Andrew Davenport

UNLABELLED: Introduction. Patients often report symptoms during haemodialysis (HD). To better understand patients' experience, we surveyed routine HD outpatients, to quantify the burden and duration of dialysis-associated symptoms. METHODS: Five hundred and eight symptom questionnaires were returned from 550 HD outpatients (92.4%). The symptoms in relation to the HD session were analysed using a visual analogue score. Multivariate logistical regression analysis was used to identify characteristics associated with total symptom burden and time to recover following a HD session. RESULTS: Fifty-four percent of the cohort were male, median age 64 years, 36% diabetic and median age unadjusted Charlson comorbidity score 3.0 (2-5). Fatigue (82%), intradialytic hypotension (76%), cramps (74%) and dizziness (63%) were the commonest symptoms reported, followed by headache (54%), pruritus (52%) and backache (51%), with fatigue occurring with a median frequency of 50% of dialysis sessions and intradialytic hypotension and cramps in 30%. Some 23% reported recovering from dialysis within minutes, 34% by the time they returned home, 16% by bed time, 24% the following morning and 3% just before the next dialysis session. Symptom burden was associated with female sex, younger age, longer duration of dialysis sessions, ethnicity and dialysis centre practice. The time taken to recover from dialysis varied from minutes to hours and was shorter for men and greater dialysis vintage but longer with increasing session time and those with increased intradialytic symptom burden. CONCLUSIONS: Despite advances in HD, intradialytic symptoms were frequently reported by our patients. There was substantial unexplained variation in symptom burden across centres, suggesting that clinical practice or policies may play a role in preventing the adverse effects of dialysis. Symptom burden was worse in women, patients of South Asian as opposed to African origin and also in those receiving a longer duration of dialysis. These patients may therefore benefit from a different approach to dialysis prescription.

There are an estimated 14,000 randomized trials published in chronic kidney disease. The most frequently reported outcomes are biochemical endpoints, rather than clinical and patient-reported outcomes including cardiovascular disease, mortality, and quality of life. While many trials have focused on optimizing kidney health, the heterogeneity and uncertain relevance of outcomes reported across trials may limit their policy and practice impact. The international Standardized Outcomes in Nephrology (SONG) Initiative was formed to identify core outcomes that are critically important to patients and health professionals, to be reported consistently across trials. We convened a SONG Implementation Workshop to discuss the implementation of core outcomes. Eighty-two patients/caregivers and health professionals participated in plenary and breakout discussions. In this report, we summarize the findings of the workshop in two main themes: socializing the concept of core outcomes, and demonstrating feasibility and usability. We outline implementation strategies and pathways to be established through partnership with stakeholders, which may bolster acceptance and reporting of core outcomes in trials, and encourage their use by end-users such as guideline producers and policymakers to help improve patient-important outcomes.

Continuous forms of renal replacement therapy (CRRT) have become established as the treatment of choice for supporting critically ill patients with acute kidney injury. Typically, these patients have activation of the coagulation cascades, peripheral mononuclear cells and platelets, but also a reduction in natural anticoagulants, and are therefore prothrombotic. For continuous modes of renal replacement therapy to be effective, in terms of both effective solute clearance and also fluid removal, the extracorporeal circuits must operate continuously. Thus, preventing clotting in the CRRT circuit is a key goal to effective patient management. As these patients may also be at increased risk of bleeding, regional anticoagulation with citrate is increasing in popularity, particularly following the introduction of commercially available CRRT machines and fluids specifically designed for citrate anticoagulation. Although regional anticoagulation with citrate provides many advantages over other systemic anticoagulants, excess citrate may lead to both metabolic complications, ranging from acidosis to alkalosis and may also potentially expose patients to electrolyte disturbances due to hyper- and hyponatraemia and hyper- and hypocalcaemia.

The mortality of patients with combined acute hepatic and renal failure remains high. Previous studies have reported both patient morbidity and mortality directly attributable to the use of extracorporeal circuits used to treat renal failure. We investigated the effect of various modes of renal replacement therapy in 30 consecutive patients referred with both fulminant hepatic and acute renal failure. Cardiac output decreased during the first hour of 30 intermittent machine haemofiltration treatments, by 15 +/- 3%, as did tissue oxygen delivery, 16 +/- 3% and tissue oxygen uptake, 13 +/- 4%, whereas there was no significant change during 30 continuous hemofiltration and/or dialysis treatments. Intracranial pressure remained stable during the continuous modes but increased from 9 +/- 2 mm Hg to 17 +/- 2 mm Hg, P < 0.01, during intermittent machine hemofiltration, with the greatest increase of 55 +/- 9% within the first hour. Mean arterial blood pressure was stable during treatment with the continuous modes, but decreased by 20 +/- 3% during the first hour of intermittent machine hemofiltration, resulting in a maximum reduction in cerebral perfusion pressure of 35 +/- 8%. In this group of critically ill patients continuous modes of renal replacement therapy resulted in superior cardiac and intracranial stability compared to standard intermittent modes of treatment.