An Assessment of Dialysis Provider's Attitudes towards Timing of Dialysis Initiation in Canada

Background: Physicians' perceptions and opinions may influence when to initiate dialysis. Objective: To examine providers' perspectives and opinions regarding the timing of dialysis initiation. Design: Online survey. Setting: Community and academic dialysis practices in Canada. Participants: A nationally-representative sample of dialysis providers. Measurements and Methods: Dialysis providers opinions assessing reasons to initiate dialysis at low or high eGFR. Responses were obtained using a 9-point Likert scale. Early dialysis was defined as initiation of dialysis in an individual with an eGFR greater than or equal to 10.5 ml/min/m 2 . A detailed survey was emailed to all members of the Canadian Society of Nephrology (CSN) in February 2013. The survey was designed and pre-tested to evaluate duration and ease of administration. Results: One hundred and forty one (25% response rate) physicians participated in the survey. The majority were from urban, academic centres and practiced in regionally administered renal programs. Very few respondents had a formal policy regarding the timing of dialysis initiation or formally reviewed new dialysis starts (N = 4, 3.1%). The majority of respondents were either neutral or disagreed that late compared to early dialysis initiation improved outcomes (85–88%), had a negative impact on quality of life (89%), worsened AVF or PD use (84–90%), led to sicker patients (83%) or was cost effective (61%). Fifty-seven percent of respondents felt uremic symptoms occurred earlier in patients with advancing age or co-morbid illness. Half (51.8%) of the respondents felt there was an absolute eGFR at which they would initiate dialysis in an asymptomatic patient. The majority of respondents would initiate dialysis for classic indications for dialysis, such as volume overload (90.1%) and cachexia (83.7%) however a significant number chose other factors that may lead them to early dialysis initiation including avoiding an emergency (28.4%), patient preference (21.3%) and non-compliance (8.5%). Limitations: 25% response rate. Conclusions: Although the majority of nephrologists in Canada who responded followed evidence-based practice regarding the timing of dialysis initiation, knowledge gaps and areas of clinical uncertainty exist. The implementation and evaluation of formal policies and knowledge translation activities may limit potentially unnecessary early dialysis initiation

Predictors of Peritonitis Among Canadian Peritoneal Dialysis Patients

Despite the decreasing incidence of peritoneal dialysis (PD) peritonitis over time, its occurrence is still associated with adverse outcomes. This thesis focuses on determining factors associated with PD peritonitis in order to facilitate identification of patients at risk. Using data collected in a multicentre Canadian database between 1996 and 2005, the study population comprised 4,247 incident PD patients, of whom 1,605 had at least one peritonitis episode. Variables independently associated with peritonitis included age [rate ratio (RR) 1.04 per decade increase, 95% CI 1.01-1.08], Black race (RR 1.37, 95% CI 1.00-1.88) and having transferred from hemodialysis (RR 1.24, 95% CI 1.11-1.38). There was an interaction between gender and diabetes (p=0.011), with an increased peritonitis risk only among female diabetics (RR 1.27, 95% CI 1.10-1.47). Choice of continuous ambulatory PD vs. automated PD did not influence peritonitis risk. These results contribute to our understanding of peritonitis risk among PD patients.MAS

The relationship between proton pump inhibitor use and serum magnesium concentration among hemodialysis patients: a cross-sectional study

Observational data suggest that serum magnesium (Mg) concentration is inversely related to vascular calcification and hyperparathyroidism among patients with end-stage renal disease (ESRD). In recent years, there have been several case reports of hypomagnesemia due to use of proton-pump inhibitors (PPI), with the hypomagnesemia attributed to inappropriate gastrointestinal (GI) Mg loss. We hypothesized that the tendency to GI Mg loss is more common than is currently reported. Since patients with ESRD have little to no renal Mg loss to affect serum Mg concentration, dialysis patients are an interesting population in whom to study the relationship between PPI use and serum Mg levels

Variation of High-Sensitivity Troponin T Results in Patients Undergoing Continuous Renal Replacement Therapy

Background: Cardiac troponins are the preferred biomarker to diagnose myocardial injury. Complicating the interpretation of serial troponins in patients with end-stage renal disease, it has been shown that the hemodialysis procedure results in a small but significant decline in high-sensitivity cardiac troponins (hs-cTnT). This raises the possibility that continuous renal replacement therapy (CRRT) might similarly alter cardiac troponin levels and affect their interpretation when cardiac ischemia is being considered. Objective: We sought to determine the effect of CRRT on hs-cTnT levels over time in a group of patients without active myocardial injury. Design: Prospective, observational study Setting: Single tertiary care hospital, Montreal, Quebec Patients: Ten critically ill patients with acute kidney injury (AKI) undergoing CRRT. Cardiac ICU (intensive care unit) patients and acute coronary syndrome patients were excluded from the study. The CRRT prescription was at the discretion of the treating intensivist and relatively high doses were used in this study. Measurements: The hs-cTnT levels were drawn pre-CRRT, within 6 hours of initiation, and approximately every 6 hours thereafter along with routine CRRT blood work. Methods: Changes in hs-cTnT, creatinine, and albumin levels were recorded over the course of CRRT. Mean change in serum analyte concentration and 95% confidence interval was determined for specified time intervals relative to baseline, with paired t tests used to determine statistical significance. Results: Among the 10 patients included in the study, the cause of AKI was primarily acute tubular necrosis from septic shock or hemorrhagic shock. Compared with baseline hs-cTnT levels prior to CRRT initiation, mean hs-cTnT level fell by 42% at 5 to 10 hours post-CRRT initiation, followed by a plateauing of levels for the duration of time on CRRT. Limitations: Single-center study only applicable to hs-cTnT assay. Conclusions: This study demonstrates a significant decrease in hs-cTnT within 5 to 10 hours of CRRT initiation. This suggests that interpretation of cardiac troponin changes during CRRT must take into consideration the timing of dialysis initiation relative to the time of sample collection

Apixaban Pharmacokinetics at Steady State in Hemodialysis Patients

It is unclear whether warfarin is protective or harmful in patients with ESRD and atrial fibrillation. This state of equipoise raises the question of whether alternative anticoagulants may have a therapeutic role. We aimed to determine apixaban pharmacokinetics at steady state in patients on hemodialysis. Seven patients received apixaban 2.5 mg twice daily for 8 days. Blood samples were collected before and after apixaban administration on days 1 and 8 (nondialysis days). Significant accumulation of the drug was observed between days 1 and 8 with the 2.5-mg dose. The area under the concentration-time curve from 0 to 24 hours increased from 628 to 2054 ng h/ml (P<0.001). Trough levels increased from 45 to 132 ng/ml (P<0.001). On day 9, after a 2.5-mg dose, apixaban levels were monitored hourly during dialysis. Only 4% of the drug was removed. After a 5-day washout period, five patients received 5 mg apixaban twice daily for 8 days. The area under the concentration-time curve further increased to 6045 ng h/ml (P=0.03), and trough levels increased to 218 ng/ml (P=0.03), above the 90th percentile for the 5-mg dose in patients with preserved renal function. Apixaban 2.5 mg twice daily in patients on hemodialysis resulted in drug exposure comparable with that of the standard dose (5 mg twice daily) in patients with preserved renal function and might be a reasonable alternative to warfarin for stroke prevention in patients on dialysis. Apixaban 5 mg twice daily led to supratherapeutic levels in patients on hemodialysis and should be avoided

Impact of Age on Peritonitis Risk in Peritoneal Dialysis Patients: An Era Effect

Background and objectives: Despite reductions in the frequency of peritoneal dialysis (PD)-related infectious complications over time, peritonitis and catheter infection remain important causes of morbidity and mortality. Given the increasing number of elderly patients reaching end-stage renal disease, making informed decisions about PD utilization is contingent on an understanding of the infectious complications of PD in this population. We therefore studied the impact of age on infection rates, organisms and outcomes

Predictors of Peritonitis in Patients on Peritoneal Dialysis: Results of a Large, Prospective Canadian Database

Background and objectives: Despite the decreasing incidence of peritonitis among peritoneal dialysis (PD) patients over time, its occurrence is still associated with significant morbidity and mortality. Determining factors that are associated with PD peritonitis may facilitate the identification of patients who are at risk