Hemodialysis Facilities Research Articles

FC 078REAL-WORLD EFFECTIVENESS OF ETELCALCETIDE VS. CINACALCET IN US HEMODIALYSIS PATIENTS: A FACILITY CALCIMIMETIC PREFERENCE APPROACH

Abstract Background and Aims Calcimimetic therapy, including oral cinacalcet and intravenous (IV) etelcalcetide, is often used to control parathyroid hormone (PTH) levels in hemodialysis (HD) patients. In a head-to-head clinical trial, etelcalcetide was superior to cinacalcet on PTH reduction. Given that oral administration of cinacalcet is susceptible to challenges of self-management and adherence, etelcalcetide may be even more effective in the real-world setting. To limit confounding by indication, we used a facility calcimimetic preference approach to investigate the comparative effectiveness of etelcalcetide vs. cinacalcet by estimating effects on PTH and other mineral and bone disorder (MBD) markers in a cohort of US HD patients. Method We used data from the US Dialysis Outcomes and Practice Patterns Study (US-DOPPS), a prospective cohort study of in-center HD patients. During a 6-month run-in period from March to August 2019, we evaluated facility calcimimetic preference by calculating the proportion of calcimimetic users in each facility who were prescribed etelcalcetide (vs. cinacalcet). Among patients with any prescription for a calcimimetic during the 6-month run-in period, we evaluated MBD marker outcomes (PTH, albumin-corrected serum calcium [Ca], serum phosphorus [P]), averaged over the subsequent 6 months, from September 2019 to February 2020. We compared HD facilities that treated >75% of calcimimetic users with etelcalcetide (“Etel-first”) vs. those that treated >75% of calcimimetic users with cinacalcet (“Cina-first”). Linear regression was used to model each continuous outcome. Modified Poisson regression was used to estimate the prevalence ratio (PR) of each MBD marker being out of target (PTH >600 pg/mL, Ca <8.4 mg/dL, P >5.5 mg/dL). All models were adjusted for patient-level and facility-level confounders and accounted for facility clustering using GEE. Results We excluded 38 HD facilities with little-to-no calcimimetic use (<10% use or <5 total users) because calcimimetic preference could not be reliably defined, and 44 HD facilities with no clear calcimimetic preference (25-75% etelcalcetide use among calcimimetic users). The analysis included 2156 calcimimetic users: 969 patients from 45 Etel-first facilities and 1187 patients from 67 Cina-first facilities. In Etel-first (vs. Cina-first) HD facilities, the mean difference in PTH levels (primary outcome) was -99 pg/mL (95% CI: -179, -19) and the prevalence of PTH >600 was lower (PR=0.75; 95% CI: 0.60, 0.94) in adjusted models. The adjusted mean levels of serum Ca and serum P (secondary outcomes) were slightly lower in Etel-first (vs. Cina-first) facilities [Table 1]. Conclusion To our knowledge, this is the first large-scale comparison of IV etelcalcetide with oral cinacalcet in the real-world setting. Our unique approach resembles a natural experiment by leveraging practice variation across the US and isolating HD facilities with a clear preference for one calcimimetic. Thus, the prescribed calcimimetic type for included patients was more likely determined by facility preference than biased by patient indication. Our results indicate better PTH control (mean levels ∼100 pg/mL lower) in US HD facilities using etelcalcetide (vs. cinacalcet) as the primary calcimimetic therapy. Further research is needed to investigate the degree to which the greater real-world effectiveness of IV etelcalcetide (vs. oral cinacalcet) may be driven by adherence to the prescribed therapy, and how clinical outcomes may be affected.

Infection prevention measures for patients undergoing hemodialysis during the COVID-19 pandemic in Japan: a nationwide questionnaire survey

BackgroundCoronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global pandemic affecting a variety of medical treatments, including hemodialysis. This study aims to investigate the implementation of infection control measures, to examine the shortage of personal protective equipment (PPE) and disinfectants, and to quantify the number of nosocomial COVID-19 transmissions in hemodialysis facilities in Japan during the pandemic.MethodsWe conducted a nationwide questionnaire survey between 20 October and 16 November 2020 (i.e., between the “second wave” and “third wave” in Japan) in the 4198 dialysis facilities of the Japanese Association of Dialysis Physicians and the Japanese Society for Dialysis Therapy. A total of 2227 facilities (53.0%) responded. The questionnaire consisted of (i) characteristics of facilities, (ii) infection prevention measures in routine dialysis practices, (iii) shortage of PPE, (iv) feasibility of various isolation measures, and (v) nosocomial transmission.ResultsHalf of the responding facilities were hospitals with multiple departments, and the other half were clinics specialized in dialysis. Several infection prevention measures such as health checks of staff and patients, donning of masks before and after hemodialysis, and disinfection of frequently contacted areas were implemented during the COVID-19 pandemic. There was a significant improvement in the implementation rate of these measures during the pandemic, compared to before it, which reached over 90%. More than half of the facilities reported a shortage of disposable masks (67.2%) and hand sanitizer alcohol (56.7%). Isolation of COVID-19 patients in private rooms was possible only in 52.7% of the facilities. The majority of facilities (73.3%) could not accept COVID-19 dialysis patients due to lack of space and manpower. Nosocomial transmission of COVID-19 occurred in 4.0% of the facilities. Of those infected, 51.9% were staff.ConclusionsThis survey revealed that most hemodialysis facilities in Japan had improved implementation of infection control measures and had shortage of PPEs and disinfectants, though some facilities did not implement infection prevention measures adequately, mainly due to the limited space of the facility. It may be recommended that each facility immediately establishes isolation measures to prepare for the pandemic of COVID-19.

MO674SHORT DAILY HOME HEMODIALYSIS PROGRAM, IN NEPHROCARE HEMODIALYSIS CENTER: REPORT STUDY

Abstract Background and Aims Several studies showed that DHHD improved survival and quality of life and allowed a lower cost for health system. The aim of this study was to describe our first experience of DHHD in our dialysis center. Method We included 9 dialyzed patients trained on Nx Stage® machine (Fresenius Medical Care) from February to December 2020. Data was retrospectively obtained through review of our medical electronic records (Euclid®). Results Among 9 patients trained, 8 were installed at home, with an average follow up of 7 months. 6 patients were dialyzed in self hemodialysis facilities. The mean age was 45 years (28-71), 6 women, BMI: 24 kg/m2 (21-30), dialysis vintage: 5 years and 7 patients are on transplant list. The Charlson score was: 5 (4-8), 5 patients had a residual diuresis> 500 ml/d. The average training duration was 5 weeks (4-8). Our training program targeted the self-puncture of AVF and the self-assembly of the machine by the patient. 100% of AVF were cannulated through Buttonhole technique. 6 patients were dialyzed 6 times a week and only one patient needed anticoagulants. The blood pressure improved on the first days of DHHD (↓ 50% of drugs for 50% of patients). Hemoglobin level maintained between 10-12 g/dl with ↓ EPO. The mineral metabolism status was improved for all patients, with stopping of binders in one case. DHHD reduced symptoms like fatigue, cramping and post-dialysis recovery for all patients, and allowed for patients a better socio-professional integration. A medico-economic analysis is conducted. Conclusion DHHD improved blood pressure, anemia, mineral status and quality of life. Through economy in medicaltransport and better socio-professional integration DHD provides savings for the health system

Effect of Treating Hyperphosphatemia With Lanthanum Carbonate vs Calcium Carbonate on Cardiovascular Events in Patients With Chronic Kidney Disease Undergoing Hemodialysis

Among patients with hyperphosphatemia undergoing dialysis, it is unclear whether non-calcium-based phosphate binders are more effective than calcium-based binders for reducing cardiovascular events. To determine whether lanthanum carbonate reduces cardiovascular events compared with calcium carbonate in patients with hyperphosphatemia at risk of vascular calcification undergoing hemodialysis. Open-label, randomized, parallel-group clinical trial with blinded end point adjudication performed in 2374 patients with chronic kidney disease from 273 hemodialysis facilities in Japan. Eligible patients had hyperphosphatemia and 1 or more risk factors for vascular calcification (ie, ≥65 years, postmenopausal, diabetes). Enrollment occurred from November 2011 to July 2014; follow-up ended June 2018. Patients were randomized to receive either lanthanum carbonate (n = 1154) or calcium carbonate (n = 1155) and titrated to achieve serum phosphate levels of between 3.5 mg/dL and 6.0 mg/dL. The primary outcome was a composite cardiovascular event (cardiovascular death, nonfatal myocardial infarction or stroke, unstable angina, transient ischemic attack, or hospitalization for heart failure or ventricular arrhythmia). Secondary outcomes included overall survival, secondary hyperparathyroidism-free survival, hip fracture-free survival, and adverse events. Among 2309 randomized patients (median age, 69 years; 40.5% women), 1851 (80.2%) completed the trial. After a median follow-up of 3.16 years, cardiovascular events occurred in 147 of 1063 patients in the lanthanum calcium group and 134 of 1072 patients in the calcium carbonate group (incidence rate, 4.80 vs 4.30 per 100 person-years; difference 0.50 per 100 person-years [95% CI, -0.57 to 1.56]; hazard ratio [HR], 1.11 [95%, CI, 0.88 to 1.41], P = .37). There were no significant differences in all-cause death (difference, 0.43 per 100 person-years [95% CI, -0.63 to 1.49]; HR, 1.10 [95% CI, 0.88 to 1.37]; P = .42) or hip fracture (difference, 0.10 per 100 person-years [95% CI, -0.26 to 0.47]; HR, 1.21 [95% CI, 0.62 to 2.35]; P = .58). The lanthanum carbonate group had an increased risk of cardiovascular death (difference, 0.61 per 100 person-years [95% CI, 0.02 to 1.21]; HR, 1.51 [95% CI, 1.01 to 2.27]; P = .045) and secondary hyperparathyroidism (difference, 1.34 [95% CI, 0.49 to 2.19]; HR, 1.62 [95% CI, 1.19 to 2.20]; P = .002). Adverse events occurred in 282 (25.7%) in the lanthanum carbonate group and 259 (23.4%) in the calcium carbonate groups. Among patients undergoing hemodialysis with hyperphosphatemia and at least 1 vascular calcification risk factor, treatment of hyperphosphatemia with lanthanum carbonate compared with calcium carbonate did not result in a significant difference in composite cardiovascular events. However, the event rate was low, and the findings may not apply to patients at higher risk. ClinicalTrials.gov Identifier: NCT01578200; UMIN Clinical Trial Registry Identifier: UMIN000006815.

COVID-19 infected patients in a Hemodialysis facility in Ecuador, 2020.

We retrospectively analyzed the data of 38 hemodialysis patients with COVID-19, including demographic and clinical characteristics were collected from the medical records of patients from Reynadial center from April to June 2020. Of 125 patients from the clinic, 38 (30.4%) were diagnosed with COVID-19. The third part of patients (12) died, the mortality rate was 31%. The mean (±SD) age of the patients was 61±13 years, 57.9% were men. The most common symptoms were shortness of breath and cough; 80% of patients had fever on admission, and more than 90% had hypertension. No significant differences were observed between survivors and non-survivors in demographic and epidemiological characteristics except for gender. We found statistically significant differences between blood pressure and weight before and after the infection by COVID-19. We found a high COVID-19 prevalence in our hemodialysis patients and a high rate of deaths among them, with non-significant statistical differences between survivors and non-survivors of the disease regarding most of the variables studied.

Home Versus Facility Dialysis and Mortality in Australia and New Zealand

Mortality is an important outcome for all dialysis stakeholders. We examined associations between dialysis modality and mortality in the modern era. Observational study comparing dialysis inception cohorts 1998-2002, 2003-2007, 2008-2012, and 2013-2017. Australia and New Zealand (ANZ) dialysis population. The primary exposure was dialysis modality: facility hemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD), automated PD (APD), or home HD. The main outcome was death. Cause-specific proportional hazards models with shared frailty and subdistribution proportional hazards (Fine and Gray) models, adjusting for available confounding covariates. In 52,097 patients, the overall death rate improved from ~15 deaths per 100 patient-years in 1998-2002 to ~11 in 2013-2017, with the largest cause-specific contribution from decreased infectious death. Relative to facility HD, mortality with CAPD and APD has improved over the years, with adjusted hazard ratios in 2013-2017 of 0.88 (95% CI, 0.78-0.99) and 0.91 (95% CI, 0.82-1.00), respectively. Increasingly, patients with lower clinical risk have been adopting APD, and to a lesser extent CAPD. Relative to facility HD, mortality with home HD was lower throughout the entire period of observation, despite increasing adoption by older patients and those with more comorbidities. All effects were generally insensitive to the modeling approach (initial vs time-varying modality, cause-specific versus subdistribution regression), different follow-up time intervals (5 year vs 7 year vs 10 year). There was no effect modification by diabetes, comorbidity, or sex. Potential for residual confounding, limited generalizability. The survival of patients on PD in 2013-2017 appears greater than the survival for patients on facility HD in ANZ. Additional research is needed to assess whether changing clinical risk profiles over time, varied dialysis prescription, and morbidity from dialysis access contribute to these findings.

Growing home dialysis: The Ontario Renal Network Home Dialysis Initiative 2012-2019.

The Ontario Renal Network (ORN), a provincial government agency in Ontario, Canada, launched an initiative in 2012 to increase home dialysis use province-wide. The initiative included a new modality-based funding formula, a standard mandatory informatics system, targets for prevalent home dialysis rates, the development of a 'network' of renal programmes with commitment to home dialysis and a culture of accountability with frequent meetings between ORN and each renal programme leadership to review their results. It also included funding of home dialysis coordinators, encouragement and funding of assisted peritoneal dialysis (PD), and support for catheter insertion and urgent start PD. Between 2012 and 2017, home dialysis use rose from 21.9% to 26.5% and then between 2017 and 2019 stabilised at 26% to 26.5%. Over 7 years, the absolute number of people on home dialysis increased 40% from 2222 to 3105, while the number on facility haemodialysis grew 11% from 7935 to 8767. PD prevalence rose from 16.6% to 20.9%, a relative increase of 25%. The initiative showed that a sustained multifaceted approach can increase home dialysis utilisation.

COVID-19 and Dialysis Patients: Unsolved Problems in Early 2021.

COVID-19 and Dialysis Patients: Unsolved Problems in Early 2021.

Elimination of Hepatitis C Virus in a Dialysis Population: A Collaborative Care Model in Taiwan

Hemodialysis facilities are high-risk environments for the spread of hepatitis C virus (HCV). Eliminating HCV from all dialysis facilities in a community may be achieved more effectively under a collaborative care model. Quality improvement study of multidisciplinary collaborative care teams including nephrologists, gastroenterologists, and public health practitioners. All dialysis patients in Changhua County, Taiwan were treated using an interdisciplinary collaborative care model implemented within a broader Changhua-Integrated Program to Stop HCV Infection (CHIPS-C). Provision of an HCV care cascade to fill 3 gaps, including screening and testing, diagnosis, and universal direct-acting antiviral (DAA) treatment implemented by collaborating teams of dialysis practitioners and gastroenterologists working under auspices of Changhua Public Health Bureau. Outcome measures included quality indicators pertaining to 6 steps in HCV care ranging from HCV screening to treatment completion to cure. A descriptive analysis. A total of 3,657 patients from 31 dialysis facilities were enrolled. All patients completed HCV screening. The DAA treatment initiation rate and completion rate were 88.9% and 94.0%, respectively. The collaborative care model achieved a cure rate of 166 (96.0%) of 173 patients. No virologic failure occurred. The cumulative treatment ratios for patients with chronic HCV infection increased from 5.3% before interferon-based therapy (2017) to 25.6% after restricted provision of DAA (2017-2018), and then to 89.1% after universal access to DAA (2019). Unclear impact of this collaborative care program on incident dialysis patients entering dialysis facilities each year and on patients with earlier stages of chronic kidney disease. A collaborative care model in Taiwan increased the rates of diagnosis and treatment for HCV in dialysis facilities to levels near those established by the World Health Organization.

Implementation of an Electronic Catheter Checklist in Outpatient Hemodialysis Facilities: Results of a Pilot Quality Improvement Project.

Performing catheter-care observations in outpatient hemodialysis facilities are one of the CDC's core interventions, which have been proven to reduce bloodstream infections. However, staff have many competing responsibilities. Efforts to increase and streamline the process of performing observations are needed. We developed an electronic catheter checklist, formatted for easy access with a mobile device, and conducted a pilot project to determine the feasibility of implementing it in outpatient dialysis facilities. The tool contained the following content: (1) patient education videos; (2) catheter-care checklists (connection, disconnection, and exit-site care); (3) prepilot and postpilot surveys; and (4) a pilot implementation guide. Participating hemodialysis facilities performed catheter-care observations on either a weekly or monthly schedule and provided feedback on implementation of the tool. The pilot data were collected from January 6 through March 12, 2020, at seven participating facilities. A total of 954 individual observations were performed. The catheter-connection, disconnection, and exit-site steps were performed correctly for most individual steps; however, areas for improvement were (1) allowing for appropriate antiseptic dry time, (2) avoiding contact after antisepsis, and (3) applying antibiotic ointment to the exit site. Postpilot feedback from staff was mostly favorable. Use of the electronic checklists facilitated patient engagement with staff and was preferred over paper checklists, because data are easily downloaded and available for use in facility Quality Assurance and Performance Improvement (QAPI) meetings. The educational video content was a unique learning opportunity for both patients and staff. Converting the CDC's existing catheter checklists to electronic forms reduced paperwork and improved the ease of collating data for use during QAPI meetings. An additional benefit was the educational content provided on the tablet, which was readily available for viewing by patients and staff while in the hemodialysis facility.

POS-559 EVALUATION OF MINERAL AND BONE DISORDERS IN PATIENTS WHO HAVE SURVIVED FOR MORE THAN 2 YEARS ON MAINTENANCE HEMODIALYSIS IN INDIA

Government initiatives and increasing social support have increased hemodialysis facilities in India. But there is a dearth of outcome data of patients on long-term chronic maintenance hemodialysis (MHD). Our study aims to assess the types of mineral and bone disorders (MBD) in patients who have been more than 2 years on MHD. We also aim to study the correlation of MBD with vascular calcification leading to cardiovascular events and bone fractures.

Suggestions for the prevention of Clostridioides difficile spread within outpatient hemodialysis facilities

Clostridioides difficile infections (CDIs) cause substantial morbidity and mortality. Patients on maintenance hemodialysis are 2 to 2.5 times more likely to develop CDI, with mortality rates 2-fold higher than the general population. Hospitalizations due to CDI among the maintenance hemodialysis population are high, and the frequency of antibiotic exposures and hospitalizations may contribute to CDI risk. In this report, a panel of experts in clinical nephrology, infectious diseases, and infection prevention provide guidance, based on expert opinion and published literature, aimed at preventing the spread of CDI in outpatient hemodialysis facilities.

Implementation of a Clinical Pharmacist in a Hemodialysis Facility: A Quality Improvement Report

Rationale & ObjectiveHemodialysis (HD) patients have complicated disease states, placing them at higher risk for medication-related problems, medication discrepancies, and nonadherence. The objective of this study is to evaluate the impact of a clinical pharmacist in a single HD facility by assessing the efficacy of medication reconciliation in HD patients and evaluating the potential impact on a single health care system.Study DesignRetrospective study.Setting & ParticipantsGreenfield Health Systems, a wholly owned subsidiary of Henry Ford Health System, operates 14 HD facilities throughout Southeast Michigan. The West Pavilion facility is located in Detroit, MI. Patients with end-stage kidney disease included in the study had a minimum of 4 encounters with the clinical pharmacist or pharmacy interns between August 2017 and October 2018.ExposureA clinical pharmacist performed medication reconciliation and medication reviews with HD patients to assess medication-related problems and identify gaps in care. Interventions made by the pharmacist were prespecified through a collaborative practice agreement.OutcomesTo evaluate the impact of a clinical pharmacist in an HD facility by assessing the efficacy of medication reconciliation in HD patients and evaluating the potential impact on this health system through an estimated cost avoidance.Analytical ApproachDescriptive statistics were used to collect medication-related problems and classified based on a modified Hepler-Strand approach.ResultsThere were 1,403 medication-related problems, with an average of 8.96 medication-related problems per patient. Adherence was the most common medication-related problem (31%). Antihypertensive medication was the most common drug class in which the pharmacist intervened (37%), followed by vitamin D analogues and calcimimetics (29%). A projected total of US $447,355 was saved.LimitationsRetrospective analysis of observational data and descriptive statistics with the potential for residual bias and confounding.ConclusionsPharmacists in HD facilities have a positive influence on HD patients through medication management that results in cost savings.

Hemodialysis Clinics in Flood Zones: A Case Study of Hurricane Harvey

Hurricane Harvey (2017) forced the closure of hemodialysis centers across Harris County, Texas (USA) disrupting the provision of dialysis services. This study aims to estimate the percentage of hemodialysis clinics flooded after Harvey, to identify the proportion of such clinics located in high-risk flood zones, and to assess the sensitivity of the Federal Emergency Management Agency (FEMA) Flood Insurance Rate Maps (FIRMs) for estimation of flood risk. Data on 124 hemodialysis clinics in Harris County were extracted from Medicare.gov and geocoded using ArcGIS Online. The FIRMs were overlaid to identify the flood zone designation of each hemodialysis clinic. Twenty-one percent (26 of 124) of hemodialysis clinics in Harris County flooded after Harvey. Of the flooded clinics, 57.7% were in a high-risk flood zone, 30.8% were within 1km of a high-risk flood zone, and 11.5% were not in or near a high-risk flood zone. The FIRMs had a sensitivity of 58%, misidentifying 42% (11 of 26) of the clinics flooded. Hurricanes are associated with severe disruptions of medical services, including hemodialysis. With one-quarter of Harris County in the 100-year floodplain, projected increases in the frequency and severity of disasters, and inadequate updates of flood zone designation maps, the implementation of new regulations that address the development of hemodialysis facilities in high-risk flood areas should be considered.

Profil épidémiologique et clinique, et survie à 90 jours des patients incidents en hémodialyse chronique au cours de la pandémie à SARS-CoV2 au Cameroun : expérience de l’hôpital général de Douala

BackgroundThe effect of COVID-19 pandemic on end stage renal disease patient who should initiated dialysis are limited in Sub-Saharan Africa is unknown. We sought to describe the epidemiologic and clinical profile of newly admitted patient in chronic haemodialysis during the COVID-19 pandemic in Cameroon and evaluate their survival between 90days of dialysis initiation. Material and methodWe conducted a cohort study of 6months from April to October 2020. End stage renal disease patients newly admitted in the haemodialysis facility of the General Hospital of Douala were included. Patients with confirmed or suspected COVID-19 were identified. Socio-demographic, clinical and biological data at dialysis initiation as well as mortality between the 90days of dialysis initiation were registered. ResultsA total of 57 incident patients were recorded from April to October 2020 with a monthly mean of 9.5 patients. The mean age was 46.95±13.12years. Twenty-four COVID-19 were identified with a frequency of 49% among emergency admission. Pulmonary œdema (79.2% vs. 42.4%; P=0.006) and uremic encephalopathy (83.4% vs. 53.6%; P=0.022) were more common in COVID-19. The overall survival at 90days was 48% with a tendency to poor survival among COVID-19 and patients with low socioeconomic level. In Cox regression, low socioeconomic level increase the risk of instant death by 3.08. ConclusionSARS-CoV2 seem to increase nephrology emergency and poor survival in haemodialysis at 90days.

Statewide evaluation of infection control measures for preventing coronavirus disease 2019 in hemodialysis facilities

OBJECTIVE:This study aimed to evaluate the occurrence of coronavirus disease 2019 (COVID-19) in hemodialysis facilities and the occurrence of and risk factors for clustering of COVID-19 cases.METHODS:We conducted a cross-sectional online survey between March and July 2020, in all dialysis facilities in São Paulo state, using Google Forms. The online questionnaire contained questions addressing specific components of infection prevention and control practices and the number of cases during the COVID-19 pandemic.RESULTS:A total of 1,093 (5%) COVID-19 cases were reported among 20,984 patients; approximately 56% of the facilities had ≥1 cluster. Most facilities implemented various measures (such as allocation of dedicated COVID-19 areas/shifts, symptom screening, environmental disinfection, and maintenance of adequate ventilation) to prevent the transmission of severe acute respiratory syndrome coronavirus 2. Clustering of COVID-19 cases was suspected in only 7% of dialysis facilities. The only variable associated with this event was the performance of aerosol-generating procedures (odds ratio: 4.74; 95% confidence interval: 1.75-12.86).CONCLUSION:Attention should be paid to avoiding the performance of aerosol-generating procedures in dialysis facilities and monitoring the clustering of cases.

A small cluster of COVID‒19 in an outpatient hemodialysis facility

A small cluster of COVID‒19 in an outpatient hemodialysis facility

Targeting COVID-19 prevention in hemodialysis facilities is associated with a drastic reduction in central venous catheter-related infections

BackgroundIn hemodialysis (HD) patients, central venous catheter (CVC) related bloodstream infections are a major cause of morbidity and mortality. Hygienic precautions are a key aspect of dialysis care for infection prevention, but they are not sufficient to completely avoid the occurrence of CVC related infections. During the COVID-19 pandemic, hygienic precautions for preventing viral transmission have been markedly reinforced. We evaluated their effects on CVC-related infection rates.MethodsAn observational retrospective study was conducted in two hemodialysis units of the same institution treating 215 chronic hemodialysis patients, 71 of whom are currently (33%) using a CVC. In the CVC cohort, we compared data on catheter-related infection rates during the maximum spread of the COVID-19 pandemic in Italy (February to May 2020) with data from the same period of the previous year and with the whole of 2019.ResultsIn 2019, we recorded a catheter-related bloodstream infection (CRBSI) rate of 1.19 (95% CI 0.81–1.68)/1000 days [2.07 (95% CI 1.12–3.52)/1000 days in the Feb-May 2019 period] and a tunnel and exit-site infection rate of 0.82 (95% CI 0.51–1.24)/1000 days [1.04 (95% CI 0.41–2.15)/1000 days in the Feb–May 2019 period]. Infection rates drastically decreased during the COVID-19 pandemic, with just one catheter-related bloodstream infection being recorded. Catheter-related bloodstream infection rates showed a significant reduction to 0.20 (95% CI 0.01–0.9)/1000 days (p < 0.05 and p < 0.005 compared to 2019 and to Feb-May 2019, respectively) and a non-significant reduction in tunnel and exit-site infections to 0.6 (95% CI 0.15–1.6)/1000 days.ConclusionsThe observed 91% reduction in catheter-related bloodstream infections compared to the same period in 2019 [IRR 0.09 (95% CI 0.002–0.64)] and the 83% reduction compared to the whole of 2019 [IRR 0.17 (95% CI 0.004–1.009)] suggest that a stricter implementation of hygienic precautions in the dialysis setting can markedly improve the problem of CVC-related infections.Graphic abstract

Relationship between measured and prescribed dialysate sodium in haemodialysis: a systematic review and meta-analysis.

Dialysate sodium (DNa) prescription policy differs between haemodialysis (HD) units, and the optimal DNa remains uncertain. We sought to summarize the evidence on the agreement between prescribed and delivered DNa, and whether the relationship varied according to prescribed DNa. We searched MEDLINE and PubMed from inception to 26 February 2020 for studies reporting measured and prescribed DNa. We analysed results reported in aggregate with random-effects meta-analysis. We analysed results reported by individual sample, using mixed-effects Bland-Altman analysis and linear regression. Pre-specified subgroup analyses included method of sodium measurement, dialysis machine manufacturer and proportioning method. Seven studies, representing 908 dialysate samples from 10 HD facilities (range 16-133 samples), were identified. All but one were single-centre studies. Studies were of low to moderate quality. Overall, there was no statistically significant difference between measured and prescribed DNa {mean difference = 0.73 mmol/L [95% confidence interval (CI) -1.12 to 2.58; P = 0.44]} but variability across studies was substantial (I2 = 99.3%). Among individually reported samples (n = 295), measured DNa was higher than prescribed DNa by 1.96 mmol/L (95% CI 0.23-3.69) and the 95% limits of agreement ranged from -3.97 to 7.88 mmol/L. Regression analysis confirmed a strong relationship between prescribed and measured DNa, with a slope close to 1:1 (β = 1.16, 95% CI 1.06-1.27; P < 0.0001). A limited number of studies suggest that, on average, prescribed and measured DNa are similar. However, between- and within-study differences were large. Further consideration of the precision of delivered DNa is required to inform rational prescribing.

Longitudinal Causal Effects of Normalized Protein Catabolic Rate on All-Cause Mortality in Patients With End-Stage Renal Disease: Adjusting for Time-Varying Confounders Using the G-Estimation Method.

In this study, we aimed to estimate the causal effect of normalized protein catabolic rate (nPCR) on mortality among end-stage renal disease (ESRD) patients in the presence of time-varying confounding affected by prior exposure using g-estimation. Information about 553 ESRD patients was retrospectively collected over an 8-year period (2011-2019) from hemodialysis facilities in Kerman, Iran. nPCR was dichotomized as <1.2 g/kg/day versus ≥1.2 g/kg/day. Then a standard time-varying accelerated failure time (AFT) Weibull model was built, and results were compared with those generated by g-estimation. After appropriate adjustment for time-varying confounders, weighted g-estimation yielded 78% shorter survival time (95% confidence interval (95% CI): -81, -73) among patients with a continuous nPCR <1.2 g/kg/day than among those who had nPCR ≥1.2 g/kg/day during follow-up, though it was 18% (95% CI: -57, 54) in the Weibull model. Moreover, hazard ratio estimates of 4.56 (95% CI: 3.69, 5.37) and 1.20 (95% CI: 0.66, 2.17) were obtained via weighted g-estimation and the Weibull model, respectively. G-estimation indicated that inadequate dietary protein intake characterized by nPCR increases all-cause mortality among ESRD patients, but the Weibull model provided an effect estimate that was substantially biased toward the null.