The first nocturnal home haemodialysis patient in Hong Kong.

We report our experience of the first use of nocturnal home haemodialysis in Hong Kong. The patient, a 40-year-old man with end-stage renal failure, was recruited into the Nocturnal Home Haemodialysis Programme at Princess Margaret Hospital in 2006. He received haemodialysis at home on alternate nights (3.5 sessions per week) for 5.5 to 6 hours per session. After 1 year of nocturnal home haemodialysis, his recombinant human erythropoietin requirement had been reduced by more than 50%. His serum phosphate level decreased by 35% and calcium phosphate product by 34%. After nocturnal home haemodialysis, his blood pressure control has been excellent and he was able to cease taking anti-hypertensive medications soon after commencing nocturnal home haemodialysis. Regression of his left ventricular hypertrophy has also been noted, with a 39% decrease in his left ventricular mass index. The haemodialysis adequacy index, weekly single-pool Kt/V, increased by 59% after switching to nocturnal home haemodialysis and his quality-of-life indices also showed significant improvement. Nocturnal home haemodialysis holds promise as an alternative dialytic therapy for patients on chronic haemodialysis in Hong Kong.

Acute renal impairment in coronavirus-associated severe acute respiratory syndrome.

BACKGROUND: Severe acute respiratory syndrome (SARS) is a newly emerged infection from a novel coronavirus (SARS-CoV). Apart from fever and respiratory complications, acute renal impairment has been observed in some patients with SARS. Herein, we describe the clinical, pathologic, and laboratory features of the acute renal impairment complicating this new viral infection. METHODS: We conducted a retrospective analysis of the plasma creatinine concentration and other clinical parameters of the 536 SARS patients with normal plasma creatinine at first clinical presentation, admitted to two regional hospitals following a major outbreak in Hong Kong in March 2003. Kidney tissues from seven other patients with postmortem examinations were studied by light microscopy and electron microscopy. RESULTS: Among these 536 patients with SARS, 36 (6.7%) developed acute renal impairment occurring at a median duration of 20 days (range 5-48 days) after the onset of viral infection despite a normal plasma creatinine level at first clinical presentation. The acute renal impairment reflected the different prerenal and renal factors that exerted renal insult occurring in the context of multiorgan failure. Eventually, 33 SARS patients (91.7%) with acute renal impairment died. The mortality rate was significantly higher among patients with SARS and acute renal impairment compared with those with SARS and no renal impairment (91.7% vs. 8.8%) (P < 0.0001). Renal tissues revealed predominantly acute tubular necrosis with no evidence of glomerular pathology. The adjusted relative risk of mortality associated with the development of acute renal impairment was 4.057 (P < 0.001). By multivariate analysis, acute respiratory distress syndrome and age were the most significant independent risk factors predicting the development of acute renal impairment in SARS. CONCLUSION: Acute renal impairment is uncommon in SARS but carries a high mortality. The acute renal impairment is likely to be related to multi-organ failure rather than the kidney tropism of the virus. The development of acute renal impairment is an important negative prognostic indicator for survival with SARS.

Prophylaxis against gram-positive organisms causing exit-site infection and peritonitis in continuous ambulatory peritoneal dialysis patients by applying mupirocin ointment at the catheter exit site.

OBJECTIVE: We evaluated the effectiveness of local application of mupirocin ointment at the catheter exit site in preventing exit-site infection and peritonitis attributable to gram-positive organisms in continuous ambulatory peritoneal dialysis patients. METHODS: This prospective randomized controlled trial included 154 patients. They were randomly allocated to a mupirocin-treated group (group M) and a control group (group C). Group M included 73 patients (47.4%) who were instructed to apply mupirocin ointment to the catheter exit site once daily after the routine daily exit-site dressing. Group C included 81 patients (52.6%) who continued their usual daily exit-site care without applying mupirocin. The two groups were followed to see whether there would be any difference in the frequency of exit-site infection and peritonitis or in the infecting organisms. RESULTS: Interim data were collected at 5 months after the start of the study. Those data showed a significantly lower incidence of exit-site infection and peritonitis attributable to gram-positive organisms in group M as compared with group C. The incidence of gram-positive exit-site infection in group C was 1 episode per 36.8 patient-months; in group M, the incidence was 1 episode per infinity patient-months (0 incidence in 5 months, p < 0.05). The incidence of gram-positive peritonitis in group C was 1 episode per 40.5 patient-months; in group M, the incidence was 1 episode per 365 patient-months (p < 0.05). Mupirocin treatment had no significant effect on the incidence of exit-site infection and peritonitis attributable to other organisms. Before mupirocin treatment, we saw a trend toward higher infection rates in diabetic patients and nasal carriers of Staphylococcus aureus as compared with non diabetic patients and nasal non carriers, although the differences were not statistically significant. Mupirocin brought the infection rate attributable to gram-positive organisms to an equally low level in diabetic and non-diabetic patients, and in nasal carriers and nasal non carriers of S. aureus. No adverse effect of local application of mupirocin was reported. CONCLUSION: Local application of mupirocin ointment at the catheter exit site is a safe and effective method of preventing exit-site infection and peritonitis involving gram-positive organisms.

Setting up a continuous ambulatory peritoneal dialysis training program.

Continuous ambulatory peritoneal dialysis (CAPD) training programs have become fundamental patient education programs in renal centers providing peritoneal dialysis (PD) services. Several key topics must be addressed in setting up a CAPD training program: Health care and organizational issues, Multidisciplinary team approach, Evidence-based practice, Pre-training patient assessment, Patient training Program evaluation. The PD nurses should identify key learning objectives for patient training. The essential elements of CAPD training are the training content and schedule, training assessment, and teaching methods. Program set-up also includes establishing a back-up system and follow-up protocols, which are essential for continuity of care in renal patients. Outcomes such as rates of peritonitis and exitsite infection, unplanned readmission, and patient satisfaction are all important indicators when the results of CAPD training programs are reviewed. The development and successful implementation of a cost-effective CAPD training program has a significant impact on patient outcomes in the renal specialty.