Chronic Kidney Disease Dialysis Research Articles

Experience with Tafamidis in peritoneal dialysis for a patient diagnosed with transthyretin cardiac amyloidosis

Abstract Cardiac amyloidosis is a cardiomyopathy resulting from the extracellular deposition of proteins such as transthyretin (TTR). We present the case of a 72-year-old male with hereditary cardiac amyloidosis (ATTRh). After confirming the diagnosis, Tafamidis, a TTR stabilizer, was administered. Remarkably, Tafamidis, when coupled with peritoneal dialysis for chronic kidney disease, maintained stability in both cardiac and renal functions. Previous studies have demonstrated Tafamidis’ efficacy in reducing all-cause mortality and cardiovascular hospitalizations, although its use in severe renal failure lacks specific evaluation. This case suggests a potential application of Tafamidis in moderate-severe kidney disease, emphasizing the need for further research in this population.

The relative potential contribution of volume load and vascular mechanisms to hypertension in non-dialysis and dialysis chronic kidney disease patients.

Hypertension is highly prevalent and particularly difficult to treat adequately in patients with chronic kidney disease (CKD). The relative contribution of volume overload and vascular mechanisms to blood pressure measures in CKD and whether these effects differ in non-dialysis compared to dialysis patients is unknown. We determined the potential impact of volume load (stroke volume) and vascular mechanisms (inverse of total arterial compliance (inv TAC) and systemic vascular resistance (SVR)) on mean and brachial and aortic systolic blood pressures in 67 non-dialysis and 48 dialysis chronic kidney disease (CKD) patients. Relationships were determined in confounder adjusted regression models. Stroke volume (p value = 0.003) was more strongly associated with mean arterial pressure than SVR (p value = 0.9) (p value for difference = 0.03). When stroke volume and SVR were entered in the same regression model (model R2 = 0.324), they contributed equally to the variation in mean arterial pressure (p value for difference = 0.5). Stroke volume (p value ≤ 0.002) and inv TAC (p value ≤ 0.001) contributed equally to the variation in systolic pressures (p value for difference ≥ 0.9). When stroke volume and inv TAC were entered in the same regression model (model R2 = 0.752 to 0.765), they contributed equally to the variation in systolic blood pressures (p value for difference = 0.7). Stroke volume, TAC and SVR were similar (p value ≥ 0.5) and associated to the same extent with blood pressure measures in non-dialysis and dialysis CKD patients (p value for difference ≥ 0.1). In receiver operator characteristic curve analysis, elevated systolic blood pressure was determined by stroke volume (p value = 0.005) and inv TAC (p value = 0.03) but not SVR (p value = 0.8). The calculated power of the study was 0.999 based on α = 0.05. The present investigation suggests that both volume load and vascular mechanisms should be considered in the management of hypertension among patients with CKD. The extent and relative potential impact of volume load and vascular mechanisms on blood pressure measures are as large in non-dialysis compared to dialysis CKD patients.

Exploring The Impact Of Dialysis On Neurological Conditions: Insights From Biochemical Data In Chronic Kidney Disease

When an individual goes through dialysis in chronic kidney disease, the substances located in the bodies of patients undergo considerable fluctuations. Creatinine and urea are considered as kidney function indicators. In this regard, urea is an indicator of kidney change, and creatinine reflects the efficiency of glomerular filtration. The following data are markers that need to be kept on the observation under individuals on dialysis. The goal of the investigation is the biochemical parameters ratio pick up that can reflect the patients’ neurological state on dialysis. To ensure the transparency and reliability of the data sources, systematic review of scientific and methodological literature represented in the electronic databases VHL, Google scholar, SciELO, and recent publications from 2014-2023 has been carried out. Development of this subject has had given to the relationship of biochemical variables to CKD, creatinine, and urea. inclusion summary is provided. Research stakeholders included studies that were associated with patients’ biochemical variables and compared the denatured changes among bio-variable changes both before and after Dialysis. With the extracted data shown and analyzed how the dialysis treatment has impacted on patients with CKD regarding bio-variable changes. Results: the systematic review lead to a great change report in biochemical patients bio-variable among persistent kidney disease. Hemodialysis was a significant intervention since it influences metabolic values towards normalcy. Creatinine and urea were seen to be affected much since their levels of changes indicated abnormalities of kidney organs. Therefore data extracted remain valuable in that, it is required for any regular check in patients undergoing dialysis treatment. Conclusion: It is imperative that healthcare providers treating patients with CKD on dialysis be well versed with biochemical indicators such as creatinine and urea, and understand their importance in patient management. Appropriate and timely monitoring of these markers enables healthcare professionals to initiate prompt intervention and treatment adjustments to enhance patient care and quality of life. Based on these findings, the current systematic review studies demonstrate the significance of biochemical data in providing insights into the neurological state and management options for CKD patients under dialysis

Dialysis disequilibrium syndrome in neurosurgery: literature review and illustrative case example.

The dialysis disequilibrium syndrome (DDS) is a complication in those undergoing dialysis for chronic kidney disease (CKD) or acute kidney injury (AKI), characterized by nonspecific symptoms that may progress to coma and death secondary to cerebral edema. This syndrome is associated with rapid change in electrolytes during dialysis with changes in intracranial pressure (ICP) and may have a higher incidence in the elderly neurosurgical patient population. Literature review and illustrative case example. A 62-year-old female presented with acute mental status change during hemodialysis (HD), with a history of a nonsurgical acute subdural hematoma (SDH) 10days prior. Imaging showed a conversion of the acute SDH to chronic SDH of 12.2mm in size with a 14.1 midline shift, for which she underwent a hemicraniectomy with SDH evacuation, with a gradual return to baseline. The literature review identified 5 publications meeting the inclusion criteria. Major theories of DDS include a reverse urea effect, intracerebral acidosis, idiogenic osmoles, and local inflammation. This complication may occur more frequently in the elderly neurosurgical patient population, likely due to age-related comorbidities, preexisting neurological insult, and increased permeability of the blood-brain barrier (BBB), leading to cerebral edema. DDS is a rare and potentially fatal complication of HD that may have a higher incidence in the elderly neurosurgical patient population, yet remains to be fully understood. Further study is recommended to characterize the pathophysiological mechanism and incidence of DDS in neurosurgical patients.

Retraction: Abdominal Cocoon: A Rare Complication of Peritoneal Dialysis in Chronic Kidney Disease.

[This retracts the article DOI: 10.7759/cureus.20341.].

Left ventricular hypertrophy (LVH) in different stages of chronic kidney disease (CKD) patients and its correlation with anaemia

Background : Chronic kidney disease (CKD) is a public health problem that increases the risk of cardiovascular morbidity and mortality. Heart failure with preserved ejection fraction characterized by left ventricular hypertrophy (LVH) and diastolic dysfunction is a common cardiovascular complication of CKD. Anaemia is present in both dialysis & non dialysis CKD patients. Anaemia causes left ventricular hypertrophy (LVH) which in turn leads to increases morbidity and mortality in CKD, even before progression of chronic kidney disease (CKD) to end stage renal disease (ESRD). Our study is aimed at to evaluate the prevalence of left ventricular hypertrophy (LVH) and its correlation with anaemia in hospitalized CKD patients. Materials and Methods : A cross-sectional study was done on 50 patients of different stages of CKD admitted in the chittagong medical college hospital (CMCH). All the clinical data were reviewed and recorded. Data was analyzed by SPSS-18 and p value <0.05 was considered statistically significant. Results : Majority of study population 64% was male, 36% was female. Most of the male patient (40%) of the study population were having abnormal left ventricular mass index (>130 gm/m2). More patients with severe left ventricular hypertrophy were found in stage 5 of CKD in female and male which was 8 and 23 respectively. Regarding correlation of Hb% with LVMI there was a significant negative correlation was found (r= -0.420, p = 0.003) between them means if Hb% decreases LVMI level increases. It was also found in male and female patients separately ( for male r = -0.778, p = 0.001 and for female r = -0.746, p = 0.001). Conclusion : Anemia is widely prevalent in our CKD patients. Severity of anemia is correlated to left ventricular hypertrophy in these patients. Hence correction of anemia early in these group of patients can halt or prevent cardiovascular morbidity and mortality. J Bangladesh Coll Phys Surg 2024; 42: 25-30

Effect of single hemodialysis session on inflammatory and oxidative stress markers of chronic kidney disease patients

Background: Chronic kidney disease (CKD), with its high prevalence, morbidity and mortality, is an important public health problem. The progression of CKD has been shown to result in inflammation and oxidative stress. For CKD hemodialysis (HD) is the most common RRT modality in India. Present study aimed to compare and evaluate the immune modality profile, oxidative marker and biochemical profile of pre and post dialysis chronic kidney disease patients. Material and method: The study included 40 CKD patients depending on inclusion and exclusion criteria, attending HAHC hospital, HIMSR, New Delhi, which were on hemodialysis. The mean age of the patient was 60±15 yrs. Patients undergoing dialysis thrice in a week for about 4 hrs per session at flow 250-300 ml/min. Inflammatory and oxidative stress markers were assessed pre and post dialysis during any one session of dialysis in chronic kidney disease patients. Result: There was significant decrease in inflammatory and oxidative stress markers after dialysis. There was also significant decrease in biochemical marker levels post dialysis. Conclusion: Hence, evident from this study improvement in inflammatory markers and renal function test after dialysis suggests that indeed haemodialysis is the most common and better treatment option for chronic kidney disease patients.

A comparative analysis of serum phosphorus levels and mineral metabolic markers in non-dialysis and dialysis chronic kidney disease patient: a cross-sectional study

Background: Chronic kidney disease is a major public health problem worldwide. As kidney function declines, it leads to several metabolic abnormalities including dysregulation of mineral metabolism. It is also reported that hyperphosphatemia in patients with advanced kidney disease is associated with an increased risk of mortality and cardiovascular events, and is higher in dialysis-dependent chronic kidney disease (CKD) patients compared to non-dialysis CKD. However, data in the Indian context is limited. Objectives were to evaluate and compare serum phosphorus levels and associated factors in non-dialysis and dialysis CKD patients. Also, the impact of dietary phosphate restriction and the use of phosphate binders on serum phosphorus is analysed. Methods: A cross-sectional study was conducted at a tertiary care hospital in Kolkata, India, with 100 CKD patients: 50 non-dialysis CKD patients and 50 dialysis-dependent CKD patients. Relevant demographic, clinical and laboratory parameters including serum phosphorus, calcium, parathyroid hormone (PTH), alkaline phosphatase, albumin and estimated glomerular filtration rate (eGFR) were collected. Data was analyzed using appropriate statistical tests. Results: Mean serum phosphorus was significantly higher in the dialysis CKD group (6.12±0.34 mg/dl) compared to the non-dialysis CKD group (4.56±0.80 mg/dl). Serum calcium and PTH were also higher while eGFR and albumin were lower in the dialysis CKD group. Serum phosphorus levels increased with advancing CKD stages in the non-dialysis group. Phosphate binder helped phosphorus control in dialysis CKD patients. Conclusions: Our study is in confluence with other reports and dietary phosphate restriction and the use of phosphate binders help optimize phosphorus levels in CKD patients.

Independent risk factors for depression in older adult patients receiving peritoneal dialysis for chronic kidney disease

BACKGROUND According to the trend of global population aging, the proportion of elderly patients with chronic kidney disease (CKD) is expected to increase. However, there are more than 20 million people in China with decompensated kidney function, of which 19.25% are elderly people. Therefore, special attention should be paid to the education years, sleep quality, anxiety status, comorbidities with diabetes, cardiovascular disease (CVD), and anemia as independent risk factors for depression in elderly CKD patients. This study explores the clinical mana-gement of elderly CKD patients that should address these risk factors to prevent depression and improve their prognosis. AIM To investigate depression risk factors in older patients receiving peritoneal dialysis, aiding future prevention of depression in these patients. METHODS This retrospective study included a primary study population of 170 patients with CKD who received peritoneal dialysis from January 2020 to December 2022. We assessed the patients’ mental status using the Beck Depression Inventory Score-II (BDI-II), Self-Rating Anxiety Scale (SAS), Anxiety Inventory Score, and the Pittsburgh Sleep Quality Index (PSQI). Logistic regression was employed to identify depression independent risk factors among these patients. RESULTS The non-depressed group had a significantly longer education period than the depressed group (P < 0.05). The depressed group exhibited significantly higher mental status scores than the non-depressed group (P < 0.001). Patients with diabetes mellitus (DM) or CVD had a higher probability of developing dep-ression. Patients with depression had significantly lower hemoglobin and albumin levels than patients without depression (P < 0.05). Spearman correlation analysis of BDI-II scale scores, measuring depression, indicated positive correlations with BDI-II and SAS scores as risk factors for depression in patients with CKD. In contrast, years of education, hemoglobin levels, and peritoneal Kt/V were negatively correlated, serving as protective factors against depression. An analysis of variance for influences with significant differences in the univariate analysis revealed that years of schooling, BDI-II, SAS, PSQI, DM, CVD, and hemoglobin levels independently influenced depression in older patients with CKD. CONCLUSION Education, BDI-II, SAS, PSQI, DM, and CVD are independent risk factors for depression in older patients with CKD; therefore, post-treatment psychological monitoring of high-risk patients is crucial to prevent depression.

Urgent Implantation of Peritoneal Dialysis Catheter in Chronic Kidney Disease and Acute Kidney Injury-A Review.

Acute kidney injury (AKI) and sudden exacerbation of chronic kidney disease (CKD) frequently necessitate urgent kidney replacement therapy (UKRT). Peritoneal dialysis (PD) is recognized as a viable modality for managing such patients. Urgent-start peritoneal dialysis (USPD) may be associated with an increased number of complications and is rarely utilized. This review examines recent literature investigating the clinical outcomes of USPD in CKD and AKI. Relevant research was identified through searches of the MEDLINE (PubMed), Scopus, Web of Science, and Google Scholar databases using MeSH terms and relevant keywords. Included studies focused on the emergency use of peritoneal dialysis in CKD or AKI and reported treatment outcomes. While no official recommendations exist for catheter implantation in USPD, the impact of the technique itself on outcomes was found to be less significant compared with the post-implantation factors. USPD represents a safe and effective treatment modality for AKI, although complications such as catheter malfunctions, leakage, and peritonitis were observed. Furthermore, USPD demonstrated efficacy in managing CKD, although it was associated with a higher incidence of complications compared to conventional-start peritoneal dialysis. Despite its cost-effectiveness, PD requires greater technical expertise from medical professionals. Close supervision and pre-planning for catheter insertion are essential for CKD patients. Whenever feasible, an urgent start should be avoided. Nevertheless, in emergency scenarios, USPD does remain a safe and efficient approach.

Does Vitamin Supplementation Play a Role in Chronic Kidney Disease?

Although the role of vitamins in the human body is proven, guidelines for patients with chronic kidney disease (CKD) remain unclear. This narrative review summarizes the findings of 98 studies of CKD and the effects of vitamin D, B, C, A, E, and K supplementation on patients on dialysis for CKD, with the aim of summarizing the existing guidelines. The findings are promising, showing the potential effectiveness of vitamin supplementation with, for example, vitamins B, D, or C. However, recommendations are still ambiguous, especially in the case of vitamins A and K, due to the potential toxicity associated with higher doses for patients. Continued research is needed to rigorously evaluate the effectiveness and carefully consider the potential risks of some vitamin supplementation for patients with CKD.

#2695 THE ENVIRONMENTAL IMPACT OF CHRONIC KIDNEY DISEASE INTERNATIONALLY: RESULTS OF A LIFE CYCLE ASSESSMENT

Abstract Background and Aims The environmental impact of healthcare is high, and kidney care for chronic kidney disease (CKD) contributes significantly to this. Haemodialysis represents the only viable kidney replacement option for certain patients with CKD, in whom the clinical benefits are lifesaving. Haemodialysis is also resource-intensive, requiring frequent sessions, and energy- and water-intensive equipment. In recognition of this, the ERA has implemented a green nephrology initiative aiming to minimize the environmental impact of kidney care. However, there is a paucity of up-to-date analysis on the environmental impact of different dialysis techniques and CKD overall. This study presents an international, holistic life cycle assessment (LCA) of the environmental impact of CKD in adults at all CKD stages. Method LCA methodology was used, conducted according to ISO 14040/14044 international standards, to estimate the annual environmental impacts of each stage (1–5) of CKD per patient. At CKD Stage 5, supportive care, haemodialysis, peritoneal dialysis, and transplantation pathways were considered. A literature review was performed to identify all studies reporting healthcare resource use in CKD, stratified by CKD stage. The study boundary is summarised in Figure 1. GaBi software was used to model the pathway based on ecoinvent Life Cycle Inventory database version 3.8. Environmental impact categories were reported according to the impact assessment methods, ReCiPE 2016 v1.1 and TRACI 2.1 (US only). Here, we describe the preliminary analysis of the international study, presenting results on the annual environmental impact of in-centre haemodialysis in the UK, based on one patient receiving haemodialysis three times weekly for four hours per session. The inputs for in-centre haemodialysis comprised dialysis consumables and their transport, energy/water used by the haemodialysis machine (including reverse osmosis), heating/cooling/lighting of the healthcare area, waste disposal, and patient transport. Results A total of 93,600 litres of water and 3,058 kWh electricity was estimated per patient for in-centre haemodialysis annually in the UK. The carbon footprint of in-centre haemodialysis in the UK per patient was estimated to be 3,900 kg CO2 equivalents, comparable to the average UK persons annual greenhouse gas footprint, effectively doubling their yearly greenhouse gas impact. Several other environmental impact categories were measured beyond the carbon footprint, including photochemical oxidation potential (ground-level ozone formation) and fine particulate matter, measured as PM2.5. Across each impact category, the parameters that drove each environmental impact differed (Figure 2). For example, dialysis consumables, haemodialysis machine, and patient transport were the main environmental contributors of fine particulate matter, while patient transport was the main driver of terrestrial ecotoxicity. Conclusion The results of this LCA build upon previous published research and demonstrate a high carbon footprint for in-centre haemodialysis, in line with other studies. The results also show that the environmental impact of in-centre haemodialysis goes beyond that of its carbon footprint, to other important environmental aspects such as PM2.5 emissions, in which long-term exposure is associated with health problems, such as cardiovascular and respiratory diseases, and an increased risk of CKD. This study hopes to highlight the need for evidence-based policy interventions around the implementation of green nephrology initiatives such as use of renewable energy to power haemodialysis, utilisation of water conserving reverse osmosis systems, and reduction in waste. Furthermore, healthcare policy initiatives that could help detect patients in the early stages of CKD and thereby enable them to be managed proactively could eventually reduce the need for resource-intensive dialysis therapy.

#3932 INSULIN RESISTANCE IN PEDIATRIC CKD PATIENTS

Abstract Background and Aims Pediatric chronic kidney disease (CKD) is associated with disturbance of glucose metabolism & insulin receptor sensitivity leading to impaired glucose tolerance & insulin resistance (IR), which are potential risk factors for cardiovascular disease (CVD). Hyperinsulinemia and IR are not extensively investigated in children with CKD, especially in different stages of CKD. The aim of our study was to detect hyperinsulinemia & IR in pediatric CKD patients. Method A total of 87 children and adolescents; 58 with chronic kidney disease (CKD); (29 CKD stage 2-4, pre-dialysis group & 29 CKD stage 5 on regular hemodialysis, CKD5d group) & 29 age & gender matched controls were enrolled in the current cross-sectional study. Homeostasis model assessment of insulin resistance (HOMA-IR) using fasting insulin & glucose, where IR was considered if HOMA-IR was 4.39. Results Fasting insulin & glucose hadn't significantly changed between CKD patients & controls (p = 0.7, 0.3 respectively), while IR represented by HOMA-IR was found in a total of 11 (12.6%) CKD patients (6, 6.89% CKD5d & 5, 5.74% CKD 2-4) with no significant difference between pre-dialysis & dialysis groups (p>0.05), while it was significant with controls (p = 0.039), meanwhile, the total means of HOMA-IR between were no statistically significant between all CKD patients & (p = 0.64). HOMA-IR correlated positively to dialysis durations (p = <0.001, <0.001 respectively), but hadn't changed with BMI. Conclusion Pre-dialysis & dialysis CKD pediatric patients are at a high risk of IR & hence CVD. CKD & dialysis durations are independent risk factors for IR.

Incidence of and Risk Factors for the Development of Significant Tricuspid Regurgitation after Isolated Aortic Valve Replacement.

The late progression of tricuspid regurgitation (TR) after mitral valve surgery is well known. However, few reports have described the progression of TR after aortic valve surgery. We investigated the incidence of and risk factors for the development of significant TR after isolated aortic valve replacement (AVR). This study analyzed patients with less than moderate TR who underwent isolated AVR at Seoul National University Hospital from January 1990 to December 2018. Significant TR was defined as moderate or higher. Echocardiographic follow-up was performed in all patients. The Fine-Gray model was used to identify clinical risk factors for the development of significant TR. In total, 583 patients (61.7±14.2 years old) were included. Operative mortality occurred in 9 patients (1.5%), and the overall survival rates at 10, 20, and 25 years were 91.1%, 83.2%, and 78.9%, respectively. Sixteen patients (2.7%) developed significant TR during the follow-up period (13 moderate; 3 severe). The cumulative incidence of significant TR at 10, 20, and 25 years was 0.77%, 3.83%, and 6.42%, respectively. No patients underwent reoperation or reintervention of the tricuspid valve. Hemodialysis or peritoneal dialysis for chronic kidney disease (hazard ratio [HR], 5.188; 95% confidence interval [CI], 1.154-23.322) and preoperative mild TR (HR, 5.919; 95% CI, 2.059-17.017) were associated with the development of significant TR in the multivariable analysis. TR progression after isolated AVR in patients with less than moderate TR is rare. Preoperative mild TR and hemodialysis or peritoneal dialysis for chronic kidney disease were significant risk factors for the development of TR.

Interest of HIF stabilizers in home dialysis

Hypoxia-inducible factor (HIF) stabilizers or dustats are orally administered small molecules with very low renal elimination (without adaptation during chronic kidney disease (CKD) analogues with antagonistic effect of 2-oxoglutarate, a naturally occurring substrate of HIF-Prolyl Hydroxylase at the origin of the inhibition of this enzyme. This results in a simulated state of hypoxia allowing the accumulation of HIF-α in the cells followed by coordinated erythropoiesis with erythropoietin synthesis, decreased hepatic hepcidin production and optimization of iron metabolism. HIF stabilizers have only been studied in non-inferiority clinical trials versus erythropoiesis stimulating agents (ESAs). The primary endpoint for the therapeutic trials of all these different molecules was the change in hemoglobin level. Dustat corrects anemia in advanced non-dialysis and dialysis CKD in a similar way to ESAs.Six HIF stabilizers molecules are in advanced development: Roxadustat, Daprodustat, Vadadustat, Enarodustat, Desidustat and Molidustat. Only Roxadustat or Evrenzo®, currently has a marketing authorization in Europe obtained in August 2021. Only two studies have been dedicated to peritoneal dialysis, one with Roxadustat, the other with Daprodustat. Home dialysis appears to be an elective indication for HIF stabilizers because of their absence of cold chain necessity and their positive impact on iron metabolism and the difficulties and imperfections of the current treatment of anemia with ESA and intravenous iron in this patient population.

A network meta-analysis of the efficacy of hypoxia-inducible factor prolyl-hydroxylase inhibitors in dialysis chronic kidney disease.

Five types of HIF-PHIs have been authorized for anemia treatment in CKD patients in China and Japan. These are enarodustat, roxadustat, daprodustat, vadadustat, and molidustat. How effectively they compare to ESAs about clinical results in CKD-DD patients is uncertain. This study examined the RCT evidence about the benefits and risks of HIF-PHIs and ESAs in dialysis CKD patients. We conducted an extensive investigation and network meta-analysis of RCTs. In these RCTs, patients with CKD-DD received one of five different HIF-PHI or ESAs, a placebo, and no medical intervention. Outcomes included hemoglobin, iron parameters, and adverse events, and there were four weeks of follow-up at least. A frequentist framework for multivariate random effects meta-analyzed the results. The effect sizes of categorical variables were displayed as odds ratios. Mean differences were employed for computing continuous outcomes with common units; otherwise, standardized mean differences were applied. The Cochrane tool evaluated the bias risk in RCTs. 26 RCTs with 14945 patients were qualified for inclusion. Compared to the placebo, HIF-PHIs and ESAs dramatically boosted hemoglobin without affecting serum iron. Roxadustat performed better hemoglobin levels than ESAs (MD 0.32, 95% CI 0.10 to 0.53) and daprodustat (0.46, 0.09 to 0.84). Roxadustat (91.8%) was the top hemoglobin treatment among all medical interventions, as determined by the SUCRA ranking. However, roxadustat caused more thrombosis and hypertension than ESAs (1.61, 1.22 to 2.12) and vadadustat (1.36, 1.01 to 1.82). The lowest rates of hypertension and thrombosis were seen in molidustat (80.7%) and ESAs (88.5%). Compared with a placebo, ESAs and HIF-PHIs all affected TSAT levels. Except for molidustat, the other four HIF-PHIs impact different iron parameters. Regarding ferritin reduction, roxadustat (90.9%) and daprodustat (60.9%) came out on top. Enarodustat (80.9%) and roxadustat (74%) placed best and second in lowering hepcidin levels. The former two medicines for TIBC improvement were vadadustat (98.7%) and enarodustat (80.9%). The most effective treatment for hemoglobin correction is roxadustat. The superior efficacy of reducing hepcidin makes roxadustat and enarodustat appropriate for patients with inflammation. However, the increased risk of hypertension and thrombosis associated with roxadustat should be noted. In patients at risk for hypertension and thrombosis, molidustat and ESAs may be preferable options. When administering roxadustat and daprodustat, clinicians should check ferritin to assess iron storage. Lower TSAT in patients receiving HIF-PHIs and ESAs treatment suggests intravenous iron supplements are needed.

Is the risk for COVID-19 outcomes the same for all patients with chronic kidney disease? A retrospective study

Coronavirus disease 2019 (COVID-19) emerged at the end of 2019 and quickly spread worldwide. Among the various comorbidities associated with severe disease, chronic kidney disease (CKD) has been identified as one of the leading conditions. However, it is not yet clear whether all stages of CKD pose the same risk for severe COVID-19 infection. Therefore, the objective of this study was to assess the impact of different stages of CKD on the clinical characteristics, disease progression, and outcomes of COVID-19.
 Methods. This retrospective study focused on CKD patients who were admitted with COVID-19. We analyzed various factors including demographic data, comorbidities, symptoms, physical findings, laboratory test results, length of hospital stay, and in-hospital outcomes. These factors were evaluated based on the different stages of CKD.
 Results. A total of 284 CKD patients infected with SARS-CoV-2 were evaluated and compared to 395 COVID-19 patients with normal kidney function. Among the CKD patients, 86 were receiving dialysis. We observed significantly higher levels of C-reactive protein, procalcitonin, D-dimer, and ferritin, as well as a significantly lower lymphocyte count, in the CKD groups compared to the control group. There were significant differences among the CKD groups in terms of biochemical markers, duration of hospital stay, rates of ICU admission, and mortality. However, we did not find significant differences between dialysis and non-dialysis CKD patients regarding the length of hospital stay, need for ICU admission, and number of deceased patients.
 Conclusions. The presence and severity of CKD should be considered crucial factors for predicting the risk of COVID-19. Patients with late-stage CKD who are hospitalized with COVID-19 require increased awareness and close monitoring to reduce rates of ICU admission and mortality.

Translation, cross-cultural adaptation and validation of the EPOCH-RRT questionnaire "Empowering Patients On Choices For Renal Replacement Therapy" for the Brazilian context.

Chronic kidney disease (CKD) is a global public health problem. In Brazil, the incidence and prevalence rates of dialysis CKD progressively increase, but the transition process is a challenge for patients and caregivers in coping with the disease. Dialysis urgency, lack of planned access or prior knowledge of treatment is a reality for most. Guidelines recommend that treatment options should include the conscious preference of a fully informed patient. However, pre-dialysis educational information is an exception, leading to a large number of unplanned initial dialysis. The original study "Empowering Patients on Choices for Renal Replacement Therapy" (EPOCH-RRT) aimed to identify patient priorities and gaps in shared decision-making about dialysis, using structured interviews with questions about demographics, clinical history and patients' perception of their health. The goal of this study was to carry out the translation, cross-cultural adaptation and validation of the questionnaires used in the EPOCH-RRT Study for the Brazilian context. This is a methodological study that consisted of the initial translation, synthesis of the translations, back translation, review by a committee of experts, pre-test and evaluation of the psychometric properties of the instrument. All ethical precepts were followed. The questionnaires were translated, adapted and validated for the Brazilian context. Additionally, it was applied to 84 chronic renal patients on hemodialysis, peritoneal dialysis and outpatients. There is a lack of an educational-therapeutic approach aimed at patients with CKD, and the EPOCH-RRT questionnaire can be a tool for Brazilian dialysis services to change this paradigm.

Integrated Osteoporosis Care to Reduce Denosumab-Associated Hypocalcemia for Patients with Advanced Chronic Kidney Disease and End-Stage Renal Disease.

The incidence of hypocalcemia is high in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) undergoing denosumab treatment. Since 2018, we have carried out a "multidisciplinary integrated care program for osteoporosis among patients with CKD and ESRD" in our hospital. The aim of this study was to compare the incidence of denosumab-associated hypocalcemia among patients with advanced CKD and ESRD before and after the integrated care program. We retrospectively reviewed the records of patients on their first dose of denosumab treatment from January 2012 to December 2021. A total of 3208 patients were included in our study. Among the 3208 patients, there were 101 dialysis patients, 150 patients with advanced CKD (stage 4 and 5), and 2957 patients with an estimated glomerular filtration rate (eGFR) higher than or equal to 30. The incidence of post-treatment severe hypocalcemia (corrected calcium level less than 7.0 mg/dl) within 30 days was significantly higher in the dialysis and advanced CKD group than in patients with an eGFR higher than or equal to 30 (6.9% vs. 2.0% vs. 0.1%, respectively, p < 0.001). Based on the results of the multivariate regression model, poor renal function (p < 0.05) and lower baseline corrected calcium level (p < 0.05) were associated with severe hypocalcemia within 30 days following the first dose of denosumab treatment. The incidence of post-treatment severe hypocalcemia within 30 days in advanced CKD and dialysis patients was significantly lower after the integrated care program (6.8% vs. 0.8%, p < 0.05). Our study shows that multidisciplinary integrated care may reduce the incidence rate of denosumab-associated severe hypocalcemia among patients with advanced CKD and ESRD.

Evaluation of Serum Lipoprotein (a) Levels and Novel Lipid Indices in Patients with Chronic Kidney DiseaseA Case-control Study

Introduction: Majority of Chronic Kidney Disease (CKD) patients are more likely to die of cardiovascular complications, before reaching End Stage Renal Disease (ESRD). Although there are many risk factors contributing to pathogenesis of cardiovascular disease in CKD subjects, dyslipidemia represents one of the modifiable risk factors. American Heart Association has recommended that CKD patients should be classified in the highest risk group for developing cardiovascular events. Kidney Disease: Improving Global Outcome (KDIGO) recommends, these patients should be evaluated for dyslipidemia and for treatment to reduce the risk of cardiovascular events. Aim: To evaluate serum Lipoprotein (a) {Lp(a)} levels and assess the significance of novel lipid indices in non dialysis patients of CKD. Materials and Methods: This analytical case-control study was conducted from January 2016 to June 2016 at Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India. It included 70 non dialysis CKD subjects and 70 healthy control subjects, adhering to inclusion and exclusion criteria. Fasting Blood Samples (FBS) were collected and analysed for: Fasting blood glucose, Fasting Lipid Profile, Serum Lp(a). Serum Lp(a) was estimated by immunoturbidimetry method and lipid profile by enzymatic method. Estimated Glomerular Filtration Rate (eGFR) was calculated using Modification of Diet in Renal Disease (MDRD) formula and staging of CKD subjects was done, based on KDIGO guidelines. Novel lipid indices were calculated using appropriate formula. Statistical analysis of the tabulated data was done using Social Sciences of the Statistical Package (SPSS) software. Results: There were significant differences in the levels of FBS, Triglycerides (TG), Lp(a) between controls and non dialysis CKD subjects (p&lt;0.001). Among Lipid Indices, Atherogenic Index of Plasma (AIP) and Lipid Tetrad Index (LTI) values were significantly higher in CKD subjects compared to controls (p&lt;0.001), but there was no significant difference was seen in Atherogenic Coefficient (AC), Castelli’s Risk Index-I (CRI-I) and CRI-II values. AIP and LTI showed significant positive correlation with Lp(a). LTI had the highest Positive Predictive Value (PPV) (77.8%) and Negative Predictive Value (NPV) (72.7%); AIP had PPV of 65.3% and NPV of 66.2%. Conclusion: The present study concludes that, among lipid indices, AIP and LTI are the most suitable for assessment of atherogenicity in non dialysis CKD. In developing countries like India, owing to high cost of tests like Serum Lp(a), novel lipid index AIP can serve as a cost-effective screening tool for monitoring cardiovascular disease risk in CKD patients.