[show abstract][hide abstract] ABSTRACT: Despite advances in preventive therapy, prognosis in chronic kidney disease (CKD) is still grim. Clinical cohorts of CKD patients provide a strategic resource to identify factors that drive progression in the context of clinical care and to provide a basis for improvement of outcome. The combination with biobanking, moreover, provides a resource for fundamental and translational studies. In 2007, the Dutch government initiated and funded the String of Pearls Initiative (PSI), a strategic effort to establish infrastructure for disease-based
[show abstract][hide abstract] ABSTRACT: This paper provides an endorsement of the KDIGO guideline on acute kidney injury; more specifically, on the part that concerns renal replacement therapy. New evidence that has emerged since the publication of the KDIGO guideline was taken into account, and the guideline is commented on from a European perspective. Advice is given on when to start and stop renal replacement therapy in acute kidney injury; which modalities should be preferentially be applied, and in which conditions; how to gain access to circulation; how to measure adequacy; and which dose can be recommended.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: There is ongoing controversy concerning optimum anticoagulation and buffering in continuous venovenous haemofiltration (CVVH). Regional anticoagulation with trisodium citrate also acting as a buffer in the replacement fluid has several advantages and disadvantages over prefilter citrate administration alone. We analysed a large cohort of patients with acute kidney injury (AKI) treated by the former method and hypothesized that it is safe and efficacious.
[show abstract][hide abstract] ABSTRACT: Objective
During continuous venovenous hemofiltration (CVVH) to replace renal function in acute kidney injury (AKI), anticoagulation of the filter is routinely required. A survival benefit for citrate has been reported, possibly due to reduced proinflammatory effects of the filter (bioincompatibility). We hypothesized that the type of anticoagulation modulates the immune response to, and clearance by CVVH of interleukin-6 (IL-6) and -8 (IL-8).Methods
Three anticoagulation regimens were compared: trisodium citrate (n = 17), unfractionated heparin (n = 8) and no anticoagulation in case of bleeding tendency (n = 13). Immediately before initiation of CVVH (cellulose triacetate membrane) pre-filter blood was drawn. Thereafter, at 10, 60, 180 and 720 min, samples were collected from the pre- and postfilter blood and from ultrafiltrate. IL-6 and IL-8 were determined by ELISA.ResultsHigh inlet levels of IL-6 and IL-8, particularly in the no anticoagulation group, were associated with non-survival. The inlet concentrations and mass rates of IL-6 and IL-8 decreased during CVVH. The course of fluxes across the filter were similar for the groups, however. Although increasing in time for IL-6 in the no anticoagulation group, mass removal and adsorption of IL-6 and IL-8 were low and did not differ among the anticoagulation groups.Conclusions
Blood to membrane contact, adsorption/clearance and anticoagulation do not increase nor attenuate high circulating levels of IL-6 and IL-8 during CVVH for AKI. This renders the hypothesis that the reported survival benefit for citrate anticoagulation is based on a reduction of bioincompatibility unlikely.
[show abstract][hide abstract] ABSTRACT: Background
The Beck Depression Inventory (BDI) is a standard and validated questionnaire to screen for depressive symptoms in chronic dialysis patients, but is relatively extensive to use repeatedly in clinical practice. We investigated whether the five-item Mental Health Inventory (MHI-5) of the 36-item Short-Form Health Survey Questionnaire (SF-36) could be applied to screen for depressive symptoms in dialysis patients. Moreover, we determined the optimal MHI-5 cut-off score to assess depressive symptoms.Methods
Chronic dialysis patients from three centres filled out the SF-36 and the BDI. A receiver operating characteristic (ROC) curve was constructed for the MHI-5 score with BDI ≥16 as reference standard to (i) calculate the area under the curve to determine whether the MHI-5 could be considered as a useful screening instrument for depressive symptoms and (ii) proxy the optimal cut-off score of the MHI-5 to assess depressive symptoms. The optimal cut-off score was determined by the value for which the sum of sensitivity and specificity had an optimum.ResultsOf 133 included patients, 23% had depressive symptoms as determined with BDI ≥16. The correlation of the BDI with MHI-5 was -0.64. The area under the ROC curve was 0.82 (95% confidence interval 0.74-0.90). The optimal cut-off point of the MHI-5 was 70. MHI-5 ≤70 had 77 sensitivity, 72 specificity, 44 positive predicting value and 91% negative predicting value with the presence of depressive symptoms determined with BDI ≥16.Conclusions
The MHI-5 may help clinicians to screen for depressive symptoms in dialysis patients without using an additional depression screening questionnaire once the SF-36 is completed. A cut-off value of 70 can be used safely for the purposes of screening applications.
[show abstract][hide abstract] ABSTRACT: As few data exist on treatment of peritonitis in patients on automated peritoneal dialysis (APD), and as pharmacokinetics of several antibiotics are reported to be unfavorable in APD, some favor switching to continuous ambulant PD (CAPD) while treating APD-related peritonitis. We explored whether treating peritonitis with patients continuing their usual PD modality had an effect on outcome.
We performed a retrospective analysis of the 508 episodes of PD-associated peritonitis seen in 205 patients in our center from January 1993 to January 2007. During this period, the standard initial therapy for PD-related peritonitis was a combination of intraperitoneal gentamicin and rifampicin.
There was no difference in cure rate between CAPD and APD groups. Likewise, initial and maximal leukocyte counts in the PD fluid (PDF), relapse rates, catheter removal rates, and death during treatment of peritonitis were similar in the CAPD and APD groups. Median (interquartile range) duration of elevated leukocyte count in PDF was longer in APD: 5.0 (3.0 - 9.0) days versus 4.0 (2.5 - 7.0) days in CAPD (p <0.001). APD patients were treated with antibiotics longer than CAPD patients: 16.0 (12.5 - 21.0) versus 15.0 (12.0 - 18.0) days (p = 0.036). Also, after correction for possible confounders, odds ratios for death and for the combined end point death or catheter removal showed no difference when patients treated for peritonitis stayed on their own modality.
Regarding rate of relapse, mortality, or the combined end point mortality plus catheter removal, we found no difference between CAPD and APD patients continuing their own PD modality during treatment of PD-related peritonitis. Intermediate end points such as duration of elevated PDF leukocyte count and duration of antibiotic treatment were longer in APD patients.
Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis. 01/2010; 31(1):39-47.
[show abstract][hide abstract] ABSTRACT: The combination of working in dialysis as well as in general medicine/nephrology after a good training program-along with ongoing interest in clinical research-makes it sufficiently appealing for many trainees to pursue a career in nephrology in the Netherlands.
Kidney International 08/2009; 76(6):597-8. · 7.92 Impact Factor
[show abstract][hide abstract] ABSTRACT: Over the past decade new solutions for peritoneal dialysis have been developed in an effort to reduce the bioincompatibility of conventional glucose-containing, lactate-buffered solutions, and thereby to improve the clinical outcomes of peritoneal dialysis. The new solutions contain either other non-glucose osmotic agents, such as glucose polymers or amino acids, or have a neutral pH; the buffer content is altered in some of the new solutions. In vitro and in vivo studies have shown the biocompatibility of these new solutions to be superior to that of standard solutions. In this paper, available clinical data on the use of these new solutions are reviewed. In general, the data indicate improved biocompatibility of the new solutions; a number of studies, however, detected no superiority when levels of accepted markers of biocompatibility, such as vascular endothelial growth factor or hyaluronic acid, were measured. This finding could be explained by the assumption that the new peritoneal dialysis solutions not only induce less damage to the peritoneal membrane but also better maintain repair mechanisms, which apparently are associated with enhanced release of such markers.
Nature Clinical Practice Nephrology 12/2007; 3(11):604-12. · 6.08 Impact Factor
[show abstract][hide abstract] ABSTRACT: Continuous venovenous hemofiltration (CVVH) requires anticoagulation to prevent circuit clotting and its use is contraindicated in patients with high bleeding risk. The aim of this study was to compare CVVH with and without regional citrate anticoagulation (RCA) with respect to filter life, azotemic control and cost.
This was a prospective sequential cohort study. The first cohort of patients with a high bleeding risk and acute renal failure was treated by anticoagulant-free predilution CVVH (n = 31). In the second cohort, CVVH was applied with RCA (n = 20).
The median filter life was 41 h (interquartile range 20-62) with RCA and 12 h (8-28) without RCA (p = 0.001). The azotemic control was better in the group with RCA. The hourly cost was comparable between the two groups.
Regional anticoagulation with citrate-based replacement solution improved filter life compared to anticoagulant-free predilution CVVH. This regimen appeared safe, feasible and without metabolic complications or increased costs.
[show abstract][hide abstract] ABSTRACT: Interdialytic hemodialysis catheter-locking solutions could contribute to a reduction of catheter-related complications, especially infections. However, they can cause side effects because of leakage from the tip of the catheter. Recently, trisodium citrate (TSC) has been advocated because of its antimicrobial properties and local anticoagulation. In a multicenter, double-blind, randomized, controlled trial, TSC 30% was compared with unfractionated heparin 5000 U/ml for prevention of catheter-related infections, thrombosis, and bleeding complications. The study was stopped prematurely because of a difference in catheter-related bacteremia (CRB; P < 0.01). Of 363 eligible patients, 291 could be randomized. The study included 98 tunneled cuffed catheters and 193 untunneled. There were no significant differences in patient and catheter characteristics on inclusion. In the heparin group, 46% of catheters had to be removed because of any complication compared with 28% in the TSC group (P = 0.005). CRB rates were 1.1 per 1000 catheter-days for TSC versus 4.1 in the heparin group (P < 0.001). For tunneled cuffed catheters, the risk reduction for CRB was 87% (P < 0.001) and for untunneled catheters was 64% (P = 0.05). Fewer patients died from CRB in the TSC group (0 versus 5; P = 0.028). There were no differences in catheter flow problems and thrombosis (P = 0.75). No serious adverse events were encountered. Major bleeding episodes were significantly lower in the TSC group (P = 0.010). TSC 30% improves overall patency rates and reduces catheter-related infections and major bleeding episodes for both tunneled and untunneled hemodialysis catheters. Flow problems are not reduced.
Journal of the American Society of Nephrology 09/2005; 16(9):2769-77. · 8.99 Impact Factor