Dialysis Access Research Articles

Impact of the COVID-19 pandemic on services for patients with chronic kidney disease: findings of a national survey of UK kidney centres

BackgroundServices for patients with kidney disease underwent radical adaptations in response to the COVID-19 pandemic. We undertook an online national survey of UK kidney centres to understand the nature, range, and degree of variation in these changes and to explore factors contributing to differing practice.MethodsThe survey was designed by a multidisciplinary team of kidney professionals, service users and researchers. It enquired about centre services and staffing, including psychosocial provision, and changes to these in response to the COVID-19 pandemic. Links to the survey were sent to all 68 UK kidney centres and remained active from December 2021 to April 2022, and a revised version to nurses in late 2022 for additional data. Quantitative data were analysed descriptively. Content analysis on free-text responses identified common themes.ResultsAnalysable responses were received from 41 out of the 68 UK centres (60%), with partial data from an additional 7 (11%). Adaptations were system-wide and affected all aspects of service provision. Some changes were almost universal such as virtual consultations for outpatient appointments, with significant variation in others. Outpatient activity varied from fully maintained to suspended. Many centres reduced peritoneal dialysis access provision but in some this was increased. Centres considered that changes to transplant surgical services and for patients with advanced CKD approaching end-stage kidney disease had the greatest impact on patients. Few centres implemented adjustments aimed at vulnerable and underrepresented groups, including the frail elderly, people with language and communication needs, and those with mental health needs. Communication issues were attributed to rapid evolution of the pandemic, changing planning guidance and lack of resources. Staffing shortages, involving all staff groups particularly nurses, mainly due to COVID-19 infection and redeployment, were compounded by deficiencies in staffing establishments and high vacancy levels. Centres cited three main lessons influencing future service delivery, the need for service redesign, improvements in communication, and better support for staff.ConclusionKidney centre responses to the pandemic involved adaptations across the whole service. Though some changes were almost universal, there was wide variation in other areas. Exploring the role of centre characteristics may help planning for potential future severe service disruptions.

The Evolution of Hemodialysis in Chile: Is Hemodiafiltration the Next Step?

Hemodialysis began in Chile during the latter half of the 20th century, primarily targeting individuals with acute renal failure. With time, dialysis facilities emerged across diverse regions of the nation, covering hospitals and private centers. This expansion widened dialysis access to chronic patients, culminating in universal coverage through the AUGE plan. Ongoing technological improvements and the integration of pharmaceutical interventions for chronic kidney disease-related complications have notably enhanced survival rates. Nonetheless, dialysis recipients continue to confront significantly elevated mortality risks in comparison to the general population. Despite advancements, complications linked to dialysis persist, significantly affecting patients' overall quality of life. Heightened rates of hospitalization and mortality are, in part, ascribed to the inherent technical limitations of hemodialysis in efficiently clearing uremic toxins. Therefore, superior purification modalities such as high-volume hemodiafiltration need to be progressively adopted to effectively address the persistent clinical needs in the care of dialysis patients within the Chilean context.

Global variability of vascular and peritoneal access for chronic dialysis.

Vascular and peritoneal access are essential elements for sustainability of chronic dialysis programs. Data on availability, patterns of use, funding models, and workforce for vascular and peritoneal accesses for dialysis at a global scale is limited. An electronic survey of national leaders of nephrology societies, consumer representative organizations, and policymakers was conducted from July to September 2018. Questions focused on types of accesses used to initiate dialysis, funding for services, and availability of providers for access creation. Data from 167 countries were available. In 31 countries (25% of surveyed countries), >75% of patients initiated haemodialysis (HD) with a temporary catheter. Seven countries (5% of surveyed countries) had >75% of patients initiating HD with arteriovenous fistulas or grafts. Seven countries (5% of surveyed countries) had >75% of their patients starting HD with tunnelled dialysis catheters. 57% of low-income countries (LICs) had >75% of their patients initiating HD with a temporary catheter compared to 5% of high-income countries (HICs). Shortages of surgeons to create vascular access were reported in 91% of LIC compared to 46% in HIC. Approximately 95% of participating countries in the LIC category reported shortages of surgeons for peritoneal dialysis (PD) access compared to 26% in HIC. Public funding was available for central venous catheters, fistula/graft creation, and PD catheter surgery in 57%, 54% and 54% of countries, respectively. There is a substantial variation in the availability, funding, workforce, and utilization of vascular and peritoneal access for dialysis across countries regions, with major gaps in low-income countries.

Evaluation of risk factors affecting the lifespan and efficiency of dialysis accesses installed in dialysis patients referees to Ahvaz therapeutic centers in a two-year cohort study

Introduction: It is crucial in order to provide optimal hemodialysis to patients with end-stage renal disease (ESRD) to establish venous access with the least amount of complications. Objectives: In this study, we examined the risk factors that affect the efficiency and longevity of dialysis access for patients receiving dialysis in Ahvaz medical centers. Patients and Methods: In our retrospective study, 180 hemodialysis patients were referred to the Golestan educational and medical center in Ahvaz, Iran. An arteriovenous fistula (AVF) or catheter was conducted to provide them with vascular access. Detailed demographic information about the patient was collected, including age, gender, height, weight, body mass index (BMI), cause of ESRD, duration of renal failure, duration of dialysis, and comorbidities. There were instances of access inefficiency as a result of infection, stenosis, closure, thrombosis, bleeding, and pseudoaneurysms. The data was analyzed using Mann-Whitney U, t test, and chi-square tests with SPSS version 22. Statistics were considered significant at a P value of 0.05. Results: The mean age of the patients was 50.08 ± 12.213 years, and the mean BMI was 27.90 ± 9.112 kg/m2 . Among dialysis patients, there was a significant relationship between male gender, clopidogrel administration, diabetes history, hypertension and access failure. It is estimated that 36.7% of vascular access failures are caused by thrombosis, while 32.8% are due to access stenosis or closure. Conclusion: Our study showed that male gender, clopidogrel administration, and a history of diabetes and hypertension were risk factors affecting dialysis access quality and efficiency. According to our study, it may be possible to develop a more appropriate approach for determining the type and location of dialysis access.

Integrating vascular access surveillance with clinical monitoring for stenosis prediction.

Arteriovenous fistula and arteriovenous graft are the most common types of vascular access for dialysis; stenosis and thrombosis are major complications leading to access failure andto an incresed risk ofmortality.The aim of the present study wasto assess the results of integrating strictvascular access blood flow surveillance with routine clinical monitoring for predicting vascular access stenosis in chronic hemodialysis patients. In this retrospective study, chronic dialysis patients with arteriovenous fistula or arteriovenous graft were included from a settingin which all patients underwent quarterly blood flow surveillance in 2017. The results of blood flow surveillance were confirmed by thorough physical examination. Predictive performance of blood flow surveillance models in detecting stenosis in patients with arteriovenous fistula or arteriovenous graft was evaluated.The predictive performance of the quarterlyblood flow surveillance model was described by confusion matrix. Differences in accuracy, positive predictive value (PPV), and negative predictive value (NPV) between blood flow surveillance models with distinct blood flow thresholds were evaluated. Of 397 included patients, 336 had anarteriovenous fistula and 61 had anarteriovenous graft. In 2017, 106 percutaneous transluminal angioplasty procedures were performed in patients with anarteriovenous fistula, and 63 in patients with anarteriovenous graft. The results revealed similar predictive performance of surveillance models using an absolute blood flow threshold of < 500 or < 400mL/min in predicting stenosis inpatients with arteriovenous fistula. Blood flow surveillance models for patients with anarteriovenous fistula had significantly higher accuracy than those for patients with anarteriovenous graft. Furthermore, the use ofarelative threshold, defined as blood flow < 1000mL/min and a 25% decline in blood flow, did not affect thepredictive performance of blood flow surveillance models. Blood flow surveillance models using thresholds of < 400 and < 600mL/min, followed by thorough physical examination, showed an accuracy of 91.54% and 72.15% in predicting stenosis inpatients with arteriovenous fistula and arteriovenous graft, respectively. These two blood flow surveillance models may be integrated with routine clinical monitoring to improve early detection and treatment of stenosis in hemodialysis patients.

Rerouting bei Infektionen des vaskulären Zugangs unter Verwendung eines biosynthetischen Gefäßtransplantats (Omniflow® II)

Abstract Background Surgical treatment of infected arteriovenous grafts (AVG) while preserving the hemodialysis access remains a challenge. Partial graft excision (PGE) directly followed by interposition grafting (IG) is an established method but is associated with a high rate of local reinfection. This retrospective study investigated the technique of rerouting using a biosynthetic vascular graft (Omniflow® II). Methods This was a retrospective analysis of all patients at a tertiary referral center undergoing surgical treatment for AVG infections using PGE and IG with the rerouting technique using Omniflow® II between January 2009 and December 2018. Follow-up data were collected until May 2021. Results Fifteen patients (53% male, median age 62 years [range 49-81]) were identified for further analysis, thereof twelve received an Omniflow® II vascular graft. Eleven patients had positive local microbial cultures, with Staphylococcus aureus being the most frequently identified pathogen (9 cases). Mortality and reoperation rates within 30 days were both 0%. Median follow-up was 32 months (range 2–101 months) with a median follow-up index of 0.92 (range 0.18–1). During follow-up a surgical intervention for reinfection was necessary in 3 patients with Omniflow® II at a median of 304 days (range 298–485 days). Conclusion Partial graft excision and direct interposition grafting using a biosynthetic Omniflow® II vascular graft is a valid treatment option in selected patients with AVG infections when total graft excision can be avoided. Using a careful rerouting technique, while preserving clinically noninfected graft sections the risk of early reinfection can be minimized and the dialysis access maintained.

Inpatient peritoneal dialysis catheters placed across the United States during a 3-year period: Lessons learned from 15,000 patients

BackgroundPeritoneal dialysis is a popular option for patients with end-stage renal disease. A recent presidential executive order has incentivized in-home end-stage renal disease treatments, leading to an increase in peritoneal dialysis use. Guidelines exist for creating and maintaining peritoneal dialysis access without addressing the optimal technique. This study evaluates nationwide peritoneal dialysis catheter placement practices and their long-term outcomes. MethodsRetrospective cohort analysis of Nationwide Readmission Database from 2017 to 2019. Patients with end-stage renal disease undergoing inpatient peritoneal dialysis catheter placement were included. Six-month readmissions, mortality, and peritoneal dialysis catheter-specific outcome measures were assessed among survivors of admission, including catheter leakage, mechanical breakdown, displacement, revision or replacement, removal, exit site infections, intra-abdominal abscess, and sepsis. Binary logistic regression analyses were performed. ResultsIn the study, 14,863 patients with inpatient peritoneal dialysis catheter insertions were identified, of which 7,096 were analyzed (4,150 [59%] laparoscopic, 1,781 [25%] fluoroscopic, 1,165 [16%] open), 847 (12%) had major complications, 931 (13%) were readmitted, and 102 (1.4%) died within 6 months. Univariate analyses demonstrated that laparoscopy had higher mechanical complications, exit-site infections, catheter revision, and removal within 6 months, and fluoroscopy had higher sepsis and mortality. Multivariate analyses showed fluoroscopy was associated with intraabdominal abscess (adjusted odds ratio, 2.36; P = .025), laparoscopy with exit-site infections (adjusted odds ratio, 0.49; P = .005), and open surgery with catheter displacement (adjust odds ratio, 2.95; P = .021). ConclusionThis is the first large-scale study on inpatient peritoneal dialysis catheter placement outcomes in the United States. Fluoroscopic and open surgical placements are routinely performed, but laparoscopy remains the mainstay with fewer exit-site infections. Overall, peritoneal dialysis is a safe option, with 1 in 9 patients having an infectious or mechanical complication within 6 months. Furthermore, large-scale prospective studies are warranted to identify the optimal placement technique.

Small Arteriovenous Anastomosis in Fistula Creation: Establishing a Functional Vascular Access while Minimizing Steal Syndrome

ObjectivesThe size selection of the arteriovenous (AV) anastomosis in dialysis access creation requires a careful balance: the diameter must be large enough to accommodate sufficient flow for hemodialysis, but small enough to minimize the complication of steal syndrome. Steal syndrome affects up to 10% of patients after creation of dialysis access with sometimes devastating consequences. Conventional teaching recommends an 7-10 mm anastomosis. We sought to assess the efficacy of using a smaller (5-6 mm) anastomosis in new arteriovenous fistula (AVF) creation. MethodsWe conducted a comparative retrospective analysis of patients who underwent fistula creation with a small versus regular size anastomosis at any upper extremity anatomic site between March 2019 and October 2020 at our institution. Anatomic sites included radiocephalic, brachiocephalic and brachiobasilic. All arteriovenous anastomoses were measured intra-operatively to be 5-6 mm in diameter for the small size groups and 8-10mm for the regular size group. Endpoints included steal syndrome, functional patency, primary patency and secondary patency. ResultsOut of 110 patients who underwent an AVF creation, 59.1% received a 5-6 mm anastomosis with a median follow-up time of 10±6 months. Patients’ demographics and comorbidities were relatively similar between the two groups except for a higher rate of hyperlipidemia (55.4% vs. 28.9%, P=0.008) in the small size group. Patients in the small size group were more likely to undergo a radiocephalic fistula (40% vs. 4.5%, P<0.001) and to have a smaller mean vein diameter on preoperative duplex ultrasound (3.2±1mm vs. 3.9±1mm, P=0.0016) when compared to their regular size counterparts. During follow-up, none of the patients in the small group developed steal syndrome (0% vs. 9%, P=0.015). At 1 year, patients in the regular size group achieved higher rates of primary patency (67.9% vs. 46.9%, P=0.02); however, no difference was seen in 1-year primary-assisted patency (84.9% vs. 73.6%, P=0.3), secondary patency (89.6% vs. 79.5%, P=0.3) nor in functional patency (87.7% vs. 82.2%, P=0.64) between the small and regular size groups, respectively. ConclusionsThe use of a 5-6 mm anastomosis in the creation of new arteriovenous fistulas of the upper extremities appears to be a technically safe option for dialysis access. Our experience suggests that smaller anastomosis still creates enough flow to maintain a functional AV access while minimizing the incidence of steal syndrome. Additionally, even with smaller vein sizes pre-operative, adequate dialysis access can be created via a small sized anastomosis, including distal arm access. Larger studies with longer follow-up are needed to evaluate long-term outcomes of small anastomosis fistulas.

Outcomes of one-stage and two-stage aneurysm repair in arteriovenous fistulae

ObjectiveMaintenance of long-term arteriovenous access is important in long-term care for patients with end-stage renal disease. Arteriovenous access is associated in the long term with the development of fistula aneurysms (FAs). This study aims to evaluate the outcomes of staged FA treatment in dialysis access arteriovenous fistulae (AVF). MethodsA retrospective review of all patients over a 12-year period with primary autogenous AVF was undertaken at a single center. Patients undergoing elective open aneurysm repair were identified and were categorized into three groups: single FA repair (single, control group) and staged and unstaged repair of two FAs (staged and unstaged). A staged repair was a procedure in which the initial intent was to treat both aneurysms in the AVF and in which the most symptomatic aneurysm was treated first. When the incision from the first surgery had healed, the second symptomatic aneurysm in the AVF was treated. An unstaged repair was a procedure in which the initial intent was to repair both symptomatic aneurysms simultaneously. All patients had a fistulogram before the FA repair. Thirty-day outcomes, cannulation failure, line placement, reintervention, and functional dialysis (continuous hemodialysis for 3 consecutive months) were examined. ResultsFive hundred twenty-seven patients presented with FA that met requirements for open intervention; 44% underwent single FA repair, whereas the remaining 34% and 22% underwent staged and unstaged repair of two FAs, respectively. The majority of patients were diabetic and Hispanic. Ninety-one percent of the patients required percutaneous interventions of the outflow tract (37%) and the central veins (54%). Thirty-day major adverse cardiovascular events were equivalent across all modalities. Thirty-day morbidity and early thrombosis (<18 days) were significantly higher in the unstaged group (4.3%) compared with the two other groups (1.3% and 2.1%, single and staged, respectively), which led to an increased need for a short-term tunneled catheter (8.9%) compared with the two other groups (3.4% and 4.4%, single and staged, respectively), Unstaged repair resulted in an increased incidence of secondary procedures (5.0%) compared with the two other groups (2.6% and 3.1%, single and staged, respectively). Functional dialysis at 5 years was equivalent in the single and staged groups but was significantly decreased in the unstaged group. ConclusionsOpen interventions are successful therapeutic modalities for FAs, but unstaged rather than staged repair of two concurrent FAs results in a higher early thrombosis, an increased secondary intervention rate, and a need for a short-term tunneled central line. Staged and single FA repairs have equivalent results. In the setting of two symptomatic FAs, staged repair is recommended.

Artificial Intelligence Prediction of Dialysis Access Complications

Artificial Intelligence Prediction of Dialysis Access Complications

On Growing Home: A Single-Centre Experience with a Dedicated Peritoneal Dialysis Access Clinic

On Growing Home: A Single-Centre Experience with a Dedicated Peritoneal Dialysis Access Clinic

Safety and efficacy of sodium zirconium cyclosilicate for the management of acute and chronic hyperkalemia in children with chronic kidney disease 4-5 and on dialysis.

Sodium zirconium cyclosilicate (SZC), an ion-exchange resin, is effective in the control of hyperkalemia in adults with chronic kidney disease (CKD); reports of use in children are limited. Prolonged therapy with SZC to relax dietary potassium restriction in CKD has not been examined. We conducted a retrospective chart review of patients 6months to 18years of age with CKD stage 4-5 or on dialysis (5D) administered SZC for sustained hyperkalemia (potassium ≥ 5.5mEq/L, three consecutive values). Patients received SZC (0.5-10g per dose; age-based) either short-term (< 30days) or long-term (> 30days). Twenty patients with median age 10.8 (inter-quartile range 3.9, 13.4) years were treated with SZC. Short-term SZC, for 5 (3, 19) days, was associated with safe management of dialysis catheter insertions (n = 5) and access dysfunction (n = 4), and was useful during palliative care (n = 1). Serum potassium levels decreased from 6.7 (6.1, 6.9) to 4.4 (3.7, 5.2) mEq/L (P < 0.001). Long-term SZC for 5.3 (4.2, 10.1) months achieved decline in serum potassium from 6.1 (5.8, 6.4) to 4.8 (4.2, 5.4) mEq/L (P < 0.001). SZC use was associated with liberalization of diet (n = 6) and was useful in patients with poor adherence to dietary restriction (n = 3). Adverse events or edema were not observed; serum sodium and blood pressure remained stable. SZC was safe and effective for the management of acute and chronic hyperkalemia in children with CKD4-5/5D. Its use was associated with relaxation of dietary potassium restriction. Studies to examine its routine use to improve diet and nutritional status in children with CKD are required.

Surgical aspects of peritoneal dialysis

Modern replacement kidney therapy belongs to a life-saving type of medical aid and includes dialysis and kidney transplantation. In the worlds nephrological practice integrated approach is preferable: the treatment starts with peritoneal dialysis as the most physiological method and later kidney transplantation or hemodialysis. Well-functioning peritoneal access is a key factor of successful peritoneal dialysis. Studies have shown that peritoneal dialysis, compared with hemodialysis, especially when performed in a dialysis center (not at home), has some clinical advantages. In particular, this treatment better preserves residual kidney function, better corrects anemia, avoids the need for vascular access, which in turn reduces the risk of access-related infectious complications, which in turn are the main cause of hospitalization and mortality among patients with end-stage renal disease. This review is focused on catheters for peritoneal dialysis access and methods of their placement. Malpractice of implantation technique can lead to unwanted consequences ranging from cuff extrusion and catheter migration to total loss of the latter. Following implantation technique by surgeons helps to avoid malpractice and improve the results. Implantation of a peritoneal catheter is an important component of peritoneal dialysis, which determines the quality of treatment, the development of non-infectious and infectious complications of peritoneal dialysis, and the duration of peritoneal dialysis therapy. A number of methods for implanting peritoneal catheters have been proposed in the world. All of them have the right to exist, each has its own advantages and disadvantages. When choosing a method, the surgeon is guided by the objective data of the patient, the patients ability to endure more invasive interventions (duration, anesthesia, volume of surgery), the capabilities of the surgical department, experience and qualifications. Expansion of indications for the use of the peritoneal dialysis technique, its complications, as well as concomitant diseases should determine the optimal method for implanting a peritoneal dialysis catheter for a given patient. It should be noted that to date, sufficient data have not been obtained on the effect of the method of peritoneal catheter implantation on the expansion of indications for peritoneal dialysis, the incidence of complications, and the need for additional surgical interventions.

Risk factors for hypotension in patients with hemodialysis-associated superior vena cava syndrome

ObjectiveWe analyzed the risk factors for hypotension in patients with hemodialysis-associated superior vena cava syndrome (SVCS) and effectiveness of endovascular intervention in hypotension related to SVCS. MethodsThis was a retrospective cohort study. A total of 194 maintenance hemodialysis patients diagnosed with SVCS who were admitted to the Department of Nephrology, West China Hospital of Sichuan University from January 2019 to December 2021 were selected and divided into a hypotension group and a nonhypotension group. Demographic and clinical data were compared. Hypotension simply refers to blood pressure levels of <90/60 mm Hg on a nondialysis day. All patients received endovascular intervention. ResultsHypotension was found in 85 of the 194 patients. The following factors were significantly different between the hypotension and nonhypotension groups: body mass index, history of hypertension, tunneled-cuffed catheter as the means of dialysis access, azygos ectasis, SVC stenosis of >70% or occlusion, occlusion at the cavitary junction, serum calcium, diastolic left ventricular (LV) posterior wall thickness, LV end-diastolic volume, stroke output, and LV ejection fraction. Multivariate logistic regression analysis showed that hypertension history (OR, 0.314; P = .027), tunneled-cuffed catheter as vascular access (OR, 3.997; P < .001), SVC stenosis of >70% or occlusion (OR, 5.243; P < .001), LV posterior wall thickness (OR, 0.772; P = .044), and serum calcium (OR, 0.146; P = .005) were independent risk factors for hypotension. The mean values of systolic and diastolic blood pressure after intravascular treatment were significantly elevated from those before intervention (P < .001). The primary patency rates of SVC were 66.8%, 58.7%, and 50.0% at 3, 6, and 12 months after the procedure. ConclusionsThe incidence of hypotension in patients with hemodialysis-associated SVCS is high. The identification of risk factors of hemodialysis-related hypotension provides insight into potential treatment strategies. Endovascular treatment is expected to improve hypotension related to SVCS in hemodialysis patients.

Practice of dialysis access interventional nephrology procedures in the Asia-Pacific region: Getting lay of the land.

This cross-sectional survey aimed to determine the prevalence of Interventional Nephrology (IN) practice amongst nephrologists in the Asia-Pacific Region (APR), specifically related to dialysis access (DA). The Association of VA and intervenTionAl Renal physicians (AVATAR) Foundation from India conducted a multinational online survey amongst nephrologists from the Asia-Pacific to determine the practice of IN in the planning, creation, and management of dialysis access. The treatment modalities, manpower and equipment availability, monthly cost of treatment, specifics of dialysis access interventions, and challenges in the training and practice of IN by nephrologists were included in the survey. Twenty-one countries from the APR participated in the survey. Nephrologists from 18 (85.7%) countries reported performing at least one of the basic dialysis access-related IN procedures, primarily the placement of non-tunnelled central catheters (n-TCC; 71.5%). Only 10 countries (47.6%) reported having an average of <4% of nephrologists performing any of the advanced IN access procedures, the most common being the placement of a peritoneal dialysis (PD) catheter (20%). Lack of formal training (57.14%), time (42.8%), incentive (38%), institutional support (38%), medico-legal protection (28.6%), and prohibitive cost (23.8%) were the main challenges to practice IN. The primary obstacles to implementing the IN training were a lack of funding and skilled personnel. The practice of dialysis access-related IN in APR is inadequate, mostly due to a lack of training, backup support, and economic constraints, whereas training in access-related IN is constrained by a lack of a skilled workforce and finances.

Prospective, Multicenter, Observational Study to Evaluate a Cell-Impermeable Endoprosthesis for Treatment of Stenosis or Occlusion within the Dialysis Outflow Circuit of an Arteriovenous (AV) Fistula or AV Graft (The WRAP Registry)

PurposeDysfunctional vascular access due to stenosis/occlusion within the arteriovenous fistula or graft (AVF/AVG) negatively affects the clinical management of patients undergoing hemodialysis. Results from the feasibility study of the WRAPSODY™ Cell-Impermeable Endoprosthesis demonstrated that the device can achieve high patency rates and maintain integrity of the dialysis outflow circuit. This study was designed to assess real-world evidence of safety and efficacy outcomes following device placement.Materials and MethodsThis is a prospective, multicenter, non-investigational, post-market observational study of 500 patients at up to 50 centers worldwide with a mature AVF/AVG dialysis access (≥ 1 hemodialysis session) who experience stenosis/occlusion of the outflow circuit prior to placement of WRAPSODY. Patients will be divided into the following two cohorts: peripheral or central thoracic. Primary outcome measures include target lesion primary patency (TLPP) at 6 months and procedure and/or device-related events through 30 days post-procedure. Secondary outcome measures include TLPP, safety events, and the number of interventions needed to maintain patency through the 24 month study period. Exploratory endpoints include time to access abandonment, resumption of successful dialysis, functional patency, and pending available imaging data, any incidence of stent fractures, migration, or edge stenosis. Study enrollment began in June 2022, the last patient visit is expected in 2026.DiscussionIt is expected that this study will provide real-world evidence regarding the performance of the WRAPSODY device in a diverse population of patients, which may encourage its use in the continuum of hemodialysis access management.Trial RegistrationNCT05062291Graphical

Assessing the Inflow Segment of a Hemodialysis Access: The Fogarty Balloon Occlusion Technique.

Dialysis access maintenance often requires a fistulogram or shuntogram of arteriovenous access. Assessment of the arterial inflow segment and arterial anastomosis is often a critical portion of the procedure. Retrograde occlusive angiography (ROA) is often used to properly assess the inflow. Manual compression using finger compression or a hemostat is often described in the literature. The Fogarty balloon occlusion technique using a 4-Fr Fogarty catheter balloon (Henry Shein) is a simple and cost-effective method that preserves image quality and decreases radiation exposure in retrograde occlusive angiography.

Does Native Vitamin D Supplementation Have Pleiotropic Effects in Patients with End-Stage Kidney Disease? A Systematic Review of Randomized Trials.

Vitamin D has been shown to have multiple pleiotropic effects beyond bone and mineral metabolism, with purported roles in cardiovascular disease, cancer, and host immunity. Vitamin D deficiency is common in patients with end-stage kidney disease (ESKD); however, current clinical practice has favored the use of the active hormone. Whether vitamin D deficiency should be corrected in patients with ESKD remains unclear, as few randomized trials have been conducted. In this systematic review, we summarize the current evidence examining whether vitamin D supplementation improves outcomes, beyond mineral metabolism, in patients with ESKD. Data from randomized controlled trials of adults with ESKD were obtained by searching Ovid MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Web of Science Core Collection from inception to February 2023. Twenty-three trials composed of 2489 participants were identified for inclusion. Data were synthesized by two independent reviewers and summarized in tables organized by outcome. Outcomes included measures of mortality, cardiovascular disease, inflammation, muscle strength/function, nutrition, patient well-being, and outcomes specific to ESKD including erythropoietin usage, pruritus, and dialysis access maturation. The Cochrane risk of Bias Tool (RoB 2, 2019) was used to assess study quality. Overall, our findings indicate a minimal and varied benefit of native vitamin D supplementation. From the largest studies included, we determine that vitamin D has no demonstrated effect on patient-reported measures of well-being or utilization of erythropoietin, nor does it change levels of the inflammation biomarker C-reactive protein. Included trials were heterogeneous with regards to outcomes, and the majority studied small participant populations with a relatively short follow-up. We conclude that vitamin D supplementation corrects vitamin D deficiency and is safe and well-tolerated in humans with ESKD. However, it is not clear from clinical trials conducted to date that a causal pathway exists between 25(OH)D and pleiotropic effects that is responsive to vitamin D treatment.

The Role of Drug-Coated Balloon in Haemodialysis Arteriovenous Fistula Stenosis Management.

Arteriovenous fistula (AVF) stenosis is a common problem leading to dialysis access dysfunction. The conventional balloon (CB) is the most commonly used device during angioplasty but suffers from poor durability of results due to neointimal hyperplasia-mediated recurrence. The drug-coated balloon (DCB) is an adjunct to balloon angioplasty that reduces neointimal hyperplasia, thereby improving post-angioplasty patency. Despite the heterogeneity of DCB clinical trials to date, the evidence suggests that DCBs of different brands are not necessarily equal, and that patient selection, adequate lesion preparation and proper DCB procedural technique are important to realize the benefit of DCB angioplasty.

Early identification of bloodstream infection in hemodialysis patients by machine learning

BackgroundBloodstream infection (BSI) is a prevalent cause of admission in hemodialysis (HD) patients and is associated with increased morbidity and mortality. This study aimed to establish a diagnostic, predictive model for the early identification of BSI in HD patients. MethodsHD patients who underwent blood culture testing between August 2018 and March 2022 were enrolled in this study. Machine learning algorithms, including stepwise logistic regression (SLR), Lasso logistic regression (LLR), support vector machine (SVM), decision tree, random forest (RF), and gradient boosting machine (XGboost), were used to predict the risk of developing BSI from the patient's clinical data. The accuracy (ACC) and area under the subject working curve (AUC) were used to evaluate the performance of such models. The Shapley Additive Explanation (SHAP) values were used to explain each feature's predictive value on the models' output. Finally, a simplified nomogram for predicting BSI was devised. ResultsA total of 391 HD patients were enrolled in this study, of whom 74 (18.9%) were diagnosed with BSI. The XGboost model achieved the highest AUC (0.914, 95% confidence interval [CI]: 0.861–0.964) and ACC (86.3%) for BSI prediction. The four most significant co-variables in both the significance matrix plot of the XGboost model variables and the SHAP summary plot were body temperature, dialysis access via a non-arteriovenous fistula (non-AVF), the procalcitonin levels (PCT), and neutrophil-lymphocyte ratio (NLR). ConclusionsThis study created an effective machine-learning model for predicting BSI in HD patients. The model could be used to detect BSI at an early stage and hence guide antibiotic treatment in HD patients.