Background To date it is unclear whether SARS-CoV-2 is present in spent dialysate from peritoneal dialysis (PD) patients with COVID-19. Our aim was to assess the presence or absence of SARS-CoV-2 in spent dialysate from chronic PD patients with confirmed diagnosis of COVID-19. Methods Spent PD dialysate samples from COVID-19 positive PD patients were collected between March and August 2020. The multiplexed real-time reverse transcriptase-polymerase chain reaction assay contained primer/probe sets specific to different SARS-CoV-2 genomic regions and to bacteriophage MS2 as internal process control for nucleic acid extraction. Demographic and clinical data were obtained from patients' electronic health records. Results A total of 26 spent PD dialysate samples were collected from 11 patients from 10 dialysis centers. Spent PD dialysate samples were collected on average 25±13 days (median 20, range 10 to 45) after onset of symptoms. The temporal distance of PD effluent collection relative to the closest positive nasal swab RT PCR was 15±11 days (median 14; range 1 to 41). All 26 PD effluent samples tested negative at three SARS-CoV-2 genomic regions. Conclusions Our findings indicate the absence of SARS-CoV-2 in spent PD dialysate collected 10 days or later after the onset of COVID-19 symptoms. We cannot rule out presence of SARS-CoV-2 in spent PD dialysate in the early stage of COVID-19.
<b><i>Background/Objectives:</i></b> On March 22, 2020, a statewide stay-at-home order for nonessential tasks was implemented in New York State. We aimed to determine the impact of the lockdown on physical activity levels (PAL) in hemodialysis patients. <b><i>Methods:</i></b> Starting in May 2018, we are conducting an observational study with a 1-year follow-up on PAL in patients from 4 hemodialysis clinics in New York City. Patients active in the study as of March 22, 2020, were included. PAL was defined by steps taken per day measured by a wrist-based monitoring device (Fitbit Charge 2). Average steps/day were calculated for January 1 to February 13, 2020, and then weekly from February 14 to June 30. <b><i>Results:</i></b> 42 patients were included. Their mean age was 55 years, 79% were males, and 69% were African Americans. Between January 1 and February 13, 2020, patients took on average 5,963 (95% CI 4,909–7,017) steps/day. In the week prior to the mandated lockdown, when a national emergency was declared, and in the week of the shutdown, the average number of daily steps had decreased by 868 steps/day (95% CI 213–1,722) and 1,222 steps/day (95% CI 668–2300), respectively. Six patients were diagnosed with COVID-19 during the study period. Five of them exhibited significantly higher PAL in the 2 weeks prior to showing COVID-19 symptoms compared to COVID-19 negative patients. <b><i>Conclusion:</i></b> Lockdown measures were associated with a significant decrease in PAL in hemodialysis patients. Patients who contracted COVID-19 had higher PAL during the incubation period. Methods to increase PAL while allowing for social distancing should be explored and implemented.
Background and Aims Vascular access dysfunction is one of the leading causes of morbidity and a major contributor to healthcare costs in hemodialysis (HD) patients. Inexpensive, non-invasive tools for routine assessment of vascular access function are needed. Hemodynamically relevant stenoses in arteriovenous fistulas (AVF) lead to a reduction in access flow rate (Qa) and changes in blood flow patterns in the AVF that may be picked up by palpation and auscultation. We hypothesized that these changes in blood flow patterns can not only be felt and heard but also seen, i.e., that they may be detectable in video recordings done with commercially available smartphones after digital motion augmentation. Methods We studied HD patients with AVF dysfunction requiring balloon angioplasty and/or stenting. One-minute video recordings of the skin above the AVF and Qa measurements were conducted before and after the endovascular intervention. Videos were recorded with an iPhone 6S (Apple Inc., Cupertino, CA, USA). Qa was measured by HVT100 endovascular flowmeter (Transonic Systems Inc., Ithaca, NY, USA). Significant access stenosis was defined as a >50% reduction of luminal diameter. Degree of stenosis was assessed by angiography. Frame-to-frame pixel changes in video images were amplified using “Eulerian Video Magnification” (Massachusetts Institute of Technology, MA, USA; http://people.csail.mit.edu/mrub/evm/#code). The time-domain data were then transformed into the frequency-domain signals. Fifty random 10-second segments were sampled per one-minute video, and the frequency with the lowest magnitude (Fmin) was determined in each sample (example shown in Fig. 1). The average Fmin was then assessed for its association with the degree of AVF stenosis. Results Ninety subjects were studied (Table 1). AVF interventions were successful in all patients. Post-intervention Qa (1638 ± 714 ml/min) was on average 1.23-fold higher than pre-intervention Qa (1373 ± 684 ml/min; P<0.01, paired t-test). Subjects were grouped by degree of stenosis, and the number of subjects in each category is shown in Fig. 1B. Higher degrees of stenosis were associated with greater increases in Qa from before to after the intervention (P<0.01, one-way ANOVA; Fig. 1C). Interestingly, the degree of AVF stenosis was also positively related with the change in Fmin from before to after the intervention (P=0.08, one-way ANOVA; Fig. 1D). Conclusion Simple smartphone video recordings of AVF appear to contain frequency-domain information that correlates with hemodynamic changes caused by AVF stenoses. While the Fmin metric employed in our analysis is not ideal, these results should encourage the quest for other parameters that exhibit higher correlations with vascular access dysfunction. If successful, this would allow commercially-available smartphones to be used as ubiquitous tools for quick, non-invasive, ambulatory surveillance of AVF function, thereby allowing timely referrals and avoidance of emergency interventions.
Background and Aims Anemia is a common complication in hemodialysis (HD) patients. Its treatment with erythropoiesis-stimulating agents (ESAs) is challenging due to a nonlinear dose-response relationship and time delays between ESA administration and hemoglobin (Hgb) response. Anemia treatment protocols are frequently used in clinical settings. However, high variability of patient-specific disease characteristics complicate attainment and maintenance of desired Hgb levels. We developed a novel fully personalized ESA dose recommendation tool and present clinical results of a multi-center, randomized controlled trial (RCT) using this software. Method We conducted an RCT in adult HD patients in six dialysis facilities in the US. Patients were randomized 1:1 and treated with our personalized ESA dose recommendation tool for twenty-six weeks (intervention group) or continued to be treated using an anemia protocol that was used as part of standard of care in those clinics (control group). The recommendation tool utilized a physiology-based model of anemia to estimate patient-specific physiological key characteristics, such as red blood cell lifespan, to create a patient-individual model from recent routine clinical data (gender, height, weight, Hgb measurements, and ESA treatment). These key characteristics and model-based outcome predictions were used to generate patient-specific ESA dose recommendations to stabilize Hgb levels in a target window of 10–11 g/dL. Dose recommendations were disseminated to the anemia managers of patients enrolled in the study for evaluation and further decision-making (Figure 1). This procedure was repeated biweekly with updated clinical data. Results Ninety-six patients were enrolled in the RCT. Patients were included in the statistical analysis when they remained in the clinical study for at least 30 days (n = 45 control group, n = 46 intervention group). We evaluated outcome measures showing efficacy and efficiency of the treatment in achieving target Hgb levels. Hgb-related outcomes were significantly different between the two study groups, with an improved Hgb control in the intervention arm, manifesting in a reduction of the Hgb distance to target by more than 30%. Epoetin-beta utilization in the intervention group was decreased by over 20%, while iron-related parameters showed no difference between the two arms (Table 1). Acceptance rate of dose recommendations was high; roughly 95% of the recommendations were accepted and implemented by the clinical staff. Conclusion A therapy software for personalized anemia management was developed for use with epoetin beta. The model-based ESA dose recommendation tool was evaluated in a clinical RCT in HD patients. Hgb control improved significantly in the group using the novel software tool, while ESA usage decreased, thus providing more efficient anemia management for the individual patient while reducing epoetin-beta drug exposure.
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