Receiving Maintenance Hemodialysis Research Articles

Redefining the concept of residual renal function with kidney sodium MRI: a pilot study.

The concept of residual kidney function (RKF) is exclusively based upon urine volume and small solute clearance, making RKF challenging to assess in clinical practice. The aim of this study was to test the technical feasibility of obtaining useable 23Na-MRI kidney images in hemodialysis (HD) participants. We conducted an exploratory prospective study to quantify the cortico-medullary sodium gradient in healthy and HD participants. Participants fasted for eight hours prior to their study visit. Urine samples were collected to measure urinary osmolarity, before MRI. Proton and sodium pictures were merged; ROIs were delineated for the medulla and cortex when feasible. In cases where cortex could not be identified, we considered the cortico to medulla gradient (CMG) to be no longer present, resulting in a medulla-to-cortex ratio of 1. 17 healthy volunteers and 21 HD participants. Median (IQR) fasting medulla to cortex ratio was significantly higher 1.56 [1.5-1.61] in healthy volunteers compared to HD patients 1.22 [1.13-1.3], p<0.0001. Medulla to cortex ratio and median urinary osmolarity were correlated (r=0.87, p<0.0001) in the whole population. We found a significant association between HD vintage and medulla to cortex ratio whereas we did not find any association with urine volume. Sodium signal intensity distribution within healthy kidney describes two different peaks- relating to well defined cortex and medulla; whereas HD participants displays only a single peak indicative of the markedly lower sodium concentration. This study is only an exploratory study with a modest number of patients. the application of kidney sodium MRI to the study of RKF in patients receiving maintenance HD is practical and provides a previously unavailable ability to interrogate the function of remnant tubular function.

Symptom profiles in patients receiving maintenance hemodialysis and their association with quality of life: a longitudinal study.

Many patients receiving maintenance hemodialysis experience one or multiple symptoms. Using a latent profile analysis to identify symptom profiles may provide insights for person-centered symptom management strategies. This is a longitudinal study based on data from patients receiving maintenance hemodialysis at three hospitals in Shanghai, China. Of the 448 patients who completed the surveys at baseline (T1), 309 completed the 12-month follow-up survey (T2). Symptoms and quality of life were measured by the Chinese version of Kidney Disease Quality of Life 36 Short Form. The optimal classification of symptoms was identified using latent profile analysis. Five symptom profiles were identified: High (9.2%), Fatigue and Gastrointestinal (7.1%), Fatigue and Skin (10.7%), Skin (23.2%), and Low (49.8%). The high-symptom profile and the-fatigue-and-skin-symptom profile were associated with a lower level of physical functioning, a higher burden of kidney disease, and more negative effects of kidney disease than the low symptom profile at T1 and T2. Multivariate regression analysis showed that the high-symptom profile predicted a poorer physical functioning at T2, and the-fatigue-and-skin-symptom profile predicted a poorer physical functioning and higher burden of kidney disease at T2. Patients receiving maintenance hemodialysis reported unique symptom experiences which could be classified into different profiles. Patients reporting an overall high level of symptoms or a high level of fatigue and skin symptoms were more likely to have a poorer quality of life.

Hemorrhagic pericardial tamponade in a hemodialysis patient with catheter-related superior vena cava syndrome: a case report

BackgroundIatrogenic complications of endovascular treatment for central venous stenosis have not yet been reported. Here we present a case of a patient on maintenance hemodialysis who developed catheter-related superior vena cava syndrome and subsequently suffered from hemorrhagic pericardial tamponade after undergoing percutaneous transluminal angioplasty and stenting.Case presentationA 72-year-old male patient presented with uremia, and had been receiving maintenance hemodialysis for the past five years. The patient initially presented with dysfunction of the dialysis catheter (a cuffed tunneled double-lumen catheter in the right internal jugular vein). Imaging examination revealed a segmental occlusion of the superior vena cava stretching from the distal end of the dialysis catheter up to right atrium entrance, apparent compensatory dilatation of the azygos vein, and abundant subcutaneous collaterals. The patient underwent percutaneous transluminal balloon dilatation and stenting (covered stent) of the superior vena cava in the Cath Lab. During the procedure, with forceful advancement of the guidewire, it was observed to progress for a distance before a “smoke” appeared, and an outward spillage of contrast agent was visible, which suggested a possible vessel puncture leading into the mediastinum. Unfortunately, postoperative hemorrhagic pericardial tamponade occurred and the patient developed cardiogenic shock. He experienced symptoms included chest tightness and breath shortness with a recorded blood pressure of 84/60mmHg. After draining 600 ml of bloody fluid through pericardiocentesis, the patient’s symptoms alleviated and his condition improved.ConclusionsThe case emphasizes the need for increased attention to iatrogenic endovascular injuries during catheter placement and endovascular treatment, such as causing pericardial hemorrhage leading to cardiac tamponade.

Copper deficiency anemia due to zinc supplementation in a chronic hemodialysis patient.

Zinc deficiency causes dysgeusia and dermatitis as well as anemia. As approximately half of dialysis patients have zinc deficiency, zinc supplementation should be considered in case of erythropoiesis-stimulating agent (ESA)-hyporesponsive anemia. We report a case of a chronic dialysis patient with copper deficiency anemia caused by standard-dose zinc supplementation. The patient was a 70-year-old woman who had received maintenance hemodialysis for 8years due to diabetic nephropathy. She had been treated with weekly administration of darbepoetin 30μg for renal anemia, which resulted in Hb 12 to 14g/dL. She had no dysgeusia. When zinc deficiency (44μg/dL) had been identified 4months earlier, 50mg daily zinc acetate hydrate (Nobelzin®), which is the standard dose, was started. Unexpectedly, her anemia progressed slowly with macrocytosis together with granulocytopenia. Her platelet count did not decrease at that time. Laboratory tests revealed a marked decrease of serum copper (< 4μg/dL) and ceruloplasmin (< 2mg/dL), although serum zinc was within the normal limit (125μg/dL). We discontinued zinc acetate and started copper supplementation including cocoa for 1month. Her anemia and granulocytopenia were dramatically restored coincident with the increase in both serum copper and ceruloplasmin. Copper supplementation also improved her iron status as assessed by transferrin saturation and ferritin. Clinicians should monitor both zinc and copper status in anemic dialysis patients during zinc supplementation, as both are important to drive normal hematopoiesis.

The futility of post-haemodialysis blood glucose levels: A retrospective cohort study.

Frequent blood glucose tests are performed for people with diabetes receiving haemodialysis. To determine the rate of out-of-range post-haemodialysis blood glucose levels that are clinically acted upon, the intervention and outcome of each intervention, and the associations between post-haemodialysis blood glucose levels and relevant clinical predictors. 12-month retrospective cohort medical record review in one Australian haemodialysis centre. Post-haemodialysis blood glucose levels, prehaemodialysis blood glucose levels, time of treatment, diabetes medications, intradialytic fluid removal, dialysate dextrose concentration, clinical actions, interventions, and outcomes on out-of-range blood glucose levels were retrieved. 22 participants with a median time receiving dialysis 3.1 years (interquartile range 2.3-4.7). The proportion of out-of-range post-haemodialysis blood glucose levels was 87.3% (95% confidence interval, 86.1%-88.5%). No out-of-range post-haemodialysis blood glucose levels were clinically acted upon. Out-of-range post-haemodialysis blood glucose levels were 4.6 times more likely if a higher dextrose bath was used (95% confidence interval: 3.3; 6.3. p < 0.001). The odds of the post-haemodialysis blood glucose levels increased by each 1 mmol/L. Intradialytic fluid removal, dialysate dextrose concentration, sex, dialysis time, anti-hyperglycaemic agents were also associated with out-of-range post-haemodialysis blood glucose levels. Routine post-haemodialysis blood glucose levels testing has limited clinical utility in care for people with diabetes receiving maintenance haemodialysis. Higher dextrose dialysate may require individual titration depending on prehaemodialysis blood glucose levels.

Efficacy, tolerability, and safety of the oral phosphate binder VS-505 (AP301).

VS-505 (AP301), an acacia and ferric oxyhydroxide polymer, is a novel fiber-iron-based phosphate binder. This two-part phase 2 study evaluated the tolerability, safety, and efficacy of oral VS-505 administered three times daily with meals in treating hyperphosphatemia in chronic kidney disease (CKD) patients receiving maintenance hemodialysis (MHD). In Part 1, patients received dose-escalated treatment with VS-505 2.25, 4.50, and 9.00g/day for 2 weeks each, guided by serum phosphorus levels. In Part 2, patients received randomized, open-label, fixed-dosage treatment with VS-505 (1.50, 2.25, 4.50, or 6.75g/day) or sevelamer carbonate 4.80g/day for 6 weeks. The primary efficacy endpoint was the change in serum phosphorus. The study enrolled 158 patients (Part 1: 25; Part 2: 133), with 130 exposed to VS-505 in total. VS-505 was well tolerated. The most common adverse events were gastrointestinal disorders, mainly feces discolored (56%) and diarrhea (15%; generally during weeks 1‒2 of treatment). Most gastrointestinal disorders resolved without intervention, and none were serious. In Part 1, serum phosphorus significantly improved (mean change -2.0mg/dL; 95% confidence interval -2.7, -1.4) after VS-505 dose escalation. In Part 2, serum phosphorus significantly and dose-dependently improved in all VS-505 arms, with clinically meaningful reductions with VS-505 4.50 and 6.75g/day, and sevelamer carbonate 4.80g/day (mean change -1.6 (-2.2, -1.0), -1.8 (-2.4, -1.2), and -1.4 (-2.2, -0.5) mg/dL, respectively). In both Parts, serum phosphorus reductions occurred within 1 week of VS-505 initiation, returning to baseline within 2 weeks of VS-505 discontinuation. VS-505, a novel phosphate binder, was well tolerated with a manageable safety profile, and effectively and dose-dependently reduced serum phosphorus in CKD patients with hyperphosphatemia receiving MHD. Clinical Trial registration number: NCT04551300.

Reversal of complete atrioventricular block in dialysis patients following parathyroidectomy: A case report

BACKGROUND Refractory secondary hyperparathyroidism (SHPT) is a common complication observed in patients with end-stage renal disease and can result in ectopic calcification. Metastatic calcification involving the heart valves and the conduction system can easily lead to arrhythmias, including atrioventricular block. This case report describes a maintenance hemodialysis patient with refractory SHPT resulting in a complete atrioventricular block (CAVB), which was eventually reversed to a first-degree atrioventricular block. CASE SUMMARY We present the case of a 31-year-old Asian female who was receiving maintenance hemodialysis because of lupus nephropathy. She developed SHPT, and an electrocardiogram revealed a first-degree atrioventricular block. Then, she underwent parathyroidectomy (PTX) with autotransplantation. Unfortunately, a few years later, she developed SHPT again, and an electrocardiogram revealed a CAVB. A few years after the second PTX surgery, the calcification of the left atrium and left ventricle improved, and her CAVB was reversed. CONCLUSION This case revealed that metastatic cardiac calcification can result in complete atrioventricular blockage. Following parathyroid surgery, calcification of the cardiac conduction system improved, leading to reversal of the atrioventricular block. It is important for dialysis patients to optimize intact parathyroid hormone therapy and pay attention to calcification metastasis.

Predicting immunogenicity of COVID-19 vaccines in hemodialysis patients with renal disease

Individuals who are diagnosed with chronic kidney disease, particularly those receiving maintenance hemodialysis treatment, face a greater likelihood of suffering from severe symptoms and fatality due to COVID-19. This study aimed to explore the optimal vaccination approach for these individuals. The study used data analysis tasks such as data preprocessing, cleaning, and exploration, and machine learning models including linear regression, random forest, XGBoost, gradient boosting, AdaBoost, decision trees, Lasso, and ridge regression were used to construct the predictive model. The study found that the Lasso model performed the best overall in predicting anti-S IgG antibodies levels in response to COVID-19 vaccines for people with kidney failure with MAE of 8.81, RMSE of 19.59, and R2 value of 0.93. The adjusted R2 value for the Lasso model was also 0.93, indicating that the model's ability to explain the variance in the data was not affected by the number of predictors in the model. The Random Forest model best predicted the duration of immunogenicity, with R2 and adjusted R2 values of 0.71 and 0.69, respectively. The ensemble model that includes all eight models, i.e., Ridge, Lasso, Linear Regression, Random Forest, AdaBoost, Gradient Boosting, XGBoost, and Decision Tree, has the best performance with the lowest MAE, the lowest RMSE, the highest R2, and the highest adjusted R2 values of 3.91, 5.00, 0.73, and 0.72, respectively. However, further research is required to validate these models and extend their application to different populations and vaccine types, as well as considering other factors that may affect immune response to COVID-19 vaccines. These findings can be helpful in improving vaccination strategies and promoting public health.

Serum ferritin and neutrophil-to-lymphocyte ratio predict all-cause mortality in patients receiving maintenance hemodialysis: a prospective study.

Introduction: Maintenance hemodialysis is an effective treatment for end-stage renal disease patients. A critical factor contributing to the deterioration and death of maintenance hemodialysis patients is inflammation. Therefore, we focused on two inflammatory markers, serum ferritin and neutrophil-to-lymphocyte ratio, to speculate whether they could predict the prognosis of maintenance hemodialysis patients. Patients and methods: We followed 168 patients with maintenance hemodialysis from July 2019 to July 2022 with the endpoint of all-cause death or follow-up completion. Receiver operating characteristic curves were plotted to assess the values of serum ferritin, neutrophil-to-lymphocyte ratio and serum ferritin combined with neutrophil-to-lymphocyte ratio to predict the outcomes of maintenance hemodialysis patients. Kaplan-Meier survival curves were constructed to compare survival rates over time. Results: Receiver operating characteristic curves demonstrated that the best cut-off value of serum ferritin for predicting the prognosis of maintenance hemodialysis patients was 346.05μg/L, and that of neutrophil-to-lymphocyte ratio was 3.225. Furthermore, a combination of both had a more excellent predicting value than either index (p < 0.05). Kaplan-Meier survival curve analyses revealed that low serum ferritin levels and low neutrophil-to-lymphocyte ratio had a higher probability of survival than high ferritin levels and high neutrophil-to-lymphocyte ratio, separately. Conclusion: Elevated serum ferritin and neutrophil-to-lymphocyte ratio are closely related to all-cause mortality among maintenance hemodialysis patients, for which they may be predictors of all-cause mortality. Additionally, the combination of the two has a much higher predictor value for the prognosis of maintenance hemodialysis patients.

Ondansetron and the Risk of Sudden Cardiac Death among Individuals Receiving Maintenance Hemodialysis.

Individuals receiving hemodialysis have high incidence of sudden cardiac death and are susceptible to QT interval prolonging medication-related cardiac complications. Ondansetron, an antiemetic with known QT prolonging potential, is associated with fatal arrythmias in the general population when administered intravenously. The cardiac safety of ondansetron in the hemodialysis population is unknown. We conducted a new-user, active-comparator, cohort study using US Renal Data System data (2012-2019) to examine the association between the initiation of oral ondansetron vs. antiemetics with lesser QT prolonging potential (promethazine, metoclopramide or prochlorperazine) and the 10-day risk of sudden cardiac death among individuals receiving hemodialysis. We used inverse probability of treatment weighted survival models to estimate adjusted hazard ratios (aHRs), risk differences (aRDs), and 95% confidence intervals (CIs). We used an intention-to-treat approach in which non-sudden cardiac death was considered a competing event. We examined additional cardiac outcomes in secondary analyses. Of the 119,254 study patients, 64,978 (54.5%) initiated ondansetron, and 54,276 (45.5%) initiated a comparator antiemetic. Initiation of ondansetron versus a comparator antiemetic was associated with higher relative and absolute 10-day risks of sudden cardiac death, aHR (95% CI) = 1.44 (1.08, 1.93); aRD (95% CI) = 0.06% (0.01%, 0.11%). The number needed to harm was 1,688. Analyses of additional cardiac outcomes yielded similar findings. Compared with initiation of antiemetics with lesser QT prolonging potential, initiation of ondansetron was associated with higher short-term cardiac risks among people receiving hemodialysis.

The impact of low and high dialysate calcium concentrations on cardiovascular disease and death in patients undergoing maintenance hemodialysis: a systematic review and meta-analysis.

The optimal dialysate calcium (Ca) concentration for patients undergoing hemodialysis remains inconclusive, particularly concerning cardiovascular protection. We conducted a systematic review of 19 randomized controlled trials (RCTs) and a meta-analysis of eight RCTs to determine the optimal dialysate Ca concentration for cardiovascular protection. We compared outcomes in patients receiving maintenance hemodialysis treated with either a low-Ca dialysate (LCD) (1.125 or 1.25mmol/L) or a high-Ca dialysate (HCD) (1.5 or 1.75mmol/L). The outcomes were coronary artery calcification score (CACS), all-cause and cardiovascular death, cardiovascular function and structure, and serum biochemical parameters. There was no significant difference between LCD and HCD concerning CACS (standardized mean difference [SMD] = -0.16, 95% confidence interval [CI]: [-0.38, 0.07]), the risk of all-cause death, and cardiovascular death in patients treated with chronic maintenance hemodialysis. Conversely, LCD was associated with a significantly lower intima-media thickness (SMD = -0.49, 95% CI [-0.94, -0.05]) and pulse wave velocity than HCD (SMD = -0.86, 95% CI [-1.21, -0.51]). Furthermore, LCD significantly decreased serum Ca levels (mean difference [MD] = 0.52mg/dL, 95% CI [0.19, 0.85]) and increased serum parathyroid hormone levels (MD = 44.8pg/mL, 95% CI [16.2, 73.3]) compared with HCD. Notably, most RCTs examined in our analysis did not include patients receiving calcimimetics. Our meta-analysis showed no significant differences in cardiovascular calcification and death between LCD and HCD and revealed a paucity of RCTs on dialysate Ca concentrations, including those involving patients on calcimimetics, indicating the urgent need for further studies.

Influence of teach-back strategy on hemodialysis related knowledge level, self-efficacy and self-management in patients receiving maintenance hemodialysis

To investigate the effect of teach-back strategy on hemodialysis related knowledge level, self-efficacy and self-management among hemodialysis patients. The research is a quasi-randomized control trial. A total of 92 patients receiving maintenance hemodialysis were randomly divided into observation group (n = 46) and control group (n = 46) by random number table method. The control group received conventional health education, and the observation group received teach-back. The intervention lasted six months. The hemodialysis related knowledge level, self-efficacy and self-management of the two groups were evaluated before and after the intervention. There were no significant difference on hemodialysis related knowledge level, self-efficacy and self-management scores between the two groups before intervention (P > 0.05). After intervention, the scores of hemodialysis knowledge in the observation group was higher than that in the control group and before intervention. The total scores of self-efficacy and items “3,4,5” were higher than those of the control group. The total scores of self-efficacy and item “1~6” in the observation group were higher than before intervention. The total scores of self-management and the three subscales of “problem solving”, “partnership” and “emotional processing” were higher than those of the control group and before intervention. All of the above differences were statistically significant (P < 0.05). Teach-back is helpful to improve the hemodialysis related knowledge level, self-efficacy and self-management level of patients receiving maintenance hemodialysis, and it is worth to be popularized clinically.

Burden of Tuberculosis in End Stage Renal Disease Patients Undergoing Maintenance Hemodialysis: A Multicenter Study and Experience from Ethiopian Dialysis Setting.

Patients with end stage renal disease (ESRD) are at a higher risk of developing tuberculosis (TB) due to the immunosuppressed state along with concomitant comorbidities and socioeconomic and demographic factors. Data on the prevalence of tuberculosis in ESRD are scarce despite the high burden of the disease in developing nations. A multicenter, cross-sectional study was conducted at eight dialysis centers in Addis Ababa on the prevalence of TB among CKD patients on maintenance hemodialysis from August 2022 to October 2022 G.C. The study enrolled 263 participants selected by systematic random sampling. Data were collected by reviewing the patient's electronic medical records. The Collected data were analyzed using SPSS version 26.0. Our study found a 27% prevalence of TB in patients with ESRD receiving maintenance hemodialysis (MHD). Pulmonary tuberculosis was the most prevalent form, and lymphadenitis was the most common extra-pulmonary tuberculosis (EPTB). Only 5.6% of the study participants had microbiologic evidence of TB. Chemistry and cytological studies from pleural fluid and imaging evidences were commonly used diagnostic modalities. The presence of HIV infection, longer duration of dialysis (>1 year), and contact history with a known TB patient were all significantly associated with higher prevalence of TB among the study participants. Although there is a strong association between TB and CKD, there are no local data from Ethiopia. Our study identified a higher prevalence of TB among CKD patients on MHD. Thus, maintaining a high index of suspicion and early diagnosis and treatment of TB among ESRD patients on MHD and use of TB preventive therapy (TPT) is important in decreasing morbidity and mortality.

Resistant Hypertension in Dialysis: Epidemiology, Diagnosis, and Management.

Apparent treatment-resistant hypertension is defined as an elevated BP despite the use of ≥3 antihypertensive medications from different classes or the use of ≥4 antihypertensives regardless of BP levels. Among patients receiving maintenance hemodialysis or peritoneal dialysis, using this definition, the prevalence of apparent treatment-resistant hypertension is estimated to be between 18% and 42%. Owing to the lack of a rigorous assessment of some common causes of pseudoresistance, the burden of true resistant hypertension in the dialysis population remains unknown. What distinguishes apparent treatment-resistance from true resistance is white-coat hypertension and adherence to medications. Accordingly, the diagnostic workup of a dialysis patient with apparent treatment-resistant hypertension on dialysis includes the accurate determination of BP control status with the use of home or ambulatory BP monitoring and exclusion of nonadherence to the prescribed antihypertensive regimen. In a patient on dialysis with inadequately controlled BP, despite adherence to therapy with maximally tolerated doses of a β -blocker, a long-acting dihydropyridine calcium channel blocker, and a renin-angiotensin system inhibitor, volume-mediated hypertension is the most important treatable cause of resistance. In daily clinical practice, such patients are often managed with intensification of antihypertensive therapy. However, this therapeutic strategy is likely to fail if volume overload is not adequately recognized or treated. Instead of increasing the number of prescribed BP-lowering medications, we recommend diet and dialysate restricted in sodium to facilitate achievement of dry weight. The achievement of dry weight is facilitated by an adequate time on dialysis of at least 4 hours for delivering an adequate dialysis dose. In this article, we review the epidemiology, diagnosis, and management of resistant hypertension among patients on dialysis.

Factors influencing fatigue among patients undergoing hemodialysis: a multi-center cross-sectional study

ABSTRACT Fatigue has been reported to be the most common symptom experienced by patients receiving hemodialysis (HD) therapy. Fatigue can lead to a reduction in their ability to engage in both routine and self-care activities, which can negatively affect their self-confidence and quality of life. This study aimed to determine the level of fatigue and the factors that affecting its level among patients receiving uHD. Methods: A cross-sectional design was utilized to explore the level of fatigue among patients receiving maintenance HD using the Mul-tidimensional Assessment of Fatigue (MAF) scale. Data were collected from four dialysis centers in two Saudi Arabia cities, Hail and Al-Qassim, between January 2022 and October 2022. Results: The questionnaire was completed by 236 patients. Older patients, male patients, and retired pa-tients reported significantly higher levels of fatigue (p < 0.001). In contrast, marital status, educational level, and financial status did not significantly affect the level of fatigue among patients (p = 0.193, 0.285, and 0.126, respectively). Patients who had seven or more dependents reported more fatigue than those who had lower levels of fatigue or who did not have dependents (p = 0.004). In addition, patients who had a regular exercise regimen reported significantly lower fatigue than those who did not have an exercise regimen (p = 0.011). Multiple linear regression demonstrated that employment status (student), comorbidity condition (one chronic disease), dialysis duration, satisfaction with dialysis time, and dialysis time were found to affect the fatigue scores (R2 = 0.302, p ˂ 0.001). Conclusion: The findings of this study gives a broader understanding of factors influencing fatigue among patients with HD that will help to develop strategies of more focused interventions to reduce fatigue among patients with HD.

Correlation between ultrafiltration rate and hemoglobin level and erythropoietin response in hemodialysis patients

This study aimed to investigate the correlation between ultrafiltration rate (UFR) and hemoglobin levels and erythropoietin (EPO) response in patients receiving maintenance hemodialysis (MHD). 225 MHD patients were divided into three groups according to the UFR: < 10 ml/h/kg, 10–13 ml/h/kg, and >13 ml/h/kg. Clinical parameters and prognosis were compared among the groups. Multiple linear correlation and regression analyses were conducted. SPSS 26.0 (IBM, Chicago, IL, USA) was used to analyze all statistics. The UFR < 10 ml/h/kg group was older than the other groups (p < 0.05). The UFR > 13 ml/h/kg group had the highest SpKt/V (p < 0.05), monthly EPO dose/weight (p < 0.001), and EPO resistance index (p < 0.001), as well as the lowest dry weight (p < 0.001), BMI (p < 0.001), hemoglobin (p < 0.001), hematocrit (p < 0.05), and red blood cell count (p < 0.05). Multiple linear regression analysis showed that sex, dry weight, UFR, calcium, phosphorus, albumin, and C-reactive protein levels were associated with hemoglobin levels. Multivariate logistic regression analysis revealed that a higher UFR was associated with lower hemoglobin levels, while male sex and higher levels of calcium and albumin were associated with higher hemoglobin levels. High UFR is associated with more severe anemia and EPO resistance in MHD. This study provides new insights into anemia management in patients undergoing hemodialysis.

Hypoxia‐inducible factor prolyl hydroxylase domain inhibitors may mitigate loss of skeletal muscle mass in haemodialysis patients

AbstractBackgroundChronic kidney disease patients particularly with renal anaemia hyporesponsive to erythropoiesis‐stimulating agents (ESAs) are at a greater risk of having skeletal muscle mass (SMM) loss. Hypoxia‐inducible factor prolyl hydroxylase domain inhibitor (HIF‐PHI), a novel therapeutic agent for renal anaemia, potentially promotes angiogenesis, muscle repair, and homeostasis. However, effects of HIF‐PHIs on SMM remain unknown.MethodsThis retrospective observational cohort study enrolled 292 Japanese adults receiving maintenance haemodialysis at our dialysis centre. The dataset included 11 patients who received daprodustat for 6 months or longer during 1 December 2020 through 30 June 2022. From the previously published pooled cohort, we enrolled 281 participants from 1 August 2018 to 31 July 2019 prior to the approval of HIF‐PHIs for renal anaemia. SMM was assessed using modified creatinine index (mg/kg/day) calculated by age, sex, serum creatinine, and single‐pool Kt/V. Annual changes of SMM [ΔSMM (%)] were analysed with the least squares regression model and mixed‐effects model during 6‐ to 12‐month follow‐up period.ResultsThe median age of the participants was 63 years [interquartile range (IQR), 54–71 years], and 33% were female. The median ΔSMM levels (IQR) in the least squares regression model were 4.0% (−1.7% to 9.3%) in the HIF‐PHI group, 0.20% (−2.1% to 2.1%) in the no ESA group, and −0.94% (−3.0% to 1.3%) in the high ESA group using darbepoetin equivalent to 20 μg or more per week. Those in the mixed‐effects model were −1.7% (−1.2% to 3.8%), 0.09% (−1.4% to 1.3%), and −0.74% (−2.0% to 0.8%), respectively. The multivariable linear regression models revealed that HIF‐PHI use was associated with greater ΔSMM compared with the high ESA group [coefficient, 3.737; 95% confidence interval (CI), 1.216–6.258 in the least squares regression model or coefficient, 1.635; 95% CI, 0.068–3.201 in the mixed‐effects model, respectively].ConclusionsHIF‐PHI use led to greater ΔSMM in maintenance haemodialysis patients. HIF‐PHIs may minimize loss of SMM in patients with end‐stage kidney disease and renal anaemia.

Comparison of Acute Health Care Utilization Between Patients Receiving In-Center Hemodialysis and the General Population: A Population-Based Matched Cohort Study From Ontario, Canada.

Patients receiving maintenance hemodialysis have multiple comorbidities and are at high risk of presenting to the hospital. However, the incidence and cost of acute health care utilization in the in-center hemodialysis population and how this compares with other populations is poorly understood. To determine the rate, pattern, and cost of emergency department visits and hospitalizations in patients receiving in-center hemodialysis compared with a matched general population. Population-based matched cohort study. We used linked administrative health care databases from Ontario, Canada. We included 25 379 patients (incident and prevalent) receiving in-center hemodialysis between January 1, 2010, and December 31, 2018. Patients were matched on birth date (±2 years), sex, and cohort entry date using a 1:4 ratio to 101 516 individuals from the general population. Our primary outcomes were emergency department visits (allowing for multiple visits per individual) and hospital admissions from the emergency department. We also assessed all-cause hospitalizations, all-cause readmissions within 30 days of discharge from the original hospitalization, length of stay for hospital admissions (including multiple visits per individual), and the financial cost of these admissions. We presented the rate, percentage, median (25th, 75th percentiles), and incidence rate per 1000 person-years for emergency department visits and hospitalizations. Individual-level health care costs for emergency department visits and all-cause hospitalization were estimated using resource intensity weights multiplied by the cost per weighted case. Patients receiving in-center hemodialysis had substantially more comorbidities (eg, diabetes) than the matched general population. Eighty percent (n = 20 309) of patients receiving in-center hemodialysis had at least 1 emergency department visit compared with 56% (n = 56 452) of individuals in the matched general population, over a median follow-up of 1.8 years (25th, 75th percentiles: 0.7, 3.6) and 5.2 (2.5, 8.4) years, respectively. The incidence rate of emergency department visits, allowing for multiple visits per individual, was 2274 per 1000 person-years (95% confidence interval [CI]: 2263, 2286) for patients receiving in-center hemodialysis, which was almost 5 times as high as the matched general population (471 per 1000 person-years; 95% CI: 469, 473). The rate of hospital admissions from the emergency department and the rate of all-cause hospital admissions in the in-center hemodialysis population was more than 7 times as high as the matched general population (hospital admissions from the emergency department: 786 vs 101 per 1000 person-years; all-cause hospital admissions: 1056 vs 139 per 1000 person-years). The median number of all-cause hospitalization days per patient year was 4.0 (0, 16.5) in the in-center hemodialysis population compared with 0 (0, 0.5) in the matched general population. The cost per patient-year for emergency department visits in the in-center hemodialysis population was approximately 5.5 times as high as the matched general population while the cost of hospitalizations in the in-center hemodialysis population was approximately 11 times as high as the matched general population (emergency department visits: CAN$ 1153 vs CAN$ 209; hospitalizations: CAN$ 21 151 vs CAN$ 1873 [all costs in 2023 CAN$]). External generalizability and we could not determine whether emergency department visits and hospitalizations were preventable. Patients receiving in-center hemodialysis have high acute health care utilization. These results improve our understanding of the burden of disease and the associated costs in the in-center hemodialysis population, highlight the need to improve acute outcomes, and can aid health care capacity planning. Additional research is needed to address the risk of hospitalization after controlling for patient comorbidities. This is not applicable as this is a population-based matched cohort study and not a clinical trial.

Randomized Controlled Trial of the Effect of an Exercise Rehabilitation Program on Symptom Burden in Maintenance Hemodialysis: A Clinical Research Protocol.

People receiving hemodialysis experience high symptom burden that contributes to low functional status and poor health-related quality of life. Management of symptoms is a priority for individuals receiving hemodialysis but limited effective treatments exist. There is emerging evidence that exercise programming can improve several common dialysis-related symptoms. The primary aim of this study is to evaluate the effect of an exercise rehabilitation program on symptom burden in individuals receiving maintenance hemodialysis. Multicenter, randomized controlled, 1:1 parallel, open label, prospective blinded end point trial. Three facility-based hemodialysis units in Winnipeg, Manitoba, Canada. Adults aged 18 years or older with end-stage kidney disease receiving facility-based maintenance hemodialysis for more than 3 months, with at least 1 dialysis-related symptom as indicated by the Dialysis Symptom Index (DSI) severity score >0 (n = 150). Supervised 26-week exercise rehabilitation program and 60 minutes of cycling during hemodialysis thrice weekly. Exercise intensity and duration were supervised and individualized by the kinesiologist as per participant baseline physical function with gradual progression over the course of the intervention. Usual hemodialysis care (no exercise program). Our primary outcome is change in symptom burden at 12 weeks as measured by the DSI severity score. Secondary outcomes include change in modified DSI severity score (includes 10 symptoms most plausible to improve with exercise), change in DSI severity score at 26 and 52 weeks; time to recover post-hemodialysis; health-related quality of life measured using EuroQol (EQ)-5D-5L; physical activity behavior measured by self-report (Godin-Shepherd questionnaire) and triaxial accelerometry; exercise capacity (shuttle walk test); frailty (Fried); self-efficacy for exercise; and 1-year hospitalization and mortality. Change in primary outcome will be compared between groups by independent 2-tailed t test or Mann-Whitney U test depending on data distribution and using generalized linear mixed models, with study time point as a random effect and adjusted for baseline DSI score. Similarly, change in secondary outcomes will be compared between groups over time using appropriate parametric and nonparametric statistical tests depending on data type and distribution. The COVID-19 pandemic restrictions on clinical research at our institution delayed completion of target recruitment and prevented collection of accelerometry and physical function outcome data for 15 months until restrictions were lifted. The application of an exercise rehabilitation program to improve symptom burden in individuals on hemodialysis may ameliorate common symptoms observed in individuals on hemodialysis and result in improved quality of life and reduced disability and morbidity over the long term. Importantly, this pragmatic study, with a standardized exercise intervention that is adaptable to baseline physical function, addresses an important gap in both clinical care of hemodialysis patients and our current knowledge.

Assessment of Hemorrhagic Risk in Maintenance Hemodialysis Population using Different Clinical Tools

BACKGROUND: End stage kidney disease (ESKD) patients receiving maintenance hemodialysis (HD) face an elevated bleeding risk. There are the factors such as body mass index (BMI), comorbidities, and medications such as antiplatelet, anticoagulants, and nonsteroidal anti-inflammatory drugs that increase the bleeding risk. The validity of bleeding risk assessment tools in the ESKD population needs to be studied. MATERIALS AND METHODS: This was a prospective, observational study in a HD unit at a tertiary care teaching hospital in Ajman. Sixty adult patients on regular maintenance HD sessions were included in the study. Severity of bleeding was categorized based on the World Health Organization (WHO) classification. Each patient’s risk of bleeding was assessed monthly using 9 different bleeding risk assessment tools (HASBLED, ATRIA, HEMORR2HAGES, ORBIT, IMPROVE, OBRI, S2TOP-BLEED, intracranial-B2 LEED3S, and Glasgow Blatchford Score for gastrointestinal bleeding) for 6 months’ period. Patients were categorized into low- and high-risk groups according to their risk scores. The predictive power of risk assessment tools was assessed by calculating its sensitivity and specificity. Receiver operating characteristic (ROC) curve was plotted, and the area under the curve was estimated for each risk assessment tool. Logistic regression model was also done using the SPSS software version 29. RESULTS: The mean age of the study group was 56 years, and the average BMI was 27 kg/m2. A total of 20 bleeding events were reported among ten patients (16.7%). The WHO category 1 and WHO category 2 bleeding were observed in 15 and 5 bleeding events, respectively. None had category 3 or 4 bleeding. Bleeding risk was found to be associated with ethnicity and obesity but not to other patient demographic factors or medication use. Based on sensitivity, specificity, positive predictive value, negative predictive value, and the area under the ROC curve, HEMORR2HAGES score showed better prediction of bleeding risk compared to the other tools used. CONCLUSION: In conclusion, most of the risk assessment tools showed poor predictive value in the maintenance HD population. Existing bleeding risk tools may not be helpful in dialysis patients. A more valid bleeding risk tool needs to be developed for the ESKD patient population.