Agitated saline bubble-enhanced ultrasound for the positioning of cuffed, tunneled dialysis catheters in patients with end-stage renal disease.

BACKGROUND: In patients with end-stage renal disease, the use of cuffed, tunneled dialysis catheters for hemodialysis has become integral to treatment plans. Fluoroscopy is a widely accepted method for the insertion and positioning of cuffed dialysis catheters, because it is easy to use, accurate and reliable, and has a relatively low incidence of complications. The purpose of our study was to evaluate the feasibility of tunneled hemodialysis catheter placement without the use of fluoroscopy but with a dynamic ultrasound-imaging-based guided technique. METHODS: From January 2015 to December 2017, we performed an observational prospective cohort study of 56 patients with end-stage renal disease who required tunneled dialysis catheter placement. RESULTS: The overall success rate for ultrasound-guided central access was 100%, with a mean number of 1.16 (±0.4) attempts per patient. There were no incidences of guide wire coiling/kinking, carotid puncture, pneumothorax, or catheter malfunction. Catheter flow during dialysis was 286 (±38) mL/min. The total number of catheter days was 7451, with a mean of 133 days and a range of 46-322 days. Life table analysis revealed primary patency rates of 100%, 96%, and 53% at 30, 60, and 120 days, respectively. CONCLUSION: Dynamic ultrasound-based visualization of microbubbles in the right atrium is a highly accurate method to detect percutaneous implantation of large-lumen, tunneled, central venous catheters without the need for fluoroscopic guidance technology. Future research should further develop and confirm these initial findings.

Lactate clearance is associated with mortality in septic patients with acute kidney injury requiring continuous renal replacement therapy: A cohort study.

The aim of the study was to assess the clinical utility of lactate measured at different time points to predict mortality at 48 hours and 28 days in septic patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT).Consecutive critically ill patients with septic AKI requiring CRRT were prospectively studied. Variables were collected at initiation of CRRT and 24 hours later.In total, 186 patients were analyzed. Overall mortality at 48 hours was 28% and at 28 days was 69%. Initial lactate, lactate at 24 hours and the proportion of patients with a lactate clearance superior to 10% were different between survivors at 28 days [2.0 mmol/L, 1.95 mmol/L and 18/45 (40%)] and nonsurvivors [3.46 mmol, 4.66 mmol, and 18/94 (19%)]. Multivariate analysis demonstrated that lactate at 24 hours and lactate clearance, but not initial lactate, were independently associated to mortality. Area under the ROC curves for 28-day mortality was 0.635 for initial lactate; 0.828 for lactate at 24 hours and 0.701 for lactate clearance.Lactate clearance and lactate after 24 hours of CRRT, but not initial lactate, were independently associated with mortality in septic AKI patients undergoing CRRT. Serial lactate measurements may be useful prognostic markers than initial lactate in these patients.

Patient's response to a simple question on recovery after hemodialysis session strongly associated with scores of comprehensive tools for quality of life and depression symptoms.

PURPOSE: Many maintenance hemodialysis patients do not feel well after the hemodialysis session and need a time to recover. The main objective of the study was to investigate whether a simple question about the need of some time to recover from hemodialysis was associated with scores of comprehensive tools of depression symptoms and health-related quality of life (HRQOL). METHODS: Cross-sectional evaluation of 800 Brazilian patients enrolled in the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO). The KDQOL-SF was used for HRQOL and the 20-item CES-D and BDI for depression symptoms. Linear and logistic models were used for multivariable adjustments. RESULTS: Patients who reported some time to recover (30%) had significantly (P < 0.001) higher depression symptoms scores (mean difference = 4.75 for CES-D and 4.48 for BDI). HRQOL scores were, in general, lower for patients who referred a time to recover, with mean differences larger than 4.0 (P < 0.05) both for physical and mental components. Strong associations of needing a time to recover and lower scores of several kidney disease-targeted HRQOL components were also observed. Differences in depression symptoms and HRQOL were largely reduced after adjustments for symptoms (muscle pain/cramps, faintness, fatigue, nausea/vomiting). CONCLUSIONS: The results support the validity of a simple question on post-hemodialysis recovery as a proxy for scores of complex instruments for depression symptoms and HRQOL. The results suggest that the poorer HRQOL and higher depression probability in patients who need a time to recover from hemodialysis could be partially explained by the presence of hemodialysis-related symptoms.

Infecçäo em diálise peritoneal intermitente / Peritonitis in intermittent peritoneal dialysis (IPD)

Com o objetivo de verificar a incidência de peritonite em diálise peritoneal intermitente (DPI), assim como morbidade, flora infectante e aspectos clínicos pertinentes, foram estudadas bacteriologicamente 101 sessöes de diálise peritoneal, dentre 547 realizadas no Hospital ana Nery (INAMPS) no período de julho de 1983 a março de 1984. Foram procedidas culturas da prótese de Deane, do dialisado no 1§ e último banhos, cultura da ponta do cateter a cada duas semanas, ou quando havia sinais clínicos de peritonite. Realizou-se também estudo citológico do mesmo material. Vinte e dois pacientes portadores de insuficiência renal crônica foram incluídos no estudo, sendo nove do sexo feminino e 13 do masculino, com idades variando de 16 a 67 anos. Todos eram submetidos a duas sessöes semanais de 20 horas, utilizando prótese de Deane. Staphylococcus epidermidis e Staphylococcus aureus foram as bactérias mais freqüentemente isoladas. Peritonite clínica, no entanto, com febre e dor abdominal e líquido francamente turvo, foi observada em apenas cinco oportuniddades. Com o líquido peritoneal de dez desses pacientes, foram procedidas curvas de crescimento bacteriano, utilizando-se inóculos de ñ 10**5 de Staphylococcus epidermidis, observando-se em alguns pacientes nítido efeito inibitório deste líquido após seis e 24 horas de incubaçäo a 37-C, quando comparado com o controle, que consistia em semelhante inóculo feito em tripticase soja (TSB). Os autores discutem os mecanismos de defesa celulares e humorais do líquido peritoneal e sugerem medidas profiláticas com vistas à reduçäo da infecçäo em DPI

Estudo epidemiológico da pressäo arterial em escolares de Salvador, Bahia / Epidemiological study of blood pressure in grammar school students in Salvador, Bahia

Com o objetivo de avaliar aspectos epidemiológicos da pressäo arterial na faixa etária de 07 a 14 anos, foram estudados 1.594 escolares de Salvador, Bahia. O tamanho da amostra, representativa de 270.000 estudantes de 1- grau da cidade, foi calculado com base em prevalência de hipertensäo arterial estimada em 3%. Houve partilha proporcional entre as escolas públicas e particulares sorteadas, tendo sido, a seguir, constituídos 8 estratos por idade. A pressäo arterial foi aferida pelo método ausculatório no braço direito, com a criança na posiçäo sentada, utilizando-se esfigmomanômetro de coluna de mercúrio e braçadeiras com manguitos apropriados. Para a pressäo diastólica, foi considerada a 4a. fase dos sons de Korotkoff, de acordo com as recomendaçöes da American Heart Association. Foram também aferidos pulso radial, peso e estatura. Nas meninas, além disso, foi registrada a idade da menarca. Considerou-se hipertenso o escolar cuja média de 3 aferiçöes da pressäo arterial ultrapassou o 95- percentil da PAS e/ou PAD para a idade, respeitados os padröes pôndero-estaturais para idade e sexo. A amostra incluiu 757 escolares (47,5%) do sexo masculino e 837 (52,5%) do sexo feminino, sendo 123 negros (7,7%), 629 mulatos (39,5%), 835 brancos (52,4%) e 7 (0,4%) da raça amarela. Novecentos e cinqüenta e seis escolares (53,7%) pertenciam à rede de ensino público e 738 (46,3%) à rede privada, sendo que, nas primeiras, predominaram os mulatos e negros (72%) e, nas últimas, os brancos (81,5%). Foram estabelecidos padröes de normalidade de peso, estatura e índice de massa corporal (Quetelet) por idade e sexo, e padröes de normalidade da pressäo arterial por idade