Vascular access surveillance : the role of the access nurse in the renal dialysis unit.

Introduction
In January 2006, the Renal Dialysis Unit at Geelong Hospital appointed a Vascular Access Nurse. A Transonic Flow Qc HDO2 Ultrasound Dilution Monitor was purchased to monitor access flow and recirculation in arteriovenous fistulae in an attempt to predict AVF stenoses requiring early surgical correction.

Methods
A bi-monthly monitoring program tested all facility-based patients. 82 patients were assessed for access flow and recirculation between February and December 2006.

Results
18 (22%) had poor AVF function; 13 with access flows <500ml/minute on initial testing and 5 with an access flow decreasing >25% over a four month period. Of the 18 patients shown to have poor access flow, 2 died within one month of measurement while 5 were too frail to attempt corrective surgery. The remaining 11 proceeded to ultrasound or fistulography. A >50% stenosis was detected in all 11 cases. Of these, 4 had successful vein patch surgery and one had PTFE grafting, each with marked improvement in access flow. One had failed vein patch surgery requiring creation of a femoral AVF, one patient required cvc insertion to await AVF creation, and one had failed stenting requiring a permanent cvc. 3 died before planned surgery.

Conclusion
5 of the 82 patients that had access flow assessment, and needed further evaluation, proceeded to successful pre-emptive surgical intervention. We believe the Transonic is a useful adjunct to routine clinical AVF surveillance, in providing early evidence of AVF failure that can be avoided by pre-emptive surgery.

The impact of nurse-led education on haemodialysis patients' phosphate binder medication adherence

Background Phosphate binder medication adherence is required to maintain optimal phosphate levels and minimise bone disease in people with end stage kidney disease.

Objectives To examine the impact of a nurse-led education intervention on bone disorder markers, adherence to phosphate binder medication and medication knowledge.

Design Descriptive study with a paired pre–post intervention survey.

Participants Adults receiving haemodialysis.

Methods Twelve-week intervention where patients self-administered their phosphate binder medication at each dialysis treatment. Nurses provided individualised education. Patients completed a pre- and post-intervention survey designed to explore their knowledge of phosphate binders.

Results There were no statistically significant changes in clinical markers but a significant improvement in the proportion of patients who took their phosphate binder correctly, increasing from 44 to 72% (p = 0.016). There were moderate to large effect size changes for improved knowledge.

Conclusions A nurse-led intervention education programme can increase patients' phosphate binder adherence. However, this does not necessarily manifest into improved serum phosphate levels.

Developing a dialysis centre foot screening culture

Foot lesions are common in the dialysis population and contribute to increased morbidity and mortality (Broersma 2004). lmportantly, patients on dialysis with and without diabetes are at increased risk of foot ulcers (Jones et al. 2012) and lower limb amputation (Kaminski, Frescos & Tucker 2012). Simple foot screening in dialysis centres can identify those at risk of foot complications and the presence of foot ulcers (Ahmad 2009; Ng et al. 2003). Valid and reliable foot screening tools have been developed in the dialysis context to identify those at risk and those with actual ulcers (Murphy et al. 2012).ln 2011, following the completion of a Diabetes and Renal Pilot Study and staff education, Moorabbin Haemodialysis Unit and Southern Health, identified the need to formalise foot screening for all patients and increase the rate at which these were conducted. The aim of this report is to present a summary of the audit evaluation of foot health screens and referrals in our dialysis centre.

How do Thai patients receiving haemodialysis cope with pain?

Intradialytic Laughter Yoga therapy for haemodialysis patients: a pre-post intervention feasibility study.

BACKGROUND: Laughter Yoga consists of physical exercise, relaxation techniques and simulated vigorous laughter. It has been associated with physical and psychological benefits for people in diverse clinical and non-clinical settings, but has not yet been tested in a haemodialysis setting. The study had three aims: 1) to examine the feasibility of conducting Laughter Yoga for patients with end stage kidney disease in a dialysis setting; 2) to explore the psychological and physiological impact of Laughter Yoga for these patients; and 3) to estimate the sample size required for future research. METHODS: Pre/post intervention feasibility study. Eighteen participants were recruited into the study and Laughter Yoga therapists provided a four week intradialytic program (30-min intervention three times per week). Primary outcomes were psychological items measured at the first and last Laughter Yoga session, including: quality of life; subjective wellbeing; mood; optimism; control; self-esteem; depression, anxiety and stress. Secondary outcomes were: blood pressure, intradialytic hypotensive episodes and lung function (forced expiratory volume). Dialysis nurses exposed to the intervention completed a Laughter Yoga attitudes and perceptions survey (n = 11). Data were analysed using IBM SPSS Statistics v22, including descriptive and inferential statistics, and sample size estimates were calculated using G*Power. RESULTS: One participant withdrew from the study for medical reasons that were unrelated to the study during the first week (94 % retention rate). There were non-significant increases in happiness, mood, and optimism and a decrease in stress. Episodes of intradialytic hypotension decreased from 19 pre and 19 during Laughter Yoga to 4 post Laughter Yoga. There was no change in lung function or blood pressure. All nurses agreed or strongly agreed that Laughter Yoga had a positive impact on patients' mood, it was a feasible intervention and they would recommend Laughter Yoga to their patients. Sample size calculations for future research indicated that a minimum of 207 participants would be required to provide sufficient power to detect change in key psychological variables. CONCLUSIONS: This study provides evidence that Laughter Yoga is a safe, low-intensity form of intradialytic physical activity that can be successfully implemented for patients in dialysis settings. Larger studies are required, however, to determine the effect of Laughter Yoga on key psychological variables. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry - ACTRN12614001130651 . Registered 23 October 2014.

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.

The role of virulence factors in the outcome of staphylococcal peritonitis in CAPD patients

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Effect of fractional urea clearance on survival of hemodialysis patients in relation to gender

Many studies have demonstrated the relationship between dialysis dose and survival. Global mortality is similar among men and women; however, the influence of dialysis dose in the survival could be more intensive between women. Therefore, we conduct an observational study to evaluate the gender-related impact of single pool Kt/V (spKt/V) on the survival of patients submitted to hemodialysis in a university hospital. We found that survival was lower in groups with spKt/V smaller than 1.2 than in those with Kt/V between 1.2 and 1.4. Among female patients, spKt/V smaller than 1.2 had a more adverse effect in survival than among men with a comparable Kt/V. Otherwise, among women, the dialysis dose had an impact in survival even with Kt/V greater than 1.4. Thus, fractional urea clearance more heavily influenced the survival of females than males in hemodialysis patients.

Inflammation and Overweight in Peritoneal Dialysis: Is There an Association?

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Advances in Peritoneal Dialysis in Acute Kidney Injury

Peritoneal dialysis (PD) is a simple, safe, cheap, and efficient renal replacement therapy method. It can correct metabolic disorders and fluid overload in acute kidney injury (AKI) patients both in and out of the intensive care unit. Use of PD in AKI is enhanced by placement of a Tenckhoff catheter, which can be safely accomplished at the bedside. Some PD modalities, such as high-volume PD and continuous-flow PD, can provide dialysis doses and efficiency comparable to extracorporeal blood purification methods. PD is particularly suitable for neonates, children, and patients with refractory heart failure or who are otherwise hemodynamically unstable. PD should be considered in situations where systemic anticoagulation and/or vascular access are problematic. PD is limited by a lower efficiency that may produce inadequate renal replacement in larger and/or severely hypercatabolic patients. Fluid removal can be unpredictable, there is a risk of infection, and possible issues with mechanical ventilation. In this article, we discuss the use of PD in AKI, with emphasis on recent advances. Copyright (c) 2012 S. Karger AG, Basel

When is dialysis indicated in acute kidney injury?

The indications for dialysis in patients with acute kidney injury (AKI), as well as the dose and timing of initiation, remain uncertain. Recent data have suggested that early initiation of renal replacement therapy (RRT) may be associated with decreased mortality but not with the recovery of kidney function. A blood urea nitrogen (BUN) level of 75 mg/dL is a useful indicator for dialysis in asymptomatic patients, but one that is based on studies with limitations. Different parameters, including absolute and relative indicators, are needed. Currently, nephrologists should consider the trajectory of disease, and the clinical condition and prognosis of the patient are more important than numerical values in the decision to initiate dialysis.

High-Volume Peritoneal Dialysis in Acute Kidney Injury: Indications and Limitations

Background and objectives Peritoneal dialysis is still used for AKI in developing countries despite concerns about its limitations. The objective of this study was to explore the role of high-volume peritoneal dialysis in AM patients in relation to metabolic and fluid control, outcome, and risk factors associated with death.Design, setting, participants, & measurements A prospective study was performed on 204 AKI patients who were assigned to high-volume peritoneal dialysis (prescribed Kt/V=0.60/session) by flexible catheter and cycler; 150 patients (80.2%) were included in the final analysis.Results Mean age was 63.8 +/- 15.8 years, 70% of patients were in the intensive care unit, and sepsis was the main etiology of AKI (54.7%). BUN and creatinine levels stabilized after four sessions at around 50 and 4 mg/dl, respectively. Fluid removal and nitrogen balance increased progressively and stabilized around 1200 ml and -1 g/d after four sessions, respectively. Weekly delivered Kt/V was 3.5 +/- 0.68. Regarding AKI outcome, 23% of patients presented renal function recovery, 6.6% of patients remained on dialysis after 30 days, and 57.3% of patients died. Age and sepsis were identified as risk factors for death. In urine output, increase of 1 g in nitrogen balance and increase of 500 ml in ultrafiltration after three sessions were identified as protective factors.Conclusions High-volume peritoneal dialysis is effective for a selected AKI patient group, allowing adequate metabolic and fluid control. Age, sepsis, and urine output as well as nitrogen balance and ultrafiltration after three high-volume peritoneal dialysis sessions were associated significantly with death. Clin J Am Soc Nephrol 7: 887-894, 2012. doi: 10.2215/CJN.11131111

Markers of uremia and pericardial effusion in peritoneal dialysis

Inadequate dialysis causes accumulation of toxic residues that may lead to the development of dialysis-associated pericardial effusion, but several other factors could be associated with this abnormality. The purpose of this study was to evaluate clinical risk factors to asymptomatic pericardial effusion in peritoneal dialysis.This cross-sectional study included 34 patients aged a parts per thousand yen18 years on peritoneal dialysis for at least 3 months, who showed no symptomatic pericardial effusion, hepatic cirrhosis, neoplasias, lupus or amputations, none in minoxidil use. Asymptomatic pericardial effusion was diagnosed by echocardiography. Risk factors were evaluated by logistic regression and Roc curve. Significance level was set at P < 0.05.Patient age was 51 +/- A 15.9 years. of the 34 patients enrolled, 16 were men and 11 diabetic. Five of them presented pericardial effusion. Logistic regression identifies low hemoglobin level (RR 0.454 CI 95%: 0.225-0.913; P = 0.027), low phase angle (RR 0.236 CI 95%: 0.057-0.984; P = 0.048) and low Kt/V (RR 0.001 CI 95%: 0.0-0.492; P = 0.03) as risk factors to pericardial effusion. Roc curve showed that hemoglobin levels below 12.2 g/dL, Kt/V lower than 1.9 and phase angle lower than 4.5A degrees were the best cutoffs to predict pericardial effusion. Four patients showed these three parameters in the unfavorable range, and all these four patients presented pericardial effusion. The other patient with pericardial effusion had two of these parameters reduced.These findings corroborate the hypothesis that uremia plays a significant role in the pathogenesis of dialysis-associated pericardial effusion.

Early nephrology consultation can have an impact on outcome of acute kidney injury patients

Background. Patients who develop acute kidney injury (AKI) in the intensive care unit (ICU) have extremely high rates of mortality and morbidity. The objectives of this study were to compare clinical and laboratory characteristics of AKI patients evaluated and not evaluated by nephrologists in ICU and generate the hypothesis of the relationship between timing of nephrology consultation and outcome.Methods. We explored associations among presence and timing of nephrology consultation with ICU stay and in-ICU mortality in 148 ICU patients with AKI at a Brazilian teaching hospital from July 2008 to May 2010. Multivariable logistic regression was used to adjust confounding and selection bias.Results. AKI incidence was 30% and 52% of these AKI patients were evaluated by nephrologists. At multivariable analysis, AKI patients evaluated by nephrologists showed higher Acute Tubular Necrosis-Index Specific Score and creatinine level, more dialysis indications, lower urine output and longer ICU stay. The mortality rate was similar to AKI patients who were not evaluated. Nephrology consultation was delayed (>= 48 h) in 62.3% (median time to consultation, 4.7 days). Lower serum creatinine levels (P - 0.009) and higher urine output (P = 0.002) were associated with delayed consultation. Delayed consultation was associated with increased ICU mortality (65.4 versus 88.2%, P < 0.001).Conclusions. In AKI, patients evaluated by nephrologists seem to be more seriously ill than those not evaluated and present similar mortality rate. The delayed nephrology consultation can be associated with increased ICU mortality.