KDOQI Guidelines Research Articles

AI-Driven Patient Education in Chronic Kidney Disease: Evaluating Chatbot Responses against Clinical Guidelines.

Chronic kidney disease (CKD) patients can benefit from personalized education on lifestyle and nutrition management strategies to enhance healthcare outcomes. The potential use of chatbots, introduced in 2022, as a tool for educating CKD patients has been explored. A set of 15 questions on lifestyle modification and nutrition, derived from a thorough review of three specific KDIGO guidelines, were developed and posed in various formats, including original, paraphrased with different adverbs, incomplete sentences, and misspellings. Four versions of AI were used to answer these questions: ChatGPT 3.5 (March and September 2023 versions), ChatGPT 4, and Bard AI. Additionally, 20 questions on lifestyle modification and nutrition were derived from the NKF KDOQI guidelines for nutrition in CKD (2020 Update) and answered by four versions of chatbots. Nephrologists reviewed all answers for accuracy. ChatGPT 3.5 produced largely accurate responses across the different question complexities, with occasional misleading statements from the March version. The September 2023 version frequently cited its last update as September 2021 and did not provide specific references, while the November 2023 version did not provide any misleading information. ChatGPT 4 presented answers similar to 3.5 but with improved reference citations, though not always directly relevant. Bard AI, while largely accurate with pictorial representation at times, occasionally produced misleading statements and had inconsistent reference quality, although an improvement was noted over time. Bing AI from November 2023 had short answers without detailed elaboration and sometimes just answered "YES". Chatbots demonstrate potential as personalized educational tools for CKD that utilize layman's terms, deliver timely and rapid responses in multiple languages, and offer a conversational pattern advantageous for patient engagement. Despite improvements observed from March to November 2023, some answers remained potentially misleading. ChatGPT 4 offers some advantages over 3.5, although the differences are limited. Collaboration between healthcare professionals and AI developers is essential to improve healthcare delivery and ensure the safe incorporation of chatbots into patient care.

Thrombotic Microangiopathy and acute kidney injury with malaria: One-year experience at SIUT

Acute Kidney Injury (AKI) may occur with malarial infection, falciparum and vivax species. AKI, anemia, jaundice and thrombocytopenia are documented associated findings. Thrombotic Microangiopathy (TMA) in relation with malarial AKI is less reported subject. Patients and Methods: Between January 2023 to December 2023, patients with diagnosis of malaria and developing AKI (according to KDOQI guidelines definition), who were brought to our institute, showing some clinical and basic laboratory features of TMA or shown delayed recovery were subjected to renal biopsy. Only those where histological diagnosis of TMA was confirmed were included in present study. Results: During last calendar year 17 adult patients fulfilled criteria of malaria, AKI and TMA, of these 15 (88%) were female. Malaria was caused by vivax species in 15 (88%), falciparum in one and one patient who arrived late here had report of malarial parasite seen in private laboratory, species was not mentioned. All had febrile illness, associated symptoms were oligo-anuria in 15(88%), vomiting 13 (76%), body aches 12(70%), and jaundice in 6 (35%). The mean age was 26.58±8.9 years, hemoglobin 7.84±1.78, urea 162.70±67.94, creatinine 8.06±4.69 and LDH 1434.05±925.36. Hemodialysis was required in 16 (94%) patients. After getting biopsy results plasma exchanges done in 15 (88%) patients. Complete recovery of renal function seen in 6 (35%), CKD in 7 (41%). Conclusion: TMA in association with malarial AKI is less reported in literature. Vivax malaria has shown devastating complications with this previously labelled “benign” species of plasmodium.

#2034 CKD-MBD management: results from a national survey on bone turnover biomarkers practice and therapeutic strategies among Italian nephrologists

Abstract Background and Aims Advanced stages of chronic kidney disease (CKD) are constantly characterized by a mineral and bone disorders (MBD) syndrome concerning a complex systemic condition that includes laboratory abnormalities of bone and mineral metabolism involving calcium, phosphorus, parathyroid hormone (PTH), or vitamin D; abnormalities in bone turnover, mineralization, volume, or strength; extra-skeletal calcifications, such as vascular or other soft tissue. CKD-MBD syndrome determines relevant consequences in terms of fragility fractures, cardiovascular events and higher mortality. The nephrologist's awareness of CKD-MBD diagnostic and management tools and therapeutic strategies is key to improving CKD patients’ prognosis and outcomes. Method A new national survey (composed of 17 online questions) was conducted among Italian nephrologists to investigate the reference laboratory availability of bone turnover markers (BTMs), the clinical attitude on secondary hyperparathyroidism (sHPT) management, and the CKD-MBD therapeutic approach in different stages of CKD and dialysis patients. Results 89 Italian nephrologists participated in the survey. The reference laboratories largely fulfill the biomarkers request of ionized calcium (97.7%), phosphorus (100%), PTH (100%), alkaline phosphatase (ALP) (100%), magnesium (100%), 25-OH and 1,25-OH vitamin D levels (92.1%; 53.9%); while most of the hospital laboratories do not regularly support the availability of specific BTMs, both for diagnosis and monitoring the bone resorption and formation (Fig. 1)—such as bone ALP (75.3%), calcifediol (37.1%), calcitriol (40.5%), fibroblast growth factor-23 (FGF-23) (intact 9% and c-terminal 4.5%), vitamin K (33.7%), Klotho (6.75%, soluble 4.5%), osteocalcin (38.2%), matrix gla protein (10.1%), tartrate-resistant acid phosphatase 5b (TRAP-5b) (6.75%), cross-linked collagen type I peptide (CTX) (32.6%) and procollagen type 1 n-terminal propeptide (P1NP) (10.1%). The nephrologist's attitude to start management and treatment of sHPT is revealed to be mainly led by KDOQI (n = 42, 47%) and KDIGO (n = 39, 44%) guidelines considering their PTH cut-off values; in 53.9% of clinicians the measure of PTH levels is then performed every 3 months according to KDOQI guidelines. In relation to the definition of high turnover metabolic bone disease by BTMs, this metabolic pattern is identified in > 50% and 30-40% of patients with CKD 4-5D by 31.5% and 21.4% of nephrologists, respectively. 65% of clinicians currently considered ALP of equal importance as alterations of PTH as a predictor of fracture events. Other biomarkers, such as FGF-23, P1NP or TRAP-5b, emerge to not be still used in regular clinical practice. In patients diagnosed with CKD-MBD and skeletal fragility, 76.4% of nephrologists consider the AIFA (Italian Medicines Agency) note 79 to support osteoporosis treatment. The therapeutic strategies of CKD-MBD include the administration of vitamin D (e.g. cholecalciferol 27-37.1%, calcifediol 9-12.4%, calcitriol 42.7-55.1%) and its analogues (e.g. paricalcitol 23.6-52.8%) and the use of antiresorptive agents (e.g. alendronate 3.4%-23.6%, denosumab 22.5%-30.3%) with variable frequencies among different advanced CKD stages and for those patients on peritoneal or hemodialysis (Fig. 2). Conclusion Results present a suboptimal use of BTMs and a current heterogeneous therapeutic management of CKD-MBD syndrome and renal osteodystrophy in Italian clinical practice. The survey represents a starting point of work to further implement awareness of diagnostic and therapeutic issues of CKD-MBD.

#2265 The challenge of renal biopsy in diabetic patients: evaluation of a single center large cohort from North-West Italy

Abstract Background and Aims Diabetic kidney disease is one of the most severe long-term complications of diabetes. Currently, the international guidelines suggest diagnosis of diabetic nephropathy to be achieved on a clinical ground only. However, in the heterogeneous cluster of different conditions putatively co-existing with diabetes, renal biopsy is a unique tool for an accurate diagnosis and a guide for patient management. The aim of the study was to retrospectively analyze monocentric case history of kidney biopsies performed in diabetic patients over a period of 10 years. Patient's data were collected both at the time of histological examination and during follow-up. Method Data of renal biopsies (RB) performed in patients with diabetes mellitus from 1st January 2014 to 31th July 2023, were collected. Patient identification was performed by reviewing clinical histories and histopathological charts. Data on the indication for RB were collected from the medical report of the hospitalisation when the procedure was performed or from the visit when the indication was given. Atypical features were categorized according to an adaptation of the 2007 KDOQI guidelines for diabetes and chronic kidney disease. The significance of baseline differences was determined by the chi-squared test, Fisher's exact test or the unpaired t-test, as appropriate. Significance of univariate analysis were confirmed through the use of multivariate analysis. Correlation analysis, linear regression and Cox regression were also performed. A two-sided P-value <0.05 was statistically significant. All statistical analyses were performed using SPSS version 26.0 (IBM, Armonk, NY, USA). Results Among 1990 patients (pts) who underwent kidney biopsy during the study period, 297 had type 1 or type 2 DM (14.9%) and were therefore included in the study, regardless of diagnostic suspicion and histological findings. Histological examination revealed diabetic nephropathy (DN) in 112 cases (group 1), DN associated with another kidney disease in 56 cases (group 2) and nondiabetic renal diseases alone in the remaining 129 cases (62%) (group 3). In group 2 the kidney disease most frequently associated with DN was focal and segmental glomerulosclerosis, FSGS (24/56 pts) followed by IgA nephropathy, IgAN (14/56 pts). In this population the histological examination led to specific therapeutic indications in 22 patients. In group 3 the most frequently observed kidney disease was FSGS (37/112 pts) followed by ANCA-vasculitis (14/112 pts), membranous nephropathy (14/112 pts) and IgAN (10/112). In this population, histological examination led to a specific therapeutic indication in 67 pts. To determine predictors for histopathological diagnosis of DKD, we ran a logistic regression model. The covariates used in this model were the duration of diabetes, presence of retinopathy, hypertension, serum creatinine values, eGFR values and 24-hours proteinuria. None of them was found to be statistically significant. It should also be noted that 47 out of 112 pts (42%) with diabetic nephropathy had no retinopathy. In contrast, 9 pts (7%) with histological evidence of NDRD had diabetic retinopathy. 215 out of 297 pts had a follow-up of at least 6 months. During a mean follow up of 41.6±31.8 months, 53 pts (24 in group 1, 15 in group 2 and 14 in group 3) reached end stage kidney disease (16.5 months). In our population the presence of DN associated with another biopsy-proven nephropathy was especially prevalent. Having double nephropathy conferred a relative risk-RR for dialysis of 1.8089 (95% CI 1.0094 to 3.2415, P = .0464). Conclusion To our knowledge this is the largest cohorts of diabetic patients receiving renal biopsy even reported in a Western country. Our data proved kidney biopsy not to be an academic exercise in diabetic pts. Clinical and laboratory features do not predict histologic findings. Renal biopsy allowed the identification of unsuspecting nondiabetic kidney injuries and double nephropathies, which could be susceptible to different outcomes, and paved the pathway for treatment of potentially manageable histological changes.

#336 Early detection of vascular access complication in pediatric CKD hemodialysis patients

Abstract Background and Aims Vascular access (VA) dysfunction is a major clinical complication in the hemodialysis (HD) population and has a direct effect on dialysis outcome. Where in patients undergoing HD, neointimal hyperplasia results in vascular stenosis and subsequent thrombosis, which lead to vascular access failure. Interleukin-10 (IL-10), hs CRP, and tumor necrosis factor- (TNF–α) are inflammatory markers which are proved to be involved in the process neointimal hyperplasia & subsequent complications. We aimed to evaluate the value of these inflammatory markers in early detection of arterio-venous fistula (AVF) failure, in pediatric patients on regular HD, together with the clinical & radiological diagnoses, for proper intervention for correcting AVF failure according to guidelines. Method It was an prospective cohort study, where we included 59 pediatric chronic kidney disease patients’ stage 5, on regular HD (CKD5d), who were following up regularly with us for 1 year. Patients with nonfunctioning AVFs due to complications as thrombus occluding fistula, infections, or large aneurysm, were excluded from the beginning of the study. Monitoring of VA by pre-cannulation physical examination was performed to detect the physical signs of dysfunction, at least once per month according to KDOQI guidelines. Venous pressure (VP) and trans-membrane pressure (TMP) were recorded at each HD session, to detect any abnormalities and to record the pressure changes with the appearance of any AVF complications. Doppler ultrasound (DUS) was performed routinely every 3 months for all HD patients, & at the time of development AVF complications. Blood samples for measuring IL10, TNF, hs CRP were collected from the patients every 2 weeks for 12 months, prior to HD sessions, where we included the most recent samples prior to, and at the time of development complications, which were clinically and radiologically confirmed. Results The mean (±SD) age of our patients was 13.97 (±2.65) years, where we had 39 (56.5%) males, and 30 (43.5%) females, with a median (IQR) HD duration of 4.0 (5.0) years. On assessing the AVF complications, 33 patients (55.9%) had experienced complications, where thrombosis was the most common reported one (17 patients, 28.8%), followed by aneurysm formation in 14 patients (23.7%), while 6 patients (10%) had stenosed AVF, early VA failure in 2 patients (3.4%),1 patient (1.7%) had pseudoaneurysm, and another patient (1.7%) had perivascular hematoma. Mean serum levels of Hs-CRP, TNF-α, IL-10 were elevated at timing of early development of complication, in comparison to their baseline levels, meanwhile serum IL10, and TNF alpha were significantly higher among patients who developed AVF stenosis. The baseline hs-CRP had related positively with AVF diameter at the time of the development of the complications. Conclusion The inflammatory markers have no clinically applied role in early detection of AVF abnormalities, therefore, physical examination and DUS are deemed sufficient.

440 Patient Education on Lifestyle Modification and Nutrition Management in Chronic Kidney Disease (CKD) using Artificial Intelligence in reference to NKF KDOQI guidelines

440 Patient Education on Lifestyle Modification and Nutrition Management in Chronic Kidney Disease (CKD) using Artificial Intelligence in reference to NKF KDOQI guidelines

The Role of Uromodulin in Chronic Kidney Disease – A Systematic Review and Meta-Analysis

Background: Numerous studies have investigated the function of the biomarker uromodulin (UMD), which has shown promise in the diagnosis and severity assessment of chronic kidney disease (CKD). However, the results continue to be contradictory and inconclusive. Consequently, our goal was to investigate the connection between UMD and CKD patients, with a focus on their diagnostic utility and association with the severity of CKD based on the Kidney Disease Improving Global Outcomes (KDIGO) classification. Methods: We systematically searched PubMed, EMBASE, and Scopus using a predefined string to identify relevant studies. Included studies diagnosed CKD based on GFR according to Kidney Disease Outcomes Quality Initiative KDOQI guidelines or by calculating eGFR using the MDRD formula, meeting predefined criteria. Quality assessment was conducted using the Newcastle Ottawa Scale (NOS). The main outcome was the mean difference (MD) in serum UMD levels across CKD stages. Results: A total of 5 articles involving 1,094 subjects fulfilled our inclusion criteria and were included in our systematic review and meta-analysis. Significant differences in UMD levels were observed across multiple comparisons. When comparing CKD patients to controls, UMD levels showed a substantial MD of –115.719 (95% CI –163.297, -68.141). Similarly, UMD levels exhibited significant MDs when comparing controls vs. CKD 1 71.185 (95% CI 39.572, 102.798), controls vs. CKD 2 81.531 (95% CI 40.570, 122.491), controls vs. CKD 3 130.886 (95% CI 99.095, 162.677), controls vs. CKD 4 180.317 (95% CI 141.373, 219.262), controls vs. CKD 5 198.033 (95% CI 155.573, 240.494) and CKD 1-2-3 vs. CKD 4-5 89.540 (95% CI 47.561, 131.518). Conclusions: In conclusion, our systematic review and meta-analysis highlights pronounced differences in UMD levels across multiple comparisons in CKD. When comparing CKD patients with controls, a significant decrease in UMD levels is evident, indicative of potential implications in renal pathology. Moreover, the observed variations in UMD levels between different CKD stages underscore its potential utility as a biomarker for disease severity and progression. These findings contribute to our understanding of UMD dynamics in CKD and suggest avenues for further research into its diagnostic and prognostic significance in clinical practice.

Real-world usage of Chronic Kidney Disease - Mineral Bone Disorder (CKD-MBD) biomarkers in nephrology practices.

Chronic kidney disease mineral bone disorder (CKD-MBD) is a condition characterized by alterations of calcium, phosphate, parathyroid hormone (PTH), and fibroblast growth factor 23 (FGF-23) metabolism that in turn promote bone disorders, vascular calcifications, and increase cardiovascular (CV) risk. Nephrologists' awareness of diagnostic, prognostic, and therapeutic tools to manage CKD-MBD plays a primary role in adequately preventing and managing this condition in clinical practice. A national survey (composed of 15 closed questions) was launched to inquire about the use of bone biomarkers in the management of CKD-MBD patients by nephrologists and to gain knowledge about the implementation of guideline recommendations in clinical practice. One hundred and six Italian nephrologists participated in the survey for an overall response rate of about 10%. Nephrologists indicated that the laboratories of their hospitals were able to satisfy request of ionized calcium levels, 105 (99.1%) of both PTH and alkaline phosphatase (ALP), 100 (94.3%) of 25(OH)D, and 61 (57.5%) of 1.25(OH)2D; while most laboratories did not support the requests of biomarkers such as FGF-23 (intact: 88.7% and c-terminal: 93.4%), Klotho (95.3%; soluble form: 97.2%), tartrate-resistant acid phosphatase 5b (TRAP-5b) (92.5%), C-terminal telopeptide (CTX) (71.7%), and pro-collagen type 1 N-terminal pro-peptide (P1NP) (88.7%). As interesting data regarding Italian nephrologists' behavior to start treatment of secondary hyperparathyroidism (sHPT), the majority of clinicians used KDOQI guidelines (n=55, 51.9%). In contrast, only 40 nephrologists (37.7%) relied on KDIGO guidelines, which recommended referring to values of PTH between two and nine times the upper limit of the normal range. Results point out a marked heterogeneity in the management of CKD-MBD by clinicians as well as a suboptimal implementation of guidelines in Italian clinical practice.

Tunneled hemodialysis central venous catheters prevalence and bloodstream infection rates in Northern Italy: A survey of the "East Lombardy Nephrological Network".

Tunneled central venous catheter (tCVCs) is a vascular access frequently employed in hemodialysis patients. Catheter-related bloodstream infections (CRBSI) are potentially life-threatening complications. We performed a retrospective survey regarding tCVCs prevalence as well as the CRBSI incidence and management within five hospitals in the Brescia province belonging to the "East Lombardy Nephrological Network"; this study was based upon 18 queries regarding the years 2020 and 2021. The data collected refer to an overall hemodialysis population of 736 patients in 2020 and 745 patients in 2021. The prevalence of tCVCs was respectively 22.1% and 24.2% with the initial placement being performed with fluoroscopy support in 80% of the centers. CRBSI incidence was respectively 0.88 and 0.77 episodes per 1000 days of tCVC use. When the CRBI was caused by Staphylococcus Aureus (SA) or Pseudomonas, differently from the recommendation of the KDOQI guidelines, the removal or the substitution of the tCVC did not occur immediately at the time of the diagnosis of the infection but only when the specific antibiotic therapy failed. A nose swab aimed at identifying SA carriers was performed in 60% of centers. The policy regarding the referral to other specialists (infectious disease specialist and microbiologist) was heterogenous across the centers according to their specific logistics. This retrospective survey performed by the "East Lombardy Nephrological Network" within the Brescia province describes the prevalence of tCVCs use as well as the incidence and management of CRBSIs in the hemodialysis patients of this area. The clinical impact of the differences in terms of clinical approach detected compared to the KDOQI guidelines will need to be clarified ideally in prospective studies.

Prescribing the dialysis dose and treatment frequency in home haemodialysis.

There is growing interest in home haemodialysis (HHD) performed with low-flow dialysate devices and variable treatment schedules. The target standard Kt/V (stdKt/V) should be 2.3 volumes/week, according to KDOQI guidelines (2015). The current formula for stdKt/V does not help prescribe the dialysis dose (eKt/V) and treatment frequency (TF). The aim of this study was to obtain a formula for stdKt/V that is able to define the minimum required values of eKt/V and TF to achieve the targeted stdKtV. Thirty-eight prevalent patients on HHD were enrolled. A total of 231 clinical datasets were available for urea modelling using the Solute-Solver software (SS), recommended by KDOQI guidelines. A new formula (stdKt/V=a+b×Kru+c×eKt/V) was obtained from multivariable regression analysis of stdKt/V vs eKt/V and residual kidney urea clearance (Kru). The values of coefficients a, b and c depend on the treatment schedules and the day of the week of blood sampling for the kinetic study (labdayofwk) and then vary for each of their foreseen 62 combinations. For practical purposes, we used only seven combinations, assuming Monday as a labdayofwk for each of the most common schedules of the 7 days of the week. The stdKt/V values obtained with SS were compared with the paired ones obtained with the formula. The mean±standard deviation stdKt/V values obtained with SS and the formula were 3.043±0.530 and 2.990±0.553, respectively, with 95% confidence interval +0.15 to -0.26. A 'prescription graph' was built using the formula to draw lines expressing the relationship between Kru and required eKt/V for each TF. Using this graph, TF could have been reduced from the delivered 5.8±0.8 to 4.8±0.8 weekly sessions. The new formula for stdKtV is reliable and can support clinicians to prescribe the dialysis dose and TF in patients undergoing HHD.

#3720 ON THE DEVELOPMENT OF SOME PAIN SYNDROMES IN PATIENTS ON DIALYSIS

Abstract Background and Aims To study the incidence and intensity of cramps in patients with end-stage CKD during dialysis. Method In a cross-sectional study in 2021, 160 male and female patients on program dialysis (PD), aged 22 to 77 (53.3±7.11) receiving for 7.7 ± 1.83 (1 to 25) lasting 12 ± 0.24 hours per week (average KT / V 1.4 ± 0.03) on Fresenius and B. Braun devices. The intensity of cramps was assessed according to a numeric rating scale (NRS) from 0 to 10, as well as its impact on quality of life. To identify patients with intradialytic hypotension (IDH), we used the KDOQI guidelines, which define IDH as a 20 mm Hg decrease in systolic blood pressure (BP) from the origin, assessed over 3 consecutive sessions. All patients' blood serum was checked for phosphorus (P), calcium (Ca), parathyroid hormone (PTH). Results Patients were divided into 2 groups, presence 81 (51.0%) or absence 79 (49.0%) of cramps (Table 1). Among patients with diabetes, the frequency of absence of cramps is 2 times higher than among patients with diabetes (6% vs. 94%, respectively) (Table 2). Among patients with hypotension, only in 15% there were no cramps, while without hypotension 85% (Table 3). No statistically significant difference was found between the groups for any of the 3 parameters (PTH, P, Ca). Conclusion Painful muscle spasms have been insufficiently studied, although their impact on the quality life of dialysis patients is clinically significant. The first steps should be on correcting for potentially modifying risk factors, development of hypotension during a procedure and correction of phosphorus levels.

Sauna bathing, renal function and chronic kidney disease: cross-sectional and longitudinal findings from the KIHD study.

It is uncertain if passive heat therapies are associated with adverse renal outcomes. We sought to evaluate the cross-sectional and longitudinal associations of the frequency of sauna bathing with renal function measures and chronic kidney disease (CKD). Baseline self-reported sauna bathing habits were assessed in 2071 men aged 42-61 years with normal kidney function. Baseline estimated glomerular filtration rate (GFR) and serum levels of creatinine, potassium (K) and sodium (Na) were measured, with only 11-year measurements of K and Na 11 years in a random subset of participants due to logistical reasons. Study participants were followed up for CKD diagnosed using KDOQI guidelines, which were collected from the National Hospital Discharge Registry. The associations of frequency of sauna bathing with renal function measures were evaluated using regression analyses. Hazard ratios (HRs) (95% CIs) were estimated for CKD. There were no significant changes in baseline levels of estimated GFR, creatinine and Na comparing 4-7 sauna sessions/week vs 1 sauna session/week; there was a slight increase in K 0.05 mmol/l (95% CI, 0.00, 0.10; p=0.033). There were no significant changes in levels of serum K and Na at 11 years. After 25.7 years overall median follow-up, 188 CKD cases were recorded. Comparing 4-7 sauna sessions/week with 1 sauna session/week, there was no evidence of an association with CKD 0.84 (95% CI, 0.46-1.53; p=.56). Cross-sectional and longitudinal observational evidence suggests that frequent sauna bathing is not associated with impaired renal function or the future risk of CKD.

The effect of immediate postoperative increase in blood flow velocity in predicting maturation of arteriovenous fistula for dialysis

Background Doppler ultrasonography is the main imaging modality for hemodialysis arteriovenous fistula (AVF) as it is safe, accurate, and noninvasive. Published literature related to the utility of early postoperative ultrasound in predicting AVF maturation is scarce. With the KDOQI guidelines recommending an AVF first catheter last approach, the quest to increase AVF maturation is of utmost importance. This study aims at measuring blood flow immediately postoperatively and assessing its predictive role in AVF maturation. Methods We correlated the ultrasound parameters with maturation in newly created AVFs measured preoperatively, immediately postoperatively, 6 weeks, and 3, 6, and12 months postoperatively. Both demographics and vascular parameters were compared between the group of patients whose AVFs successfully maturated and those whose AVFs did not. Primary endpoint was AVF maturation; secondary endpoints included patency, functional success, and predictive value of increased vein blood flow on fistula patency. Results A total of 50 procedures were performed; the mean age was 52.12 years (±6.58). The overall technical success rate was 86% (43) and 39 (90.7%) of them were functionally mature according to KDOQI guidelines for maturation. Primary patency was 93.02%, 92.7%, and 88.89%; and the primary-assisted patency was 97.7%, 95.12%, and 91.67% at 3, 6, and 12 months, respectively. Receiver-operated curve (ROC) showed a cutoff value of 322.8 ml/min increase in blood flow above which the AVF is more likely to become mature. Binary logistic regression showed that arterial depth greater than 3.92 mm, arterial flow velocity greater than 88 ml/min, preoperative average vein diameter of greater than 2.5 mm, arterial flow velocity of greater than 73 ml/min immediately postoperatively, and average vein diameter of greater than 3.94 mm immediately postoperatively were significant predictors of successful maturation at 6 weeks postoperatively (P values 0.001, <0.0001, <0.0001, <0.0001, and <0.0001, respectively). Conclusion Immediately postoperative flow measurement is a reliable parameter that can be used to predict successful fistula maturation, especially if flow velocities exceed 326.15 ml/min.

The Incidence and Severity of Pulmonary Hypertension among Patients with Chronic Kidney Disease

Purpose: Chronic kidney disease (CKD) is a major health problem and is closely linked with cardiovascular disease. Pulmonary hypertension (PH) is considered a common comorbidity in CKD patients. This study aimed at assessing the correlation between CKD and pulmonary hypertension.
 Methodology: This is a retrospective study that recruited 100 Egyptian patients with stage 3 and above Chronic Kidney Disease (CKD) (KDOQI guidelines). The study sample was composed of 100 patients with 60% overall prevalence of PH. Transthoracic echo Doppler study was performed to measure pulmonary artery systolic pressure based on tricuspid jet in the sample.
 Findings: There was significant association between PH and severity of renal disease. The hemodialysed group showed a higher prevalence of PH with a more severe PH compared to groups not on regular dialysis. The study had provided evidence that PH is a common comorbidity in CKD patients and is directly proportional with the stage and duration of CKD.
 Recommendations: Pulmonary hypertension should be regularly assessed using echocardiography in CKD patients specially those on regular dialysis.

Deprescribing the Kt/V Target for Peritoneal Dialysis in the United States: The Path Toward Adopting International Standards for Dialysis Adequacy.

Deprescribing the Kt/V Target for Peritoneal Dialysis in the United States: The Path Toward Adopting International Standards for Dialysis Adequacy.

Economic Analysis of a Ketoanalogue-Supplemented Very Low-Protein Diet in Patients With Chronic Kidney Disease in Taiwan and Thailand

A vegetarian very low-protein diet (VLPD) supplemented with ketoanalogues of essential amino acids Ketoanalogue-supplemented very low-protein diet (sVLPD) delays dialysis initiation in patients with chronic kidney disease (CKD). In this cost-effectiveness analysis, we compare an sVLPD with a conventional low-protein diet (LPD) in patients with CKD stage 4-5 using data from Taiwan and Thailand. A Markov model simulated health outcomes and care costs in patients receiving an sVLPD (0.3-0.4g/kg-day, vegetarian diet) supplemented with ketoanalogues (1 tablet/5 kg-day) or an LPD (0.6g/kg-day, mixed proteins). Health state transition probability and resource cost inputs were based on published literature and local sources, respectively. An sVLPD increased survival and quality-adjusted life years (QALYs) at a lower cost than an LPD. Total cost of care in Taiwan was 2,262,592.30 New Taiwan dollars (NTD) (68,059.35 EUR) with an LPD and 1,096,938.20 NTD (32,996.18 EUR) with an sVLPD (difference -1,165,654.10 NTD; -35,063.17 EUR). Total cost of care in Thailand was 500,731.09 Thai baht (THB) (14,584.12 EUR) with an LPD and 421,019.22 THB (12,262.46 EUR) with an sVLPD (difference -79,711.86 THB; -2,321.66 EUR). A ketoanalogue-supplemented vegetarian sVLPD increased QALYs and lowered lifetime care costs versus an LPD in patients with predialysis CKD in Taiwan and Thailand. These data, together with the new KDOQI Guidelines for nutrition in CKD, support dietary intervention using ketoanalogue-supplemented vegetarian sVLPDs to prevent CKD progression and postpone dialysis as a cost-effective approach, with beneficial effects for patients and health care providers.

Dietary sodium restriction in heart failure and chronic kidney disease: more evidence emerges

Epidemiologic studies have shown that increased dietary sodium intake is a risk factor for high blood pressure and heart failure (HF), especially in patients with underlying chronic kidney disease (CKD).1,2 Both American Heart Association and KDOQI guidelines recommend dietary restriction of sodium to <2300 mg/d (5845 mg/d NaCl) for general cardiovascular health promotion.3 Despite these guidelines, prospective randomized clinical trials have provided conflicting data in patients with HF, and there are only limited studies in patients with CKD and HF.

Investigation on maintenance hemodialysis patients with mineral and bone disorder in Anhui province, China.

Chronic kidney disease-mineral bone disorder (CKD-MBD) is a common comorbidity in patients with CKD. The study aims to describe the control rates of serum-corrected calcium (Ca), phosphate (P) and intact parathyroid hormone (iPTH) and its risk factors among maintenance hemodialysis (MHD) patients in Anhui Province of China. The study was conducted in 27 hemodialysis centers of Anhui Province between January 1st 2020 and December 31th 2020. Chi-square test was used to compare the control rates of serum-corrected Ca, P and iPTH between the present study and DOPPS 4 or Anhui Province in 2014. Binary logistic regression analysis was used to explore the risk factors of the control rates of serum-corrected Ca, P and iPTH. A total of 3 025 MHD patients were recruited in this study, with a mean age of 54.8 (SD: 12.8) years, and 60.1% were males. According to the Chinese Diagnosis and Treatment Guidelines for CKD-MBD, the control rates of serum-corrected Ca, P and iPTH in the present study were 57.9%, 20.0% and 56.0%, respectively. Based on KDOQI guidelines (2003), the control rates of the above indicators were 43.1%, 35.3% and 22.3%, respectively. The control rates of serum-corrected Ca, P and iPTH in this study were lower than those of DOPPS 4 (P < 0.001). Compared to the results of Anhui Province in 2014, the control rate of corrected Ca was higher (P < 0.001) and the control rate of iPTH was lower (P = 0.005). Age, residential area, BMI, dialysis vintage, albumin and hemoglobin levels were factors of serum-corrected Ca, P and iPTH not within target range. The control rates of serum-corrected Ca, P and iPTH in MHD patients in Anhui Province are relatively low. Monitoring and management should be strengthened to improve the prognosis of patients undergoing dialysis.

Renal function and mortality in patients with atrial fibrillation.

The aim of this study is to examine the association of the presence of chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) values with mortality in patients with atrial fibrillation. This posthoc analysis of a randomized controlled trial consisted of hospitalized patients with atrial fibrillation who were followed up for a median of 2.7 years after discharge. Kaplan-Meier curves, multivariate Cox-regression and spline curves were utilized to assess the association of CKD, CKD stages 2-5 according to the KDOQI guidelines, and the continuum of eGFR values with the primary outcome of all-cause death, and the secondary outcome of cardiovascular mortality. Out of 1064 hospitalized patients with atrial fibrillation, 465 (43.7%) had comorbid CKD. The presence of CKD was associated with an increased risk for both all-cause and cardiovascular mortality following hospitalization [adjusted hazard ratio (aHR): 1.60; 95% confidence intervals (95% CIs): 1.25-2.05 and aHR: 1.74; 95% CI: 1.30-2.33, respectively]. The aHRs for all-cause mortality in CKD stages 2-5, as compared with CKD stage 1 were 2.18, 2.62, 4.20 and 3.38, respectively (all P < 0.05). In spline curve analyses, eGFR values lower than 50 ml/min/1.73 m2 were independent predictors of higher all-cause and cardiovascular mortality. In recently hospitalized patients with atrial fibrillation, the presence of CKD was independently associated with decreased survival, which was significant across CKD stages 2-5, as compared with CKD stage 1. Values of eGFR lower than 50 ml/min/1.73 m2 were incrementally associated with worse prognosis.

MO852: Predialysis Blood-Pressure Control Based on Antihypertensive Guidelines Should Deteriorate Cardiovascular Prognosis in Patients on Maintenance Dialysis

Abstract BACKGROUND AND AIMS Guidelines of KDOQI for dialysis patients on blood-pressure (BP) targets proposed blow 140/90 mmHg at predialysis and &amp;lt; 130/80 mmHg at postdialysis. On the other hand, in dialysis patients, many reports have shown an association between predialysis hypotension and poor prognosis. Moreover, it has been reported that low systolic blood-pressure (SBP) is associated with poor prognosis in non-dialysis patients with heart failure. Therefore, predialysis BP controlled according to KDOQI guideline should worsen survival rate in dialysis patients, especially with any cardiac disease. This time, we investigated the difference on cardiovascular survival-rate between the group complied with KDOQI guidelines and the group complied with them for diastolic blood-pressure alone, by using Yoshikawa clinic dialysis-database (YCD). METHOD A total of 455 dialysis patients (264 males and 176 females) registered in YCD enrolled in this study from April 2006 on. From these patients, we extracted two groups, group G, strictly lowering on systolic and diastolic blood-pressure and group D, lowering on diastolic blood-pressure (DBP) alone, in accordance with antihypertensive guidelines. According to calculated propensity score on group G, patients were extracted by 1: 1 matching from each group. Their survival analysis was estimated by Kaplan–Meier method, and a log-rank test was used to examine the differences between the cardiovascular survival curves. The prognostic factors for cardiovascular mortality were extracted from background factors, including blood-pressure level, using Cox regression model. RESULTS In 455 patients, mean predialysis SBP and DBP were 143.3 mmHg and 73.1 mmHg, respectively. 141 patients were extracted as group G and 219 were as group D. According to calculated propensity-score, 116 pairs (group Gp and Dp) were extracted from group G and D. There was no significant difference in matching covariates except predialysis blood-pressure between the two groups. During mean-observational period of 5.8 years, 111 patients died, among that 59 were cardiovascular death (CVD). The survival curve on cardiovascular mortality in the group Gp showed significantly poor prognosis. In multivariate analysis of Cox proportional hazard model, SBP &amp;lt; 140 mmHg was extracted as a prognostic factor for CVD, and the hazard ratio was 1.892. On the other hand, in group Dp, non-cardiovascular prognosis was poor, especially in those &amp;lt; 70 years old. CONCLUSION Blood-pressure control in maintenance dialysis-patients based on current antihypertensive guidelines (KDOQI) should worsen their cardiovascular prognosis. Therefore, it is necessary to set SBP control for each case. This study is a cohort study with a single institution, and a prospective study with multiple institutions will be needed in the future.