Obstructive Sleep Apnea Severity and Overnight Body Fluid Shift before and after Hemodialysis.

BACKGROUND AND OBJECTIVES: Obstructive sleep apnea is associated with significantly increased cardiovascular morbidity and mortality. Fluid overload may promote obstructive sleep apnea in patients with ESRD through an overnight fluid shift from the legs to the neck soft tissues. Body fluid shift and severity of obstructive sleep apnea before and after hemodialysis were compared in patients with ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Seventeen patients with hemodialysis and moderate to severe obstructive sleep apnea were included. Polysomnographies were performed the night before and after hemodialysis to assess obstructive sleep apnea, and bioimpedance was used to measure fluid overload and leg fluid volume. RESULTS: The mean overnight rostral fluid shift was 1.27±0.41 L prehemodialysis; it correlated positively with fluid overload volume (r=0.39; P=0.02) and was significantly lower posthemodialysis (0.78±0.38 L; P<0.001). There was no significant difference in the mean obstructive apnea-hypopnea index before and after hemodialysis (46.8±22.0 versus 42.1±18.6 per hour; P=0.21), but obstructive apnea-hypopnea index was significantly lower posthemodialysis (-10.1±10.8 per hour) in the group of 12 patients, with a concomitant reduction of fluid overload compared with participants without change in fluid overload (obstructive apnea-hypopnea index +8.2±16.1 per hour; P<0.01). A lower fluid overload after hemodialysis was significantly correlated (r=0.49; P=0.04) with a lower obstructive apnea-hypopnea index. Fluid overload-assessed by bioimpedance-was the best predictor of the change in obstructive apnea-hypopnea index observed after hemodialysis (standardized r=-0.68; P=0.01) in multivariate regression analysis. CONCLUSIONS: Fluid overload influences overnight rostral fluid shift and obstructive sleep apnea severity in patients with ESRD undergoing intermittent hemodialysis. Although no benefit of hemodialysis on obstructive sleep apnea severity was observed in the whole group, the change in obstructive apnea-hypopnea index was significantly correlated with the change in fluid overload after hemodialysis. Moreover, the subgroup with lower fluid overload posthemodialysis showed a significantly lower obstructive sleep apnea severity, which provides a strong incentive to further study whether optimizing fluid status in patients with obstructive sleep apnea and ESRD will improve the obstructive apnea-hypopnea index.

Prevalence and Diagnostic Approach to Sleep Apnea in Hemodialysis Patients: A Population Study.

BACKGROUND: Previous observations found a high prevalence of obstructive sleep apnea (OSA) in the hemodialysis population, but the best diagnostic approach remains undefined. We assessed OSA prevalence and performance of available screening tools to propose a specific diagnostic algorithm. METHODS: 104 patients from 6 Swiss hemodialysis centers underwent polygraphy and completed 3 OSA screening scores: STOP-BANG, Berlin's Questionnaire, and Adjusted Neck Circumference. The OSA predictors were identified on a derivation population and used to develop the diagnostic algorithm, which was validated on an independent population. RESULTS: We found 56% OSA prevalence (AHI ≥ 15/h), which was largely underdiagnosed. Screening scores showed poor performance for OSA screening (ROC areas 0.538 [SE 0.093] to 0.655 [SE 0.083]). Age, neck circumference, and time on renal replacement therapy were the best predictors of OSA and were used to develop a screening algorithm, with higher discriminatory performance than classical screening tools (ROC area 0.831 [0.066]). CONCLUSIONS: Our study confirms the high OSA prevalence and highlights the low diagnosis rate of this treatable cardiovascular risk factor in the hemodialysis population. Considering the poor performance of OSA screening tools, we propose and validate a specific algorithm to identify hemodialysis patients at risk for OSA for whom further sleep investigations should be considered.

Sociodemographic characteristics and clinical features of patients with adult polycystic kidney disease undergoing hemodialysis

Aims:To analyze the socio-demographic and clinical characteristics of patients with adult polycystic kidney disease admitted to hemodialysis services in Northwestern Paraná state,Brazil. Methods: This was an observational, descriptive and retrospective longitudinal study. Medical records of patients with polycystic kidneys who initiated hemodialysis between 1995 and 2012, in four centers that treat patients of the coverage area of the 15th Regional Health Region of Paraná state where analyzed. Results:We found that 10.3% of hemodialysis patients had polycystic kidney disease as a leading cause of stage 5 of chronic kidney disease. The mean age of patients was 54.9±9.4 years (ranging between 27 and 74 years), with equal gender distribution and Caucasian predominance (72.9%). The average age of dialysis initiation was 50±10.2 years. The most common comorbidity was systemic hypertension (66.7%). Liver cyst was the main extra-renal manifestation (10.4%). Twenty-five percent of the patients required renal transplantation, and (22.9%) undergone nephrectomy. The most widely used classes of antihypertensive drugs were β-blockers (41.7%) and drugs that act on the renin-angiotensin system (31.3%), while 56.3% of patients were treated with recombinant human erythropoietin. Conclusions:This is a pioneering epidemiological study in Northwestern Paraná state. We found in this population a sociodemographic and clinical profile of adult polycystic kidney disease similar to that of North America and Europe, probably because the ethnic constitution of the sample was predominantly of Euro-descendants.

Autosomal dominant polycystic kidney disease in hemodialysis patients in southern Brazil

Introduction: Autosomal dominant polycystic kidney disease is the most common hereditary renal disease in humans. Objective: To examine the prevalence, clinical and laboratory characteristics of patients with polycystic kidneys and relate disease manifestations by gender. Methods: This was an observational and retrospective study. All the medical records of patients with polycystic kidneys who initiated hemodialysis between 1995 and 2012, in four centers that treat patients of the coverage area of the 15th regional health Paraná (Brazil), were analyzed. Results: The study included 48 patients with polycystic kidneys, the primary cause of stage 5 CKD. Disease prevalence was one in 10,912 people. The average age of dialysis initiation was 50.7 years and the follow-up time on dialysis until transplantation (36.5 months) was lower among men. Hypertension was the most frequent diagnosis in 73% of patients, predominantly in women (51.4%). The liver cyst was the most frequent extrarenal manifestations in men (60.0%). The death occurred in 10.4% of patients using hemodialysis, and 60% of men. The class of antihypertensive drug used was that acts on the renin-angiotensin system with higher frequency of use among women (53.3%). The post-dialysis urea was significantly higher in men. Conclusion: The prevalence of the disease is low among hemodialysis patients in southern Brazil. The differences observed between genders, with the exception of the post-dialysis urea, were not significant. The findings are different from those reported in North America and Europe.

Labile Plasma Iron Generation After Intravenous Iron is Time-dependent and Transitory in Patients Undergoing Chronic Hemodialysis

Iron supplementation in hemodialysis patients is fundamental to erythropoiesis, but may cause harmful effects. We measured oxidative stress using labile plasma iron (LPI) after parenteral iron replacement in chronic hemodialysis patients. Intravenous iron saccharate (100 mg) was administered in patients undergoing chronic hemodialysis (N = 20). LPI was measured by an oxidant-sensitive fluorescent probe at the beginning of dialysis session (T0), at 10 min (T1), 20 min (T2), and 30 min (T3) after the infusion of iron and at the subsequent session; P < 0.05 was significant. The LPI values were significantly raised according to the time of administration and were transitory: -0.02 +/- 0.20 mu mol/L at the beginning of the first session, 0.01 +/- 0.26 mu mol/L at T0, 0.03 +/- 0.23 mu mol/L at T1, 0.09 +/- 0.28 mmol/L at T2, 0.18 +/- 0.52 mmol/L at T3, and -0.02 +/- 0.16 mmol/L (P = 0.001 to 0.041) at the beginning of the second session. The LPI level in patients without iron supplementation was -0.06 +/- 0.16 mmol/L. Correlations of LPI according to time were T1, T2, and T3 vs. serum iron (P = 0.01, P = 0.007, and P = 0.0025, respectively), and T2 and T3 vs. transferrin saturation (P = 0.001 and P = 0.0003, respectively). LPI generation after intravenous saccharate administration is time-dependent and transitorily detected during hemodialysis. The LPI increment had a positive correlation to iron and transferrin saturation.

Sustaining a hemodialysis exercise program : a review

This article reviews the literature addressing exercise programs for dialysis patients to identify elements necessary for sustaining exercise programs in this population. Literature searches for publications (January 1980–February 2009) in Medline (OVID), PubMed, CINAHL (EBSCO), EBSCOhost EJS, ProQuest Central, Web of Science, Cochrane Library, Google Scholar, ScienceDirect, SpringerLink (Kluwer), and Wiley Interscience (Blackwell) were performed. Reference lists from relevant articles were hand-searched for further publications. Criteria for inclusion included full-text primary research and review articles focused on exercise for adult hemodialysis patients. One hundred and seventy one publications were found with a primary focus on exercise in hemodialysis. Of these, 28 primary research and 14 review articles addressed one or more aspects of sustainability of hemodialysis exercise programs. Factors contributing to sustainable exercise programs included: dedicated exercise professionals; encouragement to exercise intradialytically; dialysis and medical staff commitment; adequate physical requirements of equipment and space; interesting and stimulating; cost implications need to be addressed; exercise is not for everyone; requires individual prescription; and there is no age barrier to exercise on hemodialysis.

A simple nutrition screening tool for hemodialysis nurses

Objective : To assess the reliability of a nurse-performed nutrition screening tool (NST) for hemodialysis (HD) patients to identify nutritionally at-risk patients.

Design : Tool reliability assessment.

Setting and Participants : The setting was nine non-hospital private (n = 3) and public (n = 6) HD units in Australia (two rural and seven metropolitan). Participants were 112 HD patients.

Results : A total of 112 HD patients (male = 65, female = 47) from 9 non-hospital HD units in Australia (seven metropolitan and two rural) were screened with the NST and the outcome of dietitian referral compared with Standard Dietitians Assessment. The mean age of patients was 57.6 years. Overall, the NST showed a sensitivity of 0.84 (range, 0.71 to 0.94; P < .05) and a specificity of 0.9 (range, 0.82 to 0.98; P < .05). The NST was more sensitive (sensitivity, 0.93 [range, 0.87 to 0.99; P < .05]) and was more specific for men (specificity, 0.92 [range, 0.85 to 0.99; P < .05]). Specificity was very strong in metropolitan patients (specificity, 0.94 [range, 0.87 to 1.01; P < .05]).

Conclusions : The tool was more sensitive and specific than the NST previously reported by the same investigators. The tool is particularly specific in that it screens those patients not requiring dietitian intervention. The use of this tool may benefit HD units that do not have on-site or regular dietetic support to prioritize patients needing dietitian intervention.

Exercise during hemodialysis : the intradialytic zumba gold

People requiring dialysis have a lower exercise capacity than the non-ESRD population. Lower exercise capacity is associated with deconditioning, which leads to a reduced quality of life and increased risk of injury. Low-impact exercise programs during dialysis have been found to be safe and beneficial for this group. In addition, intradialytic exercise can alleviate the boredom of receiving dialysis, creating an exercise-focused positive environment in the dialysis center. Increased physical activity may influence people's physical function and confidence, which may further encourage patient empowerment.

Home hemodialysis : a successful option for obese and bariatric people with end-stage kidney disease

The increasing prevalence of obesity in developed countries is reflected in the chronic kidney disease, dialysis, and transplant populations. The added risk factor of obesity increases the risk of vascular events, inflammation, insulin resistance, blood pressure, dyslipidemia, and mortality risk. Nephrology center policies may exclude obese people from transplantation programs resulting in many years of dialysis. The case of a 215-kg Australian male who has successfully dialyzed at home for more than 8 years will be used to illustrate the important considerations and clinical support that these people require for successful home dialysis treatment. The aim of this paper is to report on a program that has successfully trained 23 obese (body mass index >30) people who commenced on home hemodialysis between 2001 and 2009. Body weight ranged between 94.0 and 215 kg (mean 126, SD 26.19) and body mass index ranged between 34.9 and 71 (mean 43.38, SD 9.99) at the start of home training. During the 8.5 years of follow-up, average time on home dialysis was 43.7 months. Home hemodialysis is a feasible treatment for obese people to facilitate longer and more frequent dialysis, resulting in improved hemodynamic stability and improved quality of life. For obese people with end-stage kidney disease, home hemodialysis has shown to be cost-effective and can result in greater treatment efficacy than in-center hospital dialysis.

The impact of an exercise physiologist coordinated resistance exercise program on the physical function of people receiving hemodialysis: a stepped wedge randomised control study

Background:

Renal access coordinators' impact on hemodialysis patient outcomes and associated service delivery: a systematic review

Background
Renal access coordinators contribute specifically to dialysis access care for people with chronic and end stage renal disease. Since the introduction of renal access coordinators into Australia in the early 2000s, there have been anecdotal examples of associated improvements in patient outcomes and service delivery; however scant published quantitative evidence exists. Thus, the impact of the implementation of renal access coordinators has not undergone a rigorous review to date.

Objective
The objective of this systematic review was to critically appraise and synthesize the best available evidence related to the impact of renal access coordinators on dialysis patient outcomes and associated service delivery.

INCLUSION CRITERIA

Types of participants
This review considered studies that included renal access coordinators (noting variations of the titles) and adult hemodialysis patients (aged 18 years and over).

Types of intervention(s)
This review considered studies that evaluated the effectiveness of the renal access coordinator. This role typically consists of clinical and administration duties such as providing pre dialysis access coordination, access surveillance patient education and nurse education.

Types of studies
The types of studies considered within this review included experimental and epidemiological study designs. Thus randomized controlled trials (RCT), non-randomized controlled trials, and quasi-experimental, before and after studies, prospective and retrospective cohort studies were considered as were case control studies, analytical cross sectional studies and descriptive cross sectional studies.

Types of outcomes
Patient outcomes considered included: days to first vascular access complication (such as stenosis or thrombosis) and/or primary intervention (such as angioplasty or surgical intervention); percentage of central line insertions (negative); rate of arteriovenous fistula (AVF)/arteriovenous graft (AVG)/central venous catheter (CVC) at start of dialysis (incidence); prevalent rate of AVF/AVG/CVC; time to occlusion of AVF and time from referral to surgery. Service outcomes included: knowledge/up skilling of renal nurses; cannulation skills, ultrasound skills, knowledge of anatomy and physiology and other access related knowledge.

Search strategy
The search strategy aimed to locate published and unpublished studies, utilizing a three-step searching approach. Studies published in English from 1990 to October 2013 were considered for inclusion in this review.

Methodological quality
The studies were assessed by two independent reviewers using the appropriate standardized critical appraisal instruments from the Joanna Briggs Institute.

Data collection
Data were extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute, namely JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

Data synthesis
This review aimed to conduct meta-analyses of the findings: however, because of the limitations of the data found, this was not possible and so the findings are presented in a narrative format.

Results
Five studies were identified for inclusion in the review. No RCTs were found, therefore four of the five studies were pre-post intervention cohort studies and one was a prospective quality assurance report. Data were heterogeneous and thus did not allow for meta-analysis. All studies included multidisciplinary teams with variable emphasis on the renal access coordinator role. The pre post intervention cohort studies measured incident and/or prevalent AVF, AVG and CVC rates in the hemodialysis population and the quality assurance report measured the difference in patency rates between AVF and AVG. All discussed the role of central coordination as a contributor to the success of vascular access care.

Conclusions
This review found insufficient data to make firm conclusions about the impact that renal access coordinators have on patient outcomes. The results of this review suggest an association between renal access coordinators and improved patient outcomes. These improved patient outcomes were apparent in an increase in incident and prevalent AVFs, and a decrease in the incidence and prevalence of CVCs. Both associations are correlated with a reduction in infection rates, length of hospital stay and healthcare costs.

Psychosocial aspects in home hemodialysis: A review

Psychosocial aspects related to home hemodialysis (HD) play an important role in the success of home HD programs. Once patients commence HD at home, unique psychosocial issues related to patient and care partner burden can emerge. Proactive professional support, peer support, respite care, travel support, and financial support from the home HD health care team must be a priority for patient care. If the psychosocial aspects are not proactively addressed, patients receiving HD at home may return to in-center HD and the program may struggle as a result. This review provides a psychosocial guide for new start-up home HD programs.

Saphenofemoral arteriovenous fistula as hemodialysis access

Background: An upper limb arteriovenous (AV) fistula is the access of choice for haemodialysis (HD). There have been few reports of saphenofemoral AV fistulas (SFAVF) over the last 10-20 years because of previous suggestions of poor patencies and needling difficulties. Here, we describe our clinical experience with SFAVF.Methods: SFAVFs were evaluated using the following variables: immediate results, early and late complications, intraoperative and postoperative complications (up to day 30), efficiency of the fistula after the onset of needling and complications associated to its use.Results: Fifty-six SFAVF fistulas were created in 48 patients. Eight patients had two fistulas: 8 patent (16%), 10 transplanted (20%), 12 deaths (24%), 1 low flow (2%) and 20 thrombosis (39%) (first two months of preparation). One patient had severe hypotension during surgery, which caused thrombosis of the fistula, which was successfully thrombectomised, four thrombosed fistulae were successfully thrombectomised and revised on the first postoperative day. After 59 months of follow-up, primary patency was 44%.Conclusion: SFAVF is an adequate alternative for patients without the possibility for other access in the upper limbs, allowing efficient dialysis with good long-term patency with a low complication rate.

MICROBIOLOGICAL CONTAMINATION of A HEMODIALYSIS CENTER WATER DISTRIBUTION SYSTEM

The microbiological monitoring of the water used for hemodialysis is extremely important, especially because of the debilitated immune system of patients suffering from chronic renal insufficiency. To investigate the occurrence and species diversity of bacteria in waters, water samples were collected monthly from a hemodialysis center in upstate São Paulo and tap water samples at the terminal sites of the distribution system was sampled repeatedly (22 times) at each of five points in the distribution system; a further 36 samples were taken from cannulae in 19 hemodialysis machines that were ready for the next patient, four samples from the reuse system and 13 from the water storage system. To identify bacteria, samples were filtered through 0.22 mu m-pore membranes; for mycobacteria, 0.45 mu m pores were used. Conventional microbiological and molecular methods were used in the analysis. Bacteria were isolated from the distribution system (128 isolates), kidney machine water (43) and reuse system (3). Among these isolates, 32 were Gram-positive rods, 120 Gram-negative rods, 20 Gram-positive cocci and 11 mycobacteria. We propose the continual monitoring of the water supplies in hemodialysis centers and the adoption of effective prophylactic measures that minimize the exposure of these immunodeficient patients to contaminated sources of water.

Influence of fluid volume variations on the calculated value of the left ventricular mass measured by echocardiogram in patients submitted to hemodialysis

The left ventricular mass (LVM) measurement is of major importance for renal patients, as ventricular hypertrophy is an important prognostic index. The echo-cardiogram of the ventricular mass is larger before than it is after hemodialysis, which can confuse data interpretation. The aim of this work is to study the influence of alterations in fluid volume on the variations in measurements of ventricular mass observed during the course of a hemodialysis. Sixteen patients with chronic renal insufficiency in hemodialysis were evaluated at the Dialysis Unit of the University Hospital-UNESP, Botucatu, São Paulo State. The left ventricular mass was calculated from echocardiograms taken before and after hemodialysis and simultaneous ultra-filtration (12 patients: UF GROUP) and before and after hemodialysis isovolemic phase with sequential ultra-filtration (10 patients: ISO GROUP). Six of these patients were submitted to measurements of left ventricular mass before and after hemodialysis in both isovolemic and simultaneous ultra-filtration procedures. In the UF group, there was significant reduction in the following parameters before and after dialysis: diastolic diameter from 54.0 +/- 6.0 mm to 45.6 +/- 7.6 mm; left ventricular mass from 342 +/- 114 g to 265 +/- 117 g; and its respective index (IMVE) from 214 +/- 68 g/m(2) to 168 +/- 71 g/m(2). The ISO group showed no statistically significant variation. The behavior of the variables of six patients submitted to both observations confirm these results. In conclusion, the variations in echocardiogram measurements of the left ventricular mass relating to hemodialysis appear to be induced by alterations of the volemic condition.