Calcific Uremic Arteriolopathy in Peritoneal Dialysis Populations

Calciphylaxis or calcific uremic arteriolopathy is an infrequent complication of end stage kidney disease. It is characterized by arteriolar medial calcification, thrombotic cutaneous ischemia, tissue necrosis often leading to ulceration, secondary infection and increased mortality rates. Current, multimodality treatment involves local wound care, well-controlled calcium, phosphate and parathyroid hormone levels and combination therapy with sodium thiosulfate and hyperbaric oxygen therapy. This combination therapy may be changing the historically poor prognosis of calcific uremic arteriolopathy reported in the literature. Peritoneal dialysis is considered a risk factor based on limited publications, however this remains to be proven. Clinical presentation, diagnosis, pathogenesis and treatment of calcific uremic arteriolopathy in these patients are no different from other patients manifesting with this condition

Comparison of markers of oxidative stress, inflammation and arterial stiffness between incident hemodialysis and peritoneal dialysis patients – an observational study

Background: Patients on peritoneal and hemodialysis have accelerated atherosclerosis associated with an increase in cardiovascular morbidity and mortality. The atherosclerosis is associated with increased arterial stiffness, endothelial dysfunction and elevated oxidative stress and inflammation. The aims of this study are to investigate the effects of peritoneal and hemodialysis on arterial stiffness, vascular function, myocardial structure and function, oxidative stress and inflammation in incident patients with end stage kidney disease

Stability of antibiotics for intraperitoneal administration in extraneal 7.5% icodextrin peritoneal dialysis bags (stab study)

Background and objectives: Patients with peritoneal dialysis (PD)-associated peritonitis may be advised to store PD-bags with pre-mixed antibiotics at home, although there is a paucity of antibiotic stability studies in the commonly used icodextrin solutions. The purpose of this study was to assess the stability of various antibiotics in PD-bags when stored at different temperatures over a 14-day period

A feasibility study to track the last 12 months of life in chronic kidney disease patients: Baseline characteristics

Background Chronic kidney disease (CKD) is associated with a high symptom burden and reduced quality of life particularly in individuals who are in their final year of life. A palliative care approach that targets symptom burden would benefit many patients but few collaborative renal/palliative care services exist. Aim To track the experiences and health service utilisation of people with CKD over the last 12 months of life. Methods A longitudinal, prospective design was used to follow 19 patients attending a renal service without a formal collaborative renal/palliative care approach. Inclusion criteria were age ≥18 years, CKD stages 3-5, prognosis <12 months (using “surprise question”) and cognitively sound. Measures included modified dialysis symptom index (31 symptoms; prevalence, frequency, severity and distress), Australian Karnofsky Performance Scale scores (AKPS), and if known to a palliative care service (PCS). Results Baseline characteristics were: median age 78 years (range 42 - 90); male (n=12); CKD stages 4 (n=4) and 5 (n=15); 9 non-dialysis and 10 haemodialysis; and median AKPS score was 60 (range 40-70). The most prevalent symptoms were lack of energy (n=15, 98.95%), dry mouth (n=13, 68.42%) and dry skin (n=13, 68.42%). Lack of energy and sleep problems were the most severe and distressing symptoms. At baseline only two participants were actively engaged with a PCS. Conclusion Ascertaining changes over time in symptom burden and functionality will assist with targeting the level and type of services needed along the end-of-life trajectory in CKD, and to ensure timely and appropriate renal and palliative care is provided

Tracking patients with advanced kidney disease in the last 12 months of life

There is increasing recognition of the clinical need for timely and coordinated supportive and palliative care for those with terminal organ failure.To describe symptoms, quality of life and supportive care needs in the anticipated 12-month period prior to death in adults with chronic kidney disease (CKD) stages 4 or 5.An observational, prospective, longitudinal design was used to follow 19 patients. The measures used were the Chronic Kidney Disease-Symptom Burden Index (CKD-SBI), the Australian Karnofsky Performance Scale (AKPS), the Functional Assessment of Chronic illness Therapy Palliative-14 (FACIT PAL-14), the Assessment of Quality of Life 6 Dimensions (AQoL-6D) and the Sheffield Profile for Assessment and Referral for Care (SPARC). Data were collected at study entry and three monthly until death or study end.Patients' median age was 78 years (range 42-90), most were male (63%), 10 were receiving dialysis and seven died during the study. The most prevalent symptoms reported differed from those that were most troublesome. The median AKPS score did not change over time (60). Quality of life remained steady over time [FACIT-PAL median range: 43.5-46; AQoL-6D means range: 0.66 (SD 0.19) to 0.75 (SD 0.2)]. Supportive care needs were few.We found a substantial symptom burden and slow functional decline in this group of patients. Regular assessment of both symptoms and QOL is warranted particularly if clinical experience indicates that the person is likely to be in their last year of life. Integrated supportive care programmes could assist with easing symptom burden during this time

Health service utilisation during the last year of life: a prospective, longitudinal study of the pathways of patients with chronic kidney disease stages 3-5

Chronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries' populations. Providing appropriate palliative care services (PCS) to those with advanced kidney disease is becoming paramount. Palliative/supportive care alongside usual CKD clinical treatment is gaining acceptance in nephrology services although the collaboration with and use of PCS is not consistent.The goal of this study was to track and quantify the health service utilisation of people with CKD stages 3-5 over the last 12\ua0months of life. Patients were recruited from a kidney health service (Queensland, Australia) for this prospective, longitudinal study. Data were collected for 12\ua0months (or until death, whichever was sooner) during 2015-17 from administrative health sources. Emergency department presentations (EDP) and inpatient admissions (IPA) (collectively referred to as critical events) were reviewed by two Nephrologists to gauge if the events were avoidable.Participants (n\ua0= 19) with a median age of 78\ua0years (range 42-90), were mostly male (63%), 79% had CKD stage 5, and were heavy users of health services during the study period. Fifteen patients (79%) collectively recorded 44 EDP; 61% occurred after-hours, 91% were triaged as imminently and potentially life-threatening and 73% were admitted. Seventy-four IPA were collectively recorded across 16 patients (84%); 14% occurred on weekends or public holidays. Median length of stay was 3\ua0days (range 1-29). The median number of EDP and IPA per patient was 1 and 2 (range 0-12 and 0-20) respectively. The most common trigger to both EDP (30%) and IPA (15%) was respiratory distress. By study end 37% of patients died, 63% were known to PCS and 11% rejected a referral to a PCS. All critical events were deemed unavoidable.Few patients avoided using acute health care services in a 12\ua0month period, highlighting the high service needs of this cohort throughout the long, slow decline of CKD. Proactive end-of-life care earlier in the disease trajectory through integrating renal and palliative care teams may avoid acute presentations to hospital through better symptom management and planned care pathways