Dialysis Ward Research Articles

Relative Frequency of Staphylococcal Carriage and Antibiotic Sensitivity of Isolated Staphylococci in Hemodialysis Patients in Shiraz, Iran

Objective: The purpose of this study was to determine the nasal carriage rate of Staphylococcus aureus in hemodialysis patients and the antibiogram of all isolated S. aureus from carriers. Subjects and Methods: A cross-sectional study was carried out from May to September 2007. 130 patients (49 females, 81 males; mean age 55.6 ± 15.2 years) with chronic renal failure were included in the study. The patients had undergone hemodialysis for at least 12 months in the dialysis ward of Faghihi Hospital, a referral center in Shiraz, Iran. Swab specimens were taken from the anterior nares and skin of the patients and cultured microbiologically. Next, antibiotic susceptibility tests were performed for all of the isolated S. aureus. Results: 32 (24.6%) patients (95% CI 17.5–32.9%) were nasal carriers of S. aureus versus 98 (75.4%) non-carriers. S. aureus was also isolated from skin of 5 (3.8%) patients who were nasal carriers as well. The isolated S. aureus were 100, 97.3, 73.0, 70.3, 40.5 and 21.6% sensitive to vancomycin, rifampin, ciprofloxacin, tetracycline, methicillin and erythromycin, respectively. Conclusion: Because the nasal carriage rate of S. aureus observed in dialysis patients in this study was relatively high, we recommend screening for S. aureus in hemodialysis patients to enable prompt prevention strategies.

When the state and your kidneys fail: Political etiologies in an Egyptian dialysis ward

ABSTRACTIn this article, I describe how poor Egyptian kidney‐disease patients understand and experience their illness in terms of Egypt's larger social, economic, and political ills. The suffering that patients in end‐stage renal failure endure, as they articulate it, extends beyond the pathological kidney and implicates corrupt institutions, polluted water, the mismanagement of toxic waste, and unsafe food. End‐stage kidney failure patients in Egypt depend on state‐provided medical services, which they deeply mistrust. In this context, they understand the breakdown of their kidneys, their dialysis machines, and their bodies as a direct outcome of the breakdown of the welfare state. I argue that patients' perceptions of their disease and their mistrust of medical treatment and state service provision should make us reconsider how all etiologies are political. Further, the “political etiologies” in this case inform ethical decisions about kidney transplantation and maintaining life on dialysis. [bioethics, the body, kidney disease, organ transplantation, state welfare, neoliberalism, Egypt]

The long-term dialysis patient with purple-blue toes**This paper was written in memory of Gianni d'Angelo, a dear friend and teacher.

The article depicts the situation of a 57-year-old Caucasian man, on renal replacement therapy since 1979 because of membranous and proliferative glomerulonephritis, who came to the hospital dialysis ward complaining of severe foot pain. His long clinical history included about 17 years on dialysis and 8 years of transplantation (three kidney grafts, which failed because of various combinations of acute rejection and chronic allograft disease). He experienced a myocardial infarction at the age of 45 and angina at the time of the third graft. Three months before the episode described here, he suffered a worsening of claudicatio intermittens and was treated by angioplasty, with stenting of the left iliac artery and the right superficial femoral artery; the results of the intervention were considered highly satisfactory. However, severe diffuse vascular disease was present at all the levels examined (Figure 1). Despite an initial improvement, he experienced recurrence of local pain after a couple of months and, in the last few days, had noticed a bluish discolouration of his feet (Figure 2). The most likely clinical diagnosis is cholesterol crystal emboli syndrome, superimposed on severe diffuse peripheral vascular disease. The differential diagnosis of subacute painful vascular lesions, as presented by our patient, takes into account both the evolution of peripheral vascular disease and vasculitis or vasculitis-like lesions. The vascular echo Doppler, performed taking into account the hypothesis of closure of the previously treated vessels, was unchanged and revealed the presence of diffuse vessel lesions but no critical stenosis, thus ruling out ‘simple’ large/medium vessel occlusion. As shown in Figure 2, the patient presented diffuse livedo reticularis and two small necrotic lesions. Livedo is a generic sign, common to several systemic microvascular diseases including anti-phospholipid antibodies, calciphylaxis and vasculitis [1]. It is a major form of cutaneous involvement in cholesterol crystal emboli syndrome, together with ‘blue toes’, vasculitis-like lesions and necrotic lesions [1–4]. Concerning the necrotic lesions, an interesting diagnostic clue came from the location—while ‘pure’ obstructive diseases usually lead to very distal lesions, microembolic lesions often appear in more capricious ‘non-terminal’ sites, as seen in the figures [1].

Characteristics of wet work in nurses

Nursing is known for its high prevalence of hand dermatitis, mainly caused by the intense exposure to wet work in nursing activities. We aimed to study the characteristics of wet work exposure in nursing. Trained observers monitored the duration and frequency of different wet work activities in 45 randomly chosen nurses from different wards during a morning shift, using a method of continuous observation based on labour-observation techniques. Wet work in intensive care units accounted for 24% of the overall morning shift duration, with a frequency of 49 incidents. This was 16% in dialysis wards, with a frequency of 30 incidents, and 9% on regular wards, with a frequency of 39 incidents. The wet work activities had short mean duration cycles. The mean duration of occlusion by gloves was 3.1 min on regular wards and 6.7 min in intensive care units. The characteristics of wet work in nurses differed substantially, depending on the ward. According to the German regulation TRGS 531, our observations classify nursing as a wet work occupation, due to the frequency of wet work rather than its duration. The mean duration of occlusion in our observations was short, which makes an occlusion-induced irritating effect doubtful. Reduction in wet work exposure in nursing on regular wards could focus on the reduction of the frequency of hand-washing and patient-washing. We suggest increasing the use of gloves for patient washing. Although this will increase exposure to occlusion from gloves, it may reduce the frequency of exposure to water and soap by about a quarter.

Citrate for long-term hemodialysis: Prospective study of 1,009 consecutive high-flux treatments in 59 patients

Regional citrate anticoagulation during hemodialysis is performed in selected patients at highly specialized units. We postulated that routine use of citrate at a long-term dialysis ward is safe and efficient. During a 2-year period, we studied 1,009 consecutive citrate-anticoagulated high-flux hemodialysis treatments performed in 59 patients at our long-term dialysis ward. We used a simple citrate infusion protocol, calcium-free dialysate, and intravenous calcium substitution. Simple and clear algorithms allowed adjustments of the calcium substitution rate and dialysate settings by the attending nurse. Adverse events; indications for citrate anticoagulation; clotting; technical data; blood ionized calcium, sodium, and potassium levels; and acid-base homeostasis were analyzed prospectively. Of the treatments, 99.6% were accomplished successfully. Two adverse events were attributed to citrate use. Overall, ionized calcium levels were stable during the procedures and electrolyte and acid-base balances were well controlled. The use of central venous catheters for dialysis was associated with paradoxical behavior of ionized calcium levels (increasing blood ionized calcium levels despite decreased calcium infusion). Anticoagulation was excellent. Routine use of citrate anticoagulation in the setting of a long-term hemodialysis ward is safe and efficient. Measured ionized calcium levels should be interpreted with care if central venous catheters are used for vascular access because they could be biased by recirculation.

FC03.6 Exposure of the hands to wet work in nurses

Background/objectives: Prevention of hand dermatitis among nurses can be achieved by reduction of wet work exposure. Kwodledge about the amout of wet work in nursing is import implementing hand dermatitis prevention plans. Wet work exposure in nursing can be assessed by questionnaire or observation.Method: Duration and frequency of wet work activities were assessed by a questionnaire in a population of 1471 nurses.In addition a randomly chosen sample of 53 nurses from this population was observed on duration and frequency of wet work during 112 different morning shifts.Results: questionnaire: wet work between 26 minutes (at a dialysis ward) and 100 minutes (in nursing homes). For frequency a range between 12 and 21 episodes of wet hands during morning shifts was reported. In nursing homes and regular wards gloves were reported to be used less than once during a shift.Observation: A duration of wet work of 10 minutes (dialysis ward), 28 minutes (regular ward) and 19 minutes (I.C.‐unit) and 45 minutes in a nursing home. Frequency: between 19 and 43 episodes of wet hands during morning shifts.Conclusions: A questionnaire does not accurately assess the quantity of wet activities; it overestimates the duration of wet work and underestimates the frequency of wet work. On regular wards the exposure to irritants is mainly associated with the frequency of wet hands instead of the duration of wet hands. On specialised care units skin exposure is mainly a matter of occlusion by gloves.

FC03.5 Characteristics of wet work in nurses

Background/objectives: The health care sector is known for its high prevalence of hand dermatitis, mainly because of the high exposure to wet work in nursing activities. Wet work can be activities with wet skin and activities with glove use (skin occlusion). A prevention program to reduce wet work exposure should be based on knowledge about activities that are components of wet work. We observed the frequency and duration of skin exposures to irritants with nursing activities.Method: Duration and frequency wet work activities were assessed in parts of the health care sector: 53 randomly chosen nurses were observed during their morning shift. Hand skin exposure to water, soap/detergents and occlusion by using gloves were recorded during 112 different 8‐hour morning shifts.Results: In nursing wet work activities make up 9%(dialysis ward), 16%(regular ward) and 24%(I.C.‐unit) of the duration of one shift. On a regular ward duration of wet work is mainly divided into 34% patient washing, 31% glove use and 26% hand washing. These main wet work activities have a short exposure cycle of 1.4–3.6 minutes. Hand washing, excluding the use of hand alcohol, and patient washing (without gloves) form both one third of the frequency of wet work activities.Conclusions: Wet work activities take up a substantial portion of nursing activities and are characterised by frequent short‐term exposures. Effective prevention programs on reducing the risk of hand dermatitis in nursing should primarily focus on the high frequencies of hand washing and patient washing. Using gloves in the procedure of patient washing will reduce the frequency of exposure to water and soap with 24%, at the expense of increasing exposure to occlusion by these gloves.

Detection and prevention of hepatitis C in dialysis patients and renal transplant recipients. A long-term follow up (1989-January 1997).

Hepatitis C is frequent problem in dialysis wards. A long time (1989-97) follow up of hepatitis C virus (HCV) infection in a Swedish nephrology unit was performed with anti-HCV screening, confirmatory antibody tests, viral RNA detection and molecular characterization. Case histories were reviewed with focus, onset of infection, liver morbidity and mortality. In October 1991, 10% (19 of 184) of the patients in the unit (haemodialysis-, peritoneal dialysis and transplanted patients) were verified or suspected HCV carriers, whilst the number at the end of 1996 was 8%, (13 of 157). Most patients were infected before 1991 but only in one case from a known HCV-infected blood donor. No new HCV infections associated with haemodialysis occurred during the study period. A total of 13 of 24 viremic patients had HCV genotype 2b, a pattern suggesting nosocomial transmission. This was further supported by phylogenetic analysis of HCV viral isolates in seven. HCV viremia was also common in patients with an incomplete anti-HCV antibody pattern as 8 of the 12 indeterminant sera were HCV-RNA positive. Awareness, prevention, identification of infected patients and donor testing limited transmission. Indeterminant recombinant immunoblot assays (RIBA)-results should be regarded with caution as a result of the relative immunodeficiency in uremic patients. Our data indicate nosocomial transmission in several patients.

Quality of water used for haemodialysis: bacteriological and chemical parameters.

The bacterial and chemical contamination of dialysate fluids are important problems in haemodialysis therapy and may be caused by the water used for dialysate preparation. We performed a survey of the microbiological and chemical quality of the water used in seven dialysis wards. Special attention was paid to the effects of each water treatment step, for example ion exchange, reverse osmosis and UV disinfection, on the number of bacteria (measured as colony forming units, CFU), the amount of endotoxin (endotoxin units, EU) and various chemical parameters, the main focus being on calcium, magnesium, sulphate, aluminium and heavy metals. CFU values exceeding the European Pharmacopeia value, determined at an incubation temperature of 22 degrees C, were found in the samples of raw water (20.0%, n=25), after ion exchange (66.7%, n=12), after reverse osmosis (33.3%, n=18) and also in samples of the dialysis water taken at the inlets (12.5%, n=40) and outlets (50.0%, n=18) of the machines. Whereas all raw water samples from the wards showed high mean values for endotoxin (0.56-9.10 EU/ml) and the endotoxin levels were often enhanced after ion exchange (0.13- >9.49 EU/ml), treatment by reverse osmosis led to a satisfactory decrease in endotoxin in all samples (<0.03 EU/ml). Sufficient reductions in calcium, magnesium and sulphate could only be achieved by the combined application of ion exchange and reverse osmosis. Mercury contamination was observed in the samples after ion exchange at three treatment plants, this was possibly caused by polluted regenerants. Increased amounts of aluminium, copper and zinc were found in water samples from different sites in the treatment systems and were caused by materials in contact with the water. A sufficient chemical water purification treatment system should consist of ion exchange and reverse osmosis. Attention has to be paid to the suitability of materials in contact with the water and of the chemicals used, for example regenerants or corrosion inhibitors. From the microbiological point of view, a safety UV disinfection step in the water-treatment system is favourable. To avoid bacterial recontamination periodic cleaning and disinfecting of the water-treatment and distribution systems, as well as the dialysis machine are essential. There is the need for complete guidelines regarding dialysis water that include all relevant chemical and microbiological parameters. Based on this standard, periodic examination of the water after each treatment step has to be performed.

Incidence and prevalence of hepatitis B in France

Reporting of hepatitis B is not compulsory in France, but it is estimated that 8500–9000 acute cases and 100 000 hepatitis B infections occur every year. Seroprevalence studies have been carried out in selected populations. Every blood donation is screened for HBsAg, alanine aminotransferase elevation and anti-HBc antibody. Prevalence of HBsAg has declined from 13.9 positive donations in 1986 per 10 000 to 5.3 in 1991. In pregnant women, overall seroprevalence is estimated at 0.8–1%, which represents more than 5000 children born each year to carrier mothers. Screening of HBsAg for all women when six months pregnant is now compulsory. Heterosexual patients at STD clinics were shown to have a very high risk of being infected with hepatitis B virus, with a chronic carrier rate of 4–5%. In hospital employees before the introduction of vaccination, the overall incidence of hepatitis B was 100–300 acute cases per 100 000 employees per year. Risk varied according to exposure to blood; the highest incidence was found in nurses in dialysis wards. Vaccination against hepatitis B is now compulsory for all hospital and laboratory workers and medical and paramedical students. In preventive medicine consultants, routine medical check-up showed an overall HBV prevalence of 2.2% and a carrier rate of 0.3% in men and 0.1% in women. Immunization of all newborns and adolescents has recently been adopted in France, vaccination at school of adolescents aged 10–11 years being the main target.

Detection of antibodies to hepatits C virus in dialysis patients

Dialysis patients are at risk for infection by a variety of blood-borne agents transmitted within dialysis units. The development of the hepatitis C virus (HCV) screening test prompted many studies on the prevalence of anti-HCV among dialysis patients. The authors have evaluated the prevalence of anti-HCV in 405 hemodialysis patients both by Elisa screening and 4-RIBA test system with a follow-up of two years. The study showed a difference in the incidence of antibodies to HCV by year. In 1990, 15.2% were positive with an increase to 20.8% in 1991. There was an increase of 5% in dialysis patients and only 1.9% in the personnel working in the dialysis ward. Another control group of volunteers did not show any positivity. In addition, the correlations of the antibodies against HCV with markers of hepatitis B virus (HBV) and history of transfusion were evaluated. These findings suggest that the patients found to be positive should be dialyzed on separate machines and special precautions must be undertaken to reduce the risk of transmission.

Computer aided training in a renal dialysis ward—a novel approach

This paper describes a novel approach to training renal dialysis patients in the use and management of life-saving kidney dialysis machines. The product of this approach has been the development of a low-cost sophisticated, audio-enhanced, hardware/software tool. It can be used by teachers and workers in many areas and disciplines, although the tool was originally developed for the world of renal medicine. The tool provides a structured environment in which lessons can be created quickly and cheaply. The dubbing of audio onto this lession is achieved in a similar structured manner.

Computer aided training in a renal dialysis ward—A unique approach

This paper describes a novel approach to training renal dialysis patients in the use and management of life-saving kidney dialysis machines. The product of this approach has been the development of a low-cost sophisticated, audio-enhanced, hardware/software tool. It can be used by teachers and workers in many areas and disciplines, although the tool was originally developed for the world of renal medicine. The tool provides a structured environment in which lessons can be created quickly and cheaply. The dubbing of audio onto this lesson is achieved in a similar structured manner.