Cephalic arch stenosis. Case report and literary review

Abstract

Dysfunctional AVF represents one of the leading causes of morbidity in the hemodialysis population, with venous stenosis-related dysfunction being the most common underlying problem.

Cephalic arch is a well-known site for the development of stenosis, especially in patients with brachiocephalic fistulas. The pathophysiology of cephalic arch stenosis (CAS) is still being investigated and various contributing factors have been suggested.

The treatment options for CAS are many and include angioplasty, endovascular stent insertion, access flow reduction and surgical interventions, but none of the current modalities are ideal. Therefore, the treatment of CAS is difficult, as the stenosis in this area tends to recur leading to the need for repeat angioplasty, stents or surgical revision.

A 57-year-old woman undergoing hemodialysis (HD) through a right brachiocephalic arteriovenous fistula was found to have high venous pressure during HD and prolonged bleeding after HD. Clinical examination revealed a hyperpulsatile fistula suggestive of outflow obstruction. Doppler ultrasound examination showed cephalic vein thrombosis, severe outflow stenosis and juxta-anastomotic area. A 10 x 40 mm stent (Cordis Smart stent) was positioned appropriately in the cephalic arch and deployed, the stenotic lesion in juxta-anastomotic area was dilated with angioplasty balloon with improvement in flow.

After 14 months, the fistula is still working perfectly with adequate flow.

Keywords: cephalic arch, stenosis, brachiocephalic fistula, hemodialysis

Sorry, this entry is only available in Italian. For the sake of viewer convenience, the content is shown below in the alternative language. You may click the link to switch the active language.

Introduzione

Le complicanze dell’accesso vascolare (AV) condizionano la qualità di vita e la sopravvivenza del paziente in emodialisi e rappresentano una delle principali cause di morbilità e mortalità nella popolazione emodializzata [1]. La maggiore causa di disfunzione e successiva trombosi di una fistola artero-venosa (FAV) è la stenosi venosa.

È ben noto che la localizzazione della stenosi e i segni clinici dipendono in gran parte dal tipo di AV [2]. Vari sono i segmenti della FAV soggetti a stenosi sul versante venoso; in relazione alla sede, possiamo distinguere tra: 1) stenosi a livello di inflow, in genere post-anastomotica, tipica della FAV dell’avambraccio; 2) stenosi a livello di outflow, localizzate a livello prossimale e presenti prevalentemente nelle FAV del braccio; 3) stenosi nelle zone di venipuntura e 4) stenosi riguardanti le vene centrali [3].

Un’altra sede tipica di stenosi è l’arco cefalico (AC); particolarmente interessate sono le FAV brachiocefaliche (dal 39% fino al 77%) rispetto alle FAV radiocefaliche (dal 2% al 15%) [4]. Ciò, verosimilmente, in relazione alla portata più elevata dell’AV, alla turbolenza del flusso e a fattori anatomici a causa del restringimento e della curvatura fisiologica dell’AC attraverso la fascia clavipettorale.

 

La visualizzazione dell’intero documento è riservata a Soci attivi, devi essere registrato e aver eseguito la Login con utente e password.

Effectiveness of physical exercise on cardiovascular endurance and functional capacity in hemodialysis patients: a systematic review and meta-analysis

Abstract

Background. Physical exercise is a health intervention in the treatment of numerous chronic diseases. In patients on hemodialysis, physical exercise has been introduced during hemodialysis for different outcomes. Several meta-analyses show uncertainty about the effects.
Objective. Our systematic review and meta-analysis aim at summarizing and evaluating the evidence of the effects of physical exercise on cardiovascular endurance and functional capacity of hemodialysis patients.
Results. Five studies were included in the review (462 patients). Physical exercise brought an improvement in cardiovascular endurance and functional capacity (MD, 95%CI:62.24 [18.71, 105.77], p=0.005), compared to the control group. Most trials were at high risk of bias due to lack of blinding between the patients and the personnel, and between the patients and the outcome assessor.
Conclusions. Physical exercise may have beneficial effect on cardiovascular endurance and functional capacity in hemodialysis patients. The quality of evidence is low and the strength of recommendations is weak for cardiovascular endurance. Future studies should consider a power analysis for an adequate sample size and minimize the risk of sample bias. Further research should provide the additional results required for an acceptable estimate of the effects of physical exercises in hemodialysis patients.

Keywords: physical exercise, hemodialysis, cardiovascular endurance, functional capacity, systematic review, meta-analysis

Sorry, this entry is only available in Italian. For the sake of viewer convenience, the content is shown below in the alternative language. You may click the link to switch the active language.

Introduzione

L’esercizio fisico è stato definito nel 2016 dalla GIMBE Foundation come un intervento sanitario efficace nel trattamento di numerose patologie croniche, in quanto determina benefici simili a quelli ottenuti con terapia farmacologica, oltre che nella prevenzione secondaria di patologie coronariche, nella riabilitazione post-ictus, nello scompenso cardiaco e nella prevenzione del diabete [1]. La malattia renale cronica terminale (ESKD) è un problema di salute globale [2] con una stima di 1,2 milioni di decessi nel 2015 e in aumento del 32% [3]. I pazienti in trattamento dialitico sostitutivo mostrano un’associazione tra un basso livello di attività fisica e un elevato rischio di mortalità [4]. Infatti, i livelli di attività fisica di questi pazienti sono influenzati non solo dai vincoli di tempo stabiliti dal trattamento dialitico ma anche dall’invecchiamento, dal declino della funzione fisica, dall’esacerbazione dei sintomi e da altri fattori psico-sociali come la depressione. I pazienti riferiscono anche problematiche all’allenamento fisico quali le numerose comorbilità, la sensazione di essere troppo stanchi, il fiato corto, l’essere troppo deboli, la paura dei sintomi avversi durante l’esercizio fisico, la mancanza di tempo, ed infine le scarse informazioni sulla tipologia di esercizio da svolgere e con i relativi aspetti benefici per la salute [5]. I pazienti con malattia renale allo stadio terminale vivono un progressivo declino della funzione fisica, della forza muscolare e della capacità aerobica con una progressiva atrofia muscolare.

 

La visualizzazione dell’intero documento è riservata a Soci attivi, devi essere registrato e aver eseguito la Login con utente e password.

COVID-19 in patients starting hemodialysis in the Alentejo region: case reports

Abstract

COVID-19 has a wide spectrum of clinical presentation, ranging from asymptomatic or mild symptoms to severe multiorgan failure. In Portugal, the first cases affecting patients on a chronic hemodialysis program arose in the city of Oporto.

The authors report here two cases of COVID-19 infection in patients incident in renal replacement therapy in the Alentejo region and hypothesise that the high serum concentration of urea may decapitate the appearance of typical symptoms of the SARS-CoV-2 infection. The fact that the hemodialysis population can present active infection without fever may lead to a delayed diagnosis and consequently an increased risk of mortality.

Keywords: COVID-19, hemodialysis, urea, case reports, Alentejo region

Introduction

Patients with end stage chronic kidney disease (ESKD) have a greater morbidity and mortality, mainly due to cardiovascular risk, underlying immunosuppression and advanced age with multiple comorbidities.

The disease caused by SARS-CoV-2 coronavirus emerged in the city of Wuhan in the Chinese province of Hubei in December 2019. In March 2020, the WHO declared coronavirus disease (COVID-19) a pandemic. The first case of infection in Portugal was on 1st March 2020. The first cases affecting patients on chronic hemodialysis (HD) arose in the city of Oporto. The Alentejo region was affected from late March.

COVID-19 has a wide spectrum of clinical presentation, ranging from asymptomatic to mild symptoms such as dry cough, high fever and difficulty breathing, to severe symptoms with multiorgan failure. However, despite the high risk of death for patients on hemodialysis, not all government policies advocate for their hospitalization.

The authors decided to highlight here the only two cases of COVID-19 infection in patients incident in renal replacement therapy in the Alentejo region, their clinical course and outcome.

 

Case report 1

The first patient was a 72-year-old man, with chronic bronchitis and chronic kidney disease stage 5 of unknown etiology, with a two-year-old arteriovenous fistula. The patient was admitted to our dialysis unit to start HD as he claimed to have light uremic symptoms. The first dialytic session, lasting 2 hours and with zero ultrafiltration, went well and the patient was discharged the same day. On the next day, he went to the emergency room with epistaxis. Screening for SARS-CoV-2 was positive and he was admitted to hospital.

Blood results showed elevated markers of inflammation: CRP 17.6mg/dL, ferritin 2130ng/mL, PCT 1.18ng/ml, LDH 445U/L, IL-6 84.62pg/mL (Table I). During his stay he became febrile, with respiratory distress and at day 5 after admission he had to be put on invasive mechanical ventilation and was transferred to the intensive care unit (ICU) where, on day 2, he developed multiorgan failure and died. He underwent 2 intermittent dialysis sessions.

Patient 1 Hospital Admission ICU Admission 24h ICU 48h ICU (death)
Leucocytes x109 cells/L 7200 10300 13600 13300
CRP mg/dL 17,8 31  
PCT ng/mL 1,18 3,93 2,76 2,09
Ferritin ng/mL 2130 3240 3280
LDH U/L 445 578 41403 41236
IL-6 pg/mL 84,62 214 596,1 4413
Cr mg/dL 7,11 4,21 2,96 1,38
Ur mg/dL 193 91 69 21
Table I: Blood test results for patient 1

 

Case report 2

The first patient was a 70-year-old woman with hypertension, type 2 diabetes mellitus on insulin therapy, congestive heart failure class II NYHA and chronic kidney disease stage 5, with an arteriovenous fistula built two years before. The patient resided in a Nursing Home affected by a COVID-19 outbreak, where she got infected. She was admitted to the emergency room with dyspnea, hypoxemia and generalized muscle pain. Due to the worsening of her clinical status and uremic symptoms, she was started on hemodialysis 5 days later. After her first intermittent hemodialysis session she developed fever and raised markers of inflammation (Table II). After her third dialysis session, she became obnubilated, developed polypnea and went on invasive mechanical ventilation on day 7 after her hospital admission. One month later, she died on the ICU with multiorgan failure.

Patient 2 Hospital Admission ICU Admission 24h ICU 48h ICU Discharge (death)
Leucocytes x109 cells/L 4700 5400 7200 6600 11200
CRP mg/dL 2,3
PCT ng/mL 0,46 0,95 1,15 1,49 2,31
Ferritin ng/mL 706 1570 1510 1610 1890
LDH U/L 502 422 402 431
IL-6 pg/mL 49 134.2 259,3 500,6 351,5
Cr mg/dL 12,54 3,67 4,62 1,37 0,5
Ur mg/dL 331 65 80 21 10
Table II: Blood test results for patient 2

 

Discussion and conclusions

The severity of the SARS-CoV-2 infection is associated with risk factors such as advanced age, male gender, diabetes mellitus, obesity, hypertension, lung disease and elevated serum creatinine levels [1]. In one study the authors showed that the presentation of the disease in patients undergoing dialytic treatment was similar to that of the general population. However, the prognosis was worse with 31% overall mortality and 75% mortality in patients undergoing invasive mechanical ventilation [2].

Given the increased number of SARS-CoV-2 infections in the general population, we expected that the disease would soon reach the hemodialysis population. Travelling to dialysis centres with shared ambulances and sharing the same treatment room create the ideal environment to increase the risk of transmission.

Most patients with COVID-19 do not have kidney damage. Nevertheless, those who develop acute kidney injury manifest the most severe phenotype of the disease, characterized by cytokine storm, overall respiratory failure and hypercoagulability [3]. Acute renal injury in patients with COVID-19 may result from: direct cytokine injury, myocardiopathy resulting in cardiorenal syndrome type 1, medullary renal hypoxia, increased vascular permeability, renal hypoperfusion, tubular toxicity, endotoxin injury in sepsis [4].

Despite the high number of prevalent patients in HD in Portugal, the number of COVID-19 infections in these patients has so far been unexpectedly low. In part, this can be justified by the good hygienization practice implemented quickly in the intra- and extra-hospital dialysis units, by the generalized use of masks among personnel and patients, and by good patient education. The immunosuppressed status of those who did become infected seems to prevent the emergence of the cytokine storm that is a critical mediator for the clinical worsening. Another plausible explanation is the protective role of anticoagulation, since SARS-CoV-2 infection promotes thrombogenesis. Pisani et al. (2020) present heparin anticoagulation used in hemodialysis as a possible major contribution to a more indolent, limited, less severe clinical evolution in HD patients, either because of its role in preventing the entry of SARS-CoV-2 into host cells by interacting with the recombinant receptor-binding surface SARS-CoV-2 S1 RBD, or because of its anti-inflammatory properties [5].

The situation of the dialysis population in the Alentejo region can be seen to confirm the evidence already described. Until November, only five COVID-19 cases had been reported in patients on chronic HD. Most had fever and cough initially, 3 required additional oxygen support and even 1 patient with lung cancer needed invasive mechanical ventilation for only 5 days. All received only symptomatic treatment and recovered without sequelae. By contrast, the only 2 cases of patients incident on hemodialysis had the worst outcome.

The authors hypothesise that the high serum concentration of urea and other uremic toxins in stage 5 patients not on dialysis may decapitate the appearance of typical symptoms of SARS-CoV-2 infection, such as fever. Once the dialytic treatment is initiated, clearance of those molecules will lead to the reduction of this inhibitory effect and consequently to the elevation of the baseline temperature and onset of fever, if there is an active infection. Schreiner (1961) showed that uremic patients may be unable to develop a febrile immune system response to an infection. When urea levels are corrected through dialytic treatment, however, fever appears [6].

Other authors state that, when the serum urea level is higher than 100mg/dL, patients show a decrease in body temperature as a consequence of decreased metabolism caused by uremic substances [7]. The idea of “uremic hypothermia” dates back to the 18th century [8]. The role of the kidneys in thermoregulation is well documented in the literature: the kidneys contribute to more than 10% of body heat by high aerobic metabolism [9]. One study shows that 23% of patients with chronic renal disease stage 5 pre-dialysis are hypothermic [10].

With regards to the baseline temperature of patients on chronic hemodialysis, the evidence is contradictory. If, on the one hand, there are studies that report patients in renal replacement therapy having lower baseline temperature [11], on the other, the latest evidence shows that dialysed patients may exhibit a higher temperature during an infectious state than other patient populations [12]. In the study published by Weatherall et al. (2020), patients in HD were found to have a higher baseline temperature but the mechanism for this event was not clear [13]. Some authors speculate that chronic inflammation resulting from repeated exposure to dialysis and water contaminated with Gram-negative bacteria can lead to the release of endotoxins into the filter membranes, which in turn will lead to increased pro-inflammatory cytokine production [14]; this is not at all likely anymore, with the ultrapure water in use nowadays. Other authors argue that the increased metabolic rate and peripheral vasoconstriction during hemodialysis lead to increased body temperature [11]. The role of comorbidities may also influence body temperature, as diabetic patients have lower temperatures, probably due to autonomic dysfunction [15]. Despite these various studies, the physiological mechanism of uremic hypothermia has only partially been unveiled. Jones et al. suggested in 1985 that a decrease in hypothalamic response to the action of leukocytic pyrogen (LP) and a reduced capacity in heat generation through chills and vasoconstriction in response to LP could cause a lower body temperature in the presence of higher levels of serum urea; it also concluded that the production of LP in patients with chronic kidney disease is similar in patients without renal failure [16].

The cases reported here affected patients who started intermittent hemodialysis and were under continuous renal replacement therapy in the intensive care unit, on account of their critical clinical status and hemodynamic instability. It is still controversial wheather the most severe form of COVID-19 pneumonia is characterized by acute respiratory distress syndrome and high inflammatory markers like CRP, ferritin, PCT and cytokines: there are in fact many cases where patients get severe lung injury without the so-called “cytokine storm” [17].

SARS-CoV-2 is sufficiently aggressive to cause organizing pneumonia, which is a risk factor for secondary bacterial and fungal infections. However, believing that uremic toxins can have a protective role against this hyperinflammatory phenotype, authors defend that end stage kidney disease patients should be managed with medical therapy (potassium and phosphate binders, liquid restriction), while delaying the start of hemodialysis. If this is not possible, then a lower clearance strategy should be employed to minimize the removal of uremic toxins with their protective effect.

The fact that patients with CKD stage 5 not on dialysis can present active infection without fever may lead to a delayed diagnosis and, consequently, to an increased risk of mortality. But in patients on maintenance hemodialysis COVID-19 has a different presentation. The data about patients on maintenance hemodialysis is contradictory, with papers showing that HD patients presented milder symptoms and were often asymptomatic, and other reports showing that the clinical presentation is similar to the general population. In fact, a recent report found that the mortality of patients on maintenance hemodialysis is higher, but the study has excluded asymptomatic HD patients. Furthermore, the number of patients on HD with fever was exactly the same as the number of patients in the control group and it would have been more interesting if the authors had included the different stages of CKD as a comorbidity in non-dialysis group [18].

The hemodialysis patient population has a chronic state of immunosuppression secondary to chronic kidney disease and a higher number of comorbidities, making it one of the most vulnerable populations in the current pandemic context.

The prognosis of incident and prevalent patients in HD still needs multivariate analysis and a long-term evaluation of the possible sequelae left in this population.

 

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

 

References

  1. Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, et al. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int 2020; 97:829–838. 
  2. Valeri AM, Robbins-Juarez SY, Stevens JS, Ahn W, Rao MK, Radhakrishnan J, et al. Presentation and Outcomes of Patients with ESKD and COVID-19. JASN 2020; 31:1409–1415.
  3. Betônico GN, Lima EQ, Tome AC. Challenges in COVID-19 medical response: A nephrology perspective. Eur J Clin Invest 2020; 50:e13309.
  4. Ronco C, Reis T. Kidney involvement in COVID-19 and rationale for extracorporeal therapies. Nat Rev Nephrol 2020; 16:308–310. 
  5. Pisani A, Rizzo M, Angelucci V, Riccio E. COVID-19 Experience in Hemodialysis Patients: A Cue for Therapeutic Heparin-Based Strategies? Nephron 2020; 144(8):383–385.
  6. Schreiner G. Uremia. Springfield, III, Charles C Thomas Publisher. 1961; 380–384.
  7. Ash SR. An explanation for uremic hypothermia. Int J Artif Organs 1991; 14(2):67–69.
  8. Bradford J. The influence of the kidney on metabolism. J Physiol 1899; 23:415–496.
  9. Harris SI, Balaban RS, Barrett L, Mandel LJ. Mitochondrial respiratory capacity and Na+- and K+-dependent adenosine triphosphatase-mediated ion transport in the intact renal cell. J Biol Chem 1981; 256:10319–10328.
  10. Fine A, Penner B. The protective effect of cool dialysate is dependent on patients’ predialysis temperature. Am J Kidney Dis 1996; 28:262–265.
  11. Pérgola PE, Habiba NM, Johnson JM. Body temperature regulation during hemodialysis in long-term patients: is it time to change dialysate temperature prescription? Am J Kidney Dis 2004; 44:155–165.
  12. Hasan R, Adhi M, Mahmood SF, Noman F, Awan S, Akhtar F, et al. Range for normal body temperature in hemodialysis patients and its comparison with that of healthy individuals. Nephron Clin Pract 2010; 114:c303–c308.
  13. Weatherall SL, Chambers AB, Mermel LA. Do Bacteremic patients with end-stage renal disease have a fever when presenting to the emergency department? A paired, retrospective cohort study. BMC Emergency Med 2020; 20:2.
  14. Sajadi MM, Mackowiak PA. Pathogenesis of fever. In: Cohen J, Powderly WG, Opal SM, eds. Infectious Diseases. 4th ed. Amsterdam: Elsevier 2017, pp. 605–610.
  15. Kenny GP, Sigal RJ, McGinn R. Body temperature regulation in diabetes. Temperature 2016; 3:119–145.
  16. Jones PG, Kauffman CA, Port FK, Kluger MJ. Fever in Uremia: Production of Leukocytic Pyrogen by Chronic Dialysis Patients. Am J Kidney Dis 1985; Oct; 6(4):241–244.
  17. Sinha P, Matthay MA, Calfee CS. Is a “Cytokine Storm” Relevant to COVID-19? JAMA Intern Med 2020; 180(9):1152–1154.
  18. Reis M, Almeida C, Ventura A, Ribeiro C, Gomes AM, Lopes D, et al. Is COVID-19 that different in hemodialysis patients?: A single-center experience. Port J Nephrol Hypert 2021; 35(2):93–98.

Self-efficacy and self-management in patients in hemodialysis: a narrative review of multidisciplinary theories

Abstract

Hemodialysis is the most common treatment in patients with end-stage chronic kidney disease and the wide accessibility of this therapy has prolonged the patients’ lifespan. However, it involves alterations in their emotional sphere and, often, a reduction in therapeutic compliance as the chronicity of kidney disease requires lifestyle changes difficult to maintain in the long term. The management of a chronic medical condition is in fact a complex process that necessarily requires multidisciplinary action.

The concepts of “Self-efficacy” and “Self-management” fall within the Self-Determination Theory and are relevant in this context because they refer to the beliefs that everyone has about their abilities to control behavior and determine the success in adhering to prescribed therapies.

Furthermore, the promotion of self-efficacy and self-management through an educational approach that makes use of so-called “eHealth” tools can help develop greater self-awareness in dialysis patient, a better control over their care choices and an increased adherence to therapeutic-dietary indications.

This article aims at highlighting the importance of implementing an approach based on eHealth in the management of hemodialysis patients. It also wants to raise awareness of the related multidisciplinary theories to be applied in this clinical context to promote greater therapeutic adherence, and therefore a better quality of life and care.

Keywords: self-efficacy, self-management, hemodialysis, kidney disease, eHealth

Sorry, this entry is only available in Italian. For the sake of viewer convenience, the content is shown below in the alternative language. You may click the link to switch the active language.

Background

L’insufficienza renale (IRC), in particolare nello stadio più avanzato, è tra le più importanti cause di morte e disabilità in tutto il mondo [1]. L’emodialisi costituisce il trattamento più comune per chi soffre di IRC e il suo utilizzo ha portato a prolungare la vita dei pazienti [2], tuttavia esso comporta molteplici alterazioni, tra cui disturbi del sonno, neuropatia periferica, infezioni, anemia, prurito, disagio emotivo che influenzano diversi aspetti della qualità di vita dei pazienti [3].

Al pari delle altre malattie croniche, la gestione di questi pazienti richiede un processo multidisciplinare coordinato tra operatori sanitari e pazienti [4,5]. La cronicità della malattia renale impone infatti al paziente molte modifiche del proprio stile di vita che diventano spesso difficili da mantenere a lungo termine [6]. La qualità della vita del paziente emodializzato è significativamente compromessa dal vissuto emotivo di dipendenza, che costringe a vivere la propria esistenza con incertezza e preoccupazioni esistenziali costanti, nonché dai sintomi legati all’IRC, ad altre patologie coesistenti e alle caratteristiche del trattamento sostitutivo stesso [7]. Tali condizioni generano nei pazienti in emodialisi il bisogno di rivendicare continuamente il controllo della propria vita e, allo stesso tempo, avvertono una perdita di indipendenza e di mancanza di libertà. Inoltre, la visione del paziente è a volte in conflitto con l’opinione del professionista sanitario su ciò che è meglio per sé stesso (talvolta il paziente può preferire condizioni mediche meno ottimali dal punto di vista clinico o persino scegliere di interrompere la dialisi) in cambio di una maggiore libertà o controllo sugli aspetti della propria vita quotidiana [8]. Di conseguenza è importante che il paziente in dialisi, come accade per gli altri pazienti con patologie croniche, acquisisca un certo grado di autonomia nella gestione della propria condizione di salute attraverso lo sviluppo di abilità di self-care [5,9,10].

 

La visualizzazione dell’intero documento è riservata a Soci attivi, devi essere registrato e aver eseguito la Login con utente e password.

Hyperkalemia-induced acute flaccid paralysis: a case report

Abstract

Acute flaccid paralysis is a medical emergency that may be caused by primary neuro-muscular disorders, metabolic alterations, and iatrogenic effects. Severe hyperkalemia is also a potential cause, especially in elderly patients with impaired renal function. Early diagnosis is essential for appropriate management.

Here, we report the case of a 78-year-old woman with hypertension and diabetes presenting to the emergency department because of pronounced asthenia, rapidly evolving in quadriparesis. Laboratory examinations showed severe hyperkalemia of 9.9 mmol/L, metabolic acidosis, kidney failure (creatinine 1.6 mg/dl), and hyperglycemia (501 mg/dl). The electrocardiography showed absent P-wave, widening QRS, and tall T-waves. The patient was immediately treated with medical therapy and a hemodialysis session, presenting a rapid resolution of electrocardiographic and neurological abnormalities. This case offers the opportunity to discuss the pathogenesis, the clinical presentation, and the management of hyperkalemia-induced acute flaccid paralysis.

Keywords: hyperkalemia, acute flaccid paralysis, hemodialysis, diabetes

Introduction

Hyperkalemia is associated with poor outcomes and a high mortality rate among the general population, and among patients with cardiac and renal disease [1,2]. Hyperkalemia-related clinical complications and deaths are determined mainly by the cardiac electrophysiological effects of elevated potassium levels [3]. Indeed, hyperkalemia may result in ventricular arrhythmias and sudden death. Moreover, hyperkalemia may also cause other physiologic perturbations, such as muscle weakness and paralysis, paraesthesia, and metabolic acidosis.

Here, we report a case of severe hyperkalemia presenting with dramatic neurological manifestations in the form of acute flaccid paralysis (AFP).

 

La visualizzazione dell’intero documento è riservata a Soci attivi, devi essere registrato e aver eseguito la Login con utente e password.

Hemodialysis shake-up on the front lines of the Covid-19 pandemic: the Treviglio Hospital experience

Abstract

The new coronavirus disease (Covid-19) pandemic in Italy formally started on 21st February 2020, when a 38-years old man was established as the first Italian citizen with Covid-19 in Codogno, Lombardy region. In a few days, the deadly coronavirus swept beyond expectations across the city of Bergamo and its province, claiming thousands of lives and putting the hospital in Treviglio under considerable strain.

Since designated Covid-dialysis hospitals to centrally manage infected hemodialysis patients were not set up in the epidemic areas, we arranged to treat all our patients. We describe the multiple strategies we had to implement fast to prevent/control Covid-19 infection and spread resources in our Dialysis Unit during the first surge of the pandemic in one of the worst-hit areas in Italy. The recommendations provided by existing guidelines and colleagues with significant experience in dealing with Covid-19 were combined with the practical judgement of our dialysis clinicians, nurses and nurse’s aides.

KEYWORDS: COVID-19, hemodialysis, end-stage kidney disease, coronavirus, pandemic.

Introduction

Since December 2019, an outbreak of new coronavirus disease (Covid-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has developed into a global pandemic [1]. Its outburst in Italy officially dates back to February 21st, 2020. In a few days, the number of detected cases increased beyond expectations [2]. The deadly coronavirus swept across the city of Bergamo and its province, claiming thousands of lives and putting the hospital in Treviglio under considerable strain; all departments had to be readapted and most beds were rapidly occupied by infected patients. 

La visualizzazione dell’intero documento è riservata a Soci attivi, devi essere registrato e aver eseguito la Login con utente e password.

Spondylodiscitis in hemodialysis patients: a new emerging disease? Data from an Italian Center

Abstract

Hemodialysis (HD) patients are at high risk for infectious complications such as spondylodiscitis. The aim of this retrospective study was to evaluate the cases of infective spondylodiscitis occurred between May 2005 and October 2019 among HD patients at our center.

In 14 years, there were 9 cases (mean age 69±12 years). The main comorbidities found were diabetes mellitus (55.6% of patients), hypertension (55.6%), bone diseases (22.2%), cancer (11.1%) and rheumatoid arthritis treated with steroids (11.1%). The clinical onset included back pain (100% of cases), fever (55.6%), neurological deficits (33.4%), leukocytosis (55.6%) and elevated CRP level (88.9%).

Most cases were diagnosed by magnetic resonance imaging (66.7%) with more frequent involvement of lumbar region (77.8%). Blood cultures were positive in five patients (mostly for S. aureus); three of them used catheters as vascular access and, in two cases, their removal was necessary. The mean time interval between the onset of symptoms and the diagnosis was 34±42 days.

All patients received antibiotic treatment for a mean duration of 6 weeks; most cases were initially treated with vancomycin or teicoplanin plus ciprofloxacin. Most patients (77.8%) recovered after a mean of 3.5 months; one patient had a relapse after 2 years and one patient had long-term neurologic sequelae.

Infective spondylodiscitis in HD must be suspected in the presence of back pain, even in the absence of fever or traditional risk factors. An early diagnosis could improve the outcome. Close monitoring of vascular access, disinfection procedures and aseptic techniques are important to avoid this complication.

 

Keywords: spondylodiscitis, hemodialysis, back pain, vascular access, infectious complications, bacteremia

Introduction

Septicemia and infections contribute to 12% of deaths in uremic patients [1].

Hemodialysis (HD) patients represent a risk category for bacteremia (in particular caused by S. aureus), because of the coexistence of multiple risk factors: the immunodepression typical of uremia, the frequent venopunctures of native and prosthetic fistulas and the presence of temporary or permanent venous catheters [23].

One of the possible complications of bacteremia is spondylodiscitis, defined as infection of the vertebra and intervertebral disc sometimes extended to the surrounding soft tissues [47]. The incidence of this disease varies between 1:250,000 patients/year [89] and 0,4-2,4:100.000 patients/year [5] in the general population, while the major studies carried out on HD patients report an incidence of 1:80–1:215 patients/year [1011].

Although bacterial spondylodiscitis is one of the most serious complications that can occur to dialysis patients, few cases have been reported in the literature; it is therefore not clear which is the best clinical management. Moreover, diagnosis may be often delayed due to the insidious onset of the symptoms.

Considering the cases occurred in our center, in this work we analyze the clinical features and the problems related to the diagnosis and the therapy of spondylodiscitis in HD patients; the possible risk factors related to the onset of this disease are also considered.

 

Methods

A retrospective study has been conducted by evaluating all cases of infective spondylodiscitis that occurred between May 2005 and October 2019 among the HD patients at our center (IRCCS Multimedica, Sesto San Giovanni, Milan, Italy).

Patients were identified according to a diagnosis of “spondylodiscitis” and “ESRD” from the hospital records. The diagnosis of infective spondylodiscitis was based on clinical data, laboratory results [5, 12] and diagnostic imaging tests [1213]. The exclusion criteria were as follows: post-operative spinal infection, patients affected by chronic renal insufficiency not in hemodialysis, patients who received HD for less than 14 days. We finally included 9 cases.

For each patient, demographic data, personal medical history, dialytic age and type of vascular access were collected. The baseline characteristics included age, gender, primary cause of ESRD and main comorbidities (diabetes mellitus, hypertension, malignancy, bone and joint diseases). Regarding infective spondylodiscitis, initial clinical symptoms, laboratory and culture test results, diagnostic tools and location of spinal infection were collected for each patient. We focused in particular on the time interval between the onset of symptoms and the diagnosis, often delayed.

Finally, we collected data regarding the treatments performed and the patients’ outcomes.

 

Results

In 14 years, there have been 9 cases of infective spondylodiscitis in our center, with an estimated incidence of 1:200 patients/year. The incidence was calculated by comparing the number of cases to the dialysis population over 14 years (we usually treat chronically 100 HD patients).

Table 1 shows the clinical characteristics of the patients with infective spondylodiscitis treated in our center. Sixty-seven percent of patients were male, the mean age was 69±12 years. The primary causes of ESRD included diabetic nephropathy (3 patients, 33.4%), obstructive nephropathy (2 patients, 22.2%), autosomal dominant polycystic kidney disease (1 patient, 11.1%), arterial hypertension (1 patient, 11.1%) and unknown causes (2 patients, 22.2%). Five patients (55.6%) were affected by diabetes mellitus, 11.1% by obesity, 55.6% by arterial hypertension and 22.2% by bone diseases. One patient was known for rheumatoid arthritis and was in chronic treatment with low-dose steroids and azathioprine; none of the other patients received chronic immunosuppressive therapy. One patient was affected by prostatic cancer.

All patients had back pain as an initial symptom, 55.6% had fever, while 33.4% had neurological symptoms, such as limb weakness and paresthesia (Table 2).

 

Patient Age [years] Gender Cause of ESRD Comorbidities
1 62 M Diabetes Diabetes
2 78 M Unknown Myelodysplasia
3 63 M Unknown Obesity, arterial hypertension, hypothyroidism, diabetes
4 78 F Unknown Rheumatoid arthritis, osteoporosis
5 69 F Nephrolithiasis Diabetes, secondary hyperparathyroidism
6 73 F ADPKD Diabetes, arterial hypertension, Graves’ disease, vasculopathy
7 88 M Obstructive nephropathy Arterial hypertension, prostatic cancer
8 48 M Diabetes Diabetes, arterial hypertension
9 61 M Arterial hypertension Arterial hypertension
ESRD, end stage renal disease; ADPKD, autosomal dominant polycystic kidney disease
Table 1: Characteristics of the patients with infective spondylodiscitis in care at our center.

 

Patient Back Pain Fever Neurological symptoms WBC CRP Diagnostic tools Location
1 Yes Yes No 26700 26.7 CT, MRI D9-D10
2 Yes Yes No 28000 22 MRI L5-S1
3 Yes No Yes 10200 5.83 MRI L3-L4
4 Yes No Yes 3800 9.9 MRI L4-L5
5 Yes Yes Yes 15500 10.1 MRI D4-D5
6 Yes No No 6230 8.52 CT, MRI L4-L5
7 Yes No No 5290 0.3 MRI L4-L5
8 Yes Yes No 22500 31.8 CT L4-L5
9 Yes Yes No 7130 3.7 MRI L1-L2
WBC, white blood cell count (cells/ml); CRP, c-reactive protein (mg/dl); MRI, magnetic resonance imaging
Table 2: Initial clinical presentation, initial laboratory results, diagnostic tools, location of infection.

 

Figure 1: MRI of the lumbosacral spine without gadolinium contrast showing discitis at the L4–L5 level (patient n. 6)

 

At hospital admission 55.6% of patients had leukocytosis, while 88.9% had elevated CRP levels (Table 2).

Six patients (66.7 %) had their diagnoses confirmed by magnetic resonance imaging (MRI) (Figure 1), while two had a CT performed prior to MRI (Table 2). One patient had his diagnosis confirmed by CT only (it was not possible to perform MRI because of the presence of a metallic foreign object in the patient’s body). All patients had performed a spine radiograph that turned out not to be diagnostic. In no case it was necessary to perform a FDG-PET for the diagnosis of spondylodiscitis. Echocardiography was performed in 2 cases, both negative for valvular vegetation, to exclude infective endocarditis.

The lumbar level was the most common site of infection (7 patients, 77.8 %); in 2 patients (22.2 %), the thoracic spine was also involved, while in no case the cervical spine was involved (Table 2).

The mean dialytic age was 33±38 months, as reported in Table 3. Four patients (44.4 %) used an arteriovenous fistula (AVF) as vascular access for hemodialysis, 1 patient (11.1 %) used an arteriovenous graft (AVG), 3 patients (33.4 %) used a tunneled cuffed catheter (TCC), and 1 patient (11.1 %) used a non-tunneled catheter (NTC) (Table 3). Two patients had experienced thrombosis of the arteriovenous fistula for hemodialysis and underwent endovascular surgery. The surgical interventions had not been successful; for this reason, central venous catheters for hemodialysis had been positioned (a tunneled cuffed catheter in one case, a non-tunneled catheter, then removed and replaced, in the other). Blood cultures were positive in five cases, four for S. aureus (Table 3) and one for S. agalactiae. In the first of our 9 cases, the non-tunneled catheter, which was the source of the infection, was removed and replaced. In the second case the infection was successfully treated without the need of removing the tunneled cuffed catheter. In the third and fourth cases, the patients had AVFs and no sign of local infection. In the fifth case, the removal of the TCC was necessary due to the persistence of a septic status related to the catheter. A NTC was subsequently placed and an AVF was created.

 

Patient Dialytic age [months] Vascular access Blood culture Bone biopsy Diagnostic delay
1 45 NTC S. aureus Not executed 1 month
2 24 AVF Negative Not executed 3 months
3 3 TCC S. aureus Not executed 5 days
4 57 AVF Negative Not executed 10 days
5 12 AVF S. aureus S. aureus 3 weeks
6 120 AVG Negative Negative 4 months
7 16 TCC Negative Not executed 3 weeks
8 1 TCC S. aureus Negative 3 days
9 15 AVF Streptococcus agalactiae Not executed 5 days
AVF, arteriovenous fistula; AVG, arteriovenous graft; NTC, non-tunneled catheter; TCC, tunneled cuffed catheter
Table 3: Dialytic age, vascular access for hemodialysis, culture results, time interval between onset of symptoms and diagnosis

 

A bone biopsy was performed in three instances (Table 3). In the first case, the patient developed a paraplegia with level D4 during hospitalization; she was therefore subjected to a neurosurgical operation of bone marrow decompression. The bone culture test confirmed the diagnosis of S. aureus spondylodiscitis. Despite surgical intervention and the use of targeted systemic antibiotic therapy, the recovery of lower limb function was not achieved. In the second case, a bone biopsy was performed because of the persistence of painful symptoms after months of antibiotic therapy; the cultural exam of the disc and the vertebral body was negative; the patient was then discharged with a diagnosis of chronic spondylodiscitis. In the third case, the bone biopsy was also performed due to the persistence of painful symptoms and the exam resulted negative.

The mean time interval between the onset of symptoms and the diagnosis was 34±42 days (Table 3). All patients received antibiotic treatment and the mean treatment duration was 6 weeks (Table 4). In most cases, vancomycin or teicoplanin plus ciprofloxacin were used as initial antibiotics (Table 4). The aim of the initial empiric treatment was to cover Staphylococci and Gram-negative bacilli. One patient underwent surgical intervention due to progressive neurologic deficits, as reported above. In four cases, the use of an orthopedic corset was prescribed (Table 4).

One patient had another infective spondylodiscitis within 2 years, caused by a different organism to in his first event. One patient had long-term neurologic sequelae despite surgical treatment. The others 7 patients recovered after a mean of 3.5 months (Table 4).

 

Patient Antibiotics Duration of antibiotic therapy Surgical treatment Orthopedic corset Outcome
1 Vancomycin plus gentamicin 4 weeks No Yes Recurrent after 2 years
2 Vancomycin plus ciprofloxacin; then teicoplanin plus ceftazidime 8 weeks No No Resolution after 2 months
3 Vancomycin plus ciprofloxacin plus ceftazidime 8 weeks No No Resolution after 3 months
4 Teicoplanin plus ciprofloxacin 4 weeks No Yes Resolution after 3 months
5 Vancomycin plus ciprofloxacin 8 weeks Yes, bone marrow decompression / Paraplegia D4
6 Levofloxacin plus rifampicin 4 weeks No Yes Resolution after 8 months
7 Ciprofloxacin 8 weeks No No Resolution after 3 months
8 Teicoplanin; then Linezolid 8 weeks No Yes Resolution after 4 months
9 Vancomycin plus levofloxacin 4 weeks No No Resolution after 1 month
Table 4: Treatments and outcome of patients

 

Discussion

In our center there have been 9 cases of infective spondylodiscitis over 14 years, with an estimated incidence of 1:200 patients/year, which is in line to what has been previously reported in the literature regarding HD patients [1011].

The mean age of the patients considered in our study was 69±12 years, suggesting, as is also reported in the literature, that in recent years spondylodiscitis has evolved from an acute pathology with a high mortality mostly affecting young patients to a more indolent disorder affecting elderly patients, with a reduced mortality but more frequent relapses and debilitating sequelae [14].

The most frequent comorbidities found in our patients were diabetes mellitus (55.6%), arterial hypertension (55.6%) and bone diseases (22.2%). Several risk factors for spondylodiscitis are reported in the literature: diabetes mellitus, intravenous drug abuse, liver disease, immunodeficiency, alcoholism, rheumatoid arthritis, steroid therapy, immunosuppressive therapy, tumors [1516]. The prevalence of arterial hypertension among our cases of spondylodiscitis appears lower than that of the hemodialysis population (55.6% vs 80%); however, the relationship reported in previous studies between arterial hypertension and spondylodiscitis in HD patients is an association, not a cause and effect relationship. The prevalence of diabetes mellitus in our sample appears to be higher than that reported in the literature among hemodialysis patients (55.6% vs 30%). This could indicate that diabetes can favor infectious processes, including spondylodiscitis, and confirms that diabetes mellitus could be a risk factor for vertebral infections, as reported in previous studies. It is interesting to note that in our case series one patient was treated for rheumatoid arthritis with low-dose steroids and azathioprine at the time of the spondylodiscitis episode; another patient was affected by prostatic cancer.

Our small sample of patients seems therefore representative of the main risk factors for spondylodiscitis, except for alcoholism and liver disease; in it we found diabetes mellitus, rheumatoid arthritis, steroid therapy and cancer. Moreover, other risk factors, related to the state of uremia and to dialysis treatment, may play a decisive role in the onset of spondylodiscitis: they are the immunodepression typical of uremia, the frequent use of central venous catheterization as vascular access for hemodialysis, the frequent venopuncture of the fistulas, both native and prosthetic, and the endovascular surgery procedures for thrombosis of the vascular access, with the consequent greater risk of bacteremia and infectious complications [23]. In our case series, 44.4% of patients used an AVF as vascular access for hemodialysis, 11.1% used an AVG, 33.4% used a TCC, and 11.1% used a NTC. Two patients had experienced thrombosis of the arteriovenous fistula, requiring endovascular surgery. Moreover, the blood cultures resulted positive for S. aureus in three of the four patients with central venous catheter and the catheter removal was necessary in two cases. A previous article reports that 91% of their spondylodiscitis cases used a central venous catheter instead of an arteriovenous fistula as vascular access for hemodialysis [17]. For this reason, possible preventive strategies in hemodialysis patients are the choice of AVF as vascular access, as it is associated with a lower incidence of spondylodiscitis compared to the TCC [11], and the close monitoring of the vascular access, paying particular attention to disinfection procedures and aseptic techniques [18].

In our case series, all patients had back pain at the onset of symptoms, while fever and neurological symptoms were present only in some. The literature also describes back pain as the main clinical manifestation of the disease; it is present in 90% of all cases, at the level of the affected bone metamer [15]. Fever is not a constant finding and is present only in half of the cases, while neurological symptoms are found in 30% of patients with spondylodiscitis [1516]. At hospital admission 55.6% of our patients had leukocytosis, 88.9% had elevated CRP levels. In the literature, leukocytosis is reported in 40% of cases and an increase in inflammatory indices in 80% of them [19].

Magnetic resonance imaging of the spine is the most sensitive and specific radiological method to diagnose vertebral osteomyelitis; it is also the procedure of choice to assess the extent of the disease, the involvement of soft tissues and neurological structures and the possible presence of abscesses [13]. Spine radiography is often performed first and shows alterations in 89% of cases [13]; however, it has a reduced sensitivity and specificity, especially in the early stages [20]. CT is less sensitive than MRI and is generally used when the latter is contraindicated, as well as to perform CT guided percutaneous biopsy [20]. A final exam that can help locate abnormalities and monitor the response to treatment is FDG-PET, which is especially indicated in cases where the patient cannot undergo MRI [12, 21]. In our case series, 66.7% of patients had their diagnoses confirmed by MRI, one patient had his diagnosis confirmed by CT, while two patients had a CT performed prior to MRI. In no case we performed FDG-PET.

In our sample of patients, the lumbar spine was the most common site of infection, followed by the thoracic spine. Generally, the lumbar vertebrae are the most frequently affected (60-70% of cases in the literature) given their wide vascularization [22]. As reported in previous studies, in 10% of cases the infection localizes at the cervical level (the site that can most frequently lead to neurological complications); in 20-30% of cases it is localized at the thoracic level, while the sacral localization is found in less than 10% of cases [5, 23].

In our study, blood cultures were positive in five instances, four for S. aureus and one for S. agalactiae. Spondylodiscitis are generally due to a hematogenous infection by S. aureus (50% of cases in the literature), but episodes caused by Gram-negative, P. aeruginosa, S. epidermidis, Streptococci of group C and G have been described (especially in diabetic patients) [4]. Generally, blood cultures are positive in 50-70% of patients with vertebral osteomyelitis [1516].

We performed a bone biopsy in three cases. CT-guided percutaneous vertebral disc biopsy may be considered in patients with negative blood cultures who do not respond to antibiotic therapy; it identifies the pathogen in 60-70% of cases. The possibility of identifying the causative pathogen is reduced if the patient has previously taken antibiotics. The histological examination of the biopsy may show disc necrosis and neutrophil infiltration, too [5]. In patients with suspected spondylodiscitis, with persistent symptoms despite antibiotic therapy and negative microbiological tests (blood culture and disc biopsy) it is indicated to repeat a second percutaneous biopsy and eventually proceed with an open biopsy, that is positive in 75% of cases [5, 12].

All our patients received antibiotic treatment, in most of the cases vancomycin or teicoplanin plus ciprofloxacin as initial therapy. Randomized controlled trials on empirical antibiotic therapy have not yet been conducted and therefore no antibiotic, alone or in an association, is currently considered superior to the others in treating this infection. Usually, an empirical antibiotic therapy is set up with broad-spectrum antibiotics with anti-staphylococcal activity (for example vancomycin or teicoplanin), also associating an agent with anti-negative bacilli activity [2425]. Antibiotic therapy should continue for at least 4-8 weeks (up to 6-12 weeks) [2425]. In our case series, the mean treatment duration was 6 weeks.

The recommended therapy also consists in immobilization, with bed rest with analgesia for at least 2-4 weeks, followed by the gradual mobilization with orthopedic corset; this was prescribed to four of our patients. Surgery can be indicated if there are neurological deficits, radicular compression, a need to prevent and correct instability and deformity, severe persistent pain, or when it is necessary to perform drainage of abscesses or open biopsy [6, 23]. In our case series, only one patient underwent surgical intervention due to progressive neurologic deficits.

The mortality rate for spondylodiscitis among HD patients is reported at 16.7%. In our case series, no patient died due to infection, although one had a second infective spondylodiscitis within 2 years and another suffered from long-term neurologic sequelae, despite surgical treatment. The others seven patients recovered after an average of 3.5 months.

An early diagnosis that identifies, where possible, the responsible microorganism, could prevent the development of such complications and could improve the outcome for patients, allowing for a prompt resolution of the infective episode [14]. An algorithm on the possible diagnostic/therapeutic workup for the management of suspected cases of spondylodiscitis among hemodialysis patients is shown in Figure 2.

 

Figure 2: Algorithm on the possible diagnostic/therapeutic workup for the management of suspected cases of spondylodiscitis among hemodialysis patients.

 

Our study certainly presents some limits due to the reduced number of cases and its descriptive and retrospective nature. However, it is the first Italian study that focuses on this rare disease, characterized by important mortality and complications, especially among hemodialysis patients, and on the diagnostic delay that often occurs.

 

Conclusions

Infective spondylodiscitis must be suspected in the presence of back pain in HD patients, even in the absence of fever and traditional risk factors. In order to improve the outcome for patients and obtain a prompt resolution, it is important to get an early diagnosis by identifying, if possible, the responsible microorganism, and to avoid any delays in the diagnosis. Finally, the close monitoring of vascular access, and a great attention to disinfection procedures and aseptic techniques are all important to avoid these serious infectious complications.

 

 

References

  1. United States Renal Data System. 2016 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD: 2016.
  2. Eleftheriadis T, Antoniadi G, Liakopoulos V, et al. Disturbances of Acquired Immunity in Hemodialysis Patients. Semin Dial 2007; 20:440-51. https://doi.org/10.1111/j.1525-139X.2007.00283.x
  3. Helewa RM, Embil JM, Boughen CG, et al. Risk factors for infectious spondylodiscitis in patients receiving hemodialysis. Infect Control Hosp Epidemiol 2008; 29:567-71. https://doi.org/10.1086/588202
  4. Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004; 364:369-79. https://doi.org/10.1016/S0140-6736(04)16727-5
  5. Cottle L, Riordan. T. Infectious spondylodiscitis. J Infect 2008; 56:401-12. https://doi.org/10.1016/j.jinf.2008.02.005
  6. Zarghooni K, Röllinghoff M, Sobottke R, et al. Treatment of spondylodiscitis. Int Orthop 2012; 36:405–11. https://doi.org/10.1007/s00264-011-1425-1
  7. Ramírez-Huaranga MA, Sánchez de la Nieta-García MD, Anaya-Fernández S, et al. Spondylodiscitis, Nephrology department’s experience. Nefrología 2013; 33:250-55.
  8. Digby JM, Kersley JB. Pyogenic non-tuberculous spinal infection: an analysis of thirty cases. J Bone Joint Surg Br 1979; 61:47-55. 
  9. Roblot F, Besnier JM, Juhel L, et al. Optimal duration of Antibiotic Therapy in Vertebral Osteomyelitis. Semin Arthritis Rheum 2007; 36:269-77. https://doi.org/10.1016/j.semarthrit.2006.09.004
  10. Philipneri M, Al-Aly Z, Amin K, et al. Routine Replacement of Tunneled, Cuffed, Hemodialysis Catheters Eliminates Paraspinal/Vertebral Infections in Patients with Catheter-Associated Bacteremia. Am J Nephrol 2003; 23:202-07. https://doi.org/10.1159/000071479
  11. Abid S, DE Silva S, Warwicker P, et al. Infective spondylodiscitis in patients on high-flux hemodialysis and on-line hemodiafiltration. Hemodial Int 2008; 12:463-70. https://doi.org/10.1111/j.1542-4758.2008.00310.x
  12. Zimmerli W. Vertebral Osteomyelitis. N Engl J Med 2010; 362:1022-29. https://doi.org/10.1056/NEJMcp0910753
  13. Mylona E, Samarkos M, Kakalou E, et al. A Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Semin Arthritis Rheum 2009; 39:10-17. https://doi.org/10.1016/j.semarthrit.2008.03.002
  14. McHenry MC, Easley KA, Locker GA. Vertebral Osteomyelitis: Long-Term Outcome for 253 Patients from 7 Cleveland-Area Hospitals. Clin Infect Dis 2002; 34:1342-50. https://doi.org/10.1086/340102
  15. García-García P, Rivero A, del Castillo N, et al. Infectious Spondylodiscitis in Hemodialysis. Semin Dial 2010; 23:619-26. https://doi.org/10.1111/j.1525-139X.2010.00791.x
  16. Lewis SS, Sexton DJ. Metastatic Complications of Bloodstream Infections in Hemodialysis Patients. Semin Dial 2013; 26:47-53. https://doi.org/10.1111/sdi.12031
  17. Faria B, Canto Moreira N, Sousa TC, et al. Spondylodiscitis in hemodialysis patients: A case series. Clin Nephrol 2011; 76:380-87. https://doi.org/10.5414/cn106525
  18. Lu YA, Hsu HH, Kao HK, et al. Infective spondylodiscitis in patients on maintenance hemodialysis: a case series. Ren Fail 2017; 39:179-86. https://doi.org/10.1080/0886022X.2016.1256313
  19. Cebrián Parra JL, Saez-Arenillas Martín A, Urda Martínez-Aedo AL, et al. Management of infectious discitis. Outcome in one hundred and eight patients in a University Hospital. Int Orthop 2012; 36:239-44. https://doi.org/10.1007/s00264-011-1445-x
  20. Govender S. Spinal infections. J Bone Joint Surg Br 2005; 87:1454-58. https://doi.org/10.1302/0301-620X.87B11.16294
  21. Gemmel F, Dumarey N, Palestro CJ. Radionuclide imaging of spinal infections. Eur J Nucl Med Mol Imaging 2006; 33:1226-37. https://doi.org/10.1007/s00259-006-0098-2
  22. Sapico FL, Montgomerie JZ. Vertebral osteomyelitis. Infect Dis Clin North Am 1990; 4:539-50. 
  23. Hadjipavlou AG, Mader JT, Necessary JT, et al. Hematogenous Pyogenic Spinal Infections and Their Surgical Management. Spine (Phila Pa 1976) 2000; 25:1668-79. https://doi.org/10.1097/00007632-200007010-00010
  24. Grados F, Lescure FX, Senneville E, et al. Suggestions for managing pyogenic (non-tuberculous) discitis in adults. Joint Bone Spine 2007; 74:133-39. https://doi.org/10.1016/j.jbspin.2006.11.002
  25. Berbari EF, Kanj SS, Kowalski TJ, et al. Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis 2015; 61: e26-46. https://doi.org/10.1093/cid/civ482

Long-term efficacy and safety of etelcalcetide in hemodialysis patients with severe secondary hyperparathyroidism

Abstract

Introduction: Etelcalcetide has proven effective and well tolerated in the treatment of secondary hyperparathyroidism (IPS) in patients on hemodialysis (HD). Since long-term studies are scarce, we assessed the efficacy and safety of etelcalcetide in the treatment of severe IPS in a group of HD patients over a 12-month period. Patients and Methods: We selected 24 HD patients with PTH levels > 500 pg/mL (range 502-2148 pg/mL), despite following a therapy with cinacalcet and/or vitamin D analogues. The initial dosage of etelcalcetide was 7.5 mg/week, then it was adjusted based on the trend of the levels of the total albumin-corrected serum calcium (CaALb_c) and PTH. Treatment was temporarily suspended if CaALb_c levels were <7.5 mg/dL or if hypocalcemia was symptomatic. CaALb_c, phosphorus, PTH and total alkaline phosphatase (t-ALP) were measured monthly. The main endpoint was the decrease in PTH levels >30% compared to baseline values. Results: At F-U, the reduction in PTH levels was > 30% in 83% of our patients. PTH levels decreased from 1169 ± 438 to 452±241 pg/mL at F-U (P <0.001). The percentage of reduction in PTH levels at F-U was -56 ± 25%. CaALb_c and phosphate levels decreased from 9.8 ± 0.4 mg/dL to 9.0 ± 0.6 mg/dL (P <0.001), and from 6.1 ± 1.3 mg/dL to 4.9 ± 1.3 mg/dL (P <0.01), respectively. The main side effect was hypocalcaemia, but never so severe as to require the interruption of treatment. Hypocalcemia was more pronounced in patients with higher basal levels of PTH and t-ALP. During the study, the percentage of patients treated with calcium carbonate increased from 33% to 54% and that of patients treated with paricalcitol from 33% to 79%. At F-U the average weekly dosage of etelcalcetide was 21.0 ± 9.5 mg (range 7.5-37.5 mg/week). Conclusions: The treatment of severe IPS with etelcalcetide has been proved effective and safe in the long term. Hypocalcaemia, the most frequent side effect, was more evident in patients with the most severe forms of IPS and was probably due to a reduction in bone turnover rather than to the direct effect of etelcalcetide.

 

Key words: etelcalcetide, hemodialysis, secondary hyperparathyroidism, paricalcitol, cinacalcet.

Sorry, this entry is only available in Italian. For the sake of viewer convenience, the content is shown below in the alternative language. You may click the link to switch the active language.

Introduzione

L’iperparatiroidismo secondario (IPS) è una complicanza comune e clinicamente significativa della malattia renale cronica (CKD), soprattutto nei pazienti in trattamento emodialitico (HD) [14].

Gli elevati livelli di paratormone (PTH), insieme alle alterazioni del calcio e del fosforo, si associano a calcificazioni vascolari, fratture scheletriche, aumentata morbilità e mortalità cardiovascolare [58]. In particolare, studi epidemiologici condotti in pazienti in HD hanno fornito evidenze sostanziali che livelli di PTH elevati, in particolare modo quando >600 pg/mL, sono associati ad un aumentato rischio di eventi cardiovascolari e mortalità cardiovascolare [9, 10]. Fino a pochi anni fa il trattamento dell’IPS era principalmente basato sull’impiego degli analoghi della vitamina D, dei calciomimetici e della paratiroidectomia [1, 2, 5, 1113]. Tuttavia, l’impiego degli analoghi della vitamina D è spesso gravato da effetti collaterali quali ipercalcemia ed iperfosforemia, che ne possono limitare l’impiego [14, 15]. L’impiego del calciomimetico cinacalcet, seppur più efficace rispetto agli analoghi della vitamina D nel controllo delle varie componenti della CKD-MBD [1620], è spesso limitato dalla elevata frequenza di effetti collaterali e dalla scarsa aderenza terapeutica [21]. Al fine di migliorare il trattamento dell’IPS, è stato recentemente introdotto un nuovo calciomimetico, l’etelcalcetide (Parsabiv®, Amgen Inc.), somministrabile per via endovenosa (e.v.) al termine della seduta HD [22, 23]. La sicurezza e l’efficacia dell’etelcalcetide è stata dimostrata da diversi trials clinici [2427]. L’etelcalcetide è risultato, rispetto al cinacalcet, più efficace nel controllo dei principali parametri della CKD-MBD [32]. Nel presente studio, della durata di 12 mesi, abbiamo valutato retrospettivamente l’efficacia, intesa come riduzione dei livelli di PTH >30% rispetto ai valori basali, e la tollerabilità dell’etelcalcetide in un gruppo selezionato di pazienti in HD con IPS grave nonostante fossero in trattamento con le terapie tradizionali (cinacalcet e/o paracalcitolo) o non passibili di trattamento con questi farmaci per la comparsa di effetti collaterali.

 

La visualizzazione dell’intero documento è riservata a Soci attivi, devi essere registrato e aver eseguito la Login con utente e password.

SARS-CoV-2: recommendations on nursing care for dialyzed and transplanted patient

Abstract

Coronavirus disease 2019 is an infectious respiratory syndrome caused by the virus called SARS-CoV-2, belonging to the family of coronaviruses. The first ever cases were detected during the 2019-2020 pandemic. Coronaviruses can cause a common cold or more serious diseases such as Middle Eastern Respiratory Syndromes (MERS) and Severe Acute Respiratory Syndrome (SARS). They can cause respiratory, lung and gastrointestinal infections with a mild to severe course, sometimes causing the death of the infected person. This new strain has no previous identifiers and its epidemic potential is strongly associated with the absence of immune response/reactivity and immunological memory in the world population, which has never been in contact with this strain before. Most at risk are the elderly, people with pre-existing diseases and/or immunodepressed, dialyzed and transplanted patients, pregnant women, people with debilitating chronic diseases. They are advised to avoid contacts with other people, unless strictly necessary, and to stay away from crowded places, also observing scrupulously the recommendations of the Istituto Superiore di Sanità.

In this article we detail the recommendations that must be followed by the nursing care staff when dealing with chronic kidney disease patients in dialysis or with kidney transplant patients. We delve into the procedures that are absolutely essential in this context: social distancing of at least one meter, use of PPI, proper dressing and undressing procedures, frequent hand washing and use of gloves, and finally the increase of dedicated and appropriately trained health personnel on ward.

 

Keywords: COVID-19, hemodialysis, transmission, prevention

Sorry, this entry is only available in Italian. For the sake of viewer convenience, the content is shown below in the alternative language. You may click the link to switch the active language.

Introduzione

COVID-19 acronimo dell’inglese COronaVIrus Disease-19), o malattia respiratoria acuta da SARS-CoV-2 (dall’inglese Severe Acute Respiratory Syndrome Coronavirus [1], nome del virus) o più semplicemente malattia da coronavirus 2019, è una malattia respiratoria infettiva causata dal virus denominato SARS-CoV-2 appartenente alla famiglia dei coronavirus. I primi casi sono stati riscontrati durante la pandemia del 2019-2020.

Una persona positiva può presentare sintomi dopo un periodo di incubazione che varia tra i 2 e i 14 giorni circa (raramente, ci sono stati casi di 29 giorni), durante i quali può essere contagiosa [2,3].

Per limitarne la trasmissione devono essere applicate le precauzioni divulgate dall’Istituto Superiore della Sanità.

 

Proteggere sé stessi

Adottare un’accurata igiene personale, lavarsi spesso le mani con acqua e sapone o disinfettarle, se non visibilmente sporche, con gel alcoolico >70%:

  • dopo aver tossito o starnutito nelle mani
  • dopo aver prestato assistenza alle persone malate
  • quando ci si prende cura della casa e della persona
  • prima e dopo il contatto con il cibo

Oltre all’igiene delle mani è importante:

  • indossare la mascherina protettiva qualora si venga in contatto con altre persone
  • rispettare la distanza di sicurezza

 

Proteggere gli altri

Buona regola è utilizzare sempre il gomito interno/fazzoletto quando si tossisce o starnutisce, adottando alcune precauzioni:

  • il fazzoletto, se utilizzato, va gettato immediatamente, possibilmente all’interno di una busta senza riporlo nelle tasche
  • lavare le mani o utilizzare immediatamente il gel igienizzante per evitare le contaminazioni
  • mantenere la mascherina, indossata correttamente, se a contatto con altre persone
  • mantenere la distanza di sicurezza

Coloro che ritengono di essere venuti a contatto stretto con persone positive al COVID-19 devono rimanere in quarantena e rivolgersi immediatamente agli organi preposti al fine di ricevere le appropriate indicazioni.

Il COVID-19 si annida prevalentemente nelle vie aeree superiori ed inferiori provocando inizialmente una serie di sintomi pseudo-influenzali [4,5] con manifestazione di febbre (>37.5°), tosse, difficoltà di respiro, stanchezza, malessere muscolare e generalizzato, congiuntivite e disturbi gastrointestinali [6]. L’evoluzione nei casi più gravi si presenta con polmonite, sindrome da stress respiratorio acuto, sepsi e conseguente shock settico, insufficienza renale acuta, coma e morte; sono documentate anche complicazioni cliniche extra-respiratorie che condizionano pesantemente l’evoluzione della malattia e sono in parte responsabili della mortalità, in particolare: disturbi trombo-embolici polmonari, cardiaci, neurologici e renali [7,8,9]. Allo stato attuale non vi è un vaccino e/o trattamento specifico validato; il paziente andrà necessariamente isolato e la gestione dei sintomi clinici spesso richiede supporto respiratorio [5,10] in terapia intensiva.

 

Raccomandazioni per i pazienti in trattamento dialitico

La Società Italiana di Nefrologia (sezione SIN Lombardia [11] e SIN Emilia Romagna [12]) hanno pubblicato protocolli e raccomandazioni riguardanti i pazienti affetti da Malattia Renale Cronica (MRC) sottoposti a sedute di emodialisi, stilando informazioni e consigli di buona pratica per il personale che deve seguire il paziente acuto e/o cronico durante le già menzionate procedure. La Società Infermieri Area Nefrologica (SIAN) ha pensato di redigere un documento infermieristico che potesse raccogliere le raccomandazioni per i pazienti in trattamento dialitico/trapianto e indicazioni per il personale coinvolto.

Le persone affette da MRC sono più esposte a contrarre patologie infettive in quanto presentano multi-comorbidità, immunodepressione, e sono spesso anergici e/o paucisintomatici.

Alla luce di queste considerazioni, i medici ed il personale infermieristico che prestano servizio presso le strutture di dialisi devono ricevere informazioni utili sulla trasmissione e prevenzione dell’epidemia COVID-19, avere la garanzia di adeguate misure di protezione per la sicurezza personale, devono ricevere indicazioni chiare sulla gestione dei pazienti in trattamento sostitutivo e/o con trapianto e devono saper offrire informazione continua e costante ai malati, ai loro familiari ed al personale addetto ai trasporti, al fine di garantire la migliore aderenza possibile alle prescrizioni comportamentali fornite dal personale sanitario.

 

Considerazioni generali

  1. I pazienti con MRC sono più fragili e con comorbidità; queste condizioni, se in presenza di età avanzata, modificano, aggravandola, l’evoluzione clinica della malattia e ne aumentano la mortalità.
  2. L’infermiere di dialisi può ritenersi autonomo nella gestione della seduta dialitica non prima di 6 mesi di formazione/tutoraggio intensivi e specialistici e, quindi, un eventuale diffondersi del contagio tra il personale comporta l’impossibilità di immediata sostituzione con professionisti provenienti da altre Unità Operative.
  3. Il rispetto delle precauzioni universali e di quelle specifiche per la dialisi con igiene delle mani, utilizzo della cuffia, mascherina chirurgica, occhiali o visiera, guanti, disinfezione meticolosa esterna dei monitor e delle superfici circostanti l’area del malato, note a tutto il personale infermieristico, produce una differenza fondamentale nella riduzione della possibilità di contagio, con riduzione del numero di tamponi o di quarantena del personale.
  4. L’Infermiere informa, coinvolge, educa e supporta il paziente favorendo l’adesione al suo percorso di cura (art.17 Codice Deontologico), motivando le procedure atte a contenere il contagio COVID 19, educando l’utente al corretto lavaggio delle mani e/o utilizzo del gel antibatterico, ad indossare efficacemente la mascherina chirurgica a protezione di naso e bocca e ad evitare luoghi affollati e/o aree comuni non conformi alle direttive indicate.
  5. È necessario monitorare e registrare lo stato di salute di tutti gli operatori sul posto di lavoro e condurre un monitoraggio sanitario per gli operatori di prima linea, incluso il monitoraggio della temperatura corporea e dei sintomi respiratori.
  6. La condizione di emergenza porta i professionisti ad una elevata esposizione emotiva. Va dunque considerata l’importanza di un supporto per affrontare eventuali problemi psicologici e fisiologici emergenti con gli esperti pertinenti.

 

Considerazioni specifiche di buona pratica infermieristica [13]

  1. Il professionista sanitario deve eseguire l’igiene delle mani prima e dopo qualsiasi contatto con l’assistito e con materiali e suppellettili utilizzati dal paziente, nonché prima e dopo l’utilizzo e la rimozione di tutti i dispositivi di protezione individuale. In particolare, porre attenzione ed eseguire il lavaggio delle mani con acqua e sapone o con gel alcolico al termine della fase di svestizione, per rimuovere potenziali agenti patogeni.
  2. Il professionista sanitario deve prestare particolare attenzione alla igiene delle mani che, secondo le indicazioni dell’Organizzazione Mondiale della Sanità, può essere eseguita con soluzione a base alcoolica >70% (con procedura di 20’’-30’’) o con acqua e sapone se visibilmente sporche (con procedura fino ai 60’’).
  3. Il professionista sanitario deve ricevere una formazione adeguata sull’utilizzo dei DPI e deve dimostrare adeguata comprensione dei seguenti argomenti:
    1. quando utilizzarli
    2. quale DPI è necessario in una determinata situazione
    3. come indossarli, utilizzarli e rimuoverli correttamente in modo da prevenire l’auto-contaminazione
    4. come smaltirli o disinfettarli correttamente (se riutilizzabili)
    5. come effettuare una corretta manutenzione dei DPI e loro limitazioni
    6. eventuali DPI riutilizzabili devono essere adeguatamente decontaminati e puliti dopo l’uso con corretta manutenzione degli stessi.

Le strutture dovrebbero adottare protocolli e procedure che descrivano una sequenza raccomandata per indossare e rimuovere in sicurezza i DPI. I DPI raccomandati per la cura di un paziente con COVID-19 noto o sospetto includono:

  1. Mascherina adatta alla situazione contingente (FFP2 per caso sospetto, FFP3 per caso confermato, come da indicazioni SIN Lombardia [11]), aderente al volto (si veda anche Allegato 1):
    1. va indossata prima di entrare nella stanza del paziente o nel setting di cura
    2. va rimossa e correttamente smaltita dopo essere usciti dalla stanza del paziente, o dall’area in cui si è prestata assistenza al paziente, e aver chiuso la porta
    3. eseguire l’igiene delle mani dopo aver rimosso la mascherina
  2. Protezione per gli occhi:
    1. protezioni adeguate sono ad esempio occhialini protettivi o visiera monouso che copra la parte anteriore ed i lati del viso, indossate all’ingresso della stanza o dell’area in cui si trova il paziente
    2. gli occhiali personali e le lenti a contatto non sono considerati una protezione adeguata
    3. rimuovere la protezione per gli occhi prima di lasciare la stanza del paziente o l’area in cui si è prestata assistenza al paziente
    4. la protezione riutilizzabile (ad es. occhialini) deve essere detersa e disinfettata secondo le istruzioni tecniche fornite dal produttore prima del riutilizzo
    5. la protezione monouso deve essere correttamente smaltita dopo l’utilizzo
  3. Guanti:
    1. indossare guanti puliti e non sterili all’ingresso, nella stanza del paziente, nell’area in cui si trova il paziente
    2. sostituire i guanti se strappati o contaminati
    3. rimuovere ed eliminare i guanti quando si lascia la stanza del paziente, o l’area in cui si è prestata assistenza, ed eseguire immediatamente l’igiene delle mani
  4. Camici:
    1. indossare un camice pulito idrorepellente all’ingresso della stanza o nell’area in cui si trova il paziente
    2. cambiare il camice se contaminato
    3. rimuovere e smaltire il camice in un contenitore dedicato per rifiuti infetti o biancheria infetta prima di lasciare la stanza o l’area in cui si trova il paziente
    4. i camici monouso devono essere eliminati subito

 

Considerazioni specifiche per la gestione di tutti i pazienti in dialisi [14]

  1. Sensibilizzare il paziente ad informare immediatamente il personale di dialisi qualora insorga febbre a domicilio e/o un familiare abbia sintomi infettivi.
  2. Consegnare al paziente materiale informativo riguardante le indicazioni di buona pratica.
  3. Ove possibile, telefonare al domicilio del paziente il giorno precedente la dialisi ed eseguire un pre-triage del soggetto, della famiglia e/o del care-giver, con adozione di moduli da inserire nella documentazione personale del paziente.
  4. È indispensabile eseguire il triage dei pazienti prima dell’ingresso in sala dialisi (intervista per: febbre, tosse, congiuntivite, sintomi respiratori, presenza di familiari con sintomatologia indicativa di infezione da COVID-19), limitando allo stretto necessario il numero del personale che fornisce tale assistenza.
  5. Utilizzare termometri digitali per la rilevazione della febbre; l’operatore deve essere protetto con mascherina chirurgica e guanti monouso, da sostituire ad ogni paziente trattato, praticando l’igiene delle mani con soluzioni gel su base alcolica tra un paziente e l’altro.
  6. In caso di triage positivo a uno dei criteri clinici adottati, il paziente deve indossare la mascherina chirurgica (da mantenere per tutta la seduta dialitica), eseguire lavaggio delle mani e del braccio dove si trova la fistola, indossare i guanti monouso ed essere accompagnato in uno delle postazioni dialisi dedicate ai pazienti sospetti o positivi per gli accertamenti previsti dal percorso aziendale.
    Il personale indosserà i DPI durante l’assistenza: camice idrorepellente, mascherina FPP2/FPP3, se disponibile, doppio paio di guanti e soprascarpe (se non presenti, a termine trattamento le calzature verranno irrorate con Sodio Dicloroisocianurato Diidrato). Fino all’esito del tampone, il paziente verrà trattato come positivo in isolamento funzionale.
  1. Mettere a disposizione gel antibatterico per l’igiene delle mani dei pazienti prima dell’ingresso in dialisi e mascherina chirurgica per l’igiene respiratoria, da indossare per tutta la durata del trattamento. È consigliata inoltre la sospensione della distribuzione dei generi alimentari durante la seduta emodialitica per evitare la rimozione anche momentanea della mascherina, secondo le indicazioni fornite dall’Associazione Nazionale Emodializzati (ANED) [15].
  2. Nel caso in cui il paziente sia ricoverato in altra Unità Operativa per patologia non concomitante a COVID-19, vanno rispettate le pratiche sopra citate, compreso l’utilizzo di camice repellente, per tutto il personale coinvolto nelle manovre di trasferimento da letto a letto-bilancia.
  3. Dopo ogni manipolazione di materiali e prima e dopo l’assistenza diretta del paziente i guanti vanno sostituiti previo lavaggio delle mani.

 

Considerazioni specifiche nella gestione dei pazienti COVID positivi sospetti o accertati in stanze dedicate

  1. Per l’utilizzo dei dispositivi (vestizione e svestizione) vedere indicazioni ministeriali settoriali.
  2. La vestizione dell’operatore deve essere fatta all’esterno dalla sala dedicata.
  3. La svestizione deve essere fatta all’interno della stessa, prima dell’uscita.
  4. Se l’operatore necessita del cambio, chi lo sostituisce deve provvedere alla vestizione come da procedura concordata.
  5. Uno spazio di almeno 2 metri deve essere assicurato tra un letto e l’altro.
  6. Una volta che il paziente è stato dimesso o trasferito, il personale sanitario, compreso il personale dedicato alle pulizie ambientali, dovrebbe astenersi dall’entrare nella stanza fino a quando non sia trascorso il tempo sufficiente ad un adeguato ricambio d’aria, allo scopo di permettere la rimozione delle particelle potenzialmente infette. Trascorso questo tempo, la stanza deve essere sottoposta a un’adeguata detersione e disinfezione dei monitor e delle superfici circostanti l’unità del malato, dei presidi a contatto comune e ripetuto (tastiere, PC, telefoni, interruttori, maniglie delle porte e telefoni cellulari personali) che possono risultare fortemente critici nella diffusione del contagio. Si consiglia di utilizzare Ipoclorito di Sodio 1000 mg/l e/o alcool etilico >70%, ove possibile, prima di riutilizzare la postazione per un altro paziente.

 

VESTIZIONE SVESTIZIONE
1. Rimuovere tutti i monili come orologi, anelli o altri oggetti personali

2. Osservare l’igiene delle mani utilizzando acqua e sapone o soluzione alcolica

3. Indossare un paio di guanti lunghi, interni

4. Vestire un camice impermeabile con protezione a maniche lunghe che copriranno parte dei guanti indossati

5. Indossare mascherina di protezione filtrante, facendola aderire correttamente al volto e facendo la prova di tenuta del respiro

6. Indossare visiera o, in sostituzione, occhiali di protezione

7. Proteggere il capo con un copricapo impermeabile

8. Indossare ulteriore paio di guanti corti esterni, al di sopra di quelli già indossati

1. Svestirsi del camice monouso impermeabile e gettarlo nel contenitore rifiuti speciali

2. Rimuovere il copricapo

3. Togliere il paio di guanti esterni

4. Togliere la visiera o gli occhiali di protezione pluriuso e riporli in contenitore per la successiva sanificazione

5. Disinfettare le mani guantate con gel alcolico

6. Rimuovere la mascherina facendo attenzione a maneggiarla esclusivamente dalla parte posteriore e smaltirla nel contenitore

7. Togliere il paio di guanti lunghi interni

8. Eseguire l’igiene delle mani con soluzioni alcolica o con acqua e sapone

 

È importante, durante la svestizione, prestare massima attenzione nel rimuovere i DPI contaminati, che potrebbero inavvertitamente toccare il viso, le mucose, gli occhi e la cute. A questo proposito, risulta utile utilizzare una check list e l’aiuto di uno specchio o di un secondo operatore durante questa delicata procedura, ad alto rischio infettivo. Si devono smaltire i DPI monouso in un contenitore per rifiuti speciali che deve essere posizionato nella stessa area dove avviene la vestizione. I DPI riutilizzabili, che non vanno smaltiti, devono essere attentamente decontaminati.

 

Considerazioni specifiche nella gestione dei pazienti COVID positivi accertati

Per il trattamento dialitico in unità ad Alta Assistenza o in ambiente allestito per COVID-19 è preferibile l’impiego di monitor per tecniche continue, con modalità gestionale della seduta riservata ai medici che hanno utilizzato la tecnica sino quel momento. Vi è la possibilità di utilizzare la tecnica intermittente se il reparto di Dialisi e la logistica lo permettono (impianto di carico/scarico acqua), con ausilio di osmosi portatili. È imperativo rispettare le regole imposte per i DPI e la disinfezione del materiale non monouso utilizzato.

 

Considerazioni specifiche per i coordinatori infermieristici [14]

  1. Controllare, monitorare ed assicurare l’approvvigionamento del materiale specifico con formazione di tutto il personale sulle norme corrette da mantenere, compresa la vestizione e svestizione DPI, e loro importanza.
  2. Individuare, all’esterno del servizio, una zona COVID dedicata con percorsi pulito-sporco separati e fornire indicazioni di sanificazione dell’area utilizzata.
  3. Predisporre una sala di isolamento dove trattare eventuali pazienti positivi, in condizioni che non richiedano supporto respiratorio.
  4. È consigliabile attivare turni supplementari di dialisi, per aumentare la distanza di sicurezza tra i pazienti e, in caso di necessità, per poter accogliere un numero maggiore di pazienti.
  5. Il rapporto infermiere/paziente e medico/paziente può essere modificato, in aumento o in diminuzione, in base al contesto e alla criticità del paziente (si lascia alle singole situazioni la valutazione).
  6. Per distribuire meglio il peso lavorativo e assistenziale (fisico e psicologico) su tutti gli infermieri, il Coordinatore deve verificare personalmente l’area per gestirne l’organizzazione ed individuare i punti di criticità, organizzando i turni di lavoro in modo che un infermiere resti sempre “pulito” fuori dell’area in cui è previsto l’utilizzo dei DPI. Fondamentale, quindi, risulta la rotazione degli operatori ogni 4 ore durante l’orario di servizio, ponendo attenzione alla rimozione del materiale DPI utilizzato e alla corretta igienizzazione delle mani prima di lasciare la zona contaminata [16].
  7. Il trattamento dialitico in ambiente ad Alta Intensità può raggiungere numeri impensabili in passato; in accordo con il personale medico, va ipotizzato l’incremento di postazioni dializzanti e organizzato un numero maggiore di personale reperibile.
  8. Il trasporto del paziente in dialisi dovrà essere garantito coinvolgendo la famiglia o, in caso di trasporto “organizzato” attraverso viaggio singolo, posticipato rispetto al resto dell’utenza per evitare contatti con altri pazienti. In caso di più pazienti afferenti in sorveglianza attiva domiciliare, l’orario deve essere concordato in maniera sequenziale. Il paziente deve indossare la mascherina chirurgica dal proprio domicilio, mentre il personale di trasporto deve indossare mascherina chirurgica e guanti monouso, da sostituire ad ogni turno con indicazione di disinfezione del veicolo, preferibilmente con prodotti a base di ipoclorito di sodio 1000 mg/l o etanolo >70%.
  9. Vanno sorvegliati i luoghi dove non sia possibile mantenere la distanza di sicurezza prevista dal DPCM, intervallando gli ingressi nelle sale d’attesa, spogliatoi, luoghi di ritrovo del personale.
  10. Nel caso di pazienti con COVID-19 presunto o accertato che effettuano dialisi in un centro periferico che non dispone di strutture contumaciali e/o malattie infettive e/o rianimazione, o non sia nella possibilità di effettuare dialisi fuori dal proprio reparto, i pazienti vanno centralizzati nelle strutture ospedaliere che dispongono, oltre che della nefrologia, anche di questi requisiti.
  11. La Direzione Sanitaria, attraverso i suoi organi competenti, darà disposizioni riguardanti la rilevazione della temperatura di tutti gli operatori ad ogni inizio e termine servizio lavorativo [15,16].
  12. Per l’operatore asintomatico con storia di possibile contatto con caso positivo che ha utilizzato correttamente i DPI prescritti secondo le disposizioni vigenti non è necessario adottare alcun provvedimento, in quanto non rappresenta un “contatto stretto”, come si evince dalla Circolare del Ministero della Salute 0006360-27/02/2020.
  13. Per l’operatore asintomatico con storia di possibile contatto stretto (vedi definizione Centro Europeo per la Prevenzione e controllo delle malattie ECDC) con caso positivo in ambito lavorativo, senza aver utilizzato DPI idonei, oppure in ambito extra lavorativo viene prescritta esecuzione di tampone a 48-72 ore dall’avvenuto contatto; proseguirà l’attività lavorativa indossando mascherina chirurgica sino ad esito del tampone.
    • Qualora il tampone dovesse risultare positivo: esclusione dall’attività lavorativa ed esecuzione di tampone dopo 7 giorni dal precedente e a 14 giorni dall’avvenuto contatto. Qualora il 2° tampone dovesse risultare negativo, l’operatore può riprendere il servizio lavorativo indossando la mascherina chirurgica.
    • Qualora il tampone dovesse risultare negativo: ammissione all’attività lavorativa con utilizzo di mascherina e monitoraggio clinico ad ogni inizio turno, esecuzione di tampone da ripetere ogni 48-72 ore (in accordo con il Medico Competente e secondo la turnistica dell’operatore). Se vi è comparsa di sintomi, è necessaria l’esecuzione immediata del tampone e la sospensione dal servizio.

Quando non in servizio, l’operatore dovrà sottostare alle disposizioni previste dall’isolamento domiciliare fiduciario sino ad esito del tampone del 14° giorno.

  1. Gli operatori dei Centri dialisi, se addestrati adeguatamente e con protezione idonea, possono eseguire il tampone naso-faringeo per la PCR COVID-19 qualora non sia presente un gruppo dedicato e in accordo con l’infettivologo e/o con gli organi preposti come da protocollo aziendale.
  2. Per il paziente in dialisi peritoneale è raccomandata una gestione massimale domiciliare, evitando/rallentando la frequenza di accessi in ospedale per esami o visite. Il personale manterrà un contatto telefonico o di tele-sorveglianza (ove possibile). Bisogna poi segnalare al paziente ed al care-giver la necessità, in caso di sintomi sospetti per infezione da COVID-19, di avvisare il Servizio di Igiene Pubblica (oppure seguire le specifiche indicazioni locali). Allertare il paziente che, in caso di sintomi respiratori ingravescenti, è necessario coinvolgere il 112/118.
  3. Per il paziente in trattamento dialitico peritoneale ricoverato con positività al COVID-19, il trattamento dialitico verrà eseguito al letto del paziente nel reparto di ricovero. Qualora tale situazione non fosse praticabile, il trattamento verrà eseguito nelle stanze dedicate ai pazienti infetti della SOC di Nefrologia ed Emodialisi. Il personale dovrà essere dotato dei DPI specifici.
  4. Per il paziente portatore di trapianto renale, oltre alla adozione dei comportamenti già indicati e consigliati nelle fasi immediate al post-trapianto, in particolare evitare i contatti ravvicinati con altri soggetti e il rispetto della terapia indicata [15], si aggiungono, come suggerito dal Centro Nazionale Trapianti [17]:
    1. utilizzare la mascherina chirurgica qualora si esca di casa (che va sostituita ogni 4 o 5 ore o se bagnata)
    2. evitare di ospitare amici e parenti che hanno sintomatologia riconducibile a infezione da COVID-19 o che hanno effettuato viaggi di recente
    3. far areare frequentemente l’ambiente domestico
    4. lavare frequente le mani con acqua e sapone o con gel idroalcolico
    5. evitare strette di mano, abbracci o baci

Il paziente trapiantato, per qualsivoglia problematica e/o necessità, si rivolgerà al centro di riferimento. Il personale sanitario dovrà predisporre il triage telefonico e rispettare le misure e l’utilizzo dei PDI previsti dalle procedure [17].

 

Conclusioni

La SARS-CoV-2 ha stravolto la routine e la vita delle persone e ha comportato delle conseguenze psicologiche non indifferenti. È in atto in tutto il mondo la ricerca, l’individuazione, lo studio e lo sviluppo di politiche sanitarie che vadano in aiuto dei professionisti clinici, impegnati nell’affrontare sia le conseguenze acute sia le conseguenze a lungo termine di una pandemia. Essa ha fatto emergere l’importanza della presenza di personale sanitario adeguato nel numero e nella preparazione, ridisegnando anche i sistemi di formazione dei professionisti clinici con la mission di supportare con basi terapeutiche scientifiche tutti i gruppi a rischio e le persone colpite [18]. È indubbia l’importanza, come suggerito da uno studio cinese [19], di prestare attenzione particolare ai gruppi vulnerabili come giovani, anziani, donne e lavoratori migranti. È altrettanto importante rafforzare l’accessibilità alle risorse mediche e di cura, attivare servizi di erogazione di prestazioni telematici e avviare la costruzione di un sistema complessivo di prevenzione ed intervento attivo nelle crisi che includa monitoraggio epidemiologico, screening, segnalazione ed intervento capillare e specifico, per ridurre il disagio psicologico e prevenire importanti problemi di salute mentale [19].

Ancora non esiste un vaccino per questo tipo di coronavirus e le evidenze a supporto dell’efficacia di potenziali terapie sono veramente poche. La popolazione non possiede immunità pregressa, rendendo tutti soggetti suscettibili. La sintomatologia dovuta all’infezione da SARS-CoV-2 va dalla asintomaticità alla polmonite grave, fino alla morte. Il rischio di contrarre una forma grave di malattia a seguito di infezione è da considerarsi moderato nella popolazione generale ed elevato per anziani e individui con associate patologie croniche coesistenti, come l’insufficienza renale cronica [20], e in trattamento dialitico, ove si rendono necessarie le precauzioni rappresentate.

 

 

Allegato 1: Le mascherine: tipologie, funzioni, procedure di posizionamento

I DPI sono classificati in livelli: FFP1, FFP2 e FFP3, (FFP è acronimo di Filternig Face Pier, in italiano possiamo tradurlo con “potere filtrante”). La principale differenza tra i 3 livelli è nel potere filtrante delle particelle più grandi di 0,6 micron (1 micron equivale ad un millesimo di millimetro!):

FFP1==> ne filtrano almeno il 78%

FFP2==> ne filtrano almeno il 92%

FFP3==> ne filtrano almeno il 98%

Sono denominati diversamente a seconda della certificazione e delle norme tecniche del Paese di riferimento (https://www.aerofeel.com/salute/mascherine-kn95-n95-ffp2-un-confronto/)

FFP2==> certificati secondo lo standard di riferimento europeo EN 149-2001 + A1 -2009

KN95==> certificati secondo lo standard di riferimento cinese GB2626 -2006

N95==> certificati secondo lo standard di riferimento statunitense N95 del National Institute for Occupational Safety and Health

Tali dispositivi sono equivalenti dal momento che la capacità di filtrazione è equiparabile e che garantiscono lo stesso livello di protezione. Pertanto, questi possono essere utilizzati in modo alternativo a seconda della disponibilità dei prodotti.

Si comunica, inoltre, che tutti i dispositivi e mezzi di protezione COVID – prima della loro distribuzione ai lavoratori- sono controllati da una commissione aziendale interna che ne verifica l’idoneità all’utilizzo.

Non è consentito utilizzare DPI COVID che non siano stati indirizzati al corretto iter aziendale e, quindi, preliminarmente controllati dalla commissione sopraindicata.

 

 

Bibliografia

  1. World Health Organization. Q&As on COVID-19 and related health topics. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub (consultato il 27 gennaio 2020).
  2. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) Symptoms. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html (consultato l’11 febbraio 2020).
  3. Science Media Centre. Expert reaction to news reports that the China coronavirus may spread before symptoms show. https://www.sciencemediacentre.org/expert-reaction-to-news-reports-that-the-china-coronavirus-may-spread-before-symptoms-show/ (consultato l’11 febbraio 2020).
  4. Australian Government Department of Health. Coronavirus (COVID-19). https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert (consultato l’11 febbraio 2020).
  5. European Centre for Disease Prevention and Control. Q&A on COVID-19 https://www.ecdc.europa.eu/en/covid-19/questions-answers (consultato l’11 febbraio, archiviato il 16 febbraio 2020).
  6. Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology 2020; 158(6):1518-19. https://doi.org/10.1053/j.gastro.2020.02.054
  7. Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol 2020; 77(6):1-9. https://doi.org/10.1001/jamaneurol.2020.1127
  8. Lodigiani C, Iapichino G, Carenzo L, et al. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res 2020; 191:9-14. https://doi.org/10.1016/j.thromres.2020.04.024
  9. Di Pasquale G. Coronavirus COVID-19: quali implicazioni per la Cardiologia? Giornale Italiano di Cardiologia 2020; 21(4): 243-45.
  10. Ministero della Salute. FAQ – Covid-19, domande e risposte. http://www.ministerosalute.it/portale/nuovocoronavirus/archivioFaqNuovoCoronavirus.jsp (consultato il 26 marzo 2020).
  11. Società Italiana di Nefrologia. Protocollo CORONAVIRUS & DIALISI. https://sinitaly.org/2020/02/28/protocollo-coronavirus-dialisi/
  12. Società Italiana di Nefrologia, Sezione Emilia-Romagna. Raccomandazioni riguardanti i pazienti con malattia renale che necessitano di trattamento emodialitico. http://salute.regione.emilia-romagna.it/assistenza-ospedaliera/covid-19-indicazioni-organizzative-per-le-reti-cliniche-integrate-ospedale-territorio/covid-19-dialisi-regione-emilia-romagna.pdf
  13. Ministero della Salute. La salute nelle tue mani. http://www.salute.gov.it/portale/news/p3_2_3_1_1.jsp?lingua=italiano&menu=dossier&p=dadossier&id=21 (consultato il 15 marzo 2020).
  14. Government of Canada. Public health management of cases and contacts associated with coronavirus disease 2019 (COVID-19). https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/interim-guidance-cases-contacts.html (consultato il 27 giugno 2020).
  15. Associazione Nazionale Emodializzati, Dialisi e Trapianto. Covid-19: la situazione per dializzati e trapiantati. https://www.aned-onlus.it/covid-19-la-situazione-per-dializzati-e-trapiantati (consultato il 27 giugno 2020).
  16. Evidence based nursing, speciale COVID-19. Handbook of COVID-19 Prevention and Treatment. http://www.evidencebasednursing.it/nuovo/Pubblicazioni/Covid/Handbook of COVID-19 Gestione e Nursing tradotto.pdf (consultato in data 27 giugno 2020).
  17. Centro Nazionale Trapianti, Istituto Superiore di Sanità. #COVID19 Raccomandazioni per i pazienti trapiantati. http://www.rssp.salute.gov.it/imgs/C_17_primopianoCNT_543_0_file.pdf (consultato il 26 giugno 2020).
  18. Li S, Wang Y, Xue J, et al. The impact of COVID-19 epidemic declaration on psychological consequences: a study on active Weibo users. International journal of environmental research and public health 2020; 17 (6):2032.
  19. Qiu J, Shen B, Zhao M, et al. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations, General Psychiatry 2020; 33:e100213. https://doi.org/10.1136/gpsych-2020-100213
  20. European Centre for Disease Prevention and Control (ECDC). Rapid risk assessment: Novel coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK –sixth update (12 March 2020) https://www.ecdc.europa.eu/sites/default/files/documents/RRA-sixth-update-Outbreak-of-novel-coronavirus-disease-2019-COVID-19.pdf (consultato il 28 giugno 2020).

 

Economic impact of ferric carboxymaltose in haemodialysis patients

Abstract

Intravenous iron supplementation is essential in hemodialysis (HD) patients to recover blood loss and to meet the requirements for erythropoiesis and, in patients receiving erythropoietin, to avert the development of iron deficiency. In a recent real-world study, Hofman et al. showed that a therapeutic shift from iron sucrose (IS) to ferric carboxymaltose (FCM) in HD patients improves iron parameters while reducing use of iron and erythropoietin. The objective of this economic analysis is to compare the weekly cost of treatment of FCM vs IS in hemodialysis patients in Italy. The consumption of drugs (iron and erythropoietin) was derived from Hofman’s data, while the value was calculated at Italian ex-factory prices. The analysis was carried on the total patient sample and in two subgroups: patients with iron deficiency and patients anemic at baseline. In addition, specific sensitivity analyses considered prices currently applied at the regional level, simulating the use of IS vs iron gluconate (FG) and epoetin beta vs epoetin alfa. In the base-case analysis, the switch to FCM generates savings of -€12.47 per patient/week (-21%) in all patients, and even greater savings in the subgroups with iron deficiency -€17.28 (-27%) and in anemic patients -€23.08 (-32%). Sensitivity analyses were always favorable to FCM and confirmed the robustness of the analysis. FCM may represent a cost-saving option for the NHS, and Italian real-world studies are needed to quantify the real consumption of resources in dialysis patients.

 

Keywords: ferric carboxymaltose, intravenous iron supplementation, chronic kidney disease, hemodialysis, drugs consumption, economic impact

Sorry, this entry is only available in Italian. For the sake of viewer convenience, the content is shown below in the alternative language. You may click the link to switch the active language.

Introduzione

La prevalenza dei pazienti con malattia renale cronica (MRC) è pari al 10-16% della popolazione adulta mondiale [1] con tassi di incidenza in aumento nel corso degli anni [1,2]. Questo trend rappresenta una sfida per i diversi Sistemi Sanitari e i pagatori in generale, particolarmente quando si consideri il più elevato consumo di risorse nei pazienti più anziani [3,4]. Soprattutto, va evidenziato che la mortalità legata alla MRC è quasi duplicata, tra il 1990 e il 2010, con un aumento, in termini di anni persi per morte prematura, inferiore solo a HIV-AIDS e diabete mellito [5].
 

La visualizzazione dell’intero documento è riservata a Soci attivi, devi essere registrato e aver eseguito la Login con utente e password.