Long-term Hemodialysis Therapy Research Articles

Successful creation and long-term usage of radiocephalic fistula based on the recanalized completely occluded radial artery.

The total occlusion of radial artery is a contraindication for reintervention and further usage. In this study, we report successful revascularization with creation of radiocephalic fistula from post-procedural chronically-occluded radial artery. The completely occluded radial artery was recanalized through ultrasound guided balloon angioplasty. A traditional radiocephalic fistula was created subsequently by using the recanalized radial artery for hemodialysis therapy. Though the fistula was failed at the 6 weeks caused by the juxta anastomotic stenosis, the further ultrasound guided percutaneous transluminal angioplasty restored the blood, and the hemodialysis therapy lasts for more than 1 year so far. It's feasible to create radiocephalic fistula based on the recanalized radial artery and maintain long-term hemodialysis therapy.

#826 Protein-energy wasting and sarcopenia in assessing the outcomes and quality of dialysis

Abstract Background and Aims Sarcopenia is one of the serious complications of long-term hemodialysis (HD) therapy and is one of the independent predictors of morbidity and mortality in this population. Sarcopenia is associated with low physical activity, depression and low social adaptation. There are few estimates of the sarcopenia prevalence in HD patients, and they fit into the range of 15-30% in the general group and 45-60% among patients over 60 yo. The aim: in a prospective study, to clarify the prevalence, outcomes and risk factors of sarcopenia in comparison with protein and energy wasting (PEW) severity data. The results of the first year follow-up of the first cohort in the ongoing study are presented below. Method In the group of 99 prevalent patients of single HD center (vintage 26.4; 21.8-93.3 months; age 55±17 years, HD/HDF for 4-4.5 hours three-time weekly; Kt/V 1.57±0.31), the prevalence of sarcopenia was estimated (muscle mass was assessed anthropometrically and by bioimpedance (BIA), BodyStat 5000). The presence of sarcopenia was assessed by EWGSOP2 criteria, muscle strength - by wrist expander. The reference values for men and women were >27 kg and >16 kg. The PEW degree was assessed by 24-point scale (BMI, arm circumference, skin-fat fold above the triceps, arm muscle circumference, total protein, albumin, transferrin, absolute lymphocytosis; max 3 point for each). Obesity was established at BMI >30 kg/m² or according to the fat mass index >9 kg/m² in men and >13 kg/m² in women. The quality of life was assessed by KDQOL-SF™ after exclusion of patients with significant depression by the Beck scale. Results The muscle mass indices calculated anthropometrically (IMMA) and by bioimpedance (IMMB) were well correlated: IMMA=0.15+1.06×IMMB, R²=76%; diagnostic efficacy (in detecting sarcopenia) IMMA to IMMB was 86%. The prevalence of PEW by stage: absent (scores of all assessed scales - 3) – 59%, grade 1 (average score ≥2 and <3) – 32%, grade 2 (average score ≥1 and <2); in one patient, PEW was classified as severe (average score of scales <1). In the univariate and in the multiple adjusted analysis (for age, gender, provided dialysis dose and average ultrafiltration, hemoglobin and phosphate levels), the degree of PEW or the presence of PEW was not associated with the risk of death. At the same time, the phase angle (PA) of bioimpedance had such a link: the PA increase in by 1° was associated with a 24.4% reduction in the risk of death (95%CI 3.9-40.4%; p=0.022), and the inclusion of the same set of variables in the regression analysis model as for the PEW only weakened, but did not eliminated the link (OR decrease by 26.9%; 0.3-46.4%; p=0.048). The risk of death was not associated with obesity. Sarcopenia was detected in 52% of patients. It was not associated with the presence (severity) of PEW in women, but in men it was 1.48 times more common in the presence of PEW (p=0.049); in the entire group, the higher prevalence of sarcopenia in the presence of PEW (by 34%) did not reach significance (p=0.3). In multiple regression analysis, the presence of sarcopenia was associated with a 1.95-fold higher risk of death (95% CI 1.001-3.809; p=0.050). In the presence of sarcopenia, the quality of life scores were significantly lower for the scales of Physical functioning, Energy, and Physical Composite Score. The higher prevalence of sarcopenia among men than in women remains unexplained. It is possible that uniform thresholds for muscle mass and muscle strength are not suitable for all populations and require clarification. Conclusion Sarcopenia is the feature of more than half of HD patients and is significantly associated with an increased risk of death. PEW and sarcopenia, including partially similar indicators in their estimates, turned out to be poorly related in HD patients, and sarcopenia is more closely associated with hard outcomes than PEW. A separate assessment of these conditions and a search for contributing factors for its development/progression are required in prospective studies. One of the key objectifying indicators of the PEW and sarcopenia assessment could be the phase angle of bioimpedance associated with both clinical predictors and outcomes.

#2889 Multiple renal tumors as an atypical clinical manifestation of granulomatosis with polyangiitis

Abstract Background and Aims Granulomatosis with polyangiitis (GPA) is a systemic small- vessel vasculitis associated with antineutrophilic cytoplasmic antibody (ANCA), in which kidney involvement often occurs. In some cases the course of vasculitis with kidney involvement is atypical, what complicates the diagnostic process and makes appropriate treatment difficult. Finding nodular masses in the kidneys always causes an oncological concern, while in the differential diagnosis a systemic vasculitis is rarely taken into account, what may lead to an unnecessary nephrectomy. Method We present a case of granulomatosis with polyangiitis (GPA) who presented with multiple tumors in the kidneys and adrenal gland. Results 29-year-old man experienced a sudden disease onset, at the age of 18 years, when due to peripheral oedema, nephrotic grade proteinuria (13.7 g/24 h), hematuria and presence of renal failure markers (serum creatinine 3.4 mg/dL), he was admitted to hospital. A suggestion of a rapidly progressive glomerulonephritis (RPGN) was put forward and a renal biopsy was performed (in the histopathological examination of the kidney, pauci-immune crescentic necrotizing glomerulonephritis was revealed). A treatment with plasmaphereses, high glucocorticosteroid doses and cyclophosphamide pulses was instituted. Haemodialysis therapy was also applied temporarily. ANCA and anti-glomerular basement membrane (GBM) antibodies were determined to give negative results. As a result of the remission-inducing treatment, an improvement of the renal function was obtained (serum creatinine 1.6-1.9 mg/dL). In spite of the remission-maintaining treatment with mycophenolate mofetil (MMF) and oral prednisone, after 10 years again a dramatic renal function impairment occurred, with a necessity of institution of a long-term haemodialysis therapy. Furthermore, on abdominal ultrasound examination multiple focal lesions were found in both kidneys, which rendered a kidney transplantation procedure in the patient impossible. In order to extend the diagnostic procedures, a magnetic resonance imaging (MRI) of the abdominal cavity without contrast agent administration was carried out (in both kidneys disseminated focal lesions were described: non-homogeneous, with moderately enhanced signal on T2-weighted images in the central part, without signs of water diffusion restriction; in the left kidney, of 23 x 22 mm and 19 x 15 mm dimensions; in the right kidney, of 30 x 32 mm, 26 x 22 mm and 22 x 18 mm dimensions. The picture of the lesions was unspecific and atypical. In the differential diagnosis granulomas could not have been ruled out, while disseminated proliferative lesions were less likely. Besides that, in both kidneys cysts of up to 7 mm diameters were present. In the lateral limb of the left adrenal gland a focal lesion was visible, of 23 x 14 mm dimensions, of a structure identical to that of the foci in both kidneys). On high-resolution computed tomography (HRCT) of the chest at the same time, small ground glass areas were found in the lungs. On positron emission tomography/computed tomography (PET/CT) no changes were visualised, suggesting presence of a metabolically active proliferative process. Tests for ANCA, antinuclear antibodies (ANA), anti- double-stranded DNA (dsDNA) antibodies, anti- GBM antibodies were again performed and gave negative results. He was diagnosed with granulomatosis with polyangiitis without ANCA and treated with corticosteroid and intravenous rituximab (4x 787 mg). Three months later, follow-up showed reduced mass lesions in the kidney and adrenal gland by MRI. Conclusion The case highlights the atypical clinical presentation of vasculitis and the significance of considering this possibility in differential diagnosis when confronting mass lesions present in the kidney.

Technical requirements and devices available for long-term hemodialysis in children-mind the gap!

Children requiring long-term kidney replacement therapy are a "rare disease" cohort. While the basic technical requirements for hemodialysis (HD) are similar in children and adults, key aspects of the child's cardiovascular anatomy and hemodynamic specifications must be considered. In this article, we describe the technical requirements for long-term HD therapy for children and the devices that are currently available around the world. We highlight the characteristics and major technical shortcomings of permanent central venous catheters, dialyzers, dialysis machines, and software available to clinicians who care for children. We show that currently available HD machines are not equipped with appropriately small circuits and sensitive control mechanisms to perform safe and effective HD in the youngest patients. Manufacturers limit their liability, and health regulatory agencies permit the use of devices, only in children according to the manufacturers' pre-specified weight limitations. Although registries show that 6-23% of children starting long-term HD weigh less than 15 kg, currently, there is only one long-term HD device that is cleared for use in children weighing 10 to 15 kg and none is available and labelled for use in children weighing less than 10 kg anywhere in the world. Thus, many children are being treated "off-label" and are subject to interventions delivered by medical devices that lack pediatric safety and efficacy data. Moreover, recent improvements in dialysis technology offered to adult patients are denied to most children. We, in turn, advocate for concerted action by pediatric nephrologists, industry, and health regulatory agencies to increase the development of dedicated HD machines and equipment for children.

Results of studying the diabetic retinopathy course in potential kidney and pancreatic recipients while on hemodialysis

Introduction. Kidney and pancreas transplantation is a surgical method for the treatment of patients with diabetes mellitus and terminal diabetic nephropathy. While waiting for surgical treatment, potential recipients receive maintenance hemodialysis. Dialysis initiates the loss of body fluid, which in turn can affect the state of the intraocular structures. Aim. To study the effect of long-term hemodialysis therapy on ophthalmic parameters in patients with terminal diabetic nephropathy. Material and methods. Sixty patients (120 eyes) were examined: group A included 30 patients with end-stage renal failure as a result of diabetic nephropathy, group B included 30 people without systemic and ocular pathologies. The ophthalmological status of group A was assessed at the stage of planned preparation for renal replacement therapy, at 3 and 6 months after the initiation of dialysis. Ophthalmological examination consisted of the use of traditional and special diagnostic methods (microperimetry, photorecording of the fundus, optical coherence tomography angiography). Results. Within 6 months of hemodialysis courses, the following was recorded: a decrease in the thickness of the retina (Me: from 348.5 to 306.1 µm; p <0.05) and choroid (Me: from 330.3 to 294.9 µm; p <0.05), the improvement of retinal perfusion in eyes with diabetic macular edema (Me in the superficial capillary plexus: from 10.6 to 15.8% in the fovea, from 19.7 to 25.4% in the parafovea; in the deep capillary plexus: from 15.4 to 20.9% in the fovea, from 27.5 to 33.5% in the parafovea; p <0.05), a decrease in choroidal hemoperfusion (Me in the layer of choriocapillaries: from 59.0 to 54.2% in the fovea, from 59.3 to 54.7% in the parafovea; in the deep layer of the choroids: from 55.5 to 50.7% in the fovea, from 55.3 to 50.7% in the parafovea; p<0.05),an improvement in retinal photosensitivity (Me: from 16.7 to 20.3 dB in eyes with diabetic macular edema; from 21.1 to 24.2 dB in eyes without diabetic macular edema; p<0.05) and increased visual acuity in eyes with macular edema (Me: 0.1 to 0.3; p<0.05). Conclusions. Against the background of maintenance hemodialysis hemodialysis in patients with terminal diabetic nephropathy, along with a decrease in hyperazotemia, there is an improvement in architectonics, hemodynamics of the retina and visual functions.

Surveillance and monitoring of early failing arteriovenous fistula using Doppler assessment in children on regular hemodialysis

BackgroundA well-functioning vascular access is a mainstay to perform an efficient hemodialysis procedure. Limited lifespan of arteriovenous accesses is one of the major challenges of the current long-term hemodialysis therapy. Vascular access-related morbidity accounts for up to 50% of total dialysis patient’s costs. The pediatric vascular access clinical guidelines published by the National Kidney Foundation Kidney Disease Outcome Quality Initiative recommend establishing a surveillance strategy to detect access stenosis and direct patients for early intervention. The aim of this study was to test the role of using the color Doppler ultrasonography (CDU) as a surveillance method for arteriovenous fistulae in children on regular hemodialysis and its value for detecting the early vascular access failure or dysfunction to avoid access loss.ResultsDuring 10-month duration, we prospectively conducted surveillance for 30 patients on regular hemodialysis through arteriovenous fistulae (AVF) as a vascular access, clinical assessment of AVF and radiological examination using CDU of the upper limbs. Their ages were ranging from 2 to 18 years with 1:1 male: female ratio. Doppler indices were measured in the afferent arteries, at the site of anastomosis, and the draining veins. AVF stenosis was the highest among all the detected complications (n = 9, 30%), aneurysm and pseudoaneurysmal formation (n = 8, 26%) anastomoses diameter reduction in 16.6%, and it was correlated with the dialysis adequacy measured through the Kt/v. Other complications were thrombosis (n = 2, 6.7%), central venous stenosis (n = 2, 6.7%), steal syndrome (n = 1, 3.3%) and calcifications in (n = 1, 3.3%). In total, 26% of the patients have more than one malfunction. Only one case has access failure a month after CDU examination.ConclusionIn conclusion, among pediatric patients CDU can detect early stenosis of AVF in children, which can affect the dialysis adequacy.

Non-Pharmacological Management of Pruritus in Chronic Kidney Disease Patients at Panti Waluya Sawahan Hospital

Patients of chronic kidney disease require long-term hemodialysis therapy. However, this therapy has various complications, one of which is pruritus. Pruritus can interfere with individual activities, cause sleep disturbances, lesions and hyperpigmentation on the skin, to impact the patient's quality of life. So that non-pharmacological management is needed to treat pruritus. The design was cross sectional. The population in this community service was chronic kidney failure patients undergoing hemodialysis therapy in the hemodialysis room. The sample was patients who experience pruritus and undergo hemodialysis therapy at least 1x / week as many as 45 people. The variables were health education related to non-pharmacological management and pruritus. The instruments used leaflets and counseling program units for health education, while for pruritus used the Numeric Rating Scale. The average patient experienced pruritus on a scale of 5, which was a moderate category where itching was felt by frequent scratching. After health education, patients understand how to deal with pruritus with non-pharmacological methods so that the patient's quality of life becomes better

Amyloid Arthropathy: A Review.

Amyloid arthropathy is a joint disease associated with systemic amyloidosis. Herein, we present a model case and review the clinicopathologic features and pathophysiology of this disorder. Amyloid arthropathy results from elevation of serum amyloidogenic proteins and their deposition as aggregates in synovial fluid and articular tissues. The most common proteins are beta-2-microglobulin in the context of long-term hemodialysis therapy and immunoglobulin light chains associated with plasma cell proliferations. We provide a comprehensive update on the pathogenesis, clinical manifestations, and pathologic features of amyloid arthropathy. We provide detailed insights on amyloid protein deposition and aggregation in joints and proper details for diagnosis.

Characteristics of ESRD Patients who have been on Long-term Hemodialysis Therapy in Egypt

Background: It is well-known that hemodialysis extends the life of end-stage renal disease (ESRD) patients, who would have otherwise died. The characteristics of long-term patients on hemodialysis (HD) were not evaluated before in Egypt. We aimed at identifying the specific characteristics of the patients who have survived on hemodialysis for more than 20 years in Egypt. Subjects and Methods: During the years 2018 and 2019, the twenty-seven governorate health affairs Directories of the Egyptian Ministry of Health were contacted to participate in data collection. The dialysis physicians in each hemodialysis unit were sent a questionnaire form requesting to submit information, on the characteristics of patients who have been on HD therapy for twenty years or more.
 Results: Seventy-three patients were encountered from a total number of 26000 HD patients to have been on HD therapy; with a range between 20 and 30 years. Males constituted the majority of these patients. Sixty-eight patients were dialyzed through working arteriovenous fistulas (A-V fistulas). The mean urea reduction ratio (URR) of these patients was 0.65±0.095. Acute intradialytic complications afflicted only 20.3% of these patients. More than three-quarters of the patients had a positive serology test for HCV antibodies. None of these patients has diabetes mellitus. On the other hand, complaints related to the skeletal system were present in 47.4% of the patients. There is a statistically significant higher rate of acute complications in the female gender and a statistically significant higher fertility rate after hemodialysis in the male gender.
 Conclusion: Long-term dwellers on hemodialysis therapy are not unusual in Egyptian ESRD patients and their characteristics are reasonable.

Exploring the relation between mortality and left ventricular structure and function in stable hemodialysis treated patients, a longitudinal multicenter cohort study

Left ventricular (LV) structure and function anomalies are frequent during the CKD continuum and are associated with increased risk of mortality. Cross section and longitudinal ultrasound data are available for advanced CKD and transition to ESKD. Less information is available about LV changes during stable, long-term hemodialysis (HD) treatment. All stable HD patients from 9 HD centers (1034 patients, 671 males, age 58.71 ± 12.94 years) have been enrolled in January 2015. The cohort was followed-up for 4 years, kidney transplantation or death. Yearly, two-dimensional and M-mode continuous and Pulse Doppler echocardiography were performed. During the follow-up, the prevalence of cardiovascular comorbidities significantly increased (p < 0.0001), coronary artery disease (CAD) from 73.5 to 88.8%, peripheral artery disease (PAD) from 29 to 40.9%, cerebral vascular disease (CVD) from 20.4 to 30.8%, heart valves calcification (VC) from 65.6 to 89.3% and left ventricular hypertrophy (LVH) from 67.6 to 76.5%. The mortality risk increased with the presence of CAD (1.59-fold), PAD (1.61-fold), CVD (1.59-fold), and VC (1.77-fold). Mortality risk was increased in those with LVEF < 50% (LVEF 40–49% 1.5-fold and LVEF < 40% 2.3 fold). Among the survivors of the first year, LVEF varied (> 5% decrease, > 5% increase and ± 5% variations). More than 5% increase of LVEF was associated with higher mortality risk (crude 1.5-fold, adjusted 1.43-fold) compared to stationary EF (p = 0.001). Cardiovascular disease progresses during stable long-term HD therapy and increases mortality risk. HF becomes highly prevalent but only HF with decreased LVEF < 50% is associated with increased risk of mortality.

PREDICTORS OF HCV SEROCONVERSION AMONG END-STAGE RENAL DISEASE PATIENTS IN HEMODIALYSIS UNIT

Background: In patients receiving dialysis, blood borne infections remains one of the most public causes of morbidity, hospitalization and death. Among dialysis patient’s long-term hemodialysis (HD) therapy, frequency of blood transfusions and multiple blood transfusions enhance the risk of acquiring blood-borne infections. Objective: The aim of the study was to identify predictors for HCV sero-conversion in HD patients. Method: Prospective observational study was conducted on 173 CKD patients undergoing HD. Anti HCV antibody testing was accomplished at the start of study and every 2-3 months subsequently. To identify seroconversion, patients who were sero-negative for HCV were monitored. Results: Prospective follow-up exposed an occurrence of seroconversion of 12.1% during study duration. On multivariate analysis, both increase in the duration on hemodialysis besides attending more than one center for HD were significantly associated with anti-HCV positivity (p 40IU/L also shows significant association for seroconversion (p<0.05). Conclusion: It is concluded that increase post dialysis incidence of HCV occurs as specific guidelines for HCV infected patients were not followed. Regular surveillance for HCV infection helps dramatically in decreasing the spread of HCV in hemodialysis unit.

Predictors of HCV Seroconversion among End-stage renal disease Patients in Hemodialysis Unit

Background: In patients under dialysis, blood borne infections remains one of the mostpublic causes of morbidity, hospitalization and death. Among dialysis patient’s long-term hemodialysis (HD) therapy, frequency of blood transfusions and multiple blood transfusions enhance the risk of acquiring blood-borne infections. Objective: The aim of the study was to identify predictors for HCV sero-conversion in HD patients. Method: Prospective observational study was conducted on 173 Chronic kidney disease (CKD) patients undergoing HD. Anti HCV antibody testing was accomplished at the start of study and every 2-3 months subsequently. To identify seroconversion, patients who were sero-negative for HCV were monitored.Results: Prospective follow-up exposed an occurrence of seroconversion of 12.1% during study duration. On multivariate analysis, both increase in the duration on hemodialysis besides attending more than one centre for HD were significantly associated with anti-HCV positivity (p < 0.05, OR 0.185), (p 40 IU/L also shows significant association for seroconversion (p < 0.05). Conclusion: It is concluded that increase post dialysis incidence of HCV occurs as specific guidelines for HCV infected patients were not followed. Regular surveillance for HCV infection helps dramatically in decreasing the spread of HCV in hemodialysis unit.Keywords: Hepatitis C virus, Hemodialysis, End stage renal disease, Chronic kidney disease

Physical Activity Patterns on Quality of Life in Chronic Kidney Failure Patients With Hemodialysis: Literature Review

Background: Patients with chronic kidney failure require appropriate therapy to optimize kidney function. This therapy is not a drug, but as a substitute for kidney function. Renal function replacement therapy, such as hemodialysis is a routine medical treatment for chronic kidney disease. Method: The research design used a systematic use of several research journal articles published on the basis of Health. the health databases used include: Google Scholar, the national library and Pubmed with a time span of 2012 to 2020. Results: The results of this study are that there is an influence of physical activity patterns on the quality of life of patients with chronic kidney failure with hemodialysis. Conclusion: Patients with chronic kidney failure who undergo long-term hemodialysis therapy often feel worried about unpredictable disease conditions and disturbances that occur in life due to the disease they are experiencing. The patient's mindset changes because there are activities the patient does besides thinking about his illness

P1083A TRANSITIONAL REGIME OF INCREMENTAL HAEMODIALYSIS IN PATIENTS WITH END-STAGE RENAL DISEASE (ENDURE): A FEASIBILITY TRIAL

Abstract Background and Aims Mortality rates are high in patients starting long-term haemodialysis (HD) therapy, particularly in the first 6-months. Incremental HD has been proposed as a means of making patients’ transition into long-term HD treatment less physiologically demanding with reduced burden of treatment at the start. A feasibility study is being conducted with the primary aim of evaluating the acceptability, tolerance and safety of a novel incremental HD regime. The secondary aims are to study the effect of incremental HD on residual renal function (RRF), fluid load, quality of life, functional status, blood pressure and blood markers of renal anaemia, secondary hyperparathyroidism and cardiac load. Method The regime being tested aims to start patients on twice-weekly HD with progressive increases in the duration and frequency of sessions over approximately 15 weeks (figure 1). 40 patients from pre-dialysis clinics, who have been referred for start of long-term HD therapy, will receive the study regime (incremental HD group). They will be followed-up for 12 months. Acceptability and tolerance will be gauged by documenting rates of participation and retention in the study. Completion rate of each study test will be recorded to evaluate the feasibility of their inclusion in a future trial; these tests include: 24-hour urine collection to measure RRF, bio-impedance analysis for estimation of overhydration, six-minute walk test to monitor performance status and a quality-of-life questionnaire. Rates of pre-defined safety events will be recorded and compared to a cohort of 40 matched patients who previously started conventional HD (historical controls, conventional HD group). Blood tests for estimation of RRF and markers of renal anaemia, bone disease and cardiac load will be performed at regular intervals and compared to the conventional HD group. Results Eight months in to the 18-month recruitment period, 106 patients have been screened for participation in the trial. Of these, 47 (43%) met eligibility criteria. Reasons for exclusions were: patient choosing other dialysis modalities over HD, 34; clinically unsuitable for incremental HD, 7; dialysis modality undetermined, 6; already started HD, 5; for conservative (non-dialysis) management, 4; non-compliant with treatment, 3. Of the 47 eligible patients, 35 have been approached by the study team. Of these, 16 (46%) have been consented, 10 (28%) declined and 9 (26%) remain undecided. Patients who consented were relatively older compared to those who declined (68 vs. 58 years) and to all eligible patients (68 vs. 63 years). Men were more likely to decline than women (M:F ratio 1.3 vs 4.0 among participants and decliners respectively). Not all study participants have started treatment yet. Baseline characteristics of the first 6 patients starting incremental HD and their matched controls are shown in table 1. Conclusion The ENDURE study tests the feasibility of starting patients on a novel incremental HD regime. This regime is relatively short and has fixed increments in treatment times. It aims to make patient transition smoother in to dialysis dependency. Early data point towards an encouraging levels of patient interest in the study. The outcome of this trial will be used to design a future RCT of incremental HD vs. conventional treatment.

Paying for Hemodialysis in Kerala, India: A Description of Household Financial Hardship in the Context of Medical Subsidy

IntroductionMany low- and middle-income countries are implementing strategies to increase dialysis availability as growing numbers of people reach end-stage renal disease. Despite efforts to subsidize care, the economic sustainability of chronic dialysis in these settings remains uncertain. We evaluated the association of medical subsidy with household financial hardship related to hemodialysis in Kerala, India, a state with high penetrance of procedure-based subsidies for patients on dialysis.MethodsPatients on maintenance hemodialysis at 15 facilities in Kerala were administered a questionnaire that ascertained demographics, dialysis details, and household finances. We estimated direct and indirect costs of hemodialysis, and described the use of medical subsidy. We evaluated whether presence of subsidy (private, charity, or government-sponsored) was associated with lower catastrophic health expenditure (defined as ≥40% of nonsubsistence expenditure spent on dialysis) or distress financing.ResultsOf the 835 patients surveyed, 759 (91%) reported their households experienced catastrophic health expenditure, and 644 (77%) engaged in distress financing. Median dialysis-related expenditure was 80% (25th–75th percentile: 60%–90%) of household nonsubsistence expenditure. Government subsidies were used by 238 (29%) of households, 139 (58%) of which were in the lowest income category. Catastrophic health expenditure was present in 215 (90%) of households receiving government subsidy and 332 (93%) without subsidy.ConclusionsProvision of medical subsidy in Kerala, India was not associated with lower rates of household financial hardship related to long-term hemodialysis therapy. Transparent counseling on impending costs and innovative strategies to mitigate household financial distress are necessary for persons with end-stage renal disease in resource-limited settings.

Сравнительная оценка качества жизни больных хронической болезнью почек после трансплантации почки и больных, находящихся на гемодиализной терапии

To compare the quality of life of chronic kidney disease (CKD) patients after kidney transplantation and hemodialysis patients. A prospective controlled trial comprised 110 CKD patients, divided into two groups. The study group included 51 (46.4%) kidney transplant recipients and 59 (53.6%) hemodialysis patients represented a control group. Assessment of health related quality of life was done using the KDQOL-SF questionnaire. Kidney transplant recipients reported significantly greater satisfaction with their physical and emotional health than hemodialysis patients. Kidney transplant recipients experienced fewer somatic symptoms of CKD and everyday problems. It is very important that unlike hemodialysis patients transplant recipients were physically capable of working. There were no differences between groups regarding sleep quality, sexual activity, communication with others and time spent with family and friends. Patients receiving long-term hemodialysis therapy experience a marked decrease in physical and mental components of QOL, whereas kidney transplantation results in better QOL for these parameters.

Risk factors for erectile dysfunction in end-stage renal disease patients with short- or long-term hemodialysis therapy

The influence of prolongation of hemodialysis (HD) period for erectile dysfunction (ED) has not been well evaluated. We evaluated the effects of various factors including hemodialysis duration for ED in hemodialysis patients. One hundred seventy-eight HD patients including 50 patients who received HD more than 10 years were enrolled in this study. The questionnaire of the International Index of Erectile Function (IIEF)-5 in Japanese language was used for evaluation of ED status in this cohort. Various clinical factors of these patients were collected from review of medical records, and the relationship between these factors and ED status was also evaluated. The prevalence of diabetes (p < 0.001), obesity (p = 0.011), and hyperuricemia (p = 0.010) were significantly higher in patients with less than 10 years of HD (group 1) than those in patients with more than 10 years of HD periods (group 2). The mean score of IIEF-5 in group 2 was almost similar with that in group 1 (p = 0.452). Moderate to severe ED was also equivalent to that in group 1 (p = 0.988). More than 60 years old (p < 0.001) and absence of hyperuricemia (p = 0.002) appeared to be significant risk factors for moderate to severe ED in multivariate analysis. Long periods of chronic hemodialysis therapy did not affect ED status, and absence of hyperuricemia was the risk factor for moderate to severe ED in HD patients.

A Retrospective Quality Study of Hemodialysis Catheter-Related Bacteremia in a Danish Hospital

Background: Hemodialysis catheter-related bacteremia (HD CRB) is a major complication of long-term hemodialysis (HD) therapy and bacteremia is secondary only to cardiovascular disease as the leading cause of death in patients receiving renal replacement therapy. A large part may be preventable and surveillance is a critical aspect of infection control and prevention. Aim: To analyze incidence, causative species, and treatment of HD CRB in adult chronic HD patients at Nordsjaellands Hospital (NOH), Denmark. Methods: All episodes of bacteremia in the Department of Cardiology, Nephrology and Endocrinology (KNEA), NOH from 2010 to 2013 were analyzed. Inclusion criteria: Adult chronic HD patients with a tunneled dialysis catheter diagnosed with HD CRB. Causative microorganism and antimicrobial treatment were recorded for each episode. Findings: Ninetynine episodes of HD CRB in 72 patients were found with a mean incidence rate of 0.9/1000 catheter-days. Gram-positive bacteria were isolated in 71% of the episodes, gram-negative bacteria in 25%, both in 3%, and yeast in 1%. The most frequently isolated microorganisms were Staphylococcus aureus (33%), Coagulase-negative staphylococci (29%), enterobacteriaceae (20%) and enterococci (8%). The most commonly used empiric antimicrobials were cefuroxime and vancomycin and the overall efficacy was 77%. Conclusion: The well-functioning infection prevention strategy seems to be successful resulting in a relatively low incidence rate of HD CRB compared with that shown in international studies. The high proportion of gram-negative bacteria raises the question as to whether future antimicrobial guidelines should cover both gram-positive and gram-negative bacteria.

Long-term hemodialysis therapy in neonates and infants with end-stage renal disease: a 16-year experience and outcome.

Peritoneal dialysis is the preferred mode of renal replacement therapy in infants with end-stage renal disease (ESRD). Hemodialysis (HD) is seldom used in neonates and infants due to the risk of major complications in the very young. Demographic, clinical, laboratory, and imaging data on all infants younger than 12 months with ESRD who received HD in our Pediatric Dialysis Unit between January 1997 and June 2013 were analyzed. Eighteen infants (n = 6 male) with ESRD (median age 3 months; median weight 4.06 kg) received HD through a central venous catheter (CVC) for a total of 543 months (median duration per infant 16 months). Seven of the infants (39%) were neonates, and five (28%) had serious comorbidities. There were five episodes of CVC infection, which is a rate of 0.3/1000 CVC days. Median catheter survival time was 320 days. Most infants had good oral intake, and only four (22%) required a gastric tube; 14 (78%) infants displayed normal growth. Fourteen (78%) infants had hypertension, of whom four (22%) had severe cardiac complications; eight (44%) showed delayed psychomotor development. Eleven (61%) of the infants, including six (86%) of the neonates, survived. Five (28%) infants underwent renal transplantation; 10-year graft survival was 80%. Based on these results, long-term HD in neonates and infants with ESRD is technically feasible, can be implemented without major complications, carries a very low rate of CVC infection and malfunction, and results in adequate nutrition, good growth, as well as good kidney graft and patient survivals. Future efforts should aim to prevent hypertension and its cardiac sequelae, improve neurodevelopmental outcome, and lower mortality rate in these infants.

Basics of base in hemodialysis solution: Dialysate buffer production, delivery and decontamination.

Hemodialysis requires the use of high volumes of freshly prepared, clean dialysate to foster the removal of low molecular weight metabolites (i.e., urea) and to correct the electrolyte and acid-base imbalance of chronic renal failure. Dialysate is produced by mixing clean, AAMI grade water with both an acid and base concentrate. This purpose of this report is to describe production, mixing and delivery of the buffer component of dialysate, and to also to address the cost, safety and feasibility of producing online bicarbonate. As endotoxin contaminated dialysate has been associated with the release of key mediators in acute and chronic inflammatory diseases associated with long-term hemodialysis therapy, aspects of disinfecting a bicarbonate delivery loop are also addressed.