The possibility of SARS-CoV-2 transmission in a haemodialysis unit - report from a large in-hospital centre.

Data on the possibility of transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) during the provision of chronic haemodialysis, which often entails many person-to-person contacts, are lacking. We report a follow-up of the in-centre contacts of three positive chronic haemodialysis patients. Under strict preventive measures, only one patient out of 21 patient-contacts and 29 personnel-contacts tested positive within 2 weeks after the last contact. This patient, case #3, most likely became infected during unprotected, organised group transportation to the dialysis centre.

High mortality in the first year after kidney graft failure.

BACKGROUND: The aim of our cohort study was to assess survival of the patients after kidney graft failure. METHODS: Patients starting dialysis after graft failure between January 1, 2004 and December 31, 2010 were identified from the Slovenian Renal Replacement Therapy (RRT) Registry and followed to December 31, 2011. The control group consisted of 351 incident dialysis patients, who were kidney transplant candidates. Survival data were not censored for retransplantations. RESULTS: After a median of 7.4 (interquartile range [IQR]) 0.4-13.0) years with a functioning graft and a median of 15.5 (IQR 7.8-20.7) years on RRT 82 patients started dialysis. Their mean (± standard deviation [SD]) age was 50.4 ± 12.7 years vs 49.2 ± 13.9 years for the incidental transplantation candidates (P = .49). There were sixty-one percent men (vs 64%; P = .67), and all subjects were on hemodialysis treatments. By Dec 31, 2011, 19 (23%) patients had undergone retransplantation and 27 (33%) died after a median of 1.6 (IQR 0.2-5.4) months on dialysis. The causes of death were infection (n = 15), cardio-disease-vascular (n = 6), malignancy (n = 4), or cerebrovascular (n = 2). Deceased patients were significantly older: 60.0 ± 7.9 vs 45.7 ± 12.0 years (P < .001) and more often men: (78% vs 53% P = .05). The unadjusted overall 1- and 3-year survivals rates after graft failure of 70% and 68% were significantly lower than those in the control candidate group of (98% and 93%, respectively (log-rank; P < .001). This difference remained significant upon multivariate analysis (hazard ratio [HR], 12.0; P < .001). The subgroup of 53 patients who started dialysis after chronic graft failure showed unadjusted 1- and 3-year survival rates of 82% and 80%, respectively which were still worse than the control group (P = .001), a difference that remained significant upon multivariate analysis (HR, 1.75; P < .001). CONCLUSION: After kidney graft failure patients experienced increased mortality in the first year after restarting dialysis. However, subjects who survived the first year showed good survival thereafter.

Plasma exchange and intravenous immunoglobulin in the treatment of antibody-mediated rejection after kidney transplantation: a single-center historic cohort study.

BACKGROUND: Antibody-mediated rejection (AMR) of a kidney graft has been increasingly recognized as an important cause of graft failure. Our historic cohort study sought to analyze its treatment and outcomes at our center. METHODS: All patients with AMR between 2005 and 2011 were treated with plasma exchange (PE), intravenous low-dose cytomegalovirus (CMV) hyperimmune globulin, and adjustment of basal immunosuppression. We analyzed data regarding baseline characteristics, rejection treatment with focus on PE, complications, and 1-year outcomes. RESULTS: Twenty-three AMRs occurred in 23 patients (10 male, 13 female) of mean age 41 ± 16 years, all recipients of deceased-donor kidneys with a median of 3 HLA mismatches. The subjects had a median peak panel-reactive antibodies (PRA) of 7% (interquartile range [IQR] 1%-10%). Basal serum creatinine was 174 ± 84 µmol/L estimated glomerular filtration rate (eGFR) (eGFR 42 ± 22 mL/min/1.73 m(2)), while 3 patients were dialysis- dependent. Median period between transplantation and rejection was 38 months (IQR 1.5-88.5). Concomitant T-cell-mediated rejection was treated in 78% of cases. Median number of PE procedures per patient was 10 (range, 5-17). Treatment was estimated to be successful in 83%. Donor-specific antibodies documented in 12 patients (52%) disappeared or showed reduced titers in 7/10 patients with repeated measurements. An infection was present during treatment in 7 (30%) patients. Among 237 PE, there was 1 (0.4%) mild allergic reaction to fresh frozen plasma and significant metabolic alkalosis occurred after 7 (3%) procedures. One year after rejection the mean serum creatinine level was 144 ± 52 µmol/L and Kaplan-Meier estimated graft and patient survival rates were 62% and 95%, respectively. CONCLUSIONS: Intensive treatment with PE, intravenous immunoglobulin, and adjustment of basal immunosuppression were safe and effective to reverse AMR with improved graft function in the majority of patients. However, AMR was associated with markedly decreased 1-year graft survival and the optimal treatment remains uncertain.

Regional citrate anticoagulation for hemodialysis: calcium-free vs. calcium containing dialysate - a randomized trial.

BACKGROUND: The majority of citrate protocols for hemodialysis (HD) use calcium (Ca)-free dialysate, a limited number use dialysate with Ca, aiming to simplify the procedure. This randomized clinical study sought to compare the anticoagulant effect of citrate using Ca-free dialysate and dialysate with Ca 1.25 mmol/L. METHODS: Fifty HD procedures (in 5 chronic HD patients treated by chronic citrate anticoagulation) were randomly assigned to Ca-free dialysate (25 procedures) or Ca-1.25 dialysate (25 procedures), both with Mg 0.5 mmol/L, Na 138 mmol/L, and bicarbonate 28 mmol/L. Ca-free HD: 15% Na3 citrate 80 ml/hour was infused into the arterial line, and 1 M CaCl2, 14 ml/hour into the venous line. Ca-1.25 group: 15% Na3 citrate 100 ml/hour, 1 M CaCl2 2-4 ml/hour. Polyflux H dialyzers were used. Antithrombotic effect was assessed visually after HD at 3 points: dialyzer, arterial, and venous bubble traps, using a score of 5 (no clotting) to 1 (total clotting). RESULTS: Ca-free group: arterial bubble trap score 4.7 +/- 0.5, dialyzer 4.5 +/- 0.6, venous bubble trap 4.8 +/- 0.6. Ionized calcium (iCa) at dialyzer inlet 0.34 +/- 0.17, outlet 0.21 +/- 0.06 mmol/L. All HDs were completed successfully. Ca-1.25 group: arterial bubble trap score 4.7 +/- 0.5 (NS), dialyzer 2.6 +/- 1.04 (p<0.01), venous bubble trap 2.4 +/- 0.9 (p<0.01). Volume of clot in venous bubble trap was 1.9 +/- 1.8 mL (range 0.5-6 mL). iCa at dialyzer inlet 0.24 +/- 0.05 mmol/L (p<0.05), outlet 0.63 +/- 0.11 mmol/L (p<0.01). Four of 25 HD procedures (16%) were prematurely terminated due to threatening dialyzer clotting, in 6/25 HD procedures (24%), the venous line was changed (p<0.01). CONCLUSION: Citrate anticoagulation with Ca-1.25 dialysate resulted in significantly worse anticoagulation of dialyzer and venous bubble trap compared with Ca-free dialysate, despite higher citrate dose.

Citrate anticoagulation for postdilutional online hemodiafiltration with calcium-containing dialysate and infusate: significant clotting in the venous bubble trap.

BACKGROUND: The aim of this prospective clinical study was to assess safety and antithrombotic efficacy of a regional citrate anticoagulation protocol for postdilutional online hemodiafiltration (HDF) with calcium-containing dialysate and infusate. METHODS: Nineteen postdilutional online HDF procedures with citrate anticoagulation were performed in 9 end-stage renal disease patients. Calcium-containing (1.25 mmol/L dialysate/infusate, 15% (0.51 mol/L) trisodium citrate and 1 mol/L calcium chloride (when necessary) were used; the blood flow was 300 ml/min. Antithrombotic effect was assessed visually after HDF at 3 points: the dialyzer, arterial bubble trap, and venous bubble trap, using a score of 5 (excellent anticoagulation) to 1 (total clotting). The study was terminated prematurely due to frequent clotting in the venous bubble trap. RESULTS: The mean duration of HDF was 4.3 +/- 0.9 hours; infusion volume was 13 +/- 2 L. Almost half of the HDF procedures (9/19, 47%) were completed with some difficulty: in 1 case (1/19, 5%) there was total system clotting; in the other 8 cases, system clotting was threatening and dialysis was terminated prematurely, but in only 4/19 cases (21%) prior to 4-hour duration. The main point of clot formation was the venous bubble trap (score 2.6 +/- 1.0), while anticoagulation was very good at the dialyzer (4.0 +/- 1.2) and excellent at the arterial bubble trap (4.8 +/- 0.9). No side effects were noted, and metabolic consequences were moderate. CONCLUSIONS: Regional citrate anticoagulation using calcium-containing dialysate/infusate during postdilutional online hemodiafiltration results in a high incidence of venous bubble trap clotting.