Dignity-related distress and recall among alert, non-delirious critically ill patients.

OBJECTIVES: Critical illness is associated with multiple undesired impacts, including residual psychological distress, frequently associated with recollections of critical illness. Dignity-related distress is highly prevalent among the one-fifth of critically ill patients who are alert. The distress may be associated with unpleasant recollections of care. We examined whether patients at risk for dignity-related distress had recall of their reported distress approximately 1 week after assessment and whether this recall differed from another high-risk group, specifically patients undergoing dialysis for end-stage renal disease. METHODS: The prospective cohort study included patients with critical illness and patients with end-stage renal disease enrolled from intensive care units (ICUs) and dialysis units at 1 academic center. Distress was assessed using the Patient Dignity Inventory (PDI). Participants received in-patient or telephonic follow-up 7-10 days after the initial interaction. Follow-up encounters focused on recollection of key aspects of the interpersonal interaction as well as the content of the PDI. RESULTS: A total of 32 critically ill patients participated in initial assessment and follow-up. In total, 26 dialysis patients participated in both phases. The groups' demographics differed. Fifty percent (n = 16) of critically ill patients and 58% (n = 15) of dialysis patients reported a mean score per item of >1.6, corresponding with severe distress on the PDI. Among the ICU patients, the 95% upper 2-sided confidence interval for the median level of recall was commensurate with the participant having had no recall of the initial interview beyond remembering that there was an interview. The end-stage renal disease group did not demonstrate significantly better recall. SIGNIFICANCE OF RESULTS: Dignity-related distress is high in both critically ill patients and those with end-stage renal disease; however, recollection of assessment is poor in both groups. Any intervention designed to mitigate dignity-related distress will need either to be immediately deployable or not to be reliant upon recollection for impact.

Implementing nasal povidone-iodine decolonization to reduce infections in hemodialysis units: a qualitative assessment.

BACKGROUND: A substantial proportion of patients undergoing hemodialysis carry Staphylococcus aureus in their noses, and carriers are at increased risk of S. aureus bloodstream infections. Our pragmatic clinical trial implemented nasal povidone-iodine (PVI) decolonization for the prevention of bloodstream infections in the novel setting of hemodialysis units. OBJECTIVE: We aimed to identify pragmatic strategies for implementing PVI decolonization among patients in outpatient hemodialysis units. DESIGN: Qualitative descriptive study. SETTING: Outpatient hemodialysis units affiliated with five US academic medical centers. Units varied in size, patient demographics, and geographic location. INTERVIEWEES: Sixty-six interviewees including nurses, hemodialysis technicians, research coordinators, and other personnel. METHODS: We conducted interviews with personnel affiliated with all five academic medical centers and conducted thematic analysis of transcripts. RESULTS: Hemodialysis units had varied success with patient recruitment, but interviewees reported that patients and healthcare personnel (HCP) found PVI decolonization acceptable and feasible. Leadership support, HCP engagement, and tailored patient-focused tools or strategies facilitated patient engagement and PVI implementation. Interviewees reported both patients and HCP sometimes underestimated patients' infection risks and experienced infection-prevention fatigue. Other HCP barriers included limited staffing and poor staff engagement. Patient barriers included high health burdens, language barriers, memory issues, and lack of social support. CONCLUSION: Our qualitative study suggests that PVI decolonization would be acceptable to patients and clinical personnel, and implementation is feasible for outpatient hemodialysis units. Hemodialysis units could facilitate implementation by engaging unit leaders, patients and personnel, and developing education for patients about their infection risk.

CVVHD results in longer filter life than pre-filter CVVH: Results of a quasi-randomized clinical trial.

BACKGROUND: Filter clotting is a major issue in continuous kidney replacement therapy (CKRT) that interrupts treatment, reduces delivered effluent dose, and increases cost of care. While a number of variables are involved in filter life, treatment modality is an understudied factor. We hypothesized that filters in pre-filter continuous venovenous hemofiltration (CVVH) would have shorter lifespans than in continuous venovenous hemodialysis (CVVHD). METHODS: This was a single center, pragmatic, unblinded, quasi-randomized cluster trial conducted in critically ill adult patients with severe acute kidney injury (AKI) at the University of Iowa Hospitals and Clinics (UIHC) between March 2020 and December 2020. Patients were quasi-randomized by time block to receive pre-filter CVVH (convection) or CVVHD (diffusion). The primary outcome was filter life, and secondary outcomes were number of filters used, number of filters reaching 72 hours, and in-hospital mortality. RESULTS: In the intention-to-treat analysis, filter life in pre-filter CVVH was 79% of that observed in CVVHD (mean ratio 0.79, 95% CI 0.65-0.97, p = 0.02). Median filter life (with interquartile range) in pre-filter CVVH was 21.8 (11.4-45.3) and was 26.6 (13.0-63.5) for CVVHD. In addition, 11.8% of filters in pre-filter CVVH were active for >72 hours, versus 21.2% in the CVVHD group. Finally, filter clotting accounted for the loss of 26.7% of filters in the CVVH group compared to 17.5% in the CVVHD group. There were no differences in overall numbers of filters used or mortality between groups. CONCLUSIONS: Among critically patients with severe AKI requiring CKRT, use of pre-filter CVVH resulted in significantly shorter filter life compared to CVVHD. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04762524. Registered 02/21/21-Retroactively registered, https://clinicaltrials.gov/ct2/show/NCT04762524?cond=The+Impact+of+CRRT+Modality+on+Filter+Life&draw=2&rank=1.

Disparities in dialysis modality decision-making using a social-ecological lens: a qualitative approach.

BACKGROUND: Patients with end-stage kidney disease (ESKD) may choose to undergo dialysis in-center or at home, but uptake of home dialysis in the US has been minimal despite its benefits over in-center dialysis. Factors that may have led patients to select home dialysis over in-center dialysis are poorly understood in the literature, and interventions to improve selection of home dialysis have focused on patient knowledge and shared decision-making processes between patients and providers. The purpose of this study was to explore micro- and macro-level factors surrounding dialysis modality decision-making among patients undergoing in-center and home dialysis, and explore what leads patients to select home dialysis over in-center dialysis. METHODS: Semi-structured qualitative interviews were conducted in a dialysis clinic at a large Midwestern research hospital, from September 2019 to December 2020. Participants were 18 years or older, undergoing dialysis for ESKD, and had the cognitive ability to provide consent. Surveys assessing demographic and clinical information were administered to participants following their interviews. RESULTS: Forty patients completed interviews and surveys (20 [50%] in-center dialysis, 17 [43%] female, mean [SD] age, 59 [15.99] years). Qualitative findings suggested that healthcare access and engagement before entering nephrology care, after entering nephrology care, and following dialysis initiation influenced patients' awareness regarding their kidney disease status, progression toward ESKD, and dialysis options. Potential modifiers of these outcomes include race, ethnicity, and language barriers. Most participants adopted a passive-approach during decision-making. Finally, fatigue, concerns regarding one's dialyzing schedule, and problems with fistula/catheter access sites contributed to overall satisfaction with one's dialysis modality. CONCLUSIONS: Findings point to broader factors affecting dialysis selection, including healthcare access and racial/ethnic inequities. Providing dialysis information before entering nephrology and after dialysis initiation may improve patient agency in decision-making. Additional resources should be prioritized for patients of underrepresented backgrounds. Dialysis decision-making may be appropriately modeled under the social-ecological framework to inform future interventions.

Using nasal povidone-iodine to prevent bloodstream infections and transmission of Staphylococcus aureus among haemodialysis patients: a stepped-wedge cluster randomised control trial protocol.

INTRODUCTION: Approximately 38% of haemodialysis patients carry Staphylococcus aureus in their noses, and carriers have a nearly four-fold increased risk of S. aureus access-related bloodstream infections (BSIs) compared with non-carriers. Our objective is to determine the clinical efficacy and effectiveness of a novel intervention using nasal povidone-iodine (PVI) to prevent BSIs among patients in haemodialysis units. We will survey patients and conduct qualitative interviews with healthcare workers to identify barriers and facilitators to implementing the intervention. METHODS AND ANALYSIS: We will perform an open-label, stepped-wedge cluster randomised trial to assess the effectiveness of nasal PVI compared with standard care. Sixteen outpatient haemodialysis units will participate in the study. The 3-year trial period will be divided into a 4-month baseline period and eight additional 4-month time blocks. The primary outcome of the study will be S. aureus BSI, defined as a S. aureus positive blood culture collected in the outpatient setting or within one calendar day after a hospital admission. The study team will evaluate characteristics of individual patients and the clusters by exposure status (control or intervention) to assess the balance between groups, and calculate descriptive statistics such as average responses separately for control and intervention survey questions. ETHICS AND DISSEMINATION: This study has received IRB approval from all study sites. A Data Safety and Monitoring Board will monitor this multicentre clinical trial. We will present our results at international meetings. The study team will publish findings in peer-reviewed journals and make each accepted peer-reviewed manuscript publicly available. TRIAL REGISTRATION NUMBER: NCT04210505.

BK virus histopathologic disease severity does not predict allograft outcome in renal transplant recipients.

AIMS: BK polyomavirus nephropathy (BKPyVN) is an important cause of allograft failure after renal transplantation. Despite early screening for the virus, allograft loss from BKPyVN is still experienced in up to 14% of all renal transplant recipients. The aim of this study was to investigate the association between BKPyVN histopathologic disease severity and allograft outcome at our center. METHODS: Kidney transplant recipients who had undergone transplantation between 2002 and 2014 with biopsy proven BKPyVN were eligible for this retrospective study. Each biopsy was re-evaluated by a single pathologist blinded to the clinical data and scored according to the Banff criteria for rejection and BKPyVN. Serum creatinine and BK viral load at the time of biopsy diagnosis as well as allograft outcomes to include allograft survival and serum BK viremia resolution were collected for each recipient to determine if BK virus histopathologic disease severity could predict allograft outcome. RESULTS: Twenty cases of BKPyVN were identified from 1031 total renal transplants performed. There was no statistical association between allograft loss and BKPyVN histopathology (p = 0.49). There was also no statistical association between BKPyVN histopathology and BK viral load at the time of biopsy diagnosis (p = 0.38) or serum BK viremia resolution (p = 0.16). CONCLUSIONS: BKPyVN histopathology does not appear to be useful in predicting renal allograft outcome in those recipients diagnosed with BKPyVN which is in contrast to some previously published data.

Antihypertensive Agents in the Dialysis Patient.

PURPOSE OF REVIEW: Hypertension and antihypertensive drug utilization are remarkably prevalent in ESRD patients. Management of blood pressure elevation in this population is complicated by many factors, including a multidimensional etiology, challenges in obtaining accurate and appropriately timed blood pressure measurements, highly specific drug dosing requirements, and a paucity of outcomes-based evidence to guide management decisions. The purpose of this review is to summarize and apply knowledge from existing clinical trials to enhance safe and effective use of antihypertensive agents in dialysis patients. RECENT FINDINGS: Two meta-analyses have established the benefit of antihypertensive therapy in ESRD. Data supporting the use of one antihypertensive class over another is less robust; however, beta-blockers have more clearly demonstrated improved cardiovascular outcomes in prospective randomized trials. Interdialytic home blood pressure monitoring has been demonstrated to be better associated with cardiovascular outcomes than clinic pre- or post-dialysis readings and should ideally be considered as a routine part of blood pressure management in this population. As data from small trials provides limited guidance for the management of hypertension in ESRD, more research is needed to guide medication selection and utilization. Specifically, large prospective randomized trails comparing cardiovascular outcomes of various medication classes and differing blood pressure targets are needed.

Exploring the Relationship Between Patient Activation, Treatment Satisfaction, and Decisional Conflict in Patients Approaching End-Stage Renal Disease.

BACKGROUND: Patients approaching end-stage renal disease (ESRD) experience a high level of decisional conflict because they are often not provided with sufficient support and information regarding different treatment options prior to renal failure. Decisional conflict is an important correlate of treatment satisfaction, as it is associated with disease- and treatment-related knowledge that can inform decision-making. Patient activation, the willingness and ability to independently manage one's own health and healthcare, is an individual difference factor that may have important mitigating effects on decisional conflict. PURPOSE: To identify modifiable factors that may enhance the decision-making process in patients approaching ESRD by exploring potential mediational effects between decisional conflict, treatment satisfaction, and patient activation. METHODS: Sixty-four patients approaching ESRD completed self-report measures (32% response rate). Measures included the Decisional Conflict Scale, the Kidney Disease Treatment Questionnaire, and the Patient Activation Measure Short Form. RESULTS: There was a high level of self-reported decisional conflict in this sample. Linear regressions revealed main effects among treatment satisfaction, patient activation, and decisional conflict. These variables were entered into PROCESS to assess a mediational pattern. Results showed that higher chronic kidney disease-related treatment satisfaction predicted lower decisional conflict through higher patient activation in a statistical mediational relationship. CONCLUSIONS: While the link between treatment satisfaction and decision-making is well established, these results suggest this relationship might be partially explained by patient activation, a potentially modifiable process in patients approaching ESRD. Therefore, interventions that encourage patients to become actively involved in their care could also reduce decisional conflict among patients approaching ESRD.

Comparison of the effects of energy drink versus caffeine supplementation on indices of 24-hour ambulatory blood pressure.

BACKGROUND: Cardiovascular events associated with energy drink consumption have been reported, but few data exist to delineate the hemodynamic effects of energy drinks. OBJECTIVE: To compare the effects of an energy drink versus caffeine supplementation on blood pressure (BP) indices as measured by 24-hour ambulatory BP monitoring (ABPM). METHODS: Healthy, nonsmoking, normotensive volunteers (aged 18-45 years) taking no medications were enrolled in a single-center, open-label, 2-period crossover pilot study. During each study period, subjects received either an energy drink (Red Bull Energy Drink, each dose containing 80 mg of caffeine and 1000 mg of taurine in an 8.3-oz serving) or a control (compounded caffeine solution, each dose containing 80 mg of caffeine solution in 8 oz of bottled water) at 0800, 1100, 1500, and 1900 hours and underwent 24-hour ABPM. The study periods were separated by a washout period (4-30 days). Mean 24-hour, daytime, and nighttime systolic (SBP), diastolic (DBP), and mean arterial (MAP) BP; BP load; and percent nocturnal dipping were compared between study periods. RESULTS: Nine subjects (5 females, mean [SD] age 27.7 [5.0] years) completed the study. Mean 24-hour SBP (123.2 vs 117.4 mm Hg, p = 0.04), DBP (73.6 vs 68.2 mm Hg, p = 0.02), and MAP (90.1 vs 84.8 mm Hg, p = 0.03) were significantly higher during energy drink supplementation versus caffeine supplementation. Daytime DBP (77.0 vs 72.0 mm Hg, p = 0.04) also was significantly higher with the energy drink versus caffeine supplementation. Trends in higher daytime SBP (127.0 vs 121.9 mm Hg, p = 0.05) and MAP (93.6 vs 88.6 mm Hg, p = 0.05) were recorded with energy drink supplementation versus caffeine supplementation. Nighttime SBP and DBP loads were significantly higher with the energy drink, but nocturnal dipping did not differ significantly between study periods. CONCLUSIONS: Single-day energy drink supplementation increased mean 24-hour and daytime BP compared to caffeine control in this pilot study. Additional research is warranted to better understand the hemodynamic effects of energy drink consumption.

Management of chronic kidney disease: what is the evidence?

Chronic kidney disease (CKD) is a strong risk factor for cardiovascular events and death. Hypertension, dyslipidemia, anemia, vascular calcification, and secondary hyperparathyroidism have all been implicated in the pathogenesis of cardiovascular disease associated with CKD. Numerous trials have been performed assessing the effects of modifying these risk factors on cardiovascular events and on the progression to end-stage renal disease. Many guidelines have been issued. In this article we review the guidelines and the strength of evidence supporting them. Specifically, we discuss blood pressure goals for patients with CKD, the role of renin-angiotensin system blocking agents for blood pressure control and proteinuria reduction, and the evidence for treatment recommendations of dyslipidemia. We review the trials addressing risks and benefits of different hemoglobin targets for treatment of anemia with erythropoietin. The use of phosphate-binding drugs to prevent and treat secondary hyperparathyroidism is likely beneficial, but few data support the use of vitamin D compounds. Supplementation with sodium bicarbonate may be an inexpensive treatment to retard progression to end-stage renal disease. The article concludes with a discussion of the case vignette presented in the previous article.

Chronic kidney disease: whom to screen and how to treat, part 1: definition, epidemiology, and laboratory testing.

Chronic kidney disease has become a major public health problem due to its high prevalence, its exorbitant cost, and large reductions in life expectancy and quality of life of affected people. Seventy percent of cases of end-stage renal disease are due to diabetes and hypertension, conditions which are usually managed by primary care providers. Other risk factors are cardiovascular disease, obesity, smoking, family history of kidney disease, and age greater than 55 years. Patients with these risk factors should be evaluated for the presence of chronic kidney disease during their primary care visits, because effective treatments for slowing progression are available, particularly if instituted early. Chronic kidney disease can be diagnosed by simple blood and urine tests, as recommended in guidelines issued by the National Kidney Foundation. This article begins with a case vignette, representing a common clinical scenario from a general internist's practice. We then review the definition and classification of chronic kidney disease, the epidemiology, etiology, and interconnections with cardiovascular disease. We discuss the guidelines for screening and laboratory testing, as well as the limitations of current assessment tools. A subsequent article will review evidence-based management of chronic kidney disease.

The cellular distribution of serotonin transporter is impeded on serotonin-altered vimentin network.

BACKGROUND: The C-terminus of the serotonin transporter (SERT) contains binding domains for different proteins and is critical for its functional expression. In endogenous and heterologous expression systems, our proteomic and biochemical analysis demonstrated that an intermediate filament, vimentin, binds to the C-terminus of SERT. It has been reported that 5HT-stimulation of cells leads to disassembly and spatial reorientation of vimentin filaments. METHODOLOGY/PRINCIPAL FINDINGS: We tested the impact of 5HT-stimulation on vimentin-SERT association and found that 5HT-stimulation accelerates the translocation of SERT from the plasma membrane via enhancing the level of association between phosphovimentin and SERT. Furthermore a progressive truncation of the C-terminus of SERT was performed to map the vimentin-SERT association domain. Deletion of up to 20, but not 14 amino acids arrested the transporters at intracellular locations. Although, truncation of the last 14 amino acids, did not alter 5HT uptake rates of transporter but abolished its association with vimentin. To understand the involvement of 5HT in phosphovimentin-SERT association from the plasma membrane, we further investigated the six amino acids between Delta14 and Delta20, i.e., the SITPET sequence of SERT. While the triple mutation on the possible kinase action sites, S(611), T(613), and T(616) arrested the transporter at intracellular locations, replacing the residues with aspartic acid one at a time altered neither the 5HT uptake rates nor the vimentin association of these mutants. However, replacing the three target sites with alanine, either simultaneously or one at a time, had no significant effect on 5HT uptake rates or the vimentin association with transporter. CONCLUSIONS/SIGNIFICANCE: Based on our findings, we propose that phosphate modification of the SITPET sequence differentially, one at a time exposes the vimentin binding domain on the C-terminus of SERT. Conversely, following 5HT stimulation, the association between vimentin-SERT is enhanced which changes the cellular distribution of SERT on an altered vimentin network.

Response to cyclosporine A in a patient with pure red cell aplasia due to antierythropoietin-alpha antibodies.

Reported cases of pure red cell aplasia (PRCA) from the administration of erythropoietin (EPO)-alpha molecule in the United States are rare, and the optimal treatment is still unknown. We present a patient with end-stage renal disease (ESRD) who became hyporesponsive and later unresponsive to EPO-alpha treatment a few months after initiation of hemodialysis. A comprehensive anemia examination was negative while the patient became transfusion dependent. The diagnosis of EPO-alpha-induced PRCA was confirmed by bone marrow biopsy, by undetectable serum EPO levels following the administration of a large dose of EPO-alpha, and by documenting the presence of EPO-neutralizing antibodies. Administration of cyclosporine A in addition to prednisone enabled the patient to become transfusion and EPO independent. This case further documents the possible occurrence of PRCA with EPO-alpha administration in the United States and reaffirms the potential beneficial effect of cyclosporine A.