Choice Of Renal Replacement Therapy Research Articles

Kidney Paired Donation-European Transnational Experience in Adults and Opportunities for Pediatric Kidney Transplantation.

Live donor kidney transplantation is considered the optimal choice for renal replacement therapy, providing established benefits, such as superior patient survival and improved quality of life. However, immunological challenges, including ABO blood group incompatibility and, particularly, donor-specific HLA antibodies, may impact long-term outcomes considerably or even prevent safe direct transplantation with the intended donor. In this review, the authors discuss kidney paired donation (KPD) as a viable strategy to overcome immunological barriers to living donation through organ exchanges. We thereby lay special focus on the Czech-Austrian transnational KPD program. While the benefits of KPD programs are well established for adult recipients, recent data suggest that this may hold true also for pediatric patients. Complex algorithms, considering factors like the intricate patterns of HLA sensitization, play a pivotal role in predicting suitable matches, but for pediatric patients also non-immunological factors including age and weight match may play a role. As pool size proves crucial for program efficacy, several countries in Europe have now initiated transnational collaborations to maximize match rates. Among those, the Czech-Austrian transnational joint program, established in 2015 and now expanded to a cooperation with the Israel transplant program to further increase transplant rates, represents a successful example. KPD programs, with their innovative approaches and international partnerships, hold promise for enhancing outcomes and addressing the increasing demand for kidney transplantation.

Shared decision-making in selecting modality of renal replacement therapy confers better patient prognosis after the initiation of dialysis.

The effect of shared decision-making (SDM) regarding the choice of renal replacement therapy (RRT) for chronic kidney disease (CKD) patients on their mortality after the induction of dialysis therapy has not been adequately investigated. Patients who initiated dialysis at our hospital were divided into two groups according to whether they participated in SDM in the outpatient clinic, and survival analysis was performed. We also examined the effect of SDM in the outpatient clinic on mortality. Of the 554 patients, 123 (22.2%) were in the SDM group. The survival rate was significantly higher in the SDM group (p = 0.001, log-rank test). Multivariate analysis excluding ADL, which competed with SDM, showed that SDM was significantly associated with mortality (HR 0.593, 95% CI: 0.353-0.997, p = 0.049). SDM regarding RRT selection in the outpatient clinic may be associated with a better patient prognosis after dialysis induction.

Non-compliance as ethical dilemma for kidney transplantation

IntroductionAllocating a kidney transplant to a non-compliant recipient could present a triple damage: to the donor (and family of a deceased donor), for the recipient (who will experience rejection) and for another potential recipient on the waiting list (who missed the chance for the transplant). Having in mind that kidney transplantation (TX) is the best choice of renal replacement therapy, a thorough individual endeavor to predict the outcome of a TX in a non-compliant candidate is necessary to avoid a worse option. Non-compliance could origin from maladaptation, psychological limitations or a psychiatric condition.ObjectivesHere we present a 46 years old male patient on chronic hemodialysis (HD) for 4 years due to end stage diabetic kidney disease. He is extremely non-adherent to HD related recommendations, occasionally skipping the sessions, gaining up to 10 kg weight overload between the sessions and avoided visiting psychiatrist, so far. Our objectives were to explore the presence and severity of non-compliance as ethical dilemma for kidney transplantation.MethodsReviewing the patient’s medical data.ResultsUnlike to non-obedience to dietary and behavioral medical advice, this patient is very much adherent to pharmacological medication. Staying on HD he is constantly on the edge of vital danger, risking pulmonary edema or hyperkalemia related cardiac events. The most important compliance in a kidney transplant patient is adherence to immunosuppressive therapy. In this particular patient we could predict adherence to immunosuppressive medication after a TX and getting rid of volume overload and hyperkalemia once restoring kidney transplant function.ConclusionsPretransplant non-compliance in kidney transplant candidate is not always an obstacle for kidney TX. In some cases, as in the one here described, a TX is better option than staying on HD, avoiding the previously described triple ethical damage - to the donor, the recipient and patients waiting on list, while we could predict a good outcome of the TX. Including psychiatrist into the work up and management should not be skipped.Disclosure of InterestNone Declared

Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis.

Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant. Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722). One hundred-fifty-three ICUs in 13 countries. Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ). None. Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; p < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; p = 0.007). Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.

Impact of therapeutic education on the choice of renal replacement therapy. Moroccan monocentric experience

Therapeutic patient education (TPE) is gaining importance in the management of patients with chronic kidney disease (CKD). The objective of this study is to assess the interest of TPE in the acquisition of knowledge concerning CKD and renal replacement therapy, as well as the orientation of the patients towards a personalized choice of treatment. Patients with a minimum stage 4 CKD were prospectively included between November 2016 and February 2020. We proposed TPE sessions on CKD and its treatment to all patients. We explained the theoretical part through a slideshow about the definition of end-stage renal disease, its symptoms and the various methods of renal replacement therapy. A “basket” of essential material to illustrate a session of hemodialysis (HD) or peritoneal dialysis (PD) was used to achieve the practical part of the study. Data was collected using two questionnaires: the first one, at the start of the session, included the socio-demographic and clinical characteristics of the patients and evaluated their level of basic knowledge, and the second one, at the end of the session, assessed the evolution of knowledge after TPE, leading to a therapeutic choice. The mean age of the 211 included patients was 55.59 years old (SD=15.47). Male to female ratio was 0.73. The level of education was low in 69% of the cases of whom 23.7% were employees. The glomerular filtration rate (GFR) was between 15 and 30mL/min in 56.8% of the cases. Initial nephropathy was known in 60% of patients while the stage of CKD was unknown in 66.4%. Before TPE, patients with a good level of overall knowledge were around 29%, rising to 73% after TPE. A significant correlation was found between the level of education of the patients and their knowledge score before and after TPE. The choice of renal replacement therapy was taken for PD, TR and HD respectively in 36%, 19% and 11.8% of the cases, while 33.2% asked for time to think. Elderly and/or low educated patients most often remained undecided; moreover those who are young and/or educated prefer TR. During the follow-up period, 46% of patients started renal replacement therapy (36.5% started HD, 8.1% PD and 1.4% KT). The choice made by our patients was respected in 42% of the cases: in all the patients who chose HD; in 36% of those who chose PD, and 19% of those who chose kidney transplantation (KT). The final therapeutic modality was strongly linked to the following parameters: age, GFR and level of education. This study highlighted the insufficient level of patients’ information about CKD and its treatment and allowed the patients to express their choice of their replacement therapy, which is a complicated process that must ­integrate the opinion of the nephrologist and the patient’s preference to lead to an ­optimal organization of the therapeutic modality.

#4264 PERITONEAL DIALYSIS AFTER FAILED KIDNEY TRANSPLANT: A SUITABLE OPTION

Abstract Background and Aims Despite great advances in graft survival, kidney transplant (KT) recipients frequently return to dialysis. The aim of this study was to perform an analysis of peritoneal dialysis (PD) outcomes of patients with a failed KT. Method Single-center retrospective cohort study with end-stage renal disease (ESRD) patients who started PD from 1st January 2010 to 31st December 2017. Two groups were analyzed - patients who started PD with no previous renal replacement therapy (RRT) - PD first -, and patients who transitioned directly from a failed kidney transplant. Results Among 152 patients who started PD, 115 were PD first and 15 transitioned from KT. The population included 63,1% of male gender, with a mean age of 52,4 ± 15,5 years and had PD median vintage of 30 months (IQR 20,6). Patients who transitioned from KT were significantly younger (mean age 42,8 ± 14,3 vs. 53,7 ± 15,3, p = 0,015) and had lower prevalence of diabetes mellitus (13,3% vs. 40,0%, p = 0,044). In KT patients, glucocorticoids were continued until there was residual diuresis and non-glucocorticoid immunosuppression was maintained for a median of 180 days (± 176) after PD start. Nearly a third (30,0%) of patients had no hospitalizations and 35,5% had more than 2 hospital admissions. Annual hospitalization rate was higher in prior KT group (1,40 vs. 0,48, p = 0,002). Prior KT associated with higher annual peritonitis rate (0,70 vs. 0,20, p = 0,017). A higher number of MACE was also observed in prior KT group (33,3% vs. 7,9%, p = 0,004). Residual diuresis was significantly lower in the group with previous KT. Neither ultrafiltration failure (6,7% vs. 9,9%, p = 0,974), nor technique survival (death or hemodialysis transfer 53,3% vs. 54,8%, p = 0,917; logrank 0,354) were different between groups. Conclusion Although higher incidence of diabetes mellitus was observed in PD first group, no differences were identified in ultrafiltration failure rates between groups. Despite significantly lower diuresis in prior KT group, both groups had adequate dialysis efficacy (mean Kt/V&amp;gt;1,7) and similar technique survival. Higher peritonitis rate and MACE incidence was observed in prior KT group, possibly associated with maintenance immunosuppression. Nevertheless, PD is a valid choice for RRT after a failed KT and should be offered to these patients.

Shared Decision Making for Choosing renAl Replacement Therapy in Chronic Kidney Disease Patients (SDM-ART trial): study protocol for randomized clinical trial.

Patients with chronic kidney disease (CKD) should be educated about their condition so that they can initiate dialysis at the optimal time and make an informed choice between dialysis modalities. Shared decision-making (SDM) empowers patients to select their own treatment and improves patient outcomes. This study aimed to evaluate whether SDM affects the choice of renal replacement therapy among CKD patients. This is a multicenter, open-label, randomized, pragmatic clinical trial. A total of 1,194 participants with CKD who are considering renal replacement therapy were enrolled. The participants will be randomized into three groups in a 1:1:1 ratio: the conventional group, extensive informed decision-making group, and SDM group. Participants will be educated twice at months 0 and 2. Videos and leaflets will be provided to all patients. Patients in the conventional group will receive 5 minutes of education at each visit. The extensive informed decision-making group will receive more informed and detailed education using intensive learning materials for 10 minutes each visit. Patients in the SDM group will be educated for 10 minutes each visit according to illness perception and item-based analysis. The primary endpoint is the ratio of hemodialysis to peritoneal dialysis and kidney transplantation among the groups. Secondary outcomes include unplanned dialysis, economic efficiency, patient satisfaction, patient evaluation of the process, and patient adherence. The SDM-ART is an ongoing clinical study to investigate the effect of SDM on the choice of renal replacement therapy in patients with CKD.

Influencia de los determinantes sociales de la salud en la elección de tratamiento renal sustitutivo en la enfermedad renal crónica avanzada: necesidad de un enfoque multidisciplinar

IntroductionThe influence of socioeconomic and cultural barriers in the choice of renal replacement therapy (RRT) techniques in advanced chronic kidney disease (ACKD) has been scarcely explored, which can generate problems of inequity, frequently unnoticed in health care. The aim of this study is to identify the “non-medical” barriers that influence the choice of RRT in an ACKD consultation in Spain. Material and methodsRetrospective analysis including the total number of patients seen in the ACKD consultation in a tertiary hospital from 2009 to 2020. Inclusion in the ACKD consultation began with an eligibility test and a decision-making process, conducted by a specifically trained nurse. The variables considered for the study were: age, sex, etiology of CKD, level of dependence for basic activities of daily living (Barthel scale) and instrumental activities of daily living (Lawton and Brody scale), Spanish versus foreign nationality, socioeconomic level and language barrier. The socioeconomic level was extrapolated according to home and health district by primary care center to which the patients belonged. ResultsA total of 673 persons were seen in the ACKD consultation during the study period, of whom 400 (59.4%) opted for hemodialysis (HD), 156 (23.1%) for peritoneal dialysis (PD), 4 (0.5%) for early living donor renal transplantation and 113 (16.7%) chose conservative care (CC). The choice of PD as the chosen RRT technique (vs. HD) was associated with people with a high socioeconomic level (38.7 vs. 22.5%) (p=0.002), Spanish nationality (91 vs. 77.7%) (p<0,001), to a lower language barrier (0.6 vs. 10.5%) (p<0.001), and to a higher score on the Barthel scale (97.4 vs. 92.9) and on the Lawton and Brody scale (7 vs. 6.1) (p<0.001). Neither age nor sex showed significant differences in the choice of both techniques. Patients who opted for CC were significantly older (81.1 vs. 67.7 years; p<0.001), more dependent (p<0.001), with a higher proportion of women (49.6 vs. 35.2%; p=0.006) and a higher proportion of Spaniards (94.7 vs. 81%, p=0.001) in relation to the choice of other techniques (PD and HD). Socioeconomic level did not influence the choice of CC. ConclusionDespite a regulated decision-making process, there are factors such as socioeconomic status, migration, language barrier and dependency of the population that influence the type of RRT chosen. To address these aspects that may cause inequity, an intersectoral and multilevel intervention is required with interdisciplinary teams that include, among others, social workers, to provide a more holistic and person-centered assessment.

Comorbidity and nutritional status in adult with advanced chronic kidney disease influence the decision-making choice of renal replacement therapy modality: A retrospective 5-year study.

Nutritional and inflammation status are significant predictors of morbidity and mortality risk in advanced chronic kidney disease (ACKD). To date, there are a limited number of clinical studies on the influence of nutritional status in ACKD stages 4-5 on the choice of renal replacement therapy (RRT) modality. This study aimed to examine relationships between comorbidity and nutritional and inflammatory status and the decision-making on the choice of RRT modalities in adults with ACKD. A retrospective cross-sectional study was conducted on 211 patients with ACKD with stages 4-5 from 2016 to 2021. Comorbidity was assessed using the Charlson comorbidity index (CCI) according to severity (CCI: ≤ 3 and >3 points). Clinical and nutritional assessment was carried out by prognosis nutritional index (PNI), laboratory parameters [serum s-albumin, s-prealbumin, and C-reactive protein (s-CRP)], and anthropometric measurements. The initial decision-making of the different RRT modalities [(in-center, home-based hemodialysis (HD), and peritoneal dialysis (PD)] as well as the informed therapeutic options (conservative treatment of CKD or pre-dialysis living donor transplantation) were recorded. The sample was classified according to gender, time on follow-up in the ACKD unit (≤ 6 and >6 months), and the initial decision-making of RRT (in-center and home-RRT). Univariate and multivariate regression analyses were carried out for evaluating the independent predictors of home-based RRT. Of the 211 patients with ACKD, 47.4% (n = 100) were in stage 5 CKD, mainly elderly men (65.4%). DM was the main etiology of CKD (22.7%) together with hypertension (96.6%) as a CV risk factor. Higher CCI scores were significantly found in men, and severe comorbidity with a CCI score > 3 points was 99.1%. The mean time of follow-up time in the ACKD unit was 9.6 ± 12.8 months. A significantly higher CCI was found in those patients with a follow-up time > 6 months, as well as higher mean values of eGFR, s-albumin, s-prealbumin, s-transferrin, and hemoglobin, and lower s-CRP than those with a follow-up <6 months (all, at least p < 0.05). The mean PNI score was 38.9 ± 5.5 points, and a PNI score ≤ 39 points was found in 36.5%. S-albumin level > 3.8 g/dl was found in 71.1% (n = 150), and values of s-CRP ≤ 1 mg/dl were 82.9% (n = 175). PEW prevalence was 15.2%. The initial choice of RRT modality was higher in in-center HD (n = 119 patients; 56.4%) than in home-based RRT (n = 81; 40.5%). Patients who chose home-based RRT had significantly lower CCI scores and higher mean values of s-albumin, s-prealbumin, s-transferrin, hemoglobin, and eGFR and lower s-CRP than those who chose in-center RRT (p < 0.001). Logistic regression demonstrated that s-albumin (OR: 0.147) and a follow-up time in the ACKD unit >6 months (OR: 0.440) were significantly associated with the likelihood of decision-making to choose a home-based RRT modality (all, at least p < 0.05). Regular monitoring and follow-up of sociodemographic factors, comorbidity, and nutritional and inflammatory status in a multidisciplinary ACKD unit significantly influenced decision-making on the choice of RRT modality and outcome in patients with non-dialysis ACKD.

Transitions in an integrated model of renal replacement therapy in a regional health system

Introduction and objectivesThe choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques. Material and methodsThe study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008–2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition. ResultsA total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KT). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p < 0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs KTX group 8.3%, p < 0.001) and less access to a transplant (HD group 30.4% vs PD group 51.6%; p < 0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD → PD: 0.7 years (SD 1.1) vs PD → HD: 1.5 years (SD 1.4) p < 0.001), are younger (HD → PD: 53.5 years (SD 16.7) vs PD → HD: 61.6 years (SD 14.6); p < 0.001), presented less mortality (HD → PD: 24.5% vs PD → HD: 32.0%; p < 0.001) and higher access to a transplant (HD → PD: 49.4% vs PD → HD: 31.7%; p < 0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one. ConclusionOur data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.

Factors Affecting the Choice of Renal Replacement Therapy in Patients with End Stage Renal Failure

It was aimed to investigate the factors affecting the choice of renal replacement therapy by examining the data of patients with end stage renal disease, to whom we applied a predialysis education program. Patients who were started on renal replacement therapy in our clinic were evaluated retrospectively. Renal replacement therapy were divided into three groups as hemodialysis, peritoneal dialysis and renal transplantation and compared according to their clinical and demographic characteristics. The comorbidities of the patients were calculated using the 'modified charlson comorbidity index' score. There were a total of 464 patients in the study, of whom 330 (71.1%) chose hemodialysis, 65 (14%) peritoneal dialysis, and 69 (14.9%) renal transplantation. Age was significantly different between the groups (p<0.001). According to the hemodialysis patients of renal transplantation patients; that the rate of being a university graduate (p<0.001) and never married (p=0.004) is higher. Rate of living in the urban area (p=0.021) and working patients (p=0.031) were higher in renal transplantation patients. The rate of diabetic nephropathy of renal etiology was lower in renal transplantation patients (p=0.014). When the modified charlson comorbidity index scores of the groups were examined, highest values were in the hemodialysis group and the lowest values were in the transplantation group (p<0.001). Patients sociodemographic characteristics and comorbid conditions were effective in the choice of renal replacement therapy modality. In addition to the educating given before the selection, most appropriate treatment modality should be selected by considering these features.

Evaluations of toxic heavy metals lead and mercury in regular hemodialysis smoker and nonsmoker patients by comparison with other normal population in Egyptian population

Around population, worldwide 10% are affected by chronic kidney disease (CKD). Hemodialysis is the common choice of renal replacement therapy. Cigarette smokers has high lead level than non-smoker populalion.as Tobacco leaf grown on polluted soil. Mercury poisoning depend on dose and duration of exposure. Aim of the study is to determine two important toxic heavy metals elements lead and mercury concentrations in pre hemodialysis blood sample of CKD patients on maintenance hemodialysis for more than 6 months divided into non-smoker and smoker with exclusion of cases with occupational exposures by comparison with control group non-CKD, non-smoker persons. Our study is conducted in September 2019 in Al Mokattam insurance hospital in Cairo this study involved 60 persons are divided into 3 groups both sex with no racial exclusion criteria: CKD stage 5 patients on hemodialysis 40 patients divided into 2 groups (smoker) 20 patients and (non-smoker) 20 patients with history of eating fish and seafood are taken by comparison with healthy control group. Lead and mercury are analyzed by electro thermal atomic absorption spectrophotometer in Al Borg central Lab. Our study proves that prolonged duration on hemodialysis not raise lead and mercury level in blood, smoking raises lead level in blood, eating fish and sea food more than once per week lead to increase mercury level in blood, there is relation between raised lead level and anemia in hemodialysis patients.

Mechanical and chemical cues synergistically promote human venous smooth muscle cell osteogenesis through integrin β1-ERK1/2 signaling: A cell model of hemodialysis fistula calcification.

Arteriovenous fistula (AVF) is the vascular access of choice for renal replacement therapy. However, AVF is susceptible to calcification with a high prevalence of 40%-65% in chronic hemodialysis patients. Repeated needle puncture for hemodialysis cannulation results in intimal denudation of AVF. We hypothesized that exposure to blood shear stress in the medial layer promotes venous smooth muscle cell (SMC) osteogenesis. While previous studies of shear stress focused on arterial-type SMCs, SMCs isolated from the vein had not been investigated. This study established a venous cell model of AVF using the fluid shear device, combined with a high phosphate medium to mimic the uremic milieu. Osteogenic gene expression of venous SMCs upon mechanical and chemical cues was analyzed in addition to the activated cell signaling pathways. Our findings indicated that upon shear stress and high phosphate environment, mechanical stimulation (shear stress) had an additive effect in up-regulation of an early osteogenic marker, Runx2. We further identified that the integrin β1-ERK1/2signaling pathway was responsible for the molecular basis of venous SMC osteogenesis upon shear stress exposure. Mitochondrial biogenesis also took part in the early stage of this venopathy pathogenesis, evident by the up-regulated mitochondrial transcription factor A and mitochondrial DNA polymerase γ in venous SMCs. In conclusion, synergistic effects of fluid shear stress and high phosphate induce venous SMC osteogenesis via the ERK1/2 pathway through activating the mechanosensing integrin β1signaling. The present study identified a promising druggable target for reducing AVF calcification, which deserves further in vivo investigations.

Quality of life of patients undergoing continuous ambulatory peritoneal dialysis (CAPD) in RSUP Dr. Sardjito Yogyakarta

CAPD had been recommended as the first choice of renal replacement therapy in Indonesia since 2010. Since then, many patients started initiating CAPD. The advantages and disadvantages of using CAPD may affect the patient lifestyle as well as the quality of life. However, up to now there patients’ QoL has not been evaluated. Objective of this research is to reveal the life quality of patients with chronic kidney disease who using Continuous Ambulatory Peritoneal Dialysis (CAPD) di RSUP DR. Sardjito Yogyakarta. The was a quantitative descriptive using cross sectional design. As many as 65 respondents underging CAPD was recruited using consecutive sampling technique. The research used KDQOL-36 questionnaire and data obtained were analyzed univariately. The mean score in the effect of kidney diseases and symptom/problem domain was high (87,77±11,40 & 86,15±12,73). The lowest score wa in physical health condition (38,24±6,77). And moderate score was showed in burden of kidney disease (56,73±19,56) and mental health condition obtained (56,06±7,41). The Even tough the patients experienced less symptom and problems due to the effect of kidney disease, they still had a poor physical health. Thus, nurses could arrange a specific intervention to improve their physical health.

The role of different nephrology experts in informed shared decision-making for renal replacement therapy.

Interprofessional teams and peer support are being increasingly considered in informed shared decision-making. In Germany, there appear to be deficits in the implementation of informed shared decision-making in the choice of renal replacement therapy, such as the lack of collaboration in interprofessional teams and the absence of structured peer support programmes for patients with chronic kidney disease. To explore nephrologists' and nurses' perspectives regarding their involvement in shared decision-making when choosing renal replacement therapy. Guideline-based, problem-centred interviews were used. A total of 20 nephrologists and 15 nurses were recruited from 21 dialysis units all over Germany. Interviews were audio-recorded and transcribed. They were analysed thematically using structuring and summary content analysis, supported by the qualitative data analysis software MAXQDA 12. The most important findings were the late or missing participation of nurses in the informed shared decision-making process and the unstructured peer support. Along with time and financial factors, these aspects were seen as barriers to shared decision-making with patients who are often overwhelmed by the diagnosis. Furthermore, informed shared decision-making has been insufficiently considered in professional education and training. Shared decision-making in the choice of renal replacement therapy is particularly challenging due to the patients' high disease burden. The greater incorporation of informed shared decision-making in education and training as well as the consistent involvement of nursing staff and structured peer counselling already in the predialysis phase with adequate reimbursement can address the identified hurdles.

Análisis de las transiciones en el modelo integrado de tratamiento sustitutivo renal en un sistema regional de salud

Introduction and objectivesThe choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques. Material and methodsThe study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008–2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition. ResultsA total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KTX). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p<0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs 8.3% KTX group, p<0.001) and less access to a transplant (HD group 30.4% vs DP group 51.6%; p<0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD→PD: 0.7 years (SD 1.1) vs PD→HD: 1.5 years (SD 1.4) p<0.001), are younger (HD→PD: 53.5 years (SD 16.7) vs PD→HD: 61.6 years (SD 14.6); p<0.001), presented less mortality (HD→PD: 24.5% vs PD→HD: 32.0%; p<0.001) and higher access to a transplant (HD→PD: 49.4% vs PD→HD: 31.7%; p<0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one. ConclusionOur data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.

Amiodarone-induced multiple organ damage in an Alström syndrome patient with end-stage renal disease and hepatic cirrhosis

Alström syndrome (AS) is an extremely rare disease accompanied by blindness, hearing loss, obesity, type 2 diabetes, dilated cardiomyopathy, and progressive hepatic and renal dysfunction. The life span of AS patients rarely exceeds 50years, and thus there are very few reports describing the implementation of renal replacement therapy for these patients. We here report a case of AS patient who exhibited dilated cardiomyopathy, end-stage renal disease, and hepatic cirrhosis. He underwent hemodialysis therapy more than 3years. Although he eventually died of amiodarone-induced multiple organ damage in the lungs and liver, the present case suggests that hemodialysis therapy can be a choice of renal replacement therapy for AS patients with end-stage renal disease.

MO813ANALYSING TRANSITIONS IN THE INTEGRATED MODEL OF RENAL REPLACEMENT THERAPY IN A REGIONAL HEALTH SYSTEM

Abstract Background and Aims Every year 83,000 Europeans and 6,500 Spanish CKD patients require dialysis or transplantation. The choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. A single therapy option might not be adequate across a patient’s entire lifespan and a majority of patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. Transitions should be considered as an expected progression in the patient’s treatment options. In these circumstances, there are new questions about the best sequence of techniques. Method This observational study examined a cohort of all incident patients from the Madrid Registry of Renal Patients (REMER), who initiated RRT between January 2008 and December of 2018. This study used the proportional hazards models and competitive risk models to examine the impact of transitions between RRT modalities on survival. We performed an intention-to-treat (ITT) analysis, according to the initial RRT chosen and an as treated (AT) analysis, by RRT received (Only HD, Only PD, PD then HD or HD then PD). Results A total of 8,971 patients started RRT during this period in Madrid (6.6 Million population): 7,207 on hemodialysis (HD), 1,401 on peritoneal dialysis (PD) and 363 received a pre-emptive kidney transplantation (KTX). Incident HD-patients were older and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs 8.3% KTX group, p &amp;lt;0.001) and less access to a transplant (HD group 30.4% vs DP group 51.6%; p &amp;lt;0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (66% in less than 6 months), are younger and behave like those treated only with PD. Those who change from PD to HD do so later (1.5 years on average), are older (61.6 vs 53.5 years) and present higher mortality and less access to kidney transplantation than the group who initiates in HD and transfer to PD. Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 58.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). This analysis reflects how patients who change dialysis modality share more characteristics with the second technique than the original one. Conclusion Our data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and should be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and repports of renal registries.

MO894EVALUATIONS OF TOXIC HEAVY METALS LEAD AND MERCURY IN REGULAR HEMODIALYSIS SMOKER AND NONSMOKER PATIENTS BY COMPARISON WITH OTHER HEALTHY CONTROL SUBJECTS IN EGYPTIAN POPULATION

Abstract Background and Aims Around worldwide population, 10% are affected by chronic kidney diseases (CKD); hemodialysis is the common choice of renal replacement therapy. Cigarette smokers have higher Lead level than non-smoker population. As Tobacco leaves are grown on polluted soil, it is proven that Mercury poisoning depends on dose and duration of exposure. Aim of the study was to determine two important toxic heavy metals elements Lead and Mercury concentrations in regular hemodialysis patients smoker and non-smoker by comparison with normal subjects and its correlation to anemia. Method Blood samples were collected from CKD patients on maintenance hemodialysis for more than 6 months divided into non-smoker and smoker to be compared with samples from a control group of non-CKD, non-smoker persons. This study was conducted in September 2019 in Al Mokattam Insurance Hospital – Cairo and involved 60 persons of both sex. They were divided into 3 groups: CKD stage 5 patients on hemodialysis 40 patients and sub-divided into 2 groups; (smoker) 20 patients and (non-smoker) 20 patients and the history of eating fish and seafood was taken. The third group was a control group included 20 healthy non-smoker participants. Lead and Mercury were analyzed by electro thermal atomic absorption spectrophotometer in Al Borg central Laboratory. The complete blood count (CBC), kidney function tests and Iron parameters were also detected. Results duration on hemodialysis did not raise Lead or Mercury level in blood, while smoking raises Lead level in blood, and eating fish and sea food more than once per week increased Mercury level in blood. There was a relation between raised Lead level and anaemia in hemodialysis patients. Conclusion Lead Prolonged and Mercury measurement is important in hemodialysis patients with possible symptoms of heavy metal toxicity. Lead level monitoring is recommended in resistant anemia in hemodialysis patients.

POS-754 EVALUATING THE OUTCOMES OF KIDNEY TRANSPLANTATION IN SICKLE CELL DISEASE PATIENTS: A SYSTEMATIC REVIEW.

Nephrologists increasingly face the emerging challenge of managing sickle cell disease (SCD) patients with End-stage Renal Disease (ESRD). The increasing cohort of patients is due to improvements in SCD treatment, meaning that more people go on to develop complications such as Sickle Cell-associated Nephropathy (SCAN). Nigeria has the highest burden of SCD in the world, with rising cases of SCAN. In this patient cohort, some authors have recommended kidney transplantation as the choice of renal replacement therapy (RRT). However, the outcomes of renal transplantation in SCD patients have been variable with conflicting data presented in individual studies. We decided to conduct a systematic review to critically evaluate the outcomes of kidney transplantation in sickle cell disease patients and compare data from other countries with Nigeria. We expected that the results of our review would shed more light on kidney transplant outcomes in patients with SCD as well as identify gaps and areas of interest for future studies. We conducted a systematic search of MEDLINE via PubMed to identify studies that reported on outcomes of kidney transplantation in adult SCD patients, restricting results to those published from the year 2000. We then screened papers based on eligibility criteria in stages. First, we screened titles and abstracts based on eligibility. Common reasons for exclusion were studies with participants who did not have SCD and those without any reported outcome measure. Full texts of the remaining articles were subsequently read and selected based on eligibility criteria. We extracted data using a standardised data extraction form and presented our findings in a narrative synthesis. To ensure rigour, we adhered to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines in conducting and reporting this review. Database search conducted on 1st march 2020 found 88 papers. We also identified 6 additional articles that met the inclusion criteria following bibliographic review of eligible studies. We screened 94 records by title and abstract and removed 76 that did not meet the inclusion criteria. We screened the full-text versions of 18 articles and identified 9 for inclusion in this review. 6 articles were case reports and 3 were statistical studies using registry data. Insights generated from included studies relate to short term outcomes of renal transplant recipients who have SCD, with patient survival ranging from to 90.5% to 100% in the first year post-transplant. However, long term outcomes are significantly lower and can be as low as 55.7% at six years post-transplant. Renal transplantation in SCD presents both benefits and complications which need to be communicated to patients to ensure informed consent. We can mitigate adverse outcomes with adequate preoperative care and multidisciplinary team approach in managing complications on a case-by-case basis.