MRSA in Dialysis patients

Risk for Invasive MRSA Multiplied 100-Fold in

Patients

Yael Waknine



Source : Medscape



March
9, 2007 — The incidence of invasive methicillin-resistant
Staphylococcus
aureus (MRSA) is 100
times greater among dialysis patients compared with the general population,
according to the results of a study published in the March 9 issue of
the
Morbidity and Mortality Weekly
Report.




Overall
results showed that 813 (15.4%) of 5287 reported invasive MRSA cases occurred in
dialysis patients; the overall incidence was 45.2 cases per 1000 dialysis
patients compared with 0.2 to 0.4 cases per 1000 general
population.



The
majority of infections (86%) were bloodstream infections, mainly occurring in
patients with catheters (85%) or other invasive devices in place at the time;
90% required hospitalization and 17% died as
inpatients.



The
authors note that infections account for nearly 14% of deaths and represent the
second most common cause of mortality in patients with end-stage renal disease,
about 70% of whom require long-term dialysis
treatment.



Although
patients receiving hemodialysis are particularly vulnerable to vascular-access
infections, catheters have the highest risk; intermediate risk for grafts; and
the lowest risk was seen for arteriovenous fistulas. Minimizing long-term
catheter use is therefore a basic strategy for preventing related bacteremias,
including invasive MRSA infections, according to the
authors.



According
to the authors, treatment of hemodialysis-associated infections is a key factor
in the increasing prevalence of antimicrobial resistance. MRSA strains of
healthcare origin (eg, USA100) are typically multidrug resistant; 5 of the first
6 cases of vancomycin-resistant
S
aureus occurred in
patients who had received dialysis and the first was reported in a hemodialysis
patient.

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Differential Diagnosis of Pulmonary-Renal Syndrome

Differential Diagnosis of Pulmonary-Renal Syndrome



Connective tissue disease



Polymyositis or dermatomyositis

Progressive systemic sclerosis

RA

SLE

Goodpasture's syndrome



Renal disease

Idiopathic immune complex glomerulonephritis

IgA nephropathy

Rapidly progressive glomerulonephritis with heart failure



Systemic vasculitis

Behçet's syndrome

Churg-Strauss syndrome

Cryoglobulinemia

Henoch-Schönlein purpura

Microscopic polyarteritis

Wegener's granulomatosis



Other



Drugs (penicillamine)

Heart failure

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Dialysis Recommended to Prevent NSF After Gadolinium-Based Imaging in Severe Renal Failure

Source - Medscape

Caroline Cassels

January 15, 2007 (updated March 6, 2007) — Following the recent US Food and Drug Administration (FDA) warning about an association between gadolinium-based contrast agents and nephrogenic systemic fibrosis (NSF) in patients with renal failure, a team from Yale University, which includes the world's foremost authority on the rare condition, says dialysis should be aggressively used as soon as possible after magnetic resonance (MR) investigations in such patients.

Yale maintains an international NSF registry, headed by world authority on the disease, Shawn E. Cowper, MD. The registry includes records on more than 215 NSF known cases worldwide. A survey now under way reveals that more than 95% of all NSF patients surveyed (approximately 100) were exposed to a gadolinium-based contrast agent 2 to 3 months before disease onset, said Dr. Kuo

First described in 1997 and named nephrogenic fibrosing dermopathy, the condition is characterized by increased deposits of collagen in tissue that results in thickening and hardening of the skin. In turn, this restricts movement of the joints and can result in patients being confined to a wheelchair within a matter of weeks.

The condition was renamed NSF after it was discovered that, in addition to the skin, the disease could also have systemic effects and an impact on internal organs, resulting in multiorgan failure and death.

"We estimate about 97% of the time when you give an MR contrast agent to a patient with severe renal failure, which is the susceptible population, they do not develop the disease. NSF develops in only a very small minority of cases, so there truly have to be other risk factors at play, and we're working to determine what those are," he said.

In addition to a first dialysis session within 3 hours of MR investigation with gadolinium contrast and a second session within 24 hours, the Yale team's recommendations, which they are publicizing for the purposes of information sharing and not as official practice guidelines, also include the following:

• Consider alternative imaging or nonimaging modalities that can provide the requested clinical diagnostic data at a lower potential risk.
• If administration of gadolinium-based MR contrast agent is deemed necessary, use the lowest possible dose to reliably provide the diagnostic information.
• Inform patients with stage 4 (eGFR 15–30 mL/min per 1.73 m²} or 5 (eGFR <15>2)CKD of the benefits, risks, and alternatives, based on current information.
• Perform any additional nonenhanced sequences that might be helpful and monitor the study to evaluate the continuing necessity of contrast agent.
• Consider hemodialysis in patients undergoing peritoneal dialysis and possible patients with CKD stage 4 deemed at higher risk.

The most recent FDA alert, issued on December 22, 2006, reports 90 cases of the condition in patients with moderate to end-stage renal failure who developed NSF, a debilitating and potentially fatal condition, within 2 days to 18 months of receiving gadodiamide , gadoversetamide , or gadopentetate dimeglumine for magnetic resonance imaging (MRI) or magnetic resonance angiography, where gadolinium doses are commonly 3 times higher to provide detailed imaging of the vasculature.

Renal Insufficiency Following Contrast Media Administration Trial (REMEDIAL)

(Circulation. 2007;115:1211-1217.)
© 2007 American Heart Association, Inc.

Coronary Heart Disease

Carlo Briguori, MD, PhD; Flavio Airoldi, MD; Davide D’Andrea, MD; Erminio Bonizzoni, PhD; Nuccia Morici, MD; Amelia Focaccio, MD; Iassen Michev, MD; Matteo Montorfano, MD; Mauro Carlino, MD; John Cosgrave, MD; Bruno Ricciardelli, MD; Antonio Colombo, MD

From the Laboratory of Interventional Cardiology and Department of Cardiology, Clinica Mediterranea, Naples (C.B., D.D., A.F., B.R.); Laboratory of Interventional Cardiology, "Vita e Salute" University School of Medicine, San Raffaele Hospital, Milan (C.B., F.A., N.M., I.M., M.M., M.C., J.C., A.C.); and Institute of Medical Statistics and Biometry, University of Milan, Milan (E.B.), Italy.

Correspondence to Carlo Briguori, MD, PhD, Interventional Cardiology, Clinica Mediterranea, Via Orazio, 2, I-80121, Naples, Italy. E-mail briguori.carlo@hsr.it

Received December 28, 2006; accepted January 5, 2007.

Background— Volume supplementation by saline infusion combined with N-acetylcysteine (NAC) represents an effective strategy to prevent contrast agent–induced nephrotoxicity (CIN). Preliminary data support the concept that sodium bicarbonate and ascorbic acid also may be effective in preventing CIN.

Methods and Results— Three hundred twenty-six consecutive patients with chronic kidney disease, referred to our institutions for coronary and/or peripheral procedures, were randomly assigned to prophylactic administration of 0.9% saline infusion plus NAC (n=111), sodium bicarbonate infusion plus NAC (n=108), and 0.9% saline plus ascorbic acid plus NAC (n=107). All enrolled patients had serum creatinine 2.0 mg/dL and/or estimated glomerular filtration rate <40>–1 · 1.73 m^–2. Contrast nephropathy risk score was calculated in each patient. In all cases, iodixanol (an iso-osmolar, nonionic contrast agent) was administered. The primary end point was an increase of 25% in the creatinine concentration 48 hours after the procedure (CIN). The amount of contrast media administered (179±102, 169±92, and 169±94 mL, respectively; P=0.69) and risk scores (9.1±3.4, 9.5±3.6, and 9.3±3.6; P=0.21) were similar in the 3 groups. CIN occurred in 11 of 111 patients (9.9%) in the saline plus NAC group, in 2 of 108 (1.9%) in the bicarbonate plus NAC group (P=0.019 by Fisher exact test versus saline plus NAC group), and in 11 of 107 (10.3%) in the saline plus ascorbic acid plus NAC group (P=1.00 versus saline plus NAC group).

Conclusions— The strategy of volume supplementation by sodium bicarbonate plus NAC seems to be superior to the combination of normal saline with NAC alone or with the addition of ascorbic acid in preventing CIN in patients at medium to high risk.

Diuretic Use, Residual Renal Function, and Mortality Among Hemodialysis Patients in the Dialysis Outcomes and Practice Pattern Study (DOPPS)

Jennifer L. Bragg-Gresham, MS1, Rachel B. Fissell, MD, MS2, Nancy A. Mason, PharmD23, George R. Bailie, PharmD, PhD345, Brenda W. Gillespie, PhD2, Volker Wizemann, MD6, Jose Miguel Cruz, MD7, Takashi Akiba, MD, PhD8, Kiyoshi Kurokawa, MD, PhD9, Sylvia Ramirez, MD1, Eric W. Young, MD, MS210

Received 7 July 2006; accepted 11 December 2006 published online 26 January 2007.

Background

Information about residual renal function (RRF) and outcomes associated with practices of diuretic use in patients with end-stage renal disease is not available worldwide.

Methods

Diuretic use was investigated in 16,420 hemodialysis patients from the Dialysis Outcomes and Practice Patterns Study, a prospective observational study of hemodialysis patients selected from nationally representative facilities on 3 continents. Logistic regressions were used to investigate associations between diuretic use and patient characteristics. Outcomes of interdialytic weight gain, increased serum potassium and phosphorus levels, and odds of retaining RRF after 1 year were investigated. Cox regression was used to analyze the association between mortality and diuretic use.

Results

Facility diuretic use varied substantially from 0% to 83.9% of patients. Diuretic use decreased sharply after the start of dialysis therapy. Loop diuretic use ranged from 9.2% in the United States to 21.3% in Europe, whereas use within 90 days of starting dialysis therapy ranged from 25.0% in the United States to 47.6% in Japan. Diuretic use was associated with lower interdialytic weight gain and lower odds of hyperkalemia (potassium > 6.0 mmol/L). Patients with RRF on diuretic therapy had almost twice the odds of retaining RRF after 1 year in the study versus patients not on diuretic therapy. Patients administered diuretics had a 7% lower all-cause mortality risk (P = 0.12) and 14% lower cardiac-specific mortality risk (P = 0.03) versus patients not administered diuretics.

Conclusion

Variation exists in facility practices of diuretic use. In patients with RRF, there may be benefit associated with continuing diuretic use rather than automatically discontinuing diuretic therapy at dialysis initiation.

AJKD Volume 49, Issue 3, Pages 373-382 (March 07)

Simvastatin for Secondary Prevention of All-Cause Mortality and Major Coronary Events in Patients With Mild Chronic Renal Insufficiency

Michel Chonchol, MD1, Thomas Cook, MS2, John Kjekshus, MD3, Terje R. Pedersen, MD4, JoAnn Lindenfeld, MD5

Received 19 July 2006; accepted 27 November 2006 published online 20 January 2007.

Background

A potentially modifiable risk factor for cardiovascular disease in patients with mild chronic renal insufficiency is dyslipidemia. Few studies examined the effects of statins on all-cause mortality and major coronary events in patients with renal dysfunction.

Methods

We performed a post hoc analysis from the Randomized Trial of Cholesterol Lowering in 4,444 Patients with Coronary Heart Disease: The Scandinavian Simvastatin Survival Study. Of 4,444 participants, 2,314 (52.1%) had mild chronic renal insufficiency defined as an estimated glomerular filtration rate less than 75 mL/min/1.73 m2 (<1.25>

Results

During the follow-up period, simvastatin use was associated with decreased all-cause mortality (adjusted hazard ratio [HR], 0.69; confidence interval [CI], 0.54 to 0.89) in the 2,314 participants with mild chronic renal insufficiency. Rates of major coronary events (adjusted HR, 0.67; CI, 0.56 to 0.79) and coronary revascularization (adjusted HR, 0.62; CI, 0.49 to 0.77) also were significantly lower in the simvastatin group. No significant decreases in stroke incidence were observed in the simvastatin group (adjusted HR, 0.88; CI, 0.55 to 1.39). The side-effect profile was similar between the 2 treatment groups.

Conclusion

Simvastatin therapy appears to be effective and safe for the secondary prevention of all-cause mortality and major coronary events in patients with mild chronic renal dysfunction.

Clinical performance measures in CKD -MHD patients

In the Literature: On Clinical Performance Measures and Outcomes Among Hemodialysis Patients

Patrick S. Parfrey, MD, FRCP(C)

AJKD Volume 49, Issue 3, Pages 352-355 (March 2007)

Commentary on Rocco MV, Frankenfield DL, Hopson SD, McClellan WM: Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis. Ann Intern Med 14:512-519, 2006.

The incidence and prevalence of patients treated by dialysis continues to increase.1 The mortality rate of dialysis patients is high, and worse than that of many cancers.1 Therefore it is important to identify modifiable mortality risk factors, to determine whether interventions to treat these risk factors are efficacious, to develop practice guidelines on the use of efficacious interventions in practice, and to define performance measures to monitor the outcomes of treatment.

In the October 2006 issue of Annals of Internal Medicine, Rocco et al reported that attainment of multiple performance measures in dialysis patients was associated with lower mortality and hospitalization rates.2

Rocco et al2 studied 15,287 prevalent patients

clinical performance measure targets were

1. hemoglobin value of 11 g/dL (110 g/L) or greater;
   
2. serum albumin value of 4 g/dL (40 g/L) or greater or 3.7 g/dL (37 g/L) or greater (bromcresol green and bromcresol purple laboratory methods, respectively);
   
3. use of a fistula for vascular access; and
   
4. measured single-pool Kt/V urea value of 1.2 or greater.
   

In multivariable analysis, they determined whether achieving these performance measures was associated with better mortality and hospitalization rates during the next 12 months.
During the initial period,

• 6% of patients did not meet any target,
  
• 24% met 1 target,
  
• 39% met 2 targets,
  
• 24% met 3 targets, and
  
• 7% met all 4 targets

During the 12-month follow-up,

• 55% of patients were hospitalized and
  
• 20% died.
  

Patients who met all targets were more likely to be

• male,
  
• younger,
  
• of white race,
  
• of Hispanic ethnicity,
  
• have hypertension or glomerulonephritis as the cause of ESRD,
  
• have a lower body mass index, and
  
• to have received dialysis for more years;
  
• they were less likely to have diabetes mellitus and comorbid conditions (both cardiovascular and noncardiovascular).

In other words they were healthier and they were survivors.

What Should Clinicians and Researchers Do?

Of the 4 quality indicators studied by Rocco et al,2 only a higher dialysis dose has RCT evidence to support the expectations that achievement of these targets would be associated with better hard clinical outcomes.13 Thus, a clinical performance measure to achieve Kt/V > 1.2 is justified. One cannot conclude from the Rocco et al analyses that achievement of other clinical performance targets will lead to reduction in mortality and hospitalization. However achievement of some targets should be associated with other clinical benefits. RCTs demonstrate that treatment of anemia to a target hemoglobin value of 11 g/dL (110 g/L) or greater will improve quality of life and limit blood transfusions.14 It is likely that preferential use of fistulas rather than grafts should lead to better vascular access outcomes.15 Consequently quality assurance initiatives to achieve these targets can be supported. However, a serum albumin target of 4 g/dL (40g/L) as a clinical performance measure is illusory at present, as it is not currently modifiable.