Hemodialysis Schedule Research Articles

Predialysis central arterial waveform and blood pressure changes during hemodialysis

To investigate the predictive value of the central arterial waveform for intradialytic blood pressure (BP) change, a total of 152 hemodialysis patients (mean age 68 years) on a thrice-weekly hemodialysis schedule were enrolled, and at both the first and second session of the week, BP and central arterial waveform were measured every 30 min during hemodialysis. In both sessions, a 1-standard deviation increase in baseline subendocardial viability ratio (SEVR), an index of subendocardial perfusion, as well as in baseline systolic BP (SBP) was an independent predictor of maximum SBP decrease ≥ 30 mmHg during hemodialysis. When divided into four groups based on the respective median level of SEVR in the SBP ≥ median and SBP < median groups, intradialytic SBP change was different among the subgroups. Multiple logistic regression analysis revealed that, compared with the SBP < median; low SEVR group, the SBP < median; high SEVR group had lower risk, and the SBP ≥ median; low SEVR group had higher risk of SBP decrease ≥ 30 mmHg, but the risk did not differ from that in the SBP ≥ median; high SEVR group. Predialysis subendocardial perfusion evaluated by SEVR was associated with the maximum intradialytic BP decrease, and evaluation of the central arterial waveform could be used as complementary screening for intradialytic BP change.

Comparison Between Pregabalin and Sertraline for Treatment of Uraemic Pruritus in Patients on Maintenance Haemodialysis: A Single-Centric Study.

To compare oral pregabalin with oral sertraline for treatment of uraemic pruritus. Randomised controlled trial. Place and Duration of the Study: Department of Nephrology, Pak Emirates Military Hospital Rawalpindi, Pakistan, from October 2023 to January 2024. Patients with end-stage renal disease having pruritus for at least 6 weeks were included. Exclusion criteria comprised other dermatological or systemic diseases associated with pruritus, mental health issues, thrice-a-week haemodialysis schedule, and use of other treatments for uraemic pruritus. They were randomised to receive either pregabalin 75mg daily or sertraline 50mg daily for six weeks using computer-generated sequences. The Urdu version of the 5-D Itch scale was used to document the severity of pruritus at the baseline and at the end of therapy. Side effects to the treatment were also monitored. There were 8 (16.67%) females and 40 (83.33%) males, with a mean age of 52.19 ± 12.19 years. The baseline 5-D Itch scale scores were equal in both groups. Mean improvement in 5-D Itch scale scores was 3.75 ± 1.26 and 2.08 ± 1.18 with pregabalin and sertraline, respectively (p <0.001). Side effects were reported by 2 (8.33%) patients on pregabalin and none using sertraline (p = 0.489). Pregabalin was found to be more effective than sertraline in treating uraemic pruritus, though with a statistically insignificant trend towards a higher frequency of side effects. Chronic renal failure, Pruritus, Renal dialysis, Selective serotonin reuptake inhibitors, Uraemia.

#2891 Comparing health-related quality of life and symptom burden in patients undergoing twice-weekly versus thrice-weekly haemodialysis

Abstract Background and Aims Patients with kidney failure who initiate haemodialysis (HD) have traditionally followed a thrice-weekly, 4-hour schedule. Recently, incremental dialysis (i.e. initiating HD with lower frequency and/or treatment duration) has been advocated. It has been suggested that residual kidney function is better preserved, while mortality is similar when initiating dialysis with a twice versus thrice weekly schedule. It remains unclear which impact initiating dialysis twice a week has on health-related quality of life (HRQoL) in the short and long term. Therefore, the aim of this study was first to investigate the impact of following a twice-weekly dialysis schedule on the mental and physical HRQoL and symptom burden compared to thrice-weekly dialysis during the first year of dialysis. Second, to investigate the long term impact on mental and physical HRQoL and symptom burden of patients who solely started on a twice-weekly versus thrice-weekly schedule. Method Data were obtained from the ongoing multicentre, prospective, observational Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes (DOMESTICO). This study longitudinally compares HRQoL between home and in-center dialysis. For this analysis, incident HD patients &amp;gt; 18 years were included, if they started on a twice-weekly or thrice-weekly schedule. Mental and physical HRQoL was measured using the validated 12-item Short Form Health Survey (SF12, summary scores ranging from 0 to 100). Symptom burden was measured using the dialysis symptom index (DSI), consisting of 30 items on dialysis-related symptoms, these symptoms are reported using a 5-point Likert scale. The overall burden score, ranging from 0 to 150, was calculated by summing every symptom and its severity. The first aim was longitudinally analysed using linear mixed models, using measures at 3, 6 and 12 months after start dialysis. The second aim was cross-sectionally analysed at 1, 2 and 3 years after dialysis initiation using linear regression models. All models were adjusted for possible confounders. Results A total of 1007 patients were included, of whom 205 started on a twice-weekly schedule and 802 on a thrice-weekly schedule. The total population had a mean age of 64 ± 15 years and 35% were women. There was no significant difference in baseline characteristics between twice-weekly and thrice-weekly dialysis. At baseline mental and physical HRQoL for patients on twice-weekly dialysis were 45.9 ± 9.5 and 36.0 ± 10.7, respectively. In thrice-weekly dialysis this was 45.8 ± 10.3 and 35.0 ± 9.7. The symptom burden score at baseline was 33.0 ± 19.6 for twice-weekly and 34.0 ± 21.7 for thrice-weekly patients. As shown in Table 1, there were no significant differences in HRQoL or symptom burden over the first year of dialysis when comparing twice-weekly with thrice weekly HD. In Table 2 the long-term cross-sectional analyses show that starting with a twice-weekly schedule results in physical and mental HRQoL scores gradually becoming lower, with a statistically significant decrease in physical HRQoL score at 3 years after start dialysis (ß = −0.825, 95% CI −14.11; −2.38). There was no significant difference in symptom burden between the two schedules. Conclusion We found no differences in HRQoL or symptom burden during the first year of dialysis comparing incident patients on a twice-weekly versus thrice-weekly hemodialysis schedule. Conversely, starting on a twice-weekly dialysis schedule appears to be associated with a lower HRQoL, especially physical HRQoL, in the longer term. Following our results, physicians should be cautious of the possible negative effects on HRQoL when prescribing a twice-weekly dialysis schedule.

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.

Donor-derived myeloid sarcoma in a kidney transplant recipient: clinical case study and relevance of a multidisciplinary approach in therapy and diagnosis

Background. Malignant tumors are one of the main causes of unfavorable outcomes in solid organ transplant recipients in the long term after transplantation. Localization of these tumors in a transplanted organ may cause loss of graft function. After chronic graft dysfunction and infections, malignant neoplasms come next as one of the leading causes of late kidney graft loss. The incidence of different types of malignancies varies according to the transplanted organ. Knowledge of etiology, pathogenesis, peculiarities of diagnosis and treatment of malignant tumors in solid organ transplant recipients is a significant part of screening at any stage of post-transplant period. Late diagnosis of malignancies in a transplanted kidney amidst disconnected stages of treatment and follow-up leads not only to graft loss, but also jeopardizes the life of recipients.Clinical case description. The patient is a 29-year-old female. History: IgA nephropathy with nephrosclerosis. Renal replacement therapy (RRT) with long-term hemodialysis since March 2019. Kidney transplantation from a deceased donor to the right external iliac vessels on March 13, 2019. Graft function is immediate. In October 2020, a tumor in the transplanted kidney was detected for the first time. In November 2021, an emergency graft nephrectomy was performed for health reasons. Antibacterial, antifungal therapy was carried out. Results of morphological study of the removed renal graft with immunohistochemistry (IHC) were obtained. The structure and phenotype of the tumor are consistent with myeloid sarcoma. Trephine biopsy: normocellular bone marrow.Conclusion. The 29-year-old patient was diagnosed with donor-derived myeloid sarcoma in her kidney transplant with the development of paraneoplastic syndrome and multi-organ failure. Currently, the patient is receiving RRT by long-term scheduled hemodialysis. Organ recipients need to be managed by a multidisciplinary team of specialized and highly specialized specialists, taking into account comorbid status and features of the course of the underlying disease.

TREATMENT ADHERENCE AMONG PATIENTS UNDERGOING HEMODIALYSIS IN HOSPITALS PROVIDING DIALYSIS SERVICE OF BHARATPUR NEPAL

Background: Chronic kidney disease is a worldwide public health problem. In Nepal, chronic kidney disease patients are increasing and the management of this disease is very expensive compared to other chronic diseases. The objective of this research was to assess the treatment adherence among the patient’s undergoing hemodialysis. Methods: A descriptive cross-sectional study was conducted among the hemodialysis patients in Hemodialysis unit of College of Medical Sciences-Teaching hospital, Bharatpur. Semi-structured interview schedule was used. Data was entered and analyzed using in statistical package for social science (SPSS) version 20 using descriptive statistical tools. Results: The Mean ± SD of age was 48.4 ± 13.5 years, 50% of the respondents were adherent with hemodialysis schedule, 69.69% were adherent in diet restriction, 72.73% were adherent with fluid restriction, 43.94% adherent to medication and 63.6% of the respondents were Hemodialysis adherence. Conclusions: Based on the finding of this research the hemodialysis adherence among the patients was good in others except diet and medication. Hemodialysis adherence is influenced by type of family, level of education, Time taken for hemodialysis, no. of days to receive hemodialysis treatment in a week.

Validation of formulas calculating normalized protein catabolic rate in patients undergoing home hemodialysis.

Depner and Daugirdas developed a simplified formula to estimate the normalized protein catabolic rate in patients on twice- or thrice-weekly hemodialysis (JASN, 1996). The aim of our work was to establish formulas in more frequent schedules and validate them in home-based hemodialysis patients. We realized that the structure of Depner and Daugirdas' normalized protein catabolic rate formulas has a general meaning and can be expressed as PCRn = C0/[a + b*(Kt/V) + c/(Kt/V)] + d, where C0 is pre-dialysis blood urea nitrogen, Kt/V is dialysis dose,a, b, c, dare the specific coefficients for each combination of home-based hemodialysis schedules and the day of blood sampling. The same applies to the formula that adjusts C0 (C'0) for residual kidney clearance of blood water urea (Kru) and urea distribution volume (V): C'0 = C0*[1 + (a1 + b1/(Kt/V))*Kru/V]. On this basis, we computed the six coefficients (a, b, c, d, a1, b1) for each of the 50 possible combinations and simulated a total of 24,000 weekly dialysis cycles using the Daugirdas Solute Solver software recommended by the KDOQI 2015 guidelines. From the associated statistical analyses we obtained 50 sets of coefficient values, which were validated comparing the paired normalized protein catabolic rate values (i.e., those estimated with our formulas with those modeled with Solute Solver) in 210 datasets of27patients on home-based hemodialysis. The mean values ± SD were 1.06 ± 0.262 and 1.07 ± 0.283g/kg/day, respectively, with a mean difference of 0.004 ± 0.034g/kg/day (p = 0.11). The paired values were highly correlated (R2 = 0.99). In conclusion, even if the coefficient values were validated in a relatively small sample of patients, they allow an accurate estimation of normalized protein catabolic rate in home-based hemodialysis patients.

Chimeric antigen receptor T-cell therapy in a dialysis patient with lymphoma

Chimeric antigen receptor T-cell (CAR-T) therapy has become a revolutionary cancer therapy for multiple subtypes of hematologic malignancies. Despite this progress, CAR-T use in End Stage Kidney Disease (ESKD) patients is limited. We describe the successful administration of CAR-T therapy in a patient with ESKD who had developed diffuse large B-cell lymphoma (DLBCL) from an underlying chronic lymphocytic leukemia. The patient received CAR-T therapy, preceded by lymphodepleting chemotherapy with dose-reduced fludarabine and cyclophosphamide, followed by intermittent hemodialysis on a modified basis. The treatment course was complicated by pancytopenia and Grade 2 cytokine release syndrome, managed with tocilizumab. The patient underwent an initial disease response assessment, which showed a complete response, and remains in remission 12 months after CAR-T infusion. This case report highlights the importance of individualized hemodialysis schedules and lymphodepleting chemotherapy dose adjustments in ESKD patients for a successful administration of CAR-T therapy.

#5268 PREGNANCY OUTCOMES IN DIALYSIS PATIENTS: A TEN-YEAR SERIES FROM A TERTIARY CENTER

Abstract Background and Aims Pregnancy in dialysis patients was almost prohibited a decade ago, as fetal and maternal outcomes were very poor. In the last years, there has been a paradigm shift, as the introduction of intensive hemodialysis (HD) schedules has been associated with an impressive improvement on fetal outcomes, making motherhood a possibility in these women. Nevertheless, pregnancy in women on dialysis remains associated with a high incidence of complications and is extremely demanding for both patients and clinicians. We describe the maternal, obstetric, and perinatal outcomes of pregnancies in women on dialysis followed at the Nephro-Obstetric Clinic at Centro Hospitalar Universitário Lisboa Norte (CHULN). Method Retrospective analysis of pregnancies in women on dialysis and surveilled at the Nephro-Obstetric Clinic at CHULN from 2011 to 2022. Results We considered 17 pregnancies from 16 women. One of the women accounted was submitted to voluntary termination of pregnancy. Mean age was 31.5 ± 6.1 years; 70.6% were Black (n = 11) and 29.4% (n = 5) Caucasian; 58.8% were nulliparous (n = 10). All patients had chronic hypertension (HTN), although only 75.0% were under therapy (12/16). Additionally, 3/16 patients had diabetes and 2/16 hyperthyroidism. The mean of overall renal replacement therapy (RRT) duration was 9.1 ± 8.2 years (dialysis and renal transplantation time), being on dialysis program 43.7 ± 37.5 months before gestation. One patient was on peritoneal dialysis (PD) and two patients started HD during pregnancy. Five patients (31.2%) were exposed to teratogenic drugs during gestation. Pregnancy diagnosis occurred at 13.4 ± 5.6 weeks; 70.6% of the patients were on low dose acetylsalicylic acid (n = 12). HD mean time per week according to each trimester was 13.7 ± 2.8 hours/week, 24.5 ± 7.3 hours/week and 28.0 ± 8.0 hours/week during the 1st/2nd/3rd respectively. Mean pre-dialysis urea was 62.1 ± 28.0 mg/dL during gestation. Regarding maternal outcomes, worsening HTN occurred in 62.5% (n = 10) of patients during the 1st (4/10) and 2nd trimester (7/10) and pre- eclampsia (PE) occurred in 6/16 patients (1 with HELLP syndrome). One patient developed polyhydramnios and another one cholestasis of pregnancy. Premature rupture of membranes (PRM) occurred in 3 patients (at 17, 25 and 36 weeks); One patient asked for medical termination of pregnancy due to severe growth restriction and oligohydramnios at 20 weeks. Stillbirth occurred in 4 gestations (cervical insufficiency in a twin pregnancy, severe congenital fetal cardiopathy in a patient with PE, severe growth restriction and premature rupture of membranes (PRM). In the 2 patients with early PRM, the neonates died in the following week due to severe prematurity complications. Labor was induced in 9 patients, mainly due to PE (7/9). Cesarean was performed in 10/17 patients and mean gestation age at delivery was 29.8 ± 6.6 weeks. Extreme prematurity (&amp;lt;28 weeks) occurred in 3 pregnancies and there were three term babies. Mean birth weight was 1554.0±613.6 grams with 4 newborns having extremely low birth weight (&amp;lt;1000g) and 6 requiring neonatal care. Conclusion Our study reveals that pregnancy in women on dialysis is challenging and still associated with significant maternal, obstetric and perinatal complications. This population was highly heterogenous, with a significant number of patients living under unfavorable social conditions, and with significant comorbidities. The diagnosis of pregnancy took place mainly during the 2nd trimester, preventing early initiation of intensive dialysis schedules which could have significantly improved outcomes. Pregnancy planning, early diagnosis and management by a multidisciplinary experienced team are of paramount importance to improve outcomes and reduce complications.

Inclement Weather and Risk of Missing Scheduled Hemodialysis Appointments among Patients with Kidney Failure.

Nonadherence to hemodialysis appointments could potentially result in health complications that can influence morbidity and mortality. We examined the association between different types of inclement weather and hemodialysis appointment adherence. We analyzed health records of 60,135 patients with kidney failure who received in-center hemodialysis treatment at Fresenius Kidney Care clinics across the Northeastern US counties during 2001-2019. County-level daily meteorological data on rainfall, hurricane and tropical storm events, snowfall, snow depth, and wind speed were extracted using National Oceanic and Atmosphere Agency data sources. A time-stratified case-crossover study design with conditional Poisson regression was used to estimate the effect of inclement weather exposures within the Northeastern US region. We applied a distributed lag nonlinear model framework to evaluate the delayed effect of inclement weather for up to 1 week. We observed positive associations between inclement weather and missed appointment (rainfall, hurricane and tropical storm, snowfall, snow depth, and wind advisory) when compared with noninclement weather days. The risk of missed appointments was most pronounced during the day of inclement weather (lag 0) for rainfall (incidence rate ratio [RR], 1.03 per 10-mm rainfall; 95% confidence interval [CI], 1.02 to 1.03) and snowfall (RR, 1.02; 95% CI, 1.01 to 1.02). Over 7 days (lag 0-6), hurricane and tropical storm exposures were associated with a 55% higher risk of missed appointments (RR, 1.55; 95% CI, 1.22 to 1.98). Similarly, 7-day cumulative exposure to sustained wind advisories was associated with 29% higher risk (RR, 1.29; 95% CI, 1.25 to 1.31), while wind gusts advisories showed a 34% higher risk (RR, 1.34; 95% CI, 1.29 to 1.39) of missed appointment. Inclement weather was associated with higher risk of missed hemodialysis appointments within the Northeastern United States. Furthermore, the association between inclement weather and missed hemodialysis appointments persisted for several days, depending on the inclement weather type.

The impact of scheduled hemodialysis on clinical-functional and morphometric ophthalmological status of patients with a terminal kidney disease

The literature review discusses the impact of scheduled hemodialysis on the state of the anterior part of the eye, the chorioretinal complex, the central and peripheral vision. The hemodialysis procedure is accompanied by a decrease in basal tear production, quickening of the tear film break-up, and an abnormal ocular surface disease index. Thinning of the corneal center is not accompanied by significant keratometric changes. Intradialytic thinning of the choroid and reduction of ocular perfusion pressure may be involved in the progression of ischemic eye diseases. Lower visual acuity is associated with the instability of the lens and choroid thickness. The impact of hemodialysis on the peripheral vision has not been sufficiently investigated. The correlations of ophthalmic changes with systemic effects of the dialysis are ambiguous. The inconsistency of the research results requires that the research should be continued.

Arrhythmia and Heart Rate Variability during Long Interdialytic Periods in Patients on Maintenance Hemodialysis: Prospective Observational Cohort Study.

Sudden cardiac death among hemodialysis patients is related to the hemodialysis schedule. Mortality is highest within 12 h before and after the first hemodialysis sessions of a week. We investigated the association of arrhythmia occurrence and heart rate variability (HRV) using an electrocardiogram (ECG) monitoring patch during the long interdialytic interval in hemodialysis patients. This was a prospective observational study with 55 participants on maintenance hemodialysis for at least six months. A patch-type ECG monitoring device was applied to record arrhythmia events and HRV during 72 h of a long interdialytic period. Forty-nine participants with sufficient ECG data out of 55 participants were suitable for the analysis. The incidence of supraventricular tachycardia and ventricular tachycardia did not significantly change over time. The square root of the mean squared differences of successive NN intervals (RMSSD), the proportion of adjacent NN intervals differing by >50 ms (pNN50), and high-frequency (HF) increased during the long interdialytic interval. The gap in RMSSD, pNN50, HF, and the low-frequency/high-frequency (LF/HF) ratio between patients with and without significant arrhythmias increased significantly over time during the long interdialytic interval. The daily changes in RMSSD, pNN50, HF, and the LF/HF ratio were more prominent in patients without significant arrhythmias than in those with significant arrhythmias. The electrolyte fluctuation between post-hemodialysis and subsequent pre-hemodialysis was not considered in this study. The study results suggest that the decreased autonomic response during interdialytic periods in dialysis patients is associated with poor cardiac arrhythmia events.

The ABCs of personalized incremental dialysis start, Le Mans style.

Thrice weekly hemodialysis (HD) is considered the standard of care for patients with end-stage chronic kidney disease (CKD) on extracorporeal renal replacement therapy. However, recent evidence has shown that up to one third of patients start dialysis with a residual kidney function that could allow a reduced frequency/dialysis dose. Interest towards HD schedules other than thrice weekly and the lessons learned from peritoneal dialysis, in addition to growing attention to patients' quality of life, have promoted renewed attention towards incremental HD (iHD). iHD comprises once and twice weekly schedules, makes it possible to soften the "dialysis shock" at the inception of therapy and is patient-friendly. Moreover, it might contribute to preserving residual kidney function longer. Nevertheless, iHD is performed differently in different settings and no guidelines exist on this subject. Taking advantage of the experience accrued with regard to the treatment of advanced CKD both in the outpatient clinic and in the dialysis unit in Le Mans, where two thirds of incident HD patients start in an incremental way, we aimed to present the practical aspects of iHD and discuss its advantages and drawbacks.

Paradoxical Protection of Keeping an In-Center Short Daily Hemodialysis Schedule During the First 2 Years of COVID-19 Pandemic

Paradoxical Protection of Keeping an In-Center Short Daily Hemodialysis Schedule During the First 2 Years of COVID-19 Pandemic

Pola Hidup dan Dukungan Keluarga Berhubungan dengan Rutinitas Hemodialisa pada Pasien Gagal Ginjal Kronik

Introduction: Kidney disease has a major effect on global health, both as a direct cause of global morbidity and mortality and as an important risk factor for cardiovascular disease of the heart and blood vessels. CKD is largely treatable so it deserves greater attention for decision-making for patients and families in undergoing a course of therapy. Objective: To determine the relationship between lifestyle and family support with routine hemodialysis in patients with chronic kidney failure at Ciawi Hospital, Bogor. Methods: The research design used is a descriptive correlation. The research population was all respondents in Ciawi Hospital, Bogor. By using a total sampling technique of 72 people. The instrument used a questionnaire and the analytical tool used was the Spearman rank correlation. Results: The results showed that most of the patients with chronic kidney failure who underwent hemodialysis in the Hemodialysis room at the Ciawi Hospital, Bogor were male as many as 38 respondents (52.8%), ages 44-45 as many as 34 respondents (47.2%), SMA education was 46 respondents (63.9%), and occupations with other categories were 27 respondents (37.5%). The pattern of life with routine hemodialysis implementation at Ciawi Hospital Bogor is good for as many as 49 respondents (68.1%) and there is family support for as many as 48 respondents (66.7%) so there is a relationship between lifestyle and family support with hemodialysis routines at Ciawi Hospital, Bogor with P-value = 0.016 and OR 9.4 for lifestyle relationships, while P-value = 0.022 and OR 10.1 for family support. Conclusion: There is a relationship between lifestyle and family support with the implementation of hemodialysis in patients with chronic kidney failure in the Hemodialysis Room of Ciawi Hospital, Bogor Regency. Lifestyle has a greater influence on the suitability of the hemodialysis schedule.

Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis

BackgroundPhysical and emotional symptoms are prevalent in patients with kidney-dysfunction requiring dialysis (KDRD) and the rigors of thrice-weekly hemodialysis (HD) may contribute to deteriorated health-related quality of life. Less intensive HD schedules might be associated with lower symptom and/or emotional burden.MethodsThe TWOPLUS Pilot study was an individually-randomized trial conducted at 14 dialysis units, with the primary goal to assess feasibility and safety. Patients with incident KDRD and residual kidney function were assigned to incremental HD start (twice-weekly HD for 6 weeks followed by thrice-weekly HD) vs conventional HD (thrice-weekly HD). In exploratory analyses, we compared the two treatment groups with respect to three patient-reported outcomes measures. We analyzed the change from baseline in the score on Dialysis Symptom Index (DSI, range 0–150), Generalized Anxiety Disorder-7 (GAD-7, range 0–21), and Patient Health Questionnaire-9 (PHQ-9, range 0–27) at 6 (n = 20 in each treatment group) and 12 weeks (n = 21); with lower scores denoting lower symptom burden. Analyses were adjusted for age, race, gender, baseline urine volume, diabetes mellitus, and malignancy. Participants’ views on the intervention were sought using a Patient Feedback Questionnaire (n = 14 in incremental and n = 15 in conventional group).ResultsThe change from baseline to week 6 in estimated mean score (standard error; P value) in the incremental and conventional group was − 9.7 (4.8; P = 0.05) and − 13.8 (5.0; P = 0.009) for DSI; − 1.9 (1.0; P = 0.07) and − 1.5 (1.4; P = 0.31) for GAD-7; and − 2.5 (1.1; P = 0.03) and − 3.5 (1.5; P = 0.02) for PHQ-9, respectively. Corresponding changes from week 6 to week 12 were − 3.1 (3.2; P = 0.34) and − 2.4 (5.5; P = 0.67) in DSI score; 0.5 (0.6; P = 0.46) and 0.1 (0.6; P = 0.87) in GAD-7 score; and − 0.3 (0.6; P = 0.70) and − 0.5 (0.6; P = 0.47) in PHQ-9 score, respectively. Majority of respondents felt their healthcare was not jeopardized and expressed their motivation for study participation was to help advance the care of patients with KDRD.ConclusionsThis study suggests a possible mitigating effect of twice-weekly HD start on symptoms of anxiety and depression at transition from pre-dialysis to KDRD. Larger clinical trials are required to rigorously test clinically-matched incrementally-prescribed HD across diverse organizations and patient populations.Trial registrationRegistered at ClinicalTrials.gov with study identifier NCT03740048, registration date 14/11/2018.

Inclement Weather and Risk of Missing Scheduled Hemodialysis Appointments

Background and Aim: Non-adherence to dialysis treatments results in health complications that are associated with increased morbidity and mortality in hemodialysis patients. We examined the association between different types of inclement weather conditions and missed dialysis treatments. Methods: We obtained health records on end-stage kidney disease (ESKD) patients who received hemodialysis at Fresenius Kidney Care (FKC) clinics across the Northeastern U.S. during 2001-2019. County-level daily meteorological data on rainfall, hurricane events, snowfall, snow depth, and wind speed were extracted through the National Oceanic and Atmosphere Agency (NOAA) database. A time-stratified case-crossover study design with conditional Poisson regression was employed to estimate the effect of inclement weather exposures on hemodialysis treatment adherence. We applied distributed lag non-linear model (DLNM) framework to estimate the delayed effect of inclement weather for up to one week. Results: We studied 28,620 ESKD patients from 27 northeastern counties who had any missed hemodialysis appointment. Overall, the missed appointment rate was higher for all of the inclement weather type (rainfall, hurricane, snowfall, snow depth, and wind advisory) compared to non-inclement weather days. The risk of missed appointment was highest at lag 0 for 10mm increase of rainfall (RR=1.027, 95% CI: 1.021, 1.032), snowfall (RR=1.019, 95% CI: 1.017, 1.021), and snow depth (RR=1.014, 95% CI: 1.013, 1.016). Hurricane events showed the highest RR at lag 5 (RR=1.163, 95% CI: 1.016, 1.332). Wind advisory showed sustained higher risk compared to non-exposure days through up to lag 5. Conclusions: All types of inclement weather events showed increased risk of missed hemodialysis appointments. Since inclement weather events are projected to increase due to ongoing climate change, our findings suggest the need for enhanced climate readiness by health care delivery systems that include early warning systems disaster response plans for delivering uninterrupted dialysis-related health services. Keywords: inclement weather, climate change, hemodialysis

Randomized Control Study on Hemoperfusion Combined with Hemodialysis versus Standard Hemodialysis: Effects on Middle-Molecular-Weight Toxins and Uremic Pruritus

Introduction: Classic hemodialysis schedules present inadequate middle-molecular-weight toxin clearance due to limitations of membrane-based separation processes. Accumulation of uremic retention solutes may result in specific symptoms (e.g., pruritus) and may affect clinical outcome and patient’s quality of life. Hemoperfusion (HP) is a blood purification modality based on adsorption that can overcome such limitations, and thus, it may be interesting to test the efficacy of at least one session per week of HP combined with hemodialysis. This is a randomized, open-label trial, controlled, multicenter clinical study to investigate the effect of long-term HP combined with hemodialysis on middle-molecular-weight toxins and uremic pruritus in maintenance hemodialysis (MHD) patients. Methods: 438 MHD patients from 37 HD centers in China with end-stage kidney disease (63.9% males, mean age 51 years) suffering from chronic intractable pruritus were enrolled in the study. Eligible patients were randomized into four groups: low-flux hemodialysis (LFHD), high-flux hemodialysis (HFHD), HP + LFHD, and HP + HFHD at a 1:1:1:1 ratio. Beta-2 microglobulin (β2M) and parathyroid hormone (PTH) were measured at baseline, 3–6, and 12 months. At the same time points, the pruritus score was evaluated. The primary outcome was the reduction of β2M and PTH, while the secondary outcome was the reduction of the pruritus score. Results: In the two groups HP + LFHD and HP + HFHD, there was a significant decrease of β2M and PTH levels after 12 months compared to the control groups. No significant differences were noted between HP + LFHD and HP + HFHD. Pruritus score reduction was 63% in the HP + LFHD group and 51% in the HP + HFHD group, respectively. Conclusion: The long-term HP + HD can reduce β2M and PTH levels and improve pruritus in MHD patients independently on the use of high- or low-flux dialyzers, showing that the results are linked to the effect of adsorption.

Adherence to Different Treatment Modalities among Patients on Maintenance Hemodialysis

End Stage Renal Disease is a well-known global public health problem. Maintenance hemodialysis is considered a life-saving treatment for patients with such disease. This treatment method that requires patients to be adherent to hemodialysis attendance, dietary and fluid recommendations as well as adherence to prescribed medications to ensure success. The aim of the current study was to assess adherence, perception, and counseling among hemodialysis patients to different modalities of treatment (fluid restriction, dietary recommendations, medications, and hemodialysis schedules). A cross-sectional study carried out on hemodialysis patients who attended to the dialysis centers at al- Karama teaching hospital and Madinat Al- Imamain Al- Kadhimain teaching hospital. The Arabic version of the “ end stage renal disease-adherence questionnaire ” was used in assessing adherence, perception, and counseling. The number of recruited patients were 200 adult patients (113 men and 87 women). The average of the total adherence score lies within the moderate adherence (984.9 ±174.2). Patients adherence to the hemodialysis session was good as representing by high scores of adherence for (hemodialysis-attendance, episode of hemodialysis-shortening and duration of hemodialysis-shortening) while the lowest adherence score (126.0 out of 200) was for following the fluid restriction. In terms of adherence categories, the majority (61%) of the patients had good adherence, 33.0% had moderate adherence with 6% had poor adherence. Age had significant positive association with the total adherence score. All patients perceived their hemodialysis management as highly/very important. On the other hand, some patients perceived their adherence to the recommended diet as moderately (7%) or less important (7%). Regarding the frequency of counseling received by patients for different treatment modalities. The negative answers represented 58.5% of answers about the how important is to follow a proper diet, and 25.0% of answers about the importance of taking prescribed medications as ordered. Accordingly, the overall adherence of hemodialysis patients to different treatment modalities was less than optimum with fluid and diet adherence representing most challenging tasks in the health care of hemodialysis patients.

Textual Organization of Hemodialysis Nursing Practice: An Institutional Ethnography.

Nursing today deals with organizational changes and reforms within the increased demands of care amid competing resources. In some developing countries, dealing with text documents is a challenge in hemodialysis service organizations. This study aimed to explicate the social organization of textual nursing practices in a hemodialysis unit of a public university hospital in Nepal. This is a qualitative study that followed institutional ethnography design. Ten registered nurses who worked for at least six months in the hemodialysis unit were included for in-depth interviews. Data were also collected through 167 hours of observations, field notes, and two focus groups. Texts including policy, protocols, and record documents were incorporated in the analysis. Data analysis followed Smith's (1987) institutional ethnographic analysis. Nepalese nursing work in a hemodialysis unit was mainly organized by the free hemodialysis policy of the government which was not available to the nurses at the hemodialysis unit, but it determined most of the nursing activities of patient care and documentation. Hemodialysis record form, hemodialysis schedule, and free hemodialysis claim form also had a great influence on nursing work. However, the nurses were not quite aware of how the textual documents determined their practices to meet the politico-economic interests of the hospital and government. The hospital and Nepal's health ministry established the activities and recording requirements. Identification of texts and exploration of their influences on nurses' decisions, patient care, and documentation are essential to find the optimal solutions in daily care and determine the appropriate support for nurses in hemodialysis settings.