Treatment Of Hemodialysis Patients Research Articles

Intact FGF23 predicts serum phosphate improvement after combined nicotinamide and phosphate binder treatment in hemodialysis patients.

Hyperphosphatemia is associated with increased mortality and cardiovascular morbidity of end-stage kidney failure (ESKF) patients. Managing serum phosphate in ESKF patients is challenging and mostly based on limiting intestinal phosphate absorption with low phosphate diets and phosphate binders (PB). In a multi-centric, double-blinded, placebo-controlled study cohort of maintenance hemodialysis patients with hyperphosphatemia, we demonstrated the efficacy of nicotinamide modified release (NAMR) formulation treatment in addition to standard PB therapy in decreasing serum phosphate. Here we aimed to assess the relationship between phosphate, FGF23, inflammation and iron metabolism in this cohort. We measured the plasma concentrations of intact fibroblast growth factor 23 (iFGF23) and selected proinflammatory cytokines at baseline and Week 12 after initiating treatment. We observed a strong correlation between iFGF23 and cFGF23 (C-terminal fragment plus iFGF23). We identified iFGF23 as a better predictor of changes in serum phosphate induced by NAMR and PB treatment compared with cFGF23. Recursive partitioning revealed at baseline and Week 12, that iFGF23 and cFGF23 together with T50 propensity were the most important predictors of serum phosphate, whereas intact parathyroid hormone (iPTH) played a minor role in this model. Furthermore, we found serum phosphate and iPTH as the best predictors of iFGF23 and cFGF23. Sex, age, body mass index, and markers of inflammation and iron metabolism had only a minor impact in predicting FGF23. Lowering serum phosphate in ESKF patients may depend highly on iFGF23 which is correlated to cFGF23 levels. Serum phosphate was the most important predictor of plasma FGF23 in this ESKF cohort.

Effects of a nurse-led structured home visiting program on quality of life and adherence to treatment in hemodialysis patients.

This study aimed to determine the effects of a nurse-led structured home visit program on quality of life and adherence to treatment in patients undergoing hemodialysis. The study was quasi-experimental research in which 62 hemodialysis patients referred to Bu Ali hospital in Ardabil participated in two groups: Intervention (n = 31) and control (n = 31). The intervention included a structured and planned home visit program that was performed in five stages over 3 months. Data collection tools were a demographic information form, Kidney Disease Quality of Life Short Form (KDQOL-SF™) and End Stage Renal Disease Adherence Questionnaire (ESRD_AQ) which were completed by patients before, at the end of the first, second, and third month of intervention. SPSS v20 software and descriptive and analytical tests (Chi-square, t-test, ANOVA and repeated measure) were used for data analysis. Examining demographic characteristics showed that there is a negative and significant relationship between age and quality of life scores (P = 0.004), that is, with increasing age, the quality of life score decreases, but other demographic characteristics did not have a significant relationship with quality of life scores and adherence to treatment (P > 0.05).Also, the results showed that in the intervention and control groups, during the study, the scores of quality of life and adherence to treatment increased significantly, and this increase was significantly higher in the intervention group than in the control group (P < 0.001).The scores of quality of life and adherence to treatment increased significantly both during the study in each group separately and between groups during the study (P < 0.001). According to the significant improvement in quality of life and adherence to treatment in patients following a home-visiting program during 3 months, these interventions can be utilized to improve quality of life and adherence to treatment of patients undergoing hemodialysis. Home visiting programs significantly improve the level of knowledge of patients undergoing hemodialysis and their family members, through their involvement in the care process. Having said that, it seems plausible to implement home visits in the standard care plans of hemodialysis patients.

Randomized controlled trial of nalfurafine for refractory pruritus in hemodialysis patients

Background Chronic kidney disease-associated pruritus (CKD-aP) is very common and sometimes refractory to treatment in hemodialysis patients. In a trial conducted in Japan, nalfurafine, effectively reduced itching of treatment-resistant CKD-aP. Our present bridging study aimed to evaluate the efficacy and safety of nalfurafine in Chinese cohort with refractory CKD-aP. Methods In this phase III, multicenter bridging study conducted at 22 sites in China, 141 Chinese cases with refractory CKD-aP were randomly (2:2:1) assigned to receive 5 μg, 2.5 μg of nalfurafine or a placebo orally for 14 days in a double-blind manner. The primary end point was the mean decrease in the mean visual analogue scale (VAS) from baseline. Results A total of 141 patients were included. The primary endpoint analysis based on full analysis set (FAS), the difference of mean VAS decrease between 5 μg nalfurafine and placebo group was 11.37 mm (p = .041); the difference of mean VAS decrease between 2.5 μg and placebo group was 8.81 mm (p = .110). Both differences were greater than 4.13 mm, which met its predefined success criterion of at least 50% efficacy of the key Japanese clinical trial. The per protocol set (PPS) analysis got similar results. The incidence of adverse drug reactions (ADRs) was 49.1% in 5μg, 38.6% in 2.5 μg and 33.3% in placebo group. The most common ADR was insomnia, seen in 21 of the 114 nalfurafine patients. Conclusions Oral nalfurafine effectively reduced itching with few significant ADRs in Chinese hemodialysis patients with refractory pruritus.

The effect of positive thinking training on hope and adherence to treatment in hemodialysis patients: a randomized controlled trial

BackgroundPatients undergoing hemodialysis are exposed to psychological problems, such as despair, which in turn can be a trigger for them to abandon the treatment process. This study aimed to determine the effect of positive thinking training on hope and adherence to treatment in hemodialysis patients.MethodsThis randomized controlled trial was performed on 80 hemodialysis patients referred to two hemodialysis centers in Shiraz, Iran. They were randomly divided into an intervention and a control group. Eight sessions of positive thinking skills training carried out individually on the patients' bedsides. The primary and secondary outcomes were hope and adherence to treatment, respectively. The data were collected using Snyder Hope Questionnaire, End-Stage Renal Disease Adherence Questionnaire, laboratory tests, and weight measurements. Data were analyzed by Chi-square and Paired and Independent T-test using SPSS software version 18.ResultsAfter the intervention, the mean score of hope was significantly higher in the intervention group (42.1 ± 6.1) than in the control group (38.7 ± 6.5) (p = 0.024). Moreover, after the intervention, the mean score of adherence to treatment was significantly higher in the intervention group (1070.2 ± 80.1) compared to the control group (1018.4 ± 105.3) (p = 0.019). In addition, blood urea nitrogen, phosphate and inter-dialytic weight gain were lower in the intervention group compared to the control group after the intervention.ConclusionsThe findings showed that positive thinking interventions could lead to improvement in hope and adherence to treatment in hemodialysis patients. Positive thinking training could be used in caring of hemodialysis patients to improve their hope and adherence to treatment.Trial registration RCT Registry: Iranian Registry of Clinical Trials; RCT registration number: IRCT20180915041044N1; Registration date: 19/12/2018.

Casiribimab/imdevimab treatment for hemodialysis patients with COVID-19 infection

血液透析患者の新型コロナウイルス感染症（COVID-19）に対して中和抗体の重症化抑制効果が期待されている．2021年8～9月に当院に入院したCOVID-19血液透析患者のうち，適用基準を満たしカシリビマブ/イムデビマブ（REGEN-COV）を投与した8症例を紹介する．投与例の平均年齢は72.8歳，男性5人,ワクチンの接種歴は2回4人，1回3人であった．COVID-19発症から平均3.8日目にREGEN-COVを投与した．REGEN-COV投与前に肺炎像を4人に認めた．慢性腎臓病以外の重症化リスク因子を7つ認めた症例のうち1人はREGEN-COV投与前に肺炎像を認めなかったが，投与後に新規に酸素需要と肺炎像を認め，13日目に死亡した．REGEN-COV投与後は良好な経過を辿った症例が多かったが，重症肺炎発症例も認めた．血液透析患者においてREGEN-COVは，重症化リスク因子数が多い場合に重症化を予防できない可能性がある．またオミクロン株には有効性が減弱する報告もあり，REGEN-COVの使用には重症化リスク因子数やウイルス株への配慮が必要である．

Long-Term Outcome of a "Mother-Child" Coaxial Dual-Catheter Technique for Percutaneous Transluminal Angioplasty of Central Vein Stenosis or Occlusion in Hemodialysis Patients.

This study aims to evaluate the long-term outcome and prognostic factors of a "mother-child" coaxial dual-catheter technique for percutaneous transluminal angioplasty (PTA) in the treatment of central vein stenosis (CVS) or central vein occlusion (CVO). During September 2017 to August 2020, totally, 76 hemodialysis patients with symptomatic CVS or CVO were treated with PTA using the mother-child technique. The success rate, complications, and follow-up information were collected. Cox proportional hazard analysis was used to explore the predicting factors of primary patency. Primary patency rates of different subgroups were generated with the Kaplan-Meier analysis and compared using the log-rank (Mantel-Cox) test. There were 31 CVS patients and 45 CVO patients who presented with 114 PTAs. The initial procedure success rate was 98.25%. By the end of the follow-up, 57 patients (75%) had maintained functioning fistula after initial or repeated PTAs. The primary patency rates were 88.75% at 3 months, 73.36% at 6 months, 55.83% at 12 months, and 50.75% at 18 months. The secondary patency rates were 97.14% at 6 months, 87.66% at 12 months, and 82.18% at 24 months. The predictors for primary patency were history diabetes mellitus (hazard ratio [HR] = 3.1, 95% confidence interval [CI]: 1.31-7.30, P = .010), abnormal white blood cell count (HR = 1.44, 95% CI: 1.18-1.75, P < .001), lesion at subclavian-innominate vein (HR=2.75, 95% CI: 1.34-5.63, P = .006), and occlusion (HR=0.33, 95% CI: 0.14-0.76, P = .010). The primary patency was significantly lower in the subclavian-innominate vein subgroup, with a median primary patency of 4.5 (3-12.75) months, than in the nonsubclavian-innominate vein subgroup (8.5 [5-13] months; P = .005). The median duration of each PTA was 8 months for the first PTA, 7.5 months for the second PTA, and 5 months for the third PTA. There was no significant difference in the patency duration of repeated PTAs and the primary PTA (P = .389). The mother-child coaxial dual-catheter technique has a good success rate and acceptable primary patency in the treatment of hemodialysis patients with CVS or CVO. Repeated PTA is as effective as the primary PTA. This is the follow up report on the "Mother-Child" coaxial dual-catheter technique for percutaneous transluminal angioplasty of central vein stenosis or occlusion in hemodialysis patients since we first presented it in 2019. In this paper, we can see that the long-term patency rate of this technique for central venous disease is satisfactory, and repeated use of this technique does not affect the patency time. Compared with other literature reports, the surgical success rate of this technique is significantly improved. Therefore, this technique is worth popularizing in the treatment of central venous disease.

Effects of Descurainia sophia on Oxidative Stress Markers and Thirst Alleviation in Hemodialysis Patients: A Randomized Double-Blinded Placebo-Controlled Cross-Over Clinical Trial.

Patients undergoing hemodialysis (HD) are regularly exposed to oxidative stress and inflammation and may suffer from thirst distress with no definitive treatment to address these complications. Descurainia sophia (DS) has been used to alleviate thirst in traditional Persian medicine. This study aimed to assess the effectiveness of DS on oxidation factors and thirst score in HD patients. This study was conducted on fifty-three HD patients referred to Tehran Shahid Modarres hospital. The patients were randomly divided into two groups: Group 1 received DS for six weeks, then underwent four weeks of washout period followed by six weeks of placebo treatment, while group 2 received placebo initially followed by treatment with DS. Biochemistry, malondialdehyde (MDA), and total antioxidant capacity (TAC) were measured in four phases: at the beginning, before washout, after washout, and at the end of the study. The patient's body weight was recorded at the start of each session to assess interdialytic weight gain. Thirst scores also were measured using a visual analog scale. A total of 53 patients, including 23 (43.4%) male and 30 (56.6%) female subjects, were included in the study. The results showed a reduction in thirst score (p=0.001), cholesterol levels (p=0.046), triglycerides (0.003), and MDA (p < 0.001) following the four-week administration of DS treatment in HD patients. The mean levels of TAC were increased (p < 0.001), and calcium, as well as Na+, remained unchanged (p > 0.05). Also, a significant decrease in the patient's weight was observed (p value <0.001). This effect persisted after shifting to a placebo. However, the two groups had no significant difference (p value = 0.539). DS powder-mixed syrup may benefit HD patients by facilitating free radical scavenging and alleviating thirst distress with minimal adverse effects. The seeds could therefore be utilized as a complementary therapy for hemodialysis patients.

Impact of Hydrophilic Modification of Synthetic Dialysis Membranes on Hemocompatibility and Performance.

The dialyzer is the core element in the hemodialysis treatment of patients with end-stage kidney disease (ESKD). During hemodialysis treatment, the dialyzer replaces the function of the kidney by removing small and middle-molecular weight uremic toxins, while retaining essential proteins. Meanwhile, a dialyzer should have the best possible hemocompatibility profile as the perpetuated contact of blood with artificial surfaces triggers complement activation, coagulation and immune cell activation, and even low-level activation repeated chronically over years may lead to undesired effects. During hemodialysis, the adsorption of plasma proteins to the dialyzer membrane leads to a formation of a secondary membrane, which can compromise both the uremic toxin removal and hemocompatibility of the dialyzer. Hydrophilic modifications of novel dialysis membranes have been shown to reduce protein adsorption, leading to better hemocompatibility profile and performance stability during dialysis treatments. This review article focuses on the importance of performance and hemocompatibility of dialysis membranes for the treatment of dialysis patients and summarizes recent studies on the impact of protein adsorption and hydrophilic modifications of membranes on these two core elements of a dialyzer.

Evaluation of polypharmacy and adherence to the phosphorus binding treatment in hemodialysis patients

Evaluation of polypharmacy and adherence to the phosphorus binding treatment in hemodialysis patients

Covalent Organic Framework Based on Azacalix[4]arene for the Efficient Capture of Dialysis Waste Products.

Azacalix[n]arenes (ACAs) are lesser-known cousins of calix[n]arenes that contain amine bridges instead of methylene bridges, so they generally have higher flexibility due to enlarged cavities. Herein, we report a highly substituted cationic azacalix[4]arene-based covalent organic framework (ACA-COF) synthesized by the Zincke reaction under microwave irradiation. The current work is a rare example of a synthetic strategy that utilizes the chemical functionalization of an organic macrocycle to constrain its conformational flexibility and, thereby, produce an ordered material. Considering the ACA cavity dimensions, and the density and diversity of the polar groups in ACA-COF, we used it for adsorption of uric acid and creatinine, two major waste products generated during hemodialysis treatment in patients with renal failure. This type of application, which has the potential to save ∼400 L of water per patient per week, has only been recognized in the last decade, but could effectively address the problem of water scarcity in arid areas of the world. Rapid adsorption rates (up to k = 2191 g mg–1 min–1) were observed in our COF, exceeding reported values by several orders of magnitude.

Effects and Clinical Value of Peritoneal Dialysis on Water and Water Balance, Adverse Reactions, Quality of Life, and Clinical Prognosis in Patients with Decompensated Chronic Nephropathy: A Systematic Review and Meta-Analysis.

Objective To systematically evaluate the effects of peritoneal dialysis and hemodialysis on renal function and quality of life in patients with end-stage renal disease. An evidence-based medical rationale would be provided for peritoneal dialysis or hemodialysis treatment in patients with end-stage renal disease. Methods The PubMed, EMBASE, ScienceDirect, Cochrane Library, China National Knowledge Infrastructure (CNKI), China VIP Database, Wanfang, and China Biomedical Literature Database (CBM) online databases were searched. Comparisons on the effects of peritoneal dialysis on renal function and quality of life were taken between patients with end-stage renal disease (RD). The data were extracted independently by two researchers. The bias-risk-included literatures were assessed according to the Cochrane manual 5.1.0 standard. RevMan 5.4 statistical software was used to analyze the collected data via meta-analysis. Results Seven RCT articles were finally included. A total of 745 samples were analyzed via meta-analysis. The obvious heterogeneities of serum creatinine (Scr) and blood urea nitrogen (BUN) were discovered (P < 0.00001) in the selective investigations. According to the results of this analysis, it was indicated that the renal function of patients with end-stage renal disease treated by peritoneal dialysis was significantly better than that of hemodialysis. According to the meta-analysis, there was obvious heterogeneity of life quality among the included research data. It was indicated that the score of quality of life of patients with end-stage renal disease treated by peritoneal dialysis was significantly better than that of hemodialysis. Conclusion Compared with hemodialysis in the treatment of end-stage renal disease, the renal function and quality of life of patients with peritoneal dialysis are better than those of hemodialysis. More further studies and follow-up with higher methodological quality and longer intervention time are still needed for further verification.

Mid-term results of stent-less coronary intervention using rotational atherectomy and drug-coated balloon for de-novo lesions in hemodialysis patients.

Although drug-coated balloon (DCB)-based stent-less percutaneous coronary intervention (PCI) for de-novo lesions has attracted more attention, outcomes of the DCB procedure for hemodialysis (HD) patients are reported to be inferior to those for non-HD patients, similarly to drug-eluting stent (DES). Recent several reports have shown that rotational atherectomy (RA) followed by DCB treatment (RA/DCB) could be an option of revascularization strategy particularly for calcified de-novo lesions even in the new-generation DES era; however, efficacy of the RA/DCB procedure for HD patients remains unclear. A total of 47 consecutive cases (53 lesions) undergoing RA/DCB for de-novo lesions were enrolled. According to the presence/absence of HD at baseline, the 47 cases were divided into the HD cases (N.=16) and the non-HD cases (N.=31), and the 53 lesions were divided into the HD lesions (N.=20) and the non-HD lesions (N.=33). The HD cases had a significantly lower prevalence of dyslipidemia and smoking than the non-HD cases. Final RA burr size, DCB diameter used, and angiographic success rate of PCI did not significantly differ between the 2 groups. Preprocedural, post-procedural, and follow-up QCA parameters were also similar between the 2 groups. Twelve-month clinical outcomes were comparable between the 2 groups. Mid-term outcomes of stent-less PCI using RA/DCB for de-novo lesions in HD patients might be comparable to those in non-HD patients, suggesting efficacy of pretreatment of RA prior to DCB treatment in HD patients.

The efficacy of favipiravir treatment in hemodialysis patients with COVID 19

Corona Virus 2 (SARS-CoV 2), a recent coronavirus was first discovered in Wuhan, China in December 2019 [1]. Previous coronavirus infections, namely Middle-East Respiratory Syndrome (MERS-CoV ) and SARS-CoV have been reported to damage the respiratory system and cause serious outbreaks [2]. Major complaints are shortness of breath, cough, fever, and diarrhea [3,4]. Lung involvement is the most common form of infection, and is characterized by bilateral lung infiltrates [5,6]. The infection leads to cytokine storm and organ dysfunction and may consequently death. The diagnosis is suspected in presence of contact history, respiratory symptoms, fever, chest radiology, and biochemical parameters. The diagnosis is confirmed with Reverse Transcription-Polymerase Chain Reaction (RT PCR) positivity for COVID-19 in the nasopharyngeal swab [7]. It has been reported that elderly patients are more prone to severe coronavirus disease, just as in hemodialysis patients with additional comorbidities [5]. Since the immune system is low in Chronic Kidney Disease (CKD) patients, their tendency to infections is increased [8,9]. Good supportive treatment and infection treatment should be done [10]. CKD is also associated with an increased risk for pneumonia. Mortality rates related to lung infection in CKD seem to be 15-16 times higher than in the general population [9,11]. The use of several antiviral drugs, such as chloroquine phosphate, lopinavir/ritonavir, interferonalpha, ribavirin has been studied, and some clinical trials focusing on virus RNA dependent RNA Polymerase (RdRp) inhibitors have been initiated. Favipiravir, a purine-nucleic acid analog and RdRp inhibitor which has been approved for use in influenza, is also considered in clinical trials [12,13]. The data on dialysis-dependent patients with COVID-19 are limited, and recommendations are based on expert opinion and case series. There are no studies about the use of favipiravir in patients with renal failure in the literature. In this study, we aimed to describe our experience of favipiravir treatment in dialysis-dependent patients.

Potential role of Niacin as Adjuvant to Sevelamer on Serum levels of Inorganic phosphorus, Calcium and Calcium-phosphorus product in Hemodialysis patients with Hyperphosphatemia

Hyperphosphatemia is a serious biochemical abnormality that affected almost patients undergoing maintenance hemodialysis and has independent association with high risk of mortality due to cardiovascular diseases. The mechanism linking hyperphosphatemia to cardiovascular mortality is vascular calcification that it is promoted by elevated serum phosphorus level. The control of hyperphosphatemia remains a major challenge. All currently phosphate binders have requirement for dosing with each meals that contributed to high pill burden and reduce patient compliance. Calcium-based binders preferred to be avoided due to their high risk of vascular classification, while the expensiveness of non-calcium based binder represent their major drawbacks. Niacin; a naturally occurring water-soluble vitamin and the first used antidyslipidemic drug, has been demonstrated to show therapeutic potential for hyperphosphatemia treatment in hemodialysis patients. It decreases phosphorus absorption in the GIT, thereby lowering serum phosphorus level. This study is designed to evaluate the efficacy of niacin as adjuvant therapy to sevelamer carbonate (as a phosphate binder) in hemodialysis patients. This prospective, randomized clinical trial was conducted among patients with hyperphosphatemia. Seventy nine patients were enrolled in this study; only 39 patients completed the study. Thirty nine patients were assigned randomly into two groups; group (1) 19 patients treated with sevelamer alone (2400mg/day), group (2) 20 patients treated with a combination of sevelamer (2400mg/day) and niacin (1000 mg/day) for 2 months . Clinical outcomes (Pi, Ca, Ca x P product) serum levels were evaluated at time of enrolment, after 1 month and after 2 month of treatment. Results of this study showed that the patients who administered orally niacin as adjuvant to sevelamer had the superiority over using sevelamer alone in the reduction of both serum phosphorus level and (Ca x P) product level (-30% and -37%) respectively after 2 months of treatment in respect to baseline levels. Meanwhile, there was no statistically significant difference observed in serum calcium level. Administration of niacin for hemodialysis patients is an effective strategy for reducing the serum levels of inorganic phosphorus and calcium-phosphorus product which subsequently reduce risks of cardiovascular diseases associated with hyperphosphatemia.

Effect of spironolactone on vascular stiffness in hemodialysis patients: a randomized crossover trial.

BackgroundThe role of spironolactone treatment in hemodialysis patients is debated, but a survival benefit is suggested. Mineralocorticoids and chronic kidney disease have been linked to cardiovascular fibrosis. Therefore, we hypothesized that spironolactone would affect vascular stiffness, cardiac systolic, and diastolic function in hemodialysis patients.MethodsThis was a randomized crossover study in hemodialysis patients supplemented with an echocardiographic case series. All outcomes reported here were secondary in the trial and were assessed without blinding. Block randomization and allocation determined treatment order. Participants received 50 mg spironolactone daily for 12 weeks and untreated observation for another 12 weeks. Pulse wave velocity (PWV) was measured before and after treatment and observation. Doppler-echocardiography was conducted before and after treatment. Systemic arterial compliance indexed to body surface area (SACi), left ventricular ejection fraction (LVEF), the peak early diastolic mitral inflow velocity (E), the peak late diastolic mitral inflow velocity (A), and the peak early diastolic myocardial lengthening velocity (E’) were measured. E/A and E/E’ were then calculated. Statistical analyses were conducted per protocol. A generalized linear mixed model with random participant effects was used for PWV. The Wilcoxon signed-rank test was used for echocardiographic variables.ResultsThirty participants were recruited, 18 completed follow-up, and 17 were included in PWV-analyses. Spironolactone treatment showed a tendency toward an increase in PWV of 1.34 (95% confidence interval: −0.11 to 2.78) m/s, which was not statistically significant (P = 0.07). There were no significant changes in any of the other variables (LVEF, E/A, E/Eʹ, or SACi).ConclusionsWe found no evidence supporting an effect of 12-week administration of spironolactone 50 mg daily on vascular stiffness, cardiac systolic, or diastolic function in hemodialysis patients.

Point-of-Care Ultrasound (POCUS) for Dialysis Patients: A Step Forward

Point-of-care ultrasound (POCUS) refers to the use of portable ultrasound systems by clinicians at a patient’s bedside for diagnostic and therapeutic purposes. It is not a substitute but rather a complement to clinical examination, and contrary to the classic ultrasound examination performed by radiologists, POCUS is not a detailed morphologic examination but focuses on answering specific clinical questions in an effort to reduce time to diagnosis and treatment, improve patient safety and decrease complication rates. In this article, we present the POCUS in hemodialysis units for and beyond vascular-access purposes, arguing that its implementation will help the practicing nephrologist who is treating hemodialysis patients on a daily basis to rapidly and efficiently answer several clinical questions that are common to dialysis patients, such as vascular-access assessment and cannulation, and assessment of volume status. POCUS aims to answer specific clinical questions, so a question-answer format is used. This review is divided in two parts. In the first part we will answer specific clinical questions exclusively concerning vascular access. The second part is dedicated to the use of POCUS for the assessment of volume status and dry-weight determination.

Predictors of Adherence to Treatment in Hemodialysis Patients: A Structural Equation Modeling.

Background: Non-compliance to the treatment is a major problem in hemodialysis patients. This study aimed to determine factors predicting adherence to treatment in hemodialysis patients in selected cities of Khuzestan province, Iran. Methods: This cross-sectional study was conducted on 500 patients undergoing hemodialysis in Ahvaz, Shush, Shushtar, and Dezful cities. The data collection tools were ESRD-AQ, perceived health, perceived social support, Beck Depression, self-efficacy, and demographic and clinical factors questionnaires. Data were analyzed using descriptive statistics, t-test, ANOVA, and Pearson’s correlation coefficient. Structural equation modeling (SEM) was employed to analyze the relationship between various exogenous and endogenous or mediating variables. Results: The results showed that all predicting variables of perceived social support, depression, self-efficacy, and perceived health had been associated with the variable of adherence to treatment. Accordingly, there was a reverse correlation between social support and depression (p< 0.001, r= -0.94), as well as depression and self-efficacy (p< 0.001, r= -0.87). There was a direct correlation between self-efficacy and perceived health (p< 0.001, r= 0.79), perceived health and adherence to treatment (p< 0.001, r= 0.72). Fitness indices also indicate the adequacy of the proposed model (X2/df= 4.94, CD=0.937, SRMR=0.076, TLI= 0.870, CFI= 0.873, RMSEA= 0.071). Conclusion: The results showed that high social support, low level of depression, high perceived self-efficacy, and high perceived health predicted better compliance with the treatment in hemodialysis patients. The proposed model can be used as a framework to improve adherence to treatment regimens in hemodialysis patients.

The impact of CASR A990G polymorphism in response to cinacalcet treatment in hemodialysis patients with secondary hyperparathyroidism

The objective of this study was to determine the impact of calcium sensing receptor (CASR) A990G genetic polymorphism on parathyroid hormone (PTH) lowering response to cinacalcet treatment when controlling for significant influencing clinical factors. This retrospective study was conducted on 135 Thai hemodialysis (HD) patients with secondary hyperparathyroidism (SHPT). CASR A990G genotypes were determined. The patients were identified as either G carriers (heterozygous or homozygous CASR 990G allele carriers) or noncarriers (homozygous CASR 990A carriers). Tested covariates were baseline PTH level (bPTH), baseline serum phosphate (bPhos), baseline serum calcium (bCa), baseline calcitriol equivalent dose (bCtriol), baseline ergocalciferol dose (bErgo), and age. The ANCOVA showed that intact PTH levels after 12 weeks of cinacalcet treatment (PTHw12) was significantly lower among G carriers compared with noncarriers after controlling for bPTH, bPhos, bCtriol, and bErgo (F(1, 127) = 15.472, p < 0.001), with the adjusted mean difference of 253.7 pg/mL. The logistic regression analysis revealed that the odds of a G carrier achieving 30% PTH reduction after 12-week cinacalcet treatment were 3.968 times greater than the odds for a noncarrier after adjusting for bPhos, bCtriol, and age. In conclusion, the CASR A990G polymorphism significantly influences cinacalcet response in HD patients with SHPT.

Use of Sertraline in Hemodialysis Patients.

Depression and anxiety are the most common psychiatric disorders in end-stage renal disease (ESRD) patients treated with hemodialysis (HD) and may correlate with lower quality of life and increased mortality. Depression treatment in HD patients is still a challenge both for nephrologists and psychiatrists. The possible treatment of depressive disorders can be pharmacological and non-pharmacological. In our article, we focus on the use of sertraline, the medication which seems to be relatively safe and efficient in the abovementioned population, taking under consideration several limitations regarding the use of other selective serotonin reuptake inhibitors (SSRIs). In our paper, we discuss different aspects of sertraline use, taking into consideration possible benefits and side effects of drug administration like impact on QTc (corrected QT interval) prolongation, intradialytic hypotension (IDH), chronic kidney disease-associated pruritus (CKD-aP), bleeding, sexual functions, inflammation, or fracture risk. Before administering the medication, one should consider benefits and possible side effects, which are particularly significant in the treatment of ESRD patients; this could help to optimize clinical outcomes. Sertraline seems to be safe in the HD population when provided in proper doses. However, we still need more studies in this field since the ones performed so far were usually based on small samples and lacked placebo control.

Long-term results and patient survival after first rib resection and endovascular treatment in hemodialysis patients with subclavian vein stenosis at the thoracic outlet

ObjectiveHemodialysis patients with upper extremity vascular access and subclavian vein stenosis at the thoracic outlet can present with significant arm edema and threatened dialysis access that is frequently refractory to endovascular therapy without bone decompression. We have presented our long-term results of first rib resection, followed by endovascular therapy. MethodsWe performed a retrospective review of 15 consecutive hemodialysis patients with subclavian vein stenosis treated with first rib resection and endovascular therapy from 2013 to January 2021. The diagnosis was confirmed by ultrasound and venography. Bone decompression was performed with transaxillary or infraclavicular rib resection. ResultsDuring the study period, we treated 1440 unique dialysis patients. Of these 1440 patients, 346 had undergone subclavian vein angioplasty. Of the 346 patients, 15 had undergone first rib resection and were the subject of the present report. Of the 15 patients, 10 were women and 5 were men. Their mean age was 56.4 years (range, 30-82 years). The most commonly associated medical conditions were hypertension and diabetes. The mean previous hemodialysis duration was 5.4 years (range, 1-13 years). Fourteen patients had preexisting functioning access and severe arm edema. Nine patients (60%) with subclavian vein occlusion had undergone vein recanalization before the bone decompression procedure. Of the 15 patients, 5 had undergone transaxillary and 10 had undergone infraclavicular first rib resection. In addition, nine patients had undergone simultaneous vein stenting, six had undergone vein stenting within 4 weeks, and one had undergone stenting at 13 months. A stent-graft was used in eight patients and a bare metal stent was used in seven. All preexisting dialysis access sites were used the day after the procedure. The average postoperative stay was 2.6 days (range, 1-8 days). No complications developed. The average follow-up was 35.13 months (range, 4-86 months). The freedom from any subsequent intervention was 50% at 10.5 months. The average number of endovascular procedures per patient during follow-up was 4.6. Ten patients had required access surgery during follow-up. Secondary patency was 100%. The median patient survival was 69.3 months. ConclusionsSymptomatic hemodialysis patients with threatened vascular access caused by subclavian vein stenosis at the thoracic outlet were safely and successfully treated with first rib resection, followed by endovascular techniques. The procedure resulted in no morbidity and preserved dialysis access function in all patients during follow-up. Our experience has confirmed that excellent secondary patency and long-term clinical success can be obtained with regular follow-up, although with multiple secondary interventions. The median survival of 69 months after the procedure suggests it is worthwhile to expend this effort to maintain the hemodialysis access function of these patients.