecting PAD. Malnutrition is an important cause of intractable complications. We examined the relationship between low SPP and various indicators of nutritional status. Methods A total of 120 patients on maintenance HD were enrolled for SPP measurement. SPP was measured at the soles of both feet during HD, and patients were divided into low SPP (L-SPP) and normal SPP (N-SPP) groups by 50 mmHg. The following values were determined by averaging four blood samples taken before SPP measurements every 3 months for one year: hemoglobin, total protein, albumin (Alb), total cholesterol, urea nitrogen, creatinine (Cr), potassium, calcium, phosphate, intact parathyroid hormone, iron (Fe), transferrin saturation (T-SAT), and C-reactive protein (CRP). We calculated the percent Cr production rate, dialysis index (Kt/V), normalized protein catabolic rate (nPCR), geriatric nutritional risk index (GNRI), and estimated salt intake using the required formulas. In addition, the age, body mass index, and presence of diabetes mellitus (DM) were compared between both groups along with all other measurements. Data were expressed as the mean ± standard deviation or median with interquartile range as appropriate. Differences in continuous variables between the two groups were analyzed by Student’s t-test or Wilcoxon’s rank-sum test, as appropriate. Multivariate logistic analysis and receiver operating curve (ROC) analysis were performed for significant variables. The results were expressed as odds ratios with respective 95% confidence intervals (CIs). Results The enrolled patients were 82 men and 38 women, with a mean age of 66.9 ± 13.3 years and HD duration of 4.76 (2.13–12.28) years (median interquartile range). Twenty patients belonged to the L-SPP group, suggesting PAD. Comparison between the L-SPP and N-SPP groups showed significant differences in age, Cr, Fe, T-SAT, CRP, nPCR, GNRI, DM, and estimated salt intake. When the GNRI, estimated salt intake, CRP, and DM were applied as independent variables for multiple logistic regression analysis, the GNRI (odds ratio: 0.857, 95% CI 0.781–0.941, p = 0.001), CRP (2.406, 1.051–3.980, p = 0.035), and DM (9.194, 2.497–33.853, p = 0.001) were found to be significant for L-SPP, and a cutoff level of 92.1 (sensitivity 80%, specificity 72%, AUC: 0.742, 95% CI 0.626–0.858, p = 0.001) in the GNRI obtained by ROC was consistent with the risk index in the elderly presented previously. Conclusions SPP measurement is an essential tool for detecting high-risk PAD in maintenance HD, which is affected by malnutrition, DM, and inflammation. The GNRI is important for the determination of malnutrition.

Urgent-start peritoneal dialysis for end-stage renal disease patients: literature review and worldwide evidence-based practice

The prevalence of end-stage renal disease (ESRD) is on the rise worldwide. Meanwhile, the number of older people requiring dialysis therapy is increasing as a result of this population. We found that starting dialysis in an unplanned manner is a common occurrence, even for patients with nephrology follow-up. Most centers choose hemodialysis with a high rate of central venous catheter use at the time of initiation of dialysis. Current data has found that central venous catheter use is independently associated with increased mortality and high bacteremia rates. Peritoneal dialysis is one option to avoid bacteremia. The International Society for Peritoneal Dialysis guidelines suggests a break-in period of at least two weeks prior to an elective start of peritoneal dialysis, without mentioning urgent-start peritoneal dialysis. For unplanned ESRD patients, it is unrealistic to wait for two weeks before initiating peritoneal dialysis therapy. Urgent-start peritoneal dialysis has been suggested to be a practical approach of prompt initiation of peritoneal dialysis after catheter insertion, which may avoid an increased risk of central venous catheter-related complications, including bacteremia, central venous stenosis, and thrombosis associated with the temporary use of hemodialysis. Peritoneal dialysis is the alternative option, and many studies have presented an interest in urgent-start peritoneal dialysis. Some reports have compared urgent-start hemodialysis to peritoneal dialysis and found that urgent-start peritoneal dialysis is a safe and effective alternative to hemodialysis for an unplanned dialysis patient. This review aims to compare each literature report regarding techniques, prescriptions, outcomes, complications, and costs of urgent-start peritoneal dialysis.

Reverse pseudohyperkalemia in a newly diagnosed pediatric patient with acute T-cell leukemia and hyperleukocytosis: a case report and literature review

Background Hyperkalemia is a serious medical condition that requires immediate intervention. However, pseudohyperkalemia and reverse pseudohyperkalemia are misleading clinical manifestations that can result in incorrect diagnosis and consequent harmful intervention. Case presentation An 11-year-old girl manifested an incidental finding of hyperleukocytosis (WBC > 400 × 109/L), with 90% blast cells during routine pre-operative investigations for adenotonsillectomy. Initial investigations demonstrated elevated serum potassium levels (7.5 mmol/L), despite concomitantly normal levels in venous blood gas samples (3.9–4.4 mmol/L) and being clinically stable with normal 12-lead ECG. Surprisingly, plasma potassium level was exacerbated, in comparison to the serum level by > 1 mmol/L. This finding is consistent with reverse pseudohyperkalemia that is associated with hyperleukocytosis in acute leukemia that does not require any active intervention. Conclusion This case report emphasizes the significance of interpreting potassium levels accurately, preferably utilizing whole-blood potassium level over serum and plasma level in newly diagnosed leukemia cases with hyperleukocytosis. Additionally, having a high index for the possibility of reverse pseudohyperkalemia, secondary to leakage from fragile leukocytes, avoids unnecessary treatment that might cause harm to the patient.

A case of Sphingomonas paucimobilis causing peritoneal dialysis-associated peritonitis and review of the literature

Background Peritoneal dialysis (PD)-associated peritonitis caused by Sphingomonas paucimobilis (S. paucimobilis) is very rare, and most of the characteristics of such cases are still unknown. Case presentation An 80-year-old Japanese woman on PD was diagnosed with PD-associated peritonitis and received ceftazidime and cefazolin. The number of cells in the peritoneal dialysate decreased quickly. However, because S. paucimobilis was detected, the antibiotic was changed to meropenem according to the susceptibility test results. She was treated with meropenem for two weeks and discharged. After 21 days, she was hospitalized for relapsing peritonitis. S. paucimobilis was detected again, and improvement after the administration of meropenem was poor, eventually resulting in catheter removal. Conclusions S. paucimobilis may be resistant to empirical antibiotics; furthermore, catheter removal may still be required, even with sensitive-antibiotic treatment.

Fear of falling and physical activity in hemodialysis patients: a pilot study

Background Hemodialysis (HD) patients are at a high risk of falls and fractures. The amount of physical activity (PA) they perform may be limited by psychosomatic factors associated with fear of falling, leading to frailty progression. This study aimed to clarify the relationship between fear of falling and PA in patients undergoing HD. Methods This cross-sectional study included 46 HD patients. Fear of falling was evaluated using the Modified Falls Efficacy Scale (MFES). A 3-axis accelerometer was used to measure PA, including number of steps; 1 to 1.9 METs = static PA, 2 to 2.9 = light PA, and 3 or more = moderate to vigorous PA (MVPA). We examined correlation of MFES with each type of PA. Factors affecting fear of falling were determined using multiple regression analysis. Results The median MFES was 9.2 (7.4, 10.0). MFES was associated with the number of steps (r = 0.608, p < 0.001), light PA (r = 0.421, p = 0.004), and MVPA (r = 0.546, p < 0.001). Eighteen participants (39.1%) experienced at least one fall in a year and had lower MFES than the non-fall group (fall group: 7.4 [5.1, 9.0] vs. non-fall group: 9.7 [8.5, 10.0], p < 0.001). Multiple regression analysis showed that MFES was independently associated with the number of steps (B = 279.7, 95% confidence interval [CI] = 90.5–469.0, p = 0.005) and MVPA (B = 3.52, 95% CI = 1.14–5.90, p = 0.005), respectively. Conclusions Fear of falling was associated with amount of PA among patients undergoing HD. Interventions that target the fear of falling may be effective in reducing HD patients’ fall risk by enhancing PA.