Modality Of Renal Replacement Therapy Research Articles

Impact of Intensity of Continuous Renal Replacement Therapy on Duration of Ventilation in Critically Ill Patients: A Secondary Analysis of the RENAL Trial

Introduction: More intensive renal replacement therapy (RRT) has been associated with prolonged mechanical ventilation (MV). However, such finding may be dependent on RRT modality. We hypothesized that, when using continuous renal replacement therapy (CRRT), RRT intensity would not be associated with prolonged MV. Methods: In a secondary analysis of the Randomized Evaluation of Normal versus Augmented Level (RENAL) Replacement trial comparing different CRRT intensities, we applied Fine-Gray competing risk analysis with time to successful extubation within 28 days as primary outcome. Results: We studied 531 patients in the higher intensity and 551 in the lower intensity group. Higher intensity patients had more hypophosphatemia (66.7 vs. 58.1%; p = 0.004) and more days with hypophosphatemia (2.2 ± 2.8 vs. 1.6 ± 2.2; p < 0.001). There was no difference in the number of patients extubated within 28 days (60.1% vs. 62.4%; adjusted subdistribution hazard ratio [SHR], 0.95 [95% CI, 0.86 to 1.06]) or time to extubation (8 [5–16] vs. 8 [5–15] days; adjusted median difference, 0.65 [95% CI, −0.41 to 1.70]). Among patients from the upper tertile of days with hypophosphatemia, higher intensity CRRT was associated with a lower chance of successful extubation within 28 days (SHR, 0.67 [95% CI, 0.55 to 0.82]; p for heterogeneity = 0.013). Conclusions: In the RENAL trial, higher intensity CRRT was not associated with delayed extubation. However, it was associated with a greater rate of hypophosphatemia and more days with hypophosphatemia was associated with a lower chance of successful extubation.

Caspofungin sequestration in a polyacrylonitrile-derived filter: Increasing the dose does not mitigate sequestration

Critically ill patients frequently require continuous renal replacement therapy. Echinocandins are recommended as first-line treatment of candidemia. Preliminary results suggested echinocandin sequestration in a polyacrylonitrile filter. The present study aimed at determining whether increasing the dose might balance sequestration. STX® filter, Baxter-Gambro was used. A liquid chromatography-mass spectrometry method was used for dosage of caspofungin. In vitro drug disposition was evaluated by NeckEpur® technology using a crystalloid medium instead of diluted/reconstituted blood, focusing on the disposition of the unbound fraction of drugs. Two concentrations were assessed. At the low dose, the mean measured initial concentration in the central compartment (CC) was 5.1 ± 0.6 mg/L. One hundred percent of the initial amount was eliminated from the CC within the 6-hour session. The mean total clearance from the CC was 9.6 ± 2.5 L/h. The mean percentages of elimination resulting from sequestration and diafiltration were 96.0 ± 5.0 and 4.0 ± 5.2%, respectively. At high dose, the mean measured initial concentration in the CC was 13.1 mg/L. One hundred percent of the initial amount was eliminated from the CC within the 6-hour session. The mean total clearance from the CC was 9.5 L/h. The mean percentages of elimination resulting from sequestration and filtration were 88.5 and 11.5%, respectively. Increasing the dose does not mitigate caspofungin sequestration in STX® filter. The results raise caution about the simultaneous use of caspofungin and polyacrylonitrile-derived filters. Intermittent modes of renal replacement therapy might be considered. For sensitive species, fluconazole might be an alternative.

Initiation of continuous renal replacement therapy versus intermittent hemodialysis in critically ill patients with severe acute kidney injury: a secondary analysis of STARRT-AKI trial.

There is controversy regarding the optimal renal-replacement therapy (RRT) modality for critically ill patients with acute kidney injury (AKI). We conducted a secondary analysis of the STandard versus Accelerated Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial to compare outcomes among patients who initiated RRT with either continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD). We generated a propensity score for the likelihood of receiving CRRT and used inverse probability of treatment with overlap-weighting to address baseline inter-group differences. The primary outcome was a composite of death or RRT dependence at 90-days after randomization. We identified 1590 trial participants who initially received CRRT and 606 who initially received IHD. The composite outcome of death or RRT dependence at 90-days occurred in 823 (51.8%) patients who commenced CRRT and 329 (54.3%) patients who commenced IHD (unadjusted odds ratio (OR) 0.90; 95% confidence interval (CI) 0.75-1.09). After balancing baseline characteristics with overlap weighting, initial receipt of CRRT was associated with a lower risk of death or RRT dependence at 90-days compared with initial receipt of IHD (OR 0.81; 95% CI 0.66-0.99). This association was predominantly driven by a lower risk of RRT dependence at 90-days (OR 0.61; 95% CI 0.39-0.94). In critically ill patients with severe AKI, initiation of CRRT, as compared to IHD, was associated with a significant reduction in the composite outcome of death or RRT dependence at 90-days.

Evaluating shared decision making for dialysis initiation: A qualitative study on patient refusal of long-term dialysis in Taiwan.

Previous studies have explored shared decision making (SDM) implementation to determine the renal replacement therapy modality; however, the SDM approach for dialysis initiation, especially when patients refuse physician suggestions for long-term dialysis, remains unclear. This study aimed to explore physicians' responses towards patients' refusal of long-term dialysis during the SDM process and the thinking processes of both physicians and patients regarding dialysis refusal. We conducted in-depth semi-structured interviews with 10 patients diagnosed with end-stage renal disease, each of whom refused long-term dialysis after physicians employed the SDM framework, and nine nephrologists at the Chang Gung Memorial Hospital, Taiwan, from March to May 2020. Interviews were audio-recorded, transcribed, and translated from Mandarin to English. They were then thematically analysed. Three main themes on dialysis initiation SDM implementation and the differences between physician and patient perceptions on patient treatment refusal were yielded. While the SDM approach for dialysis initiation developed by nephrologists in Taiwan respects patient decisions, physicians often actively persuade patients to undergo dialysis in case of treatment refusal. The motivation behind this approach is to promote the patient's best medical interests, particularly post-dialysis life quality, and to ensure a 'rational' medical decision is made. However, patients' perceptions of treatment refusal differ significantly from those of physicians, and their decision-making process is often iterative and based on comprehensive evaluation of immediate concerns beyond biomedical factors. Findings suggest that the current physician-led SDM approach for dialysis initiation characterises active persuasion with physicians' perspectives predominating the clinical encounter. To improve SDM implementation, we propose that physicians should acknowledge and understand patients' reasoning for dialysis refusal and the distinction between objective health and subjective well-being during the decision-making process.

Renal Disease in Bangladesh Perspective

Bangladesh is one of the most densely populated areas in the world. Renal diseases are increasingly recognized and encompasses a large share of the health sector. About 20 million people are suffering from chronic kidney disease, and of them, approximately 35,000–40,000 develop endstage renal disease each year. Chronic glomerulonephritis, diabetes mellitus and hypertension are the principal causes of chronic kidney disease. Hypovolemia, sepsis, obstetric complications and drugs (including herbal and homeopathic remedies) are common causes of acute kidney injury. All three renal replacement therapy modalities (hemodialysis, peritoneal dialysis and renal transplantation) are performed in Bangladesh, yet only 25% of end-stage renal disease patients have access to treatment due to inadequate facilities and high healthcare costs. Nephrology as a specialty started its journey in 1973 in Bangladesh and now about 300 Nephrologists are managing the subject. Still there is huge need for more Nephrologists, as only one nephrologist is available for about every 0.8 million people. The country has improved financially from low- to low-middleincome country. Health sector is also more improving gradually. The government is now setting up renal care at rural level, introducing screening programs for early detection and prevention of kidney and other noncommunicable diseases. At the same time steps are under way to improve the advanced renal services at secondary and tertiary health institutes. Kidney transplantation started in 1982 and only live related transplantation are being done in several government and private organization. ABO-incompatible kidney transplantation has already been performed. Recently decease renal transplantation has also been performed. Research and training opportunities are expanding in collaboration with international organizations. Renal services appears up to date in this country but needs more and more enhancement to cope up the ever increasing burden.&#x0D; Bangladesh J Medicine 2023; 34(3): 180-185

Linezolid dosing in critically ill patients undergoing various modalities of renal replacement therapy: a pooled population pharmacokinetic analysis

Altered pharmacokinetics (PK) of linezolid is pronounced in critically ill patients undergoing different modalities of renal replacement therapy (RRT). This study aimed to provide a pooled population PK analysis of linezolid in RRT patients and to evaluate the pharmacodynamic (PD) target attainment of linezolid standard dosing (600 mg q12h). A total of 414 pooled linezolid concentration observations from 69 patients undergoing intermittent hemodialysis (IHD), sustained low-efficiency dialysis (SLED), or continuous renal replacement therapy were used to develop the population PK model. Probability of target attainment (PTA) for the efficacy markers of 85% T>MIC and AUC/MIC>100 was evaluated, and the risk of toxicity was estimated based on the trough concentration threshold of 10 mg/L. Linezolid concentration data were adequately described by a two compartmental model. Renal function and body weight were identified as significant modifiers for endogenous clearance of linezolid. Simulations demonstrated that the PTA of 85% T>MIC and AUC/MIC>100 targets was all unacceptably low (0-58.6%, MIC ≥ 1 mg/L) in RRT patients with preserved renal function, while desirable 85% T>MIC attainment (≥ 90%, MIC ≤ 2 mg/L) was achieved in anuric RRT patients. The predicted risk of toxicity is negligible (<1.0%) in the patients with preserved renal function (regardless of the RRT modalities), while the probability of reaching the trough level of 10 mg/L was high (17.9-20.9%) for anuric patient population undergoing IHD or SLED. In conclusion, standard linezolid dosing is adequate for anuric RRT patients with an MIC ≤ 2 mg/L.

Management of peritoneal dialysis in an adolescent with septic shock, AKI, multi-organ failure and COVID-19: a case report

The kidneys is the most commonly injured organs in sepsis, which might manifest as acute kidney injury (AKI). Peritoneal dialysis (PD) is the preferred modality of renal replacement therapy (RRT), especially in the developing countries. Furthermore, the COVID-19 pandemic has made hemodialysis (HD) unavailable due to infection concerns. We present a critically-ill 16-year-old male with morbid obesity (BMI 43.3 kg/m2), diabetic ketoacidosis, acute pancreatitis, acute kidney injury, and COVID-19 pneumonia. The patient looked somnolent on admission with very high random blood glucose and hypernatremia. Blood gas analysis showed metabolic acidosis. The patient was treated with 1 g/day Meropenem, 0.5 µg/kg/min norepinephrine, 0.04 unit/kg/h vasopressin, and correction of electrolyte imbalance and metabolic acidosis. After 48 h, the diuresis and the creatinine levels worsened. We placed a Tenckhoff catheter and started PD. The patient showed improvement after 72 h of peritoneal dialysis.&#x0D; This case report highlighted the use of PD as a modality of RRT in sepsis-induced AKI, multi-organ failure, and COVID-19. Although it remains controversial, we observed an improvement in diuresis and creatinine levels following PD. PD is more cost-effective and provides a similar outcome compared to other modalities.&#x0D; Abbreviations: AKI - Acute Kidney Injury; BMI- Body Mass Index; CRRT- Continous Renal Replacement Therapu; GCS- Glasgow Coma Scale; HD- Hemodialysis; ICU- Intensive Care Unit; PD- Peritoenal Dialysis; RRT- Renal Replacement Therapy; S-AKI- Sepsis-Associated Acute Kidney Injury; SIRS- Systemic Inflammatory Response Syndrome&#x0D; Key words: Septic shock; Acute kidney injury; Peritoneal dialysis&#x0D; Citation: Andiantoro DS, Sedono R, Jennefer J. Management of peritoneal dialysis in an adolescent with septic shock, AKI, multi-organ failure and COVID-19: a case report. Anaesth. pain intensive care 2023;27(4):600−603.&#x0D; DOI: 10.35975/apic.v27i4.2163&#x0D; Received: February 14, 2023; Reviewed: April 17, 2023; Accepted: April 22, 2023

Clinical Profile of End Stage Renal Disease Patients Undergoing Hemodialysis in a Tertiary Care Hospital of Nepal

BACKGROUND Maintenance hemodialysis is a popular treatment modality of renal replacement therapy for end stage renal disease patients. The clinical profile of end-stage renal disease (ESRD) and dialysis in Mid Western Nepal are scarce. This study aimed to study the clinical profile of ESRD patients undergoing hemodialysis at the tertiary care Hospital.&#x0D; METHODS This study was a single center based cross sectional observational study carried out over a period from 15th December 2022 to 15th February 2023 in Department of Medicine. A total of 40 patients undergoing maintenance hemodialysis were enrolled in the study. Data about Socio demographic profiles , clinical data, duration of chronic kidney disease (CKD), major comorbidity, the presumed etiology of ESRD, duration of haemodialysis, laboratory parameters including Renal function tests etc were entered in MS Excel and analyzed through SPSS 21.&#x0D; RESULTS A total of 40 patients were enrolled in the study. Males were 25(62.5%) and females were 15(37.5%). The mean age of the patient was 45.75±15.2 years. The most common cause of end stage renal disease and reasons for admission were hypertension nephropathy 36(90%) and Type 2 diabetes mellitus 9(22.5%) respectively. Anemia was the most common hematological findings in ESRD patients (&gt;90%) followed by hypocalcemia in 65%.&#x0D; CONCLUSIONS Hypertensive nephropathy was the commonest cause for CKD followed by diabetic nephropathy and glomerulonephritis. Early detection and effective management of these illnesses can delay the onset, progression of CKD to end stage and subsequent morbidity and the requirement of renal replacement therapy.

N-acetylcysteine treatment attenuates hemodialysis access-related limb pathophysiology in mice with chronic kidney disease.

The objective of the present study was to determine if treatment with N-acetylcysteine (NAC) could reduce access-related limb dysfunction in mice. Male and female C57BL6J mice were fed an adenine-supplemented diet to induce chronic kidney disease (CKD) prior to the surgical creation of an arteriovenous fistula (AVF) in the iliac vascular bundle. AVF creation significantly increased peak aortic and infrarenal vena cava blood flow velocities, but NAC treatment had no significant impact, indicating that fistula maturation was not impacted by NAC treatment. Hindlimb muscle and paw perfusion recovery and muscle capillary density in the AVF limb were unaffected by NAC treatment. However, NAC treatment significantly increased the mass of the tibialis anterior (P = 0.0120) and soleus (P = 0.0452) muscles post-AVF. There was a significant main effect of NAC treatment on hindlimb grip strength at postoperative day 12 (POD 12) (P = 0.0003), driven by significantly higher grip strength in both male (P = 0.0273) and female (P = 0.0031) mice treated with NAC. There was also a significant main effect of NAC treatment on the walking speed at postoperative day 12 (P = 0.0447), and post hoc testing revealed an improvement in NAC-treated male mice (P = 0.0091). The area of postsynaptic acetylcholine receptors (P = 0.0263) and motor endplates (P = 0.0240) was also increased by NAC treatment. Interestingly, hindlimb skeletal muscle mitochondrial oxidative phosphorylation trended higher in NAC-treated female mice but was not statistically significant (P = 0.0973). Muscle glutathione levels and redox status were not significantly impacted by NAC treatment in either sex. In summary, NAC treatment attenuated some aspects of neuromotor pathology in mice with chronic kidney disease following AVF creation.NEW & NOTEWORTHY Hemodialysis via autogenous arteriovenous fistula (AVF) is the preferred first-line modality for renal replacement therapy in patients with end-stage kidney disease. However, patients undergoing AVF surgery frequently experience a spectrum of hand disability symptoms postsurgery including weakness and neuromotor dysfunction. Unfortunately, no treatment is currently available to prevent or mitigate these symptoms. Here, we provide evidence that daily N-acetylcysteine supplementation can attenuate some aspects of limb neuromotor function in a preclinical mouse model of AVF.

Extracorporeal blood purification therapies for sepsis-associated acute kidney injury in critically ill patients: expert opinion from the SIAARTI-SIN joint commission

Sepsis-Associated Acute Kidney Injury is a life-threatening condition leading to high morbidity and mortality in critically ill patients admitted to the intensive care unit. Over the past decades, several extracorporeal blood purification therapies have been developed for both sepsis and sepsis-associated acute kidney injury management. Despite the widespread use of extracorporeal blood purification therapies in clinical practice, it is still unclear when to start this kind of treatment and how to define its efficacy. Indeed, several questions on sepsis-associated acute kidney injury and extracorporeal blood purification therapy still remain unresolved, including the indications and timing of renal replacement therapy in patients with septic vs. non-septic acute kidney injury, the optimal dialysis dose for renal replacement therapy modalities in sepsis-associated acute kidney injury patients, and the rationale for using extracorporeal blood purification therapies in septic patients without acute kidney injury. Moreover, the development of novel extracorporeal blood purification therapies, including those based on the use of adsorption devices, raised the attention of the scientific community both on the clearance of specific mediators released by microorganisms and by injured cells and potentially involved in the pathogenic mechanisms of organ dysfunction including sepsis-associated acute kidney injury, and on antibiotic removal. Based on these considerations, the joint commission of the Italian Society of Anesthesiology and Critical Care (SIAARTI) and the Italian Society of Nephrology (SIN) herein addressed some of these issues, proposed some recommendations for clinical practice and developed a common framework for future clinical research in this field.Graphical abstract

The Spectrum of Intradialysis Complications in Renal Patients Accessing Care in A Tertiary Hospital in South East Nigeria

Background: Haemodialysis (HD) is currently the most common mode of renal replacement therapy (RRT) in the Sub-Saharan Africa. It is however, fraught with many complications which sometimes cause morbidity and mortality outside the primary kidney problems. Hence, there must be concerted effort to identify them early. This would enable the clinician institute preventive measures or treat them efficiently when these adverse effects occur. Materials and Method: A prospective study was carried out among chronic kidney disease (CKD) and acute kidney injury (AKI) patients in failure assessing HD care at the Nnamdi Azikiwe University Teaching Hospital (NAUTH) Nnewi dialysis center. Subjects were one hundred and twenty six in number: 84 CKD and 42 AKI. Sixty five (65) were males while sixty one (61) were females. A total of three hundred and sixty nine (369) HD sessions were done. Sociodemographic data and medical history were obtained from each subject and relevant physical examinations and laboratory investigations were carried out prior to and intra dialysis for each subject. Results were analyzed using Statistical Package for Social Sciences (SPSS) software version 17. Results: Intradialytic complications occurred in 86 out of 126 subjects. The commonest intradialytic complication was hypotension (20.6% for patient-based analysis and 21.1% for session-based analysis). This was followed by hypertension (19.8% for patient-based analysis and 16.5% for session-based analysis). Other complications noted were fever (9.95%), chest pain (9.95%), cramps (1.0%) and seizure (1.0%). Conclusion: In this study population, intradialysis hypotension was the most common complication followed by intradialysis hypertension. Patients on HD should be assessed and monitored actively to identify and possibly prevent or treat these complications when they occur.

The Challenge of the Best Therapeutic Modality for Renal Replacement Therapy

The Challenge of the Best Therapeutic Modality for Renal Replacement Therapy

#4543 EFFECT OF COMORBIDITIES ON HEALTHCARE EXPENDITURES FOR PATIENTS ON KIDNEY REPLACEMENT THERAPY IN A FRENCH COHORT

Abstract Background and Aims End stage kidney disease (ESKD) is associated with a substantial economic burden. In France, the cost of care for such patients represents 2.5% of the total French healthcare expenditures, but serves less than 1% of the population. These patients’ healthcare expenditures are high because of the specialized and complex treatment needed as well as the presence of multiple comorbidities. This study aims to describe and assess the effect of comorbidities on healthcare expenditures (direct medical cost and non-medical costs including transportation and compensatory allowances) for patients with ESKD in France, while considering the modality and duration of renal replacement therapy (RRT). Method This retrospective observational study included adults who started RRT for the first time between 2012 and 2014 in France and were followed for 5 years. Linear models were built to predict mean monthly cost (MMC) by integrating first the time duration in the cohort, then patient characteristics and finally the duration of use of each treatment modalities. A complementary analysis stratified on age group was also performed. The variables included in this analyses were: body mass index, age, sex, RRT modality, time in the cohort, coronary artery disease, heart failure, chronic respiratory disease, active cancer, diabetes, lower-limb arterial disease, HIV/AIDS, abdominal aneurism, rhythm disorders, stroke or transient ischemic attack, liver disease, mobility limitations. All RRT modalities available in France were also included: renal transplant (RT), hemodialysis (HD) in center, HD in self-care unit, HD in out-center, HD at home, assisted continuous ambulatory peritoneal dialysis (aCAPD), non-assisted continuous ambulatory dialysis (naCAPD), assisted automated peritoneal dialysis (aAPD), non-assisted automated peritoneal dialysis (naAPD). Results A total of 22,506 patients were included in the study. The mean MMC was 6,391€ (95% CI 6,345-6,438 €). The comorbidities with the highest effect on MMC were inability to walk +1,434€ (95% CI 1,434-1,434€), lower-limb arterial disease stage III-IV 777€ (95% CI 777-777€), active cancer +594€ (95% CI 594-594€), HIV positivity +507€ (95% CI 507-507€), and diabetes +395€ (95% CI 395-395€). Other comorbidities were also positively associated with MMC. KT and naAPD were negatively associated with the MMC by -161€ (95% CI -161 - -161€) and -2€ (95% CI -2 - -2€). The remaining RRT modalities were positively associated with the MMC. Hemodialysis in center had the highest effect on the MMC, adding 291€ (95% CI 291-291€). An age-stratified analysis showed an interaction between age groups and comorbidities. The presence of diabetes, cancer and respiratory disease had a great impact on MMC in younger patients. Conclusion This study confirms the importance of considering patient characteristics, comorbidities and type of RRT when assessing healthcare expenditures for patients with ESKD. Better care of comorbidities prior to RRT could reduce cost for individual patients as well as potentially reduce the incidence of patients in ESKD. Even though the Euro value is specific to France, other countries might benefit from evaluating and anticipating healthcare costs for patients in RRT by assessing patient comorbidities.

#6306 SUSTAINED LOW-EFFICIENCY DIALYSIS VERSUS CONTINUOUS VENO-VENOUS HEMODIAFILTRATION OUTCOME IN CRITICALLY ILL PATIENTS

Abstract Background and Aims Acute kidney injury due to sepsis is the most common cause of AKI in critical care settings. Different modalities of renal replacement therapies (RRT) have been used to manage this condition including Continuous Renal Replacement Therapy (CRRT) and sustained low efficiency dialysis (SLED). The aim of this work was to compare the outcome of SLED and CRRT in the form of continuous veno-venous hemodiafiltration (CVVDHF) as methods of dialysis in sepsis induced AKI. Method We retrospectively analysed data from 120 patients; 20 patients received CVVHDF to manage AKI in the context of sepsis, 47 patients received SLED to manage AKI in the context of sepsis and the third group included 53 patients who have been treated with SLED to manage AKI not due to sepsis. Age was found to be significantly higher in sepsis induced AKI patients treated with SLED than patients treated with CVVHDF (65±10.1# 59.5±9.3 y, p = 0.03). Sex distribution or incidences of hypertension, diabetes mellitus, malignancy or liver disease were not statistically different between groups. Results Unadjusted 30 day mortality was 44.7% (21pt) in the SLED group Vs 50% (10pt) in the CVVHDF group, p = 0.07. Adjusted mortality was not statically significant between SLED and CVVHDF (OR 0.97, CI = 0.95-1.06). Hypotension occurred more frequently in patients treated with SLED (24 pt = 51.1% #5 pt = 25%, p &amp;lt; 0.001).Clotting occurred more frequently in the CVVHDF group as compared to SLED group (7 pt = 35% Vs 4pt = 8.5% p &amp;lt; 0.001). Conclusion Sustained low efficiency dialysis (SLED) and CVVHDF had comparable 30 day mortality as modalities of RRT in critically ill Patients with sepsis induced AKI. SLED still an attractive alternative to CRRT modalities due to lower cost and lower incidence of complications. Further larger studies are recommended.

#3859 THE TREND OF RENAL REPLACEMENT THERAPY IN N. MACEDONIA FROM 2015 TO 2020: DATA FROM THE ERA-EDTA ANNUAL REGISTRY

Abstract Background and Aims Kidney Failure (KF) is treated with three modalities of renal replacement therapy (RRT): kidney transplantation (Tx), hemodialysis (HD), and peritoneal dialysis (PD). Our study aimed to present the trend of RRT in N. Macedonia from 2015 to 2020. Method The epidemiological retrospective study analyzed the patients with kidney failure by gender, age, etiology of kidney disease, and modality of RRT. The data were processed from the annual reports of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA). The study patients were divided into group 1 (prevalent) with patients on the RRT at the current year, group 2 (incidence at Day 1) with patients on the RRT with a duration of at least 1 day, and group 3 (incidence at Day 91) with patients on the RRT with a duration beyond 91 days. Results A total of 10395 patients were analyzed with a mean age of 59.2 ± 9.5 years (median 60.4 years), of which 60.2% were male. From 2015 to 2019, there was an increasing trend in all groups, and most patients were reported in 2019. In group 1, 1598 patients were registered in 2015, and 1762 patients were registered in 2020, which is an increasing trend of 10.3%. The number of patients in group 2 was increasing every following year, with the highest growth in 2019 up to 12.1%, compared to 2018. The number of patients in group 3 also showed significant growth from 253 patients in 2015 to 324 patients in 2019, but there was a decrease of 16.4% in 2020 (271 patients). Deviations are observed in 2020, with a decrease in the number of patients in group 1 and group 3, as well as a slowdown in the growth dynamics of patients in group 2, which might be associated with the start of the SARS-CoV-2 pandemic. According to the modality, most of the patients (84.7%) were on HD in 2015 and 85.9% in 2020. The most frequent age group of patients was from 45 to 64 years, from 36.3% to 49.4%. There was an increasing trend of patients from older age groups (over 64 years) and male patients. The increasing number of patients from the age group 75+ years was also noted in all groups. Etiology of kidney disease: hypertension (25.8%) and diabetes mellitus (17.4%) were the leading causes of KF in patients requiring RRT. Conclusion The study showed a constantly increasing trend of patients with KF requiring RRT. The largest number of patients were men, aged from 45 to 64 years. Hypertension and diabetes mellitus were the leading causes of KF, and most of the patients were treated with HD.

#5231 INCREMENTAL PERITONEAL DIALYSIS VERSUS CONSERVATIVE MANAGEMENT IN PATIENTS WITH ESRD

Abstract Background and Aims At its start, Peritoneal dialysis (PD) was implemented only in advanced renal disease with a myriad of symptoms and signs. However, many subsequent literatures have highlighted possible benefits of early rather than late start of PD. Nevertheless, when to start PD has been a matter of controversy. This debate has created a new era of starting dialysis early during the course of the disease, in a small dose that was termed ‘incremental’ dialysis. By this modality, the dose of PD, is low at the initiation of RRT, and could be progressively increased over time in parallel with the reduction of RKF. Although incremental dialysis is growing worldwide, there has been no substantial agreement on the benefits of this approach. Moreover, the few available observational studies have compared incremental versus full-dose PD, with controversial results. On the other hand, studies comparing incremental dialysis with the conservative management for non-symptomatic ESRD patients are mostly deficient in the published literature. The present work is a retrospective, case-control, longitudinal study, aimed to evaluate the adequacy of incremental peritoneal dialysis as a modality of renal replacement therapy in ESRD patients, and whether it adds superior benefits over the conservative and the standard peritoneal dialysis (STPD) managements. Method Data were collected retrospectively from Complesso Integrato Columbus Policlinico Gemelli, nephrology and dialysis unit archives. The study comprising three groups: first included 23 patients who were treated with IPD and second group included 30 patients who were managed with the standard dose of PD (STPD), and a third group include 19 ESRD patients who had GFR values of &amp;lt; 15ml/min and were off dialysis and received only conservative treatment. The collected data for each patient included demographic, clinical assessment (volume excess and nutritional state), pharmacological data, laboratory records (Hb concentration, and sodium, potassium, phosphorus), creatinine clearance and rate of hospitalization, in addition to dialysis regimen and rate of dialysis related infection in IPD and STPD patients, data from these patients were collected at the baseline (time just before starting PD), and every 6 months for 24 months or whenever there is cessation of PD, whichever occurs first. Results In the present study all IPD group patients started PD with increment dose 1 or 2 exchanges per day, with a solution volume 1.5 to 2 L/ exchange for 8 to 16 hours/day. Data analysis revealed improvement in the nutritional state, a better control of the blood electrolyte and body volume in IPD and STPD groups while they deteriorated significantly in the conservative group (P = 0.005, P = 0.001 &amp; P = 0.001, respectively). Dialysis groups succeed in maintain the Hb level within target level with smaller dose of ESA therapy and also ESA Resistive Index (ERI) decreased in this groups while it significantly increased in the conservative group (P1 = 0.019).There was no statistically significant differences between the rate of decline of creatinine clearance between the patients on conservative, those on IPD and STPD (P = 0.295), Also there was no statistically significant difference in the rate of hospitalization between study groups (P = 0.69).Those who had a mean creatinine clearance (CrCl) more than 9.4±2.8 ml/min/1.73m2 could be managed with one exchange to achieve the target Kt/V, a mean CrCl of less than 3.6±0.8 ml/min/1.73m2 failed to reach adequacy even with two exchanges a day and needed to be transferred to full dose while those with a mean CrCl in between the above values could only achieve Kt/V above 1.7 with two exchanges per day. Conclusion Incremental peritoneal dialysis, a rapidly growing new modality, is superior to the conservative treatment in patients with end-stage renal disease that can be adequately applied to patients with a GFR of 4 ml/min or more without adding the burden of full dose dialysis.

#5153 CHARACTERISTICS AND MORTALITY OF PATIENTS STARTING HAEMODIALYSIS IN A PORTUGUESE TERTIARY HOSPITAL: A DESCRIPTIVE ANALYSIS

Abstract Background and Aims Portugal has one of the highest incidences and prevalence of end-stage kidney disease in Europe, with haemodialysis (HD) being the most common modality of renal replacement therapy. The aim of our study was to analyse a cohort of patients who started HD in a large tertiary care hospital in Lisbon and describe the evolution of the patient characteristics throughout the studied years. Method This study was a retrospective analysis of all adult individuals who started HD between January of 2014 and December of 2019 in tertiary care hospital in Lisbon. Data was attained from individual electronic clinical records. The primary outcome was mortality. Statistical significance was defined as a P-value lower than 0.05. Results We included 1122 patients (mean age 64.9 ±16.8 years, 21.2% at least 80 years old; 60.9% male and 79.7% caucasian). At HD start, mean eGFR was 8.98 ±5.66mL/min/1.73 m2 and the vascular access was a central venous catheter in 56.0%, an arteriovenous fistula in 40.6% and an arteriovenous graft in 3.4%. The number of patients that started HD per year was variable between 169-204 and the percentage of elderly patients increased throughout the years. There was a trend of initiating dialysis with progressively lower eGFR. The percentage of patients with central venous catheter increased. In total 392 patients died (7.5% within the first 90 days of starting HD). Mortality rate within the first 90 days and first year declined from 2015 to 2019. As expected mortality was higher in older patients (Fig. 1), as well as in patients that started HD with a central venous catheter (Fig. 2). Conclusion We describe a large cohort of Portuguese patients that started HD between 2014-2019 that correlates well with the available recent data from the national and european registries. There was a greater percentage of patients initiating HD by catheter, which was associated with higher mortality, Although, considering the increase in elderly patients starting HD, their underlying comorbidities might impair vascular access placement and also have an impact on mortality. Additionally, despite the increase in elderly patients, mortality within the first 90 days and first year declined, highlighting the quality of care provided, in addition to a better acknowledgment and referal to conservative care.

#3961 A COMPARATIVE ANALYSIS OF EMOTIONAL RECOGNITION AND DIFFERENTIATION TWO YEARS FOLLOWING KIDNEY TRANSPLANTATION VERSUS HEMODIALYSIS.

Abstract Background and Aims Cognitive impairment is common in patients with End Stage Kidney Disease. There are conflicting reports regarding the degree and interval of improvement of cognitive functions with the different modalities of renal replacement therapy. Most of the published reports relied on screening tests not covering the emotional aspects of cognition. Also, the timings of assessment are different being at most during the first year of establishing the modality. Method Ninety age, gender, and educational level-matched participants were enrolled in the study. The participants were divided into three equal groups, thirty kidney transplant (KT) patients, thirty hemodialysis patients (HD) for more than two years, and thirty control non-diseased participants. The participants included were below 60 years of age and with no previous history of a neurological defect. All patients were subjected to three Computerized Neurocognitive Battery tests (Age differentiation test, emotional recognition, and differentiation). All the tests were judged for accuracy and the time consumed to answer. Results The median value of transplant duration was 59 months (24- 168), and 66 months (27- 180) of HD duration. Both groups were comparable in age, gender, educational level, socioeconomic, and marital status. KT patients were comparable to controls at all parameters of testing. KT patients' answers were significant of higher accuracy than HD patients (P = 0.04 for age differentiation and emotion recognition, and 0.005 for emotion differentiation). KT and HD had comparable response times. Total correct responses of emotional differentiation tests were negatively correlated with KT duration (rho = −0.348, P = 0.02), and (rho = −0.345, P = 0.01) for HD duration. The cumulative steroid dose was not correlated with any of the tested parameters in the KT group. Conclusion KT offers a much better emotional and social cognitive improvement, an effect that is expected to positively impact the quality of life and involvement in society.

Economic Analysis of Renal Replacement Therapy Modality in Acute Kidney Injury Patients With Fluid Overload.

Decision analytical model comparing health outcomes and healthcare costs of CRRT versus IHD initiation for AKI patients with FO. The model had an inpatient phase (over 90-d) followed by post-discharge phase (over lifetime). The 90-day phase had three health states: FO, fluid control, and death. After 90 days, surviving patients entered the lifetime phase with four health states: dialysis independent (DI), dialysis dependent (DD), renal transplantation, and death. Model parameters were informed by current literature. Sensitivity analyses were performed to evaluate results robustness to parametric uncertainty. ICU. AKI patients with FO. IHD or CRRT. The 90-day horizon revealed better outcomes for patients initiated on CRRT (survival: CRRT 59.2% vs IHD 57.5% and DD rate among survivors: CRRT 5.5% vs IHD 6.9%). Healthcare cost was 2.7% (+$2,836) higher for CRRT. Over lifetime, initial CRRT was associated with +0.313 life years (LYs) and +0.187 quality-adjusted life years (QALYs) compared with initial IHD. Even though important savings were observed for initial CRRT with a lower rate of DD among survivors (-$13,437), it did not fully offset the incremental cost of CRRT (+$1,956) and DI survival (+$12,830). The incremental cost-per-QALY gained with CRRT over IRRT was +$10,429/QALY. Results were robust to sensitivity analyses. Our analysis provides an economic rationale for CRRT as the initial modality of choice in AKI patients with FO who require renal replacement therapy. Our finding needs to be confirmed in future research.

Two plus one port laparoscopic assisted continuous ambulatory peritoneal dialysis insertion modified technique: a case series.

A retrospective case series from the medical records at Semarang Tertiary Hospital was identified between 2017 and 2021. Demographic, clinical, intraoperative, and postoperative complication data were collected with a 1-year follow-up after the CAPD procedure. This study included 49 patients with a mean age of 43.2±13.6 years, and diabetes was the main cause (51.02%). This modified technique showed no complications intraoperatively. The postoperative complications were found to include one case of hematoma (2.04%), eight cases of omental adhesion (16.3%), seven cases of exit-site infection (14.28%), and two cases of peritonitis (4.08%). Malposition of the Tenckhoff catheter was not found 1-year after the procedure. The two plus one port modified laparoscopic assisted CAPD technique could prevent malposition of the Teckhoff catheter because it is already fixated in the pelvic. A long-term follow-up of 5 years is necessary to know the long-term survival of the Tenckhoff catheter in the next study.