Regular Hemodialysis Treatment Research Articles

#879 Impacts on ionized magnesium and total magnesium by the conversion to higher dialysate magnesium concentration

Abstract Background and Aims Hypermagnesemia is detrimental to hemodialysis patients whose renal function is compromised. However, recent observational study suggested the lower mortality rate was observed in the patients with mild hypermagnesemia. Even though the serum magnesium concentration (tMg) of the patients were frequently higher than the reference range of the tMg, one study reported 90% of the cases were within the reference range of the ionized magnesium (iMg) which is a physiologically active fraction of magnesium (Mg) in the blood. This is due to the higher serum phosphorous level in the hemodialysis patients, and negative correlation between iMg and the serum phosphorous, and anion gap. Current guideline recommends Mg level should be managed to be 3.0 mg/dL at pre-dialysis blood test. However, not much are known what iMg level is optimal. This study aimed to assess the impacts on iMg and tMg level of the patients by the conversion of the routinely-used dialysate containing 1.0 mEq/L (0.5 mmol/L) Mg to higher dialysate Mg concentration. Method This longitudinal study was conducted at Shingashi Renal Centre, Fujimino Renal Centre, and Kawagoe-minami Renal Centre. Out of 289 stable maintenance hemodialysis patients agreed to participate in the study, 42 were excluded due to death, changing hospital, or hospitalization. A total of 247 patients who are on regular hemodialysis treatment at least 6 months with commercially available dialysate mixture TA1 (Mg concentration: 1.0 mEq/L (0.5 mmol/L)) were included for the analysis. Dialysate Mg concentration was then increased to 1.25 mEq/L (0.625 mmol/L) by using a commercially available dialysate mixture TA5. Blood tests were carried out on the day of the first hemodialysis session of the week (Monday or Tuesday) before dialysate Mg concentration conversion and at 1, 4, 12, and 24 weeks. The iMg concentrations were analyzed using the ion-selective electrode on blood gas analyzer StatProfile Prime Plus (Nova Biomedical, Waltham, MA, USA). The tMg concentrations were determined by using Xylidylblue. Results Mean age of the 247 enrolled patients was 70.3ion-selective electrode on blood gas analyzer StatProfile Prime Plus (Nova Bidecreased significantly (TA1-pre:2.58±0.36mg/dL→TA1-post:2.18±0.16mg/dL, TA5-pre (24wk): 2.74±0.35mg/dL→TA5-post: 2.44±0.15mg/dL). After conversion to higher Mg dialysate TA5, post-dialysis tMg increased in comparison with TA1. After conversion to the higher Mg dialysate, iMg increased as well significantly (TA1-pre:0.64±0.11mmol/L→TA1-post:0.49±0.05mmol/L, TA5-pre:0.70±0.11mmol/L→0.60±0.04mmol/L) . However, iMg of TA1-post was close to the lower limit of the reference range of iMg (Fig. 1). Conclusion Hemodialysis patients’ iMg level became manageable within reference range by the conversion of the dialysate from TA1 to TA5 and the clinical advantage of iMg monitoring with hemodialysis patients were demonstrated. A slight increase in dialysate Mg concentration from 1.0 mEq/L to 1.25 mEq/L increased the iMg/tMg ratio, and iMg was within the normal range even when the pre-dialysis reference value of 3 mg/dL was not reached.

#2870 Association between frailty and a history of falls in patients on hemodialysis

Abstract Background and Aims Patients with end-stage renal disease on hemodialysis have a higher prevalence of frailty that is associated with relevant outcomes such as disability, hospitalization, and mortality. Moreover, these patients have musculoskeletal and physical function impairments that contribute to a higher risk of falling. Therefore, the aim of this study was to evaluate the association between frailty and a history of falls in patients on hemodialysis. Method This cross-section multicenter study included patients aged ≥18 years who were undergoing regular hemodialysis treatment for at least three months. Patients were excluded if presented severe and unstable comorbidities, psychiatric or cognitive disorders, and physical limitations including neurological, musculoskeletal and osteoarticular diseases which prevented the correct execution of the physical function tests. Frailty was assessed by Fried phenotype and the criteria were as follows: unintentional weight loss ≥ 4.5 kg in the past year; exhaustion was assessed using the vitality domain of the SF-36 quality of life questionnaire; weakness was measured using a handgrip dynamometer; walking speed was assessed by timing the 4.6 m distance covered at the participant's normal pace; and physical activity level was measured by the Human Activity Profile questionnaire. Patients were stratified into three groups: a score of 0/5 for non-frail, a score of 1-2/5 for pre-frail, and a score of 3-5/5 for frail. The retrospective history of falls was assessed for the last 12 months, and a fall was defined as an “unexpected event in which the individual comes to rest on the ground, floor or lower level”. The association between frailty stratification and a history of falls was analyzed using multivariate multinomial logistic regression model with non-frail group as reference. Then, a model adjusted for potential confounders was constructed. Results This study included 199 patients (59.1 ± 12.5 years, 41.2% female). The prevalences of frailty and pre-frailty were 17.6% and 54.8%, respectively. Patients classified as non-frail showed lower prevalence of a history of falls compared to patients classified as pre-frail and frail (26%, 36% and 54%, respectively, p < 0.001). The absence of a history of falls decreased the chance of patients being classified as frail (OR = 0.23, 95% CI = 0.07-0.78, p = 0.018). After adjusting for age, educational level, time on dialysis, hemoglobin and presence of cardiovascular disease, this association remained significant (OR = 0.16, 95% CI = 0.04-0.57, p = 0.005). Conclusion The prevalence of pre-frailty was approximately three times higher than that of frailty in patients on hemodialysis. A history of falls was associated with frailty in these patients.

Development and validation of a model for predicting the risk of cardiovascular events in maintenance hemodialysis patients

The mortality rates for patients undergoing hemodialysis (HD) remain unacceptably high compared to the general population, and more specific information about the causes of death is not known. The study aimed to develop and validate a risk prediction model that uses common clinical factors to predict the probability of cardiovascular events in maintenance hemodialysis (MHD) patients. The study involved 3488 adult patients who received regular scheduled hemodialysis treatment at 20 hemodialysis centers in southwest China between June 2015 and August 2020, with follow-up until August 2021. The optimal parameter set was identified by multivariable Cox regression analyses and Cross-LASSO regression analyses and was used to establish a nomogram for predicting the risk of cardiovascular events in maintenance hemodialysis patients at 3 and 5 years. The performance of the model was evaluated using the consistency index (Harrell’s C-index), the area under the receiver operating characteristic (ROC) curve, and calibration plots. The model was validated by tenfold cross-validation and bootstrapping with 1000 resamples. In the derivation cohort, the model yields an AUC of 0.764 [95% confidence interval (CI), 0.737–0.790] and 0.793 [CI, 0.757–0.829] for predicting the risk of cardiovascular events of MHD patients at 3 and 5 years. In the internal validation cohort AUC of 0.803 [95% CI, 0.756–0.849], AUC of 0.766 [95% CI, 0.686–0.846], and the external validation cohort AUC of 0.826 [95% CI, 0.765–0.888], AUC of 0.817 [95% CI, 0.745–0.889] at 3 and 5 years. The model’s calibration curve is close to the ideal diagonal. By tenfold cross-validation analyses, the 3- and 5-year risk of cardiovascular events (AUC 0.732 and 0.771, respectively). By the bootstrap resampling method, the derivation cohort and validation cohort (Harrell’s C-index 0.695 and 0.667, respectively) showed good uniformity with the model. The constructed model accurately predicted cardiovascular events of MHD patients in the 3rd and 5th years after dialysis. And the further research is needed to determine whether use of the risk prediction tool improves clinical outcomes.

Complement-mediated dialysis reaction during regular hemodialysis treatment: a case report

BackgroundHemodialysis reactions (HDRs) are similar to complement activation-related pseudo allergy (CARPA), a hypersensitivity reaction that occurs when administering certain (nano)drugs intravenously. The pathomechanism of CARPA was described based on animal experiments. Typical CARPA-like dialysis reactions, which occur at the start of hemodialysis, have been reported using polysulfone dialyzers. However, to our knowledge, this is the first dialysis reaction that occurred towards the end of hemodialysis treatment.Case presentationThis report describes a 52-year-old Caucasian male patient who had been receiving chronic hemodialysis for 3 years and exhibited a CARPA reaction during his third hour of treatment. Upon activation of the microbubble alarm, the extracorporeal system recirculated for five minutes. Following reconnection, the patient exhibited a drop in systemic blood pressure, chest pain, and dyspnea after five minutes. Symptoms disappeared spontaneously after reducing the speed of the blood pump, placing the patient in a Trendelenburg position, and administering a bolus infusion from the dialysis machine. The remaining dialysis treatment was uneventful.ConclusionNumerous case reports about reactions occurring with modern high-efficiency polysulfone dialyzers have been published. However, due to changes in the material structure by the manufacturers, we have not encountered such cases lately. The recently reported increase in thromboxane-B2 and pulmonary arterial pressure and complement activation upon re-infusion of extracorporeal blood following dialysis may explain the reaction observed here.

Social support, family resilience and psychological resilience among maintenance hemodialysis patients: a longitudinal study

BackgroundPsychological distress is common in maintenance hemodialysis patients, and high psychological resilience can promote psychological well-being. The current research focuses on psychological resilience protective factors such as family resilience and social support. However, the trajectories of psychological resilience, family resilience, and social support over time and their longitudinal relationships in maintenance hemodialysis patients have not been fully explored yet. Therefore, this study aims to explore the longitudinal relationship between these factors.MethodsPatients who received regular hemodialysis treatment for more than three months at dialysis centers of three tertiary hospitals in Zhejiang, China, were recruited from September to December 2020. A total of 252 patients who met the inclusion and exclusion criteria completed three follow-up surveys, including social support, family resilience, and psychological resilience assessments. A repeated measures ANOVA was used to explore differences in their respective scores at different time points. The cross-lagged analysis was performed in AMOS using the maximum likelihood method to examine the the reciprocal predictive relationships between these factors.ResultsSocial support and psychological resilience remained relatively stable over time, whereas family resilience indicated a little increasing trend. According to the cross-lagged analysis, higher T1 social support predicted higher family resilience at T2 [β = 0.123, 95% CI (0.026–0.244)]. Further, the effects of T2 social support to T3 family resilience [β = 0.194, 95%CI (0.039–0.335)] and psychological resilience [β = 0.205, 95%CI (0.049–0.354)] were significant. Finally, the effects of T2 family resilience to T3 social support [β = 0.122, 95%CI (0.010–0.225)] and psychological resilience [β = 0.244, 95%CI (0.119–0.359)] were also significant.ConclusionsThe study showed that the directionality of the relationship appears to be from social support or family resilience to patients’ psychological resilience but not vice versa. This finding reminds healthcare professionals to emphasize the vital role of social and family resources in providing appropriate support and interventions for maintenance hemodialysis patients to promote psychological resilience and mental health development.

#4487 AN UNEXPECTED CASE OF 2,8-DIHYDROXYADENINE NEPHROPATHY AFTER KIDNEY TRANSPLANTATION RELATED TO NEW VARIANTS OF ADENINE PHOSPHORIBOSILTRANSFERASE GENE

Abstract Background and Aims Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive disorder of the purine metabolism which results in the conversion of adenine into 2,8 dihydroxyadenine (DHA) due to the activity of the xanthine oxidoreductase (XOR). Patients affected by APRT deficiency if not treated with inhibitors of XOR may develop 2,8-DHA nephropathy that might progress to end-stage kidney disease (ESKD) with the need of kidney transplant. The high rate of misdiagnosis of 2,8-DHA nephropathy in native kidneys could lead to the failure of kidney graft in transplanted patients affected by APRT deficiency. Method Here, we report the case of a female, 63-years old patient with ESKD of unknown cause on regular hemodialysis treatment from 2018 after a period of three years on peritoneal dialysis, who underwent kidney transplantation in our Center in 2022. Her medical history showed a metabolic syndrome. She did not experience episodes of renal colic whereas family history reported a brother affected by frequent renal colic of unknown cause. In March 2022, she underwent kidney transplantation from a deceased death brain donor. Induction therapy includes basiliximab, tacrolimus, mycophenolic acid and steroids. Due to the persistence of delay graft function, ten days after kidney transplantation an allograft biopsy has been performed. The histological examination revealed tubular damage surrounded by inflammation cells and intratubular crystals in the renal cortex. The crystals were reddish brown tinged in hematoxylin and eosin stain and were birefringent under polarized light Fig. 1 A, B, so they were strongly related to the hypothesis of DHA crystals. Consistently, the urinalysis showed yellow-brown crystals of DHA. Thus, a genetic analysis of APRT gene has been performed showing two novel heterozygous variants c.388_397p.(Leu130ValfsTer4) and exon 3 deletion, expected pathogenic. The patient was treated with bolus of methylprednisolone (4mg/kg alternate to 50 mg) and a therapy with febuxostat 80 mg/die was started to reduce the amount of plasma DHA. In addition, based on our previous experience of recurrence DHA nephropathy after transplantation, we treated the patient with six consecutive hemodiafiltration (HDF) sessions without ultrafiltration, to promptly remove the serum DHA avoiding their precipitation in the graft while waiting for the lowering effect of febuxostat. At discharge the patient showed an increase of the urine output not associated with a complete recovery of kidney function (sCr 3.88 mg/dl, uric acid 1.6 mg/dl), so two other hemodialysis treatments were performed in the next two weeks. Results At present, almost one year after kidney transplant, the patient is doing well and the graft function is stable with a sCr of 1.6 mg/dl without significant presence of DHA crystals in the urine. Conclusion In conclusion, we find out an unexpected recurrence of 2,8-DHA nephropathy due to novel expected pathogenetic variants of APRT gene in patient without medical history of kidney stones successfully treated with steroid, febuxostat and hemodiafiltration.

#3798 A MULTICENTER CLINICAL STUDY OF CELLULOSE TRIACETATE MEMBRANES AND POLYSULFONE MEMBRANE DIALYZERS IN MAINTENANCE HEMODIALYSIS PATIENTS

Abstract Background and Aims With the continuous improvement of dialysis membrane materials, polysulfone (PS) has replaced traditional cellulose membranes with excellent biocompatibility and dominates the market applications. In our clinical work, we found that the allergic reaction disappeared after the application of cellulose triacetate (CTA) in patients who were allergic to PS. In this study, we compared the differences in biocompatibility and solute clearance of CTA and PS dialyzers during long-term dialysis treatment. Method In this study, a multicenter clinical study was conducted, and patients attending Fuxin Mining Bureau Hospital, Northeast International Hospital and Shenyang Medical College Affiliated Central Hospital receiving maintenance hemodialysis from April 2019 to April 2020 were selected as the study population. The patients were divided into a polysulfone membrane group (n = 10) and a cellulose triacetate membrane group (n = 13) based on whether they tolerated the polysulfone membrane dialyzer, and all patients in the CTA group had an allergic reaction to the polysulfone membrane dialyzer. The effects of the two membranes on White Blood Cell (WBC), platelet (PLT), Hemoglobin(Hb), Complement3(C3), Complement4(C4), Tumor Necrosis Factor-α (TNF-α), Interleukin-1 (IL-1), interleukin-6 (IL-6), hypersensitive C-reactive protein (hs CRP), IgE, serum phosphorus (P), creatinine (CR), blood urea nitrogen (BUN), parathyroid hormone (PTH) were compared before and after the single dialysis session and after 12 months of dialysis,and Urea removal rate (URR) and spKt /V were calculated. Results There were no statistically significant differences between the two groups in the comparison of basic information such as age, gender, dialysis age and primary disease. Before the application of CTA and PS dialyzer treatment, there was no statistically significant comparison between groups for all observed indicators. After application of CTA and PS single dialysis: (i) The difference between the 2 groups of β2-MG (Z = -2.039, P = 0.041) and TNF-α (Z = -2.491, 0.013) was statistically different. (ii) There were no statistically significant differences between two groups in the comparison of hematological system, such as WBC, PLT, HB; complement, such as C3, C4; inflammatory factors, such as: IL-1, IL-6, hs CRP, IgE; uremic toxins, such as: P, CR, BUN, PTH (P>0.05). After the 12th month of regular hemodialysis treatment with PS and CTA: (i) The differences between the 2 groups for P (Z = -2.096, P = 0.036), BUN (Z = -2.038, P = 0.042), and spKt/V (t = -2.147, P = 0.049) were statistically significant. (ii) The difference between the 2 groups after 12 months of dialysis P (t = 0.114, P = 0.041) and before dialysis was statistically different between groups, and the other indexes mentioned above were not statistically different. Conclusion After a single dialysis session, TNF-αin the PS group was elevated and the biocompatibility of CTA was better than PS. The CTA group had better clearance of β2-MG than PS, and spKt/V reached the standard. After long-term dialysis, the effect of CTA on inflammation and complement system was not different compared with PS, and there was no difference in biocompatibility between the two membranes. spKt/V in the CTA group reached the standard, and the clearance of BUN and P was better than that of PS.

#6447 ASSOCIATION BETWEEN PHYSICAL ACTIVITY LEVEL AND A HISTORY OF FALLS IN PATIENTS ON HEMODIALYSIS

Abstract Background and Aims Patients with end-stage renal disease on hemodialysis have a lower physical activity level in daily life and a higher prevalence of sedentary lifestyle. Moreover, these patients have clinical, musculoskeletal, and physical function complications that contribute to a higher risk of falling. Therefore, the aim of this study was to evaluate the association between physical activity level and a history of falls in a retrospective 12-month interval in patients on hemodialysis. Method A retrospective study was conducted with patients aged ≥18 years who were undergoing regular hemodialysis treatment for at least three months. Patients were excluded if presented severe and unstable comorbidities, psychiatric or cognitive disorders, uncorrected visual impairments, and hospitalization in the past three months. The retrospective history of falls was assessed for the last 12 months, and a fall was defined as an “unexpected event in which the individual comes to rest on the ground, floor or lower level”. The daily step counts were recorded in the ActiGraph accelerometer (wGT3X-BT) during seven days, and analyzed by excluding the first and last day of recording and calculating the mean among the valid days (≥ 8 hours of wear time). Normality of data was analyzed using the Shapiro-Wilk test. The Student's t-test and the Mann-Whitney U test were used for between-group comparisons (patients with and without a history of falls). The univariate and multivariate linear regression models investigated the association between daily step counts and a history of falls. A p value <0.05 was considered as statistically significant. Results This study included 103 patients (59.2 ± 12.6 years, 59.2% male). Of these patients, 49.5% had a history of falls. Patients with a history of falls showed lower prevalence of workers (9.8% vs. 26.9%, p = 0.025) and daily step counts [2989 (2595) vs. 4550 (2966) steps, p = 0.018], and higher educational level [9 (7) vs. 5 (5) years, p = 0.033] compared to patients without a history of falls. The univariate linear regression model showed that daily step counts was significantly associated with a history of falls (p = 0.017). After adjusting for age, gender, educational level, work status, hemoglobin, and diabetes mellitus, this association remained significant in multiple linear regression model with a coefficient of determination of 0.21 and an adjusted coefficient of determination of 0.16 (p = 0.001). Conclusion Physical activity level was associated with a history of falls in a retrospective 12-month interval in patients on hemodialysis.

Patients with end-stage renal disease requiring hemodialysis benefit from percutaneous coronary intervention after non-ST-segment elevation myocardial infarction.

Percutaneous coronary intervention (PCI) treatment significantly improves outcomes after acute myocardial infarction (AMI). It remains unclear whether the benefits of PCI exist in patients with end-stage renal disease (ESRD) and non-ST-segment elevation myocardial infarction (NSTEMI). The present study was designed to investigate the effects of PCI on the short- and long-term prognosis of patients with ESRD and NSTEMI. We conducted a retrospective study from 1 January 2015 to 1 January 2020, which includes 148 consecutive patients with ESRD and NSTEMI. All patients were estimated glomerular filtration rate (eGFR) < 15mL/min/1.73 m2 and had received regular hemodialysis treatment before hospitalization. Logistic regression analyses were used to identify the risk factors for in-hospital mortality. Cox proportional hazard model was used to identify independent predictors of 1-year major adverse cardiac events (MACE). In this study, 62 patients received PCI treatment. Univariable logistic regression analysis showed that PCI treatment was associated with the trend of reduction in the risk of in-hospital mortality (11.3% vs 43%, P = 0.022), but was not independently related to lower in-hospital mortality risk after multivariable logistic regression analysis (P = 0.131). After a 1-year follow-up, Kaplan-Meier survival analysis demonstrated that MACE rate was significantly lower in patients with ESRD and NSTEMI who had received PCI treatment during hospitalization (P < 0.001). After multivariate Cox proportional hazard analysis, no PCI treatment was independently associated with 1-year MACE (hazard ratios 3.217, 95% CI 2.03-8.489, P = 0.003). PCI treatment during hospitalization is associated with reduced 1-year MACE in patients with ESRD and NSTEMI, which suggests that more aggressive therapies may be beneficial for this special higher risk population.

A study of Thyroid dysfunction in patients with chronic kidney disease undergoing maintenance haemodialysis among the patients of tertiary care hospital

Introduction: Thyroid hormones are necessary for the growth and development of the kidney and for the maintenance of water and electrolyte homeostasis. The kidney normally contributes to the clearance of iodine, primarily by glomerular filtration. Thus iodide excretion is diminished in advanced renal failure, leading sequentially to an elevated plasma inorganic iodide concentration and an initial increment in thyroidal iodide uptake. Materials and Methods: The present study was conducted in a tertiary care hospital in Belagavi, Karnataka State. 50 cases that were on regular maintenance hemodialysis treatment were selected and 50 controls were taken for study. Age & sex matched controls with normal renal function and no previous history of thyroid dysfunction was included in the study as controls. The quantitative determination of serum T3, T4 & TSH was done. The assay principle combines a one step enzyme immunoassay sandwich method with a final fluorescent detection (ELFA). Serum urea and creatinine was estimated by urease/glutamate dehydrogenase method and modified. Results: There was a significant difference between the control and study group with respect to serum TSH & T3 levels, serum T4 levels were found to be not statistically significant. The serum TSH level was increased in 8 patients (16%) among those with CKD; the mean serum TSH concentration was 5.49±11.03 in CKD patients which was significantly increased than in controls (3.27±2.06). Serum T3 concentration was less than the normal range in 10 of the 50 (20%) CKD patients, the mean serum total T3 concentration was 1.69±0.67 in CKD patients was significantly lower than that in the control subjects (2.03±1.2). Serum concentration of T4 was less in cases (81.34±23.87) than in controls (101.41±19.12) but the results were statistically not significant (P=0.083). Conclusion: The present study finds thyroid dysfunction to be very common in CKD patients and reveals the significant association between CKD progression and thyroid dysfunction and mean of T3, T4 decreases and TSH increases significantly in cases as compared to controls. The diagnosis of hypothyroidism can be easily missed in Haemodialysis patients. Timely diagnosis and treatment of hypothyroidism may prevent deterioration of the patient’s condition and prolong survival.

Time-series deep survival prediction for hemodialysis patients using an attention-based Bi-GRU network

Background and objectiveThe number of end-stage renal disease (ESRD) patients treated with hemodialysis (HD) has significantly increased, but the prognosis remains poor. Time-series features have been included in only a few studies to predict HD patient survival, and how to utilize such features effectively remains unclear. This article aims to develop a more accurate, interpretable, and clinically practical personalized survival prediction model for HD patients. MethodsThis study proposed and evaluated an attention-based Bi-GRU network using time-series features for survival prediction. A distance-based loss function was proposed to improve performance. We used data from 1232 ESRD patients who received regular hemodialysis treatment for ≥ 3 months from 2007 to 2016 at the First Affiliated Hospital of Zhejiang University. The proposed model was compared with representative sequence modeling deep learning architectures and existing survival analysis methods in terms of the C-index and IBS value. Post hoc tests were used to test statistical significance. The attention map was used to assess feature importance over time. The impact of time-series changes on survival was investigated after controlling initial values (using BMI as an example). ResultsThe proposed method outperformed other sequence modeling architectures and the state-of-the-art survival analysis approaches in terms of the C-index and the integrated Brier score (IBS) value. Our method achieved a C-index of 0.7680 (95% confidence intervals [CI]: 0.7645, 0.7716) and an IBS of 0.1302 (95% confidence intervals [CI]: 0.1292, 0.1313), showing an improvement of up to 5.4% in terms of the C-index and a decrease of 3.2% in terms of the IBS value. The addition of the distance-based loss function improved the performance. The predicted risk and actual risk levels closely agreed. This study also found that even after controlling the initial body mass index (BMI) values, different 3-month BMI trends could produce different survival outcomes. ConclusionsThis study proposed a more effective and interpretable method to use time-series information in survival analysis. The proposed method may help promote personalized medicine and improve patient prognosis.

Feasibility of remote speech analysis in evaluation of dynamic fluid overload in heart failure patients undergoing haemodialysis treatment.

AimsThis study aimed to assess the ability of a voice analysis application to discriminate between wet and dry states in chronic heart failure (CHF) patients undergoing regular scheduled haemodialysis treatment due to volume overload as a result of their chronic renal failure.Methods and resultsIn this single‐centre, observational study, five patients with CHF, peripheral oedema of ≥2, and pulmonary congestion‐related dyspnoea, undergoing haemodialysis three times per week, recorded five sentences into a standard smartphone/tablet before and after haemodialysis. Recordings were provided that same noon/early evening and the next morning and evening. Patient weight was measured at the hospital before and after each haemodialysis session. Recordings were analysed by a smartphone application (app) algorithm, to compare speech measures (SMs) of utterances collected over time. On average, patients provided recordings throughout 25.8 ± 3.9 dialysis treatment cycles, resulting in a total of 472 recordings. Weight changes of 1.95 ± 0.64 kg were documented during cycles. Median baseline SM prior to dialysis was 0.87 ± 0.17, and rose to 1.07 ± 0.15 following the end of the dialysis session, at noon (P = 0.0355), and remained at a similar level until the following morning (P = 0.007). By the evening of the day following dialysis, SMs returned to baseline levels (0.88 ± 0.19). Changes in patient weight immediately after dialysis positively correlated with SM changes, with the strongest correlation measured the evening of the dialysis day [slope: −0.40 ± 0.15 (95% confidence interval: −0.71 to −0.10), P = 0.0096].ConclusionsThe fluid‐controlled haemodialysis model demonstrated the ability of the app algorithm to identify cyclic changes in SMs, which reflected bodily fluid levels. The voice analysis platform bears considerable potential as a harbinger of impending fluid overload in a range of clinical scenarios, which will enhance monitoring and triage efforts, ultimately optimizing remote CHF management.

The Role of Oxidative Stress Markers in Predicting Acute Thrombotic Occlusion of Haemodialysis Vascular Access and Progressive Stenotic Dysfunction Demanding Angioplasty.

Haemodialysis vascular access (VA) dysfunction is a major cause of morbidity in haemodialysis (HD) patients. Primary venous outflow occlusion and restenosis after percutaneous transluminal angioplasty (PTA) are two major obstacles for the long-term use of dialysis VA. It remains unclear whether oxidative stress markers can be used as predictors for thrombotic occlusion of VA and progressive stenosis dysfunction demanding PTA. All routine HD patients at one teaching hospital participated in this study including ankle-brachial index (ABI) examinations and serum oxidative stress markers. The serum oxidative stress markers (high-sensitivity C-reactive protein (hs-CRP), matrix metalloproteinase-2 (MMP-2), MMP-9, homocysteine, asymmetrical dimethylarginine (ADMA), nitrate oxidase (NO), tumour necrosis factor-α (TNF-α), monocyte chemotactic protein 1 (MCP-1), interleukin-1β (IL-1β), and transforming growth factor-β (TGF-β)) were measured using immunosorbent assays in 159 HD patients (83 men and 76 women; mean age: 65 ± 12 years). The participants met the following criteria: (1) received regular HD treatment for at least 6 months, without clinical evidence of acute or chronic inflammation, recent myocardial infarction, unstable angina or circulatory congestion; and (2) received an arteriovenous fistula (AVF)/arteriovenous graft (AVG: polytetrafluoroethylene, PTFE) as the current VA for more than 6 months, without interventions within the last 6 months. All the participants were followed up clinically for up to 12 months to estimate the amount of primary thrombotic occlusion and VA dysfunction demanding PTA. During the 12-month observation, 24 patients (15.1%) had primary thrombotic occlusion of VAs. Another 24 patients (15.1%) required PTA because of clinical dysfunction of access. Additionally, during the follow-up period, restenosis occurred in 12 patients (50% of 24 patients). The access types of arteriovenous grafts (AVGs) and a diagnosis of peripheral arterial occlusive disease (PAOD) were two strong predictors for acute thrombotic events of VA (hazard ratio (HR): 16.93 vs. 2.35; p < 0.001 vs. 0.047). Comparing dysfunctional with non-dysfunctional VAs, up to 27.7% of patients with high levels of ADMA (>0.6207 μM, N = 65) received required PTA compared with 4.4% of those with low levels (≤0.6207 μM; N = 90; p < 0.001). In multivariate analysis, the plasma baseline levels of ADMA independently conferred nearly 4.55 times the risk of primary stenotic dysfunction of HD VA (HR: 4.55; 95% confidence interval: 1.20 to 17.26; p = 0.026). In conclusion, our findings suggest the role of ADMA in the development of symptomatic VA dysfunction. Additionally, PAOD severity can be used in clinical practice to predict whether acute thrombotic occlusion of VA will easily occur in HD patients.

The function of matrix metalloproteinase-9 (MMP-9) and its tissue inhibitor (TIMP-1) in several clinical conditions: Results and analysis of our survey.

The goal of this research was to evaluate the plasma concentration of MMP-9 and its tissue inhibitor (TIMP-1) in different clinical conditions. It included several groups of subjects: 31 overweight subjects; 91 obese adults divided into two subgroups according to the BMI value (BMI 30-35 Kg/m2 and BMI > 35 Kg/m2); 90 subjects with metabolic syndrome (MS) divided into two subgroups (with and without diabetes mellitus); 100 subjects with preclinical carotid atherosclerosis (PCA) divided according to the number of cardiovascular risk factors and to the insulin resistance degree; 48 subjects with obstructive sleep apnoea syndrome (OSAS) divided according to the apnoea/hypopnea index (AHI); 27 subjects with chronic kidney disease (CKD) on conservative management; 31 subjects with CKD on regular haemodialysis treatment. We have found a significant increase of MMP-9 and TIMP-1 in overweight subjects, in obese adult and in MS subjects. In obese adults, the behaviour of these two parameters was not influenced by the degree of obesity, while in the group of MS subjects both these parameters were clearly influenced by the presence of diabetes mellitus. In subjects with PCA, we observed an increase of MMP-9 associated with a significant decrease of TIMP-1; the same trend was found by subdividing the entire group in accordance with the number of cardiovascular risk factors and with the insulin resistance degree. In subjects with OSAS, we noted an increase in MMP-9 and TIMP-1; this increase was more evident in subjects with OSAS having AHI > 30. In individuals with CKD on conservative and haemodialysis treatment we have found, at baseline, a marked increase in MMP-9 and a significant decrease of TIMP-1. In dialyzed subjects, after a standard dialysis session was noted, a significant increase in MMP-9 was associated with a further decrease in TIMP-1.

Assessment of lens autofluorescence in patients with well-controlled essential hypertension and those with renal failure secondary to hypertension undergoing hemodialysis.

To compare the lens autofluorescence (AF) levels among patients with end-stage renal failure and undergoing hemodialysis secondary to hypertension, patients with well-controlled hypertension, and healthy controls. This study was a prospective, cross-sectional, comparative study conducted between February and April 2018. Two groups of patients and a group of healthy individuals were included in the study. The first group of patients included individuals with a renal insufficiency due to essential hypertension who underwent regular hemodialysis treatment (dialysis group). The second group included patients with well-controlled essential hypertension (hypertension group). Lens autofluorescence was measured via a scanning confocal lens fluorescence biomicroscope optical system for all participants. The measurement of fluorescence ratio is given as a numerical data. The AF results were compared in all groups. The study included 87 individuals. There were 29 individuals (33.3 %) in the dialysis group, 30 (34.5 %) in the hypertension group, and 28 (32.2 %) in the healthy group. The mean fluorescence ratio(FR) was 0.20 ± 0.06, 0.20 ± 0.04, and 0.17 ± 0.04 in the dialysis, hypertension, and healthy groups respectively. There was a significant difference in the mean FR measurements between the three groups (p = .004). As a result of a binary comparison, mean FR values for patients in the dialysis group were higher (0.20 ± 0.06) than for healthy individuals (0.17 ± 0.04), which was statistically significant (p = .025). Mean FR measurements of hypertensive patients were higher (0.20 ± 0.04) than healthy individuals (0.17 ± 0.04), which was also statistically significant (p = .02). However, there was no statistically significant difference among the mean FR measurements between the hypertension and dialysis groups (p = .63). We demonstrated that lens autofluorescence increased in patients with renal failure undergoing hemodialysis and those with well-controlled hypertension. The mean lens autofluorescence levels were significantly higher in both patient groups than the healthy control group.

Social Support, Sense of Coherence, and Self-Management among Hemodialysis Patients.

Self-management is essential for patients who require regular hemodialysis treatment. This study aimed to explore the relationships between social support, sense of coherence (SOC), and self-management in hemodialysis patients and to examine whether SOC plays a mediating role. In a cross-sectional study, 402 hemodialysis patients from four tertiary hospitals were recruited. Data were analyzed using structural equation modeling. Social support, SOC, and self-management were significantly correlated with each other. The proposed model provided a good fit to the data. Social support had a direct effect on self-management and SOC, partially mediated the effect of social support on self-management (β = 0.248, p = 0.001). Social support and SOC explained 69% of the variance in self-management. Our findings indicate that health care providers can enhance social support with an emphasis on strengthening SOC strategies to better improve self-management in hemodialysis patients.

Glucose tolerance in patients with and without type 2 diabetes mellitus during hemodialysis

AimsThe disposal of a glucose bolus was studied to identify glucose metabolism in patients with and without type 2 diabetes mellitus (T2DM) during their regular hemodialysis (HD) treatment. MethodsPlasma glucose, insulin, and c-peptide concentrations were measured during a 60 min observation phase following a rapid glucose infusion (0.5 g/kg dry weight). Glucose disposition and elimination rates were determined from kinetic analysis, and insulinogenic index was calculated. Insulin resistance (RHOMA) was determined by homeostatic model assessment (HOMA). Results35 HD patients (14 with T2DM) distinguished by a higher age (median: 70 vs. 55 y, p < 0.01) in T2DM patients were studied. Glucose kinetic data showed only small differences between patients with or without T2DM, but as RHOMA measured in all patients increased, a larger fraction of glucose was removed by the extracorporeal system (r = 0.430, p = 0.01). One hour after glucose bolus injection the glucose level was not different from that before HD also in patients with T2DM (p = 0.115). ConclusionsThe larger glucose amount recovered in dialysate in patients with increasing RHOMA indicates that impaired glucose disposal could be measured during HD using a non-invasive dialysis quantification approach without blood sampling. Glucose infusion during HD is safe also in patients with T2DM.

Safe Needling of Arteriovenous Fistulae in Patients on Hemodialysis: Literature Review and a New Approach

Although buttonhole cannulation has some benefits compared to rope-ladder cannulation, the increase of infection rates represents a major obstacle to patient safety, and its use is questionable in routine clinic practice. On the other hand, rope-ladder cannulation is difficult to implement even with a prescribed protocol, leading the cannulator in daily practice to a possible use of the area technique. This article provides a reflection on the impact of cannulation technique on the safety of patients on regular hemodialysis treatment and describes a new approach for arteriovenous fistula cannulation, the Multiple Single Cannulation Technique (MuST). The MuST has not been described before, but it has been used with promising results. Further studies are needed to confirm the benefits of this cannulation technique.

1-7PROFILE OF HYPERTENSION IN HEMODIALYSIS PATIENTS IN CIKINI CCI HOSPITAL: A DESCRIPTIVE STUDY

Background: Chronic kidney disease (CKD) is one of the most common health problems in Indonesia. Some CKD patients may develop to end-stage renal disease (ESRD), which requires renal replacement therapy such as hemodialysis. Many people with ESRD have hypertension. There was no research about the profile of hypertension in hemodialysis patients in Cikini CCI hospital before. Objective: To study hypertension among hemodialysis patients in Cikini CCI hospital. Method: This is a cross-sectional descriptive study. The subjects of the study are ESRD adult patients on the regular hemodialysis treatment in Cikini CCI hospital. Data were obtained from 121 patients from July to December 2019. The medical record of each patient was reviewed to identify the hypertension of ESRD. We studied the hypertension profile on hemodialysis patients such as hypertension in gender, age group, how long they take hemodialysis, and frequencies in a week. Result: The result showed that 106 patients (87.6%) are hypertension. Most of the patients were male (53.7%). Most of hypertension in the age between 40 to 60 years old (49%). Based on the duration of hemodialysis, the majority of hypertension was found in patients undergoing hemodialysis for less than one year (53.7%). Hypertension is more common in the group that doing hemodialysis three times a week (80.1%) rather than twice a week (19.8%). Conclusion: Hypertension is almost found in the majority of patients undergoing hemodialysis in Cikini CCI hospital.

P1351MARKERS FOR AVF DYSFUNCTION; A RETROSPECTIVE ANALYSIS

Abstract Background and Aims The native Arterio venous fistula (AVF) is the recommended first choice for regular hemodialysis treatment. However, its patency is mainly limited due to stenosis and thrombosis, leading to insufficient dialysis, costly interventions, subsequent in-hospital care and follow ups. Primary aim: To find medical or laboratory markers associated with dysfunctional AVF. Method Retrospective analysis of radiologic examinations and medical records was made due to clinical suspicion of AVF dysfunction (cases) from two hospitals during 2006-2014. Comparison was made with data from 52 patients without complications (controls) with repeated blood sampling during the same period. Differences between groups were calculated with Mann- Whitney test and paired statistics with Wilcoxon U test before and after examination. Results Mean age in both groups was 65 years. In 153 patients 473 radiological examinations were performed due to clinical suspicion of dysfunction. Angiography and PTA were made when suitable according to guidelines. In 171 of these examinations no intervention was performed. Cases versus controls had lower access flow (599±442 vs 1140±523, p&amp;lt;0.001), blood pump speed (291±49 vs 313±34, p&amp;lt;0.001), PTH (31±39 vs 39±29 pmol/L, p=0,021), Ca-phosphate product (3.9±1.1 vs 4.2±1.0, p=0.025), C-reactive protein (17±25 vs 24±38, p=0.004) and, higher in regard to recirculation (5.1±11 vs 0.5±3.4, p&amp;lt;0.001), HbA1c (52±16 vs 47±17, p=0.027), dose of tinzaparin (14330±8000 vs 12743±5400U/week, p= 0.025), weekly dose of erythropoietin stimulating agent (ESA, 8900±7100 vs 4900±4600U/week, p&amp;lt;0,001), and higher weekly iron supplement dosing (60±61 vs 41±54mg/week, p&amp;lt;0.001). Alfa- and Beta-blockers against hypertension were more often used among cases. Conclusion The reason for AVF problems in cases showed limited disturbances in Ca-phosphate hemostasis and inflammation. Instead, it seems that higher dosing of ESA and LMWH (as indicator of clotting) are factors that could be associated with development of AVF malfunction.