Daily Dialysis Research Articles

Stage V Chronic Kidney Disease: A plea for Home Dialysis

Summary
 Overall, home dialysis remains underutilized in much of the world. It is only in some parts of the world, such as Hong Kong, Mexico, Thailand, the Netherlands, Finland, Denmark, Iceland, Australia, Canada and New Zealand, that home dialysis is used for more than 20% of the dialysis population. It is observed that in most high- and middle-income countries, home dialysis is generally more economical than center-based dialysis.
 According to the results of the REIN 2020 registry, the share of out-of-center dialysis in France has been increasing since 2012. This is mainly due to the increase in the number of patients treated in low medicalized dialysis units (LMDUs) (+7.3% per year between 2012 and 2016, then +3.8% between 2016 and 2020). In contrast, the proportion of patients treated at home has changed little. The percentage of patients on peritoneal dialysis is decreasing (-1.8% per year). Home hemodiaysis is increasing (+10.3% per year) but remains very marginal (1% of dialysis patients). Finally, the advanced age of dialysis patients, which is constantly increasing, cannot be ignored. The proportion of these very old patients has increased from 10.5% in 2012 to 12.5% in 2020. However, during the COVID-19 epidemic, several articles in the literature have demonstrated the protective effect of home dialysis in all its forms (peritoneal dialysis and home hemodialysis) against SARS-CoV-2 infection.
 We report on the status of home dialysis in France, its advantages and proposals for its development, as presented at the Home Dialysis Day (DIADOM) of University Seminars of Nephrology (SUN) in Paris in January 2022.

Evaluation of the relationship between hemodialysis-related glycemic variability and hormonal profiles in patients with type 2 diabetes on hemodialysis: a pilot study

BackgroundThe number of dialysis patients with diabetes is currently increasing in Japan and a similar proportion worldwide. It was suggested that approximately 20% of these patients had hypoglycemia after dialysis session and most of these hypoglycemia were unconscious. Furthermore, it was suggested that glucose variabilities induced by hemodialysis may be related to insulin and insulin-counter hormones, such as glucagon, adrenocorticotropic hormone (ACTH), and cortisol and growth hormone, but conclusive evidence has not still been obtained.MethodsWe investigated in detail the glucose and hormonal profiles in 7 patients with type 2 diabetes on hemodialysis (all male, HbA1c 6.8 ± 2.1%, glycated albumin 24.7 ± 10.2%). All participants were attached continuous glucose monitoring (iPro2®). Blood glucose level, C-peptide immunoreactivity, plasma glucagon, ACTH, cortisol and growth hormone were measured by 7 points blood tests at before breakfast, after breakfast (predialysis), 2 h and 4 h after starting dialysis, after lunch and before/after dinner on the dialysis day and 6 points at before/after each meal on the non-dialysis day, and these relationship with blood glucose dynamics were examined. The meal contents were set to the indicated energy amount, and the same menu was served daily for breakfast, lunch, and dinner on dialysis and non-dialysis days of this study period. In addition, the start time of lunch on non-dialysis day was the same as the start time of lunch on the dialysis day.ResultsSerum C-peptide level was significantly increased by taking breakfast and lunch on the hemodialysis day, significantly decreased during hemodialysis, and was significantly lower before and after lunch on the hemodialysis day than on the non-hemodialysis day. Plasma glucagon level significantly decreased during hemodialysis and that before lunch on hemodialysis day was significantly lower than on non-hemodialysis day. ACTH, cortisol, and growth hormone did not show any changes related to hemodialysis.ConclusionsIt was suggested that C-peptide and glucagon play an important role in hemodialysis-related glycemic variabilities in patients with type 2 diabetic hemodialysis.Trial registration UMIN Clinical Trial Registry (Registration Number UMIN000018707). Registered 18 August 2015, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&language=J&recptno=R000021647.

Continuous glucose monitoring in diabetes patients with chronic kidney disease on dialysis: a meta-analysis.

This review investigates the effectiveness of continuous glucose monitoring (CGM) in diabetes patients who were on routine dialysis. Literature search was conducted in electronic databases and studies were selected by following precise eligibility criteria. Random-effects meta-analyses were performed to estimate: 1) correlations of CGM with other indicators including glycated hemoglobin A<inf>1c</inf> (HbA<inf>1c</inf>), glycated albumin and mean amplitude of glucose excursions (MAGE); 2) mean differences (MDs) in CGM and MAGE values between dialysis and off-dialysis days or during vs before dialysis. There was a good correlation between CGM and self-monitoring of blood glucose values (r=0.837 [95% CI: 0.67, 0.92]). Correlation coefficient between CGM and HbA<inf>1c</inf> was 0.523 (95% CI: 0.422, 0.604) in diabetes patients on dialysis and 0.592 (95% CI: 0.354, 0.757) in diabetes patients without renal failure. Correlation coefficient between CGM and glycated albumin in diabetes patients on dialysis was 0.544 (95% CI: 0.254, 0.744). Average CGM and MAGE values on dialysis day were not significantly different from those of off-dialysis day in diabetes patients (MDs: -0.40 mmol/L [95% CI: -1.06, 0.26]; P=0.23; and MAGE 0.50 mmol/L [95% CI: -0.01, 1.00]; P=0.05). Compared to pre-dialysis values, average CGM and MAGE values were significantly lower during dialysis in diabetes patients (MDs: -2.11 mmol/L [95% CI: -3.25, -0.97]; P=0.0003 and MAGE -2.24 mmol/L [95% CI: -3.99, -0.50]; P=0.01). CGM is an efficient method of glycemic monitoring in diabetes patients on dialysis. CGM had similar correlations with HbA<inf>1c</inf> and glycated albumin.

Association between inflammatory potential of diet and markers of malnutrition in haemodialysis patients.

In this study, we aimed to examine the relationship between energy-adjusted dietary inflammatory index (E-DII) and a comprehensive profile of malnutrition in Iranian haemodialysis (HD) patients. In this cross-sectional study, 291 participants on HD for at least 6 months before enrollment were included. The current dietary intakes of participants were assessed using a 4-d diet diary-assisted recall, including 2 non-dialysis days and 2 dialysis days to calculate E-DII. To determine the malnutrition status of HD patients, BMI, subjective global assessment (SGA), dialysis malnutrition score (DMS) and malnutrition inflammation score (MIS) were used. Overall, 291 HD patients comprised our study population. After controlling for potential confounders, E-DII was associated with a higher risk of malnutrition, as evidenced by SGA (OR = 2·23; 95 % CI: 1·11, 4·49), DMS (OR = 2·31; 95 % CI: 1·16, 4·60) and MIS (OR = 2·50; 95 % CI: 1·28, 4·88). No significant association was detected between E-DII and BMI either before (OR = 1·78; 95 % CI: 0·83, 3·81) or after adjustment for possible confounders (OR = 1·43; 95 % CI: 0·58, 3·54). This study showed that E-DII was significantly associated with reliable malnutrition markers including SGA, DMS and MIS in HD patients. However, further longitudinal studies are warranted to infer a cause-and-effect relationship between DII and malnutrition.

Prescribing Nirmatrelvir/Ritonavir for COVID-19 in Advanced CKD.

Prescribing Nirmatrelvir/Ritonavir for COVID-19 in Advanced CKD.

Utility of Citrate Dialysis in Patients with Contraindication for Heparin in a Limited-Resource Setting

Background: Hemodialysis among critical care patients with acute kidney injury (AKI) is challenging, especially if heparin is contraindicated. Objectives: This study assessed the utility of citrate dialysis for such patients in a limited-resource setting. Methods: In this prospective study, patients were divided into group A (heparin-free saline flush dialysis), group B (heparin-free citrate dialysis without flushing), and group C (heparin-free citrate dialysis with flushing). The subjects underwent completed sustained low-efficiency daily dialysis (blood flow = 150 mL/minute, dialysate = 300 mL/minute) or intermittent hemodialysis (blood flow = 250 mL/minute, dialysate flow = 500 mL/minute). Statistical tests using SPSS software (version 26) were used to determine safety and effectiveness differences. Results: Among 25 patients studied with multiple hemodialysis sessions, blood flow and dialysate flow were observed to be better in heparin-free citrate dialysis with flushing. There were further advantages of lesser dialyzer clotting and more reuse of dialyzers. Metabolic differences were insignificant. Heparin-free citrate dialysis with or without flushing was equally effective and safe, compared to heparin-free saline flush dialysis, in patients with or without liver impairment. Conclusions: Citrate dialysis is observed to be a safe and effective alternative to heparin-free saline flushing dialysis in intensive care unit patients with AKI. More such studies are required in limited-resource settings to utilize citrate dialysis in patients with heparin contraindication.

Comparison of Dietary Inflammatory Index Scores with Inflammatory and Anthropometric Metrics in Individuals Receiving Maintenance Hemodialysis

ObjectivesThe modified dietary inflammatory index (DII) is a scoring tool that reflects inflammatory influence of diet components and has been studied as a predictor of inflammatory markers. This study explored correlations between modified DII scores, C-reactive protein (CRP), and conicity index (Ci) in patients receiving maintenance hemodialysis (MHD). MethodsThis study was a secondary analysis of 142 participants in the Rutgers Nutrition and Kidney Disease database. Food intake data were collected using the NHANES multi-pass method and were reflective of a dialysis treatment day. The modified DII scores were divided into tertiles; tertile 1 had the least inflammatory (negative) and tertile 3 had the most inflammatory (positive) scores. Correlations between DII scores, CRP, and Ci were measured using Spearman’s and Pearson’s Coefficients. Between tertile differences were compared using Kruskal-Wallis and ANOVA. ResultsThe median age was 55.3 years and 59.2% were male. The majority were African American (83.8%) and non-Hispanic (77.5%). The range of modified DII scores was –9.7 to 536.0, and the median score was 203.2, indicating a pro-inflammatory diet. The median scores for tertille 3 (338.1) were significantly higher than tertiles 1 or 2 (114.6 and 201.5, p-value < 0.001). Tertile 3 consumed more omega-3 fats, fiber, calories, total fat, and saturated fat. The median CRP and Ci were 5.6 mg/L and 1.33 ± 0.1, and did not differ significantly by tertile. A non-significant, small, positive correlation was observed between DII scores and CRP (r = 0.161, p = 0.071), but not for Ci (r = 0.046, p = 0.586). ConclusionsThis sample consumed a mostly pro-inflammatory diet. Food selections may be the result of consuming convenience foods on dialysis days, which are generally pro-inflammatory. Regardless, in our sample the pro-inflammatory dietary intakes did not correlate with markers of inflammation, likely due to homogeneity across the tertiles. While exploratory, this tool may assist clinicians in assessing patients on MHD who may benefit from individualized nutrition therapy to reduce their risks for chronic inflammation. Funding SourcesResearch reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (awards 1R15DK090593-01A1,6R15DK090593-02, and 3R15DK090593-02S1).

The Release of a Highly Cytotoxic Paullone Bearing a TEMPO Free Radical from the HSA Hydrogel: An EPR Spectroscopic Characterization.

This study shows the potential of a thermally induced human serum albumin (HSA) hydrogel to serve as a drug depot for sustained release of a highly cytotoxic modified paullone ligand bearing a TEMPO free radical (HL). The binding of HL to HSA was studied by electron paramagnetic resonance (EPR) spectroscopy and imaging. The EPR protocol was also implemented for the study of matrix degradation, and ligand diffusion rate, in two additional spin-labeled hydrogels, containing 5-doxylstearate and 3-carbamoyl-proxyl. The results showed that the hydrogel is an efficient HL reservoir as it retained 60% of the ligand during 11 days of dialysis in physiological saline. Furthermore, upon incubation with Colo 205 human colon adenocarcinoma cells for 3 days, the HL/HSA hydrogel did not exhibit cytotoxic activity, demonstrating that it is also an efficient ligand depot in the presence of living cells. It was observed that the percentage of HL release is independent of its initial concentration in the hydrogel, suggesting that HSA possesses a specific binding site for the ligand, most likely Sudlow site 2, as predicted by molecular docking. The intrinsic property of albumin to bind and transport various substances, including hydrophobic drugs, may be fine-tuned by appropriate physical/chemical hydrogel preparation procedures, providing optimal drug delivery.

Utilization of Home Dialysis and Permanent Vascular Access at Dialysis Initiation Following a Structured CKD Education Program

Rationale & ObjectiveTreatment options for kidney failure are complex, and the majority of patients transitioning to dialysis lack important information about treatment options and are not prepared to make informed decisions about their care. Correspondingly, the majority of patients who start dialysis default to in-center hemodialysis using a central venous catheter for vascular access as the initial modality; furthermore, hospital admissions, mortality, and infections are exceedingly common over the first few months.Study DesignMatched retrospective cohort study.Setting & Patients2,398 adult patients with chronic kidney disease (CKD) who attended a structured CKD education program and pair-matched control patients who did not receive education before starting dialysis between January 2018 and June 2019.ExposureCKD education attendance documented from 2 months (60 days)-3 years before dialysis initiation. CKD education consisted of a 1-time, 90-minute, inperson or virtual class.OutcomePrimary outcomes were dialysis modality and vascular access type on the first day of dialysis (day 0) and at day 90 after dialysis initiation. Secondary outcomes included hospitalizations and deaths during the first year of receiving dialysis.Analytical ApproachGeneralized linear models were used to compare outcomes between patients receiving CKD education and controls.ResultsCompared with controls, CKD education patients were more frequently receiving home dialysis (38.5% vs 12.6%, P < 0.001) and used a permanent vascular access (57.9% vs 33.8%, P < 0.001) at dialysis initiation; differences were minimally attenuated and remained statistically significant at day 90. Hospitalization rates were lower among CKD education patients than among controls during the first year of receiving dialysis (1.00 vs 1.38 admissions per patient-year; P < 0.001). CKD education patients also had lower mortality over the first year of receiving dialysis (P < 0.001).LimitationsBias and confounding cannot fully be accounted for in an observational study. Analyses only included patients with commercial and Medicare insurance who received CKD care before dialysis initiation and may not be generalizable to other patient populations.ConclusionsOur findings indicate that attending a CKD education class before starting dialysis resulted in positive clinical outcomes, including reduction in hospitalization and mortality rates. Broad implementation of structured CKD education may result in more patients choosing home dialysis as their first treatment option and reduce the risk of adverse outcomes in the crucial early period after dialysis initiation.

MO886: Outcomes in Incident Patients Treated With Incremental Haemodialysis as Compared With Thrice-Weekly Haemodialysis and Peritoneal Dialysis: The Geneva Experience

Abstract BACKGROUND AND AIMS Preservation of residual kidney function (RKF) in maintenance haemodialysis (HD) patients is associated with better survival and quality of life. RKF may be better preserved with an incremental HD (frequency &amp;lt; 3x/week) regimen in patients starting HD. Since 2013, incremental HD is routinely used at our centre. METHOD Incremental HD was implemented in incident HD patients with a urine output of &amp;gt;600 mL/day, a urea clearance (KRU) ≥2 mL/min and an interdialytic weight gain &amp;lt; 2.5 kg. Patients were clinically assessed every week and a 24-h urine collection was ordered every other month in order to measure RKF. RESULTS From January 2013 to December 2020, 296 patients started chronic dialysis, with 162 on thrice-weekly HD, 63 on incremental HD and 71 on peritoneal dialysis (PD). Patients on incremental HD did not differ from those on thrice-weekly HD or PD in terms of age, gender and comorbidity score. Diuresis, eGFR and KRU at incremental HD initiation were 1842 ± 749 mL/day, 6.7 ± 3.1 mL/min and 4.0 ± 1.8 mL/min, respectively. Among patients on incremental HD, four could retrieve a sufficient RKF to become dialysis-independent and two were transplanted. Among the 57 remaining patients on incremental HD, median duration until transition to a thrice-weekly HD regimen or death was 10 (6–20) months. Within the first year of dialysis, median survival and hospital-free days were higher in patients starting with incremental HD as compared with thrice-weekly HD: 91% versus 77%, P = 0.02 and 348 (316–362) versus 338 (295–354) days; P = 0.03. CONCLUSION These preliminary results show that incremental HD can be implemented in incident HD patients as long as regular clinical and RKF assessments are found adequate. A median duration of 10 months before transition to thrice-weekly HD can be expected in this setting. Results of randomised clinical trials assessing long-term survival and quality of life in incremental HD are awaited prior to its large-scale implementation.

MO715: The Role of Duration and Modality Choice on Sodium and Water Removal for Peritoneal Dialysis Patients

Abstract BACKGROUND AND AIMS Hypervolemia is common in peritoneal dialysis (PD) and contributes to hypertension and left ventricular hypertrophy, thus increasing the cardiovascular risk of these patients. The achievement of adequate water and sodium balance is considered a major determinant of dialysis adequacy and seems to have a greater effect on PD outcome than Kt/V and small solute clearances. However, the contribution of different PD modalities to dialytic sodium removal remains not well defined. The aim of this study was to explore the effect of different PD modalities on sodium and water removal. METHOD This is a single-center cohort study of 21 patients (m = 12, f = 9). They were examined according to their modality of PD: CAPD (continuous ambulatory PD n = 9) and APD (continuous cycler PD n = 12). CAPD patients’ median age was 74 years (66–79), median time on PD was 37 months (24–59), median Kt/V 2.4 (1.9–3.1) and median eGFR 9.9 mL/min (3.5–12.4). APD patients’ median age was 47 years (32–75), median time on PD 65 months (52–87), median Kt/V 2.439 (2.12–2.8) and median eGFR 2.3 mL/min (0–5). We used the modified peritoneal equilibration test (PET with DW 4.25%) and double mini-PET to calculate the small solute transport rate (D/P of creatinine), water removal (FWT—free water transport, ΔNa—sodium dip, OCG—osmotic conductance of glucose) and mesothelial cell integrity (CA125 appearance rate in dialysis effluent). We also calculate the total amount of sodium excretion from the 24 h PD effluent collection and urine collection. Using bioimpedance spectroscopy we calculate the patients’ total body water, the overhydration and the intracellular and extracellular volume (ECV). RESULTS We did not find between the two groups any statistically significant difference for water movement through the membrane (ΔNa P = 0.427; FWT P = 0.384; OCG P = 0.27), for the marker of mesothelial cell mass (CA125AR P &amp;gt; 0.05) or for hydration status (OH, ECV). There was a statistically significant difference between the two groups for the small solute transport rate (Cr d/p, P = 0.025), for the total daily amount of sodium excretion through the membrane (P &amp;lt; 0.001), i.e. patients on APD having faster solute movement and excrete more sodium during the day compared to CAPD patients. Additionally, from the regression analysis there was statistically significant correlation between the daily dialysis sodium excretion and solute movement (P = 0.007, r = 0.58) and total time on PD (P = 0.004, r = 0.612). CONCLUSION These results indicate that there is no inferiority of APD compared to CAPD for sodium excretion due to the smaller time duration of the cycles (sodium sieving). Additionally, we notice that even though the patients on APD remained longer on PD and received larger daily volumes of PD effluent there was not any difference in mesothelial cell marker or water transport indicators. Inevitable time probably through neo angiogenesis results in faster solute transport.

Safety and Efficacy of Short Daily Hemodialysis with Physidia S3 System: Clinical Performance Assessment during the Training Period.

Background: A growing body of scientific evidence indicates that clinical outcomes of hemodialysis patients can be improved with short daily dialysis treatment. Current in-center hemodialysis machines do not fulfill the requirements needed for self-care home hemodialysis (HHD) treatment. In line with the reviviscence of home therapy, several hemodialysis devices have been developed and deployed for treatment. Physidia S3 is one of these new dialysis delivery systems featuring an appealing design and functionalities intended for daily HHD treatment. Methods: In this French multicenter proof-of-concept study enrolling 13 training centers, we report our preliminary experience with a special focus on quantifying clinical performances in short daily HHD treatment performed during the training period of the patients. Results: Among the 80 patients included in this study, a total of 249 sessions could be analyzed. Dialysis dose, estimated from weekly standardized Kt/V, was maintained at 2.22 [1.95–2.61] with a normalized protein catabolic rate of 0.93 [0.73–1.18] g/kg/24 h. Furthermore, anemia and nutritional status were adequately controlled as indicated by 11.6 ± 1.4 g/dL of hemoglobin level and 39.4 ± 5.7 g/L of serum albumin as well as electrolyte disorders. Conclusions: The safety and efficacy of the S3 therapy concept relying on a short daily hemodialysis treatment using a bagged delivery system are in total agreement with daily HHD recommendations. Clinical performances are aligned to the metabolic needs of the vast majority of HHD patients. Currently ongoing studies at home will provide further evidence and value of this therapeutic approach.

Abstract No.: ABS0279: Retrospective analysis of acute dialysis in ICU setting in a tertiary care hospital

Background and Aims:To study the clinical profile and evaluate in-hospital and 30-day mortality in patients undergoing acute dialysis in the intensive care unit (ICU) in a multi-disciplinary hospital.Methods:Thirty one consecutive patients who underwent acute dialysis between August 2020 and August 2021 in ICU were included in the study. All patients were evaluated with basic clinical assessment, laboratory investigations, indications for dialysis, the process of dialysis, the time lag for initiation of dialysis following the clinician’s orders, an increase in requirement of vasopressors following dialysis, and access for dialysis. Any other complications occurring during dialysis were also noted. All the patients were further evaluated with sequential organ failure assessment (SOFA) score and all the parameters mentioned above as possible predictors of in-hospital and 30-day mortality with logistic regression analysis.Results:Out of 31 patients, 17 had sepsis, six had acute febrile illness, and five had acute myocardial infarction, resulting in dialysis. Common indications were anuria >24 hours, pulmonary oedema, and severe metabolic acidosis. SOFA score was an independent predictor of both in-hospital (p = 0.03) and 30-day mortality (p = 0.048) with an increase of each unit, increasing the 30-day mortality by 1.5 times. Sustained low-efficiency daily dialysis (SLEDD) had 13.5 times higher mortality risk compared to ischaemic heart disease (IHD), inferring that patients with greater haemodynamic lability or vasopressor requirement had higher 30-day mortality.Conclusion:Sepsis remains the most common cause of dialysis in ICU, followed by acute febrile illness, including leptospirosis and dengue. Each unit of increase in SOFA score increases the 30-day mortality by 1.5 times in these patients. SLEDD was associated with a 13.5 times increased risk of mortality over IHD, inferring that patients with haemodynamic lability or vasopressor requirement had higher 30-day mortality.

Delayed gastric emptying in nondiabetic patients with end-stage kidney disease

Objective This study aimed to assess the gastric emptying capacity in nondiabetic patients with end-stage kidney disease (ESKD) by ultrasound. Methods Consecutive hemodialysis patients with ESKD (n = 37) and healthy controls (n = 37) were enrolled. All ESKD patients underwent ultrasound examinations on the day of hemodialysis (dialysis day) and the day after hemodialysis (nondialysis day). Standard ultrasound examinations were performed after overnight fasting, immediately after a light meal, and at 6 h after a meal. The antral cross-sectional area and gastric emptying according to the Perlas grading system were evaluated. Results Compared with the controls, patients with ESKD, on both dialysis and non-dialysis days, had significantly larger antral areas when examined in the supine position (p = 0.002 and p = 0.003, respectively), but not in the right lateral decubitus position (p = 0.452 and p = 0.512, respectively). In the supine position, the antral area of ESKD patients before dialysis (8 a.m. on the dialysis day) was larger than that at the same time on the nondialysis day (p = 0.028). The controls had a Perlas grade of either 0 or 1 at 6 h after a meal, whereas five patients (13.5%) and 11 patients (29.7%) in the ESKD group had Perlas grade 2 on the dialysis and non-dialysis days, respectively. Among patients with or without delayed gastric emptying, no differences were detected in the dialysis duration or levels of biochemical markers, except blood urea nitrogen (p = 0.038) and serum creatinine (p = 0.003). Conclusion Nondiabetic patients with ESKD had significantly delayed gastric emptying. Hemodialysis might improve gastric emptying and reduce gastric emptying delay.

Incidence and management of patients with methotrexate delayed elimination in the clinical practice: A Delphi study.

High-dose methotrexate (HDMTX) is administered for the treatment of some cancers. HDMTX is usually safe but may crystallize in renal tubules causing acute kidney injury (AKI). Consequently, MTX elimination is delayed, resulting in a severe and life-threatening condition. No studies have been published about the impact of MTX toxicity in Spain. This study aims to estimate the incidence and management of MTX delayed elimination and toxicity. A two-round Delphi study was performed to reach consensus between 10 medical experts on haemato-oncology and paediatric oncology with experience in the management of HDMTX treated patients from leading Spanish hospitals. An online questionnaire was developed based on national and international guidelines and previous evidence regarding HDMTX-related toxicity. Consensus was established at 80% agreement. Median and interquartile ranges were calculated, and incidence data were extrapolated to the Spanish general population. Out of 1.475 patients estimated to receive HDMTX treatment annually in Spain, 27.5% present MTX delayed elimination and 11.6% develop HDMTX-induced AKI (35.4% with severe systemic toxicities (>grade 3) and 18.8% develop chronic renal disease). Mortality is estimated in 4.2%. Immuno-enzymatic assay is used in most of the hospitals (90%) for MTX serum level monitoring. All experts use increased supportive care and high leucovorin as first-line treatment. Available treatments in experts' hospitals in case toxicity persists are haemodialysis (90% of hospitals), glucarpidase (60%) and hemofiltration (50%). Most prevalent non-renal systemic toxicities are haematologic and mucositis (21-40% of patients). Patients with HDMTX-induced AKI require from intensive care (5% of patients), more than 3 sessions and 4 days of dialysis, and about 8.5 days of hospitalization (non-ICU patients) and 12 days in case of patients requiring ICU. These results are the first evidence regarding HDMTX-induced AKI in Spain. Incidence and mortality results are in line with previous studies. Clinical management is based on preventive measures and the treatment depend on the availability in the hospital. The need for effective, safe and rapid treatment for the reduction of MTX toxic levels and the improvement of monitoring methods were noted by experts as urgent needs. Further observational studies to validate these results would be needed.

Impact of measurement timing on reproducibility of testing among haemodialysis patients

Accurate evaluation of physical function in patients undergoing haemodialysis is crucial in the analysis of the impact of exercise programs in this population. The aim of this study was to evaluate the reproducibility of several physical functional tests, depending on the timing of their implementation (before the HD session vs. non-HD days). This is a prospective, non-experimental, descriptive study. Thirty patients in haemodialysis were evaluated twice, 1 week apart. The test session was performed before the haemodialysis session started and a retest was performed in non-dialysis day. The testing battery included the short physical performance battery, sit-to-stand tests, 6 min walk test, one-leg stand test, timed up and go, and handgrip strength with and without forearm support. The intra-rater reproducibility was determined by the intraclass correlation coefficients and the agreement was assessed by Bland–Altman analysis. The intraclass correlation coefficients values ranged from 0.86 to 0.96, so that all tests showed good to very good relative reliability. The mean differences between trials of sit to stand 10 and 60, timed up and go and all the handgrip tests were close to zero, indicating no systematic differences between trials. Large range of values between trials was observed for the 6 min walk test, gait speed, one-leg stand test and short physical performance battery, indicating a systematic bias for these four tests. In conclusion, the sit to stand 10 and 60, timed up and go and handgrip tests had good to excellent test–retest reliability in measuring physical function in different dialysis days of patients undertaking haemodialysis. The minimal detectable change values are provided for this population. Bias were found for the 6 min walk test, gait speed, Short physical performance battery or one-leg stand test when the testing day changed.

Intradialytic hypotension and objectively measured physical activity among patients on hemodialysis

Intradialytic hypotension is related to patient-reported outcomes such as post-dialysis fatigue, but its impact on physical activity has not been fully studied. We aimed to examine the relationship between intradialytic blood pressure (BP) and objectively measured physical activity. In this cross-sectional study, 192 hemodialysis patients underwent 4weeks of physical activity measurement using triaxial accelerometers to measure step counts and moderate-to-vigorous physical activity (MVPA). Intradialytic BP parameters (pre-dialysis BP, post-dialysis BP, nadir BP, and fall in BP) were measured during all dialysis sessions. Mixed-effects linear regression models were used to analyze associations between intradialytic BP parameters and physical activity (1) after dialysis sessions on dialysis days and (2) on the following non-dialysis days. The mean age of the patients was 71years, and 47% had diabetes mellitus. Valid physical activity data were obtained in a total of 1938 dialysis days and 2629 non dialysis days. Lower nadir diastolic BP was significantly associated with lower step counts and shorter moderate-to-vigorous physical activitynot only on dialysis days but also on the following non-dialysis days. Nadir diastolicBP showed a higher discrimination capacity for physical inactivity, defined as a step count < 4000 on non-dialysis days, than the other BP parameters. The optimal cutoff point of nadir diastolicBP for discriminating physical inactivity was 68mmHg; its sensitivity and specificity were 66% and 67%, respectively. Lower nadir diastolicBP was strongly associated with lower physical activity on both dialysis and non-dialysis days. Nadir diastolicBP may be a predictor for physical inactivity.

Influence of mild pulmonary congestion on diaphragmatic mobility and activities of daily living in chronic kidney disease: An experimental and clinical study

BackgroundPulmonary congestion is a strong predictor of mortality and cardiovascular events in chronic kidney disease (CKD); however, the effects of the mild form on functionality have not yet been investigated. The objective of this study was to assess the influence of mild pulmonary congestion on diaphragmatic mobility (DM) and activities of daily living (ADL) in hemodialysis (HD) subjects, as well as compare ADL behavior on dialysis and non-dialysis days. In parallel, experimentally induce CKD in mice and analyze the resulting pulmonary and functional repercussions. MethodsThirty subjects in HD underwent thoracic and abdominal ultrasonography, anthropometric assessment, lung and kidney function, respiratory muscle strength assessment and symptoms analysis. To measure ADL a triaxial accelerometer was used over seven consecutive days. Twenty male mice were randomized in Control and CKD group. Thoracic ultrasonography, TNF-α analysis in kidney and lung tissue, exploratory behavior and functionality assessments were performed. ResultsMild pulmonary congestion caused a 26.1% decline in DM (R2=.261; P=.004) and 20% reduction in walking time (R2=.200; P=.01), indicating decreases of 2.23mm and 1.54min, respectively, for every unit increase in lung comet-tails. Regarding ADL, subjects exhibited statistically significant differences for standing (P=.002), walking (P=.034) and active time (P=.002), and number of steps taken (P=.01) on days with and without HD. In the experimental model, CKD resulted in increased levels of TNF-α on kidneys (P=.037) and lungs (P=.02), attenuation of exploratory behavior (P=.01) and significant decrease in traveled distance (P=.034). Thoracic ultrasonography of CKD mice showed presence of B-lines. ConclusionThe mild pulmonary congestion reduced DM and walking time in subjects undergoing HD. Individuals were less active on dialysis days. Furthermore, the experimental model implies that the presence of pulmonary congestion and inflammation may play a decisive role in the low physical and exploratory performance of CKD mice.

Accelerometry Correlates in Body Composition, Physical Fitness, and Disease Symptom Burden: A Pilot Study in End-Stage Renal Disease.

There is strong evidence that hemodialysis (HD) patients with a sedentary lifestyle have a higher risk of death compared to peers who engage in regular physical activity. Therefore, monitoring physical activity is of utmost importance. However, there is a lack of data on objectively measured physical activity behaviors in HD patients. Therefore, this study aimed to objectively measure physical activity in HD patients throughout the week, with particular attention to dialysis and non-dialysis days. We also examined how objectively measured physical activity correlated with physical fitness, body composition, and disease burden. Daily physical activity, body composition, serum parameters, comorbidity index, sit-to-stand, and hand-grip strength tests were measured in 14 HD patients. Daily physical activity was measured using the Actigraph GT9X accelerometer. The Dialysis Symptom Index questionnaire was also used. We found significant differences in anthropometric variables (weight, body mass index, overhydration, lean tissue index, and fat tissue index, all p < 0.05) and phase angle (p < 0.01) between HD patients reaching and patients not reaching physical activity guidelines for patients with chronic diseases. HD patients showed to be less active during dialysis days compared to non-dialysis days as indicated in sedentary time (–11.7%; p = 0.001), light (–47.3%; p = 0.003), moderate (–51.5%; p = 0.001), moderate to vigorous (–49.3%; p = 0.001), and vigorous (–34.3%; p = 0.067) physical activity. No significant correlations were found among serum parameters, symptom burden, and comorbidity burden, but a very large and positive correlation was found between phase angle and total moderate to vigorous physical activity (p < 0.01). Our findings support the need to implement physical activity on dialysis days in HD units to mitigate the effects of sedentary behavior. Prospective, long-term studies evaluating the use of accelerometers in HD patients and their effects on physical activity are needed.

Quality assuring early dialysis care: evaluating rates of death and recovery within 90 days of first dialysis using the UK Renal Registry.

Kidney disease registries typically report populations incident to kidney replacement therapy (KRT) after excluding reversible disease. Registry-based audit and quality assurance is thus based on populations depleted of those with the highest early mortality. It is now mandatory for UK kidney units to report all recipients of dialysis, both acute and chronic. This work presents 90-day survival and recovery outcomes for all reported adults. Seventy adult centres reporting to the UK Renal Registry were included. Those assessed as underreporting death and recovery were excluded. Survival was evaluated using a Kaplan-Meier estimator. Cox regression was used to describe hazard ratios (HRs) for age, sex and acute/chronic dialysis coding on day 1. Analysis of all-cause 90-day mortality with recovery as a competing risk is presented. Twenty-four centres were assessed as underreporting, with rates of death/recovery below the 99.7th centile. Of 5784 dialysis starters in the remaining 46 centres, 2163 (37.4%) were coded as receiving acute dialysis on day 1. Ninety days after starting, 3860 (66.7%) of all starters were receiving KRT, 1157 (20.0%) were alive having stopped, 716 (12.4%) were dead and 51 (0.9%) were lost to follow-up. Mortality was higher among those coded as receiving acute dialysis on day 1 (HR 4.88, P<0.001). The sub-HR for recovery among those coded as receiving acute compared with chronic dialysis was 56.14 (P<0.001). Death and recovery rates are substantially higher than reported in conventional incident populations. This work highlights a vulnerable subgroup of patients largely overlooked by most national quality assurance systems.