Dialysis Treatment Research Articles

A comprehensive exploration of chronic kidney disease and dialysis in Canada's Indigenous population: from epidemiology to genetic influences.

This study aims to review the escalating prevalence of chronic kidney disease (CKD) and end-stage renal disease (ESRD) among Canada's Indigenous population, focusing on risk factors, hospitalization and mortality rates, and disparities in kidney transplantation. The study explores how these factors contribute to the health outcomes of this population and examines the influence of genetic variations on CKD progression. The review synthesizes data on prevalence rates, hospitalization and mortality statistics, and transplantation disparities among Indigenous individuals. It also delves into the complexities of healthcare access, including geographical, socioeconomic, and psychological barriers. Additionally, the manuscript investigates the impact of racial factors on blood characteristics relevant to dialysis treatment and the genetic predispositions influencing disease progression in Indigenous populations. Indigenous individuals exhibit a higher prevalence of CKD and ESRD risk factors such as diabetes and obesity, particularly in regions like Saskatchewan. These patients face a 77% higher risk of death compared to their non-Indigenous counterparts and are less likely to receive kidney transplants. Genetic analyses reveal significant associations between CKD and specific genomic variations. Through analyses, we found that healthy Indigenous individuals may have higher levels of circulating inflammatory markers, which could become further elevated for those with CKD. In particular, they may have higher levels of C-reactive protein (CRP) fibrinogen, as well as genomic variations that affect IL-6 production and the function of von Willebrand Factor (vWF) which has critical potential influence on the compatibility with dialysis membranes contributing to complications in dialysis. Indigenous people in Canada are disproportionately burdened by CKD and ESRD due to socioeconomic factors and potential genetic predispositions. While significant efforts have been made to assess the socioeconomic conditions of the Indigenous population, the genetic factors and their potential critical influence on compatibility with dialysis membranes, contributing to treatment complications, remain understudied. Further investigation into these genetic predispositions is essential.

The combined effect of leucine-enriched essential amino acid supplements and locomotion training on physical functions and quality of life in hemodialysis patients

BackgroundLocomotive syndrome (LS) is a condition of reduced mobility (locomotive organ impairment) that is associated with reduced quality of life (QOL) in patients undergoing hemodialysis (HD), and effective interventions for patients with LS undergoing HD are unclear. We conducted a clinical trial to assess the effects of exercise and oral nutritional supplementation (ONS) on QOL in this cohort.MethodsThis study was an open-label, randomized controlled trial. The participants were patients with LS undergoing HD. The intervention period was 3 months. The primary outcome was a change in the physical component summary (PCS) of QOL, and the secondary outcomes were changes in other QOL scores, physical function, body composition, and nutritional status assessed by using the geriatric nutritional risk index. Participants were divided into the locomotion training (LT) and LT + ONS groups. Both groups were instructed on LT that comprised one-leg standing and squats to be carried out four or more times per week. The ONS consisted of 3 g leucin-rich essential amino acids and 800 IU vitamin D per pack, and the participants in the LT + ONS group received one pack of the supplement per day.ResultsIn total, 40 individuals undergoing HD were included in the study; 3 patients in the LT + ONS group were excluded from the analysis because of hospitalization and incomplete assessment. The median age was 73 years (interquartile range: 62–80 years), 23 participants were men (62%), and the duration of dialysis treatment was 6 years (interquartile range: 3–16 years). The change in PCS of the LT + ONS group did not differ from that in the LT group [LT + ONS: −1.6 (−5.3, 6.8) versus LT: −0.1 (−5.3, 6.2), p = 0.94]. In contrast, the LT + ONS group showed maintenance in mental health (MH) and improvement of the two-step value.ConclusionsThe LT + ONS group did not show an effect on PCS in QOL compared with only LT in patients with LS undergoing HD. However, maintenance of MH and improvement of two-step value were confirmed in the LT + ONS group. Future research is need to confirm whether leucine-rich essential amino acids and vitamin D help mental health and physical function in patients with LS undergoing HD with larger sample sizes and long-term interventions.Clinical trial registration University Hospital Medical Information Network Center (UMIN 000032457).

Health status of Hemodialysis Patients with End Stage Kidney Disease in Kirkuk City

Background: Hemodialysis is a treatment for end-stage renal disease (ESRD) in which a machine filters waste and excess fluids from the blood for patients whose kidneys can no longer perform this function on their own. The health status of a hemodialysis patient can vary depending on several factors, including the underlying cause of their kidney disease, their overall health and medical history, the effectiveness of their dialysis treatments, and their adherence to their treatment plan. Aim: This study aimed to assess health status of hemodialysis patients with end stage kidney disease in Kirkuk city: 2023-2024. Methods: Cross –sectional study design conducted from 10 February 2023 to 22 May 2024.This study was conducted at Kirkuk City Hospitals . A purposive sample (non-probability) consisting of 100 patients under hemodialysis at Kirkuk city hospitals . . Data were collected using an interview-structured questionnaire. The structured questionnaire consisted of three main domain includes demographic data, medical data and health status domain which includes (independency, daily physical activity, psychosocial, and life adaptation. A three-point Likert scale was employed, with (3) representing always, (2) some times and (1) for never. Mean of score categorized as low significant less than 1.8, moderate significant :1.8 to 2.39 and high significant between 2.4 to 3. The data were prepared, organized and entered into the computer file; Statistical Package for Social Science (SPSS) (23 version .The significance level for statistical analysis was set at p<0.05.. The descriptive data analysis (frequencies, percentages) and inferential statics by use Anova and T, test was used for categorical variables Results: The results shows the male more than female and constitute 60 (60.0%), most of "Age Groups", between (50-59) years and constitute 35.0% in the dialysis patients Conclusions: health status of patients with hemodialysis patients different according to independency, daily physical activities, psycho- social aspects, and adaptation of life., mean score for hemodialysis patients were high and moderate in most items, Health status of hemodialysis patients were poor, Socio-demographic characteristics of hemodialysis patients age, gender, marital status and occupation has significant effect on health status at p<0.05.

Adherence to Fluid Restrictions among Haemodialysis Patients In Private Haemodialysis Centres in Kuala Lumpur Malaysia

End stage kidney disease (ESKD) is an irreversible progressive kidney function that requires kidney replacement therapy. Over two million people have currently received dialysis treatment worldwide. Haemodialysis treatment has been developed as a practical, safe and efficient method for the care of patients with ESRD. However, HD treatments generally have a more negative impact on patients' quality of life (QoL), high morbidity and mortality rate, as well as major adverse cardiovascular events. Compliance to dietary, fluid restrictions, medications and treatment regimens is one of the contributors to the quality of life observed in patients ESKD undergoing haemodialysis treatment. This study is aimed on the measurement of the fluid restriction adherence of 132 haemodialysis patient in MAIWP-PICOMS haemodialysis centres. An interdialytic weight gain (IDWG) was used as an indicator to describe the level of adherence level. Method: An observational study was conducted among consenting patients on HD for ≥3 months with criteria of age from 18 to 65 years old using end-stage renal disease-adherence questionnaire (ESRD-AQ). Result: Of 132 participated patients were observed, 53% were female and 47% were male with a mean age of 49.05 ±11.52 years and HD duration mean length of 1.33 ranging from 1-5 years. Statistically, a significant association between level of fluid adherence behaviour and treatment duration (p < .01) was found in this study. Meanwhile, the level of adherence to fluid restrictions was range between 45.5% - 50%, which was considered good. Conclusion: Significantly, adhered to fluid restriction among haemodialysis patients may prevent patients from many adverse consequences and improve the quality of life. Therefore, nurses and healthcare providers has been suggested to play a pivotal role in delivering education on fluid restriction for haemodialysis patient.

Does using a higher dialysate sodium concentration result in lower sodium losses with dialysis treatments?

IntroductionMany dialysis centres prescribe a uniform dialysate sodium (DialNa) concentration, but as there is no consensus on the choice of a universal DialNa, we wished to determine dialysate sodium balance comparing DialNa of 140 and < 140 mEq/L.MethodsWaste dialysate was continuously collected during sessions and thoroughly mixed, and sodium was measured in both the waste and fresh dialysate. Sodium removal was calculated as the difference in concentrations, dialysate flow rate, session time and ultrafiltration.ResultsDialysate sodium balance was measured during 139 dialysis treatments (34 DialNa 140 versus 105 DialNa < 140, median 136 mEq/L), in 111 patients, 63% male, mean age 64.0 ± 16.2 years and 33.3% diabetic. There was no difference using the higher DialNa [net loss median 482 (238–573) versus 312 (124–599) mEq], ultrafiltration losses [226 (131–280) versus 204 (125–290)mEq] and non-ultrafiltration losses [217 (0–384) versus 173 (−90 to 350)mEq]. We also compared haemodiafiltration and haemodialysis (118 versus 23 sessions), and there were no differences in net loss [311 (91–608) versus 381 (167–597)], ultrafiltration [212 (127–290) versus 169 (110–258)mEq] and non-ultrafiltration losses [180 (−51 to 386) versus 192 (−74 to 387)mEq].ConclusionsAlthough most dialysis centres prescribe a universal dialysate sodium concentration, there is no consensus on the optimum universal concentration. We found no difference in net dialysate sodium balance when comparing patients dialysing with a dialysate sodium concentration of 140 or < 140 mEq/L. Similarly, we found no differences in dialysate sodium balance between haemodiafiltration and haemodialysis sessions.

Pain Assessment in Patients during Hemodialysis Treatment: Quality Improvement Project.

Pain is a prevalent symptom in patients with chronic kidney disease, related to disease progression, comorbidities, and required immobility during dialysis treatment. Nurses must perform detailed pain assessments to manage pain effectively during hemodialysis treatment. This quality improvement project, reported using SQUIRE 2.0, aims to describe pain characteristics in chronic kidney disease patients in a hemodialysis unit clinic in Portugal, implement strategies to improve the pain assessment process in patients with chronic kidney disease during hemodialysis treatment, and assess nurses' satisfaction with the implemented strategies. The study was conducted in a Portuguese hemodialysis clinic, with patients and nurses, in three phases: diagnostic study, protocol implementation, and a descriptive study to assess nurse satisfaction. Seventy-five patients (mean age 71 ± 12.6 years) participated, with 64% reporting moderate chronic pain daily and 48% during hemodialysis treatment. Thirteen nurses considered the pain assessment protocol important, rating their satisfaction at 7.92 ± 1.32 (0-10). Standardizing practices through protocol implementation is likely to improve care and increase nurse satisfaction.

Preventive dental care reduces risk of cardiovascular disease and pneumonia in hemodialysis population: a nationwide claims database analysis

This study aims to investigate the impact of dental care utilization status on the occurrence of fatal complications such as cerebral/cardiovascular disease (CVD) and infectious diseases in patients with end-stage renal disease (ESRD) undergoing hemodialysis. This retrospective cohort study was performed using the Japanese claims database and included patients who first underwent hemodialysis between April 2014 and September 2020. The exposure variable of interest was the pattern of dental utilization, which was categorized into three groups, “dental treatment group”, “preventive dental care group”, and “no-dental visit group”. The primary outcomes were the time interval until a composite end point of first major cardiovascular event (acute myocardial infarction, heart failure, or cerebral infarction) of infectious disease (pneumonia and sepsis). The secondary outcomes were the time interval until the incidence of each component of primary outcomes. Survival analyses, including log-rank tests and Cox proportional hazards regression analyses, were performed. Among the 10,873 patients who underwent the first dialysis treatment, 6152 were assigned to the no-dental visit group, 2221 to the dental treatment group, and 2500 to the preventive dental care group. The preventive dental care group had significantly lower hazard ratios (HRs) of the incidence of CVD (adjusted hazard ratio [aHR]: 0.86, 95% confidence interval [CI]: 0.77–0.96) and infectious diseases (aHR: 0.86, 95% CI: 0.76–0.97). As for pneumonia, preventive dental care and dental treatment groups had significantly lower HRs (aHR: 0.74 and 0.80, 95% CI: 0.61–0.88, 0.66–0.96) than the no-dental visit group. This study demonstrated that dental visits for preventive dental care were associated with a significant risk reduction in CVD and infectious complications in patients with ESRD undergoing hemodialysis.

Pediatric Emergent Peritoneal Dialysis in Intensive Care Units: Indications, Techniques, and Outcomes

Plain Language SummaryIn our study, we looked at medical records of young patients, from newborns to 18-year-olds, who needed an emergency procedure called peritoneal dialysis after heart surgery. Peritoneal dialysis is a treatment that cleans the blood when the kidneys can’t do it properly. It involves placing a special tube in the belly to filter out waste using a cleansing fluid. We found that this emergency treatment was most often needed after complex surgery for heart problems present from birth. It is a serious situation, and unfortunately, many children did not survive. We learned that starting the dialysis treatment as soon as possible after surgery might help increase the chances of survival. We also noticed that some issues like infections or problems with the tube used in the treatment could lead to stopping the dialysis, which happened in about a third of the patients. Our goal was to understand what makes this emergency treatment work well or not. Knowing these factors can help doctors and medical teams improve how they care for very sick children after surgery and potentially save more lives. We hope that our findings will lead to better ways to manage and prevent problems that come up with this life-saving treatment.

#3003 Increased focus on peritoneal dialysis gives patients improved quality of life and saves millions for the region

Abstract Background and Aims Is it possible to improve PD patients' quality of life and everyday life in combination with the challenge of mastering large geographical distances and at the same time a desire to make healthcare more patient safe and enable patients to be co-creators in their dialysis care? With an area of 48,935 km2, which corresponds to 12% of Sweden's area and larger than the whole of Denmark, Östersund Hospital is the only hospital in a region that takes care of 132,670 inhabitants. In 2018, 85% of patients were dialyzed with hemodialysis at Östersund Hospital. Several of the patients had to travel 200-300 km one way, three to four times a week to receive their dialysis treatment. In addition to high medical travel costs for the region, this also contributed to a low quality of life for the patients. Patients of working age found it difficult to maintain their jobs due to long journeys to the hospital. In a study by (Van Bulck et al, 2018), he shows that patients on dialysis have low participation in their care compared to other patient groups. Method A first step towards a change to provide an increased quality of life for the patients was to invest in self-care with peritoneal dialysis. Several studies describe peritoneal dialysis as a treatment with increased freedom that offers the patient independence with the opportunity to continue working if they are of working age (IIkka et al, AJKD 2012). In addition, several studies show several medical benefits, such as preserving the patient's residual function, which indirectly associates with better patient survival (Van de Luijtgaarden et al, NDT 2011). To continue its work, the dialysis clinic needed approval from the region to start using a night machine connected to a cloud service. After a long wait, the dialysis clinic received approval to use the new technology. Results Since the digital platform was introduced, remote dialysis treatment has increased in the Jämtland Härjedalen region. Digitalization gives healthcare professionals the opportunity to follow the patient's treatment results daily and optimize dialysis treatments without the patient needing to visit the hospital. Today, work is more proactive and provides the conditions to prevent problems before they arise. Five years ago, 85% of dialysis treatments were performed at the hospital. Today, as many as 60% of dialysis treatments with peritoneal dialysis take place in the patient's home. Already in the first year of increased self-care, the region saved SEK 6 million on reduced patient travel. Success factors for a successful result and our way of working today: Conclusion With a patient centric approach, a clear goal focuses and collaboration between several different professional categories. Östersund Hospital has managed to increase the proportion of patients with home treatment from 15% to 60%. Through the implementation of new technology in the form of a digital platform tied to a dialysis machine, the patient's treatment can be evaluated and adjusted remotely. From previously working reactively and solving problems when they arise, now working proactively and planning care for the patient. Emergency hospitalizations can be avoided. In addition to reducing the patient's suffering and providing a better quality of life with fewer hospital visits, it also promotes the hospital's finances. By having the courage to dare to try when others say impossible, learn from their mistakes instead of seeing it as a failure, the clinic's work has improved self-care and participation for this patient group.

#2570 Non-invasive blood pressure monitoring in dialysis patients using pulse wave velocity

Abstract Background and Aims Dialysis patients are at high risk of circulatory dysregulation and hypotension during treatment. Intradialytic hypotension (IDH) is a potentially life-threatening complication. The main causes are high ultrafiltration volumes and high ultrafiltration rates when patients tend to gain a lot of weight between dialysis treatments. A lack of patient compliance with regard to drinking volumes and a lack of residual diuresis are risk factors for this. Close circulatory monitoring and therapy settings to avoid absolute or relatively high UF rates to prevent IDH are frequently used. These are primarily the frequent non-invasive measurement of blood pressure using cuffs, the measurement of relative blood volume and the adjustment of ultrafiltration rates to these values. Prophylactically, the dialysis time can be extended, ultrafiltration profiles or ultrafiltration breaks can be planned, the dialysate temperature can be lowered and the composition of the dialysate can be adjusted. Despite all attempts, however, the incidence of IDH in everyday clinical practice is too high. The non-invasive measurements with cuffs are not carried out frequently enough, the measurement of the relative blood volume only covers a partial range, sudden changes in vascular tension or cardiac output are not recorded. Method The pulse wave velocity (PWV) is a well-known parameter for describing the propagation of the pressure wave after ejection of the heart beat volume in the arteries. The PWV is dependent on blood pressure, vessel wall tension and cardiac output. Changes in blood pressure can therefore be recognised by measuring the PWV. With the help of a measuring device (PESAS) for the ECG signal and peripheral pulse plethysmography, PWV can be measured non-invasively, continuously, for every heartbeat and, above all, hardly noticed by the patient. The PESAS allows the time-synchronised measurement of ECG and peripheral plethysmography curves and thus the determination of PWV. It is an experimental device. We would like to present a study showing the use of a measuring device (PESAS) in 15 prevalent dialysis patients for the detection of IDH. All study participants were examined during 3 dialysis treatments. Results The measurement of PWV in chronic dialysis patients during treatment is technically feasible. The measurement is tolerated by the patients. Changes in PWV could be detected in the patients during the course of dialysis; these were also dependent on the ultrafiltration rates. Individual patient reactions to volume withdrawal varied, with both increases and decreases in PWV being demonstrated. An acute change in PWV was usually associated with a drop in blood pressure. Continuous measurement allowed IDH events to be detected earlier than intermittent blood pressure measurement with cuffs. Sudden drops in blood pressure could be detected better and earlier with the PESAS system than by measuring the relative blood volume. Conclusion The PESAS system is suitable for monitoring dialysis patients to prevent IDH. Further adjustments and optimisation of the evaluation algorithms are necessary.

#1498 Higher body mass index in patients with diabetes mellitus and hemodialysis associated with a better survival in contrast to peritoneal dialysis

Abstract Background and Aims The association between Body Mass Index (BMI) and the risk of mortality in patients with end stage renal diseases and dialysis treatment is debated. The aim of this study was to assess the association between BMI and the risk of all-cause mortality in patients with diabetes mellitus (DM) on maintenance hemo- (HD) versus peritoneal dialysis (PD). Method We used the data from Swedish Renal Registry (SRR) which included 3235 patients with diabetes mellitus on dialysis treatment (2452 on HD and 783 on PD). The follow-up period was 3.9 ± 3.5 years and patients who switched from PD to HD, or vice versa, during the study period were excluded. The patients were divided in six groups by mean value of BMI according to classification of BMI by WHO. The relationships between mean value of BMI and mortality were examined by time-dependent Cox models to estimate hazard ratios (HR) and 95% confidence intervals (CI) in univariate and multivariate analyses, with adjustment for demographics, laboratory findings and comorbidities. The group with BMI 18.5&amp;lt;BMI≤25.0 kg/m2 was used as a reference group. Results During the follow-up period 1688 (53%) deaths occurred (1275 on HD, 413 on PD). The mean value of BMI was 27 ± 6 kg/m2 in HD and 26 ± 5 kg/m2 in PD. In the multivariate analyses, patients on HD with a low BMI≤18.5 kg/m2 had a higher risk for all-cause mortality (HR1.94, CI 1.47-2.54; p &amp;lt; 0.01) compared to the reference group. However, HD-patients with a higher BMI 25.1-30.0 kg/m2 (HR 0.84, CI 0.73-0.96; p &amp;lt; 0.01), 30.1-35 kg/m2 (HR 0.66, CI 0.55-0.78; p &amp;lt; 0.01), and 35.1-40.0 kg/m2 (HR 0.65, CI 0.49-0.85; p &amp;lt; 0.01) had a significantly decreased risk of all-cause mortality compared to the reference group. In multivariate analyses, patients on PD, BMI groups of 25.1-30 kg/m2 (HR 0.86, CI 0.67-1.09), 30.1-35 kg/m2 (HR0.94, CI 0.67-1.31), and 35.1-40 kg/m2 (HR 0.93, CI 0.48-1.77) were not-significantly associated with a risk of mortality. Conclusion In patients with diabetes mellitus on maintenance hemodialysis underweight (BMI≤18.5 kg/m2) was associated with an increased risk of all-cause mortality; however overweight (BMI 25.1-30.0 kg/m2), class 1 obesity (BMI 30.1-35.0 kg/m2) and class 2 obesity (BMI 35.1-40.0 kg/m2) were associated with better survival. In contrast, in patients with diabetes mellitus on maintenance peritoneal dialysis no association between BMI and risk of all-cause mortality was found.

#605 Shared decision-making intervention regarding dialysis modality in patients with CKD stage 5

Abstract Background and Aims Patients with kidney failure must make complicated decisions about the dialysis modalities used either at home or in-hospital. Different options have varying levels of impact on patients’ physical and psychological conditions and their social life. The purpose of this study was to evaluate the implementation of an intervention designed to achieve shared decision making (SDM) in patients’ options for dialysis. Method SDM was performed after consent was written for stage 5 chronic kidney disease patients before dialysis, and 435 cases were performed in 408 patients from December 16, 2019 to June 30, 2021. Among these, 101 patients were compared by SDM measurement scale, patient satisfaction, disease recognition scale survey, and dialysis method. Results The average age of participants was 56 years, with a gender composition of 55 males (54.5%) and 46 females (45.5%). Following SDM, the final dialysis methods decided upon by patients and clinicians were peritoneal dialysis (67 patients, 66.3%), hemodialysis (22 patients, 21.8%), and kidney transplantation (1 patient, 1.0%). Looking at the items, “My doctor and I chose treatment together” (94% in the PD group, 87.5% in the HD group, P = .012) and “My doctor and I agreed on a course of treatment” (97% in the PD group, 81.3% in the HD group, P = .058), the group of patients that selected treatment with PD had a significantly higher percentage of positive answers of 4 points or higher in comparison to the group of patients that selected HD Conclusion Among participating patients, SDM was effective when used to decide on dialysis treatment, and patients were satisfied with the dialysis method decision process. On the disease awareness scale, those who participated in this project had relatively high positive and low negative perceptions, so it can be concluded that SDM was relatively effective. The implementation of SDM was helpful in selecting patients’ best dialysis methods, and SDM scale results were higher in the peritoneal dialysis group than in the hemodialysis group.

#341 Dialysis modality patterns across six continents in Apollo Dial DB

Abstract Background and Aims Data is often collected during kidney dialysis treatments, providing data on a large scale and at a constant flow. As multinational datasets are scarce, Apollo Dial DB was created by a global provider that contains longitudinal observational data across six continents. This database is fully anonymised and can be used to better understand modality practice of global patients from a variety of healthcare systems for quality improvement and research efforts. Our aim was to detail patterns of dialysis modalities used among patients treated in 40 countries across six continents represented in the first version of the global database. Method Apollo Dial DB, a global anonymised dialysis database, contains demographics, diagnoses, laboratories, medications, treatments, quality of life, and outcomes from six continents and 40 countries. Data was harmonised from different electronic systems and anonymised based on logic established in a re-identification risk assessment. Data is consolidated and stored in a central cloud environment. The initial version of the dataset contains data on more than 360 variables from January 2018 to March 2021 and will be updated periodically. Results The first version of the Apollo Dial DB includes data on 543,169 patients, with 4.6% from Asia-Pacific (AP), 13.9% from Europe, Middle East, and Africa (EMEA), 7.0% from Latin America (LA), and 74.5% from North America (NA) countries. Most of the patients included in the database are between 45-64 years old at the initiation of dialysis. Overall, Apollo Dial DB contains information on 140,016,249 dialysis treatment observations. Depending on the region, different treatment patterns could be observed (Table 1 and Fig. 1). In EMEA a higher proportion of patients received hemodiafiltration with post-dilution, especially in Northern and Southern Europe as well as in South Africa. Peritoneal dialysis was more frequently used in LA and NA than in other regions. CCPD was mainly used in NA, whereas CAPD was common in LA and EMEA. For a more detailed look across the six continents Fig. 1 illustrates incentre hemodialysis modality patterns on a minor world region level. For incentre hemodialysis treatments, the majority of treatments from the minor regions in AP, LA, and NA had HD treatments. However, the majority treatments from EMEA minor regions are receiving incentre HDF treatments. Conclusion In a descriptive analysis, we defined modality treatment patterns in major world regions. These findings act as benchmarks for the nephrology community and expand upon scarce point prevalent information on modality practice patterns used throughout the world [1]. Apollo Dial DB offers opportunities for investigators to conduct global analytics and advance the state of the art.

#1600 The effect of integrated real-time hemodialysis surveillance on staff workload and time efficacy—a multicenter prospective study

Abstract Background and Aims For many years, dialysis data have been manually registered and transferred to the patients’ electronic health records by dialysis staff. However, manual documentation can be associated with poor data completeness, delayed recognition of inadequate dialysis prescriptions, and high staff workload. We studied the effect of introducing a new integrated, digitalized haemodialysis surveillance system, the Treatment Guidance System (TGS), on staff workload and time saving in clinics from a large multi-national dialysis provider. To measure the effect of introducing the new TGS system on staff workload and time saving. Method This was a prospective, observational multicenter study conducted between November 2021 and January 2023 in five countries: Saudi Arabia, Spain, Portugal, UK, and Kazakhstan. Inclusion criteria were clinics with adequate digital infrastructure, introducing the TGS. Only staff without prior experience with TGS were included in this study. Staff workload was determined using the NASA Task Load Index (TLS) at three timepoints: 1: two weeks prior to introduction of the TGS, 2: one month after introduction of the TGS, and 3: three months after introduction of the TGS. Time saving was determined by observation of the time used for dialysis data documentation by an independent person at timepoints 1 and 3. Differences in staff workload were determined by Friedman's two-way analysis of variance by ranks with Bonferroni correction for multiple tests, while time saving was determined by Wilcox signed rank test. Results In total, 223 participants from 20 clinics were included in the study, 56% were female, age distribution was 32.1% &amp;lt;30 years, 58.8% 30-49 years, and 9.1% ≥50 years, and dialysis experience was 17.5% ≤2 years, 27.9% 2-5 years, 33.3% 5-10 years, and 21.2% &amp;gt;10 years. The staff adaptability to the introduction of TGS at their workplace and the workload perception improved significantly over all domains of the NASA TLS (Table 1). While most domains improved by approximately 50%, median physical demand improved by more than 60% (Table 1). There was some variation of the observed time used for documentation between different countries, however, the observed time decreased in all countries from median (25-75%) 9:35 (5:36-14:41) minutes at timepoint 1 to 5:22 (2:05-9:22) minutes at timepoint 3 (p &amp;lt; 0.001). The largest saving was noted in the United Kingdom (14:06 (11:01-18:25) to 5:17 (4:56-5:45) minutes), while the smallest saving was noted in Kazakhstan, where only 3 individuals were observed (3:37 to 3:08). Conclusion Introduction of the novel, digitalized, integrated real-time dialysis documentation system TGS greatly reduced staff workload and time spent with documentation of dialysis treatments. Digitalization and automation of haemodialysis treatment has the potential to improve dialysis treatment, which will be further elucidated by the analysis of data quality and completeness in the current study.

#1119 Iodine contrast does not contribute to impaired kidney function or need for dialysis

Abstract Background and Aims Imaging diagnostics play a crucial role in the management of patients with acute and critical conditions or suspected underlying disease like infections or malignancy. These examinations are often enhanced by intravenous iodine-based contrast, to improve the imaging quality and the diagnostic accuracy. For long, there has been a conception that these contrast materials are nephrotoxic, but the last decade has provided a significant quantity of modern studies suggesting that this is not the case. The present study evaluates if earlier contrast exposure has contributed to progress in CKD and the need of initiating dialysis treatment in patients who were in maintenance dialysis treatment at the Västerås hospital at the time of inclusion. Method All patients admitted to the dialysis ward in Västerås the 1st of January 2022 were included and copies of all radiology surveys and all lab values from the electronical records for this study population for the last 10 years were extracted to check for contrast exposure. For some patients, this occurred when they were already on maintenance dialysis treatment, others were pre-dialytic at the time or had not yet developed any kidney impairment. For every contrast exposure, we checked the previous creatinine and the earliest creatinine after the examination to check for acute kidney injury, AKI, as defined by KDIGO. As a secondary outcome, we investigated the frequency of examinations where contrast otherwise would be indicated, but was withhold, due to fear of contrast induced AKI. Results In total, 83 patients were included in this study, and among them there were 121 cases of contrast exposure. There were no events of AKI when eGFR was &amp;gt; 30 ml/min. In the subgroup of patients with eGFR &amp;lt; 30 ml/min, but not in dialysis at the time of the examination, there were only 25 cases of contrast exposure, and only one event of AKI, but this was considered largely due to overhydration and decompensated heart failure and resolved with proper treatment. Among the patients already in dialysis, there were 65 contrast exposures, and no event where any subjects lost their residual kidney function due to contrast induced AKI. In the meantime, there were 249 examinations where contrast material was withheld due to low eGFR, even though it normally would be indicated by the reason of the examination. Conclusion There was none significant event of potential contrast induced AKI among the patients in our study and no patient had any lasting impact on their kidney function from contrast exposure. Contrast exposure does not seem to be a common contributing cause of progressing to end stage renal disease. This is well in line with previous, modern observation studies, suggesting that the risk of contrast induced nephropathy is overrated or possible even a myth. Perhaps even more importantly, contrast enhancement was often inadequately withheld, even though it normally would be necessary to accurately make the diagnosis that was the purpose of ordering the study. Poor imaging quality limits the ability to make correct diagnoses, resulting in substandard treatment for the CKD-population.

#1252 Non-standardized definition of chronic dialysis within German health claims data results in varying estimates for incidence and mortality

Abstract Background and Aims Chronic dependency on dialysis in patients with chronic kidney failure (CKF) demands invasive, high-risk, and costly treatments. At present, there is no standardized definition for dialysis-dependent CKF within German health claims data from statutory health insurance (SHI) funds. Method Random samples from four year tranches (2012, 2014, 2016, 2018), each with 62,200 individuals aged ≥70 years, of German health claims data of the SHI AOK Nordost were analysed. Four literature-based definitions of dialysis-dependent CKF (1–4) and a newly developed definition, based on a billing logic with criteria required for monetary reimbursement for chronic dialysis treatments in patients with CKF by SHIs, were selected. The definitions were compared with regard to sociodemographic and clinical characteristics, dialysis-dependent CKF prevalence and incidence (standardized by year-, age group-, and sex-specific weights for Northeast-Germany), overall mortality, and direct health care costs. Results All definitions of dialysis-dependent CKF resulted in varying estimates of 12-month prevalence (0.33–0.61%) and six-month incidence (0.058–0.100%). Depending on the definition, 27.6% to 61.8% of incident individuals had a preceding acute kidney injury (AKI). Survival probabilities of individuals with dialysis-dependent CKF ranged from 70.2% to 88.1% and 60.5 to 81.3% after three and six months, respectively (Fig. 1). After stratification, survival probabilities differed less between the definitions in individuals without a preceding AKI. Monthly health care cost ranged from 6,010 to 9,606 EUR and varied strongly in out- and inpatient treatment costs depending on the definition. Cost was highest in inpatients with preceding AKI. Conclusion Due to a non-standardized definition of dialysis-dependent CKF in claims data we found varying case numbers, mortality, and health care costs, most probably in large part explained by the discrepant inclusion of individuals with short-term dialysis treatment due to AKI.

#1705 Central delivery of acid concentrate for haemodialysis: a single-center experience

Abstract Background and Aims Dialysate is produced by mixing ultra-purified water with acid and bicarbonate concentrates. Acidic concentrate for hemodialysis can be supplied to the dialysis machine through single-use bags or central concentrate supply. Central delivery of acid concentrate represents an innovation in hemodialysis settings in terms of practicality and eco-sustainability as this system is able to produce and distribute ready-to-use acid dialysis concentrate without the use of acid concentrate bags. The aim of our study was to compare the amount of material (including packaging) used to supply acid concentrate using a single-use bag (3.8 L or 4.5 L) or central acid supply at the Nephrology Dialysis and Renal Transplant Unit of Azienda Ospedaliero Universitaria di Modena, Modena, Italy. In particular, we reviewed the amount of consumable material before (January-December 2019) and after the implementation of central concentrate supply (July 2022-June 2023). Lastly, a survey was delivered to all dialysis nurses who work in our dialysis Center to evaluate their feedback on central concentrate supply. Method Our center is equipped with 46 dialysis stations for patients on chronic hemodialysis that in 2019 delivered 30 000 hemodialysis treatments distributed across morning, afternoon, and evening shifts. Granumix system® (Fresenius Medical Care, Bad Homburg, Germany) was installed in 2022. It produces and distributes acid concentrate fluid with two different concentrations of K+ (2 and 3 mEq/L) and a unique concentration of Ca2+ 1.5 mmol/L (see Figure). Results The data collected in 2019 at our Dialysis Center showed that 30 000 acid bags corresponding to 121 000 L of acid concentrate fluid were used to perform hemodialysis. Utilization of bags generated 3 750 kg of pallets, 4 500 kg of plastic and 5 367 kg of boxes. Considering that approximately 10% of the acid concentrate fluid remains unused during each dialysis treatment, approximately 12 000 L of unutilized acid concentrate fluid was wasted. Following the introduction of the Granumix® system, there was a significant reduction (−80.6%) in the utilization of single-use acid concentrate bags (n = 5 805) and, consequently, in the use of boxes (n = 2 294 vs. n = 11 667) and pallets (n = 40 vs. n = 208). The centralized distribution system of acid concentrate led to a significant reduction in waste including boxed, plastic and pallets (2 642 kg vs. 13 617 kg), disposal of residual acidic solution (2 351 liters vs. 12 100 liters), and handling of materials by dialysis staff (37 522 kg vs. 158 117 kg). Another advantage of this system is the optimized usage of acid concentrate fluid. This system ensures that only the required amount of acid for a specific treatment is used, effectively minimizing waste and decreasing the production of special waste. The results of the survey (response rate 75%) documented that 79.5% of the nurses received adequate training for its use; 94.9% experienced a reduction in fatigue and 84.6% declared that had more time to dedicate to patients. Lastly, the survey showed that 96.4% of the participants were completely satisfied with the implementation of this new system. Conclusion Central delivery of acid concentrate is an innovative solution with eco-sustainable potentialities in reducing the consumable materials and workload in hemodialysis. Overall, most nurses expressed satisfaction as this system reduces dialysis staff workload and allows more time for patient care.

#1129 Systematic reporting of extracorporeal blood losses in a large dialysis provider organization

Abstract Background and Aims The assessment of adverse safety events is important for the risk assessment of major blood loss from the extracorporeal blood circuit during hemodialysis (HD). Such blood loss has been proven to result in a low double-digit number of fatal events per year in the USA. The frequency in Europe is not mandatorily recorded. The mechanisms of blood loss in the venous leg of the system, undetected by the alarm system of the dialysis machines, are not generally known and further patient and structure-related risks are not yet systematically recorded, evaluated and improved. Method We set up a web-based intranet database (“Event Management”) to record serious adverse events affecting patients during or around dialysis treatments in all 174 kidney centers of the Kuratorium für Dialyse und Nierentranspantation in Germany (KfH). This system is accessed via intranet within the KfH organization. Nursing and medical staff are regularly trained and informed about this system. The entry of event data that have endangered or harmed patients is mandatory. Results 141 reports of blood loss were identified for a total of approximately 3 million hemodialysis treatments performed in 174 renal centers in between 2020 and 2022, including venous needle loss due to complications in the extracorporeal blood circuit, 15 of which required inpatient treatment. The breakdown of the causes and consequences of blood losses is shown in the Figure. Conclusion Venous disconnection must be reduced by earlier detection with appropriate technical and patient-adapted measures. Patients should be educated about their individual risk and about individual measures to manage risk. Identification of patient-specific and shunt-specific risk factors is necessary. Patient-related risk factors include cognitive impairment, frailty, and dialysis in special areas (ICU, isolation area, nocturnal dialysis). Monitoring systems (blood sensors) currently on the market have good technical blood detection sensitivity. Such systems should be investigated with regard to their clinical benefit according to the rules of evidence-based medicine before their broad introduction into routine care.

#703 Usability of a mobile health app for peritoneal dialysis patients: a pilot study

Abstract Background and Aims Technology has changed how people interact with the world, so health apps may be useful for patients with long term conditions, facilitating adherence and enabling remote monitoring. Usability is a critical factor when evaluating the quality of a mobile health app, as it indicates the ease with which a user can use it to achieve specific clinically orientated goals with effectiveness, efficiency, and satisfaction. Method The mHealth App Usability Questionnaire (MAUQ), a reliable and validated tool, was used to evaluate the MyPD® mobile health app's usability for adult peritoneal dialysis (PD) patients. The arm using the My PD app in a pilot randomized clinical study in six renal clinics in Colombia from September 2022 to August 2023 was evaluated. The MAUQ questionnaire includes 18 items assessing 3 domains related to ease of use (5 items), interface and satisfaction (7 items) and usefulness (6 items). Patients rated each item on a seven-point Likert scale, with one (1) strongly disagreeing and seven (7) strongly agreeing. The overall rating is the mean of eighteen items (standalone version); closer to seven (7), higher usability. The socio-demographic and clinical characteristics of all patients were summarized descriptively. Results MyPD app allows patients to collect and view their clinical information and dialysis treatment. Figure 1 shows a general overview of the different navigation windows. A total of 65 patients were included in this analysis; the mean age was 52.2 years, 44.6% were in CAPD, and 21.5 % achieved elementary school education or were illiterate (Table 1). The overall usability was 6.5 (SD 0.7), the maximum possible score is 7. The items related to satisfaction and interface have a mean of 6.8 (SD 0.5). Regarding ease of use, the mean was 6.6 (SD 0.8), a very high figure given the socio-cultural context of a middle-income country. In relation to usefulness, the mean was 6.1 (SD 1.5). Patients rated the overall satisfaction item with the app as 6.8 (SD 0.6). See details in Table 2. These results are better than those reported by other authors (Table 3). Conclusion The usability of the health app MyPD® was rated very high by patients, which will allow this application to be used widely as a tool that supports the outpatient care of PD patients.

#1563 Family feedback survey on quality of dialysis withdrawal and end-of-life care on hemodialysis patients in an ICU – a single-center study from India

Abstract Background and Aims End-of-life care in hemodialysis is emerging, with limited implementation in developing countries. There is a sparsity of data on dialysis withdrawal and the quality of end-of-life care in these regions. Developing countries differ in their cultural, social, and spiritual practice compared to the Western world and family plays a major role in decision-making. No survey has been done on family's perception of dialysis withdrawal and end-of-life care in our settings. So, we studied feedback from families regarding the quality of dialysis withdrawal and end-of-life care provided to maintenance hemodialysis (MHD) patients admitted to our intensive care unit (ICU). Method This study was conducted at Kasturba Medical College, Manipal, MAHE, Manipal, India between January 2020 to October 2022 involving the data from end-stage kidney disease (ESKD) patients on MHD admitted in the ICU, who had withdrawn from dialysis before death and received end-of-life care as per the hospital policy (Blue Maple) from Renal supportive and Palliative care team. The baseline data was collected for all patients and indications for withdrawal of dialysis and ICU treatment and end-of-life care provided were collected. The next of kin were interviewed by telephone by a single interviewer using a modified Quality of Death and Dying questionnaire. The data was analyzed using SPSS 20 Results Among 98 ESKD patients on maintenance hemodialysis who died in our ICU, 23 were referred to Palliative care, counselled, had withdrawal of dialysis at least 48 hours before death and received end-of-life care. Table 1 outlines baseline characteristics. The mean age was 57 ± 12.09 years, with a male predominance (82.6%). Common comorbidities included hypertension (100%), type 2 diabetes (69.5%), and ischemic heart disease (65.2%). The primary cause for ICU admission was infectious disease (47.8%). The majority of reasons for dialysis withdrawal and end-of-life care were worsening hemodynamic status (82.6%) and illness deterioration (69.5%). After consent and establishment of futility, dialysis withdrawal was done for all patients (100%), No CPR for 100%, withdrawal of inotropes in 50%, and withdrawal of ventilator was done in 80% of the patients. A successful telephonic interview/survey was conducted with 21 out of the 23 subjects, with the majority of next of kin being the spouse (47.6%) followed by children (33.3%) and siblings (14.3%). The questionnaire and response are given in Table 2. All expressed a need for palliative care involvement. 82% accepted the decision of dialysis withdrawal and end-of-life care put forth by the doctor's team without difficulty;74% of families were present with the patient in their final hours and were grateful for the same 20% had their spiritual leader to visit during the end-of-life event. None of the family members (100%) interviewed had a guilty feeling and all had a positive rating on the involvement of the palliative care team and the need to ease patients' distress and suffering during their final hours (100%). Unfortunately, none of the patients had prior discussions of advance care planning (ACP) with their doctors regarding end-of-life care before the specific event Conclusion Our study highlights that families agree with the withdrawal of artificial life support measures, such as MHD, CPR, withdrawal of inotropes, and/withdrawal of ventilator in ICU settings when these interventions are considered futile for end-of-life care in ESKD patients. It also emphasizes the need for ACP, and early integration of palliative care for discussions about dialysis withdrawal, and withholding futile interventions at end-of-life care in ESKD patients, especially in resource-constrained settings like ours, for high-quality end-of-life care. This will also lead to better end-of-life care outcomes and improved patient and family satisfaction with care.