Adult Hemodialysis Patients Research Articles

Association of aortic arch and aortic valve calcifications with cardiovascular risk in patients on maintenance hemodialysis.

This study aimed to investigate the association of aortic arch calcification (AoAC) and aortic valve calcification (AVC) with major adverse cardiovascular events (MACE) and cardiovascular and all-cause mortality in patients on maintenance hemodialysis (MHD). This study enrolled 297 adult patients with end-stage kidney disease who were on MHD. They were divided into those with an AoAC score <2 without AVC (n = 70, 23.6%), those with an AoAC score <2 with AVC (n = 96, 32.3%), and those with an AoAC score ≥2 regardless of AVC status (n = 131, 44.1%). We analyzed the risks of MACE, cardiovascular and overall mortality among the three groups using Cox proportional hazard analyses. Survival probabilities were estimated using the log-rank test via the Kaplan-Meier method. Kaplan-Meier analysis revealed that the MACE-free rate and the survival rates of cardiovascular and overall mortality were significantly higher in adult chronic hemodialysis patients with AoAC score <2 without AVC, followed by those with AoAC score <2 with AVC, and then those with AoAC score ≥2 (log-rank test; all p < 0.01). The grade of AoAC is a significant risk factor for MACE, cardiovascular mortality, and overall mortality after adjusting for age and gender Relative to AoAC score <2 without AVC, adult chronic hemodialysis patients with AoAC score ≥2 remained an independently significantly risk factor of MACE (adjusted hazard ratio, 2.17; 95% confidence interval 1.11-4.20; p = 0.023) after adjusting for age, sex, and all significant variables in baseline characteristics. AoAC grade was positively correlated with a higher risk of MACE and cardiovascular and overall mortality. Furthermore, the presence of AVC modified the adverse cardiovascular risk associated with AoAC in patients on MHD.

Associations of Air Pollution and Serum Biomarker Abnormalities in Individuals with Hemodialysis-Dependent Kidney Failure.

Ambient particles with a median aerodynamic diameter of <2.5 µm (PM2.5) is a ubiquitous air pollutant with established adverse health consequences. While postulated to promote a systemic inflammatory response, limited studies have demonstrated changes in serum biomarkers related to PM2.5 exposure. We aim to examine associations between short-term PM2.5 exposure and commonly measured biomarkers known to be affected by inflammation among patients receiving maintenance in-center hemodialysis. We conducted a retrospective open cohort study from January 1, 2008, to December 31, 2014. Adult hemodialysis patients were identified from the United States Renal Data System and linked at the patient level to laboratory data from a large dialysis organization. Daily ambient PM2.5 was estimated on a 1-km grid and assigned to cohort patients based on the ZIP codes of dialysis clinics. Serum albumin, serum ferritin, transferrin saturation (TSAT), and serum hemoglobin were ascertained from the dialysis provider organization database. Mixed-effect models were used to assess the changes in biomarker levels associated with PM2.5 exposure. The final cohort included 173,697 hemodialysis patients. Overall, the daily ZIP-level ambient PM2.5 averages were 8.4-8.5 µg/m3. A 10-µg/m3 increase in same-day ambient PM2.5 exposure was associated with higher relative risks of lower albumin (relative risk [RR], 1.01; 95% confidence interval [95% CI], 1.01 to 1.02) and lower hemoglobin (RR, 1.02; 95% CI, 1.01 to 1.03). Associations of same-day ambient PM2.5 exposure and higher ferritin and lower TSAT did not reach statistical significance. Short-term PM2.5 exposure was associated with lower serum hemoglobin and albumin among patients receiving in-center hemodialysis. These findings lend support to the role of inflammation in PM2.5 exposure-outcome associations.

Lung Ultrasound Estimates the Overhydration and Benefits Blood Pressure Control in Normal or Mild Symptomatic Hemodialysis Patients.

Lung ultrasound (LUS) is used for dry weight guidance by assessment of pulmonary congestion in hemodialysis (HD) patients. The aim of this study was to estimate amounts of accumulated fluid by total LUS scores (TLUSS), which were scarcely reported in HD patients who were normal or had a mild functional abnormality. In addition, the correlations between the LUS score of each area and TLUSS were determined to suggest fewer specific areas valuable to shorten the examination time of LUS. This cohort study was conducted in adult HD patients who have New York Heart Association Classes I-II. LUS and multifrequency bioimpedance (BIA) were performed at baseline and the individual prescribed dry weight was set. Then each LUS was conducted at 28 areas of bilateral intercostal spaces and calculated as TLUSS weekly for eight weeks in which dry weight was adjusted. The second BIA was also measured at week eight. The difference of pre-HD weight and target weight (weight gain; WG) represented the amount of fluid accumulation. Twenty patients with a mean age of 62.2±14.0 years were enrolled. One hundred and sixty-six LUS were performed in which forty episodes of them were simultaneously measured with BIA. Optimum dry weight adjusted by TLUSS which benefited in mean reductions of blood pressure, and cardiothoracic ratios. WG amounts were significantly correlated with TLUSS (r=0.38), and with extracellular fluid (r=0.35) and overhydration fluid (r=0.39) assessed by BIA. Estimations of mean fluid overload were 2.18 (TLUSS ≤15), 2.72 (TLUSS 16-24), 3.17 (TLUSS 25-33), 3.65 (TLUSS 34-38) and 5.03 (TLUSS ≥39) in liters. The cut-off points of sum scores of 12 specific lung areas represented the none-mild were <8, moderate at 8-16, and severe pulmonary congestions were >16. TLUSS estimated accumulated fluid useful for volume and blood pressure controls. Performance of LUS in 12 specific lung areas may reduce spending time and support routine uses of LUS in clinical practice.

Effectiveness of COVID-19 vaccines in a large European hemodialysis cohort.

Hemodialysis patients have high-risk of severe SARS-CoV-2 infection but were unrepresented in randomized controlled trials evaluating the safety and efficacy of COVID-19 vaccines. We estimated the real-world effectiveness of COVID-19 vaccines in a large international cohort of hemodialysis patients. In this historical, 1:1 matched cohort study, we included adult hemodialysis patients receiving treatment from December 1, 2020, to May 31, 2021. For each vaccinated patient, an unvaccinated control was selected among patients registered in the same country and attending a dialysis session around the first vaccination date. Matching was based on demographics, clinical characteristics, past COVID-19 infections and a risk score representing the local background risk of infection at vaccination dates. We estimated the effectiveness of mRNA and viral-carrier COVID-19 vaccines in preventing infection and mortality rates from a time-dependent Cox regression stratified by country. In the effectiveness analysis concerning mRNA vaccines, we observed 850 SARS-CoV-2 infections and 201 COVID-19 related deaths among the 28110 patients during a mean follow up of 44 ± 40 days. In the effectiveness analysis concerning viral-carrier vaccines, we observed 297 SARS-CoV-2 infections and 64 COVID-19 related deaths among 12888 patients during a mean follow up of 48 ± 32 days. We observed 18.5/100-patient-year and 8.5/100-patient-year fewer infections and 5.4/100-patient-year and 5.2/100-patient-year fewer COVID-19 related deaths among patients vaccinated with mRNA and viral-carrier vaccines respectively, compared to matched unvaccinated controls. Estimated vaccine effectiveness at days 15, 30, 60 and 90 after the first dose of a mRNA vaccine was: for infection, 41.3%, 54.5%, 72.6% and 83.5% and, for death, 33.1%, 55.4%, 80.1% and 91.2%. Estimated vaccine effectiveness after the first dose of a viral-carrier vaccine was: for infection, 38.3% without increasing over time and, for death, 56.6%, 75.3%, 92.0% and 97.4%. In this large, real-world cohort of hemodialyzed patients, mRNA and viral-carrier COVID-19 vaccines were associated with reduced COVID-19 related mortality. Additionally, we observed a strong reduction of SARS-CoV-2 infection in hemodialysis patients receiving mRNA vaccines.

Predictors of shorter- and longer-term mortality after COVID-19 presentation among dialysis patients: parallel use of machine learning models in Latin and North American countries

BackgroundWe developed machine learning models to understand the predictors of shorter-, intermediate-, and longer-term mortality among hemodialysis (HD) patients affected by COVID-19 in four countries in the Americas.MethodsWe used data from adult HD patients treated at regional institutions of a global provider in Latin America (LatAm) and North America who contracted COVID-19 in 2020 before SARS-CoV-2 vaccines were available. Using 93 commonly captured variables, we developed machine learning models that predicted the likelihood of death overall, as well as during 0–14, 15–30, > 30 days after COVID-19 presentation and identified the importance of predictors. XGBoost models were built in parallel using the same programming with a 60%:20%:20% random split for training, validation, & testing data for the datasets from LatAm (Argentina, Columbia, Ecuador) and North America (United States) countries.ResultsAmong HD patients with COVID-19, 28.8% (1,001/3,473) died in LatAm and 20.5% (4,426/21,624) died in North America. Mortality occurred earlier in LatAm versus North America; 15.0% and 7.3% of patients died within 0–14 days, 7.9% and 4.6% of patients died within 15–30 days, and 5.9% and 8.6% of patients died > 30 days after COVID-19 presentation, respectively. Area under curve ranged from 0.73 to 0.83 across prediction models in both regions. Top predictors of death after COVID-19 consistently included older age, longer vintage, markers of poor nutrition and more inflammation in both regions at all timepoints. Unique patient attributes (higher BMI, male sex) were top predictors of mortality during 0–14 and 15–30 days after COVID-19, yet not mortality > 30 days after presentation.ConclusionsFindings showed distinct profiles of mortality in COVID-19 in LatAm and North America throughout 2020. Mortality rate was higher within 0–14 and 15–30 days after COVID-19 in LatAm, while mortality rate was higher in North America > 30 days after presentation. Nonetheless, a remarkable proportion of HD patients died > 30 days after COVID-19 presentation in both regions. We were able to develop a series of suitable prognostic prediction models and establish the top predictors of death in COVID-19 during shorter-, intermediate-, and longer-term follow up periods.

Utilisation de l’application mobile TestObs pour l’évaluation de l’observance thérapeutique dans une population d’hémodialysés chroniques : modèle de monitoring technologique de l’adhérence au traitement et ses facteurs déterminants

IntroductionNon-adherence behaviors are very common in chronic hemodialysis patients, it is estimated that only one patient out of two complies with medical prescriptions, these behaviors are associated with a higher risk of morbidity and adverse events as well as increased expenses for health systems. The aim of our study was to assess adherence to long-term prescribed medications in chronic hemodialysis patients, using a mobile application named TestObs, as well as to determine the main factors influencing medication adherence. MethodsWe conducted a prospective descriptive study, between January and June 2019. We developed a mobile application named TestObs, downloadable on playstore for android devices, which assesses with the Girerd questionnaire, the adherence to the main medications taken by chronic hemodialysis patients. We included adult patients, with a duration of dialysis of more than 6 months, all patients who downloaded TestObs, tested their adherence to their medication by answering the questionnaire. We created a web-based platform, where data was collected from the application and then analyzed and tabulated. Regarding the statistical analysis, the normal distribution of the variables was studied by the Kolmogorov-Smirnov test, the analysis of the qualitative variables used the Pearson's Chi2 and Fisher's statistical test, the Hosmer Lemeshow test was used to examine the quality of the final logistic regression model. ResultsWe collected 90 adult chronic hemodialysis patients, 51 of them (56%) were selected to enter the study. We found good compliance in 46.15% of patients, minor noncompliance in 32.87%, and noncompliance in 20.98%. In multivariate analysis, the factors influencing adherence were the presence of other comorbidities (diabetes and vision problems) and the number of pills per day. DiscussionIn this study, we report treatment adherence problems in 53.85% of patients, our results are close to the data reported in hemodialysis patients in the literature, different factors influence the quality of treatment adherence, in our study poly-medication and the presence of other comorbidities were the statistically significant determinants. The new technology assessment instruments were used in hemodialysis patients and were able to provide real-time monitoring of adherence behaviors. ConclusionWe believe that mobile health technologies hold promise for assessing and improving medication adherence in hemodialysis patients, so we suggest that TestObs represents an accessible and free of charge tool, based on a validated questionnaire, that can allow patients to benefit from new technologies for medical monitoring, and may eventually constitute an interventional program to improve medication adherence; however, this technological tool should not replace traditional therapeutic education; prior targeting of non-adherent patients and an optimal combination of several tools can help improve adherence in these patients.

Plasma porphyrins among end stage renal disease patients and cutaneous symptoms- is there still an association?

IntroductionSeveral abnormalities of porphyrin metabolism leading to Porphyria Cutanea Tarda (PCT) have been described in early studies of End Stage Renal Disease (ESRD) patients, with a reported prevalence of 5–18%. We aimed to evaluate porphyrin levels and correlation to skin manifestations in modern dialysis era. MethodsThe study cohort included adult hemodialysis patients from a single center tertiary medical center. All patients underwent a full skin examination, completed the Dermatology Life Quality Index questioner, and provided a blood sample for porphyrin levels assessment. ResultsA total of 94 adult hemodialysis patients were recruited to the study. No clinical PCT was diagnosed. Porphyrin levels did not correlate with any clinical or dialysis quality parameters. ConclusionsIn modern hemodialysis era, possibly due to improved porphyrins' metabolism and dialysis removal, PCT is much less prevalent among hemodialysis patients than previously reported in the past.

Consistency of MIS with other malnutrition screening tools among adult and elderly hemodialysis patients

Background and aimMalnutrition and inflammation commonly occur concomitantly among hemodialysis patients. Malnutrition inflammation score (MIS) is a tool that helps clinical and nutritional evaluation of patients regardless of age. This study aimed to determine the best approach by comparing different tools/indices to evaluate the malnutrition and inflammation status of patients having hemodialysis treatment regarding their age and to examine the clinical benefits and consistency of MIS with other malnutrition tools. MethodsThe study was conducted with a sample of 140 hemodialysis patients (70 adults and 70 elderly patients). The biochemical data of the patients were retrospectively obtained, and the research dietitian conducted the anthropometric measures. In addition to MIS, 7 point-SGA (7p-SGA), Nutrition Risk Index (NRI) for adults, and Mini Nutritional Assessment (MNA), Geriatric Nutritional Risk Index (GNRI) for elderly patients were used. The model's discriminatory power was examined by receiver operating characteristics curve analysis. ResultsPatients who were “at-risk” according to MIS had significantly lower scores of 7p-SGA and NRI than those who had “no risk” (p<0.001). Moreover, those who are “at-risk” have significantly lower MNA scores than those who are not (p=0.002). Among adult patients, MIS displayed lower sensitivity but higher specificity with NRI than 7p-SGA. However, for elderly patients, MIS showed fair sensitivity and specificity with MNA but the highest sensitivity with GNRI. ConclusionAlthough different screening tools are available to screen malnutrition among dialysis patients regarding their age, MIS might be more clincally useful as it is more susceptible to assess both malnutrition and inflammation that occur concomitantly.

WITHDRAWN: Soluble urokinase plasminogen activator receptor and its complicated role in hemodialysis (HD) patients with Covid-19 infection

Soluble urokinase plasminogen receptor (suPAR) is a protein in the blood that has been described to reflect the severity status of systemic inflammation. We investigated the association between admission suPAR levels and severity and outcome of HD patients with Covid-19 infection. In an observational study of adult HD patients hospitalized for Covid-19, we measured suPAR levels in plasma samples. The time table for those measurements were as follows: at the beginning of admission, after a hemoperfusion (HP) session for those patients that received them, and just before discharge. Of the 17 patients (7 were male), 13 patients received HP (mean age: 74 years old). The median suPAR level was 12.94ng/ml. For those who undertook HP in HD unit the median suPAR level before the session was 12.95ng/mil and 6.2ng/ml at the end of each session (p<0.05). 3 patients had a suPAR level below 7ng/ml. 2 of them survived without developing pleural effusions. 7 patients were discharged from the hospital with median suPAR level 12.08ng/ml which did not differ significantly from the median suPAR level of the deceased ones (13.68ng/ml). Admission levels of suPAR in HD patients hospitalized for Covid-19 do not seem to be predictive for their clinical course in general. Chronic Kidney Disease and its relation to suPAR independently of patients' inflammation status may be the key component for our notice. Despite that, in patients where low levels of suPAR combined with absence of pleural effusions the prognosis was excellent.

High Inferior Vena Cava Diameter with High Left Ventricular End Systolic Diameter as a Risk Factor for Major Adverse Cardiovascular Events, Cardiovascular and Overall Mortality among Chronic Hemodialysis Patients.

Background: Little is known about the association of inferior vena cava diameter (IVCD) and left ventricular end-systolic diameter (LVESD) with mortality in patients undergoing hemodialysis (HD). Methods: The single medical center observational cohort study enrolled 241 adult chronic HD patients from 1 October 2018 to 31 December 2018. Echocardiography results of IVCD and LVESD prior to dialysis were retrieved and patients were divided into high IVCD and low IVCD groups. Patients who received HD via a tunneled cuffed catheter were excluded. Study outcomes included all-cause mortality, cardiovascular mortality, and major adverse cardiovascular events (MACE). Subgroup analyses of HD patients with high and low LVESD were also performed. Results: The incidence of all-cause mortality, cardiovascular mortality, and MACE were higher in chronic HD patients with high IVCD (p < 0.01). High IVCD patients had significantly greater all-cause mortality, cardiovascular mortality, and MACE (log-rank test; p < 0.05). High IVCD patients are also associated with an increased risk of all-cause mortality and MACE relative to low IVCD patients (aHRs, 2.88 and 3.42; 95% CIs, 1.06–7.86 and 1.73–6.77, respectively; all p < 0.05). In the subgroup analysis of patients with high or low LVESD, the high IVCD remained a significant risk factor for all-cause mortality and MACE, and the HR is especially high in the high LVESD group. Conclusions: Dilated IVCD is a risk factor for all-cause mortality and MACE in chronic HD patients. In addition, these patients with high LVESD also have a significantly higher HR of all-cause mortality and MACE.

The Epidemiology of Multidrug-Resistant Sepsis among Chronic Hemodialysis Patients.

Sepsis is one of the leading causes of hospitalization and death among hemodialysis patients. Infections due to multidrug-resistant organisms (MDROs) are common among these patients, but empiric broad-spectrum coverage for every septic patient is associated with unfavorable outcomes. A retrospective case–control study was conducted at Shamir Medical Center, Israel (July 2016–April 2020), to determine predictors of MDRO infections among septic (per SEPSIS-3) ambulatory adult hemodialysis patients with permanent dialysis access (i.e., fistula, graft, or tunneled Perm-A-Cath). MDROs were determined according to established definitions. Least Absolute Shrinkage and Selection Operator (LASSO) regression was used to construct a prediction score and determine its performance. Of 509 patients, 225 (44%) had microbiologically confirmed infection, and 79 patients (35% of 225) had MDROs. The eventual independent predictors of MDRO infections were Perm-A-Cath access (vs. fistula or graft, aOR = 3, CI-95% = 2.1–4.2) and recent hospitalization in the previous three months (aOR = 2.3, CI-95% = 1.6–3.3). The score to predict MDRO sepsis with the highest performances contained seven parameters and displayed an area under the receiver operating characteristic curve (ROC AUC) of 0.74. This study could aid in defining a group of hemodialysis patients for which empiric broad-spectrum agents could be safely avoided.

Effects of Chronic Kidney Disease on Nanomechanics of the Endothelial Glycocalyx Are Mediated by the Mineralocorticoid Receptor.

Endothelial mechanics control vascular reactivity and are regulated by the mineralocorticoid receptor (MR) and its downstream target, the epithelial Na+ channel (ENaC). Endothelial dysfunction is a hallmark of chronic kidney disease (CKD), but its mechanisms are poorly understood. We hypothesized that CKD disrupts endothelial mechanics in an MR/ENaC-dependent process. Methods: Primary human endothelial cells were cultured with uremic serum derived from children with stage 3–5 (predialysis) CKD or adult hemodialysis (HD) patients or healthy controls. The height and stiffness of the endothelial glycocalyx (eGC) and cortex were monitored by atomic force microscopy (AFM) using an ultrasensitive mechanical nanosensor. Results: In a stage-dependent manner, sera from children with CKD induced a significant increase in eGC and cortex stiffness and an incremental reduction of the eGC height. AFM measurements were significantly associated with individual pulse wave velocity and serum concentrations of gut-derived uremic toxins. Serum from HD patients increased MR expression and mechanical stiffness of the endothelial cortex, an effect reversed by MR and ENaC antagonists, decreased eNOS expression and NO bioavailability, and augmented monocyte adhesion. Conclusion: These data indicate progressive structural damage of the endothelial surface with diminishing kidney function and identify the MR as a mediator of CKD-induced endothelial dysfunction.

The Safety and Efficacy of Clonidine in Hemodialysis Patients: A Systematic Review and Meta-Analysis

Background: Clonidine is a frequently prescribed long-term antihypertensive medication in hemodialysis (HD) patients in the USA, but its safety and efficacy has not been clearly established in the HD population. Objective: To evaluate, we conducted a systematic review and meta-analysis on the safety and efficacy of clonidine in HD patients. Methods: Keyword search of “clonidine” and “dialysis” was conducted through April 2021 in PubMed, Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov databases. Inclusion criteria were as follows – study design: randomized controlled trials, cohort studies, prospective studies, retrospective studies, or case series; subjects: adult HD patients; main outcome: blood pressure (BP) and safety; language: English; and article type: peer-reviewed publications. Studies that examined the effects of clonidine in populations other than adult HD patients were excluded. Meta-analysis was performed on BP reduction outcomes. Results: Eight studies met the inclusion criteria for the systematic review, including prospective pre-post studies (2), double-blind controlled trial (1), single-blinded placebo-controlled trial (1), crossover open-label clinical trial (1), retrospective analysis (1), and case report series (2). Three studies included in the meta-analysis ranged from 2 to 12 weeks duration, with a collective sample size of 24 (ages 12–77 years). Risk of bias, assessed using the ROBINS-1 tool, was high for all included studies. Significant adverse effects reported included hypotension, light-headedness, drowsiness, dry mouth, rebound hypertension, and contact dermatitis from patch application. Short-term clonidine use was associated with significant improvement in systolic BP (pooled effect: −12.985 mm Hg, 95% CI [−7.878, −18.092], p < 0.001), while changes in diastolic BP were not statistically significant (−11.119 mm Hg, 95% CI [−22.725, 0.487], p = 0.060). No data currently support the long-term efficacy of clonidine in HD patients. This study was unfunded and was developed using PRISMA guidelines and registered on PROSPERO (CRD42018112042). Conclusions: There is no evidence supporting the long-term use of clonidine in the HD population and a significant side-effect profile. There is low-quality evidence demonstrating the efficacy of clonidine in lowering BP in HD patients in short-term use, but significant safety concerns remain. Fluid removal strategies and other antihypertensives should be used over clonidine for long-term BP control in the HD population.

Prevalence of ABO Blood Grouping among Hemodialysis Patients in Dubai

Background: Beyond their vital role in blood transfusion, ABO antigens were speculated to be involved in developing various human illnesses, including infectious, neoplastic, cardiovascular, and many others. Many researchers attempted to highlight the relationship between kidney disease and ABO phenotypes. The majority of these reports showed a predominance of blood group O antigen among patients with chronic kidney disease, while few had opposed these findings. We aimed in this study to elaborate on blood group typing among our hemodialysis patients and whether it has a prognostic effect on the overall mortality. Methods: This is an observational, cross-sectional, retrospective study among chronic adult hemodialysis patients being dialyzed at Dubai Hospital over the past six months, from Jan 2021 till June 2021. The patient's demographic characteristics (age, sex, etiology of chronic kidney disease, medical comorbidities, and blood groups) were retrieved using an electronic hospital medical record system. Results: Our study population constituted 224 hemodialysis patients; their mean age was 55.4 years (16-94 years), 83.6% were UAE nationals, and 59.8% were males. Diabetic nephropathy was the etiology of end-stage kidney disease in 46%. ABO blood group distribution among our study population was as follows; group O was the commonest (45%), followed by group B positive (23%) and A Positive (20.9%). Among the UAE national patients group, O+ constitutes 46.9%, followed by B+ in 24%, and A+ in 21%. Nevertheless, group O+ was still the commonest among the nonnational hemodialysis patients in 37.7%, A+ in 28.8%, and B+ in 24.4%. Additionally, group O-positive was the predominant group among all diabetic dialysis patients (47%). Nine patients died during the study period of different causes; out of them, 4 patients (44.4%) had group O positive. Conclusion: Blood group O was the commonest blood group among our hemodialysis patients. Additionally, it was the commonest group in all diabetic dialysis patients. More studies from Arab countries are needed to comprehend the relationship between ABO blood phenotypes and kidney disease and whether certain blood groups have any role in a patient's progression to ESKD.

Difelikefalin in the Treatment of Chronic Kidney Disease-Associated Pruritus: A Systematic Review.

Chronic kidney disease-associated pruritus (CKD-aP) is a chronic condition that significantly reduces the quality of life of patients with end-stage renal disease. The etiology is not fully understood, but imbalance in the activity of the opioid pathways, including downregulation of the kappa-opioid receptor, may contribute to itching sensation. Difelikefalin is a selective, peripherally acting kappa-opioid receptor (KOR) agonist. Recently, difelikefalin has been approved as a first drug for the treatment of pruritus associated with chronic kidney disease (CKD) in adult hemodialysis patients. A systematic review of currently available clinical trials was performed to assess the efficacy and safety of difelikefalin in patients with uremic pruritus. A literature review was conducted in May 2022 based on the PRISMA 2020 guidelines. The analyzed clinical trials showed that difelikefalin was effective in reducing pruritus in patients as assessed by the Worst Itching Intensity Numerical Rating Scale. Improvement in quality of life assessed on the basis of the Skindex score and the 5-D itch scale was also noticed. The most commonly reported side effects were mild and included nausea, vomiting, dizziness, and diarrhea. Due to its proven efficacy and good safety profile, difelikefalin is a promising drug for the treatment of pruritus in patients with chronic kidney disease.

Modifiable Risk Factors Are Important Predictors of COVID-19-Related Mortality in Patients on Hemodialysis.

Patients with end-stage kidney disease face a higher risk of severe outcomes from SARS-CoV-2 infection. Moreover, it is not well known to what extent potentially modifiable risk factors contribute to mortality risk. In this historical cohort study, we investigated the incidence and risk factors for 30-day mortality among hemodialysis patients with SARS-CoV-2 infection treated in the European Fresenius Medical Care NephroCare network using conventional and machine learning techniques. We included adult hemodialysis patients with the first documented SARS-CoV-2 infection between February 1, 2020, and March 31, 2021, registered in the clinical database. The index date for the analysis was the first SARS-CoV-2 suspicion date. Patients were followed for up to 30 days until April 30, 2021. Demographics, comorbidities, and various modifiable risk factors, expressed as continuous parameters and as key performance indicators (KPIs), were considered to tap multiple dimensions including hemodynamic control, nutritional state, and mineral metabolism in the 6 months before the index date. We used logistic regression (LR) and XGBoost models to assess risk factors for 30-day mortality. We included 9,211 patients (age 65.4 ± 13.7 years, dialysis vintage 4.2 ± 3.7 years) eligible for the study. The 30-day mortality rate was 20.8%. In LR models, several potentially modifiable factors were associated with higher mortality: body mass index (BMI) 30-40 kg/m2 (OR: 1.28, CI: 1.10-1.50), single-pool Kt/V (OR off-target vs on-target: 1.19, CI: 1.02-1.38), overhydration (OR: 1.15, CI: 1.01-1.32), and both low (<2.5 mg/dl) and high (≥5.5 mg/dl) serum phosphate levels (OR: 1.52, CI: 1.07-2.16 and OR: 1.17, CI: 1.01-1.35). On-line hemodiafiltration was protective in the model using KPIs (OR: 0.86, CI: 0.76-0.97). SHapley Additive exPlanations analysis in XGBoost models shows a high influence on prediction for several modifiable factors as well, including inflammatory parameters, high BMI, and fluid overload. In both LR and XGBoost models, age, gender, and comorbidities were strongly associated with mortality. Both conventional and machine learning techniques showed that KPIs and modifiable risk factors in different dimensions ascertained 6 months before the COVID-19 suspicion date were associated with 30-day COVID-19-related mortality. Our results suggest that adequate dialysis and achieving KPI targets remain of major importance during the COVID-19 pandemic as well.

Age-based comparison of vascular access outcomes in maintenance hemodialysis population.

The hemodialysis population is aging, worldwide. In Israel, more than half of the dialysis population is older than 68 years. The policy for vascular access among this population is still a matter of debate, with several studies demonstrating conflicting results. This study compared vascular access outcomes across age groups (<65, 65-75, >75 years) in a single hemodialysis center in Israel. This was a retrospective, single center analysis of all vascular accesses created in adult hemodialysis patients in our institution, from January 1, 2006, through December 31, 2012. Patient characteristics, primary and secondary access failure, and complications were collected from electronic medical records. Follow-up was until death or up to 5 years. A total of 612 vascular accesses created among maintenance hemodialysis patients were included, of which 196 were in patients >75 years, 184 in patients 65-75 years, and 232 in patients <65 years. Mean age of the >75 years group was 80.5 ± 4.3 years and 60.7% were men. Vascular access site was the most important predicator for primary access failure (odds ratio for primary failure of radiocephalic arteriovenous fistula was 3.5 (95% CI 2.1-6), whereas age did not affect the primary failure rate (odds ratio 1.5, p = 0.648). Radiocephalic fistulas were more prone to secondary failure than other vascular access sites were. Complications were slightly more common in the oldest group. Eight percent of the patients >75 years died before access was used. In our cohort, age did not affect vascular outcomes, whereas VA site seemed to be the most important parameter in primary and secondary VA failures. Our results support considering VA on an individual basis and supply valuable information regarding complication and failure rates of VA among patients >75 years.

EE394 Outcomes and Costs Associated with Central Venous Catheter-Related S. Aureus Bloodstream Infections in Adult Hemodialysis Patients with S. Aureus Nares Colonization

Despite advances in infection control and catheter care, central venous catheter (CVC)-related S. aureus bloodstream infections (SA-BSI) rates in adult patients on hemodialysis using a CVC (CVC-HD) remains high, especially among CVC-HD patients with SA nares colonization. This study sought to estimate the yearly costs associated with CVC-related SA-BSIs in adult CVC-HD patients with SA nares colonization.

The rate, cost and outcomes of parathyroidectomy in the united states dialysis population from 2016–2018

BackgroundIn end-stage kidney disease, patients may undergo parathyroidectomy if secondary hyperparathyroidism cannot be managed medically. This study was designed to estimate the parathyroidectomy rate in the United States (US) and to quantify changes in costs and other outcomes after parathyroidectomy.MethodsThis was a retrospective observational cohort study using US Renal Data System data for 2015–2018. Parathyroidectomy rates were estimated for adult hemodialysis and peritoneal dialysis patients alive at the beginning of 2016, 2017, and 2018 who were followed for a year or until parathyroidectomy, death, or transplant. Incremental differences in economic and clinical outcomes were compared before and after parathyroidectomy in adult hemodialysis and peritoneal dialysis patients who received a parathyroidectomy in 2016 and 2017.ResultsThe rate of parathyroidectomy per 1,000person-years decreased from 6.5 (95% CI 6.2-6.8) in 2016 to 5.3 (95% CI5.0-5.6) in 2018. The incrementalincrease in 12-month cost after versus before parathyroidectomy was $25,314(95% CI $23,777-$27,078). By the secondmonth after parathyroidectomy, 58% of patients had a corrected calcium level< 8.5 mg/dL. In the year afterparathyroidectomy (versus before), hospitalizations increased by 1.4 perperson-year (95% CI 1.3-1.5), hospital days increased by 12.1 per person-year(95% CI 11.2-13.0), dialysis visits decreased by 5.2 per person-year (95% CI4.4-5.9), and office visits declined by 1.3 per person-year (95% CI1.0-1.5). The incremental rate per 1,000person years for hematoma/bleed was 224.4 (95% CI 152.5-303.1), for vocal cordparalysis was 124.6 (95% CI 59.1-232.1), and for seroma was 27.4 (95% CI0.4-59.0).ConclusionsParathyroidectomy was a relatively uncommon event in the hemodialysis and peritoneal dialysis populations. The incremental cost of parathyroidectomy was mostly attributable to the cost of the parathyroidectomy hospitalization. Hypocalcemia occurred in over half of patients, and calcium and phosphate levels were reduced. Clinicians, payers, and patients should understand the potential clinical and economic outcomes when considering parathyroidectomy.

Plasma Nitrate and Nitrite Kinetics after Single Intake of Beetroot Juice in Adult Patients on Chronic Hemodialysis and in Healthy Volunteers: A Randomized, Single-Blind, Placebo-Controlled, Crossover Study

Nitric oxide (NO) contributes to maintaining normal cardiovascular and renal function. This bioactive signalling molecule is generally formed enzymatically by NO synthase in the vascular endothelium. NO bioactivity can also be attributed to dietary intake of inorganic nitrate, which is abundant in our diet, especially in green leafy vegetables and beets. Ingested nitrate is reduced to nitrite by oral commensal bacteria and further to NO systemically. Previous studies have shown that dialysis, by means of removing nitrate and nitrite from the body, can reduce NO bioactivity. Hence, dietary intervention approaches aimed to boost the nitrate–nitrite–NO pathway may be of benefit in dialysis patients. The purpose of this study was to examine the kinetics of plasma nitrate and nitrite after a single intake of nitrate-rich concentrated beetroot juice (BJ) in adult hemodialysis (HD) patients and in age-matched healthy volunteers (HV). Eight HD patients and seven HV participated in this single center, randomized, single-blind, placebo-controlled, crossover study. Each participant received a sequential single administration of active BJ (70 mL, 400 mg nitrate) and placebo BJ (70 mL, 0 mg nitrate) in a random order separated by a washout period of seven days. For the kinetic analysis, blood samples were collected at different time-points before and up to 44 h after BJ intake. Compared with placebo, active BJ significantly increased plasma nitrate and nitrite levels both in HD patients and HV. The area under the curve and the maximal concentration of plasma nitrate, but not of nitrite, were significantly higher in HD patients as compared with HV. In both groups, active BJ ingestion did not affect blood pressure or plasma potassium levels. Both BJs were well tolerated in all participants with no adverse events reported. Our data provide useful information in planning dietary nitrate supplementation efficacy studies in patients with reduced NO bioactivity.