Non-dialysis Day Research Articles

Assessment of Nutritional Intake in Patients With Kidney Failure Treated by Haemodialysis on Dialysis and Non-dialysis Days

Introduction/Aims/ObjectiveInadequate nutritional intake in haemodialysis (HD) patients increases the risk of muscle wasting, nutrient deficiencies, leading to an increased risk of additional morbidity and mortality. We aimed to assess nutritional intake on the dialysis and non-dialysis day of patients established on HD. MethodsWe employed a two-day dietary record, one on the day of dialysis and one on the non-dialysis day, and then determined nutritional intake using the Nutritics software. Muscle strength was assessed by hand grip strength (HGS) and body composition determined using multifrequency bioelectrical impedance recorded post-dialysis. ResultsWe recruited 51 established HD patients dialysing between May-July 2022, mean age 60±15 years, 52.9% male, and 51% diabetic. Only 25% achieved the calorie and protein intake recommended by Kidney Disease Outcomes Quality Initiative (KDOQI). Most patients had inadequate consumtion of fibre (96%), calcium (86%), iron (80%), zinc (82%), selenium (92%), folate (82%), vitamin A (88%), and (100%) vitamin D. On the other hand, the great majority followed the restriction guidelines for potassium (96%), phosphorus (86%), and sodium (84%), repectively. However, consumption was greater for potassium (P=0.007), phosphorus (P=0.015), and zinc (P=0.032) on non-dialysis vs dialysis days, but there was no difference in protein or calorie intake between days. ConclusionOur results suggest that many of our HD patients do not achieve the recommended nutritional targets. Patient compliance with restricting sodium, potassium and phosphate limits protein and calorie intake. HD patients are at increased risk of sarcopenia, so failure to achieve dietary protein intake will further increase this risk.

Risk factors for hypotension in patients with hemodialysis-associated superior vena cava syndrome

ObjectiveWe analyzed the risk factors for hypotension in patients with hemodialysis-associated superior vena cava syndrome (SVCS) and effectiveness of endovascular intervention in hypotension related to SVCS. MethodsThis was a retrospective cohort study. A total of 194 maintenance hemodialysis patients diagnosed with SVCS who were admitted to the Department of Nephrology, West China Hospital of Sichuan University from January 2019 to December 2021 were selected and divided into a hypotension group and a nonhypotension group. Demographic and clinical data were compared. Hypotension simply refers to blood pressure levels of <90/60 mm Hg on a nondialysis day. All patients received endovascular intervention. ResultsHypotension was found in 85 of the 194 patients. The following factors were significantly different between the hypotension and nonhypotension groups: body mass index, history of hypertension, tunneled-cuffed catheter as the means of dialysis access, azygos ectasis, SVC stenosis of >70% or occlusion, occlusion at the cavitary junction, serum calcium, diastolic left ventricular (LV) posterior wall thickness, LV end-diastolic volume, stroke output, and LV ejection fraction. Multivariate logistic regression analysis showed that hypertension history (OR, 0.314; P = .027), tunneled-cuffed catheter as vascular access (OR, 3.997; P < .001), SVC stenosis of >70% or occlusion (OR, 5.243; P < .001), LV posterior wall thickness (OR, 0.772; P = .044), and serum calcium (OR, 0.146; P = .005) were independent risk factors for hypotension. The mean values of systolic and diastolic blood pressure after intravascular treatment were significantly elevated from those before intervention (P < .001). The primary patency rates of SVC were 66.8%, 58.7%, and 50.0% at 3, 6, and 12 months after the procedure. ConclusionsThe incidence of hypotension in patients with hemodialysis-associated SVCS is high. The identification of risk factors of hemodialysis-related hypotension provides insight into potential treatment strategies. Endovascular treatment is expected to improve hypotension related to SVCS in hemodialysis patients.

Assessment of Nutrient Intake and its Association with Protein Energy Wasting in Haemodialysis Patients

Background: Protein Energy Wasting (PEW) is one of the complications associated with HD, a multi-factorial, maladaptive metabolic state characterized by loss of body protein mass and energy reserves, which is a major cause of morbidity and mortality amongst these patients. Adequate nutrient intake in dialysis patients is, therefore, a challenge due to poor appetite, and anorexia because of the build-up of uremic toxins. Therefore, this study aims to assess PEW and nutrient intake consumption in the HD population to add to the Indian database. Methods: The study adopted a cross-sectional design conducted at a tertiary care hospital in Mumbai, India. A total of 54 chronic haemodialysis patients were recruited for the study through convenience sampling. Post dialysis session, measurement of weight was recorded. An interviewer-administered questionnaire was used to record the patient details. Results: The nutrient intake on dialysis day was observed to be lower as compared to non-dialysis day. Only 5% of patients were diagnosed with PEW. A significant correlation between Energy, Protein on dialysis, and non dialysis day, along with Carbohydrate, Sodium, and Potassium intake (p-value 0.001) was observed. Conclusion: The present study found that nutrient intake of Energy, Protein, CHO, Fats, Sodium and Potassium were lower on dialysis day as compared to non dialysis day. Majority of the patients were well nourished and only 5% of patients were Protein Energy Wasted. Keywords: Protein Energy Wasting (PEW), Nutrient intake, Haemodialysis, Appetite, Diet.

#4580 ELEVATED LEVELS OF UREMIC SOLUTES IN THE CEREBROSPINAL FLUID OF HEMODIALYSIS PATIENTS

Abstract Background and Aims Uremic solutes are considered as contributing factors to impaired cognitive function in end stage kidney disease (ESKD) [1]. However, the distribution and accumulation of uremic solutes in the central nervous system (CNS) of ESKD patients are not well understood. We measured four uremic solutes in the cerebrospinal fluid (CSF) and plasma of two ESKD patients and investigated the role of routine hemodialysis (HD) in clearing these solutes from their CNS. Method We accessed CSF in HD patients with a ventriculo-peritoneal shunt. A review of about 160,000 electronic health records revealed 30 eligible patients, two of whom consented to participate in this IRB-approved one-week study (Western IRB #20172182). On dialysis days, CSF and plasma were collected 2 hours pre- and 2 hours post-HD. Non-dialysis day samples were collected 20 hours post-HD. Samples from healthy subjects were purchased from BioIVT (Westbury, NY). Urea was measured using Horiba C400 Chemical Analyzer. Indoxyl sulfate (IS), p-cresol sulfate (pCS) and trimethylamine N-oxide (TMAO) were analyzed using Agilent Ultivo triple quadrupole mass spectrometer. The dialytic reduction ratio (RR; in %) was calculated as 100 × (pre-HD level – post-HD level) / pre-HD-level. Results In both CSF and plasma, levels of all four uremic solutes were elevated in HD patients compared to healthy subjects (Table 1). The ratio of CSF-to-plasma levels was &amp;lt;100% for all solutes. Ratios for HD patients are altered compared to those reported in healthy subjects (Table 1). Longitudinal plasma and CSF solute levels are shown in Figure 1. Plasma RRs for IS, pCS, TMAO and urea were 32%, 23%, 77%, and 67%, respectively. The respective CSF RRs were 29%, 20%, 3%, and 25%. Conclusion To the best of our knowledge, this is the first report on CSF levels of IS, pCS, and TMAO in HD patients. Our results indicate that uremic solute levels are elevated in the CSF from HD patients compared to healthy subjects. Moreover, HD only moderately reduces uremic solute levels in CSF. Whether increased CNS levels of uremic solutes are related to cognitive impairment warrants further investigation.

HEMODIALYSIS EFFECTS ON AUTONOMIC FUNCTION: RESULTS OF LINEAR AND NON-LINEAR ANALYSIS OF HEART-RATE-VARIABILITY AT REST AND IN RESPONSE TO PHYSICAL AND MENTAL STRESS TESTS

Objective: Cardiac arrhythmias are the most common cause of death in hemodialysis. Autonomic dysfunction plays a central role in this arrhythmogenic background. Previous studies on hemodialysis-related changes in heart-rate-variability(HRV) give contradictory results. This study investigated HRV indices both at rest and in response to physical and mental stimulation maneuvers at multiple time-points around and during the hemodialysis procedure. Design and method: Autonomic function was assessed by linear and non-linear HRV indices at pre-dialysis, during-dialysis(3 equal time-periods), post-dialysis, and on the non-dialysis day in 36 hemodialysis patients. Continuous measurement of beat-by-beat heart-rate was recorded with Finometer-PRO(The Netherlands) at rest and after orthostatic, sit-to-stand, handgrip and mental-arithmetic test. Results: The RMSSD, SD1, and SD2 indices significantly increased during dialysis(early-HD, mid-HD, late-HD periods) compared with the pre-dialysis levels(p&lt;0.05) and returned to baseline post-dialysis(RMSSD: 54.39±83.73 vs 137.98±109.53* vs 119.85±97.34* vs 144.47±88.74* vs 85.82±121.43msec, *p&lt;0.05 vs pre-dialysis and post-dialysis). No differences were detected in the above indices between the pre-dialysis and non-dialysis day. However, post-dialysis, the HRV responses to orthostatic and sit-to-stand tests were more exaggerated than in the pre-dialysis measurements (p&lt;0.05). The HRV responses both at resting and physical tests in the non-dialysis day were similar to the pre-dialysis levels. HRV indices in mental-arithmetic test during hemodialysis were much higher than at the non-dialysis day(RMSSD: 77.05 (180.41) vs 19.75 (105.47)msec; p = 0.031) were detected. Conclusions: Hemodialysis causes marked changes in autonomic function. Resting HRV indices return to baseline post-dialysis, but HRV responses to physical stress remain exaggerated and return to baseline on the non-dialysis day. Detecting patients with significant autonomic dysfunction may help towards reduction of arrhythmia risk through individualized approaches.

Impact of Abdominal Fat Distribution on Mortality and Its Changes Over Time in Patients Undergoing Hemodialysis: A Prospective Cohort Study

Measures of fat distribution and visceral fat accumulation maintain a direct association with mortality in the general population. However, among patients undergoing hemodialysis (HD), there are few reports of this association. This study aimed to investigate the impact of computed tomography (CT)-measured abdominal fat levels, including the visceral fat area (VFA) and subcutaneous fat area (SFA), on all-cause mortality in patients undergoing HD and investigate whether there are sex-specific particularities regarding the associations between the abovementioned parameters. A total of 258 participants were selected from the population of patients undergoing stable HD. The baseline characteristics were collected by records and interviews. The following variables were assessed at baseline and every year: body mass index, abdominal circumference, VFA, and SFA. Abdominal circumference and body fat distribution were assessed at the level of the umbilicus via CT. All CT scans were performed on a nondialysis day with the subject in a supine position. The primary end point was the 5-year all-cause mortality. This prospective cohort study revealed that age, cardiothoracic ratio, %VFA (VFA/[VFA+SFA]), and albumin were independent predictors of death via multivariable analyses. Regarding the %VFA, its area under the curve (0.599), which did not suffice to predict mortality, was higher than that of VFA, SFA, and body mass index. Also, the effect was recognized mainly in male patients. The %VFA of patients who survived for 60months increased over time. These data suggest that patients (especially men) with a high VFA-to-abdominal fat ratio have a high risk of death. Thus, more attention should be paid to such patients.

Olaparib in an ovarian cancer patient with end-stage renal disease and hemodialysis

PurposeFor patients with severe renal impairment (CrCl ≤ 30 ml/min) or end-stage renal disease (ESRD), olaparib intake is not recommended as the pharmacokinetics and safety of olaparib have not been evaluated in this patient group. Therefore, this valuable patient group is generally excluded from poly(ADP-ribose) polymerase inhibitor (PARPi) therapy. Here we report the pharmacokinetics (PK), efficacy, safety and tolerability of olaparib capsules 200 mg BID in a patient with recurrent epithelial ovarian cancer (EOC) and ESRD requiring hemodialysis.MethodsBlood and dialysate samples of the patient were collected on a dialysis and non-dialysis day. Olaparib total plasma concentrations were determined through high-performance liquid chromatography with tandem mass spectrometric detection. Actual scheduled sample times were used in the PK analysis to determine multiple dose PK parameters at steady state.ResultsMaximum concentration was achieved 1.5 h after drug administration on non- dialysis and after 1 h on dialysis day. The steady-state trough concentration and the maximal plasma concentration were similar on dialysis and non- dialysis day. On non-dialysis day, the AUCss was 30% higher (24.0 µg.h/mL vs. 16.9 µg.h/ml) than on dialysis day. The plasma clearance CLss/F was lower on non-dialysis day. Olaparib was not detectable in the dialysate samples.ConclusionA total dose of olaparib 200 mg BID capsule formulation was well tolerated by our patient with ESRD and hemodialysis. Moreover, this maintenance therapy led to 16 months of progression free survival. Further trials on PARPi therapy in patients with hemodialysis are warranted.

Six-minute walk test may be a reliable predictor of peak oxygen uptake in patients undergoing hemodialysis

BackgroundCardiorespiratory fitness seems to play an important role in the general health of patients undergoing hemodialysis (HD). However, the prediction of peak oxygen uptake (V̇O2peak) in a clinical setting is not widely adopted for these patients.ObjectivesEvaluate the agreement and reliability between directly and indirectly V̇O2peak measurements in patients undergoing HD.MethodsThis is a cross-sectional study with patients undergoing HD that performed a cardiopulmonary exercise test (CPET) with 5/10 watts incremental load in each minute using a cycle ergometry to directly evaluate the V̇O2peak, and the 6-min walk test (6MWT) in a 30-m corridor to indirect measures it. Both tests were performed on a midweek non-dialysis day. Bland–Altman analysis of agreement limits was used with direct and indirect V̇O2peak values. Intraclass correlation coefficient (ICC) and Cronbach’s Alpha was used to evaluate the reproducibility and reliability between direct and indirect V̇O2peak values.ResultsTwenty-six patients (54.4 ± 14.5 years, 53.8% of male) were evaluated. The V̇O2peak direct mean obtained through CPET was 15.91 ± 5.26 (ml/kg/min), while the indirect mean obtained through 6MWT was V̇O2peak of 14.89 ± 4.21 (ml/kg/min). There was a strong positive correlation between both V̇O2peak values (r = 0.734; p < 0.001). The Bland–Altman analysis demonstrated that the methods agreed with each other (p = 0.103). Also, the ICC (0.829) and Cronbach's Alpha (0.846) showed excellent reproducibility and reliability.Conclusions6MWT is a reliable tool for estimating V̇O2peak in patients undergoing HD.

Hemodialysis Effects on Autonomic Function: Results of Linear and Nonlinear Analysis of Heart Rate Variability at Rest and in Response to Physical and Mental Stress Tests

Introduction: Cardiac arrhythmias are the most common cause of death in hemodialysis. Autonomic dysfunction plays a central role in this arrhythmogenic background. Previous studies on hemodialysis-related changes in heart rate variability (HRV) give contradictory results. This study investigated HRV indices both at rest and in response to physical and mental stimulation maneuvers at multiple time-points around and during the hemodialysis procedure. Methods: Autonomic function was assessed by linear and nonlinear HRV indices at predialysis, during dialysis (3 equal time-periods), postdialysis, and on the nondialysis day in 36 hemodialysis patients. Continuous measurement of beat-by-beat heart rate was recorded with Finometer-PRO (The Netherlands) at rest and after orthostatic, sit-to-stand, handgrip, and mental-arithmetic test. Results: The RMSSD, SD1, and SD2 indices significantly increased during dialysis (early-HD, mid-HD, late-HD periods) compared with the predialysis levels (p < 0.05) and returned to baseline postdialysis (RMSSD: 54.39 ± 83.73 vs. 137.98 ± 109.53* vs. 119.85 ± 97.34* vs. 144.47 ± 88.74* vs. 85.82 ± 121.43msec, *p < 0.05 vs. predialysis and postdialysis). No differences were detected in the above indices between the predialysis and nondialysis day. However, postdialysis, the HRV responses to orthostatic and sit-to-stand tests were more exaggerated than in the predialysis measurements (p < 0.05). The HRV responses both at resting and physical tests in the nondialysis day were similar to the predialysis levels. HRV indices in the mental arithmetic test during hemodialysis were much higher than at the nondialysis day (RMSSD: 77.05 [180.41] versus 19.75 [105.47] msec; p = 0.031). Conclusions: Hemodialysis causes marked changes in the autonomic function. Resting HRV indices return to baseline postdialysis, but HRV responses to physical stress remain exaggerated and return to baseline on the nondialysis day. Detecting patients with significant autonomic dysfunction may help towards reduction of arrhythmia risk through individualized approaches.

Estimation of pulmonary artery systolic pressure in hemodialysis patients and its association with cardiorespiratory fitness and pulmonary function.

To evaluate the estimated pulmonary arterial systolic pressure (PASP) through transthoracic echocardiography in hemodialysis (HD) patients and associate it with cardiorespiratory fitness and pulmonary function. This study was a cross-sectional analysis of HD patients that performed evaluations of cardiac function, cardiorespiratory fitness, and pulmonary function, through transthoracic echocardiography, cardiopulmonary exercise test, spirometry, and manovacuometry, respectively. All patients underwent the evaluations on a non-dialysis day. Thirty-five HD patients were evaluated and separated according to the presence of probable pulmonary hypertension (PH) (estimated PASP ≥ 35mmHg) or not (estimated PASP < 35mmHg). Those HD patients with probable PH had the worst cardiorespiratory fitness, evaluated by the peak oxygen consumption (VO2peak) (17.11 ± 4.40 versus 12.90 ± 2.73mL/kg/min; p = 0.011), and pulmonary function, evaluated by absolute and predicted of forced vital capacity (FVC) (85.52 ± 12.29 versus 71.38 ± 11.63%; p = 0.005) and absolute and predicted of forced expiratory volume in the first second (FEV1) (83.37 ± 14.98 versus 69.21 ± 13.48%; p = 0.017). The secondary analysis showed that estimated PASP was correlated with VO2peak (r = -0.508; p = 0.002), FVC (r = -0.450; p = 0.007), and FEV1 (r = -0.361; p = 0.033). Moreover, the adjusted odds ratio by HD vintage, dry weight and gender showed that increments in VO2peak (OR 1.62; CI 95% 1.04-2.54; p = 0.034), FVC (OR 39.67; CI 95% 1.74-902.80; p = 0.021), and FEV1 (OR 39.54; CI 95% 1.89-826.99; p = 0.018) were associated with 1-fold and 39-fold higher chance, respectively, for not having PH. However, all these associations were lost when age was included in the analysis. The HD patients with probable PH had the worst cardiorespiratory fitness and pulmonary function. Exploratory analyses showed that greater cardiopulmonary fitness was associated with better cardiac function. Moreover, increments in cardiorespiratory fitness and pulmonary function may increase the chance of not having PH.

Exercise guide to help on arteriovenous fistula maturation and maintenance.

The arteriovenous fistula is the main vascular access in hemodialysis. Arteriovenous fistula access is generally evaluated by a vascular surgeon after 2 weeks of its surgery, however, exercise programs may begin earlier for improving outcomes. Therefore, we propose this guide with simple, but potentially effective exercises, using low-cost materials that can be safely performed by the patients at home or in the dialysis center. It also provides to the dialysis staff team a starting point for implementing an upper-limb exercise program that may facilitate arteriovenous fistula maturation and maintenance. This exercise routine for arteriovenous fistula maturation can be performed three to four times a day, every day, from 2 to 4 weeks. After its maturation, it can be performed on every non-dialysis day for conventional treatment and every other day, before dialysis, for short daily treatment. Based on the available evidence, we have gathered some exercises, in a very easy and understandable language, that may potentially help arteriovenous fistula maturation and maintenance for hemodialysis patients.

Evaluation of the relationship between hemodialysis-related glycemic variability and hormonal profiles in patients with type 2 diabetes on hemodialysis: a pilot study

BackgroundThe number of dialysis patients with diabetes is currently increasing in Japan and a similar proportion worldwide. It was suggested that approximately 20% of these patients had hypoglycemia after dialysis session and most of these hypoglycemia were unconscious. Furthermore, it was suggested that glucose variabilities induced by hemodialysis may be related to insulin and insulin-counter hormones, such as glucagon, adrenocorticotropic hormone (ACTH), and cortisol and growth hormone, but conclusive evidence has not still been obtained.MethodsWe investigated in detail the glucose and hormonal profiles in 7 patients with type 2 diabetes on hemodialysis (all male, HbA1c 6.8 ± 2.1%, glycated albumin 24.7 ± 10.2%). All participants were attached continuous glucose monitoring (iPro2®). Blood glucose level, C-peptide immunoreactivity, plasma glucagon, ACTH, cortisol and growth hormone were measured by 7 points blood tests at before breakfast, after breakfast (predialysis), 2 h and 4 h after starting dialysis, after lunch and before/after dinner on the dialysis day and 6 points at before/after each meal on the non-dialysis day, and these relationship with blood glucose dynamics were examined. The meal contents were set to the indicated energy amount, and the same menu was served daily for breakfast, lunch, and dinner on dialysis and non-dialysis days of this study period. In addition, the start time of lunch on non-dialysis day was the same as the start time of lunch on the dialysis day.ResultsSerum C-peptide level was significantly increased by taking breakfast and lunch on the hemodialysis day, significantly decreased during hemodialysis, and was significantly lower before and after lunch on the hemodialysis day than on the non-hemodialysis day. Plasma glucagon level significantly decreased during hemodialysis and that before lunch on hemodialysis day was significantly lower than on non-hemodialysis day. ACTH, cortisol, and growth hormone did not show any changes related to hemodialysis.ConclusionsIt was suggested that C-peptide and glucagon play an important role in hemodialysis-related glycemic variabilities in patients with type 2 diabetic hemodialysis.Trial registration UMIN Clinical Trial Registry (Registration Number UMIN000018707). Registered 18 August 2015, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&language=J&recptno=R000021647.

Effect of twelve-week concurrent aerobic and resisted exercise training in non-dialysis day on functional capacity and quality of life in chronic kidney disease patients.

Several researchers have evaluated the impact of exercise training on patients with chronic kidney disease (CKD). However, few studies have evaluated the impact of concurrent training (aerobic and resisted exercise) on non-dialysis days on the functional capacity and quality of life (QOL) of such patients. Our current study evaluated the effects of concurrent training on functional capacity and QOL of patients with CKD. Forty-three patients, aged ≥ 25 years, were recruited in this randomized study. They were divided into intervention and control groups (22 per group). The intervention group received concurrent aerobic and resistance exercises (three sessions per week for twelve weeks on alternative days). The control group continued their regular lifestyle practices and medical treatment without any exercise intervention. Before and after twelve weeks of training, the participant's functional capacity and quality of life (QOL) were measured. Compared to the control group, the intervention group displayed a significant improvement in the distance walked in the 6-minute walk test and sit-to-stand test (STS1/s and STS-60) with p<0.001; furthermore, a significant improvement was observed in physical function, body pain, general health, role functioning/physical, vitality, and social functioning (p<0.05) of QOL assessed with the SF-36 questionnaire. The twelve-week concurrent aerobic and resistance exercise training had a positive impact on functional capacity and QOL in CKD patients. Concurrent exercise training should be recommended as an interventional modality in physical therapy and rehabilitation protocols in CKD patients.

MO755: Comparison of Techniques for Fluid Status Assessment in Chronic Hemodialysis Patients

Abstract BACKGROUND AND AIMS Several methods have been developed to assess hydration status in chronic haemodialysis (HD) patients. The aim of this study was to compare multifrequency body bioimpedance spectroscopy (MBIS) with ultrasound lung comet scores (ULCs) and inferior vena cava diameters (IVCD) using ultrasound to estimate dry weight on the non-dialysis day. METHOD We evaluated MBIS, ULCs at 28 typical sites and IVCD during expiration in 40 HD patients. All measurements were performed on a non-dialysis day. For MBIS measurement, we used the Body Composition Monitor (Fresenius Medical Care, Bad Homburg, Germany), and for ULCs and IVCD, we used an ultrasound device (Esaote MyLabOmega, Genoa, Italy). Overhydration was defined as &amp;gt; 2L with MBIS, &amp;gt; 15 ULCs, and &amp;gt; 11.5 mm/m2 IVCD. RESULTS Mean age of patients was 65 (40–89) years, and 29 (72.5%) were men. Other descriptive data are in Table 1. We found a significant correlation between MBIS and ULCs (r = 0.464, P &amp;lt;0.003) and between MBIS and IVCD (r = 0.589, P &amp;lt;0.001). Multiple regression analysis with the MBIS as the dependent variable and ULCs, IVCD, albumin and haemoglobin as independent variables confirmed a statistically significant relationship between MBIS and IVCD (β = 0.436; P &amp;lt; 0.001). According to the overhydration criteria, 14 (35%) patients were overhydrated by MBIS, 8 (20%) patients by ULCs and 9 (22.5%) patients by IVCD. Only 4 (10%) patients met overhydration criteria simultaneously by all three methods (MBIS, ULCs and IVCD). CONCLUSION All methods were able to describe overhydration in HD patients on a non-dialysis day. The MBIS was associated with the IVCD.

MO723: Ankle-Brachial Index is Associated with Subendocardial Viability Ratio in Chronic Hemodialysis Patients

Abstract BACKGROUND AND AIMS Ankle-brachial index (ABI) is a marker of peripheral arterial disease and is associated with increased cardiovascular morbidity and mortality. Structural alterations in the arterial walls lead to functional central haemodynamic changes, potentially impacting pulse wave reflection and, consequently, myocardial perfusion. The aim of this study was to determine the association between ABI and subendocardial viability ratio (SEVR) as a non-invasive measure of coronary perfusion in chronic haemodialysis patients. METHOD We measured ABI using an automated non-invasive waveform analysis device (MESI®, Slovenia) and SEVR using applanation tonometry (Sphygmocor, Atcor Medical, Sydney, Australia). All the measurements were performed on a non-dialysis day and SEVR on the non-arteriovenous fistula (non-AVF) hand. ABI was calculated as the ratio between systolic blood pressure on the non-AVF hand and systolic blood pressure on the calves of both legs. Mean ABI of both sides was used in the statistical analysis. RESULTS A total of 29 patients (mean age 63.6 ± 10.5 years, 69.0% male) were included. In Table 1, descriptive parameters are presented. Of those, 4 patients (13.8%) have an ABI &amp;lt;0.9 and the other 25 patients (86.2%) have a normal ABI between 0.9 and 1.3. Using the independent-samples T-test, patients with a lower ABI have a statistically significant lower SEVR compared with patients with normal ABI (109 versus 142%; P = 0.039). CONCLUSION Low ABI is independently associated with decreased subendocardial perfusion in chronic haemodialysis patients, suggesting that both methods of ABI and SEVR measurement may reflect an atherosclerotic process in peripheral and coronary arteries.

Delayed gastric emptying in nondiabetic patients with end-stage kidney disease

Objective This study aimed to assess the gastric emptying capacity in nondiabetic patients with end-stage kidney disease (ESKD) by ultrasound. Methods Consecutive hemodialysis patients with ESKD (n = 37) and healthy controls (n = 37) were enrolled. All ESKD patients underwent ultrasound examinations on the day of hemodialysis (dialysis day) and the day after hemodialysis (nondialysis day). Standard ultrasound examinations were performed after overnight fasting, immediately after a light meal, and at 6 h after a meal. The antral cross-sectional area and gastric emptying according to the Perlas grading system were evaluated. Results Compared with the controls, patients with ESKD, on both dialysis and non-dialysis days, had significantly larger antral areas when examined in the supine position (p = 0.002 and p = 0.003, respectively), but not in the right lateral decubitus position (p = 0.452 and p = 0.512, respectively). In the supine position, the antral area of ESKD patients before dialysis (8 a.m. on the dialysis day) was larger than that at the same time on the nondialysis day (p = 0.028). The controls had a Perlas grade of either 0 or 1 at 6 h after a meal, whereas five patients (13.5%) and 11 patients (29.7%) in the ESKD group had Perlas grade 2 on the dialysis and non-dialysis days, respectively. Among patients with or without delayed gastric emptying, no differences were detected in the dialysis duration or levels of biochemical markers, except blood urea nitrogen (p = 0.038) and serum creatinine (p = 0.003). Conclusion Nondiabetic patients with ESKD had significantly delayed gastric emptying. Hemodialysis might improve gastric emptying and reduce gastric emptying delay.

Impact of measurement timing on reproducibility of testing among haemodialysis patients

Accurate evaluation of physical function in patients undergoing haemodialysis is crucial in the analysis of the impact of exercise programs in this population. The aim of this study was to evaluate the reproducibility of several physical functional tests, depending on the timing of their implementation (before the HD session vs. non-HD days). This is a prospective, non-experimental, descriptive study. Thirty patients in haemodialysis were evaluated twice, 1 week apart. The test session was performed before the haemodialysis session started and a retest was performed in non-dialysis day. The testing battery included the short physical performance battery, sit-to-stand tests, 6 min walk test, one-leg stand test, timed up and go, and handgrip strength with and without forearm support. The intra-rater reproducibility was determined by the intraclass correlation coefficients and the agreement was assessed by Bland–Altman analysis. The intraclass correlation coefficients values ranged from 0.86 to 0.96, so that all tests showed good to very good relative reliability. The mean differences between trials of sit to stand 10 and 60, timed up and go and all the handgrip tests were close to zero, indicating no systematic differences between trials. Large range of values between trials was observed for the 6 min walk test, gait speed, one-leg stand test and short physical performance battery, indicating a systematic bias for these four tests. In conclusion, the sit to stand 10 and 60, timed up and go and handgrip tests had good to excellent test–retest reliability in measuring physical function in different dialysis days of patients undertaking haemodialysis. The minimal detectable change values are provided for this population. Bias were found for the 6 min walk test, gait speed, Short physical performance battery or one-leg stand test when the testing day changed.

Advanced Glycation End Products and Inflammatory Cytokine Profiles in Maintenance Hemodialysis Patients After the Ingestion of a Protein-Dense Meal

The goal of this investigation was to evaluate circulating and skeletal muscle inflammatory biomarkers between maintenance hemodialysis (MHD) and demographic-matched control subjects (CON) before and after ingestion of a protein-rich meal. CON (n=8; 50±2years; 31±1kg/m2) and MHD patients (n=8; 56±5years; 32±2kg/m2) underwent a basal blood draw and muscle biopsy and serial blood draws after the ingestion of a mixed meal on a nondialysis day. Plasma advanced glycation end products (AGEs) and markers of oxidation were assessed via liquid chromatography-tandem mass spectrometry before and after the meal (+240min). Circulating inflammatory cytokines and soluble receptors for AGE (sRAGE) isoforms (endogenous secretory RAGEs and cleaved RAGEs) were determined before and after the meal (+240min). Basal muscle was probed for inflammatory cytokines and protein expression of related signaling components (RAGE, Toll-like receptor 4, oligosaccharyltransferase subunit 48, TIR-domain-containing adapter-inducing interferon-β, total IκBα, and pIκBα). Basal circulating AGEs were 7- to 343-fold higher (P<.001) in MHD than those in CON, but only MG-H1 increased in CON after the meal (P<.001). There was a group effect (MHD>CON) for total sRAGEs (P=.02) and endogenous secretory RAGEs (P<.001) and a trend for cleaved RAGEs (P=.09), with no meal effect. In addition, there was a group effect (MHD<CON; P<.05) for circulating fractalkine, interleukin (IL)10, IL17A, and IL1β and a trend (P<.10) for IL6 and macrophage inflammatory protein 1 alpha, whereas tumor necrosis factor alpha was higher in MHD (P<.001). In muscle, Toll-like receptor 4 (P=.03), TIR-domain-containing adapter-inducing interferon-β (P=.002), and oligosaccharyltransferase subunit 48 (P=.02) expression was lower in MHD than that in CON, whereas IL6 was higher (P=.01) and IL8 (P=.08) tended to be higher in MHD. Overall, MHD exhibited an exaggerated, circulating, and skeletal muscle inflammatory biomarker environment, and the meal did not appreciably affect the inflammatory status.

Different circadian patterns of arterial stiffness are responsible for increased cardiovascular mortality in hemodialyzed patients.

We hypothesized that volume changes during 48‐h are associated with different circadian patterns of arterial stiffness on non‐dialysis day compared to dialysis day and that the night‐time increase of arterial stiffness is associated with higher mortality. The patients whose night‐time mean pulse wave velocity levels drop or rise more than 0.5 m/s compared with the day‐time period were defined as pulse wave velocity dippers and risers. The patients whose night‐time mean augmentation index drop or rise more than 10% compared with the day‐time period were defined as augmentation index dippers and risers. There was significantly higher number of patients with dipping and rising pattern of augmentation index and pulse wave velocity on non‐dialysis day when compared to dialysis day. On the non‐dialysis day both nocturnal augmentation index and pulse wave velocity levels were higher in deceased group with significantly higher number of augmentation index and pulse wave velocity dippers when compared to survived patients. In the linear regression model, the strongest association of survival was with augmentation index and pulse wave velocity risers on the non‐dialysis day. On logistic regression only pulse wave velocity rising pattern on non‐dialysis day had increased HR of 1.78 for cardiovascular mortality. The present study is the first which analyzed circadian patterns of arterial stiffness in patients on hemodialysis and compared their impact on cardiovascular mortality. A significantly greater number of patients had an augmentation index and pulse wave velocity rising pattern in the deceased group compared to the survived group of patients. Survival had the strongest association with augmentation index and pulse wave velocity risers on the non‐dialysis day.

Central versus ambulatory blood pressure for predicting mortality and cardiovascular events in hemodialysis patients: a multicenter cohort study.

Studies in the general population suggest that central blood pressure (BP) may be superior to peripheral BP in risk assessment. Although ambulatory brachial BP is recognized as the most reliable BP measurement in the dialysis population, there is no comparison of office central BP with ambulatory BP regarding risk stratification in these patients. In a multicenter prospective study of dialysis patients, central BP was measured noninvasively on a midweek nondialysis day, with interdialytic ambulatory BP and predialysis BP also collected. The primary outcomes were a composite of major adverse cardiovascular events (MACE) and all-cause mortality. Agreement between central and ambulatory BP was assessed using Cohen's Kappa index and Bland--Altman plot. Linear and nonlinear Cox regression models were used to determine the association of BP parameters with outcomes. A total of 368 patients were recruited and 366 underwent central BP measurement. Central BP had a moderate agreement with ambulatory BP in defining hypertension (κ = 0.42) with wide limits of agreement in Bland--Altman analysis. After a median follow-up of 51.5 months, central pulse pressure, ambulatory SBP and ambulatory pulse pressure were associated with all-cause mortality, whereas all BP parameters, except for predialysis DBP, were significant predictors of MACE. However, whenever evaluated in a stepwise variable selection Cox model, only ambulatory pulse pressure, but not any central BP, was determined as the best candidate for prediction of both all-cause mortality and MACE. Nonlinear Cox models revealed no significant nonlinear trend of the association between central BP and outcomes. Central BP is predictive of all-cause mortality and cardiovascular events in dialysis patients but its prognostic value does not outperform ambulatory peripheral BP. Our data support the superiority of ambulatory BP in the dialysis population.