Emergency medicine evaluation and management of the end stage renal disease patient

A Qualitative Study on Nurses' Caring Experiences With Individuals With Kidney Failure Receiving Haemodialysis

BACKGROUND

Kidney failure is a major health issue globally, particularly in Ghana and other low- and middle-income countries. Nurses are centrally involved in the direct care and technical operations of managing individuals with kidney failure, and they have first-hand exposure to the complexities of kidney failure management, including haemodialysis within resource-constrained settings.

OBJECTIVE

This study explored the experiences of nurses who provide care to individuals with kidney failure receiving haemodialysis in Ghana.

METHODS

A qualitative exploratory descriptive approach was used. Sixteen participants were selected using purposive sampling. Data was collected through in-depth interviews and analysed using reflexive thematic analysis.

RESULTS

Four main themes that reflect the experiences of nurses caring for individuals with kidney failure receiving haemodialysis in Ghana were identified, showing that nurses caring for these individuals consider their care as expensive, demanding, suboptimal and emotionally distressing for nurses.

CONCLUSION

This study provides valuable insights that could enhance the understanding of the meaning and significance of caring for individuals receiving haemodialysis. Improving the haemodialysis caring experiences of nurses in Ghana requires addressing issues related to cost, emotional stress and workload of nurses, and resource availability. Changes to the healthcare system are needed to enhance the experience of patients and medical professionals involved in haemodialysis.

lncRNA FAS-AS1 served as a diagnostic biomarker of end-stage renal disease and mediated vascular calcification via regulating oxidative stress and inflammation

PURPOSE

Vascular calcification is a frequently occurring complication of end-stage renal disease (ESRD). This study focused on the significance of long non-coding RNA Fas cell surface death receptor-antisense 1(lncRNA FAS-AS1) in ESRD-related vascular calcification aiming to explore a potential biomarker for the detection.

METHODS

The study enrolled 65 healthy individuals, 79 ESRD patients (48 patients with vascular calcification), and 93 early-stage (I-IV) chronic kidney disease (CKD) patients. The expression of FAS-AS1 in serum was evaluated by real-time quantitative polymerase chain reaction (PCR). The diagnostic potential of FAS-AS1 was assessed in discriminating ESRD patients, vascular calcification, and the severity of vascular calcification. In vitro, the vascular smooth muscle cells (VSMCs) were treated with a hyperphosphatemia medium to evaluate the effect of FAS-AS1 on VSMCs calcification.

RESULTS

Elevated serum FAS-AS1 was observed in ESRD patients, which could discriminate from healthy individuals and early-stage CKD patients. FAS-AS1 was associated with the development of ESRD and the occurrence of vascular calcification. FAS-AS1 was also upregulated in vascular calcification patients, especially the patients with severe calcification, which showed diagnostic significance in evaluating vascular calcification degrees. Calcified VSMCs showed significantly increased levels of Ca2+, reactive oxygen species (ROS), tumor necrosis factor-α (TNF-α), and interleukin 6 (IL-6), which was attenuated by silencing FAS-AS1.

CONCLUSIONS

FAS-AS1 discriminated ERSD patients and was associated with the occurrence of vascular calcification. The knockdown of FAS-AS1 suppressed hyperphosphatemia-induced vascular calcification via alleviating oxidative stress and inflammation.

Factors affecting access to dialysis for patients with end-stage kidney disease in Sub-Saharan Africa: A scoping review

AIMS

This scoping review examined the factors affecting access to dialysis for patients with end-stage kidney disease in Sub-Saharan Africa.

DESIGN

Scoping review.

METHODS

The scoping review is conducted following the Joanna Briggs Institute methodology for scoping reviews and modelled by Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review.

RESULTS

A descriptive content analysis of 30 included articles revealed three main findings affecting access and use of dialysis: Health system-related factors, health provider-related factors and patient factors.

PATIENT OR PUBLIC CONTRIBUTION

Equity in renal replacement therapy access and use will require concerted advocacy for good public policy, healthcare delivery, workforce capacity and education.

Transcriptomic analysis identifies novel candidates in cardiorenal pathology mediated by chronic peritoneal dialysis

Peritoneal dialysis (PD) is associated with increased cardiovascular (CV) risk. Studies of PD-related CV pathology in animal models are lacking despite the clinical importance. Here we introduce the phenotypic evaluation of a rat model of cardiorenal syndrome in response to chronic PD, complemented by a rich transcriptomic dataset detailing chronic PD-induced changes in left ventricle (LV) and kidney tissues. This study aims to determine how PD alters CV parameters and risk factors while identifying pathways for potential therapeutic targets. Sprague Dawley rats underwent Sham or 5/6 nephrectomy (5/6Nx) at 10 weeks of age. Six weeks later an abdominal dialysis catheter was placed in all rats before random assignment to Control or PD (3 daily 1-h exchanges) groups for 8 days. Renal and LV pathology and transcriptomic analysis was performed. The PD regimen reduced circulating levels of BUN in 5/6Nx, indicating dialysis efficacy. PD did not alter blood pressure or cardiovascular function in Sham or 5/6Nx rats, though it attenuated cardiac hypertrophy. Importantly PD increased serum triglycerides in 5/6Nx rats. Furthermore, transcriptomic analysis revealed that PD induced numerous changed transcripts involved with inflammatory pathways, including neutrophil activation and atherosclerosis signaling. We have adapted a uremic rat model of chronic PD. Chronic PD induced transcriptomic changes related to inflammatory signaling that occur independent of 5/6Nx and augmented circulating triglycerides and predicted atherosclerosis signaling in 5/6Nx LV tissues. The changes are indicative of increased CV risk due to PD and highlight several pathways for potential therapeutic targets.

Dialysis attendance patterns and health care utilisation of Aboriginal patients attending dialysis services in urban, rural and remote locations

Background

Aboriginal people in the Northern Territory (NT) suffer the heaviest burden of kidney failure in Australia with most living in remote areas at time of dialysis commencement. As there are few dialysis services in remote areas, many Aboriginal people are required to relocate often permanently, to access treatment. Missing dialysis treatments is not uncommon amongst Aboriginal patients but the relationship between location of dialysis service and dialysis attendance (and subsequent hospital use) has not been explored to date.

Aim

To examine the relationships between location of dialysis service, dialysis attendance patterns and downstream health service use (overnight hospital admissions, emergency department presentations) among Aboriginal patients in the NT.

Methods

Using linked hospital and dialysis registry datasets we analysed health service activity for 896 Aboriginal maintenance dialysis patients in the NT between 2008 and 2014. Multivariate linear regression and negative binomial regression analyses explored the associations between dialysis location, dialysis attendance and health service use.

Results

We found missing two or more dialysis treatments per month was more likely for Aboriginal people attending urban services and this was associated with a two-fold increase in the rate of hospital admissions and more than three-fold increase in ED presentations. However, we found higher dialysis attendance and lower health service utilisation for those receiving care in rural and remote settings. When adjusted for age, time on dialysis, region, comorbidities and residence pre-treatment, among Aboriginal people from remote areas, those dialysing in remote areas had lower rates of hospitalisations (IRR 0.56; P < 0.001) when compared to those who relocated and dialysed in urban areas.

Conclusion

There is a clear relationship between the provision and uptake of dialysis services in urban, rural and remote areas in the NT and subsequent broader health service utilisation. Our study suggests that the low dialysis attendance associated with relocation and care in urban models for Aboriginal people can potentially be ameliorated by access to rural and remote models and this warrants a rethinking of service delivery policy. If providers are to deliver effective and equitable services, the full range of intended and unintended consequences of a dialysis location should be incorporated into planning decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07628-9.

A Heideggerian Phenomenological Study of the Lived Experiences of Ghanaian Patients Living With End-Stage Renal Disease

There is a lack of knowledge regarding perceptions, feelings, and experiences of Ghanaian patients living with ESRD. This study aimed to discover the experience and meaning of living with ESRD. This qualitative study was conducted using Heideggerian hermeneutic phenomenology. A total of 13 participants were purposefully selected, and data was collected through individual semi-structured interviews. The recorded interviews were transcribed and analyzed using Diekelmann, Allen, and Tanner method. After the final analysis, five main themes emerged: Spiritual fluctuation, Living in uncertainty, Period of agony and frustration, Tough fortification, and Changed roles and status. This study provided deep insight and understanding regarding the lived experiences of patients living with end-stage renal disease in Ghana. The results of this study may benefit nursing care in terms of considering the patients' lived experiences to provide quality and person-centered care.

Effects of photobiomodulation in salivary glands of chronic kidney disease patients on hemodialysis

This randomized placebo-controlled trial evaluates the impact of photobiomodulation (PBMT) on the salivary flow and biochemistry of patients with chronic kidney disease (CKD) on hemodialysis. Forty-four patients on hemodialysis self-responded two questionnaires for oral health and salivary gland function perception. The subjects were evaluated for function of salivary glands and randomly allocated to two groups: PBMT group (three irradiations at 808 nm, 100 mW, 142 J/cm², and 4 J per site); and placebo group. Patients were submitted to non-stimulated and stimulated sialometry and after the treatment at baseline and 14 days. Salivary volume and biochemical of the saliva were analyzed. At baseline, most subjects had self-perception of poor oral health (52.6%) and salivary dysfunction (63.1%). Clinical exam revealed that 47.3% of subjects presented dry mucosa. PBMT promoted increase of the non-stimulated (p = 0.027) and stimulated saliva (p = 0.014) and decrease of urea levels in both non-stimulated (p = 0.0001) and stimulated saliva (p = 0.0001). No alteration was detected in total proteins and calcium analysis. Patients with kidney disease can present alteration in flow, concentrations, and composition of saliva, affecting oral health, but our findings suggest that PBMT is effective to improve hyposalivation and urea levels in saliva of patients with CKD.

Emergency department use by patients with end-stage renal disease in the United States

Background

We sought to describe the national characteristics of ED visits by patients with end-stage renal disease (ESRD) in the United States in order to improve the emergency treatment and screening of ESRD patients.

Methods

We analyzed data from 2014 to 2016 ED visits provided by the National Hospital Ambulatory Medical Care Survey. We sampled adult (age ≥ 18 years) ED patients with ESRD. By proportion or means of weighted sample variables, we quantified annual ED visits by patients with ESRD. We investigated demographics, ED resource utilization, clinical characteristics, and disposition of patients with ESRD and compared these to those of patients without ESRD. Logistic regression models were used to estimate the association between these characteristics and ESRD ED visits.

Results

Approximately 722,692 (7.78%) out of 92,899,685 annual ED visits represented ESRD patients. Males were more likely to be ESRD patients than females (aOR: 1.34; 95% CI: 1.09–1.66). Compare to whites, non-Hispanic Blacks were 2.55 times more likely to have ESRD (aOR: 2.55; 95% CI: 1.97–3.30), and Hispanics were 2.68 times more likely to have ESRD (95% CI: 1.95–3.69). ED patients with ESRD were more likely to be admitted to the hospital (aOR: 2.70; 95% CI: 2.13–3.41) and intensive care unit (ICU) (aOR: 2.21; 95% CI: 1.45–3.38) than patients without ESRD. ED patients with ESRD were more likely to receive blood tests and get radiology tests.

Conclusion

We described the unique demographic, socioeconomic, and clinical characteristics of ED patients with ESRD, using the most comprehensive, nationally representative study to date. These patients’ higher hospital and ICU admission rates indicate that patients with ESRD require a higher level of emergency care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00420-8.

Emergent initiation of dialysis is related to an increase in both mortality and medical costs

The number of patients with end-stage renal disease (ESRD) has been increasing, with dialysis treatment being a serious economic problem. To date, no report in Japan considered medical costs spent at the initiation of dialysis treatment, although some reports in other countries described high medical costs in the first year. This study focused on patient status at the time of initiation of dialysis and examined how it affects prognosis and the medical costs. As a result, all patients dying within 4 months experienced emergent dialysis initiation. Emergent dialysis initiation and high medical costs were risk factors for death within 2 years. High C-reactive protein levels and emergent dialysis initiation were associated with increasing medical costs. Acute kidney injury (AKI) contributed most to emergent dialysis initiation followed by stroke, diabetes, heart failure, and short-term care by nephrologists. Therefore, emergent dialysis initiation was a contributing factor to both death and increasing medical costs. To avoid the requirement for emergent dialysis initiation, patients with ESRD should be referred to nephrologists earlier. Furthermore, ESRD patients with clinical histories of AKI, stroke, diabetes, or heart failure should be observed carefully and provided pre-planned initiation of dialysis.

Predictive Value of 1-Week Postoperative Ultrasonography Findings for the Patency Rate of Arteriovenous Fistula

Introduction

Most guidelines in different countries recommend waiting more than 2 weeks for the initial cannulation of an arteriovenous fistula (AVF) after its creation. Although an experienced examiner can subjectively determine if an AVF is ready for early cannulation, there is a lack of objective information to guide whether early cannulation is appropriate or how early cannulation may affect an AVF’s primary patency. The current study examined the relationship between the initial cannulation and the prognosis of AVF, considering ultrasonography (US) findings.

Methods

This retrospective observational study enrolled 103 patients with end-stage renal disease who had started hemodialysis therapy from 2013 to 2015 at the Juntendo University Hospital. All patients had been given a primary AVF before or after the initiation of dialysis, had undergone US examinations both before and 7 days after surgery, had initially cannulated the AVF at ≥7 days after surgery, and were observed for over 1 year.

Results

The factor associated with the loss of primary patency was a resistance index of brachial artery ≥0.65 on US examination at 7 days after surgery. There was no significant difference in patency rate between the early (within 14 days after surgery) and late initial cannulation groups (≥15 days after surgery).

Conclusion

Because a resistance index <0.65 on US findings at 7 days after surgery was a good indicator for predicting an excellent patency rate when we performed first cannulation of AVF located in the forearm within 2 weeks after its creation, 1-week postoperative US evaluation may provide crucial information.

"Please Keep Mom Alive One More Day"-Clashing Directives of a Dying Patient and Her Surrogate

All medical care providers are legally and ethically bound to respect their patients' wishes. However, as patients lose decision-making capacity and approach end of life, their families or surrogates, who are confronted with grief, fear, self-doubt, and/or uncertainty, may ask physicians to provide treatment that contradicts the patients' previously stated wishes. Our work discusses the legal and ethical issues surrounding such requests and provides guidance for clinicians to ethically and compassionately respond-without compromising their professional and moral obligations to their patients.

Exosomal miRNA-215-5p Derived from Adipose-Derived Stem Cells Attenuates Epithelial-Mesenchymal Transition of Podocytes by Inhibiting ZEB2

Background

Podocyte migration is actively involved in the process of podocyte loss and proteinuria production, which is closely associated with the development of diabetic nephropathy (DN). Exosomes from adipose-derived stem cells (ADSCs-Exos) effectively inhibit podocyte apoptosis in the treatment of DN. However, how ADSCs-Exos affect the migration of podocytes is obscure. This study is aimed at exploring the regulatory role of ADSCs-Exos on cell migration and the underlying mechanism.

Methods

ADSCs-Exo was authenticated by transmission electron microscopy (TEM), western blotting, and flow cytometry. Cell viability and migration ability of podocytes were measured by CCK8 and Transwell assays, respectively. Relative expressions of miRNAs and mRNAs were determined by qRT-PCR. The transmitting between PKH26-labeled exosome and podocytes was evaluated by IF assay. Dual luciferase reporter assay was employed to detect the relationship between miR-215-5p and ZEB2.

Results

The exposure to serum from DN patient (hDN-serum) significantly inhibited cell viability of podocytes, but ADSCs-Exo addition notably blunts cytotoxicity induced by the transient stimulus of hDN-serum. Besides, ADSCs-Exo administration powerfully impeded high glucose- (HG-) induced migration and injury of podocyte. With the podocyte dysfunction, several miRNAs presented a significant decline under the treatment of HG including miR-251-5p, miR-879-5p, miR-3066-5p, and miR-7a-5p, all of which were rescued by the addition of ADSCs-Exo. However, only miR-251-5p was a key determinant in the process of ADSCs-Exo-mediated protective role on podocyte damage. The miR-251-5p inhibitor counteracted the improvement from the ADSCs-Exo preparation on HG-induced proliferation inhibition and migration promotion. Additionally, miR-215-5p mimics alone remarkably reversed HG-induced EMT process of podocyte. Mechanistically, we confirmed that ADSCs-Exos mediated the shuttling of miR-215-5p to podocyte, thereby protecting against HG-induced metastasis, possibly through inhibiting the transcription of ZEB2.

Conclusion

ADSCs-Exo has the protective effect on HG-evoked EMT progression of podocytes thru a mechanism involving ZEB2. Potentially, the ADSCs-Exo preparation is a useful therapeutic strategy for improving podocyte dysfunction and DN symptoms clinically.

Identification of CD2, CCL5 and CCR5 as potential therapeutic target genes for renal interstitial fibrosis

Background

We aimed to explore potential gene biomarkers of renal interstitial fibrosis (RIF) due to a lack of effective and non-invasive methods for diagnosis.

Methods

Three data sets (GSE22459, GSE76882 and GSE57731) including 350 samples were acquired from Gene Expression Omnibus (GEO) database. We used bioconductor limma package to perform background adjustment. Cluster analysis was conducted by 'edgeR' package to identify the differentially expressed genes (DEGs). We generated heat maps with using heatmap package in R software. Function annotation of genes was performed by Gene Ontology (GO) enrichment analysis. STRING (Search Tool for the Retrieval of Interacting Genes) database was employed to construct the protein-protein interaction (PPI) network and the results were visualized by Cytoscape 3.6.1. At last, we applied Graphpad Prism 7.0. to explore the correlation between three hub genes and pathological degrees of RIF.

Results

By applying the "edgeR" package in R, we detected 116 DEGs with three data sets. These genes were enriched in 19 GO biological process categories. Three main hub genes (CD2, CCL5 and CCR5) were identified after construction of PPI network. In Pearson correlation coefficient, CD2, CCL5 and CCR5 was found to hold higher expression patterns in RIF samples based on independent data set GSE57731. Besides, their gene expression levels were found significantly positive correlation with the degree of RIF (CD2: P<0.05, r=0.29; CCL5: P<0.05, r=0.31; CCR5: P<0.05, r=0.38).

Conclusions

CD2, CCL5 and CCR5 might serve as potential early biomarkers of RIF. The mechanism between these genes and RIF remains to be further studied.

Sudden sensorineural hearing loss with end-stage renal disease: a report of 32 cases

Background: Patients with end-stage renal disease (ESRD) have a higher risk of suffering sudden sensorineural hearing loss (SSNHL), but little is known about this population. Aims and objectives: To investigate the clinical characteristics, treatment and recovery of SSNHL patients with ESRD. Materials and methods: Records of 32 SSNHL patients with ESRD were reviewed, including clinical characteristics and hearing recovery. Patients were divided into intratympanic steroid (ITS) group and oral steroid (OS) group, and hearing recovery was compared between two groups. Results: Twenty-six patients (81.3%) exhibited tinnitus, and 18 patients (56.3%) suffered vertigo. Mean pure-tone threshold at the initial presentation was 73.2 ± 19.4 dB, and the audiogram configuration was ascending in 9.4%, descending in 9.4%, flat in 34.4% and profound in 46.9% cases. At 3-month follow-up, percentages of patients in complete recovery, partial recovery, slight recovery, and no improvement were 18.8%, 31.3%, 21.9% and 28.1%, respectively. Furthermore, the overall recovery rate, complete recovery rate and hearing improvement were significantly higher in the ITS group than those in the OS group. Conclusion: SSNHL patient with ESRD often suffered a severe hearing loss with a high rate of accompanying tinnitus and vertigo. ITS may provide better audiological results for SSNHL with ESRD than OS.

Risk Factors for Emergency Department Unscheduled Return Visits

Background and Objectives: This study aims to identify reasons for unscheduled return visits (URVs), and risk factors for diagnostic errors leading to URVs, with comparisons to data from a similar study conducted in the same institution 9 years ago. Materials and Methods: This retrospective study included adult patients who attended the emergency department (ED) of a tertiary hospital in Singapore between January 2014 and June 2014, with re-attendance within 72 h for the same or similar complaint. The primary outcome was wrong or delayed diagnoses. Secondary outcomes include admission to the ED observation unit or ward on return visit. Findings were compared with the previous study performed in 2005 to identify trends. Results: Of 67,422 attendances, there were 1298 (1.93%) URVs from 1207 patients (median age 34, interquartile range 24 to 52 years; 59.7% male). The most common presenting complaint was abdominal pain (22.2%). One hundred ninety-one (15.8%) patients received an initial wrong or delayed diagnosis. Factors (adjusted odds ratio; 95% CI) associated with this were: presenting complaints of abdominal pain (2.99; 2.12–4.23), fever (1.60; 1.1–2.33), neurological deficit (4.26; 1.94–9.35), and discharge without follow-up (1.61; 1.1–2.26). Among re-attendances, 459 (38.0%) required admission. Factors (adjusted odds ratio; 95% CI) associated with admission were: male gender (1.88; 1.42 to 2.48); comorbidities of diabetes mellitus (2.07; 1.29–3.31), asthma (5.23; 1.59–17.26), and renal disease (7.48; 2.00–28.05); presenting complaints of abdominal pain (1.83; 1.32–2.55), fever (3.05; 2.10–4.44), and giddiness or vertigo (2.17; 1.26–3.73). There was a reduction in URV rate compared to the previous study in 2005 (1.93% versus 2.19%). Abdominal pain at the index visit remains a significant cause of URVs (22.2% versus 25.1%). Conclusions: Presenting complaints of neurological deficits, abdominal pain, fever, and discharge without follow-up were associated with wrong or delayed diagnoses among URVs.

N-Acetylcysteine and Sulodexide Reduce the Prothrombotic Effect of Uremic Serum on the Venous Endothelial Cells

BACKGROUND/AIMS

Thromboembolic episodes are a frequent problem in end stage renal failure patients. The pathomechanism of the disorder is complex, including bioincompatibility of renal replacement therapy, endothelial dysfunction, increased blood level of procoagulant factors and uremic toxins. We studied changes in the functional properties of venous endothelial cells (VEC) in the presence of uremic serum and evaluated their possible modulation by N-acetylcysteine (NAC) or sulodexide (SUL).

METHODS

Serum samples from 12 uremic patients treated with hemodialysis were studied ex vivo on in vitro cultured VEC. In separate experiments, NAC 1 mmol/L or SUL 0.5 LRU/mL were added to uremic serum samples. Both changes in the gene expression and secretory activity of VEC were studied.

RESULTS

Uremic serum increased the expression of the following genes: IL6 +97%, p < 0.002; VEGF +28%, p < 0.002; vWF +47%, p < 0.002; PECAM +76%, p < 0.002; ICAM-1 +275%, p < 0.002; t-PA +96%, p < 0.002. Changes in gene expression were reflected by the increased secretory activity of VEC treated with the uremic serum. Exposure of VEC to uremic serum supplemented with NAC or SUL resulted in weaker stimulation of the studied genes' expression. Also, secretion of the studied solutes, with the exception of ICAM-1, was reduced in the presence of NAC: IL6 -34%, p < 0.01; VEGF -40%, p < 0.005; vWF -25%, p < 0.001; t-PA -47%, p < 0.01, and MMP9 -37%, p < 0.001. SUL reduced the uremic serum-induced secretion of all solutes: IL6 -24%, p < 0.05; ICAM-1 -43%, p < 0.01; VEGF -38%, p < 0.01; vWF -23%, p < 0.01; t-PA -49%, p < 0.01, and MMP9 -25%, p < 0.05.

CONCLUSIONS

Uremic serum induces prothrombotic changes in VEC, which may cause a predisposition to thrombotic disorders in patients with renal failure. NAC and SUL reduce the effects of the uremic serum in VEC, which suggests their potential therapeutic application in uremic patients.