Hemodialysis Modalities Research Articles

Comparison of the effects of peritoneal dialysis and hemodialysis on spontaneous brain activity in CKD patients: an rs-fMRI study.

To compare the effects of peritoneal dialysis and hemodialysis on spontaneous brain activity in patients with end-stage renal disease. A total of 52 dialysis patients with end-stage renal disease, including 25 patients with chronic kidney disease undergoing hemodialysis (HD-CKD) and 27 patients with chronic kidney disease undergoing peritoneal dialysis (PD-CKD), and 49 healthy controls (normal control) were included. All participants underwent neuropsychological testing (Mini-Mental State Examination and Montreal cognitive assessment) and resting-state functional magnetic resonance imaging. Fractional amplitude of low frequency fluctuations and Regional Homogeneity algorithms were employed to evaluate spontaneous brain activity. Statistical analysis was performed to discern differences between the groups. When compared with the normal control group, the PD-CKD group exhibited significant alterations in fractional amplitude of low frequency fluctuations in various cerebellum regions and other brain areas, while the HD-CKD group showed decreased fractional amplitude of low frequency fluctuations in the bilateral pericalcarine cortex. The Regional Homogeneity values in the PD-CKD group were notably different than those in the normal control group, particularly in regions such as the bilateral caudate nucleus and the right putamen. Both peritoneal dialysis and hemodialysis modalities impact brain activity, but manifest differently in end-stage renal disease patients. Understanding these differences is crucial for optimizing patient care.

The effect of hemodiafiltration vs. high-flux hemodialysis on alpha 1-microglobulin level and dialysate albumin loss using a dialyzer surface area of 2.6 m²

Dialysis therapy has remarkably evolved through the innovation in dialyzers and hemodialysis modalities, enhancing patients’ quality of life. The efficacy of dialysis can be determined by measuring the reduction ratio (RR) of middle molecules, such as alpha 1-microglobulin (A1M). In this study, we tested a high-flux dialyzer, BIOPURE (Biorema) 260 HF, with a surface area (SA) of 2.6 m2, in terms of A1M removal and concurrent albumin loss in dialysate while receiving high-flux hemodialysis (HF-HD) and post-dilution online hemodiafiltration (OL-HDF). This crossover study comprised 25 patients who received a session of HF-HD using the BIOPURE (Biorema) 260 H, followed by a session of post-dilution OL-HDF. A washout period of 2 weeks was instilled between the two sessions, during which the patients received HF-HD using high-flux dialyzers (maximum SA 2.0 m2). All patients’ hourly dialysate albumin and pre/post dialysis concentrations of A1M were measured. The dialyzer used in this study resulted in significantly higher A1M RR of 41.9±7.93% with HDF than with HF-HD 27.12±7.65% (p<0.001), and a median cumulative dialysate albumin loss of 2.97g (IQR 1.98 – 3.37), and 0.67g (IQR 0.49 – 1.13) with HDF and HF-HD, respectively. In conclusion, the dialyzer BIOPURE (Biorema) 260 HF (SA 2.6 m2) is efficient in eliminating A1M, especially with OL-HDF compared to HF-HD, with acceptable albumin loss in the dialysate.

#3286 ENVIRONMENTAL PERFORMANCE OF HEMODIALYSIS THROUGH LIFECYCLE ASSESSMENT (LCA): IN-CENTRE HEMODIALYSIS VS HOME-HEMODIALYSIS

Abstract Background and Aims Despite being energy and resource-intensive, hemodialysis (HD) is the most common therapy for end stage kidney disease. Considering the extensive amount of energy, water, and consumables involved, this modality is expected to have a significant environmental impact. Through a comparative lifecycle assessment (LCA), this study aims to analyze the environmental impacts of hemodialysis in British Columbia, Canada. Method A process-based life cycle assessment was performed for three hemodialysis modalities: i) in-centre HD (ICHD), ii) home HD with NxStage machine (HHD-Nx), and iii) home HD with Baxter AK-98 machine (HHD-B). The scope of study included patient and staff commute, supply transportation, dialysis services, patient training for home hemodialysis, and waste management. The functional unit considered is HD energy and material consumption for one patient per year. Based on the patient's record, two prescriptions including standard (three dialysis sessions per week for 4 hours daily) and extended (six HD sessions per week for 8 hours daily) were considered. LCAs were performed using ISO 14040, 14041 standards in which ReCiPe (world) midpoint method and a cut-off criterion of 0.5% was used to assess the environmental impacts of selected impact categories. Results For both prescriptions, ICHD had highest impact on all environmental impact categories (climate change, human toxicity, freshwater eutrophication, particulate matter formation, marine ecotoxicity and water depletion), except ozone depletion in which HHD-B had highest impact. The fewest impacts were associated with HHD-Nx. CO2 emissions observed for a standard HD prescription are 3590 kg carbon dioxide equivalents (CO2eq) per patient/year by ICHD, 1350 kg CO2eq/patient/year by HHD-B and 733 kg CO2eq/patient/year by HHD-Nx. For extended prescriptions, the highest impact observed is from HHD-B (2210 kg CO2eq/patient/year) followed by HHD-Nx (1110 kg CO2eq/patient/year). With respect to ICHD, HHD-Nx only accounts for 13% (standard) and 18% (extended) of total environmental impact. Patient and staff commute in ICHD (40% of total impact) and dialysis services in HHD (75% in HHD-B and 63% in HHD-Nx) are the highest contributors to the majority of environmental impacts. Conclusion Our study demonstrates the environmental impacts of various modes of HHD through LCA. HD modalities have substantial differences in their environmental impacts as compared to ICHD, both HHD systems have lower impact, with NxStage having less impact than Baxter. Our results also demonstrate that a shift from standard to extended prescriptions increases overall environmental impact by 5%. Combined with existing clinical and economic data, these results could assist policy and decision-makers to optimize the provision of kidney replacement therapies. Lower environmental impact of HHD may add to the patient and provider appeal of these therapies, and when clinical equipoise exists, NxStage may be preferred over Baxter in eligible patients.

#5254 COMPARISON OF EFFICACY OF DIFFERENT VANCOMYCIN ADMINISTRATION REGIMENS IN ACUTE KIDNEY INJURY ON HEMODIALYSIS PATIENTS: A RANDOMIZED CLINICAL TRIAL

Abstract Background and Aims Sepsis is the main cause of Acute Kidney Injury (AKI), requiring dialysis in critically ill patients, with vancomycin being widely used. Its pharmacokinetics and pharmacodynamics (PK/PD) change during hemodialysis (HD), increasing the risk of subtherapeutic concentrations. Objective: To compare different vancomycin administration protocols to assess serum concentrations and area under the curve/minimum inhibitory concentration (AUC/MIC) ratio from PK/PD. Methods Randomized, non-blind clinical trial, including critically ill adults diagnosed with septic AKI on conventional (4 hours) and prolonged HD (6 and 10 hours) and using vancomycin for at least 72 hours from May/2019 to May /2021. Sessions of patients were analyzed and randomized into three groups (G): G control (C, dose of 15 mg/kg after HD session), G intervention (I) 2 hours (dose of 7.5 mg/kg in the second hour of HD and 7.5 mg/kg after the session) and IG continuous infusion (dose of 30 mg/kg in continuous infusion pump, in 24 hours). Patients on chronic dialysis, pregnant women, and those whose session was interrupted for clinical or technical reasons were excluded. Results Of the 316 patients recruited, 87 were randomized, and 174 HD sessions were monitored. There was a predominance of males (69.5%), age 61±11 years, APACHE II 31±6, ATN-ISS 0.79±0.14. For the analysis, 28 sessions belonged to the CG, 47 sessions to the 2-hour IG, and 31 to the continuous infusion IG. The groups were similar in age, weight, comorbidities, severity scores, use of diuretics and nephrotoxic drugs, urine output, albumin, CRP, hematocrit, HD modality, recovery of renal function, and death. When HD sessions were analyzed, there was no difference between the groups regarding Kt/V, ultrafiltration, system coagulation, or hypotension. The CG had a higher frequency of subtherapeutic serum levels at the end of HD compared to the 2-hour IG and continuous infusion (86.7% vs. 42.2% vs. 3.2%, p<.0001), higher clearance dialysis (p = .04) and lower AUC/MIC (p<.0001). The IG continuous infusion had a higher frequency of supratherapeutic concentrations (71%). Logistic regression identified the initial concentration variable as a risk factor (OR 1.16, p = .001) for a non-therapeutic concentration (AUC/MIC less than 400 mg·h/L or greater than 600 mg·h/L) of vancomycin. In contrast, the 2-hour intervention group was identified as a protective factor (OR 0.24, p = .04). Conclusion Our results suggest that administering vancomycin during dialysis resulted in a lower proportion of supratherapeutic or subtherapeutic concentrations compared to administration in continuous infusion or after the end of the session, respectively. New studies are needed to suggest more appropriate doses and assess these findings' impact on clinical outcomes.

#4731 THE CHANGING HAEMODIALYSIS POPULATION IN A SINGLE UK CENTRE: A POST PANDEMIC PHENOMENON?

Abstract Background and Aims Following the Covid-19 pandemic, UK dialysis centres have seen a sharp increase in numbers of patients requiring renal replacement therapy (RRT) particularly haemodialysis (HD). This has resulted in pressures on dialysis capacity and staffing. There may also have been negative effects on other aspects of quality of care, such as a fall in the proportion of patients dialysing via an Arterio-venous fistula (AVF) or worsening anaemia. To study this further, we conducted a retrospective observational study to describe the incident and prevalent HD populations in the post-Covid pandemic period and compare these against pre-pandemic patterns, in a single UK dialysis centre. Method We reviewed data on prevalent HD patient numbers across our service. We specifically collected data from all patients commencing HD between January 2021 and December 2022 using electronic medical records. We collected information on time known to renal prior to starting dialysis, clinic data including which types of clinic attended, documentation of pre-dialysis decisions about modality as well as vascular access referrals, vascular access clinics and vascular access surgery as well as haemoglobin (Hb) at first dialysis. We compared figures with published pre-pandemic data from the 23rd annual UK Renal Registry report on data collected to December 2019 for our centre. We defined a planned start to dialysis as patients who were known to renal >90 days. This aligns with the registry definition. We compared proportional data using the chi square test. Results Comparing prevalent data in Dec. 2022 with Dec 2019, there was a 17% increase in the prevalent HD population from 298 to 349. The proportion of patients dialysing via an AVF fell from 88% to 80% (p = 0.006). The spread across different types of HD in Dec.2022 remained static at 71% In-Centre HD (72% in Dec 2019), 11% Satellite HD (9% in 2019) and 17% HHD (18% 2019) with overall numbers rising across all HD modalities (p for trend = 0.37). PD numbers also rose from 58 to 71 keeping the total percentage on home therapies stable at 31% in our unit. From Jan. 2021- Dec. 2022 inclusive 147 people commenced HD of whom 115 (78%) had planned starts. This compares to 58 starting HD in 2019 and 79% planned (p = 0.85). There was a significant fall in the proportion of planned start HD patients who commenced dialysis with an AVF/AVG, from 81% in 2019 to 56% in 2021-22 (p = 0.003). Themes emerged n planned starters who did not start HD with an AVF/AVG and are detailed in Figure 1. Median Hb level of planned starts on HD was lower at only 94 for 2021-22 and 99 in 2019. Looking in detail at those missing appointments in clinics, 33% had prior documented evidence of fear of Covid-19. Delays in AVF surgery consisted of delayed and cancelled theatre dates, failed AVF requiring re-do or AVF awaiting further intervention at time of dialysis initiation. In the group with a last minute change in decision sighted reasons included: worsening eyesight, development of dementia in partner, reducing mobility. Others changed their mind after further input from the PD team. Despite attending the Advanced Kidney Clinic (AKC) there were still a number of patients with no decision at all. Cancellation of group sessions for dialysis education persisted in our centre until mid-2022 and may have contributed to reduced timely decision making as well as late modality switches. All those with an early failure of PD (defined as < 90 days) had chosen PD prior to the Covid-19 pandemic with intervening remote visits in AKC. Conclusion Following the Covid-19 pandemic, unexpected and unprecedented changes in the HD incident population have been observed, resulting in pressures on dialysis services. In particular, we report an increase in absolute number of dialysis patients, a significant fall in the proportion of patients initiating dialysis with definitive vascular access and a rise in those starting anaemic. This was not related to a change in the proportion of patients with planned starts but may be related to delayed shared decision making as a result of remote consultations and greater delays in vascular access surgery. We have identified a number of areas for service improvement.

Removal of Middle Molecules and Dialytic Albumin Loss: A Cross-over Study of Medium Cutoff and High-Flux Membranes with Hemodialysis and Hemodiafiltration.

Key Points HDF and MCO have shown greater clearance of middle-size uremic solutes in comparison with HF dialyzers; MCO has never been studied in HDF.MCO in HDF does not increase the clearance of B2M and results in a higher loss of albumin. Background Middle molecule removal and albumin loss have been studied in medium cutoff (MCO) membranes on hemodialysis (HD). It is unknown whether hemodiafiltration (HDF) with MCO membranes provides additional benefit. We aimed to compare the removal of small solutes and β2-microglobulin (B2M), albumin, and total proteins between MCO and high-flux (HFX) membranes with both HD and HDF, respectively. Methods The cross-over study comprised 4 weeks, one each with postdilutional HDF using HFX (HFX-HDF), MCO (MCO-HDF), HD with HFX (HFX-HD), and MCO (MCO-HD). MCO and HFX differ with respect to several characteristics, including membrane composition, pore size distribution, and surface area (HFX, 2.5 m2; MCO, 1.7 m2). There were two study treatments per week, one after the long interdialytic interval and another midweek. Reduction ratios of vitamin B12, B2M, phosphate, uric acid, and urea corrected for hemoconcentration were computed. Dialysis albumin and total protein loss during the treatment were quantified from dialysate samples. Results Twelve anuric patients were studied (six female patients; 44±19 years; dialysis vintage 35.2±28 months). The blood flow was 369±23 ml/min, dialysate flow was 495±61 ml/min, and ultrafiltration volume was 2.8±0.74 L. No significant differences were found regarding the removal of B2M, vitamin B12, and water-soluble solutes between dialytic modalities and dialyzers. Albumin and total protein loss were significantly higher in MCO groups than HFX groups when compared with the same modality. HDF groups had significantly higher albumin and total protein loss than HD groups when compared with the same dialyzer. MCO-HDF showed the highest protein loss among all groups. Conclusions MCO-HD is not superior to HFX-HD and HFX-HDF for both middle molecule and water-soluble solute removal. Protein loss was more pronounced with MCO when compared with HFX on both HD and HDF modalities. MCO-HDF has no additional benefits regarding better removal of B2M but resulted in greater protein loss than MCO-HD.

PREVALENCE OF HYPERTENSION IN LOW FLUX VERSUS HIGH FLUX MODALITIES OF MAINTENANCE HEMODIALYSIS - A COMPARATIVE STUDY

Background:Hypertension is common in patients on dialysis. Hemodialysis dialyzer membrane may me either High-flux or Low-flux type and biocompatibility of membranes also may be less or more in both these types. There has been no study comparing the control of hypertension across these Low and High-flux modalities with use of same Ultrapure water and same High biocompatible membrane for both the modalities. Methods: Pre-dialytic BP has been recorded one hour before starting and Post-dialytic BP two hours after finishing Hemodialysis. Intra-dialytic BP has been measured at every 30 minutes interval. All BP recordings have been done for all patients for five hemodialysis sessions and recordings are compared. Number of antihypertensive drugs required in each group have been compared. Fluid overload causing hypertension have been excluded by excluding Intra-Dialytic Weight Gain more than 4.5%. Results:While comparing Pre-dialytic, Intra-dialytic and Post-dialytic BP across Low and High-flux modalities, the p value obtained in each of the case was greater than 0.05, and requirement of antihypertensive drugs and Intra-Dialytic Weight Gain also have no significant difference across these Low and High-flux modalities. Conclusions:It has been concluded from this study that both the Low flux and High flux modalities of hemodialysis are equally efficacious in terms of BP control when same Ultrapure water and High biocompatible membrane is used, and there is no difference in requirement of antihypertensive drugs and Intra-Dialytic Weight Gain across these two modalities.

Cost-effectiveness analysis of autogenous arteriovenous fistula, arteriovenous graft, and tunneled-cuffed catheter for hemodialysis in patients with end-stage kidney disease in Southern China.

To evaluate the cost-effectiveness of three permanent vascular accesses for maintenance hemodialysis patients from a hospital perspective throughout 5 years, which is the average life expectancy of patients with end-stage kidney disease. We conducted a EuroQol(EQ-5D) questionnaire survey between January 2021 and March 2021 with 250 patients to estimate the health utility of various states in patients under different hemodialysis vascular access. We designed a Markov model and conducted a cost-effectiveness analysis to compare the cost-effectiveness of three hemodialysis vascular access in Guangzhou throughout 5 years. The mean costs were US$44,481 with tunneled-cuffed catheter (TCC), and US$68,952 and US$59,247 with arteriovenous graft (AVG) and autogenous arteriovenous fistula (AVF), respectively. The mean quality-adjusted life-years (QALYs) was 1.41 with TCC, and 2.37 and 2.73 with AVG and AVF, respectively. AVG had an incremental cost-effectiveness ratio (ICER) of US$25,491 per QALY over TCC; AVF had an ICER of -US$26,958 per QALY over AVG. At a willingness to pay below US$10,633.8 per QALY, TCC is likely the most cost-effective vascular access. At any willingness to pay between US$10,633.8 and US$30,901.4 per QALY, AVF is likely the most cost-effective vascular access. These findings illustrate the value of AVF given its relative cost-effectiveness to other hemodialysis modalities. Although AVG costs much more than TCC for slightly higher QALYs than TCC, AVG still has a greater advantage over TCC for patients with longer life expectancy due to its lower probability of death.

Use of regional citrate anticoagulation with medium cut-off membrane: pilot report

BackgroundRegional citrate anticoagulation during hemodialysis provides an immediate and complete anticoagulant effect, which is limited to the extracorporeal circuit. Citrate has become the standard anticoagulant in acute renal replacement therapy and is widely used in various intermittent hemodialysis modalities, especially for patients with contraindications for heparin. With the increased adoption of medium cut-off membranes, experience with regional citrate anticoagulation is needed. To our knowledge, this is the first report to assess the feasibility of regional citrate anticoagulation in expanded hemodialysis.MethodsWe prospectively analyzed 5 expanded hemodialysis procedures in 5 patients in which a medium cut-off membrane (Theranova®) was used. We followed our standard citrate protocol developed and tested for high-flux membrane. Anticoagulation was performed with a continuous infusion of 8% trisodium citrate into the arterial line and supplementation of 1 M calcium chloride into the venous line. We monitored ionized calcium and magnesium, sodium and blood gas analysis. Anticoagulation effectiveness was assessed by post-filter ionized calcium and by visual inspection of the anticoagulation in the circuit.ResultsThere were no prematurely terminated procedures due to anticoagulation-related complications. With a blood flow of 250 mL/min and a dialysate flow of 500 mL/min, we were able to maintain serum ionized calcium in the range of 0.89–1.29 mmol/L and serum sodium in the range of 136–144 mmol/L. The mean pre- and post-dialysis arterial circuit pH was 7.42 (± 0.04) and 7.53 (± 0.23), respectively. The mean pre- and post-dialysis serum ionized magnesium was 0.54 (± 0.04) mmol/L and 0.43 (± 0.03) mmol/L, respectively (measurements were done on a point-of-care ionometer with a lower normal range for ionized magnesium).ConclusionWe have shown that our standard citrate protocol for high-flux hemodialysis membrane could be successfully adopted for use in expanded hemodialysis with a medium cut-off membrane. Overall, electrolyte and acid-base balances were relatively well-controlled and anticoagulation effectiveness was excellent.Trial registrationThis is a pilot report with results taken from a larger ongoing trial (registered at ClinicalTrials.gov on October 25, 2019 under number NCT04139525) comparing citrate and heparin anticoagulation during expanded hemodialysis.

Effect of different hemodialysis modalities on hepcidin clearance in patients undergoing maintenance hemodialysis.

Hepcidin is a master regulator of iron utilization and takes part in the pathophysiology of anemia in maintenance hemodialysis (MHD) patients. Hepcidin is a moderate-molecular-weight substance and partially binds to plasma proteins in the circulation, which theoretically might be removed efficiently by hemoperfusion (HP). This study aimed to compare the effect of different dialysis modalities on hepcidin removal and discuss its effect on the iron and anemia status in MHD patients. In a longitudinal interventional study of 26 stable MHD patients, the serum hepcidin, β2-microglobulin (β2-MG), and intact parathyroid hormone (iPTH) were measured before and after one treatment session of hemodialysis (HD), hemodiafiltration (HDF), HD + HP, and HDF + HP, separately. One-way analysis of variance (ANOVA) was used to identify the effect of dialysis modalities on the intra-dialysis clearance ratios. The combined dialysis modalities (HD + HP and HDF + HP) achieved greater clearance ratios of serum hepcidin than HD and HDF alone, HD + HP vs. HD (16 ± 15% vs. 4 ± 13%, p < 0.001), HDF + HP vs. HDF (18 ± 5% vs. 10 ± 13%, p = 0.0036). Similarly, the combined dialysis modalities also performed better than HD and HDF alone in removing β2-MG. There was no significant difference in iPTH clearance among these four modalities, except that HDF + HP achieved a greater clearance ratio than HD. Furthermore, the anemia was improved after the 6-month treatment with regular HD/HDF plus HP, which was indicated by increasing hemoglobin (p = 0.0004) and reduction of erythropoiesis-stimulating agents (ESAs) resistance index (ERI) (p = 0.0431). Our findings suggest that the combined dialysis modalities of HD/HDF plus HP could achieve better clearance ratios of hepcidin than HD/HDF alone, thereby, might improve iron utilization, and benefit anemia management in MHD patients. Further studies with larger sample-size patients and longer follow-up duration are still needed.

In-center Nocturnal Hemodialysis Reduced the Circulating FGF23, Left Ventricular Hypertrophy, and All-Cause Mortality: A Retrospective Cohort Study.

Fibroblast growth factor 23(FGF23) is the most important biomarker and pathogenic factor in Chronic Kidney Disease–Mineral and Bone Disorder (CKD–MBD). In the moderate and severe stages of chronic renal failure, abnormally elevated circulating FGF23 can lead to some complications, including myocardial hypertrophy, which is positively correlated with all-cause mortality. However, the circulating FGF23 level of different hemodialysis modalities, the underlying essential regulatory factors, and potential clinical benefits remain to be elucidated. In this retrospective cohort study, 90 in-center nocturnal hemodialysis (INHD) and 90 matched conventional hemodialysis (CHD) patients were enrolled. The complete blood count, intact FGF23(iFGF23), calcium, phosphorus, PTH, and other biochemical and echocardiographic parameters of INHD and CHD patients were collected and analyzed at 1-year follow-up. The all-cause mortality was recorded during the 7-year follow-up. Furthermore, the regulatory factors of iFGF23 and its association with echocardiographic parameters and mortality were investigated by multivariate regression. The levels of iFGF23 and serum phosphate in patients undergoing INHD were significantly lower than those in patients undergoing CHD. The left ventricular volume index (LVMI) in patients with INHD was significantly attenuated and positively correlated with the drop of serum iFGF23. The INHD group had reduced all-cause mortality compared to the CHD group. Multivariate analysis showed that iFGF23 was positively correlated with serum calcium, serum phosphorus, and calcium-phosphate product. The calcium-phosphate product is an independent determining factor of serum iFGF23. Compared with the CHD group, the INHD group presented with a significantly reduced circulating iFGF23 level, which was closely associated with attenuation of left ventricular hypertrophy, but INHD reduced all-cause mortality in an FGF23 independent manner.

Association of intermittent versus continuous hemodialysis modalities with mortality in the setting of acute stroke among patients with end-stage renal disease

Patients with end-stage renal disease (ESRD) are 8–10 times more likely to suffer from a stroke compared with the general public. Despite this risk, there are minimal data elucidating which...

MO124: Intradialytic Symptomatology is Largely Patient-Specific in both Haemodialysis and Haemodiafiltration: A Randomized Cross-Over Trial between Four Intermittent Dialysis Modalities

Abstract BACKGROUND AND AIMS Standard haemodialysis is associated with a considerable burden of intradialytic symptoms. Although haemodialysis with cool dialysate is associated with less intradialytic discomfort in general, the incidence of cold sensations increases significantly. Whether treatment with online post-dilution high-volume haemodiafiltration [target convection volume (CV) ≥23 L/session] reduces adverse intradialytic symptoms and provokes cold sensations is unknown. METHOD We performed a randomized controlled cross-over trial in 40 prevalent dialysis patients, who were subjected to two haemodialysis modalities: standard haemodialysis [sHD; dialysate temperature (Td) of 36.5°C] and cool haemodialysis (cHD; Td 35.5°C) and two haemodiafiltration modalities: low-volume haemodiafiltration (lvHDF, CV 15 L/1.73 m2/session, Td 36.5°C) and high-volume haemodiafiltration (hvHDF, CV ≥23 L/1.73 m2/session, Td 36.5°C). Every dialysis modality lasted 2 weeks. Intradialytic symptoms were evaluated after the last session of each dialysis modality, with a slightly modified Dialysis Symptom Index (mDSI). Intradialytic thermal sensations were scored on the Visual Analogue Scale Thermal Perception (VAS-TP) before and after 1 and 3 h of each treatment session. Patients were trained to use the mDSI and VAS-TP, in order to reduce incidental stress and unwanted learning responses due to the trial environment. Repeated measures analysis of variance (ANOVA) and one-way ANOVA were used to measure potential differences in intradialytic symptoms between the dialysis modalities (intraindividual differences) and to assess potential interindividual differences in intradialytic symptoms. Linear mixed models with an interaction term between time and modality were used to determine differences in rate of change of VAS-TP between the four modalities. When appropriate, stratified models were fitted subsequently. RESULTS With the exception of cold sensations during cHD (P = .01), intradialytic symptoms did not differ between modalities, but varied markedly between patients (P &amp;lt; .05 in 11/13 items, Table 1). While the VAS-TP score remained unaltered in sHD, lvHDF and hvHDF, patients felt significantly more cold sensations during cHD (P = .007)(Figure 1). Stratified models showed a decrease of 0.43 points/h on the VAS-TP scale (P = .007) in the first hour of cHD and remained unaltered thereafter [+0.10 points/h (P = .20)]; thermal perception remained unaltered [0.04 points/h (P = .77)] in the other modalities. CONCLUSION Intradialytic symptomatology was, except for the symptom feeling cold, by and large similar in all modalities, but it varied markedly between patients. Hence, adverse intradialytic symptoms seem largely patient-specific. Patients experienced more cold sensations during cool HD, but not during haemodiafiltration.

MO818: PTH Levels and Mortality in Incident Haemodialysis Patients

Abstract BACKGROUND AND AIMS Serum intact parathyroid hormone (iPTH) is associated with the prognosis of haemodialysis (HD) patients; however, its optimal range for reducing mortality remains unknown. The aim of this study was to assess the association between different serum iPTH levels and mortality in incident HD patients. METHOD We conducted a retrospective single-centre study of incident HD patients between January 2013 and 2020. According to the iPTH level measured at baseline, patients were categorized into four groups: &amp;lt;150 pg/mL, 150–300 pg/mL, 301–600 pg/mL and &amp;gt;600 pg/mL. Clinical, analytical and demographic data were compared among groups. All-cause mortality over a mean follow-up of 3.2 years was assessed using standard survival methods. Statistical analysis was performed using SPSS (Version 23 for Mac OSX). RESULTS The mean age of 149 patients was 74.14 ± 14.17 years, 95 (63.8%) were male, 75 (50.3%) were diabetic, 85 (57%) had congestive heart failure (CHF) and 110 (73.9%) had hypertension. A total of 46 patients (30.9%) were treated with vitamin D analogues, 2 (1.3%) with calcimimetics and 25 (16.8%) with oral phosphate binders. A total of 57 (38.3%) patients had iPTH &amp;lt; 150 pg/mL, 44 (29.5%) 150–300 pg/mL, 35 (23.5%) 301–600 pg/mL and 13 (8.7%) &amp;gt; 600 pg/mL. There were no age, gender, comorbidity or HD modality differences among groups. Patients with iPTH &amp;lt; 150 pg/mL had higher c-reactive protein (CRP) (P = .042), higher serum bicarbonate (P = .020), lower albumin (P = .001), lower serum phosphate (P = .009) and lower bone-specific alkaline phosphatase (BAP) (P = .008). During the study follow-up period, 82 patients (55%) died. Multivariate Cox regression showed that patients with iPTH &amp;lt; 150 pg/mL had an increased risk of all-cause mortality when compared with those with iPTH 301–600 pg/mL {HR: 0.59, [95% confidence interval (95% CI) 0.36–0.96]; P = .035} and iPTH &amp;gt; 600 pg/mL [HR: 0.36, 95% CI 0.19–0.70; P = .02] in both unadjusted and adjusted models for age, albumin, diabetes, CHF and hypertension. No significant difference was found between iPTH &amp;lt; 150 pg/mL and iPTH 150–300 pg/mL groups. When the reference was changed to iPTH &amp;gt; 600 pg/mL, patients in this group had a decreased mortality risk when compared with those with iPTH &amp;lt; 150 pg/mL (HR: 2.75, 95% CI 1.43–5.29; P = .02) and iPTH 150–300 pg/mL (HR: 2.23, 95% CI 1.14–4.36; P = .02), but not iPTH 300–600 pg/mL. CONCLUSION In our study, the baseline iPTH level was associated with all-cause mortality in incident HD patients. Our results suggest that the optimal serum iPTH level conferring the lowest mortality risk is &amp;gt; 300 pg/mL in this group of patients.

Informed decision-making in delivery of dialysis: combining clinical outcomes with sustainability.

ABSTRACTAs the prevalence of chronic kidney disease is expected to rise worldwide over the next decades, provision of renal replacement therapy (RRT), will further challenge budgets of all healthcare systems. Most patients today requiring RRT are treated with haemodialysis (HD) therapy and are elderly. This article demonstrates the interdependence of clinical and sustainability criteria that need to be considered to prepare for the future challenges of delivering dialysis to all patients in need. Newer, more sustainable models of high-value care need to be devised, whereby delivery of dialysis is based on value-based healthcare (VBHC) principles, i.e. improving patient outcomes while restricting costs. Essentially, this entails maximizing patient outcomes per amount of money spent or available. To bring such a meaningful change, revised strategies having the involvement of multiple stakeholders (i.e. patients, providers, payers and policymakers) need to be adopted. Although each stakeholder has a vested interest in the value agenda often with conflicting expectations and motivations (or motives) between each other, progress is only achieved if the multiple blocs of the delivery system are advanced as mutually reinforcing entities. Clinical considerations of delivery of dialysis need to be based on the entire patient disease pathway and evidence-based medicine, while the non-clinical sustainability criteria entail, in addition to economics, the societal and ecological implications of HD therapy. We discuss how selection of appropriate modes and features of delivery of HD (e.g. treatment modalities and schedules, selection of consumables, product life cycle assessment) could positively impact decision-making towards value-based renal care. Although the delivery of HD therapy is multifactorial and complex, applying cost-effectiveness analyses for the different HD modalities (conventional in-centre and home HD) can support in guiding payability (balance between clinical value and costs) for health systems. For a resource intensive therapy like HD, concerted and fully integrated care strategies need to be urgently implemented to cope with the global demand and burden of HD therapy.

Buttonhole Cannulation of Arteriovenous Fistulas: a Dialysis Nurse's Perspective

End stage renal disease patients who choose a hemodialysis modality are burdened with the reality that their life is now tied to a dialysis machine between 3- 6 days/week. The impact on their medical, social and psychological well-being is dramatic. One of the biggest fears patients have expressed to us regarding hemodialysis is having to be “stuck with big needles” at each treatment. The average in-center hemodialysis patient is “stuck with large bore needles” 6 times/week or ~288 times/year barring any “missed sticks” or infiltrations. The home hemodialysis patient increases that number to ~10 x’s/week or ~500 times/yr. Understanding that the average person recoils from the thought of needles, and that ~25% of adults present with a real clinical diagnosis of trypanophobia or “needle phobia” [5], it seems only fitting that we seek out options that would reduce this burden.

Changing trends in dialysis modalities utilization and mortality in children, adolescents and young adults with acute kidney injury, 2010\u20132017

The aim of the study was to assess trends in the relative use of dialysis modalities in the hospital-based pediatric cohort and to determine risk factors associated with in-hospital morality among pediatric patients receiving dialysis for acute kidney injury (AKI). Patients aged < 20 years who received dialysis between 2010 and 2017 were identified from electronic health records databases of a Taiwan’s healthcare delivery system. The annual uses of intermittent hemodialysis (HD), continuous and automated peritoneal dialysis (PD) and continuous kidney replacement therapy (CKRT) were assessed using Cochran-Armitage Tests for trend. Among patients who received their first dialysis as inpatients for AKI, a multivariate logistic regression model was employed to assess mortality risks associated with dialysis modalities, patient demographics, complexity of baseline chronic disease, and healthcare service use during their hospital stays. Kidney dialysis was performed 37.9 per patient per year over the study period. Intermittent hemodialysis (HD) (73.3%) was the most frequently used dialysis modality. In the inpatient setting, the relative annual use of CKRT increased over the study period, while HD use concomitantly declined (P < 0.0001). The overall in-hospital mortality rate after dialysis for AKI was 33.6%, which remained steady over time (P = 0.2411). Patients aged < 2 years [adjusted odds ratio: (aOR) 3.36; 95% confidence interval (CI) 1.34–8.93] and greater vasoactive regimen use (aOR: 17.1; 95% CI: 5.3–55.21) were significantly associated with dialysis-related mortality. Overall treatment modality used for dialysis in pediatric patients increased slowly in the study period, and HD and CRKT modality uses largely evolved in the inpatient setting. Younger ages and use of more vasoactive medication regimens were independently associated with increased early mortality in patients on AKI-dialysis.

Age, diabetes mellitus, and dialysis modality are associated with risk of poor muscle strength and physical function in hemodialysis and peritoneal dialysis patients

BackgroundDue to the poor outcomes associated with the impairment of physical function and muscle strength in patients on maintenance dialysis, it is important to understand the factors that may influence physical function and muscle strength. The aim of this study was to explore the factors associated with physical function in hemodialysis and peritoneal dialysis patients.MethodsPatients with chronic kidney disease on dialysis for at least 3 months, aged 18 years old or above, were enrolled. Physical function was assessed by handgrip strength, gait and sit-to-stand tests, and the Short Physical Performance Battery (SPPB). Clinical and laboratory data were collected to verify the association with physical function parameters through binary logistic regression.ResultsOne-hundred ninety patients on maintenance dialysis were included; 140 patients (73.7%) on hemodialysis and 50 (26.3%) on peritoneal dialysis. The mean age was 57.3 ± 14.9 years, 109 (57.4%) were male, and 87 (45.8%) were older than 60 years. The median SPPB was 8.0 points (6.0–10.0 points) and the mean ± standard deviation of handgrip strength was 24.7 ± 12.2 kg. Binary logistic regression showed that age, type of renal replacement therapy, diabetes mellitus, and serum creatinine were significantly associated with both higher 4-meter gait test times and lower SPPB scores. Only age and diabetes mellitus were associated with higher sit-to-stand test times, while age and ferritin were associated with lower handgrip strength.ConclusionAge, diabetes mellitus, serum creatinine, and hemodialysis modality are factors related to physical function in dialysis patients.

Cardiac Implantable Electronic Devices in Hemodialysis and Chronic Kidney Disease Patients-An Experience-Based Narrative Review.

Cardiovascular implantable electronic devices (CIEDs) are a standard therapy utilized for different cardiac conditions. They are implanted in a growing number of patients, including those with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). Cardiovascular diseases, including heart failure and malignant arrhythmia, remain the leading cause of mortality among CKD patients, especially in ESKD. CIED implantation procedures are considered minor surgery, typically with transvenous leads inserted via upper central veins, followed by an impulse generator introduced subcutaneously. A decision regarding optimal hemodialysis (HD) modality and the choice of permanent vascular access (VA) could be particularly challenging in CIED recipients. The potential consequences of arteriovenous access on the CIED side are related to (1) venous hypertension from lead-related central vein stenosis and (2) the risk of systemic infection. Therefore, when creating permanent vascular access, the clinical scenario may be complicated by the CIED presence on one side and the lack of suitable vessels for arteriovenous fistula on the contralateral arm. These factors suggest the need for an individualized approach according to different clinical situations: (1) CIED in a CKD patient; (2) CIED in a patient on hemodialysis CIED; and (3) VA in a patient with CIED. This complex clinical conundrum creates the necessity for close cooperation between cardiologists and nephrologists.

Hemodialysis-related headache: Still a challenge in 2020? Effect of conventional versus online hemodiafiltration from a study in Casablanca, Morocco.

Hemodialysis-related headache (HRH) is a well-known clinical event. It is considered as one of the most commonly reported neurological symptoms among hemodialysis patients. Its epidemiological, physiological, clinical, and therapeutic data remain scarce and are poorly studied. Our aim was to determine the frequency of HRH in the region of Casablanca, Morocco, to describe its clinical characteristics and to explore the hypothesis that renal replacement techniques, such as conventional versus online hemodiafiltration may have an association on clinical adverse effects like HRH. A descriptive, cross-sectional, and multicentric study was carried out among 100 chronic hemodialysis patients for at least 6months. HRH was defined according to criteria published by the International Classification of Headache Disorder third edition beta version (ICHD3β) [1]. Two different HD-modalities (standard HD and OL-HDF) have been investigated in order to explore their impact on HRH. Headache was reported by 60% of the patients including 41.6% of hemodialysis-related headache. HRH had on average a duration of 7.4hours, pulsatile among 38% of interviewed patients and of moderate intensity in 48% of cases. In total, 51.3% of patients undergoing conventional hemodialysis modality reported HRH compared to 12.5% undergoing online hemodiafiltration technique (OL-HDF) (P=.008). Hemodialysis-related headache remains a poorly studied clinical event despite its high prevalence. Its diagnosis, management, and especially its prevention remain a challenge for the neurologist and the nephrologist. Our results suggest that OL-HDF is a promising therapeutic and preventive tool to reduce the incidence of HRH.