Hemodialysis Patients Research Articles

The effects of death anxiety on diet‐fluid restriction non‐adherence in hemodialysis patients

AbstractIntroductionThe study was performed to examine the effects of death anxiety on diet‐fluid restriction non‐adherence in hemodialysis patients.MethodsThis descriptive, cross‐sectional, and correlational study was performed with 118 hemodialysis patients who received treatment in the dialysis unit of a university hospital and a state hospital in Elazığ, eastern Turkey. The study data were obtained with the “Descriptive Data Form”, “Death Anxiety Scale”, and “Dietary and Fluid Restriction Non‐Adherence Scale”.FindingsThe average Death Anxiety Scale total score of the patients was 10.00 ± 4.75. The “Duration of non‐adherence with diet” mean score was 1.66 ± 1.70, “Degree of non‐adherence with diet” mean score was 1.24 ± 1.19, “Duration of non‐adherence with fluid restriction” mean score was 1.61 ± 1.71, and “Degree of non‐adherence with fluid restriction” mean score was 1.16 ± 1.13. The independent variable Death Anxiety Scale significantly and negatively affected the dependent variable “Duration of non‐adherence with diet”, “Degree of non‐adherence with diet”, “Duration of non‐adherence with fluid restriction”, and “Degree of non‐adherence with fluid restriction”.DiscussionHemodialysis patients face serious death anxiety, their degree of non‐adherence with diet‐fluid restriction was low as death anxiety scores increased, and the degree of non‐adherence with diet‐fluid restriction decreased.

Diuretics and mortality reduction in incident dialysis patients: a two-year observational study

Fluid overload predicts morbidity and mortality in dialysis patients. Diuretics can reduce fluid overload, but their effects on morbi-mortality following inception remain ill-defined. To determine whether diuretics reduce mortality and hospitalization rates in incident dialysis patients in the first 2 years after inception. Adult patients starting dialysis between 2009 and 2015 in the REIN registry were matched with the SNDS database and divided into four subgroups according to loop diuretics exposure: < 5%, 5–50%, 50–80% or > 80% over the observation period of each patient. The incidence of hospitalization was described based on the primary diagnoses of the discharge summaries and codes. In this study, which included 67,736 patients, 53,829 (79.5%) who had varying degrees of diuretic exposure exhibited a significantly lower mortality rate at 2 years compared to those without diuretic exposure (24.8% [95% CI 24.4–25.2], vs 37.5% [95% CI 36.7–38.3] respectively). However, the duration of diuretic exposure significantly impacted outcomes. The all-cause mortality rate at two years was highest in the group with ≥ 80% exposure (68.2% [95% CI 67.3–69.1]), followed by those with 50–80% exposure (15.7% [95% CI 15.0–16.4]), and those with 5–50% exposure (6.6% [95% CI 6.3–7.0]). An inverse probability weighting (IPW) propensity score analysis supported these findings. Stratified analyses showed consistent results regardless of a history of congestive heart failure and were similar for both hemodialysis and peritoneal dialysis patients. Additionally, the number of hospitalizations and length of stay were generally higher in the group with the longest exposure to loop diuretics. Diuretic exposure was generally associated with a lower mortality rate in dialysis patients. However, prolonged exposure (≥ 80%) was linked to an increased risk of mortality and hospitalization. This prolonged exposure may indicate residual diuresis at the cost of chronic fluid overload.

A preregistered meta-meta-analysis on the global distribution of Hepatotropic Viruses

Introduction. Hepatotropic viruses (HAV, HBV, HCV, HDV, and HEV) significantly impact global health, with varying prevalence across regions. Objective. This study aims to systematically consolidate data from diverse meta-analyses to provide a contemporary reference on virus distribution and prevalence. Materials and methods. Adhering to PRISMA guidelines, the study utilized a mixed effects model for data integration. Quality evaluation was carried out with QUOROM and AMSTAR tools, with heterogeneity assessed via the Higgins I2 statistic, Q-statistic and Tau squared (τ2) values. Results. The study analyzed 86 meta-analyses from 56 studies (2017–2022) with minimal overlap. Prevalence rates by region were as follows: MENA – 29.2%, Afghanistan – 9.14%, Africa – 8.10%. Prevalence rates by virus type: HAV – 82.5%, HBV – 8.6%, HCV – 15.1%, HDV – 8.9%, HEV – 13.9%, dual HBV-HCV coinfection – 2.2%. Prevalence rates by risk groups: general population – 8.3%, healthcare workers – 4.0%. Continent-specific HBV-HCV prevalence rates: Africa – 9.2%, China – 6.9%, others. HCVprevalence rates among at-risk groups: healthcare workers – 5.58%, hemodialysis patients – 34.8%. Regional HCV rates: Africa – 7.42%, Middle East – 25.30%. Conclusion. Diverse global hepatotropic virus prevalence patterns are influenced by multifaceted factors. MENA faces higher rates due to healthcare challenges, while Africa struggles with limited resources. Tailored public health strategies, including vaccination and awareness campaigns, are essential to alleviate burdens and enhance global health. This consolidated data serves as a valuable resource for informed decision-making.

External evaluation of intravenous vancomycin population pharmacokinetic models in adults receiving high‐flux intermittent haemodialysis

AimsPatients undergoing haemodialysis (HD) are at greater risk of methicillin‐resistant Staphylococcus aureus infections requiring intravenous vancomycin. Close vancomycin therapeutic drug monitoring is warranted in HD patients as renal clearance is the primary elimination pathway. Clinically, population pharmacokinetics (popPK) model‐informed dosing is commonly used. This study aimed to perform an external evaluation of published vancomycin popPK models developed for adults undergoing high‐flux intermittent HD, and to create a dosing nomogram derived from the model that performed best.MethodsA literature review was conducted through PubMed and EMBASE to identify relevant popPK models. an external dataset was collected retrospectively from patients of 2 healthcare centres in Quebec, Canada. Selected models were implemented in NONMEM (v7.5; ICON Development Solutions). Predictive performance was assessed through prediction and simulation‐based diagnostics.ResultsIn total, 2386 vancomycin concentrations were collected from 274 patients and 476 antibiotic courses. Four vancomycin popPK models were selected for evaluation. None of the models demonstrated overall satisfactory or clinically acceptable predictive performance. Nonetheless, Bae et al.’s model performed best with a median prediction error of 16.25% and median absolute prediction error of 34.66%. Different predictive performance was also observed for vancomycin concentrations from samples collected during and between HD sessions.ConclusionAll evaluated models presented poor overall predictive performance. Further studies are required, through existing popPK model parameter re‐estimation or new model development, to adequately describe vancomycin pharmacokinetics for our high‐flux intermittent HD patient cohort.

Core stabilization exercise is potentially an optimal exercise for hemodialysis patients

Core stabilization exercise is potentially an optimal exercise for hemodialysis patients

AVG delamination: a cause of early cannulation arteriovenous graft dysfunction in hemodialysis patients

Background A series of cases have reported graft delamination as a rare complication of early-cannulation arteriovenous graft (ecAVG). The unique multilayer structure of ecAVGs contributes to the property of cannulation as early as hours after implantation, but on other hand it takes the risk of graft delamination. However, the underlying mechanism and management of graft delamination as well as its effects on the long-term patency of ecAVGs have not been systemically analyzed. Methodsz A retrospective study was conducted in a cohort of patients who required an ecAVG for hemodialysis (HD) access in our center between April 2017 and December 2021. The characteristics of graft delamination and the outcomes of its different treatments were analyzed. Results A total of 144 ecAVGs were established in 141 end-stage renal disease (ESRD) patients, including 124 (86.1%) Acuseal grafts and 20 (13.9%) Flixene grafts. During follow-up 24.5(11.5, 45.8) months, 11 (7.6%) subjects had graft infection with an incidence of 0.03 patient-year. Thirteen (9.0%) subjects had graft delamination at 9.3(5.0,12.4) months after ecAVG implantation, with an incidence of 0.04 per patient-year. ecAVG delamination was observed in both Acuseal grafts (0.037 per patient-year) and Flixene grafts (0.055 per patient-year). Thrombosis or venous hypertension was the most common complaints. Seven delamination was observed at 1.3 (0.1, 4.2) months after an endovascular procedure. The primary patency, primary assistant patency and secondary patency in delamination group were significantly lower than that in non-delamination group (p < 0.05). Post-procedure primary patency of group A (percutaneous transluminal angioplasty, PTA), group B (stenting) and group C (partial graft replacement, PGR) were 1.3 (0.45,4.22) months, 5.3 (3.05,6.85) months and 8.45 (4.78,14.53) months respectively (p = 0.029). Conclusions Graft delamination was not a rare complication of ecAVGs in this cohort. It significantly reduced the long-term patency of AVGs. PGR might be a more effective therapeutic way than endovascular treatments.

Pentoxifylline improves anemia through its novel effect on hypoxia-inducible factor-2 alpha in hemodialysis patients: a randomized, double-blind, placebo-controlled clinical trial

ABSTRACT Objectives This randomized, double-blind, placebo-controlled clinical trial aimed to prospectively examine the effect of pentoxifylline (PTX) on hypoxia-inducible factor-2 alpha (HIF-2α) and its role in controlling anemia in hemodialysis (HD) patients. Methods Eighty patients on HD were randomized to receive 400 mg of PTX or placebo twice daily for 6 months. The hemoglobin (Hb) and other hematologic parameters, the weekly erythropoiesis-stimulating agents (ESAs), and the ESA resistance index (ERI) were assessed monthly during the study. The HIF-2α, transforming growth factor-β1 (TGF-β1), and high-sensitivity C-reactive protein (hs.CRP) were measured before and after the intervention. Results In the pentoxifylline group, an appreciable increase in Hb from 9.7 (9.3, 10.3) g/dl to 10.5 (9.3, 11.4) g/dl and hematocrit (Hct) from 31.3 (29.6, 32.4)% to 33.2 (29.4, 35.9)% was observed after one month of PTX administration, and this effect was maintained over the study time (p < 0.001). This was along with a decrease in the ESA doses required from 8000 (8000, 11500) IU/wk to 4000 (2000, 8000) IU/wk (p < 0.001), and an improvement in the ERI from 11.6 (8.07, 16.97) IU/kg/wk/g/dl to 5.79 (2.01, 10.09) IU/kg/wk/g/dl (p < 0.001). Additionally, the HIF-2α increased significantly at the end of the intervention in patients who received PTX from 3245.35 (2886.8, 4691.56) pg/ml to 7208.75 (5382, 9182.7) pg/ml, while TGF-β1 and hs.CRP decreased significantly from 657.78 (539.78, 1146.62) pg/ml and 88.08 (39.93, 100.4) mg/l to 329.94 (228.67, 793.18) pg/ml and 48.65 (34.44, 84.61) mg/l, respectively. The percent changes in HIF-2α, TGF-β1, and hs.CRP levels in the pentoxifylline group were also statistically significant in comparison with the placebo group. Conclusions PTX could be a promising agent for correcting anemia in HD patients via increasing HIF-2α levels. Clinical trial registration Clinicaltrials.gov, February 2023, registry number: NCT05708248.

Hemodialysis Patients May Benefit from Cholecalciferol Treatment Targeting High Level of 25(OH)D

Hemodialysis Patients May Benefit from Cholecalciferol Treatment Targeting High Level of 25(OH)D

Absolute blood volume and long-term survival in chronic hemodialysis patients

Absolute blood volume and long-term survival in chronic hemodialysis patients

Incidence of Acute Pulmonary Edema Before and After the Systematic Use of Ultrasound B-Lines

Introduction: Acute pulmonary edema (APE) due to fluid overload is considered the most feared complication in hemodialysis patients. Various diagnostic tests have been proposed to assess the fluid status in patients with end-stage kidney failure (ESKF); among these, lung ultrasound (measuring the number of B-lines) is emerging as a promising tool to identify pulmonary congestion in this patient population. Methods: We compared the incidence of APE before and after the implementation of lung ultrasound as a routine practice in our unit. The pre (from 1 January 2007 to 31 December 2008)- and post (from 1 January 2017 to 31 December 2018)-B-line implementation periods included 98 and 108 hemodialysis patients, respectively. By accurately reviewing their electronic medical records, all episodes of APE were collected. The 10-year interval between the two periods was specifically chosen to ensure no overlap between patients of the two cohorts whereas the single-center design was adopted to minimize the influence of center effect on the study results. Results: APE episodes occurred more frequently in patients from the pre-B-line implementation group (18/98, i.e., 18.4%) compared with those from the post B-line implementation group (6/108, i.e., 5.5%) (p = 0.004). An analysis based on repeated APE events showed that the incidence rate of APE was significantly higher during the pre-implementation period (2.0 APE episodes per 100 person-months, 95% CI: 1.4–2.7) than during the post-implementation period (0.3 APE episodes per 100 person-months, 95% CI: 0.1–0.7), with an incidence rate ratio (post- versus pre-) of 0.17 (95% CI: 0.07–0.40; p &lt; 0.001). The odds of experiencing APE episodes were 74% lower (odds ratio: 0.26, 95% CI: 0.10–0.69) in patients from the post B-line implementation period compared with those from the pre-implementation period. Notably, adjusting for potential confounders did not affect the strength of this association, which remained statistically significant (p ≤ 0.030). Finally, dominance analysis indicated that the implementation of B-lines was the primary factor explaining the difference in APE episodes between the two periods, followed by dialysis duration and intra-dialysis weight gain. Conclusions: The systematic use of lung ultrasound (a simple, easy-to-learn, rapid and non-invasive method, easily performed at the patient’s bed) in everyday clinical practice was associated with a drastic reduction in episodes of APE in hemodialysis patients. Further observational and interventional studies are needed to confirm these results.

Centre-level fluid management practices in the BISTRO trial and their lack of association with participant fluid status and blood pressure in non-anuric haemodialysis patients.

Fluid assessment and management is a key aspect of good dialysis care and is affected by patient-level characteristics and potentially centre-level practices. In this secondary analysis of the BISTRO trial we wished to establish whether centre-level practices with the potential to affect fluid status were stable over the course of the trial and explore if they had any residual associations with participant's fluid status. Two surveys (S) of fluid management practices were conducted in 32 participating centres during the trial, (S1: 2017-18 and S2: 2021-22). Domains interrogated included: dialysate sodium concentration, (D-[Na+]), fluid and salt intake, residual kidney function, use of diuretics, incremental start, approaches to fluid assessment, management and dialysate temperature, (D-oC). Associations of these practices with the closeness of the participant's post-dialysis target weight to their normally hydrated weight, pre- and post-dialysis systolic (SBP) and diastolic blood pressure, (DBP), were analysed using intra-class correlations and multilevel modelling with adjustment for visit, age, sex and comorbidity burden. Variations in centre practices were reported but did not change during the trial, apart from some relaxation in salt and fluid restriction in S2. For our measures of fluid status, measured 2501 times in 439 non-anuric incident haemodialysis patients, centre-level intraclass correlations were extremely low, whereas patient-level correlations ranged between 0.12 and 0.47, strongest for pre- and post-dialysis-SBP, less so for post-dialysis-DBP. Multi-level analysis found no associations between D-[Na+], or assessment methods of fluid status. In S2, one centre, routinely using a D-Co of 35°C had more divergence between the target and normally hydrated weight, but this was not observed in S1, and no other associations were found. Centre-level fluid management practices were stable over the course of the BISTRO trial, and in contrast to patient-level factors, no centre-level associations were detected with fluid status or blood pressure. This may be because the trial imposed a standardised approach to fluid assessment in all trial participants who at least initially had residual kidney function, potentially over-riding the effects of other centre practices. Survey responses revealed substantial scope for developing and evaluating standardised protocols to optimise fluid management.

Association of uremic toxins and systemic inflammation with depression and anxiety among hemodialysis patients in Montenegro.

The purpose of this study was to examine the association between uremic toxins, inflammation, depression and anxiety among hemodialysis patients in Montenegro. The cross-sectional study included 88 patients undergoing hemodialysis. Depression and anxiety symptoms were assessed by Patient Health Questionnaire (PHQ-9) and Beck Anxiety Inventory (BAI). The standard laboratory methods were used to measure uremic toxins and systemic inflammation (C-reactive protein, Neutrophil-to-Lymphocyte Ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR)). Clinically significant depression (PHQ-9 ≥ 10) and anxiety (BAI ≥16) were found in 55.7% and 27.2%, respectively. Logistic regression analyses revealed that serum urea, beta 2-microglobulin (B2M), and systemic inflammation (CRP, NLR, PLR) were significantly and independently associated with depressive symptoms, whereas serum urea, creatinine, uric acid, B2M, and systemic inflammation (CRP nad NLR) were associated with anxiety symptoms. Depressive symptoms and anxiety are common among hemodialysis patients in Montenegro, and are associated with increased levels of systematic inflammation, serum urea, and beta 2-microglobulin.

The Effect of Fordyce Happiness Training on Life Expectancy and Quality of Life in Hemodialysis Patients: An Intervention Study in Yazd, Iran

Background: Dialysis patients frequently experience issues such as fear, reduced social activity, and hopelessness due to lifestyle changes and treatment requirements. Objectives: This study aimed to determine the effect of Fordyce happiness training on quality of life and life expectancy in hemodialysis patients. Methods: This quasi-experimental intervention study involved 48 hemodialysis patients who were referred to Shahid Rahnemoun Hospital in Yazd, Iran, and selected through simple random sampling. Data collection tools included the Quality-of-Life Questionnaire for Kidney Patients (KDQOL-36) and the Miller Life Examination Questionnaire. Patients participated in ten 60-minute training sessions, held twice weekly. Data were collected at baseline and one month after the intervention and analyzed using SPSS 21 software. Results: Following Fordyce's happiness training, levels of potassium (K), creatinine (Cr), and blood urea nitrogen (BUN) in patients significantly decreased. Before the intervention, the mean scores for quality of life and life expectancy in dialysis patients were 51.9 ±28.27 and 169.75 ±11.95, respectively, which increased to 64.66 ±27.17 and 179.95 ±9.37 after the intervention. Paired t-test results indicated that Fordyce happiness training had a statistically significant positive effect on patients' quality of life (P &lt; 0.05) and life expectancy (P &lt; 0.05). Conclusions: The Fordyce happiness training program can improve quality of life and life expectancy in dialysis patients. In other words, happiness training may serve as a preventive strategy against mental disorders such as depression, anxiety, and life dissatisfaction in dialysis patients.

Does the hemodialysis program affect the prostate-specific antigen (PSA) serum levels in patients with end-stage renal disease (ESRD)? A cross-sectional descriptive study.

This study aims to investigate the effect of high-flux membrane hemodialysis on total prostate-specific antigen (tPSA) serum levels in hemodialysis patients and to evaluate the clinical significance of any observed changes. A cross-sectional descriptive study was conducted involving 75 hemodialysis patients at An-Najah National University Hospital. tPSA and hematocrit (Hct) serum levels were measured before and after one hemodialysis session. The correlation between changes in tPSA and Hct levels was analyzed using the Statistical Package for Social Sciences (SPSS). The mean age of the patients was 54.25 ± 15.27 years, with a mean hemodialysis duration of 40 ± 38 months. The mean tPSA levels before and after hemodialysis were 0.95 ± 0.81 ng/ml and 1.15 ± 0.96 ng/ml, respectively. Significant increases were observed in both tPSA (t = -3.264, p = 0.002) and Hct levels (t = -7.861, p < 0.001). The percentage changes in tPSA and Hct were 20% and 12%, respectively, with no significant correlation between the changes (r = 0.152, p = 0.215). Hemodialysis significantly elevates tPSA serum levels; however, no significant correlation was found between changes in tPSA and Hct. None of the patients showed clinically significant elevations in tPSA that would necessitate prostate biopsy. Therefore, high-flux membrane hemodialysis does not appear to compromise the diagnostic value of tPSA in hemodialysis patients.

Over-the-Wire Retrieval of Infectious Hemodialysis Catheter-Related Right Atrial Thrombus Causing Recurrent Pleural Empyema and Sepsis: A Case-Based Review

Introduction: Infectious catheter-related right atrial thrombus (CRAT) is a potentially fatal but often underestimated contingency associated with central venous catheter (CVC) in patients on hemodialysis. Management guidelines for CRAT are lacking, and its occurrence poses clinical challenges. Here, we describe the case of an infectious CRAT in a young patient on hemodialysis with peculiar clinical complications and perform a literature review. Case presentation and literature review: A 30-year-old man on hemodialysis after bilateral nephrectomy due to polycystic disease presented with hyperpyrexia resistant to broad-spectrum antibiotics. A pleural empyema caused by methicillin-resistant Staphylococcus aureus (MRSA) was diagnosed. Since fever persisted despite targeted antibiotic therapy, a transthoracic echocardiogram to exclude infective endocarditis was performed, showing a right atrial thrombus. CVC was promptly removed and the thrombus was aspirated through a percutaneous retrieval system. The thrombus cultural exam resulted positive for MRSA. After performing an extensive literature review, we could not find another case reporting the concomitance of these two rare complications. Conclusions: CRAT is a life-threatening complication in hemodialysis patients. While various treatment options exist, evidence-based guidelines are lacking, leading to individualized management strategies. Minimizing CVC use remains the best option for preventing such a complication.

Association of hypoalbuminemia with hospitalization and mortality in hemodialysis patients with COVID-19.

Hypoalbuminemia is associated with poor nutritional status and inflammatory response in infectious diseases. It is commonly observed in COVID-19 patients. The aim of this study is to assess the association of serum albumin with hospitalization and mortality in dialysis patients with COVID-19. We retrospectively collected 250 dialysis patients, with and without COVID-19. Demographic characteristics, clinical symptoms, and laboratory tests on admission or the confirmation of COVID-19 were collected. Univariate logistic regression model was used to evaluate the association of various factors with hospitalization and death in these patients. A total of 250 patients were included between December 1, 2022, and February 1, 2023, in our dialysis center. Among them, 218 were dialysis patients with COVID-19, and 32 were without COVID-19. Ten patients died due to COVID-19, and 8 patients had clinical data. In dialysis patients with COVID-19, a significant difference in serum albumin levels was observed between outpatients (37.28 ± 4.01 g/L) and hospitalized patients (33.42 ± 3.82 g/L), as well as between survivors (37.12 ± 4.07 g/L) and non-survivors (31.92 ± 2.52 g/L). Univariate logistic regression showed that the reduced albumin levels were associated with an increased risk of hospitalization and mortality in dialysis patients with COVID-19. Our study revealed that reduced serum albumin is associated with an increased risk of hospitalization and mortality in dialysis patients with COVID-19. Low serum albumin levels suggest a poor prognosis and nutritional support may improve clinical outcomes.

Beyond dialysis: Assessing therapeutic regimen compliance and sleep quality in chronic renal failure patients undergoing maintenance hemodialysis in Saudi Arabia.

Given its potential to impact physical and mental health, sleep quality is one of the most significant clinical outcomes among hemodialysis patients. Patients undergoing hemodialysis are required to adhere to an intricate treatment plan that consists of regular hemodialysis treatments, dietary and fluid restrictions, and a multi-drug regimen. Investigate the relationship between adherence to a therapeutic regimen and sleep quality among chronic renal failure patients undergoing maintenance hemodialysis. A descriptive correlational research design was followed. The study was conducted at the hemodialysis units in Hafr Albatin City, specifically at Hafr Albatin Central Hospital and King Khaled Hospital, Saudi Arabia. A convenience sample of 100 adult patients was selected for the study. The Hemodialysis Patients Adherence Questionnaire and Pittsburgh Sleep Quality Index were utilized to collect the data in 5 months from September 20, 2023 to February 15, 2024. The study revealed that more than half of the studied patients adhered to the therapeutic regimen, while (46%) did not adhere to it. More than half of the patients had poor sleep quality and were nonadherent to diet and fluid restrictions. Overall adherence score is negatively correlated with the global sleep quality score (r = -0.368, p < 0.001), indicating that poorer sleep quality is associated with lower overall adherence to the therapeutic regimen. While a significant proportion of the patients demonstrated adherence to overall therapeutic regimens, including dialysis sessions and medication intake, there was notable nonadherence to fluid and diet restrictions. Poor sleep quality, prevalent among two-thirds of the participants, correlates negatively with adherence to therapeutic regimens.

Platelet count has a U-shaped association with mortality in hemodialysis patients

Our previous manuscript showed that thrombocytopenia predicts all-cause mortality in Chinese hemodialysis (HD) patients. Based on the role of platelets in coagulation, clot formation, and systemic inflammation, we speculate that high platelets increase risk of thrombo-embolic events, hence the mortality. However, research evidence is currently lacking. Therefore, we utilized data from a very large international cohort study to explore the association of platelet counts with mortality and cardiovascular (CV) death in hemodialysis (HD) patients. International data from 396 facilities enrolled in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 5 (2012–2015) were analyzed. Participants were divided into 3 groups according to their platelet counts (low: <100, normal: 100–300, high: >300*109). Associations between platelet counts and all-cause and CV mortality were analyzed using Cox regression, adjusted for confounders. There were 13,631 patients with median age of 65 years old. Males accounted for 61.2%. Mean platelet count was 205*109/L overall and ranged from 173 *109/L in China to 227 *109/L in Sweden. Overall, 2,348 (17.2%) patients died and 1017 (7.5%) died from CV disease. Both low (HR:1.48, 95% CI 1.21–1.80, p < 0.001) and high (HR:1.17, 95% CI 1.00- 1.35, p = 0.044) platelet counts were associated with higher all-cause mortality after adjustment for covariates; results for CV death were consistent. Platelet count has a U-shaped association with all-cause and CV mortality in HD patients, and thus may be used as an outcome predictor that is readily available among HD patients.

Analysis of the dynamics of transition from non-colonization to colonization and Staphylococcus aureus bacteremia in hemodialysis patients using Markov models.

Background Hemodialysis patients are frequently colonized by Staphylococcus aureus, leading to severe infections with high mortality rates. However, little is known about transition from non-colonization to colonization or bacteremia over time. The aim was to analyze the behavior of S. aureus colonization, identifying the probability of transition from non-colonized to colonized state or bacteremia, and the influence of specific covariates. Methods The study was conducted in a dialysis unit associated with a tertiary care hospital in Medellín between October 2017 and October 2019. An initial measurement was taken to evaluate S. aureus colonization, and follow-up measurements were performed 2 and 6 months later. Bacteremia evolution was monitored for 12 months. A two-state recurrent continuous-time Markov model was constructed to model transition dynamics from non-colonization to S. aureus colonization in hemodialysis patients. Subsequently, the model was applied to a third state of bacteremia. Results Of 178 patients on hemodialysis, 30.3% were colonized by S. aureus. Transition intensity from non-colonization to colonization was three times higher (0.21; CI: 0.14-0.29) than from colonization to non-colonization (0.07; CI: 0.05-0.11). The colonization risk increased in patients with previous infections (HR: 2.28; CI: 0.78-6.68), hospitalization (HR: 1.29; CI: 0.56-2.99) and antibiotics consumption (HR: 1.17; CI: 0.53-2.58). Mean non-colonized state duration was 10.9 months, while in the colonized state was 5.2 months. In the 3-state model, it was found that patients colonized were more likely to develop S. aureus infection (13.9%). Conclusion A more likely transition from non-colonization to colonization was found, which increases with factors such as previous infection. In addition, the development of bacteremia was more likely in colonized than in non-colonized patients. These results underline the importance of surveillance and proper management of S. aureus colonization to prevent serious complications, such as bacteremia, and improve prognosis in this vulnerable population.

Ultrasonographic Evaluation of Systemic Venous Congestion in Maintenance Hemodialysis Patients During Fluid Removal.

Fluid overload is a frequent and serious complication in hemodialysis patients. The combination of multiple point of care ultrasound (POCUS) measurements can identify significant venous congestion but its usefulness to determine ultrafiltration (UF) requirements and dry weight is unknown. Therefore, we evaluated prospectively patients in maintenance hemodialysis to establish the correlations between changes in venous congestion parameters and fluid removal. This was a prospective, single-center, observational study. POCUS venous congestion measurments were performed in 22 patients during 32 online post-dilutional hemodiafiltration sessions and findings were correlated with UF volume, central venous pressure and body water composition determined by multifrequency bioelectric impedance analysis (BIA). The pre dialysis weight was on average 1.9 kg above the BIA estimated dry weight, the average initial IVC diameter was <2 cm. An initial abnormal Hepatic Vein (HV) waveform was present in 26% (8) of the measurements. The average UF volume was 2084 ± 655 ml and correlated with changes in inferior vena cava (IVC) diameter (R= 0.34, CI 95% (0.18, 0.56) p < 0.05) but not with any other POCUS venous congestion parameters. Normalization of the IVC diameter and HV waveform was observed during the first UF hour in all initially altered measurements. Diameter reduction in the IVC correlated with total body water volume reduction estimated with BIA when measured immediately after fluid removal (R= 0.34, CI 95% (0.08, 0.56) p<0.05) Conclusion. Reduction in IVC diameter had a modest but significant correlation with UF volume in our patients on maintenance hemodiafiltration. POCUS may be used to monitor patients during UF.