Dialysis Period Research Articles

Correlation between postdialysis blood pressure assessed at different time points and home blood pressure monitoring

Abstract Background Hemodialysis patients undergo blood pressure (BP) measurements during the predialysis, intradialytic and postdialysis (POSBP) periods at the dialysis sessions. However, there is no consensus regarding the time point when POSBP measurement should be performed. Purpose This study investigated the relationship of POSBP measurements performed at different time points with home blood pressure monitoring (HBPM). Methods This prospective study included 98 long-term dialysis patients (67% men; age=59.4 ±17.7 years; 79% using antihypertensive medications). During one week, POSBP measurements were obtained in sitting patients by trained health staff using oscillometric BP monitors lodged in the dialysis machines at all dialysis sessions in three different periods: 1) immediately after the dialysis period ended (POSBP1); 2) after returning the patient's blood (POSBP2) and 3) after hemostasis of the fistula or catheter sealing (POSBP3). In the same week, HBPM was performed using validated devices and was calculated as the mean of BP measurements obtained on six consecutive days, comprising three readings in the morning and in the evening after at least 3 min of rest, before antihypertensive medications were taken, with the patients seated. Abnormal BP was defined as HBPM≥135/85 mmHg. Based on the optimal cut-point values derived from ROC curves analysis, we built cutoffs for POSBP1 (143/79 mmHg), POSBP2 (153/78 mmHg) and POSBP3 (151/80 mmHg) corresponding to HBPM values of 135/85 mmHg. Results The values of POSBP1, POSBP2, POSBP3 and HBPM were 138±21/72±13, 143±24/73±13, 142±22/72±13 and 128±19/76±13 mmHg, respectively. Systolic HBPM showed greater correlation with systolic POSBP3 (r=0.71), followed by POSBP1 (r=0.68), POSBP2 (r=0.67), while diastolic HBPM showed greater correlation with diastolic POSBP2 and POSBP3 (both r=0.56), followed by POSBP1 (r=0.49) (all p<0.05). The POSBP3 cutoff showed the highest association (odds ratio [95% CI]= 8.06 [3.21, 20.27]), accuracy (area under the curve [95% CI]= 0.74 [0.65, 0.83]) and concordance (kappa coefficient=0.47) to identify elevated BP at HBPM in comparison with the POSBP1 and POSBP2 cutoffs (Figure). Conclusion(s) POSBP3 exhibited the strongest correlation with HBPM and had the highest accuracy to detect elevated HBPM in dialysis patients and may be a potentially preferable POSBP measurement in clinical practice.

Trends in Patient Characteristics on the Japanese Waiting Lists for Deceased-Donor Kidney Transplantation. Are There no Eligibility or Ineligibility Criteria for Registration and Renewal?

BackgroundControversial issues in registering candidates for deceased-donor kidney transplantation (DDKT) comprise various factors, including age, life expectancy, and dialysis duration. We investigated patient characteristics on the waiting list and discussed suitable criteria in Japan, which has a long waiting period. MethodsThis study included 592 patients on the waiting list for DDKT at our institute between 1982 and 2023. We retrospectively reviewed patients’ medical charts and obtained their clinical information. Patient characteristics according to outcomes and eligibility criteria for applying for or renewing registration were investigated. No prisoners were used in the study, and the participants were neither coerced nor paid. ResultsApproximately 70%, 45%, and 14.5% of the registered patients were aged >60, >70, and 80 years, respectively. The number of patients aged ≥70 years gradually decreased over time. The median waiting periods of patients who underwent and interrupted DDKT were 13 and 7 years, respectively. Patients in their 70s with a >15-year dialysis period tended to have opportunities for DDKT. Living-donor kidney transplantation was performed in patients aged <60 years. Waiting patients were significantly younger and had a shorter dialysis duration. Advanced age at registration was associated with a significantly high risk of interruption. ConclusionsAdvanced age and longer dialysis periods were considered at registration because patients with these factors tended to experience interruptions despite the long waiting period and high cost. Although older patients can undergo DDKT, factors including surgical cost and risks are considered. Eligibility/ineligibility criteria should be established for DDKT waiting lists in Japan.

A Quick and Sensitive LC-MS/MS Method for Simultaneous Quantification of Sofosbuvir Metabolite (GS-331007) in Human Plasma: Application to Hepatitis C Infected Patients with End-Stage Renal Disease.

Sofosbuvir (SOF) is a revolutionary treatment for patients with hepatitis C virus (HCV). However, its efficacy and safety among patients with end-stage renal disease (ESRD) remains controversial. In this study, we examined the levels of SOF metabolite (GS-331007) (SOF-007) in human plasma of patients infected with HCV having ESRD using an optimized liquid chromatography-mass spectrometry (LC-MS) analytical method. In this case-control study, 10 clinically confirmed cases and five controls were enrolled. SOF-007 was extracted from plasma using methanol precipitation. The limit of detection (LOD) for the drug and its metabolite were 0.85 and 2.3, respectively. Such a wide range of quantification in a period of separation time shorter than 3.0 minutes (run time) allowed monitoring of the plasma concentration of analytes up to 4 hours (pre-dialysis and post-dialysis) for 12 weeks in non-cirrhotic patients with HCV infection undergoing dialysis. SOF-007 in the plasma of HCV patients with healthy kidneys showed no cumulative effect. An analysis comparing patients with ESRD and healthy participants showed that their behaviour was similar, followed by dialysis with a relatively small cumulative effect. The plasma concentrations of SOF-007 decreased significantly after the 4-hour period of dialysis compared with the plasma concentrations hemodialysis of pre-dialysis in HCV patients with ESRD.

Chronic Kidney Disease - Peridialysis Period: Predialysis, Dialysis Preparation, and Initial Dialysis Prescription

Summary Two periods adjacent to starting dialysis are called “chronic kidney disease - peridialysis.” The predialysis period is of varying duration, while the dialysis period lasts up to 3 months after the first dialysis session. During the peridialysis period of chronic kidney disease, complications, mortality, and treatment costs increase significantly. The rate of glomerular filtration rapidly decreases, which requires intensive treatment. Management of the peridialysis period is a challenging clinical problem. This review aims to acquaint all working with patients with chronic kidney disease with the novelties published in the medical literature in recent years about the principle of work in patients with glomerular filtration below 15 ml/min per 1.73 m².

Evaluation of peritoneal dialysis prescriptions in uremic rats.

Patients with end-stage kidney disease (ESKD) require dialysis or transplantation for their survival. There are few experimental animal models mimicking the human situation in which the animals are dependent on dialysis for their survival. We developed a peritoneal dialysis (PD) system for rats to enable long-term treatment under controlled conditions. Rats were chemically nephrectomised using orellanine to render them uremic. Two studies were performed, the first with highly uremic rats on PD for 5 days, and the other with moderately uremic rats on PD for 21 days. Blood and dialysate samples were collected repeatedly from the first study and solute concentrations analysed. Based on these values, dialysis parameters were calculated together with generation rates allowing for kinetic modelling of the effects of PD. In the second study, the general conditions of the rats were evaluated during a longer dialysis period. For rats with estimated glomerular filtration rate (GFR) 5-10% of normal (moderately uremic rats), five daily PD cycles kept the rats in good condition for 3 weeks. For highly uremic rats (GFR below 3% of normal), more extensive dialysis is needed to maintain homeostasis and our simulations show that a six daily and four nightly PD cycles should be needed to keep the rats in good condition. In conclusion, the PD system described in this study can be used for long-term studies of PD on uremic dialysis-dependent rats mimicking the human setting. To maintain whole body homeostasis of highly uremic rats, intense PD is needed during both day and night.

Peritoneal dialysis related non-infectious complications: Asingle-center experience over 20 years.

Non-infectious complications of peritoneal dialysis (NICPD) are common and could be an important cause of technical failure, especially in the early period of peritoneal dialysis (PD) initiation. NICPD are also center- and provider-dependent. This study aimed to investigate the frequency, etiology, and associated outcomes of NICPD in a single center over a period of 20 years. Data were retrospectively collected in 262 patients who were initiated on PD between April 2001 and April 2021. Inclusion criteria were age 18 years or older and a minimum follow-up period of 3 months. Patients were grouped according to the reason of NICPD: catheter-related, increased intra-abdominal pressure-related, metabolic, and other complications. There were 142 females and 120 males in the study, with a mean age of 44±16.9 years. The mean time on PD was 52.6±40 months. During the follow-up period, 185 (71%) patients experienced 382 NICPD episodes. 26 patients (9.9%) were switched to maintenance hemodialysis (HD) due to NICPD. Outflow failure was the most common NICPD (n=97). It was also the most common reason for catheter revision (n=23) and PD discontinuation (n=12). Catheter intervention was required in 32 patients (12.2%). Prior HD treatment and male gender were independent risk factors for NICPD and catheter-related complications (OR 2.076; p=0.037; OR: 1.797, p=0.042, respectively). Early-start PD was associated with a lower risk for NICPD development (OR: 0.393, p=0.013). In this select cohort of PD patients, we found that NICPD are common and outflow failure is the most common cause of NICPD. NICPD are associated with major complications requiring catheter removal or transfer to in-center HD. Early recognition and appropriate management of NICPD are essential to prolonging time on PD in end-stage renal disease patients.

BI28 Phaeohyphomycosis in the immunosuppressed patients: the challenges of treatment

Abstract Phaeohyphomycosis is a group of multisystem mycoses owed to heterogeneous organisms called ‘dematiaceous’ or ‘melanized’ fungi. The presence of melanin in their cell walls is a distinguishing feature, likely to be acting as a virulence factor. Widely abundant in the environment, these organisms commonly infect humans through traumatic inoculation and have many clinical forms of presentation, including cutaneous, subcutaneous, systemic, and rarely disseminated. Both immunocompetent and immunocompromised hosts are affected. Diagnosis of the cutaneous infection is primarily reliant on histology and culture; treatment is not standardized and is based on clinical experience. We report a case of a 39-year-old man who presented to the dermatology clinic with ‘lumps’ on his lower limbs. His background included poorly controlled hypertension and diabetes mellitus type 2 leading to nephropathy and necessitating a renal transplant, which failed. A 5-year period of dialysis involving a sedentary lifestyle was followed by a repeat renal transplant during which time he developed multiple warty-looking nodules of varying size, with pseudomilia cysts on his lower limbs in addition to stasis changes. Histology reported a pigmented mould infection (probably phaeohyphomycosis), and there was no growth on culture. The patient was trialled on two azole antifungals at different times, but on both occasions, he dived into congestive cardiac failure needing intensive care unit admissions. Reducing immunosuppression therapy was difficult considering his previous failed renal transplant. Owing to the extent and multiplicity of the lesions on the background of immunosuppression, the surgical treatment option poses significant risks. Currently, he is managed on topical treatment with some stabilization of the lesions; however, it is unclear how these will progress in the future. Although uncommon, the number of patients with phaeohyphomycosis has increased due to awareness of melanized fungi on a background of the global COVID-19 pandemic, with SARS-CoV-2, and the use of immunosuppressive agents such as glucocorticoid therapy increasing the risk of infections of deep mycosis. Treatment for phaeohyphomycosis has largely been surgical excision for localized lesions in addition to oral antifungals. Our case highlights that, in transplant patients, therapeutics are difficult, with life-threatening complications from oral antifungals and the risks of surgical intervention including ulceration, bleeding and infections. In addition, the cosmetic appearance of the prevalent noticeable lesions for a relatively young patient is also significant and patient counselling is vital, especially when treatment options are minimal.

#5450 EXTERNAL VALIDATION OF A RISK PREDICTION TOOL IN DETERMINING EARLY DEATH AMONG ELDERLY PATIENTS INITIATED ON DIALYSIS

Abstract Background and Aims The increase in the senior population is one of the factors that has been attributed to the rise in the number of dialysis patients in the Philippines. The elderly generally has an increased risk for poor dialysis-associated outcomes, and studies have been conflicting if they have better survival with initiation of dialysis as compared to conservative management. The decision-making process in this regard for clinicians, patients, and their families may be ameliorated by the Thamer Risk Scoring tool which uses simple variables such as age, albumin level, nursing home residence, need for assistance in daily living, cancer, heart failure, and hospitalization to predict early mortality in elderly patients after initiating dialysis [1]. This tool has not been validated in the Philippine setting, hence this study aimed to validate the prognostic property of the Thamer Risk Scoring tool in predicting early death among elderly patients initiated on dialysis in a tertiary institution, in Davao City, Philippines. Method A retrospective cohort research design was used. All the charts of patients diagnosed with end-stage renal disease aged 60 years and above, who were admitted and initiated on either hemodialysis or peritoneal dialysis within a 4-year period from 2018 to 2021 were reviewed. Patients with periods of dialysis lasting less than 90 days followed by recovery of kidney function, and patients with lacking data to meet all pre-requisite variables for the risk scoring were excluded. Results A review of 1,583 patient charts was done, with 1,402 omitted based on the exclusion criteria. A total of 181 patients were included in the study. Most of the patients were male (56.35%), and initiated on hemodialysis (97.24%). The mean age of the population was 67.34 years with majority in the 60–69 year age group (66.3%). Those who survived had a mean age of 66.53 years and those who expired had a mean age of 68.63 years. All-cause mortality was 38.12% at 3 months, and 3.57% at 6 months after dialysis initiation. The all-cause mortality at 3 months in this study was three times higher than the Thamer study with a mortality of 12.5%. Patients with heart failure (p-value = 0.007), cancer (p-value = 0.040), asthma (p-value = 0.040), and need for assistance in daily living (p-value = 0.022), had significantly higher mortality rates, while patients who had higher albumin (p-value = 0.010), and creatinine (p-value = 0.014) had higher survival rates. Similar to the Thamer study, this study also showed that the tool becomes less sensitive and more specific as the scores increased for the 3-month, 6-month, and over-all mortality groups. The accuracy of the tool rises with a higher score as well. In the Thamer study, their validation cohort had an area under the receiver operating characteristic curve (AUROC) = 0.691 for their risk scoring tool while this study showed an AUROC = 0.6245, 0.2847, and 0.5993 in the 3-month, 6-month, and over-all mortality groups respectively which does not show statistical strength. Conclusion Patients with older age, comorbidities such as heart failure, cancer, asthma, and those who need assistance in daily living had higher mortality rates. Despite the poor performance of the Thamer risk scoring tool in predicting mortality in terms of AUROC in this study, the sensitivity, and specificity had a similar performance in the Thamer study. Furthermore, the consistent trend of accuracy of predicting mortality in these groups reflect that a higher score portends to a higher accuracy in predicting mortality.

First Multicenter Clinical Trial on Machine Perfusion Preservation for Marginal Donor Kidney Transplantation in Japan

Machine perfusion has not been widely used because of its low demand in Japan; however, we believe its advantages may increase the number of organ transplants. Here, we report the first clinical trial of machine perfusion for kidney transplantation in Japan. We used the CMP-X08 perfusion device (Chuo-Seiko Co, Ltd, Asahikawa, Hokkaido, Japan) to preserve the donated organs. The flow rate, perfusion pressure, renal resistance, and temperature were monitored during continuous hypothermic perfusion. From August 2020 to the present, 13 cases of perfusion-preserved kidney transplantation have been performed. Of these, ten and 3 cases were performed using organs donated after brain death (DBD) and cardiac death (DCD), respectively. The average age of the recipients was 55.9 ± 7.3 (45-66) years. The average dialysis period was 14.8 ± 8.4 (0-26) years. The donor's final creatinine level before organ retrieval was 1.58 ± 1.0 (0.46-3.07) mg/dL. The warm ischemic times of the 3 DCD donors were 3, 12, and 18 minutes. The average total ischemic time was 12.0 ± 3.7 (7.17-19.88) hours. The average MP time was 140 (60-240) minutes. A total of 7 cases had delayed graft function. The best creatinine level during hospitalization was 1.17 ± 0.43 (0.71-1.85) mg/dL. There were no primary non-functional cases, and perfusion preservation was safely performed in all cases. Therefore, we present this report as the first clinical trial on machine perfusion for kidney transplantation from marginal donors with DBD and DCD in Japan.

The benefit of planned dialysis to early survival on hemodialysis versus peritoneal dialysis: a nationwide prospective multicenter study in Korea

Optimal preparation is recommended for patients with advanced chronic kidney disease to minimize complications during dialysis initiation. This study evaluated the effects of planned dialysis initiation on survival in patients undergoing incident hemodialysis and peritoneal dialysis. Patients newly diagnosed with end-stage kidney disease who started dialysis were enrolled in a multicenter prospective cohort study in Korea. Planned dialysis was defined as dialysis therapy initiated with permanent access and maintenance of the initial dialysis modality. A total of 2892 patients were followed up for a mean duration of 71.9 ± 36.7 months and 1280 (44.3%) patients initiated planned dialysis. The planned dialysis group showed lower mortality than the unplanned dialysis group during the 1st and 2nd years after dialysis initiation (1st year: adjusted hazard ratio [aHR] 0.51; 95% confidence interval [CI] 0.37–0.72; P < 0.001; 2nd year: aHR 0.71; 95% CI 0.52–0.98, P = 0.037). However, 2 years after dialysis initiation, mortality did not differ between the groups. Planned dialysis showed a better early survival rate in hemodialysis patients, but not in peritoneal dialysis patients. Particularly, infection-related mortality was reduced only in patients undergoing hemodialysis with planned dialysis initiation. Planned dialysis has survival benefits over unplanned dialysis in the first 2 years after dialysis initiation, especially in patients undergoing hemodialysis. It improved infection-related mortality during the early dialysis period.

Impact of anemia treatment for left ventricular hypertrophy using long-acting erythropoietin-stimulating agents from the pre-dialysis to maintenance dialysis period in patients with chronic kidney disease, retrospective longitudinal cohort study

BackgroundAnemia in patients with chronic kidney disease (p-CKDs) may initiate or exacerbate left ventricular hypertrophy (LVH). This study aimed to determine whether treatment using long-acting erythropoietin-stimulating agents (L-ESAs) is independently associated with LVH during the pre-dialysis to maintenance dialysis period in p-CKDs.MethodsPhysical and laboratory examinations were performed 120 days before initiating dialysis in p-CKDs (baseline). To evaluate the left ventricular mass index (LVMI) after starting dialysis, the mean hemoglobin (Hb) was defined as the average at the start of dialysis and 6 months after starting dialysis. Changes in the LVMI were observed in three groups according to mean Hb levels (Hb < 10.1, 10.1 < Hb < 11.0, and Hb > 11.0 g/dL for Groups 1, 2, and 3, respectively). LVMI was evaluated using echocardiography at the pre-dialysis, initiation, and maintenance dialysis periods.ResultsA lower LVMI at dialysis initiation and an improvement in LVMI were detected in the highest tertile group of mean Hb (11.0 g/dl). Consequently, in the high Hb group (Hb level > 11.0 g/dl), LVMI remained low from dialysis initiation until after 6 months.The relationship between Hb and LVMI was not significant; however, a constant correlation with β ≥ 0.4 in the absolute value was maintained.ConclusionL-ESAs may correlate with Hb and LVMI after administration, independent of the baseline LVMI and Hb values. These findings have therapeutic implications in the treatment strategies for p-CKDs during the pre-dialysis to maintenance dialysis period.

The Impact of Medical Nutrition Intervention on the Management of Hyperphosphatemia in Hemodialysis Patients with Stage 5 Chronic Kidney Disease: A Case Series

The treatment and interdisciplinary management of patients with chronic kidney disease (CKD) continue to improve long-term outcomes. The medical nutrition intervention's role is to establish a healthy diet plan for kidney protection, reach blood pressure and blood glucose goals, and prevent or delay health problems caused by kidney disease. Our study aims to report the effects of medical nutrition therapy-substituting foods rich in phosphorus-containing additives with ones low in phosphates content on phosphatemia and phosphate binders drug prescription in stage 5 CKD patients with hemodialysis. Thus, 18 adults with high phosphatemia levels (over 5.5 mg/dL) were monitored at a single center. Everyone received standard personalized diets to replace processed foods with phosphorus additives according to their comorbidities and treatment with prosphate binder drugs. Clinical laboratory data, including dialysis protocol, calcemia, and phosphatemia, were evaluated at the beginning of the study, after 30 and 60 days. A food survey was assessed at baseline and after 60 days. The results did not show significant differences between serum phosphate levels between the first and second measurements; thus, the phosphate binders' initial doses did not change. After 2 months, phosphate levels decreased considerably (from 7.322 mg/dL to 5.368 mg/dL); therefore, phosphate binder doses were diminished. In conclusion, medical nutrition intervention in patients with hemodialysis significantly reduced serum phosphate concentrations after 60 days. Restricting the intake of processed foods containing phosphorus additives-in particularized diets adapted to each patient's comorbidities-and receiving phosphate binders represented substantial steps to decrease phosphatemia levels. The best results were significantly associated with life expectancy; at the same time, they showed a negative correlation with the dialysis period and participants' age.

Long-term outcomes of spine surgery in dialysis patients, focusing on activities of daily living, life expectancy, and the risk factors for postoperative mortality

BackgroundBecause of the high incidence of major perioperative adverse events, spine surgery in dialysis patients should be recommended carefully after consideration of its risks and benefits. However, the benefits of spine surgery in dialysis patients remain unclear because of the lack of long-term outcomes. The purpose of this study is to elucidate the long-term outcomes of spine surgery in dialysis patients, focusing on activities of daily living (ADLs), life expectancy, and risk factors for postoperative mortality. MethodsData for 65 dialysis patients who underwent spine surgery at our institution and were followed up for a mean duration of 6.2 years were retrospectively reviewed. ADLs, number of surgeries, and survival times were recorded. The postoperative survival rate was calculated using the Kaplan-Meier method, and risk factors for postoperative mortality were investigated using a generalized Wilcoxon test and multivariate Cox proportional-hazards model. ResultsCompared with preoperative ADLs, ADLs significantly improved at discharge after surgery and at the final follow-up. However, 16 of the 65 patients (24.6%) underwent multiple surgeries, and 34 (52.3%) died during the follow-up period. Kaplan-Meier analysis revealed that the survival rate after spine surgery was 95.4% at 1 year, 86.2% at 3 years, 69.6% at 5 years, 59.7% at 7 years, and 28.7% at 10 years, and the overall median survival time was 99 months. Multivariate Cox regression analysis showed that a dialysis period of ≥10 years was a significant risk factor. ConclusionsSpine surgery in dialysis patients improved and maintained ADLs in the long term and did not shorten life expectancy. However, dialysis patients undergoing spine surgery require multiple surgeries more frequently, and a dialysis period of ≥10 years is a significant risk factor for postoperative mortality.

Comparison of mortality according to baseline, first year, and mean albumin levels in peritoneal dialysis: a retrospective study

Background The relationship between hypoalbuminemia in peritoneal dialysis (PD) and mortality, risk of peritonitis, and decreased residual renal function (RRF) is known. However, we have not encountered a comprehensive study on which of the mean albumin values, at the beginning of peritoneal dialysis, in the first year, and during the peritoneal dialysis period, provide more predictive predictions regarding mortality, peritonitis risk, and RRF reduction. Methods A total of 407 PD patients in whom PD was initiated and followed up and PD was terminated were included in the study. Albumin levels, peritonitis, and RRF at the beginning of PD and at 3-month periods during PD were recorded. Results In the evaluation of the patients, there was a significant relationship between mean, first-year albumin values in RRF loss (p = 0.001, p = 0.006, respectively) and peritonitis (p < 0.001), but no significant correlation was found with baseline albumin values (p = 0.213, p = 0.137, respectively). In the comparison of mortality ROC analysis of PD patients, a significant correlation was found with mortality at baseline, first year, and mean albumin values (p < 0.001). However, in the multivariate Cox regression analysis, it was determined that there was a more significant relationship between first-year albumin and mean albumin values compared to baseline albumin values (HR 0.918 [95% CI 0.302–0.528] (p < 0.001)), (HR 1.161 [95% CI 0.229–0.429] (p < 0.001)), (HR 0.081 [95% CI 0.718–1.184] (p = 0.525)). Conclusions In conclusion, mean and first-year mean albumin levels provide more determinative predictions for mortality, risk of peritonitis, and maintenance of residual renal functions in peritoneal dialysis patients compared to baseline albumin.

Pitavastatin Compared with Differential Intervention Trial by Standard Therapy on Cardiovascular Events in Patients with Dyslipidemia on Chronic Hemodialysis (DIALYSIS): A Randomized Controlled Trial

Introduction: Statin has been reported to reduce cardiovascular events. However, the comparative efficacy of statin with standard therapy on cardiovascular events has not been sufficiently reported in patients on chronic hemodialysis. Thus, this study aimed to compare the effects of pitavastatin and standard therapy on mortality and cardiovascular events in chronic hemodialysis patients with dyslipidemia in Japan. Methods: Patients on chronic hemodialysis with dyslipidemia were randomized into pitavastatin-administered (pitavastatin group) or dietary therapy as standard therapy (control) group. Primary outcomes are all-cause mortality and myocardial infarction; secondary outcomes are cardiac arrest and fatal myocardial infarction. The composite outcomes included the incidence of coronary intervention, stroke, fracture, and hospitalization due to heart failure and unstable angina. The clinical outcome analyses used a logistic regression model to categorize the variables. A p value of <0.05 was considered statistically significant. Results: This study included 848 patients (422 in the control group and 426 in the pitavastatin group) from 79 health facilities. The mean age of the patients was 60.1±10.3 years, and the dialysis period was 7.2±7.6 years. The mean observation period was 36.5 months. The low-density lipoprotein cholesterol level was significantly lower than the baseline value in the pitavastatin group after 12 months of trial (79.8±26.1 vs. 107.8±25.5 mg/dL, p < 0.001). Moreover, the total number of deaths was 85, of which 50 occurred in the control group and 35 in the pitavastatin group. In an analysis adjusted for confounding factors due to participant attributes, there was a significant difference between the control group and the pitavastatin group in the primary and composite endpoints (p = 0.007 and p = 0.022, respectively). Conclusion: Our study has demonstrated that aggressive intervention with pitavastatin is more effective than the standard (dietary) therapy for improving the clinical outcomes in patients with dyslipidemia on chronic hemodialysis.

PS-C19-9: CLINICAL EFFECTS OF ARNI (SACUBITRIL/VALSARTAN) IN PATIENTS WITH CHRONIC KIDNEY DISEASE WITH HYPERTENSION

Purpose: ARNI (Sacubitril / Valsartan) is known to have natriuretic effects in addition to vasodilatory effects, cardiac hypertrophy, and antifibrosis. Therefore, it is considered to have a great effect on blood pressure and is used as an antihypertensive drug. However, the details of improvement of blood pressure changes in CKD patients are clearly unknown. Here we examine the clinical effects of ARNI administration in CKD patients by stage of renal function. Subject and Method: 41 CKD patients who started enresting for hypertension from September 27, 2021 to February 28, 2022, and 26 of them were able to follow up for a period of 3 months or more after oral administration. Patient profiles by renal function are 9 persons stage G3 (eGFR30–59), 4 persons stage G4 (eGFR15–29), 9 persons stage G5 (less than eGFR15), 3 persons stage G5D (during dialysis) PD, and 1 person HD + PD. Blood Pressure, eGFR, protein quantification, and NT-proBNP are measured before and after administration for a period of 3 months or more, and analysis was performed by two-way ANOVA with a mixed model using SPSS. In addition, ABPM was performed before and after ARNI administration in 9 of them (6 treatment-resistant hypertension), and the diurnal variation pattern, changes in proteinuria and renal function were also examined. Result: Before and after ARNI administration, blood pressure decreased and edema improved in most patients. There was no interaction with the rate of decrease in GFR (significance probability 0.972). In addition, urinary protein increased to 1.57 g/gCre (mean difference 95% confidence interval 0.175–2.966, significance probability 0.006 interaction). NT-proBNP decreased before and after administration. In stage G3, the dipper type of ABPM did not change, and the non-dipper type improved slightly. In stage G5 it was improved the degree of descent at night, and a change in category. However, in the case of peritoneal dialysis, the mean blood pressure did not improve, and the effect of pattern improvement was not observed. Discussion / Conclusion: ARNI was found to exert a strong antihypertensive effect on CKD patients that has not been treated with dialysis. And ARNI did not affect the antihypertensive effect even if there is residual urine during the dialysis period. In addition, edema can be expected to have a reducing effect regardless of proteinuria, and if blood pressure can be lowered firmly, it can also be expected to have a reducing effect on proteinuria.

Effect of Haemodialysis on Serum Magnesium Level in Patients with Chronic Renal Failure: A Cross-sectional Study

Introduction: The dialysate Magnesium (Mg) concentration is the primary determinant of serum Mg levels in individuals on maintenance haemodialysis. A stable dialysate Mg content of 0.5 mmol/L is currently recommended. An alteration in this concentration can lead to altered serum magnesium levels. Few studies indicate that dialysate Mg concentration needs to be altered for maintenance of stable serum magnesium level. Aim: To compare pre and postdialysis serum magnesium levels in patients with chronic renal failure and the effect of drug intake and duration of dialysis on serum magnesium levels. Materials and Methods: This prospective observational cross- sectional study was conducted in a tertiary care hospital of Coimbatore, Tamil Nadu, India, for a period of three months, from June 2021 to August 2021. The predialysis and postdialysis serum magnesium levels of 100 chronic renal failure patients undergoing maintenance haemodialysis were measured. Parameters such as dialysis period, predialysis weight, predialysis routine blood chemistry variables (estimated glomerular filtration rate, serum urea, serum creatinine, serum sodium, serum potassium and serum calcium, serum phosphate measurements) history of diabetes, history of hypertension and history of medications, were assessed for all the patients. Statistical analysis of the data were done using Analysis Of Variance (ANOVA), Students’ t-test and Pearson’s correlation coefficient. Results: Total 71% of the study population were males and 29% were females. The mean age of the study population was found to be 51.34 years. The mean predialysis serum magnesium levels was 2.28±0.48 mg/dL. The mean postdialysis serum magnesium level was 1.69±0.52 mg/dL. Total 2% of the chronic renal failure patients had hypomagnesemia before dialysis, while 27% of the patients developed hypomagnesemia after dialysis. There was significant difference between pre and postdialysis Mg levels, p&lt;0.001. There was no significant correlation between pre and postdialysis magnesium levels and drug intake. Patients undergoing dialysis for more than 300 days had a significantly decreased serum magnesium levels than those undergoing dialysis for less than 90 days. Conclusion: The risk of hypomagnesemia is definite in patients undergoing dialysis. Uniformity of dialysis fluids for all patients may not be advisable. Dialysate should be titrated in individual patients according to the predialysis serum magnesium levels.

혈액투석 환자의 악력, 혈압, 투석적절도, 투석증상 및 우울 간의 관계

Purpose: This study aimed to determine relationships among handgrip strength (HGS), blood pressure, dialysis adequacy, dialysis symptoms, and depression in hemodialysis patients. Methods: Data from 150 subjects were obtained and analyzed, following a descriptive approach. Results: The average grip strength of the subjects was lower than the standard value for both men and women, and the grip strength differed significantly according to age, gender, education level, monthly income, and BMI. The physiological indicators that showed significant results with the study variables were hemoglobin, serum calcium, and serum phosphorus. The average dialysis adequacy (Kt/V) of the subjects was higher than the normal standard, and there were significant differences according to age, gender, education level, monthly income, dialysis period, number of accompanying diseases, and BMI. The subject’s depression score had a significant negative correlation with dialysis adequacy, and the dialysis symptom score and depression score had a significant positive correlation. Conclusion: General characteristics, dialysis-related characteristics, and physiological indicators of hemodialysis patients were analyzed in detail, and differences between these characteristics and grip strength, blood pressure, dialysis adequacy, dialysis symptoms, and depression were also examined. It is necessary to provide delicate nursing according to the individual characteristics of the patient.

Renal Cell Carcinomas in Patients on Chronic Dialysis

Patients on chronic dialysis for end-stage renal disease (ESRD) show an increased incidence of renal cell carcinoma (RCC). We investigated the clinicopathological characteristics and outcomes of 54 patients who underwent nephrectomy for RCC due to ESRD between 1992 and 2019. The patients consisted of 44 men and 10 women, with a median age of 62.9 years. The median duration of dialysis before surgery was 12.9 years. The clinical stage of the 54 RCCs was stage I in 44, stage II in 1, stage III in 1, and stage IV in 8. With a median follow-up of 5.1 years after surgery, the 5-year cancer-specific and overall survival rates were 84.3 and 61.8%, respectively. Patients with symptomatic RCC had a longer period of dialysis, presented with larger tumors of higher grade and stage, and had worse prognosis compared with those with incidentally discovered RCC. Cox proportional hazards analysis performed with clinicopathological features and symptomatic/incidental detection showed that older age and symptomatic RCC were independently associated with worse overall survival. Our data show that early detection is important for a good prognosis.

Chinese Clinical Practice Guideline for the Management of “CKD-PeriDialysis”-the Periods Prior to and in the Early-Stage of Initial Dialysis

The National Experts Group on Nephrology have developed these guidelines to improve the management of pre-dialysis and initial dialysis patients with chronic kidney disease (CKD) (two periods contiguous with dialysis initiation termed here 'PeriDialysis CKD'). The pre-dialysis period is variable, whereas the initial dialysis period is more fixed at 3 months to 6 months after initiating dialysis. The new concept and characteristics of 'CKD-PeriDialysis' are proposed in the guideline. During the CKD-PeriDialysis period, the incidence rate of complications, mortality and treatment cost significantly increases and the glomerular filtration rate (GFR) rapidly decreases, which requires intensive management. The guideline systematically and comprehensively elaborates the recommendations for indicators to be used in for disease evaluation, timing and mode selection of renal replacement therapy, dialysis adequacy evaluation, and diagnosis and treatment of common PeriDialysis complications. Finally, future research directions of CKD-PeriDialysis are proposed. CKD-PeriDialysis management is a difficult clinical issue in kidney disease, and the development and implementation of these guidelines is important to improve the management of CKD-PeriDialysis patients in China, which could ultimately improve survival rates and quality of life, and reduce the medical burden.