The International Quotidian Dialysis Registry: annual report 2007

A hospital-based intermittent nocturnal hemodialysis program for children and adolescents

OBJECTIVE

To establish a hospital-based nocturnal hemodialysis (NHD) program for children and adolescents.

STUDY DESIGN

Sixteen patients (age, 0.5 to 17 years) were prospectively included. Uremia-associated measures as well as amount and dosage of medication were enumerated. Quality of life also was evaluated. Results were compared with data of the same patients on conventional hemodialysis and with matched control subjects (conventional HD).

RESULTS

NHD was well tolerated. Median Kt/V values increased. Predialytic mean arterial pressure, urea, phosphate, and parathyroid hormone levels decreased. There was an increase in protein catabolic rate. Dietary and fluid restrictions could be lifted. Amount and dosage of phosphate and potassium binders and antihypertensive medication could be reduced. Quality of life improved and days of absence from school decreased in all patients.

CONCLUSIONS

In addition to a better control of uremia-associated measures, NHD allows free dietary and fluid intake and improves patient well-being. Given the continuing shortage of donor organs for kidney transplantation and the high morbidity and mortality on conventional HD, intensified dialysis regimens are a much-needed therapeutic option.

Staphylococcus aureus bacteremia and buttonhole cannulation: long-term safety and efficacy of mupirocin prophylaxis

BACKGROUND AND OBJECTIVES

Buttonhole (constant-site) cannulation (BHC) continues to gain popularity with home and in-center dialysis programs worldwide. However, long-term safety data are lacking. This paper reports the authors' single-center experience with Staphylococcus aureus bacteremia (SAB) and the efficacy of topical mupirocin prophylaxis (MP).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study was a retrospective prepost comparison of SAB rates after establishing MP. Fifty-six consecutive patients on home nocturnal hemodialysis via arteriovenous fistulae, mean age 51.5 +/- 10.6 years, 38% women, and vintage 44.5 +/- 34.5 months were observed for a total of 93.4 (pre-MP) and 193.5 (post-MP) patient-years.

RESULTS

Ten episodes of SAB were observed, with metastatic complications in four cases, including pneumonia (n = 2), septic arthritis, and a fatal C3 epidural abscess. When analyzed by observation period, the odds ratio (OR) for SAB before versus after the introduction of MP was 6.4 [95% confidence interval (CI) = 1.3 to 32.3; P = 0.02]. Two SAB episodes occurred after the MP started. Both patients had discontinued the MP for 3 weeks (nonadherent) preceding infection; hence, no SAB episodes were observed on treatment. In an as-treated analysis, the OR for SAB in the absence of MP was 35.3 (95% CI = 2.0 to 626.7; P = 0.01).

CONCLUSIONS

BHC is associated with a significant risk of SAB with metastatic complications. In this prepost comparison of SAB rates, no infections were observed with MP. While awaiting more definitive studies, this simple intervention should be considered for patients using BHC.

International Quotidian Dialysis Registry: annual report 2009

The International Quotidian Dialysis Registry (IQDR) is a global initiative designed to study practices and outcomes associated with the use of hemodialysis regimens of increased frequency and/or duration. Several small studies suggest that compared with conventional hemodialysis (HD), short-daily, nocturnal, and long conventional HD regimens may improve surrogate endpoints and quality of life. However, methodologically robust comparisons on hard outcomes are sorely lacking. The IQDR represents the first-ever attempt to aggregate long-term follow-up data from centers utilizing alternative HD regimens worldwide, and will have adequate statistical power to examine the effects of these regimens on multiple clinical endpoints, including mortality. To date, the IQDR has enrolled patients from Canada, the United States, Australia, and New Zealand, with plans in place to begin linking with additional commercial databases and national registries. This fifth annual report of the IQDR describes (1) a proposed governance structure that will facilitate international collaboration, stakeholder input and funding; (2) data sources and participating registries; (3) recruitment to date and patient baseline characteristics; and (4) an agenda for future research.

International variations and trends in home hemodialysis

Home hemodialysis, once a valid, viable dialysis choice, faded as facility-based care was preferentially funded and supported through the 1970s and 1980s. It was simply more comfortable for providers, physicians, and nurses to capture dialysis patients through clinic schedules and clinical protocols. Home patients were unpredictable, out of sight and out of control, trouble, and best avoided. This was so except in Australia and New Zealand where funding and support remained strong for what was seen there as an effective, outcome-rich, and cost-effective modality. The renaissance of home hemodialysis began in Canada when home-based nocturnal dialysis emerged in the 1990s. Home patients soon appreciated the self-determination and re-employment opportunities that overnight dialysis delivered. This article explores the origins, the near demise, the foundations of renewal, and the now-expanding potential of home and nocturnal hemodialysis in regions as diverse as North America, Australia and New Zealand, South East Asia, the United Kingdom, and Finland. Home dialysis fed by cost containment, outcome success, patient acceptance, and new smart equipment has emerged as a bright new modality option. Trainee nephrologists would be wise to take more notice as this near ghost of the past forges an exciting future.

Intensified hemodialysis regimens: neglected treatment options for children and adolescents

During recent years, the importance of intensified dialysis regimens has gathered increasing interest, especially after the Hemodialysis (HEMO) Study Group reported that a higher dose of thrice-weekly hemodialysis failed to improve clinical outcomes. Long nocturnal hemodialysis (three to six times per week) or short daily hemodialysis are the currently used forms of intensified dialysis. There is substantial evidence for cardiovascular and quality-of-life improvements as well as financial benefits with intensified hemodialysis. Preliminary experience with daily hemodialysis and hemodiafiltration in children has been reported. Given the continuing shortage of donor organs for kidney transplantation, the increasing incidence of end-stage renal disease (ESRD) and recognition of the deleterious effects of long-lasting ESRD, growth retardation, and poor social rehabilitation, more intensified dialysis regimens are a much-needed therapeutical option in both adults and children.