Hospitalized Dialysis Patients Research Articles

Vitamin D Insufficiency and Deficiency in Chronic Kidney Disease Patients on Hemodialysis

About one billion people in the world suffer from vitamin D deficiency or insufficiency. Moreover, many data points indicate that vitamin D insufficiency and deficiency are highly prevalent among patients with chronic kidney disease (CKD) or undergoing dialysis. This study aimed to evaluate the level of vitamin D for dialysis patients at the Tripoli dialysis and treatment center. In this single center observational study, hospitalized dialysis patients who were diagnosed of Stage 5 CKD and healthy (control) groups had taken measurement of serum 25(OH)D in the Tripoli dialysis and treatment center. In this regard, One hundred and four patients were included in this study, of which (37%) were in Vitamin D insufficiency state while (30%) were in Vitamin D deficiency state. For the comparison between vitamin D levels among dialysis patients and control group which revealed that there were no significant differences between them with a p-value of 0.094. Furthermore, the correlation between serum 25 (OH) vitamin D, creatinine, PTH, and urea showed that there was a weak negative correlation between serum vitamin D and creatinine (r = -0.364, p = 0.255), between vitamin D and PTH (r = -0.378, p = 0.226), and between vitamin D and urea (r = -0.347, p = 0.269). Obviously, although vitamin D deficiency is strongly linked to kidney failure, the tests that work for this disease are limited, so introducing vitamin D for dialysis patients with CKD helps in understanding the patient's condition and helps in disease management.

Reduced Risk of Progression from Non-Severe to Severe COVID-19 in Hospitalized Dialysis Patients by Full COVID-19 Vaccination.

Coronavirus disease 2019 (COVID-19) vaccination reduces the risk of progression to severe COVID-19 in the general population. To examine that preventive effect in dialysis patients, the association of vaccination status with severe COVID-19 progression was investigated in this retrospective observational study conducted from December 2020 to May 2022 of 100 such patients hospitalized for non-severe COVID-19 at Inoue Hospital (Suita, Japan). Fifty-seven were fully vaccinated, defined as receiving a COVID-19 vaccine second dose at least 14 days prior to the onset of COVID-19, while 43 were not. Among all patients, 13 (13.0%) progressed to severe COVID-19 with a median (interquartile range) time of 6 (2.5-9.5) days, while 87 (87.0%) were discharged after 11 (8-16) days. Kaplan-Meier analysis showed that fully vaccinated patients had a significantly lower rate of progression to severe COVID-19 (p = 0.001, log-rank test). Cox proportional hazard analysis also indicated that full COVID-19 vaccination was significantly associated with reduced instances of progression to severe COVID-19 (hazard ratio 0.104, 95% confidence interval 0.022 to 0.483; p = 0.004) after balancing patient background characteristics using an inverse probability of treatment weight method. These results suggest that full vaccination status contributes to reducing the risk of progression from non-severe to severe COVID-19 in dialysis patients.

The Clinical Frailty Scale as a triage tool for ICU admission of dialysis patients with COVID-19: an ERACODA analysis.

BackgroundSeveral guidelines recommend using the Clinical Frailty Scale (CFS) for triage of critically ill coronavirus disease 2019 (COVID-19) patients. This study evaluates the impact of CFS on intensive care unit (ICU) admission rate and hospital and ICU mortality rates in hospitalized dialysis patients with COVID-19.MethodsWe analysed data of dialysis patients diagnosed with COVID-19 from the European Renal Association COVID-19 Database. The primary outcome was ICU admission rate and secondary outcomes were hospital and ICU mortality until 3 months after COVID-19 diagnosis. Cox regression analyses were performed to assess associations between CFS and outcomes.ResultsA total of 1501 dialysis patients were hospitalized due to COVID-19, of whom 219 (15%) were admitted to an ICU. The ICU admission rate was lowest (5%) in patients >75 years of age with a CFS of 7–9 and highest (27%) in patients 65–75 years of age with a CFS of 5. A CFS of 7–9 was associated with a lower ICU admission rate than a CFS of 1–3 [relative risk 0.49 (95% confidence interval 0.27–0.87)]. Overall, mortality at 3 months was 34% in hospitalized patients, 65% in ICU-admitted patients and highest in patients >75 years of age with a CFS of 7–9 (69%). Only 9% of patients with a CFS ≥6 survived after ICU admission. After adjustment for age and sex, each CFS category ≥4 was associated with higher hospital and ICU mortality compared with a CFS of 1–3.ConclusionsFrail dialysis patients with COVID-19 were less frequently admitted to the ICU. Large differences in mortality rates between fit and frail patients suggest that the CFS may be a useful complementary triage tool for ICU admission in dialysis patients with COVID-19.

MO899: The Clinical frailty Scale is Useful for ICU Triage in Dialysis Patients With COVID-19–An Eracoda Analysis

BACKGROUND AND AIMSduring the COVID-19 pandemic, several guidelines have recommended the use of the Clinical Frailty Scale (CFS) for triage of critically ill patients with COVID-19 in case of shortage in ICU resources. However, no data on using CFS assessment for ICU triage for dialysis patients is yet available. This study evaluates whether CFS is associated with mortality rates in a cohort of hospitalized dialysis patients with COVID-19.METHODthe analyses are based on data of the European Renal Association COVID-19 Database (ERACODA). Dialysis patients who presented with COVID-19 between 1 February 2020 and 30 April 2021 and with complete information on CFS and vital status at 3 months were included. Study outcomes were hospital and ICU admission rates and hospital and ICU mortality at 3 months after hospital admission. Cox regression analyses were performed to assess the association of CFS category (≤5 versus ≥ 6) and study outcomes in line with Dutch ICU triage guidelines for COVID-19. Furthermore, additional subgroup analyses were performed to assess the association between CFS and 3-month mortality by age category (<65, 65–75 and >75 years).RESULTSamong a total of 2206 dialysis patients (mean age = 67.2 (14.1) years, male sex = 61%), 1694 (77%) had CFS ≤ 5 and 514 (23%) had CFS ≥ 6. Hospitalization rate was comparable in patients with CFS ≤ 5 and in patients with CFS ≥ 6 (67 and 71%, respectively), whereas the rate of ICU admission was higher in patients with CFS ≤ 5 than in patients with CFS ≥ 6 (16 versus 9%, p = 0.001). Among 1501 hospitalized patients, 3-month mortality was 26% of patients with CFS ≤ 5 and 59% in patients with CFS ≥ 6 (P < 0.001). Multivariate analysis with adjustment for patient demographics, smoking status and BMI revealed that CFS ≥ 6 was associated with hospital mortality [aHR 2.27 (1.88–2.74) versus CFS ≤ 5; P < 0.001) with a significant interaction for age (P = 0.029). aHR was 4.00 (2.56–6.37; CFS ≥ 6 versus CFS ≤ 5; P < 0.001) in patients < 65 years, aHR was 1.87 (1.33–2.64; CFS ≥ 6 versus CFS ≤ 5; P < 0.001) in patients 65–75 years and aHR was 2.12 (1.64–2.75; CFS ≥ 6 versus CFS ≤ 5; P < 0.001) in patients >75 years. Among 219 ICU admitted patients, 3-month mortality was 60% of the patients with CFS ≤ 5 and 91% in the patients with CFS ≥ 6, respectively. Multivariate analysis with adjustment for patient demographics, smoking status and BMI revealed that CFS ≥ 6 was associated with ICU mortality [aHR 1.80 (1.17–2.77); CFS ≥ 6 versus CFS ≤ 5; P = 0.002].CONCLUSIONmore frail dialysis patients with CFS ≥ 6 who are hospitalized for COVID-19 were less often admitted to the ICU, but in case they were admitted to the ICU they have a very high mortality of 91% in this cohort study. In fit to mildly frail dialysis, patients who were admitted to the ICU, mortality rates are lower. The association between frailty and hospital mortality is interacted by age with the strongest association in patients younger than 65 years. These findings suggest that CFS may be a useful complementary triage tool for ICU admission of dialysis patients during the ongoing COVID-19 pandemic.

Users of a Web-Based Communications Platform for Care Coordination of Hospitalized Dialysis Patients

Users of a Web-Based Communications Platform for Care Coordination of Hospitalized Dialysis Patients

Epidemiology of COVID-19 Infection in Hospitalized End-Stage Kidney Disease Patients in a Predominantly African-American Population

Background: End-stage kidney disease patients on dialysis are particularly susceptible to COVID-19 infection due to comorbidities, age, and logistic constraints of dialysis making social distancing difficult. We describe our experience with hospitalized dialysis patients with COVID-19 and factors associated with mortality. Methods: From March 1, 2020, to May 31, 2020, all dialysis patients admitted to 4 Emory Hospitals and tested for COVID-19 were identified. Sociodemographic information and clinical and laboratory data were obtained from the medical record. Death was defined as an in-hospital death or transfer to hospice for end-of-life care. Patients were followed until discharge or death. Results: Sixty-four dialysis patients with COVID-19 were identified. Eighty-four percent were African-American. The median age was 64 years, and 59% were males. Four patients were on peritoneal dialysis, and 60 were on hemodialysis for a median time of 3.8 years, while 31% were obese. Fever (72%), cough (61%), and diarrhea (22%) were the most common symptoms at presentation. Thirty-three percent required admission to intensive care unit, and 23% required mechanical ventilation. The median length of stay was 10 days, while 11 patients (17%) died during hospitalization and 17% were discharged to a temporary rehabilitation facility. Age >65 years (RR 13.7, CI: 1.9–100.7), C-reactive protein >100 mg/dL (RR 8.3, CI: 1.1–60.4), peak D-dimer >3,000 ng/mL (RR 4.3, CI: 1.03–18.2), bilirubin >1 mg/dL (RR 3.9, CI: 1.5–10.4), and history of peripheral vascular disease (RR 3.2, CI: 1.2–9.1) were associated with mortality. Dialysis COVID-19-infected patients were more likely to develop thromboembolic complications than those without COVID-19 (RR 3.7, CI: 1.3–10.1). Conclusion: In a predominantly African-American population, the mortality of end-stage kidney disease patients admitted with COVID-19 infection was 17%. Age, C-reactive protein, D-dimer, bilirubin, and history of peripheral vascular disease were associated with worse survival.

Monitoring Hospitalized Dialysis Patients With COVID-19: Repurposing Baby Monitors for Patient and Staff Safety

Monitoring Hospitalized Dialysis Patients With COVID-19: Repurposing Baby Monitors for Patient and Staff Safety

Delivering Safe and Effective Hemodialysis in Patients with Suspected or Confirmed COVID-19 Infection: A Single-Center Perspective from Italy.

New “Severe Acute Respiratory Syndrome Coronavirus 2” (SARS-CoV-2) is responsible for a clinical entity named Coronavirus Disease 2109 (COVID-19) by the World Health Orgazination, which is now a pandemic (1). In Europe, Italy was the first, and so far the largest, epicenter of the epidemic. It is now clear that many asymptomatic and paucisymptomatic patients went undetected, causing significant diffusion of the disease. Asymptomatic infections are common: among 634 confirmed patients on board the “Diamond Princess” cruise ship, 306 were symptomatic and 328 asymptomatic at the time of testing (2). It is now clear that when a patient with atypical severe pneumonia was diagnosed as COVID-19 in a small city, Codogno, in a previously healthy 38-year-old man, on February 20, 2020, more patients with undetected COVID-19 were present in Northern Italy. In addition to the cluster around Codogno, about 50 km south of Milan, which was promptly put under strict lockdown, two additional relevant clusters emerged near the cities of Bergamo and Brescia. The delay in enforcing a lockdown in the latter areas is probably one of the leading causes of the more severe outbreak now affecting these provinces. Extensive testing in the initial phase of disease diffusion was adopted in the Italian Veneto area, resulting in better containment of new cases. A nationwide lockdown measure was passed by the Italian government when Northern Italy, which has the highest concentration of well organized hospitals in the country, started showing signs of difficulty handling the rapid increase of patients in need of treatment in intensive care units (ICUs). A comparison of Chinese and Italian data on COVID-19 may be of interest to other countries where the disease is now spreading. The Chinese Center for Disease Control and Prevention described the characteristics of a large cohort of COVID-19 patients (3), showing that …

LB007-SUN: The Effect of Increased Energy to Hospitalized Dialysis Patients Undergoing Enteral Nutritional Management

LB007-SUN: The Effect of Increased Energy to Hospitalized Dialysis Patients Undergoing Enteral Nutritional Management

Association of a Change in Erythropoiesis-Stimulating Agent Dose During Hospitalization and Subsequent Hemoglobin Levels and Transfusions in Hemodialysis Patients

Erythropoiesis-stimulating agent (ESA) doses are often increased in hospitalized dialysis patients in response to acute anemia with unknown consequences. We sought to determine whether increases in ESA dose during hospital admission were associated with changes in transfusion requirement and risk of exceeding recommended hemoglobin targets. Retrospective cohort study. Linked administrative, laboratory, and blood transfusion data were used to identify a total of 700 hospitalizations involving 484 long-term hemodialysis patients between 2004 and 2008 in the Calgary Health Region, Canada. Change in ESA dose was determined by comparing the average weekly dose over the 6 weeks preceding admission to that administered during the 14 days following admission. Cox proportional hazards models adjusted for baseline patient characteristics were used to model the association between changes in ESA dose and outcomes, including exceeding recommended hemoglobin targets, receipt of blood transfusion, cardiovascular outcomes, and death. There was a significant increase in the risk of exceeding recommended hemoglobin targets as the ESA dose was increased by ≥40 μg/wk (equivalent darbepoetin alfa dose) above baseline (HR, 2.21; 95% CI, 1.19-4.10). However, an increase in ESA dose was not associated with reduced need for blood transfusion, risk of cardiovascular outcomes, or death. Residual confounding by clinical events that may lead to changes in the management of patients and may have influenced the observed relationship between predictor and outcomes. Increasing the ESA dose at hospitalization in hemodialysis patients is associated with higher risk of exceeding recommended hemoglobin targets, but does not appear to be associated with the need for transfusion, risk of cardiovascular outcomes, or death.

Evaluation of deficiencies in current discharge summaries for dialysis patients in Canada

BackgroundDeficits in the transfer of information between inpatient and outpatient physicians are common and pose a patient safety risk. This is particularly the case for vulnerable populations such as patients with end-stage renal disease requiring dialysis. These patients have unique and complex health care needs that may not be effectively communicated on standard discharge summaries, which may result in potential medical errors and adverse events.ObjectiveTo evaluate Canadian dialysis center directors’ perceptions of deficiencies in the content and quality of hospital discharge summaries for dialysis patients.MethodsA web-based, cross-sectional survey of Canadian dialysis center directors was performed between September and November 2010. The survey consisted of three parts. The first part was designed to assess dialysis center directors’ attitudes on the quality of discharge summaries they receive. The second part was designed to elicit respondents’ preferences for discharge summary content, and the third part consisted of questions regarding demographic and practice information.ResultsOf 79 dialysis center directors, 21 (27%) completed the survey. Sixty-two percent felt that current discharge summaries inadequately communicate dialysis-specific information. Receipt of antibiotics for line sepsis or peritonitis, modifications to vascular access, and changes in target weight/dialysis prescription were rated as essential dialysis-specific information to include in discharge summaries by respondents.ConclusionOver three quarters of dialysis center directors find the current practice of transferring discharge information for hospitalized dialysis patients grossly inadequate. The inclusion of dialysis-specific information may improve the quality of discharge summaries for dialysis patients.

The Role of Functional Status in Discharge to Assisted Care Facilities and In-Hospital Death Among Dialysis Patients

Functional status is an important component in the assessment of hospitalized patients. We set out to determine the scope, severity, and prognostic significance of impaired functional status in acutely hospitalized dialysis patients. Retrospective cohort study. 1,286 hospitalized dialysis patients admitted and discharged from 1 of 11 area hospitals in Manitoba, Canada, from September 2003 to September 2010 with an activity of daily living (ADL) assessment within 24 hours of admission. The 12-point ADL score assesses 6 domains (bathing, toileting, dressing, incontinence, feeding, and transferring) and scores them as independent or supervision only (score, 0), partial assistance (1), and full assistance (2). Thus, higher score indicates worse functional status. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics. Multivariable logistic regression and Cox proportional hazards assessed the association between functional status, in-hospital death, and discharge to an assisted care facility. During the study period, 250 (19.4%) and 72 (5.6%) patients experienced the outcomes of in-hospital death or discharge to an assisted care facility. Abnormalities in functional status were present in >70% of the cohort. ADL score within 24 hours of admission combined with age differentiated risks of death and discharge to an assisted care facility home, ranging from 4.8%-46.6% and 0.6%-17.8%, respectively. After adjustment, ORs of death and discharge to an assisted care facility were 1.16 (95% CI, 1.11-1.22; P < 0.001; C statistic = 0.79) and 1.25 (95% CI, 1.14-1.36; P < 0.001; C statistic = 0.91) per 1-point increase in ADL score, respectively. Findings were consistent after accounting for the competing outcomes of in-hospital death or discharge to an assisted care facility versus discharge to home. A 1-time measurement of ADLs could not differentiate temporary from long-term deterioration in functional status. Impaired functional status is common at the time of admission in the dialysis population. A single ADL score measurement at admission combined with age is highly predictive of poor outcomes in the hospitalized dialysis population.

B‐Type Natriuretic Peptide–Directed Ultrafiltration Improves Care in Acutely Hospitalized Dialysis Patients

In an observational study in 19 consecutive acutely hospitalized dialysis patients, ultrafiltration (UF) volume was determined by B-type natriuretic peptide (BNP) levels. Patients were ultrafiltrated daily until they achieved a target BNP level <500 pg/mL. The UF volumes ranged from 2 to 5 L per session. All patients were male veterans aged 68+/-11 years (mean +/- SD), 74% were diabetic, 47% were African Americans, 58% underwent prevalent dialysis, and 53% had an arteriovenous fistula. Left ventricular ejection fraction on 2-dimensional echocardiography was 43.8%+/-27.9% (n=16). The admission BNP was 2412+/-1479 pg/mL (range, 561-5000 pg/mL) and BNP at hospital discharge was 1245+/-1173 pg/mL (range, 345-5000 pg/mL) (nonparametric Wilcoxon P=.0013). Admission weight was 88.9+/-27.9 kg and at discharge was 78.1+/-25.6 kg (P=.0002). The number of antihypertensive medications taken was 3.8+/-2.0 at admission and 2.3+/-1.7 at discharge (P=.0005). The number of patients with >2 blood pressure medications decreased from 14 to 6 (Fisher exact test, P=.02). The systolic/diastolic/mean arterial blood pressure decreased from admission to discharge (153.6+/-43.8/80.6+/-21.8/102.4+/-27.3 to 132.1+/-27.9/68.9+/-14.6/89.9+/-16.5 mm Hg; P=.0222/.0139/.0329, respectively). Although all patients were volume-overloaded at admission according to BNP criteria (>500), only 42% were identified as having heart failure. BNP-directed UF is safe because it minimizes symptomatic hypotension, identifies occult congestive heart failure in a large number of patients, and significantly reduces blood pressure in addition to reducing body weight and number of medications used.

Prevalence of Colonization With Community-Associated Methicillin-ResistantStaphylococcus aureusAmong End-Stage Renal Disease Patients and Healthcare Workers

To evaluate the prevalence, epidemiologic features, and molecular characteristics of colonization with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) among hospitalized dialysis patients and their healthcare workers (HCWs). Prospective observational clinical and laboratory study of nasal colonization. A 600-bed urban academic medical center. One hundred twenty hospitalized dialysis inpatients and 100 HCWs. Of 120 patients, 40 (33%) were colonized with S. aureus; 26 (65%) of these 40 were colonized with MRSA. Among the 26 MRSA isolates, 10 (38.5%) carried staphylococcal cassette chromosome (SCC) mec type IV (ie, CA-MRSA), and 7 of these 10 carried the genes for the Panton-Valentine leukocidin (PVL) toxin. Patients colonized with healthcare-associated MRSA strains and those colonized with CA-MRSA strains were similar, except for a higher frequency of a history of congestive heart failure among those with healthcare-associated MRSA strains (P=.014). Among 10 patients who presented with or developed an S. aureus infection while hospitalized, 8 were colonized with S. aureus, 7 with MRSA, and 3 with SCCmec type IV strains. Among 100 HCWs, 31 were colonized with S. aureus, including 6 with MRSA; 2 of the MRSA isolates belonged to CA-MRSA strains, and soft-tissue infections were reported in one of the HCWs and in the family member of the other HCW colonized with these strains. There is a high rate of colonization with MRSA and CA-MRSA among hospitalized dialysis patients and their HCWs. As other studies have found, it appears that individuals are being colonized with both CA-MRSA strains and healthcare-associated MRSA strains.

The Graying of Methicillin-Resistant Staphylococcus aureus

From Rush University Medical Center and Stroger Hospital of Cook County, Chicago, Illinois (both authors). Received August 12, 2008; accepted August 17, 2008; electronically published December 1, 2008. Infect Control Hosp Epidemiol 2008; 30:9-12 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2009/3001-0003$15.00. DOI: 10.1086/592709 Not so long ago, methicillin-resistant Staphylococcus aureus (MRSA) was a quintessential nosocomial pathogen. Over the past few years, however, cases of infection with communityassociated MRSA (CA-MRSA) stricto sensu—that is, infections in patients with no healthcare exposures—have emerged. Most populations affected early appeared to share a characteristic of increased risk of disease spread by direct person-to-person contact (Figure). Since the emergence of CA-MRSA strains, several terms have been used to classify S. aureus strains on the basis of epidemiologic, genotypic, and phenotypic characteristics (Table). These classifications provide rough estimates of likely sources of strains and can be used for epidemiologic tracking. As more healthcare exposures occur among the general population, “healthcare-associated MRSA infection”—cases in which healthcare exposures or risk factors are present in patients whose MRSA infection manifests in the community— have gained attention. However, the lines between categories may be “graying,” with community-associated strains encroaching on hospitals, hospital-associated strains entering the community, and healthcare exposures increasing. The study by Johnson and colleagues in this issue of the journal evaluates MRSA colonization among hospitalized dialysis patients and among healthcare workers on an inpatient dialysis unit. As background, it is known that nasal colonization with S. aureus can be persistent, intermittent, or always absent; that it occurs more frequently in some populations, including hemodialysis patients; and that it usually precedes infection. Surveys of the general US population indicate that the prevalence of nasal colonization with MRSA rose from 0.8% in 2001–2002 to 1.5% in 2003–2004, while the prevalence of S. aureus colonization overall (ie, including both susceptible and resistant strains) decreased from 32.4% to 28.6%. On the basis of nasal culture results, Johnson et al. determined that 33% of dialysis patients in their study were colonized with S. aureus and 21.7% were colonized with MRSA—a 14-fold higher prevalence than national estimates. Johnson et al. identified isolates as being CA-MRSA on the basis of the presence of SCCmec IV genetic elements; colonization with such strains occurred in 38.5% of dialysis patients colonized with MRSA and in 8.3% of the total dialysis population. Among healthcare workers, 31% were colonized with S. aureus, 6% with MRSA, and 2% with CA-MRSA. In case-control analyses, there were few significant differences in demographic characteristics or risk factors between patients colonized with MRSA and patients colonized with methicillin-susceptible S. aureus (MSSA) or between patients colonized with MRSA strains that carried SCCmec II and patients colonized with strains that carried SCCmec IV. Because dialysis patients and healthcare workers were evaluated in different periods, inferences about patient-staff cross-transmission may be unreliable. What is the significance of the findings of Johnson et al.? The 6% prevalence of MRSA colonization among healthcare workers is consistent with the findings of recent studies that examined MRSA colonization among emergency-department

Editorial: The Evolving Ecology of Risk for Hospitalized Dialysis Patients

Despite an increased focus on patient safety, changes in resident work rules and contemporary hospital culture often combine to create an environment of potential hazard for the hospitalized dialysis patient. Clinical scenarios are presented to illustrate some of these risks, and suggestions are offered for the protection of patients.

The Prevalence of Resistant Bacterial Colonization in Chronic Hemodialysis Patients

Backgound: Hospitalized dialysis patients are at increased risk for colonization and infection with resistant bacterial strains. Methods: We performed a cross-sectional analysis of the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) colonization in 198 hemodialysis outpatients, 75 of whom had longitudinal screening data from prior hospitalization. Nasal specimens for MRSA, perirectal specimens for VRE, and permanent catheter exit site specimens were collected. Results: MRSA colonization was present in 5.6% and VRE colonization in 3.14%. Univariate analyses revealed that prior exposure (defined as infection/colonization) with MRSA, hospitalization, and low serum albumin were associated with MRSA colonization. VRE colonization was associated with hospitalization, prior VRE or MRSA exposure, low serum albumin, and low ferritin. Multivariate analyses revealed MRSA colonization was predicted by prior MRSA exposure and VRE colonization was predicted by prior VRE exposure and number of hospitalizations. Among the 75 participants with longitudinal screening data, MRSA colonization was associated with prior MRSA history, and VRE colonization was associated with prior MRSA or VRE. Conclusions: Generally low rates of MRSA and VRE colonization were observed in hemodialysis outpatients. Prior hospital screening was predictive of future outpatient colonization and may be useful in risk assessment.

Darbepoetin Alfa Therapeutic Interchange Protocol for Anemia in Dialysis

Erythropoiesis-stimulating proteins, such as erythropoietin alfa and darbepoetin alfa, have positively impacted anemia management. These medications improve patient outcomes and quality of life. Their costs, however, remain a major barrier for health systems. To evaluate the development, implementation, and cost-effectiveness of an inpatient therapeutic interchange protocol for erythropoiesis-stimulating proteins at a large, tertiary care, university-affiliated health system. Virginia Commonwealth University Health System (VCUHS) developed and implemented a therapeutic interchange program to convert therapy for all inpatients undergoing dialysis from erythropoietin alfa to darbepoetin alfa for treatment of chronic kidney disease-related anemia. An evaluation of the economic impact of this program on drug expenditures over a fiscal quarter (2003) was conducted using historical comparator data (2002). Preliminary evaluation of the program demonstrated cost-savings and reduced drug utilization of erythropoiesis-stimulating proteins in hospitalized dialysis patients. For the first quarter of 2003 compared with the first quarter of 2002, VCUHS realized a cost-savings of nearly 10,000 US dollars, which was related to the program's aggressive screening procedure. When these data were normalized for equal numbers of patients in each group receiving one of the drugs, the actual cost-savings was over 2000 US dollars. These cost-savings are largely due to reduced utilization of these expensive biotechnology products with implementation of a dosing protocol. VCUHS has successfully developed and implemented a darbepoetin alfa therapeutic interchange protocol for hospitalized dialysis patients. This has translated into reduced use of erythropoiesis-stimulating proteins, resulting in cost-savings for the health system.

Hospital‐Based Nocturnal Hemodialysis—A Novel Approach to Solving Old Problems

It is unlikely that there is a solitary hospital‐based dialysis unit that can claim an unlimited amount of available chronic spots. Many units, in fact, constantly face a problem of overcrowding, long patient waiting lists, and ongoing shortages of nurses trained in highly specialized areas such as dialysis. In addition, conventional dialysis does not afford the best outcomes to patients with lifestyle, fluid control, hypotension, or hypertension issues.Objective: We developed an in‐hospital nocturnal program with the goal of solving some of these issues related to wait lists, overcrowding, and shortages of trained hemodialysis nurses.Method: In the first year, a four‐bed room was converted into a 4 station unit. Nurses from the 24 bed in‐patient Nephrology/Urology/Ophthalmology unit were trained to perform hemodialysis. Stable, hospitalized dialysis patients or in‐center dialysis patients were selected if they met criteria drawn up by the medical director. Staffing for the unit was established at 3 : 1 or 4 : 1 patient to nurse ratio. Support staff included a hemodialysis‐trained ward nurse with an assignment of 5–6 hospitalized patients. Back‐up support included assistance with trouble‐shooting and break coverage for the nocturnal nurse.Results: We currently have 12 nurses from the ward trained to do hemodialysis. The nocturnal unit has been operating 3 nights/week, with plans to expand to 6 nights/week within the year. We have 3 patients on the program with plans to increase to 6–8 patients as more nurses are trained. Initiation of hospital‐based nocturnal hemodialysis has led to the opening of in‐center dialysis spots as well as shortening wait periods for patients in the Pre‐Renal Clinic, awaiting initiation of chronic dialysis. This model has also provided the in‐center dialysis unit with a greater pool of skilled hemodialysis nurses to draw from during shortages. Anecdotal reports from patients indicate that they feel much better, and 1 patient no longer requires antihypertensives for their blood pressure control.Conclusion: We conclude that hospital‐based nocturnal hemodialysis is a novel and extremely viable solution for many of the issues facing dialysis units today.

Clinical and dietary indicators associated with uremic status in hospitalized dialysis patients

Objective: The objective of this study was to determine whether any differences existed between specific admission variables and uremic status in patients with chronic renal failure receiving dialysis. Design and Setting: This was a prospective, observational study conducted at BryanLGH Medical Center East Campus in Lincoln, Nebraska. Patients: The subjects were hemodialysis and peritoneal dialysis patients admitted to an acute care facility, who met the following inclusion criteria: (1) they had a primary or secondary underlying diagnosis of chronic renal failure, and (2) they were not receiving parenteral or enteral tube feeding nutritional support on admission. Intervention: The patients were separated into 2 groups by their blood urea nitrogen (BUN) concentrations. Group 1 had a BUN concentration less than 50 and group 2 had a BUN concentration greater than or equal to 50. Admission data (age, sex, percentage of ideal body weight, reported retrospective weight loss over time, type of dialysis, gastrointestinal history, BUN and creatinine concentrations, and dietary prescription) were collected from patient medical records. Two-day kilocalorie and protein counts were conducted on the patients within 24 hours of admission to the acute care facility. Chi-square and 1-way analysis of variance were performed to compare the groups. Results: The total number of participants in the study was 42, with 21 in each BUN group. The mean age was 60 years, and the dietary intake was a mean of 10 kcal/kg and 0.4 g protein/kg. Only 14.3% and 7.1% of the patients met their kcal and protein needs, respectively. The mean percentage ideal body weight was 125 and the mean reported weight loss per week was 2.6 pounds. Gastrointestinal symptoms, specifically nausea and a kilocalorie-restricted diet prescription, were significantly different between the 2 groups. Patients in group 2 were more likely to have gastrointestinal symptoms overall (P <.05) specifically, nausea (P <.05). Group 1 patients were also more frequently placed on a kilocalorie-restricted diet (P <.05) than patients in group 2. Conclusions: A BUN concentration between 50 and 110 has been shown to be associated with a lower risk of death and a better nutritional status. These findings indicate symptoms commonly associated with uremia, such as nausea, may be associated with the dialysis patient's nutritional status when BUN concentrations are greater than 50. These dialysis patients were not receiving sufficient kilocalories and protein on admission into the hospital, and this can affect their nutritional and, eventually, survival status. © 2002 by the National Kidney Foundation, Inc.