In patients with severe acute kidney injury (AKI) but no urgent indication for renal replacement therapy (RRT), the optimal time to initiate RRT remains controversial. While starting RRT preemptively may have benefits, this may expose patients to unnecessary RRT. To study this, we conducted a 12-center open-label pilot trial of critically ill adults with volume replete severe AKI. Patients were randomized to accelerated (12 h or less from eligibility) or standard RRT initiation. Outcomes were adherence to protocol-defined time windows for RRT initiation (primary), proportion of eligible patients enrolled, follow-up to 90 days, and safety in 101 fully eligible patients (57 with sepsis) with a mean age of 63 years. Median serum creatinine and urine output at enrollment were 268 micromoles/l and 356 ml per 24 h, respectively. In the accelerated arm, all patients commenced RRT and 45/48 did so within 12 h from eligibility (median 7.4 h). In the standard arm, 33 patients started RRT at a median of 31.6 h from eligibility, of which 19 did not receive RRT (6 died and 13 recovered kidney function). Clinical outcomes were available for all patients at 90 days following enrollment, with mortality 38% in the accelerated and 37% in the standard arm. Two surviving patients, both randomized to standard RRT initiation, were still RRT dependent at day 90. No safety signal was evident in either arm. Our findings can inform the design of a large-scale effectiveness randomized control trial.
Reductions in BP with NHD are accompanied by regression of LVH.
Hemodialysis (HD) for critically ill patients with acute renal failure has been provided as intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). IHD is often complicated by hypotension and inadequate fluid removal, and CRRT by high cost of solutions and problems with anticoagulation. Sustained low-efficiency daily dialysis (SLED) has been suggested as an alternative treatment. This is an observational, prospective pilot study describing the introduction of SLED at our institution. We compared SLED (23 patients, 165 treatments) with CRRT (11 patients, 209 days), focusing on cost, anticoagulation, and small solute removal. SLED consisted of 8 h of HD 6 days a week, with blood flow of 200 ml/min, dialysate flows of 350 ml/min, and hemofiltration with 1 l of saline/h. CRRT patients were anticoagulated with either heparin or citrate, and SLED patients with either heparin or saline flushes. The weekly costs to the hospital were $1431 for SLED, $2607 for CRRT with heparin, and $3089 for CRRT with citrate. Sixty-five percent of SLED treatments were heparin-free; filter clotting occurred in 18% of heparin treatments and 29% of heparin-free treatments (NS). Weekly Kt/V was significantly higher for SLED (8.4+/-1.8) and time-averaged serum creatinine was lower; equivalent renal clearance (EKRjc) was 29+/-6 ml/min for SLED, similar to that for CRRT. In summary, SLED may be routinely performed without anticoagulation; it provides solute removal equivalent to CRRT at significantly lower cost.
Abstract. Hemodialysis patients in whom permanent vascular access cannot be achieved are dependent on a central venous catheter. In such patients, catheter-related infections are a common and serious complication. This study was a randomized clinical trial to determine if topical Polysporin Triple antibiotic ointment applied to the central venous catheter insertion site could reduce the incidence of catheter-related infections. A total of 169 patients receiving hemodialysis through a central venous catheter were randomized to receive Polysporin Triple or placebo using a double-blind study design. In the 6-mo study period, infections were observed in more patients in the placebo group than in the Polysporin Triple group (34 versus 12%; relative risk, 0.35; 95% CI, 0.18 to 0.68; P ϭ 0.0013). The number of infections per 1000 catheter days (4.10 versus 1.02; P Ͻ 0.0001) and the number of bacteremias per 1000 catheter days (2.48 versus 0.63; P ϭ 0.0004) were also greater in the placebo group. Within the 6-mo study period, there were 13 deaths in the placebo group as compared with 3 deaths in the Polysporin Triple group (P ϭ 0.0041). When all available follow-up information was included, the difference in survival remained significant (19 versus 9 deaths; P ϭ 0.0027). Within the first 6 mo, infections were observed in 7 of the 13 placebo subjects who died (54%) as compared with no infections in the three Polysporin Triple subjects who died. The prophylactic application of topical Polysporin Triple antibiotic ointment to the central venous catheter insertion site reduced the rate of infections and was associated with improved survival in hemodialysis patients. charmaine.lok@uhn.on.caInfection is the most common cause of morbidity and the second most common cause of death in hemodialysis (HD) patients (1-5). Bacteremia accounts for more than 75% of these infectious deaths (4). Hemodialysis vascular access is implicated as the source of bacteremias in 48 to 73% (3,6 -7) of cases with patients dependent on central venous catheters (CVC) being at highest risk (2,7-9). Currently, approximately 20% of patients are dialyzed using permanent catheters; both their placement rate and length of use has increased (1,4). Staphylococcus aureus has previously been the primary etiologic agent implicated in causing approximately half of the bacteremic episodes (7,10) and 70% of the vascular access site infections (11-12). However, recent studies have reported a greater percentage and variety of Gram-negative bacteria isolated in catheter-related infections (13-16). Polysporin Triple (PT) is an antibiotic ointment composed of 500 U/g bacitracin, 0.25 mg/g gramicidin, and 10,000 U/g polymyxin B and is active topically against most skin flora (e.g., S. aureus, coagulase negative staphylococcus, and most Gram-negative bacteria). Previous studies have demonstrated success in preventing catheter-related infections using topical povidone-iodine (17) or mupirocin (12,18,19), antibiotic or silver-coated catheters (20 -22), and other novel metho...
The apparent survival advantage of peritoneal dialysis in Canada is due to lower comorbidity and a lower burden of acute onset end-stage renal disease at the inception of dialysis therapy. Hemodialysis and peritoneal dialysis, as practiced in Canada in the 1990s, are associated with similar overall survival rates.
Citrate 4% has equivalent or better outcomes with regards to catheter exchange, TPA use and access-related hospitalizations compared with heparin locking. It is a safe and less expensive alternative. Randomized trials comparing these anticoagulants with a control group would definitively determine the optimal haemodialysis catheter locking solution.
On multivariate analysis, a positive T-SPOT.TB test was associated with a history of active tuberculosis, radiographic markers of previous infection, and birth in an endemic country, whereas a physician panel diagnosis also was associated with a history of previous tuberculosis contact. The TST is insensitive in hemodialysis patients and is not recommended to be used in isolation to diagnose latent tuberculosis infection. It is suggested that a combination of T-SPOT.TB testing and medical assessment may be the most accurate screening method.
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