Management Of Dialysis Patients Research Articles

#2714 An AI based tool for hydration management in dialysis patients.

Abstract Background and Aims Hemodialysis patients often experience over-hydration (OH), a critical factor derived from excess extracellular water and associated with cardiovascular complications and overall morbidity. Accurate estimation of pre-dialysis OH is essential for optimizing fluid management and improving patient outcomes. Traditional methods for assessing OH, such as the Body Composition Monitor (BCM) are, in general, time-consuming for clinical staff and costly for healthcare providers. In this study, we present a machine learning model combining data automatically recorded by dialysis machine sensors and medical information captured in electronic chart records to estimate pre-dialysis OH. The aim of this study is to evaluate the possibility of a tool that predicts OH from patient's data without, or less frequently using, a bioimpedance device for OH measurements. Method We collected a comprehensive dataset from a cohort of CKD patients undergoing hemodialysis, including demographic information, clinical parameters, and hydration status parameters. The value of OH was assessed using BCM device. A feature selection approach, guided by a balance between prediction accuracy and model complexity, was used to identify the optimal set of input variables. All variables utilized in the model are either regularly gathered in clinical practice or automatically recorded from the dialysis machine. We tried different combinations of features using an XGBoost regressor algorithm. We focused the study on the comparison of the prediction of OH with the input variable of the average BCM OH value in the past year (Model 1) and without this variable (Model 2). Mean absolute error (MAE), Root mean square error (RMSE), R2, calibration and residuals plots were used to assess the models’ accuracy. The measurement unit is in litres. The models were validated with nested 5-fold cross-validation, dividing the data repeatedly into disjunct train, validation and test folds and 5 outer loops, totalling 25 folds. Results The dataset contains the observations from 37,011 patients for a total of 934,386 BCM assessments collected in the EuCliD database by Fresenius Medical Care clinics in Cech Republic, Italy, Portugal, Slovakia, Spain, and the United Kingdom between January 2016 to September 2023. The average value of OH is 2.06 (std 1.88). Model 1 generalizes on unseen data samples with an MAE of 0.74, RMSE of 1.02 and R2 of 0.57 after evaluating the performance on the test folds. Model 2 MAE is 0.93, RMSE is 1.25 and R2 is 0.36. The degradation of the accuracy between the two models indicates the importance of patients’ past BCM information for the prediction of the next OH. This degradation is also clear in the calibration and residuals plots (Fig. 1). Nevertheless, model 2 is able to predict OH with an acceptable level of accuracy. Conclusion Fluid management is a critical task for physicians and nurses. We present an AI-based tool that can be utilized to support clinicians in their daily decisions about fluid management, with and without the use of a device to measure OH. The results, as expected, show an important degradation of the accuracy between model 1 and 2, however, model 2 has sufficient overall accuracy to consider the approach valuable, meriting further exploration. In general, this approach can be used to reduce the number of direct OH assessments.

Treatment of Gout in Patients with CrCl ≤30 mL/min and/or on Hemodialysis: A Review

Gout is highly prevalent in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD), owing to impaired uric acid excretion. However, treating gout in this population is challenging due to concerns about medication safety and efficacy with reduced kidney function. This review examines the evidence of various pharmacologic and non-pharmacologic approaches to managing gout in CKD/ESRD. For acute gout flares, there is insufficient evidence to guide optimal dosing of NSAIDs, colchicine, and corticosteroids in advanced CKD. The risks generally outweigh the benefits of NSAIDs and colchicine. Corticosteroids appear safer but require individual risk-benefit assessments. Interleukin-1 inhibitors show promise, but larger studies are needed. For long-term urate lowering, xanthine oxidase inhibitors like allopurinol and febuxostat are preferred over probenecid and other uricosurics. However, studies specifically evaluating urate-lowering therapies in CKD are scarce, resulting in conflicting expert guidelines. Starting with low allopurinol doses and gradual titration can mitigate the risks. Higher allopurinol doses may be needed to reach urate targets in some CKD patients. Febuxostat’s safety in advanced CKD remains debated. Optimal gout management in dialysis patients is also unclear, including when to continue urate-lowering therapy. Overall, gout is often suboptimally treated in CKD/ESRD, highlighting the need for more research to guide therapy in this population. Improving management can significantly reduce the burden of these comorbid diseases.

Iron Overload in Dialysis Patients: Serum Ferritin Underestimates Liver Iron Measured By MRI

Background: Parenteral iron supplementation and erythropoietin-stimulating agents are the mainstay management for anemia in patients requiring dialysis. Traditionally, iron status in this patient population is determined by monitoring of widely available and inexpensive serum ferritin level. However, serum ferritin is an acute phase reactant and its usefulness is disease specific. Therefore, several non-invasive methods to evaluate body iron storage have been studied, with measurement of liver iron concentration (LIC) by MRI FDA approved. In this retrospective chart review, we explored the utility of serum ferritin for predicting LIC in a convenience sample of adults on dialysis who had LIC measured by MRI. Methods: Seven adults on dialysis who had been referred to an academic hematology clinic between July 2020 to June 2023 for elevated ferritin and subsequently had completed LIC by MRI were included in this chart review. Liver iron was quantified by T2* Relaxometry in a 1.5 Tesla MRI . Patients age, gender, etiology of end stage renal disease, duration on dialysis, initial LIC, and the ferritin and hemoglobin levels within three month of LIC were collected from patient medical records. Clinical recommendation for holding parenteral iron or starting chelation and patient-follow through were also recorded. In 2 patients, repeat LIC was available. The clinical recommendation for all patients with elevated LICs was to hold parenteral iron and not to start chelation but repeat LIC in 6 month intervals. Result: The median age was 56 years (min 26 years - max 73 years) and 4 of 7 patients were female. The median time of first LIC from initiation of dialysis was 88.5 months (min 19 months - max 130 months). The median of initial LIC was 6.6 mg/g (min 4.6 mg/g - max 12.5 mg/g). The median ferritin was 1120 ng/mL (min 736 ng/mL - max 2650 ng/mL). The median hemoglobin was 10.8 g/dL (min 8.4 g/dL - max 13.7 g/dL). Figure 1A demonstrates that despite similar ferritin levels (bolded group or underlined group), LICs were very variable. Additionally, it is visible in figure 1A that serum ferritin underestimates the LIC (italicized) in this patient population. Holding iron infusion for 2 years in patient 4, resulted in LIC trending down from 6.3 mg/g to 3.2 mg/g (Figure 1B) with minimal impact on hemoglobin. Despite clinical recommendation to hold iron infusion in patient 5 with an initial LIC of 6.8 mg/g, iron infusion was continued. Repeat LIC for this patient 6 months later remained unchanged at 7.0 mg/g, while serum ferritin trended down from 1084 to 843. Conclusion: Ferritin underestimates liver iron concentration in dialysis patients. More investigation is required to determine if liver iron assessment by MRI improves iron management in dialysis patients and optimize serum ferritin utility. This data also suggests that, chelation is not required in iron overloaded dialysis patients, and holding IV iron can result in decline in liver iron concentration.

Comparison of percutaneous coronary intervention versus medication in dialysis patients with coronary artery disease

Abstract Background There is a lack of evidence for the optimal management of dialysis patients complicated with coronary artery disease (CAD). Based on the favorable results from patients with normal or near-normal kidney function, percutaneous coronary intervention (PCI) has extended to patients on maintenance dialysis. However, it is unknown whether this extrapolation is accurate. Purpose We sought to investigate the benefits of PCI in dialysis patients with CAD. Methods Between January 2015 and June 2021, 455 617 consecutive cardiac catheterizations from 30 cardiac centers in China were reviewed retrospectively through medical records. Patients with normal coronary anatomy, those who did not receive dialysis therapy or received dialysis for less than 3 months, those who received coronary artery bypass grafting, repeat admissions, and those with less than one year of follow-up were excluded. Patients were followed up via telephone interviews or clinic visits until June 2022. The primary outcome of interest was 1-year all-cause mortality, and the secondary outcome of interest was 1-year cardiac death. Cox proportional hazards regression model was used to assess the association of PCI with outcomes. Inverse probability of treatment weighting was used to control for imbalances in patient characteristics. Results Of 1 119 patients who met the final criteria, 799 (71.4%) received PCI. The mean age was 61.9±10.6 years, and 828 (74.0%) were male. Compared with medically treated patients, patients in the PCI group were more likely to present with a high Gensini score, be with multivessel diseases, and receive dual antiplatelet and statin therapy. Overall, 201 (16.4%) all-cause deaths were documented, with 153 (13.7%) cardiac deaths. Patients treated with PCI experienced significantly lower cumulative rates of 1-year all-cause deaths (15.5% vs. 24.1%, log-rank p<0.001) as well as cardiac deaths (11.5% vs. 19.1%, p<0.001). Multivariate analyses showed that PCI was independently associated with a lower risk of either all-cause deaths (hazard ratio 0.48, 95% confidence interval 0.36-0.64, p<0.001) or cardiac mortality (hazard ratio 0.45, 95% confidence interval 0.30-0.61, p<0.001). These findings were further confirmed in the inverse probability of treatment weighting cohort. Conclusion This cohort study found that in real-world practice, among dialysis with CAD, use of PCI was associated with significantly lower risks for 1-year all-cause death or cardiac mortality compared with medical management. Further prospective studies are needed to confirm these findings.

Predictive value of the stress hyperglycemia ratio in dialysis patients with acute coronary syndrome: insights from a multi-center observational study

BackgroundVarious studies have indicated that stress hyperglycemia ratio (SHR) can reflect true acute hyperglycemic status and is associated with poor outcomes in patients with acute coronary syndrome (ACS). However, data on dialysis patients with ACS are limited. The Global Registry of Acute Coronary Events (GRACE) risk score is a well-validated risk prediction tool for ACS patients, yet it underestimates the risk of major events in patients receiving dialysis. This study aimed to evaluate the association between SHR and adverse cardiovascular events in dialysis patients with ACS and explore the potential incremental prognostic value of incorporating SHR into the GRACE risk score.MethodsThis study enrolled 714 dialysis patients with ACS from January 2015 to June 2021 at 30 tertiary medical centers in China. Patients were stratified into three groups based on the tertiles of SHR. The primary outcome was major adverse cardiovascular events (MACE), and the secondary outcomes were all-cause mortality and cardiovascular mortality.ResultsAfter a median follow-up of 20.9 months, 345 (48.3%) MACE and 280 (39.2%) all-cause mortality occurred, comprising 205 cases of cardiovascular death. When the highest SHR tertile was compared to the second SHR tertile, a significantly increased risk of MACE (adjusted hazard ratio, 1.92; 95% CI, 1.48–2.49), all-cause mortality (adjusted hazard ratio, 2.19; 95% CI, 1.64–2.93), and cardiovascular mortality (adjusted hazard ratio, 2.70; 95% CI, 1.90–3.83) was identified in the multivariable Cox regression model. A similar association was observed in both diabetic and nondiabetic patients. Further restricted cubic spline analysis identified a J-shaped association between the SHR and primary and secondary outcomes, with hazard ratios for MACE and mortality significantly increasing when SHR was > 1.08. Furthermore, adding SHR to the GRACE score led to a significant improvement in its predictive accuracy for MACE and mortality, as measured by the C-statistic, net reclassification improvement, and integrated discrimination improvement, especially for those with diabetes.ConclusionsIn dialysis patients with ACS, SHR was independently associated with increased risks of MACE and mortality. Furthermore, SHR may aid in improving the predictive efficiency of the GRACE score, especially for those with diabetes. These results indicated that SHR might be a valuable tool for risk stratification and management of dialysis patients with ACS.

Trace Elements and Their Management in Dialysis Patients—Pathophysiology and Clinical Manifestations

Recently, as the number of elderly dialysis patients has been increasing, complications associated with low nutritional status such as infectious disease have had a strong influence on the prognosis of dialysis patients. Nutritional disorders are caused by the inadequate intake of the three major nutrients—proteins, fats, and carbohydrates—as well as vitamin and mineral deficiencies. Minerals are composed of various elements, including small-amount elements and trace elements, which are present in the human body in very small quantities lower than that of iron. In dialysis and predialysis patients, zinc, manganese, and selenium are the three major elements that are significantly depleted as compared to normal subjects; these deficiencies are sometimes symptomatic. Zinc deficiency is manifest as anemia, taste abnormality, and delayed wound healing, while selenium deficiency is associated with impaired cardiac function and immunocompromised condition. Zinc has multiple functions, since various enzymes, including DNA polymerase and RNA polymerase, need zinc as a cofactor, while selenium is a component of selenoproteins, including glutathione peroxidase and thioredoxin reductases, which are major antioxidative stress enzymes. These elements can only be supplemented exogenously and contribute to the sustainable QOL of dialysis patients. On the other hand, as regards other trace elements, including copper, chromium, manganese, lead, arsenic, etc., the association of their deficiency or intoxication with various involvements of dialysis patients were investigated, although all investigations were performed in cross-sectional studies or observational studies. Therefore, the supplementation of these elements is inconclusive, given the scarcity of other intervention studies. More conclusive studies are endorsed for the establishment of proper supplementation strategies.

Management of dialysis patients with hepatitis C virus in the era of direct-acting antiviral therapy.

The clinical use of direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infection has dramatically changed management of patients with HCV liver disease since 2014; this is also true for patients undergoing dialysis. Due to the high tolerability and antiviral efficacy of anti-HCV therapy, most dialysis patients with HCV infection should currently be candidates for this treatment. Many patients with HCV antibodies no longer have HCV infection, and it is difficult to identify patients with actual HCV infection based only on HCV antibody assays. Despite the high rate of successful HCV eradication, the risk of liver-related events such as hepatocellular carcinoma (HCC), the major complication of HCV infection, persists even after HCV cure, and patients at risk of HCC should undergo continuous HCC surveillance. Finally, the rarity of HCV reinfection and the survival benefit of HCV eradication in dialysis patients should be explored in further studies.

MO756: Roxadustat Versus Erythropoietin: Comparison of Efficacy in Reversing Ventricular Remodeling in Dialysis Patients with Anemia

Abstract BACKGROUND AND AIMS Renal anemia is one of the main complications of dialysis patients, which has been identified as an important independent risk factor for left ventricular hypertrophy and progression of heart failure, as well as adverse cardiovascular outcomes. Recent studies suggest that hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) Roxadustat represents a novel pharmacological treatment for renal anemia. This study aimed to compare the role of the Roxadustat and erythropoietin in reversing ventricular remodeling in dialysis patients with anemia. METHOD This was a retrospective cohort study that compared the treatment of Roxadustat and recombinant human erythropoietin (rhEPO) in dialysis patients for at least 24 weeks from January 2016 to October 2021. A total of 182 participants underwent echocardiography at least twice every 6 months. Baseline and follow-up examinations focused on the change of cardiac structure and function (doppler echocardiography), clinical and biochemical parameters and blood pressure. Participants were treated with oral iron supplements and controlled blood pressure (target value ≤ 130/80 mmHg). RESULTS Compared with baseline, left ventricular mass index (LVMI) decreased from 139.8 ± 36.0 to 126.5 ± 35.0 g/m2 (P<0.001) in the Roxadustat hemodialysis subgroup after 6-month treatment. Left ventricular end-diastolic diameters (LVEDd) and left ventricular wall thickness (LVPWT) were both significantly improved (from 5.13 ± 0.66 to 4.92 ± 0.65 cm; P= 0.002, and from 1.12 ± 0.17 to 1.07 ± 0.13 cm; P = 0.033, respectively). There was significant difference in LVMI before and after treatment in rhEPO group (from baseline 134.3 ± 36.8 to 131.8 ± 37.5 g/m2). There was greater reduction in LVMI from baseline to 6 months in Roxadustat group (–13.3 ± 22.4 g/m2 versus –5.02 ± 21.3 g/m2 for Roxadustat versus rhEPO; P= 0.028). In the peritoneal dialysis subgroups, Roxadustat also caused a significant improvement in LVMI and LVEDd (from baseline 133.9 ± 28.0 to 118.5 ± 28.2 g/m2; P= 0.001; from baseline 5.12 ± 0.55 to 4.86 ± 0.58 cm; P = 0.002). In addition, Roxadustat increased hemoglobin, serum albumin level and TIBC, and reduced the level of blood pressure, low density lipoprotein, TC and SF in Roxadustat hemodialysis subgroup. However, there were significant differences in the changes of systolic blood pressure, diastolic blood pressure and TIBC between the two hemodialysis groups. CONCLUSION In addition to the efficacy in the treatment of renal anemia, Roxadustat was found to be closely associated with improvement of LV diastolic function in dialysis patients. Our findings may provide new insights into anemia management in dialysis patients. Prospective clinical trials are necessary to further evaluate the role of Roxadustat or other HIF-PHIs in reversing ventricular remodeling.

POS-272 Roxadustat versus erythropoietin: comparison of efficacy in reversing ventricular remodeling in dialysis patients with anemia

Renal anemia has been identified as an important independent risk factor for left ventricular hypertrophy and progression of heart failure, as well as adverse cardiovascular outcomes. Recent studies suggest that hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) Roxadustat may represent a novel pharmacological treatment for renal anemia. This study aimed to compare the role of Roxadustat and erythropoietin in reversing ventricular remodeling in dialysis patients with anemia. This was a retrospective cohort study compared the treatment of Roxadustat and erythropoietin in dialysis patients for at least 24 weeks from January 2016 to August 2021. A total of 181 participants underwent echocardiography at least twice every 6 months. Baseline and follow-up examinations focused on the change of cardiac structure and function (doppler echocardiography), clinical and biochemical parameters and blood pressure. Participants were treated with oral iron supplements and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and controlled blood pressure (target value≤130 / 80 mmHg). There were no significant difference in age, sex and body mass index between two groups. However, left ventricular mass index (LVMI) and LV end diastolic dimension (LVDd) significantly decreased from 137.81±36.88 to 129.79±35.33 g/m2 (P=0.003), and from 5.19±0.68 to 5.02±0.69 cm (P=0.001) in Roxadustat-treated dialysis patients, respectively. In addition, Roxadustat increased hemoglobin and serum albumin level and reduced the level of diastolic blood pressure, low density lipoprotein, and lipoprotein(a). Interestingly, there was no obvious effect on LVMI or any other parameters of LV remodeling in erythropoietin-treated dialysis patients although the level of hemoglobin and serum albumin was increased and lipoprotein(a) level was decreased. In addition to the efficacy in the treatment of renal anemia, Roxadustat was found to be closely associated with improvement of LV diastolic function in dialysis patients. Our findings may provide new insights into anemia management in dialysis patients. Prospective clinical trials are necessary to further evaluate the role of Roxadustat or other HIF-PHIs in reversing ventricular remodeling.

Update and Perspectives in the Personalized Management of Sodium, Water, Volume and Hemodynamic Disorders of Dialysis Patients

Sodium and water-related disorders are major components of chronic kidney disease (CKD) and contribute significantly to cardiovascular (CV) complications and mortality. Usually, they are marked by gradual accumulation of sodium, water and have hemodynamic consequences (i.e., fluid overload, hypertension and cardiac disorders) along with the progression of kidney failure culminating in end stage kidney disease. Renal replacement therapy which is then required to sustain life is intended to restore sodium, fluid and pressure disorders along with the objective of reducing the uremic toxin load. Unfortunately, the intermittent nature of conventional short hemodialysis relying on a so called ‘dry weight’ probing approach, only partially restores the sodium-water overload related disorders, thereby exposing patients to further multi-organ damage through the resultant dialysis-induced systemic stress (DISS). Fluid volume management in dialysis patients has emerged as a very challenging condition that requires further attention and more precise tools. Furthermore, recent findings indicate that the physiology of sodium is more complex than that previously summarized by the kidney-centric two-compartment model (volemia and Interstitium) linked to osmotically active sodium (water-bound sodium). A third tissue compartment (skin, muscle) of sodium has now been identified, taking the form of free-water sodium [glycosaminoglycans (GAGs) or gel-like component] with newly-identified pathophysiologic metabolic consequences. All these findings suggest that restoration of sodium homeostasis in dialysis-dependent chronic kidney disease patients should encompass a more holistic approach to improve cardiac health and reduce cardiovascular burden in this highly vulnerable population. In this context, new tools for monitoring and managing dialysis patients to ensure a more precise and personalized control of their sodium and water homeostasis, volemic and hemodynamic disorders are needed. Several monitoring and management tools (e.g., bioimpedance, lung ultrasound, blood volume control, thermal balance control) are already available with potential value. The conductivity measurement-based automated sodium control module represents the latest and very appealing addition to this list of innovative tools. Although establishing the clinical value of these tools requires further outcome-based studies, current clinical use of this new tools has shown promising indications towards the goal of reducing CV morbidity and mortality in kidney dialysis patients. A brief review of these new pathophysiologic findings as well as clinical interests of these new tools is provided in this narrative review.

Malnutrition-Inflammation Score: A Valid Tool to Assess Nutritional Status in Patient with End-stage Renal Disease.

Nutritional assessment is a basic and necessary process in the nutritional management of dialysis patients. Malnutrition is a prevalent complication in patients on maintenance hemodialysis (HD). The study aimed to evaluate its relationship with the duration of dialysis, demographic and socioeconomic profile of HD patients, and to assess malnutrition inflammation score (MIS) in HD patients. In this descriptive-analytical study, 153 HD patients were selected with random sampling. All the patients were interviewed and the MIS of the patients was recorded. Evaluate the relationship of malnutrition with the duration of dialysis, demographic and socioeconomic profile of HD patients, and to assess MIS in HD patients. Patients were followed up for 3 months. Data were analyzed with Chi-square and t-tests and Pearson correlation coefficient. A total of 153 patients were studied, 53 (34.64%) patients had good nutritional status and 100 (65.35%) patients had malnutrition. The mean of patients MIS score was 10.71 ± 5.14. Malnutrition rates in males and females were not significantly different. There was a positive and significant relationship between age and MIS score (P = 0.035). There was also a significant correlation between the level of education and MIS score (P = 0.042). The mean dialysis duration was 25.52 ± 2 6.27 months. There was a significant difference in the duration of dialysis in mild to severely malnourished patients (P = 0.002). A significant correlation between MIS score and the serum calcium and serum iron results (r = 0.402). The rise in serum prealbumin level was significantly greater at 3 months. MIS score is the best tool to assess nutritional status in patients with ESRD undergoing HD, because it can recognize various degrees of malnutrition that may remain undetected by a single laboratory assessment. The correlation between MIS score and age and dialysis period was significant.

Design and evaluation of a web-based personal health record for patients under dialysis

BackgroundIn the end stages of chronic kidney disease, patients need kidney replacement therapy, such as dialysis and transplantation. Self-care and self-management are essential in dialysis patients at this stage. One of the tools that can facilitate self-management for patients is Personal Health Records (PHRs). This study aimed to design, develop and evaluate a PHR for patients under dialysis. Materials and methodsIn this study, a PHR was developed in three phases. In the first phase, the minimum data set for the PHR was determined by literature review as well as surveys of patients and experts. In the second phase, the PHR was designed by the PHP web programming language. In the third phase, the usability of designed system was evaluated by the heuristic evaluation method. ResultsLiterature review and surveys of patients and experts led to the identification of 17 main data sets. In this study, 114 fields were created through 41 tables in the MySQL database. After evaluating the designed system, 26 unique problems were identified. The highest percentage of problems with 19% (n = 5) was related to “error prevention”. ConclusionsThe designed PHR for patients undergoing chronic dialysis had satisfactory usability. Therefore, this web-based system can be efficiently used for the disease management of dialysis patients.

Role of Clinical Pharmacist in the Management of Anemia in Dialysis Patients

Background: Anemia management is complicated in patients with End Stage Renal Disease (ESRD) on hemodialysis. Clinical pharmacists have been involved in the care of ESRD patients in various settings. Aims of the study: The aim of this study was to explore the therapeutic and pharmacoeconomic outcome of a clinical pharmacist- implemented anemia management in dialysis patients through a randomized, controlled, open label design clinical study. Methods: The study was carried out over a period of three months at renal /hemodialysis unit of King Hussein Medical Center at the Royal Medical Services. A total 203 patients of both genders on hemodialysis were randomized into an intervention or control arm, 102 patients were allocated to the intervention arm and 101 patients to the control arm. In the intervention arm, patients received physician-pharmacist collaborative care. In the control arm, patients received usual care. Results: In this study, clinical pharmacist interventions had a positive impact on achieving target goal of Hb concentrations among HD patients. The percent of patients who achieved target Hb and Hct at the end of the study was 87.2% in the intervention arm versus 36.6% in the control arm, p = 0.02). Patients in the intervention arm used less epoetin α, leading to a savings of 5723.4 JD. The average amount of epoetin α vials used in the intervention arm was significantly lower than that in the control arm (p = 0.002). Conclusion: Clinical pharmacists can positively contribute to the care of ESRD patients and reduce the gaps in current patient care.

Bioimpedance Spectroscopy and Fluid Management in Dialysis Patients: From Laboratory to Clinic

許多透析病人為年長、罹患多重共病且營養狀況不良。透析醫護人員經由水分及營養規則性評估是改善病人水分及營養狀態的重要方法。經由人體及身體組成的量測方式，可以提供透析病人的重要營養訊息。然而，由於此些檢驗方式的預先假設，以及透析改變了體內水分的狀態，限制了此些測量於透析病人的應用性。另一方面，身體組成測量方式，是經由單一或多個電生物阻抗在健康民眾推估實驗而設立。此外，大多數電生物阻抗法推估出的預後模組，於透析病人存在其根本問題。近幾年，根據生物阻抗頻譜分析水分及生理改變的型態，設計出監測透析病人體內是否水分過多組成的儀器。由於具有非侵襲性、使用方便等特性，全世界越來越多的透析機構及醫療人員運用此儀器於床邊評估透析病人水分。此外，生物阻抗頻譜分析儀對於評估營養狀況及透析病人的透析是否充足也有臨床重要性。我們回顧及整理近幾年此議題的文獻並提供重要相關性。

Influencing factors of resource utilisation in haemodialysis patients-Based on socioecological pyramid model.

Aims and objectivesTo describe the current situation and analyse influencing factors of resource utilisation in maintenance haemodialysis patients.BackgroundThe self‐management level of patients undergoing maintenance haemodialysis in China is low. The applicability of the Chronic Illness Resources Survey in Chinese maintenance haemodialysis patients has been validated, and this survey can be used to assess the utilisation of self‐management support resources among haemodialysis patients. Determining the influencing factors of resource utilisation can help improve the self‐management behaviour of haemodialysis patients and control the progression of the disease.DesignA descriptive study design was chosen.MethodsA convenience sample of 314 patients undergoing haemodialysis was recruited from dialysis centres in three hospitals in western Xinjiang from June 2018–April 2019. SPSS19.0 software was used to describe the current situation of resource utilisation. Moreover, t test, analysis of variance and multivariate linear regression were applied to explore the influencing factors of patients’ resource utilisation. Standards for observational studies STROBE Statement checklist‐v4 were chosen on reporting the study process.ResultsThe average score of the total resource utilisation was 2.95 ± 0.51. The average item score of seven dimensions from high to low was 3.46 for medical staff, 3.32 for personal, 3.22 for family and friends, 3.16 for work‐related, 3.12 for media policy, 2.55 for neighbourhood/community and 2.23 for organisation. Multiple linear regression showed that there have six main factors, which explained 65.4% of the variance of haemodialysis patients’ resource utilisation.ConclusionsThe personal, family and friends, work and media and policy subscales were rated the highest, with support from neighbourhood/community and organisation rated the lowest. In general, participants perceived moderate levels of support. Government and healthcare team should pay more attention on haemodialysis patients who had low level of education, poor economic conditions and poor mental condition.Relevance to clinical practiceESRD has caused a burden on healthcare expenditure and has become a critical public health problem worldwide. Self‐management is particularly important for dialysis patients which have attracted extensive interest. In the future research, we can use this questionnaire to evaluate the related resources of disease management of dialysis patients, encourage patients to make full use of the resources around them and focus on those patients with low education and monthly income level and bad mental state.

MO834LOWER POST DIALYSIS POTASSIUM AND HIGHER ULTRAFILTRATION RATE ARE INDEPENDENT PREDICTORS OF ALL-CAUSE MORTALITY IN DIALYSIS PATIENTS

Abstract Background and Aims Dialysis is a life-saving procedure for the end-stage kidney disease, but mortality in this category of patients is still high. The survival of these patients is much lower compared to the general population. Factors affecting this survival has been studied for years and still continue to be an important part of current studies. While ultrafiltration rate is known to be associated with mortality in prevalent dialysis patients an important predictor of survival is the control of potassium profile. The aim of our study was to assess the hemodynamic and biochemical data, and to identify any significant association between post-dialysis potassium and all-cause mortality. Method This is a prospective study of 308 patients on maintenance dialysis, followed for seven years, ending 2019. All patients are dialysis dependent for ESKD and getting treatment in a single-center. Hypokalemia was defined as a serum potassium level < 3.5 mEq/L and high ultrafiltration rate (UFR) > 13 ml/kg/h. Other hemodynamic and metabolic data were also evaluated The survival rate was analysed by Kaplan-Meier curves and Cox regression analysis. Results A total of 308 patients were enrolled in this study. Mean age was 52 ± 15.6 years; 62.3% of pts were male; BMI 24.7±4.2. Of these, 55 patients (17.9%) died during the follow-up period. Our data showed the presence left ventricular hypertrophy (p=0.010), peripheral artery disease (p<0.0001), diastolic disfunction (p<0.01) and ultrafiltration rate during dialysis >13ml/kg/h (p=0.002) were the most important predictors of mortality. Metabolic abnormalities, low albumin (p<0.0005), hyperphosphatemia (p=0.011), post-dialysis potassium (p=0.037) were significantly associated with higher mortality. Logistic regression analysis of the metabolic data identified post-dialysis potassium (OR 0.242, 95% CI 0.074 – 0.793, p=0.019), and logistic regression analysis of the hemodynamic data identified ultrafiltration ratio (OR 0.149, CI 0.033 – 0.673, p=0.013) as independent predictors of all-cause mortality. Conclusion Lower post dialysis potassium levels and higher ultrafiltration rate are independently associated with higher all-cause and CV mortality in prevalent hemodialysis patients. Therefore the potassium profile and the UFR of the dialysis patients needs close monitoring and optimal control. The individualization of the dialysis prescription is recommended for each patient and it has an important role in preventing the occurrence of complication with immediate and long term effects. Management of dialysis patients should focus especially on reducing the risk of hypokalemia, not only that of hyperkalemia.

The Impact of a National Surgical Mask Wearing Policy on COVID-19 Transmission in Haemodialysis Units in the Republic of Ireland

The Impact of a National Surgical Mask Wearing Policy on COVID-19 Transmission in Haemodialysis Units in the Republic of Ireland

Fabry Disease on Peritoneal Dialysis with Cardiac Involvement.

Fabry disease (FD) is an X-linked lysosomal storage disorder resulting from a lack of alpha-galactosidase A (AGALA) activity in lysosomes. We herein report a patient with FD revealed by a renal biopsy who survived seven years after the introduction of peritoneal dialysis despite having severe heart failure due to left ventricular hypertrophy (LVH). FD was diagnosed based on a renal biopsy and biochemical analysis showing a low enzymatic activity of AGALA. A microscopic examination at the autopsy revealed marked hypertrophy and vacuolation of cardiac muscle cells. In our case, cardiac involvement determined the prognosis. Peritoneal dialysis is the modality of choice in the long-term management of dialysis patients with FD.

The Role of Point-of-Care Ultrasound in the Management of Dialysis Patients with COVID-19

The Role of Point-of-Care Ultrasound in the Management of Dialysis Patients with COVID-19

Management of hemodialysis facilities and services during the COVID-19 pandemic: Adapted clinical guidelines of the Ukrainian Association of Nephrologists and Kidney Transplant Specialists

The global COVID-19 pandemic is a critical time for hemodialysis patients as hypertension, diabetes or other co-morbidities, as well as hemostasis disorders, are risk factors for adult distress syndrome, the formation of which significantly worsens the prognosis.
 Several national associations of nephrologists have created expert working groups to prepare constantly updated clinical guidelines for the management of dialysis patients in the context of the COVID-19 pandemic.
 According to the experts, to minimize COVID-19 infection of patients and health care workers, the medical staff of dialysis units should undergo training and further retraining, following changes in constantly updated practical recommendations.
 The expert group of the Ukrainian Association of Nephrologists and Kidney Transplant Specialists has also created the Adapted Clinical Guidelines for the Management of Hemodialysis Facilities and Services During the COVID-19 pandemic.
 All of the following clinical guidelines have a level of evidence of 2C.