ABSTRACT
Introduction: Kidney transplantation (KT) is the sine qua non consummate form of renal replacement therapy for ESRD with higher patient survival, improved quality of life, and lower healthcare costs. In the US, pre-emptive kidney transplantation (PEKT), defined as KT prior to progression to ESRD and maintenance dialysis, occurred in 17% of recipients overall, and in 31% of living donor kidney transplantation recipients. Advantages of PEKT over KT after starting maintenance dialysis are fewer pretransplant blood transfusions, increased rate of patients continuing employment, improved longterm graft survival, lower rates of delayed graft function, fewer episodes of acute rejection and decreased healthcare expenditures. Annual dialysis payer expenses in the US range from $60,000 - $125,000 excluding dialysis access-related costs which range from $7,000 - $19,000. Although KT has relatively high initial costs associated with induction immunosuppression and the initial hospitalization, maintenance immunosuppression costs range between $18,000 - $23,000, annually. Conversely, PEKT may arguably be unnecessary for some patients with eGFR in the 15-25 range who are otherwise asymptomatic, and where eGFR decline is slow. We have such a dilema. Case Description: 71-yo male patient with CKD stage 4, controlled hypertension and ADPKD, current eGFR of 17 ml/min/1.73 m2 BSA, as at January 2022. He is presently otherwise asymptomatic, is normally active, working from home since the COVID-19 pandemic, appetite is good, and exercise tolerance is good and unchanged over the past year. Electrolytes are normal or controlled, and hemoglobin was 14.0 g/dL. Serum creatinine was 1.1 mg/dL in September 2003. However, serum creatinine increase in the past 42 months has only been very slow (Figure). Discussion(s): The QUESTION: To Transplant or Not to Transplant? (See Survey Link). (Figure Presented).
ABSTRACT
Background: The maintenance of blood fluidity in the extracorporeal circuit during hemodialysis (HD) often requires systemic anticoagulation. While effective, these anticoagulants cause bleeding, have other side effects, cannot be used in critically ill patients and in the peri-operative period, and add to costs. We recently described a novel mecahnical rotational approach to anticoagulation-free HD using the "Locke-Onuigbo" maneuver (Figure 1).1 Methods: Prototype Completion: In collaboration with the University of Vermont Center for Biomedical Innovation (UVM CBI), five Senior Engineering students from the UVM, under the supervision of Yves Dubief PhD, Associate Professor of Mechanical Engineering, UVM, the first author and his Home Dialysis Program at the UVM Medical Center, have successfully prototyped an AI-modulated hemodialysis filter rotator that enables anticoagulation-free HD using the NxStage HD machine (Figure 2). Result(s): The Hemodialysis Filter Rotator Prototype running test on the HD machine (Figure 2) Conclusion(s): This Hemodialysis Filter Rotator enhances the capabilities of enabling sustainable Home HD for ESRD patients and represents a most welcome option in a "post-COVID" world and expands the offering of a convenient, safe and effective Home HD option to thousands of patients who prefer this choice of treatment. Moreover, we would argue that our novel prototype will deliver the unmet need for anticoagulation-free HD in critically ill patients, in the peri-operative period, and in hospitalized patients, in general. Investors and sponsors are welcome. (Figure Presented).
ABSTRACT
Hybrid dialysis is traditionally identified as the combined utilization of peritoneal dialysis (PD) and hemodialysis (HD) in patients with ESRD. In this case study, we have described the successful application of a new Hybrid HD model that combined Home HD + in-center HD. To our knowledge, our report is the first of its kind and was designed and implemented primarily for the patient’s wellbeing;to suit the new exigencies and circumstances at his home, family, and workplace, on a long-term, sustainable basis. Our Home Dialysis Program this year encountered major family-related and work-related constraints that had increasingly prevented a 41-year-old man on home HD from completing the prescribed four times weekly HD sessions. He works full-time and is on-call on weekends plus has 2 young children under the age of 5 resulting in long days and multiple missed HD sessions. HD inadequacy led to worsening physiology and a risk of being de-listed from a kidney transplant program. He was successfully transitioned to a new hybrid dialysis regimen of twice-weekly Home HD + twice weekly in-center HD. We were able to enable a young family to continue with some form of sustainable HD care while circumnavigating the intricacies of the COVID-19 pandemic, childcare, work pressure, and family health challenges, while waiting for a kidney transplant. The potential burden of home dialysis on the patients and caregivers cannot be overemphasized. There is therefore an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. In response, patients, payers, regulators and health-care systems are increasingly demanding improved value, which can only come about through truly patient-centered innovation that supports high-quality high-value care. We posit that a large-scale review, evaluation, and extended study of our new hybrid HD care model should be supported by the appropriate public health and governmental authorities, both here in the USA and globally, as we continue to find new, innovative ways to improve the health of the ever-burgeoning ESRD population around the world.
ABSTRACT
Introduction: Hybrid dialysis is traditionally identified as the combined utilization of peritoneal dialysis (PD) and hemodialysis (HD) in patients with end-stage renal disease. From current literature, its reported use is quite limited outside of Japan. We in the past year encountered major family-related and work-related constraints that prevented a 41-yo man with ESRD on home HD from completing the prescribed four-times weekly HD treatments. The resulting HD inadequacy led to worsening of the patient’s physiology and a possible risk of being de-listed from a kidney transplant list. He was successfully transitioned to a new hybrid dialysis regimen of twice-weekly Home HD + twice weekly in-center HD. HD adequacy was re-established and the patient’s physiology improved to acceptable status. This is the first such report. Methods: Case Report. Results: A 41-yo man with ESRD secondary to SLE and hypertension who had successfully been on home HD, 4 x weekly, for 32 months, with the wife as a caregiver, had in the second half of 2020 experienced new family-related stressors with the non-availability of day-care for two young children, ages 3 and 5 years, respectively, due to the COVID-19 pandemic, and concurrent spousal illness. In addition, the patient who is a product delivery driver, had new demands from his employment. As a result of these obstacles, he missed several of his Home HD sessions. The result was inadequate HD delivery and worsening laboratory indices and he was potentially going to be de-listed from the kidney transplant list. In February 2021, he was switched to new hybrid dialysis regimen of twice-weekly Home HD + twice weekly in-center HD - 2 in-center HD treatments on Tuesdays and Thursdays, and 2 Home HD treatments, one during the weekend and one during the week. Each HD session lasts 3.5 hours, 2000 units Heparin bolus, and his left brachiocephalic AVF is accessed by the button-hole method. The Home Dialysis Staff continued to coordinate and monitor his dialysis care. HD adequacy was re-established and the patient’s physiology improved to acceptable status. Conclusions: Hybrid dialysis is traditionally identified as the combined utilization of peritoneal dialysis (PD) and hemodialysis (HD) in patients with end-stage renal disease. A 2020 Italian report described another type of hybrid dialysis that consisted of once-weekly in-hospital HD and home peritoneal dialysis to limit patient exposure to the hospital environment during the COVID-19 pandemic. We have described the successful application of a new Hybrid HD system that combined Home HD + in-center HD. To our knowledge, our report is the first of its kind and was designed and implemented primarily for the patient to suit the new exigencies and circumstances at home on a long-term continuous basis. Overall, patient and family are happy with the new arrangement with improved HD adequacy and normalized laboratory data. We revisit any observed other advantages and problems that may be associated with this form of Hybrid HD care. No conflict of interest
ABSTRACT
Introduction: Hybrid dialysis is traditionally defined as the combination of peritoneal and hemodialysis (HD) in patients with end-stage renal disease. Its reported use is quite limited outside of Japan. We recently encountered major family-related and employmentrelated constraints that prevented a 39-yo man with ESRD on home HD from completing the four-times weekly HD treatments with HD inadequacy and worsening of patient's physiology. We successfully switched him to a new hybrid of twice-weekly Home HD + twice weekly In-Center HD. This is the first such report. Case Description: A 41-yo male with ESRD secondary to SLE and hypertension on home HD, 4 x weekly, for some years experienced family-related constraints including non-availability of day-care for two young children due to COVID-19 pandemic, spousal illness and new work-related challenges with more travel and was missing his HD sessions. The result was inadequate HD delivery and worsening laboratory indices. He now receives 2 in-center HD treatments on Tuesdays and Thursdays, and 2 home HD treatments, one during the weekend and one during the week. This was started in February 2021. Each HD session lasts for 3.5 hours, 2000 units Heparin bolus, and his left brachiocephalic AVF is accessed by the button-hole method. The Home Dialysis Staff coordinates his dialysis care. Standardized Kt/V for May 2021 was 2.6. Discussion: Hybrid dialysis is traditionally defined as the combination of peritoneal and HD in patients with ESRD. A 2020 Italian report described another type of hybrid dialysis that consisted of once-weekly in-hospital HD and home peritoneal dialysis to limit patient exposure to the hospital environment during the COVID-19 pandemic. We have described the successful application of a new Hybrid HD system that combined Home HD + In-center HD. To our knowledge, our report is the first of its kind and was designed and implemented primarily for the purpose of overcoming increasing family and employment demands on the patient. This new hybrid dialysis option was designed to facilitate a family-friendly work-friendly HD on a long-term continuous basis. The patient, the family with two young children and his employers are happy and very satisfied. Simultaneously, the patient has continued to do well with adequate dialysis and meeting all the required goals of management in the past 3 months.
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BACKGROUND AND AIMS: Severe COVID-19 infection may result in hypoxemic respiratory failure necessitating invasive mechanical ventilation. We revisit the phenomenon of asymptomatic patients despite very low pulse oximetry readings, the so-called 'sweet hypoxia' or 'happy hypoxia' or 'silent hypoxemia'. We describe for the first time, the sequential chest radiographic images of the progressive radiological trajectory of COVID-19 pneumonia. METHOD: Case Report. RESULTS: A 62-year old hypertensive obese Caucasian male, an ex-smoker, was diagnosed with mild community-acquired pneumonia in mid-March 2020, following evaluation for low grade fever. He had traveled to Florida and Texas in the previous month. He tested positive for COVID-19 by RT-PCR. A week later, he was admitted to a Community Hospital with one day history of new shortness of breath and loose stools. Vital signs were stable. Pulse oximeter was 96% on room air. He was fatigued with few bibasilar lung crackles. CBC was normal. Creatinine was 1.0 mg/dL. Abnormal laboratory: sodium 131 mmol/L, AST 50 iu/L, ALT 96 iu/L. Chest radiograph revealed new patchy left lower lobe airspace infiltrate (Figure 1B). EKG showed regular sinus rhythm of 96/min, QT interval 445 msec and PVCs. Treatment included nasal cannula oxygen, IV fluids, IV Azithromycin and IV Ceftriaxone. He improved the next day, requested discharge home, vital signs were stable, pulse oximetry was 91% on room air, sodium had normalized at 137 mmol/L and he was discharged home on Azithromycin 500 mg daily x 3 days and Cefdinir 300 mg BID x 5 days. He cheerfully went home. Later that night he quickly developed worsening dyspnea. He was readmitted about 18 hours post-discharge. Temperature 99.40F, blood pressure 161/101, pulse 100/min. He was tachypneic and pulse oximetry was 82% on room air. This improved to 93% on 4.5 LPM nasal cannula oxygen. Initial EKG was normal. New pertinent laboratory data: Bicarbonate 17 mmol/L, phosphorus 5.5 mg/dL, calcium 7.2 mg/dL, creatinine 1.1 mg/dL, BNP 31 pg/mL and lactic acid 1.2 mmol/L. PTT was 28.3 sec. HIV-1 p24 AG, HIV-1 AB, HIV-2 AB, HbSAG and Hepatitis C AB were negative. Chest radiograph showed worsening bilateral infiltrates (Figure 1C). He very quickly desaturated in the ED down to 81% despite high flow oxygen therapy. He was promptly intubated (Figure 2A). Oxygenation immediately improved. He was transferred to the ICU on IV Vancomycin and IV Cefepime. He developed septic shock and required IV Norepinephrine. With worsening chest radiographs, (Figures 2B & 2C), he was transferred to a tertiary medical center. On transfer, pertinent new data: creatinine 1.38 mg/dL, albumin 2.8 g/dL, Ferritin 2,573 ng/mL, LDH 534 u/L, CRP 6.0 mg/L, INR 1.2, D-Dimer 1.04, procalcitonin 0.38 ng/mL, WBC 13.3 x 109/L. EKG showed sinus bradycardia. Urine Legionnaire AG and Strep. Pneumonia AG were negative. IV Azithromycin 500 mg daily and IV Ceftriaxone 2 gm daily were administered for 8 days. Chloroquine phosphate 500 mg 2x daily was added. IV Norepinephrine was continued. IV fluids were withheld. The head of the bed was elevated to >30°. DVT prophylaxis with SQ Enoxaparin and Vitamin C were administered. New blood cultures remained negative. COVID-19 RT-PCR after 3 days remained positive. He was extubated after 4 days and discharged home after 9 days with normalized creatinine of 1.03 mg/dL. CONCLUSION: We have for the first time demonstrated the sequential chest radiographic images of the progressive radiological trajectory of COVID-19 pneumonia. The place of non-invasive ventilation demands further study. The so-called 'sweet hypoxia' or 'happy hypoxia' or 'silent hypoxemia' in COVID-19 is revisited - indeed, it is not exactly limited to COVID-19 patients. The need to mitigate lung barotrauma is mandatory. Finally, prognostication of pneumonia in COVID-19 is unpredictable. Too early premature discharge fromthe hospital is strongly discouraged.
ABSTRACT
Since the global coronavirus disease 2019 (COVID-19) pandemic hit most parts of the world, the nephrology community has primarily focused on the associated incidence of often severe acute kidney injury (AKI) with the disease pandemic. For patients on maintenance in-center outpatient hemodialysis, the primary concern has been on prevention of the spread of COVID-19 among this vulnerable patient group. Our recent experience with one end-stage renal disease (ESRD) patient early in the Spring of 2020 has led us to speculate that ESRD patients may well exhibit an unusually prolonged period of persistence of COVID-19. This may explain the recent report of the unanticipated demonstration of a high rate of positive COVID-19 antibody testing among the staff of a Pediatric Outpatient Hemodialysis Unit in New York. Further studies are mandated as these investigations would help guide the implications of preventative measures against the spread of COVID-19 among both patients and staff of hemodialysis units around the world.