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S 31 Parallel Session

Title: The acutely unwell patient
Monday, September 8, 16:00 – 17:30
Omega 1

Programme of the Session

GS: Loreto Gesualdo (Italy)
Cardiovascular Risk in patients with end stage renal disease

O 58
Dialysis commencement and survival

Eva Nagy (Hungary)

O 59
Chlorhexidine gluconate containing transparent dressing and needlefree valve port for catheter patients on haemodialysis

Rabia Papila (Turkey)

O 60
Evaluation of daily activities and mobility in haemodialysis patients

Emine Unal (Turkey)

O 61
Comparison of infection frequency between haemodialysis and peritoneal dialysis among geriatric

Sevginar Senturk (Turkey)


Cardiovascular risk in patients with end stage renal disease
L. Gesualdo1
1University of Bari, Italy

Chronic kidney disease (CKD) is a worldwide public health problem, with an increased incidence in the last years.  CKD is strictly associated with the incidence of cardiovascular disease (CVD); in this setting, multiple risk factors, such as diabetes, hypertension, obesity, dyslipidemia, inflammation, oxidative stress and malnutrition, contribute to kidney disease progression.

Recent studies showed a fundamental role of nutritional management in CKD. After all, it is well established that some dietary patterns, like the Mediterranean Diet, play a protective role by controlling cardiovascular risk factors.
In this context, an active involvement of gut microbiota in the onset and/or in the progression of kidney disease is conceivable. As evidenced in other gastrointestinal and systemic diseases, also in CKD a gut microbiota dysbiosis is present. For instance, Vaziri ND et al. showed that certain families in the Bacteroidetes and Firmicutes were less prevalent in the uremic rats, especially in Lactobacillaceae and Prevotellaceae species.
On the other hand, it has been demonstrated that in CKD patients a compensatory mechanism occurs, as a consequence of nephrons failure. This mechanism, aimed at the elimination of waste products and the preservation of electrolytes, involves the colon as a replacement excretion system. A massive urea discharge and uric acid and oxalate epithelial secretion occurs, altering colonic microenvironment and subsequently affecting the gut microbial population.
In addition to microbiota modelling in CKD, other studies have reported that hemodialysis patients, as compared with control subjects, have a significantly minor dietary fibres intake, an important source of fermentable carbohydrates in the colon. Moreover, in these patients, an altered protein assimilation in the small intestine, with the consequent increase in abundance of dietary protein bio-availability in the colon has been observed. This leads to a decreased amount of available carbohydrate in the large intestine, favouring a switch from a saccharolytic to a proteolytic catabolism. In this context, bacteria hydrolyze urea, carrying to high ammonia concentration and alkaline pH, which in turn favours proteolytic species proliferation.
Protein fermentation leads to the generation of different waste metabolites, such as phenols and indoles, mainly represented by p-cresol and indoxyl sulphate, which are known as the main uremic toxins found in CKD patients and promoting disease progression. In fact, the administration of indoxyl sulphate in uremic rats induced the renal expression of genes related to tubulointerstitial fibrosis, such as TGF-beta 1, tissue inhibitor of metalloproteinase, and pro-alpha 1 collagen.
Besides being involved in merely metabolic processes in health and disease, microbiota could also explain inflammatory and oxidative co-morbidities found in CKD.  Uremia per se alters the intestinal barrier integrity, inducing an increase in intestinal permeability, probably by colonic epithelial tight-junction disruption. The increased intestinal permeability allows bacterial translocation, which is responsible for endotoxemia. In detail, endotoxin is a potent immune system activator which induces the inflammatory cascade and leads to systemic, low-grade inflammation in CKD patients.

1) Montemurno E, Cosola C, Dalfino G, Daidone G, Deangelis M, Gobetti M, Gesualdo L: What would you like to eat Mr CKD microbiota? A mediterranean diet, please! Kidney Blood Press Res 2014;39:114-123
2) Ruiz-Canela M, Martinez-Gonzalez MA: Lifestyle and dietary risk factors for peripheral artery disease. Circ J 2014;78:553-559.
3) Vaziri ND, Yuan J, Rahimi A, Ni Z, Said H, Subramanian VS: Disintegration of colonic epithelial tight junction in uremia: a likely cause of CKD-associated inflammation. Nephrol Dial Transplant 2012;27:2686-2693.
4) Zhang Q-L, Rothenbacher D: Prevalence of chronic kidney disease in population-based studies: Systematic review. BMC Public Health 2008; 8:117.


O 58
Dialysis commencement and survival

E. Nagy1, T. Csitkovics Toth1, I. Szakacs1, I. Kulcsar1,2
1B. Braun Avitum Hungary cPlc. Dialysis Centre No. 6, Szombathely, Hungary;
21st Department of Medicine , Markusovszky Teaching Hospital, Szombathely, Hungary

Background: The ratio of patients entering a planned dialysis (HD) programme is decreasing year on year.
Objectives:To investigate the 91-day versus the 1-year survival between patients entering either the planned or the emergency haemodialysis (HD) programme.
Methods: During the past 6 years (2008-2013) a total of 524 CKD stage 5 patients entered the chronic dialysis programme in our dialysis centre (439 HD, 85 PD).
Results:Dialysis was initiated as a planned procedure in only 216 patients (85 to PD, 131 received HD).  In 308 patients (70%) - HD was started as an emergency treatment using temporary venous access.  Only 61.5% of all patients survived up to day 91 (85.2% of those starting electively and only 44.8% of those starting as an emergency).
The difference was essentially attributable to the HD programme where 82.4% of patients starting via planned dialysis, and only 41.2% of those starting via the emergency route, reached 3-months survival.
The 1-year survival rate of patients starting a planned programme only slightly changed (82.9%), while among the patients starting their dialysis in a non-planned way only 27.6% reached 1-year survival.
Conclusion/Application to practice: The survival of patients requiring dialysis treatment is influenced by numerous factors.  Whether CKD patients start a dialysis programme in an elective or an emergency manner has critical importance in their survival.  The fate of patients is mostly decided in the first 3-months.  The 1-year survival data shows a further pronounced decrease for patients who start dialysis treatment in a non-planned manner.

Disclosure: No conflict of interest declared

O 59
Chlorhexidine gluconate containing transparent dressing and needle-free valve port for catheter patients on haemodialysis

R. Papila1, T. Akyurek2, O. Yazici3, F. Yuksel4, V. Cakar5, C. Sayan6, L. Norcinli6, F. Kircelli1,  E. Unal1
1NephroCare, Fresenius Medical Care, Istanbul, Turkey; 2Sisli Dialysis Center, Fresenius Medical Care, Istanbul, Turkey; 3Atasehir Dialysis Center, Fresenius Medical Care, Istanbul, Turkey; 4Sakarya Education and Research, Hospital Dialysis Center, Istanbul, Turkey; 53M, Istanbul, Turkey; 6Haseki Dialysis Center, Fresenius Medical Care, Istanbul, Turkey

Background: Use of an aseptic technique for catheter exit site care is very important for infection control and has been shown to contribute to improved patient survival in haemodialysis patients with catheters. However, this technique is costly and causes additional work.
Objectives: To evaluate the effects of transparent dressing with chlorhexidine gluconate (i.e. conventional) and needle-free valve port application (i.e. modified dressing regimen-MDR) on catheter-related bacteraemia and nursing workload in haemodialysis patients.
Methods: 56 haemodialysis patients with a permanent central catheter from 5 dialysis centres were included in this prospective observational study. 22 patients (average age: 62.2 ± 11.3 years) received MDR and 34 patients (average age: 61.9 ± 11.8 years)the conventional method. The distribution of diabetics and gender was similar in both groups. Nurses and patients were surveyed by means of questionnaires about the dressing regimen (at baseline and at 4 weeks).
Evaluation of the questionnaires revealed the following effects for MDR vs. the conventional regimen:
-      No difference in the occurrence of bacteraemia
-      A trend (without statistical significance) for less redness, leakage, pain around catheter entry site and itching
-      The mean time for haemodialysis connection was 3.47 ± 1.03 vs. 7.68 ± 0.81 min and disconnection 4.14 ± 0.71 vs. 7.44 ± 2.17 min.
These statistically significant reductions in connection and disconnection times have been associated with an increased patient and nurse satisfaction.
Conclusion/Application to practice: While both methods provided similar bacteraemia control, modified regimen was associated with significantly less extra work load and with increased nurse and patient satisfaction.

Disclosure: No conflict of interest declared

O 60

Evaluation of daily activities and mobility in haemodialysis patients
C. Sayan1, E. Yada2, S. Meryem Sahin3, K. Demir3, A. Gozkonan3, F. Kircelli4, E. Ok4, N. Can4,  R. Papila4, E. Unal4
1RTS Avrupa Dialysis Centre, Fresenius Medical Care, Istanbul, Turkey; 2Avcilar 2 Dialysis Centre, Fresenius Medical Care, Istanbul, Turkey; 3Haseki Dialysis Centre, Fresenius Medical Care, Istanbul, Turkey; 4NephroCare Head Quarter, Fresenius Medical Care, Istanbul, Turkey

Background: Dependency profiles of Turkish haemodialysis patients are unknown. It can only be hypothesized that identifying dependency profiles of haemodialysis patients in a unit/organization and developing a strategic plan on the basis of the results may not only improve the quality of care but also efficiency of nursing care.
Objectives:To identify the dependency profile of a large group of haemodialysis patients to customize patient care accordingly.
Methods: We evaluate the patients’ level of dependency using the Modified Barthel Index (a validated method to evaluate 10 items, e.g. personal hygiene, bathing, feeding, toilet use, climbing stairs, dressing, bowel and bladder control, ambulation or wheelchair, chair/bed transfer). It measures patients’ activities of daily living and mobility. In this study, the responsible head-nurse applied the Barthel Index to 4,046 haemodialysis patients from 34 dialysis units.
Results:Mean dependency score was 90.1±19.7: 2.6% had total dependency (n=105), 4.8% severe (n=194), 7.4% moderate (n=301), 9.2% mild (n=372), and 12.8% minimal dependency (n=519). 63.1% were fully independent (n=2,555). This corresponded to 14.8% of the haemodialysis patients having a level of dependency above moderate. In adjusted models, age, haemodialysis duration, serum albumin, and creatinine levels, diabetic status, vascular access type, interdialytic weight gain, URR, effective blood flow rate were associated with the level of dependency.
Conclusion/Application to practice: By adding dependency data to absolute patient numbers, the workload of the staff can be adjusted to the patients’ individual needs, clinical care improved, and the work pressure of the staff reduced.

Disclosure: No conflict of interest declared

O 61
Comparison of infection frequency between hemodialysis and peritoneal dialysis among geriatric patients

S. Senturk1, C. Alparslan2, M. Tanrisev3, E. Uguztemur3
1Peritoneal Dialysis , Tepecik Training and Research Hospital, Izmir, Turkey; 2Pediatrics, Tepecik Training and Research Hospital, Izmir, Turkey; 3Nephrology, Tepecik Training and Research Hospital, Izmir, Turkey

Background: With the increase in the elderly population the numbers of elderly people requiring RRT has increased. The preferred modality for this group is haemodialysis. Mortality in this group is due to infection. In the literature, data about infection rates between HD and PD patients of this group is limited. In elderly patients the possibility of infections related to PD does not preclude them from choosing PD as a dialysis option.In this study, our aim was to determine infection frequency and related risk factors between HD and PD in this population group over a 1-year peroid.
Methods:This study, across a number of renal centres, focused on geriatric patients, who were on PD and HD from January 2012 to December 2013. Information, both demographic and medical was recorded  using  a standard form in each center. All data was transferred to IBM SPSS 20.0 software(SPSS, Chicago,Illinois USA) and chi-square and student t-test were performed.A p-value<0.05 was considered as significant.
Results: 148 patients participated in this study. The mean age was 72.41±5.41years.Diabetes mellitus was the primary cause of kidney disease (in62 patients,41.9).There were  no any additional co-morbidity in 41patients (27.7%).The numbers on HD and PD was equal. Infection frequency in PD and HD over a one year period was; 30 patients(40.5%) and in 29 patients (39.2%) (p=0.028),respectively.Peritonitis was the leading cause of infection(in12 patients,16.2%) in PD. In HD catheter related infection was the most common cause (in10patients,13.6%).There was no difference determined in laboratory features of patients.
Conclusion/Application to practice:In our study,our results showed there was little difference between PD and HD in geriatric patients.Decisions about which type of RRT should be made by the clinican in consultation with the patient and caregiver/family member.

Disclosure: No conflict of interest declared

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