Issue:11
FEBRUARY, 2008 REPROCESSING OF A DIALYZER
Hon. Editor: Prof. K.V. Dakshina Murthy M.D D.M NIMS, Hyderabad
BY AUTOMATED AND MANUAL METHOD Page : 3
DIALYSIS PATIENTS AND DIET
PROTEINURIA
Massachusetts General Hospital (MGH) researchers have
The kidney's filtering activity takes place in clusters of
identified a new molecular pathway that appears to be
blood vessels called glomeruli. Within those structures,
involved in urinary protein loss (proteinuria). This early-
extensions from cells called podocytes wrap around
stage kidney disease affects 100 million people around
blood vessels. Tiny slits in the podocytes filter out excess
the world and is caused by a breakdown in the kidney's
water and waste materials, keeping larger proteins and
filtering structures. Blocking this pathway could be a
blood cells inside the vessels. In several types of kidney
treatment for the condition and might significantly slow
disease, podocytes shrink and lose their structure, which
the process of kidney failure.
compromises the filtering slits, allowing protein molecules to leak into the urine.
"We've identified a mechanism that underlies common forms of urinary protein loss and have data showing that
In the current study, the authors establish for the first
it is operative in humans and in animal models of
time that the podocyte extensions called foot processes
proteinuria," says Jochen Reiser, MD, PhD, director of
are capable of motion. In some kidney disorders, excess
the Program in Glomerular Disease at the MGH Renal
motility of these structures may be involved in the
Division, the study's senior author.
breakdown of podocytes that leads to proteinuria. To
"Targeting this mechanism with antibodies or small
investigate this possibility, the researchers focused their
molecule compounds can prevent or decrease proteinuria
attention on molecules known to be associated with
in animals, which may represent a novel therapy for
cellular motility in a number of situations. One of these
kidney diseases such as diabetic nephropathy and focal
is the urokinase receptor (uPAR), which is known to be
segmental glomerulosclerosis," adds Changli Wei, MD,
involved in wound healing and inflammation, as well as
PhD, first author of the article.
tumor invasion and metastasis.
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PIOGLITAZONE A new study confirms that chronic kidney disease (CKD) increases the already high risk of serious cardiovascular events in diabetic patients with damage to the large blood vessels and suggests that treatment with the anti diabetic drug pioglitazone may help to lower this risk, reports the January Journal of the American Society of Nephrology. "The data confirm that chronic kidney disease is an independent risk factor for major adverse cardiovascular events and death, even amongst a very high risk population of patients with diabetes and pre existing macrovascular disease," comments Dr. Christian A. Schneider of University of Cologne, Germany. "In these patients with moderate to severe renal disease, pioglitazone reduced all-cause death, myocardial infarction, and stroke, independently of renal function." The study was based on data from PROactive, a largescale study of over 5,000 patients with type 2 diabetes who were at high cardiovascular risk because of macrovascular complications of diabetes. ("Macrovascular" disease means damage to the large blood vessels, such as the coronary arteries and the arteries supplying the legs.) In PROactive, patients were randomly assigned to treatment with the anti diabetic drug pioglitazone or an inactive placebo. Dr. Schneider and colleagues focused on 597 patients who had moderate to severe CKD in addition to diabetes and macrovascular disease. "It is well known that patients with diabetes and CKD are at particularly high risk for cardiovascular disease," Dr Schneider explains.
"However, the impact of CKD on recurrent cardiovascular events among patients with diabetes and established macrovascular disease has not been studied previously." The CKD patients treated with pioglitazone versus placebo were compared for their rates of death or cardiovascular disease events, such as myocardial infarction (heart attack) and stroke. Overall, 27.5 percent of diabetic patients with CKD died or experienced a cardiovascular event significantly higher than the 19.6 rate among patients with normal kidney function. "In a high cardiovascular risk group of patients with type 2 diabetes and pre-existing macrovascular disease, CKD appears to identify a subpopulation of patients at even higher risk for cardiovascular disease," comments Dr. Schneider. Within the CKD group, patients assigned to pioglitazone had a significantly lower risk of death or cardiovascular events. Overall, the rate of death, myocardial infarction, or stroke was reduced by one-third in patients taking pioglitazone, compared with placebo. Most of the reduction occurred among patients with lower levels of kidney function. Dr. Schneider concludes, "Our analysis from PROactive suggests that patients with diabetes, macrovascular disease, and CKD (moderate to severe renal failure) can be treated effectively to reduce the occurrence of major cardiovascular endpoints." The researchers warn that their conclusions do not necessarily apply to diabetic patients at lower cardiovascular risk. Dr. Schneider adds, "These benefits of pioglitazone in patients with CKD must be viewed with caution until confirmatory data of our findings are provided."
This Publication Is Made Possibe With An Unrestricted Educational Grant From
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REPROCESSING OF A DIALYZER BY AUTOMATED AND MANUAL METHOD
Hari Ragi Dialysis Tech , Dr.RML Hospital NewDelhi.
The past decade has seen marked improvement in the quality
anyone who talks about reuse. We just looked at a number of
of dialysis treatment of patients with ESRD .
ways that it can be done improperly. Reuse is an acceptable
The decreased mortality rate is probably the result of a no of
practice to save money and provide the patient with the best
factors including understanding of the rule of comorbidity ,
of care. If you save money, you can increase the quality of the
treatement unit characteristics,barriers to adequate dialysis ,nutrition ,anemia,low flux dialysis and dialyzer membrane improvement and the desired dialysis dose.
treatment you give the patient by getting better dialyzers and doing better things for the patients Automated procedure:
During this same period of time, automated dialyser reprocessing has increased steadily all over. Manual dialyser reuse has been practiced since the beginning of chronic haemodialysis, initially because of the economic savings associated with dialyzer reuse and later because of improved patient responses to dialysis with reprocessed
Automated dialyzer reprocessing machine
dialyzers. and mainly we can avoid the first use syndrome with the cellulose dialyzers after doing reuse. Despite manufacturer introduction of less expensive dialyzers labeled for single use. By 1997 dialyser reuse was practiced in 82% of dialysis centers. If dialyzers are not going to be reprocessed within two hours of completion of treatment, then they must be refrigerated for not more than 36 hours to slow bacterial growth After returning the patient’s blood with normal saline, heparinize the remaining saline index in extracorporeal circuit to recirculate for one to two minutes at 300 blood flow. We cap the dialyzers and thus dialysate ports. Make sure the blood compartment is fluid filled and no air has been introduced into the dialyzer, and return the dialyzer to the reuse room.
World wide Growth
Reuse is safe and effective if performed correctly. You will
350,000 U.S
480,000 ROW
250,000 Japan
1998
270z,000 Europe
250,000 U.S.
298,000 ROW
187,000 Japan
215,000 Europe
2003
World wide reuse
hear that statement from anyone who does reuse and
Process is going on
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Automated reprocessing is utilized by over 60%of the centers practicing dialyser reuse. Dialysis care providersand their management teams are faced with the task of impoving the quality of patient care while maintaining and redusing the cost of care. It decreases the hazardous to the dialyser reuse personnel and it avoid blood leaks with reuse dialyzers by doing pressure tests.
Cleaning: After giving water wash in the blood compartment, close one end of dialyser port and give presurised (20 psi)rinse
Automated reuse: Renatron
from one end for 10 min , this technique removes blood stains
The Renatron is a single-station machine, modular up to six
from internal side and improve no of reuses.
machines. It uses Renalin only. It has a computerized database and 8 to 10 minutes per dialyzer; pressure and volume tests only. Automated reuse: Seratronics DRS4 Automated machines-I will start off with the Seratronics DRS4. That is a four-station machine, approximately 35 minutes for four dialyzers. Cleaning agent can take multiple cleaning agents, not at the same time. Obviously you set your machine up for the one that you’ve chosen. The disinfectants-the same thing. Computerized database. And it has the pressure, the volume, and ultrafiltration rate tests.
Cleaning:
Hydrogen
peroxide/peracetic
acid
Hydrogen peroxide, peracetic acid, does not remove proteins; ultrafiltration decreases; clearance of middle molecules significantly reduced in certain dialyzers.
Automated reuse: Mesa medical - Echo The Mesa medical’s - Echo is a single station. The cleaning agent is multiple disinfectant as well as multiple. There is no
REUSE CALCULATIONS The average reuse no for dialysers were calculated in two ways
database. Eight to 30 minutes per dialyzer, and does pressure and volume tests only.
The conventional method: This method is calculated by determining the mean of no of dialysis treatments performed
Some imp methods of manual reuse :
with a discarded dialyser for a given month. Formula: I “ ( no of reuses per dialyser discarded in the month ) ( no of resuse dialysers discarded )
The Hart line method: This method is calculated by divided total no of treatments by the no of reuse dialysers discarded for the month Cleaning: Depyrogenated RO water Depyrogenated RO water used alone is very cheap, it is nontoxic, and very effective when used with reverse ultrafiltration.
Formula: II ( no of reuse treatments per month ) no of reuse dialysers discarded
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New technical practices to improve no of reuses : ❑ ❑
Reuse is a difficult balance of risks and benefits. It provides
Standardize heparin stoppage 30 min before
significant economic benefits to dialysis providers and allows
treatment end before it is 60 min
the use of expensive high-flux/high-efficiency dialyzers
Prime the dialyzer with 1000IU/l normal saline before
routinely.
it is 500IU/l ❑
Raise the venous end up during recirculation
❑
Standardize administration of heparin loading dose
Contact Author : hariragi@yahoo.co.in / gmail.com Cell No:09868633506
before initiating treatment ❑
Avoid air returning of blood
❑
Recirculation of heparenized (1000IU) saline at the
EGOTISM
end of treatment for 5-10 min flow rate of 350-400ml/ ❑
min
There was once a scientist who discovered the art of
Maintain current practice
reproducing himself so perfectly that it was impossible to tell
Advantages of reuse
production from the original.
The advantage of reuse is decreased treatment costs. We are
One day he learnt that the Angel of Death was searching for
seeing some of our clinics now moving to non-reuse with the
him so he reproduced a dozen copies of himself. The Angel
advent of the low-cost dialyzers, such as the F6. But obviously
was at a loss to know which of the thirteen specimens before
with clinics that are using the more expensive F80 dialyzers,
him was the scientist, so he left them all alone and returned
reuse is very much effective. It just doesn’t make economical
to heaven.
sense to go to non-reuse and having half the patients using
But not for long, for being an expert in human nature. The
F80s. It would cost them too much money to do that. We can
angel came up with a clever device. He said, “sir, you must
have shorter treatment times by using the high-flux dialyzers,
be a genius to have succeeded in making such perfect
improved biocompatibility and reduction of first-use
reproductions of yourself. However, I have discovered a flaw
syndrome.
in your work, just one tiny little flaw.” The scientist immediately jumped out and shouted,
Disadvantages of reuse
“Impossible! Where is the flaw?” “Right here,” said the Angel,
Patient and staff exposure to toxic chemicals when using
as he picked up the scientist from among the reproductions
formaldehyde, Renalin, glutaraldehyde… there is potential
and carried him off.
bacterial endotoxin contamination of the dialyzers if the
Levels of Learning
guidelines are not followed. Changing in dialyzer clearance,
L1.A. While our skill takes us high, our ego pulls us down.
change in dialyzer ultrafiltration rate, and the potential for cross-contamination is always there.
B. At times our ego finds our end. L2.A. Share an incident where your ego let you down.
Conclusion
B. Share an experience of someone known to you who had to
So the conclusions we come to with our reuse programs: Reuse
pay a heavy price because of his ego.
can be performed safely with established written of protocols,
C. Share what ego means to you.
following the recommendations of the dialyzer and germicide
L3.A. If your ego is the flaw in you, what prevents you from
manufacturer, the Association for the Advanced Medical
rectifying it?
Instrumentation - that’s AAMI, the National Association of Nephrology Technicians-NANT, and the Center for Disease Control-the CDC in Atlanta.
B. What is the nature of ‘ego’? C. Where does my ego come from?
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NNCC CERTIFICATION EXAM OFFERED The Nephrology Nursing Certification Commission (NNCC) will be offering the Certified Nephrology Nurse (CNN) Examination, the Certified Dialysis Nurse (CDN) Examination, the Certified Nephrology Nurse-Nurse Practitioner (CNN-NP) Examination, and the Certified Clinical Hemodialysis Technician (CCHT) Examination on Saturday, April 26, from 12:30 p.m. to 5 p.m. Separate registration fees and forms are required for each exam. For more information and applications, call the NNCC National Office toll free at 888-884-6622 or 856-256-2321. Applications may be downloaded online from NNCC's Web site, http:// www.nncc-exam.org. The American Nephrology Nurses' Association (ANNA) will hold its 39th National Symposium April 27-30, 2008, in Philadelphia, PA, at the Philadelphia Marriott and Pennsylvania Convention Center. Education sessions span the nephrology nursing specialty and will be presented by the industry's leading experts. The latest advances and treatment innovations will be explored and are reflected in the conference theme: "Evidence and Nursing Informatics to Improve Safety and Outcomes." Nephrology nurses and health care providers at every level will learn the latest information and treatment advances. Participants will also have the opportunity to earn continuing nursing education credits, network with colleagues, visit the exhibit hall and attend special events. Topics include hemodialysis, peritoneal dialysis, and other treatment modalities; bioethics, sleep disorders, cultural challenges, leadership development and much more. The full conference program and registration details are available on ANNA's Web site, http://www.annanurse.org.
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SMS Quiz
Who Won AAKP Award ? SMS Your Answer To 919849551183. SMS Your Answer & Win A Gift The First Correct Entry Will Receive A Surprise Gift
AAKP The American Association of Kidney Patients (AAKP) is pleased to recognize Todd S. Ing, MD, as the 2008 recipient of the Medal of Excellence Award. The Medal of Excellence Award is one of AAKP's highest honors. It recognizes a renal physician who has dedicated his or her career to the advancement and treatment of kidney disease, and the care of kidney patients. Dr. Ing has dedicated more than 40 years of service to the renal community. Currently he is courtesy staff physician in the Department of Medicine at the Veterans Affairs Hospital in Hines, IL, as well as Professor Emeritus of Medicine at Loyola University Chicago, Stritch School of Medicine. He is a key member of the renal community both nationally and internationally with his prior and current appointments to the editorial boards for, Hemodialysis International, Peritoneal Dialysis International, Transactions of the American Society for Artificial Internal Organs, Journal of the American Society of Paraplegia, Kidney and Hong Kong Journal of Nephrology. From 1985 - 2004, Dr. Ing was also the U.S. editor for the International Journal of Artificial Organs.
Nephro -Network Dear Reader, D-Tech wishes to bring together Nephrology community and promote communication. We invite you to join Nephro-Network. Please send your name, designation, and contact details by E-mail to dtecheditor@yahoo.com or write to D-Tech 3-3-62A, New Gokhale Nagar, Ramnthapur , Hyderabad - 500 013.
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HEPARIN ALERT The FDA informed healthcare professionals of important warnings and instructions for Heparin Sodium Injection use. There have been reports of serious adverse events including allergic or hypersensitivity-type reactions, with symptoms of oral swelling, nausea, vomiting, sweating, shortness of breath, and cases of severe hypotension. Most events developed within minutes of heparin initiation although the possibility for a delayed response has not been excluded. The reports have largely involved use of multiple-dose vials. However, there have been several cases in which product from multiple, single-dose vials have been combined to administer a bolus dose. Heparin sodium is an anticoagulant (blood thinner) that is used in patients undergoing kidney dialysis, certain types of cardiac surgery, and treatment or prevention of other serious medical conditions, including deep venous thrombosis and pulmonary emboli. Heparin treatment is initiated using high doses (5000-50,000 units) given directly into the blood stream (intravenously) as a bolus. Serious adverse events have recently been reported in patients who received these higher bolus doses. The manufacture of multiple-dose vials of heparin sodium has been suspended pending the completion of an extensive ongoing investigation to determine the root cause of the problem. Because heparin sodium is a medically necessary product and serious public health consequences would result if there were a sudden shortage of the drug, the multiple-dose vials of heparin sodium manufactured by Baxter that are currently in distribution will not be recalled. See the FDA Public
Health Advisory for Agency recommendations to healthcare professionals on the use of heparin sodium for injection. Read the complete 2008 FDA MedWatch Safety Summary including a link to the FDA Public Health Advisory, Q & A Document, and News Release regarding this issue at: http://www.fda.gov/medwatch/safety/2008/ safety08.htm#HeparinInj2 Baxter Healthcare andRthe FDA notified healthcare professionals of a voluntary recall of certain lots of Heparin as a precaution due to an increase in reports of adverse patient reactions associated with these lots. Baxter is in the process of an in-depth investigation to determine the root cause of the reported reactions. Reported adverse events include abdominal pain, decreased blood pressure, burning sensation, chest pain, diarrhea, dizziness, drug ineffectiveness, dyspepsia, dyspnea, erythema, flushing, headache, hyperhidrosis, hypoesthesia, hypotension, increased lacrimation, loss of consciousness, malaise, nausea, pallor, palpitations, paresthesia, pharyngeal edema, restlessness, vomiting/ retching, stomach discomfort, tachycardia, thirst, trismus, and unresponsiveness to stimuli. There have been no reports involving fatality. See the recall notice for a list of affected lots. Read the complete 2008 FDA MedWatch Safety Summary including a link to the firm's recall notice, at: http://www.fda.gov/medwatch/safety/2008/ safety08.htm#HeparinInj
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