Minimally invasive peritoneal access: A new approach of catheter placement for peritoneal dialysis.

BACKGROUND: Catheter implantation techniques for peritoneal dialysis (PD) have advanced significantly in recent years. We aimed to analyze the survival and associated complications of catheters inserted using a new technique that is guided by ultrasound and fluoroscopy and requires minimal tissue dissection. The procedure was performed by nephrologists in the outpatient basis, we compared these results of the minimally invasive insertion with traditional implantation using trocars. METHODS: A total of 152 PD catheters were placed in 152 patients with stage 5 chronic kidney disease; 62.5% of the patients were men, with a mean age of 56.6 ± 18.5 years. The following two methods were used: minimally invasive insertion (MI group, n = 73) and trocar insertion (T group, n = 79). Patients in both the groups were followed prospectively for 26 months from the date of the first implantation. RESULTS: Gender, age, and prevalence of diabetes mellitus were not significantly different between the groups, while the body mass index, presence of obesity, and abdominal scars from previous surgeries were higher in the MI group (p = 0.021). The incidence of catheter dysfunction was lower in the MI group compared to group T (6.8% vs 20.3%; p = 0.019). Exit site infection was also lower with the new technique (4.1% vs. 18.9%; p = 0.005). Further, the cumulative incidence of peritonitis also reduced with MI (p = 0.034). Finally, the overall catheter survival at 1 year was 89%, which has been shown as higher in group MI (95% vs 82% in group T; p = 0.025). CONCLUSION: The MI technique for catheter insertion showed low complication rates and excellent catheter survival as compared to traditional implantation methods; thus, it may be an alternative method for PD catheter placement.

Evaluation of central venous catheter and other risk factors for mortality in chronic hemodialysis patients with COVID-19 in Brazil.

PURPOSE: Hemodialysis patients with COVID-19 are at increased risk of death. We aimed to describe the characteristics of a cohort of Brazilian hemodialysis patients with COVID-19 and assess their mortality rate and risk factors for death. METHODS: Retrospective cohort study of 741 Brazilian hemodialysis patients with confirmed COVID-19 from Feb-Dec/2020, of 52 dialysis centers of the country. We analyzed comorbid conditions, sociodemographic factors, and dialysis-related parameters. To detect risk factors for mortality in hemodialysis patients, we performed multivariable Cox proportional hazard regression analysis. Survival was analyzed by Kaplan-Meier. RESULTS: From 9877 hemodialysis patients, 741 were diagnosed with COVID-19. Mean age was 57 ± 16 years, 61% were male, and 51% white. The most frequent symptoms were fever (54.1%), cough (50.9%), and dyspnea (37.2%); 14.2% were asymptomatic. There were 139 deaths (18.8%), with 66% within the disease's first 15 days. 333 patients (44.9%) required hospitalization, and 211 (28.5%) were admitted to an intensive care unit. The cumulative probability of survival at 90 days of diagnosis was 79% (95% CI 76-82%). In the fully adjusted multivariate model, the risk factors significantly associated with death were diabetes mellitus (HR 1.52, 95% CI 1.05-2.19, P = 0.026), use of a central venous catheter (CVC) (HR 1.79, 95% CI 1.22-2.64, P = 0.003), age (HR 1.03, 95% CI 1.01-1.04, P < 0.001), and origin from the North vs. Southeast region (HR 2.60, 95% CI 1.01-6.68, P = 0.047). CONCLUSIONS: Hemodialysis patients using a CVC as the vascular access, aside from diabetic and elderly ones, should be closely monitored due to their high risk of death in the course of the COVID-19.

Monitoring peripheral perfusion in sepsis associated acute kidney injury: Analysis of mortality.

Microcirculatory disorders have been consistently linked to the pathophysiology of sepsis. One of the major organs affected is the kidneys, resulting in sepsis-associated acute kidney injury (SA-AKI) that correlates considerably with mortality. However, the potential role of clinical assessment of peripheral perfusion as a possible tool for SA-AKI management has not been established. To address this gap, the purpose of this study was to investigate the prevalence of peripheral hypoperfusion in SA-AKI, its association with mortality, and fluid balance. This observational cohort study enrolled consecutive septic patients in the Intensive Care Unit. After fluid resuscitation, peripheral perfusion was evaluated using the capillary filling time (CRT) and peripheral perfusion index (PI) techniques. The AKI was defined based on both serum creatinine and urine output criteria. One hundred and forty-one patients were included, 28 (19%) in the non-SA-AKI group, and 113 (81%) in the SA-AKI group. The study revealed higher peripheral hypoperfusion rates in the SA-AKI group using the CRT (OR 3.6; 95% CI 1.35-9.55; p < 0.05). However, this result lost significance after multivariate adjustment. Perfusion abnormalities in the SA-AKI group diagnosed by both CRT (RR 1.96; 95% CI 1.25-3.08) and PI (RR 1.98; 95% CI 1.37-2.86) methods were associated to higher rates of 28-day mortality (p < 0.01). The PI's temporal analysis showed a high predictive value for death over the first 72 h (p < 0.01). A weak correlation between PI values and the fluid balance was found over the first 24 h (r = - 0.20; p < 0.05). In conclusion, peripheral perfusion was not different intrinsically between patients with or without SA-AKI. The presence of peripheral hypoperfusion in the SA-AKI group has appeared to be a prognostic marker for mortality. This evaluation maintained its predictive value over the first 72 hours. The fluid balance possibly negatively influences peripheral perfusion in the SA-AKI.

Percutaneous and surgical insertion of peritoneal catheter in patients starting in chronic dialysis therapy: a comparative study.

Percutaneous peritoneal catheter insertion can be performed by trained nephrologists. The objective of this study was to compare the outcome of peritoneal dialysis (PD) catheters percutaneous inserted with the traditional surgical technique. One hundred twenty-one PD catheters were placed in 121 stage-5 Chronic kidney disease patients using three techniques: percutaneous insertion (Group P, n = 53), percutaneous insertion guided by radioscopy (Group R, n = 26), and surgical insertion (Group S, n = 42). The mean age of the whole cohort was 57 ± 16 years and 54% were male. Patients and catheter outcomes were followed up prospectively for 19 months. Gender, age, body mass index, previous abdominal surgeries, and the prevalence of diabetes mellitus were not significantly different among the groups as well as the incidence of bleeding and the presence of catheter dysfunction. In addition, the incidence of exit-site infections and peritonitis was not significantly different among the groups. Finally, the survival catheter rate was not significantly different by the end of the follow-up of 19 months (70% in P group, 85% in R, and 70% in S group (log rank = 0.88, p = 0.95). The outcome of percutaneous implanted catheters, which were inserted by a trained nephrologist, did not demonstrate to be inferior as compared with the traditional surgical approach.

Vitamin D and skin repair: a prospective, double-blind and placebo controlled study in the healing of leg ulcers.

OBJECTIVE: To analyze the relation between vitamin D insufficiency and wound healing in patients with venous ulcers; to correlate vitamin D insufficiency with characteristics of the ulcer (size and pain) and to evaluate if reposition of vitamin D in these subjects expedites ulcer healing. METHODS: We selected 26 patients with leg ulcers, and 26 control patients without ulcers, matched for gender, age, systemic arterial hypertension and tobacco use. The venous ulcer group was divided in two subgroups: one that received placebo (nine patients) and other receiving vitamin D, 50.000 IU per week over two months (13 patients). Blood was collected for 25 OH vitamin D dosage before and after the medication. In the ulcer group, we obtained data concerning demographics, leg ulcer size, as well as pain severity, measured by an analogical visual scale. Data was grouped in contingency and frequency tables, the tests of Fisher and chi-squared being used for nominal variables and Mann-Whitney for numerical variables. The adopted significance was of 5%. RESULTS: We found vitamin D insufficiency in the great majority of the patients. The median level in the ulcer group was 17.05 ng/dl and 22.75 ng/dl in the group without ulcer (p=0,0182) No relation was found between the ulcer size without treatment and the level of vitamin D. After treatment, the average size of the ulcer changed from 25 cm² to 18 cm² in the patients that took vitamin D and from 27 cm² to 24,5 cm² in the placebo group (p=0,7051 and p=0,7877, respectively). Considering the variability of the size of the ulcer in the treatment group versus placebo group, the average size was equal to -0,75 cm² in the first group and +4cm² in the second (p=0,0676) CONCLUSION: Patients with leg ulcers have more vitamin D deficiency. No difference in the ulcer characteristics was noted between those with and without vitamin D deficiency. There was a trend toward a better healing in those with vitamin D reposition.

Changes in clinical and laboratory parameters in obese patients with type 2 diabetes mellitus submitted to Roux-en-y gastrojejunal bypass without ring.

OBJECTIVES: 1) To assess the changes in body weight and body mass index in grade 2 and 3 obese patients with type 2 diabetes mellitus, pre and postoperatively; 2) to assess the changes in pre and postoperative fasting blood glucose, postprandial glucose, glycated hemoglobin and insulin. METHODS: A prospective study was undertaken with 40 selected patients with grade 2 and 3 obesity and type 2 diabetes mellitus, all with indication for surgical treatment of obesity. All patients underwent Roux-en-Y gastric bypass without ring. The clinical parameters weight and body mass index were analyzed, as well as the laboratory parameters fasting blood glucose, postprandial glucose, glycated hemoglobin, and insulin. The analyses were carried out in the preoperative period and at 60 days postoperatively. Statistical analysis was conducted with Student's t and the Kolmogorov-Smirnov tests. RESULTS: Mean preoperative weight was 107.3 kg, declining to 89.5 kg postoperatively. Mean initial body mass index was 39.5 kg/m², and 32.9 kg/m² at 60 postoperative days. Preoperative fasting blood glucose was 132 mg/dL, which was reduced to 40.4 mg/dL, on average, postoperatively. Postprandial blood glucose was 172 mg/dL in the preoperative period and 111.6 mg/dL in the postoperative measurement. Initial glycated hemoglobin was 7%, declining to 5.7% postoperatively. Preoperative and postoperative insulin levels were 29.6 µIU/mL and 13.9 µIU/mL, respectively. The level of significance was p<0.001 for all variables. CONCLUSION: There was a statistically significant reduction in body weight and body mass index between the pre and postoperative periods, as well as in fasting blood glucose, postprandial glucose, glycated hemoglobin.

Minocycline-EDTA lock solution prevents catheter-related bacteremia in hemodialysis.

There is growing concern about the development of antibacterial resistance with the use of antibiotics in catheter lock solutions. The use of an antibiotic that is not usually used to treat other serious infections may be an alternative that may reduce the clinical impact should resistance develop. We conducted a randomized controlled trial to compare a solution of minocycline and EDTA with the conventional unfractionated heparin for the prevention of catheter-related bacteremia in hemodialysis patients during a period of 90 d. The study included 204 incident catheters (27.8% tunneled); 14 catheters were excluded because of early dysfunction and 3 because of protocol violations. We observed catheter-related bacteremia in 19 patients in the heparin group (4.3 per 1000 catheter-days) and in 5 patients in the minocycline-EDTA group (1.1 per 1000 catheter-days; P = 0.005). We did not detect a significant difference in the rate of catheter removal for dysfunction. Catheter-related bacteremia-free survival was significantly higher in the minocycline-EDTA group than in the heparin group (P = 0.005). In conclusion, a minocycline-EDTA catheter lock solution is effective in the prevention of catheter-related bacteremia in hemodialysis patients.

Effects of hemodialysis on the cardiovascular system: quantitative analysis using wave intensity wall analysis and tissue velocity imaging.

Cardiovascular disease is the leading cause of death in patients with end-stage renal disease (ESRD). The aim of this study was to investigate the changes in cardiovascular function induced by a single session of hemodialysis (HD) by the analysis of cardiovascular dynamics using wave intensity wall analysis (WIWA) and of systolic and diastolic myocardial function using tissue velocity imaging (TVI). Gray-scale cine loops of the left common carotid artery, conventional echocardiography, and TVI images of the left ventricle were acquired before and after HD in 45 patients (17 women, mean age 54 years) with ESRD. The WIWA indexes, W(1) and preload-adjusted W(1), W(2) and preload-adjusted W(2), and the TVI variables, isovolumic contraction velocity (IVCV), isovolumic contraction time (IVCT), peak systolic velocity (PSV), displacement, isovolumic relaxation velocity (IVRV), isovolumic relaxation time (IVRT), peak early diastolic velocity (E'), and peak late diastolic velocity (A'), were compared before and after HD. The WIWA measurements showed significant increases in W(1) (P < 0.05) and preload-adjusted W(1) (P < 0.01) after HD. W(2) was significantly decreased (P < 0.05) after HD, whereas the change in preload-adjusted W(2) was not significant. Systolic velocities, IVCV (P < 0.001) and PSV (P < 0.01), were increased after HD, whereas the AV-plane displacement was decreased (P < 0.01). For the measured diastolic variables, E' was significantly decreased (P < 0.01) and IVRT was significantly prolonged (P < 0.05), after HD. A few correlations were found between WIWA and TVI variables. The WIWA and TVI measurements indicate that a single session of HD improves systolic function. The load dependency of the diastolic variables seems to be more pronounced than for the systolic variables. Preload-adjusted wave intensity indexes may contribute in the assessment of true LV contractility and relaxation.

A single session of haemodialysis improves left ventricular synchronicity in patients with end-stage renal disease: a pilot tissue synchronization imaging study.

BACKGROUND: Mechanical left ventricular (LV) dyssynchrony impairs cardiac function in patients with heart failure and LV hypertrophy (LVH) and may be a factor contributing to the high incidence of cardiac deaths in patients with end-stage renal disease (ESRD). Objectives. To evaluate the possible presence of LV dyssynchrony in ESRD patients, and acute effect of haemodialysis (HD) on LV synchronicity using a tailored echocardiographic modality, tissue synchronization imaging (TSI). METHODS: In 13 clinically stable ESRD patients (7 men; 65 +/- 10 years) with LVH, echocardiography data were acquired before and after a single HD session for subsequent off-line TSI analysis enabling the retrieval of regional intraventricular systolic delay data. Six basal and six midventricular LV segments were evaluated. Dyssynchrony was defined as a regional difference in time to peak systolic velocity >105 ms. RESULTS: Before HD, all patients had at least one dyssynchronous LV segment. The percentage of delayed segments correlated positively to LV end-diastolic diameter (r = 0.68, P < 0.05). HD induced a substantial decrease in the percentage of delayed segments from 36 +/- 25% to 19 +/- 14% (P < 0.01), reduced average maximal mechanical systolic LV delay from 300 +/- 89 to 225 +/- 116 ms (P < 0.05) and completely normalized LV synchronicity in three patients (23%). CONCLUSIONS: LV dyssynchrony appears to be present frequently in ESRD patients with LVH. The severity of LV dyssynchrony correlates with LV end-diastolic diameter and decreases after a single session of HD suggesting a mechanistic relevance of volume overload and possibly other toxins accumulating in HD patients.

Accuracy of physical examination and intra-access pressure in the detection of stenosis in hemodialysis arteriovenous fistula.

Both physical examination (PE) and intra-access pressure (IAP) measurements have been used in the identification of stenosis in an arteriovenous access. The aim of this study was to evaluate the accuracy of PE and IAP in the diagnosis of arteriovenous fistula (AVF) stenosis. A total of 84 patients were enrolled in the study (54% men, mean age of 50.7 +/- 12.7 years and mean AVF patency of 24.9 +/- 7.8 months, 52% radiocephalic). Abnormalities of pulse and thrill were used as the diagnostic tools for the detection of stenosis using the physical examination. For IAP, stenosis was suspected when the ratio between IAP at the arterial puncture site and the mean blood pressure was <0.13 or >0.43. The diagnosis of stenosis was confirmed by Doppler ultrasound (DU). Sensitivity (S), specificity (SP), positive predictive value (PPV), negative predictive value (PNV), and accuracy were calculated for the two early detection tests. According to DU, 50 (59%) AVF were considered positive for the presence of stenosis. Fifty-six (66%) AVF were considered positive for the presence of stenosis by PE and 34 (40%) by IAP. S, SP, PPV, and NPV for PE and IAP were 96%, 76%, 86%, and 93% and 60%, 88%, 88%, and 60%, respectively. The accuracy for PE and IAP was 88% and 71%, respectively. PE proved to be an accurate method for the diagnosis of stenosis and should be part of all surveillance protocols of stenosis detection in AVF.

Acute effects of low and high intravenous doses of furosemide on myocardial function in anuric haemodialysis patients: a tissue Doppler study.

BACKGROUND: In patients with pulmonary oedema and preserved renal function, furosemide has not only a renal, but also a vascular effect, causing a rapid fall in left ventricular filling pressure accompanied by an increase in venous compliance. Previous studies have shown conflicting findings regarding the vascular effects of furosemide in patients with end-stage renal disease (ESRD). The objective of our study was to investigate whether furosemide induces changes in central cardiac haemodynamics in anuric ESRD patients, using conventional echocardiography and colour tissue Doppler velocity imaging (TVI), a new quantitative and sensitive method. METHODS: Repeated low doses (40 mg followed by an additional dose of 40 mg after 30 min) of i.v. furosemide were administered to 12 (61.6 +/- 16 years, 7 men) and a high dose (250 mg) of i.v. furosemide to 6 (64.1 +/- 3.6 years, 5 men) clinically stable anuric haemodialysis (HD) patients. Conventional two-dimensional echocardiography and colour TVI images were recorded immediately before (0 min) the furosemide infusion in both groups, and in the group receiving the repeated low-dose infusion (at 0 and 30 min), 10, 20, 30, 40, 50 and 70 min after the administration of the first infusion. In the group receiving the single high dose of furosemide the ultrasound investigation was repeated 10, 20, 30 and 40 min after the infusion. The myocardial tissue velocities (v; cm/s) for isovolumetric contraction (IVC), peak systole (PS), early (E') and late (A') myocardial diastolic filling velocities were measured in the left ventricle (LV) at six sites (infero-septal, antero-lateral, inferior, anterior, infero-lateral and antero-septal walls) at the basal region. IVC time (IVCT), IV relaxation time (IVRT), PS time (PSt), RR interval, mitral annulus motion (MAM), strain rate (SR), left ventricular filling pressure (E/E') and cardiac output were also measured. The average of the different walls was used to evaluate global function. Right ventricle (RV) dynamics was evaluated from measurements of IVC velocity (IVCv), peak systolic velocity (PSv), E' and A' from the RV free wall. RESULTS: No significant changes in cardiac output, IVCv, PSv, SR, MAM, E', A', E'/A', IVRT and LV filling pressure were observed, indicating that neither 40 mg (plus additional 40 mg after 30 min) nor 250 mg of furosemide had any measurable effects on LV filling pressure and LV and RV systolic and diastolic function. CONCLUSIONS: In anuric HD patients, low and high doses of furosemide had no significant effects on central cardiac haemodynamics. Therefore, the use of furosemide infusion in anuric ESRD patients with acute pulmonary oedema is not supported by the results of this study.

Analysis of mitral annulus motion measurements derived from M-mode, anatomic M-mode, tissue Doppler displacement, and 2-dimensional strain imaging.

BACKGROUND: Left ventricular longitudinal shortening plays an important role in cardiac contraction and can be measured by the mitral annulus motion (MAM) toward the cardiac apex. MAM can be evaluated by conventional M-mode, anatomic M-mode (AM-mode), tissue Doppler displacement (TDD), and 2-dimensional strain imaging (2DSI). OBJECTIVE: The aim of the study was to compare these 4 different methods for measuring MAM. METHODS: MAM was evaluated in 25 patients by M-mode, AM-mode, TDD, and 2DSI. Two walls (septal and lateral) in apical 4-chamber view were analyzed. RESULTS: The angle correction between M-mode and AM-mode was significantly higher in the lateral wall (septum 2.2 +/- 1.6 vs lateral 4.1 +/- 1.6 degrees, P < 0.01). However, with angle correction up to 8 degrees, the measurements obtained were not significantly different from those obtained by M-mode. No significant differences were found among 2DSI, M-mode, and AM-mode either, although all of them were significantly higher in comparison with TDD measurements in both septal (M-mode [11.0 +/- 2.4 mm], AM-mode [11.8 +/- 2.4 mm], 2DSI [11.0 +/- 3.4 mm] vs TDD [9.2 +/- 3.3 mm], P < .01) and lateral (M-mode [11.9 +/- 2.3 mm], AM-mode [12.4 +/- 2.8 mm], 2DSI [10.4 +/- 3.9 mm] vs TDD [8.9 +/- 3.0 mm], P < .05) walls. The +/- 2SD variation from the mean difference in septal and lateral walls were, respectively, between: M-mode and TDD, -2.4 to 5.9 and -2.2 to 8.2 mm; M-mode and 2DSI, -5.7 to 5.7 and -5.8 to 8.7; AM-mode and TDD, -2.5 to 5.6 and -2.7 to 9.6; AM-mode and 2DSI, -5.7 to 5.87 and -5.9 to 9.8 and TDD and 2DSI, -3.2 to 6.6 and -5.3 to 8.4. CONCLUSIONS: AM-mode and M-mode measurements did not differ significantly. Despite the good correlation among all methods they were not interchangeable. TDD measurements were significantly lower than M-mode, AM-mode, and 2DSI measurements. M-mode and AM-mode are angle dependent and can, therefore, underestimate or overestimate MAM. The new method of 2DSI is promising because it tracks natural acoustic markers and is not angle dependent and, therefore, measures the true local tissue motion.