Daily Dialysis Research Articles

Association between the dietary inflammatory index and markers of endothelial and systemic inflammation in hemodialysis patients.

The current survey aimed to investigate the link between energy-adjusted dietary inflammatory index (E-DII) and risk factors for CVD including markers of endothelial and systemic inflammation in Iranian hemodialysis patients. Patients on hemodialysis for at least 6 months prior to enrollment were considered eligible in this cross-sectional study. The usual dietary intakes of the hemodialysis individuals were examined through 4 non-consecutive days including 2 dialysis days and 2 non-dialysis days using a 24-h recall approach to calculate E-DII. Multiple linear regression analysis was utilized to investigate the link between E-DII and selected biomarkers of inflammation and oxidative stress including high-sensitive C reactive protein (hs-CRP), serum intercellular adhesion molecule (sICAM), serum vascular cell adhesion molecule (sVCAM), malondialdehyde, and nitric oxide (NO), sE-selectin, and endothelin-1, and beta (β) and 95% confidence interval (CI) was reported. Value of p < 0.05 was considered statistically significant. Overall, 291 hemodialysis patients make up our study population. In the crude model, the E-DII score was positively associated with a higher sVCAM-1 (β = 177.39; 95% CI: 60.51, 294.26; ptrend = 0.003). Further adjustment for potential confounders attenuated the findings in a way that an increase of 128.72 in the sVCAM-1 was observed when the E-DII score increased from -2.68 to -1.14 (95% CI: 13.50, 243.94). After controlling for potential confounders, E-DII was associated with sE-selectin in hemodialysis patients in the highest category of E-DII as compared to the lowest category (β = 4.11; 95% CI: 0.22, 8.00; ptrend = 0.039). The present findings suggest that adherence to a pro-inflammatory diet among hemodialysis patients is associated with a higher inflammatory status as evidenced by sVCAM-1 and sE-selectin; however, bidirectionality may exist and the role of residual confounders should be taken into account. Therefore, more longitudinal investigations are needed to elucidate the role of diet on the inflammatory status of hemodialysis patients.

Impact of suboptimal donor to suboptimal recipient kidney transplant on delayed graft function and outcome.

The demographics of donor and recipient candidates for kidney transplantation (KT) have substantially changed. Recipients tend to be older and polymorbid and KT to suboptimal recipients is associated with delayed graft function (DGF), prolonged hospitalization, inferior long-term allograft function, and poorer patient survival. In parallel, donors are also older, suffer from several comorbidities, and donations coming from circulatory death (DCD) predominate, which in turn leads to early and late complications. However, it is unclear how donor and recipient risk factors interact. In this retrospective cohort study, we assess the impact of a KT from suboptimal donors to suboptimal recipients. We focused on: 1) DGF; 2) hospital stay and number of dialysis days after KT and 3) allograft function at 12 months. Among the 369 KT included, the overall DGF rate was 25% (n = 92) and median time from reperfusion to DGF resolution was 7.8 days (IQR: 3.0-13.8 days). Overall, patients received four dialysis sessions (IQR: 2-8). The combination of pre-KT anuria (<200 ml/24 h, 32%) and DCD procurement (14%) was significantly associated with DGF, length of hospital stay, and severe perioperative complications, predominantly in recipients 50 years and older.

A Comparative Analysis of Fasciotomy Results in Children and Adults Affected by Crush-Induced Acute Kidney Injury following the Kahramanmaraş Earthquakes.

Background and Objectives: The current study aims to determine the impact of fasciotomy on mortality and morbidity in children and adults with crush-related AKI following the 2023 Kahramanmaraş earthquakes. Materials and Methods: The study included individuals who had suffered crush injuries after the 2023 Kahramanmaraş earthquakes and were identified as having an acute kidney injury (AKI). Patients with an AKI were divided into two groups based on age: those under 18 years and those over 18 years. A comparative analysis was conducted between the mortality and morbidity rates of patients who underwent fasciotomy and those who did not. Disseminated intravascular coagulopathy (DIC), sepsis, and adult respiratory distress syndrome (ARDS) have all been identified as contributors to morbidity. Results: The study was conducted with a total of 40 patients (21 males and 19 females) aged between 4 and 83 years. A total of 21 patients underwent fasciotomy, and the patients underwent varying numbers of fasciotomy, ranging from 0 to 11. The mortality rate was 12.5%, corresponding to five adult patients. No instances of mortality were reported in the paediatric cohort. The application of fasciotomy in instances of crush-induced AKI did not result in elevated levels of mortality in either the paediatric or adult demographic. Within the adult population, a substantial difference in the duration of dialysis was observed between individuals who underwent fasciotomy and those who did not. A statistically significant increase in the number of fasciotomy incisions was observed in patients diagnosed with sepsis compared with those without sepsis. The study found a significant positive correlation between the number of fasciotomy incisions and dialysis days. Conclusions: Neither adult nor paediatric patients with crush-induced AKI showed an increased risk of death after fasciotomy. The number of fasciotomy incisions significantly correlated with the development of sepsis. Despite experiencing delays in hospital admission for paediatric patients, the incidence of both crush syndrome and mortality rates among children remained relatively low.

Incremental peritoneal dialysis and survival outcomes: a propensity-matched cohort study.

The advantages of an incremental dialysis start are not fully clear.We aimed to evaluate the association of incremental initiation of peritoneal dialysis with mortality. Incident peritoneal dialysis patients with a catheter placed at our hospital between 2008 and 2017 were included. All patients were followed up until December 31, 2019. Patients were categorized into different groups according to the initial daily dialysis exchanges, and were matched at a ratio of 1:2 with propensity score matching. Multiple variables including age, sex, residual kidney function, urine volume, hemoglobin, serum albumin and other important variables were included for the matching. Primary outcomes were all-cause and cardiovascular mortality. A total of 1315 patients with a mean age of 45.9years were enrolled. The mean glomerular filtration rate was 4.32ml/min/1.73 m2 at start ofdialysis. Two hundred eighty-fivepatientsin the incremental group and 502 in the full dose group were matched for age, sex, residual kidney function, urine volume, hemoglobin, serum albumin and other important variables. Patient survival and cardiovascular event-free survival were similar between the two groups. However, during the first 6 years of peritoneal dialysis, patients inthe incremental group had bettersurvival (P = 0.011) and cardiovascular event-free survival (P = 0.044) than the full dose group, while such advantages disappeared when dialysis vintage became longer. Further analysis showed that the incremental group (vs full dose dialysis) had a 39% lower risk (95% CI 0.42-0.90, P = 0.012) of all-cause mortality and a 41% decreased risk (95% CI 0.35-0.99, P = 0.047) of cardiovascular mortality during the first 6 years of dialysis. Additionally, the cumulative hazard for anuria was significantly lower in the incremental group versus the full dose group (P = 0.006). Our study shows a time-related survival advantage for incremental peritoneal dialysis patients, suggesting that an incremental regimen for startingperitoneal dialysis is feasibleand is not associated with worse outcomes. Graphical Abstract presenting schematically the measurements of the solvation response function by processing the relevant streak camera images and the time-correlated photon counting (TCSPC) data and appropriately combining them together.

Correction to: #3739 Shunt portosystemic complicated by hyperammonemia and hepatic encephalopathy supported by daily dialysis in a chronic hemodialysis patient.

Correction to: #3739 Shunt portosystemic complicated by hyperammonemia and hepatic encephalopathy supported by daily dialysis in a chronic hemodialysis patient.

Assessment of Nutrient Intake and its Association with Protein Energy Wasting in Haemodialysis Patients

Background: Protein Energy Wasting (PEW) is one of the complications associated with HD, a multi-factorial, maladaptive metabolic state characterized by loss of body protein mass and energy reserves, which is a major cause of morbidity and mortality amongst these patients. Adequate nutrient intake in dialysis patients is, therefore, a challenge due to poor appetite, and anorexia because of the build-up of uremic toxins. Therefore, this study aims to assess PEW and nutrient intake consumption in the HD population to add to the Indian database. Methods: The study adopted a cross-sectional design conducted at a tertiary care hospital in Mumbai, India. A total of 54 chronic haemodialysis patients were recruited for the study through convenience sampling. Post dialysis session, measurement of weight was recorded. An interviewer-administered questionnaire was used to record the patient details. Results: The nutrient intake on dialysis day was observed to be lower as compared to non-dialysis day. Only 5% of patients were diagnosed with PEW. A significant correlation between Energy, Protein on dialysis, and non dialysis day, along with Carbohydrate, Sodium, and Potassium intake (p-value 0.001) was observed. Conclusion: The present study found that nutrient intake of Energy, Protein, CHO, Fats, Sodium and Potassium were lower on dialysis day as compared to non dialysis day. Majority of the patients were well nourished and only 5% of patients were Protein Energy Wasted. Keywords: Protein Energy Wasting (PEW), Nutrient intake, Haemodialysis, Appetite, Diet.

429-P: Evaluation of Hypoglycemic Risk in Patients with Type 2 Diabetes on Hemodialysis under Tight Glycemic Control

Patients with type 2 diabetes on hemodialysis (T2HD) have unique glycemic profile resulting from hemodialysis, especially hemodialysis-related hypoglycemia, which is present in approximately 20% of them. We analyzed 48-hour sensor glucose level (SGL) on dialysis and non-dialysis days, and time in range (TIR, 70-180 mg/dL), time below range (TBR, &amp;lt;70 mg/dL) in 115 T2HD using continuous glucose monitoring (CGM) and evaluated the difference in clinical parameters between well-controlled group (TIR &amp;gt;70% and TBR &amp;lt;4%) and hypoglycemia group (TIR &amp;gt;70% and TBR ≥4%). Sixty-six patients of well-controlled group (46 males, age 62±12 years, HbA1c 6.0±0.9%, glycated albumin (GA) 18.5±4.1%) and 11 cases of hypoglycemia group (8 males, age 65±13 years, HbA1c 5.9±0.7%, GA 17.4±3.6%) were selected for retrospective analysis. There were no differences in sex, age, dry weight, body mass index, duration of diabetes, or duration of dialysis between two groups. Likewise, HbA1c and GA were not significantly different (P=0.7044, P=0.4151). Glucose levels at both the beginning and the end of dialysis were significantly lower in the hypoglycemia group (164.1±42.8 mg/dL vs. 131.0±49.2 mg/dL (P=0.0227) and 118.8±40.2 mg/dL vs. 86.8±26.1 mg/dL (P=0.0130), respectively). On the other hand, CGM data showed significantly lower mean SGL (P=0.0005) and significantly higher coefficient of variation of SGL (P=0.0014) in the hypoglycemia group. Thus, both HbA1c and GA are not sufficient to predict the presence of hypoglycemia in strict glycemic control in T2HD. Therefore, for good glycemic control without hypoglycemia in T2HD, it is important to measure glucose levels at the beginning and end of dialysis and to evaluate glucose profiles by CGM. Disclosure A.Hayashi: Research Support; Abbott Japan Co., Ltd., Roche Diabetes Care, Speaker's Bureau; Abbott Japan Co., Ltd., Medtronic, Terumo Corporation. N.Shimizu: None. A.Suzuki: None. R.Fujishima: None. K.Matoba: None. T.Masaki: None. T.Miyatsuka: Speaker's Bureau; Eli Lilly Japan K.K., Novo Nordisk, Sanofi K.K., Mitsubishi Tanabe Pharma Corporation, Sumitomo Dainippon Pharma Co., Ltd., Teijin Pharma Limited, Sanwa Kagaku Kenkyusho, Daiichi Sankyo. Funding TERUMO Life Science Foundation (21-III-5030); Japan Association for Diabetes Education and Care (2021-YNG-028); Japan Society for the Promotion of Science (22K15674)

#4310 DEVELOPMENT OF A HOME DIALYSIS PATIENT SUPPORT SYSTEM WITH EXERCISE FUNCTION PART I - SYSTEM DEVELOPMENT AND EVALUATION

Abstract Background and Aims Although many people use communications infrastructure, direct connection of electronic medical records to the Internet is restricted at medical institutions in Japan. Therefore, patient information outside the medical institution cannot be viewed on systems inside the medical institution. We are developing a safe and secure dialysis support system that connects dialysis patients and medical institutions, which is separate from the system within medical institutions. We have developed a dialysis support system that can share vital data, dialysis records, meal records, etc., between patients and medical institutions. In this study, to support dialysis patients’ exercise and its continuation, we created an ergo-storage device combining an ergometer and storage device for this research and added functions to the existing dialysis support system. This system with additional exercise function could encourage patients to exercise, store the amount of exercise as the amount of electricity used, this electricity represented a reward to the patient for exercising. These additional features allow the patient to exercise at home on both dialysis and non-dialysis days. Method An ergometer was used as exercise equipment for dialysis patients with a hub dynamo to convert the rotations of the ergometer through a belt into electricity. This allowed the dynamo to take over the rotation of the ergometer. In addition, we developed a new circuit that converts the power generated by the dynamo to USB voltage. A simple USB voltage and current checker was added to allow the integrated power to be displayed making it possible to visualize momentum as power generation. In addition, the generated power could be stored in the USB charger. To record the amount of exercise of the patient, the information from the ergometer was output to a tablet in CSV format. This CSV file was sent to the developed system and linked with the patient information in the existing system. This system made it possible to visualize and display the exercise information along with the patient's daily dialysis information and meal information on the developed system. Results Momentum could be converted to electrical energy using the ergo-storage device. The patient could now see and store the amount of exercise they have done, enabling the patient to exercise on both dialysis and non-dialysis days. As the amount of exercise could be visualized at a glance, the patient was encouraged and prompted to exercise daily. In addition, as the amount of exercise could be stored as electricity, this electricity represented a reward to the patient for exercising. The patients reported that it was good to be able to enjoy exercising instead of having a quota, and that they were able to continue exercising. Patients began exercising voluntarily instead of being forced to exercise by health care workers. In addition, it was possible to link the system with the patient's dialysis records and share the amount of exercise, making it easier for medical professionals to understand the patient's physical condition. Conclusion A function that allows dialysis patients to exercise was added to the developed system. Using this system, patients and medical institutions could share dialysis records, such as the patient's amount of exercise. The patients could exercise on both dialysis and non-dialysis days, and the amount of exercise and dialysis records could be shared with medical institutions. In addition, the amount of exercise was stored as electricity, which increased the patient's motivation to exercise. The patients began to exercise voluntarily. This research was supported in part by Gakushin Kaken (JP20H03982).

#3957 SUSTAINED RECOVERY OF KIDNEY FUNCTION IN PATIENTS WITH ESKD UNDER CHRONIC DIALYSIS TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background and Aims The prevalence of recovery of kidney function (RKF) in patients under maintenance dialysis is poorly defined mainly because of different definitions of RKF. The accurate assessment of sustained RKF is critical because the survival and quality of life of patients treated by maintenance dialysis are dramatically poor as compared to patients under conservative treatment. The sustained withdrawal of chronic dialysis has moreover a significant social and economic impact, considering the high burden of dialysis on health resources. Method Therefore, to gain more insights into the epidemiology of RKF, we performed a systematic review and meta-analysis of studies addressing the prevalence of sustained (at least for 30 days) RKF in patients under maintenance dialysis. Acute kidney injury (AKI) and RKF in the first 90 days of dialysis were the main exclusion criteria. Results Overall, 7 studies (10 cohorts) including 2,444,943 chronic dialysis patients (range: 430-1,900,595 patients) were meta-analyzed. The period of observation ranged from 4 to 43 years. The prevalence of RKF was 1.49% (95% C.I.:1.05-2.11; p&amp;lt;0.001] with high heterogeneity I2: 99.8%, P&amp;lt;0.001 (Figure 1). The weighted mean dialysis vintage before RKF was 294±165 days; RKF persisted for a weighted mean of 27.5 months. The percentage of RKF was higher in studies from the U.S. (1.96% [95% C.I.: 1.24-3.07]) as compared to other countries (1.04% [95%C.I.: 0.66-1.62]; P = 0.049). Conclusion In conclusion, sustained RKF unrelated to AKI occurs in about 1.5% of patients under maintenance dialysis. On average, RKF patients discontinue chronic dialysis about ten months after starting treatment and live free of dialysis for more than two years. The higher prevalence of RKF reported in the U.S. versus other countries suggests a major role of country-specific policies for dialysis start.

#4311 DEVELOPMENT OF A HOME DIALYSIS PATIENT SUPPORT SYSTEM WITH EXERCISE FUNCTION PART II: RESULTS OF A TRIAL OF ADDED EXERCISE FUNCTION

Abstract Background and Aims In Japan, peritoneal dialysis patients are required to record daily dialysis information in continuous ambulatory peritoneal dialysis (CAPD) notes. However, as the CAPD notes are a list of numbers, it is difficult for medical staff to quickly understand the patient's physical condition. Although many people now use communications infrastructure, access to medical information on the Internet is restricted from the viewpoint of patient information security in medical institutions in Japan. Therefore, patient information outside the medical institution cannot be viewed on the system inside the medical institution. Therefore, we are developing a safe and secure dialysis support system to connect dialysis patients’ homes and medical institutions. We have developed a dialysis support system that can share the patient's vital data, dialysis records, meal records, etc., between patients and medical institutions. Here, we added a function to support the exercise of dialysis patients, and present the results of a trial. Method The display and recording items of the previously developed system include vital data, and exchange start time as records necessary for peritoneal dialysis, dialysate concentration, drainage volume, fluid injection volume, drainage volume, drainage time, drainage confirmation, blood pressure, and blood sugar level. In addition to these items, we have added a new function to the system that can automatically input the patient's exercise records from ergo-storage device. This added functionality links movement information from the ergo-storage device with relevant patient information in the previously developed system. It also enables medical staff to view and share the graphical data as visible information from within the facility. The patients exercise using the developed ergo-storage device, and the amount of exercise is stored in the charger. Patients can exercise with this ergo-storage device on both dialysis and non-dialysis days. Results To prevent erroneous input, the dialysis records could be entered automatically or selected using radio buttons. In addition, when confirming drainage, it was possible to transmit images to medical institutions. In the added exercise function, the strength of pedaling on the ergo-storage device, the number of rotations, etc., could be output in CSV format. The amount of exercise was sent to the previously developed system. In addition, the system allowed storage of the electricity generated by rotating the pedals in the storage device. This added exercise function encouraged and sustained exercise in dialysis patients. It not only supported the patient's exercise, but also encouraged continuation by compensation for the amount of exercise via storage of electricity to charge devices. Therefore, the patients were motivated not only to exercise but also to continue to exercise. The accumulation of exercise data enabled the patients to understand changes over time, leading to self-management. Furthermore, exercise could be continued even on non-dialysis days. Medical institutions could also share not only the patient's dialysis records, but also information on their amount of exercise, leading to improved patient care. Conclusion This developed system with new exercise function supported patients’ exercise and its continuation on both dialysis and non-dialysis days. The amount of exercise by the patient was stored as electricity, which could be used to charge the patient's cell phone, etc. This increased the patients’ motivation to exercise. Furthermore, this information can be shared with medical institutions. This research was supported in part by Gakushin Kaken (JP20H03982).

#6838 SAFETY OF RAMADAN FASTING IN DIALYSIS PATIENTS: A TUNISIAN PROSPECTIVE MULTICENTER STUDY

Abstract Background and Aims Hemodialysis patients are generally exempt from Ramadan Fasting (RF) because they are more vulnerable to the risk of malnutrition as well as fluid and electrolyte imbalance. In addition, many muslim hemodialysis patients feel the spirituel need to fast during Ramadan, even when they are not compelled to do so. Moreover, there are no medical recommendations that specify who should and should not fast. The aim of our study is to explore the experiences of Muslim Hemodialysis patients fasting Ramadan in Hemodialysis centers. Method This prospective multicenter study involved patients from eight different hemodialysis centers in Monastir and Mahdia cities. Biochemical, clinical parameters and bioimpedance monitoring were performed before, during and after Ramadan with a group of Fasting Ramadan patients (RFG) and a group of Ramadan non-fasting hemodialysis patients (RNFG). Patients in RFG did so as a personal choice and they wouldn't skip fasting on dialysis days due to fear of the side effects of fasting. Oral consent was taken from all the patients included in the study. Results One hundred and four (104) patients were enrolled in this study. Among them, 44 were in the RFG, and the remaining sixty (60) patients were in the RNFG. The mean age of RFG and RNFG was 47, 13 +/- 12 years and 54, 7 +/- 15 years, respectively. 32 patients (52, 3 %) were males in RFG and 38 were males (63, 3%) in RNFG. In RFG, about 6, 8% (n = 3) and 43, 2% (n =19) had diabetes and hypertension, respectively. The mean duration on hemodialysis was 7 +/- 6, 27 years. There were no significant differences between RFG and RNFG except in diabetic and hypertension status. Comparing biological findings pre,during and post-fasting,in RFG, no significant differences were noted in serum sodium (135,9 +/- 4 ; 135,8 +/- 2,5 and 136,3 +/- 2,4 mmol/l respectively) ; and there were no drop in serum albumin during fasting (40,4 +/- 3,4 ; 40,8 +/- 3,7 and 40,6 +/- 4,34 g/l respectively). However, mean serum potassium was higher during RF (5,59 +/- 0,8 ; 5,6 +/- 1 and 5,2 +/- 0,88 mmol/l respectively) and, mean serum Phosphorus was also higher during RF (1,54 +/- 0,57; 1,73 +/- 0,52 and 1,69 +/- 0,7 mmol/l respectively). Furthermore, with bioimpedance monitoring, comparing pre, during and post Fasting, more fluid retention in patients was observed during fasting (51, 67 +/- 7; 54, 3 +/- 7, 4 and 53, 2 +/- 6 % respectively). But the mean of the inter dialytic weight gain (IDWG) remained the same (2,57 +/- 0,8 ; 2,53 +/- 0,82 and 2,61 +/- 0,7 Kg respectively), and none presented with pulmonary oedema or other emergency that might need hospitalization. However, there was positive change to body composition between pre and during fasting, shown as lower body fat mass (FM) percentage during fasting (29,4 and 28,2% respectively) and also, lower body mass index (BMI) (26,5 and 25,9 respectively). Nevertheless, when comparing findings between RFG and RNFG, there was no significant difference in any parameters. Conclusion The overall conclusions suggest that fasting is relatively well tolerated by hemodialysis patients and does not affect the morbidity and mortality rates. However, careful monitoring of fluid balance, serum electrolytes, and albumin is advisable.

#4580 ELEVATED LEVELS OF UREMIC SOLUTES IN THE CEREBROSPINAL FLUID OF HEMODIALYSIS PATIENTS

Abstract Background and Aims Uremic solutes are considered as contributing factors to impaired cognitive function in end stage kidney disease (ESKD) [1]. However, the distribution and accumulation of uremic solutes in the central nervous system (CNS) of ESKD patients are not well understood. We measured four uremic solutes in the cerebrospinal fluid (CSF) and plasma of two ESKD patients and investigated the role of routine hemodialysis (HD) in clearing these solutes from their CNS. Method We accessed CSF in HD patients with a ventriculo-peritoneal shunt. A review of about 160,000 electronic health records revealed 30 eligible patients, two of whom consented to participate in this IRB-approved one-week study (Western IRB #20172182). On dialysis days, CSF and plasma were collected 2 hours pre- and 2 hours post-HD. Non-dialysis day samples were collected 20 hours post-HD. Samples from healthy subjects were purchased from BioIVT (Westbury, NY). Urea was measured using Horiba C400 Chemical Analyzer. Indoxyl sulfate (IS), p-cresol sulfate (pCS) and trimethylamine N-oxide (TMAO) were analyzed using Agilent Ultivo triple quadrupole mass spectrometer. The dialytic reduction ratio (RR; in %) was calculated as 100 × (pre-HD level – post-HD level) / pre-HD-level. Results In both CSF and plasma, levels of all four uremic solutes were elevated in HD patients compared to healthy subjects (Table 1). The ratio of CSF-to-plasma levels was &amp;lt;100% for all solutes. Ratios for HD patients are altered compared to those reported in healthy subjects (Table 1). Longitudinal plasma and CSF solute levels are shown in Figure 1. Plasma RRs for IS, pCS, TMAO and urea were 32%, 23%, 77%, and 67%, respectively. The respective CSF RRs were 29%, 20%, 3%, and 25%. Conclusion To the best of our knowledge, this is the first report on CSF levels of IS, pCS, and TMAO in HD patients. Our results indicate that uremic solute levels are elevated in the CSF from HD patients compared to healthy subjects. Moreover, HD only moderately reduces uremic solute levels in CSF. Whether increased CNS levels of uremic solutes are related to cognitive impairment warrants further investigation.

#3739 SHUNT PORTOSYSTEMIC COMPLICATED BY HYPERAMMONEMIA AND HEPATIC ENCEPHALOPATHY SUPPORTED BY DAILY DIALYSIS IN A CHRONIC HEMODIALYSIS PATIENT

Abstract Background and Aims Hepatic encephalopathy is a neuropsychiatric syndrome that may develop as a consequence of liver insufficiency. In acute liver failure, hepatic encephalopathy suggests the severity of the disease. In end-stage chronic liver diseases, episodes of hepatic encephalopathy are frequently fully and spontaneously reversible. Clinical manifestations vary from mild neuropsychiatric disorders to coma. The pathogenesis of hepatic encephalopathy is complex and not clearly understood. Ammonia plays a key role. In the healthy individual, ammonia is, during its first hepatic passage, directly degraded into urea, itself excreted by the kidney and the stools, and to a lesser degree in glutamine. Ammonia is also metabolized by the muscle striped. In case of liver failure and/or shunts portosystemic, there is a defect in hepatic clearance ammonia which is then found in excess in systemic circulation. Decreased muscle mass, linked to malnutrition, frequent in the patient cirrhotic and chronic hemodialysis, also helps to decrease metabolism ammonia. Due to the increase in permeability of the blood-brain barrier, the brain is exposed to excessive concentrations ammonia causing functional brain abnormalities and structural, which can partly explain the signs neurology of hepatic encephalopathy. In end stage chronic renal failure, clearance of ammonia via extracorporeal treatment has not been systematically evaluated. Several studies with small samples have demonstrated the effectiveness of hemodialysis, compared to peritoneal dialysis, in terms of ammonium purification in chronic renal failure, on dialysis or not on dialysis. The aim of this study was to evaluate the effectiveness of daily dialysis for the purification of ammoniumin a chronic hemodialysis patient with hepatic encephalopathy. Case Report A 40-year-old man undergoing chronic hemodialysis was referred to gastroenterology department of Mohammed VI University center of Marrakesh for inoperable shunt portosystemic complicated by hyperammonemia causing hepatic encephalopathy consisting of headaches and seizures. His medical history was significant for liver cirrhosis caused by infection with hepatitis B, end stage kidney disease due to membranoproliferative glomerulonephritis, for which the patient is on hemodialysis at the rate of 3 sessions per week. The patient went on to develop portal hypertension and ascites requiring frequent hospital admissions and treatment with diuretics. He was on a low-protein and low-sodium diet. While on oral furosemide 250 mg daily and spironolactone 100 mg daily, his diuresis was adequate. Before referral, this patient had already suffered 4 episodes of tonic clonic seizures. His 1st hemodialysis session in our training was on January 10, 2023, he was given daily hemodialysis sessions with daily blood tests, including immediate pre and post dialysis ammonia. Pre-dialytic ammonia levels varied between 103 and 161 µmol/l, as well as post-dialytic ammonia levels varied between 24 and 37 µmol/l, knowing that the normal value of laboratory ammonia varied between 10 and 51 µmol/l. The evolution was marked by a clear clinical improvement, with a disappearance of the seizures without a significant drop in ammonia after 14 daily hemodialysis sessions. Serum creatinine and urea declined, and sodium increased. Accumulation of ascites slowed and the patient could eat and sleep normally and was again independent with self care. The patient returned home on January 24. Conclusion This study shows the interest of daily hemodialysis sessions as a potential treatment for hyperammonemia in a patient on chronic intermittent hemodialysis, with a portosystemic shunt. The interest lies in the fact that the improvement is mainly clinical than biological (persistent hyperammonemia).

Venetoclax pharmacokinetics in subjects with end-stage renal disease undergoing hemodialysis.

e19042 Background: Venetoclax is a first-in-class Bcl-2 inhibitor approved for the treatment of chronic lymphocytic leukemia (CLL) and acute myeloid leukemia(AML) and is currently being investigated as a treatment for t(11;14)-positive relapsed/refractory multiple myeloma (MM). Renal insufficiency is a common comorbidity in patients with hematologic malignancies, and no clinical study has been conducted to assess how end stage renal disease might affect venetoclax pharmacokinetics. This study aimed to assess the pharmacokinetics of venetoclax after oral administration of a single 100 mg dose of venetoclax in subjects with normal renal function and end-stage renal disease, including those undergoing hemodialysis. Methods: Venetoclax was administered as a single 100 mg dose to 7 healthy female subjects with normal renal function (eGFR &gt; 90 ml/min) and 6 female subjects with end-stage renal disease (ESRD) (eGFR &lt; 15 ml/min) both prior to hemodialysis (Period 1) and between hemodialysis days (Period 2). Intensive PK and protein binding samples were collected from all subjects. Arterial and venous samples were collected from ESRD subjects during hemodialysis to assess the effect of hemodialysis on the pharmacokinetics of venetoclax. Pharmacokinetic parameters were estimated using non-compartmental methods. Results: There was no difference in plasma venetoclax concentrations between arterial and venous samples, suggesting that hemodialysis did not affect the PK of venetoclax. The fraction unbound (fu) of venetoclax increased approximately 2-fold for subjects with ESRD compared to subjects with normal renal function.The unbound Cmax and AUC0-48 of ESRD subjects, between dialysis days were comparable to unbound Cmax and AUC0-48 observed in the normal renal function subjects. The harmonic mean t1/2 between groups (normal renal function vs. ESRD) ranged from 11 and 12.2 hours, demonstrating that end-stage renal disease did not affect the half-life of venetoclax. Conclusions: End-stage renal disease does not alter unbound venetoclax plasma concentrations and no dose adjustment is neededfor patients with renal insufficiency based on pharmacokinetics. Clinical trial information: NCT04810598 .

Optimization of glycemic control with continuous glucose monitoring in a patient with type 1 diabetes mellitus undergoing maintenance hemodialysis

Patients with type 1 Diabetes Mellitus (T1DM) on renal replacement therapy with maintenance hemodialysis (MHD) are prone to develop hypoglycemia, as well as high glycemic variability on both dialysis and non-dialysis days. Reliability of glycated hemoglobin in dialysis patients with DM as a marker of carbohydrate metabolism compensation is reduced due to the influence of anemia, uremia, mechanical damage of erythrocytes during diffusion through the dialyzing membrane. Continuous glucose monitoring (CGM) is one of the methods for monitoring and correction glycemic variability in dialysis patients with DM.This article presents a description of a clinical case of the patient with T1DM on MHD receiving insulin therapy using an insulin pump in combination with CGM (FreeStyle Libre portable system) and highlights the difficulties of correcting insulin therapy on dialysis and non-dialysis days.The discussion section presents the JBDS-IP 2022 (UK) recommendations for the correction of insulin therapy in patients with DM on dialysis (it is recommended to reduce the insulin dose by 25% on dialysis days, immediately after the start of the HD procedure). Particular attention is focused on the need for a personalized approach to the correction of insulin therapy in dialysis patients with DM due to the comorbidity of this group of patients and the difficulties in extrapolating recommendations into real clinical practice.

Accuracy of Continuous Glucose Monitoring in an Insulin-Treated Population Requiring Haemodialysis.

Continuous glucose monitoring (CGM) is revolutionizing diabetes care by giving both patients and the healthcare professionals unprecedented insights into glucose variability and patterns. It is established in National Institute for Health and Care Excellence (NICE) guidance as a standard of care for type 1 diabetes and diabetes in pregnancy under certain conditions. Diabetes mellitus (DM) is recognized as an important risk factor for chronic kidney disease (CKD). Around a third of patients receiving in-center haemodialysis as renal replacement therapy (RRT) have diabetes, either as a direct cause of renal failure or as an additional co-morbidity. Evidence of poor compliance with the current standard of care (self-monitoring of blood glucose [SMBG]) and overall greater morbidity and mortality, suggests this patient population as an ideal target group for CGM. However, there exists no strong published evidence showing the validity of CGM devices in insulin-treated diabetes patients requiring haemodialysis. We applied a Freestyle Libre Pro sensor to 69 insulin-treated diabetes haemodialysis (HD) patients on a dialysis day. Interstitial glucose levels were obtained, and time matched within 7 minutes to capillary blood glucose testing and any plasma blood glucose levels sent. Data cleansing techniques were applied to account for rapidly correcting hypoglycaemia and poor SMBG technique. Clarke-error grid analysis showed 97.9% of glucose values in an acceptable range of agreement (97.3% on dialysis days and 99.1% on non-dialysis days). We conclude that the Freestyle Libre sensor is accurate in measuring glucose levels when compared to glucose as measured by capillary SMBG testing and laboratory obtained serum glucose in patients on HD.

Switching from continuous veno-venous hemodiafiltration to intermittent sustained low-efficiency daily hemodiafiltration (SLED-f) in pediatric acute kidney injury: A prospective cohort study.

Continuous kidney replacement therapy (CKRT) is the preferred modality in critically ill children with acute kidney injury. Upon improvement, intermittent hemodialysis is usually initiated as a step-down therapy, which can be associated with several adverse events. Hybrid therapies such as Sustained low-efficiency daily dialysis with pre-filter replacement (SLED-f) combines the slow sustained features of a continuous treatment, ensuring hemodynamic stability, with similar solute clearance along with the cost effectiveness of conventional intermittent hemodialysis. We examined the feasibility of using SLED-f as a transition step-down therapy after CKRT in critically ill pediatric patients with acute kidney injury. A prospective cohort study was conducted in children admitted to our tertiary care pediatric intensive care units with multi-organ dysfunction syndrome including acute kidney injury who received CKRT for management. Those patients receiving fewer than two inotropes to maintain perfusion and failed a diuretic challenge were switched to SLED-f. Eleven patients underwent 105 SLED-f sessions (mean of 9.55 +/- 4.90 sessions per patient), as a part of step-down therapy from continuous hemodiafiltration. All (100%) our patients had sepsis associated acute kidney injury with multiorgan dysfunction and required ventilation. During SLED-f, urea reduction ratio was 64.1 +/- 5.3%, Kt/V was 1.13 +/- 0.1, and beta-2 microglobulin reduction was 42.5 +/-4%. Incidence of hypotension and requirement of escalation of inotropes during SLED-f was 18.18%. Filter clotting occurred twice in one patient. SLED-f is a safe and effective modality for use as a transition therapy between CKRT and intermittent hemodialysis in children in the PICU.

Caracterización de la población con fracaso renal agudo durante la hospitalización por COVID-19 en España: tratamiento renal sustitutivo y mortalidad. Datos del Registro FRA-COVID SEN

Background and objectivesAcute kidney injury (AKI) is common among hospitalized patients with COVID-19 and associated with worse prognosis. The Spanish Society of Nephrology created the AKI-COVID Registry to characterize the population admitted for COVID-19 that developed AKI in Spanish hospitals. The need of renal replacement therapy (RRT) therapeutic modalities, and mortality in these patients were assessed. Material and methodIn a retrospective study, we analyzed data from the AKI-COVID Registry, which included patients hospitalized in 30 Spanish hospitals from May 2020 to November 2021. Clinical and demographic variables, factors related to the severity of COVID-19 and AKI, and survival data were recorded. A multivariate regression analysis was performed to study factors related to RRT and mortality. ResultsData from 730 patients were recorded. A total of 71.9% were men, with a mean age of 70 years (60–78), 70.1% were hypertensive, 32.9% diabetic, 33.3% with cardiovascular disease and 23.9% had some degree of chronic kidney disease (CKD). Pneumonia was diagnosed in 94.6%, requiring ventilatory support in 54.2% and admission to the ICU in 44.1% of cases.The median time from the onset of COVID-19 symptoms to the appearance of AKI (37.1% KDIGO I, 18.3% KDIGO II, 44.6% KDIGO III) was 6 days (4–10). A total of 235 (33.9%) patients required RRT: 155 patients with continuous renal replacement therapy, 89 alternate-day dialysis, 36 daily dialysis, 24 extended hemodialysis and 17 patients with hemodiafiltration. Smoking habit (OR 3.41), ventilatory support (OR 20.2), maximum creatinine value (OR 2.41) and time to AKI onset (OR 1.13) were predictors of the need for RRT; age was a protective factor (0.95). The group without RRT was characterized by older age, less severe AKI, shorter kidney injury onset and recovery time (p<0.05). 38.6% of patients died during hospitalization; serious AKI and RRT were more frequent in the death group. In the multivariate analysis, age (OR 1.03), previous chronic kidney disease (OR 2.21), development of pneumonia (OR 2.89), ventilatory support (OR 3.34) and RRT (OR 2.28) were predictors of mortality while chronic treatment with ARBs was identified as a protective factor (OR 0.55). ConclusionsPatients with AKI during hospitalization for COVID-19 had a high mean age, comorbidities and severe infection. We defined two different clinical patterns: an AKI of early onset, in older patients that resolves in a few days without the need for RRT; and another more severe pattern, with greater need for RRT, and late onset, which was related to greater severity of the infectious disease. The severity of the infection, age and the presence of CKD prior to admission were identified as risk factors for mortality in these patients. In addition chronic treatment with ARBs was identified as a protective factor for mortality.

Exploring Fatigue Patterns and Associated Factors Among Patients on Hemodialysis

Fatigue in patients on hemodialysis varies based on disease and treatment situations. Most studies have assessed the effectiveness of interventions based on average fatigue during the past week. However, two different types of fatigue are identified: post-dialysis fatigue and continuous fatigue. Identifying different types of fatigue and related factors may facilitate the development of more-effective, type-specific measures to reduce patient fatigue. The purpose of this study was to explore fatigue patterns and predictors in patients on hemodialysis during their eight-day dialysis cycle. A perspective, observational research design was adopted. One hundred and two patients were recruited from three hospitals and one hemodialysis clinic in New Taipei City. During the dialysis, patients answered a structured questionnaire that included a demographic datasheet, Taiwanese depression questionnaire, hemodialysis social support scale, trait anxiety inventory, Pittsburgh sleep quality index, and fatigue visual analogy scale. After dialysis on each day, patients completed the fatigue visual analogy scale for a period of eight consecutive days every morning, noon, and night. Biochemical data and inter-dialysis weight gain were collected from medical charts. This study found three distinct fatigue status groups: fatigue adaptation, rapid change and continuous fatigue. After the day of dialysis, fatigue level was the lowest in the fatigue adaptation group, followed by the continuous fatigue group. The rapid change group reported the highest level of fatigue. With regard to the degree of increase in fatigue after dialysis (fatigue score after dialysis minus fatigue score before dialysis), the rapid change group had the highest average increase in score after dialysis, while the continuous fatigue group had the lowest. Sleep quality, trait anxiety, and health caregiver support were also found to be predictors of group affiliation. Nurses can provide individual social support interventions and methods to improve sleep quality and alleviate anxiety to reduce fatigue in patients on hemodialysis.

Assessment of physical activity in hemodialysis and factors associated with a sedentary lifestyle

Background A sedentary lifestyle is an important risk factor for mortality, especially cardiovascular mortality. This risk is increased in hemodialysis patients owing to the presence of other comorbidities. The aims of this study were to assess physical activity in hemodialysis patients and to figure out factors associated with sedentary lifestyle. Patients and methods This was a cross-sectional, descriptive, analytical study. It was conducted over a 2-month period. The study included patients who had been on regular hemodialysis for at least 6 months. Patients with physical disability were not included. Physical activity was assessed using an accelerometer. Results There were 30 included patients, of whom 22 were male and eight female. The mean age of the patients was 43.40 ± 15.14 years. The average number of steps per day was 7464.32 ± 4166.82 steps/day. The average number of steps per dialysis day was 6605.41 ± 4251.27 steps/day. According to the number of steps per day, 26.7% of patients were sedentary, 26.7% of patients were less active, and 46.6% were active. Factors associated with sedentary behavior were the sex (P=0.028), the age (P=0.001), and the day of dialysis (P=0.0001). Conclusion Sedentary lifestyle was frequent in our study. This high frequency is explained by several factors related to chronic kidney disease and hemodialysis itself.