Chronic Hemodialysis Treatment Research Articles

Identifying key predictors of mortality in young patients on chronic haemodialysis-a machine learning approach.

The mortality risk remains significant in paediatric and adult patients on chronic haemodialysis (HD) treatment. We aimed to identify factors associated with mortality in patients who started HD as children and continued HD as adults. The data originated from a cohort of patients <30 years of age who started HD in childhood (≤19 years) on thrice-weekly HD in outpatient DaVita dialysis centres between 2004 and 2016. Patients with at least 5 years of follow-up since the initiation of HD or death within 5 years were included; 105 variables relating to demographics, HD treatment and laboratory measurements were evaluated as predictors of 5-year mortality utilizing a machine learning approach (random forest). A total of 363 patients were included in the analysis, with 84 patients having started HD at <12 years of age. Low albumin and elevated lactate dehydrogenase (LDH) were the two most important predictors of 5-year mortality. Other predictors included elevated red blood cell distribution width or blood pressure and decreased red blood cell count, haemoglobin, albumin:globulin ratio, ultrafiltration rate, z-score weight for age or single-pool Kt/V (below target). Mortality was predicted with an accuracy of 81%. Mortality in paediatric and young adult patients on chronic HD is associated with multifactorial markers of nutrition, inflammation, anaemia and dialysis dose. This highlights the importance of multimodal intervention strategies besides adequate HD treatment as determined by Kt/V alone. The association with elevated LDH was not previously reported and may indicate the relevance of blood-membrane interactions, organ malperfusion or haematologic and metabolic changes during maintenance HD in this population.

Early diagnosis of miliary tuberculosis in a hemodialysis patient by combining two interferon-\u03b3-release assays: a case report

BackgroundPatients with end-stage renal disease undergoing chronic hemodialysis (HD) are at high risk to develop tuberculosis (TB) associated with a high mortality rate. TB diagnosis is often delayed due to non-specific symptoms, frequent extra-pulmonary manifestations, and rare microbiological confirmation. This case report illustrates the clear added value of combined interferon-γ -release assays (IGRA) in response to different mycobacterial antigens for an early diagnosis of TB in HD patients.Case presentationWe report the case of an Egyptian patient under chronic HD treatment, who presented with recurrent episodes of fever and myalgia of unknown origin, associated with an important inflammatory syndrome. These episodes resolved partially or completely within less than 1 month without any treatment but recurred 10 times within 3 years. Chest Computed Tomography and 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18FDG PET-CT) demonstrated several active mediastinal lymphadenopathies. TB was the first suspected diagnosis but cultures and polymerase chain reaction (PCR) remained negative on a mediastinal lymph node aspiration. In contrast, the results from two different IGRA performed on blood were highly suggestive of TB disease. Several granulomas, some of them with central non-caseating necrosis, were demonstrated on a pulmonary nodule obtained by thoracoscopic resection, but PCR and culture remained negative for M. tuberculosis. Three years after the initial symptoms, a new PET-CT revealed a retro-clavicular lymphadenopathy in addition to the mediastinal lymphadenopathies, and the M. tuberculosis culture performed on the resected lymphadenopathy was positive. Antibiotic treatment for TB was started and resulted in a clear improvement of the patient’s clinical condition, allowing him to successfully receive a renal graft.ConclusionsIn view of the high frequency of TB in patients undergoing chronic HD and of the limitations of the classical diagnosis procedures, nephrologists have to diagnose TB mostly on clinical suspicion. We demonstrate here that the use of a combined IGRA to two different mycobacterial antigens may significantly raise the index of suspicion and help clinicians to decide starting anti-TB treatment in HD patients.

P1435RELATIONSHIP BETWEEN INTRA-DIALYTIC OXYGEN EXTRACTION RATIO (OER) CHANGE AND IDH

Abstract Background and Aims Intradialytic hypotension (IDH) involves a reduced tolerance to hemodialysis (HD), a poor quality of life and is associated with mortality. Intradialytic monitoring systems (blood pressure, heart rate, volemia) are not able to identify patients at greater risk of IDH. IDH is a hemodynamic phenomenon and attention has recently been given to the evaluation of oxygen saturation to evaluate its role in IDH. Oxygen Extraction Ratio (OER), the ratio between SaO2 and ScvO2, is a parameter used to monitor parenchyma oxygen consumption and stress. Recent evidence showed that HD patients with a greater delta OER (ΔOER) during HD (threshold 40%)had higher mortality risk. OER could be a new monitoring instrument to measure hemodialysis induced sub-clinical parenchyma hypoxia and stress, two elements included in the pathogenesis of IDH. The aim of the study was to evaluate the relationship between OER and IDH incidence. Method Inclusion criteria: age ≥18 years, chronic HD treatment by means of permanent jugular CVC, no evidence of acute underlying illness. We evaluated OER ([(SaO2 − ScvO2)/SaO2] × 100) before HD and at 15’, 30’, 60’ and post HD in three HD sessions (HD OER sessions). For the statistic analysis we considered for each patient the median OER value obtained from the three HD OER sessions. Then we started the follow-up study with a minimum follow-up of three months and end follow-up of two years, to record IDH (defined according to K/DOQI guidelines) for each patient. We divided the population in two groups using as a threshold the median percentage number of IDH in our population and evaluate the differences between the obtained two groups in pre HD OER, Delta OER and intradialytic OER trends. Results During the follow-up period (mean 12 ± 1.2 months), we enrolled 28 patients with permanent jugular CVC: 13 males and 15 females, aged 74±2.6 years, HD vintage 46 ± 6.5 months. The HD OER sessions for each patient were asymptomatic. Pre HD OER was 34 ± 1.4, post HD OER 46 ± 1.8, with a Delta OER of 39 ± 5 %. OER change during HD was evident since after 15 minutes (OER% 15’: 40 ± 1.2 p&amp;lt;.001) and continued to increase progressively (OER% end HD 46 ± 1.8; p&amp;lt;.0001). During the follow up period we monitored 4342 HD sessions of which 186 with IDH, the median incidence of IDH was 3.6% of all HD sessions. We divided patients into two groups based on the median value of IDH incidence: (IDH % ≤ 3.6 and IDH % &amp;gt; 3.6). The two groups were not different for age (76 ± 2.4 vs 73 ± 3.0 years; p &amp;lt;ns), HD vintage (52 ± 8.6 vs 40 ± 4.0 months; p &amp;lt;ns), systolic (125 ± 3.2 vs 129 ± 4.0 mmHg; p &amp;lt;ns) and diastolic blood pressure (67 ± 2.2 vs 70 ± 2.2 mmHg; p &amp;lt;ns) and heart rate (70 ± 2.2 vs. 76 ± 2.3 bpm; p &amp;lt;ns) (Tab. 2). The IDH % &amp;gt;3.6 group had 159 IDH out of a total of 1911 sessions (9%), while IDH % ≤ 3.6 group had 27 IDH out of 2431 sessions (0.9%). Pre HD OER values were not different between the groups while the IDH % &amp;gt;3.6 group had greater delta OER% than the IDH % ≤ 3.6 group (43 ± 4.8 vs. 35 ± 3.0 %; p &amp;lt;.05) (Figure). Evaluating the OER trend during HD session a higher ΔOER% was found at 15 minutes of HD treatment in the IDH % &amp;gt; 3.6 group (ΔOER 20± 3.0 % vs. 8.0 ± 3.0 %; IDH % &amp;gt; 3.6 group vs. IDH % ≤ 3.6 group, p &amp;lt;.05), data confirmed at 30' (24 ± 3.0 % vs. 13 ± 5.0 %; p &amp;lt;.05), and post HD (43 ± 5.0 % vs 35 ± 3.0 %; p &amp;lt;.05), but not at 60 minutes of HD treatment (19 ± 4.0 % vs. 17 ± 4.6 %; p &amp;lt;ns). Conclusion Our data show that intradialytic ΔOER, representative of the extent of tissue hypoxic stress, identifies patients at greater risk of IDH. In particular, a ΔOER of 20% after the first 15 minutes of HD and of 43% at the end of the HD session characterizes the more hemodynamically fragile patients. The measurement of the OER can be a new and easy monitoring instrument to identify the most hemodynamically fragile patients already after the first 15 minutes of HD treatment.

P1566SKELETAL MUSCLE MASS BY COMPUTED TOMOGRAPHY AT THE LEVEL OF THE THIRD LUMBAR VERTEBRA AND MORTALITY IN END-STAGE KIDNEY DISEASE

Abstract Background and Aims Protein-Energy Wasting (PEW) is highly prevalent in patients with end-stage kidney disease on chronic hemodialysis (ESKD-HD). In such clinical setting PEW is associated to poor outcomes. The assessment of nutritional status is essential for the identification of patients at risk for the development of PEW. In the contest of nutritional evaluation, increasing attention is currently paid to the assessment of muscle mass, which represent the major protein asset in the body. Currently available bedside tools used for the assessment of nutritional status are not accurate enough for the assessment o skeletal muscle mass. In this clinical setting, the use of “gold standard” imaging methods (such as CT sca, DEXA or MRI) could allow a more accurate assessment of body composition. The aim of our study was to assess the correlation between skeletal muscle mass on the level of the third lumbar vertebra (L3) assessed by CT scan with mortality in ESKD-HD. Method In a retrospective observational study, 1260 ESKD-HD patients undergoing chronic hemodialysis treatment were identified between 2008 and 2015 in the Dialysis Centers of the National Health Service in the province of Parma. Among these patients, those with at least one available abdomen CT scan after the patient had already been on dialysis for at least 6 months were enrolled. The CT images obtained at the level corresponding to the L3 were analyzed using a dedicated software, in order to extrapolate the data related to the quantity of skeletal muscle tissue. Results We enrolled 183 ESKD-HD patients, aged 68.8 (± 15.1) yrs, 64% (117/183) males, median hemodialysis vintage 43.9 (range 6 – 208) months. The cohort was characterized by a high comorbidity burden, with a median Charlson Comorbidity Index of 9 (range 2-17). Baseline skeletal muscle mass at L3 was 118.5 cm2 (± 30.6). Median follow-up was 65.6 (range 6.6 – 132.5) months. During follow-up, 67% (122/183) of patients died. Patients were divided based on quartiles of muscle mass. Patients in the first quartile had 83% mortality, while mortality of patients in the fourth quartile was 52% (OR = 4.16 95% CI = 1.59 – 10.87; P = 0.003). Kaplan-Meier analysis identified significantly lower survival in patients in the first quartile of muscle mass compared to those in the fourth quartile (P = 0.03 at the Mantel-Cox Log-rank test) (Figure 1). Conclusion Low muscle mass by CT scan appears to be associated with an increased risk of mortality in ESKD on chronic hemodialysis.

P1463EARLY VASCULAR ACCESS CREATION IS NOT ASSOCIATED WITH BETTER OUTCOME IN PATIENTS AFTER CHRONIC DIALYSIS INITIATION

Abstract Background and Aims Although initiation of chronic hemodialysis with central venous catheters are associated with higher mortality compared to that with arteriovenous fistula, the association between the timing of vascular access (VA) creation and outcome after dialysis initiation is not fully investigated. Thus, we conducted single center retrospective cohort study on incident hemodialysis patients to investigate the effect of VA types and timing of VA creation on all-cause and cardiovascular mortality after dialysis initiation. Method A total of 1052 patients with accurate clinical data and outcomes was extracted from 1069 patients who started chronic hemodialysis treatment at Osaka General Medical Center between 2006 and 2015. Clinical status at dialysis initiation, all-cause and cardiovascular mortality were compared by three patient groups categorized by VA types and timing of VA creation: temporary catheter (TC) group, dialysis initiation with TC; early VA (EVA) group, dialysis was initiated more than one month after VA creation; late VA (LVA) group, dialysis was initiated within one month after VA creation. Cox proportional hazards analysis was used to examine predictive factors for outcomes. Results Median age was 70 years and 64% of patients were male. Patient number of each group was 285 (27%), 441 (42%), and 326 (31%) for TC, EVA, and LVA groups, respectively. Although there was no significant difference in eGFR at dialysis initiation among three groups ([median] 5.4 vs. 5.4 vs. 5.4 mL/min/1.73m2, respectively, P=0.881), hemoglobin and albumin were lower in TC group compared to EVA and LVA groups (hemoglobin [median] 8.3 vs. 9.5 vs. 8.9 g/dL, respectively, P&amp;lt;0.001; albumin [median], 3.0 vs. 3.5 vs. 3.2 g/dL, respectively, P&amp;lt;0.001). Kaplan-Meier curves revealed significant difference among three groups for all-cause (P&amp;lt;0.001) and cardiovascular mortality (P&amp;lt;0.001). On multivariate Cox proportional hazards analysis, timing of VA creation was not associated with all-cause and cardiovascular mortality. Although temporary catheter usage at dialysis initiation was significantly associated with all-cause mortality (HR, 1.91; 95%CI, 1.30-2.83; P=0.001), it was not associated with cardiovascular mortality (HR, 1.64; 95%CI, 0.79-3.43; P=0.186). Conclusion Timing of VA creation was not associated with all-cause and cardiovascular mortality, whereas hemodialysis initiation with TC was significantly associated with increased all-cause mortality.

Global Dialysis Perspective: Japan.

Hemodialysis therapy was first performed in Japan at United States military base hospitals during the Korean War (1950–1953) to treat injured American soldiers with crush syndrome transferred from the combat zone. Encouraged by such experiences, several university hospitals started to offer acute hemodialysis treatment in 1955 and chronic hemodialysis treatment in the early 1960s. The health insurance program started to cover chronic hemodialysis treatment in 1967. Initially, the costs were not fully covered by the program: a 30% to even 50% copayment was required for patients who were not beneficiaries of the public insurance plan. In 1972, the national government started a program that also covered copayment on the basis of the Basic Act for Persons with Disabilities as a result of lobbying activities by patient groups and academic societies. Since then, hemodialysis treatment has become almost free of charge, except for high-income patients (up to 20,000 Japanese Yen [JPY] or approximately United States $200 per month). Typically, the total monthly cost for a patient on maintenance dialysis is approximately 320,000 JPY or approximately United States $3000, excluding any additional fees or medications. The cost consists of the medical management fee, including routine laboratory tests (22,500 JPY per month), and technical fees (21,400 JPY × approximately 14/mo). The reimbursement system is updated every 2 years. In April 2006, the costs for erythropoiesis-stimulating agents were bundled with the technical fees of hemodialysis and with anticoagulant and normal saline for rinsing. Roxadustat has recently been approved and bundled. According to the recent annual report of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) (1), a total of 334,505 patients (2640.0 per million people in the general population) are receiving dialysis treatment in Japan as of 2017. In 40,959 incident patients (323 per million people in the general population), the average …

Automedicação em pacientes renais crônicos hemodialíticos

Objective: To analyze self-medication in chronic kidney disease patients on hemodialysis. Methods: A quantitative descriptive cross-sectional study was conducted at a hemodialysis center in Southwestern Bahia in March 2015 using a form to collect sociodemographic, clinical and drug therapy data from 170 patients in March 2015. The sample comprised patients undergoing chronic hemodialysis treatment for over one year aged 18 years or older. Epidata 3.1 was used as a database. Descriptive analysis was performed and binary logistic regression was used to check for associations between self-medication and independent variables using the SPSS software version 21.0. Results: In all, 64.1% (109) of the participants were men and the mean age was 50.5 years (±14.9). 57% (98) of the participants earned less than one minimum wage, 20% (34) had never studied, 48.2% (82) had been on dialysis for one to five years, and 92.9% (158) had no health insurance. We confirmed self-medication of 104 drugs, particularly calcitriol (9.6%) and clonidine (6.7%). Patients with higher levels of education (OR=1.32; 95%CI=1.32-28.72) and those who use leftover drugs at home (OR=22.48; 95%CI=6.53-77.38) were more likely to self-medicate. Conclusion: The rate of self-medication in chronic kidney disease patients is low and it is associated with the use of drugs stored at home and low levels of education.

Association between fatigue, motivational measures (BIS/BAS) and semi-structured psychosocial interview in hemodialytic treatment

BackgroundNowadays there is a growing interest in exploring causes of fatigue symptoms and the possible linked aspects in patients with Chronic Kidney Disease (CKD) receiving hemodialysis (HD) treatment. Inflammatory processes were demonstrated to influence motivational systems functioning in chronic conditions. However, there is a lack of connection between quantitative motivational systems measure and patients self-report motivational and fatigue issue. Thus, the aim of this study was to identify an association between HD patients reward mechanisms, fatigue severity and psychosocial variables emerging from semi-structured interviews.MethodsInterviews were held for a sample of ninety-four patients (54 males, 40 females; Mage = 62.98 ± 17.94; dialytic mean age in months = 76.55 ± 84.89) receiving chronic HD treatment and consequently analyzed by means of quantitative and qualitative analysis. Behavioral motivation systems reflecting inhibition/approach tendency to rewards were measured by Behavioral Inhibition/Activation System (BIS/BAS) scale and the fatigue severity experienced by HD patients was measured with the Fatigue Severity Scale. Scale results were correlated to psychosocial variables and topics derived from the semi-structured interviews.ResultsFindings highlight the presence of two effects: one related to the Behavioral Activation System (BAS) as a protective factor against the HD treatment pervasive consequences; the other one deals with the self-reported levels of fatigue that seemed to significantly interfere with patients’ daily life, as a function of gender.ConclusionsSuch results encourage the use of a mixed method approach to understand the complexity of the subjective experience of patients’ facing chronic disease and treatments.

Hypertension, diabetes, cognitive impairment, renal cancer, polymyalgia rheumatica and chronic hemodialysis treatment: so many diseases or just only one?

Hypertension, diabetes, cognitive impairment, renal cancer, polymyalgia rheumatica and chronic hemodialysis treatment: so many diseases or just only one?

Molecular bases of muscular definition: the role of myostatin and proteinkinase β in progression of protein-energy waste in patients on hemodialysis

Improving the nephrology service and increasing the availability of hemodialysis create the prerequisites for a deeper analysis of the associated complications and associated diseases. One of the main clinical conditions that worsen the patient’s prognosis is protein-energy deficiency (BPH), which is manifested by loss of muscle mass, strength and performance of skeletal muscles, which also leads to a decrease in quality of life, and often to disability and death. The aim : assess of the relationship between myostatin and protein kinase β, as markers of the catabolic cascade, with the manifestations of PEW in hemodialysis patients. Materials and methods : 80 people took part in the study (47 men and 33 women), the median age was 51.7 ± 11.6 years. All patients had CKD 5D stages with chronic hemodialysis treatment for an average duration of 33.5 (0.5; 236) months. All patients were carried out a detailed clinical and anamnestic examination, we estimated the anthropometric measurement, muscular strength were using the hand dynamometry method. The levels of MSTN and AKT were determined in serum by enzyme immunoassay (ELISA Kit, USA). Statistical analysis was carried out using STATISTICA 10.0 (StatSoft Inc., USA) and Microsoft Office Excel 2010 (Microsoft Corp., USA). Results: A dependence of the local increase in skin folds with an increase in the MSTN level, as well as a decrease in the thickness of the subcutaneous fatty tissue with a decrease in AKT (p = 0.03) was detected. We proposed a muscle catabolism index for assessing the degree of muscle degradation. IT had a statistically proven association with degree PEW and clinical manifestations of it. Analysis of the effects of markers of systemic inflammation with MSTN did not give statistically significant results. However, in the subgroup with elevated AKT with the activation of anabolic processes, we observed a decrease in β2-microglobulin and an increase in serum iron (p = 0.04). In the subgroup with a high level of MSTN, higher concentrations of parathyroid hormone (PTH) were determined. We found a direct correlation between the increase in protein kinase β and the annual PTH fluctuation (r = 0.83, p = 0.01). Conclusion . In our study, we were found that in patients with CKD5D receiving therapy with chronic hemodialysis, the activity of myostatin and protein kinase β varies. This leads to an increase in protein degradation over the processes of synthesis, which creates prerequisites for the development of sarcopenia. Taking into account the data obtained, further study of the intermolecular interactions of these markers in the catabolic cascade of muscle proteins is of research interest.

Changes in Body Mass Index and Rates of Death and Transplant in Hemodialysis Patients: A Latent Class Joint Modeling Approach.

The relationship between body mass index (BMI) and patient survival in end-stage kidney disease is not well understood and has been the subject of much debate over recent years. This study used a latent class joint modeling approach to identify latent groups that underpinned associations between patterns of change in BMI during hemodialysis and two competing events: transplant and death without transplant. We included all adult patients who initiated chronic hemodialysis treatment in Australia or New Zealand between 2005 and 2014. There were 16,414 patients included in the analyses; 2,365 (14%) received a transplant, 5,639 (34%) died before transplant, and 8,410 (51%) were administratively censored. Our final model characterized patients based on five broad patterns of weight change (BMI trajectories): "late BMI decline" (about 2 years after commencing hemodialysis); "rapid BMI decline" (immediately after commencing hemodialysis); "stable and normal/overweight BMI"; "stable and morbidly obese BMI"; or "increasing BMI." Mortality rates were highest among classes with declining BMI, and the timing of weight loss coincided with the timing of increases in mortality. Within the two stable BMI classes, death rates were slightly lower among the morbidly obese. The findings from this descriptive analysis suggest a paradoxical association between obesity and better survival. However, they also suggest that the shape of the BMI trajectory is important, with stable BMI trajectories being beneficial. Future research should be aimed at understanding the causes of weight changes during dialysis, to determine whether there could be strategies to improve patient survival.

Case Report:Chronic Myeloid Leukemia Treatment in a Hemodialysis Patient

INTRODUCTIONChronic myeloid leukemia is a rare hematologic malignancy. The incidence and prevalence of the disease vary between countries. However, the treatment success rate is over 90%, and the first choice for treatment is tyrosine kinase inhibitors. The most important factor in the success of treatment is the compliance of the medicine treatment and using effective dosage of the TKI.The incidence of patients with chronic renal disease (CKD) and hemodialysis (HD) treatment is much higher than that of CML. Although there is no data about the incidence of CKD in CML patients.The rate of CKD in CML patients is stated as % 2.6 by Hoffman et al. at a review about EUTOS population based registry of CML.The frequency of hemodialysis patients in CML patients is unknown.There is no data on the use of TKI in CML patients undergoing hemodialysis both drug approval procedure and during the post marketing period. In this case report, we want to share our experience about CML therapy in a patient with hemodialysis treatment who applied to our clinic.This is the fifth patient case report in the literature. CASE REPORTA 53-year-old female patient was referred to our hematology clinic after detection of leukocytosis in a whole blood test. Patient is followed up due to renal atrophy and treated with hemodialysis in our nephrology department.When the hemogram values of the last ten years were examined, it was determined that neutrophilic leukocytosis started on February 2017 and progressed gradually. Following the exclusion of possible causes of leukocytosis during the evaluation, peripheral blood smear test ,bone marrow biopsy and aspiration ,genetic tests was done from bone marrow blood examples.She was diagnosed with chronic phase CML according to the results of genetic tests and bone marrow biopsy pathology evaluation .After diagnosis confirmed, imatinib was began at a dose of 100 mg /day. Third month of treatment,the molecular response evaluation was found to be consistent with the complete molecular response (MR:4.5), and it was seen that this response was also preserved in the 6-month. In the course of this 6-month period, imatinib was first increased to 200 mg / day and then to 300 mg / day without any side effect or response loss. DISCUSSIONIn the literature, the relationship between CML and renal disease has been studied under the headings of tumor lysis syndrome, cancer related membranous glomerulopathy, imatinib after renal transplantation, acute renal damage with imanitinib.Due to the rarity of CML, data on CML therapy in CKD and especially in hemodialysis patients are scarce. A total of 4 cases together with our case were identified in the literature. (3 cases Onaka et al., American Journal of Hematology, 2012 and 1 case Özdemir et al., American Journal of Hematology, 2006).Due to the very rare association, and the complex nature of CKD including altered drug metabolism, accompanying diseases, hemodialysis-specific conditions, treatment decisions are even more difficult to obtain.There is insufficient data on the use of imatinib mesylate in hemodialysis patient.There is no data on the safety and efficacy of imatinib mesylate in hemodialysis patients.The imatinib dose used in reported cases is between 100 mg and 400 mg and is given between 1 and 4 hours after hemodialysis. The response status of the treatment is changing from case to case. For this reason, it is not possible to make a definite recommendation. In our case,we started with 100 mg / day dose, and we gradually increased dose 300 mg/day dose and response is major molecular response.Data from this group of patients during multicentre clinical trials must be shared. DisclosuresNo relevant conflicts of interest to declare.

Alprostadil treatment of critical limb ischemia in hemodialysis patients : Aretrospective single-center analysis.

Peripheral artery disease and critical limb ischemia are common in patients undergoing chronic hemodialysis treatment and are associated with ahigh rate of amputation and mortality. The effect of treatment with prostanoids in this specific group of patients is unknown. Aretrospective single-center analysis of hemodialysis patients with critical limb ischemia was performed who were treated with the prostanoid analogue alprostadil as an infusion during hemodialysis in the period from 2000 to 2013. The primary study outcome was acombined end-point including amputation and death 1year after start of alprostadil. Kaplan-Meier curves were used to describe amputation-free survival and overall survival. Amultivariable adjusted Cox proportional hazards model was calculated for the primary outcome. Atotal of 86patients (60males, 69.7%) were studied. The median alprostadil treatment period was 1.8months. The 1‑year amputation-free survival was 41%. In 36% of patients an amputation was necessary and 35% died. Despite alprostadil treatment, 36% of the study patients additionally underwent an endovascular procedure and 16% had bypass surgery. Men had asignificantly higher amputation rate (45%) than women (15%) (P = 0.009). Male sex and dialysis vintage were significantly associated with an increased risk for primary outcome CONCLUSIONS: Despite treatment with alprostadil the mortality, amputation rate and the need for revascularization procedures in hemodialysis patients with critical limb ischemia remained high. The outcome, however, was comparable with that of other treatment, such as endovascular procedures and bypass surgery. The effect of any current treatment strategy on amputation rate or mortality in that patient group remains uncertain.

Use of Renin-Angiotensin System Blockers Increases Serum Potassium in Anuric Hemodialysis Patients

Background: Angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are increasingly used in uremic patients (pts). However, their effect on serum potassium (sK) concentrations in anuric pts on chronic hemodialysis treatment (HD) is controversial. The aim of the study was to evaluate sK before and after the start of ACEi/ARB therapy. Methods: In the period 1/1/2015 – 31/12/2015, 112 out of 240 prevalent HD pts on thrice weekly HD treatment followed at our institution started the ACEi/ARB therapy. The mean age was 67 ± 14 years, 67/112 were men, dialysis vintage was 6–212 months. In the 3 months before (PRE; N° 36 HD sessions) and after (POST; N° 36 HD sessions) the start of ACEi/ARB therapy, the following variables were evaluated in pre dialysis after the long interdialysis interval: sK (mean of 12 determinations; mmol/L), maximum sK (maximum K value observed during observations; sKmax; mmol/L), serum sodium (sNa; mmol/L), pre dialysis systolic blood pressure (SBP; mm Hg) and diastolic blood pressure (DBP; mm Hg), body weight (BW; Kg), interdialytic weight gain (IWG; Kg), Kt/V, serum bicarbonate concentrations (sBic; mmol/L), protein catabolic rate (PCRn; g/KgBW/day). SBP, DBP, IWG are the mean of the 24 HD sessions. Out of 112 patients, 102 were on antihypertensive therapy. The duration of HD and blood and dialysate flow rates were kept constant. Data are expressed as mean ± SD. Student t test for paired and unpaired data for normally distributed variables, Mann-Whitney test for medians, χ² test for categorical data were employed to compare groups. A significant difference was defined as p < 0.05. Results: sK increased from 5.0 ± 0.4 mmol/L PRE to 5.7 ± 0.5 mmol/L POST (p < 0.0001). sKmax increased from 5.3 ± 0.5 mmol/L PRE to 6.2 ± 0.6 mmol/L POST (p < 0.0001). The percentage of pts with normal sK concentrations decreased from 82% PRE to 29% POST (p < 0.0001). Mild hyperkalemia increased from 18 to 52% (p < 0.001); in 31% of the patients, it was necessary to reduce the K dialysate concentration. None of the patients had severe hyperkalemia PRE, but 19% developed severe hyperkalemia POST (p < 0.0001) necessitating treatment withdrawal. Mean sK in these pts varied from 5.2 ± 0.3 mmol/L PRE to 6.5 ± 0.2 mmol/L at the moment of withdrawal (p < 0.0001) and sKmax from 5.5 ± mmol/L PRE to 6.9 ± 0.3 mmol/L (p< 0.0001). After withdrawal of ACEi/ARB, sK and sKmax concentrations decreased to basal levels within 1 month. There were no significant changes of BW, IWG, SBP, DBP, Na, Hb, Kt/V, sBic, and PCRn in both periods. Conclusions: ACEi/ARB therapy is associated with an increased risk of hyperkalemia in anuric hemodialysis patients. The proportion of patients with normal sK concentrations decreased from 82 to 29% and with mild hyperkalemia increased from 18 to 52%. Severe hyperkalemia necessitating the interruption of ACEi/ARB therapy developed in 19% of patients. This suggests great caution in the widest utilization of this class of drugs in HD patients.

Acute effect of photobiomodulation therapy on handgrip strength of chronic kidney disease patients during hemodialysis

Pre-exercise photobiomodulation therapy (PBMT) reduces fatigue and enhances performance in different populations. However, PBMT benefits have never been tested on chronic kidney disease (CKD) patients, who present muscle weakness, fatigue, and reduced functional performance. The objective of this study was to evaluate the acute effect of three different doses of the PBMT on maximal handgrip strength of CKD patients. Fifteen volunteers (58 ± 8years, 10 male/5 female) under chronic hemodialysis treatment (6 ± 4years) participated in a randomized, crossover, double-blind, placebo-controlled trial. Each patient was assessed at four hemodialysis sessions with 1week interval between evaluations. Placebo or PBMT (cluster probe with five 850nm/200mW laser diodes) were applied at three sites along the flexors of the finger (total doses of 60, 90, or 120J per arm). The maximal handgrip strength was evaluated before and after PBMT/placebo treatment in each session. Repeated measures ANOVA and intraclass correlation coefficients (ICC) confirmed no learning effect on handgrip tests, and high scores for test-retest reliability (ICC scores = 0.89 to 0.95). Significant strength increases occurred after PBMT application with doses of 60J/arm (4.85%, p = 0.005, ES = 0.32) and 90J/arm (4.45%, p = 0.013, ES = 0.25), while no changes were detected with placebo or 120J/arm. In conclusion, in consensus with a recent systematic review, a single bout of the 60J/arm was the best dose/response for increased strength of the small muscles (handgrip strength). In view of the increasing implementation of exercise programs during hemodialysis, the current study opens a new field for PBMT for CKD patients.

Lived experiences of patients on hemodialytic treatment: A discursive perspective on fatigue and motivational issues.

Fatigue is an incapacitating symptom for patients on chronic hemodialysis treatment. This study explored the relationship between hemodialysis patients’ subjective experience and motivation. The investigation of patients’ narratives and fatigue-related factors was performed by holding semi-structured interviews with 31 hemodialysis patients. Fatigue Severity Scale and Behavioral Inhibition/Activation System questionnaire were used to assess fatigue severity and motivational mechanisms. Results showed significant differences in the use of specific topics and words (such as “family,” “to manage,” “dialysis,” “psychological issues”) depending on high, medium, and low Behavioral Inhibition System, Behavioral Activation System, and Fatigue Severity Scale scores, indicating that hemodialysis patients’ narratives contain keywords related to the motivational sphere.

Potentially inappropriate prescribing of drugs in elderly patients on chronic hemodialysis treatment .

The aim of this study was to determine the prevalence of potentially inappropriate drug prescription (PIP) in older patients who were on chronic hemodialysis treatment and to explore the factors that lead to PIP. The study was performed at the Department of Nephrology, Clinical Center Niš, Serbia. It included patients who were 65 years old and older who suffered from the end-stage of kidney failure and were treated by hemodialysis. Univariate and subsequent multivariate logistic regression was used to analyze risk factors for PIP or omission (PPO) according to the STOPP and START criteria. The study included 83 patients. According to the START criteria, PPO was found in 18 (22%) patients, and 32 (39%) patients experienced PIPs according to the STOPP criteria. The following factors were associated with PIP according to the START criteria: a number of comorbidities, reading the patient leaflet, and having the habit of drinking coffee. According to the STOPP criteria, polypharmacy was associated with PIP (OR=1.287, p=0.021): each additional drug increased the risk of potentially inadequate medications (PIM) by 28.7%. Adequate consideration of potential risk factors, as well as the implementation of valid criteria for assessment of PIP, are just some of the measures that would contribute to solving complex therapeutic problems and designing strategies for rational prescribing according to the individual characteristics of patients. .

Comment to: Ranković et al. Potentially inappropriate prescribing of drugs in elderly patients on chronic hemodialysis treatment. Clin Nephrol. 2017. Epub ahead of print.

Comment to: Ranković et al. Potentially inappropriate prescribing of drugs in elderly patients on chronic hemodialysis treatment. Clin Nephrol. 2017. Epub ahead of print.

The Effect of Intradialytic Exercise Training on Cardiac and Arterial Health in Hemodialysis Patients

INTRODUCTION AND AIMS: Patients with kidney failure undergoing chronic hemodialysis (HD) treatment have excessively high rates of cardiovascular (CV) morbidity and mortality. Exercise training as a part of a comprehensive treatment program has been shown to reduce the risk of CV events in patients with established CV disease. However, much less is known about the CV effects of exercise training in HD patients. The aim of this study was to determine the effect of 12 months of intradialytic exercise with concomitant protein supplementation on CV health in HD patients. METHODS: This is a secondary analysis of CV parameters measured from a subset of patients participating in the IHOPE trial (NCT#01234441). This analysis includes data from 98 HD patients (54±12 yrs; 59% male) randomized either to usual care (CON) or intradialytic exercise training + protein supplementation (EX) for 12 months. Patients in the EX group performed supervised moderate intensity exercise (RPE = 12-14) on cycle ergometers for 30-45 minutes with a concomitant oral protein supplement (30g whey) during treatment. Ultrasound exams were performed to measure cardiac systolic function (ejection fraction), diastolic function (early diastolic filling pressure; E, early diastolic tissue velocity; E’) and carotid arterial wall thickness (intima-media thickness, IMT). Outcomes were assessed at baseline, 6, and 12 months. RESULTS: There were no significant changes in any CV parameter between groups at 12-months (Group x Time interaction, p > 0.05 for all measures). However, there was a significant main effect of Time for EE’ in the overall study population, indicating a general worsening of left ventricular filling capacity at 12-months that was larger in CON compared to EX (p< 0.05). There was a similar trend for an increase in carotid IMT at 12-months in CON (p<0.05), that was not evident in EX. CONCLUSION: These data indicates that declines in cardiac diastolic function and increases in carotid IMT that manifest over time in HD patients may be attenuated by intradialytic exercise training. Surprisingly few studies have investigated the effects of exercise on CV structure and function in HD patients, thus, these findings warrant further investigation.

Can hemodialysis change QRS axis in patients without cardiovascular disease?

Due to rapid changes in volume and electrolyte concentration during hemodialysis (HD), some electrocardiographic (ECG) changes or arrhythmias can be seen. The aim of this study was to assess ECG QRS axis changes and other ECG parameters after HD in patients with end-stage renal disease (ESRD). A total of 46 patients (65% male, mean age 52±15 years) with a sinus rhythm and without cardiovascular disease who were undergoing chronic HD treatment were included to the study. Blood samples, 12-lead electrocardiograms, and echocardiograms were recorded immediately before and at the end of an HD session. The QRS axis and other electrocardiographic, echocardiographic, electrolyte parameter, and volume changes were analyzed. The serum urea, creatinine, potassium, and B-type natriuretic peptide concentrations significantly decreased after HD, and the serum calcium levels significantly increased after HD. Body weight significantly decreased after HD. There was no significant difference in the QRS duration, PR interval, P-wave axis, QRS axis, or QT and QTc interval following HD. Based on a comparison of variables according to the any QRS axis change after HD treatment, there was no significant difference in biochemical values, HD time, ultrafiltration volume, left ventricular ejection fraction, or other echocardiographic findings. ESRD and HD are complex and dynamic processes, and the change in the QRS axis is rarely emphasized in these patients. In our study, there was no significant change in the QRS axis with HD in patients without cardiovascular disease.