Protocol for haemodialysis in Ebola patients

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The [b]American Society of Nephrology Kidney Week 2014[/b] was held last week and studies presented include a protocol presented by clinicians who recently accomplished the first known successful delivery of renal replacement therapy with subsequent recovery of kidney function in a patient with Ebola virus disease.

Acute kidney injury occurs frequently in Ebola virus disease; however, providing haemodialysis to these patients was previously thought to be too risky because it involves large needles or catheters and potential contact with highly infectious blood. The report by Dr Michael Connor, Jr, Dr Harold Franch, ([b]Emory University School of Medicine[/b]), and their colleagues details the measures the clinicians took to maximise safety and minimise risk of secondary transmission of Ebola virus, including careful considerations to the types of equipment used and the protocols that clinical staff followed.

None of the staff developed Ebola virus disease after a 21-day observation period, and no detectable Ebola virus genetic material was found in the patient’s dialysis waste fluids. ‘In our opinion, this report confirms that with adequate training, preparation, and adherence to safety protocols, renal replacement therapies can be provided safely and should be considered a viable option to provide advanced supportive care in patients with Ebola’ said Connor.

In light of their success, the team has proposed a set of clinical practice guidelines for acute renal replacement therapy in Ebola virus disease. ‘More than anything else, in our report, we found that extra training of our volunteer ICU nurses made success possible. We thank them for their bravery and commitment.’ said Franch. ‘Our case also shows that dialysis is not a death sentence for patients suffering from Ebola virus disease and recovery of kidney function is possible.’

Transplanted kidneys may not function long-term if they come from donors with variants in a particular gene, according to a study presented at the conference. [s]Science Daily[/s] reports that previous research from a single centre in [b]North Carolina[/b] found that risk variants in the apolipo-protein L1 gene (APOL1) in African American deceased kidney donors were linked with shorter survival of transplanted kidneys.

The APOL1 gene creates a protein that is a component of HDL, or good cholesterol. Variation in the APOL1 gene is associated with up to 40% of all kidney disease in African Americans who undergo dialysis or kidney transplantation, and APOL1 kidney risk variants are present only on the chromosomes of individuals who possess recent African ancestry. Researchers led by Barry Freedman ([b]Wake Forest School of Medicine[/b]) looked for the potential link between APOL1 risk variants and shorter survival of transplanted kidneys in a larger group of patients.

The new multi-centre study included 675 deceased donor kidney transplants from African American donors. Results from the study confirmed that 2 APOL1 gene variants in donor kidneys were associated with more than a 2-fold increased risk of organ failure after transplantation. ‘These results warrant consideration of rapidly genotyping deceased African American kidney donors for APOL1 risk variants at the time of organ recovery,’ said Dr Freedman. ‘APOL1 genotype data should be incorporated in the organ allocation and informed-consent processes.’

Diabetes is a major risk factor for kidney disease. But, according to a [s]Daily Rx[/s] report, research suggests that adding sleep apnoea to the mix, can cause the kidneys to decline even faster. The new study found that diabetes patients who had sleep apnoea lost kidney function more rapidly than those who did not have the sleep disorder.

Dr Roberto Pisoni, from the [b]Medical University of South Carolina in Charleston[/b], and colleagues reviewed data on 56 patients with diabetes and chronic kidney disease (diabetic nephropathy). The patients completed a survey with questions that could indicate whether they also had obstructive sleep apnoea. Based on the survey answers, the team found that 61% of the patients had a high-risk score for obstructive sleep apnoea. They had a much greater loss of kidney function than those with a low-risk apnoea score.

Sleep apnoea is thought to contribute to high blood pressure, hypoxia (depriving a region of the body of oxygen) and inflammation – all factors that may contribute to kidney disease. Pisoni and colleagues measured kidney damage by loss of estimated glomerular filtration rate (eGFR). This test measures the amount of blood that passes through the glomeruli – that filter waste from the blood – in one minute.

‘This study shows that a high-risk score for obstructive sleep apnoea is common in (chronic kidney disease) patients with diabetic nephropathy and is associated with more rapid loss of (kidney) function,’ the authors wrote. ‘This simple approach identifies patients at higher risk of (chronic kidney disease) progression.’

A year-long programme of simple exercise-based rehabilitation for chronic kidney disease(CKD) patients significantly slowed the rate of kidney function decline and improved cardio-respiratory fitness. Heart disease is the leading cause of death in CKD patients. Because exercise capacity is significantly reduced in CKD patients, Dr Sharlene Greenwood, [b]King’s College Hospital[/b], in London, and her colleagues examined the effect of 12 months of exercise training on kidney function and measures of heart disease risk in patients with progressive CKD stages 3-4.

For the study, 20 patients were randomised to a rehabilitation group (REHAB, n = 10) that received exercise training (3 times per week) or standard care (UC, n = 10). A total of 18 participants completed the study (8 from the REHAB group and 10 from the UC group).

The researchers found that the rehabilitation significantly slowed the rate of kidney function decline and improved cardio-respiratory fitness compared with standard care. ‘Exercise-based rehabilitation has the potential to be a kidney-protective therapy for patients with progressive stages 3-4 CKD, and larger studies are planned,’ said Dr. Greenwood. ‘Exercise, besides protecting the kidneys, also will improve fitness, general health, and quality of life and has the potential to reduce cardiovascular risk, a major cause of mortality and morbidity in patients with CKD.’

In another study, Dr Francesca Mallamaci, ([b]National Research Council Institute of Clinical Physiology[/b], in Italy) and her colleagues tested the effectiveness of a low-intensity, easy-to-implement, home exercise programme on physical performance in dialysis patients.

For the EXCITE trial, 151 patients were instructed to follow the cadence of an inexpensive metronome while walking, while 146 patients maintained their normal physical activity. After 6 months, performance in a 6-minute walking test improved in the exercise group (with participants walking 41 meters more in that amount of time), but remained unchanged in the control group. A ‘sit to stand’ test also improved in the exercise group but not in the control group. ‘The simplicity and adaptability of the programme make it suitable to the needs of a high-risk population such as the dialysis population,’ the researchers concluded.

Full American Society of Nephrology release on Ebola-related haemodialyis
Journal of the American Society of Nephrology abstract
Full Science Daily report
Nature abstract
Full Daily Rx report
More ASN Kidney Week 2014 research
Full ASN release on British and Italian studies on effect of exercise in CKD patients
ASN Kidney Week — All the abstracts

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