Predialysis Period Research Articles

Experience of Patients and Caregivers During the Predialysis Period: A Thematic Analysis

Experience of Patients and Caregivers During the Predialysis Period: A Thematic Analysis

Cardiopulmonary Response to Acute Exercise before Hemodialysis: A Pilot Study.

Disparities in physical fitness between immediately before dialysis (pre-D) and the day following dialysis (non-D) have not been investigated despite potential adverse factors such as fluid status, uremia, and electrolyte levels in the pre-dialysis period. The effect of acute exercise immediately before hemodialysis (HD) on HD-related hypotension remains unclear. We hypothesized that cardiopulmonary performance and muscular strength would be inferior in the immediate pre-D period compared to those non-D. Twenty patients receiving chronic HD treatments underwent symptom-limited incremental cardiopulmonary exercise testing (CPET) and isokinetic testing both 1-2 h prior to dialysis (pre-D) and non-D. This investigation was a sub-study of a clinical trial assessing the efficacy of a pre-D exercise training program. Blood pressure profiles during HD post-CPET and pre-D exercise training were compared with those during usual HD sessions. No adverse events were observed during the 80 exercise tests. Prior to dialysis, the nadir of the ventilatory equivalent of CO2 was slightly elevated, the resting heart rate was lower, and the peak systolic blood pressure was higher than those non-D. Contrary to our hypothesis, peak <inline-formula><mml:math id="m1" xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:mrow><mml:mover accent="true"><mml:mi mathvariant="normal">V</mml:mi><mml:mo>˙</mml:mo></mml:mover><mml:msub><mml:mi mathvariant="normal">O</mml:mi><mml:mn>2</mml:mn></mml:msub></mml:mrow></mml:math></inline-formula> and quadriceps peak torque showed no differences. Blood pressure profiles during HD post-exercise were similar to those during sessions without prior exercise, except for a lower resting systolic blood pressure at the beginning of HD. Cardiopulmonary response and muscular strength in the 1-2 h prior to HD were comparable with those on the day following HD, with only minor clinically insignificant differences. Acute exercise prior to HD did not affect the magnitude of hypotension during HD. This study suggests a potential alternative timing for exercise training or testing in patients undergoing chronic HD.

#1694 The Cl-/HCO3-ratio as a predictor of decompensated metabolic acidosis in CKD stages G4 and G5

Abstract Background and Aims Metabolic acidosis (MA) is a common disorder in patients with chronic kidney disease (CKD) and is associated with both a normal anion gap (AGMA) and a high anion gap (HAGMA). AGMA is typically detected early in the course of CKD, whereas HAGMA appears later in the course of CKD due to the accumulation of non-chloride anions such as phosphate, sulphate, and an array of organic acids. The anion gap (AG) is usually calculated as the difference between serum concentration of cations and anions using the formula AG=Na+-(Cl−+HCO3−). The most important anions in serum are chlorides (Cl−) and bicarbonates (HCO3−). The more advanced the CKD, the higher the AG. As eGFR decreases, a reciprocal decrease in HCO3− and an increase in chloride concentration is observed to correct the AG. The aim of this study is to determine whether the Cl−/HCO3− ratio can be used to predict decompensated metabolic acidosis with pH decline in CKD stages G4 and G5. Method A total of 115 patients (median age 63 ± 17 years), with CKD stage G4 or G5 were enrolled in this cross-sectional study. Demographic and comorbidity data was obtained from medical records, and the Charlson Comorbid Index (CCI) was calculated. A two-year clinical follow-up was conducted to assess the clinical status of each patient. The number of patients, the time dialysis was started, and deaths were all recorded. All patients were qualified for arteriovenous fistula creation in predialysis period. The arterial (A) and venous (V) blood samples were taken during surgery, directly after vessel dissection, and evaluated in a point of care testing analyzer (POCT). The ratio of arterial Cl− and HCO3− concentration were calculated. According to mean arterial pH (pH-A) the group was divided into Group A pH-A&amp;lt;7.33 and Group B pH-A≥7.33 (Table 1). Results In Group A was significantly lower pH-A, pH-V, HCO3−-A, HCO3−-V, pCO2-A, pCO2-V, and significantly higher both arterial and venous Cl− and the Cl−/HCO3− ratios compared to Group B. No such differences were observed in the case of AG. Cl−/HCO3−-A ratio negatively correlated with pH (r = −0.77, p &amp;lt; 0.01) (Fig. 1A). The discriminative power of Cl−/HCO3−-A ratio for predicting pH-A≤7.33 was 0.917 (95% confidence interval [CI] = 0.87–0.97; p &amp;lt; 0.01) which provided 87% sensitivity and 84% specificity (Fig. 1B). The best cut-off was 6.22 (mmol/l)/(mmol/l). Conclusion The Cl−/HCO3− ratio lower than 6.22 (mmol/l)/(mmol/l) may be used as predictor of decompensated metabolic acidosis.

Indices of Nutrition Status of Kidney and Pancreas Transplant Candidates

Nutritional assessment is used to implement early nutritional interventions and reduce complications associated with malnutrition, which plays a crucial role in improving postoperative outcomes for patients undergoing pancreas and/or kidney transplantation. ObjectiveThe aim of this study was to analyze the nutritional status (NS) in patients eligible for kidney transplantation (KTx) and simultaneous kidney-pancreas transplantation (SPKTx). MethodsWe analyzed the database of hospitalized patients from 2020 to 2023 to identify preoperative parameters of NS in patients eligible for KTx and SPKTx. A total of 59 patients participated in the study, all of whom were candidates for KTx-23 or SPKTx-36. The study population consisted of 35 women (W) and 24 men (M), with an overall mean age of 44.8 ± 10.2 years (43.5 ± 10.2 years for W and 46.2 ± 10.9 years for M). Both groups included patients on hemodialysis (n = 34) and peritoneal dialysis (n = 12), and patients in the predialysis period (pre-emptive, n = 13). The examined parameters included Onodera's prognostic nutritional index (PNIO), the nutritional risk index (NRI), proper body mass calculated using the Lorenz formula, and the neutrophil-to-lymphocyte ratio (NLR). All patients were assessed according to the NRS 2002 scale. ResultsAnalysis of the obtained results revealed that the NLR was only one differentiating parameter between Ktx and SPKtx group. Multivariate analysis adjusted for patients’ age and gender, comparing quantitative NS indicators was performed. Albumin serum concentration was not dependent on patients’ group (KTx/SPKTx) neither age nor gender P = .382. BMI was dependent on patients’ age and gender, but not a group (KTx/SPKTx) P = .008. PNIO, NRI, and NRL were not dependent on patients’ group (KTx/SPKTx) neither age nor gender. ConclusionsAdditional effort should be devoted to the development of a proper nutrition plan for SPKTx a especially in peritoneal dialysis patients. Toward patients on the waiting list, the regular assessment of nutritional status should be performed which is not a rule in dialysis centers. SPKTx candidates in the perioperative period should receive proper nutrition taking into account their caloric and protein needs.

Symptom Trajectories in the Electronic Health Record during the Transition to Maintenance Dialysis.

How symptoms recorded in the electronic health record change during the transition to dialysis has not been fully explored. We used the Optum deidentified Integrated Claims-Clinical dataset to identify individuals with CKD stages 4 or 5 who transitioned to dialysis. We searched structured data elements from clinical notes, identified by natural language processing, for symptoms recorded across weekly intervals in the 6 months before and after dialysis initiation and estimated changes in the odds of a symptom being recorded with an interrupted time series analysis using segmented logistic regression. The cohort comprised 728 individuals (aged 68±13 years, 44% women, 56% White, 30% Black). Before dialysis initiation, 83% were recorded as having pain, 68% fatigue/weakness, 66% shortness of breath, 61% nausea/vomiting, and 37% difficulty concentrating. Before dialysis initiation, odds of pain being recorded increased (slope: odds ratio [OR] 1.02 per week, 95% confidence interval [CI], 1.01 to 1.03); initiation was associated with a decrease (intercept change: OR 0.70, 95% CI, 0.59 to 0.82). After initiation, odds of pain were unchanged (postdialysis slope: OR 1.00 per week, 95% CI, 0.99 to 1.01), although this represented an improved trajectory relative to the predialysis period (change in slope: OR 0.98 per week, 95% CI, 0.96 to 0.99). For fatigue/weakness, odds increased before initiation (OR 1.03 per week, 95% CI, 1.02 to 1.04) but decreased on initiation (OR 0.62, 95% CI, 0.51 to 0.75) and thereafter (OR 0.98 per week, 95% CI, 0.97 to 0.99), representing a reduction in slope (OR 0.95 per week, 95% CI, 0.94 to 0.97). Patterns for shortness of breath, nausea/vomiting, and difficulty concentrating were similar to those of pain. Thus, the odds of five key symptoms being recorded in the electronic health record increased over time in the 6 months before dialysis initiation, decreased immediately on initiation, and, generally, remained unchanged in the 6 months thereafter.

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.

Serum Erythropoietin in Patients with Chronic Renal Failure in the Predialysis Stage

Summary A prospective study was carried out of serum erythropoietin levels in patients with chronic renal failure/chronic kidney disease in the predialysis period. The study is part of scientific project № 2/2022, financed by Medical University-Pleven. Fifty patients were tested – 22 males and 28 females (average age 63.7±13.0), with average serum creatinine 253±127 mcmol/l and average glomerular filtration rate of 22.6±11.8 ml/min/1,72 m2. The results showed that the serum erythropoietin level varied from 1.86 to 48.50 U/l and was below the borderline in only three patients. There were no significant differences between serum erythropoietin and haemoglobin values in both genders. No differences were found between the average haemoglobin values of patients with different values of serum erythropoietin. Non-significant differences were found in the values of serum erythropoietin in patients with different haemoglobin values. A statistically significant difference between the average value of serum erythropoietin was seen in the group of patients who were not undergoing treatment for anaemia with recombinant erythropoietin (8.5±5.9 U/l) and the groups treated with a dose above 3000 UI/weakly (from 18.6±11.3 to 19.7±8.8 U/l).

Anemia and Left Ventricular Hypertrophy in Chronic Renal Failure

Summary Chronic renal failure (CRF) syndrome significantly alters patients’ quality of life. Anaemia, hypertension, and cardiovascular diseases are common complications of CRF. The study aimed to determine the incidence of arterial hypertension (AH), anaemia, and left ventricular hypertrophy (LVH) in patients with CRF and to analyze the relationship between them. The study included 212 patients with CRF, treated at the Clinic of Nephrology and Dialysis at the University Hospital “Dr. G. Stranski,” Pleven, during 2008-2020. The AH accounted for 88.2% of the patients with CRF. The incidence of AH is comparable to that in patients in the predialysis period – 88.6% and among patients on dialysis – 87.9%. LVH was diagnosed in 94.3% of patients with CRF. The incidence of LVH in the predialysis period was 94.3%, and among dialysis patients -94.4%. The incidence of LVH among hypertensive and normotensive patients was comparable. The incidence of anaemia among patients with CRF was 86.3%. Anaemia was present in 94.4% of the patients on dialysis and in 78.1% of the patients in the predialysis period. The difference was significant (p &lt;0.05). There was no correlation between anaemia and AH, nor between AH and LVH. A significant dependence of LVH on the duration of chronic renal failure and dialysis treatment was established.

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.

How to determine the prognosis of renal function in CKD?

The presented material raises the most important question in practical nephrology – how to correctly assess kidney function to understand the prognosis and duration of the predialysis period in a particular patient with chronic kidney disease (CKD)? From the standpoint of onto- and phylogenesis, the hierarchy of kidney functions was assessed. It is noted that the existing approaches to such an assessment are convenient for practice, but do not sufficiently take into account individual characteristics and are devoid of a load component that can show kidney reserves. The authors focused on the functional renal reserve (FRR) and the possibility of its detection. The above technique with 0.45 % saline allows revealing the true functional capabilities of the kidneys and understanding the patient's capabilities in the pre-dialysis period. Conclusions are drawn about the convenient use of the KDIGO scale, a more individual approach when using the QxMD calculator, and the possibility of a personalized approach when assessing the FRR.

A new technique for the detection of dry weight in hemodialysis patients: Estimated pulmonary capillary wedge pressure. A tissue Doppler imaging study

Background and objectiveFluid overload is an important factor of morbidity and mortality in hemodialysis patients. Today correct determination of dry weight (DW) remains an important issue of hemodialysis practice. Within this context, it is subjected to new method searching. The objective of this study was to calculate estimated pulmonary capillary wedge pressure (ePCWP) with Tissue Doppler Imaging (TDI) in hemodialysis patients and to evaluate its correlation with the other volume markers and to evaluate whether it can be a new method for detection of DW. Materials and methodsEchocardiographic, hemodynamic, and biochemical volume markers of 41 hemodialysis patients were evaluated in the pre- and post-dialysis periods. Patients were divided into two groups based on ePCWP values (Group 1 ePCWP<20mmHg, Group 2 ePCWP>20mmHg). ResultsIn the pre-dialysis period; parameters related to volume load including ePCWP, systolic blood pressure, mean arterial pressure, pulse pressure, left atrial diameter, left atrial volume, E/é, ratio and E/Vp ratio were statistically significantly higher in Group2 compared to Group1. On the other hand, strong correlations were found between pre-dialysis ePCWP and systolic blood pressure, mean arterial pressure, pulse pressure, NT-ProBNP, left atrial diameter, E/é ratio and E/Vp ratio. ConclusionsStrong correlations found between ePCWP which was calculated with TDI and the other volume markers both in pre-dialysis and post-dialysis periods. These findings can provide a significant contribution to routine evaluating of DW in hemodialysis patients. From this aspect, the prediction of ePCWP with TDI can be a new practical and reproducible method for the determination of DW.

The dynamics of the general practitioner-nephrologist collaboration for the management of patients with chronic kidney disease before and after dialysis initiation: a mixed-methods study.

Background:Effective collaboration between general practitioners (GP) and nephrologists is crucial in CKD care. We aimed to analyse GPs’ and nephrologists’ presence and involvement in CKD care and assess how they intertwine to shape patients’ trajectories.Methods:We conducted a mixed-methods study that included all patients with CKD who started dialysis in France in 2015 (the REIN registry) and a sample of nephrologists and GPs. We quantified professionals’ presence through patients’ reimbursed healthcare from the French National Health Data System, 2 years before and 1 year after dialysis start. Involvement in CKD care was derived from the nephrologists’ and GPs’ interviews.Results:Among 8856 patients included, nephrologists’ presence progressively increased from 29% to 67% of patients with a contact during the 2 years before dialysis start. However, this was partly dependent on the GPs’ referral practices. Interviews revealed that GPs initially controlled the therapeutic strategy on their own. Although unease grew with CKD’s management complexity, reducing their involvement in favour of nephrologists, GPs’ presence remained frequent throughout the pre-dialysis period. Upon dialysis start, nephrologists’ presence and involvement became total, while GPs’ greatly decreased (48% of patients with a contact at month 12 after dialysis start). Collaboration was smooth when GPs maintained contact with patients and could contribute to their care through aspects of their specialty they valued.Conclusions:This mixed-methods study shows presences and forms of involvement of GPs and nephrologists in CKD care adjusting along the course of CKD and unveils the mechanisms at play in their collaboration.

Nutritional Status, Selected Nutrients Intake and Their Relationship with the Concentration of Ghrelin and Adiponectin in Patients with Diabetic Nephropathy.

Background: Overnutrition is one of the risk factors of chronic kidney disease (CKD). The factors related to both obesity and CKD are adiponectin and ghrelin. The aim of the study was to assess if there is a link of nutritional status and selected nutrients intake with adiponectin and ghrelin in patients with diabetic nephropathy (DN). Methods: The study involved 55 patients diagnosed with DN in the pre-dialysis period (two groups: GFR < 30 and >30 mL/min/1.73 m2). In all participants standard blood tests, total ghrelin and total adiponectin plasma concentrations and anthropometric measurements (BMI, WHR- waist–hip ratio, body composition analysis) were performed. The evaluation of energy and nutrient intakes was made using the three-day food record method. Results: Excessive body weight was found in 92.80% patients. The average daily energy intake was 1979.67 kcal/day (14.45% protein energy, 28.86% fat, and carbohydrates 56.89%). In the group with eGFR < 30 mL/min/1.73 m2 the analysis showed a negative relationship between ghrelin and WHR value, and the creatine and albumin concentrations. There was a positive correlation between ghrelin concentration and the consumption of carbohydrates and sucrose. In the group of patients with eGFR > 30 mL/min/1.73 m2, a positive correlation was found between the concentration of ghrelin and the consumption of vegetable protein, carbohydrates, and glucose. Conclusions: The study confirms the high prevalence of obesity in patients with DN-Excessive supply of protein was found in the patients’ diets, which may contribute to the deterioration of the course of the disease and its prognosis. In patients with eGFR < 30 there was a negative correlation between ghrelin concentration and nutritional status, and in patents with eGFR > 30 between ghrelin concentration and some nutrients intake.

Cognitive disorders in patients with chronic kidney disease in pre-dialysis period

Objective: to study the cognitive status of patients in the pre-dialysis period depending on the stage of chronic kidney disease (CKD) and the category of cardiovascular risk (CVR). Materials and Methods. We examined 98 patients with CKD in the pre-dialysis period (mean age 47.1±11.2 years). The patients were divided into three groups according to the criteria of CVR stratification. Group 1 consisted of 32 patients with a low or moderate CVR, and CKD stage C1 or C2; Group 2 included 34 patients with a high CVR and CKD stage C3a or C3b; Group 3 comprised 32 patients with a very high CVR and CKD stage C4. We used the SAGE test (Self-Administered Gerocognitive Examination) to evaluate cognitive functions. Results. Cognitive impairment (CI) was detected in 57% of the patients: 37.5% in Group 1, 44.1% in Group 2, and 90.5% in Group 3. Dementia was diagnosed in 19% of patients with CI. A correlation was found between the severity of CI, the degree of decrease in glomerular filtration rate, and the education level of CKD patients in the pre-dialysis period (p≤0.001). We established that the examined subjects with CKD were characterized by memory, constructive, spatial and logical thinking disorders. Conclusion. Chronic kidney disease is an independent risk factor for the development of CI. The latter progressed with both CKD stage and the patient’s CVR category, and was detected in 37.5% of patients with a low or moderate CVR, 44.1% of patients with a high CVR, and 90.5% of patients with a very high CVR.

A new technique for the detection of dry weight in hemodialysis patients: Estimated pulmonary capillary wedge pressure. A tissue Doppler imaging study

Background and objectiveFluid overload is an important factor of morbidity and mortality in hemodialysis patients. Today correct determination of dry weight (DW) remains an important issue of hemodialysis practice. Within this context, it is subjected to new method searching. The objective of this study was to calculate estimated pulmonary capillary wedge pressure (ePCWP) with Tissue Doppler Imaging (TDI) in hemodialysis patients and to evaluate its correlation with the other volume markers and to evaluate whether it can be a new method for detection of DW. Materials and methodsEchocardiographic, hemodynamic, and biochemical volume markers of 41 hemodialysis patients were evaluated in the pre- and post-dialysis periods. Patients were divided into two groups based on ePCWP values (Group 1 ePCWP<20mmHg, Group 2 ePCWP>20mmHg). ResultsIn the pre-dialysis period; parameters related to volume load including ePCWP, systolic blood pressure, mean arterial pressure, pulse pressure, left atrial diameter, left atrial volume, E/é, ratio and E/Vp ratio were statistically significantly higher in Group2 compared to Group1. On the other hand, strong correlations were found between pre-dialysis ePCWP and systolic blood pressure, mean arterial pressure, pulse pressure, NT-ProBNP, left atrial diameter, E/é ratio and E/Vp ratio. ConclusionsStrong correlations found between ePCWP which was calculated with TDI and the other volume markers both in pre-dialysis and post-dialysis periods. These findings can provide a significant contribution to routine evaluating of DW in hemodialysis patients. From this aspect, the prediction of ePCWP with TDI can be a new practical and reproducible method for the determination of DW.

Preexisting comorbidities are associated with the mortality rate as well as the predialysis adverse events in incident dialysis patients.

BackgroundOptimal estimated glomerular filtration rate (eGFR) to start maintenance dialysis is controversial. Observational studies have reported that initiation of dialysis at high eGFRs is associated with worse postdialysis survival.MethodsWe retrospectively investigated 1,038 incident dialysis patients who started maintenance dialysis during 2010–2015. Patients were assessed for comorbidities and adverse events during the transitional period of dialysis initiation. Patients were classified as planned dialysis (PD) vs. unplanned dialysis (UD) according to indications for dialysis initiation.ResultsUD group comprised 352 patients (33.9%). Mean eGFR at dialysis initiation was higher in UD patients than PD patients (7.9 ± 5.1 vs. 5.9 ± 3.4 mL/min/1.73 m2, p < 0.001). Mean Davies comorbidity index in the UD group was higher (vs. PD group, 1.3 ± 1.0 vs. 0.9 ± 1.0, p < 0.001). Patients with more comorbidities experienced more ischemic heart disease (hazard ratio [HR], 4.36; 95% confidence interval [CI], 1.71–11.14) in the medium-risk group and HR of 8.84 (95% CI, 3.06–25.55) in the high-risk group (vs. low-risk group, p < 0.001)) during the predialysis period. High-risk group had increased postdialysis mortality (HR, 2.48; 95% CI, 1.46–4.20; p = 0.001). Adjusted HR of mortality was higher in the medium-risk group of UD patients (HR, 1.72; 95% CI, 1.16–2.56; p = 0.007).ConclusionPatients with more comorbidities were at increased risk of predialysis ischemic heart disease and postdialysis mortality. UD patients in the medium-risk population had increased risk of postdialysis mortality. Dialysis start should be individualized by considering comorbidities.

Exhausted Capacity of Bicarbonate Buffer in Renal Failure Diagnosed Using Point of Care Analyzer

Background: Metabolic acidosis in patients with chronic kidney disease (CKD) is a common complication. A bicarbonate concentration in venous blood (V-HCO3−) is a key index for diagnosis and treatment initiation. The aim of our study is to evaluate usability of acid–base balance parameters of in blood taken simultaneously from peripheral artery and the vein. Methods: A total of 49 patients (median age 66 years [interquartile range IQR 45–75]), with CKD stage G4 or G5 were enrolled in this cross-sectional study. All patients were qualified for arteriovenous fistula creation in pre-dialysis period. The samples were taken during surgery, directly after dissection, and evaluated in a point of care testing analyzer. The arteriovenous difference in bicarbonate levels (Δ-HCO3−) was calculated. According to glomerular filtration rate (eGFR) the group was divided into Group A eGFR ≥ 10 mL/min/1.73 m2) and Group B eGFR < 10 mL/min/1.73 m2). Results: In Group A Δ-HCO3− was significantly higher compared to Group B. No such differences were observed in the case of V-HCO3−. Δ-HCO3− positively correlated with eGFR. The discriminative power of Δ-HCO3− for predicting eGFR < 10 mL/min/1.73 m2 was 0.72 (95% confidence interval [CI] = 0.551–0.88; p = 0.01) which provided 67% sensitivity and 75% specificity. The best cut-off was 0.5 mmol/L. Conclusions: The Δ-HCO3− lower than 0.5 mmol/L may be used as predictor of exhaust buffer capacity. The value of this tool should be tested in larger population.

Predialytic versus Intradialytic Nutrition: A Study to Assess Effects on Intradialytic Blood Pressure, Dialysis Adequacy, and Urea Removal

Background: Provision of oral protein in hemodialysis (HD) is desirable due to improved compliance to protein requirements and better nutritional status, but the risks of hypotension and underdialysis need to be considered. This study compared 2 different timings for administering oral nutritional supplements (ONS), predialysis and mid-dialysis, with respect to hemodynamics, dialysis adequacy, urea removal, and tolerability. Methods: This single-center, prospective crossover study analyzed 72 stable patients with ESRD on twice a week maintenance HD with a mean age of 38.7 (±11.2) years and a dialysis vintage of 28.2 (±13.1) months. In the first week, all the patients received ONS (450 kcal energy, 20 g protein) 1 h prior to start of dialysis (group 1) and in the next week, the supplement was administered after 2 h of start of dialysis (group 2), with a predialysis fasting period of at least 3 h in both groups. Blood pressures, serum, and spent dialysate samples were collected and nausea occurrence was noted by severity. Results: Predialytic intake (group 1) was associated with higher predialysis and 1st hour blood urea, dialysis adequacy, and urea removal than group 2. Both groups achieved mean Kt/V > 1.2, and the occurrence of symptomatic hypotensive episodes and nausea was not significantly different between the groups. On repeated measures ANOVA, changes in blood urea over time showed significant group effect. Conclusions: Predialytic supplementation was associated with better dialysis adequacy and urea removal than intradialytic supplementation. However, both timings were equally tolerated and not associated with underdialysis.

Role of angiotensin-converting enzyme inhibitors in reducing cardiovascular and cerebral complications in chronic kidney disease: focus perindopril

In the development of renocardial relationships in chronic kidney disease, an important role is given to the activation of the renin-angiotensin-aldosterone system (RAAS), as the main component of the progression and development of cardiovascular complications..The presented review is devoted to the analysis of modern scientific data on the effect of high RAAS activity in chronic kidney disease on the course and prognosis of cardiovascular complications, as well as the protective capabilities of angiotensin-converting enzyme inhibitors, in particular perindopril. The results of scientific research on the role of the RAAS in the progression of chronic kidney disease are summarized. Data on chronic kidney disease as a risk factor for cardiovascular and cerebral complications are presented. Attention is focused on the possibilities of prolonging the pre-dialysis period of chronic kidney disease when using angiotensin-converting enzyme inhibitors. The role of perindopril as a lipophilic angiotensin-converting enzyme inhibitor with a high affinity for tissue RAAS was emphasized in reducing cardiovascular and cerebral risk in chronic kidney disease.

Prevalence of Cardiac Abnormalities in Children with Chronic Kidney Disease: A Cross-sectional Study from a Developing Country.

Improved therapeutic modalities in chronic kidney diseases (CKD) children and consequent extension of life expectancy, draws more attention towards secondary complications. Cardiovascular adaptations precipitating such terminal events, begin in pre-dialysis CKD. Hence, it's imperative to identify modifiable risk factors to direct care and resources in haltering CKD progression, evade long-term dialysis and anticipate kidney transplantation to avert cardiac complications in predialysis period. One hundred and six pre-dialysis patients aged one year to 15 years, with estimated glomerular filtration rate of <90 mL/min/1.73 m2 and proteinuria were included. Patient's history, weight, height and blood pressures (BPs) performed. Left ventricular mass index (LVMI) calculated to correct for patient height to determine raised values of >38.6 g/m2.7 and of left ventricular hypertrophy (LVH) >55 g/m2.7. Shortening fraction and ejection fraction measured to assess systolic function. Diastolic function assessed by Doppler measuring the mitral inflow (e/a) ratio. Hemoglobin, calcium phosphorous product, parathyroid hormone and hypertension measured to assess cardiac risk factor. The total prevalence of cardiac abnormality was found in 66.9% (95% confidence interval [CI] 57.6%-75.2%. Raised LVMI was seen in 64%, among which 34.9% had LVH. Diastolic and systolic dysfunction was found in 12.2% and 11.3% respectively. The cardiac abnormality was more prevalent in CKD grade IV and V. The independent risk factors were anemia and abnormal diastolic BP index which increase the risk for LVH by 3-fold and 5-fold respectively. Proportion of cardiac abnormalities were more prevalent in CKD IV and V. Anemia and diastolic hypertension were independent risk factors for LVH.