Treatment Of Hemodialysis Patients Research Articles

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.

Outcome of Treatment for Hepatitis C Infection in Hemodialysis Patients with Direct-Acting Second-Generation anti-HCV Drugs at Azzawiyah Kidney Hospital, Libya

Background: Hepatitis C virus infection is the most common viral infection in patients on hemodialysis and is a leading cause of chronic liver disease in end-stage renal disease patients. The main aim of this study was to review the outcome of the treatment of HCV in hemodialysis patients with second-generation anti-HCV drugs at Azzawiyah Kidney Hospital. Patients and Methods: Thirty-two hemodialysis patients with proven HCV infection (HCV-polymerase chain reaction-positive) received antiviral treatment for 12 weeks and followed up for 12 months, with liver function tests and repeated HCV-RNA. The primary outcome was the proportion of patients who achieved sustained virological response at 12 weeks posttreatment (SVR-12). Results: 32 patients (32/280, 11.4%) out of the total number of (280) regular hemodialysis patients were proven to have HCV infection, during the period from December 2016 to December 2019. The median age of the study population was 53.5 ± 12 years, and 55% were females. The median duration of dialysis was 9.6 years (range 3–25 years). The causes of chronic kidney disease were diabetes mellitus at 43.7%, hypertension at 25.5%, adult polycystic kidney disease at 12.5%, and chronic glomerulonephritis at 9.3%. Twenty nine (29/32) patients received antiviral treatment with sofosbuvir/daclatasvir (SOF/DLC) and (3/32) patients with elbasvir and grazoprevir (ERB/GZR). 96.9% of SOF/DLC achieved SVR 12 and 100% of EBR/GSR by the end of the treatment, only one patient (3.1 %) failed to achieve it. No significant side effects were reported for the treatment drugs. Conclusion: This study confirmed that the treatment of hemodialysis patients with chronic hepatitis C infection with second-generation anti-HCV drugs is safe and has elicited a sustained negative virological response.

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.

Interleukin-31 Serum And Pruritus Dimension After Acupuncture Treatment In Hemodialysis Patients: A Randomized Clinical Trial

BACKGROUND: Interleukin (IL)-31 serum levels were significantly higher in hemodialysis patients with pruritus, whereas acupuncture in LI11 was shown to improve symptoms of pruritus. However, there is limited information that IL-31 serum levels that correlate with decreased dimensions of the pruritus after acupuncture in LI11 in a hemodialysis patient. AIM: The aim of the study was to demonstrate the impact of acupuncture in LI11 and IL-31 serum level and its correlation with dimensions of the pruritus in hemodialysis patients. METHODS: A randomized clinical trial has been carried out from August 2019 to December 2019 at H. Adam Malik General Hospital, Medan, Indonesia. Sixty patients underwent hemodialysis who were randomly allocated to two groups, one group got acupuncture in Quchi LI11 (intervention group), and the other group got a placebo (control group). IL-31 serum levels and pruritus were measured before and after 6 weeks of acupuncture in both groups. RESULTS: Acupuncture did not significantly reduce IL-31 (p = 0.931) and decreased dimensions: Degree, duration, disability, and distribution of the pruritus between the intervention group and the control group after 6 weeks of acupuncture in LI11. It can be shown that there is no significant correlation between IL-31 serum levels and dimensions of the pruritus. CONCLUSION: This study demonstrates the effect of acupuncture on reducing dimensions of the pruritus not related to IL-31 serum levels. Identifying the action mechanism of acupuncture to minimize pruritus considerably enhances knowledge of the impacts of acupuncture on reducing pruritus in hemodialysis patients.

Two Faces of Vitamin C in Hemodialysis Patients: Relation to Oxidative Stress and Inflammation.

Hemodialysis (HD) is the most common method of renal replacement therapy. Besides toxins, it eliminates nutrients from the circulation, such as ascorbic acid (AA). HD-patients present AA deficiency more often than representatives of the general population, also due to dietary restrictions. This condition aggravates oxidative stress and inflammation related to uremia and extracorporeal circulation and increases cardiovascular risk followed by mortality. Supplementation of AA seems to be a promising approach in the treatment of hemodialysis patients. Many successful interventions restored plasma AA concentration in HD patients by enteral or intravenous supplementation, concomitantly inhibiting oxidative stress and inflammation. A significant number of studies reported opposite, serious pro-oxidant effects of AA. In this narrative review, we present studies, commenting on their limitations; on AA plasma or serum concentration and the influence of its supplementation on protein and lipid peroxidation, DNA damage, reactive oxygen species generation, paraoxonase activity, advanced glycation endproducts, and C-reactive protein (CRP) concentration. Moreover, in terms of safety, the possible development of oxalosis in HD patients regarding the intravenous or enteral route of AA administration is discussed. Unequivocal clinical results of recent studies on hemodialysis patients are displayed.

The Effect of Family Empowerment Model on Self-care in Hemodialysis Patients of Zahedan, Iran

Background: Self-care is one of the important aspects of treatment in hemodialysis patients. This study was done to determine the effect of the family-centered empowerment model on the self-care of hemodialysis patients. Methods: This study was performed on 100 hemodialysis patients referring to the Zahedan hemodialysis department in 2018. For the intervention group, the family-centered empowerment model was executed in four stages, including understanding the threat, problem-solving, educational participation, and evaluation according to the steps of the model, and the control group received the usual care of the department. The data collection tools were the demographic information questionnaire and self-care questionnaire. Data were analyzed using SPSS V.22 by analysis of variance (ANOVA), independent t-test, repeated measures t-test, and Chi-square test. Results: Based on the independent t-test, the mean self-care score of patients in the intervention and control group was significantly different (P &lt; 0.001). There was a significant difference in the "main caregiver relation" variable (P = 0.006). The results of the "time" and "intervention" effects of this test also showed that these two variables had a significant effect on mean self-care scores (P &lt; 0.001). The results of ANOVA showed that self-care score changed in the two groups there was an increase in the self-care score in the intervention group compared with the control group (P &lt; 0.001). Conclusions: Implementing the family-centered empowerment model in hemodialysis patients by strengthening the ability of the patient and their families to care provides a platform for their promotion and maintenance of their self-care.

The effective use of hyperbaric oxygen therapy (HBOT) in the management of air embolism – rare and potentially fatal acute complication of hemodialysis

Introduction: Air embolism is a rare and potentially fatal acute complication. Its causes are mainly iatrogenic. It requires rapid diagnostics and treatment, including hyperbaric oxygen therapy (HBOT). Aim: The main aim was to present the potential causes of air embolism during hemodialysis (HD) and show the importance of quick clinical diagnosis and therapy – on the base of clinical case. Case study: 65-years old male patient with diabetic nephropathy was treated with HD. The permanent dialysis catheters were used as vascular access due to the difficulties with formation of arteriovenous fistula. The massive air embolism occurred during one of the dialysis sessions. The clinical suspicion was confirmed by CT scan which showed the presence of gas bubbles in abdominal arteries. The cause of air embolism was sensor failure. The presence of patent foramen ovale (PFO) with reversed leakage caused the air ingress into arterial system. Patient was qualified for the immediate hyperbaric therapy. The quick improvement in the condition of the patient took place. Results and discussion: The massive air embolism may occur in HD patients, particularly in those who are dialyzed with use of catheters as vascular access. This rare complication should be considered in the case of sudden worsening of patient condition during HD procedure. The use of CT scan to confirm the air embolism suspicion and availability of HBOT are necessary for successful management of this complication. Conclusions: HBOT is a safe and effective method of air embolism treatment in HD patients.

Comparison of the effect of educational and self-management interventions on adherence to treatment in hemodialysis patients: A systematic review and meta-analysis of randomized controlled trials.

Adherence to fluid intake, diet, and drug management is very important in hemodialysis patients. Educational and self-management interventions are frequently used to improve adherence to treatment in hemodialysis patients. To synthesize a comparison of the effect of educational and self-management interventions on adherence to treatment in hemodialysis patients in randomized controlled trials. Systematic searches were conducted using 11 multidisciplinary databases in June 2020. The PRISMA checklist was used. The subgroup analysis was used to compare the effect of educational and self-management interventions on adherence to fluid intake, diet, and drug management. In the included studies, educational interventions were performed ranging from 15 to 60minutes, in 1-72 sessions. Self-management interventions were performed ranging from 10 to 120minutes, in 1-84 sessions. The overall effect of educational interventions was small on adherence to fluid intake (P=.019, Hedges' g=-0.39), diet in serum phosphorus level (P=.001, Hedges' g=-0.35), drug management (P=.002, Hedges' g=-0.44), and not significant on adherence to diet in serum potassium level (P=.181). The overall effect of self-management interventions was small on adherence to fluid intake (P=.001, Hedges' g=-0.19) and diet in serum phosphorus level (P<.001, Hedges' g=-0.42). Additionally, the overall effect of self-management interventions was moderate on adherence to diet in serum potassium level (P=.002, Hedges' g=-0.75) and drug management (P<.001, Hedges' g=-0.55). There was no difference between the educational and self-management interventions on adherence to fluid intake, diet, and drug management (P>.05). The analysis shows that educational and self-management interventions had a beneficial effect on adherence to fluid intake, diet, and drug management and no difference between these interventions. Therefore, these interventions can be used by healthcare professionals. It is also recommended that these interventions be well defined and transferable to routine clinical practice.

RELATIONSHIP SOCIAL SUPPORT AND RESILIENCE WITH STRESS LEVELS OF FAMILY CAREGIVERS HEMODIALYSIS PATIENTS SURABAYA

Introduction: Hemodialysis is a life-long treatment for end-stage renal disease (ESRD). ESRD has physical and psychosocial challenges to experience stress which not only affects but patients but also family members who care for them or also called family caregivers. Analyzing the relationship of social support and resilience to the level of stress in the family caregiver of hemodialysis patients at Haji Hospital Surabaya.Methods: A cross-sectional study with a population of family caregiver members of hemodialysis patients at RSU Haji Surabaya. The sample size was 92 respondents with criteria, namely families who treat hemodialysis patients at RSU Haji Surabaya, live in one house with patients, aged &gt; 18 years, and can read and write. The variables of this study are social support, resilience, and stress levels. Data collection was performed using a questionnaire and analyzed using Spearman’s Rho test. Results : There was a significant negative relationship between social support and stress levels (p = 0.004 and r = -0.296) and resiliency with stress levels (p = 0.003 and r = -0.311).Discussion: The level of stress in a family caregiver hemodialysis patient can be influenced by the social support received and the level of resilience they have. The social support has an important role for family caregivers obtained from the family and significant other.

Replicating Randomized Trial Results with Observational Data Using the Parametric g-Formula: An Application to Intravenous Iron Treatment in Hemodialysis Patients.

BackgroundReproducibility of clinical and epidemiologic research is important to generalize findings and has increasingly been scrutinized. A recently published randomized trial, PIVOTAL, evaluated high vs low intravenous iron dosing strategies to manage anemia in hemodialysis patients in the UK. Our objective was to assess the reproducibility of the PIVOTAL trial findings using data from a well-established cohort study, the Dialysis Outcomes and Practice Patterns Study (DOPPS).MethodsTo overcome the absence of randomization in the DOPPS, we applied the parametric g-formula, an extension of standardization to longitudinal data. We estimated the effect of a proactive high-dose vs reactive low-dose iron supplementation strategy on all-cause mortality (primary outcome), hemoglobin, two measures of iron concentration (ferritin and TSAT), and erythropoiesis-stimulating agent dose over 12 months of follow-up in 6325 DOPPS patients.ResultsComparing high- vs low-iron dose strategies, the 1-year mortality risk difference was 0.020 (95% CI: 0.008, 0.031) and risk ratio was 1.20 (95% CI: 1.07, 1.33), compared with null 1-year findings in the PIVOTAL trial. Differences in secondary outcomes were directionally consistent but of lesser magnitude than in the PIVOTAL trial.ConclusionOur findings are somewhat consistent with the recent PIVOTAL trial, with discrepancies potentially attributable to model misspecification and differences between the two study populations. In addition to the importance of our results to nephrologists and hence hemodialysis patients, our analysis illustrates the utility of the parametric g-formula for generalizing results and comparing complex and dynamic treatment strategies using observational data.

Older Age and High Serum Ferritin Levels Associated With the Risk of Chronic Cytopenia in Hemodialysis Patients.

Leukopenia or thrombocytopenia is sometimes observed in end-stage renal disease (ESRD) patients, but the association between chronic leukopenia or thrombocytopenia and hemodialysis (HD) is still unclear. We aimed to investigate the incidence of chronic leukopenia or thrombocytopenia in patients with ESRD who received HD and to determine the risk factors of this complication. We retrospectively analyzed ESRD patients treated with HD at Ditmanson Medical Foundation Chia-Yi Christian Hospital in 2018. The risk factors for the occurrence of chronic leukopenia and thrombocytopenia were analyzed by Cox regression models. Of the 473 patients in our study cohort, 46 (9.7%) patients had a hematologic abnormality, including 18 patients with chronic leukopenia, 18 with chronic thrombocytopenia, and 10 with pancytopenia. Multivariate analysis revealed that patient age ≥60 years at the initiation of dialysis was a significant predictor for both chronic leukopenia [adjusted hazard ratio (aHR), 2.71; 95% confidence interval (CI), 1.06-6.89] and chronic thrombocytopenia (aHR, 2.83; 95% CI, 1.08–7.35). Chronic liver disease (aHR, 3.31; 95% CI, 1.27–8.61) and serum ferritin levels >800 mg/dl (aHR, 3.29; 95% CI, 1.29–8.39) were risk factors for chronic thrombocytopenia. A trend showed that vitamin D from intravenous supplementation (aHR, 0.13; 95% CI, 0.01–1.16, P = 0.066) and serum phosphorous level (aHR, 0.73; 95% CI, 0.53–1.02, P = 0.068) may be associated with chronic thrombocytopenia. Our study demonstrated that hematological abnormality was a long-term complication of HD. These results reveal that older patients with HD and high serum ferritin levels are at an elevated risk for chronic cytopenia. Healthcare professionals should be aware of this risk when treating HD patients in order to improve their prognosis.

Elevated Circulating Cell-Free DNA in Hemodialysis-Treated Patients Is Associated with Increased Mortality

Background: Predicting the mortality risk of patients un­dergoing hemodialysis (HD) is challenging. Cell-free DNA (cfDNA) is released into circulation from dying cells, and its elevation is predictive of unfavorable outcome. In a pilot study, we found post-HD cfDNA level to be a predictor of all-cause mortality. Thus, the aim of this study was to confirm the prognostic power of cfDNA in a larger prospective cohort study conducted at 2 medical centers. Methods: CfDNA levels were measured by a rapid fluorometric assay on sera obtained before and after 1 HD session. One hundred fifty-three patients were followed up to 46 months for mortality during which time 47 patients died. We compared the predictive value of cfDNA to age, comorbidities, and standard blood tests. Results: Examining standard blood tests, only post-HD cfDNA levels were elevated in the non-survivor group compared to survivors (959 vs. 803 ng/mL, p = 0.04). Pre- and post-HD cfDNA levels correlated with age and diabetes. Patients with elevated cfDNA (>850 ng/mL) showed lower survival than those with normal levels. A Cox proportional hazard regression model demonstrated a significant hazard ratio of 1.92 for post-HD cfDNA levels. Logistic regression models showed that post-HD cfDNA was a significant predictor of mortality at 1–3 years with odd ratios of 4.61, 4.36, and 6.22, respectively. Conclusions: Post-HD cfDNA level was superior to standard blood tests and could serve as a biomarker to assist in decision-making for HD-treated patients.

Treating Home Versus Predialysis Blood Pressure Among In-Center Hemodialysis Patients: A Pilot Randomized Trial

Observational studies have reported a U-shaped association between blood pressure (BP) before a hemodialysis session and death. In contrast, because a linear association between out-of-dialysis-unit BP and death has been reported, home BP may be a better target for treatment. To test the feasibility of this approach, we conducted a pilot trial of treating home versus predialysis BP in hemodialysis patients. A 4-month, parallel, randomized, controlled trial. 50 prevalent hemodialysis patients in San Francisco and Seattle. Participants were randomly assigned using 1:1 block randomization, stratified by site. To target home systolic BP (SBP)of 100-<140 mm Hg versus predialysis SBP of 100-<140mm Hg. Home and predialysis SBPs were ascertainedevery 2 weeks. Dry weight and BP medications were adjusted to reach the target SBP. Primary outcomes were feasibility, adherence, safety. and tolerability. 50 of 70 (71%) patients who were approached agreed to participate. All enrollees completed the study except for 1 who received a kidney transplant. In the home BP treatment group, adherence to obtaining/reporting home BP was 97.4% (and consistent over the 4 months). There was no increased frequency of high (defined as SBP>200mm Hg; 0.2% vs 0%) or low (defined as<90mm Hg; 1.8% vs 1.2%) predialysis BP readings in the home versus predialysis treatment arms, respectively. However, participants in the home BP arm had higher frequency of fatigue (32% vs 16%). Small sample size. This pilot trial demonstrates feasibility and high adherence to home BP measurement and treatment in hemodialysis patients. Larger trials to test the long-term feasibility, efficacy, and safety of home BP treatment in hemodialysis patients should be conducted. National Institutes of Health, Satellite Healthcare, and Northwest Kidney Centers. Registered at ClinicalTrials.gov with study number NCT03459807.

Multi-sites polycyclodextrin adsorbents for removal of protein-bound uremic toxins combining with hemodialysis

Accumulation of protein-bound uremic toxins (PBUTs) has a high incidence in the blood of hemodialysis-treated patients with chronic kidney disease. Development of adsorbent for the high-efficient, selective, and removal of various PBUTs is still challenging because of their strong interactions to the corresponding binding proteins and the complex blood background. Herein, we reported poly-cyclodextrins adsorbents with multi adsorption-sites for PBUTs removal from plasma. Compared to poly-α-cyclodextrin and poly-γ-cyclodextrin, poly-β-cyclodextrin (PβCD) showed the best adsorption capability and the maximum p-cresol sulfate (PCS, a model PBUT) binding capacity of PβCD (263 mg g−1). Combining with hemodialysis, PβCD adsorbents added into the dialysate can remove 96 % PCS in the plasma via adsorbent once-through mode. Additionally, various PBUTs co-exsiting in the plasma could be effectively removed, exhibiting high-concentrition PBUT adsorption property of PβCD. We expect that the PCD adsorbents combining with hemodialysis therapy may become a promising potential for clinical PBUT removal.

Early diagnosis of miliary tuberculosis in a hemodialysis patient by combining two interferon-\u03b3-release assays: a case report

BackgroundPatients with end-stage renal disease undergoing chronic hemodialysis (HD) are at high risk to develop tuberculosis (TB) associated with a high mortality rate. TB diagnosis is often delayed due to non-specific symptoms, frequent extra-pulmonary manifestations, and rare microbiological confirmation. This case report illustrates the clear added value of combined interferon-γ -release assays (IGRA) in response to different mycobacterial antigens for an early diagnosis of TB in HD patients.Case presentationWe report the case of an Egyptian patient under chronic HD treatment, who presented with recurrent episodes of fever and myalgia of unknown origin, associated with an important inflammatory syndrome. These episodes resolved partially or completely within less than 1 month without any treatment but recurred 10 times within 3 years. Chest Computed Tomography and 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18FDG PET-CT) demonstrated several active mediastinal lymphadenopathies. TB was the first suspected diagnosis but cultures and polymerase chain reaction (PCR) remained negative on a mediastinal lymph node aspiration. In contrast, the results from two different IGRA performed on blood were highly suggestive of TB disease. Several granulomas, some of them with central non-caseating necrosis, were demonstrated on a pulmonary nodule obtained by thoracoscopic resection, but PCR and culture remained negative for M. tuberculosis. Three years after the initial symptoms, a new PET-CT revealed a retro-clavicular lymphadenopathy in addition to the mediastinal lymphadenopathies, and the M. tuberculosis culture performed on the resected lymphadenopathy was positive. Antibiotic treatment for TB was started and resulted in a clear improvement of the patient’s clinical condition, allowing him to successfully receive a renal graft.ConclusionsIn view of the high frequency of TB in patients undergoing chronic HD and of the limitations of the classical diagnosis procedures, nephrologists have to diagnose TB mostly on clinical suspicion. We demonstrate here that the use of a combined IGRA to two different mycobacterial antigens may significantly raise the index of suspicion and help clinicians to decide starting anti-TB treatment in HD patients.