Daily Dialysis Research Articles

POS-791 EVALUATION OF EFFECTIVENESS OF AN ALTERNATIVE PRESCRIPTION PATTERN OF CINACALCET FOR BETTER CONTROL OF PARATHYROID HORMONE LEVELS IN HEMODIALYSIS PATIENTS

Due to the high pill burden, non-adherence (NA) to medications is highly prevalent among hemodialysis patients. NA to Cinacalcet in particular, poses a significant challenge in controlling parathyroid hormone (PTH) levels. Perhaps an effective way to improve adherence to Cinacalcet is to reduce the frequency of administration. There is limited knowledge of the effectiveness of controlling PTH level with three times per week (TIW) Cinacalcet compared with conventional daily dosing. The objective of this longitudinal retrospective single-center observational study was to evaluate the effectiveness of three times a week (TIW) Cinacalcet dosing compared with conventional daily dosing (DD) in subsequent levels of Parathyroid Hormone (PTH) in hemodialysis patients. All adult hemodialysis patients on Cinacalcet for secondary hyperparathyroidism (sHPT) for more than six months were selected. Patients who did not have any adherence issues continued oral Cinacalcet daily (QID) while patients who were suspected to be NA to Cinacalcet or suffered from intolerance were given oral Cinacalcet three times a week (TIW) on dialysis days under direct observation of the dialysis nurse. The dose of Cinacalcet was determined by the physician to maintain PTH levels within 130 - 600 pg/ml as per KDIGO guidelines. PTH levels were monitored every other month and the dose was titrated accordingly. All these patients also received intravenous alfacalcidol and phosphate binders at the discretion of the physician to maintain adjusted calcium and phosphate levels within the KDIGO recommendations. The primary endpoint of the study was to assess whether TIW dosing was more effective than QID dosing in terms of maintaining PTH levels within the KDIGO recommended range. Data regarding patients’ acceptability, tolerability, hypocalcemia, and required weekly cumulative Cinacalcet dose were also collected. Patients were followed up for 12 months. There were 40 patients in the QID group and 52 in the TIW group. All participants in the TIW group reported acceptability and improved tolerability and hence better adherence to the dosing regimen. Some in the TIW model even reported perceived improvement in their commitment to adherence. In terms of effectiveness, the TIW group showed better monthly PTH trends compared to the QID group as illustrated by the graph below. This appeared to be sustained over the 12 months follow up period. Concomitantly, the required cumulative dose of Cinacalcet per week was also much less in the TIW group (270 mg/week) compared to the QID group (420 mg/week) suggesting a significant healthcare cost saving in long run. While there were cases of hypocalcemia observed in the QID group no such events were noticed in the TIW group. Taken together, the results of our study confirm that patients on the TID model of prescription were able to achieve and sustain the PTH levels consistent with KDIGO recommendation with much lower cumulative Cinacalcet dose with consequent lower healthcare costs. Nevertheless, we do agree that this alternative model of prescription (TIW) needs to be further validated in a prospective study before drawing stronger conclusions.

16 Sustained Low Efficiency Dialysis (SLED) in Burn Patients with Acute Kidney Injury

Abstract Introduction Acute Kidney Injury (AKI) is common among patients with major burns and may require treatment with renal replacement therapy (RRT). Although continuous renal replacement therapy (CRRT) modalities are widely used and offer many advantages over traditional intermittent hemodialysis (IHD), CRRT is expensive, labour-intensive, and may not be available in some burn centers. Sustained Low Efficiency Dialysis (SLED) is a moderately efficient alternative to IHD, but its use in burn patients with AKI has not been described. The purpose of this study was to review our experience with SLED. Methods Retrospective review of adult burn patients with AKI treated by SLED between 07/2013 and 03/2020 at an adult regional ABA-verified burn center. Data was obtained from the electronic medical record including daily dialysis forms completed by the nephrology service. Values are shown as mean +/- SD or median (IQR) as appropriate. Results We evaluated 367 distinct SLED sessions provided to 33 patients [age 55.8 +/- 14 yrs., %TBSA burn 33 +/-19, % TBSA full thickness burn 10.5 (0, 35.8), and 54.5% with inhalation injury]. The serum creatinine (sCr) prior to the start of SLED was 2.96 (2.3, 4.17) mg/dL. SLED was initiated 5 (3, 10.8) days (range 0–24 d) post burn, and 7 (3.3, 12.8) sessions (range 1–44) with a duration of 4 (4,6) hours each were given per patient. Heparinization was required in 22 sessions (6%), and 46 sessions (12.5%) were aborted, most commonly due to clotting of the lines or circuit, and rarely (4%) due to hypotension. The net ultrafiltrate removal was 1.2 (0.7–2) L, with a dialysate flow rate of 350 (350, 500) mL/min. Among 208 sessions where patients were not on vasopressors (VPs) Pre-SLED, one or more VPs were required in 19 sessions (9%) during or at the termination of SLED. Among 116 sessions where patients were receiving norepinephrine (NEpi) infusions pre-SLED, the NEpi dose dropped from 7.3 +/- 4.2 µgm/min to 6 +/- 4.5 µgm/min (p=0.03). Pre and Post SLED values for blood pressure, creatinine, and potassium are shown in the table. The mortality rate was 36.4%, hospital length of stay was 42 (20.5, 61.5) days, and among surviving patients, 2 (9.5%) required dialysis post discharge. Conclusions SLED was effective and well tolerated. Hemodynamic instability was infrequently encountered.

Effective glutamate clearance from the systemic circulation by hemodialysis: Potential relevance for cerebral ischemia management.

High glutamate levels after head trauma or cerebral ischemia have neurotoxic effects. The objective of the present study was to evaluate the efficacy of hemodialysis to remove glutamate from the blood and to assess the behavior of this small molecule. Ten patients with end-renal disease on hemodialysis were included in the study. Glutamate clearance was evaluated within the first hour of hemodialysis on a midweek dialysis day on five patients who underwent low flux hemodialysis, whereas the other five patients underwent highly efficient hemodialysis (high flux hemodialysis on one day and online hemodiafiltration on another day). Glutamate clearance with hemodialysis was very effective and did not show any differences between the techniques (low flux: 214 [55], high flux: 204 [37], online hemodiafiltration: 202 [16], median (interquartile range), P=.7). Glutamate clearance was almost equivalent to vascular access plasma flow and it was not affected by dialyzer permeability or ultrafiltration rate. After a hemodialysis session, a significant decrease in glutamate blood level was observed (prehemodialysis: 59.7 [36.1], posthemodialysis 37.0 [49.2], P=.005). Dialysis performed under fasting condition showed higher glutamate reduction rate (60%) than that under feeding condition (20%). Hemodialysis may be an effective method to reduce glutamate blood levels, and the molecule clearance does not differ between the different techniques used. Considering previous results in experimental models, hemodialysis without hemodynamic stress, could be considered for reducing glutamate neurotoxic effects in acute ischemic strokes of patients in chronic hemodialysis programs.

Fatigue characteristics on dialysis and non-dialysis days in patients with chronic kidney failure on maintenance hemodialysis

BackgroundFatigue is prevalent in hemodialysis patients who for survival follow a strict dialysis treatment regimen – dialysis and non-dialysis days. As a result, the daily activities, symptom burden, and clinical outcomes of hemodialysis patients vary significantly between dialysis and non-dialysis days. Fatigue is one of the most reported debilitating symptoms by hemodialysis patients with profound negative impact on their quality of life. Prior studies assessed fatigue during the preceding 7 or 30 days and did not discriminate fatigue characteristics between dialysis and non-dialysis days. We aimed to characterize and compare fatigue severity and fatigue interference with daily activities between dialysis and non-dialysis days.MethodsHemodialysis patients self-reported fatigue on consecutive dialysis and non-dialysis days using the 9-item Brief Fatigue Inventory. The differences in fatigue characteristics between dialysis and non-dialysis days were analyzed using one-way ANCOVA.ResultsGlobal fatigue burden was worse on a dialysis day compared to a non-dialysis day (P for all < 0.001). Age and education were associated with fatigue, but hemodialysis-related variables were not. A significant inverse association of physical activity with fatigue severity observed on non-dialysis day; there was also a negative association between the normalized protein catabolic rate and fatigue severity on both dialysis and non-dialysis days. The positive association of depression with fatigue severity and fatigue interference were consistent on both dialysis and non-dialysis days. None of these factors, however, explained differences in fatigue characteristics between dialysis and non-dialysis days.ConclusionsFatigue, measured in severity and interference, was more pronounced on a dialysis day relative to a non-dialysis day. These differences were not explained by age, sex, education, hemodialysis-related variables, habitual exercise, nutritional status, and or depression. The quantitative measures of fatigue characteristics may facilitate future interventional trials design and better fatigue management for hemodialysis patients.

Physical activity in hemodialysis patients on nondialysis and dialysis days: Prospective observational study

The physical decline in patients with end-stage kidney disease (ESKD) is associated with morbidity and mortality. Prior studies have attempted to promote physical activity at the time of dialysis; however, physical activity patterns on the nondialysis days are unknown. This study aimed to quantify physical activity on dialysis and nondialysis days in hemodialysis patients using a wearable actigraph. In this prospective study, subjects receiving hemodialysis were recruited from two outpatient dialysis units in urban San Diego and rural Imperial County, CA, between March 2018 and April 2019. Key inclusion criteria included: (1) receiving thrice weekly hemodialysis for ≥3 months, (2) age ≥ 18 years, and (3) able to walk with or without assistive devices. All participants wore a Fitbit Charge 2 tracker for a minimum of 4 weeks. The primary outcome was the number of steps per day. Each participant completed the Physical Activity Questionnaire, the Patient Health Questionnaire (PHQ)-9, the PROMIS Short form Fatigue Questionnaire at baseline, and the Participant Technology Experience Questionnaire at day 7 after study enrolment. Of the 52 recruited, 45 participants (urban = 25; rural = 20) completed the study. The mean age was 61 ± 15 years, 42% were women, 64% were Hispanic, and the mean dialysis vintage was 4.4 ± 3.0 years. For those with valid Fitbit data (defined as ≥10 hours of wear per day) for 28 days (n = 45), participants walked an average of 3688 steps per day, and 73% of participants were sedentary (<5000 steps/day). Participants aged >80 years were less active than younger (age < 65 years) participants (1232 vs. 4529 steps, P = 0.01). There were no statistical differences between the groups when stratified by gender (women vs. men [2817 vs. 4324 steps, respectively]), urbanicity (rural vs. urban dialysis unit [3141 vs. 4123 steps, respectively]), and dialysis/nondialysis day (3177 vs. 4133 steps, respectively). Due to the small sample size, we also calculated effect sizes. The effect size was medium for the gender differences (cohen's d = 0.57) and small to medium for urbanicity and dialysis/nondialysis day (d = 0.37 and d = 0.33, respectively). We found no association between physical activity and self-reported depression and fatigue scale. The majority of participants (62%, 28/45) found the Fitbit tracker easy to wear and comfortable. ESKD participants receiving hemodialysis are frequently sedentary, and differences appear more pronounced in older patients. These findings may assist in designing patient-centered interventions to increase physical activity among hemodialysis patients.

Hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli infection in Argentina: update of serotypes and genotypes and their relationship with severity of the disease.

Shiga toxin-producing Escherichia coli (STEC) infection is the most common cause of hemolytic uremic syndrome (HUS). Only few studies correlated serotypes and stx genotypes with disease severity. This study aimed to update STEC serotypes, stx genotypes, and virulence factors (eae and ehxA) in a cohort of patients with STEC-HUS and investigate whether they influence the severity of disease. In this multicentric study, children hospitalized between 2005 and 2016 with STEC-HUS confirmed by the National Reference Laboratory were included. Serotypes (O157, O145, O121, and others), stx genotypes (stx1a, stx2a, stx2c, stx2d, and others), and virulence factors were analyzed, and their association with dialysis requirement (>10 days); severe neurological, cardiovascular, and/or bowel involvement; and death was assessed. The records of 280 patients were reviewed; 160 females, median age 21 months (IQR18m). STEC O157 was isolated in 206 (73.6%) patients, O145 in 47 (16.8%), O121 in 15 (5.4%), and other serotypes in 12 (4.2%). The stx2a/2c genotype was carried by 179 (63.9%) strains, stx2a by 94 (33.6%), stx1a/stx2a by five (1.8%), and stx1a only by two (0.7%). All strains except six harbored eae and ehxA genes. Fifty-nine (21.1%) patients had severe neurological involvement, 29 (10.4%) severe bowel injury, 14 (5%) cardiovascular involvement, 53 (18.9%) required > 10 days of dialysis, and 12 (4.3%) died. Neither serotypes nor stx genotypes detected were significantly linked to severity. Serotype O157 and virulence stx2a/2c, eae, ehxA genotype are prevalent in Argentina, and no relationship was found between severity and serotypes and genotypes of STEC detected.

And Then There Were Three: Effects of Pretransplant Dialysis on Multiorgan Transplantation.

Background.Simultaneous liver-kidney (SLK) and simultaneous heart-kidney (SHK) transplantation currently utilize 6% of deceased donor kidneys in the United States. To what extent residual kidney function accounts for apparent kidney allograft survival is unknown.Methods.We examined all adult SLK and SHK transplants in the United States during 1995–2014. We considered the duration of dialysis preceding SLK or SHK (≥90 d, 1–89 d, or none) as a proxy of residual kidney function. We used multinomial logistic regression to estimate the difference in the adjusted likelihood of 6- and 12-month apparent kidney allograft failure between the no dialysis versus ≥90 days dialysis groups.Results.Of 4875 SLK and 848 SHK recipients, 1775 (36%) SLK and 449 (53%) SHK recipients received no dialysis before transplant. The likelihood of apparent kidney allograft failure was 1%–3% lower at 12 months in SLK and SHK recipients who did not require pretransplant dialysis relative to recipients who required ≥90 days of pretransplant dialysis. Among 3978 SLK recipients who survived to 1 year, no pretransplant dialysis was associated with a lower risk of apparent kidney allograft failure over a median follow-up of 5.7 years (adjusted hazard ratio 0.73 [0.55–0.96]).Conclusions.Patients with residual kidney function at the time of multiorgan transplantation are less likely to have apparent failure of the kidney allograft. Whether residual kidney function facilitates function of the allograft or whether some SLK and SHK recipients have 3 functional kidneys is unknown. Sustained kidney function after SLK and SHK transplants does not necessarily indicate successful MOT.

Factors Influencing Adherence to Hemodialysis Sessions among Patients with End-Stage Renal Disease in Makkah City.

Adherence to hemodialysis (HD) treatment remains a challenging task for patients suffering from end-stage renal disease (ESRD). Interventions to improve adherence need to identify factors influencing such behavior among ESRD patients. The objective of the study is to identify factors influencing adherence to HD among ESRD patients. A cross-sectional survey research was conducted in three HD centers at three major governmental hospitals in Makkah city, Saudi Arabia. The Andersen Behavioral Model was used as the analytic framework, and the variables were categorized into predisposing, enabling, and need factors. Frequency distribution and percentages were employed to characterize the participants, and hierarchical logistic regression analysis was employed to determine the factors influencing adherence to HD sessions among ESRD patients in Makkah. Three hundred and sixty-one patients have completed the survey questionnaire and participated in this study. 55.96% of the participants were adherent to HD sessions. The factors, marital status, belief in the importance of following dialysis schedule, using personal transportation, days of dialysis, having a busy lifestyle, being advised by medical professionals about the importance of not missing dialysis treatment, and frequency of advice from medical professionals about the importance of staying for the entire dialysis time were significantly associated with adherence to HD sessions. Nonadherence to dialysis is still a major challenge among ESRD patients, and a representative sample is needed to inform policy- and decision-making related to improving adherence to dialysis sessions in Saudi Arabia.

Outcomes after Acute Peritoneal Dialysis for Critical Cardiorenal Syndrome Type 1

Introduction: The aim of the study was to demonstrate the outcomes of peritoneal dialysis (PD) in critically ill cardiorenal syndrome type 1 (CRS1). Methods: A cohort of 147 patients with CRS1 who received PD from 2011 to 2019 in a referral hospital in Thailand was analyzed. The primary outcome was 30-day in-hospital mortality. Ultrafiltration and net fluid balance among survivors and nonsurvivors in the first 5 PD sessions were compared. Results: The 30-day mortality rate was 73.4%. Most patients were critically ill CRS1 (all patients had a respiratory failure of which 68% had cardiogenic shock). Blood urea nitrogen and creatinine at the commencement of PD were 60.1 and 4.05 mg/dL. In multivariable analysis, increasing age, unstable hemodynamics, and positive fluid balance in the first 5 PD sessions were associated with the risk of in-hospital mortality. The change of fluid balance per day during the first 5 dialysis days was significantly different among survivor and nonsurvivor groups (−353 vs. 175 mL per day, p = 0.01). Conclusions: PD is a viable dialysis option in CRS1, especially in a resource-limited setting. PD can save up to 27% of lives among patients with critically ill CRS1.

Development and Validation of a Novel Food-frequency Questionnaire for Hemodialysis Patients in Lucknow, India.

Introduction:Food-frequency questionnaire (FFQ) is a preferred tool for longitudinal dietary assessment and has been recently validated in patients on hemodialysis in other countries. As dietary habits vary vastly across regions, this study was planned to develop and validate a novel dialysis FFQ in northern India.Materials and Methods:Dietary recall data from patients on hemodialysis available from the previous year were used for identifying food items for inclusion in the FFQ. A nutrient database was created to estimate energy, protein, calcium, phosphorus, and potassium content of the foods included in the food list. The FFQ was validated against a 2-day dietary recall method (one predialysis, one on the dialysis day) in patients on maintenance hemodialysis in a tertiary care hospital in Lucknow, northern India.Results:Dietary recall data from 78 patients on hemodialysis were used for the generation of the FFQ. A total of 84 patients completed the validation study. All the nutrients measured by the FFQ correlated significantly with the means of the 2-day dietary record (r values 0.31–0.76) both in crude- and energy-adjusted intakes. De-attenuation further improved the correlation (0.35–0.80). Bland-Altman plots showed higher estimates by FFQ than by dietary recall. Cross-classification analysis showed correct classification in the exact or adjacent quintile (average 60%) by both methods and 2% gross misclassification. Weighted kappa showed fair agreement for energy intake and slight agreement for others.Conclusion:This novel semiquantitative FFQ is a valid tool for measuring energy and nutrient intakes in hemodialysis patients.

Physical Function and Clinical Outcomes in Hemodialysis Patients: China Dialysis Outcomes and Practice Patterns Study

Background: Hemodialysis (HD) patients usually have impaired physical function compared with the general population. Self-reported physical function is a simple method to implement in daily dialysis care. This study aimed to examine the association of self-reported physical function with clinical outcomes of HD patients. Methods: The Dialysis Outcomes and Practice Patterns Study (DOPPS) is a prospective cohort study. Data on 1,427 HD patients in China DOPPS5 were analyzed. Self-reported physical function was characterized by 2 items of “moderate activities limited level” and “climbing stairs limited level.” Demographic data, comorbidities, hospitalization, and death records were collected from patients’ records. Associations between physical function and outcomes were analyzed using COX regression models. Results: Compared to “limited a lot” in moderate activities, “limited a little” and “not limited at all” groups were associated with lower all-cause mortality after adjusted for covariates (HR: 0.652, 95% CI: 0.435–0.977, and HR: 0.472, 95% CI: 0.241–0.927, respectively). And, not limited in moderate activities was associated with lower risk of hospitalization than the “limited a lot” group after adjusted for covariates (HR: 0.747, 95% CI: 0.570–0.978). Meanwhile, compared to “limited a lot” in climbing stairs, “limited a little” and “not limited at all” groups were associated with lower all-cause mortality (HR: 0.574, 95% CI: 0.380–0.865 and HR: 0.472, 95% CI: 0.293–0.762, respectively) but not hospitalization after fully adjusted. Conclusion: Higher limited levels in self-reported physical function were associated with higher risk of all-cause mortality and hospitalization in HD patients.

Covid-19 and Renal Replacement Therapy: A Single-Center Perspective from Southern Italy

Introduction: The outbreak of cases of coronavirus disease (COVID-19), a very contagious disease, poses a serious threat to human health, especially in the elderly and in co-morbid populations like patients with kidney disease requiring renal replacement therapy (RRT). Furthermore, data about HD patients and how to best dialyze them during the COVID-19 pandemic are scarce. The aim of the study is to describe the organizational model and clinical outcomes of patients confirmed COVID-19 needing RRT, admitted in a COVID Hospital in Southern Italy. Methods: This study is a cohort study of hospitalized patients with COVID-19 enrolled at Miulli General Hospital, one of the major designated hospitals providing medical care for COVID-19 patients in the Apulia Region. We included all consecutive patients requiring RRT, either due to ESKD or AKI. Demographic data, information on clinical symptoms or signs at presentation, and laboratory results were extracted by the electronic medical record. A group of pair-matched COVID-19 patients, with normal renal function, were considered as controls. All the RRT sessions were performed with the Genius system. Results: From March 10 through May 24, 2020, Miulli Hospital admitted 217 patients with COVID-19 infection, including 11 (5%) maintenance HD and 29 critically ill patients (13.3%) referred for ICU admission, of whom 3 with AKI. Overall, 140 bedside treatments were performed in the COVID Hospital, 122 bicarbonate standard in 11 HD patients, and 18 sustained low-efficiency daily dialysis (SLEDD) in 3 patients with AKI. Mean session time and mean weekly sessions were 3.64 ± 0.40 hours, and 3.4 ± 0.45 HD/week; while session time has been 7.4 ± 0.58 hours for SLEDD. The phenotype and clinical symptoms at the admission were not different between HD patients and controls. Compared to non-HD, HD patients showed lower serum levels of inflammatory markers, but only C-reactive protein reached significant levels (p=0.030), and lower hospital stay (p=0.020). In-hospital mortality was not different between the two groups. All AKI patients showed a severe systemic hyperinflammation at the admission and died in ICU. Conclusions: Our data show that an organizational model based on the HD bedside with the Genius system, adopting the strict protocol, allows a personalized treatment with efficacy and safety for the patients and staff. The HD patients, SARS-Cov-2 infected, seem to have a lower inflammatory profile and shorter in-hospital stay compared with non-HD COVID-19 patients.

Cytocompatibility of Modified Silk Fibroin with Glycidyl Methacrylate for Tissue Engineering and Biomedical Applications.

Hydrogel with chemical modification has been used for 3D printing in the biomedical field of cell and tissue-based regeneration because it provides a good cellular microenvironment and mechanical supportive ability. As a scaffold and a matrix, hydrogel itself has to be modified chemically and physically to form a β-sheet crosslinking structure for the strength of the biomaterials. These chemical modifications could affect the biological damage done to encapsulated cells or surrounding tissues due to unreacted chemical residues. Biological assessment, including assessment of the cytocompatibility of hydrogel in clinical trials, must involve testing with cytotoxicity, irritation, and sensitization. Here, we modified silk fibroin and glycidyl methacrylate (Silk-GMA) and evaluated the physical characterizations, residual chemical detection, and the biological effect of residual GMA depending on dialysis periods. Silk-GMA depending on each dialysis period had a typical β-sheet structure in the characterization analysis and residual GMA decreased from dialysis day 1. Moreover, cell proliferation and viability rate gradually increased; additionally, necrotic and apoptotic cells decreased from dialysis day 2. These results indicate that the dialysis periods during chemical modification of natural polymer are important for removing unreacted chemical residues and for the potential application of the manufacturing standardization for chemically modified hydrogel for the clinical transplantation for tissue engineering and biomedical applications.

Apixaban in patients on haemodialysis: a single-dose pharmacokinetics study.

Apixaban, a direct oral anticoagulant inhibiting factor Xa, has been proven to reduce the risk of atrial fibrillation-related stroke and thromboembolism in patients with mild to moderate renal insufficiency. Patients on renal replacement therapy, however, were excluded from randomized controlled trials. Therefore, uncertainty remains concerning benefits, dosing and timing of intake in haemodialysis population. We conducted a Phase II pharmacokinetics study in which 24 patients on maintenance haemodialysis were given a single dose (2.5 mg or 5 mg) of apixaban, either 30 min before or immediately after dialysis on the mid-week dialysis day. Apixaban 5 mg resulted in higher area under the curve (AUC0-48) in comparison with 2.5 mg, although significance could only be reached for dosing pre-dialysis (2.5 mg versus 5 mg, P = 0.008). In line, peak concentrations (Cmax) after dosing pre-dialysis were significantly higher in the 5 mg than in the 2.5 mg groups (P = 0.02). In addition, dialysis resulted in significant reduction of drug exposure. AUC0-48 pre-dialysis were on average 48% (2.5 mg) and 26% (5 mg) lower than the AUC0-48 post-dialysis, in line with Cmax. As a result, a dose of 2.5 mg post-dialysis and a dose of 5 mg pre-dialysis resulted in similar AUC0-48. In contrast, significant differences were found between the 5 mg group post-dialysis and the 2.5 mg group pre-dialysis (P = 0.02). Our data suggest that exposure to apixaban in patients on maintenance haemodialysis is dependent not only on drug dose but also on timing of intake relative to the haemodialysis procedure.

Effects of Hemodialysis and Peritoneal Dialysis on Glycometabolism in Patients with End-Stage Diabetic Nephropathy

Objective: The objective is to study the fluctuation pattern of blood glucose spectrum in patients with end-stage diabetic nephropathy (ESDN) receiving hemodialysis (HD) and peritoneal dialysis (PD), respectively, and to compare the influences of these 2 dialysis methods on glycometabolism. Methods: Sixty-four dialysis patients with ESDN were recruited, including 35 HD patients and 29 PD patients. The 24-h blood glucose on dialysis days of the 2 groups was monitored by the continuous glucose monitoring system, and the relevant glycometabolism indexes were recorded and compared. Results: The control of blood glucose in both groups was not satisfactory. At the same blood glucose level, the dosage of exogenous insulin needed by patients in the PD group was larger than that in the HD group (p < 0.05). However, the fluctuation of blood glucose and consequently the incidence of hyperglycemia and hypoglycemia in HD group were greater than that in PD group (p < 0.05). The patients’ blood glucose levels decreased progressively during the course of HD. The mean blood glucose (MBG) values estimated by glycosylated hemoglobin (HbA1c) in both groups were lower than the actual measured blood glucose values (p < 0.05). Preliminary correlation analysis showed that the deviation of the MBG values estimated by HbA1c was positively correlated with the degree of anemia. Conclusion: HD patients have larger glycemic variability as compared with PD patients, while PD patients have overall increased blood glucose levels. Hypoglycemic programs should be made according to the corresponding changes in blood glucose. The HbA1c value of dialysis patients has a large deviation, so it is necessary to explore its influencing factors and develop more accurate blood glucose assessment indicators.

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

This study evaluates 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 a) correlations of CGM with other indicators including glycated hemoglobin A1c (HbA1c), glycated albumin and mean amplitude of glucose excursions (MAGE), and b) 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% confidence interval (CI): 0.67, 0.92]. Correlation coefficient between CGM and HbA1c was 0.523 [95% CI: 0.422, 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 offdialysis day in diabetes patients (MDs: -0.40 millimole/liter (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, respectively). Compared to predialysis 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, respectively).CGM is an efficient method of glycemic monitoring in diabetes patients on dialysis. CGM had similar correlations with HbA1c and glycated albumin.

Impact of Physical Activity on Dialysis and Nondialysis Days and Clinical Outcomes Among Patients on Hemodialysis

Patients undergoing hemodialysis (HD) have different physical activity (PA) patterns on HD and non-HD days. Nonetheless, whether these differences are associated with clinical outcomes remains unclear. We examined the association of PA levels on HD and non-HD days with cardiovascular (CV) hospitalizations and mortality. Outpatients undergoing HD from 2002 to 2019 were retrospectively enrolled. The number of steps performed over 3 HD days and 4 non-HD days was recorded via accelerometry. Outcomes were all-cause mortality and a composite of CV hospitalizations and mortality. Patients were divided into two groups, each according to the median number of steps performed on HD (2371 steps/day) and non-HD days (3752 steps/day). Further, we categorized them into 4 groups according to each median values: "more active on HD/more active on non-HD (MM)," "more active on HD/less active on non-HD (ML)," "less active on HD/more active on non-HD (LM)," and "less active on HD/less active on non-HD (LL)." Cox and mixed-effects Poisson regression models were used for these outcomes. We analyzed 512 patients (median follow-up, 3.4years). Higher PA on HD (hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.54-0.65), and non-HD (HR, 0.84; 95% CI, 0.80-0.88) was associated with lower mortality risk, respectively. Further, the ML group (HR, 1.20; 95% CI, 1.13-1.28), LM group (HR, 1.82; 95% CI, 1.53-2.17), and LL group (HR, 1.83; 95% CI, 1.65-2.02) had higher mortality risks than the MM group. Associations of PA with multiple CV hospitalizations and mortality were similar to those between PA and mortality. Higher PA on HD and non-HD days was associated with lower risks of CV hospitalizations and mortality. However, higher PA levels on either HD or non-HD days alone did not improve clinical outcomes.

Comparison of different anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study

BackgroundCritically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH).MethodsRetrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT.ResultsIn patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM: ±5.6 h), in the citrate group 45.6 h (SEM: ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h (P = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM: ±1.3 h), with argatroban 8.0 h (SEM: ±0.9 h), and with LMWH 11.8 h (SEM: ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h (P = .008) and 3.8 h (P = .002), respectively.ConclusionsUFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment.Graphical abstract

Apixaban Anti-Xa Level Monitoring in Treatment of Provoked Acute Upper Extremity Deep Vein Thrombosis for Patient on Dialysis: A Case Report

Background. Patients with end stage renal disease on dialysis are at higher risk of major bleeding and recurrent thrombosis and as such, treatment of acute venous thromboembolism (VTE) is challenging. Ideally, treatment would avoid inpatient admission as for most other patients with acute VTE. DOACs represent the easiest option but there are concerns over bioaccumulation increasing bleeding risk. Despite the absence of a standardized therapeutic range, anti-Xa trough level is measured to monitor potential DOACs bioaccumulation and thus, used for safety surveillance. Methods. We describe a case of a 51 yo female, 36 kg, on chronic hemodialysis with a provoked acute upper extremity deep vein thrombosis. Due to a lack of subcutaneous fat and calciphylaxis we were reluctant to use low molecular weight heparin and warfarin. She was treated with apixaban 2,5 mg twice daily for 6 weeks. Over 4 weeks, the apixaban anti-Xa trough levels were measured on dialysis days 12 hours after the morning dose. Results. The anti-Xa trough levels ranged from 58 to 84 ng/mL, similar to what is expected in patients with normal kidney function. There were no adverse events in the 3 months after anticoagulation initiation. Conclusion. We saw no evidence of bioaccumulation. This indicates a potential role for apixaban low doses in acute venous thromboembolism for patients on dialysis. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: The use of Apixaban for treatment of acute venous thromboembolism in patient on dialysis has not been approved.

Preparation and characterization of electrospun polyethersulfone/polyvinylpyrrolidone-zeolite core–shell composite nanofibers for creatinine adsorption

Dialysis needs innovative dialysis membranes. This method is the primary treatment for patients with kidney failure. Moreover, a wearable artificial kidney (WAK) has been proposed as one of the easy and effective approaches of daily dialysis for patients with the end-stage renal disease (ESRD). Therefore, this study developed a core–shell electrospinning composite nanofiber to remove creatinine for blood purification. Hence, functional core–shell structured composite nanofibers were prepared by electrospinning two polymers and two types of zeolite in a coaxial system. In addition, the blood compatible core–shell structured nanofibers consisted of varying concentrations of polyvinylpyrrolidone and zeolite (PVP and zeolite, shell) and polyethersulfone (PES, core). It has been found that PES/PVP-zeolite core–shell nanofiber could selectively adsorb creatinine. Moreover, scanning electron microscopy (SEM), Energy dispersive spectroscopy (EDS), Fourier transform infrared spectroscopy (FTIR), thermogravimetric analysis (TGA), and X-ray diffraction (XRD) have been used to fully investigate the structure and properties of the obtained core–shell nanofibers. Furthermore, the study considered four important blood compatible factors, including Zeta potential, BSA adsorption, platelet adherent, and cytotoxicity for PES/PVP-zeolite core–shell nanofibers. The EDS results indicated that over 90% of zeolites in the solution has successfully incorporated into the PVP nanofibers. Consequently, performance of the core–shell nanofiber in the retention of bovine serum albumin (BSA) revealed the effectiveness of the negative charge. Finally, the effect of the core–shell nanofiber on the removal of creatinine from solution was evaluated, and it has been found that removal of creatinine significantly increased with the Beta zeolite (4831.19 µg/g). The MTT assay also revealed that core–shell nanofiber with the best performance was biocompatible to L929 fibroblast cells. As a result, no platelet adhesion has been seen on the PES/PVP-Beta zeolite core–shell nanofiber.