Regular Hemodialysis Treatment Research Articles

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.

Effects of hemodialysis on plasma oxylipins.

Chronic kidney disease (CKD) is an important risk factor for cardiovascular and all‐cause mortality. Survival rates among end‐stage renal disease (ESRD) hemodialysis patients are poor and most deaths are related to cardiovascular disease. Oxylipins constitute a family of oxygenated natural products, formed from fatty acid by pathways involving at least one step of dioxygen‐dependent oxidation. They are derived from polyunsaturated fatty acids (PUFAs) by cyclooxygenase (COX) enzymes, by lipoxygenases (LOX) enzymes, or by cytochrome P450 epoxygenase. Oxylipins have physiological significance and some could be of regulatory importance. The effects of decreased renal function and dialysis treatment on oxylipin metabolism are unknown. We studied 15 healthy persons and 15 CKD patients undergoing regular hemodialysis treatments and measured oxylipins (HPLC‐MS lipidomics) derived from cytochrome P450 (CYP) monooxygenase and lipoxygenase (LOX)/CYP ω/(ω‐1)‐hydroxylase pathways in circulating blood. We found that all four subclasses of CYP epoxy metabolites were increased after the dialysis treatment. Rather than resulting from altered soluble epoxide hydrolase (sEH) activity, the oxylipins were released and accumulated in the circulation. Furthermore, hemodialysis did not change the majority of LOX/CYP ω/(ω‐1)‐hydroxylase metabolites. Our data support the idea that oxylipin profiles discriminate ESRD patients from normal controls and are influenced by renal replacement therapies.

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.

P1307HEMORRHAGIC VERSUS ISCHEMIC RISK IN PATIENTS WITH ATRIAL FIBRILLATION ON HEMODIALYSIS

Abstract Background and Aims Patients with renal replacement therapy and atrial fibrillation (AF) have a particularly high risk of both stroke and bleeding, but no high-quality evidence-based recommendations exist to properly manage these patients. Therefore, we aim to evaluate the ischaemic versus the haemorrhagic risk in a hemodialysis (HD) population. Method We selected patients that started hemodialysis in our hospital between 2011 and 2015. Only incident patients that were on regular hemodialysis treatment for more than 3 months were considered. Both patients that already had AF before HD, or developed AF during the follow-up, were included. At the time of AF diagnosis or beginning of HD, the risk factors were analyzed based on CHA2 DS2 -VASC and HAS-BLED scores. The outcomes were hemorrhagic events (only the events that needed hospitalization were taken into account), ischaemic events (i.e. that result from embolic arterial ischaemia) and death related to any of these events. Results From 302 incident patients on hemodialysis, 46 (15.23 %) were included. Mainly man (65%), with a mean age of 75 ± 10 years old. Most of the patients (63%) already had AF when they started hemodialysis. There was no significant difference between the incidence of ischaemic and haemorrhagic events (p=0.219). Three patients died of an ischemic event and two of haemorrhagic shock.Twenty one patients (45.6%) started oral anticoagulation. No difference was found between the proportion of haemorrhagic events between patients with oral anticoagulation and patients with no anticoagulation (p=0.157). Similarly, oral anticoagulation was not associated with any effect on the incidence of ischaemic events (p=0.366). The results after adjustment for the risk factors included in the HAS-BLED and CHA2 DS2-VASC scores were the same. Previous stroke, transient ischaemic attack or thromboembolic event significantly increased the risk of an ischaemic event, when adjusted to oral anticoagulation, age, diabetes, vascular disease and hypertension (OR 6.78, C.I 95% 1.236-37.278, p=0.028). This risk factor was not associated with an increase of haemorrhagic events. No other risk factor included in the scores was associated with any significant effect in the outcomes. Conclusion As we know, AF increases the risk of ischaemic events in general population. However, in hemodialysis patients, we didn’t observe any difference between the incidence of ischaemic and haemorrhagic events. Therefore, the benefit of oral anticoagulation in such patients remains questionable. It is worth noting that patients with previous stroke, transient ischemic attack or thromboembolic event seem to have higher risk of new ischaemic events. In these patients, there may be some advantage in oral anticoagulation. Since this is a single center, retrospective, observational study, these results should be interpreted with caution.

P0902DAILY TERIPARATIDE TREATMENT AND PHARMACOKINETICS IN HEMODIALYSIS PATIENTS WITH LOW BONE MASS

Abstract Background and Aims Daily 20µg teriparatide (PTH1-34) is an osteoanabolic agent approved for use treating osteoporosis. However, there are few reports about concerning use of this agent in hemodialysis patients. Method We conducted an observational study, single centre study on 5 patients with low bone mineral density (BMD) and low iPTH levels defied as iPTH below 60 pg/mL, who were treated with recombinant human PTH1-34; teriparatide 20 µg 3 times per week between January 2012 and January 2015. All patients were 20 years of age or older, had undergone regular hemodialysis treatment and were without skeletal malignancies and bone metastasis. Low BMD in this study was defined either as BMD T-score -2.5 at the lumbar spine (LS) or /and femoral neck (FN) and distal one –third radius (RS) analyzed by dual-energy X-ray absorptiometry (DXA), or BMD T-score of -2.5 to -1.0 with history of fragility fractures. We analyzed the biochemical data including bone metabolic makers (intact amino-terminal propeptide of type I collagen (iP1NP), bone alkaline phosphatase (BAP), and tartrate-resistant acid phosphatase-5b (TRACP-5b) at baseline, and after 3, 6, and 12 months of teriparatide treatment. BMD at LS and FN were evaluated at 6months of treatment. Results Data from five patients (mean age: 69.2±7.4years; mean hemodialysis time: 23.2±6.2years) were reviewed. Laboratory data at baseline were iPTH: 34.2±24.2 pg/mL, BAP: 13.0±4.9 µg/L, iP1NP: 45.3±14.3 ng/mL, TRACP-5b: 350±201 mU/dL, corrected Ca (cCa): 9.7±0.3 mg/dL, and P:4.1±0.7 mg/dL. Baseline BMD T-score at LS and FN were -2.8±1.7 and -3.0±0.6, respectively. During a 12 month- teriparatide treatment, mean cCa levels significantly decreased from 9.7±0.3 to 9.1±0.2 mg/dL at 3 months (P &amp;lt; 0.05) and returned to 9.5±0.4 mg/dL at 12 months. As for bone metabolic markers, BAP and iP1NP significantly increased from baseline by 31.3±12.9 (P &amp;lt; 0.05) and 47.4±14.5% (P &amp;lt; 0.05) at 6 months of teriparatide treatment, while TRACP-5b significantly decreased by 10.5±2.5% at 3 months, which did not reach a statistical significance. BMD changes from baseline at LS and FN were 2.1±2.5% and 1.2±1.5% at 6 months of treatment with a significant change at LS. Pharmacokinetics of Teriparatide The time-course of changes in plasma teriparatide acetate concentration was evaluated in one patient who had undergone parathyroidectomy 20 years before enrollment in this study and her serum endogenous iPTH level was undetectable at baseline. After teriparatide injection, serum teriparatide acetate levels peaked at 30 minutes at 157.2 pg/mL, and then rapidly decreased to undetectable levels at 240 minutes. Conclusion We report that teriparatide improved LS and FN BMD in hemodialysis patients with low iPTH. Pharmacokinetics showed this agent might not accumulate in dialysis patients and can be used safely. Adequate Ca supplementation might be needed to adjust serum Ca levels.

Application of health education based on self-efficacy theory in weight management of maintenance hemodialysis patients

Objective To explore the application effect of health education based on self-efficacy theory in weight management of maintenance hemodialysis patients, and to provide health education basis for weight management of hemodialysis patients. Methods Using convenient sampling method, a total of 88 patients who had regular hemodialysis treatment in Yantaishan Hospital of Yantai from February 2017 to February 2018 were selected as the study objects. According to the dialysis time, the patients were divided into the observation group (48 cases) and the control group (40 cases) . Patients in the control group were given routine nursing and health education, while in addition to this, those in the observation group were given health education based on self-efficacy theory. Before and after the intervention, the weight control effect and weight management behavior of the two groups were compared. Results At last, 36 patients in the control group and 41 patients in the observation group completed the study. Before intervention, there was no significant difference between the two groups in weight managemnt behavior score and weight control effect (P>0.05) . After intervention for two months, the percentage of weight gain in the observation group was lower than that in the control group, and the difference was statistically significant (P 0.05) . Conclusions Health education based on self-efficacy theory can improve weight control behavior and weight control effect of hemodialysis patients. Key words: Dialysis; Maintenance hemodialysis; Weight management; Self-efficacy

Ultrafiltration Rate, Residual Kidney Function, and Survival Among Patients Treated With Reduced-Frequency Hemodialysis

Patients receiving twice-weekly or less-frequent hemodialysis (HD) may need to undergo higher ultrafiltration rates (UFRs) to maintain acceptable fluid balance. We hypothesized that higher UFRs are associated with faster decline in residual kidney function (RKF) and a higher rate of mortality. Retrospective cohort study. 1,524 patients with kidney failure who initiated maintenance HD at a frequency of twice or less per week for at least 6 consecutive weeks at some time between 2007 and 2011 and for whom baseline data for UFR and renal urea clearance were available. Average UFR during the first patient-quarter during less-frequent HD (<6, 6-<10, 10-<13, and≥13mL/h/kg). Time to all-cause and cardiovascular death, slope of decline in RKF during the first year after initiation of less-frequent HD (with slopes above the median categorized as rapid decline). Cox proportional hazards regression for time to death and logistic regression for the analysis of rapid decline in RKF. Among 1,524 patients, higher UFR wasassociated with higher all-cause mortality; HRs were 1.43 (95% CI, 1.09-1.88), 1.51 (95% CI, 1.08-2.10), and 1.76 (95% CI, 1.23-2.53) for UFR of 6 to<10, 10 to<13, and≥13mL/h/kg, respectively (reference: UFR< 6mL/h/kg). Higher UFR was also associated with higher cardiovascular mortality. Baseline RKF modified the association between UFR and mortality; the association was attenuated among patients with renal urea clearance≥5mL/min/1.73m2. Higher UFR had a graded association with rapid decline in RKF; ORs were 1.73 (95% CI, 1.18-2.55), 1.89 (95% CI, 1.12-3.17), and 2.75 (95% CI,1.46-5.18) at UFRs of 6 to<10, 10 to<13, and≥13mL/h/kg, respectively (reference: UFR< 6mL/h/kg). Residual confounding from unobserved differences across exposure categories. Higher UFR was associated with worse outcomes, including shorter survival and more rapid loss of RKF, among patients receiving regular HD treatments at a frequency of twice or less per week.

Is there an association between alpha 2-Heremans-Schmid glycoprotein (AHSG) gene Thr256Ser polymorphisms with aortic calcification in regular hemodialysis patients in Medan, Indonesia.

Aim Alpha2-Heremans-Schmid glycoprotein (AHSG), a circulating plasma protein, plays an essential role in bone and vascular mineralization. The impact of AHSG gene polymorphisms on aortic calcification in haemodialysis patients was inconsistent. We performed this study to clarify precise association among AHSG gene Thr256Ser single-nucleotide polymorphisms and aortic calcification. Methods Patients on stable regular haemodialysis treatment for more than thirty months were included in a cross-sectional study at Rasyida Renal Hospital Medan. Lateral spine X-rays were performed to evaluate the aortic calcification. Genotyping for the polymorphisms was carried out using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) techniques. Results Aortic calcification was detected in 69.8% of patients. From 106 patients, 49 patients (46.2 %) had CC (Thr/Thr), 54 (51.0%) had CG (Thr/Ser) and three (2.8%) patients had GG (Ser/ Ser) polymorphism. The proportion of patients with heterozygous or homozygous G allele (CG and GG genotypes) is more likely (91.2%) to have aortic calcification. The bivariate analysis showed that Thr256Ser polymorphism (G allele) was associated with increased risk for aortic calcification (PR=2.03; 95% CI 1.48-2.80; p<0.001). However, overall results from multivariate analysis showed that Fetuin-A level <204 pg/mL (PR=22.0; 95% CI 3.32-145.91; p=0.001) and IL-6 level ≥53.05 mg/dL (PR=19.50; 95% CI 2.87-132.41; p=0.002) were the major risk factors for the occurrence of aortic calcification. Conclusion AHSG Thr256Ser gene polymorphism showed an association with aortic calcification in regular haemodialysis patients, but Fetuin-A and IL-6 have a dominant role in the development of aortic calcification.

Comparison of clinical effect of different dialysis frequency and methods in the treatment of chronic renal failure uremic patients

Objective To observe the clinical efficacy of different dialysis frequency and methods in the treatment of chronic renal failure uremia patients, and to provide a reliable reference for clinical practice. Methods From February 2016 to February 2017, 140 chronic renal failure uremic patients who admitted to the Department of Nephrology at Taizhou Central Hospital were selected and divided into the observation group and the control group by complete random distribution method, with 70 cases in each group.The patients in the control group received 3 times of regular hemodialysis treatment per week, while the observation group received 3 times of regular hemodialysis combined with 1 time of hemodiafiltration treatment per week.The clinical treatment effects and complications of the two groups were compared. Results Compared with blood uric acid(BUA)[(532.09±71.05)mmol/L], serum creatinine(Scr)[(734.34±63.08)μmol/L], blood urea(BUN)[(23.84±2.58)mmol/L], serum phosphorus[(1.98±0.37)mmol/L], parathyroid hormone(PTH)[(464.37±113.92)ng/L], β2 microglobulin(β2-MG)[(13.48±6.38)mg/L]in the control group, BUA[(495.89±58.23)mmol/L], Scr[(684.34±77.32)μmol/L], BUN[(20.62±1.77)mmol/L], serum phosphorus[(1.74±0.44)mmol/L], PTH[(352.14±123.25)ng/L], β2-MG[(9.58±5.45)mg/L] were significantly lower in the observation group, the differences were statistically significant (t=3.29, 4.19, 8.61, 3.49, 5.59, 3.88, all P 0.05). Conclusion Hemodialysis 3 times combined with 1 time of hemodiafiltration per week has significant advantage in the treatment of chronic renal failure uremia patients, which can effectively remove urine toxin molecules and reduce the incidence of complications, and it is worthy of clinical application. Key words: Renal failure, chronic; Uremia; Hemodialysis; Hemodiafiltration; Comparative effectiveness research

Higher glutathione demand may be necessary for assisting haemodialysis patients to cope with increased oxidative stress.

The removal of cysteine during a dialysis procedure may affect glutathione (GSH) concentration, allowing haemodialysis (HD) patients to become more susceptible to oxidative damage. This study was performed to determine whether the change of GSH/glutathione disulfide (GSSG) redox state and GSH redox potential were linked with the change of cysteine or oxidative stress in patients receiving HD treatment. Sixty-seven HD patients who had received regular HD treatment were recruited. Plasma GSH, GSSG, cysteine and malondialdehyde (MDA) were measured at both pre- and post-HD. Plasma cysteine, GSH and GSSG levels significantly decreased after the completion of HD, compared to the levels at pre-HD. Plasma MDA concentration, GSH/GSSG ratio and GSH redox potential remained constant during the dialysis session. Plasma GSH and GSSG were positively associated with plasma MDA at post-HD, while GSH redox potential was negatively associated with plasma MDA at post-HD. However, plasma GSH, GSSG, GSH/GSSG ratio and GSH redox potential were not associated with plasma cysteine at either pre- or post-HD. The GSH and GSSG levels were significantly utilized during a HD session, and their levels were significantly associated with increased oxidative stress. HD patients may require higher GSH demands to cope with increased oxidative stress during an HD session.

Prognostic value of high-sensitive cardiac troponin I in asymptomatic chronic hemodialysis patients.

Increased levels of cardiac troponins (cTn) are a hallmark of acute myocardial infarction (AMI), along with symptoms and electrocardiographic (ECG) changes. Stably elevated cTn concentrations are frequently observed in asymptomatic patients with chronic kidney disease (CKD) and/or on hemodialysis (HD); the meaning of this elevation, as assessed by conventional techniques, remains unclear. Aim of our study was to evaluate the clinical significance of cTnI levels in asymptomatic HD patients by employing a newer high-sensitive cTnI (hs-cTnI) assay. We enrolled 49 patients undergoing regular HD treatment for more than 3months; all patients were asymptomatic for chest pain and had no history of acute coronary syndrome in the past 2months. For every patient we measured hs-cTnI, cTnI and brain natriuretic peptide (BNP) before initiation of one HD session at baseline (T0), after 3 (T1) and 9months (T2). Demographic, anamnestic, dialytic and echocardiographic characteristics of the examined population were evaluated. We also recorded the number of cardiovascular events from T0 to 12months after T2. Fifteen patients were lost to follow-up: 6 died, 2 underwent kidney transplantation, 7 did not match the inclusion criteria later during observation. At T0 (49 patients) we observed 14 hs-cTnI positive patients vs. 4 standard c-TnI positive patients (28,5% vs 8,1%); at T1 (40 patients) 16 vs 3 (26.4% vs 7.5%); at T2 (34 pz) 9 vs 0 (26.4% vs 0%). During the study we recorded 10 cardiovascular events, 8 of which in patients that were hs-cTNI positive, leading to death in 3. Hs-cTnI levels were predictive of cardiovascular events at all times and predictive of cardiovascular mortality at T0 and T1 (p < 0.001). In a multivariate analysis, a history of coronary artery disease (CAD) was an independent variable of high hs-cTnI levels at T0 (p < 0.04) and T1 (p < 0.03). Our study shows that a novel sensitive assay detects more asymptomatic HD patients compared to previously used methods, being at the same time predictive of cardiovascular mortality and morbidity. The only independent variable of high hs-cTnI concentrations was a positive history of cardiovascular disease, suggesting a possible role of hs-cTnI in identifying a high-risk subset of patients.

Arteriovenous fistula maturation in patients with permanent access created prior to or after hemodialysis initiation.

Multiple factors and comorbidities have been implicated in the ability of arteriovenous fistulas (AVF) to mature, including vessel anatomy, advanced age, and the presence of coronary artery disease or peripheral vascular disease. However, little is known about the role of uremia on AVF primary failure. In this study, we attempt to evaluate the effect of uremia on AVF maturation by comparing AVF outcomes between pre-dialysis chronic kidney disease (CKD) stage five patients and those who had their AVF created after hemodialysis (HD) initiation. We included 612 patients who underwent AVF creation between 2003 and 2015 at the University of Miami Hospital and Jackson Memorial Hospital. Effects of uremia on primary failure were evaluated using univariate statistical comparisons and multivariate logistic regression analyses. Primary failure occurred in 28.1% and 26.3% of patients with an AVF created prior to or after HD initiation, respectively (p = 0.73). The time of HD initiation was not associated with AVF maturation in multivariate logistic regression analysis (p = 0.57). In addition, pre-operative blood urea nitrogen (p = 0.78), estimated glomerular filtration rate (p = 0.66), and serum creatinine levels (p = 0.14) were not associated with AVF primary failure in pre-dialysis patients. Our results show that clearance of uremia with regular HD treatments prior to AVF creation does not improve the frequency of vascular access maturation.

Problems Associated With Access to Renal Replacement Therapy: Experience of the Sindh Institute of Urology and Transplantation.

The prevalence of end-stage renal disease is increasing worldwide. It is also one of the main health problems in Pakistan. Currently, hemodialysis represents the main mode of treatment for patients with end-stage renal disease in this country. Despite 24-hour free dialysis at the Sindh Institute of Urology and Transplantation (Karachi, Pakistan), a significant number of patients do not turn up for regular dialysis or miss regular sessions of dialysis. We conducted this study to identify and highlight the factors leading to poor compliance with regular hemodialysis treatment despite free dialysis treatment offered at our center. In 2014, 4565 patients with end-stage renal disease were registered at the Sindh Institute of Urology and Transplantation. Among these, 610 patients (13.4%) missed more than 2 sessions of dialysis and were included in the present study. Patients provided written informed consent before study participation. Data were collected from a questionnaire survey and analyzed by SPSS software (SPSS: An IBM Company, version 20.0, Chicago, IL, USA). Despite 24-hour dialysis facilities, the patient drop-out rate (779; 18%) was high. In addition, a significant minority of patients (610; 13.4%) was erratic in adherence to maintenance hemodialysis schedules, with > 2 missed appointments. The mean age of these 610 patients was 33.4 ± 7.4 years, and 345 patients (57%) were males. The main factors leading to poor compliance included cost of travel (33.2%), lack of affordable lodging and boarding facilities near dialysis center (30.9%), long distances from dialysis center (20.1%), and lack of family support (15.6%). This study shows that there is significant drop-out and poor compliance rates for regular dialysis despite free dialysis facilities.

Imbalanced plasma ACE and ACE2 level in the uremic patients with cardiovascular diseases and its change during a single hemodialysis session

Background: The renin-angiotensin system (RAS) has significant influences on heart and renal disease progression. Angiotensin converting enzyme (ACE) and angiotensin converting enzyme II (ACE2) are major peptidases of RAS components and play counteracting functions through angiotensin II (Ang II)/ATIR and angiotensin-(1–7) (Ang-(1–7))/Mas axis, respectively.Methods: There were 360 uremic patients on regular hemodialysis (HD) treatment (inclusive of 119 HD patients with cardiovascular diseases (CVD) and 241 HD patients without CVD and 50 healthy subjects were enrolled in this study. Plasma ACE, ACE2, Ang II and Ang-(1–7) levels of the HD patients were determined.Results: We compared pre-HD levels of plasma ACE, ACE2, Ang II and Ang-(1–7) in the HD patients with and without CVD to those of the controls. The HD patients, particularly those with CVD, showed a significant increase in the levels of ACE and Ang II, whereas ACE2 and Ang-(1–7) levels were lower than those in the healthy controls. Therefore, imbalanced ACE/ACE2 was observed in the HD patients with CVD. In the course of a single HD session, the plasma ACE, ACE/ACE2 and Ang II levels in the HD patients with CVD were increased from pre-HD to post-HD. On the contrary, ACE2 levels were decreased after the HD session. These changes were not detected in the HD patients without CVD.Conclusions: Pathogenically imbalanced circulating ACE/ACE2 was detected in the HD patients, particularly those with CVD. HD session could increase ACE/Ang II/AT1R axis and decrease ACE2/Ang-(1–7)/Mas axis activity in the circulation of HD patients with CVD.

Exhaled breath volatile organic and inorganic compound composition in end-stage renal disease.

Patients with end-stage renal disease (ESRD) are characterized by uremia and increased oxidative stress. The aim of this study was to investigate the influence of hemodialysis on breath ammonia and volatile oxidative stress parameters. Breath analysis was performed in 18 ESRD patients prior, during, and 30minutes after a hemodialysis session. Parameters of hemodialysis efficiency and oxidative stress (lipid peroxides, total antioxidative capacity, myeloperoxidase, and malondialdehyde) were measured in blood at the beginning, after 30minutes, and at the end of the dialysis session. 11 healthy volunteers with normal renal function served as a control group. Ion-molecule reaction mass spectrometry was used for breath-gas analysis. Initial elevated concentrations of breath ammonia decreased during hemodialysis and correlated with serum urea levels (r2=0.74), whereas isoprene concentrations increased. Breath concentrations of malondialdehyde and pentane (MDA-P) were significantly elevated in ESRD patients (p <0.01). Within the blood, a significant decrease of malondialdehyde was notable during hemodialysis treatment, whereas levels of lipid peroxides and myeloperoxidase increased. Exhaled breath of patients with ESRD on regular hemodialysis treatment is characterized by an increase in ammonia and MDA-P. The efficient decrease of breath ammonia and its close correlation to serum urea during hemodialysis suggests its possible use as a noninvasive marker to monitor dialysis efficacy.

Chemiluminescence analysis of antioxidant capacity for serum albumin isolated from healthy or uremic volunteers.

Regular hemodialysis treatment induces an elevation in oxidative stress in patients with end-stage renal failure, resulting in oxidative damage of the most abundant serum protein, albumin. Oxidation of serum albumin causes depletion of albumin reactive thiols, leading to oxidative modification of serum albumin. The aim of this study was to screen the antioxidant capacity of albumins isolated from uremic patients (HD-ALB) or healthy volunteers (N-ALB). From high-performance liquid chromatography spectra, we observed that one uremic solute binds to HD-ALB via the formation of disulfide bonds between HD-ALB and the uremic solute. Furthermore, we found using chemiluminescent analysis that the antioxidant capacities for N-ALB to scavenge reactive oxygen species including singlet oxygen, hypochlorite and hydrogen peroxide were higher than HD-ALB. Our results suggest that protein-bound uremic solute binds to albumin via formation of disulfide bonds, resulting in the depletion of albumin reactive thiols. The depletion of albumin reactive thiols leads to a reduced antioxidant capacity of HD-ALB, implying postmodification of albumin. This situation may reduce the antioxidant capacity of albumin and increase oxidative stress, resulting in increase in complications related to oxidative damage in uremic patients. Copyright © 2016 John Wiley & Sons, Ltd.

Hemodiyaliz Hastasında Sık Rastlanılan Kaşıntının Nadir Sebebi: Kyrle Hastalığı

Uremic pruritus is a common complication of chronic renal failure. It affects approximately half of patients undergoing dialysis treatment. Even if the pruritus is not hazardous alone, it causes physical and mental fatigue, insomnia, chronic fatigue, decrease in self care ability and life quality. The causes of pruritus and the pathophysiology are stil not fully understood. Xerosis, intradermal microprecipitation of divalent ions, secondary hyperparathyroidism, peripheral neuropathy, allergic reactions, hypersensitivity and histamine have been considered as pathogenetic factors. Kyrle’s disease is a rare disorder of keratinization which is one of the perforating disorders of the skin. Herein, we report a case of Kyrle’s disease which is seen rarely, as a cause of pruritus in a 68 year old female patient who is on regular hemodialysis treatment secondary to end stage renal failure due to diabetic nephropathy, in the light of existing literature. key words: Pruritus, Hemodialysis, Kyrle’s disease

Study the Effect of High Dialysate Potassium Solution in Comparison to Low Potassium Dialysate Solution in End Stage Renal Disease Patients

Background: Nowadays cardiovascular diseases remain as the single most common cause of death in chronic dialysis patients; the aim of this study was to evaluate the effects of two different regimens of dialysis potassium removal in patients with a tendency to develop arrhythmias during haemodialysis (HD). Methods and Materials: There were 88 (36 men and 52 women) end stage renal disease (ESRD) patients recruited for the study. They received regular haemodialysis three times per week at the haemodialysis units of a university medical centre (Golestan hospital) during year 2011. We compared the arrhythmogenic effects of two dialysis techniques. Results: There was a tendency in the HD solution with constant (3 mEq/l) K for premature ventricular complex (PVC) appearance in to be reduced as compared with constant (2 mEq/l) K in the time of dialysis period, although this reduction was not statistically significant(P = 0.09). There was a significant reduction in SVC in the HD solution with constant (3 mEq/l) K as compared with constant (2 mEq/l) K. Discussion: In conclusion, the use of a model of intra-HD potassium that is more close to potassium serum concentration of ESRD patients can reduce the arrhythmogenic effect of HD in patients on regular HD treatment.