Peritoneal dialysis catheter malfunction compromises dialysis adequacy. Standard imaging methods in the case of peritoneal catheter malfunction include abdominal X-ray, fluoroscopic catheter peritoneography, and computed tomography. Ultrasound has only recently been utilized to evaluate the intraperitoneal part of the catheter. In clinical routine, catheter function is assessed by the time needed to fill or drain a defined quantity of peritoneal dialysis fluid. Visual functional testing of the catheter can be performed by fluoroscopy or by contrast-enhanced ultrasound. We developed and tested a color Doppler ultrasound technique for dynamic imaging of the peritoneal catheter based on signal generation by dialysis fluid flow. The feasibility of the color Doppler approach was evaluated utilizing a phantom. Furthermore, the technique was applied in 28 peritoneal dialysis patients, most of whom presented peritoneal catheter malfunction. Color Doppler examination improved the cathetervisualization, especially in cases in which the catheter is embedded between the intestinal loops. Furthermore, this technique highlightedcatheter side holeocclusionsbyadhesions or intraluminal thrombi. The examination can be performed either during filling or draining of dialysis fluid. The color Doppler ultrasound technique appears to be helpful inidentifying problem-solving strategies in malfunctioning peritoneal catheters.

This retrospective longitudinal cohort study aimed to compare the clinical differences between patients with diabetic nephropathy (DN) and non-diabetic nephropathy (NDN) undergoing maintenance hemodialysis and to investigate the influencing factors and clinical significance of phase angle (PhA) in DN patients. Hemodialysis patients (n = 48), including 23 with DN and 25 with NDN, were enrolled in this study. Body composition parameters were assessed using bioelectrical impedance analysis (BIA), and various biochemical indices were collected. The follow-up period was extended to 5 years. To investigate the relationship between PhA, nutritional status, and other clinical factors, univariate analysis, principal component analysis (PCA), and logistic regression analysis were employed. Comparative analysis demonstrated significant pathophysiological divergence between groups. DN patients exhibited reduced dialysis adequacy (kt/V: 1.424 ± 0.215 vs. 1.57 ± 0.210, p = 0.021) and impaired cellular integrity evidenced by lower PhA values (4.358 ± 1.044 vs. 5.031 ± 1.23°, p = 0.048). Fluid overload patterns distinctly characterized DN patients, with elevated extracellular water ratios (ECW/TBW: 40.265 ± 1.262% vs. 39.282 ± 1.858%, p = 0.039; ECW/ICW: 63.426 ± 3.774 vs. 61.128 ± 3.244, p = 0.028). PhA demonstrated strong inverse correlations with fluid retention parameters (ECW/TBW: r = -0.954, p<0.001; ECW/ICW: r = -0.946, p < 0.001) and positive associations with nutritional metrics including Fat-Free Mass Index (FFMI)(r = 0.496, p = 0.016), muscle circumference index (MCI) (r = 0.494, p = 0.017), Geriatric Nutritional Risk Index (GNRI) (r=0.511, p = 0.013), and serum creatinine (Cr) levels (r = 0.448, p=0.032). High hydration status and low muscle mass were identified as critical factors influencing the reduced PhA observed in DN patients. Significant differences in body composition and PhA exist between maintenance hemodialysis patients with DN and NDN. Low PhA is closely associated with malnutrition and can serve as an effective indicator for evaluating the nutritional status of DN patients.

Introduction: Reducing dialysate flow (Qd) to 400 mL/min has proven to be sufficient, safe, and effective in meeting dialysis adequacy requirements in adults, with the added advantage of decreasing water consumption per dialysis session. Expanded hemodialysis (HDx), which uses dialyzers with membranes capable of enhanced clearance of medium-sized molecules due to expanded pore capacity, has higher efficiency and reduces the importance of the dialysate-to-blood flow ratio (Qd/Qb) for molecule removal. The objective of this study was to evaluate dialysis effectiveness by analyzing the reduction rate of medium-sized molecules in patients weighing ≤70 kg, comparing Qd 400 mL/min vs. 500 mL/min in HDx using Theranova® membrane. Methods: A post hoc analysis of the COREXH study population was performed. This observational, analytical, retrospective cohort study included 23 patients, of whom 11 (47%) had Qd 400 mL/min and 12 (52.1%) had Qd 500 mL/min. Results: No statistically significant differences were observed in the reduction rate of medium-sized molecules between the Qd 400 mL/min and 500 mL/min groups. Additionally, water consumption was lower in the Qd 400 mL/min group, with an average saving of 24 L per patient per session and 13,824 L over 12 weeks. Conclusion: Using Qd 400 mL/min in HDx vs. 500 mL/min did not affect dialysis effectiveness in terms of molecule reduction rates and resulted in substantial water savings in Qd 400 mL/min group.

To evaluate whether acquisition of independent dialysis facilities by large chains is associated with changes in clinical quality metrics and patient-reported experiences of care. We conducted a longitudinal cohort study using 2016-2020 data from Medicare Dialysis Facility Care Compare (DFC) and In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS). Facility acquisition was defined as the transition of a nonchain-owned facility to chain ownership. We estimated within-facility changes in clinical and patient-reported outcomes after acquisition using linear regression with facility and year fixed effects, adjusting for ownership type and facility size. Among 4,627 facilities in the DFC sample and 1,377 in the ICH-CAHPS sample, acquisition was associated with a 3.0% relative increase in hospitalization rates, a 9.4% increase in infection rates, and a 0.5% decline in dialysis adequacy. Patient-reported experiences showed a statistically significant 1.0% decline in reported information sharing while other experience metrics trended negatively but were not statistically significant. Facility acquisition was associated with worsening clinical performance and small declines in patient experience. These findings suggest consolidation may negatively affect dialysis care quality, underscoring the need for closer oversight of industry mergers.

To determine the prevalence of frailty in maintenance hemodialysis (MHD) patients and its influencing factors. A systematic review and meta-analysis. PubMed, Embase, Web of Science, Cochrane Library, CINAHL, SinoMed, China Knowledge Resource Integrated Database, Wanfang Database, and Weipu Database were searched from inception until June 2025. Reviewers independently selected studies, extracted data, and assessed study quality. Data were analyzed using STATA software version 17.0. The PRISMA checklist was used to review this study. A total of 30 studies were included in this meta-analysis, involving 6,944 participants. The overall prevalence of frailty in MHD patients was 36.5%. Twenty-nine influencing factors were included in the analysis, and we screened ten risk factors associated with MHD frailty. Among socio-demographic factors, older age (P < 0.001) and living alone (P = 0.033) were significant predictors of frailty in MHD patients. Comorbidities (P = 0.014) are also one of the important risk factors. Complications include Charlson comorbidity index (P = 0.002), diabetes mellitus (P = 0.028), cardiovascular disease (P = 0.014), and cerebrovascular diseases (P = 0.029). In dialysis-related factors, only inadequate dialysis adequacy (P = 0.027) showed a significant correlation with MHD frailty. Depression (P = 0.005) is the only psychological factor associated with MHD frailty. Among physiological factors, lower serum albumin (P = 0.004), C-reactive protein (P = 0.005), nutrition with lower the Malnutrition-Inflammation Score (P = 0.002), lower grip strength (P = 0.001), and sleep disorders (P = 0.047) are the main risk factors. The results of this study suggest that frailty has a relatively high prevalence in MHD patients. Ten risk factors for frailty in MHD patients were identified. Healthcare professionals should regularly assess the signs of frailty in MHD patients and construct risk prediction models to identify high-risk groups. In addition, we should pay further attention to modifiable risk factors and provide early targeted interventions to reduce the incidence of adverse events.

Dialysis adequacy revisited: Kt/V's blind spot for phosphorus and iodine

Abstract Background and Aims Many individuals receive twice-weekly haemodialysis with an aim to increase dialysis frequency or as a step towards withdrawing renal replacement therapy. We aim to describe a cohort of individuals who receive long term twice-weekly haemodialysis in a single centre and compare their clinical outcomes, quality of life (QoL) measures and dialysis efficacy with a matched group receiving thrice-weekly dialysis in the same centre. Method In this centre with 110 haemodialysis patients, 16.3% receive twice-weekly dialysis. 15 twice-weekly patients were matched by age and sex with 26 patients on thrice-weekly dialysis. Data on biochemical parameters, dialysis adequacy and hospital admissions were retrospectively collected for a 12-month period from electronic patient records and IPOS-Renal QoL questionnaires were collected for service evaluation. Results Twice-weekly (n = 15) and thrice-weekly (n = 26) groups were of comparable Charlson Comorbidity index (6.87 vs. 7.04). The Edmonton Frailty Scale was higher in the thrice-weekly group (mean= 7.1 vs. 5.8). Median dialysis vintage in the twice- and thrice-weekly groups were 37 months (Q1–Q3 = 59) and 37 months (Q1–Q3 = 45) respectively. One third of the twice-weekly group had reduced the number of days since commencing dialysis. This subgroup had spent approximately half (54.2%) of their time on dialysis receiving twice-weekly treatment. Thrice-weekly patients received a mean 11.28 (±1.47) hours/week of haemodialysis, compared to 6.91 (±1.26) hours/week in the twice-weekly cohort. Haemoglobin and potassium levels remained within safe parameters in the twice-weekly cohort with a mean Kt/V of 1.46 (±0.31) (Fig. 1). In a single 24-hour urine collection, the twice-weekly patients had greater urinary volumes [0.87 (0.64) vs. 0.37 (0.62) L/24 hrs, median (Q1–Q3)]. The thrice-weekly patients had more than double the number of hospital presentations in the study year (4.54 vs. 2.13, per person-year). The greatest cause for presentation was infection in both groups (44% vs. 43%) (Table 1). More of the thrice-weekly group reported itching, sore or dry mouth and poor appetite. However, fewer of this group reported shortness of breath and drowsiness (Fig. 2). Reporting of psychological symptoms did not appear to differ between the groups. More of the thrice-weekly group reported that practical problems from their illness had not been addressed (50% vs. 20%), and that up to, or more than half of their day is wasted on healthcare appointments (45% vs. 10%). Conclusion We observed comparable dialysis safety and adequacy in twice- and thrice-weekly haemodialysis patients matched for age and sex. The twice-weekly population were less frail, had fewer hospital presentations and reported better QoL in some domains. This supports the hypothesis that in carefully selected individuals, long-term twice-weekly haemodialysis schedules may be safe, and potentially beneficial. In a dialysis population that is increasingly old and frail, person-centred care becomes even more paramount. Tailoring haemodialysis prescription to meet shared goals of care may improve QoL of older people treated with haemodialysis. Further work must identify more clearly which patients could be offered twice-weekly dialysis without risk of adverse outcomes.

Abstract Background and Aims Sleep disturbances, including sleep-disordered breathing (SDB), insomnia, and poor sleep quality, are highly prevalent among hemodialysis patients. These issues not only impair quality of life but also worsen cardiac comorbidities, increasing morbidity and mortality risks. Despite their impact, sleep disturbances are often underrecognized and undertreated, particularly in resource-limited settings where costly diagnostics like polysomnography are inaccessible. This study aimed to identify risk factors for poor sleep quality and sleep disorders and demonstrate how validated, cost-effective screening questionnaires can identify high risk hemodialysis patients and eventually improve dialysis outcomes in Filipino hemodialysis patients. Method A cross-sectional study was conducted involving 51 hemodialysis patients. Data on demographics, dialysis adequacy (Kt/V), body mass index (BMI), and sleep outcomes were collected. Validated tools, including the Berlin q uestionnaire, Insomnia Severity Index (ISI), and Pittsburgh Sleep Quality Index (PSQI), were used to assess sleep disturbances. Statistical analyses were performed to identify significant associations. Results The prevalence of SDB, moderate insomnia, and poor sleep quality was 68.6%, 31.4%, and 72.5%, respectively. Male sex was significantly associated with SDB (77.1% vs. 25%, P = 0.0005), moderate insomnia (81.3% vs. 51.4%), and poor sleep quality (73% vs. 28.6%). Inadequate dialysis adequacy (Kt/V &amp;lt;1.2) was strongly associated with SDB (54.1% vs. 0%), moderate insomnia (75% vs. 22.9%), and poor sleep quality. Overweight and obese patients were also more likely to have SDB (31.4% and 11.4%) and moderate insomnia (50%). Conclusion Male sex, poor dialysis adequacy, and elevated BMI are significant risk factors for sleep disturbances in hemodialysis patients. Routine screening using validated questionnaires (Berlin, ISI, PSQI) offers a cost-effective strategy to identify high-risk individuals in resource-limited settings like the Philippines. Early detection allows nephrologists to implement timely interventions that improve dialysis adequacy, address weight management, and reduce complications such as cardiac comorbidities. For high-risk patients, recommending more objective assessments like polysomnography ensures comprehensive care and supports better long-term health outcomes and quality of life.

Abstract Background and Aims Retention of larger middle molecules is a factor for increased mortality in maintenance hemodialysis patients. With their unique architecture, medium cut-off (MCO) membranes provide the benefit of removal of middle and large middle molecules. Such property of hemodialysis with MCO membranes removing an expanded set of molecules adds the name of expanded hemodialysis (HDx) to this modality. HDx may be comparable to post-dilution hemodiafiltration (HDF) for large middle molecules removal. Furthermore, HDx may be more favorable than HDF as this modality results in less albumin loss than HDF. This study aimed to analyze the removal of middle molecule β2-microglobuline and larger molecules IL-6 and TNF-alfa after switching from high-flux dialyzers to MCO membranes in a group of maintenance hemodialysis patients. Two different MCO dialyzers (Nipro-Elisio™-17H and Baxter-TheranovaTM-B400) are also compared with each other. Method Maintenance hemodialysis patients who have been dialyzed thrice weekly with high-flux membranes for more than a year were eligible to be involved in the study. Those who had active infections, malignancies, bleeding diathesis or received any immunosuppressive agents in the last 6 months were excluded from the study. After receiving patients’ informed consent, high-flux membranes were switched to one of the MCO dialyzers. Allocation to one of the MCO dialyzers was decided with a lottery. Patients received HDx thrice weekly for a month. Ultrafiltration was adjusted according to dry weight of the patients. At the end of one month, patients’ dialysis adequacy, average heparin dose, complete blood count, electrolytes, parathormone, C-reactive protein, cholesterol, ferritin, albumin, β2-microglobuline, IL-6 and TNF-alfa levels were compared with the day when high-flux membranes were switched to one of the MCO membranes. Results The study included 60 patients, 29 used Elisio™-17H and 31 used TheranovaTM-B400 membranes. Patients were 58.7 ± 13.4 years old and their dialysis vintage was 65.8 ± 58.6 months. At the end of one month with MCO membranes, a statistically significant decrease in β2-microglobuline levels (33.8 ± 9.3 mg/L vs 30.3 ± 7.3 mg/L; P = 0.02) was observed. There was also a significant tendency of decreasing low density lipoprotein (LDL) levels (71.5 ± 30.3 mg/dL vs 61.1 ± 29.5 mg/dL; P &amp;lt; 0.01). However, albumin loss was also significant with decreased levels at the end of one month with MCO membranes (38.1± 2.9 g/L vs 36.9 ± 3.2 g/L). Comparisons of other parameters can be found in Table 1. In addition, a switch to MCO dialyzers resulted in more clotting episodes in extracorporeal circuit and higher heparin doses had to be used (3768.5 ± 1287.5 vs 3972.2 ± 1438.7 IU; P &amp;lt; 0.01). When changes in these parameters were compared between two different MCO dialyzers, there was no statistically significant differences. Conclusion MCO dialyzers provide the benefit of better removal of middle-sized molecule such as β2-microglobuline. However, more albumin loss and circuit clotting may be observed with these membranes and necessary precautions should be taken in order to increase the efficiency of using these dialyzers.

Abstract Background and Aims The substitution of acetate with citrate, as a stabilizer, in hemodialysis fluid induces hemodynamic stability, producing less hypotension and inflammation and improves nutritional status [1]. It also modifies several parameters of bone mineral metabolism as it lowers preHD ionic calcium and elevates PTH levels [1]. Plasma vitamin C is positively associated with the lumbar spine bone mineral density (BMD) in young and early middle-aged men [2]. It is also considered to reduce erythropoietin supplementation needs through elimination of inflammation [3, 4]. However, impact of long-term use of citrates- VitC dialysate has not been described. Method We randomized 48 stable hemodialysis patients to receive either citrate-VitCD or acetateD as a stabilizer in hemodialysis fluid and checked them prospectively for 12 months. BMD, CKD-MBD markers, electrolytes, HCO3−, dialysis adequacy and hemoglobin were compared at start, 6 months and 12 months of observation. Medication and adverse events were recorded. Results There was no difference between two groups in demographic characteristics, biochemical parameters and BMD markers (Tscore femur-spine, Zscore femur-spine) on time 0, 6, 12 months. However, BMD markers deteriorated irrespective of the dialysate type during the follow up year. In patients on citrate-VitCD, Tscore spine and Tscore femur worsened on 6 months and stabilized on 12 months (Tspine0 vs Tspine6, P = 0.003, Tspine6 vs Tspine12 P = 0.17 and Tfemur0 vs Tfemur6, P = 0.0005, Tfemur6 vs Tfemur12, P = 0.014 respectively). As for patients on acetateD, Tscore spine and Tscore femur also worsened (Tspine0 vs Tspine6, P = 0.268 Tspine6 vs Tspine 12, P = 0.01 and Tfemur0 vs Tfemur6, P = 0.03, Tfemur6 vs Tfemur2, P = 0.9 respectively). Ratio ESA/Hb did not differ between two groups during the follow-up period. No adverse events were recorded. Conclusion In the present cohort use of citate-vitC dialysate did not seem to improve Bone Density Markers. In both groups, osteopenia deteriorated following the same pattern at the end of the follow-up year. Contrary to previous reports ionized calcium levels were unaffected from the use of citrate-vitCD in the long term. Dialysis adequacy was similar between the two groups. Likewise, erythropoietin supplementation needs did not alter during this time. In the absence of long-term studies, our results are valid and indicative of real-world impact of citrate-vitC dialysate.

Abstract Background and Aims Many fields are shifting towards a more sustainable approach. This includes nephrology, with the rise of “Green Nephrology.” Dialysis, a lifesaving therapy for millions of patients, is undeniably one of the medical practices with the most significant environmental impact, due to its production of non-recyclable waste materials and its substantial water consumption. Considering an average reduction in dialysate flow (Qd) of 150 mL/min per patient, each individual undergoing chronic dialysis, would reduce water consumption by approximately 5,200 litres annually. If we multiply this to the estimated 3.5 million patients globally receiving chronic dialysis, this reduction would result in a total savings of approximately 18 billion litres of water per year. Our study aims to investigate the short-term outcomes of Qd reduction on dialysis adequacy, in terms of serum potassium concentration [K+] and Kt/V. This analysis was conducted in both hemodialysis (HD) and hemodiafiltration (HDF). Method We conducted a prospective experimental study involving 11 patients (5 male, 6 female; mean age 72.2, range 34–93) who were selected based on their stability in terms of hemodynamic and vascular access and divided into two groups: 6 patients in hemodialysis (HD) and 5 in hemodiafiltration (HDF). The study design alternated between high dialysate flow (Qd) (600 mL/min in HD, 500 mL/min in HDF) and low dialysate flow (Qd) (400 mL/min in both HD and HDF; 1 patient in HDF 300 mL/min) dialysis therapies over 10 consecutive dialysis sessions. Pre- and post-dialysis [K+] and Kt/V were measured; Kt/V was calculated by taking the arithmetic mean of the Kt/V values obtained from the dialysis machine and the Kt/V single pool calculated using the Daugirdas formula. Regarding HDF, the substitution volume was also measured. Throughout the entire evaluation period, all patients were treated using the same dialysis machine, filters and dialysate potassium concentration. Additionally, all patients underwent dialysis sessions of the same duration, maintaining fixed blood flow rates (Qb) (9 out of 10 Qb 300 mL/min, 1 patient Qb 250 mL/min due to vascular access issues). Results In Group 1 (HD), the mean Kt/V was 1.5 with high Qd and 1.4 with low Qd (P = 0.33). Pre-dialysis mean [K+] was similar between high and low Qd (5.1 vs 5.2 mEq/L, P = 0.59), and post-dialysis mean [K+] was also comparable (3.7 vs 3.9 mEq/L, P = 0.52). 4 out of 6 patients in Group 1 achieved a Kt/V ≥ 1.2 in both high and low Qd sessions. Only 1 patient (HD) demonstrated, after just four dialysis sessions, mean Kt/V values ≥ 1.2 during sessions with Qd 600 mL/min and mean Kt/V values &amp;lt; 1.2 during sessions with Qd 400 mL/min. Consequently, this patient was excluded from the study to prevent potential long-term issues due to a reduced dialysis adequacy. 1 patient (HD), who received hemodialysis with a Qb of 250 mL/min due to vascular access-related issues, presented mean Kt/V values &amp;lt; 1.2, both during hemodialysis with high Qd (600 mL/min) and low Qd (400 mL/min). In Group 2 (HDF), the mean Kt/V was 1.67 with high Qd and 1.62 with low Qd (P = 0.57). Pre-dialysis mean [K+] was 5.3 mEq/L with high Qd and 5.2 mEq/L with low Qd (P = 0.55), and post-dialysis mean [K+] was also comparable (3.8 mEq/L vs 3.9 mEq/L, P = 0.46). All patients in Group 2 achieved a Kt/V ≥ 1.2 in both high and low Qd sessions. None of the patients analysed experienced death or critical events during the course of the study. Conclusion We hypothesize that hemodynamically stable patients with good vascular access often exceed the optimal Kt/V threshold. In these selected individuals, reducing the dialysate flow (Qd) could lead to significant water savings without compromising dialysis adequacy, in terms of Kt/V and serum potassium concentration. However, consistent with the limited studies currently available in the literature, Kt/V fluctuations may occur, which could benefit, albeit minimally, from a higher Qd. A minority of patients may achieve a Kt/V below the threshold considered optimal with low Qd, while achieving a Kt/V within optimal limits with high Qd. Therefore, further analysis of long-term effects, considering additional parameters will be essential.

Introduction: The standard dialysate flow (Qd) for hemodialysis (HD) is currently set at 500 mL/min. One potential, sustainable, and cost-effective solution for eco-friendly HD may involve reducing Qd to limit wastewater. However, the effect of reduced Qd on small molecule and middle molecule (MM) removal remains to be investigated. Methods: In this prospective observational study, 74 patients on different maintenance dialysis modalities with Qd set at 500 mL/min (Qd500) were assigned to receive Qd at 400 mL/min (Qd400) for 3 months. Dialysis adequacy, including small solute removal and MM reduction ratio (RR), was evaluated at enrollment and after 3 months. Results: Compared to Qd500, Qd400 after 3 months achieved similar single-pool Kt/V (1.41 ± 0.30 vs. 1.43 ± 0.33, p = 0.58), equilibrated KT/V, urea RR, creatinine RR, and phosphate RR. Qd400 vs. Qd500 provided significantly higher beta2-microglobulin RR (77.0 [71.4–81.7] vs. 74.7 [68.4–79.4] %, p = 0.009) and lower kappa free light chain (FLC) RR (54.2 [42.1–64.4] vs. 57.6 [41.6–65.0] %, p = 0.03), whereas myoglobin and lambda FLC RR were similar. Qd400 resulted in higher pre-dialysis urea (20.2 ± 5.5 vs. 18.2 ± 6.2 mmol/L, p = 0.002), creatinine (694.0 ± 179.5 vs. 665.6 ± 220.4 µmol/L, p = 0.029), beta2-microglobulin (26.5 [23.0–30.0] vs. 23.5 [20.0–28.0] mg/L, p = 0.0001), and myoglobin (174.0 [122.0–251.0] vs. 159.5 [119.0–195.0] µg/L, p = 0.033) levels. Pre-dialysis levels of albumin, potassium, bicarbonate, phosphate, and calcium were similar between Qd400 and Qd500. Conclusion: Three months of Qd at 400 mL/min appears to provide similar small molecule and MM removal, but with an increase in pre-dialysis urea, creatinine, beta2-microglobulin, and myoglobin levels. Although this strategy could help preserve water, its potential impact on long-term clinical outcomes deserves further evaluation.

Abstract Background and Aims Remote ischemic preconditioning (RIPC), characterized by transient cycles of ischemia-reperfusion, has demonstrated organ-protective effects against ischemic injury. Hemodialysis (HD) is associated with microcirculatory disturbances, endothelial dysfunction, oxidative stress, and systemic inflammation, which may exacerbate tissue ischemia. This study aimed to evaluate the impact of RIPC on dialysis adequacy, hematological parameters, and cardiovascular outcomes in HD patients. Method In this single-blind randomized controlled trial, 55 patients on maintenance HD (&amp;gt;1 year) were allocated to an intervention group (n = 30) receiving RIPC (three cycles of 5-minute ischemia at 200 mmHg via sphygmomanometer cuff on the non-access arm, followed by 5-minute reperfusion) prior to each HD session for 12 weeks, or a control group (n = 25). Dialysis adequacy was assessed via single-pool Kt/V and urea reduction ratio (URR). Hematological parameters (hemoglobin, hematocrit, neutrophil-lymphocyte ratio) and cardiovascular metrics (trans-thoracic echocardiography) were evaluated Results Baseline demographics (age: 41 ± 10 vs. 36 ± 12 years; sex, dialysis vintage) were comparable between groups (P &amp;gt; 0.05). Post-intervention, intragroup analysis revealed a significant increase in Kt/V within the RIPC group (1.24 ± 0.23 to 1.36 ± 0.23, P = 0.04), though between-group differences in Kt/V (P = 0.6) and URR (P = 0.5) were nonsignificant. Hemoglobin levels were higher in the RIPC group versus controls (11.7 ± 1.2 vs. 11.1 ± 1.0 g/dL, P &amp;lt; 0.05), with no significant changes in hematocrit, platelets, or inflammatory markers. Echocardiography demonstrated a reduction in intraventricular septal diameter post-HD in the RIPC group (1.39 ± 0.34 to 1.17 ± 0.30 cm) versus controls (1.33 ± 0.29 to 1.32 ± 0.26 cm; P = 0.01), suggesting cardioprotective effects. Conclusion RIPC may offer potential benefits in anemia management and cardiovascular remodeling in HD patients, though its impact on dialysis adequacy remains inconclusive. These findings warrant further investigation into RIPC as an adjunctive therapy to mitigate HD-associated complications.

Abstract Background and Aims On October 7, 2023, following the attack by Hamas, the “Iron Swords” war broke out in Israel. Since the onset of the war approximately half of the dialysis units in various regions and at different times have been under threat of rocket attacks. This unpredictable attacks may have negative psychological effects on the general population and, in particular, on dialysis patients. Depression and anxiety among dialysis patients may negatively impact their mental health. Prolonged mental stress can worsen existing conditions, affect the effectiveness of dialysis treatments, reduce adherence and persistence in treatments, and shorten dialysis sessions. To the best of our knowledge, no studies have been published examining the impact of war and terrorist attacks on the development of depression and anxiety symptoms among patients undergoing chronic hemodialysis. The current study aimed to assess the impact of the “Iron Swords” war on the development and persistence of symptoms of depression and anxiety among chronic hemodialysis patients in the Nephrology and Hypertension Department at Barzilai University Medical Center in Ashkelon, located less than 20 kilometers from Gaza, with more than 1000 rocket attacks during the first few weeks of the war. The study also sought to evaluate factors that may contribute to the development of these symptoms and to examine their impact on dialysis quality. Method This is a prospective, descriptive, and quantitative study that included 30 adult patients, who have been on chronic hemodialysis for at least six months. After signing informed consent, participants completed PHQ9 and GAD7 questionnaires to assess the presence of symptoms of depression and anxiety upon entering the study, during the “Iron Swords” war, and four months later for follow-up. Demographic, socioeconomic, educational, and marital status data were collected, as well as information on comorbidities, including psychiatric disorders and regular medication use. Additionally, dialysis data and routine laboratory tests taken at the start of the study and four months later were gathered, including assessments of dialysis adequacy and quality. Results Depression symptoms developed in 43.3% of the patients in the study, and anxiety symptoms developed in 23.3% of participants at the beginning of the study, with the onset of the “Iron Swords” war. Depression and anxiety symptoms significantly improved in most patients, and after 4 months, decreased to 21% and 12.5%, respectively. More women developed symptoms of depression. Depression and anxiety symptoms were more common among patients who were unmarried, secular, and had higher education levels. 53% of the patients lacked a secure room in their homes, and about 23% temporarily moved to other dialysis units. Depression symptoms did not affect dialysis dose and adequacy or lab indicators, except for significantly lower albumin levels at the beginning of the study and a significant decrease in dry weight during the study. Depression and anxiety symptoms resolved or significantly improved in most patients by the end of the study. The development of depression and anxiety symptoms did not affect the number of hospitalization days or mortality rates. Conclusion The development of depression and anxiety symptoms was common among chronic hemodialysis patients during the “Iron Swords” war, without affecting the dosage or adequacy of dialysis, but impacting patients’ nutritional status. These symptoms were short-lived and improved significantly without intervention. Given the findings of the study and the high prevalence of depression and anxiety symptoms among dialysis patients during wartime, especially considering the prolonged, indefinite duration of the war, there is an urgent need to establish a psychological and social support infrastructure for dialysis patients, with an emphasis on emergency situations.

Abstract Background and Aims Identifying and reducing preventable readmissions is essential for improving patient outcomes and optimizing healthcare costs. The LACE index, Length of stay (L), Acuity of admission (A), Comorbidities (C), and Emergency department visits (E), is widely utilized as a predictive for rehospitalization risk. In patient on maintenance hemodialysis integrating additional predictive factors can enhance its precision. The incorporation of the IPPS, (Individual Patient Performance Score developed by Diaverum in 2021) with scoring systems with variable weights for vascular access, anemia, CKD-MBD, dialysis adequacy, intradialytic weight gain, Blood Pressure control, and others with a total score of 100. Incorporating such vital information for the original LACE model can result in a more sensitive tool for patients on maintenance Hemodialysis the LACE-HD model. Method Retrospective analysis of all hospitalization episodes reported in electronic medical records among 4500 patients on maintenance hemodialysis across 40 Diaverum dialysis clinics in Saudi Arabia between (2022–2024) including demographics, clinical parameters, cause of hospitalization, IPPS score, and LACE score, we created LACE-HD model (Fig. 1) with IPPS score incorporated as step (5) where IPPS &amp;gt; 90 score (0), IPPS 75–89 score (3) and the highest risk for the IPPS &amp;lt; 75 score (6). in LACE HD score with output risk categories Low Risk (0 –10) (Green), Intermediate Risk (11–15) (Yellow), High Risk (16–19) (Orange) and Very High Risk (20–25) (Red). Results We retrospectively analyzed hospitalization episodes over 36 months period of (2022-2024), We reported 3393 episodes of hospitalization. Hospitalized patients were predominantly males 1837 (54.1%) age Mean±SD (58.2±15.8) years, and dialysis vintage of &amp;gt;12 months for 2713 patients (79.9%), 6–12 months for 512 patients (15.1%), and &amp;lt;6 months for 168 patients (5%). Hospitalization episodes were predominately planned n (%) 2054 (60.5%) versus Urgent 1339 (39.5%). Categories were n (%) infection 795 (23.4%); cardiac and cerebrovascular 674 (19.9%) vascular access related 307 (9.1%); and others different causes 1617 (47.7%). 30-day rehospitalization occurred in n(%) 913 (26.9%) of all episodes. IPPS groups n (%) scoring ≥90 1366 (40.3%), 1215 (35.8%) scoring between 75–89, and 812 (23.9%) scoring &amp;lt;75. LACE score most patients 2505 (73.8%) scored ≥10, while 888 patients (26.2%) scored &amp;lt;10. For LACE-HD score 1832 (53.9%) scored &amp;lt;15, whereas 1561 (46.1%) scored ≥15. LACE score Mean±SD 11.43 ± 3.11, LACE-HD score 13.94 ± 4.11. As shown in Fig. 2 The ROC analysis comparing the LACE-HD versus LACE score showed for all-cause hospitalization LACE-HD statistically significantly higher Area Under the Curve (AUC = 0.682) compared to LACE (AUC = 0.616) (P &amp;lt; 0.001). This indicates a stronger discriminative ability of LACE-HD to correctly identify patients at risk of 30-rehospitalization rehospitalization among our cohort. Moreover, the cause-specific analysis showed the Cardiac hospitalization category, LACE-HD (AUC = 0.673) significantly higher than LACE (AUC = 0.590) (P &amp;lt; 0.001). Similarly, in the Cerebrovascular LACE-HD (AUC = 0.824) compared to LACE (AUC = 0.677) (P &amp;lt; 0.001). Infection category, the LACE-HD (AUC=0.642) outperformed the LACE (AUC= 0.593) (P &amp;lt; 0.001). these findings demonstrate the superior predictive ability of LACE-HD over standard LACE in predicting 30 days of rehospitalization among our cohort. Conclusion LACE-HD score provides a comprehensive risk assessment tool for predicting 30-day rehospitalization among patients on maintenance hemodialysis. This enhancement improves sensitivity and specificity across various hospitalization categories, making it a valuable instrument for healthcare systems to detect patients at higher risk of early rehospitalization, perform targeted Interventions, and optimize resource allocation.

Abstract Background and Aims Tradition markers of dialysis adequacy in peritoneal dialysis (PD) correlate poorly with both patient symptoms and outcomes, and residual kidney function remains the better determinant of each. Largely in response to these findings, guidelines now recommend focusing on patient-reported outcome measures (PROMs) where they have been shown to predict mortality, technique survival and hospitalisations. We aim to assess whether PROMs correlated with traditional markers of dialysis adequacy and predicted future patient outcomes. Method This was a retrospective study on adult PD patients who underwent a Palliative care Outcome Scale Symptom (POS-S)-renal questionnaire within 2-weeks of their routine Peritoneal Equilibrium Test (PET)-Adequest test. We assessed for the association between POS-S renal scores with adequacy measures (Kt/V and creatinine clearance or CCr) and whether POS-S renal scores predicted future outcomes (remaining on PD, transition to haemodialysis, kidney transplantation or death on PD). Results There were 107 patients with at least one paired PET-Adequest and POS-S questionnaire. There was no correlation between markers of dialysis adequacy (CCr and Kt/V) and symptom burden measured by POS-S renal questionnaire. Higher symptom burden predicted less favourable outcomes including technique failure, hospitalisations and death (P &amp;lt; 0.05). There was also an association between a higher symptom burden and a lower serum albumin level (P &amp;lt; 0.001). Conclusion There was no association between dialysis adequacy markers and PROMs, but PROMs were able to predict technique failure, hospitalisations and death compared to markers of dialysis adequacy. The measurement of PROMs may provide a beneficial addition to dialysis assessment in routine PD care.

Abstract Background and Aims Chronic kidney disease, particularly for those treated by haemodialysis (HD), contributes a heavy burden of increased mortality, multi-symptomatic morbidity and decreased quality of life. Intervention trials in HD therapy do not typically adhere to an agreed portfolio of defined outcomes, the relative importance of which may differ between different stakeholders (patients, carers, health care professionals (HCPs). The international Standardised Outcomes in Nephrology (SONG) initiative is a global project aiming to identify a standardised core outcome set to be reported in future clinical trials in kidney disease[1]. To date, there has not been a focused local investigation in Ireland of the proposed tiered system of outcomes. This study aims to determine the relative priorities accorded by Irish HD patients and HCPs to outcome measures in HD. It also aims to interrogate the degree of concordance with the 3-tiered hierarchical clusters of 15 biomedical and 19 patient related outcome measures (PROMs) identified, and previously tier-allocated, by the international SONG-HD group[2]. Method 144 participants (109 patients, 35 HCPs) from the Department of Renal Medicine, Cork University Hospital completed the survey, using convenience sampling techniques. Participants were aged ≥18 years and had ≥3 months experience in/of HD. Participants completed a survey listing the 34 outcome measures proposed by SONG-HD. Each outcome was ranked using a 9-point Likert scale. For each outcome mean, median and proportion rating as 7–9 was calculated. Outcomes were considered ‘critically important’ (Tier 1) if they met 2 of the following criteria: median score ≥8, mean score ≥7.5, and proportion rating the outcome as 7–9 ≥75%. Results 27 (79%) of outcomes were accorded the same Tier allocation by SONG-HD and by our group. Cardiovascular Disease, Vascular Access, Mortality and Fatigue were ranked as ‘critically important’ (Tier 1) by SONG-HD. The first two of these were also ranked in Tier 1 by our group, as was Blood Pressure. Mortality and Fatigue, by contrast, were ranked in Tier 2. For Tiers 2 and 3, our group ranked Ability to Work, Pain and Washed Out after Dialysis lower than did SONG-HD; Sleep was ranked higher. HD patients ranked the importance of six outcomes significantly higher (mean difference, 95% CI) than did HCPs. Ability to Travel (+2.2, 1.5, 2.9) was the most pronounced, followed by Mobility, Impact on Family/Friends, Drops in Blood Pressure, Sleep and Fatigue. HCP ranked 11 outcomes significantly higher than did patients. Dialysis Adequacy (+3.2, 2.3, 4.1), Potassium (+3.0, 2.1, 3.9], Hospitalisation (+2.7, 1.9, 3.5] and Anxiety/Stress (+2.2; (1.4, 2.9) being most prominent followed by Nausea/Vomiting, Restless Leg Syndrome, Pain, Cramps, Anaemia, Mortality and Infection/Immunity. For the Top 10 ranked outcomes, PROMs accounted for 7/10 in HD patients and 1/10 in HCPs. Conclusion The tiered hierarchy of outcomes proposed by SONG-HD aligns strongly with that generated by an Irish cohort of HD patients and nephrology HCPs. As with SONG-HD findings, patients generally prioritised PROMs over biomedical parameters, while HCPs prioritised the latter. This reinforces a mutual appreciation for the need to include both domains as core outcome measurements in future clinical trials in haemodialysis.

Abstract Background and Aims Mineral and bone metabolism are often disrupted in hemodialysis (HD) patients, raising the risk of hyperphosphatemia. Management of serum phosphorus levels typically involves restrictive diets with limited variety, focusing on the reduction of certain foods. This study aims to explore whether adopting a Mediterranean diet versus a western dietary pattern may offer a protective effect on serum phosphorus levels. Method This was an observational, cross-sectional, multicenter study with 564 HD patients from 37 dialysis centers. Demographic, anthropometric, body composition, biochemical parameters and dialysis treatment data were collected. Dietary intake was obtained through a food frequency questionnaire. Dietary patterns were derived from principal component analysis based on 22 food groups. Pearson's chi-squared test was used to analyze categorical variables. Mean differences were evaluated using T test and Mann-Whitney test for discrete variables. Spearman's correlation test and linear regression analysis were performed to evaluate the correlation and impact of dietary phosphorus intake and dietary patterns in serum phosphorus. Multivariate analysis included adjustment for age, sex, presence of diabetes mellitus, energy intake, phosphorus/protein intake ratio, dialysis adequacy, dialysis vintage, vascular access, parathyroid hormone (PTHi), and albumin. A p-value &amp;lt;0.05 was considered statistically significant. Results Patients’ median age and HD vintage was 71 (61–78) years and 65 (43–105) months, respectively. Two different dietary patterns were identified: a “Mediterranean” with higher intake of vegetables, legumes, fruit, starchy products, fish, olive oil, eggs, cookies and sweets, and alcohol; a “Western” with higher intake of soft drinks, red meat, fried and salted foods, fast food, soft drinks, and caffeine. Despite the higher intake of protein, carbohydrates, calories, phosphorus, and potassium in the Mediterranean diet group, serum phosphorus levels, calcium/phosphorus product, and PTHi were significantly lower in the group following a more Mediterranean dietary pattern. No statistically significant differences were observed in serum potassium levels between the two groups. Fiber intake was significantly higher in the Mediterranean group. The correlation between phosphorus intake and serum phosphorus was weak and not statistically significant (r: 0.066, P = 0116). Nevertheless, when we analyze the whole dietary pattern instead of phosphorus intake (“alone”) we observe that the Western dietary pattern was associated with higher serum phosphorus levels (r: 0.171; P &amp;lt; 0.001). In addition, the Western dietary pattern, compared to the Mediterranean pattern, was independently associated with higher serum phosphorus levels. After full adjustment to potential cofounders, the β-coefficient was 0.290 (95% CI: 0.039–0.542; P = 0.024). This association was also significant in the unadjusted model (β = 0.350, 95% CI: 0.159–0.542; P &amp;lt; 0.001). Conclusion Although dietary phosphorus intake was higher in HD patients following a Mediterranean dietary pattern, this group exhibited lower serum phosphorus levels. These findings raise the question of whether considering the overall dietary pattern is more relevant than focusing solely on individual food items based on their phosphorus content. These results highlight the importance of phosphorus bioavailability, the role of other nutrients such as fiber, and the impact of processed foods and additives in managing hyperphosphatemia in the HD population.

Abstract Background and Aims End-stage renal disease patients receiving hemodialysis (HD) have an exceedingly high risk of cardiac sudden death, that may occur between treatments (extra dialytic sudden death, SD) or during the dialysis session (intradialytic SD). Even considering that these two entities may represent different clinical situations, the identification of potentially modifiable risk factors for SD in HD patients seems fundamental for the implementation of strategies to reduce the incidence of such events. Some HD registry-based observational studies have suggested some factors eventually implicated in SD risk, but the results are conflicting and further clarification is needed. The aim of our study was to evaluate the variables associated with the risk of SD in a large population of HD patients. Method We performed a retrospective cohort study using data from an international HD provider database. All patients in maintenance HD during 2024 were included. Deaths occurring during the year were gathered and divided in two groups: Group 1) non-sudden deaths; Group 2) sudden deaths, defined as unexpected, natural deaths occurring within 1 hour of symptom onset if witnessed or, if unwitnessed, within 24 hours of having been last seen alive and symptom-free. The last demographic, clinical and analytical data available before the event were collected and the two groups compared using ANOVA and Kruskal-Wallis test for continuous variables and Chi-square (X²) test for categorical variables. We used Cox regression analyses to evaluate survival, adjusted for age, gender, time on dialysis, diabetic status, Charlson comorbidity index (CI), type of vascular access, body mass index (BMI), dialysis adequacy (eKt/V), interdialytic fluid gain, intradialytic blood flow, hemoglobin, albumin, calcium and phosphorus. Results were presented as hazard ratios (HR) and 95% confidence intervals (95% CI) and a p-value below 0.05 was considered statistically significant. Results A total of 4,820 occurred during the period, 28% of which meeting the criteria for sudden death. Of all the sudden deaths, 34.1% were attributed to a cardiac event and 65.9% to unknown causes. The sudden death occurred more significantly in patients of male gender, longer time on dialysis, diabetic, higher BMI, higher fluid gain between HD treatments, higher blood flow during the treatment, use of central venous catheter as dialysis access and higher levels of hemoglobin, albumin and phosphorus. No differences between groups were found in age, CI and eKt/V. In the survival analysis, diabetics status, presence of a tunneled catheter and higher values of plasmatic phosphorus were independently associated with higher HR of sudden death (Table 1). Conclusion Sudden death is a common phenomenon in HD patients, being responsible for more than a quarter of all deaths. In our population, diabetes, the presence of a tunneled central venous catheter and higher phosphate levels were independently associated with a higher risk of SD. Our findings may provide preliminary evidence on some modifiable factors related to SD in HD patients and create the basis for the implementation of multidimensional interventions aiming at reducing the occurrence of sudden fatal events in this population.

Abstract Background and Aims This study aims to compare clinical and laboratory parameters between high-risk and low-risk dialysis patients classified based on the individual patient performance score (IPPS) and Charlson comorbidity index (CCI) and to investigate differences in hospitalization rates between these groups. The IPPS, adopted by Diaverum in 2021, comprehensively evaluates dialysis patient outcomes across various domains, including vascular access management, dialysis adequacy, anemia management, CKD-MBD management, fluid management, Hypertension management, nutritional parameters, vaccination status, and kidney transplant eligibility with a total score of 100. Method A total of 4667 patients on maintenance hemodialysis in 40 dialysis clinics in Diaverum Saudi Arabia were initially assessed. excluding 436 (9.4%) patients due to age below 18 years (20; 0.4%), dialysis duration of less than 6 months (315; 6.7%), or incomplete data (112; 2.4%), total 4231 (90.6%) patients were included in the study with follow up for 24 months (2023–2024). Patients were classified into high-risk (CCI ≥6 or IPPS &amp;lt;75) and low-risk (CCI &amp;lt;6 and IPPS ≥75) groups. Demographic, clinical, and laboratory data, including age, gender, BMI, dialysis modality, vascular access type, dialysis duration, and key laboratory parameters (serum albumin, hemoglobin, phosphorus, calcium-phosphorus product, hemoglobin A1c), were collected. Hospitalization rates and % of patients Hospitalized during the 12-month follow-up period were also evaluated. Statistical analysis was performed using t-tests for continuous variables and chi-squared tests for categorical variables, with a significance threshold of P &amp;lt; 0.05. Results Of the 4231 patients, 2482 (58.7%) were classified as high-risk, while 1749 (41.3%) were classified as low-risk. The high-risk group had a higher mean age (55.4 ± 16.2 vs. 54.1 ± 15.8 years, P = 0.009) and a significantly higher prevalence of diabetes mellitus (52.7% vs. 45.3%, P &amp;lt; 0.001) and hypertension (87.8% vs. 84.2%, P &amp;lt; 0.001). The high-risk group also had a significantly lower IPPS score (75.1 ± 10.1 vs. 92.8 ± 9.1, P &amp;lt; 0.001) and higher comorbidity index score (7.4 ± 2.8 vs. 3.8 ± 1.7, P &amp;lt; 0.001). Regarding dialysis modality, more patients in the high-risk group were on hemodialysis (65.1% vs. 61.3%, P &amp;lt; 0.001), and fewer were on hemodiafiltration (34.9% vs. 38.7%, P &amp;lt; 0.001). The median duration on dialysis was longer in the high-risk group (63 months vs. 55 months, P &amp;lt; 0.001). Hospitalization rates were significantly higher in the high-risk group (22.9% vs. 10.5%, P &amp;lt; 0.001), with 569 (22.9%) hospitalized patients from the high-risk group compared to 229 (10.5%) from the low-risk group. Further analysis of the components of the high-risk group by its primary elements as in Fig. 1 showed that Low-risk patients G1 (CCI &amp;lt; 6 and IPPS ≥ 75) tend to have a relatively stable health status and lower comorbidity burden, leading to lower hospitalization rates. High-risk patients G2 (CCI &amp;lt; 6 and IPPS &amp;lt; 75), and G3 (CCI ≥ 6 and IPPS ≥ 75) show increasing hospitalization rates of 16.7% &amp; 23.6% respectively due to different combinations of IPPS and CCI values. G4 (CCI ≥ 6 and IPPS &amp;lt; 75) with a high comorbidity burden and low IPPS score combination represents the most vulnerable group, with the highest hospitalization rate 31%. Conclusion Our results highlight the significance of the high-risk group with a greater burden of comorbidities, lower IPPS scores, had higher hospitalization rates. These findings underscore the predictive value of IPPS and CCI scores in guiding clinical decision-making and the need for targeted interventions to improve outcomes in high-risk dialysis patients.