Dialysis Frequency Research Articles

Pulmonary Artery Pressure Status in Hemodialysis Patients and Its Association with Nutritional and Biochemical Markers

Background: The prevalence of pulmonary hypertension (PH) is reported between 17% and 56% in hemodialysis patients. The pathogenesis of PH in hemodialysis patients is still unclear. Malnutrition may be associated with impaired pulmonary function in hemodialysis patients. Objectives: The present study aimed to investigate the association between PH and nutritional and biochemical markers in hemodialysis patients. Methods: In this cross-sectional study, 80 patients undergoing hemodialysis at the Kowsar Medical Center, Semnan, Iran, from 1 March 2016 to 31 August 2016 were enrolled by complete enumeration. Pulmonary artery pressure was determined by echocardiography between hemodialysis sessions. Arm circumference, triceps fat mass, and body mass index (BMI) were determined. Other laboratory tests included transferrin, serum albumin, cholesterol, triglyceride, and hemoglobin. The source of receiving protein was recorded in a questionnaire. The data were analyzed by the chi-square test and logistic regression analysis at a significance level of less than 0.05. Results: Pulmonary hypertension ( > 25 mmHg) was found in 32 (40%) of the 80 patients studied. The mean of pulmonary pressure in patients with PH was 34.66 ± 5.6 mmHg compared to 16.85 ± 3.7 mmHg in patients without PH. Age, gender, arm circumference, frequency of dialysis per year, and serum levels of albumin, transferrin, triglyceride, and total cholesterol were not significantly different between patients with and without PH. There was a significant difference in the mean hemoglobin level between patients with and without PH (P = 0.003). The likelihood of developing PH was reduced by 0.3 in those with hemoglobin ≥ 11 g/dL compared to patients with hemoglobin levels below 11 g/dL (OR = 0.400, P = 0.003). The likelihood of developing PH in patients with albumin ≥ 3.8 g/L decreased by 0.126 compared to those with albumin less than 3.8 (OR = 0.126, P = 0.003). Conclusions: The results of our study indicated a higher incidence of PH in patients with lower levels of hemoglobin and albumin. So, patients undergoing hemodialysis are recommended to be regularly screened for these two variables.

#4379 SURVIVAL RATES AND ANALYSIS OF PREDICTORS OF MORTALITY AMONG INCIDENT HEMODIALYSIS PATIENTS: A SINGLE CENTER FIVE-YEAR COHORT STUDY

Abstract Background and Aims Studies on improving survival rate among maintenance hemodialysis patients have been extensive. However, only a handful of studies have focused on the factors that determine mortality risk among incident hemodialysis patients, considering that the first few months of hemodialysis initiation are the most critical. Survival rates and factors predicting mortality may vary from one geographic area to another. Local data on these factors, however, are quite lacking. Identification of factors that can be optimized during this crucial period can greatly impact survival of Filipino hemodialysis patients. This study was designed primarily to determine 1-year, 3-year and 5-year survival rates of incident hemodialysis patients enrolled at the National Kidney and Transplant Institute (NKTI). Demographic and clinical factors that may influence mortality risk were identified and analyzed. Method This is a retrospective cohort study which evaluated the data of all incident adult patients enrolled at NKTI Outpatient Dialysis Unit, over a period of 5 years (January 2016 to December 2020). Patients were followed, retrospectively, from initiation until censorship (end of study, loss to follow up, transfer, conversion to peritoneal dialysis or kidney transplant) and the following factors were compared between those who remained alive and those who expired: etiology of kidney disease, age, sex, mode and frequency of dialysis, access, socioeconomic class and biochemical parameters. Descriptive statistics was used to describe and summarize the baseline data. Frequency and proportion were used for categorical variables, and median and inter-quartile range (IQR) for non-normally distributed interval/ratio variables. Survival probabilities were estimated using the Kaplan-Meier method. Cox regression was done to determine factors of overall survival. All valid data were included in the analysis. Null hypothesis was rejected at 0.05α-level of significance. Stata 15.0 was used for data analysis. Results A total of 562 incident hemodialysis patients were enrolled, 94 of whom expired. Among those who expired, there were more patients who were aged above 60 years (56.38% vs 29.91%, p <.001) and with low serum phosphorus level (29.21% vs 16.78%, p=.029) in comparison to those who were alive. Computed 1-year, 3-year, and 5-year survival rate among patients were 89.51% (95% CI 86.10% - 92.12%), 73.03 (95% CI 66.46 – 78.52%) and 42.06% (95% CI 29.52% - 54.99%), respectively. Patients who are older than 60 years (HR 2.75, p= 0.013), hepatitis C positive (HR 3.92, p= 0.021) and those with low phosphorus (HR 1.86, p= 0.015) were noted to have increased risk of mortality. Conclusion Survival rate of incident hemodialysis patients at NKTI is at par with survival estimates abroad. Risk factor identification and optimization of modifiable ones are key in improving patient survival.

#2559 THE EFFECT OF INTRADIALYTIC EXERCISE ON CARDIAC OUTCOMES IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Cardiovascular disease is the main cause of death of hemodialysis patients, accounting for 42% of all deaths. Because exercise can reduce many risk factors of cardiovascular disease in these patients, we observed the effect of intradialytic exercise on left ventricular structure and function. Method A randomized controlled trial was used. Participants were randomly divided into control group and exercise group. Among them, the exercise group carried out intradialytic aerobic and resistance exercise for 3 months, 5-6 times every two weeks, according to their dialysis frequency. The left ventricular end-diastolic volume, mass and ejection fraction were measured by echocardiography before and 12 weeks after the intervention. (ClinicalTrial registration number: NCT05718765). Results At first, 60 people were recruited and completed the baseline assessment (30 people in each group). The average age of patients in the intervention group was 47.81-11.76 years old, and the average hemodialysis vintage was 17.23-3.09 months. There were 18 men in total. The average age of patients in the control group was 48.56-16.83 years old, and the average hemodialysis period was 17.67-2.83 months. There were 25 men in total. Before the intervention, the two groups of patient indicators were balanced, and the difference was not statistically significant (P>0.05). Finally, 53 patients completed the trial protocol (27 control group and 26 exercise group). After 3 months of intervention, there were significant differences in left ventricular mass, left ventricular end diastolic volume and left ventricular ejection fraction between the two groups (P<0.05). Moreover, the cardiac outcomes of the intervention group were lower than those of the control group, as shown in Table 1. Conclusion The exercise for 3 months can effectively reduce the left ventricular mass and significantly improve the left ventricular function and structure of hemodialysis patients. This will help to improve the research and development of exercise on cardiac in hemodialysis patients.

#5036 THE OUTCOME OF LUMASIRAN TREATMENT IN 10 PAEDIATRIC PATIENTS WITH PRIMARY HYPEROXALURIA TYPE 1

Abstract Background and Aims In primary hyperoxaluria type 1 (PH 1) a rare enzymatic defect in the liver leads to a hepatic overproduction of oxalate. The resulting hyperoxaluria can cause nephrocalcinosis, urolithiasis and renal failure. Conservative treatment options such as hyperhydration, citrate and pyridoxine aim to slow the progression of the disease with a liver transplant currently being the only curative treatment. Since November 2020 Lumasiran is approved for use in patients with PH 1. Lumasiran reduces the hepatic oxalate production by RNA interference and may hence reduce hyperoxaluria. To date there is limited real world data available on the effectiveness of the treatment with Lumasiran. Method This observational study looked at the outcome of Lumasiran treatment in 10 patients under the age of 18 years with genetically confirmed PH 1. The primary end point was percentage reduction in plasma oxalate in the two patients on haemodialysis and percentage reduction of urinary oxalate excretion in the patients with preserved renal function. Secondary end points were change in nephrocalcinosis, urolithiasis and renal function. The follow up time was 6 months in one patient and 12 months in the other nine patients. Results Four of the patients were girls and the median age at the start of treatment was 5.25 years (range 0.3-17.9 years). One of the two patients on haemodialysis showed a decrease in plasma oxalate which allowed for a reduction of dialysis frequency from 5x/week to 3x/week whilst the other patient's dialysis had to be intensified due to worsening systemic oxalosis. In the patients with preserved renal function the median reduction of urinary oxalate was 71% (range 10–91%) after 6 months and 78% (range 61–86%) after 12 months. Two patients reached values in the age specific normal range (Matos et al.). Lumasiran was discontinued after 4 months in one patient and after 8 months in another one due to treatment failure. An improvement in nephrocalcinosis was seen in three patients and two patients showed a subjective reduction in urolithiasis. Renal function improved slightly in one patient and remained stable in the others. Injection site reactions were the only observed side effects. Conclusion Our data highlights the heterogeneity of the disease and treatment response to Lumasiran. Despite promising data regarding the benefits of Lumasiran 2 of 10 patients did not benefit from Lumasiran injections. Hence, it is imperative to regularly re-evaluate hyperoxaluria during treatment with Lumasiran. Ideally the data should be entered into a registry for PH 1 patients to monitor the effectiveness and side effects of this novel drug not only in the short- but also the long term.

Clinical and Epidemiological Profiles of Patients with End Stage Kidney Disease on Dialysis at Dialysis Centers in Addis Ababa, Ethiopia.

End-stage kidney disease is increasing worldwide, primarily in the developing countries. It is affecting mainly the productive age group. Though the prevalence of the disease is increasing in Ethiopia, there are few studies. We therefore sought to describe the clinical and epidemiological characteristics of hemodialysis patients. A descriptive cross-sectional study was conducted at 17 hemodialysis centers in Addis Ababa. Patients who received hemodialysis for at least three months were included in the study. Socio-demographic and clinical data were collected via questionnaires from October to November 2021. This study involved 318 participants with males making up 197 (61.9%) of the participants. Among the total, 248 (78.0%) were in the age group of 20 to 60 years and 155 (48.7%) were unemployed. Hypertension and diabetes mellitus were the major risk factors for end-stage kidney disease. The mean duration of dialysis was 2.26 years. The frequency of dialysis was twice weekly in 150 (47.2%) of the patients and thrice weekly in 138 (43.4%) of the patients. Arterio veneous fistula was used in approximately three-quarters of patients, i.e. 237 (74.5%). The majority of the patients on hemodialysis, 193 (60.7%), pay their own expenses, and 52 (16.4%) of the patients received hemodialysis at public hemodialysis centers. More than two-third of the patients were not in the process of undergoing a kidney transplant due to a variety of factors, including inability to find a donor, 106 (47.7%), being unfit for surgery, 56 (25.2%), and financial constraints, 38 (17.1%). The majority of the patients on dialysis were men, middle-aged, and unemployed. The majority of the patients underwent dialysis in private institutions and were self-funded, and most of them had inadequate dialysis doses. The inability to find a living donor was the most difficult aspect of undergoing kidney transplantation.

Prevalence and risk factors of pre-frailty and frailty in maintenance haemodialysis patients in China: A cross-sectional Study.

To examine the prevalence and risk factors of pre-frailty and frailty in maintenance haemodialysis patients in China. A cross-sectional study. From January to July 2017, using the convenience sampling method, a total of 503 maintenance haemodialysis patients from six hospitals in Lianyungang, China, were recruited for this study. The participants' socio-demographic, lifestyle factors and health information were assessed using a general information questionnaire. Frailty was evaluated based on the Fried frailty phenotype. Multi-categorical logistic regression was performed to examine factors associated with pre-frailty and frailty in this population, including age, sex, living alone, employment, educational level, body mass index, per capita monthly household income, smoking status, exercise status, primary diagnosis, dialysis age, frequency of dialysis, vascular access, congestive heart failure, other cardiac diseases, cerebrovascular disease, peripheral blood diseases, pain, albumin level and haemoglobin level. Among the 503 participants with an average age of 53.02 years (standard deviation 14.99), 178 had pre-frailty (35.3%) and were mostly young and middle-aged. The prevalence of pre-frailty among participants <60 years old was more than 40%. Regression analysis showed that lack of exercise, dialysis age ≤12 months, congestive heart failure and other cardiac diseases were positively associated with pre-frailty. Two hundred and eighteen participants were frail (43.3%), most of whom were aged ≥60. The prevalence of frailty in participants ≥60 was 71.4%. Regression analysis showed that advanced age, being female, obesity, low per capita monthly household income, lack of exercise, diabetes as the primary disease, dialysis age ≤12 months, congestive heart failure, other cardiac diseases, pain and low albumin level, were positively associated with frailty. In addition, more than half of the participants hardly exercised (64.6%), while lack of exercise was a risk factor for pre-frailty and frailty. A third of the participants had pain (33.4%), while pain was an independent risk factor for pre-frailty and frailty in these participants. Pre-frailty and frailty are common in patients with maintenance haemodialysis. Most of the elderly maintenance haemodialysis patients are frail, and most of the young and middle-aged patients are pre-frail. Clinicians should actively screen the pre-frailty and frailty among patients with maintenance haemodialysis, especially those with dialysis age ≤12 months. Many factors affect pre-frailty and frailty in this population. Tailored intervention measures should be designed and implemented based on these factors, giving priority to exercise guidance and pain management for patients to help them prevent or reverse pre-frailty and frailty.

Evaluation of factors related to depression in peritoneal dialysis patients: a multicenter cross-sectional study

BackgroundEnd-stage renal disease (ESRD) is serious global public health challenge in many developing countries. Treatment of ESRD is carried out through renal replacement therapy like peritoneal dialysis (PD). Depression is the most common mood disorder which has a strong impact on the quality of life in patients with ESRD. Little is known about the prevalence and risk factors of depression in peritoneal dialysis patients.Method and materialsA multicenter cross-sectional study was conducted on 164 adult ESRD patients undergoing peritoneal dialysis for at least three months who referred to the peritoneal dialysis centers of Al-Zahra, Noor & Ali Asghar hospitals, Isfahan, Iran from May to August 2019. Beck Depression Inventory Second Edition questionnaire was used to measure the symptoms of depression and its severity.Results43.5% of patients had some levels of depression. Assessing the association of depression with demographic and PD-related factors showed that there was no significant difference regarding age, BMI, dialysis adequacy and residual kidney function, dialysis frequency, type of dialysis solution used, disease duration, and age at the start of dialysis. Ordinal logistics regression analysis showed significant association between depression severity categories and gender (OR = 0.397, CI: 0.160–0.985, p = 0.046), marital status (OR = 2.983, CI: 1.180–7.541, p = 0.021), having a separate room for dialysis (OR = 2.511, CI: 1.108–5.692, p = 0.027).ConclusionAs our findings have revealed 43.5% of our participants suffered from mild-to-severe depression, we suggest careful attention and routine evaluation for depression in PD patients, especially women and single patients and those who have low socioeconomic status.

Predictors for Unsuccessful Reductions in Hemodialysis Frequency during the Pandemic

Patients receiving in-center hemodialysis are at a high risk of coronavirus disease 2019 (COVID-19) infection. A reduction in hemodialysis frequency is one of the proposed measures for preventing COVID-19 infection. However, the predictors for determining an unsuccessful reduction in hemodialysis frequency are still lacking. This retrospective observational study enrolled patients who were receiving long-term thrice-weekly hemodialysis at the Thammasat University Hospital in 2021 and who decreased their dialysis frequency to twice weekly during the COVID-19 outbreak. The outcomes were to determine the predictors and a prediction model of unsuccessful reduction in dialysis frequency at 4 weeks. Bootstrapping was performed for the purposes of internal validation. Of the 161 patients, 83 patients achieved a dialysis frequency reduction. Further, 33% and 82% of the patients failed to reduce their dialysis frequency at 4 and 8 weeks, respectively. The predictors for unsuccessful reduction were diabetes, congestive heart failure (CHF), pre-dialysis overhydration, set dry weight (DW), DW from bioelectrical impedance analysis, and the mean pre- and post-dialysis body weight. The final model including these predictors demonstrated an AUROC of 0.763 (95% CI 0.654-0.866) for the prediction of an unsuccessful reduction. The prediction score involving diabetes, CHF, pre-dialysis overhydration, DW difference, and net ultrafiltration demonstrated a good performance in predicting an unsuccessful reduction in hemodialysis frequency at 4 weeks.

Anemia and Mineral Bone Disorder in Patients with End Stage Renal Diseases on Maintenance Hemodialysis

Background: Chronic kidney disease characterised by urinary disturbances or excretory kidney dysfunction, which is likely to result in functional nephron damage. Glomerulonephritis is an immune-mediated kidney inflammation that affects both the glomerulus and other parts of the kidney. The most common cause of end-stage renal disease is glomerulonephritis. The aim of this study to determine the anemia, mineral bone disorder and high low PTH level during hemodialysis. Study Design: This was cross-sectional study and conducted in the Ali Fatima Hospital Lahore, for six months March 2022 to August 2022. Materials and Methods: There were total 350 participants. The participants were selected by sampling technique were interviewed in the Khyber teaching hospital Peshawar. We analyzed dependent and independent variables. Data analysis statistically by SPSS 20 version. Results: There were total 350 participants which include71.4% males and 29% females in this research. The majority of the participants were in the age group (40-60) years or (n=350) 87% in the hemodialysis. The majority participants were mean age 49.2 ± 0.59 years. The participants were 69% financially depend upon family dialysis. The dialysis frequency of patients about 76% thrice per week and 24.2% were on twice per week. The hemoglobin level was &lt;11 g/dL or mean 12.19±2.65 g/dL which show significantly reduced Hb level. The mean value of serum calcium, sodium, phosphorous and parathyroid levels in bone diseases were 165.40±6.91, 6.675±0.79, 6.89±2.64, and 255.63±233.71, which significantly changed in hemodialysis patients. Anti HCV is 80% positive in hemodialysis patients as compared to general population. Conclusion: The participants who suffered to maintained hemodialysis for &gt; 3 months, majority have low level of Hb which cause anemia, low PTH which associate with the mineral bone diseases and also reduced serum Ca, P, k, Na and albumin level. Keywords: End stage renal disorder (ESRD), chronic kidney disorder (CKD).

Quality of Life of Patients on Peritoneal Dialysis and Contributing Factors

In recent years, interest in Health-Related Quality of Life (HRQoL) as a major indicator of clinical efficacy and treatment outcome in patients of End-Stage Renal Disease (ESRD) has grown significantly. This study aimed to determine the contributing factors affecting the quality of life (QoL) of ESRD patients undergoing peritoneal dialysis (PD). A cross-sectional study was conducted on PD patients presented at PD centres of Al-Zahra and Noor hospitals in Isfahan, Iran, from May to August 2019. A total of 173 patients having peritoneal dialysis for more than 3 months filled the validated 36-item short-form health survey questionnaire (SF-36). Baseline demographic details and dialysis-related factors were collected from patients’ medical records. The overall QoL score of patients was 50.28 ± 20.87. Male patients had a higher QoL score than female patients (58.18 in males, compared to 48.18 in females; P = 0.04). A significant association between frequency of dialysis and quality of life was observed, where three sessions of dialysis per day yielded the highest quality of life (QoL score = 59.62; P = 0.047). A significant positive correlation was discovered between QoL score and residual renal function (P = 0.013). In addition, a higher QoL score was observed in self-employed patients (60.95), compared to housewives (46.49) (P = 0.001). QoL assessment should be included as an integral part of patient follow-up to evaluate treatment outcomes and implement possible interventions to improve patient’s quality of life.

Association of Anemia with Parathyroid Hormone Levels and Other Factors in Patients with End-Stage Renal Disease Undergoing Hemodialysis: A Cross-Sectional, Real-World Data Study in Pakistan.

End-stage renal disease (ESRD) patients are mostly managed with maintenance hemodialysis (MHD). ESRD patients on MHD also present with many complications, such as anemia, hyperparathyroidism, and hepatitis prevalence. This study depicts the real-world scenario of anemia among MHD and end-stage renal disease patients in the Pakistani population. A retrospective, multicentric, and real-world data analytical study was conducted at 4 dialysis centers in Pakistan. The study had a sample size of n = 342 patients on maintenance hemodialysis. The data were gathered from the medical records of patients. Data analysis was performed using STATA Version 16. Statistical significance was gauged at a 0.05 level of significance. According to our results, the mean age of the patients was 45 (±15) years. Most of the patients were male (n = 234, 68.4%), whereas 58.1% of the patients were maintained on twice-weekly hemodialysis. The most commonly reported comorbidities were hypertension and diabetes mellitus. The frequency of dialysis (P < 0.01) and comorbidities (P = 0.009) had a significant association with anemia in MHD patients. The majority of the patients had hyperparathyroidism (52%) with anemia. Upon performing binary logistic regression, multivariate analysis displayed a similar odds value for having anemia in patients with every additional month in the duration of hemodialysis (OR 1.01, P = 0.001), the odds of anemic patients having a positive antihepatitis-C antibody (OR 2.22, P = 0.013), and the odds of having anemia in patients in the age category below 45 years (OR 1.93, P = 0.013). In conclusion, the study results depict that every additional month in the duration of hemodialysis, age (<45 years), and positive anti-HCV antibody status, these variables were more likely to have anemia in our study MHD patients. While in our final multivariate model, no statistically significant association was observed between hyperparathyroidism and anemia.

Avantages cliniques de l’hémodialyse à domicile et les obstacles à son développement: Clinical benefits of home hemodialysis and barriers to its development

In 2023, home hemodialysis (HHD) is a dialysis modality used safely and performed independently at home by patients with chronic kidney disease (CKD). HHD requires adequate training and appropriate installation which includes the management of medical devices and consumables in the environment of each patient. According to each patient, HHD can be performed daily, every other day or overnight (nocturnal). The duration of the session varies from a few hours (less than three) during the day to several hours (six to ten) during the night. Over the past 10 years, we have been part of a revival in HHD with the availability of small machines better suited to homes and patients. Few controlled interventional studies and extensive registry data support the hypothesis that increase of frequency and duration of dialysis is associated with improved patient survival, cardiovascular risk profile, and quality of life. In addition to the physiological benefits of HDD, there are clear quality of life, social and economic benefits. There are, however, some disadvantages of HHD, including the application and time required for training, the risk of burnout, and the reluctance to "hospitalize" at home. Overall, these limits can be anticipated and overcome by appropriate training, multidisciplinary monitoring, and a dedicated organization. This review recalls the main clinical advantages of HDD related to both physiology and lifestyle as well as the main obstacles and proposes perspectives to guarantee its development. © 2022 Société francophone de néphrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.

Variability of toe pressures during haemodialysis: comparison of people with and without diabetes; a pilot study

BackgroundDiabetes, end stage renal disease (ESRD), and peripheral arterial disease (PAD) are associated with a higher risk of diabetes-related lower limb amputation. Timely identification of PAD with toe systolic blood pressure (TSBP) and toe-brachial pressure index (TBPI) is critical in order to implement foot protection strategies to prevent foot complications in people with ESRD. There is limited evidence describing the effect of haemodialysis on TSBP and TBPI. This study aimed to determine the variability of TSBP and TBPI during haemodialysis in people with ESRD, and to determine whether any observed variability differed between people with and without diabetes.MethodsTSBP and TBPI were taken before dialysis (T1), one hour into dialysis (T2) and in the last 15 min of dialysis (T3) during a single dialysis session. Linear mixed effects models were undertaken to determine the variability in TSBP and TBPI across the three time points and to determine whether this variability differed between people with and without diabetes.ResultsThirty participants were recruited, including 17 (57%) with diabetes and 13 (43%) with no diabetes. A significant overall reduction in TSBP was observed across all participants (P < 0.001). There was a significant reduction in TSBP between T1 and T2 (P < 0.001) and between T1 and T3 (P < 0.001). There was no significant overall change in TBPI over time (P = 0.62). There was no significant overall difference in TSBP between people with diabetes and people with no diabetes (mean difference [95% CI]: -9.28 [-40.20, 21.64], P = 0.54). There was no significant overall difference in TBPI between people with diabetes and people with no diabetes (mean difference [95% CI]: -0.01 [-0.17, 03.16], P = 0.91).ConclusionTSBP and TBPI are an essential part of vascular assessment of the lower limb. TBPI remained stable and TSBP significantly reduced during dialysis. Given the frequency and duration of dialysis, clinicians taking toe pressures to screen for PAD should be aware of this reduction and consider how this may have an impact on wound healing capacity and the development of foot related complications.

A case of tumoral calcinosis in hemodialysis

Dear Editor, Tumoral calcinosis is a rare syndrome which presents as painless, firm, tumor-like masses around the joints leading to pain, and limitation of joint movements. Commonly affected joints are shoulders, elbows, and hip joints. Spinal, temporomandibular joint, metacarpals, and metatarsal involvement have also been described. A 50-year-old female on twice weekly maintenance hemodialysis for the last 3 years presented with complaints of pain and restriction of movements at right hip joint and knee. On examination, range of movements was restricted at the hip joint. On palpation, there were subcutaneous hard nodules in the right hip region. Plain radiographic images of the pelvis were obtained and they showed irregular periarticular masses [Figure 1a]. Plain radiographs of hand, skull, and shoulder joins showed similar lesions [refer to adjoining Figure 1b-d]. On metabolic work, she had parathyroid hormone level of 162 pg/mL, phosphorus of 8.5 mg/dL, calcium of 9.8 mg/dL, albumin of 3.5 g/dL, and Vitamin D level of 29 ng/mL. She was poorly compliant with dietary restrictions and taking phosphate-binding medications. Diagnosis of secondary tumoral calcinosis was made. The patient was managed with phosphate-restricted diet, phosphate-binding medication, and increasing the dialysis frequency from twice weekly to thrice weekly.Figure 1: X-ray images showing (a) irregular peri articular masses around the hip joint. Similar findings were seen in X-ray images of (b) hand (c) skull and (d) shoulder joints as wellTeutschlaender initially described this disease in his studies in 1930’s and it came to be known as Teutschlaender disease.[1] The term tumoral calcinosis was coined by Inclan in 1943.[2] Smack et al. retrospectively studied 122 cases of tumoral calcinosis and proposed a classification system.[3] They classified it as (1) primary normophosphatemic type, (2) primary hyperphosphatemic type, and (3) secondary tumoral calcinosis. Secondary causes include renal insufficiency, hyperparathyroidism, or hypervitaminosis D, with renal insufficiency being the most common identifiable condition. Even though soft-tissue calcifications are common in hemodialysis patients, the prevalence of periarticular masses is low. Most of cases in chronic kidney disease are thought to occur due to the presence of hyperparathyroidism although it may occur in its absence as well. The calcification process results from elevated calcium–phosphorus product with hyperphosphatemia being the most important component. Diagnosis is based on characteristic imaging findings. Imaging typically shows amorphous, cystic, and multi-lobulated deposits in periarticular areas.[4] Computed tomography may show cystic loculi with fluid levels giving rise to sedimentation signs. Treatment of secondary tumoral calcinosis in the setting of renal failure is predominantly medical therapy. Calcium- and phosphate-restricted diets and phosphate binders are used as first-line management. Intravenous pamidronate is also shown to be effective.[5] Partial or total parathyroidectomy can be considered in refractory cases in case hyperparathyroidism is the cause.[6] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Multifactorial analysis of renal anemia-associated substandard hemoglobin levels and prevalence of anemia in patients on maintenance hemodialysis in Liaoning Province: a cross-sectional study

In hemodialysis (HD) patients, anemia is greatly improved due to regular weekly use of iron and erythropoietin (EPO), but a large number of patients still show persistent anemia. We do a survey to elucidate the influencing factors that contribute to the failure of hemoglobin (Hb) to meet the standard and provide epidemiological data reference for promoting the recognition of renal anemia and improving the treatment effect of renal anemia. The clinical data of End-Stage Renal Disease (ESRD) HD patients in 22 tertiary hospital HD centers in Liaoning Province from September 2021 to June 2022 were collected by convenient sampling. According to the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) anemia diagnostic criteria. The standard of Hb compliance: Hb ≥110 g/L is considered as Hb compliant, and Hb <110 g/L as Hb non-compliant. The factors influencing Hb up-to-standard in ESRD HD patients and their correlations were analyzed by comparison between the two groups. The results of this study showed that among the 1,652 ESRD patients investigated in Liaoning Province, the prevalence rate of anemia was 89.29% (1,475/1,652), and the Hb compliance rate was 46.25% (764/1,652). The Hb compliance rate in maintenance hemodialysis (MHD) patients with different primary diseases was statistically significant (P<0.05). Compared with the Hb non-standard group, the gender, dialysis access, HD frequency, concurrent infection, primary disease of ESRD patients, red blood cell (RBC) count, hematocrit (HCT), mean RBC Hb concentration, mean RBC Hb content, platelet (PLT), albumin (ALB), total protein (TP), serum creatinine (Cr), serum calcium (Ca), serum potassium (K), ferritin (Fer), serum iron (SI), and transferrin (TRE) saturation were significantly different between both groups (P<0.05). Adrenaline was an independent risk factor affecting Hb failure in ESRD patients (OR =1.001, 95% CI: 1.000-1.002); dialysis frequency (OR =0.726, 95% CI: 0.601-0.878), ALB (OR =0.959, 95% CI: 0.929-0.990), TP (OR =0.982, 95% CI: 0.968-0.996), serum Cr (OR =0.959, 95% CI: 0.929-0.999), and SI (OR =0.961, 95% CI: 0.940-0.982) were protective factors affecting Hb failure in ESRD patients (P<0.05). Pearson correlation analysis showed that ALB, TP, serum Cr, serum Ca, serum K, SI, and TRE saturation were positively correlated with Hb (P<0.05). The anemia rate of ESRD patients treated with MHD in Liaoning Province is high. Based on the results, increasing the frequency of dialysis can improve anemia. Parathyroid hormone levels need to be controlled.

Identification of Effective Factors on the Survival of Hemodialysis Patients Using the LASSO-Cox Approach

Background: Hemodialysis is a method for removing excess fluid and uremic waste from the body of chronic renal failure (CRF) patients. It stops death in patients with CRF. Various factors can affect the survival of patients undergoing hemodialysis treatment. The current study aimed to determine some factors affecting hemodialysis patients’ survival using the LASSO-Cox approach. Methods: This cross-sectional study examined 252 patients undergoing hemodialysis from 2010 to 2016 in all hospitals of Bandar Abbas, Iran, whose data had been recorded in the hemodialysis unit, or it was possible to obtain their files. The Cox model under the LASSO variable selection technique (LASSO-Cox) was applied for data analysis. The collected data were analyzed using SPSS 23.0 (IBM) software and glmnet and survival packages in R software, version 3.5.1. Results: Overall, 35 (13.9%) death events were observed in this study. The mean follow-up time of 252 patients was equal to 10.93±7.82 years. Based on the results of the Cox-Lasso method, the risk of mortality for patients with a diploma was 49% lower than that of the illiterate group (HR=0.51; 95% CI: 0.02, 0.57; P=0.021). The risk of death for unemployed patients and farmers was 0.66 (HR=1.66; 95% CI: 1.51, 25.79; P=0.004) and 0.29 (HR=1.29; 95% CI: 1.14, 27.40; P=0.005) higher than that of employees, respectively. Further, by an increase in the frequency of dialysis per week, the risk of death was reduced by 0.34 (HR=0.66; 95% CI: 0.04, 0.82; P=0.022), and one unit increase in the duration of dialysis per hour increased the risk of death by 2.23 times (HR=2.23; 95% CI: 1.41, 27.1; P=0.010). Conclusion: Education level, job, frequency of hemodialysis per week, and duration of hemodialysis per hour were the most important variables in the survival of hemodialysis patients. As a result, it seems that more education for nurses working in hemodialysis wards and the involved patients can be useful to heed the recommendations of physicians in terms of the required duration for hemodialysis per hour and the number of sessions per week.

Study to assess role of homeopathy in management of CKD

Background: The incidence of Chronic Kidney Disease (CKD) is rising every single day and is presently, a global threat to mankind. Worldwide incidence is appx 1.8 million/ year, which has been doubled in the last 15 years. In India alone approximately 100 million people are already suffering from CKD. The options available with Modern Medicine are just dialysis and transplant with poor outcomes and high cost. There is not even a single pill, worldwide, in Modern Medicine, which can reduce Creatinine or Urea by even a percent. On the other hand, Homeopathy offers complete treatment for patients of CKD, for all stages.ObjectivesTo establish homeopathy as being foremost for prevention of CKD.To establish Homeopathy, not only as the safest and most effective treatment for CKD but also as first line of treatment, worldwide.To establish Homeopathy as safe, cheap and most effective alternate of Dialysis and Transplant.Establish greater role of Homeopathy in National Health Policy.Method: Randomized controlled single blind drug evaluation method was used .Only previously diagnosed cases of CKD were selected. The inclusion criteria for the study was Serum Creatinine (>1.5), Blood Urea (>40), BUN (>14) and estimated GFR (≤90).Result: A total of 1121 patients contacted the centre (NIH) for CRF. Out of them 783 patients were available for proper follow-up. 450 (57.47%) cases were improving while 185 (23.60 %) maintained status quo and 148 (18.93%) did not show any improvement.Conclusion: Homeopathic drugs were found extremely effective in enhancing the efficiency of kidney. There was marked reduction in the level of S. Creatinine and in some cases not only it reduced significantly, but also its level came down in some cases and continued to be normal. Therefore Homeopathy can be established as an alternate to prevent or reduce the frequency of Dialysis and can help to postpone Renal Transplant.

Assessment of factors associated with the refusal of recommended thricea weekdialysis in CKD patients: Reality Vs.Recommendations

In developing countries like Pakistan, it is observed that the patients who are on dialysis do not follow the prescribed frequency of dialysis which has increased the morbidity, mortality, and burden on nephrology emergencies. To identify the most common factors associated with the refusal of recommended thrice-a-week dialysis. This observational study was carried out between June 1 and August 14, 2022, in the Department of Nephrology and Hemodialysis at the Services Hospital Lahore. The WHO calculator (version 1.1) was used to determine the sample size of 137. The patients in this study comprised those on maintenance twice-weekly hemodialysis who were anuric and advised for thrice-weekly dialysis but declined it. The senior faculty of the nephrology unit created a form with demographic information and a questionnaire to evaluate the likely reasons. The reason was categorized into three categories including socioeconomic psychology and healthcare-related factors. Using the program SPSS, the data was examined (V. 25). Mean and median were used to describe quantitative factors, and frequency or percentage were used to convey qualitative data. Based on the inclusion criteria, a total of 137 people were included in this study. 62% of the sample in our study were men. Our cohort's median age was 49.54 ± 9.50 years. 52% of the participants were in the 36 to 55 age range. 68 % of the patients who declined three times weekly dialysis were married. Only 28% of patients had higher education, while only 46% had a high school diploma and 19% had none at all. 71% of the people in our research were employed, yet the majority made less than twenty thousand PKR per month. Among the healthcare-related factors, the most common factor was the unavailability of dialysis centres (66.2%). From the results of the study, we can conclude that the lack of education and support from the organization they work for, increase responsibilities after married, low socioeconomic status and inadequate healthcare facilities are the major hurdle in compliance for advised thrice a week dialysis. These factors along with the nature of disease cause many psychological problems that further worsen the situation.

The occurrence and influencing factors of fatigue and sleep disturbance in maintenance hemodialysis patients

Objective: To investigate the occurrence and influencing factors of fatigue and sleep disturbance in Maintenance Hemodialysis (MHD) patients. Methods: A total of 170 patients with end-stage renal disease who underwent MHD treatment in the hemodialysis room of Shaanxi Provincial Hospital of Traditional Chinese Medicine from October 2021 to March 2022 were selected as the research subjects. The basic information and laboratory indicators of the patients were collected by cross-sectional survey. The survey methods were evaluated by the revised Piper Fatigue Scale and the Pittsburgh Sleep Quality Rating Scale and the incidence and influencing factors of fatigue and sleep disturbance in MHD patients were analyzed. Results: Fatigue occurred in 135 cases, the incidence rate was 79.41%; sleep disturbance occurred in 124 cases and the incidence rate was 72.94%. After one-way analysis of variance, factors such as exercise, Albumin (ALB, serum Creatinine(CRE), Phosphorus(P) and Hemoglobin(HGB) in MHD patients can affect fatigue; while age, gender, exercise, primary disease, dialysis frequency, Phosphorus(P), Hemoglobin(HGB) and high-sensitivity C-Reactive Protein (hs-CRP) factors can affect sleep. A multiple linear regression model was constructed for the factors affecting fatigue (F = 81.110, p &lt; 0.001), and it showed that 70.3% of fatigue (adjusted R2 = 0.703) was related to albumin (ALB), serum creatinine(CRE), and hemoglobin(HGB) (all p &lt; 0.05); A multiple linear regression model was constructed based on the factors of 58% (F = 26.933, p &lt; 0.001), which showed that 58% of sleep disorders (adjusted R2 = 0.580) were significantly related to age, gender, exercise or not, phosphorus(P), high-sensitivity C-reactive protein(hs-CRP) (all p &lt; 0.05) related. Pearson correlation analysis was used to analyze sleep disturbance and fatigue in MHD patients and the results showed that there was a positive correlation between the two (r = 0.478, p &lt; 0.001). Conclusion: The proportion of fatigue and sleep disturbance in MHD patients is relatively high, mainly mild to moderate and the two influence each other. Exercise intervention and nutritional support can effectively improve the occurrence of fatigue and sleep disturbance in MHD patients.

Armed conflicts and kidney patients: a consensus statement from the Renal Disaster Relief Task Force of the ERA.

During conflicts, people with kidney disease, either those remaining in the affected zones or those who are displaced, may be exposed to additional threats because of medical and logistical challenges. Acute kidney injury developing on the battlefield, in field hospitals or in higher-level hospital settings is characterized by poor outcomes. People with chronic kidney disease may experience treatment interruptions, contributing to worsening kidney function. Patients living on dialysis or with a functioning graft may experience limitations of dialysis possibilities or availability of immunosuppressive medications, increasing the risk of severe complications including death. When patients must flee, these threats are compounded by unhealthy and insecure conditions both during displacement and/or at their destination. Measures to attenuate these risks may only be partially effective. Local preparedness for overall and medical/kidney-related disaster response is essential. Due to limitations in supply, adjustments in dialysis frequency or dose, switching between hemodialysis and peritoneal dialysis and changes in immunosuppressive regimens may be required. Telemedicine (if possible) may be useful to support inexperienced local physicians in managing medical and logistical challenges. Limited treatment possibilities during warfare may necessitate referral of patients to distant higher-level hospitals, once urgent care has been initiated. Preparation for disasters should occur ahead of time. Inclusion of disaster nephrology in medical and nursing curricula and training of patients, families and others on self-care and medical practice in austere settings may enhance awareness and preparedness, support best practices adapted to the demanding circumstances and prepare non-professionals to lend support.