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The present study aimed to evaluate the impact of a filmed research-based drama-Fit for Dialysis-and an exercise program on patients' physical activity and fitness outcomes.Nineteen (10 at the intervention site, 9 at the control site) older patients with a medical diagnosis of hemodialysis-dependent end-stage renal disease were recruited from two acute care hospitals in urban central Canada where they were receiving out-patient hemodialysis care. Participants at the intervention site viewed Fit for Dialysis prior to participating in a 16-week exercise program. Participants at the control site participated only in the 16-week exercise program. Physical activity, measured by total intradialytic exercise time (TIDE), and physical fitness, measured by the Two-Minute Walk Test (2MWT). Secondary measures included: Timed Up and Go (TUG), Grip Strength, Duke Activity Status Index (DASI), Godin Leisure-Time Exerciser Questionnaire (GLTEQ), and pedometer step count.TIDE, TUG, and GLTEQ were better at the intervention site compared to the control site at all time points measured. However, the change over time was not different between the sites. The 2MWT improved over time at the intervention site for those who exercised consistently. No significant differences between sites, or over time were found for any of the other measures.Further research is needed to determine the effectiveness of this intervention to facilitate the incorporation of exercise into the care and treatment of HD patients.

Previous studies have demonstrated venous stenosis and thrombosis in hemodialysis patients who had repeated or prolonged cannulation of the subclavian vein. 1,2 Early reports, however suggested that patients with catheters placed in the internal jugular vein were not at risk of such complications.3-6 We conducted a retrospective case series to determine if this was correct. We report a series of seven patients who were found to have stenosis of the upper neck veins despite having never had subclavian vein cannulation. We suggest that previous reports suggesting a superior safety profile with internal jugular catheters may have been misleading and propose that all measures be taken to encourage wider use of arteriovenous grafts and fistulae.

Living kidney donation offers a unique setting to study changes in phosphate and vitamin D homeostasis attributable to mild isolated decreases in estimated glomerular filtration rate (eGFR).Cross-sectional study.198 living kidney donors and 98 nondonor controls from 9 transplant centers across 3 countries. For donors, median time after donation was 5.3 years. At assessment, donors had a lower eGFR than controls (73 vs 98 mL/min/1.73 m(2)).Living kidney donation (mildly decreased eGFR).Biochemical markers of chronic kidney disease-mineral and bone disorder.Serum creatinine, total serum calcium, serum and urine inorganic phosphate, plasma intact parathyroid hormone, serum calcidiol and calcitriol, renal fractional excretion of inorganic phosphate, and intact serum fibroblast growth factor 23 (FGF-23).Serum FGF-23 levels were significantly higher in donors (38.1 vs 29.7 pg/mL; P0.001). For every 10-mL/min/1.73 m(2) decrease in eGFR, FGF-23 level was higher by 3.2 (95% CI, 2.0-4.4) pg/mL. Compared with controls, donors showed higher renal tubular fractional excretion of inorganic phosphate (17.8% vs 12.3%; P0.001), lower serum phosphate (0.97 vs 1.02 mmol/L; P = 0.03), and lower serum calcitriol values (63 vs 77 pmol/L; P0.001). Serum calcium levels were not significantly different between the 2 groups. Plasma intact parathyroid hormone levels were significantly higher in donors (5.7 vs 5.0 pmol/L; P = 0.03), but were not correlated with FGF-23 or calcitriol levels.Enrollment of a small proportion of past donors at participating centers; assessment of only postdonation values; unable to assess seasonal variation or other temporal patterns in biochemical markers; assessment of kidney function was based on eGFR, not measured GFR.The FGF-23 pathway may be activated in living kidney donors who show early biochemical changes compatible with chronic kidney disease-mineral and bone disorder. Whether these changes influence bone mineral density and fracture rates warrants consideration.

Peritonitis caused by enteric organisms in peritoneal dialysis (PD) patients is associated with greater morbidity and mortality than peritonitis with non-enteric organisms. One reported risk factor for enteric peritonitis (EP) is gastric acid suppression, with two small studies providing conflicting results. The objective of this study was to determine, using a larger patient population, whether gastric acid suppressants are associated with an increased risk of EP.Using a single-center case-control design, information on episodes of EP occurring between 2003 and 2006 was collected. Control episodes were all non-enteric episodes of peritonitis that occurred during the same time interval. Proton pump inhibitor (PPI) or H(2)-blocker (H(2)B) use prior to development of peritonitis was documented.A total of 228 peritonitis episodes among 137 patients met inclusion criteria. In 32% of episodes, the causative organism was enteric. Gastric acid suppressant use was documented in 46% of episodes, with the majority on PPIs. Overall, gastric acid suppression was not associated with a higher EP risk (p = 0.17). In a post hoc analysis, PPIs were not associated with EP [odds ratio (OR) 1.3, 95% confidence interval (CI) 0.7-2.4; p = 0.42], whereas H(2)Bs were associated with a higher risk of EP (OR 2.9, 95% CI 1.1-7.7; p = 0.04), although the number of patients on H(2)Bs was small.Overall, gastric acid suppression was not associated with an increased risk of peritonitis with enteric organisms. While PPI use appears to be safe for PD patients with appropriate indications, the potential risk of EP with H(2)Bs requires further investigation.

Patients returning to peritoneal dialysis after renal allograft loss are an increasing segment of the end-stage renal disease population. Non-transplant nephrologists will be managing the short- and long-term complications of chronic immunosuppression in these patients. In this case report, the use of sirolimus is described in a patient who developed a significant peritoneal dialysis catheter exit-site leak delaying the initiation of dialysis. The risk of impaired wound healing at the time of peritoneal dialysis catheter implantation must be considered when bridging patients from transplantation to peritoneal dialysis. Particular caution should be paid to the use of sirolimus during this period.

Background Older dialysis patients have a high burden of mortality and morbidity. Frailty and functional disability are common. One of the main determinants of functional disability in nondialysis populations is acute hospitalization. Such episodes are predictive of increased mortality and a future need for long-term care. Based on the high prevalence of disability in the dialysis population, we undertook a pilot study to determine functional impairment at the time of admission and again at 1 week after discharge. Study Design Prospective cohort study. Setting & Participants Prevalent dialysis patients older than 65 years admitted to a single acute-care institution during a 3-month period. Outcomes The proportion of dialysis patients with difficulty with activities of daily living at baseline and 1 week after discharge. Measurement Basic activities of daily living; Lawton Brody Instrumental Activities of Daily Living score; timed up-and-go and handgrip tests; Trails A & B, and the clock test. Results At the time of admission, only 8 of 35 individuals reported being independent with basic activities of daily living. None of the patients was independent with instrumental activities of daily living. At 1 week after discharge, patients showed deterioration in all aspects of function except the ability to use the telephone and manage their financial affairs. A total of 73.3% of patients (95% confidence interval, 54.1 to 87.7) experienced a decline in personal functional independence in association with hospitalization. Limitations This is a pilot study with a small number of patients who were studied at only 2 times (admission and 1 week after discharge). Conclusions Results of this study suggest that hospitalization is associated with a high rate of disability in elderly dialysis patients. Further study is required to determine whether the functional deterioration seen with hospitalization improves over time.

During the past few decades, the demographics of end stage renal disease have been changed significantly with the emerging predominance of elderly patients. Elderly dialysis patients are usually more dependent and may need long-term placement in a long-term care facility. Failure to meet the needs of these patients may have a significant impact on the peritoneal dialysis program. We report our experience of starting peritoneal dialysis program in a community-based Long Term Care Facility (LTCF).During the period of 2000-2001, after appropriate training of nursing home personnel, we admitted 8 peritoneal dialysis patients to one community-based nursing home. All information presented here has been collected through chart review.At the time of admission the average age of the 8 patients was 77.3 +/- 7.2 years (range 69 to 91 years). All patients had several comorbid diseases and six of the eight were bed-ridden. The patients stayed in the facility for a total of 29.57 patient months. One patient had three episodes of peritonitis within three months (all culture negative) and has been excluded from the analysis of the overall peritonitis rate. The peritonitis rate for the other seven patients was 1 per 7.54 patient month. Six patients were readmitted to hospital because of peritonitis, severe malnutrition and hip fracture. Four of them died in the hospital. One died in the nursing home. One patient remains in the nursing home at the present time.Our experience suggests that peritoneal dialysis can be achieved in a community-based nursing home. This requires a systematic training program for the LTCF personnel and the availability of a "dedicated" nephrology dialysis staff. This is crucial to the success of the program. It is important that patients, their families and ESRD care professionals are informed of the limited survival expectation particularly for very old and severely impaired patients.

To develop a set of comprehensive, standardized, evidence-based guidelines for the use of antiviral therapy to prevent cytomegalovirus disease in adult patients having undergone renal transplantation.The use of medication, at the time of induction therapy or at the earliest sign of viremia. Treatments were evaluated by patient and donor serologic groups and the induction regimen used.The control of symptoms and features of cytomegalovirus disease over the first 6 mo to 1 yr after transplantation.Articles, compiled using a MEDLINE search from 1976 to July 1997, were reviewed by representatives of nephrology, microbiology, pharmacy, and epidemiology. Additional information was obtained from recent review articles and conference abstracts, and from experts in the field.The evidence-based methods and values of the Canadian Task Force on the Periodic Health Examinations were used. High value was placed on studies with a randomized controlled design and blinded outcome observers. Study quality was classified as poor when cointervention was present (especially with regard to immunosuppressive regimens), when more than 20% of patients were lost to follow-up, and when intention to treat analysis was not performed. Recommendations were made with a graded system (grades A and B: Use of the intervention advised, based on high or fair quality evidence, respectively; grades D and E: Use of the intervention not advised, based on high or fair quality evidence, respectively: grade C: No recommendation made because of insufficient or conflicting evidence).(1) Seropositive recipient; donor seropositive or seronegative; immunosuppression with antilymphocyte products. Prophylaxis with antiviral therapy recommended (grade A recommendation). (2) Seronegative recipient; seropositive donor; immunosuppression with antilymphocyte products. Prophylaxis with antiviral therapy recommended (grade A recommendation) (3) Seronegative recipient; seropositive donor; conventional immunosuppression. Prophylaxis with antiviral therapy recommended (grade B recommendation). (4) Seronegative recipient; seronegative donor; any immunosuppressive regimen. No prophylaxis with antiviral therapy required (grade D/E recommendation). (5) Seropositive recipient: donor seropositive or seronegative; conventional immunosuppression. Prophylaxis left to the discrimination of the physician in charge (grade C recommendation).