Healthcare Epidemiology Research Articles

807. Same-day Transmission Analysis of Nosocomial Transmission Using Nanopore Whole Genome Sequencing

Abstract Background Healthcare associated infections (HAIs) are a major contributor to patient morbidity and mortality worldwide. HAIs are increasingly important due to the rise of multidrug resistant pathogens which can lead to deadly nosocomial outbreaks. Current methods for investigating transmissions are slow, costly, or have poor detection resolution. A rapid, cost-effective and high-resolution method to identify transmission events is imperative to guide infection control. Whole genome sequencing of infecting pathogens paired with a single nucleotide polymorphism (SNP) analysis can provide high-resolution clonality determination, yet these methods typically have long turnaround times. Here we examined the utility of the Oxford Nanopore Technologies (ONT) platform, a rapid sequencing technology, for whole genome sequencing based transmission analysis. Methods We developed a SNP calling pipeline customized for ONT data, which exhibit higher sequencing error rates and can therefore be challenging for transmission analysis. The pipeline leverages the latest basecalling tools as well as a suite of custom variant calling and filtering algorithms to achieve highest accuracy in clonality calls compared to Illumina-based sequencing. We also capitalize on ONT long reads by assembling outbreak-specific genomes in order to overcome the need for an external reference genome. Results We examined 20 bacterial isolates from 5 HAI investigations previously performed at Day Zero Diagnostics as part of epiXact®, our commercialized Illumina-based HAI sequencing and analysis service. Using the ONT data and pipeline, we achieved greater than 90% SNP-calling sensitivity and precision, allowing 100% accuracy of clonality classification compared to Illumina-based results across common HAI species. We demonstrate the validity and increased resolution of our SNP analysis pipeline using assembled genomes from each outbreak. We also demonstrate that this ONT-based workflow can produce isolate to transmission determination (i.e. including WGS and analysis) in less than 24 hours. SNP calling performance ONT-based SNP calling sensitivity and precision compared to Illumina-based pipeline Conclusion We demonstrate the utility of ONT for HAI investigation, establishing the potential to transform healthcare epidemiology with same-day high-resolution transmission determination. Disclosures Mohamad Sater, PhD, Day Zero Diagnostics (Employee, Shareholder) Remy Schwab, MSc, Day Zero Diagnostics (Employee, Shareholder) Ian Herriott, BS, Day Zero Diagnostics (Employee, Shareholder) Tim Farrell, MS, Day Zero Diagnostics, Inc. (Employee, Shareholder) Miriam Huntley, PhD, Day Zero Diagnostics (Employee, Shareholder)

Adapting and thriving, the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA) partnership

Adapting and thriving, the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA) partnership

Epidemiology, etiology, and diagnosis of health care acquired pneumonia including ventilator-associated pneumonia in Nepal.

Epidemiologic data regarding health care acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) from Nepal are negligible. We conducted a prospective observational cohort study in the intensive care unit (ICU) of a major tertiary hospital in Nepal between April 2016 and March 2018, to calculate the incidence of VAP, and to describe clinical variables, microbiological etiology, and outcomes. Four hundred and thirty-eight patients were enrolled in the study. Demographic data, medical history, antimicrobial administration record, chest X-ray, biochemical, microbiological and haematological results, acute physiology and chronic health evaluation II score and the sequential organ failure assessment scores were recorded. Categorical variables were expressed as count and percentage and analyzed using the Fisher's exact test. Continuous variables were expressed as median and interquartile range and analyzed using Kruskal-Wallis rank sum test and the pairwise Wilcoxon rank-sum test. 46.8% (205/438) of the patients required intubation. Pneumonia was common in both intubated (94.14%; 193/205) and non-intubated (52.36%; 122/233) patients. Pneumonia developed among intubated patients in the ICU had longer days of stay in the ICU (median of 10, IQR 5-15, P< 0.001) when compared to non-intubated patients with pneumonia (median of 4, IQR 3-6, P< 0.001). The incidence rate of VAP was 20% (41/205) and incidence density was 16.45 cases per 1,000ventilator days. Mortality was significantly higher in patients with pneumonia requiring intubation (44.6%, 86/193) than patients with pneumonia not requiring intubation (10.7%, 13/122, p<0.001, Fisher's exact test). Gram negative bacteria such as Klebsiella and Acinetobacter species were the dominant organisms from both VAP and non-VAP categories. Multi-drug resistance was highly prevalent in bacterial isolates associated with VAP (90%; 99/110) and non-VAP categories (81.5%; 106/130). HAP including VAP remains to be the most prevalent hospital-acquired infections (HAIs) at Patan hospital. A local study of etiological agents and outcomes of HAP and VAP are required for setting more appropriate guidelines for management of such diseases.

Antibiotic Therapies for Clostridioides difficile Infection in Children.

While rates of Clostridioides difficile infection (CDI) are increasing among children in the United States, studies assessing CDI treatment in children are severely lacking. Thus, treatment guidelines have historically relied on evidence from limited observational data in children and randomized controlled trials (RCTs) conducted in adults to form recommendations. Currently, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) recommend metronidazole and/or vancomycin for pediatric CDI depending on disease severity. Recently however, the first and only RCT of CDI treatment in children demonstrated fidaxomicin to be non-inferior to vancomycin, proving its safety and efficacy in this population. Additionally, observational data published since the IDSA/SHEA guidelines were released suggest metronidazole has lower rates of clinical improvement when compared to vancomycin in hospitalized children with non-severe CDI. Given these recent publications, fidaxomicin and vancomycin, instead of metronidazole, appear to be more appropriate, evidence-based options for the treatment of CDI in children.

Role of a Pharmacist in AST Activity and Pharmaceutical Education in a Mid-sized Japanese Community Hospital

At small or mid-sized medical institutions, such as Japanese community hospitals, adequate infectious disease physicians (IDP) are lacking, mainly due to shortages of full-time pharmacists and IDPs who support antimicrobial stewardship team (AST) activities. With our hospital AST, we developed a multidisciplinary approach based on the interim reports of culture results or detected resistant bacteria for physicians, which are written by pharmacists and clinical laboratory technicians. At the AST conference, a pharmacist works as a chairman and reviews abstracts of cases which need to be discussed. We performed a retrospective analysis of the process and outcome of AST implementation, and introduced the use of reduction data for our hospital, obtained from Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE). This program is important for pharmacists to promote the diagnostic process and comprehensive judgment necessary for bedside practice with infectious disease cases. We offer opportunities for pharmacy students to participate in the AST conference to learn how pharmacists consult with doctors about diagnosis and treatment. At present, the cooperation between AS and diagnostic stewardship (DS) has been emphasized, and improvements in a pharmacist's overall judgment regarding infectious disease cases are required to appropriate antimicrobial use. In addition, improving communication skills is essential for building a multidisciplinary approach. Regardless of the size of the facility, the role of pharmacists in AST should be implemented for the guidance of pharmacy students, which will help develop and secure future human resources at the facility.

Community-acquired pneumonia: is less more?

Community-acquired pneumonia is a topic of maximum interest because it remains a leading cause of morbidity and mortality due to an infection. 1 Metlay JP Waterer GW Long AC et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200: e45-e67 Crossref PubMed Scopus (870) Google Scholar At the same time, antimicrobial resistance and antimicrobial stewardship programmes are essential issues surrounding community-acquired pneumonia. 2 Viasus D Vecino-Moreno M De La Hoz JM Carratalà J Antibiotic stewardship in community-acquired pneumonia. Expert Rev Anti Infect Ther. 2017; 15: 351-359 Crossref PubMed Scopus (15) Google Scholar , 3 Barlam TF Cosgrove SE Abbo LM et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016; 62: e51-e77 Crossref PubMed Scopus (1273) Google Scholar , 4 Postma DF van Werkhoven CH van Elden LJ et al. Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med. 2015; 372: 1312-1323 Crossref PubMed Scopus (238) Google Scholar Narrow-spectrum antibiotics for community-acquired pneumonia in Dutch adults (CAP-PACT): a cross-sectional, stepped-wedge, cluster-randomised, non-inferiority, antimicrobial stewardship intervention trialIn patients hospitalised with moderately severe community-acquired pneumonia, a multifaceted antibiotic stewardship intervention might safely reduce broad-spectrum antibiotic use. Full-Text PDF

Cutting edges in Clostridioides difficile infections.

Clostridioides difficile is the most common cause of hospital-acquired diarrhoea and one of the most important causes of hospital-acquired infections. It results in significant morbidity, mortality and economic burden - especially in the context of recurrent infections. After initial antibiotic therapy of a C. difficile infection, recurrence occurs in about 20% of all patients, which increases the risk of further recurrence to about 45%. Traditional therapeutic options for treatment of C. difficile infection include metronidazole or vancomycin. Newer therapy options such as fidaxomicin, the administration of monoclonal antibodies or faecal microbiota transplantation demonstrate significant advantages over traditional therapies, particularly regarding the reduction of the recurrence rate. This article highlights the main differences between the recommendations of the Swiss Society for Infectious Diseases on the management of "Clostridioides difficile infection" and the IDSA/SHEA reference guideline "Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)" and discusses some important challenges in -treatment of C. difficile.

Prevention practices for nonventilator hospital-acquired pneumonia: A survey of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN).

Prevention practices for nonventilator hospital-acquired pneumonia: A survey of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN).

Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults.

This clinical practice guideline is a focused update on management of Clostridioides difficile infection (CDI) in adults specifically addressing the use of fidaxomicin and bezlotoxumab for the treatment of CDI. This guideline was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). This guideline is intended for use by healthcare professionals who care for adults with CDI, including specialists in infectious diseases, gastroenterologists, hospitalists, pharmacists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the management CDI are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the management of CDI in adults. The panel followed a systematic process which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development, and Evaluation). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Surveillance practices and air-sampling strategies to address healthcare-associated invasive mold infections in Society for Healthcare Epidemiology of America (SHEA) Research Network hospitals-United States, 2020.

With this survey, we investigated healthcare-associated invasive mold infection (HA-IMI) surveillance and air sampling practices in US acute-care hospitals. More than half of surveyed facilities performed HA-IMI surveillance and air sampling. HA-IMI surveillance was more commonly performed in academic versus nonacademic facilities. HA-IMI case definitions and sampling strategies varied widely among respondents.

Multisociety statement on coronavirus disease 2019 (COVID-19) vaccination as a condition of employment for healthcare personnel.

This consensus statement by the Society for Healthcare Epidemiology of America (SHEA) and the Society for Post-Acute and Long-Term Care Medicine (AMDA), the Association for Professionals in Epidemiology and Infection Control (APIC), the HIV Medicine Association (HIVMA), the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Diseases Society (PIDS), and the Society of Infectious Diseases Pharmacists (SIDP) recommends that coronavirus disease 2019 (COVID-19) vaccination should be a condition of employment for all healthcare personnel in facilities in the United States. Exemptions from this policy apply to those with medical contraindications to all COVID-19 vaccines available in the United States and other exemptions as specified by federal or state law. The consensus statement also supports COVID-19 vaccination of nonemployees functioning at a healthcare facility (eg, students, contract workers, volunteers, etc).

Updated Guidelines for Managing

Sponsoring Organization: Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology (SHEA)Target Audience: Infectious

Recent advances in Clostridioides difficile infection epidemiology, diagnosis and treatment in children.

The US Centers for Disease Control and Prevention (CDC) classified Clostridioides difficile as an 'urgent' public health threat that requires 'urgent and aggressive action'. This call to action has led to new discoveries that have advanced C. difficile infection (CDI) epidemiology, diagnosis and treatment, albeit predominantly in adults. In 2017, the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America published clinical practice guidelines for both adults and children. At that time, recommendations in children were generally limited to relatively low-quality evidence. Since publication of this guidance, there have been many advancements in the understanding of CDI in children. These include better understanding of healthcare settings as uncommon sources of C. difficile acquisition in children; risk factors for recurrent and community-associated CDI; performance of diagnostic tests in children and strategies for optimizing their use; and a more rigorous evidence base for CDI treatment in children, including the first-ever randomized controlled trial of CDI treatment in children and the largest study of fecal microbiota transplantation in children. This review highlights the most recent salient advancements in paediatric CDI knowledge and practice that supplement published clinical guidance provided prior to these advancements.

Protective Environment for Hematopoietic Cell Transplant (HSCT) Recipients: The Infectious Diseases Working Party EBMT Analysis of Global Recommendations on Health-Care Facilities

▪BACKGROUND: An international global perspective for guidelines for health-care facilities in which HSCT recipients are treated was announced in 2009 by Center for International Blood & Marrow Transplant Research, National Marrow Donor Program, European Society for Blood and Marrow Transplantation (EBMT), American Society for Blood and Marrow Transplantation, Canadian Blood and Marrow Transplant Group, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, Association of Medical Microbiology and Infectious Disease, and Centers for Disease Control. With respect to guidelines on hospital room design and ventilation for HSCT setting, a set of 10 recommendations were presented (Tomblyn et al, 2009).OBJECTIVE: Since the issue is clearly of practical importance to world-wide transplant community, the IDWP-EBMT created a survey in order to present the current status on protective environment for recipients of HSCT, and to analyze the trends and needs in hospital transplant room design and ventilation.METHODS: The questionnaire consisted of 37 questions in all and was divided into 6 sections that included the contact information and details of the protective isolation facility including air filtration, air changes, maintenance, combination of isolation, protective environment room/unit and floor.RESULTS: In all, 177 centres from 36 countries responded to the survey, with average 33% country response rate. Physicians completed 62%, nurses 19% and support staff 19% of the surveys. A total number of 71% of answers were provided to all questions. The total number of unanswered questions was lowest among physicians (23% vs 49%; p<0.001). (A) Among all HSCT centers, in 99.4% patient rooms are equipped with HEPA filters, with central or point-in-use room system in 45.8% and 48%, respectively. The use of HEPA filters with 99.97% efficiency for removing particles ≤0.3µm in diameter, and room ventilation with the rate of at least 12 air changes per hour were confirmed by 70.1% and 71.2% of centers, respectively. Only 29.4% center staff were aware of and could confirm regular replacement of filters based on manufacturers' recommendations, while 53.7% centers have a written procedure for regular filter maintenance and removal and to monitor filtration efficiency in order to best determine appropriate time for replacement, especially in case of ongoing construction. (B) In 59.3% centers, the airflow is directed so that air intake occurs at one side of the room while the air exhaust occurs at the opposite side. Consistent positive air pressure differential between the patient's room and the hallway ≥2.5 Pa (i.e., 0.01 inches by water gauge) was reported by 38.4% centers having a permanently installed device/mechanism to constantly monitor the differential air pressure between the room and the corridor, while the pressure in the anteroom is positive in 19.2% centers, and an air pressure monitoring device/mechanism in the anteroom in addition to the patient room is present in 17.5% of centers. Well-sealed rooms are used in order to prevent infiltration of air from outside the room that could allow entry of spores and hinder maintenance of proper pressure differential, with respect to: windows (in 70.6%), monolithic ceilings (in 35%), and all plumbing pipes in the room (in 51.4% of centers). In order to guarantee the continuous positive pressure, a monitoring system that will set off an alarm when the pressure differential between any protective environment room and adjacent hallway or anteroom falls to less than 2.5 Pa to alert staff to possible engineering failures is installed in 33.9% of centers, and self-closing doors to maintain constant pressure differentials are present in 37.3% of centers. (C) The sensor monitor in the patient room used to determine when the HEPA filters require changing is installed in 18.1% of centers. The nursing staff is able to observe the HSCT recipient by the windows that are installed in the door/wall of the HSCT recipient's room or by the monitoring system in 61.6% of centers.CONCLUSIONS: Knowledge about the maintenance of protective environments in the HSCT setting was inadequate, reflecting a lacking information between health personnel working in the ward and hospital offices. Only 6 centers were able to meet all 10 recommendations listed by Tomblyn et al and few centers were able to meet all the relevant technical requirements. DisclosuresNo relevant conflicts of interest to declare.

Assessing the healthcare epidemiology environment-A roadmap for SHEA's future.

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Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults

Abstract This clinical practice guideline is a focused update on management of Clostridioides difficile infection (CDI) in adults specifically addressing the use of fidaxomicin and bezlotoxumab for the treatment of CDI. This guideline was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). This guideline is intended for use by healthcare professionals who care for adults with CDI, including specialists in infectious diseases, gastroenterologists, hospitalists, pharmacists, and any clinicians and healthcare providers caring for these patients. The panel’s recommendations for the management CDI are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the management of CDI in adults. The panel followed a systematic process which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development, and Evaluation). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Epidemiology and Microbiological Profile of Common Healthcare Associated Infections among Patients in the Intensive Care Unit of a General Hospital in Kuwait: A Retrospective Observational Study

BackgroundPatients admitted to the Intensive Care Unit (ICU) are prone to develop nosocomial infections due to Multidrug-Resistant (MDR) organisms. Inappropriate and overuse of antibiotics play an important role in the emergence of MDR organisms, which cause life-threatening infections resulting in significant morbidity and mortality.MethodsRetrospective surveillance-based study on healthcare-associated infections. The study conducted over two consecutive years 2018 and 2019, looking at ICU related infections of a regional secondary care general hospital and the data were recorded using the methods and definitions of the Kuwait National Healthcare-associated infections Surveillance System (KNHSS).ResultsA total of 1408 patients, admitted to ICU for 7922 days during the 2 years period. Eighty-nine patients were included in this study, where 48 developed one Hospital-acquired Infections (HAI) in the ICU while 25 and two patients presented with two and three HAIs, respectively. The HAIs included Bloodstream Infections (BSI) — 42.3%, pneumonia — 28.8%, Urinary Tract Infections (UTI) — 15.3%, skin and soft tissue infections — 9.6% and Clostridium difficile infection — 3.4%. The overall infection rate was 13.14 per 1000 patient-days. The rates for Device-associated (DA)-HAIs were 6.27 for Central Line-associated BSI (CLABSI) per 1000 Central Line (CL)-days, 4.21 for Ventilator-associated Pneumonia (VAP) per 1000 Mechanical Ventilator (MV)-days, and 1.91 Catheter-associated UTI (CAUTI) per 1000 Urinary Catheter (UC)-days. Data showed that device use ratios for CL, MV, and UC were 0.81, 0.74, and 0.98, respectively. Acinetobacter baumannii and Klebsiella pneumoniae were the most common organisms isolated from the ICU infections with highest rates of antibiotic resistance.ConclusionAmong DA-HAIs CLABSI was found to be most common in our ICU, followed by VAP and CAUTI. Gram-negative organisms with A. baumannii and K. pneumoniae being the leading causative agents with high antimicrobial resistance profiles.

Modeling transmission of pathogens in healthcare settings.

Mathematical, statistical, and computational models provide insight into the transmission mechanisms and optimal control of healthcare-associated infections. To contextualize recent findings, we offer a summative review of recent literature focused on modeling transmission of pathogens in healthcare settings. The COVID-19 pandemic has led to a dramatic shift in the modeling landscape as the healthcare community has raced to characterize the transmission dynamics of SARS-CoV-2 and develop effective interventions. Inequities in COVID-19 outcomes have inspired new efforts to quantify how structural bias impacts both health outcomes and model parameterization. Meanwhile, developments in the modeling of methicillin-resistant Staphylococcus aureus, Clostridioides difficile, and other nosocomial infections continue to advance. Machine learning continues to be applied in novel ways, and genomic data is being increasingly incorporated into modeling efforts. As the type and amount of data continues to grow, mathematical, statistical, and computational modeling will play an increasing role in healthcare epidemiology. Gaps remain in producing models that are generalizable to a variety of time periods, geographic locations, and populations. However, with effective communication of findings and interdisciplinary collaboration, opportunities for implementing models for clinical decision-making and public health decision-making are bound to increase.

IL-16 and BCA-1 Serum Levels Are Associated with Disease Severity of C. difficile Infection.

Clostridioides difficile infection (CDI) is associated with a high risk for complications and death, which requires identifying severe patients and treating them accordingly. We examined the serum level of six cytokines and chemokines (IL-16, IL-21, IL-23, IL-33, BCA-1, TRAIL) and investigated the association between them and patients’ disease severity. Concentrations of six cytokines and chemokines were measured using the MILLIPLEX®MAP kit (Billerica, MA, USA) in serum samples attained from CDI patients within 24–48 h after laboratory confirmation of C. difficile presence. Demographic and clinical data were collected from medical records. The disease severity score was determined according to guidelines of the “Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America” (SHEA-IDSA). Out of 54 patients, 20 (37%) had mild to moderate disease and 34 (63%) had severe disease. IL-16 (p = 0.005) and BCA-1 (p = 0.012) were associated with a more severe disease. In conclusion, IL-16 and BCA-1, along with other cytokines and chemokines, may serve as biomarkers for the early prediction of CDI severity in the future. An improved and more accessible assessment of CDI severity will contribute to the adjustment of the medical treatment, which will lead to a better patient outcome.

Corrigendum to “Interdialytic Weight Gain Effects on Hemoglobin Concentration and Cardiovascular Events” [Kidney Int. Rep. 2020 1670–1678]

The authors regret that the published version of the above article contained a number of errors. The correct and final version follows. The authors would like to apologise for any inconvenience caused. DOI of original article: https://doi.org/10.1016/j.ekir.2020.07.027DOI of corrected article: 10.1016/j.ekir.2021.05.016 Correspondence: Yosuke Yamamoto, Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan. E-mail: [email protected] Interdialytic Weight Gain Effects on Hemoglobin Concentration and Cardiovascular EventsKidney International ReportsVol. 6Issue 7PreviewAlthough predialysis hemoglobin concentration is affected by interdialytic weight gain (IDWG), the interaction between these parameters is not well understood. Full-Text PDF Open AccessInterdialytic Weight Gain Effects on Hemoglobin Concentration and Cardiovascular EventsKidney International ReportsVol. 5Issue 10PreviewAlthough predialysis hemoglobin concentration is affected by interdialytic weight gain (IDWG), the interaction between these parameters is not well understood. Full-Text PDF Open Access