renal replacement therapy

Background: Haemodialysis is the commonest method of Renal Replacement Therapy in Nigeria. Despite an advancement in the technicality and better understanding of haemodialysis, a number of complications are known to be associated with this procedure.. Objective: We aimed to highlight our experiences and share some of the uncommon complications encountered during haemodialysis and present the outcome of our patients. Subjects and methods: A retrospective review of 101 patients during the last two years was done. Data extracted include: sociodemographic characteristic, aetiology of kidney disease, type of vascular access, intradialytic complication and outcome of treatment. Results: The total number of dialysis session during the period was 823. Males constituted a higher proportion (64.4%) and were found to be older than female patients 49.8 vs 42.8 years (P=0.001). Majority (89.1%) had chronic kidney disease while chronic glomerulonephritis was the main cause of CKD as seen in about 45% of the patient. Due to the cost implication, only 2(1.98%) were able to undergo 3 sessions of dialysis per week for up to 1 month. Vascular access was femoral (66.3%), internal jugular vein (25.7%), while only 2% used Artero-venous-fistula and one patient had femoral vessel pseudoaneurysm from frequent cannulation. The commonest complication was hypotension which was present in 15.8%. Twenty-eight deaths were recorded, 44(43%) were either lost to follow up or absconded while 5% were transplanted at a referral centre. Conclusion: Challenges of renal replacement therapy is overwhelming in our country due to poor human and financial resources. Early diagnosis and adequate government support are advocated.

Introduction: Acute kidney injury (AKI) is one of the complications associated with severe COVID-19 infection, and it can present in up to 20% to 40% of the cases; of these, approximately 20% will require renal replacement therapy (RRT). Objective: To establish clinical and laboratory characteristics in a group of patients from Colombia with COVID-19 infection and AKI that received intermittent and prolonged RRT with the GENIUS® 90 technology in between March and July 2020. Design: Cross-sectional study. Results: 78.9% of participants were men and 21.1% were women. The main comorbidities were the following: Hypertension (65.3%), diabetes mellitus (38.9%), obesity (26.3%), cancer (5.3%), Chronic obstructive pulmonary disease (11.6%), cardiovascular disease (23.2%), active smoking (11.6%). 33.7% had chronic kidney disease (CKD) in the average serum creatinine on admission was 4.4 mg/dl. The following inflammatory markers were elevated: C-reactive protein (CRP), d-dimer and ferritin (20.3 mg/dl, 931mcg/l and 1174 ng/ml, respectively). 63.5% of patients underwent sustained low-efficiency dialysis (SLED) (6 to 12 hours) and the rest of the patients (36.35%) underwent conventional hemodialysis (less than 4 hours). The mortality of the total patient sample was 36.9%, lower in patients with CKD than in patients with no previous renal disease history (18.7% and 40.1%, respectively). Conclusion: Renal complications are frequent in patients with severe COVID-19. The development of AKI could be an isolated prognostic marker associated with an increase in mortality in patients with COVID-19, and one of the options is intermittent and prolonged RRT with the GENIUS® 90 system.

Severe Acute Kidney Injury (AKI) is a common, serious problem affecting critically ill children that lacks effective treatment options. Currently, there are no treatment options for AKI other than supportive care. Continuous renal replacement therapy (CRRT) is employed to reduce Fluid Overload (FO) burden and treat metabolic disturbances in AKI. Identifying patients upon admission who may require CRRT has potential clinical care implications. The aim of this study was to determine if the RAI had diagnostic capabilities to identify patients who would require CRRT. The analytic cohort consisted of patients who required CRRT and illness severity score matched controls who did not require CRRT at a single center. Patients who required CRRT had higher mortality rates, length of stay, and use of ventilatory and inotropic support. Sensitivity, specificity and area under the receiver operating characteristic curve (AUC) assessed and compared the discriminatory accuracy of three scores: 1) the renal angina index (RAI), 2) serum-creatinine (sCr) based AKI on day 0 and 3) modified RAI created with an additional RAI injury tranche that corresponded to severe stage 3 AKI sCr elevation. Compared to Day0AKI (AUC 0.78, 0.70-0.87; sensitivity 0.63, 0.45-0.79; specificity 0.93, 0.870.97) and RAI (AUC 0.76, 0.69-0.82; sensitivity 0.94, 0.81-0.99; specificity 0.57, 0.47-0.66), the modified RAI had the highest AUC (0.79; 0.72-0.85) with a high sensitivity (0.91; 0.77-0.98) and moderate specificity (0.65; 0.56-0.75) for prediction of CRRT requirements. As a more accurate tool for discriminating patients in need of CRRT, a modified RAI has numerous potential implications. Identifying patients who ultimately require CRRT at an earlier timepoint may influence timing of CRRT initiation in an attempt to avoid further FO, or may influence nephrotoxin administration. The diagnostic capabilities of the modified RAI may be refined by the addition of urinary biomarkers. These findings should be validated in a larger cohort.

In Portugal, around 2500 patients with end-stage chronic kidney disease (CKD stage 5) start a renal replacement therapy (RRT) for the first time each year [1]. They have four main treatment options: kidney transplantation (TX); haemodialysis (HD); peritoneal dialysis (PD) and conservative treatment (CT). RRT selection is quite complex due to the specificities of each option and to their profound effect on patient’s quality of life. Patients must play a decisive role in the choice of treatment modality and select the option that best suits to their values and needs.

Acute Kidney Injury (AKI) is defined as an abrupt decrease in kidney function within hours to days and is caused by multiple factors. Community-acquired AKI (CA-AKI) is common in developing countries, and it is crucial to bring awareness about its epidemiology and simple preventive strategies that can tackle this potentially serious complication. Infections, use of over-the-counter medicines, traditional herbal remedies, animal (and insect) bites, and pregnancy-related complications are common causes of CA-AKI in developing countries. The incidence of vector-borne disease-related AKI and obstetric causes of AKI have decreased following better public health policies in most developing countries. Appropriate fluid management is critical in AKI, both in terms of prevention of development and progression of AKI. Timely initiation and de-escalation of fluid therapy are both equally important. Kidney replacement therapy (KRT) is indicated when AKI progresses to stage 3 and/or patients develop refractory fluid overload or electrolyte imbalances and/or uremic complications. Hemodialysis is the most common modality of KRT in adults, whereas peritoneal dialysis is the dominant modality in small children. Convective renal replacement therapy, such as hemofiltration, is increasingly used in critically sick patients with AKI and hemodynamic instability. To summarize, CA-AKI is a common, serious, and often preventable complication of certain conditions acquired in the community, and is, therefore, a matter of utmost concern from the public health perspective. 

Hemodialysis catheter placement, particularly Internal Jugular Catheter insertion, is a very common procedure for patients who require urgent access to renal replacement therapy. Most of these procedures are done under ultrasound guidance as recommended by KDIGO 2019 vascular access guidelines. However, catheter tip misplacement can still occur even in the experts’ hands and despite the use of ultrasound. In this case report, we will discuss a hemodialysis catheter tip placement in the right internal mammary vein and how we managed it.

Cognitive impairment (CI) can be defined as a clinical syndrome characterized by a decline in at least two of several domains of cognitive function. Chronic kidney disease (CKD) is an independent risk factor for cognitive decline, and the prevalence in patients with end-stage renal disease is estimated at 50% - 80%. However, it appears that CI in patients on renal replacement therapy (RRT) may be underdiagnosed. In this cross-sectional study, 33 patients on Peritoneal Dialysis from the AOU Federico II were recruited, and matched by sex, age, and dialysis age to 33 patients on Hemodialysis and 33 controls belonging to healthy volunteers. The total 66 patients and their 33 controls were assessed for cognitive function using the Cognitive Reserve Index Questionnaire (CRIq) test. Between PD and HD patients, a statistically significant difference emerged in all subscores and in the total CRI. Between PD patients and controls, a statistically significant difference emerged in education, CRI- CRI-leisure time, and the total CRI. Therefore, CI may occur in patients undergoing PD earlier and with a greater frequency than in the general population, but with a lower incidence than in patients on HD. These considerations should be communicated to patients when they are educated about different replacement methods.

Peritoneal dialysis (PD) is a well-tolerated home renal replacement therapy for patients with end-stage renal disease. One of the critical points for the success of a PD program is the care of the peritoneal catheter and the exit site. A target for the incidence of infections/year should not exceed 0,40. The aim of the study was to observe whether our exit-site cleansing and dressing method, which involves the application of silver-releasing dressing may be associated with a reduction in the incidence of exit-site infections compared to the data reported in the literature.The data of 51 patients attending the Peritoneal Dialysis DH of the AOU Federico II in Naples in the period between July 2021 and September 2023 were analyzed.Overall, 27670 catheter days were analyzed with an average incidence of 0.23 infections/year/patient. The average incidence (0.23) is lower than the target suggested by the ISPD (0.4 infections/year/patient) and the average estimated in the USA (0.5-0.6 infections/year/patient). The average incidence from 2021 to 2023, equal to 0.23 episodes/year/patient, is therefore lower than the incidence of 2014-2015 (0.38 episodes/year/patient), a two-year period in which we did not use dressings with silver Exit-Pad.The use of Exit-Pad silver ion-releasing dressings Ag may further hinder the development of such infections by reducing the failure of peritoneal treatment and the transition to hemodialysis.

Double-Positive Patients (DPPs), characterized by the simultaneous presence of Anti-Neutrophil Cytoplasmic Antibody (ANCA) and anti-Glomerular Basement Membrane (anti-GBM) antibodies, represent a rare subset in systemic vasculitis. We present two cases of DPPs with renal involvement and review the existing literature to elucidate the clinical characteristics, histopathological findings, management strategies, and prognostic outcomes associated with this condition. Both cases exhibited renal involvement with rapidly progressive glomerulonephritis, requiring renal replacement therapy. Renal biopsies confirmed crescentic glomerulonephritis with features of both anti-GBM disease and ANCA-associated vasculitis. Management included high-dose glucocorticoids, cyclophosphamide, and consideration of plasma exchanges. Double-positive ANCA and anti-GBM vasculitis pose challenges in management and prognosis. Further research is essential to improve therapeutic strategies for this rare and heterogeneous condition.