Hemodialysis Research Articles

P091 PROENKEPHALIN CONCENTRATION AND ITS DETERMINANTS IN PATIENTS WITH END-STAGE KIDNEY DISEASE TREATED WITH HEMODIALYSIS AND PERITONEAL DIALYSIS

Background and Objective. Proenkephalin (PENK) has been recently shown to reflect glomerular dysfunction and predict new-onset acute kidney injury and heart failure. While previous studies investigated PENK utility in individuals with preserved renal function, PENK concentration in patients with end-stage kidney disease (ESKD) remained to be established. The study aimed to assess plasma PENK concentration in patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) and peritoneal dialysis (PD) and to investigate its correlation with heart failure. Additionally, we aimed to determine whether PENK is removed during a hemodialysis session. Methods. 88 patients with ESKD (41 females) undergoing HD (n=66, 75%) and PD (n=22, 25%) were enrolled in this cross-sectional study. Blood samples for PENK determination were collected before and at the end of the hemodialysis session in HD patients and at a single time point in PD patients. Plasma proenkephalin concentration was assessed using a sandwich ELISA immunoassay. Samples for measurement of creatinine, urea, and NT-proBNP were drawn simultaneously. Results. The median (IQR) plasma PENK concentration in the overall population was 1.492 ng/ml (1.071-4.380). Both median eGFR (5 mL/min/1.73 m2 [4-7] vs. 5 mL/min/1.73 m2 [4-8], p=0,856) and plasma PENK levels (1.368 ng/ml [1.068-4.030] vs. 1.706 ng/ml [1.211-5.858], p=0.305) did not differ significantly between HD and PD patients. In HD patients, median PENK concentration was significantly higher before than after hemodialysis (1.368 vs. 2.061; p=0.003). No correlation was found between PENK level and urea (p=0.192), eGFR (p=0.922), duration of dialysis (p=0.637), and residual urine output (p=0.784). Heart failure (p=0.961), EF (p=0.361), and NT-proBNP (p=0.949) were not associated with increased PENK concentration. Conclusions. Our study proved that PENK is not removed during hemodialysis session. PENK concentration does not reflect renal function and cardiac status in patients with ESKD. The fact that PENK is not removed by hemodialysis calls into question the usefulness of PENK as an everyday use biomarker in acute kidney injury.

Chronic Kidney Disease-Associated Pruritus Burden: A Patient Survey Study

Rationale & ObjectiveChronic kidney disease–associated pruritus (CKD-aP) is a common, underrecognized condition in patients with chronic kidney disease (CKD), especially those receiving hemodialysis (HD). The present study analyzed the clinical treatment journey and overall burden of pruritus among patients with CKD-aP. Study DesignCross-sectional, patient-reported online survey. Setting & ParticipantsData from adult patients undergoing HD (December 2021-May 2022) in the United States. ExposurePatients participated in an online survey and responded to questions on validated patient-reported outcome (PRO) instruments related to CKD-aP. OutcomesSelf-reported measures analyzed at the end of this survey include itch characteristics, symptom management, healthcare provider (HCP) engagement, and impact on HD, quality of life (QoL), sleep, and work productivity. Analytical ApproachBivariate analysis assessed the association of itch severity with CKD-specific QoL. ResultsOverall, 354 patients with CKD-aP were included in analyses, of which 49% and 30% had moderate and severe itch, respectively (22% were mild). Around 68% reported symptoms to HCPs, most commonly a nephrologist or primary care provider, and 55% received a treatment recommendation. The most common treatments were topical lotions/moisturizers (75%) and corticosteroids (48%); use of oral prescriptions was low (20%), with limited satisfaction with treatments. Overall, 23% of patients reported shortening and 17% reported missing HD sessions due to itch. In bivariate analysis, patients with more severe CKD-aP reported significantly worse disease and function scores [kidney disease (KD) score, cognitive function, quality of social interaction, sleep (all, P<0.001), and sexual function (P<0.05)], suggesting a direct impact of CKD-aP on QoL. LimitationsPossible recall bias, especially for questions with longer recall periods. ConclusionsCKD-aP is often inadequately treated, and disruptive of dialysis treatment, even among patients who report itch to HCPs. Worse itch severity is associated with poorer QoL, sleep quality, and functional/work impairment.

Dietary Needs, Barriers, and Facilitators Among Patients on Hemodialysis and Their Caregivers: The GoodRENal Project in Spain

ObjectiveDietary restrictions are common in patients undergoing hemodialysis (HD). These restrictions result in a complex diet that becomes difficult for patients to understand and to follow. Therefore, we aimed to identify dietary needs, and barriers and facilitators that influence the adherence to dietary recommendations as perceived by patients on HD and their caregivers. MethodsSeventy-two Spanish patients on HD and fifty-seven caregivers participated in this explorative study by replying a questionnaire consisting of 20 and 10 questions respectively. The responses were assessed using a Likert scale varying from 1 to 5 (strongly agree, agree, neither disagree or disagree, disagree, strongly disagree, respectively) to evaluate the perception of patients and caregivers regarding dietary needs, barriers and facilitators to adhere to the recommended diet. For analysis purposes, the responses were grouped in three categories (agree, neither agree or disagree, disagree). ResultsSeventy percent of the patients agreed that knowing the food sources of potassium, protein and phosphate was a need for them to know to be able to adhere to the dietary recommendations. Moreover, patients stated that not being able to eat what they liked, and feeling thirsty, were important barriers. For caregivers, the support of a renal dietitian was mentioned as an important facilitator to assist those they cared for to adhere to the diet. ConclusionsKnowing food sources of potassium, phosphate, and protein, exploring foods patients like to eat and adjusting fluid intake to avoid feeling thirsty were identified as important by the patients. These findings can be used to develop strategies and educational material to improve the dietary adherence in patients undergoing HD. Moreover, the presence of a renal dietitian was identified as an important resource by the caregivers.

The effect of itching on sleep quality and comfort in patients with hemodialysis and renal transplantation: A multi-center cross-sectional study

BackgroundThe aim of this study was to determine the effect of itching on sleep quality and comfort in hemodialysis (HD) and renal transplant (Tx) patients with itching. MethodsThis descriptive, correlational seeking and cross-sectional study was conducted in four hospitals affiliated with a private health group in Istanbul between April and June 2021. The sample of the study consisted of 42 patients receiving HD treatment and 49 patients with renal transplantation. Data were collected using the Patient Information Form, 5-D Itch Scale, Richards-Campbell Sleep Questionnaire and General Comfort Questionnaire. ResultsThere was a significant difference between the HD and renal transplantation groups in the Direction (p = 0.01) and Disability dimension (p = 0.002) of the 5- D Itch scale in favor of the renal transplant group. The mean sleep quality and comfort scores of the groups were similar and moderate. Itching negatively affects sleep quality in patients receiving HD treatment, and 22 % of the change in sleep quality is explained by disability of itching (R2 = 0.22; p = 0.002). Itching negatively affects comfort in both groups. Itching explains 27 % of the change in comfort level in the HD group (R2 = 0.27; p = 0.002) and 25 % of the change in comfort level in the renal transplantation group (R2 = 0.25; p = 0.001). ConclusionsAccording the study results during the hemodialysis treatment process, itching is more intense in terms of distribution and disability and affects the quality of sleep of patients. Itching has a significant impact on patients' perception of comfort. Patients experience itching both during HD treatment and after renal transplantation, which significantly impairs their comfort. Therefore, itching should be carefully monitored during renal replacement therapy and its effects on patients should be evaluated.

Transitioning to peritoneal dialysis: it does not matter where you come from.

Patients with end-stage renal disease (ESRD) frequently change renal replacement (RRT) therapy modality due to medical or social reasons. We aimed to evaluate the outcomes of patients under peritoneal dialysis (PD) according to the preceding RRT modality. We conducted a retrospective observational single-center study in prevalent PD patients from January 1, 2010, to December 31, 2017, who were followed for 60 months or until they dropped out of PD. Patients were divided into three groups according to the preceding RRT: prior hemodialysis (HD), failed kidney transplant (KT), and PD-first. Among 152 patients, 115 were PD-first, 22 transitioned from HD, and 15 from a failing KT. There was a tendency for ultrafiltration failure to occur more in patients transitioning from HD (27.3% vs. 9.6% vs. 6.7%, p = 0.07). Residual renal function was better preserved in the group with no prior RRT (p < 0.001). A tendency towards a higher annual rate of peritonitis was observed in the prior KT group (0.70 peritonitis/year per patient vs. 0.10 vs. 0.21, p = 0.065). Thirteen patients (8.6%) had a major cardiovascular event, 5 of those had been transferred from a failing KT (p = 0.004). There were no differences between PD-first, prior KT, and prior HD in terms of death and technique survival (p = 0.195 and p = 0.917, respectively) and PD efficacy was adequate in all groups. PD is a suitable option for ESRD patients regardless of the previous RRT and should be offered to patients according to their clinical and social status and preferences.

Evaluating the effects of humor therapy on fatigue levels of hemodialysis patients: A single-blind, randomized clinical trial study

Background: This study investigated the effects of humor therapy on the fatigue levels of patients receiving hemodialysis (HD). Materials and Methods: A single-blind, randomized clinical trial of 66 HD patients for 3 weeks was conducted, in which two groups were randomly allocated – humor therapy and control. In the intervention group, humor therapy sessions were conducted twice a week for 3 weeks. As a pre- and postintervention assessment, the Fatigue Symptom Inventory (FSI) was completed. Results: According to the repeated-measures ANOVA test, FSI values exhibited a significant decline in the humor therapy group and an increase in the control group at the first, second, and third visits (humor therapy vs. control: 30.38 ± 8.75 and 61.80 ± 13.92, P &lt; 0.001; 35.71 ± 10.05 and 69.53 ± 15.32, P &lt; 0.001; and 34.85 ± 9.24 and 70.34 ± 22.26, P &lt; 0.001, respectively) compared with baseline (humor therapy vs. control: 49.26 ± 5.19 and 52.09 ± 11.69, P = 0.204). Conclusion: Findings suggest that humor therapy can effectively reduce fatigue levels in patients presenting with HD.

Coronary and Systemic Vasodilator Responsiveness of Patients Receiving Conventional Intermittent or Nocturnal Hemodialysis.

Nocturnal hemodialysis (nHD) restores the attenuated brachial artery vasodilator responsiveness of patients receiving conventional intermittent hemodialysis (iHD). Its impact on coronary vasodilatation is unknown. We evaluated 25 patients on hemodialysis who fulfilled transplant criteria: 15 on iHD (4-hour sessions, 3 d/wk) and 10 on nHD (≈40 h/wk over 8-10-hour sessions) plus 6 control participants. Following diagnostic angiography, left anterior descending (LAD) coronary flow reserve and mean luminal diameter were quantified at baseline and during sequential intracoronary administration of adenosine (infusion and bolus), nitroglycerin (bolus), acetylcholine (infusion), acetylcholine coinfused with vitamin C, and, finally, sublingual nitroglycerin. Coronary flow reserve in those receiving nHD was augmented relative to iHD (3.28±0.26 versus 2.17±0.12 [mean±SEM]; P<0.03) but attenuated, relative to controls (4.80±0.63; P=0.011). Luminal dilatations induced by intracoronary adenosine and nitroglycerin were similar in nHD and controls but blunted in the iHD cohort (P<0.05 versus both). ACh elicited vasodilatation in controls but constriction in both dialysis groups (both P<0.05, versus control); vitamin C coinfusion had no effect. Sublingual nitroglycerin increased mid-left anterior descending diameter and reduced mean arterial pressure in controls (+15.2±2.68%; -16.00±1.60%) and in nHD recipients (+14.78±5.46%; -15.82±1.32%); iHD responses were markedly attenuated (+1.9±0.86%; -5.89±1.41%; P<0.05, all comparisons). Coronary and systemic vasodilator responsiveness to both adenosine and nitroglycerin is augmented in patients receiving nHD relative to those receiving iHD, whereas vasoconstrictor responsiveness to acetylcholine does not differ. By improving coronary conduit and microvascular function, nHD may reduce the cardiovascular risk of patients on dialysis.

Risk Factors associated with Central Vein Stenosis Development in Hemodialysis Vascular Access among Patients with Normal Preoperative Venography

We aimed to discover risk factors for central vein stenosis (CVS) in hemodialysis patients with normal preoperative venography. Among the 411 individuals who underwent upper arm venography for hemodialysis access evaluation in 2017, we reviewed venography and medical record data from 349 patients with normal preoperative venography who subsequently underwent arteriovenous fistula creation. We compared the data between patients with and without CVS development. Among the 349 patients, 22 (6.3%) developed CVS during a median 20.9-month follow-up. The development of CVS appeared to be associated with preoperative venography findings (the presence of collateral vessels and cephalic arch stenosis), location of hemodialysis access, and history and duration of ipsilateral hemodialysis catheter placement (p < 0.05). Multivariate analysis identified two or more collateral vessels on venography, left-sided arteriovenous fistula, and a previous history of ipsilateral hemodialysis catheter placement as independent risk factors for CVS development (p < 0.05). Even in patients with normal preoperative venography findings, there is an increased possibility of CVS development after arteriovenous fistula creation if they have more than two collateral vessels on venography, a left-sided arteriovenous fistula, or a history of ipsilateral hemodialysis catheter placement.

Increased preload and echocardiographic assessment of diastolic function.

Echocardiographic diastolic parameters are used to diagnose and monitor increased left ventricular filling pressure (LVFP) and we hypothesized that increased loading conditions cause increased E/e'. Our aim was to assess the effect of preload augmentation on diastolic parameters among both healthy subjects and subjects with known cardiac disease. We included 129 subjects merged from two cohorts; one dialysis cohort (n=47) and one infusion cohort (n=82). Echocardiography was performed immediately before and after hemodialysis (HD) or saline infusion, under low and high loading conditions. Elevated LVFP was defined as septal E/e'≥15 and/or lateral E/e'≥13 at high-loading conditions. The population was divided according to elevated LVFP (n=31) and normal LVFP (n=98). The load difference for the population was 972±460mL, with no differences in load difference between elevated and normal LVFP (p NS). The subjects with elevated LVFP were older (63±11 vs. 46±16 years, p<.001), and had lower LV ejection fraction (50±14vs. 59±8.1%, p<.01). After augmented preload, EDV increased in the normal LVFP group (p<.01) but remained unchanged in the elevated LVFP group (p NS). Both E and e' increased among the subjects with normal LVFP, whereas E/e' remained unchanged (∆E/e' +.1 [-.5-1.2]), p NS). Among the subjects with elevated, LVFP we observed increased E but not e', resulting in significantly increased E/e' (∆ average E/e' +2.4 [0-4.0], p<.01). Augmented preload does not seem to affect E/e' among subjects with normal LVFP, whereas E/e' seems to increase significantly among subjects with elevated LVFP.

The effect of virtual reality distraction on haemodialysis patients' pain and anxiety during arteriovenous fistula puncture: a randomised controlled trial.

Pain and anxiety during arteriovenous fistula (AVF) puncture are crucial factors affecting haemodialysis (HD) patients' quality of life. The aim of this study is to assess the effect of virtual reality (VR) distraction on pain, anxiety, satisfaction and haemodynamics during AVF puncture. This randomised controlled trial study was conducted in a Haemodialysis unit at Mansoura University Hospital. Ninety-six patients were randomly divided into the intervention (n = 48) and control (n = 48) groups. Six minutes prior to the puncture, patients in the intervention group used VR glasses to experience a 360° 'Relax River VR tour', whereas patients in the control group received no intervention. Following the intervention, pain, anxiety, systolic blood pressure and heart rate were significantly lower, and satisfaction scores were significantly higher in the intervention group than in the control group (p < 0.05). VR distraction may help alleviate pain, anxiety and increase satisfaction. It may be considered a safe and cost-effective non-pharmacological therapy for HD patients undergoing AVF puncture.

The Pathological Mechanisms and Therapeutic Molecular Targets in Arteriovenous Fistula Dysfunction.

The number of patients with end-stage renal disease (ESRD) requiring hemodialysis is increasing worldwide. Although arteriovenous fistula (AVF) is the best and most important vascular access (VA) for hemodialysis, its primary maturation failure rate is as high as 60%, which seriously endangers the prognosis of hemodialysis patients. After AVF establishment, the venous outflow tract undergoes hemodynamic changes, which are translated into intracellular signaling pathway cascades, resulting in an outward and inward remodeling of the vessel wall. Outward remodeling refers to the thickening of the vessel wall and the dilation of the lumen to accommodate the high blood flow in the AVF, while inward remodeling is mainly characterized by intimal hyperplasia. More and more studies have shown that the two types of remodeling are closely related in the occurrence and development of, and jointly determining the final fate of, AVF. Therefore, it is essential to investigate the underlying mechanisms involved in outward and inward remodeling for identifying the key targets in alleviating AVF dysfunction. In this review, we summarize the current clinical diagnosis, monitoring, and treatment techniques for AVF dysfunction and discuss the possible pathological mechanisms related to improper outward and inward remodeling in AVF dysfunction, as well as summarize the similarities and differences between the two remodeling types in molecular mechanisms. Finally, the representative therapeutic targets of potential clinical values are summarized.

Encuesta nacional y elaboración de un documento de consenso sobre estrategias de dosificación de antibióticos beta-lactámicos frente a bacterias gramnegativas multirresistentes (BGN-MDR) en pacientes críticos sometidos a técnicas de soporte vital extracorpóreas: protocolo de estudio DOSEBL

IntroductionInfections caused by multidrug-resistant gram-negative bacilli (MDR-GNB) in critically ill patients present a challenge for timely and appropriate antibiotic treatment. This is particularly important in patients undergoing extracorporeal life support techniques such as renal replacement therapy and extracorporeal membrane oxygenation. These techniques can introduce additional pharmacokinetic alterations, potentially leading to suboptimal exposure to antibiotics. This study aims to outline dosing strategies and therapeutic drug monitoring protocols for new β-lactam antibiotics effective against MDR-GNB in critically ill patients undergoing extracorporeal life support techniques at a national level. Additionally, the study seeks to develop a consensus document, based on available evidence. MethodsThe project will comprise two main phases: I) A national survey, and II) the development of a consensus document. This consensus document, undertaken according to ACCORD guidelines, will encompass: a) establishment of a multidisciplinary panel of experts, b) prospective registration of the consensus, c) evidence synthesis, d) modified Delphi rounds. The antimicrobials to be included will be: meropenem, ceftazidime/avibactam, ceftolozane/tazobactam, cefiderocol, meropenem/vaborbactam, imipenem/relebactam, and aztreonam. Extracorporeal life support techniques will include continuous renal replacement therapy, conventional intermittent hemodialysis, and extracorporeal membrane oxygenation. DiscussionThe availability of extracorporeal life support techniques has expanded significantly in recent years, alongside a rise in the prevalence of infections caused by multidrug-resistant gram-negative bacilli (MDR-GNB). There is a need to develop evidence-based tools of high quality to standardize dosing and monitoring strategies for new β-lactam antibiotics.

Hemodynamic Instability during Intermittent Hemodialysis in ICU Patients with Abnormal Capillary Refill Time

Intradialytic Hemodynamic Instability (IHI) may cause delay in renal recovery and also increases risk of mortality. Capillary Refill Time (CRT) was a stress free method used for peripheral perfusion that becomes worse during circulatory failure. Objective: To determine Hemodynamic Instability during Intermittent Hemodialysis in ICU Patients with Abnormal Capillary Refill Time at a tertiary care hospital, Karachi, Pakistan. Methods: This was the 06 months’ data collection, 1-year prospective observational study. Overall 137 patients were evaluated via sampling technique of non-probability consecutive sampling technique. For each intermittent hemodialysis session, index CRT was recorded. IHI was noted down 30 minutes before the beginning of intermittent hemodialysis and then 60 minutes, 120 minutes and 180 minutes. Entire data were recorded as a predesigned proforma. The natural distribution of patients into subgroups was done using Chi Square test considering p-value ≤0.05 as significant Results: The total population was 98 men (71.5%) and 39 women (28.5%) Average age was 61.51 ± 15.37 years. 45(17.5%) patients observed abnormal Capillary refill time. 20(14.6%) patients experienced intradialytic hemodynamic instability. Among patients diagnosed with intradialytic hemodynamic instability, 9(45%) had abnormal CRT. Compared to patients with normal CRT, individuals with aberrant CRT had a higher risk of hemodynamic instability (OR = 5.564, p &lt; 0.001). Conclusion: IHI was most at risk when it comes to initiating intermittent hemodialysis, especially in the first hour of the first session. The increase in index capillary refill time was linked to IHI.

Potential Trimethylamine (TMA)-Producing Bacteria in patients with chronic kidney disease undergoing hemodialysis.

Trimethylamine (TMA), produced by gut microbiota, is the precursor of trimethylamine-N-oxide (TMAO), a uremic toxin that accumulates in patients with chronic kidney disease (CKD). Elevated TMAO plasma levels are associated with cardiovascular complications and CKD progression. To evaluate the association between gut microbiota composition and TMAO plasma levels in CKD patients undergoing hemodialysis (HD). This is a cross-sectional study with 25 patients evaluated (60% female, 53 (18) years, body mass index (BMI) 25.8 (6.75)Kg/m2). They were divided into two groups according to their TMAO plasma levels: normal (≤ 7.4μM) and high (> 7.4μM). Uremic toxins such as indoxyl sulfate (IS), p-cresyl sulfate (pCS), and indol acetic acid (IAA) were measured with RP-HPLC, and TMAO plasma levels were quantified using LC-MS/MS. Fecal DNA was extracted with a commercial kit, PCR amplified the V4 region of the 16S rRNA gene, and short-read sequencing was performed on the Illumina platform. Dietary intake, anthropometric measurements, and inflammation markers were also evaluated. Nrf2, NF-κB, IL-1β, and NLRP3 mRNA expressions were measured from peripheral blood mononuclear cells (PBMC) using quantitative real-time polymerase chain reaction (qPCR). There were significant positive correlations between TMAO and plasma levels of pCS, NLPR3 inflammasome mRNA expression, serum phosphorus levels, and negative correlations with dietary lipid intake. The group with TMAO > 7.4μM showed an increase in the microbiome abundance of Saccharibacteria (genus incertae sedis), Colidextribacter, Dorea, and Staphylococci genera, and a decrease in abundance in the genera Lachnospira, Lactobacilli, and Victivallis. TMAO plasma level was positively correlated with the abundance of bacteria of the genera Colidextribacter and Helicobacter and was negatively correlated with Sphingomanos, Lachnospira, Streptomyces, and Bacillus genera. Saccharibacteria (genus incertae sedis), Colidextribacter, Dorea, and Staphylococci genera showed higher abundance in patients with high TMAO levels. In addition, we observed that elevated plasma TMAO levels are associated with inflammation markers, dietary lipid intake, and serum phosphorus levels in patients undergoing HD.

Association between TMSE/MoCA and MIS/NAF in ESKD patients undergoing hemodialysis: a cross-sectional study

BackgroundBoth cognitive impairment and malnutrition are common in hemodialysis (HD) patients and are associated with increased hospitalization rates, infection, poor clinical outcomes, and mortality. The study investigated the association between cognitive and nutrition status among end-stage kidney disease (ESKD) patients undergoing hemodialysis.MethodsIn this cross-sectional study, we enrolled 115 patients with ESKD who underwent regular hemodialysis (HD). Data collection included the use of screening tools for mild cognitive impairment (MCI), specifically Thai Mental State Examination (TMSE) and Montreal Cognitive Assessment (MoCA). In addition, we collected data using nutritional screening tools including Malnutrition Inflammation Score (MIS) and Nutrition Alert Form (NAF). Our primary outcome was to demonstrate whether there was a relationship between TMSE/MoCA and MIS/NAF scores in this population. Secondary outcomes were a prevalence of MCI and malnutrition status in ESKD patients, an association between TMSE and MoCA with other surrogate nutritional markers, and factors affecting MCI in such patients.ResultsA total of 109 patients undergoing HD completed our protocol. Their mean age was 63.42 (± 15.82) years, and 51.38% were male. Mean TMSE and MoCA were 23.98 (± 5.06) points and 18.3 (± 6.40) points, respectively. The prevalence of TMSE ≤ 23 and MoCA ≤ 24 were 39.45% and 83.49%, respectively. TMSE had a statistically significant negative correlation with MIS (R2 = 0.16, p < 0.001) and NAF. MoCA also negatively correlated with MIS and NAF. The age, total educational year, the status of whether having a caregiver, serum albumin, serum phosphorus level, handgrip strength, and lean mass tissue were correlated with TMSE.ConclusionNutritional parameters, including MIS score, NAF score, serum albumin, lean tissue mass, and lean tissue index, significantly correlate with TMSE and MoCA.

Effects of far infrared therapy in hemodialysis arterio-venous fistula maturation: A meta-analysis.

Hemodialysis patients rely on stable vascular access to perform effective hemodialysis and reach good dialysis quality. However, an obstructed or under-matured arteriovenous fistula (AVF) may increase infection rate and mortality in hemodialysis patients. Far infrared (FIR) therapy might help to promote AVF maturation and reduce obstruction rate. Therefore, this meta-analysis was conducted to evaluate the effect of FIR therapy on AVF obstruction rate and maturation. PubMed, Embase, the Cochrane Library, and other databases which provide publications in randomized controlled trials (RCTs) of FIR to improve AVF in patients with CKD (Chronic Kidney Disease) or HD (hemodialysis) were used to collect articles which published before February 2023. Two authors selected relevant articles independently based on pre-defined inclusion and exclusion criteria, and assessed the quality of the articles by using the Cochrane Handbook before performing a meta-analysis in Review Manager (RevMan) 5.4 software. Four RCTs with 475 patients were included. The results of the meta-analysis showed that the FIR therapy groups had better physiological maturation at 3 months (RR = 1.22; 95% CI = 1.07 to 1.39; p = .002) and clinical maturation at 12 months (RR = 1.35; 95% CI = 1.14 to 1.60; p < .001) than the control groups without FIR therapy. The obstruction rates within 12 months were much lower in the FIR therapy groups than in the control groups (RR = 0.24; 95% CI = 0.08 to 0.68; p = .007), also, there was no statistical heterogeneity. FIR could promote fistula maturation and reduce the incidence of AVF obstruction.

Sonographic Appearance of Hemodialysis Reliable Outflow Graft (HeRO Graft)

HeRO Graft (Hemodialysis Reliable Outflow Graft) consists of 3 components; an arterial graft component, a titanium connector and a venous outflow component. It is implanted under the skin of end-stage renal failure patients as a subcutaneous permanent access. It is a vascular graft that traverses central venous stenosis and has no venous anastomosis, thus providing blood flow from an artery direct into the central venous system. Ultrasound imaging of the 3 components of the HeRO graft is performed and described in this article. Equipment used include Phillips ultrasound machines CX-50, iU22, and EPIQ 7 with linear transducers of frequency 3 to 15 MHz and curvilinear transducers of frequency 1 to 5 MHz. HeRO graft is often the last hemodialysis access available for patients on long-term dialysis who would have typically exhausted all other hemodialysis options like the native arterio-venous fistula (AVF) and arterio-venous graft (AVG). As long-term dialysis patients run out of typical AVF/AVG accesses coupled with the increasing longevity of persons in countries where advanced medical technology is available, subcutaneously implanted grafts such as the HeRO graft may become more commonplace. Description of the sonographic appearance of the various components of the HeRO graft may help sonographers who are not familiar with the graft to image the components.

Cardiopulmonary Response to Acute Exercise before Hemodialysis: A Pilot Study.

Disparities in physical fitness between immediately before dialysis (pre-D) and the day following dialysis (non-D) have not been investigated despite potential adverse factors such as fluid status, uremia, and electrolyte levels in the pre-dialysis period. The effect of acute exercise immediately before hemodialysis (HD) on HD-related hypotension remains unclear. We hypothesized that cardiopulmonary performance and muscular strength would be inferior in the immediate pre-D period compared to those non-D. Twenty patients receiving chronic HD treatments underwent symptom-limited incremental cardiopulmonary exercise testing (CPET) and isokinetic testing both 1-2 h prior to dialysis (pre-D) and non-D. This investigation was a sub-study of a clinical trial assessing the efficacy of a pre-D exercise training program. Blood pressure profiles during HD post-CPET and pre-D exercise training were compared with those during usual HD sessions. No adverse events were observed during the 80 exercise tests. Prior to dialysis, the nadir of the ventilatory equivalent of CO2 was slightly elevated, the resting heart rate was lower, and the peak systolic blood pressure was higher than those non-D. Contrary to our hypothesis, peak <inline-formula><mml:math id="m1" xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:mrow><mml:mover accent="true"><mml:mi mathvariant="normal">V</mml:mi><mml:mo>˙</mml:mo></mml:mover><mml:msub><mml:mi mathvariant="normal">O</mml:mi><mml:mn>2</mml:mn></mml:msub></mml:mrow></mml:math></inline-formula> and quadriceps peak torque showed no differences. Blood pressure profiles during HD post-exercise were similar to those during sessions without prior exercise, except for a lower resting systolic blood pressure at the beginning of HD. Cardiopulmonary response and muscular strength in the 1-2 h prior to HD were comparable with those on the day following HD, with only minor clinically insignificant differences. Acute exercise prior to HD did not affect the magnitude of hypotension during HD. This study suggests a potential alternative timing for exercise training or testing in patients undergoing chronic HD.

COVID-19 increases mortality in hemodialysis patients: exploring links with inflammation and telomere attrition.

An increased risk of mortality and hospitalization was consistently demonstrated in hemodialysis (HD) patients affected by pandemic coronavirus infection (COVID-19). In this study, we analyzed parameters that may impact mortality in COVID-19 HD patients, including neutrophil-to-lymphocyte ratio (NLR), lactate dehydrogenase (LDH), C-reactive protein (CRP), COVID-19 disease status and telomere length in peripheral blood cells (TL). A total of 130 chronic hemodialysis patients were enrolled and followed up for 18 months. Patients were categorized into groups based on their COVID-19 disease history and subsequent data about their survival status at the end of the study. Routine laboratory parameters were assessed using standard automated methods and TL was determined using the modified Cawthon method. Survival predictors were analyzed using Kaplan-Meier analysis. Deceased patients (30%) were older with higher body mass index (BMI), higher levels of LDH, NLR index, CRP and lower TL and lymphocytes count compared to survivors. Kaplan-Meier survival analysis showed six parameters were significant mortality predictors in the following order of significance: COVID-19 history, 2-years cardiovascular mortality risk score, NLR, TL, CRP, LDH. Using binary logistic regression analysis Summary risk score, a combination of these six parameters revealed as the best predictor of patient's survival in this group of parameters (log rank 25.4, p < 0.001). Compared to the general population, the mortality rate among HD patients persists at a higher level despite advancements in HD technology and patient care. The situation has been exacerbated by COVID-19, by significant increase in mortality rate among these patients.

Evaluation of Factors Affecting the Health-Related Quality of Life in End-Stage Renal Disease Patients Receiving Hemodialysis Treatment in Northern Cyprus.

Introduction Health-related quality of life (HR-QoL) is recognized as an important predictor of mortality and morbidity in end-stage renal disease (ESRD) patients receiving hemodialysis (HD). The goal of this study was to obtain HR-QoL scores using the Kidney Disease and Quality of Life questionnaire (KDQOL-36TM) (RAND Corporation, Santa Monica, CA) and to assess the factors affecting HR-QoL in ESRD patients receiving HD. Methods A multicenter cross-sectional study was performed using the KDQOL-36TM for the assessment of HR-QoL of ESRD patients receiving HD in Northern Cypriotstate hospitals. Alongside KDQOL-36TM scores for assessing HR-QoL, sociodemographic as well as relevant laboratory data were collected. Spearman Correlations and multiple linear regression analyses using the 'stepwise' method were carried out to identify predictors of HR-QoL. Nonparametric tests were used to determine significantly (p<0.05) associated variables. Ethical approvals were received from the Northern Cypriot Ministry of Health and Eastern Mediterranean University Research and Publication Ethics Boards. Results One hundred and thirty-eight participants were recruited in this study, corresponding to 85.1% of the total study population. Participants had a mean age of 66.49 ± 13.35. 65.2% of the participants were males. Participants had low scores on most dimensions of quality of life, namely, Burden of Disease, Physical Component Summary (PCS), and Mental Component Summary (MCS) subscales. Particularly, females, unemployed patients, and patients with more comorbidities had significantly lower scores (p=0.003, p<0.001, and p=0.005, respectively). Spearman correlation analyses revealed multiple significant moderate correlations between sociodemographic data, laboratory variables, and scores. Furthermore, multiple linear regression analysis identified gender (p=0.006), total number of comorbidities (p=0.005), age (p<0.001), and patient care (p=0.019) as significant predictors of KDQOL-36TM scores. Conclusion This study has shown that the quality of life of hemodialysis patients was highly impaired. Gender, current employment status, and presence of comorbidities were all significant independent factors affecting HR-QoL mean scores. Lastly, further studies regarding the implementation of routine HR-QoL surveillance and targeted interventions are required to better understand their potential therapeutic benefits.