Objective Older adults with chronic kidney disease have a high rate of uncontrolled hypertension. Home monitoring of blood pressure (BP) is an integral part of management, but requires that patients bring records to clinic visits. Telemonitoring interventions, however, have not targeted older, less technologically-skilled populations. Methods Veterans with stage 3 or greater chronic kidney disease and uncontrolled hypertension were randomized to a novel telemonitoring device pairing a Bluetooth-enabled BP cuff with an Internet-enabled hub, which wirelessly transmitted readings (n= 28), or usual care (n= 15). Home recordings were reviewed weekly and telemonitoring participants were contacted if BP was above goal. The prespecified primary endpoints were improved data exchange and device acceptability. Secondary endpoint was BP change. Results Forty-three participants (average age 68 years, 75% white) completed the 6-month study. Average start-of-study BP was 147/78mmHg. Those in the intervention arm had a median of 29 (IQR 22, 53) transmitted BP readings per month, with 78% continuing to use the device regularly, whereas only 20% of those in the usual care group brought readings to in-person visits. The median number of telephone contacts triggered by the wireless monitoring was 2 (IQR 1, 4) per patient. Both groups had a significant improvement in systolic BP (P< 0.05, for both changes); systolic BP fell a median of 13 mmHg in monitored participants compared with 8.5mmHg in usual care participants (P for comparison 0.31). Conclusion This low-cost wireless monitoring strategy led to greater sharing of data between patients and clinic and produced a trend toward improvements in BP control over usual care at 6 months.

Background KDIGO (Kidney Disease: Improving Global Outcomes) guidelines recommend lateral abdominal radiographs to assess vascular calcification in incident dialysis patients. However, nearly all dialysis patients in the US receive chest radiographs at dialysis inception which may provide readily available information on coronary artery calcification (CAC) and aortic arch calcification (AAC). We determined the prevalence of CAC and AAC visible on plain chest radiographs and their associations with mortality in our dialysis population. Study Design Retrospective Analysis Setting & Participants 93 participants who received maintenance hemodialysis at the San Diego VAMC in 2009–2010 Predictor Presence of CAC and AAC as evaluated by a radiologist Outcome All cause mortality Results The average age was 64; 22% were African-American, and 97% were male. CAC and AAC prevalence were 25% and 58%, respectively. During 20 months’ follow-up, 28% died. CAC was strongly associated with mortality in models including cardiovascular (HR, 2.41; 95% CI 1.04–5.59) and dialysis-related (HR, 2.86; 95% CI 1.24–6.6) risk factors. AAC was associated with a HR of 5.25 (95% CI, 1.46–17.72) in cardiovascular risk-factor adjusted models and 7.31 (95% CI, 2.03–26.34) in dialysis models. When CAC and AAC were both included in models, both CAC (HR, 3.40; 95% CI, 1.24–9.36) and AAC (HR, 6.23; 95% CI, 1.64–23.66) remained significantly associated with mortality. Limitations The study sample is relatively small and mostly male. Conclusions CAC and AAC are highly prevalent on chest radiographs in dialysis patients, and strongly associated with mortality independent of one another. Since these images are nearly ubiquitous, inexpensive, and often already obtained for other indications, they should be considered for risk assessment in hemodialysis patients. Future studies are required to determine whether CAC or AAC on chest radiography is additive or duplicative of the risk of aorto-iliac calcification on lateral abdominal radiographs currently suggested by KDIGO.

Background The albumin-creatinine ratio (ACR) in spot urine samples is recommended for albuminuria screening instead of measured albumin excretion rate (mAER) in 24-hour urine collections. In those with extremes of muscle mass, differences in spot urine creatinine may lead to under- or over-estimation of mAER by ACR. We hypothesized that calculating estimated AER (eAER) using spot ACR and estimated creatinine excretion rate (eCER) may improve albuminuria assessment. Study Design Diagnostic test study. Setting & Participants 2711 community-living individuals from the general population of the Netherlands participating in the Prevention of Renal and Vascular Endstage Disease (PREVEND) Study. Index Test eAER was computed as the product of ACR and eCER. eCER was computed using three previously validated methods (Ix, Ellam, Walser). Reference Test mAER, based on two 24-hour urine collections. Accuracy of the eAER and ACR were defined as the percentage of participants falling within 30% (P30) of mAER. Results The mean age was 49 years, 46% were male, mean eGFR was 84 ± 15 ml/min/1.73 m2 and median mAER was 7.2 (IQR, 5.4–11.0) mg/d. The mean measured CER was 1381 mg/d, the median ACR was 4.9 mg/g. Using the Ix equation, the median eAER was 6.4 mg/d. In the full cohort, eAER was more accurate and less biased compared to ACR (P30: 48.9% vs. 33.6%; bias, −34.2% vs −14.1%, respectively). In subgroup analysis, improvement was most notable in the middle and highest weight tertiles and in males. Using the other methods for eCER produced similar results. Limitations Little ethnic heterogeneity and generally healthy cohort make extension of findings to other races and chronically ill uncertain. Conclusions In a large community-dwelling cohort, eAER was more accurate than ACR in assessing albuminuria.

BackgroundThere are as many as 300,000 visits to the emergency department in the USA with animal bites every year. The most common infection after cat or dog bite is with Pasteurella Multocida. Many people infected will also have long-term central venous access for dialysis or for other reasons. No prior reports or guidelines exist regarding the management of P. multocida bacteremia due to line infection or bacteremia in the presence of long-term central venous access. We describe the successful treatment of an individual with P. multocida bacteremia secondary to tunnelled line infection managed with line retention.Case presentationA 21 year-old man with a history of granulomatosis with polyangiitis on home hemodialysis presented with fever and hypotension 3 days after dialysis catheter replacement. The patient was found to be bacteremic with Pasteurella Multocida and he subsequently reported a history of cat bite to his dialysis catheter. He declined removal of the tunnelled catheter and was thereafter treated for a total of 2 weeks with intravenous ceftazidime post-dialysis and gentamicin line-locks without recurrence of infection.ConclusionsPasteurella Multocida bacteremia in the presence of a long-term central venous catheter is potentially curable using 2 weeks of intravenous antibiotics and line retention. Further data regarding outcomes of treatment in this setting are required though in select cases clinicians faced with a similar scenario could opt for trial of intravenous therapy and retention of central venous catheter.