Risk factors associated with the development of active tuberculosis among patients with advanced chronic kidney disease.

OBJECTIVES: The risk of developing active TB is greater in those receiving haemodialysis. This study aimed to describe the incidence of active tuberculosis among patients referred for management of kidney disease and dialysis in a high incidence UK city, with the purpose of informing latent TB testing and treatment practice. METHODS: Information from the tuberculosis register was cross-referenced with the Department of Renal Medicine patient information system. All patients seen between 1st January 2005 and 1st October 2016 were included in the analyses with the exception of those with prior TB. RESULTS: 68 cases of active TB were identified, an incidence of 126/100,000 patient-years (95% CI 97-169). Incidence was lowest in those with CKD 1 or 2 and rose as high as 256/100,000 patient-years (95% CI 183-374) in those receiving renal replacement therapy. 48% of cases were pulmonary and 87% of TB patients gave their ethnicity as either black/black British or Asian/Asian British, significantly more than in the non-TB renal group. Cases occurred steadily over the time period in which patients were in the cohort. CONCLUSION: TB incidence was very high among those receiving renal replacement therapy or CKD 4 or 5. Most cases occurred in those of an Asian/Asian British or black/black British background. Testing and treating such patients for latent TB is justified and should include those who have been receiving renal replacement therapy for some years.

Meticillin-resistant Staphylococcus aureus and meticillin-susceptible Staphylococcus aureus screening in a cohort of haemodialysis patients: carriage, demographics and outcomes.

BACKGROUND: Patients on haemodialysis are vulnerable to colonization with Staphylococcus aureus due to frequent hospital contact, indwelling devices, and impaired immunity. Additionally colonization is associated with increased risk of infection. AIM: To determine the prevalence of both meticillin-resistant S. aureus (MRSA) and meticillin-susceptible S. aureus (MSSA) carriage in our haemodialysis cohort and to identify any risk factors predisposing to carriage, recolonization, or persistent carriage following a decolonization programme. METHODS: All haemodialysis patients screened for S. aureus carriage between June 2009 and May 2011 were retrospectively followed up for 18 months using hospital electronic records. Statistical analysis was performed using IBM SPSS version 19. FINDINGS: Out of 578 patients screened, 288 patients (49%) had at least one positive swab (10% MRSA, 90% MSSA). Of these patients, 265 completed a course of decolonization therapy following which 36% successfully eradicated (eradicators) and 64% did not (non-eradicators). There was no statistically significant difference in patient demography, type of vascular access, 18-month patient mortality, or number of hospital admissions between the two groups. Those who failed to eradicate were more likely to have had an episode of S. aureus bacteraemia within the study period compared to those who successfully decolonized (P = 0.003). CONCLUSION: Half of our haemodialysis cohort was colonized with S. aureus at any one time over an 18-month period. Following decolonization, one-third of patients remained successfully eradicated for 18 months. Non-eradicators have an increased risk of bacteraemia, which is associated with poor mortality. We would recommend routine screening and aggressive attempts to decolonize.

End-of-life decision making: withdrawing from dialysis: a 12-year retrospective single centre experience from the UK.

AIM: Withdrawal from dialysis is a common mode of death in patients undergoing dialysis. Anecdotally most patients have a physician-directed dialysis withdrawal (DW) following an acute medical precipitant, rather than a patient-narrated planned withdrawal as part of a collaborative end-of-life care plan. We report a 12-year retrospective experience of patients undergoing dialysis who died following DW, and suggest clinical parameters which can be used to identify patients who are able to direct their end-of-life care process. METHODS: Retrospective 12-year review of inhouse electronic and paper records. RESULTS: 867 patients undergoing dialysis died during the study period. 93 patients died from DW. 9 (10%) patients electively withdrew in the absence of an acute medical precipitant and 84(90%) withdrew from dialysis for medical reasons. Patients who chose to withdraw were 10 years younger at dialysis initiation and withdrawal, had greater reported sessional difficulties/intolerances (p<0.05), greater general deterioration in terms of comorbidity and physical dependency during the course of dialysis (p<0.05), were more likely to rehabilitate following an acute medical precipitant, and were more likely to reside in their own home on DW (p<0.05). All had decision-making capacity compared with 35(42%) patients who had dialysis withdrawn for medical reasons (p<0.05). CONCLUSIONS: Comorbidity, physical dependence, dialysis tolerance, cognitive decline, rehabilitation post an acute medical precipitant and, place of residence are parameters which differentiate between patients who choose to withdraw from dialysis and those who have dialysis withdrawn for medical reasons. These parameters can be used to identify terminal patients on dialysis who are able to be directive in their end-of-life advanced care planning.

Short and long-term outcome of patients with severe acute kidney injury requiring renal replacement therapy.

BACKGROUND: Severe acute kidney injury (AKI) occurs in 2-7% of all hospital admissions and is an independent poor prognostic marker. Nevertheless, information on the long-term outcome of AKI and the factors influencing this is limited. AIM: To describe the short- and long-term outcome of patients requiring renal replacement therapy (RRT) for severe AKI and to examine factors affecting patient survival and renal recovery. DESIGN AND METHODS: Single centre retrospective analysis of 481 consecutive patients over a period of 39 months. FOLLOW-UP: 12 months. PRIMARY AND SECONDARY OUTCOMES: overall mortality and RRT dependency at 30 days, 90 days and 1 year. RESULTS: Survival at 30 days, 90 days and 1 year was 54.4, 47.2 and 37.6%, respectively. RRT independency at 30 days, 90 days and 1 year was 35.2, 27.2 and 25.8%, respectively. Of those RRT independent at 90 days, 55% had ongoing chronic kidney disease. There were two distinct groups of patients: Group A (haemofiltration in ITU) and Group B (intermittent haemodialysis in the renal unit). Patient survival was worse in Group A while RRT independence was higher. Independent predictors of survival included renal cause of AKI and lower CI score in Group A and renal or post-renal cause of AKI, younger age and the absence of malignancy in Group B. Independent predictors of renal recovery included the presence of sepsis in Group A and pre- or post-renal cause of AKI in Group B. CONCLUSIONS: The short- and long-term survival outcome of severe AKI requiring RRT remains poor. Among those who survive, a significant number either continue to require RRT or have residual renal impairment necessitating ongoing follow-up.