Modality Of Renal Replacement Therapy Research Articles

Comparison of gastrointestinal symptoms and findings in renal replacement therapy modalities

ObjectiveChronic kidney disease (CKD) affects gastrointestinal system (GIS) and causes histological, functional and mucosal changes. There are scarce data investigating GIS symptoms and findings in patients with CKD stage III-V, receiving hemodialysis (HD) and peritoneal dialysis (PD). In this study, we aimed to evaluate the frequency of gastrointestinal symptoms and findings and compare between renal replacement therapies.MethodA total of 290 patients (97 in CKD stage III-V, 92 PD, 101 HD) were included in this study. Gastrointestinal complaints, diseases, background characteristics of patients and drugs they used were questioned by interviews, forms were filled and examinations of patients were performed. Results of upper GIS endoscopy, colonoscopy, abdominal ultrasonography and tomography of patients were evaluated.ResultsThe most common signs were dyspepsia (50%), nausea (45%) and epigastric pain (44%) among all patients, generally. Gastrointestinal disorders like gastritis (62%) and gastroesophageal reflux (39%) were frequent in patients. Prevalence of patients with weight loss was 20% in predialysis and 8% in PD and the ratio was higher in predialysis group statistically significantly (p = 0,016). The prevalence of gastritis was 70% in PD, 55% in HD and the prevalence of hemorrhoids was 24% in PD and 12% in HD. The prevalence of gastritis and hemorrhoids was higher in the PD group than in the HD group statistically significantly (p = 0.043, p = 0.028), otherwise, there wasn’t a difference between the PD and predialysis groups, statistically significantly.ConclusionThis study showed that; gastrointestinal symptoms and disorders were very common in CKD, besides this; while gastritis and hemorrhoids were more frequent in the PD, esophagitis and hiatal hernia were more frequent in the HD.

Transitions in an integrated model of renal replacement therapy in a regional health system

Introduction and objectivesThe choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques. Material and methodsThe study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008–2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition. ResultsA total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KT). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p < 0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs KTX group 8.3%, p < 0.001) and less access to a transplant (HD group 30.4% vs PD group 51.6%; p < 0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD → PD: 0.7 years (SD 1.1) vs PD → HD: 1.5 years (SD 1.4) p < 0.001), are younger (HD → PD: 53.5 years (SD 16.7) vs PD → HD: 61.6 years (SD 14.6); p < 0.001), presented less mortality (HD → PD: 24.5% vs PD → HD: 32.0%; p < 0.001) and higher access to a transplant (HD → PD: 49.4% vs PD → HD: 31.7%; p < 0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one. ConclusionOur data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.

Using root cause analysis as a tool to reduce central venous catheters in haemodialysis patients.

Haemodialysis remains the most common modality of renal replacement therapy. National and international guidelines continue to promote arteriovenous fistulas or grafts as the preferred vascular access for haemodialysis, given the increased risks associated with use of central venous catheters (CVCs). Our renal centre pursues a 'fistula first' culture and uses root cause analysis and a patient safety incident based approach to meet the recommended standards of minimal CVC use in dialysis patients. We undertook a retrospective observational review looking at patterns of CVC use amongst our patients to identify themes and changes over time. Using data collected over a 5 year period, we examined 100 patient safety incidents involving CVC use in planned haemodialysis patients. We used a contributory factors framework to identify systemic contributors to each incident. During the study period our centre achieved the national standard of at least 60% of incident dialysis patients commencing planned haemodialysis via arteriovenous access. About 26% of cases of CVC use in incident dialysis patients were deemed potentially avoidable. The most common contributory factor identified in these cases was poor communication. Using a root cause analysis based methodology to examine CVC use in haemodialysis is a novel approach to quality improvement in this area. Our methodology can be used as a framework by other centres to optimise the provision of safe, effective, and timely vascular access for dialysis, with multiple benefits for both renal services and individual patients.

USE OF INDIGENOUSLY MANUFACTURED APD CYCLER IN PAKISTAN: THE BAHRIA TOWN INTERNATIONAL HOSPITAL EXPERIENCE.

Patients with end stage renal disease have the option of utilizing peritoneal dialysis (PD) as their mode of renal replacement therapy. There are basically 2 types of PD which include chronic ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis. APD is the most preferred type of PD utilized globally because of convenience of nighttime therapy but requires a cycler machine. Unfortunately the APD cycler is not available in Pakistan, hence APD utilization in Pakistan is zero. Byonyks Private Limited have recently manufactured an indigenous device for APD in Pakistan. This abstract is the first experience with that device in Pakistan at Bahria Town International Pakistan Lahore after approval from the local institutional research board and ethical committee (IRBEC).

Predicting mortality in critically ill patients requiring renal replacement therapy for acute kidney injury in a retrospective single-center study of two cohorts

Half of the critically ill patients with renal replacement therapy (RRT) dependent acute kidney injury (AKI) die within one year despite RRT. General intensive care prediction models perform inadequately in AKI. Predictive models for mortality would be an invaluable complementary tool to aid clinical decision making. We aimed to develop and validate new prediction models for intensive care unit (ICU) and hospital mortality customized for patients with RRT dependent AKI in a retrospective single-center study. The models were first developed in a cohort of 471 critically ill patients with continuous RRT (CRRT) and then validated in a cohort of 193 critically ill patients with intermittent hemodialysis (IHD) as the primary modality for RRT. Forty-two risk factors for mortality were examined at ICU admission and CRRT initiation, respectively, in the first univariate models followed by multivariable model development. Receiver operating characteristics curve analyses were conducted to estimate the area under the curve (AUC), to measure discriminative capacity of the models for mortality. AUCs of the respective models ranged between 0.76 and 0.83 in the CRRT model development cohort, thereby showing acceptable to excellent predictive power for the mortality events (ICU mortality and hospital mortality). The models showed acceptable external validity in a validation cohort of IHD patients. In the IHD validation cohort the AUCs of the MALEDICT RRT initiation model were 0.74 and 0.77 for ICU and hospital mortality, respectively. The MALEDICT model shows promise for mortality prediction in critically ill patients with RRT dependent AKI. After further validation, the model might serve as an additional clinical tool for estimating individual mortality risk at the time of RRT initiation.

Peritoneal Dialysis as a Renal Replacement Therapy Modality for Patients with Acute Kidney Injury.

Since the advent and predominant use of extracorporeal therapies for renal replacement therapies for acute kidney injury, the use of peritoneal dialysis has largely been limited to specific resource-limited settings. This review highlights the current data available for the utilization of peritoneal dialysis for acute kidney injury. Though the current randomized controlled trials have small patient numbers, they have demonstrated peritoneal dialysis to be an appropriate modality for dialysis therapy in acute kidney injury. Current outcomes do not show a difference in mortality, renal recovery rates, or infectious complications when compared to extracorporeal treatments. However, there is a marked heterogeneity in these trials, and more standardized reporting of trial design, techniques, complications, and outcomes is needed.

Dialysis practices during the COVID-19 pandemic: a survey from India

Introduction: The COVID-19 pandemic has been a challenging time for dialysis units worldwide. Nephrologists are faced with the difficult task of providing renal replacement therapy to COVID-19 patients and simultaneously prevent spread of COVID-19 in dialysis units. Objectives: We aimed to study the dialysis practices being followed during the COVID-19 pandemic. Patients and Methods: A questionnaire assessing treatment and preventive practices being followed in dialysis units during the COVID-19 pandemic was emailed to nephrologists and nephrology trainees practising in India. Responses were recorded electronically. Results: We received 173 valid responses. About 83.2% nephrologists were providing dialysis for COVID-19. Hemodialysis/slow low-efficient dialysis was the most common modality (65.2%) of renal replacement therapy (RRT) in COVID-19 acute kidney injury. In dialysis patients with suspicious symptoms, most common test to rule out COVID-19 was RT-PCR (reverse transcriptase polymerase chain reaction) + chest imaging ( 42.2%) followed by RT-PCR alone (34.1%). Around 80.9% nephrologists sought a negative RT-PCR in patients who had recovered from COVID-19 before discontinuation of isolation measures. Adherence to COVID-19 preventive measures varied between 15.2% (portable reverse osmosis disinfection) to 97.1% (mask wearing). Healthcare worker (HCW) training programme was present in 88.4% cases, paid leaves for COVID-19 in 89% and daily HCW symptom screen in 65.3%. The most frequently identified barrier to chronic kidney disease care was a delay in transplantation (66.5%). Accordingly, 20.8% reported a temporary closure of dialysis unit due to COVID-19 outbreak. Moreover, 63% of nephrologists counseled patients to choose peritoneal dialysis above hemodialysis as permanent RRT. Conclusion: Hemodialysis/slow low efficient dialysis is the preferred modality of RRT in COVID 19-AKI. Many nephrologists are counseling for peritoneal dialysis as superior to hemodialysis during COVID-19 for maintenance RRT. Preventive measure adherence is variable across centers. HCW safety has been addressed in most centers.

Peritonitis as the Cause of Death of CAPD Patients at RSUD Dr. Saiful Anwar Malang 2014-2020

Background: Continuous Ambulatory Peritoneal Dialysis (CAPD) is an effective modality of renal replacement therapy in patients with kidney failure. Peritonitis associated with peritoneal dialysis remains a significant challenge and complication to success long-term peritoneal dialysis. Aim: This study aims to report the peritonitis as a cause of death of CAPD patients for six years in end-stage renal failure (ESRD) patients at RSUD Dr. Saiful Anwar Malang. Methods: A descriptive study was conducted involving 40 patients with end-stage renal failure who underwent CAPD therapy with peritonitis as the cause of patient mortality by taking data from the CAPD Center medical record at RSUD Dr. Saiful Anwar from August 2014 to July 2020. Results: From 674 end-stage renal failure patients who underwent CAPD, 248 patients (36.8%) died, and 426 patients (63.2%) survived to 5 years. CAPD peritonitis is the second most common cause of 40 (16.1%) mortality cases after cardiovascular disease. The most common bacteria causing CAPD peritonitis was coagulate-negative Staphylococcus, with as many as 15 (37.5%) cases. Conclusion: the most common cause of mortality was Staphylococcus coagulase-negative (37.5 %,), a bacteria that come from touch contamination or infection at the exit site. So that patients and caregivers must be trained to carry out proper exit-site, and it is essential to maintain good hand hygiene before performing exit-site. Appropriate prevention and management of peritonitis are critical to patients' long-term success on peritoneal dialysis.

Comparison of Peritonitis Relapse Incidence in End-Stage Renal Disease Patients with Peritoneal Dialysis According to the Culture Results

Background: Peritoneal dialysis (PD) is one of the modalities of renal replacement therapy (RRT) in end-stage renal disease (ESRD). One of the complications that are often found in the use of PD is peritonitis. Presence of the culture from the peritoneal fluid was known to be associated with the incidence of peritonitis relapse among ESRD patients with PD. Aim: Comparing the incidence of relapse in patients with continuous ambulatory peritoneal dialysis (CAPD) with culture-negative and culture-positive in RSUD Dr. Saiful Anwar Malang. Methods: This study measured the incidence of relapse after administration of CAPD peritonitis therapy. Descriptive data are presented in percentages, and numerical data is presented in Mean ± SD. The analysis test was carried out using the Mann-Whitney with p&lt;0.05, significant. Results: According to the culture results, it was found that 25.4% (18 of 71 PD peritonitis cultures) were culture-negative in patients with CAPD peritonitis. This result is slightly higher than the ISPD recommendation, with 20% culture-negative results. There were 3 out of 53 relapses in culture-positive subjects and 1 in 18 relapses in culture-negative subjects. There was no significant difference in the two groups, with an OR of 0.721 in the culture-positive group lead the culture-positive tended to experience no relapse by 0.721 times less than the patient with culture-negative. Conclusion: In peritoneal dialysis peritonitis, there was no significant difference in the incidence of relapse in the positive and culture-negatives.

Intraoperative dialysis with the use of a mobile dialysis system during liver transplantation

PurposeOver the last few years, transplant centers have started to use various intraoperative renal replacement therapy (ioRRT) modalities during liver transplantation (LT) in patients with pre-existing renal impairment. Here, we present a study on the safety and clinical outcomes of intraoperative hemodialysis (ioHD) performed using a mobile dialysis system during LT. Patients and methodsWe retrospectively analyzed 102 adult patients undergoing LT with ioHD; pre-existing renal failure and/or intraoperative metabolic derangement were ioHD treatment indications. ResultsOur study cohort consisted of three groups: LT with preoperative serum creatinine (sCr) ​< ​2 ​mg/dL (Group 1:n ​= ​22), LT with preoperative sCr ≥2 ​mg/dL (Group 2:n ​= ​73), and simultaneous liver-kidney transplantation (Group 3:n ​= ​7). Among the procedures, 30% were re-transplantations. The mean calculated Model for End-stage Liver Disease score in Group 2 was 39.2, and 67% of patients were hospitalized in the intensive care unit. Patients in Group 1 were less acutely ill but developed severe intraoperative derangements and, therefore, underwent urgent ioHD intraoperatively. However, it was delayed when compared to Group 2. All groups achieved post-reperfusion potassium levels <4 ​mmol/L and a decrease in central venous pressure. No serious procedural complications occurred. Post-reperfusion syndrome occurred in 12.7% of patients. Elevated mortality was likely due to the high illness severity in the cohort. ConclusionsPerforming ioHD with a mobile dialysis system during LT was safe and effective, while being easier to perform than continuous techniques. Its effect on intra- and postoperative outcomes should be addressed in a study with a control group.

FC058: Long-Term Renal Survival of Anca-Associated Vasculitis Patients Included in the Euvas Randomized Clinical Trials

Abstract BACKGROUND AND AIMS Kidney involvement is common in ANCA-associated vasculitis (AAV) and prognosis is largely determined by the severity of the kidney damage at diagnosis and by the response to treatment. Rapidly progressive glomerulonephritis is the most common severe clinical manifestation of AAV. Current therapy with immunosuppressive and glucocorticoid treatment plays a crucial role to rescue kidney function, but the rate of patients reaching end-stage renal disease (ESRD) remains high. The aim of the study is to determine the renal prognosis and predictive factors of patients included in EUVAS randomized controlled trials (RCTs) by the European Vasculitis Society from 1995 to 2012: MEPEX, NORAM, CYCAZAREM, CYCLOPS, IMPROVE, RITUXVAS and MYCYC. METHOD Questionnaires were sent to the principal investigators of the original RCTs and 490 were returned (70% of the potential patients). The dataset comprised 848 patients, all newly diagnosed with AAV, well characterized at inclusion in the trials, as was the type and duration of induction therapy. RESULTS Median follow-up time for the entire cohort was 8 years [interquartile range (IQR): 2.9–13.6]. 478 (56%) patients had granulomatosis with polyangiitis (GPA) and 370 (47%) microscopic polyangiitis (MPA). Mean age at diagnosis was 57.5 ± 14.2 years. Renal involvement was detected in 644 (76%) patients at diagnosis, with a median eGFR of 42.1 (IQR: 16.2–88.6) mL/min/1.73 m2. At baseline, 199 patients had an eGFR &amp;lt;15 mL/min/1.73 m2 and another 144 an eGFR 15–30 mL/min/1.73 m2. A totla of 107 patients needed dialysis at initial presentation. However, 37 out of the 107 recovered renal function later and 11 patients were temporarily dialysis independent but needed subsequent dialysis. A total of 105 started renal replacement therapy (RRT) after the end of the initial RCTs. A total of 175 patients required RRT during long-term follow-up. A total of 35 patients received a kidney transplant and they showed better survival than patients receiving other modalities of RRT (LR: 42.2; P-value &amp;lt; 0.001) (Figure 1). Among patients with ESRD, 67 (38%) had GPA and 108 (62%) had MPA-RLV. Median baseline eGFR was 13.2 (IQR: 7.3–26) mL/min/1.73 m2. Patients with ESRD were older at entry (62.3 ± 13.4 versus 57 ± 14.1 years) (P-value &amp;lt; 0.001), had baseline lower hemoglobin level (9.2 ± 1.8 versus 10.3 ± 2 g/dL) (P-value &amp;lt; 0.001) and lower baseline platelets count (366 ± 182 versus 406 ± 164 *109/L) (P-value: 0.006). The cumulative incidence of ESRD at 5 and 10 years was 16.7% and 22.5%, respectively. A total of 118 deaths were found among the patients who developed ESRD (67.4%). Those with ESRD had reduced survival when compared with those with preserved kidney function (log-rank: 97.2; P-value &amp;lt; 0.001) (HR: 2.8; P-value &amp;lt; 0.001).The most frequent causes of death were infection (29.7%) followed by cardiovascular disease (16.9%) and malignancy (5.9%). GPA patients who had ESRD had better prognosis compared to MPA-RLV (HR: 5.4; P-value: 0.02) (Figure 2). When compared to a matched general population (matched by age, sex and country), even those patients with AAV and mild renal impairment (eGFR &amp;gt; 30 mL/min/1.73 m2) had a worse prognosis. CONCLUSION Our findings, which were derived from a large number of patients with AAV enrolled in EUVAS’ RCTs over the past 25 years, estimate the 5- and 10-year cumulative incidence of ESRD to 16.7% and 22.5%, respectively. ESRD is tightly associated with decreased patient survival.

MO671: Should We Undergo Peritoneal Dialysis in Malnourished Chronic Kidney Disease Patients?

Abstract BACKGROUND AND AIMS The implementation of peritoneal dialysis (PD) in end-stage renal disease has been associated with various long-term pathophysiologic changes, which result in adverse consequences, such as malnutrition, occurring in 30–50% of patients. Specific factors to PD might be associated with poor oral intake as continuous absorption of glucose from PD solutions and abdominal fullness induced by the dialysate can suppress appetite. There are several accepted strategies for stratifying malnutrition in PD, such as laboratory markers [serum albumin and normalized protein catabolic ratio (nPCR)] and the recent use of bioimpedance spectroscopy (BIS) (with low lean tissue index). We aimed to evaluate if PD patients with a poor nutritional status at the beginning of the technique had worse outcomes (peritonitis, PD failure, hospitalizations, and death). METHOD We studied a cohort of incident patients from a single PD unit between 1 July 2011 and 31 August 2021, who had one BIS measurement and a peritoneal equilibration test in the first 3 months after the start of PD. We also collect laboratory data within 6 months from the BIS evaluation (serum albumin). Besides demographic parameters, we evaluated established endpoints (peritonitis, PD failure, hospitalizations and death). RESULTS There were included 91 PD patients. The mean age of patients was 65.40 $ \pm $ 13.88 years with a median dialysis vintage of 24 (IQR 14–31.61) months; 59.3% were male and 28% had diabetes. During the follow-up period, 5.5% of the cohort died, 56% were hospitalized and 47.3% had at least one episode of peritonitis. Furthermore, the transfer to hemodialysis occurred in 18 cases (19.8%) and 15 (16.5%) received a renal transplant. There was no difference in nutritional markers median in patients that had clinical endpoints versus those who had not (Table 1). In a multivariable analysis, neither nPCR, nor albumin nor lean tissue index were predictors of peritonitis, PD failure or hospital admissions. CONCLUSION In this study, we found that malnourished patients, prevalent in PD, did not have worse clinical endpoints (higher rate of infections, hospital admissions and PD failure). Although adequate nutrition has been deemed vital to the success of PD, this modality of renal replacement therapy did not result in worse outcomes, despite the malnutrition markers at the beginning of PD. Further studies are warranted to evaluate the positive impact of PD in nutrition status.

MO478: The Epidemiology of Anca-Associated Vasculitis at a Single Centre Over Two Decades

Abstract BACKGROUND AND AIMS ANCA-associated vasculitis (AAV) refers to a group of conditions in which the end result is systemic injury of small blood vessels, resulting in damage to distinct organ systems including the lung, kidneys, ear, nose and throat. A characteristic, although not exclusive feature, is the development of anti-neutrophil cytoplasmic antibodies (ANCA) against specific proteins within the neutrophil-leucocyte proteinase 3 (PR3) and myeloperoxidase (MPO). The incidence varies according to geographic location but is ∼20 cases/million/year. The age of onset is usually between 45–75 years old, with a male: female ratio of 1:1. Without treatment, it is life-threatening; the aim of treatment is to induce remission with a strong immunosuppressive induction regimen followed by a maintenance phase. The risk of relapse remains. Here, we assessed the epidemiology of AAV &amp;gt;2 decades at our centre (Salford Royal Hospital, UK) with particular reference to severity of disease at presentation, ANCA positivity and outcomes. METHOD Patients with a diagnosis of AAV (either granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) or eosinophilic granulomatosis with polyangiitis (EGPA)) were identified from our database between January 2000 and December 2021 (see Figure 1). Diagnosis was based on clinical features, ANCA result and kidney biopsy findings. A total of 47 were excluded and demographic data, co-morbidities, laboratory values (including baseline creatinine, eGFR, proteinuria, ANCA positivity), treatment given and outcomes were collected in the remaining sample. Analysis determined (i) basic demographic description of our cohort, (ii) median baseline creatinine, eGFR and proteinuria, (iii) those with an initial requirement for renal replacement therapy (RRT) at presentation, (iv) ANCA positivity rates and (v) outcomes including progression to RRT and mortality. RESULTS The evaluable cohort totalled 369 patients (see Table 1). Of these, 194 were male (52.6%), and the median age at presentation was 73 (IQR 60–82) years; 91.9% were Caucasian. Median baseline creatinine was 165 µmol/L (93–338), eGFR 33 mL/min/1.73 m2 (15–66) and proteinuria 98 g/mol (25–258). ANCA was measured in 363 (98.4%), of which c-ANCA and or PR3 positivity was seen in 142 (39.1%), and p-ANCA and or MPO positivity was seen in 148 (40.8%). In a small number, atypical ANCA was seen (1.9%) or ANCA was obscured by anti-nuclear factor (ANF) (2.8%). An immediate requirement for RRT at presentation was seen in 26 (7%). Progression to RRT at any time point over the follow up period was observed in 86 (23.3%), with the first RRT modality being haemodialysis in 64 (17.3%), peritoneal dialysis in 20 (5.4%) and transplant in 2 (0.5%). A total of 147 patients (39.8%) died over the follow-up period. A combined outcome of progression to RRT or death was seen in 191 (51.8%). CONCLUSION We show that patients present with AAV at an advanced age and with significant renal involvement (median baseline eGFR of 33 mL/min/1.73 m2 in our study). The distribution of PR3 and MPO positive vasculitis is similar, although there were a significant number of ANCA negative patients in our cohort. There were differences in concordance between c-ANCA and PR3 positivity, along with p-ANCA and MPO positivity, which may be explained by historical differences in testing. There remains a significant risk of progression to the requirement for RRT or death: 51.8% observed over our follow-up period of two decades.

Unusual Pathogen in a Patient With Peritoneal Dialysis-Related Peritonitis: A Case Report

Peritoneal dialysis (PD) is an effective modality for renal replacement therapy. A serious complication that can arise from PD is peritonitis. Over the last few decades, there have been cases of PD-related peritonitis secondary to Pasteurella multocida infections. We present the case of a 44-year-old female who presented to the emergency department with a one-day history of abdominal pain and cloudy peritoneal fluid on evaluation. Along with her physical examination findings, laboratory results of the peritoneal fluid demonstrated elevated white blood cells and neutrophils, characteristic of peritonitis. Ultimately, the culture results were positive for P. multocida. Although P. multocida is not the most common cause of peritonitis, it is a common cause in PD patients who have domesticated animals. With two out of three people being pet owners and the increased number of people on home therapies such as PD for kidney failure, it is important to educate patients about the proper precautions and techniques to prevent peritonitis and its associated complications. Additionally, proper antibiotic management should be implemented for patients with an increased risk of infection.

Half a century of haemodialysis: two patient journeys.

ABSTRACTThe history of renal replacement therapy (RRT) for end-stage kidney disease (ESKD) started in 1960 and has reached, in these six decades, goals initially unforeseen. This report describes two patients who commenced dialysis at the age of 17 and 27, for 53 and 45 years, respectively, whereby the modality of RRT was mostly in the form of home haemodialysis. The history of these two patients, who started RRT in distant parts of the world, Australia and Croatia, highlights not only the advances made over time, to significantly delay the onset and reduce the morbidity and mortality associated with ESKD, but also underlines the importance of empowerment and commitment, added values in home haemodialysis.

Continuous renal replacement therapy versus intermittent hemodialysis as first modality for renal replacement therapy in severe acute kidney injury: a secondary analysis of AKIKI and IDEAL-ICU studies

BackgroundIntermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) are the two main RRT modalities in patients with severe acute kidney injury (AKI). Meta-analyses conducted more than 10 years ago did not show survival difference between these two modalities. As the quality of RRT delivery has improved since then, we aimed to reassess whether the choice of IHD or CRRT as first modality affects survival of patients with severe AKI.MethodsThis is a secondary analysis of two multicenter randomized controlled trials (AKIKI and IDEAL-ICU) that compared an early RRT initiation strategy with a delayed one. We included patients allocated to the early strategy in order to emulate a trial where patients would have been randomized to receive either IHD or CRRT within twelve hours after the documentation of severe AKI. We determined each patient’s modality group as the first RRT modality they received. The primary outcome was 60-day overall survival. We used two propensity score methods to balance the differences in baseline characteristics between groups and the primary analysis relied on inverse probability of treatment weighting.ResultsA total of 543 patients were included. Continuous RRT was the first modality in 269 patients and IHD in 274. Patients receiving CRRT had higher cardiovascular and total-SOFA scores. Inverse probability weighting allowed to adequately balance groups on all predefined confounders. The weighted Kaplan–Meier death rate at day 60 was 54·4% in the CRRT group and 46·5% in the IHD group (weighted HR 1·26, 95% CI 1·01–1·60). In a complementary analysis of less severely ill patients (SOFA score: 3–10), receiving IHD was associated with better day 60 survival compared to CRRT (weighted HR 1.82, 95% CI 1·01–3·28; p < 0.01). We found no evidence of a survival difference between the two RRT modalities in more severe patients.ConclusionCompared to IHD, CRRT as first modality seemed to convey no benefit in terms of survival or of kidney recovery and might even have been associated with less favorable outcome in patients with lesser severity of disease. A prospective randomized non-inferiority trial should be implemented to solve the persistent conundrum of the optimal RRT technique.

528 Evaluation of phosphate replacement practices in burn patients

IntroductionBurn injury causes acute shifts in phosphorus leading to hypophosphatemia and negative sequelae, such as motor neuropathy, muscle weakness, cardiac failure, and respiratory failure. These patients require frequent phosphorus level monitoring and repletion beyond the needs of a general critical care patient. Data suggests patients with normal phosphorus levels have lower incidence of ventilator wean failure and positive clinical outcomes. There is limited data evaluating phosphate replacement practices in burn patients for their intensive care unit (ICU) length of stay while also evaluating those who concomitantly receive continuous renal replacement therapy (CRRT) as it is the primary mode of renal replacement therapy in this population and further depletes phosphorus levels.MethodsThis was a single-center, retrospective, observational study of patients with a burn injury admitted and discharged from a burn intensive care unit (BICU) from January 1, 2016 to June 30, 2020 who received phosphate. Patients less than 18 years of age and those admitted to the BICU for non-burn injuries were excluded. Burn injury type, number of phosphorus doses per day, and phosphorus levels were collected. Normal phosphorus was defined as 2.5-4.9 mg/dL and hypophosphatemia as < 2.5mg/dL. Patient data was evaluated in 24-hour time intervals as defined as midnight to midnight. Phosphorus lab values were included in data analysis if there was corresponding phosphate administration in that 24-hour interval. The primary objective was to assess the temporal dose-response to phosphate replacement in burn patients.ResultsThere were 291 patients who met criteria, 116 were selected in chronological order by admission date and were included in data analysis. The mean age was 51.51 years and the mean total body surface area burned was 21.48%. Flame burn accounted for 83.6 % (n=97) of patients and 37.06% (n=43) of patients had concomitant inhalation injury. The mean amount of phosphate given to a patient per day was 28.38 mmol and patients on CRRT received a mean amount of phosphate of 33.34 mmol per day. In response to phosphate administration, the mean change in phosphorus was 0.334 ± 1.08 mg/dL. In patients on CRRT, the mean change in phosphorus was 1.4 ± 1.89 mg/dL. Patients experienced hypophosphatemia 69.63% of the days that they received phosphate repletion and patients on CRRT had hypophosphatemia 87.39% of the days they received phosphate repletion.ConclusionsHypophosphatemia is common in the burn injury population and current phosphate replacement practices are insufficient to replete phosphorus in burn injury patients.

Effects of Expanded Hemodialysis with Medium Cut-Off Membranes on Maintenance Hemodialysis Patients: A Review.

Kidney failure is associated with high morbidity and mortality. Hemodialysis, the most prevalent modality of renal replacement therapy, uses the principle of semipermeable membranes to remove solutes and water in the plasma of patients with kidney failure. With the evolution of hemodialysis technology over the last half century, the clearance of small water-soluble molecules in such patients is adequate. However, middle molecules uremic toxins are still retained in the plasma and cause cardiovascular events, anemia, and malnutrition, which significantly contribute to poor quality of life and high mortality in maintenance hemodialysis patients. A new class of membrane, defined as a medium cut-off (MCO) membrane, has emerged in recent years. Expanded hemodialysis with MCO membranes is now recognized as the artificial kidney model closest to natural kidney physiology. This review summarizes the unique morphological characteristics and internal filtration–backfiltration mechanism of MCO membranes, and describes their effects on removing uremic toxins, alleviating inflammation and cardiovascular risk, and improving quality of life in maintenance hemodialysis patients.

Evaluation of Clinical Features and Renal Replacement Therapy in Children with Typical Hemolytic Uremic Syndrome

Objective: A subset of typical Hemolytic-uremic syndrome (HUS) patients requires initiation of renal replacement therapy (RRT) despite aggressive medical intervention. This study aims to evaluate the clinical and laboratory findings of patients diagnosed with typical HUS and efficacy and safety of peritoneal dialysis (PD) and hemodialysis (HD) were compared in managing these cases. Material and Methods: Patients having a diagnosis of typical HUS were retrospectively determined, and assessment the effects of RRT modalities on renal survival. Results: The present study included 49 children with typical HUS, and the mean age was 2.99 ± 1.88 years. Neurological involvement was detected in 15 (30.6%) patients. The neutrophil/lymphocyte ratio (NLR) was significantly higher in the neurological involvement group [odds ratio (OR) 15.42, 95% CI (3.39-70.1), p = 0.005]. In total, 43 (87.7%) patients received RRT and the median time from the first recorded symptom to RRT was six days (range 3-11). While throughout RRT, 10.2% of patients required mechanical ventilation. In this study, 26 (53.1%) patients were managed with PD, and 17 (34.6%) patients were managed with HD. During follow-up, 10.2% of all patients progressed to chronic kidney disease (CKD), proteinuria was detected in 6.1% and hypertension in 4.08%. The risk of CKD was significantly lower in the 3-month period in PD patients than in HD patients (odds ratio (OR) 7.69, 95% CI (0.77-76.07), p = 0.04). Conclusion: We concluded that PD might be as effective and safer as HD concerning kidney recovery. Clinical features and inflammatory markers can predict neurological involvement in typical HUS cases.

POS-710 CHARACTERISTICS OF PERITONEAL DIALYSIS PATIENTS IN dr. ZAINOEL ABIDIN HOSPITAL BANDA ACEH

Background: Chronic kidney disease (CKD) in Indonesia is increasing. Indonesian Renal Registry (IRR) shows the number of CKD patients undergoing Peritoneal Dialysis (PD) in Indonesia increased (2,105 patients in 2018).1 Peritoneal dialysis (PD) is a well-established modality of renal replacement therapy. The PD is a relatively simple technique that can be done alone at home, can also reduce transportation costs to dialysis centers, and is very suitable for patients with hemodynamic problems or with certain conditions.2,3. Aims : to find out the characteristics of patients undergoing PD in dr. Zainoel abidin hospital, Banda aceh, Indonesia. Research methods: This is a cross-sectional study conducted in dr. Zainoel Abidin hospital, Banda Aceh Indonesia, from January-August 2021. We included all adults’ patients who had undergoing PD for at least three month. Serum concentrations of hemoglobin, levels of 25-hydroxyvitamin D , calcium, phosphate, parathyroid hormone, potassium, sodium, magnesium, albumin, lipid profile, uric acid, ferritin, and blood glucose were measured at the same time as Echocardiography examination. Univariate analysis were performed to analyze data. Results: A total of fourty four patients underwent PD were recruited. Average age of was (43.11±13.74) years old consisting of 18 women (40.90%) and 26 men (59.09%) with an average length of PD undergoing 22.50(4-156) months. The mean BMI ( Body Mass Index) of the patients was (24.98±4.8) Diabetic patients was 15.80% and all patients had comorbid hypertension. From the laboratory examination, it was found that the average level of hemoglobin (9.03±1.95) g/dl, calcium (7.85±1.13) mg/dl, phosphate (1.80±0.53) mg/dl, 25-hydroxyvitaminD (14.89±5.60) ng/ml, intact parathyroid hormone (743.35±592.83) pg/dl, potassium (3.48±11.03) mg/dl, sodium (141.61±5.04) mg/dl, magnesium (1.97±0.36) mg/dl, albumin (3.28±0.57) mg/dl, ferritin (774.60±896.06) mcg/l, triglycerides (129.72±60.38) mg/dl ,LDL (low-density lipoprotein) (136,52±46.10), HDL (high-density lipoprotein) (44.70±12.73), total Cholesterol (191.29±49.66) uric acid (6.60±1.24) mg/dl , blood sugar level (109.02±32.58) mg/dl. Echocardiography examination show thay LVH (Left ventricular Hypertrophy) was 81.8% and diastolic dysfunction was 65.9%. Conclusion