Prospective, randomized study of long-term hemodialysis catheter removal versus guidewire exchange to treat catheter-related bloodstream infection.

BACKGROUND: Long-term (tunneled cuffed) hemodialysis catheters are frequently used vascular access in renal failure patients. Catheter-related bloodstream infection (CRBSI) is a common complication of long-term hemodialysis catheters, with severe morbidities and high risk of mortality. Management of CRBSI by systemic antibiotics while keeping the catheter in place is not effective. Among the different modalities of CRBSI management are catheter removal (CR) and guidewire exchange (GE) of the catheter. The aim of this study was to compare the clinical outcome of CRBSI treated with two different strategies: GE vs CR with new catheter insertion 3 to 7 days later. METHODS: This prospective randomized study analyzed the outcomes of all cases of long-term hemodialysis CRBSI during a 5-year period. The catheter infection-free survival time was analyzed in the two groups of patients (GE group, 339 patients; CR group, 339 patients). Three weeks of systemic antibiotic therapy was used according to culture in both groups. The catheter infection-free survival was analyzed using Kaplan-Meier analysis. RESULTS: No statistically significant difference was found in catheter infection-free survival time for GE and CR groups (P = .69), which is not affected by age, sex, presence of diabetes mellitus, or type of causative organism. CONCLUSIONS: Our study did not demonstrate a difference in the clinical outcome of CRBSI treated with GE or CR with new catheter insertion 3 to 7 days later. However, guidewire catheter exchange saves veins for future access, reduces the cost and number of procedures, and avoids complications of new venipuncture.

Hypoxic metabolism in human hematopoietic stem cells.

BACKGROUND: Adult hematopoietic stem cells (HSCs) are maintained in a microenvironment, known as niche in the endosteal regions of the bone marrow. This stem cell niche with low oxygen tension requires HSCs to adopt a unique metabolic profile. We have recently demonstrated that mouse long-term hematopoietic stem cells (LT-HSCs) utilize glycolysis instead of mitochondrial oxidative phosphorylation as their main energy source. However, the metabolic phenotype of human hematopoietic progenitor and stem cells (HPSCs) remains unknown. RESULTS: We show that HPSCs have a similar metabolic phenotype, as shown by high rates of glycolysis, and low rates of oxygen consumption. Fractionation of human mobilized peripheral blood cells based on their metabolic footprint shows that cells with a low mitochondrial potential are highly enriched for HPSCs. Remarkably, low MP cells had much better repopulation ability as compared to high MP cells. Moreover, similar to their murine counterparts, we show that Hif-1α is upregulated in human HPSCs, where it is transcriptionally regulated by Meis1. Finally, we show that Meis1 and its cofactors Pbx1 and HoxA9 play an important role in transcriptional activation of Hif-1α in a cooperative manner. CONCLUSIONS: These findings highlight the unique metabolic properties of human HPSCs and the transcriptional network that regulates their metabolic phenotype.

Prospective, randomized study of cutting balloon angioplasty versus conventional balloon angioplasty for the treatment of hemodialysis access stenoses.

OBJECTIVE: The aim of this trial was to compare the rates of patency achieved by cutting and conventional balloon angioplasty to treat hemodialysis access stenoses. METHODS: End-stage renal failure patients (at three tertiary referral centers) with significant hemodialysis access stenoses were prospectively randomized to have percutaneous transluminal angioplasty (PTA) by either cutting or conventional balloons. Patients with more than one hemodynamically significant stenosis were excluded. Kaplan-Meier method was used to compare the primary assisted patency rates for the two groups. RESULTS: The study randomized 623 patients into two groups, and the duration of follow-up was 15 ± 3 months. In the cutting balloon angioplasty group, the clinical success rate was 89% (282 of 316 stenoses). In the conventional balloon angioplasty group, the clinical success rate was 86% (265 of 307 stenoses; P = .637). Assisted primary patency for cutting PTA was statistically significantly higher at 6 months and 1 year (86% and 63%) than that for conventional PTA (56% and 37%, respectively; P = .037) in the treatment of stenosis of the graft-to-vein anastomosis. In the venous stenosis subgroup, equivalent primary assisted patency at 6 months and 1 year was observed for cutting PTA (84% and 55%) and conventional PTA (70% and 46%, respectively; P = .360). In the intragraft stenosis subgroup, primary assisted patency was equivalent at 6 months and 1 year for cutting PTA (67% and 39%) and conventional PTA (62% and 49%, respectively; P = .371). In the arterial anastomotic stenosis subgroup, assisted primary patency at 6 months and 1 year was equivalent for cutting PTA (70% and 30%) and conventional PTA (75% and 33%, respectively; P = .921). CONCLUSIONS: Cutting balloon angioplasty proved to be a safe and effective treatment of graft-to-vein anastomotic stenosis, with significantly higher patency than that of conventional balloon angioplasty.

A "good death": perspectives of Muslim patients and health care providers.

BACKGROUND AND OBJECTIVES: Twelve "good death" principles have been identified that apply to Westerners. This study aimed to review the TFHCOP good death perception to determine its validity for Muslim patients and health care providers, and to identify and describe other components of the Muslim good death perspective. SUBJECTS AND METHODS: Participants included 284 Muslims of both genders with different nationalities and careers. We used a 12-question questionnaire based on the 12 principles of the TFHCOP good death definition, followed by face-to-face interviews. We used descriptive statistics to analyze questionnaire responses. However, for new themes, we used a grounded theory approach with a "constant comparisons" method. RESULT: On average, each participant agreed on eight principles of the questionnaire. Dignity, privacy, spiritual and emotional support, access to hospice care, ability to issue advance directives, and to have time to say goodbye were the top priorities. Participants identified three main domains. The first domain was related to faith and belief. The second domain included some principles related to self-esteem and person's image to friends and family. The third domain was related to satisfaction about family security after the death of the patient. Professional role distinctions were more pronounced than were gender or nationality differences. CONCLUSION: Several aspects of "good death," as perceived by Western communities, are not recognized as being important by many Muslim patients and health care providers. Furthermore, our study introduced three novel components of good death in Muslim society.