Consecutive Dialysis Sessions Research Articles

WHITE-COAT AND MASKED HYPERTENSION IN HEMODIALYSIS PATIENTS

Objective: Unlike the general population or patients with earlier stages of chronic kidney disease, there are no clear diagnostic criteria for white-coat and masked hypertension in the hemodialysis population. In the present study, we aimed to estimate the prevalence of these 2 BP phenotypes using routine predialysis BP recordings in combination with 44-hour ambulatory BP monitoring (ABPM). Design and method: In a cohort of 70 hemodialysis patients, hypertension was assessed with 2 methods: (i) the average of routine predialysis BP recordings over 6 consecuitive dialysis sessions; (ii) ABPM over an entire 44-hour interdialytic period (BP measurements at 20-minute intervals; Microlife WatchBP O3 device). The thresholds of 140/90 mmHg and 130/80 mmHg were used to define abnormal predialysis and ambulatory BP, respectively. Results: Study participants (45 males and 25 females) had a mean age of 65.3±13.3 years and a median dialysis vintage of 15 months. The prevalence of hypertension was 88.6% by predialysis BP recordings and 90% by ABPM. In all, 61 patients were being treated with an average of 1.5±0.6 antihypertensive medications daily. In all, 51.4% of patients had either normotension or adequately controlled hypertension confirmed by the 2 different BP monitoring techniques, whereas 18.6% of patients had uncontrolled hypertension confirmed by both techniques. The prevalence of white-coat hypertension was 24.3% and the prevalence of masked hypertension was 5.7%. A 2-week averaged routine predialysis BP at the threshold of 140/90 mmHg provided 77.8% sensitivity and 30.8% specificity for the diagnosis of an average 44-hour ambulatory BPequal or higher than 130/80 mmHg. The agreement between these 2 techniques for the identification of patients with adequately controlled hypertension was poor (k-statistic: 0.378, P<0.001). Conclusions: This study shows that in approximately 30% of hemodialysis patients, there is lack of concordance between routine predialysis BP recordings and ABPM for the determination of BP control status. Routine predialysis BP recordings, even when averaged over 6 consecutive dialysis sessions, are inaccurate estimates of the actual BP load, as assessed by ABPM.

Remote Surveillance Technology of Dialysis Arteriovenous Access: Retrospective Evaluation in a UK Renal Centre

Background: Early identification of dysfunctional arteriovenous haemodialysis (HD) vascular access (VA) is important for timely referral and intervention. Method: We retrospectively calculated VA risk score using Vasc-Alert surveillance software technology from HD treatment sessions in 2 satellite HD units over 18 months. We included in the analysis HD patients dialysing with arteriovenous fistula or graft (AVF/G) with available Vasc-Alert data for≥ 2 months. For group one (eventful) that included patients who developed vascular access thrombosis or stenosis over the study period, we collected Vasc-Alert risk score 2 months prior to the event and, for group two (uneventful), over 5 consecutive months. Vasc-Alert technology utilises routinely collected data during HD to calculate VA risk score and triggers an alert if the score is ≥7 in 3 consecutive dialysis sessions. Patients with >2 alerts (vascular access score ≥7) per month were considered to have positive alerts. Results: From 140 HD patients, 81 patients dialysed via AVF/G. 77/81 had available Vasc-Alert data and were included in the final analysis. Out of 17 eventful patients, 11 (64.7%) had positive alerts 2 months prior to the vascular event. Out of the 60 patients without vascular events, 20 patients (33.3%) had positive alert. Vasc-Alert’s sensitivity and specificity for vascular events were 64.7% and 66.6%, respectively. Within the 6 patients with thrombosed access, 2 patients (33.3%) detected by Vasc-Alert were not detected with clinical monitoring. Conclusion: Vascular access risk score can be a useful non-invasive vascular access surveillance method to assist clinical decision making.

Abstract 25 — Remitting Seronegative Symmetric Synovitis with Pitting Edema (RS3PE) in Dialysis Patient

Background Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome is characterized by acute symmetrical synovitis, and pitting edema involving, the dorsal part of hands and feet. It affects more men aged more than 50 years. The inflammatory markers are usually elevated, with negative rheumatoid factor. The underlying etiology is not clear but has been associated with drugs exposure, infections, malignancy in 30% of cases, and coexist with other autoimmune diseases. The clinical course is benign with significant improvement to low-dose prednisolone therapy for 2 to 3 months. It has been rarely reported in dialysis patients. Methods and case description A 54 years old male, known to have long standing uncontrolled diabetes mellitus, hypertension, chronic kidney disease and diabetic retinopathy. Recently, he was treated for left foot cellulitis and advanced renal failure (813 micromol/L) initiated on hemodialysis. He presented one week later with progressive painful bilateral upper limb and lower limb pitting edema, with limited range of movement in hands and reduce urine output. He was resumed on hemodialysis for management of volume overload. Despite removal of almost 12 liters of fluids during consecutive dialysis sessions and improvement of lower limb edema, his bilateral hand edema was persistence with pain and limited movement. Further investigations were done to evaluate for rheumatological condition. Results Hand X ray was normal and ultrasound of the hand revealed features of synovitis, diffuse subcutaneous oedema and possible cellulitis. He was started on IV antibiotics without major improvement and blood culture was negative. CT chest showed left pleural effusion. The ESR was elevated 120, while serology for HBV. HCV, HIV, and parvovirus were negative. In addition, the autoimmune workup were negative (CCP, RF, ANA, ANCA, C3, C4, ACEI). He was diagnosed with remitting seronegative symmetric synovitis with pitting edema (RS3PE). He was treated with IV hydrocortisone once 100 mg, followed by oral prednisolone 10 mg for 5 days with dramatic improvement in bilateral hand edema and movement. He had hyperglycemia steroid related managed with adjustment of insulin therapy. At follow up in 1 week, patient regain full function of both hands, and he was on regular hemodialysis trice per week. Conclusion RS3PE is rare in hemodialysis patients, with favorable response to steroid therapy. We used shorter duration of 5 days steroid therapy with complete recovery and no recurrence at 1 year follow up. Screening for underlying autoimmune, infection or malignancy in RS3PE is essential.

#6576 SERUM INTERLEUKIN-6 LEVELS AS A PREDICTOR OF ALL-CAUSE MORTALITY IN MAINTENANCE HEMODIALYSIS PATIENTS WITH COVID-19-OMICRON INFECTION: AN OBSERVATIONAL STUDY

Abstract Background and Aims Interleukin-6 (IL-6) is a key mediators of inflammation and has been linked to the severity and mortality of COVID-19-Omicron in the general population. With higher mortality rates observed in maintenance hemodialysis (MHD) patients infected with COVID-19-Omicron, the study aimed to examine the correlation between IL-6 levels and mortality in this patient population and to indentify the optimal IL-6 level for predicting the risk of death. Method The retrospective observational study was conducted in MHD patients diagnosed with COVID-19-Omicron infection between December 01, 2022 and January 31, 2023 at the Third Affiliated Hospital of Southern Medical University during the first wave of infection in COVID-19-Omicron outbreak in China. Clinical and biochemical data were collected during the infection, IL-6 levels of the patients were measured before consecutive dialysis sessions by a commercial kit. The Cox model was used to investigate the risk factors of mortality, meanwhile, ROC curve to determine the cut off value of IL-6 levels on mortality. Results A total of 162 MHD patients infected with COVID-19-Omicron were included in this study. During a median follow-up period of 40 days, 10 (6.2%) deaths occurred due to COVID-19 infection. IL-6 levels were significantly higher in patients who died. Univariate Cox regression analyses showed that the risk factors associated with death included IL-6 levels (HR: 1.009; p<0.001), C-reactive protein (HR: 1.01; p = 0.016), serum potassium (HR: 2.258; p = 0.015, procalcitonin(PCT) (HR: 1.01; p = 0.048), and the Charlson comornidity index(CCI)(HR: 1.34; p = 0.002). However, in multivariate analysis, only IL-6 levels was independently associated with all-cause mortality(HR: 1.01; p = 0.001).The ROC curve and Kaplan-Meier survival analysis revealed a significantly worse survival risk among MHD patients with higher serum IL-6 levels (≥104.87 pg/mL) (sensitivity:100%; specificity:78.2%; AUC: 0.92; p = 0.001). Conclusion Serum IL-6 levels greater than 104.87 pg/mL were associated with an increased risk of all-cause mortality in MHD patients infected with COVID-19-Omicron. Hemoperfusion or hemofiltration to remove IL-6 may provide appropriate treatment options for hemodialysis patients with COVID-19-Omicron.

Differences in bioimpedance-derived fluid status between two versions of the Body Composition Monitor

ObjectivesThe Body Composition Monitor (BCM) (Fresenius Medical Care) measures body impedances in alternating currents to subsequently calculate fat and lean tissue mass, fluid compartments, and overhydration (OH). The aim of this study was to investigate differences between two versions of the BCM (an older version, 3.2.5, and a newer version, 3.3.3). MethodsBetween September 2021 and December 2021, 28 hemodialysis patients were included to undergo BCM measurements before each of 14 consecutive dialysis sessions with versions 3.2.5 and 3.3.3 devices. Measurements were performed according to instructions provided by the manufacturer. Differences between BCM devices were tested for statistical significance using paired Wilcoxon tests, neglecting clustering. ResultsA total of 288 measurement pairs of 27 patients were left after exclusion of 43 flawed data points. The mean difference in OH between both BCM devices was 0.548 L (higher for version 3.2.5). Analysis of impedance data revealed differences in the high-frequency spectrum, quantifiable by the intracellular resistance, Ri (median Ri version 3.2.5 = 1750.3 Ω; Ri version 3.3.3 = 1612.45 Ω; P < 0.001), and the time delay, Td (median Td version 3.2.5 = 1.85 ns; Td version 3.3.3 = 8.88 nanoseconds; P < 0.001). ConclusionsThis study finds that results between the two versions of the BCM differed in a clinically meaningful fashion and that the newer version 3.3.3 device had a bias toward less OH. Circulating BCM devices should be checked for versions and only devices of the same version should be used for each patient to ensure better within-patient consistency.

Fluctuations in Interleukin-6 Levels during Hemodialysis Sessions with Medium Cutoff Membranes: An Analysis on COVID-19 Case Series

Introduction: Interleukin-6 (IL-6) is one of the most important mediators of inflammation. It is also the culprit for a severe disease course in COVID-19. While COVID-19 has higher mortality in hemodialysis (HD) patients, medium cutoff (MCO) membranes were previously suggested as promising tools for better patient outcomes by purging inflammatory mediators. The aim of this study was to analyze changes in IL-6 levels of HD patients who were dialyzed via MCO membranes during their COVID-19 treatments. Methods: This is an observational study on a group of HD patients who were admitted with COVID-19 diagnosis in a university hospital and intermittently dialyzed using MCO membranes during their hospital stay. IL-6 levels of the patients were measured before and after consecutive dialysis sessions by a commercial kit. Measurements were interpreted together with the clinical data. Results: Nine patients with a total of 54 measurements were evaluated. IL-6 levels were significantly higher in patients who died (median and interquartile ranges [IQRs] of IL-6 levels for patients who died and survived were 112.0 pg/mL [48.3–399.4] and 5.3 pg/mL [2.2–27.4], respectively; p < 0.001). In the comparison of changes in IL-6 levels with dialysis sessions, patients who survived had lower post-dialysis levels (median: 4.5 pg/mL; IQR: 2.2–7.6). However, IL-6 levels had a tendency to increase with dialysis sessions in patients who could not survive COVID-19 (median: 237.0 pg/mL; IQR: 53.8–418.2). Conclusion: This study describes over time variations in IL-6 levels of COVID-19 patients undergoing HD with MCO membranes. The trend for the changes of IL-6 levels during dialysis sessions was not uniform for all patients. Surviving patients had decreasing levels of IL-6 with consecutive dialysis sessions, while nonsurvivors had an increasing trend.

Comparison of the injection of low-molecular weight heparin in the arterial vs. venous blood line for preventing extracorporeal circuit clotting during hemodialysis.

Low-molecular weight heparins (LMWH) are widely used for preventing clotting during hemodialysis (HD). Although injection in the venous blood line is recommended to avoid initial loss of LMWH through the dialyzer, LMWH is still frequently administered in the arterial blood line at the start of dialysis. This study aimed to compare the safety and efficacy of the same enoxaparin dose administered through the venous blood line or arterial blood line. We also evaluated antifactor Xa (aXa) activity according to the injection route and dialysis modalities: high-flux (HF) HD, medium cut-off (MCO) HD, and online hemodiafiltration (OL-HDF). Forty-three patients were studied over 18 consecutive dialysis sessions using a fixed enoxaparin dose (20 or 40 mg), first administered through the arterial blood line bolus and then through the venous blood line for another 18 sessions. Compared to arterial blood line administration, venous blood line bolus resulted in a significant increase in median post-dialysis aXa activity: 0.16 (0.1-0.6) IU/ml versus 0.31 (0.1-1.3) IU/ml, respectively, p=0.006. After arterial blood line bolus of 40 mg enoxaparin, median post-dialysis aXa activity was significantly lower with OL-HDF compared to HF-HD: 0.14 (0.1-0.35) versus 0.32 (0.15-0.49), p=0.02. A trend for lower clotting within lines and bubble trap using venous blood line bolus was observed. In conclusion, venous blood line enoxaparin injection is safe in OL-HDF patients. However, in HF-HD and MCO-HD, venous blood line injection of 40 mg enoxaparin may increase overdosing risk. Thus, aXa activity should be monitored in HF-HD and MCO-HD patients at risk of bleeding and/or on vitamin K antagonists and careful surveillance is required when administering a 40 mg enoxaparin dose through the venous blood line route.

Comparison of the injection of low molecular weight heparin in arterial or venous bloodline for preventing extracorporeal circuit clotting during hemodialysis

Low molecular weight heparins (LMWH) are widely used for preventing clotting during hemodialysis (HD). Although injection in venous bloodline (VBL) is recommended to avoid initial loss of LMWH through the dialyzer, LMWH is still frequently administered in the arterial blood line (ABL) at the start of dialysis. The aim of this study was to compare the efficacy and safety of same enoxaparin dose administered through VBL or ABL. We also evaluated antifactor Xa (aXa) activity according to the injection route and dialysis modalities: high-flux (HF) HD, medium cut-off (MCO) HD and on-line hemodiafiltration (OL-HDF). This open, single-center prospective study was conducted at the Poitiers university Hospital HD unit. Forty-three patients were studied over 18 consecutive dialysis sessions using a fixed enoxaparin dose (20 or 40 mg) first administered through ABL bolus and then through VBL for another 18 sessions. Compared to ABL, VBL bolus resulted in significant increase in median post-dialysis aXa activity: 0.16 (0.1–0.6) IU/mL vs. 0.31 (0.1–1.3) IU/mL, respectively, P = 0.006. After ABL bolus of enoxaparin 40 mg, median post-dialysis aXa activity was significantly lower with OL-HDF compared to HF-HD: 0.14 (0.1–0.35) vs. 0.32 (0.15–0.49), P = 0.02. A trend for lower clotting within lines and bubble trap using VBL bolus was observed. In conclusion, VBL enoxaparin injection is safe in OL-HDF patients. However, in HF-HD and MCO-HD, VBL injection of enoxaparin 40 mg may increase overdosing risk. Thus, aXa activity should be monitored in HF-HD and MCO-HD patients at risk of bleeding and/or on vitamin K antagonists, and careful surveillance is required when administering enoxaparin dose 40 mg through the VBL route.

Efficacy and Safety of Plastic Cannulae Compared with Metal Needles in the Initial Use of an Arteriovenous Fistulae in Incident Hemodialysis Patients: A Randomized Controlled Study

Introduction: Successful cannulation of an arteriovenous fistula (AVF) is important in patients starting hemodialysis (HD). Metal needles have been used for decades, but the usefulness of plastic cannulae has recently been demonstrated as a new technique. Methods: This was a prospective, randomized, open-label study of incident HD patients. Eligible patients were randomized into 2 groups in a 1:1 ratio (n = 45/group). Maturation of the AVF was confirmed using Doppler ultrasound prior to first needling, and 2 well-trained nurses implemented the AVF cannulation. The primary endpoint was the initial cannulation failure rate, defined as the failure of successful completion of 3 consecutive dialysis sessions. The secondary endpoints were time for hemostasis at the end of HD, degree of patients’ pain, degree of cannulation difficulty felt by the nursing staffs, and achieving optimal HD adequacy. Results: The mean elapsed time from AVF creation to the first cannulation was 48.1 ± 16.7 days. A total of 17 cases of cannulation failure occurred, and the failure risk tended to be higher in the metal needle group than the plastic cannula group (hazard ratio 2.6, 95% confidence interval 0.95–7.41) after adjusting for age, gender, comorbidities, and AVF location. The overall incidence of vessel injury was higher and time for hemostasis was significantly longer in the metal group than the plastic group. The use of plastic cannula was associated with a better HD adequacy compared to a metal needle. However, the patients’ pain score (p = 0.004) and nursing staff’s cannulation difficulty score (p = 0.084) were higher in the plastic group, emphasizing the great importance of practice using plastic cannulae. Conclusion: The vascular outcomes of plastic cannulae were much favorable compared to metal needles in incident HD patients. The use of plastic cannulae could be a new and innovative way to improve the quality of dialysis.

A study of Factors Affecting Dialysis Recovery Time in Haemodialysis Patients in India.

Background:Patients on maintenance haemodialysis (MHD) often complain of fatigue and tiredness following haemodialysis sessions leading to poor compliance with the dialysis schedule. There is limited Indian data on dialysis recovery time (DRT). The present study was designed to assess the factors affecting DRT in our haemodialysis population.Methods:We recorded self-reported patient recovery times of 120 patients who satisfied the inclusion criteria, over three consecutive dialysis sessions by asking the question, 'How long does it take to recover from a dialysis session'? Data recorded included patient factors like age, sex, co-morbidities, Charlson comorbidity index score (CCI), dialysis vintage, duration of kidney disease, interdialytic weight gain (IDWG), treatment factors like ultrafiltration rate (UFR), SpKt/V, blood pump speed, dialysate sodium, session length, pre and post HD blood pressure and laboratory parameters. Health-related quality of life (HRQoL) was assessed with the KDQOL-SF v. 1.3 questionnaire. Results from the SF-36 score were summarised into the physical composite score (PCS), mental composite score (MCS) and kidney disease composite score (KDCS).Results:The mean age of the study population was 50.6 ± 12.6 years. Among the 120 patients, 77 (64.2%) were males. Thirty-nine patients (32.5%) were diabetic and 95 (79.1%) patients were hypertensive. The mean dialysis vintage of the study population was 26.1 ± 18.6 months, 41 (34.2%) patients reported DRT <2 h; 48 (40%) reported DRT between 2–6 h and 31 (25.8%) reported DRT >6 h. On multivariate regression analysis, higher IDWG, CCI score and UFR were associated with prolonged DRT. Reported DRT also inversely correlated with PCS (r = - 0.66), MCS (r = - 0.65) and KDCS (r = - 0.59) scores which was statistically significant.Conclusion:The present study showed that higher CCI scores, IDWG and UFR were associated with prolonged DRT in Indian haemodialysis patients and patients with longer recovery time had poor HRQoL. Interventions to reduce DRT need to be assessed in further trials in Indian MHD patients.

Paradoxical Association Between Intradialytic Blood Pressure Change and Long-Term Mortality with Different Levels of Interdialytic Weight Gain.

BackgroundA greater interdialytic weight gain (IDWG) implies a greater ultrafiltration rate, which might lead to hemodynamic instability and intradialytic blood pressure (BP) change in hemodialysis patients. However, current studies have not explicated the impact of IDWG on the association between intradialytic BP changes and prognosis, especially in patients without cardiac dysfunction and diabetes. In this study, we aimed to explore the relationship between absolute intradialytic BP changes and mortality with different IDWG levels.MethodsA total of 204 hemodialysis patients (without cardiac dysfunction and diabetes) were included in this prospective observation study, with a mean follow-up of 55.32±20.99 months. Initially, we collected IDWG, IDWG% (percentages according to dry weight), and pre-/post-BPs of 36 consecutive dialysis sessions during three months enrollment. And the average value of them was defined as baseline value. Patients were divided into 3 cohorts according to IDWG% tertiles (<3.3%, 3.3%–4.6%, ≥4.6%). Comparisons between different tertiles were analyzed.ResultsCompared to the low IDWG% group (tertile 1, T1), patients of high IDWG% group (tertile 3, T3) were younger, had higher ultrafiltration rate, less residual kidney function, lower BMI and dry weight, longer dialysis vintage and higher N terminal pro B type natriuretic peptide levels (P<0.05). Correlations were found between IDWG% and intradialytic BP changes. Kaplan–Meier analysis and multivariate Cox regression model adjusted for demographic data, dialysis information and predialysis BPs indicated that greater absolute intradialytic BP changes were associated with worse prognosis in T1 group (P<0.05). While in T3 group, less absolute intradialytic BP changes were associated with higher mortality (P<0.05).ConclusionThere is a paradoxical association between absolute intradialytic BP changes and long-term mortality with different IDWG levels. Both BP stability and volume balance are crucial to patients’ prognosis.

P1247INTERDIALYTIC WEIGHT GAIN IN HEMODIALYSIS: EPIDEMIOLOGY AND OUTCOMES

Abstract Background and Aims Interdialytic weight gain (IDWG) has been linked to various complications in hemodialysis (HD) patients, especially cardiovascular (CV) complications. We aimed to evaluate the effect of IDWG in HD patients on the rate of hospital admissions over a 12-month period, and the impact of high IDWG on the frequency of IDH. Method The study included 120 patients; who had been receiving HD for at least 3 months. The presence of various comorbidities has been recorded including. Laboratory data included; serum creatinine, serum albumin, and hemoglobin level. The estimated IDWG was calculated based on the average between pre- and post- dialysis weights that were recorded on 3 consecutive dialysis sessions. Results Among those who had IDWG ≥ 4%, 81% of these patients had at least one hospital admission due to volume overload or the need for extra HD session(s). On the other hand, only 19% of those having IDWG &amp;lt; 4% had been admitted or got extra HD sessions (p&amp;lt;0.001). Of those who were admitted (over 12 months) due to volume overload; 74.1 % had IDWG ≥ 4%, while 25.9% had IDWG &amp;lt; 4% (p&amp;lt; 0.001). Regarding IDH, 87% of patients having IDWG ≥ 4% had at least one episode of IDH/week. On the other hand, only 22.5% of those with IDWG &amp;lt; 4% had one episode of IDH/week (p&amp;lt;0.001). When analyzing those who had at least one IDH episode/week; 72.9% of them had IDWG ≥ 4%, while only 27.1% had IDWG &amp;lt; 4% (p&amp;lt;0.001). Conclusion In HD patients, the frequency of hospital admission due to volume overload and the need for extra HD sessions is strongly related to the amount of IDWG (&amp;gt; 4% in our patients), the same stands for the frequency of IDH. Thus, a control of IDWG in HD patient is of great importance, keeping in mind the importance the nutrition status of HD patients that may also impact IDWG.

P1249SEVERE HEMODYNAMIC INSTABILITY DURING DIALYSIS - DRY, STUNNED OR ALLERGIC? STATE OF THE ART ECHOCARDIOGRAPHY COMBINED WITH SIMULTANEOUS LUNG ULTRASOUND

Abstract Background and Aims Intradialytic hypotension is a fairly common and serious adverse phenomenon. Associated comorbidities include e.g. heart failure, hypovolemia, allergic reactions with the dialysis apparatus and electrolyte disturbancies. Excessive ultrafiltration may explain later onset hypotension, but early-onset hemodynamic collapse remains poorly understood. Preventive interventions may include incremental dialysis, increasing dry weight, increasing dialysis time and changing dialysis membranes/apparatus. This study combines Echocardiography (Echo) and Lung Ultrasound (LUS) for hemodynamic phenotyping of patients with severe, early onset intra-dialytic hypotension. The aim is to figure out possible preventive strategies depending on underlying abnormalities. Method We enrolled dialysis patients with a symptomatic decrease in systolic arterial pressure &amp;lt; 90 mmHg requiring norepinephrine during the first 60 minutes of at least two consecutive dialysis sessions in our dialysis department. Echo + LUS was done simultaneously to everyone at baseline, i.e. BEFORE dialysis begun, and later at onset of a hypotension episode during dialysis. Patients with active bleeding or any other obvious temporary etiology for hypotension were excluded. Echo concentrated especially on volemic state and filling pressures, while LUS evaluated the lungs and pleurae for signs of pulmonary congestion. Cardiac structure and function (e.g. valves, ejection fraction) was also evaluated. Results Between 1.10.2019 - 31.12.2019 10 patients were enrolled. All patients eventually required norepinephrine despite fluid challenge. No patients had signs or symptoms of an allergic reaction, such as urticaria or stridor/obstructive respiration, nor significant electrolyte disturbancies. 5/10 patients had severe systolic cardiac dysfunction at baseline (LVEF &amp;lt; 30 %) and these 5 patients also simultaneously showed signs of congestion and fluid overload on ultrasound. On the contrary, the other 5/10 patients without severe cardiac failure all had low left-sided filling pressures and a collapsed inferior vena cava on Echo ALREADY at baseline, i.e. before initiation of dialysis. All of these hypovolemic patients had an excellent residual diuresis (&amp;gt; 1500ml/d). All 10 patients in this study showed a significant drop in body volume measurement (BVM) -curves and left-sided filling pressures on Echo prior to onset of hypotension. Of the 5 patients with severe cardiac dysfunction, 2/5 were transmitted into palliative care without dialysis, while 3/5 could be managed without future norepinephrine by longer, more frequent dialysis sessions using more convective and less diffusive dialysis. Of the latter 5 “dry” patients without severe cardiac dysfunction, 3/5 had no more hypotensive episodes after increasing dry weight and using incremental dialysis programs, and the remaining 2 dry patients could be completely switched off dialysis due to vivid residual function. 3/5 of the “dry patients” had a baseline pulse pressure &amp;gt; 120 mmHg and 3 had coronary artery disease, both possibly predisposing to diastolic under-filling. No patients in this study presented with significant myocardial stunning, defined as a &amp;gt; 10 % decrease in LVEF compared to baseline. Conclusion Severe, intra-dialytic hypotension requiring vasopressors may be prevented by individual tailoring of dialysis prescription. Ultrasound may help phenotyping patients requiring different dialysis strategies, including stopping dialysis entirely. Stunning and allergic reactions seemed rare. At baseline, patients seemed to be mainly 1) either over-dialyzed (hypovolemic or hypo-osmotic) or 2) having significant cardiac disease, naturally requiring quite opposite preventive strategies. A decrease in left ventricular preload furthermore occurred in all patients at onset of hypotension, suggesting crossover of a patient-specific preload threshold.

Agreement Between Two Nutritional Assessment Scores as Markers of Malnutrition in Patients with End-stage Renal Disease.

BackgroundMalnutrition is directly related to morbidity and mortality in end-stage renal disease. This should be picked up using simple techniques.MethodsAdult patients on maintenance haemodialysis were included using a consecutive sampling technique. Compliance was assessed from attendance register (minimum 75% attendance for good compliance). Hypoalbuminemia signified malnutrition. Blood samples for measurement of haemoglobin, serum albumin, calcium and phosphate levels were drawn from the dialyser tubing at the start of the first of the two haemodialysis sessions for each patient. Height and weight were recorded at the end of the first haemodialysis session for each patient. Mini Nutritional Assessment Questionnaire and Council on Nutrition Appetite Questionnaire were administered in direct face-to-face interviews during two consecutive dialysis sessions.ResultsThere were 116 patients aged 53.46± 14.39 years. Majority were males (83.6%) and on twice a week haemodialysis (69.0%). Malnutrition was present in 30 (25.9%) patients. Serum albumin had a significant relationship with both haemoglobin (R = 0.399; p < 0.001) and serum phosphate levels (R = 0.253; p = 0.006) but not body mass index (R = 0.028; p = 0.769). Mean Mini Nutritional Assessment and Council on Nutrition Appetite scores were 19.45± 5.10 and 26.76± 6.28, respectively. Based on Mini Nutritional Assessment scores, 31 (26.7%) patients were malnourished, 59 (50.9%) were at risk of malnutrition, and 26 (22.4%) had normal nutritional status. Council on Nutrition Appetite scores were low in 65 (56.0%) patients, indicating risk of weight loss in next six months. Serum albumin had significant correlation with Mini Nutritional Assessment scores (R = 0.381; p < 0.001) and Council on Nutrition Appetite scores (R = 0.290; p = 0.002). Slopes of linear regression for Mini Nutritional Assessment and Council on Nutrition Appetite scores were not statistically different (p = 0.202).ConclusionsMini Nutritional Assessment and Council on Nutrition Appetite scores had a similar correlation with serum albumin levels. Either of the two could be used for evaluation of malnutrition in end-stage renal disease.

SAT-240 INTER-DIALYTIC WEIGHT GAIN IN HEMODIALYSIS PATIENTS - EPIDEMIOLOGY AND EVALUATION OF THE CLINICAL OUTCOMES

Inter-dialytic weight gain (IDWG) has been linked to various complications in hemodialysis (HD) patients, especially cardiovascular (CV) complications. High ultrafiltration (UF) rate in relation to dialysis time has also a similar impact in various studies. Furthermore, high IDWG has been associated with all cause and CV mortality. The IDWG is also influenced by the nutritional status of HD patients. We investigated the trends of IDWG in patients on regular HD aiming to examine: (1) trends of IDWG among patients in relation to different variables and comorbidities e.g. age, hypertension, diabetes, CV disease...etc.; (2) associations of high IDWG with frequency of hospitalization due to systemic volume overload and the need for extra dialysis sessions, and (3) the impact of high IDWG on the frequency of intra-dialytic hypotension (IDH). One hundred and twenty maintenance HD patients were enrolled in this study. All patients had been receiving HD for at least 3 months, on a 4 hour, thrice weekly basis. The data collected included; age, gender, duration on HD (in months), pre- and post-HD body weights (on 3 successive sessions), pre- and post-HD blood pressure (BP) measurements (on 3 successive sessions), the type of vascular access and the average blood flow rate, dialysis efficiency (based on average Kt/V), and the presence or absence of residual kidney function. The presence of various comorbidities has been recorded including; diabetes, hypertension, coronary artery and peripheral vascular diseases, heart failure, cerebrovascular disease, and other disorders. The estimated IDWG was calculated based on the average between pre- and post- dialysis weights that were recorded on 3 consecutive dialysis sessions. The estimated IDWG was expressed in kilograms and as a percentage of the patients’ dry weight. We considered an estimated average IDWG of 4% as a cutoff value between low and high IDWG. We defined IDH as the drop of systolic blood pressure of 20 mmHg or more during HD compared to the pre-dialysis blood pressure and/or a systolic blood pressure that is less than 90 mmHg. We have recorded that 50.0% of those younger than 55 years had IDWG ≥ 4%. On the other hand, only 31.7% of those aged 55 years or more had IDWG ≥ 4% (p=0.041). There was no significant gender difference regarding IDWG. Among those who had IDWG ≥ 4%, 81% of these patients had at least one hospital admission due to volume overload or the need for extra HD session(s). On the other hand, only 19% of those having IDWG < 4% had been admitted or got extra HD sessions (p<0.001). Of those who were admitted (over 12 months) due to volume overload; 74.1 % had IDWG ≥ 4%, while 25.9% had IDWG < 4% (p< 0.001). Regarding IDH, 87% of patients having IDWG ≥ 4% had at least one episode of IDH/week. On the other hand, only 22.5% of those with IDWG < 4% had one episode of IDH/week (p<0.001). When analyzing those who had at least one IDH episode/week; 72.9% of them had IDWG ≥ 4%, while only 27.1% had IDWG < 4% (p<0.001).View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) In HD patients, the frequency of hospital admission due to volume overload and the need for extra HD sessions is strongly related to the amount of IDWG (> 4% in our patients). The same stands for the frequency of IDH. Thus a control of IDWG in HD patient is of great importance, keeping in mind the importance the nutritional status of HD patients that may also impact IDWG.

Diameter Criteria Have Limited Value for Prediction of Functional Dialysis Use of Arteriovenous Fistulas

To determine the value of diameter measurements for prediction of functional dialysis use (FDU) of arteriovenous fistulas (AVF). Review of access operations and dialysis databases from January 1, 2007 to August 1, 2015. Follow up until July 1, 2016. FDU defined as six consecutive dialysis sessions with two needles on the AVF. Artery and vein diameters measured by portable ultrasound in access clinic. Contribution of diameter to predict FDU assessed with logistic regression. Diagnostic accuracy assessed by sensitivity, specificity, positive and negative predictive values (PPV and NPV). 803 AVF operations were analysed: 507 (63%) radiocephalic fistulas (RCAVF), 237 (30%) brachiocephalic fistulas (BCAVF), and 59 (7%) brachiobasilic fistulas (BBAVF). Women had lower FDU in RCAVF (0.65, 95% CI 0.58–0.72 vs 0.86, 95% CI 0.81–0.89; p < .0001), but not in BCAVF (0.83, 95% CI 0.75–0.89 vs 0.81, 95% CI 0.73–0.88; p = .75). Female gender was an independent negative predictor of FDU in RCAVF (OR 0.31; 95% CI 0.20–0.49). Vascular kidney disease was an independent negative predictor for FDU in RCAVF (OR 0.33; 95% CI 0.17–0.64) and BCAVF (OR 0.22; 95% CI 0.09–0.57) in multivariable analysis. Artery and vein diameter did not improve the model for RCAVF. Vein diameter as categorical variable improved the model for BCAVF. Diameter cut off of radial artery ≥ 2 mm has 96% sensitivity, 86% PPV, 9% specificity, and 29% NPV in men. Radial artery diameter ≥2 mm had 96% sensitivity, 67% PPV but 13% specificity and 62% NPV in women. Diameter is a poor predictor of FDU of AVF. Arterial diameter measurements add no diagnostic value for BCAVF. Poor specificity suggests a diameter under 2 mm at the wrist should not preclude AVF formation. Vascular kidney disease is an independent negative predictor for FDU in all AVF.

Diameter Criteria Have Limited Value for Prediction of Functional Dialysis Use of Arteriovenous Fistulas

To determine the value of diameter measurements for prediction of functional dialysis use (FDU) of arteriovenous fistulas (AVF). Review of access operations and dialysis databases from January 1, 2007 to August 1, 2015. Follow up until July 1, 2016. FDU defined as six consecutive dialysis sessions with two needles on the AVF. Artery and vein diameters measured by portable ultrasound in access clinic. Contribution of diameter to predict FDU assessed with logistic regression. Diagnostic accuracy assessed by sensitivity, specificity, positive and negative predictive values (PPV and NPV). 803 AVF operations were analysed: 507 (63%) radiocephalic fistulas (RCAVF), 237 (30%) brachiocephalic fistulas (BCAVF), and 59 (7%) brachiobasilic fistulas (BBAVF). Women had lower FDU in RCAVF (0.65, 95% CI 0.58-0.72 vs. 0.86, 95% CI 0.81-0.89; p<.0001), but not in BCAVF (0.83, 95% CI 0.75-0.89 vs. 0.81, 95% CI 0.73-0.88; p=.75). Female gender was an independent negative predictor of FDU in RCAVF (OR 0.31; 95% CI 0.20-0.49). Vascular kidney disease was an independent negative predictor for FDU in RCAVF (OR 0.33; 95% CI 0.17-0.64) and BCAVF (OR 0.22; 95% CI 0.09-0.57) in multivariable analysis. Artery and vein diameter did not improve the model for RCAVF. Vein diameter as categorical variable improved the model for BCAVF. Diameter cut off of radial artery ≥ 2mm has 96% sensitivity, 86% PPV, 9% specificity, and 29% NPV in men. Radial artery diameter ≥2mm had 96% sensitivity, 67% PPV but 13% specificity and 62% NPV in women. Diameter is a poor predictor of FDU of AVF. Arterial diameter measurements add no diagnostic value for BCAVF. Poor specificity suggests a diameter under 2mmat the wrist should not preclude AVF formation. Vascular kidney disease is an independent negative predictor for FDU in all AVF.

Investigating the Impact of Foot Reflexology on Severity of Fatigue in Patients Undergoing Hemodialysis: A Clinical Trial Study

Background: Fatigue is a debilitating complication in hemodialysis patients. Foot reflexology is one of the complementary medicine techniques with low complications that can control fatigue. Objectives: The aim of this study was to determine the effect of foot reflexology massage on fatigue severity in hemodialysis patients. Methods: In this clinical trial, 90 patients undergoing hemodialysis at Ali ibn Abi Talib hospital in Zahedan, Iran, in 2017 were randomly selected and then divided into two groups of intervention and control (n = 45 per group). The data collection tools included a demographic checklist and the fatigue severity scale developed by Krupp et al. Foot reflexology massage was performed in the intervention group for half an hour (15 minutes for each foot) by a trained researcher for three consecutive dialysis sessions. After completion of dialysis sessions, a questionnaire was completed as post-test in both groups. For data analysis, independent t-test, paired t-test, and chi-square test were run in SPSS, version 21. Results: There was no significant difference in the mean fatigue scores between the control and intervention groups before foot reflexology massage in the three sessions of dialysis. After the intervention, the independent t-test showed a significant difference in the mean fatigue score between the control and intervention groups (P < 0.001). Conclusions: The findings of this study showed that foot reflexology massage is an uncomplicated technique for reducing fatigue severity in patients undergoing hemodialysis.

The main determinants of intradialysis hypertension during dialysis in chronic hemodialysis patients; a single-center study

Introduction: Raising or lowering blood pressure and muscle cramps are the main barriers for dialysis. Meanwhile, lowering blood pressure is more common and its mechanism is somewhat clear. But the mechanism for increasing blood pressure is not yet clear fully. Objectives: In this study, we examined the prevalence of intradialytic hypertension (IDH) and its related factors, especially changes in plasma renin activity, hematocrit, heart rate, and electrolytes in end-stage renal disease (ESRD) patients undergoing chronic hemodialysis. Patients and Methods: In a cross-sectional study, patients with chronic end-stage renal disease under chronic hemodialysis were included to the study in the absence of a specific infection, as well as in lack of intravenous fluid providing during dialysis due to hypotension. Blood pressure and heart rate before and after hemodialysis were measured in four consecutive dialysis sessions. Elevating mean arterial blood pressure by 15 mm Hg between beginning and end of dialysis or raising blood pressure within four consecutive dialysis sessions were considered as IDH. Results: Around 17 of the 88 (19.3%) patients with hemodialysis had IDH. These subjects were compared with non-IDH patients who were similar in age and gender. The most common underlying disease in both groups was diabetes mellitus followed by hypertension. Comparison of measured parameters before and after dialysis showed that serum potassium level was significantly decreased in both groups. Serum sodium level increased in both groups, but this increase was significant only in the control group. There were no significant changes in renin plasma activity, heart rate and hematocrit levels in both groups. Conclusion: In this study, plasma renin activity in IDH group increased after dialysis compared to pre-dialysis. This finding requires to more test with larger sample size.

The impact of blood flow rate on dialysis dose and phosphate removal in hemodialysis patients.

The inadequacy of dialysis and hyperphosphatemia are both associated with morbidity and mortality in chronic hemodialysis (HD) patients. Blood flow rate (BFR) during HD is one of the important determinants of increasing dialysis dose. The aim of this study was to determine the effect of increasing BFR on dialysis dose and phosphate removal. Forty-four patients were included in a cross-sectional study. Each patient received six consecutive dialysis sessions as follows: three consecutive sessions with a BFR of 250 mL/min, followed by three others with BFR of 350 mL/min without changing the other dialysis parameters. Patients' body weight was recorded, and blood samples (serum urea and phosphate) were collected before and after each dialysis session. For assessing the efficacy of dialysis, urea reduction ratio (URR), Kt/VDiascan (Kt by Diascan and V by Watson), Kt/V Daugirdas (Daugirdas 2nd generation), equilibrated Kt/V, and phosphate reduction rate (PRR) were used. The increase of BFR by 100 mL/min resulted in a significant increase of URR, Kt/V Diascan, Kt/VDaugirdas, equilibrated Kt/V, and PRR: URR; 75.41 ± 5.60; 83.51 ± 6.12; P <0.001), (Kt/VDiascan; 1.28 ± 0.25; 1.55 ± 0.15; P <0.001), (Kt/VDaugirdas; 1.55 ± 0.26; 2.10 ± 0.61; P = 0.001), equilibrated Kt/V; 1.40 ± 0.19; 1.91 ± 0.52; P = 0.001), and (PRR; 50.32 ± 12.22; 63.66 ± 13.10; P = 0.010). Adequate dialysis, defined by single-pool Kt/V ≥1.4, was achieved using two different BFRs: 250 and 350 mL/min, respectively, in 73% and 100% of the cases. Increasing the BFR by 40% is effective in increasing dialysis dose and phosphate reduction rate during high-flux HD. The future prospective studies are needed to evaluate the impact of increasing BFR on phosphate removal using the total amount of phosphate removed, and also evaluate the cardiovascular outcome of phosphate reduction and dialysis improvement.