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Clinical Journal of the American... Feb 2017Given the high comorbidity in patients on hemodialysis and the complexity of the dialysis treatment, it is remarkable how rarely a life-threatening complication occurs... (Review)
Review
Given the high comorbidity in patients on hemodialysis and the complexity of the dialysis treatment, it is remarkable how rarely a life-threatening complication occurs during dialysis. The low rate of dialysis emergencies can be attributed to numerous safety features in modern dialysis machines; meticulous treatment and testing of the dialysate solution to prevent exposure to trace elements, toxins, and pathogens; adherence to detailed treatment protocols; and extensive training of dialysis staff to handle medical emergencies. Most hemodialysis emergencies can be attributed to human error. A smaller number are due to rare idiosyncratic reactions. In this review, we highlight major emergencies that may occur during hemodialysis treatments, describe their pathogenesis, offer measures to minimize them, and provide specific interventions to prevent catastrophic consequences on the rare occasions when such emergencies arise. These emergencies include dialysis disequilibrium syndrome, venous air embolism, hemolysis, venous needle dislodgement, vascular access hemorrhage, major allergic reactions to the dialyzer or treatment medications, and disruption or contamination of the dialysis water system. Finally, we describe root cause analysis after a dialysis emergency has occurred to prevent a future recurrence.
Topics: Azotemia; Embolism, Air; Emergencies; Equipment Failure; Hemolysis; Hemorrhage; Humans; Hypersensitivity; Needles; Renal Dialysis; Root Cause Analysis; Water Supply
PubMed: 27831511
DOI: 10.2215/CJN.05260516 -
International Journal of Molecular... Apr 2022Peritoneal dialysis (PD) is an efficient renal replacement therapy for patients with end-stage renal disease. Even if it ensures an outcome equivalent to hemodialysis... (Review)
Review
Peritoneal dialysis (PD) is an efficient renal replacement therapy for patients with end-stage renal disease. Even if it ensures an outcome equivalent to hemodialysis and a better quality of life, in the long-term, PD is associated with the development of peritoneal fibrosis and the consequents patient morbidity and PD technique failure. This unfavorable effect is mostly due to the bio-incompatibility of PD solution (mainly based on high glucose concentration). In the present review, we described the mechanisms and the signaling pathway that governs peritoneal fibrosis, epithelial to mesenchymal transition of mesothelial cells, and angiogenesis. Lastly, we summarize the present and future strategies for developing more biocompatible PD solutions.
Topics: Dialysis Solutions; Epithelial-Mesenchymal Transition; Humans; Peritoneal Dialysis; Peritoneal Fibrosis; Peritoneum; Quality of Life
PubMed: 35563220
DOI: 10.3390/ijms23094831 -
Renal Failure Dec 2022A significant proportion of incident and prevalent hemodialysis patients have central venous catheters for vascular access. No consensus is available on the prevention... (Review)
Review
BACKGROUND
A significant proportion of incident and prevalent hemodialysis patients have central venous catheters for vascular access. No consensus is available on the prevention of catheter dysfunction or catheter-related bloodstream infections in patients undergoing hemodialysis by means of catheter lock solutions.
METHOD
We reviewed the effects of single and combined anticoagulants with antibacterial catheter lock solutions or other antimicrobials for the prevention of thrombosis or infections in hemodialysis patients. Relative risks with 95% confidence intervals for trials of the same type of catheter locking solution were pooled.
SOURCES OF INFORMATION
We included original research articles in English from PubMed, EMBASE, SpringerLink, Elsevier and Ovid using the search terms 'hemodialysis,' 'central venous catheter,' 'locking solution,' 'UFH,' 'low molecular weight heparin,' 'EDTA,' 'citrate,' 'rt-PA,' 'urokinase,' 'gentamicin,' 'vancomycin', 'taurolidine,' 'sodium bicarbonate,' 'hypertonic saline' and 'ethanol' and 'catheter'.
FINDINGS
Low-dose heparin lock solution (< 5000 U/ml) can efficiently achieve anticoagulation and will not increase the risk of bleeding. Low-concentration citrate (< 5%) combined with rt-PA can effectively prevent catheter infection and dysfunction. Catheter-related infections may be minimized by choosing the appropriate antibiotic and dose.
LIMITATIONS
There is a lack of follow-up validation data for LMWH, EDTA, taurolidine, sodium bicarbonate, ethanol, and other lock solutions.
IMPLICATIONS
Since catheterization is common in hemodialysis units, studies on long-term treatment and preventative strategies for catheter dysfunction and catheter-related infection are warranted.
Topics: Anti-Bacterial Agents; Anticoagulants; Catheter-Related Infections; Catheterization, Central Venous; Central Venous Catheters; Citrates; Citric Acid; Edetic Acid; Heparin; Heparin, Low-Molecular-Weight; Humans; Renal Dialysis; Sodium Bicarbonate
PubMed: 36047812
DOI: 10.1080/0886022X.2022.2118068 -
Seminars in Dialysis 2013Over 383,900 individuals in the U.S. undergo maintenance hemodialysis that exposes them to water, primarily in the form of dialysate. The quality of water and associated... (Review)
Review
Over 383,900 individuals in the U.S. undergo maintenance hemodialysis that exposes them to water, primarily in the form of dialysate. The quality of water and associated dialysis solutions have been implicated in adverse patient outcomes and is therefore critical. The Association for the Advancement of Medical Instrumentation has published both standards and recommended practices that address both water and the dialyzing solutions. Some of these recommendations have been adopted into Federal Regulations by the Centers for Medicare and Medicaid Services as part of the Conditions for Coverage, which includes limits on specific contaminants within water used for dialysis, dialysate, and substitution fluids. Chemical, bacterial, and endotoxin contaminants are health threats to dialysis patients, as shown by the continued episodic nature of outbreaks since the 1960s causing at least 592 cases and 16 deaths in the U.S. The importance of the dialysis water distribution system, current standards and recommendations, acceptable monitoring methods, a review of chemical, bacterial, and endotoxin outbreaks, and infection control programs are discussed.
Topics: Female; Hemodialysis Solutions; Humans; Infection Control; Kidney Failure, Chronic; Male; Medicaid; Medicare; Patient Safety; Practice Guidelines as Topic; Quality Control; Renal Dialysis; United States; Water; Water Microbiology
PubMed: 23859187
DOI: 10.1111/sdi.12113 -
BMC Nephrology Jan 2017Haemodialysis (HD) patients suffer from an increased risk of cardiovascular disease (CVD). Skin autofluorescence (SAF) is a strong marker for CVD. SAF indirectly...
BACKGROUND
Haemodialysis (HD) patients suffer from an increased risk of cardiovascular disease (CVD). Skin autofluorescence (SAF) is a strong marker for CVD. SAF indirectly measures tissue advanced glycation end products (AGE) being cumulative metabolites of oxidative stress and cytokine-driven inflammatory reactions. The dialysates often contain glucose.
METHODS
Autofluorescence of skin and plasma (PAF) were measured in patients on HD during standard treatment (ST) with a glucose-containing dialysate (n = 24). After that the patients were switched to a glucose-free dialysate (GFD) for a 2-week period. New measurements were performed on PAF and SAF after 1 week (M1) and 2 weeks (M2) using GFD. Nonparametric paired statistical analyses were performed between each two periods.
RESULTS
SAF after HD increased non-significantly by 1.2% while when a GFD was used during HD at M1, a decrease of SAF by 5.2% (p = 0.002) was found. One week later (M2) the reduction of 1.6% after the HD was not significant (p = 0.33). PAF was significantly reduced during all HD sessions. Free and protein-bound PAF decreased similarly whether glucose containing or GFD was used. The HD resulted in a reduction of the total PAF of approximately 15%, the free compound of 20% and the protein bound of 10%. The protein bound part of PAF corresponded to approximately 56% of the total reduction. The protein bound concentrations after each HD showed the lowest value after 2 weeks using glucose-free dialysate (p < 0.05). The change in SAF could not be related to a change in PAF.
CONCLUSIONS
When changing to a GFD, SAF was reduced by HD indicating that such measure may hamper the accumulation and progression of deposits of AGEs to protein in tissue, and thereby also the development of CVD. Glucose-free dialysate needs further attention. Protein binding seems firm but not irreversible.
TRIAL REGISTRATION
ISRCTN registry: ISRCTN13837553 . Registered 16/11/2016 (retrospectively registered).
Topics: Adult; Aged; Aged, 80 and over; Biomarkers; Cardiovascular Diseases; Female; Glucose; Glycation End Products, Advanced; Hemodialysis Solutions; Humans; Male; Middle Aged; Optical Imaging; Renal Dialysis; Reproducibility of Results; Retrospective Studies; Sensitivity and Specificity; Skin
PubMed: 28056864
DOI: 10.1186/s12882-016-0418-0 -
Seminars in Nephrology Nov 2018In the United States, end-stage renal disease patients receiving hemodialysis have an exceedingly high risk of sudden cardiac death (SCD), accounting for 29% of death... (Review)
Review
In the United States, end-stage renal disease patients receiving hemodialysis have an exceedingly high risk of sudden cardiac death (SCD), accounting for 29% of death events, likely relating to their uremic milieu, recurring exposure to fluid and electrolyte fluxes, and underlying cardiovascular pathology. Furthermore, epidemiologic studies have shown that SCD events, as well as mortality and hospitalizations, occur most frequently on the first dialysis day after the long interdialytic gap, suggesting that abrupt fluctuations in the accumulation and removal of electrolytes, fluid, and uremic toxins over the dialysis cycle may be contributory. Some population-based observational studies have suggested that lower dialysate potassium concentrations appear to be associated with a heightened risk of postdialysis cardiac arrest in hemodialysis patients, although the optimal serum-to-dialysate potassium gradient remains unclear. Some observational studies have suggested that low dialysate calcium concentrations and high serum-to-dialysate calcium gradients may predispose patients to SCD. There is ongoing controversy about an association between higher dialysate bicarbonate concentrations and higher risk of cardiac arrest, likely owing to confounding by indication. Some observational studies also have shown that large interdialytic weight gains, fluid retention, and high ultrafiltration rates are linked with higher risk of SCD and mortality. However, there remains considerable controversy regarding the pros and cons of designating a specific upper ultrafiltration limit with extended treatment times as a clinical practice measure, and further studies are needed to define the optimal tools, metrics, targets, and implementation measures for volume control in the hemodialysis population. In this review, we highlight the epidemiology and pathophysiology of how specific aspects of the hemodialysis procedure may relate to the risk of SCD, as well as preventative strategies and future research directions that can address this risk.
Topics: Acid-Base Imbalance; Bicarbonates; Calcium; Death, Sudden, Cardiac; Hemodialysis Solutions; Humans; Kidney Failure, Chronic; Magnesium; Potassium; Renal Dialysis; Time Factors; Water-Electrolyte Balance
PubMed: 30413252
DOI: 10.1016/j.semnephrol.2018.08.003 -
Seminars in Interventional Radiology Jun 2009Tunneled, cuffed, double-lumen catheters are commonly used for long-term venous access in hemodialysis patients. Complications of these catheters, including...
Tunneled, cuffed, double-lumen catheters are commonly used for long-term venous access in hemodialysis patients. Complications of these catheters, including catheter-related infection, are a major cause of morbidity and resource utilization in the hemodialysis population. Treatment of catheter-related bloodstream infections includes the use of antibiotics and evaluation of the need for catheter removal or exchange. Measures to prevent catheter-related infections include use of an aseptic technique and antiseptic cleaning solution, elimination of Staphylococcus aureus nasal carriage, topical exit site application of antibiotics, use of antibiotic lock solutions, and use of catheters and cuffs coated or impregnated with antimicrobial or antiseptic agents. This review article will provide an update on the prevalence, diagnosis, treatment, and prevention of catheter-related infections in the hemodialysis population.
PubMed: 21326505
DOI: 10.1055/s-0029-1222458 -
International Journal of Nephrology and... 2018Peritoneal dialysis is an effective treatment modality for patients with end-stage renal disease. The relative use of peritoneal dialysis versus hemodialysis varies... (Review)
Review
Peritoneal dialysis is an effective treatment modality for patients with end-stage renal disease. The relative use of peritoneal dialysis versus hemodialysis varies widely by country. Data from a 2004 survey reports the percentage of patients with end-stage renal disease treated with peritoneal dialysis to be 5%-10% in economically developed regions like the US and Western Europe to as much as 75% in Mexico. This disparity is probably related to the availability and access to hemodialysis, or in some cases patient preference for peritoneal over hemodialysis. Peritoneal dialysis-related peritonitis remains the major complication and primary challenge to the long-term success of peritoneal dialysis. Fifty years ago, with the advent of the Tenckhoff catheter, patients averaged six episodes of peritonitis per year on peritoneal dialysis. In 2016, the International Society for Peritoneal Dialysis proposed a benchmark of 0.5 episodes of peritonitis per year or one episode every 2 years. Despite the marked reduction in peritonitis over time, peritonitis for the individual patient is problematic. The mortality for an episode of peritonitis is 5% and is a cofactor for mortality in another 16% of affected patients. Prevention of peritonitis and prompt and appropriate management of peritonitis is essential for the long-term success of peritoneal dialysis in all patients. In this review, challenges and solutions are addressed regarding the pathogenesis, clinical features, diagnosis, treatment, and prevention of peritoneal dialysis-related peritonitis from the viewpoint of an infectious disease physician.
PubMed: 29928142
DOI: 10.2147/IJNRD.S123618 -
Seminars in Dialysis 2011Adequate dialysis is difficult to define because we have not identified the toxic solutes that contribute most to uremic illness. Dialysis prescriptions therefore cannot...
Adequate dialysis is difficult to define because we have not identified the toxic solutes that contribute most to uremic illness. Dialysis prescriptions therefore cannot be adjusted to control the levels of these solutes. The current solution to this problem is to define an adequate dose of dialysis on the basis of fraction of urea removed from the body. This has provided a practical guide to treatment as the dialysis population has grown over the past 25 years. Indeed, a lower limit to Kt/V(urea) (or the related urea reduction ratio) is now established as a quality indicator by the Centers for Medicare and Medicaid for chronic hemodialysis patients in the United States. For the present, this urea-based standard provides a useful tool to avoid grossly inadequate dialysis. Dialysis dosing, however, based on measurement of a single, relatively nontoxic solute can provide only a very limited guide toward improved treatment. Prescriptions which have similar effects on the index solute can have widely different effects on other solutes. The dose concept discourages attempts to increase the removal of such solutes independent of the index solute. The dose concept further assumes that important solutes are produced at a constant rate relative to body size, and discourages attempts to augment dialysis treatment by reducing solute production. Identification of toxic solutes would provide a more rational basis for the prescription of dialysis and ultimately for improved treatment of patients with renal failure.
Topics: Blood Proteins; Hemodialysis Solutions; Humans; Renal Dialysis; Urea
PubMed: 21929590
DOI: 10.1111/j.1525-139X.2011.00979.x -
Seminars in Dialysis Nov 2017Homeostatic regulation of plasma osmolality (POsm) is critical for normal cellular function in humans. Arginine vasopressin (AVP) is the major hormone responsible for... (Review)
Review
Homeostatic regulation of plasma osmolality (POsm) is critical for normal cellular function in humans. Arginine vasopressin (AVP) is the major hormone responsible for the maintenance of POsm and acts to promote renal water retention in conditions of increased POsm. However, AVP also exerts pressor effects, and its release can be stimulated by the development of effective arterial blood volume depletion. Patients with end-stage renal disease on hemodialysis, particularly those with minimal or no residual renal function, have impaired ability to regulate water retention in response to AVP. While hemodialysis can assist with this task, patients are subject to relatively rapid shifts in volume and electrolytes during the procedure. This can result in the development of transient osmotic gradients that lead to the movement of water from the extracellular to the intracellular space. Hypotension may result-both as a consequence of water movement out of the intravascular compartment, but also from impaired AVP release and inadequate vascular tone. In this review, we explore the evidence for POsm changes during hemodialysis, associations with adverse outcomes, and methods to minimize the rapidity of changes in POsm in an effort to reduce patient symptoms and minimize intra-dialytic hypotension.
Topics: Blood Pressure; Hemodialysis Solutions; Humans; Hypotension; Kidney Failure, Chronic; Neurophysins; Osmolar Concentration; Protein Precursors; Renal Dialysis; Vasopressins; Water-Electrolyte Balance
PubMed: 28691402
DOI: 10.1111/sdi.12629