1ST POSTING: ---------- EPIDEMIOLOGY AND PATHOPHYSIOLOGY

Posting: EPIDEMIOLOGY
By: Dyad2: Gil Legarda/ Joanalyn Balino


ESRD patients in 2004: global overview of patient numbers, treatment modalities and associated trends
By: Aileen Grassmann, Simona Gioberge, Stefan Moeller and Gail Brown


This research study is carried out in a descriptive correlational research design and used a survey tool written in English to study the differences between treatment modalities and associated trends among the 122 countries. This type of research design for data collection and generation will allow for the exploration in the different treatment modalities for ESRD patients. PURPOSE: In order to facilitate effective future planning by healthcare authorities, reliable and up-to-date information on ESRD patient numbers, provide a base for comparison between specified patient populations and an understanding of treatment practices and policies and their implications for the well-being of those undergoing treatment for ESRD. The number of participants involved in this study came from the 122 countries selected by the Fresineus Medical Care with a total of 5.9 Billion which represents the 92% of the total world population. All of the countries with Established dialysis programmes by the Fresinius Medical Care were selected in this study. The Country demographic and economic data were sourced from publicly available and internationally recognized sources and inserted in the forms before distribution. It was conducted at the end of each calendar year focused on the total number of patients treated for ESRD, the treatment modality selected, products used, treatment location and ESRD patient care structure and funding. The settings of this study were in the 122 countries by which the Fresinius Medical Care has an establishment of their dialysis programmes. The researcher used a questionnaire prepared in English and in other cases is in the relevant local language which are distributed to professionals in the field of renal who are in a position to insert ESRD-relevant country. The results are validated centrally by means of cross-reference with the most recent sources of national End Stage Renal Disease information and the result of earlier surveys performed over the past previous years. In addition, responses were subjected to a validation procedure, in which input fields with significant information are linked and checked for consistency. All information gathered was consolidated at different regional levels within the database and validation checks were repeated for groups of countries There were some 1 783 000 people worldwide undergoing treatment for ESRD at the end of 2004. 1 371 000 (77%) were on dialysis treatment and 412 000 (23%) were undergoing renal transplant. The limitation of this research report is only for those ESRD patients only and for those dialysis centres and hospitals with establishments of dialysis programmes by the Fresinius Medical Care.

Compared to year 2003 the total numbers of treated ESRD patients, dialysis and transplant patients each increased by 6 to 7 percent. The result of global average prevalence values for treated ESRD, dialysis and transplant patients were 280, 215 and 65. The prevalence shows significant variation between the designated regions. Remarkably, the average prevalence of both treated ESRD and dialysis in the Europe was lower than in North America and Japan. In totting up, substantial intra-regional variations were reported.

In this research shows a prognosis that ESRD patients will continuously grow and can reached up to 2 million in the year 2010. Also the geographic distribution of ESRD patients in each country will also change. The economic growth of a country is also one of the basis that can affect the increasing number of ESRD patients. The preference of the patients in having a high-flux or low



Reference:

Grassman A. et al. (2005). ESRD patients in 2004: global overview of patient numbers, treatment modalities and associated trends. Journal of the American Society of Nephrology Vol. 20 pages 2587–2593.





Posting: PATHOPHYSIOLOGY
By: Dyad 2: Gil Legarda/ Joanalyn Balino

Nephrotic Ascities: an analysis of 16 cases and review of literature
By: Elloumi H, Arfoui D, Zayane A, Ajmi S.

When your kidneys are permanently failed to work that is End stage renal disease. Hemorrhage, weakness, fatigue, rash, muscle cramps, poor appetite, severe vomiting, fever, diarrhea or bloody diarrhea, abdominal pain, oliguria or polyuria, swelling of the tissues, history of recent infection, and detectable abdominal mass. Blood test that determines blood cell counts, electrolyte level and kidney functions; urine test; chest-x-ray (diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film); renal Ultrasound which is a non-invasive test in which a transducer is passed over the kidney producing sound waves. Those diagnostic procedure can dtect End Stage Renal Disease.

A clinical diagnosis which is a refractory ascites in patients with end-stage renal disease is Neprogenic ascites. The cause of ascites formation is unknown. Moderate to massive ascites and cachexia are frequently present to patients. The ascetic fluid is an exudates. In order to come-up with a diagnosis they need to exclude the other causes of exudative ascites. The effective ways in controlling the ascites formation are continuous ambulatory peritoneal dialysis and renal transplantation. The prognosis is dismal. 138 Patients reported in the literature to have had ascites associated with end-stage renal disease in which their characteristics, clinical outcomes, and proposed pathophysiologic mechanisms were being reviewed. The contributing mechanisms include fluid overload, hypoprotenuria, peritoneal membrane changes which is not necessarily related to peritoneal dialysis, and lymphatic drainage disturbances. Extensive evaluations could reveal an underlying disease in 15% of cases. Kidney transplantation is the most effective.

Peritoneal Dialysis is one of the two types of dialysis to eliminate the waste products that build up in the blood when the kidneys are not able to function. Kidneys become unable to carry workload of fluid balance in the body which the kidneys most important function then becomes ineffective or ceases completely.


References:

Elloumi H, Arfaoui D, Zayane A, Ajmi S. (2002) Nephrologic Acities, An analysis of 16 cases and review of the literature. Medicine Baltimore. 77(4):233-45.

Uegesk L (1993). Nephrologic Ascities. Case Report and review of the literature. Journal Of NephrologY. 28(3):311-4.




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This is the link for the full text of the journal that we used on our epidemiology: The title is ESRD patients in 2004: global overview of patient numbers, treatment modalities and associated trends
by Aileen Grassmann, Simona Gioberge, Stefan Moeller and Gail Brown
http://ndt.oxfordjournals.org/cgi/reprint/20/12/2587

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Response by: Dyad 4: Zaño, Alexis/Balajadia, Bond

Timing, causes, predictors and prognosis of switching from peritoneal dialysis to hemodialysis: a prospective study

Hemodialysis (HD) and peritoneal dialysis (PD) represent the two main modalities for renal replacement therapy. PD is typically considered a home dialysis program, as the patients have the autonomy to perform the treatment in their home environment, whereas most HD patients must travel to a dialysis center, usually three times a week, to receive their treatment. Despite the potential benefit of PD compared to HD in quality of life and associated patient satisfaction, prevalent use of PD has declined in the United States since 1994–1995, by as much as 67% in some regions of the country. The number of incident end-stage renal disease (ESRD) patients initiating PD has also declined over the same time period. This decline in PD utilization has been observed not only in the United States but also in Europe and elsewhere. Technique failure is known to be much higher in PD than HD patients and this likely plays a significant role in the declining prevalence of PD utilization. Peritonitis has been described as one of the leading causes of transfer from PD to HD and only a small group of patients can return to PD after severe peritonitis and Tenckhoff catheter removal. Over the past decade, very few studies in the United Sates have analyzed both the cause of switching from PD to HD and the timing of this switching process after initiation of PD. Further, there is a paucity of studies, particularly in the United States, aimed at identifying risk factors associated with switching from PD to HD in ESRD patients and subsequent patient outcomes. The purpose of this study was to determine patient characteristics associated with the risk of switching from PD to HD and to assess patient survival following dialysis modality switches in a cohort of incident peritoneal dialysis patients.

The use of peritoneal dialysis (PD) has declined in the United States over the past decade and technique failure is also reportedly higher in PD compared to hemodialysis (HD), but there are little data in the United States addressing the factors and outcomes associated with switching modalities from PD to HD. In a prospective cohort study of 262 PD patients enrolled from 28 peritoneal dialysis clinics in 13 U.S. states, we examined potential predictors of switching from PD to HD (including demographics, clinical factors, and laboratory values) and the association of switching with mortality. Cox proportional hazards regression was used to assess relative hazards (RH) of switching and of mortality in PD patients who switched to HD. Among 262 PD patients, 24.8% switched to HD; with more than 70% switching within the first 2 years. Infectious peritonitis was the leading cause of switching. Patients of black race and with higher body mass index were significantly more likely to switch from PD to HD, RH (95% CI) of 5.01 (1.15–21.8 ) for black versus white and 1.09 (1.03–1.16) per 1 kg/m2 increase in BMI, respectively. There was no difference in survival between switchers and non-switchers, RH (95% CI) of 0.89 (0.41–1.93).

Switching from PD to HD occurs early and the rate is high, threatening long-term viability of PD programs. Several patient characteristics were associated with the risk of switching. However, there was no survival difference between switchers and non-switchers, reassuring providers and patients that PD technique failure is not necessarily associated with poor prognosis.

With the results presented above, it can play an important role in the field of nursing profession. Nurse researchers and Clinical nurse can work hand in hand in order to meticulously create and develop a plan of care or a program for patients undergoing PD and HD. The plan or program should focus on decreasing the rate of switching from PD to HD, thus decreasing the risk of developing unexpected complications for the patients.

Reference: Jaar, Bernard G, et. al. Timing, causes, predictors and prognosis of switching from peritoneal dialysis to hemodialysis: a prospective study. PMC. February 6 2009

MRFIT: Proteinuria, E GFR strong predictors of long-term ESRD risk

This is another study (Ishani, 2006) which reinforces the fact that a simple diagnostic test such as the urine dipstick testing to determine level of proteinuria , coupled with assessing the estimated glomerular filtration rate (eGFR) may be used to determine whether an individual could develop long-term end-stage renal disease (ESRD). This study was conducted with 12 866 men (ages 35 to 57) who were enrolled in the Multiple Risk Factor Intervention Study (MRFIT). The MRFIT was a randomized trial study (which was started in 1973 up to 1999) from various centers which was created to determine the effect of a life-style modification program which specifically aims to lower the blood pressure and serum cholesterol levels and the same time modify diet and cease smoking in men who are susceptible to cardiovascular disease. The study conducted by Ishani and colleagues used the data from this previous study to determine their ability to predict the risk in ESRD. The baseline information they got included renal function and hematocrit levels. One advantage of this study is that the baseline data used came from another study spanning 25 years in terms of data collection. Other previous studies involved subjects with known kidney disease and looked at factors related to combined outcome of doubling serum creatinine or ESRD.

The result of the study indicated that a subject with urine dipstick result of 1+ are three times more at risk for developing ESRD as compared with those men with normal result. The risk increased fifteen times for those with 2+ results. Moreover, the risk becomes progressive at 41 times higher for subjects having abnormal urine dipstick results and the same time have an abnormal eGFR result than those who got normal results for both tests. According to Dr. Ishani of the Minneapolis Veterans Affairs Medical Center, this study proved that eGFR alone is only a moderate predictor of ESRD. Whereas, the use of a standard urine protein assessment could be a strong basis in forecasting a deterioration of one’s health to end stage renal disease. Hence, an individual with proteinuria and at the same time has decreased GFR definitely had worse outcomes. She also mentioned t It was also interesting to note that the study revealed that hematocrit results could not be used to predict the development of ESRD.

The findings of this study is significant not just to the nursing profession but more importantly to those afflicted with afflicted with diseases which could develop to ESRD if not properly monitored. Considering the high cost involved in treating the disease, the fact that relatively low cost diagnostic tests could be done as needed to monitor current helath status of the patient. The ordinary urine dipstick test and the GFR test are cost effective enough not to contribute to the burden of the ill patient as well as thier loved ones. Regular monitoring of these critical diagnostics tests could spell the difference in prolonging the life of the patient.


Reference
Ishani A, Grandits GA, Grimm RH, et al. Association of single measurements of dipstick proteinuria, estimated glomerular filtration rate, and hematocrit with 25-year incidence of end-stage renal disease in the Multiple Risk Factor Intervention Trial. J Am Soc Nephrol 2006; 17:1444-1452.

Dyad three:
Byron Webb A. Romero
Von Deneb Vitto
Raymond Ursal

People of low socioeconomic status (SES) appear to be at increased risk of ESRD (Ward, 2008). The incidence of ESRD was found to be greater in geographic areas with less educated populations and lower household incomes. Associations between SES and risk of ESRD were found in both whites and blacks when race-stratified analyses were performed. Low-SES groups may have a greater prevalence of ESRD because they may be more likely affected by diseases that can cause ESRD. However, SES also was associated with the risk of ESRD caused by specific diseases, such as diabetes mellitus. Previous studies examined populations in selected states or local areas or included only patients in selected age groups or who were white or black or those with a specific primary renal disease.

Ward’s (2008) study included a national sample of all adults with ESRD and examined whether the association between SES and incidence of ESRD was similar across demographic groups. SES may be associated with risk of ESRD through environmental influences on the biological characteristics of renal disease or through differences in health behaviors in persons of different SES. The researcher hypothesized that one aspect of SES that could contribute to the risk of ESRD was the availability of specific treatments that could prevent or decrease progression to ESRD. Therefore, Ward (2008) specifically contrasted associations among patients with 3 different primary renal diseases that differ in the availability of specific treatments: diabetes mellitus, systemic lupus erythematosus, and autosomal dominant polycystic kidney disease
(ADPKD). In patients with diabetes mellitus, strict glycemic control can decrease the development of diabetic nephropathy and, by inference, ESRD. Although immunosuppressive therapies are available for patients with lupus nephritis, not all patients respond, and some progress to ESRD despite optimal available treatment. Conversely, there is no specific treatment for patients with ADPKD other than control of hypertension. Differences among patients with ADPKD in rates of progression to ESRD are believed to be related largely to the biological characteristics of this disease. If access to effective treatment was an important mechanism explaining the association of SES and ESRD, one would predict stronger associations between SES and risk of ESRD caused by diabetes mellitus than for ESRD caused by lupus nephritis and little or no association between SES and risk of ESRD caused by ADPKD.

The incidence of ESRD was greater in patients in the lower SES categories in all sex-race subgroups and decreased progressively with higher SES. These associations tended to be stronger in women than men and were weakest in blacks. This study confirms that the incidence of ESRD is greater in patients of lower SES.

Reference:
Ward, M.M. (2008). Socioeconomic Status and the Incidence of ESRD. American Journal of Kidney Diseases. 51 (4). Retrieved June 21, 2009 from http://www.mdconsult.com/das/article/body/144786582-6/jorg=journal&source=MI&sp=20546642&sid=854656887/N/635667/s0272638607016095.pdf?SEQNO=1&issn=0272-6386

Peritonitis associated with PD is most often due to contamination with pathogenic skin bacteria, with Staphylococcus epidermidis and S. aureus accounting for the majority of cases. (See "Microbiology and therapy of peritonitis in continuous peritoneal dialysis").

The intact peritoneum and the defense mechanisms of the mesothelium are probably the most important barriers to the development of peritonitis in PD patients. The incidence of systemic bacteremia in association with PD peritonitis is extremely low (less than one percent) in contrast to the reported 30 percent with surgical peritonitis [2] and 39 to 76 percent of spontaneous peritonitis in cirrhotic patients with ascites [3,4].

A number of factors contribute to the development of peritonitis in this setting even when the patient is maximally skilled with the dialysis technique:

* The patient on continuous ambulatory peritoneal dialysis (CAPD) usually connects and disconnects from the transfer set many times a day and therefore must perform a large number of sterile exchanges per year; it would be naive to assume that bacterial contamination does not occur at times. In comparison, a patient on continuous cycling peritoneal dialysis (CCPD) needs to connect or disconnect from the transfer set far fewer times, and the peritonitis rate is predicted to be lower than that in patients on CAPD (see below).

* The continuous presence of nonphysiologic fluid in the peritoneal cavity can impair host defenses. Standard dialysis fluids have a high glucose concentration, are hyperosmolar, have a low pH, and markedly dilute resident peritoneal macrophage and cytokine levels. Newer peritoneal dialysis fluids containing glucose polymers (such as icodextrin) may be relatively less harmful to neutrophil and macrophage function. (See "Peritoneal dialysis solutions").

* Macrophages and cytokines that are activated during a potential infection are constantly removed during each exchange of dialysis fluids. As a result, a relatively small inoculum of bacteria, as often occurs with a touch contamination, can readily induce peritonitis in a PD patient; in contrast, a similar inoculation during surgical laparotomy seldom causes peritonitis [5,6].

* Mesothelial surfaces have extraordinary host defense mechanisms when the surfaces are allowed close proximity to each other. These defense mechanisms are compromised by the presence of dialysis solution.

* The chronic indwelling catheter bridges both a sterile and nonsterile environment. Bacteria can track along the catheter and its tunnel. In addition, the catheter itself can be a nidus of retained microbes directly growing into the material (fungi) or through the creation of biofilm/slime layers, under which the bacteria are protected from host defenses or antibiotics (see below). (See "Tunnel and peritoneal catheter exit site infections in continuous peritoneal dialysis").

* The normal healthy peritoneal mesothelial cells play an important role in orchestrating host defense/peritoneal inflammation and fibrosis. The function of these mesothelial cells may be altered over time.

* Seasonal variation in peritonitis with an increased risk in hot and humid months or climates, suggests a catheter or technique-related underlying cause of many episodes [7].

Infection Control for Peritoneal Dialysis (PD) Patients

Peritoneal dialysis (PD) is a practical and widespread treatment for kidney failure. Because a soft tube
(catheter) is present in the abdominal cavity for this treatment, special care must be taken by PD patients
and their medical providers to prevent infection, especially following natural disasters when flooding may
be present, access to medical supplies may be limited, or PD patients who may be living in temporary
housing.

Exit Site Infection

Acute exit-site infection is defined as drainage with blood and/or pus from the exit site which may be
associated with redness (twice the size of the catheter diameter), tenderness, overgrown granulated
tissue, and swelling.

Chronic exit-site infection is characterized by granulation tissue at the external exit which is sometimes
covered by a large stubborn crust or scab. Pain, redness, and swelling are frequently absent in chronic
infections.

Peritonitis

Staphylococcus aureus is the most frequent germ associated with infections in PD patients and is usually
caused by auto-inoculation by touch or contamination with respiratory secretions. However, following a
disaster involving flooding, one might see an increase in the number of infections associated with Gram-
negative waterborne bacteria.

Some of the most common symptoms of peritonitis are:
Abdominal pain Abdominal tenderness Abdominal distention Cloudy PD fluid Fever Nausea and vomiting
Preventing Exit Site Infections

It is normally recommended that patients should avoid all fresh water (e.g., lakes, rivers, and streams)
swimming, hot tubs, jacuzzis, soaking tubs, and public pools. Exposure to fresh water (e.g., swimming,
showering, or bathing) has been associated with Gram-negative catheter-related infections and peritonitis
in PD patients (1-5). To date, there are no studies that prove that wearing a dressing over a healthy,
healed exit site prevents infections; however, dressings should be worn when the exit site is likely to get
dirty (e.g., farmers working outside or persons hiking in a dusty environment) or wet, and dressings often
help to secure the catheter (6,7). Routine use of antimicrobial solutions (e.g., ciprofloxacin
ophthalmologic solution) and ointments, such as mupiricin and gentamicin, have been shown to decrease
the incidence of peritonitis and catheter-related infections (8-10). While the use of antimicrobial creams, ointments, and solutions has been reported to decrease infections, there have been limited comparisons in
studies, making it difficult to recommend a specific guideline.

There are steps one can take to reduce the risk of developing exit site infections. If a PD dressing is used,
it should be changed any time it becomes soiled or wet. The PD catheter exit site should also be cleaned
any time the area becomes soiled.

General Exit Site Care

1. Wash hands or use an alcohol hand gel; wear clean gloves.
2. Remove dressing, if present.
3. Check exit site for redness, swelling, drainage, or soreness.
4. Check catheter for cracks or tears.
5. Gently touch the catheter tunnel, noting swelling, discharge, or pain.
6. When bathing, clean the skin around the catheter with antibacterial liquid soap
and rinse.
7. Dry exit site with sterile gauze.
8. Optional: cover with antimicrobial preparation and drain sponges.
9. Secure the catheter to the abdomen using immobilizer or tape to avoid tension on
the catheter.
Exit Site Care with Vinegar Solution for Wet, Red, or Sore Sites

Seek consultation and assistance with available healthcare staff or medical providers while in
evacuation centers or alternate housing situations. These procedures are recommended when: 1)
the exit site has been submerged; 2) water used to clean the exit site may be contaminated; or 3) the
exit site is red or sore:

1. Procedure for Preparing Vinegar Solution:
a. Prepare vinegar solution in a very clean jar
b. Add 6 ounces (3/4 cup) boiled or bottled water
c. Add 4 ounces (1/2 cup) white vinegar
d. Add 1 ? teaspoon table salt
e. Shake until dissolved
spray bottle
f. Pour solution into a clean

2. Procedure for Exit Site Care:
a. Clean your exit site
b. When showering, clean your exit site last using liquid antibacterial soap. Use a clean wash
cloth for your exit site.
c. Rinse off the soap with water.
d. Spray your exit site with vinegar solution.
e. Pat dry with dry washcloth. You may use a hair dryer on !°low.!± Be sure to hold the drye
pointing downward at least 12-15 inches from your skin. Dry under the catheter.
f. Secure your catheter with a small amount of slack to prevent pulling at the exit site.

If your exit site is red, sore or infected:
1. Clean your exit site twice a day with liquid antibacterial soap and rinse with water.
2. Saturate a 4x4 gauze with the vinegar solution and lay it around your catheter for 20 minutes.
This solution should feel soothing. Discontinue use if solution burns your skin and seek medical
Do not store the vinegar solution for more than 1 week. Discard any unused portion at the end of each
week and make a fresh solution.

Other Infection Control Considerations

Waste PD fluid from HBsAg-positive patients can be disposed of into a sanitary sewer if handled with
proper aseptic technique. Disposable gloves should be worn by medical personnel who handle any PD
fluid, and the fluid should enter the sewer system in such a manner that no splashing occurs. Where
available, the spent PD fluid can be disposed of into a sink, toilet, or other drain. The tubing from the bag
should be placed below into the drain or below the surface of the water to prevent splashing while the bag
drains (11). The sink, drain, and any inadvertent spills or splashes should be disinfected with 1:10
dilution household bleach or an appropriately labeled EPA-registered disinfectant
). Persons cleaning such spills should wear
(http://www.epa.gov/oppad001/list_d_hepatitisbhiv.pdf
disposable gloves. All contaminated material including PD bags should be placed in heavy tightly sealed
plastic bags for disposal.

For patients in evacuation centers, a toilet rather than a sink should be used to discard PD fluid.