End-stage Kidney Disease Patients Research Articles

Splenectomy Before Kidney Transplantation for Hypersplenism: A Case Report

Hypersplenism, although a rare hematological complication seen in chronic kidney disease patients, poses a significant challenge for successful kidney transplantation due to potential complications such as cytopenias and inadequate immunosuppressive therapy. We present a 40-year old end-stage kidney disease patient on dialysis with hypersplenism who underwent a laparoscopic splenectomy prior to high immunological risk renal transplantation. Post-splenectomy, there was a remarkable improvement in cytopenias, and effective immunosuppressive therapy could be administered prior to renal transplantation. Splenectomy remains a valuable strategy for managing hypersplenism, ensuring correction of cytopenias, for optimal immunosuppression prior to kidney transplantation. Pre-transplant vaccination further mitigates the risk infections with capsulated organisms. Our case underscores the importance of a multidisciplinary approach in decision-making and highlights splenectomy as a safe and effective intervention to address cytopenias due to hypersplenism prior to renal transplantation.

Patients, healthcare providers, and general population preferences for hemodialysis vascular access: a discrete choice experiment

BackgroundA patient-centered dialysis treatment option requires an understanding of patient preferences for alternative vascular accesses and nephrologists often face difficulties when recommending vascular access to end-stage kidney disease (ESKD) patients. We aimed to quantify the relative importance of various vascular access characteristics to patients, healthcare providers and general population, and how they affect acceptability for patients and healthcare providers.MethodsIn a discrete choice experiment, patients with maintenance hemodialysis (MHD), healthcare providers, and individuals from the general population were invited to respond to a series of hypothetical vascular access scenarios that differed in five attributes: cumulative patency, infection rate, thrombosis rate, cost, and time to maturation. We estimated the respondents’ preference heterogeneity and relative importance of the attributes with a mixed logit model (MXL) and predicted the willingness to pay (WTP) of respondents via a multinomial logit model (MNL).ResultsHealthcare providers (n = 316) and the general population (n = 268) exhibited a favorable inclination toward longer cumulative patency, lower access infection rate and lower access thrombosis rate. In contrast, the patients (n = 253) showed a preference for a 3-year cumulative patency, 8% access infection rate, 35% access thrombosis rate and 1.5 access maturity time, with only the 3-year cumulative patency reaching statistical significance. Among the three respondent groups, the general population found cumulative patency less important than healthcare providers and patients did. Patients demonstrated the highest WTP for cumulative patency, indicating a willingness to pay an extra RMB$24,720(US$3,708) for each additional year of patency time.ConclusionPatients and healthcare providers had a strong preference for vascular access with superior patency. While the general population preferred vascular access with lower thrombosis rates. These results indicate that most patients prefer autogenous arteriovenous fistula (AVF) as an appropriate choice for vascular access due to its superior patency and lower complications than other vascular access types.

Associations Between Social Support and Patient-Reported Outcomes in Hemodialysis Patients: Results from the TACcare Study.

End Stage Kidney Disease (ESKD) patients experience high symptom burden which has been associated with a negative impact on their interpersonal relationships. However, there is limited research exploring associations of social support and patient-reported outcomes among hemodialysis (HD) patients. The current study is a secondary, cross-sectional analyses of the sociodemographic and clinical correlates of perceived social support (Multidimensional Scale of Perceived Social Support; MSPSS) at baseline. The study examined the extent to which perceived social support is associated with pain, depression, fatigue, anxiety, sleep, and HRQoL (SF-12 Mental Component Score; MCS) and Physical Component Score; PCS)). Of the 160 randomized patients: mean (SD) age was 58 ±14 years; years on dialysis was 4.1 + 4.2; 45% were female; 29% Black, 13% American Indian, 18% Hispanic; 88% had at least high school education; and 27% were married. Mean baseline levels of perceived social support were comparable to other chronically ill populations. At least a high school education (p = 0.04) and being married (p = 0.05) were associated with higher total MSPSS scores. Higher MSPSS scores were correlated with lower levels of fatigue (r = 0.21, p =0.008; higher fatigue scores signify lower fatigue), pain (r = -0.17, p = 0.03), depressive symptoms (r = -0.26, p < 0.001), anxiety (r = -0.23, p = 0.004), better sleep quality (r = -0.32, p < 0.001) and SF-12 MCS (r = 0.26, p <0.001). Moderation analyses revealed male sex and non-Hispanic ethnicity resulted in stronger positive associations of perceived social support with SF-12 MCS. The level of perceived social support observed among thrice weekly HD patients in TACcare was similar to those observed in other chronic conditions. Because of the associations between perceived social support and patient-reported outcomes, particularly psychosocial and behavioral health outcomes, targeting social support appears to be warranted among HD patients.

Usefulness of the clinical frailty scale in patients with end-stage kidney disease

Abstract Background The Frailty Index (FI) is commonly used to estimate frailty in end-stage kidney disease (ESKD) patients. The Clinical Frailty Scale (CFS) is a less time-consuming alternative. We aimed to determine the test performance of the CFS for (pre-) dialysis patients and patients receiving conservative therapy from the Dialysis Centre Apeldoorn. Methods In this cross-sectional study, haemodialysis, peritoneal dialysis, pre-dialysis patients and patients receiving conservative therapy from Dialysis Centre Apeldoorn were included and subjected to frailty score assessment. Nephrologists not familiar with the CFS completed the frailty score after medical consultation. The sensitivity, specificity and area under the curve (AUC) of the CFS were determined. The FI was used as the golden standard. Results Included were 144 patients of whom 60 (41.7%) were considered frail according to the FI. Mean age was 67.4 ± 13.5 years and 56 (38.9%) were females. The cut-off point of the CFS for ‘vulnerable’ (CFS ≥ 4) had a sensitivity of 63.3%, a specificity of 81.0% and an AUC of 0.72. The cut-off point of the CFS for ‘frail’ (CFS ≥ 5) had a sensitivity of 50.0%, a specificity of 91.7% and an AUC of 0.71. Conclusions The CFS is a quick and easy to use tool for the determination of frailty in ESKD patients with a high prevalence of frailty. Nevertheless, the sensitivity of the CFS in the present study was considered too low to implement into daily clinical practice. The sensitivity might be increased by training the nephrologists in using the CFS.

Interstitial fibrosis increases the risk of end-stage kidney disease in patients with lupus nephritis.

To evaluate the risk of end-stage kidney disease (ESKD) in lupus nephritis (LN) patients using tubulointerstitial lesion scores. Clinical profiles and histopathological presentations of 151 biopsy-proven LN patients were retrospectively examined. Risk factors of ESKD based on characteristics and scoring of their tubulointerstitial lesions (e.g. interstitial inflammation [II], tubular atrophy [TA], and interstitial fibrosis [IF]) were analyzed. The mean age of 151 LN patients was 36 years old, and 136 (90.1%) were female. The LN cases examined included: class I/II (n = 3, 2%), class III/IV (n = 119, 78.8%), class V (n = 23, 15.2%), and class VI (n = 6, 4.0%). The mean serum creatinine level was 1.4 mg/dl. Tubulointerstitial lesions were recorded in 120 (79.5%) patients. Prior to receiving renal biopsy, 9 (6.0%) patients developed ESKD. During the follow-up period (mean, 58 months), an additional 47 patients (31.1%) progressed to ESKD. Multivariate analyses identified serum creatinine (hazard ratio [HR]: 1.7, 95% confidence interval [CI]: 1.42-2.03, p < 0.001) and IF (HR: 3.2, 95% CI: 1.58-6.49, p = 0.001) as independent risk factors of ESKD. Kaplan-Meier analysis further confirmed a heightened risk of ESKD associated with IF. Tubulointerstitial involvement is commonly observed in histopathological presentation of LN. However, IF, rather than II, or TA, was found to increase the risk of ESKD in our cohort. Therefore, to predict renal outcome in LN patients prior to adjusting immunosuppressive treatment, degree of IF should be reviewed.

Vascular Access Outcomes in Patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD).

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a leading hereditary cause of end-stage kidney disease (ESKD), often utilising hemodialysis as a form of kidney replacement therapy. Patients with ADPKD may also present with extrarenal manifestations, including arterial aneurysms. The gold standard for hemodialysis access is an arteriovenous vascular access (VA), such fistulas (AVFs) or grafts (AVGs). However, limitations, such as low VA flow and inadequate AVF outward remodelling, impact VA utilization. This study aimed to explore whether ADPKD impacts patency rates of AVFs/AVGs in comparison to other underlying ESKD causes. We conducted a retrospective cohort study using data from the Swedish Renal Registry from 2011 to 2020, with follow-up until 2022. We included 496 ADPKD patients and 4321 propensity-score matched controls. VA patency rates of ADPKD patients were compared to those of non-ADPKD patients using Kaplan-Meier survival curves and the Mantel-Cox log-rank test. Interventions to maintain or restore patency were also analysed. Patients with ADPKD constituted 8.0% of all patients, with a higher proportion in the pre-ESKD phase during VA creation (51.6% vs. 40.6%). No significant differences were observed in primary, post-cannulation primary, secondary, or functional patency between ADPKD and non-ADPKD patients. However, more VAs were ligated in ADPKD patients (10.5% vs. 7.7%, p=0.03), and they underwent more first interventions to re-establish flow (49.4% vs. 41.9%, p=0.02). These findings suggest that AVF/AVG patency remains comparable in ESKD patients with or without ADPKD, and vascular access monitoring and treatment strategies for ADPKD patients should align with those for individuals with other ESKD causes.

The impact of teach-back training method (TBTM) on treatment adherence in hemodialysis patients: a randomized controlled trial.

Ensuring adherence to treatment is vital for individuals undergoing haemodialysis. The demanding treatment frequency and duration often present challenges for patients in maintaining a consistent routine. Non-adherence can result in adverse health effects and an increased risk of hospitalization. This study aimed to evaluate the impact of teach-back training on treatment adherence among haemodialysis patients. A randomized controlled trial involved 60 end-stage kidney disease patients undergoing haemodialysis. Participants were randomly assigned to either the control or intervention group. Data were collected using the End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ), assessing adherence in four dimensions: HD incidence, medication use, fluid restriction, and diet recommendations. The intervention group received feedback-based training on diet and fluid restriction during four 45-60-min sessions, while the control group received regular indoor training. Following the intervention, significant differences in mean scores for HD frequency, medication use, and fluid restriction were observed between the two groups (P<0.001). However, there was no significant difference in the mean score for food recommendations (P=0.108). The teach-back training method (TBTM) is an effective communication strategy that enhances treatment adherence in haemodialysis patients. This intervention has the potential to improve patient outcomes and overall quality of life by simplifying medical information and encouraging patient engagement.

Multidisciplinary management of penile calciphylaxis in a patient undergoing hemodialysis

Penile necrosis in end-stage chronic kidney disease patients on hemodialysis presents complex pathophysiology involving vascular, metabolic, and dialysis-related factors. This clinical case emphasizes the significance of prompt multidisciplinary management. Surgical interventions like penectomy with scrotal pedicled flaps offer effective reconstruction, preventing complications. Long-term success mandates diligent oversight of metabolic and vascular issues. A comprehensive approach integrating urology, vascular surgery, and nephrology specialists is essential for optimal patient outcomes and quality of life.

Glycosylation and Characterization of Human Transferrin in an End-Stage Kidney Disease.

Chronic kidney disease (CKD) is a global health concern affecting approximately one billion individuals worldwide. End-stage kidney disease (ESKD), the most severe form of CKD, is often accompanied by anemia. Peritoneal dialysis (PD), a common treatment for ESKD, utilizes the peritoneum for solute transfer but is associated with complications including protein loss, including transferrin (Tf) a key protein involved in iron transport. This study investigated Tf characteristics in ESKD patients compared to healthy individuals using lectin microarray, spectroscopic techniques and immunocytochemical analysis to assess Tf interaction with transferrin receptors (TfRs). ESKD patients exhibited altered Tf glycosylation patterns, evidenced by significant changes in lectin reactivity compared to healthy controls. However, structural analyses revealed no significant differences in the Tf secondary or tertiary structures between the two groups. A functional analysis demonstrated comparable Tf-TfR interaction in both PD and healthy samples. Despite significant alterations in Tf glycosylation, structural integrity and Tf-TfR interaction remained preserved in PD patients. These findings suggest that while glycosylation changes may influence iron metabolism, they do not impair Tf function. The study highlights the importance of a glucose-free dialysis solutions in managing anemia exacerbation in PD patients with poorly controlled anemia, potentially offering a targeted therapeutic approach to improve patient outcomes.

WCN24-391 Predictive Factors of Renal Recovery and Progression to End-Stage Kidney Disease in Patients with ANCA-Associated Vasculitis with Severe Kidney Disease

WCN24-391 Predictive Factors of Renal Recovery and Progression to End-Stage Kidney Disease in Patients with ANCA-Associated Vasculitis with Severe Kidney Disease

Hemodiafiltration versus Hemodialysis in End-Stage Kidney Disease: A Systematic Review and Meta-Analysis

Rationale & ObjectiveThe use of hemodiafiltration (HDF) as a kidney replacement therapy (KRT) in patients with end-stage kidney disease (ESKD) has sparked a debate regarding its advantages over conventional hemodialysis (HD). The present study aims to shed light on this controversy by comparing mortality rates and cause-specific deaths between ESKD patients receiving HDF and those undergoing HD. Study DesignSystematic review and meta-analysis of randomized controlled trials (RCTs). The search was conducted on PubMed, EMBASE, and Cochrane Central on July 01, 2023. Setting & ParticipantsAdult patients with ESKD on regular KRT. Selection Criteria for StudiesRCTs evaluating HDF versus HD. Crossover trials and studies with overlapping populations were excluded. Data ExtractionTwo authors independently extracted the data following predefined search criteria and quality assessment. Analytical ApproachPrimary outcomes were all-cause mortality, cardiovascular (CV) mortality, deaths related to infections, and kidney transplant. We also evaluated the endpoints for deaths related to malignancy, myocardial infarction, stroke, arrhythmias, and sudden death. The risk of bias was accessed with Cochrane’s RoB2 tool. ResultsWe included 5 RCTs with 4,143 patients, of which 2,078 (50.1%) underwent HDF, while 2065 (49.8%) were on HD. Overall, HDF was associated with a lower risk of all-cause mortality (RR 0.81; 95% CI 0.73-0.91; p<0.001; I2=7%) and a lower risk of CV-related deaths (RR 0.75; 95% CI 0.61-0.92; p=0.007; I2=0%). The incidence of infection-related deaths was also significantly different between therapies RR 0.69; 0.50-0.95; p=0.02; I2 = 26%). LimitationsIn individual studies, the HDF groups achieved varying levels of convection volume. ConclusionsCompared to those undergoing HD, patients receiving HDF experienced a reduction in all-cause mortality, CV mortality, and infections-related mortality. These results provide compelling evidence supporting the use of HDF as a beneficial intervention in ESKD patients undergoing KRT.

Correlation between Duration of Placement of Non-tunneled Hemodialysis Catheter and Positive Bacterial Culture Incidence in Hemodialysis Patients

Non-tunneling hemodialysis catheter is one of the most convenient vascular accesses for hemodialysis in End Stage Kidney Disease (ESRD) patients. However, these catheters have the highest morbidity among all available accesses. Current guidelines recommend that non-tunneled hemodialysis catheters be placed for no more than 2 weeks to prevent bacterial contamination. This study was conducted in Dr. Hasan Sadikin General Hospital, Bandung, Indonesia, throughout January-December 2021. A correlation test with a prospective observational analysis design was applied to find the link between the duration of non-tunneled hemodialysis catheter placement and the incidence of positive bacterial culture on the catheter. Pearson correlation test was used to see the strength of the correlation, with a significance limit of 0.05. This study involved 28 subjects. The most common location for catheter placement was in the jugular vein, and laboratory examinations showed no correlation between leukocyte values and positive bacterial culture results. Hypertension and diabetes mellitus were not significant risk factors (p-value 0.887). At ≤14 days of catheter placement, only 1 (6.7%) of the subjects presented a positive culture result. Most of the positive bacterial culture results were found at a duration of 15-30 days of placement, (n=8; 53.3%). The results of the Pearson test showed a p-value of 0.036 and an r-value of 0.399, indicating a significant result with a strong correlation between the two variables. The duration of placement of hemodialysis catheters has a positive correlation with the incidence of positive bacterial cultures, which can increase the risk of systemic infection associated with hemodialysis catheters.

The impact of icodextrin on the outcomes of incident peritoneal dialysis patients.

The aim of the study is to investigate the effects of icodextrin on the risks of death, technique failure and the first episode of peritonitis in peritoneal dialysis (PD) patients. From medical records of a medical center in Taiwan, a total of 725 newly diagnosed end-stage kidney disease patients receiving PD for at least 90 days from January 1, 2007 to December 31, 2018 were identified. These patients were grouped as 190 icodextrin users and 535 non-users. Users were defined as utilization of icodextrin for ≥ 50% of their PD duration. The use of icodextrin was considered a time-varying exposure in the Cox proportional hazard model. The risks of death, technique failure and the first episode of peritonitis were compared between two cohorts by the end of 2018. Compared to the non-users, the icodextrin users had significant lower risks of mortality (6.5 vs.7.2 per 100 person-years; adjusted HR = 0.62, 95% CI = 0.42-0.91) and technique failure (12.7 vs. 15.2 per 100 person-years; adjusted HR = 0.61, 95% CI = 0.47-0.81), and the first peritonitis episode (5.0 vs. 17.0 per 100 person-years; adjusted HR = 0.22, 95% CI = 0.14-0.35). The risk of peritonitis reduced further in icodextrin users with diabetes and with cardiovascular disease. Icodextrin was associated with lower risks of mortality, technique failure, and the first episode of peritonitis.

Different outcomes between downward and lateral peritoneal dialysis catheter exit-site directions

BackgroundThe International Society for Peritoneal Dialysis guidelines suggest lateral or downward exit positions for peritoneal dialysis (PD) catheter. In cases with straight inter-cuff design (used in Thailand), downward exit may lead to more complications due to catheter memory force. We compared lateral (lateral group) and downward (downward group) exits in PD patients.MethodsWe retrospectively studied end-stage kidney disease patients with PD catheters from 2011 to 2021 at Chao Phraya Abhaibhubejhr Hospital, Thailand. We analysed catheter malfunction, exit-site infection (ESI) and patient survival.ResultsA total of 425 patients, aged 11–87 years (57% female and 59% with diabetes mellitus). 326 had downward exits, and 99 had lateral exits. Both groups had similar 2-years patient survival (p = 0.592), 1-year survival catheter dysfunction requiring removal (p = 0.146) and First-year ESI (p = 0.432). In the lateral exit group, the percent of catheter dysfunction requiring removal was slightly lower (1.01 vs. 3.99, p = 0.204) while the percent of patient with ESI at first year was slightly higher (8.08 vs. 6.13, p = 0.494) compared to downward exit group.ConclusionsLateral exit and downward exit with a straight inter-cuff design have similar outcome of catheter survival/function, exit site infection and patient survival. Lateral exit site is a good option in context of a straight inter-cuff design.

Diabetes is associated with higher body composition and bone mineral density in hemodialysis patients

Abstract Background The relationship between bone mineral density (BMD) and body composition in hemodialysis (HD) patients with end-stage kidney disease (ESKD) is still inconclusive. Methods A number of 124 ESKD patients who received regular HD were included. Body mass index (BMI) was calculated. Body fat mass (BFM), soft lean mass (SLM), fat-free mass (FFM), skeletal muscle mass (SMM), percent body fat (PBF), and skeletal muscle mass index (SMI) were measured using bioelectrical impedance analysis. BMD of the proximal radius of the selected subjects was measured by dual-energy X-ray absorptiometry. Results Among 124 ESKD patients, 32 (25.8%) had diabetes. BMD, BMI, BFM, SMI, and PBF were significantly higher in HD patients with diabetes than in those without diabetes (P &lt; 0.05). In patients with diabetes, BMD, SLM, FFM, and SMM were significantly higher in male patients than in female patients (P &lt; 0.05), while BFM and PBF were lower in female patients (P &lt; 0.05). Spearman correlation analysis showed that SLM, FFM, and SMM were positively associated with BMD in HD patients (P &lt; 0.05). Multiple linear regression analysis showed that SMI was positively correlated with BMD in non-diabetes HD patients. Logistic regression analysis showed that diabetes was independently associated with a lower risk of developing osteoporosis than non-diabetes (odds ratio [OR] = 0.169, 95% confidence intervals [CI] = 0.043–0.661, P = 0.011). Conclusion BMI, SMI, and BMD were higher in HD patients with diabetes than in non-diabetes. Diabetes may be associated with a lower risk of developing osteoporosis in HD patients.

Recovery Dynamics and Prognosis After Dialysis for Acute Kidney Injury

The interplay among baseline kidney function, severity of acute kidney disease (AKD), and post-AKD kidney function has significant associations with patient outcomes. However, a comprehensive understanding of how these factors are collectively associated with mortality, major adverse cardiac events (MACEs), and end-stage kidney disease (ESKD) in patients with dialysis-requiring acute kidney injury (AKI-D) is yet to be fully explored. To investigate the associations of baseline kidney function, AKD severity, and post-AKD kidney function with mortality, MACEs, and ESKD in patients with AKI-D. This nationwide, population-based cohort study of patients with AKI-D was conducted between January 1, 2015, and December 31, 2018, using data from various health care settings included in the Taiwan nationwide population-based cohort database. Data analysis was conducted from April 28, 2022, to June 30, 2023. Exposure to severe AKI and baseline and post-AKD kidney function. The primary outcomes were all-cause mortality and incident MACEs, and secondary outcomes were risks of permanent dialysis and readmission. A total of 6703 of 22 232 patients (mean [SD] age, 68.0 [14.7] years; 3846 [57.4%] male) with AKI-D with post-AKD kidney function follow-up and AKD stage data were enrolled. During a mean (SD) 1.2 (0.9) years of follow-up, the all-cause mortality rate was 28.3% (n = 1899), while the incidence rates of MACEs and ESKD were 11.1% (n = 746) and 16.7% (n = 1119), respectively. After adjusting for known covariates, both post-AKD kidney function and baseline kidney function, but not AKD severity, were independently associated with all-cause mortality, MACEs, ESKD, and readmission. Moreover, worse post-AKD kidney function correlated with progressive and significant increases in the risk of adverse outcomes. In this cohort study of patients with AKI-D, more than one-quarter of patients died after 1.2 years of follow-up. Baseline and post-AKD kidney functions serve as important factors associated with the long-term prognosis of patients with AKI-D. Therefore, concerted efforts to understand the transition from post-AKD to chronic kidney disease are crucial.

Accelerated neuropathy among chronic kidney disease patients undergoing hemodialysis: Analysis of an institutional cluster.

Accelerated neuropathy is a rare syndrome of rapidly worsening peripheral neuropathy, typically described in end-stage kidney disease (ESKD) patients undergoing dialysis. In our center, we encountered a surge in the occurrence of accelerated neuropathy among ESKD patients undergoing hemodialysis, which prompted systematic research. In this case-control study, we present the clinical features, electrophysiologic findings, and outcome of a series of patients who developed accelerated neuropathy after commencing hemodialysis for ESKD. Those who initiated hemodialysis and did not develop accelerated neuropathy were included as controls. We used logistic regression to identify predictors of accelerated neuropathy. Among 436 ESKD patients who initiated hemodialysis over 4 years, 17 were diagnosed with accelerated neuropathy. The median-time (interquartile range) from hemodialysis initiation to presentation with accelerated neuropathy was 3 weeks (2-6). It typically presented as acute onset of unsteadiness of gait necessitating assistance for ambulation. Electrophysiology revealed length-dependent symmetric sensorimotor axonal neuropathy. Diabetes mellitus (odds ratio [OR] 4.1, 95% CI 1.2-13.9, p = 0.02), pre-existing peripheral neuropathy (OR 9.25, 95% CI 2.79-30.6, p < 0.001), and serum alkaline phosphatase (OR 1.2 for every 10 U increase, 95% CI 1.00-1.52, p = 0.04) significantly predicted accelerated neuropathy. With continued dialysis and supportive care, neurologic status improved, total-neuropathy score (summary score of peripheral nerve dysfunction incorporating clinical and electrophysiological parameters) declined from 26.5 to 18.4 (p < 0.001) and most regained unassisted ambulation. This study presents the largest series of patients with accelerated neuropathy and has identified predictors. However, in view of the unusually high incidence of accelerated neuropathy we speculate that other unidentified factor(s) could be underlying its pathogenesis.

Kidney supportive care for advanced chronic and end-stage kidney disease: a retrospective cohort study.

Kidney supportive care is an interdisciplinary model of person-centred medicine, suitable for patients with advanced Chronic Kidney Disease (CKD) and with End-Stage Kidney Disease (ESKD). There is little information on routine care, and palliative careremains poorly integrated into standard nephrology care. The aim of this study was to describe our experience in integrating a palliative care approach into the nephrology care of advanced chronic and end-stage kidney disease. A retrospective cohort study was conducted from 1 June, 2017 until 31 December, 2020 on 67 advanced CKD and ESKD patients admitted to a palliative care service. The patients' median age was 83.6years, 62.7% were male, 16.4% had CKD stage 4 and 83.6% stage 5. Almost half (47.8%) of the patients were on kidney replacement therapy, and 52.2% were on conservative therapy. The majority (77.6%) received home-based palliative care, 17.9% hospice care and 4.5% day-hospice care. The median number of nephrologists' visits per patient was 3.5. Access to palliative care specialists was set at 100% and the median number of palliative clinicians' visits was 8. Eighty-five percent of patients did not require hospitalisation and 94% did not access to theemergency room; 86.2% of the patients died in hospice or at home. This study reports onthe first stepstaken to change practice in nephrology, by applying the Italian guideline for an integrated pathway of palliative carein nephrology. Nephrologists' and the palliative careteam created a multi- and inter-disciplinary team, sharing their professional skills to support patients in hospice or at home.

Immune dysfunction in patients with end stage kidney disease; Immunosenescence - Review.

The body's defense against environmental factors is realized by physical barriers and cells of both the innate and adaptive immune systems. Patients with end stage kidney disease (ESKD), especially those treated by hemodialysis, have changes in both the function and the number or percent of different leukocyte subsets. Changes were described at the level of monocytes and lymphocyte subsets, which are associated with immunodeficiencies and pro-inflammatory status correlated with degenerative changes and increased cardiovascular risk. These abnormalities have been compared over the past years with alterations appearing as a result ageing. Also, similitudes regarding immunosenescence observed in ESKD patients, in combination with chronic inflammation, are described as the so-called "inflammaging syndrome".

Predictive Factors of Renal Recovery and Progression to End-Stage Kidney Disease in Patients With Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis With Severe Kidney Disease

IntroductionA significant number of patients with anti-neutrophil cytoplasmic antibodies (ANCA) associated vasculitis (AAV) with glomerulonephritis (AAV-GN) still progress to end-stage kidney disease (ESKD, eGFR<15mL/min/1.73m2) despite advances in remission-induction treatment. MethodsA retrospective cohort study on MPO- or PR3-ANCA positive patients with AAV (MPA or GPA) and eGFR<15 ml/min/1.73 m2 or ESKD at presentation. Renal recovery, dialysis discontinuation and persistence of end-stage kidney disease (ESKD) after standard remission-induction, with or without the use of PLEX were analyzed. ResultsWe analyzed 166 patients with biopsy proven active AAV-GN and eGFR <15mL/min/1.73m2 at the time of diagnosis. Patients received glucocorticoids with CYC (n=84) or with RTX (n=72) for remission-induction, and 49 also received PLEX. The predictors for renal recovery were erythrocyte sedimentation rate, serum creatinine (SCr) at diagnosis and minimal or mild chronicity changes. We further analyzed 71 patients who started dialysis with or without PLEX within 4 weeks of AAV-GN diagnosis. The predictors for dialysis discontinuation were minimal chronicity changes in kidney biopsy at diagnosis (OR=6.138,[95%CI,1.389-27.118],p=0.017). Predictors for persistence of ESKD within 12 months included higher serum creatinine (SCr) at diagnosis (IRR=1.086,[95%CI,1.005-1.173],p=0.037), and moderate (IRR=3.797,[95%CI,1.090-13.225],p=0.036), or severe chronicity changes in kidney biopsy (IRR=5.883,[95%CI,1.542–22.439],p=0.009). ConclusionIn our cohort, kidney recovery, dialysis discontinuation, and persistence of ESKD in patients with AAV-GN and eGFR<15mL/min/1.73m2 depended on SCr and histologic findings on kidney biopsies at the time of diagnosis and was not affected by the addition of PLEX.