Initiation of maintenance hemodialysis through central venous catheters: study of patients' perceptions based on a structured questionnaire.

Background: Despite well-publicized suggestions to utilize arteriovenous fistulae and grafts to initiate hemodialysis, too many patients in the United States start dialysis via central venous catheters despite their well-known association with increased morbidity, mortality, and cost.

Methods: To determine the reasons for this high rate of catheter use, and, ultimately, ways to reduce it, we developed a questionnaire designed to determine where in the process of patient care the process to fistula or graft placement was not completed, thus requiring the use of central venous catheters. The questionnaire was reviewed by several nephrologists not involved with the study.

Clinical performance and skill retention after simulation-based education for nephrology fellows.

We previously demonstrated that simulation-based education (SBE) improved temporary hemodialysis catheter (THDC) insertion skills by nephrology fellows. SBE, featuring deliberate practice and rigorous achievement standards, was a powerful method to enhance THDC insertion skills in nephrology fellows. However, experts have called for further research to evaluate skill transfer from the simulated environment to actual clinical care and skill retention.

Interventions to reduce late referrals to nephrologists.

Background: Despite the adverse health outcomes with late nephrology referral for patients with chronic kidney disease (CKD), little is known about the underlying mechanisms and reasons for late referral patterns.

Methods: We conducted a Medline search for peer-reviewed articles focused on nephrology referral among adults with CKD. We critically reviewed this literature in regard to late nephrology referral, highlighted its shortcomings, and provided a theoretically based framework for future research.

A case of simultaneous, biopsy-proven, classic, ANCA-positive Wegener's granulomatosis and anti-GBM disease, but without detectable circulating anti-GBM antibodies.

Wegener's granulomatosis (WG) is a systemic, necrotizing, granulomatous vasculitis of unknown etiology. Approximately 75% of cases present as classic WG with both pulmonary and renal involvement, while the remaining 25% of patients present with a limited form with either predominantly upper or lower respiratory tract symptoms. Ninety percent of WG patients have circulating anti-neutrophil cytoplasmic antibodies (ANCA), and approximately 10% have both circulating ANCA antibodies and concomitant anti-glomerular basement membrane (anti-GBM) disease on renal biopsy.

Outcomes of patients with hepatitis C undergoing simultaneous liver-kidney transplantation.

Background/aims: The number of simultaneous liver-kidney transplants (SLK) has increased since the MELD era. Data on short- and long-term outcomes of hepatitis C virus positive (HCV+) SLK compared to HCV+ liver transplant alone (LTA) recipients are limited.

Methods: A case-control study comparing outcomes of HCV+SLK versus transplant year-matched HCV+ LTA (1:1) was performed.

Mastery learning of temporary hemodialysis catheter insertion by nephrology fellows using simulation technology and deliberate practice.

Background: Temporary hemodialysis catheter (THDC) insertion is a required skill for nephrology fellows. Traditional fellowship training may provide inadequate preparation to perform this procedure. Our aim was to use a central venous catheter (CVC) simulator to assess nephrology fellows' THDC insertion skills and evaluate the impact of an educational intervention on skill development to mastery standards.

Resolution of SLE-related soft-tissue calcification following haematopoietic stem cell transplantation.

Background: Calciphylaxis and calcinosis can both cause severe morbidity and mortality in patients with systemic lupus erythematosus (SLE). Haematopoietic stem cell transplantation (HSCT) has been successfully used to treat patients with refractory SLE. It was hypothesized that in calciphylaxis and calcinosis, ongoing inflammatory activity contributes to the calcium deposition in the media of small arteries, as well as perivascular and periarticular tissues.

Early onset of tenofovir-induced renal failure: case report and review of the literature.

Tenofovir is an acyclic nucleotide analogue reverse transcriptase inhibitor that is commonly prescribed as part of a highly active antiretroviral therapy (HAART) regimen in HIV-infected patients. Although it is generally well tolerated, renal insufficiency has been associated with its use. We report a biopsy-proven case of acute renal failure that developed within weeks of initiating a HAART regimen containing tenofovir, and review the literature with specific attention to cases of renal failure occurring within 8 weeks of tenofovir initiation.

Acid-base and potassium disorders in liver disease.

Acid-base and potassium disorders occur frequently in the setting of liver disease. As the liver's metabolic function worsens, particularly in the setting of renal dysfunction, hemodynamic compromise, and hepatic encephalopathy, acid-base disorders ensue. The most common acid-base disorder is respiratory alkalosis.

Stabilization of glomerular filtration rate in advanced chronic kidney disease: a two-year follow-up of a cohort of chronic kidney disease patients stages 4 and 5.

This study examines whether stabilization of the glomerular filtration rate (GFR) is possible in patients with advanced chronic kidney disease (CKD), managed in a CKD clinic. A cohort of 82 patients with stages 4 and 5 CKD was followed for a period of 2 years after initiation of erythropoietin for anemia to determine the GFR and the frequency of primary outcomes (dialysis, transplantation, or death). GFR, calculated by the abbreviated Modification of Diet in Renal Disease formula, was determined every 3 months.

Effect of predialysis eating on measurement of urea reduction ratio and Kt/V.

Physicians utilize the measurement of the urea reduction ratio (URR) and Kt/V as surrogates for the adequacy of hemodialysis, as well as to follow the course of patients longitudinally. These measurements are affected by the duration of a dialysis treatment, the type and size of the dialyzer membrane used during the treatment, the blood flow rate during the treatment, and the adequacy of vascular access. We, and others, have noted that eating during dialysis can be associated with decreases in URR and Kt/V.

Differential effects of acute administration of 19-Nor-1,25-dihydroxy-vitamin D2 and 1,25-dihydroxy-vitamin D3 on serum calcium and phosphorus in hemodialysis patients.

Background: Treatment of hyperparathyroidism includes the use of 1,25-dihydroxy-vitamin D3 (1,25D3) to suppress parathyroid hormone (PTH), but dosing of 1,25D3 is limited by the development of hypercalcemia and a high calcium x phosphorus (Ca x P) product because of gut absorption of calcium and phosphorus and enhanced bone resorption. The vitamin D analogue 19-nor-1,25(OH)2-vitamin D2 (19-Nor) causes less hypercalcemia and elevated Ca x P, whereas it still suppresses PTH in rats.

Methods: To determine whether 19-Nor had similar effects in humans, we performed a prospective crossover study to assess bone mobilization.

Improving dialysis access management.

Renal replacement therapy requires either placement of a functional hemodialysis vascular access or peritoneal dialysis catheter. Early provision of a dialysis access improves patient care with reduction in morbidity and reduces the economic burden incurred as a result of delayed access placement. Vascular access dysfunctions (thrombosis and infection) pose the greatest burden on the end-stage renal disease population.