Comparison of catheters or new arteriovenous fistulas for commencement of haemodialysis in pregnant women with chronic kidney disease: an international observational study.

BACKGROUND: Evidence surrounding vascular access options for commencing dialysis in pregnancy complicated by chronic kidney disease (CKD) is limited. Creation of new arteriovenous fistulas (AVFs) in pregnant women is rare. METHODS: Retrospective cohort study of approaches to vascular access in pregnancy in centres in Australia, the United Kingdom (UK) and Canada (2002-2018). RESULTS: Twenty-three women with advanced CKD commenced dialysis in pregnancy (n = 20) or planned to commence (n = 3). Access at dialysis start was a tunnelled catheter (n = 13), temporary catheter (n = 1), AVF created pre-conception but used in pregnancy (n = 3) and AVF created during pregnancy (n = 3). No women commencing dialysis with an AVF required a catheter. No differences in perinatal outcomes were observed comparing AVFs and catheters at dialysis commencement. No AVFs were created in pregnancy in Canadian women. From Australia and the UK, 10 women had a new AVF created in pregnancy, at median gestation 14.5 weeks (IQR 12.5, 20.75). Four women still needed a catheter for dialysis initiation and 3 eventually used the new AVF. Six AVFs were successfully used in pregnancy at median gestation 24 weeks (IQR 22.5, 28.5), 2 were successfully created but not used and 2 had primary failure. No catheter-associated complications were identified except one episode of catheter-related sepsis. CONCLUSIONS: Catheter-related complications were minimal. In selected women, with sufficient pre-planning, an AVF can be created and successfully used during pregnancy to minimise catheter use if preferred. Pre-conception counselling in advanced CKD should include discussing vascular access options reflecting local expertise and patient preferences.

Pregnancy outcomes in women with hyponatraemia and preeclampsia: Case series and literature review.

OBJECTIVES: To determine the prevalence, clinical course, complications and management of preeclampsia complicated by hyponatraemia. STUDY DESIGN: A ten year retrospective audit of women delivering at a tertiary referral hospital with preeclampsia complicated by hyponatraemia (defined as serum sodium < 130 mmol/L). MAIN OUTCOME MEASURES: The prevalence, time to delivery, complications, treatment and time to recovery of hyponatraemia in women with preeclampsia associated with hyponatraemia. RESULTS: There were 129 cases of preeclampsia associated with hyponatraemia, representing 9% of women with preeclampsia, and 0.27% of deliveries overall. Hyponatraemia was associated with a significant rate of complications of preeclampsia; acute kidney injury in 34.1%, HELLP syndrome in 17.1%, fetal growth restriction in 36.4%, stillbirth in 2.3%, the use of magnesium sulphate in 44.2%, and postpartum maternal admission to an intensive care unit in 28.7%. Moderate/severe hyponatraemia was associated with greater risk of acute kidney injury, fetal growth restriction and post-partum maternal admission to an intensive care unit than mild hyponatraemia. Urgent delivery was required in 71% of women for either obstetric or fetal indications within 24 h of diagnosis of moderate/severe hyponatraemia. In almost all cases, hyponatraemia rapidly resolved postpartum without requirement for fluid restriction or intravenous saline. CONCLUSIONS: Hyponatraemia should be regarded as a marker of severity in the setting of preeclampsia, and in the absence of an alternative cause may be an indication for expedited delivery. Hyponatraemia typically recovers rapidly following delivery without the need for specific therapy.

Changes in proteinuria and diagnosing preeclampsia in CKD pregnancy.

The diagnosis of preeclampsia superimposed on underlying kidney disease is complicated by physiological changes in renal function, blood pressure and proteinuria during pregnancy. Previous studies have demonstrated a significant increase in proteinuria during pregnancy in women with diabetic nephropathy in the absence of superimposed preeclampsia. There is a paucity of studies addressing changes in proteinuria during pregnancy in other conditions causing chronic kidney disease. A retrospective audit of changes in urine protein:creatinine ratios in 68 pregnancies to women with preconception proteinuria was performed, to determine whether changes in proteinuria may be useful in diagnosing preeclampsia. A 100% or greater increase in proteinuria from baseline increase was regarded as a significant change. In 51 pregnancies (75%) the peak urine protein:creatinine ratio did not rise significantly from values at the start of pregnancy. Where a greater than doubling of urine protein:creatinine ratio was seen, 12 of 17 pregnancies (70%) were judged clinically to have superimposed preeclampsia A significant increase in proteinuria also occurred in 3 women with lupus nephritis, and 2 with diabetic nephropathy, in the absence of preeclampsia. Larger studies of women with chronic kidney disease would be important to determine whether changes in proteinuria during pregnancy may be of diagnostic value for superimposed preeclampsia.

Risk of appendiceal endometriosis among women with deep-infiltrating endometriosis.

OBJECTIVE: To determine whether deep-infiltrating endometriosis (DE) carries an increased risk of appendiceal endometriosis (AppE) as compared with superficial endometriosis or no endometriosis. METHODS: In a retrospective study, data were obtained by chart review of an internal database for women who underwent coincidental appendectomy during benign gynecologic surgery between July 2009 and February 2014 at a tertiary referral center in the USA. Univariate, bivariate, and regression analyses were performed. The primary exposure was surgically documented endometriosis (DE, superficial, or no endometriosis). The primary outcome was AppE. RESULTS: Endometriosis was diagnosed for 151 (38.2%) of 395 women; 82 (54.3%) had DE. The prevalence of AppE was 13.2% (52/395) overall; 8 (11.6%) of 69 women with superficial endometriosis and 32 (39.0%) of 82 with DE were affected. Frequency of AppE was increased among women with DE, abnormal appendix appearance, and surgical indication (all P<0.001). Women with DE had a 5.9-fold (95% confidence interval [CI] 2.9-11.9) higher risk of AppE compared with women without endometriosis, controlling for appendiceal appearance and surgical indication, and a 2.7-fold (95% CI 1.2-6.2) higher risk of AppE compared with those with superficial endometriosis. CONCLUSION: Women with DE have increased risk of AppE. Coincidental appendectomy should form part of complete endometriosis excision for these patients.

The SIESTA Trial: A Randomized Study Investigating the Efficacy, Safety, and Tolerability of Acupressure versus Sham Therapy for Improving Sleep Quality in Patients with End-Stage Kidney Disease on Hemodialysis.

Objectives. To compare the effectiveness of real acupressure versus sham acupressure therapy in improving sleep quality in patients receiving hemodialysis (HD) or hemodiafiltration (HDF). Methods. A multicenter, single-blind, randomized controlled trial was conducted in two Australian dialysis units located in Princess Alexandra Hospital and Logan Hospital, respectively. Forty-two subjects with self-reported poor sleep quality were randomly assigned to real (n = 21) or sham (n = 21) acupressure therapy delivered thrice weekly for four consecutive weeks during routine dialysis sessions. The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) score measured at week four adjusted for baseline PSQI measurements. Secondary outcomes were quality of life (QOL) (SF-8), adverse events, and patient acceptability (treatment acceptability questionnaire, TAQ). Results. The two groups were comparable on global PSQI scores (difference 0.19, 95% confidence interval [CI] -1.32 to 1.70) and on the subscale scores. Similar results were observed for QOL both in the mental (difference -3.88, 95% CI -8.63 to 0.87) and the physical scores (difference 2.45, 95% CI -1.69 to 6.58). There were no treatment-related adverse events and acupressure was perceived favorably by participants. Conclusion. Acupressure is a safe, well-tolerated, and highly acceptable therapy in adult hemodialysis patients in a Western healthcare setting with uncertain implications for therapeutic efficacy.

Adrenal cortical carcinoma mimicking early severe preeclampsia.

Preeclampsia is a common disorder in pregnancy and may affect multiple maternal and foetal organ systems. Less common disorders with similar features may imitate preeclampsia though require different management strategies and with different prognostic implications for mother and baby. We present a case of a pregnant woman who developed severe hypertension and proteinuria in pregnancy. The early onset of these changes prompted investigation for causes other than preeclampsia, leading to a diagnosis of Cushing's syndrome due to stage III adrenocortical cancer. The changes in management strategy, the importance of a multidisciplinary approach to care, and the prognostic implications for the mother are discussed.

Predictors, treatment, and outcomes of non-Pseudomonas Gram-negative peritonitis.

Non-Pseudomonas Gram-negative (NPGN) peritonitis is a frequent, serious complication of peritoneal dialysis; however, previous reports have been limited to small, single-center studies. To gain insight on the frequency, predictors, treatment, and outcomes of NPGN peritonitis, we analyzed data in the ANZDATA registry of all adult Australian peritoneal dialysis patients over a 39-month period using multivariate logistic and multilevel Poisson regressions. There were 837 episodes of NPGN peritonitis (23.3% of all peritonitis) that occurred in 256 patients. The most common organism isolated was Escherichia coli, but included Klebsiella, Enterobacter, Serratia, Acinetobacter, Proteus, and Citrobacter, with multiple organisms identified in a quarter of the patients. The principal risk factor was older age, with poorer clinical outcome predicted by older age and polymicrobial peritonitis. The overall antibiotic cure rate was 59%. NPGN peritonitis was associated with significantly higher risks of hospitalization, catheter removal, permanent transfer to hemodialysis, and death compared to other organisms contributing to peritonitis. Underlying bowel perforation requiring surgery was uncommon. Hence, we show that NPGN peritonitis is a frequent, serious complication of peritoneal dialysis, which is frequently associated with significant risks, including death. Its cure with antibiotics alone is less likely when multiple organisms are involved.

Patterns of metastases in familial and non-familial melanoma.

Family history is a strong risk factor for the development of primary melanoma and is associated in a subset with inherited mutations in melanoma susceptibility genes. This study sought to determine whether differences in metastatic pattern exist between patients with a positive family history (FH+) and those with a negative family history (FH-). Such differences could have importance for clinical management and in the determination of the function of both known and putative melanoma susceptibility genes. A retrospective, nested case-controlled study was performed. Of the FH+ cohort (n = 38), 26 were from kindreds with two histologically verified affected first-degree relatives and 12 were from kindreds with three or more affected members, at least two of whom were first-degree relatives. Three FH- controls from the Sydney Melanoma Unit database were matched to each case for age, sex, stage at diagnosis, number of primary melanomas and year of diagnosis (n = 114). There were no statistically significant differences between the two groups with regard to overall survival from initial diagnosis (FH+, 57.4 months; FH-, 50.0 months; P = 0.99), median survival from time of first metastasis (FH+, 15.4 months; FH-, 15.9 months; P = 0.94), or median disease-free interval (FH+, 26.4 months; FH-, 29.7 months; P = 0.73). On multivariate conditional logistic regression analysis, there was no statistically significant difference between the two groups in the probability of developing initial metastases or of ever developing metastases at specific sites. Survival, disease-free interval and distribution of metastatic sites are similar in both familial and non-familial melanoma. Genetic susceptibility for melanoma may lower the threshold for entering an otherwise common molecular pathway for tumour development and evolution.