European Best Research Articles

Reference Change Values for Sodium Are Ignored by the American and European Treatment Guidelines for Hyponatremia

Updated revised expert panel recommendations on the evaluation and treatment of hyponatremia were published in the United States in 2013 (1). In 2014, a separate set of guidelines were issued by a group representing the European Society of Intensive Care Medicine, the European Society of Endocrinology, and the European Renal Association–European Dialysis and Transplant Association represented by European Renal Best Practice (2). The recommended rates of correction of chronic hyponatremia from the US group are 4–8 mmol/L per day for patients at low risk of osmotic demyelinating syndrome (ODS)4 and 4–6 mmol/L per day if that risk is high. The limits not to exceed are 8 mmol/L in any 24-h period when the ODS risk is high, and when the ODS risk is low, 10–12 mmol/L in any 24-h period and 18 mmol/L in any 48-h period. If 8 mmol/L is exceeded in a 24-h period, there should be no active therapeutic intervention for the next 24 h (1). Regarding frequency of sodium analysis, serum sodium should be measured at 4- to 6-h intervals until mildly hyponatremic concentrations ≥125 mmol/L have been reached. The section on counteracting overcorrection of chronic hyponatremia by >6–8 mmol/L in the first 24 h of therapy discusses the uses of 2–4 μg desmopressin with repeated 3-mL/kg infusions of 5% dextrose in water administered over 1 h combined with the measurement of serum sodium after each infusion, i.e., hourly until the therapeutic target for the patient has been reached when the starting serum sodium is <120 mmol/L. When using vasopressin receptor antagonists (vaptans) and when treating diuretic-induced hyponatremia, measurements of serum sodium are set at a 6- to 8-h minimum until a stable sodium value >125 mmol/L has been reached. When diuretics have caused hyponatremia-induced seizures, hypertonic saline is recommended to raise the …

'To block or not to block'; whether to continue renin-angiotensin-aldosterone system blockade in advanced chronic kidney disease.

In patients with chronic kidney disease (CKD), proteinuria and high blood pressure predict cardiovascular morbidity, mortality and progression to end-stage kidney disease (ESKD) [1–3]. A large evidence base now supports the use of blockers of the renin–angiotensin–aldosterone system (RAAS) to lower blood pressure, reduce proteinuria and retard the progressive loss of renal function in this population [4–7]. Evidence for renoprotection, and the associated individual and economic benefits, is particularly strong in patients with diabetes and diabetic nephropathy, and has been endorsed in guidelines including the 2012 ‘KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease’, which recommend the use of RAAS inhibitors as first-line treatment in all adult CKD patients with blood pressure >130/80 and albuminuria >30 mg/24-h [8, 9]. However, few patients with advanced CKD were included in the trials on which the guidelines were based [10], raising concerns about the generalizability of recommendations across the spectrum of CKD. Of note, the European Renal Best Practice position statement on the 2012 KDIGO hypertension guidelines specifically questions the continuous use of RAAS blocking drugs into advanced (stage 4 and 5) CKD [11]. Studies showing an accelerated disease progression in patients with advanced CKD, treated with ACE inhibitors (ACEi) and ARBs [12, 13], have added to these concerns, as has an observational study from the UK which showed substantial and sustained improvement in estimated glomerular filtration rate (eGFR) following withdrawal of RAAS blockade in 52 elderly patients with CKD stage 4–5 [14]. Furthermore, rapidly declining eGFR may be an independent predictor of cardiovascular events and mortality [15, 16] in CKD, lending support to the view that the continued use of ACEi and ARBs in CKD stage 4 and 5 may be harmful. In practice, ACEi and ARB therapy may be discontinued in advanced CKD, most commonly due to the development of hyperkalaemia, or following a rapid decline in eGFR; and often in the setting of dehydration or an intercurrent illness, and in the elderly [10]. Drug withdrawal was a frequent event in the pivotal trials of ACEi and ARBs in CKD. In The Reduction of Endpoints in NIDDM with Angiotensin II Antagonist Losartan (RENAAL) Study, 46.5% of patients in the treatment arm discontinued losartan [4]. A recent retrospective cohort study of 3039 patients initiated on an ACEi included 165 patients with serum creatinine ≥177 μmol/L (2 mg/dL) before treatment. In this group, 11.5% discontinued the drug within the first 3 months, and only 30% were still on the ACEi after 1 year [17]. It is unclear whether stopping therapy may have additional, potentially adverse, effects due to exposure of patients to an activated RAAS, and the effects of unopposed angiotensin II on arterioles, including glomerular efferent arterioles, resulting in an increased systemic and glomerular hypertension [18]. In animal experiments, the natriuretic and blood pressure lowering effects of ACE inhibitionmay last for weeks after withdrawal [19]. Whether long-term suppression, or post-withdrawal activation, of the RAAS has effects on inflammation, cell proliferation, endothelial function, cardiac hypertrophy/remodelling or renal fibrosis in humans [18] is not known. Thus, there is considerable uncertainty about the use, and effects, of blockade of the RAAS, and specifically the possible benefits or adverse consequences of withdrawal of ACEi and ARBs, in patients with CKD stage 4 and 5. To address this uncertainty, Bhandari et al. [20] describe the protocol of the ongoing, multicentre, open-labelled, randomized controlled ‘STOP-ACEi’ trial. This study will include 410 patients with progressive CKD stage 4 and 5 (not requiring renal replacement therapy), treated with an ACEi, an ARB or

Nephrologists' perceptions regarding dialysis withdrawal and palliative care in Europe: lessons from a European Renal Best Practice survey.

There is a variation in dialysis withdrawal rates, but reasons for this variation across European countries are largely unknown. We therefore surveyed nephrologists' perceptions of factors concerning dialysis withdrawal and palliative care and explored relationships between these perceptions and reports of whether withdrawal actually occurred in practice. We developed a 33-item electronic survey, disseminated via an email blast to all European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) members. In our data analyses, we distinguished those respondents who reported occurrence from those reporting no dialysis withdrawal in their unit. With multilevel logistic regression, we investigated the association between respondents' characteristics and perceptions and whether they reported occurrence of dialysis withdrawal or not. Five hundred and twenty-eight nephrologists from 45 countries completed the questionnaire; 42% reported occurrence of withdrawal in their unit in the past year, and 56% perceived that stopping life-prolonging treatment in terminally ill patients was allowed. Few respondents reported presence in their unit of protocols on withdrawal decision making (7%) or palliative care (10%) or the common involvement of a geriatrician in withdrawal decisions (10%). The majority stated that palliative care had not been part of their core curriculum (74%) and that they had not recently attended continuous medical education sessions on this topic (73%). Respondents from Eastern and Southern Europe had a 42 and 40% lower probability, respectively, of reporting withdrawal compared with those from North European countries. Working in a public centre [odds ratio (OR), 2.41; 95% confidence interval (CI), 1.36-4.25] and respondents' perception that stopping life-prolonging treatment in terminally ill patients was allowed (OR, 1.96; 95% CI, 1.23-3.12), that withdrawal decisions were commonly shared between doctor and patient (OR, 1.97; 95% CI, 1.26-3.08) and that palliative care was reimbursed (OR, 1.81; 95% CI, 1.16-2.83) increased the odds of reporting occurrence of withdrawal. Reports of dialysis withdrawal occurrence varied between European countries. Occurrence reports were more likely if respondents worked in a public centre, if stopping life-prolonging treatments was perceived as allowed, if withdrawal decisions were considered shared between doctors and patients and if reimbursement of palliative care was believed to be in place. There is room for improvement regarding protocols on withdrawal and palliative care processes and regarding nephrologists' training and education on end-of-life care.

Setting Priorities for Optimizing Vascular Access Decision Making--An International Survey of Patients and Clinicians.

BackgroundMany decisions around vascular access for haemodialysis warrant a collaborative treatment decision-making process, involving both clinician and patient. Yet, patients’ experiences in this regard have been suboptimal. Although clinical practice guidelines could facilitate collaborative decision making, they often focus on the clinicians’ side of the process, while failing to address the patients’ perspective. The objective of this study was to explore and compare kidney patients’ and clinicians’ views on what vascular access-related decisions deserved priority for developing guidelines that will contribute to optimizing collaborative decision making.MethodsIn the context of updating their vascular access guideline, European Renal Best Practice surveyed an international panel of 85 kidney patients, 687 nephrologists, 194 nurses, and 140 surgeons/radiologists. In an electronic questionnaire, respondents rated 42 vascular access-related topics on a 5-point Likert scale. Based on mean standardized ratings, we compared priority ratings between patients and each clinician group.ResultsSelection of access type and site, as well as prevention of access infections received top priority across all respondent groups. Patients generally assigned higher priority to decisions regarding managing adverse effects of arteriovenous access and patient involvement in care, while clinicians more often prioritized decisions around sustaining patients’ access options, technical aspects of access creation, and optimizing fistula maturation and patency.ConclusionApart from identifying the most pressing knowledge gaps, our study provides pointers for developing guidelines that may improve healthcare professionals’ understanding of when to involve patients along the vascular access pathway.

The relationship between symptoms and blood pressure during maintenance hemodialysis.

Intradialytic hypotension (IDH) is a detrimental complication of maintenance hemodialysis, but how it is defined and reported varies widely in the literature. European Best Practice Guideline and Kidney Disease Outcomes Quality Initiative guidelines require symptoms and a mitigating intervention to fulfill the diagnosis, but morbidity and mortality outcomes are largely based on blood pressure alone. Furthermore, little is known about the incidence of asymptomatic hypotension, which may be an important cause of hypoperfusion injury and impaired outcome. Seventy-seven patients were studied over 456 dialysis sessions. Blood pressure was measured at 15-minute intervals throughout the session and compared with post-dialysis symptom questionnaire results using mixed modeling to adjust for repeated measures in the same patient. The frequency of asymptomatic hypotension was estimated by logistic regression using a variety of commonly cited blood pressure metrics that describe IDH. In 113 sessions (25%) where symptoms were recorded on the questionnaire, these appear not to have been reported to dialysis staff. When symptoms were reported (293 sessions [64%]), an intervention invariably followed. Dizziness and cramp were strongly associated with changes in systolic blood pressure (SBP), but not diastolic blood pressure. Nausea occurred more frequently in younger patients but was not associated with falls in blood pressure. Thresholds that maximized the probability of an intervention rather than a session remaining asymptomatic were SBP <100 mmHg or a 20% reduction in SBP from baseline. The probability of SBP falling to <100 mmHg in an asymptomatic session was 0.23. Symptoms are frequently not reported by patients who are hypotensive during hemodialysis, which leads to an underestimation of IDH if symptom-based definitions are used. A revised definition of IDH excluding patient-reported symptoms would be in line with literature reporting morbidity and mortality outcomes and include sessions in which potentially detrimental asymptomatic hypotension occurs.

European Renal Best Practice Guideline on Kidney Donor and Recipient Evaluation and Perioperative Care

Abstract The Clinical Practice Guideline on evaluation of the kidney donor and transplant recipient was developed following a rigorous methodological approach aiming to provide information and aid decision-making to the transplant professionals. Thus, this document should help caregivers to improve the quality of care they deliver to patients with no intention it is defined as a standard of care. In this short version of the guidelines we present 112 statements about the evaluation of the kidney transplant candidate as well as the potential deceased and living donor, the immunological work-up of kidney donors and recipients and the perioperative recipient care. The extended version of the guidelines with methods, rationale and references is published in Nephrol Dial Transplant (2013) 28: i1-i71; doi: 10.1093/ndt/gft218 and can be downloaded freely from http://www.oxfordjournals.org/our_journals/ndt/era_edta.html.

Nephrology Crosswords: Hemodialysis

ACROSS 1 These dialysis membranes clear 10–20 kDa solutes and have a pore size of 3–6 nm. (8) 3 Low concentrations of potassium and ____ have been associated with sudden cardiac death in dialysis patients. (7) 8 This alternate form of anticoagulation on hemodialysis has been speculated to worsen secondary hyperparathyroidism. (7) 10 This large randomized trial showed that statins had no reduction in either overall or cardiovascular mortality in patients with chronic kidney disease who reached end-stage renal disease. (5) 12 In the Frequent Hemodialysis Network trial that looked at in-center hemodialysis six times per week versus three times per week, the group that had more frequent dialysis had more ___ related complications. (6) 13 After initiating dialysis, the mortality is the highest in the first ___ weeks. (3) 14 This uremic toxin is toxic to endothelium and leads to vasculogenesis. (12) DOWN 1 ____ impairs the absorption and recycling of iron and inhibits the proliferation of erythroid progenitor cells. (8) 2 This landmark trial showed that patients undergoing hemodialysis thrice weekly appear to have no major benefit from a higher dialysis dose than that recommended by current U.S. guidelines or from the use of a high-flux membrane. (4) 4 Frequency ____ of dialysis and membrane type are important considerations for removal of low-molecular-weight uremic toxins. (6) 5 Low ____ concentrations have been shown to be associated with symptomatic or asymptomatic intradialytic hypotension. (9) 6 Based on the European Best Practice Guidelines, the minimum frequency and dose of dialysis is ___ hours per treatment three times per week for most patients. (4) 7 Relative plasma volume may be a useful technique to assess __ _____ among hypertensive hemodialysis patients. (9) 9 The most common cause of end-stage kidney disease in the United States. (8) 11 Dialysate ____ is a potential culprit substance that leads to intradialytic hypotension. (7) 12 This uremic protein-bound toxin reduces nitric oxide synthesis and provokes an increase in systemic vascular resistance and hypertension. (Abbrv) (4) http://www.kidney-international.org m a k e y o u r d i a g n o s i s

Clinical Practice Guideline on Diagnosis and Treatment of Hyponatraemia

Abstract Hyponatraemia, defined as a serum sodium concentration &lt;135 mmol/l, is the most common disorder of body fuid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution-and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.

A survey on the methodological processes and policies of renal guideline groups as a first step to harmonize renal guidelines.

Worldwide, several bodies produce renal guidelines, potentially leading to duplication of effort while other topics may remain uncovered. A collaborative work plan could improve efficiency and impact, but requires a common approved methodology. The aim of this study was to identify organizational and methodological similarities and differences among seven major renal guideline bodies to identify methodological barriers to a collaborative effort. An electronic 62-item survey with questions based on the Institute of Medicine standards for guidelines was completed by representatives of seven major organizations producing renal guidelines: the Canadian Society of Nephrology (CSN), European Renal Best Practice (ERBP), Kidney Disease Improving Global Outcome (KDIGO), Kidney Health Australia-Caring for Australians with Renal Insufficiency (KHA-CARI), Kidney Disease Outcome Quality Initiative (KDOQI), Sociedad Latino-Americano de Nefrologia e Hipertension (SLANH) and United Kingdom Renal Association (UK-RA). Five of the seven groups conduct systematic searches for evidence, two include detailed critical appraisal and all use the GRADE framework. Five have public review of the guideline draft. Guidelines are updated as new evidence comes up in all, and/or after a specified time frame has passed (N = 3). Commentaries or position statements on guidelines published by other groups are produced by five, with the ADAPTE framework (N = 1) and the AGREEII (N = 2) used by some. Funding is from their parent organizations (N = 5) or directly from industry (N = 2). None allow funders to influence topic selection or guideline content. The budgets to develop a full guideline vary from $2000 to $500 000. Guideline development groups vary in size from <5 (N = 1) to 13-20 persons (N = 3). Three explicitly seek patient perspectives, for example, by involving patients in the scoping process, and four incorporate health economic considerations. All provide training in methodology for guideline development groups and six make their methods public. All try to avoid overlapping topics already planned or published by others. There is no common conflict of interest policy. Overall, there is considerable commonality in methods and approaches in renal guideline development by the different organizations, although some procedural differences remain. As the financial and human resource costs of guideline production are high, a collaborative approach is required to maximize impact and develop a sustainable work plan. Coming to consensus on methods and procedures is the first step and appears feasible.

European Renal Best Practice Guideline on kidney donor and recipient evaluation and perioperative care.

The European Best Practice Guideline group (EBPG) issued guidelines on the evaluation and selection of kidney donor and kidney transplant candidates, as well as post-transplant recipient care, in the year 2000 and 2002. The new European Renal Best Practice board decided in 2009 that these guidelines needed updating. In order to avoid duplication of efforts with kidney disease improving global outcomes, which published in 2009 clinical practice guidelines on the post-transplant care of kidney transplant recipients, we did not address these issues in the present guidelines.The guideline was developed following a rigorous methodological approach: (i) identification of clinical questions, (ii) prioritization of questions, (iii) systematic literature review and critical appraisal of available evidence and (iv) formulation of recommendations and grading according to Grades of Recommendation Assessment, Development, and Evaluation (GRADE). The strength of each recommendation is rated 1 or 2, with 1 being a 'We recommend' statement, and 2 being a 'We suggest' statement. In addition, each statement is assigned an overall grade for the quality of evidence: A (high), B (moderate), C (low) or D (very low). The guideline makes recommendations for the evaluation of the kidney transplant candidate as well as the potential deceased and living donor, the immunological work-up of kidney donors and recipients and perioperative recipient care.All together, the work group issued 112 statements. There were 51 (45%) recommendations graded '1', 18 (16%) were graded '2' and 43 (38%) statements were not graded. There were 0 (0%) recommendations graded '1A', 15 (13%) were '1B', 19 (17%) '1C' and 17 (15%) '1D'. None (0%) were graded '2A', 1 (0.9%) was '2B', 8 (7%) were '2C' and 9 (8%) '2D'. Limitations of the evidence, especially the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.We present here the complete recommendations about the evaluation of the kidney transplant candidate as well as the potential deceased and living donor, the immunological work-up of kidney donors and recipients and the perioperative recipient care. We hope that this document will help caregivers to improve the quality of care they deliver to patients. The full version with methods, rationale and references is published in Nephrol Dial Transplant (2013) 28: i1-i71; doi: 10.1093/ndt/gft218 and can be downloaded freely from http://www.oxfordjournals.org/our_journals/ndt/era_edta.html.

Raymond Vanholder: a titan of uraemic toxicity

Raymond Vanholder: a titan of uraemic toxicity

Hemodialysis tunneled central venous catheters: five-year outcome analysis.

Tunneled central venous catheters (tCVCs) are considered inferior to arteriovenous fistulas (AVFs) and grafts in all nephrology guidelines. However, they are being increasingly used as hemodialysis vascular access. The purpose of this study was to document the natural history of tCVCs and determine the rate and type of catheter replacement. This was a prospective study of 141 patients who underwent hemodialysis with tCVCs between January 2008 and December 2012. The patients used 154 tCVCs. Standard protocols about management of tCVCs, according to European Renal Best Practice, were well established. All catheters were inserted in the internal jugular vein. Criteria for catheter removal were persistent bloodstream infection, detection of an outbreak of catheter-related bloodstream (CRBS) infections, or catheter dysfunction. Event rates were calculated per 1,000 catheter days; tCVC cumulative survival was estimated by Kaplan-Meier analysis. Catheter replacement occurred in 15 patients (0.29 per 1,000 days); catheter dysfunction was the main cause of replacement (0.18 per 1,000 days), typically within 12 months of surgical insertion. A total of 53 CRBS events in 36 patients were identified (0.82 per 1,000 days); 17 organisms, most commonly Gram-positive pathogens, were isolated; 87% of CVC infections were treated by systemic antibiotics associated with lock therapy. tCVC cumulative survival was 91% at 1 year, 88% at 2 years and 85% at 4 years. Our data show a high survival rate of tCVCs in hemodialysis patients, with low incidence of catheter dysfunction and CRBS events. These data justify tCVC use for hemodialysis vascular access, also as first choice, especially in patients with exhausted peripheral access and limited life expectancy.

Risk of intradialytic hypotension in patients on thrice-weekly versus twice-weekly hemodialysis

Being afraid of inadequate dialysis, thrice-weekly HD has been regarded as a standard renal replacement therapy (RRT) for ESRD patients [1]. Nevertheless, twice-weekly HD remains prevalent in the developing countries and also could be found in some developed countries [2,3]. Thus far, scarce data are available for the clinical outcomes, especially intradialytic hypotension (IDH), of twice-weekly HD patients. Few studies have used a rigorous definition of IDH according to the European Best Practice Guidelines (EBPG), which defines as both a fall blood pressure and the occurrence of symptoms requiring an intervention [4].

European Renal Best Practice Guideline on Kidney Donor and Recipient Evaluation and Perioperative Care

Abstract The Clinical Practice Guideline on evaluation of the kidney donor and transplant recipient was developed following a rigorous methodological approach aiming to provide information and aid decision-making to the transplant professionals. Thus, this document should help caregivers to improve the quality of care they deliver to patients with no intention it is defined as a standard of care. In this short version of the guidelines we present 112 statements about the evaluation of the kidney transplant candidate as well as the potential deceased and living donor, the immunological work-up of kidney donors and recipients and the perioperative recipient care. The extended version of the guidelines with methods, rationale and references is published in Nephrol Dial Transplant (2013) 28: i1-i71; doi: 10.1093/ndt/gft218 and can be downloaded freely from http://www.oxfordjournals.org/our_journals/ndt/era_edta.html.

Clinical practice guideline on diagnosis and treatment of hyponatraemia

Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.

Clinical practice guideline on diagnosis and treatment of hyponatraemia

Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.

Clinical practice guideline on diagnosis and treatment of hyponatraemia

Hyponatraemia, defined as a serum sodium concentration <135 mmol/L, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. Hyponatraemia is present in 15-20% of emergency admissions to hospital and occurs in up to 20% of critically ill patients. Symptomatology may vary from subtle to severe or even life threatening. Despite this, the management of patients remains problematic. Against this background, the European Society of Intensive Care Medicine, the European Society of Endocrinology and the European Renal Association-European Dialysis and Transplant Association, represented by European Renal Best Practice have developed a Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia.

Are there better alternatives than haemoglobin A1c to estimate glycaemic control in the chronic kidney disease population?

Although measurement of haemoglobin A1c has become the cornerstone for diagnosing diabetes mellitus in routine clinical practice, the role of this biomarker in reflecting long-term glycaemic control in patients with chronic kidney disease has been questioned. Consensus review paper based on narrative literature review. As a different association between glycaemic control and morbidity/mortality might be observed in patients with and without renal insufficiency, the European Renal Best Practice, the official guideline body of the European Renal Association-European Dialysis and Transplant Association, presents the current knowledge and evidence of the use of alternative glycaemic markers (glycated albumin, fructosamine, 1,5-anhydroglucitol and continuous glucose monitoring). Although reference values of HbA1C might be different in patients with chronic kidney disease, it still remains the cornerstone as follow-up of longer term glycaemic control, as most clinical trials have used it as reference.

Nutritional status in stage V dialyzed patient versus CKD patient on conservative therapy across different economic status

Background: This aim of this multi-centric cross-sectional study was to assess the nutritional status in Indian chronic kidney disease (CKD) patients and to compare the nutritional indicators between stage 5 dialyzed (CKD-D) patients below the poverty line (BPL), and stage 3–4 non-dialyzed (CKD-ND) patients above (APL) and below the poverty line. Methods: Patients were selected from a government medical college hospital, a charity-based outpatient dialysis unit, and a non-profit tertiary care center. The study groups included BPL CKD-ND (n = 100), BPL CKD-D (n = 98), and APL CKD-ND (n = 92) patients, based on a cut-off of per capita income US $1.25 a day. Patients were enquired by a qualified renal dietitian about their pattern of diet, and daily energy and protein intake by 24 h recall method. Anthropometric measurements and biochemical investigations were made and compared. Results: Nutritional indicators were low in all three groups compared to those prescribed by European Best Practice Guidelines (EBPG). BPL CKD-D patients had low serum albumin levels (32.44444 ± 6.279961 g/L; p = 0.017) and 41.83% of them were underweight. The APL CKD-ND group registered the lowest mean daily energy (22.576 ± 6.289 kcal/kg/day) and protein intake (0.71 ± 0.06 g/kg/day), due to dietary restrictions imposed on them by themselves and unqualified renal dietitians. The APL group had better indicators of nutritional status in terms of mid-upper arm circumference (p = 0.001), triceps skin fold thickness (p < 0.001), and serum hemoglobin (p < 0.001). Conclusion: Several nutritional parameters were below the recommended international guidelines for all the three groups, though the high income group had better parameters from several indicators. There is an urgent need for nutritional counseling for CKD-D and CKD-ND patients.

Infection control in hemodialysis units: a quick access to essential elements.

Infection is the most common cause of hospitalization and the second most common cause of mortality among hemodialysis (HD) patients, after cardiovascular disease. HD patients as well as the dialysis staff are vulnerable to contracting health-care-associated infections (HAIs) due to frequent and prolonged exposure to many possible contaminants in the dialysis environment. The extracorporeal nature of the therapy, the associated common environmental conditions and the immune compromised status of HD patients are major predisposing factors. The evident increased potential for transmission of infections in the HD settings led to the creation and implementation of specific and stricter infection prevention and control measures in addition to the usual standard precautions. Different international organizations have generated guidelines and recommendations on infection prevention and control for implementation in the HD settings. These include the Centers for Disease Control and Prevention (CDC), the Association of Professionals in Infection Control (APIC), the Kidney Disease Outcomes Quality Initiative (K/DOQI), the European Best Practice Guidelines/European Renal Best Practice (EBPG/ERBP) and the Kidney Disease: Improving Global Outcomes (KDIGO). However, these guidelines are extensive and sometimes vary among different guideline-producing bodies. Our aim in this review is to facilitate the access, increase the awareness and encourage implementation among dialysis providers by reviewing, extracting and comparing the essential elements of guidelines and recommendations on infection prevention and control in HD units.