LIGHT EXPOSURE DURING HAEMODIALYSIS DOES NOT CAUSE HAEMOLYSIS OR OXIDATIVE STRESS

J LI1,2, K MCNICHOLAS1,2,  K TORPEY1, L THORBURN1,  C DELANEY3,  A ROWLAND4, J GLEADLE1,2
1Dept of Renal Medicine, Flinders Medical Centre, Sturt Road, Bedford Park, Australia, 2College of Medicine and Public Health, Flinders University, Bedford Park, Australia, 3Dept of Vascular Surgery, Flinders Medical Centre, Sturt Road, Bedford Park, Australia, 4Dept of Clinical Pharmacology, Flinders University, Bedford Park, Australia

Aim: It was reported that light exposure caused red blood cell lysis over 90 years ago. The mechanism of such lysis and the clinical consequences are unclear. The effects of prolonged light exposure on the blood of haemodialysis patients are uncertain. We tested the hypothesis that light exposure during haemodialysis leads to haemolysis and increased levels of oxidative stress markers in blood.
Background: During haemodialysis, a patient’s entire blood volume traverses a transparent circuit of tubing every 20 mins. Given 3 haemodialysis sessions a week, a patient’s blood is exposed to ambient light up to 50 times in a week. This raises the concern whether the light exposure may increase haemolysis and contribute to oxidative stress. We measured the levels of free haemoglobin and the oxidative stress marker, F2-isoprostane (15-F2t-IsoP) in patients’ blood in conventional versus light-shielded haemodialysis.
Methods: In a cross-over trial spanning 2 weeks, we took bloods from 32 patients pre and post dialysis. Each patient had one week of conventional haemodialysis alternating with one week of light-shielded haemodialysis in which all extracorporeal circuitry was covered to prevent light exposure of blood. Plasma 15-F2t-IsoP was measured by competitive ELISA and free haemoglobin measured as a marker of haemolysis.
Results: Free haemoglobin levels did not change significantly (p=0.32) in patient bloods undergoing conventional dialysis (0.01 pg/mL) compared to light-shielded dialysis (-0.01 pg/mL). The mean concentration of 15-F2t-IsoP in conventional dialysis patient plasma (3,613 pg/mL) was not significantly different from light-shielded dialysis (3,223 pg/mL) (p=0.316).
Conclusions:Haemolysis as judged by free haemoglobin was not increased in conventional haemodialysis versus light-shielded nor did exposure to light increase the plasma level of oxidative stress marker, 15-F2t-IsoP.


Biography:
Bio to be advised

NUTRITIONAL OUTCOMES OF END-STAGE RENAL FAILURE PATIENTS RECEIVING INTRA-DIALYTIC PARENTERAL NUTRITION; A CASE SERIES

S BAHCECI1, M CHAN1
1St George Hospital , Sydney, Australia

Aim: To examine the effectiveness of supplemental Intradialytic Parenteral Nutrition (IDPN) on nutritional outcomes of malnourished haemodialysis (HD) patients.
Background: IDPN has been demonstrated in the literature to be a feasible mode of nutrition support; however it is not commonly used for malnourished HD patients in Australia.
Methods: Three malnourished patients identified using the subjective global assessment (SGA B-C) at a tertiary facility HD unit who did not respond to conventional nutrition support commenced supplemental IDPN. These patients also continued to receive concurrent nutrition support including oral nutrition supplementation and dietary counselling by the dietitian. These patients received the standard IDPN formula of electrolyte free amino acids and lipids as per the hospital dietetic protocol providing a total of 1000ml IDPN, 1213kcal, 53g protein, 100g fat, 0g carbohydrates each dialysis session three times per week. The patients’ nutritional parameters including anthropometry, biochemistry, oral intake and nutritional status were monitored over a ten week period.
Results: All three patients responded to nutrition support with supplemental IDPN and improved their nutritional status over the 10 week period. All patients on average improved their nutritional parameters, including total dry body weight (5%) total caloric intake (63%), oral caloric intake (16%), albumin (13%), and hand grip strength (4%). All three patients reported markedly improved levels of energy and stimulation of appetite. Nil adverse events were reported.
Conclusions: IDPN was found to be a safe and effective mode of nutrition support for malnourished HD patients. These observations may pave way for the wider acceptance of such use in Australia.


Biography:
Su Bahceci is a clinical dietitian working at St George Hospital, Sydney with extensive experience in a number of medical and surgical clinical areas and has been specialising for over four years in the renal acute inpatient and chronic outpatient settings. She has undertaken post-graduate training in renal nutrition. Su has a vested interest in research, particularly in nutrition support for malnourished renal patients and examining the role of intradialytic parenteral nutrition on nutritional outcomes. She is also enthusiastic about mentoring fellow dietitians and students in the area of renal nutrition.

35 HOURS OF CONTINUOUS HI FLUX HAEMODIALYSIS AFTER FAILED CONTINUOUS VENOUS-VENOUS HAEMODIAFILTRATION FOR SEVERE LACTIC ACIDOSIS DUE TO A 132g METFORMIN OVERDOSE

A FLAVELL1, S COHNEY1,2, C NELSON1,2
1Western Health, , Australia, 2The University of Melbourne, , Australia

Background: Metformin is the initial recommended glucose lowering agent in type two diabetes mellitus, and one of the most commonly prescribed medications in Australia. Metformin-associated lactic acidosis (MALA) is an uncommon but feared side effect usually precipitated by acute illness in combination with renal, hepatic or cardiac dysfunction. Inadvertent or intentional drug overdose can also cause MALA and there is limited evidence to guide management of such cases.
Case: A 55-year-old female presented to hospital 6 hours after intentional polypharmacy overdose, which included 132g of extended release metformin. The patient was hypotensive, anuric, and had a lactic acidosis with arterial blood pH 7.18, lactate 12mmol/L, and bicarbonate 14mmol/L. She continued to deteriorate despite high dose vasopressors, intravenous bicarbonate therapy and 5 hours of continuous venous-venous haemodiafiltration (CVVHDF), after which her pH was 6.8, lactate 24mmol/L, and bicarbonate 3mmol/L. CVVHDF was replaced by high flux haemodialysis (HFHDx) using a Polyflux® 210H (Gambro) dialyser, pump speed 300mL/min, dialysate flow 500mL/min and dialysate bicarbonate 40mmol/L. An initial 8 hours of HFHDx led to stabilisation of her biochemical parameters, but she rapidly deteriorated when HFHDx was temporarily withdrawn. HFHDx was continued for a further 27 hours after which the patient biochemically and haemodynamically improved. The patient required intermittent HFHDx support for a further 30 days until renal recovery.
Discussion: This case of severe MALA followed a polypharmacy overdose that included 132g metformin. The resultant refractory lactic acidosis did not improve until institution of 35 hours of continuous HFHDx, which was both more effective than CVVHDF and well tolerated. Prolonged continuous HFHDx should be considered in all cases of severe MALA, particularly those refractory to CVVHDF.


Biography:
Advanced Trainee in Nephrology

CORRELATION BETWEEN SERUM ALBUMIN AND SERUM IONIZED CALCIUM IN PATIENTS UNDERGOING ROUTINE HEMODIALYSIS

W SYAMSURI1, M RUDIANSYAH2, R ROESLI1, A MARTAKUSUMAH1, R SUPRIYADI1, R BANDIARA1
1Division of Nephrology & Hypertension, Departement of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital , Bandung, Indonesia, 2Division of Nephrology & Hypertension, Departement of Internal Medicine, Faculty of Medicine, University of Lambung Mangkurat/Ulin General Hospital, Banjarmasin, Indonesia

Aim: The aim of this study is to assess the correlation between serum albumin levels and ionized calcium levels in patients undergoing routine hemodialysis.
Background: In patients with chronic kidney disease who undergo hemodialysis (CKD-5D), serum ionized calcium levels may associate with severity and duration of proteinuria.
Method: This is a cross-sectional study carried out in Hemodialysis Unit at Hasan Sadikin General Hospital Bandung. There were 181 patients with CKD-5D who undergoing routine hemodialysis, 74 patients were analyzed. Serum albumin levels and serum ionized calcium levels were measured and Spearman Rank test was done to determine correlation between these two variables.
Results: Among 74 CKD-5D patients, 39 (52.7%) were males and 35 (47.3%) were females, aged 46±12 years and median duration of hemodialysis was 43 (12-168) months. Serum albumin levels 4.0 ± 0.3 g/dl and serum ionized calcium levels 4.3 ± 0.6 mmol/L. Spearman Rank correlation test between serum albumin levels and serum ionized calcium levels was significant (r=0.279; R2= 0.078; p=0.008).
Conclusion: There is significant correlation between serum albumin levels and serum ionized calcium levels in CKD-5D


Biography:
Wizhar Syamsuri, MD
Karawang, March 26th, 2018
Graduate from Medical Faculty Udayana University Bali Indonesia
Internal Medicine Specialist from Andalas University Padang Indonesia
Trainee in Division of Nephrology and Hypertension University of Padjadjaran Bandung Indonesia

APIXABAN USE IN CHRONIC KIDNEY DISEASE PATIENTS.

K  TIRUMALA ECHAMPATI1, R SINGER1
1Canberra Hospital, Phillip, Australia

Background: There are safety and efficacy concerns surrounding use of warfarin use in haemodialysis patients. Efficacy of warfarin for stroke prevention in dialysis patients is controversial. Warfarin is associated with complications such as haemorrhage and calciphylaxis. Apixaban is an alternative anticoagulant but currently there is no outcome data in patients with eGFR of <25ml/min. Since 2014, FDA labelling has permitted the use of apixaban in this group but such use is off-label in Australia. Dialysis patients with atrial fibrillation (AF) or a clotted arteriovenous fistula (AVF) may fit the PBS criteria for Apixaban funding.
Aim: To monitor the efficacy and safety of Apixaban in chronic kidney disease patients.
Methods: All patients with eGFR <25 mL/min/173m2 prescribed apixaban within the renal unit eligible for inclusion in the monitoring study. Patients provided informed consent for off-label use of apixaban as part of routine clinical care. Trough anti-Xa levels were measured 1 week post commencement.
Results: During the monitoring period from 1/1/2018 to 11/4/2018 a total of 7 patients were prescribed Apixaban. The most common reason given by the prescriber was labile international normalized ratio (INRs). Six of the patients were haemodialysis dependant and 5 were anti coagulated to maintained fistula patency. The anti-Xa concentration ranged between 35 to 99 ng/ml (laboratory target therapeutic range 50-200 ng/ml) (table 1). Due to sample timing issues a trough level was not available for one patient. All patients tolerated Apixaban without apparent adverse events. There were no episodes of excess bleeding or thrombosis.
Conclusion: In this small observational study, apixaban use appears to be safe with a relatively narrow range of anti-Xa levels noted for a given dose of apixaban.


Biography:
Obtained medical degree from India and came to Australia to pursue further education. Finished his Basic Physician Training and currently working as a renal advance trainee (second year) at Canberra Hospital. Interested in the transplant medicine and general nephrology.

HEMODIALYSIS INDUCED CARDIAC DYSFUNCTION AND RELATED FACTORS

I MERTHA1, H PRASANTO2, I KUSWADI3
1Sarjito Hospital, Yogyakarta, Indonesia, 2Sardjito Hospital, Yogyakarta, Indonesia, 3Sardjito Hospital, Yogyakarta, Indonesia

Background. Heart failure (HF) is highly prevalent and associated with high mortality in hemodialysis patients. We studied cardiac dysfunction and related factors in hemodialysis patients at Sarjito Hospital Yogyakarta.
Methods. In a cross-sectional study we investigated 45 routine hemodialysis patients at Sarjito Hospitals, from Januari to july 2016. They were male 27 (60%), female 18 (40%), with heart failure in New York Heart Association class I and II. Data analyzed by Pearson Chi Square method.
Results. Mean age 51±9,3 years,mean Hb consentrations 9,0±1,57, mean ferritin consentrations 1221,7±1409,67, Neutrophil to Lymphocyte ratio mean 3,33±2,67, mean Length of duration HD 5,36±3,4 years and mean of Pulse pressure 66,44±17,58 mmHg, The pearshon chi square, showed that cardiac performance and functions in hemodialisis patients correlates with Length of hemodialysis (p=0,001), ferritin consentrations (p=0,001) Neutrophil-Lymphocyte ratio (p=0,001), duration of HD (p=0,001), Pulse pressure (p=0,001) and Sex (p=0,001).
Conclusions. The study demonstrates that hemodialysis patients hade correlated with cardiac dysfunction, and related with factors were sex, length of dialysis time, with Feritin level, albumin, hemoglobin and pulse pressure.


Biography:
Fellow on Renal and Hypertension Medical Division, Sardjito Hospital Yogyakarta Indonesia

HEMODIALYSIS INDUCED CARDIAC DYSFUNCTION AND RELATED FACTORS

I MERTHA1, H PRASANTO2, I KUSWADI3
1Sarjito Hospital, Yogyakarta, Indonesia, 2Sarjito Hospital, Yogyakarta, Indonesia, 3Sarjito Hospital, Yogyakarta, Indonesia

Background. Heart failure (HF) is highly prevalent and associated with high mortality in hemodialysis patients. We studied  cardiac dysfunction and related factors in hemodialysis patients at Sarjito Hospital Yogyakarta.
Methods. In a cross-sectional study we investigated 45 routine hemodialysis patients at Sarjito Hospitals, from Januari to july 2016. They were male  27 (60%), female 18 (40%), with heart failure in New York  Heart Association class I and II. Data analyzed by Pearson Chi Square method.
Results. Mean age  51±9,3 years,mean Hb consentrations 9,0±1,57, mean ferritin consentrations 1221,7±1409,67, Neutrophil to Lymphocyte ratio mean 3,33±2,67, mean Length of duration HD 5,36±3,4 years and mean of Pulse pressure 66,44±17,58 mmHg, The pearshon chi square, showed that cardiac performance and functions in hemodialisis patients correlates with Length of hemodialysis  (p=0,001), ferritin consentrations (p=0,001) Neutrophil-Lymphocyte ratio (p=0,001), duration of  HD (p=0,001), Pulse pressure (p=0,001) and  Sex (p=0,001).
Conclusions. The study demonstrates that hemodialysis patients  hade correlated with cardiac dysfunction, and related with factors  were sex, length of dialysis time, with Feritin level, albumin, hemoglobin and pulse pressure.


Biography:
Fellow on Renal and Hypertension Division, Internal Medicine Department, Sardjito Hospital Yogyakarta Indonesia

 

 

UTILIZING IPOS RENAL TOOL TO IDENTIFY COMMON SYMPTOMS IN HAEMODIALYIS PATIENTS TO ENHANCE PATIENT CARE AND HEALTH OUTCOMES

J CHIMYONG1
1Peninsula Health , Frankston, Australia

Aim: To improve the management of the symptom burden in haemodialysis patients through evaluation of IPOS renal tool.
Background: Patients receiving haemodialysis treatment experience significant symptom burden that is often undetected and hence undertreated. Inability to describe these symptoms is one of the reasons why these symptoms are undertreated. IPOS renal tool features common symptoms renal patients’ experience, including physical symptoms, emotional, psychological and spiritual needs.
Method: Introduce IPOS renal tool to all patients receiving haemodialysis treatment at Peninsula Health satellite units. A baseline IPOS renal tool is implemented to establish initial co-morbidity burden load. IPOS renal is then repeated with each patient nephrology review to highlight current medical issues. Patient scores are collated and discussed at clinic review to improve patient outcomes.Patient Participation: The study examined the responses of 75 patients across three haemodialysis units. The average age of the patient participation was 66.83years. (Range 24-89 years) There was 43 males and 32 female patients.
Results: Following collation of patient response there was significant burden in the following areas: Pain (32%) Weakness or lack of energy (48%), Poor mobility (38.6%) and difficultly sleeping (37.33%). Within this group anxiety (46.6%) and depression (40%) was also prevalent along with 52% of participants unable to share their feelings with loved ones.
Conclusion: The study improved channels of communication between patients and medical staff with the introduction of IPOS renal. IPOS review highlighted areas of concern for patients, previously not identified. Majority of patients experienced both physical and psychological discomfort. Recognising untreated symptoms has led to increased referral to various services such as chronic pain clinic, exercise physiologist and social worker to help patients overcome these burdens.


Biography:
Julie Chimyong
Lives on the Mornington Peninsula ,working at Peninsula Health as a Nephrology Nurse Practitioner. Patient focus groups includes CKD stage 3-5, including haemodialysis and peritoneal dialysis patients

AN AUDIT OF ENVIRONMENTAL SUSTAINABILITY ACROSS TERTIARY DIALYSIS FACILITIES IN TASMANIA

N ABEYSEKERA1, J REYNOLDS2, R FENTON3, T BATTAGLINI-SMITH4, R MACE4, M JOSE1,3
1School of Medicine, Hobart, Australia, 2North West Renal Satellite Unit, Burnie, Australia, 3Southern Tasmania Renal Unit, Hobart, Australia, 4Northern Tasmania Renal Unit, Launceston, Australia

Aim : The Green Dialysis survey aimed to establish a baseline for environmental sustainability across Tasmanian dialysis facilities.
Background : Dialysis is responsible for high resource consumption, resulting in a high economic burden and cost to the environment.
Methods : Nurse unit managers of all Tasmanian public dialysis facilities received an online survey, which asked 23 questions relevant to the environmental sustainability of dialysis services. The survey used was a modified version of the survey used to assess Victorian & UK dialysis facilities.
Results : Responses were received from 6/6 dialysis units in Tasmania. Energy saving initiatives included the use of fluorescent lighting (n=6, 100%), motion sensor lights (n=1, 17%), thermostat controlled heating (n=6, 100%) and automatic hibernation settings of fax machines and computers (n=6, 100%). Five units (83%) were supplied with energy by Aurora and one unit (17%) from TasNetworks. Water saving initiatives included motion sensor taps (n=3, 50%) but no units harvested rainwater nor recycled reverse osmosis water. Recycling initiatives included waste segregation in all units and four recycled PVC plastic. Sustainable transport initiatives included active and public transport (n=3, 50%). Three units (50%) also provided bicycle parking with access to shower and changing facilities. None of the units used virgin paper and all had double-sided printing as an automatic setting. All units used a combination of paper and digital medical records. All units used paper towels and food sourcing was unknown. All units supported green initiatives, but no unit had an environmental sustainability policy nor had performed an audit of their environmental sustainability.
Conclusions : This survey provides a baseline for practices that impact the environmental sustainability of dialysis units in Tasmania.


Biography:
Miss Natasha Abeysekera is a medical student at the University of Tasmania at the Hobart Clinical School. She is a current fourth year medical student working with the renal department at the Royal Hobart Hospital on several projects. Natasha has an interest in kidney transplantation, clinical genetics and paediatric nephrology.

A COMPARISON OF WASTE GENERATION AND DISPOSAL PRACTICES AND COSTS WITHIN TWO HAEMODIALYSIS UNITS

D SENEVIRATNE EPA1, K BARRACLOUGH1, A WHITE1
1The Royal Melbourne Hospital, Parkville, Australia

Aim: The aim of this study was to audit and compare waste generation and disposal practices and costs within two haemodialysis units in Melbourne.
Background: Dialysis has among the highest recurrent, per capita resource consumption and waste generation profile of any healthcare sector. The environmental and financial costs are high and unsustainable. Research into dialysis waste management in the Australian setting is scarce.
Methods: Three haemodialysis treatment sessions were observed within each haemodialysis unit (units A and B). All waste items generated were identified and weighed. Segregation into general, recycling and clinical waste streams was directly observed. The cost implications of current versus ideal waste practice were calculated.
Results: The average weight of waste generated from a single haemodialysis session at units A and B were 3.9kg and 2.1kg respectively; the excess for unit A was due to non-drainage of left-over fluid prior to container disposal. Clinical waste accounted for 61.5% of unit A’s total waste, compared with 49.4% for unit B. This difference was due to optimal and superior waste segregation at unit B. Because of the increased cost of clinical compared to other waste disposal, the total cost of waste disposal per treatment was $2.23 AUD at unit A compared with $1.55 AUD at unit B, despite the per kg general waste disposal cost at unit B being three times that of unit A. If waste management were to be optimized at unit A, yearly savings of AUD 9064 would accrue.
Conclusions: Optimal dialysis waste practice creates potential for environmental and financial savings. All dialysis units should consider auditing waste management and instituting measures to improve waste management.


Biography:
Dan Seneviratne Epa is a second year Nephrology Advanced Trainee, undertaking training at The Royal Melbourne Hospital and Box Hill Hospital in Victoria.He has a keen interest in research and continuous quality improvement. This project was undertaken in an effort to boost financial and environmental sustainability in the practice of haemodialysis.

 

 

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