Events In Hemodialysis Patients Research Articles

Association of serum resolvin D1 with the risk of major adverse cardiovascular events in hemodialysis patients.

Resolvin D1 (RvD1) inhibits inflammation, reduces oxidative stress, and forecasts the risk of cardiovascular events, but relevant evidence in hemodialysis patients is lacking. This study intended to investigate the predictive value of RvD1 for major adverse cardiovascular events (MACE) risk in hemodialysis patients. Totally, 252 patients who underwent hemodialysis were included. Serum RvD1 was measured by enzyme-linked immunosorbent assay. Patients were followed up with a median of 12.1months. MACE was recorded during the follow-up period. RvD1 was inversely correlated with diabetes history (P = 0.002), cardiac troponin T (TnT) (P = 0.029), and high sensitivity C-reactive protein (hsCRP) (P < 0.001) in hemodialysis patients. 25 hemodialysis patients experienced MACE. RvD1 was reduced in hemodialysis patients with MACE versus those without MACE (P = 0.004). RvD1 exhibited a certain value in forecasting MACE risk, with an area under curve (AUC) of 0.675 [95% confidence interval CI: 0.565-0.786]. Increased RvD1 cut by median (P = 0.043) and cut by quartile (P = 0.042) were related to decreased accumulating MACE in hemodialysis patients. Moreover, RvD1 independently predicted declined MACE risk [odds ratio (OR) = 0.644, P = 0.045], but age (OR = 1.048, P = 0.039) and TnT (OR = 1.006, P = 0.005) independently predicted ascended MACE risk in hemodialysis patients. The combination of these independent factors displayed a good value for estimating MACE risk in hemodialysis patients with an AUC of 0.744 (95% CI: 0.640-0.849). Serum RvD1 is inversely correlated with diabetes history, TnT, and hsCRP in hemodialysis patients. More importantly, it could serve as a potential marker to predict MACE risk in these patients.

Treatment strategies of the thromboembolic risk in kidney failure patients with atrial fibrillation.

The incidence and prevalence of atrial fibrillation (AF) in patients affected by kidney failure, i.e. glomerular filtration rate <15ml/min/1.73 m2, is high and probably underestimated. Numerous uncertainties remain regarding how to prevent thromboembolic events in this population because both cardiology and nephrology guidelines do not provide clear recommendations. The efficacy and safety of oral anticoagulant therapy (OAC) in preventing thromboembolism in patients with kidney failure and AF has not been demonstrated for either vitamin K antagonists (VKA) or direct anticoagulants (DOAC). Moreover, it remains unclear which is more effective and safer between them, because estimated creatinine clearance<25-30ml/min was an exclusion criterion of the randomized control trials (RCTs). Three RCTs comparing DOACs and VKAs in kidney failure failed to reach the primary endpoint because they were underpowered. The left atrial appendage is the main source of thromboembolism in the presence of AF. Left atrial appendage closure (LAAC) has recently been proposed as an alternative to OAC. RCTs comparing the efficacy and safety of LAAC vs. OAC in kidney failure were terminated prematurely due to recruitment failure. A recent prospective study showed a reduction in thromboembolic events in hemodialysis patients with AF and undergoing LAAC compared to patients taking or not taking OAC. We review current treatment standards and discuss recent developments in managing the thromboembolic risk in kidney failure patients with AF. The importance of shared decision-making with the multidisciplinary team and the patient, to consider individual risks and benefits of each treatment option is underlined.

#1736 Correlation between chronic kidney disease-mineral and bone disorder parameters and clinical events in hemodialysis patients

Abstract Background and Aims Patients with chronic kidney disease experience mineral and bone metabolism alterations, collectively known as Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD), linked to elevated cardiovascular mortality. A significant biochemical change is the development of secondary hyperparathyroidism—an adaptive response to uremic conditions that, when surpassing critical thresholds, becomes maladaptive, heightening clinical risk. Presently, optimal parathyroid hormone (PTH) values for hemodialysis (HD) patients lack a clear definition, with recent evidence challenging international guideline limits. This study aimed to evaluate the impact of PTH values on mortality in a population of patients in HD. Method A prospective observational study involving chronic hemodialysis patients commenced in January 2020, with a 40-month follow-up for mortality recording. Exclusion criteria comprised parathyroidectomy, primary hyperparathyroidism evidence, prior kidney transplant, or transplant plans within three months. Clinical and biochemical data, aligned with the 2017 KDIGO guidelines for PTH, calcium (Ca), and phosphorus (Ps) target values, were recorded. Our laboratory PTH values ranged from 25 to 88 pg/ml, and stable PTH values within 180 to 700 pg/ml were deemed adequate in HD patients. Patients were categorized based on the average of three values over 12 months for PTH, Ca, and Ps parameters. Results One hundred patients (average age: 71 ± 13.59) were enrolled. Seventy-seven percent achieved PTH targets (180-700 pg/ml), 73% for Ca, and 19% for phosphorus (Table 1). During follow-up, 36 deaths (36%) occurred. While percentages of target achievement were similar between survivor and non-survivor groups, non-survivor patients exhibited higher PTH values (423.08 ± 277 vs. 360.44 ± 214.92; p = 0.05) without differences in Ca and Ps levels between the two groups (Table 2). Stratifying based on the median PTH value (330 pg/ml) revealed higher mortality in patients with PTH &amp;gt; 330 pg/ml (Log-rank test p = 0.05) (Fig. 1). Conclusion Despite comparable target achievements for PTH, Ca, and Ps, deceased patients had elevated average PTH values, especially those exceeding 330 pg/ml, indicating a higher risk of death during our follow-up. In line with recent literature, these findings underscore PTH's role as a uremic toxin, suggesting a revaluation of current PTH targets for hemodialysis patients

The impacts of dietary antioxidants on cardiovascular events in hemodialysis patients: An update on the cellular and molecular mechanisms.

Cardiovascular-related complications (CVCs) are the primary cause of death in patients undergoing hemodialysis (HD), accounting for greater than half of all deaths. Beyond traditional risk factors, chronic inflammation, extreme oxidative stress (OS), and endothelial dysfunction emerge as major contributors to accelerated CVCs in HD patients. Ample evidence shows that HD patients are constantly exposed to excessive OS, due to uremic toxins and pro-oxidant molecules that overwhelm the defense antioxidant mechanisms. The present study highlights the efficiency of natural antioxidant supplementation in managing HD-induced inflammation, OS, and consequently CVCs. Moreover, it discusses the underlying molecular mechanisms by which these antioxidants can decrease mitochondrial and endothelial dysfunction and ameliorate CVCs in HD patients. Given the complex nature of OS and its molecular pathways, the utilization of specific antioxidants as a polypharmacotherapy may be necessary for targeting each dysregulated signaling pathway and reducing the burden of CVCs.

Role of High-sensitivity C-reactive Protein in Future Cardiovascular Events in Hemodialysis Patients.

The pathogenesis of cardio-vascular disease (CVD) in hemodialysis (HD) patients involves inflammation and oxidative stress. High-sensitivity C-reactive protein (hs-CRP) is an established inflammatory biomarker associated with CVD. Several studies have suggested that the inflammatory biomarker pentraxin-3 (PTX-3) and the oxidative stress-related biomarker soluble lectin-like low-density lipoprotein receptor-1 (sLOX-1) are novel biomarkers for CVD in non-HD populations. This study aimed to clarify the association of these established and novel biomarkers with future cardiovascular (CV) events in HD patients. This was a single-center prospective cohort study that included 255 HD patients. The primary outcome was the composite of nonfatal and fatal CV events. The event-free survival rate between the two groups according to the median plasma level of each biomarker at baseline was evaluated using the Kaplan-Meier method. The risk for CV events at elevated levels of each biomarker was estimated using Cox proportional hazard model. We observed 44 CV events during the median follow-up period of 743 days. The event-free survival rate significantly differed between the two groups in hs-CRP but not in PTX-3 or sLOX-1. The unadjusted hazard ratio (HR) for CV events in patients with hs-CRP levels above the median was 2.63 [95% confidence interval (CI)=1.37-5.02]. The HR remained significant after adjusting for age, sex, history of CVD, and diabetes (HR=2.30; 95%CI=1.20-4.43). In HD patients, hs-CRP may have a predictable role for future CV events, whereas PTX-3 and sLOX-1 do not.

Impact of coronary flow reserve on the mortality and major adverse cardiac and cerebrovascular event in hemodialysis patients, regardless of diabetes

Abstract Background Ischemic heart disease (IHD) is still a major problem not only in general patients but also in regular hemodialysis (HD) patients. We have reported about prognostic value of coronary flow reserve (CFR) derived from N13-ammonia PET in HD population for all-cause mortality and major adverse cardiac event (MACE) in prior studies. We investigated the impact of diabetes and low CFR on the mortality in HD population. Methods A total 1,027 HD patients who undergone 13N-ammonia PET for suspected IHD were enrolled. We divided them into four groups according to CFR (cut off value = 2.0) and whether DM or not. We collected and evaluated their all-cause mortality, cardiovascular (CV) mortality and MACE, and analyzed using Kaplan-Meier methods and uni/multivariate cox regression model. Results The number of DM with better CFR group was 194, DM with worse CFR was 244, non-DM with better CFR was 361 and non-DM with worse CFR was 221. We found 285 case of all-cause mortality, 121 case of CV mortality, 164 case of CV mortality and 424 case of MACCE. Whether DM or not, CFR predicts HD patients’ prognosis precisely (See figure). Furthermore, multivariate Cox regression model showed CFR (continuous value) was an independent predictor for all-cause mortality (hazard ratio (HR); 0.774, 95% confidential interval (CI) 0.606-0.979, p value=0.037) and MACCE (HR0.769, 95%CI0.630-0.932, p=0.009) in DM and HD population. Furthermore, CFR predicted all-cause mortality (HR0.731, 95%CI 0.569-0.940, p=0.015) and non-CV death (HR0.636, 95%CI0.451-0.896, p=0.010) in non-DM and HD population. Conclusion The HD patients with DM and low CFR had worst prognosis in all-cause mortality, CV death, non-CV death and MACCE.

Effect of renin-angiotensin system inhibitors on cardiovascular events in hemodialysis patients with hyperphosphatemia: A post hoc analysis of the LANDMARK trial.

The clinical benefits of renin-angiotensin system inhibitors (RASi) in patients undergoing hemodialysis remain obscure. This is a post hoc cohort analysis of the LANDMARK trial investigate whether RASi use was associated with cardiovascular events (CVEs) and all-cause mortality. A total of 2135 patients at risk for vascular calcification were analyzed using a Cox proportional hazards model with propensity-score matching. The risk of CVEs was similar between participants with RASi use at baseline and those without RASi use at baseline and between participants with RASi use during the study period and those without RASi use during the study period. No clinical benefits of RASi use on all-cause mortality were observed. Serum phosphate levels were significantly associated with the effect of RASi on CVEs. RASi use was not significantly associated with a lower risk of CVEs or all-cause mortality in hemodialysis patients at risk of vascular calcification.

Association between YKL-40 and Cardiovascular Events in Hemodialysis Patients

Association between YKL-40 and Cardiovascular Events in Hemodialysis Patients

Elevated serum FGF21 is an independent predictor for adverse events in hemodialysis patients from two large centers: a prospective cohort study

Introduction We explored the relationship and the predictive value of serum fibroblast growth factor 21 (FGF21) with all-cause mortality, major adverse cardiovascular events (MACEs) and pneumonia in hemodialysis (HD) patients. Methods A total of 388 Chinese HD patients from two HD centers were finally enrolled in this prospective cohort study (registration number: ChiCTR 1900028249) between January 2018 and December 2018. Serum FGF21 was detected. Patients were followed up with a median period of 47 months to record the MACEs and pneumonia until death or 31 December 2022. Results The incidence of all-cause mortality, MACEs and pneumonia in HD patients were 20.6%, 29.6%, and 34.8%, respectively. The optimal cutoffs for FGF21 to predict all-cause mortality, MACEs and pneumonia were 437.57 pg/mL, 216.99 pg/mL and 112.79 pg/mL. Multivariate Cox regression analyses showed that FGF21, as a categorical variable, was an independent predictor for all-cause mortality, MACEs and pneumonia (HR, 3.357, 95% CI, 2.128–5.295, p < 0.001; HR, 1.575, 95% CI, 1.046–2.371, p = 0.029; HR, 1.784; 95% CI, 1.124–2.830; p = 0.014, respectively). The survival nomogram, MACEs-free survival nomogram and pneumonia-free survival nomogram based on FGF21 constructed for individualized assessment of HD patients had a high C-index with 0.841, 0.706 and 0.734. Conclusion Higher serum FGF21 is an independent predictor of all-cause mortality, MACEs and pneumonia in HD patients.

An analysis of the relationship of bloodpressure and its variability withresidual kidney function loss inhemodialysis patients.

This study aims to investigate the relationship of blood pressure (BP) and systolic BP (SBP) variability with residual kidney function (RKF) loss in hemodialysis (HD) patients. The demographic and clinical information and data on RKF loss events in HD patients were collected. The baseline characteristics of the patients were compared among groups according to pre- and postdialysis SBP (< 120, 120-139, 140-159, and ≥ 160 mmHg) and diastolic BP (DBP) (< 80, 80-89, 90-99, and ≥1 00 mmHg). Participants were divided into two groups based on the mean intradialytic and interdialytic SBP variability. Kaplan-Meier analysis and Cox regression analysis were used to evaluate the risk of RKF loss. A total of 157 participants with an average HD vintage of 35.97 months were included. The group with the lowest predialysis SBP showed the longest duration of residual urine. However, Kaplan-Meier analysis and Cox regression analysis indicated that BP and SBP variability were not independent risk factors for RKF loss. Higher serum albumin levels showed protective effects against RKF loss, and diabetes mellitus (DM) and higher serum calcium were the independent risk factors for RKF loss. BP and SBP variability were not independent risk factors for RKF loss in HD patients. DM, serum albumin, and calcium were independent factors related to RKF loss.

#4654 THROMBOEMBOLIC EVENTS AND THEIR RELATIONSHIP WITH COVID-19 IN HEMODIALYSIS PATIENTS: MYTH OR TRUE ?

Abstract Background and Aims Since the beginning of COVID-19 pandemic, there has been more than 668 million of diagnosis and more than 6 million deaths worldwide. This pandemic also has had a dramatic impact on chronic patients, such as those with end stage renal disease (ESRD) on hemodialysis (HD). Many studies have hypothesized that COVID-19 could induce a hypercoagulability state, activating coagulation cascade. Post-mortem studies revealed vascular injuries in more than 60% of lung tissues and many patients diagnosed with COVID-19 have suffered neurological pathologies, as ischemic stroke. Patients with ESRD are also at higher risk of thromboembolic events than healthy subjects. In this study, we analyze thromboembolic events in HD patients with or without COVID-19 diagnosis. Method We performed a retrospective observational study between March 2020 and December 2022 with 4679 HD patients (2635 COVID-19 positive patients (Group 1) and 2044 COVID-19 negative (Group 2)) from 50 Spanish clinics. The baseline dates of the non COVID-19 patients were randomly chosen. Follow-up time was 1 year since COVID-19 diagnosis (Group 1) or since selection (Group 2). We identified patients who has suffered any thromboembolic event during follow-up time. We compared usual clinical parameters between groups using Chi2 and Mann-Whitney U tests. Survival analysis was performed by Kaplan-Meier and Cox regression. Continuous variables were categorized to perform the Cox analysis. Results Small differences between Group 1 and 2 were found in age (70.45 (62-81) vs 68.94 (61-80); p&amp;lt;0.001), proportion of men (63% vs 67.2%; p&amp;lt;0.05), HD vintage (34 (14-71) vs 30 (11-65); p&amp;lt;0.05), preHD systolic blood pressure (SBP) (140.73 (126-155) vs 142.65 (128-157); p&amp;lt;0.05), plasma hemoglobin (Hb) (11.19 (10.40-11.90) vs 11.31 (10.5-12); p&amp;lt;0.05) and proportion of patients with antithrombic medication (604 (22.9%) vs 401 (19.6%); p&amp;lt;0.05). No statistically significant differences were found in time to first thromboembolic event between the two groups (Figure 1). In univariate Cox regression (Table 1) thromboembolic events showed significant relation with gender, Charlson Index above 8, preHD relative overhydration (relOH) above 13.4% and preHD SBP above 155 mmHg. In multivariate analysis (Table 1), Charlson Index and preHD SBP showed hazard ratio above 1.5 for thromboembolic event (p&amp;lt;0.05). COVID-19 diagnosis did not show relationship with thromboembolic events. Conclusion Publications on thromboembolic events in HD patients who have suffered from COVID-19 are scarce and with small size samples. In our large HD sample, thromboembolic events were not related to COVID-19. Only Charlson Index and preHD SBP showed a significant relationship in the multivariate analysis.

#6287 EFFECT OF REMOTE ISCHEMIC PRECONDITIONING ON NUTRITIONAL STATUS, COGNITIVE FUNCTION, AND BONE IN HEMODIALYSIS PATIENTS: A RANDOMIZED CONTROLLED TRIAL

Abstract Background and Aims Remote ischemic preconditioning (RIPC) is a process in which a brief period of ischemia is induced in one part of the body to protect another part from damage due to subsequent periods of more severe ischemia. Hemodialysis sessions are considered an ischemic process because it involves reducing blood flow to certain parts of the body, which can lead to tissue damage .Malnutrition, deterioration of cognitive function, bone disorders, cardiovascular disease, and hemodynamic instability can result from ischemia induced by hemodialysis sessions. These adverse effects increase mortality in HD patients. RIPC has been studied as a potential therapeutic strategy to reduce the risk of cardiovascular events in hemodialysis patients; however, the effect of RIPC on cognitive function, nutritional status, and bone disorder among hemodialysis patients has not been enough studied. Aim: to assess the effect of remote ischemic preconditioning on nutritional status, bone disorders, and cognitive function in hemodialysis patients at the urology and nephrology center, Mansoura University. Method Fifty patients who received regular hemodialysis for more than one year in our dialysis unit were included. The patients were randomized (single-blind) into two groups a control group (20 patients) and an intervention group (30 patients). Before each HD session, sphygmomanometer cuffs was placed around the non-vascular access arm. Three cycles of ischemia for five minutes were performed followed by reperfusion for five minutes. Ischemia was induced by inflating the sphygmomanometer cuffs to 200 mmHg. This maneuver was done before each HD session for 12 weeks. The Montreal Cognitive Assessment (MOCA) was used to assess cognitive function. The nutritional state was assessed by anthropometric measurement (body weight, BMI), laboratory (serum albumin and serum cholesterol), and Subjective Global Assessment Form (SGA). Serum calcium (s.Ca) and serum phosphorus (s.po), serum alkaline phosphate (s. ALP) and intact parathyroid hormone (iPTH) were used as indices for bone profile. Results The intervention group include 30 patient with mean age (36+/-10), 19 male (63.3%) and 11 females (36.7%). The control group include 20 patient with mean age (46+/-9), 12 male (60%) and eight female (40%). None of these patients’ demographic data (age, sex, original kidney disease, and duration of dialysis) were significantly different between the study groups (P&amp;gt;0.05). MOCA test score at baseline was (24.5 +/-2.6) at intervention group and (24.4+/-3.2) at control group, and after 12 weeks intervention was (24.8 +/-2.2) at intervention group and (24.4+/-2.8) at control group. there were no statistical significance regarding cognitive function between the two group over time (p = 0.4). NO significant Statistical changes in anthropometric measurements (Body weight (p = 0.3) and BMI (P = 0.6) were found between the two groups. Additionally, no significant changes (serum albumin and cholesterol) were detected. SGA score at baseline was at intervention group (1.2+/-0.4) and control group (1.1 +/- 0.3), and after 12 week was at the intervention group (1.4 +/-0.5) and control group (1.6 +/-0.5). SGA showed no statistical significance between the two groups over time (p = 0.2). No significant statistical changes regarding bone profile (s.ca (p = 0.5), s.PO (p = 0.2), s.ALP (p = 0.7) and iPTH (p = 0.5)). Conclusion Although some studies showed a beneficial effect of RIBC on reduction of cardiovascular risk, our study found no significant effect on cognitive function, nutritional status, and bone disorders among hemodialysis patients.

#5115 8-ZONE LUNG ULTRASOUND AND BIOIMPEDANCE ANALYSIS FOR ASSESSMENT OF HYDRATION STATUS IN HEMODIALYSIS: A PROSPECTIVE SINGLE CENTRE EXPERIENCE

Abstract Background and Aims Chronic volume overload is a major contributor to cardiovascular mortality in patients receiving maintenance hemodialysis (HD). Hence, accurately assessing volume status in this population is crucial. Bioelectrical impedance analysis (BIA) is a validated, non-invasive, and straightforward bedside technique that estimates total body water (TBW), extracellular water (ECW), intracellular water (ICW), and over hydration (OH). However, it is not suitable for use in patients with limb amputation or metallic medical devices. On the other hand, lung ultrasound (LUS) is used to evaluate extravascular lung water (EVLW) and has been shown to predict all-cause mortality and cardiac events in HD patients. Although a 28-zone LUS is the reference standard for LUS studies, recent studies have shown that an 8-zone LUS protocol can be as accurate. The aim of this study was to compare the performance of an 8-zone LUS protocol with bioelectrical impedance analysis to evaluate hydration status in an outpatient haemodialysis unit. Method Adult patients under thrice-weekly 4h HD sessions using high-flux membrane dialyzers for at least 1 month were prospectively enrolled between June and August 2022. We excluded patients with systemic infections, advanced neoplasia, metallic medical devices, decompensated cirrhosis, and limb amputations. The dry weight (DW) was established by the attending nephrologist, blind to the results. All measurements were performed in the first session of the week. BIA was assessed before HD using a portable whole body BIA device (BCM—Fresenius Medical Care D GmbH) and the OH was normalized to ECW. LUS using 8-zone protocol was performed before and after HD, with patients in the near-to-supine or supine position using a 2–5 MHz convex probe (Acuson X150®, Siemens, Germany), and the total number of B lines was recorded. Results A total of 37 patients with median age of 60 (IQR 15) years, 75% males, 65% with residual diuresis &amp;gt;300 mL/24 h were included. The median HD vintage was 9 (IQR 10) months, and median body mass index (BMI) of 22.7 (IQR 9) Kg/m2. At the beginning of HD, the median systolic blood pressure (BP) was 140 (IQR 24) mmHg and the median diastolic BP was 79 (IQR 16) mmHg. The median interdialytic weight gain was 4.2% (IQR 2.8) and median ultrafiltration (UF) was 2600 (IQR 1300) mL. The BIA showed median TBW of 38.2 (IQR 11) L, ECW 18.2 (IQR 7.73) L, ICW 20.8 (IQR 6.55) L, and normalized OH 0.138 (IQR 0.147). There was a positive correlation between BMI, TBW (r = 0.375, p = 0.045), and ECW (r = 0.486, p = 0.006), but not with ICW (r = 0.061, p = 0.755), nor normalized OH (r = 0.14, p = 0.468). Systolic BP, but not diastolic, was correlated with the water volume measured in both compartments (ECW: r = 0.498, p = 0.005; ICW: r = 0.421, p = 0.023, TBW: r = 0.423, p = 0.022). The 8-zone LUS showed a statistically significative (p&amp;lt;0.001) reduction in the number of B lines between pre and post HD evaluation (16.5 (IQR 17.25) lines to 8.5 (IQR 10.25) lines). Total evaluation time was under 8 minutes. When comparing LUS before HD with BIA assessment we found that the number of B lines correlated with the normalized OH (r = 0.454, p = 0.018), ECW (r = 0.501, p = 0.007), TBW (r = 0.418, p = 0.030), but not ICW (r = 0.239, p = 0.23). The total number of B lines post HD was also correlated with the ECW (r = 0.568, p = 0.002), TBW (r = 0.465, p = 0.017), and normalized OH (r = 0.408, p = 0.039). Conclusion The 8-zone LUS protocol provides a quick and efficient way to evaluate patients prior to HD sessions. Our study reveals a strong correlation between the total number of B lines determined by the 8-zone protocol and BIA parameters such as TBW, ECW, and normalized OH. This demonstrates that the 8-zone protocol can effectively be used in routine evaluations of HD patients. Although these techniques reflect different over-fluid compartments, they have a complementary role for fluid overload determination and dry weight guidance.

Intra-dialytic blood pressure variability is a greater predictor of cardiovascular events in hemodialysis patients

BackgroundShort-term and long-term blood pressure variability (BPV) in hemodialysis (HD) population are risk factors of cardiovascular diseases (CVD) and all-cause mortality. There is no full consensus on the best BPV metric. We compared the prognostic role of intra-dialytic and visit-to-visit BPV metrics for CVD morbidity and all-cause mortality in HD patients.MethodsA retrospective cohort of 120 patients on HD was followed up for 44 months. Systolic blood pressure (SBP) and baseline characteristics were collected for 3 months. We calculated intra-dialytic and visit-to-visit BPV metrics, including standard deviation (SD), coefficient of variation (CV), variability independent of the mean (VIM), average real variability (ARV) and residual. The primary outcomes were CVD events and all-cause mortality.ResultsIn Cox regression analysis, both intra-dialytic and visit-to-visit BPV metrics were associated with increased CVD events (intra-dialytic CV: HR 1.70, 95% CI 1.28–2.27, p < 0.01; visit-to-visit CV: HR 1.55, 95% CI 1.12–2.16, p < 0.01), but not associated with increased all-cause mortality (intra-dialytic CV: HR 1.32, 95% CI 0.99–1.76, p = 0.06; visit-to-visit CV: HR 1.22, 95% CI 0.91–1.63, p = 0.18). Overall, intra-dialytic BPV showed greater prognostic ability than visit-to-visit BPV for both CVD event (AUC of intra-dialytic BPV and visit-to-visit BPV metrics respectively: SD 0.686, 0.606; CV 0.672, 0.425; VIM 0.677, 0.581; ARV 0.684, 0.618; residual 0.652, 0.586) and all-cause mortality (SD 0.671, 0.608; CV 0.662, 0.575; VIM 0.669, 0.581; ARV 0.529, 0.588; residual 0.651, 0.602).ConclusionCompared to visit-to-visit BPV, intra-dialytic BPV is a greater predictor of CVD event in HD patients. No obvious priority was found among various BPV metrics.

Management of Thrombosed Dialysis Access Circuits.

Thrombotic occlusion of autologous arteriovenous fistulas or synthetic arteriovenous grafts is a serious adverse event in hemodialysis patients and declotting should be performed before next hemodialysis session, in order to avoid a central venous catheter. Various techniques exist to declot a thrombosed vascular access, including open surgical thrombectomy, catheter-directed thrombolysis and use of different types of percutaneous thrombo-aspiration catheters and mechanical thrombectomy devices. These devices can be categorized as devices with direct wall contact and hydrodynamic devices without direct wall contact. Technical and early clinical outcome results of percutaneous hemodialysis declotting are high and ranging between 70 and 100%; late clinical patency results are much lower related to restenosis or re-thrombosis; these patency results are higher for autologous arteriovenous fistulas compared to synthetic arteriovenous grafts and mainly depend on the combined efficacy of successful thrombectomy and durable treatment of the underlying stenoses, associated with the acute thrombosis.

Prediction of Intradialytic Blood Pressure Variation Based on Big Data

Introduction: Cardiovascular (CV) events are the major cause of morbidity and mortality associated with blood pressure (BP) in hemodialysis (HD) patients. BP varies significantly during HD treatment, and the dramatic variation in BP is a well-recognized risk factor for increased mortality. The development of an intelligent system capable of predicting BP profiles for real-time monitoring is important. Our aim was to build a web-based system to predict changes in systolic BP (SBP) during HD. Methods: In this study, dialysis equipment connected to the Vital Info Portal gateway collected HD parameters that were linked to demographic data stored in the hospital information system. There were 3 types of patients: training, test, and new. A multiple linear regression model was built using the training group with SBP change as the dependent variable and dialysis parameters as the independent variables. We tested the model’s performance on test and new patient groups using coverage rates with different thresholds. The model’s performance was visualized using a web-based interactive system. Results: A total of 542,424 BP records were used for model building. The accuracy was greater than 80% in the prediction error range of 15%, and 20 mm Hg of true SBP in the test and new patient groups for the model of SBP changes suggested the good performance of our prediction model. In the analysis of absolute SBP values (5, 10, 15, 20, and 25 mm Hg), the accuracy of the SBP prediction increased as the threshold value increased. Discussion: This databae supported our prediction model in reducing the frequency of intradialytic SBP variability, which may help in clinical decision-making when a new patient receives HD treatment. Further investigations are needed to determine whether the introduction of the intelligent SBP prediction system decreases the incidence of CV events in HD patients.

Correlation between fluid parameter and cardiovascular events in hemodialysis patients based on repeated body composition analyses

Objective: To explore the correlation between fluid load index and cardiovascular events in hemodialysis patients based on repeated body composition analyses. Methods: A prospective cohort study was conducted to collect the clinical data of patients undergoing maintenance hemodialysis (MHD) in the Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine from July to September 2020. The pre-dialysis fluid overload (FO) index-overhydration (OH) was measured by bioelectrical impedance method, and the follow-up monitoring was conducted every 6 months. According to the baseline OH value, patients were divided into non-FO group (OH≤2.5 L) and FO group (OH>2.5 L). Moreover, according to the repeated measurements, the patients were divided into continuous non-FO group, continuous FO group and intermittent FO group. All patients were followed up until October 1, 2022, and the outcomes were recorded. The end point of follow-up was cardiovascular events. The cumulative incidence of cardiovascular events was calculated by the Kaplan-Meier method, and the risk factors of cardiovascular events were analyzed by Cox proportional hazards regression model. Results: A total of 289 patients were included, including 88 patients (30.4%) with FO and 201 patients (69.6%) with non-FO. There were 168 males (58.1%) and 121 (41.9%) females, with an average age of (58±13) years and an average follow-up time of (22.0±6.5) months. Kaplan-Meier analysis showed that the incidence of cardiovascular events in the baseline FO group was higher than that in the non-FO group (log-rank χ2=14.44, P<0.001). The incidence of cardiovascular events in both the continuous FO group and the intermittent FO group was higher than that in the continuous non-FO group (log-rank χ2=41.47, P<0.001; log-rank χ2=18.36, P<0.001). After adjustment for gender, age, comorbidities, and biochemical indicators, the incidence of cardiovascular events in the baseline FO group was 1.850 times of the non-FO group (95%CI: 1.046-3.271, P=0.034). The incidence of cardiovascular events in the continuous FO group was 4.679 times of the continuous non-FO group (95%CI: 2.189-10.002, P<0.001). The incidence of cardiovascular events in the intermittent FO group was 3.410 times of the continuous non-FO group (95%CI: 1.696-6.857, P=0.001). Conclusions: OH value measured by bioelectrical impedance can be used as an important reference index for clinical monitoring of cardiovascular events in MHD patients. Continuous chronic and intermittent exposures to FO are risk factors for cardiovascular events in hemodialysis patients.

Extremely Low Dose of Erythropoiesis-Stimulating Agent May Be Associated with Increased Mortality in Hemodialysis Patients

Introduction: Although high-dose erythropoiesis-stimulating agent (ESA) has been shown to increase mortality risk and adverse cardiovascular events in hemodialysis patients, the safety of extremely low-dose ESA is unclear. Methods: We retrospectively analyzed the association between ESA dose and mortality in the monthly dosing range of 0–43,000 U of equivalent epoetin alfa in 304 Taiwan hemodialysis patients by using Cox proportional hazard model and cubic spline model. Results: Compared with mean monthly ESA dose of 15,000–25,000 U (mean ± standard deviation 20,609 ± 2,662 U), monthly ESA dose of less than 15,000 U (mean ± standard deviation 7,413 ± 4,510 U) is associated with increased mortality. Monthly ESA dose of 25,001–43,000 U (mean ± standard deviation 31,160 ± 4,304 U) is not associated with higher mortality risk than monthly ESA dose of 15,000–25,000 U. The results were consistent in Cox proportional hazard models and cubic spline models. Subgroup analyses showed no significant heterogeneities among prespecified subgroups. Conclusions: Extremely low dose of ESA in hemodialysis patients may be associated with increased mortality risk. Future studies are warranted to prove this association.

Real-World Effectiveness of SARS-CoV-2 Vaccine Booster in Hemodialysis Patients with COVID-19 Receiving Molnupiravir.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine booster is one of the most essential strategies against coronavirus disease 2019 (COVID-19) in the era of emerging variants. However, the effectiveness of SARS-CoV-2 vaccine boosters has not much been investigated in hemodialysis (HD) patients receiving oral antiviral agents. In this retrospective study involving 258 HD patients with COVID-19 receiving molnupiravir, we stratified the study cohort according to vaccination status and compared the baseline characteristics and risks of 30-day composite events (COVID-19-related acute care visits, hospitalization, or mortality) among groups. Our analysis demonstrated that the SARS-CoV-2 vaccine boosters markedly decreased the risk of composite events in HD patients (hazard ratio (95% confidence interval), 0.163 (0.063-0.423) for three vs. ≤ two doses of vaccination, p < 0.001; 0.309 (0.115-0.830) for four vs. ≤ two doses of vaccination, p = 0.020). The benefits of vaccine boosters were similar between patients receiving mRNA-based and protein-based boosters and between those with post-booster intervals of ≤ 120 and > 120 days. In conclusion, for HD patients with initially mild or asymptomatic COVID-19 receiving molnupiravir, the benefits of SARS-CoV-2 vaccine boosters are prominent, irrespective of booster vaccine types.

Prognosis of Heart Valve Calcification on Cardiovascular Events in Hemodialysis Patients without Central Venous Catheters

Introduction: Heart valvular calcification (HVC) is an important predictor of cardiovascular events (CEs) and all-cause mortality in dialysis patients. Patients in the early stage of dialysis or those with central venous catheters (CVC) are also at high risk of cardiovascular and all-cause mortality. It could be a confounding factor for the prognosis of HVC on CE. Methods: From March 2017 to April 2022, the prognosis of HVC on CE and all-cause mortality was studied retrospectively in 158 hemodialysis (HD) patients who used arteriovenous fistulas or arteriovenous grafts as vascular access and entered HD for more than 12 months. Results: Out of 158 patients, 70 (44.3%) were diagnosed with HVC via echocardiography. A total of 180 CEs occurred during follow-up. Among them, acute heart failure accounted for 62.66%, and its prevalence was significantly higher in the HVC group than that in the non-HVC group (p < 0.0001). The cumulative incidence of CE-free survival in the HVC group was significantly lower than that in the non-HVC group (p = 0.030). Only 11 patients died, and there was no significant difference in all-cause mortality between the two groups (p = 0.560). Multivariate COX regression analyses showed that HD vintage, mitral valve calcification, and aortic valve regurgitation (AR)/aortic valve stenosis (AS) but not aortic valve calcification were risk factors for CE (p < 0.05). Conclusion: After excluding the factors of the early stage of HD and CVC, HVC remained a predictor of adverse CE in HD patients.