Start Of Hemodialysis Research Articles

Hypoxia during maintenance hemodialysis-the critical role of pH.

The impact and management of subclinical hypoxia during hemodialysis is a significant medical challenge. As key determinants of O2 availability and delivery, proposed mechanisms contributing to hypoxia include ischemia, alkalemia and pulmonary leukocyte sequestration. However, no study has comprehensively investigated and compared these interrelated mechanisms throughout a typical hemodialysis treatment week. This study aimed to comprehensively assess the physiological mechanisms that contribute to hypoxia during hemodialysis. In 76 patients, we measured arterial blood gases and pH at four time-points during hemodialysis (start, 15min, 60min, end) over the course of a standard treatment week. For the mid-week hemodialysis session, we additionally measured central hemodynamics (non-invasive cardiac output monitoring) and white blood cell count. Linear regression modelling identified changes in pH, but not central hemodynamics or white blood cell count, to be predictive of changes in PaO2 throughout hemodialysis (e.g. at 60min, β standardized coefficient pH=0.45, model R2=0.25, P<.001). Alkalemia, hypokalemia, decreased calcium and increased hemoglobin-O2 affinity (leftward shift in the oxyhemoglobin dissociation curve) were evident at the end of hemodialysis. pH and hemoglobin-O2 affinity at the start of hemodialysis increased incrementally over the course of a standard treatment week. These data highlight the important role of pH in regulating O2 availability and delivery during hemodialysis. Findings support routine pH monitoring and personalized dialysate bicarbonate prescription to mitigate the significant risk of alkalemia and subclinical hypoxia.

Mortality in elderly patients starting hemodialysis program.

The incidence of older patients over 80 years old with chronic kidney disease who start hemodialysis (HD) program has been increasing in the last decade. We aimed to identify risk factors for morbidity and mortality in patients older than 80 years with end-stage renal disease who started HD. We conducted a retrospective observational study of the Catalan Renal registry (RMRC). A total of 2833 patients equal or older than 80 years (of 15,137) who started HD between 2002 and 2019 from the RMRC were included in the study. In this group, the first dialysis was performed through an arteriovenous fistula in 44%, percutaneous catheter in 28.2%, and tunneled catheter in 26.6%. Conventional dialysis was used in 65.7% and online HD in 34.3%. The most frequent cause of death was cardiac disease (21.8%), followed by social problems (20.4%) and infections (15.9%). Overall survival in older HD during the first year was 84% versus 91% in younger than 80 years (p< 0.001). Cox regression analysis identified the start of HD in the period 2002-2010, chronic obstructive pulmonary disease (COPD), and the onset of HD through vascular graft depicted as risk factors for first-year mortality after dialysis initiation in patients older than 80 years with end-stage renal disease who started HD. In conclusion, patients older than 80 years who started HD program had higher mortality, especially those who presented exacerbation of kidney disease, those with COPD, and those who started with a vascular graft.

Early as compared to late initiation of twice-weekly hemodialysis and short-term survival among end-stage renal disease patients.

The impact of timing of hemodialysis (HD) for end-stage renal disease (ESRD) patients treated with twice-weekly HD remains unclear. We aimed to determine the effects of late initiation of HD on short-term mortality and hospitalization. A multicenter cohort study was conducted in 11 HD centers in Northeastern Thailand (HEmodialysis Network of the NorthEastern Thailand study group). We recruited adult ESRD patients who were treated with twice-weekly HD for more than 3 months and had data on eGFR at HD initiation. Clinical and laboratory values at the time of recruitment were recorded. Late and early (eGFR at start <5 and >5 ml/min/1.73 m2 ) initiations were defined. Outcomes were disease-related death (excluding any accidental deaths) and first hospitalization. Data analysis was performed by multivariable cox-regression analysis. A total of 407 patients who had data on eGFR at HD initiation (303 in late group and 104 in early group) were included for analysis. There were 56.8% male with a mean age of 55 years. During the 15.1months of follow-up, there were 27 (6.6%) disease-related deaths. The 1-year survival rate was similar among late and early initiation groups. The incidence density of first hospitalization in the late group was significantly lower than those in the early group (HR adjusted, 0.63; 95% CI, 0.40-0.99, p= 0.047). Among 303 patients who were in the late start group, patients with diabetes had a higher mortality rate (HR, 3.49; 95% CI, 1.40-8.70, p= 0.007) when compared to non-diabetic patients. Early initiation of HD at eGFR >5ml/min/1.73 m2 had no short-term survival benefit compared to the late group in ESRD patients treated with twice-weekly HD for at least 3 months in a resource-limited setting. A survival benefit from an early start of HD was found among diabetic patients.

Blood Glucose Fluctuation in Older Adults with Diabetes Mellitus and End-Stage Renal Disease on Maintenance Hemodialysis: An Observational Study.

IntroductionPatients with diabetes mellitus and end-stage renal disease are at a high risk of developing coronary, cerebrovascular, and peripheral vascular diseases. This study aimed to characterize hypoglycemia and blood glucose fluctuations associated with maintenance hemodialysis in older adult patients with diabetes mellitus and end-stage renal disease using a continuous glucose monitoring system.MethodsSeven patients were enrolled in this study, and 13 pairs of continuous glucose monitoring system data were collected. Each pair included data of 1 dialysis-on day and 1 dialysis-off day. Information on basic patient characteristics, including age, diabetes mellitus duration, hemodialysis duration, and proportions of hemoglobin A1c and glycated albumin, were collected. Differences in blood glucose fluctuation were compared between dialysis-on days and dialysis-off days.ResultsThe mean blood glucose on dialysis-on days (6.96 ± 2.57 mmol/L) was significantly lower than that on dialysis-off days (7.68 ± 2.31 mmol/L; P < 0.05). In contrast, the following parameters had significantly higher values (all P < 0.05) on dialysis-on days compared to dialysis-off days: large amplitude of glycemic excursion level (5.82 ± 2.86 mmol/L versus 4.21 ± 1.71 mmol/L), large amplitude of glycemic excursion level from 8 a.m. to 2 p.m. (3.6 ± 1.74 mmol/L versus 2.8 ± 1.33 mmol/L), mean amplitude of glycemic excursion level (4.78 ± 1.68 mmol/L versus 3.89 ± 1.67 mmol/L), mean amplitude of glycemic excursion level from 8 a.m. to 2 p.m. (4.01 ± 1.03 mmol/L versus 3.12. ± 0.97 mmol/L), standard deviation of blood glucose (1.55 ± 0.89 mmol/L versus 1.03 ± 0.4 mmol/L), and time below a target glucose range of less than 3.9 mmol/L (8.27% versus 4.25%).ConclusionFluctuations in blood glucose levels were larger on dialysis-on days, particularly from the start of hemodialysis to 2 h post-hemodialysis, than on dialysis-off days. Hypoglycemia, as indicated by the time below a target glucose range of less than 3.9 mmol/L, occurred more frequently on dialysis-on days than on dialysis-off days.Graphical

FC 101: The Impact of Vascular Access Types on Survival in Hemodialysis: Time for a Shift in Paradigm? A Prospective Cohort Study

Abstract BACKGROUND AND AIMS Despite arteriovenous native fistula (AVF) is the vascular access (VA) of choice due to a better outcome than central venous catheter (CVC) [1], catheter use is still common among haemodialysis (HD) patients. Our study aims to describe the survival and epidemiological features of a cohort of dialysis patients with a focus on the role of VA type. METHOD Our cohort comprises a prospective follow-up conduced from 2001 to 2020, which led to recruit 754 patients in HD. We identified a subgroup of patients survived less than 7 months (n 124) and a subgroup of patients survived more or equal than 7 months and up to 60 months (n = 472). In addition to this, every subgroup was subdivided into two different age groups, including patients of age ≤74 years old and those ≥75 years old. Other analysed characteristics were demographic features and baseline clinical data, like primary cause of ESKD, co-morbidities at the beginning of the HD treatment and type of VA both at start of HD and at the end of the follow-up. Starting HD without planning, namely being ‘late referral’, was also considered. Descriptive analysis was performed on baseline data. Moreover, we analysed predictive variables of death for any cause with Univariate and Multivariate Logistic Regression. Predictors of survival were analysed through univariate and multivariate Cox regression. RESULTS At the multivariate logistic regression, the use of tunnelled CVC at the start of HD resulted protective against death from any cause (aOR, 0.43; P = 0.017) in the whole cohort (n = 754). In the subgroup analysis of patients (n = 124) with a follow-up &amp;lt; 7 months, malignancy (aOR, 4.57; P = 0.002), severe cardiomyopathy (aOR, 4.35; P = 0.001) and vascular disease (aOR, 3.22; P = 0.008) were estimated as significantly predictors of death. At the multivariate Cox analysis, being ‘late referral’ was associated with decreased survival within 6 months (aHR, 3.79; P = 0.001). In the subgroup of elderly (≥75 years old; n = 201/472) survived within 7–60 months, multivariate logistic regression showed that the use of tunnelled CVC at the start of HD (Figure 1) resulted even more protective against death (aOR 0.25; P = 0.021). Moreover, vascular disease resulted as the main risk factor for death (aOR 5.11; P = 0.000), and it was confirmed as the only independent risk factor at the COX analysis (aHR 1.58; P = 0.017; see Figure 2). CONCLUSION Vascular disease is the main risk factor for death in haemodialysis patients. Furthermore, cardiovascular disease influences patient outcome more than the VA type, confirming the assumption that the choice of VA might be influenced by several issues as age and comorbidities [2, 3]. In the short-term survival subgroup, neither VA nor age emerged to be predictor of mortality, suggesting that health status before starting maintenance HD might explain an important part of the risk often attributed to catheter use.[4] Moreover, starting RRT without proper planning (‘late referral’) was extremely relevant in determining short-term survival. Tunnelled CVC might be the option of choice as VA, specifically in the elderly with vascular disease. In conclusion, our long-term experience suggests that the choice of VA should not necessarily follow the ‘fistula first’ approach, but it should be based on dialytic life expectancy and comorbidities.

MO477: Predicting 1-Year Mortality After Haemodialysis Start: The Role of the Cha₂Ds₂-VASC Score

Abstract BACKGROUND AND AIMS Chronic kidney disease (CKD) is a significant cause of morbidity, cardiovascular and all-cause mortality. CHA2DS2VASc is a score system used in patients with atrial fibrillation to predict thromboembolic risk. However, it also appears to be useful to predict mortality risk. The aim of the study was to evaluate the CHA2D2SVASc score as a tool to predict 1-year mortality after starting haemodialysis and identify factors associated with higher mortality. METHOD Retrospective analysis of patients who started haemodialysis between January of 2014 and December of 2019 at Centro Hospitalar Universitário Lisboa Norte. We evaluated mortality within 1 year of starting haemodialysis. The CHA2D2SVASc score was calculated at the start of haemodialysis. Variables were submitted to univariate and multivariate analysis to determine factors predictive of 1-year mortality after HD start. We assessed the logistic regression method of the CHA2DS2VASc to predict 1-year mortality and the discriminatory ability was determined using the receiver operating characteristic curve. RESULTS Of 856 patients analyzed, the mean age was 68.3 ± 15.5 years, the majority were male (61.1%) and Caucasian (84.5%). Mortality within 1 year after haemodialysis started was 17.8% (n = 152). The CHA2D2SVASc score was significantly higher (4.4 ± 1.7 versus 3.5 ± 1.8; P &amp;lt; .001) in patients who died and accurately predicted the 1-year risk of mortality {AUC: 0.646, [95% confidence interval (95% CI) 0.6–0.7]; P &amp;lt; .001}, with a sensitivity 71.7% and specificity of 49.1%, a positive predictive value of 23.9% and a negative predictive value of 89.2%. In the multivariate analysis, CHA2D2SVASc ≥3.5 (adjusted OR: 2.24, 95% CI 1.48–3.37; P &amp;lt; .001] and central venous catheter at dialysis start (adjusted HR: 3.06, 95% CI 1.93–4.85) were significant predictors of 1-year mortality. CONCLUSION CHA2D2SVASc score ≥ 3.5 and central venous catheter at haemodialysis start were predictors of 1-year mortality, allowing for risk stratification in haemodialysis patients.

MO874: Incidence of Severe Infections in Home Haemodialysis and Peritoneal Dialysis Patients

Abstract BACKGROUND Dialysis patients have a more than ten-fold risk of dying from infections compared with general population. In earlier studies, the risk of infections was similar in peritoneal dialysis (PD) and haemodialysis (HD), but comparison to home HD has not been performed. Our aim was to study the incidence of severe infections after start of home HD as compared with continuous ambulatory PD (CAPD) and automated PD (APD). METHODS We included all 536 adult patients, who were on home dialysis at day 90 from start of kidney replacement therapy (KRT) between 2004 and 2017 in Helsinki healthcare district. Severe infections were identified from patients’ laboratory data as a plasma C-reactive protein over 100 mg/L and confirmed from the patient data system. The cumulative incidence of the first severe infection was estimated considering death as a competing risk event. Hazard ratios of first severe infection were assessed using Cox regression with propensity score adjustment. Incidence rate (IR) and ratios (IRR) of all severe infection episodes were calculated. RESULTS The probability of getting a severe infection during the first year of dialysis was 35% for CAPD, 25% for APD and 11% for home HD patients. During a 5-year follow-up, the hazard ratio of severe infection was 2.8 [95% confidence interval (95% CI) 1.6–4.8] for CAPD and 2.2 (95% CI 1.4–3.5) for APD in comparison to home HD with adjustment for propensity scores. IR of infections/100 patient-years was 54 for CAPD, 37 for APD and 20 for home HD patients. The IR of peritonitis was 37 for CAPD and 25 for APD patients. When infection episodes caused by peritonitis were excluded, the IR of severe infections was not higher among PD than home HD patients. CONCLUSION The risk of severe infection was considerably lower among home HD than PD patients. This difference was mainly explained by the peritonitis episodes among the PD patients.

MO783: Reduction of the Incidence of Dialysis Catheter-Associated Bacteraemia in Intensive Care Units after Systematic Application of Taurolock in the Sealing of the Catheter

Abstract BACKGROUND AND AIMS Dialysis catheter-associated bacteraemia in Intensive Care Units (ICUs) increases morbidity and mortality, prolongs hospital admission and increases admission costs. TauroLock™ is a lock solution containing (cyclo)-taurolidine (1.35%) and citrate (4%). (Cyclo)-taurolidine has broad antimicrobial activity against gram-positive and gram-negative bacteria and fungi. The objective of this study was to analyse the effect of systematic sealing of haemodialysis catheters in the ICUs of the Hospital Clínic de Barcelona on the incidence of bacteraemia associated with haemodialysis catheters (BACH). METHOD BACH episodes of patients who underwent intermittent haemodialysis (IHD) during ICU admission were reviewed. The period analysed as pre-Taurolock™ was from 2010 to 2014 and post-TauroLock™ from 2015 to 2018. Patients who only received renal replacement therapy with continuous techniques were excluded. RESULTS A total of 279 patients received IHD in the pre-TauroLock™ period and 331 in the post-TauroLock™ period. The number of BACH in the pre-TauroLock™ period was 18 (6.45%) and 9 (2.72%) in the post-TauroLock™ period. All infections were from percutaneous catheters (acute patients) except three catheters that were tunnelled. In the pre-TauroLock™ period, femoral catheters predominated (61.1%) while in the post-TauroLock they were jugular (66.7%). There was no association between the location of the catheter and the incidence of BACH. Of the 27 patients with BACH, 14 (51.8%) were men with a mean age of 63 years, with no significant differences between the two groups. The most frequent reasons for admission to the ICU in the pre-TauroLock™ period were post-cardiac surgery, cardiogenic, septic or hypovolemic shock and acute myocardial infarction (3 patients per group) and in the post-TauroLock™ period, septic shock and pancreatitis (3 and 2 patients respectively). The most frequent isolated bacteria were Gram-positive (in total 48.38%: pre-TauroLock™ 47.61% and post-TauroLock™ 50%), with a global predominance of staphylococcus epidermidis (32.25%) (Table). There were no significant differences in the median days from the start of haemodialysis to bacteraemia (23.5 pre-TauroLock™ versus 21 post-TauroLock™). There were also no significant differences between the days of ICU stay in the BACH in both groups or in mortality, being the overall mortality of 70.4%. CONCLUSION In our cohort, the systematic application of TauroLock™ in the sealing of dialysis catheters in critically ill patients reduces the incidence of BACH in ICUs.

Idiopathic factor V inhibitor in a patient starting haemodialysis.

A 74-year-old Pacific Island man with end-stage renal failure planning to start haemodialysis presented with persistent bleeding after tunnelled dialysis catheter insertion. The laboratory findings revealed a prolonged activated partial thromboplastin time of 118 s, prothrombin ratio of 4.2, factor V activity of <2% and a factor V inhibitor of 40 Bethesda Units. No clear underlying aetiology was identified. The bleeding settled with conservative measures and the factor V inhibitor was successfully treated with oral cyclophosphamide for 6 weeks.

The Practiced Pattern of Vascular Access used in Hemodialysis

Background: The incidence of end-stage renal disease (ESRD) is increasing considerably worldwide; moreover, most of the patients start their therapy by hemodialysis (HD). Arteriovenous fistula (AVF) is the best type of vascular access for use in such therapy, due to its decreased rate of complications, followed by arteriovenous graft (AVG) and finally, central venous catheters, which are associated with, increased mortality and morbidity. In this study, we aim to find out the proportion of the current to initial vascular access used, the timing of creating permanent access, and any complications experienced. Patients and Methods: A cross-sectional study was conducted on two hundred eighteen patients currently on regular hemodialysis program. Their records were reviewed and the data was analyzed for vascular accesses type used at the start of hemodialysis and at the current time, the timing of the creation of permanent access, and the complications occurred. Data collected were statistically analyzed using IBM-SPSS statistics software Inc. Chicago, IL, USA. Results: Out-of-the 218 patients on hemodialysis, 193 patients (88.5%) started hemodialysis via Central venous catheters (CVC), 23 patients (10.5%) had an arterio-venous fistula (AVF), and only two patients (0.9%) used tunneled CVC, while no one has AV-graft. Currently, 82.1% of patients have AVF, 7.8% have chronic CVC, 5.9% have acute CVC and only 4.1% have AV-Graft, Many complications are noted in all types of access with different percentages of occurrence. Conclusion: We concluded that although a high percentage of patients have AVF, still pre-emptive AVF counts very low percentage, serious complications are still happening and we recommend the establishment of joined pre-dialysis clinic with surgeons and psychologists in each dialysis center.

Early mortality in incident hemodialysis patients – A retrospective case-control study

Introduction: Chronic kidney disease has significant morbidity and mortality worldwide. Various studies have demonstrated that incident patients experience a higher mortality rate within the first 3 months of dialysis. Methods: A single-center retrospective case-control study (1:3) was performed to determine early (&lt;90 days) mortality rate and associated risk factors in incident hemodialysis patients from January 2013 to December 2018. We compared variables between survivors and non-survivors at 90 days after initiation of hemodialysis. Multivariate logistic regression was used to calculate the adjusted odds ratio with 95% confidence intervals for the variables associated with early mortality and a predictive model was developed. Results: From a total of 626 incident hemodialysis patients, 48 (7.7%) died before 90 days of treatment. Non-survivors were older [OR 1.07 (1.03-1.11)], had higher rates of non-recovering acute kidney injury [OR 7.91 (3.63- 17.24)], emergency start of hemodialysis [OR 4.31 (2.15-8.62)], congestive heart failure [OR 5.68 (2.81-11.48)], ischemic cardiomyopathy [OR 4.50 (2.25-8.99)], chronic obstructive pulmonary disease [OR 3.60 (1.44-8.95)], Charlson comorbidity index [OR 1.47 (1.27-1.70)] and dependence of assistance in daily living activities [OR 3.46 (1.76-6.82)]. Patients were less likely to have 90-day mortality if they had nephrologist appointments at least 90 days prior to end-stage renal disease [OR 0.25, 95% CI (0.13-0.50); p&lt;0.001] or a higher serum albumin [OR 0.34, 95% CI (0.19-0.62); p&lt;0.001]. Multivariate analysis risk factors independently associated with early mortality were older age [aOR 1.06 (1-01-1.10), p=0.022], acute kidney injury as cause of end-stage renal disease [aOR 12.62 (4.50-35.40), p&lt;0.001], congestive heart failure [aOR 3.79 (1.58-9.11), p=0.003], and Charlson comorbidity index [aOR 1.30 (1.09-1.56), p=0.005]. The model showed very good discriminative ability [AUROC (95% CI) 0.88 (0.83-0.94)]. Conclusion: Early mortality occurred in 7.7% of our population. Our model could be used to identify patients at higher risk of death during the first 90 days of hemodialysis and aid informed decision-making regarding end-stage renal disease treatment options.

Interdisciplinary Care and Preparedness for Kidney Failure Management in a High-Risk Population

Rationale & ObjectiveInterdisciplinary care may improve health outcomes in patients with chronic kidney disease (CKD). Few studies have evaluated this model of health care delivery in racial and ethnic minorities.Study DesignRetrospective cohort study.Setting & ParticipantsIncident end-stage kidney disease (ESKD) patients at Montefiore Medical Center from October 1, 2013, to October 31, 2019.ExposurePre-ESKD interdisciplinary care.OutcomesPre-ESKD transplant listing and optimal kidney replacement therapy (KRT) start (use of arteriovenous access at hemodialysis initiation, outpatient hemodialysis start, preemptive transplant, or peritoneal dialysis as the first modality).Analytical ApproachWe constructed multivariable logistic regression models adjusted for sociodemographic and clinical factors to determine the odds of transplant listing and optimal KRT start between interdisciplinary versus the usual care group.ResultsOf the 295 incident ESKD patients included in our study, 84 received interdisciplinary care and 211 received usual nephrology care. The mean age was 59.9 years (standard deviation, 13.9 years), 47% were women, and 87% were African American or Hispanic. Baseline characteristics were similar between the groups, except that the interdisciplinary care group had a lower prevalence of hypertension (60% vs 75%). Compared with usual care, a higher proportion of patients in the interdisciplinary care group were listed for kidney transplant (44% vs 16%) and had an optimal KRT start (53% vs 44%). Receipt of interdisciplinary care was associated with a higher odds (OR, 5.73; 95% CI, 2.78-11.80; P < 0.001) of transplant listing compared with usual care after adjusting for important sociodemographic and clinical factors. The odds of an optimal KRT start also favored interdisciplinary care (OR, 1.60; 95% CI, 0.88-2.89; P = 0.12) but did not achieve statistical significance.LimitationsThe study was non-randomized and had a small sample size.ConclusionsInterdisciplinary care is associated with better ESKD preparedness compared with usual nephrology care alone in racial and ethnic minorities. Larger studies are needed to determine the effectiveness of interdisciplinary care in patients with advanced CKD.

Comparison of bone microstructures via high-resolution peripheral quantitative computed tomography in patients with different stages of chronic kidney disease before and after starting hemodialysis

Chronic kidney disease (CKD) negatively affects bone strength; however, the osteoporotic conditions in patients with CKD are not fully understood. Moreover, the changes in bone microstructure between pre-dialysis and dialysis are unknown. High-resolution peripheral quantitative computed tomography (HR-pQCT) reveals the three-dimensional microstructures of the bone. We aimed to evaluate bone microstructures in patients with different stages of CKD. This study included 119 healthy men and 40 men admitted to Nagasaki University Hospital for inpatient education or the initiation of hemodialysis. The distal radius and tibia were scanned with HR-pQCT. Patient clinical characteristics and bone microstructures were evaluated within 3 months of initiation of hemodialysis (in patients with CKD stage 5 D), patients with CKD stage 4–5, and healthy volunteers. Cortical bone parameters were lower in the CKD group than in healthy controls. Tibial cortical and trabecular bone parameters (cortical thickness, cortical area, trabecular volumetric bone mineral density, trabecular-bone volume fraction, and trabecular thickness) differed between patients with CKD stage 5 D and those with CKD stage 4–5 (p < 0.01). These differences were also observed between patients with CKD stage 5 and those with CKD stage 5 D (p < 0.017), but not between patients with CKD stage 4 and those with CKD stage 5, suggesting that the bone microstructure rapidly changed at the start of hemodialysis. Patients with CKD stage 5 D exhibited tibial microstructural impairment compared with those with CKD stage 4–5. HR-pQCT is useful for elucidation of the pathology of bone microstructures in patients with renal failure.

Determine the Frequency of Hepatitis B and C in Patients Undergoing Hemodialysis

Aim: To determine the frequency of hepatitis b and c in patients undergoing hemodialysis. Study Design: Descriptive study. Place and duration of study: Department of Gastroenterology, Chandka Medical College Hospital/Shaheed Mohtarma Benazir Bhutto Medical University Larkana &amp; Dialysis Unit, Chandka Medical College Hospital, Larkana from 1st October 2020 to 30th September 2021. Methodology: One hundred patients undergoing hemodialysis were tested for hepatitis B and C after their informed written approval gain. The age, gender and clinical history were recorded. Each patient 5cc blood was withdrawn and EDTA was added for creating whole blood which was then stored at 4ºC for a day and tested. The blood was first tested before hemodialysis start and then after every month until 6 months of hemodialysis was tested for presence of hepatitis B and C through polymerase chain reaction (PCR). Results: The mean age was 51.27±12.0 years with 14-77 years of patients enrolled for hemodialysis. Majority of the patients were men with a percentage of 52% while women as 48% in the total cases. The serological results showed that hepatitis B positive was presented as 8% and hepatitis C positive as 4% in total hemodialysis cases. Hepatitis B was more common in those cases where blood transfusion was performed more than 5-10 times or more. Conclusion: Prevalence of HBV was higher in hemodialysis patients who had more blood transfusions. Keywords: Frequency, Hepatitis B, Hepatitis C, Pakistani population

Electrocardiographic changes during haemodialysis and the potential impact on subcutaneous implantable cardioverter defibrillator eligibility

IntroductionHaemodialysis patients who require defibrillator therapy are expected to benefit from the entirely avascular subcutaneous defibrillator (S-ICD), but haemodialysis is associated with dynamic changes in R and T wave amplitude which can impact S-ICD eligibility. A continuous assessment of S-ICD eligibility during haemodialysis has not previously been performed. Material and methodsContinuous surface ECG recordings were obtained from a cohort of patients undergoing maintenance haemodialysis, but without an indication for an ICD. Automated vector screening was retrospectively performed at one-minute intervals throughout the dialysis session. Variations in S-ICD eligibility were calculated and in vectors with high degrees of variation, the underlying mechanism was identified. Results72 vector recordings (mean duration 254.1 ± 6.0 min) were obtained from 24 patients (mean age 64.3 ± 5.5 years, 68% male). At the start of haemodialysis 47 vectors were S-ICD eligible (65.2%). At the end of session, all of these vectors had remained eligible, and an additional 6 vectors had also become eligible (73.6%). High vector score variability was observed in 7 patients and the commonest cause was a progressive change in R:T ratio (71.5%). ConclusionIn a haemodialysis population, a single haemodialysis session can be associated with a potential change in S-ICD eligibility in 8.4% of vectors, with up to 12.5% of vectors showing high degrees of variability, most commonly due to variations in R:T ratio. In an S-ICD population with similar characteristics S-ICD screening prior to haemodialysis would be expected to more accurately identify vectors that retain eligibility.

Feasibility of Dialysate Bolus-Based Absolute Blood Volume Estimation in Maintenance Hemodialysis Patients.

BackgroundAbsolute blood volume (ABV) is a critical component of fluid status, which may inform target weight prescriptions and hemodynamic vulnerability of dialysis patients. Here, we utilized the changes in relative blood volume (RBV), monitored by ultrasound (BVM) upon intradialytic 240 mL dialysate fluid bolus-infusion 1 h after hemodialysis start, to calculate the session-specific ABV. With the main goal of assessing clinical feasibility, our sub-aims were to (i) standardize the BVM-data read-out; (ii) determine optimal time-points for ABV-calculation, “before-” and “after-bolus”; (iii) assess ABV-variation.MethodsWe used high-level programming language and basic descriptive statistics in a retrospective study of routinely measured BVM-data from 274 hemodialysis sessions in 98 patients.ResultsRegarding (i) and (ii), we automatized the processing of RBV-data, and determined an algorithm to select the adequate RBV-data points for ABV-calculations. Regarding (iii), we found in 144 BVM-curves from 75 patients, that the average ABV ± standard deviation was 5.2 ± 1.5 L and that among those 51 patients who still had ≥2 valid estimates, the average intra-patient standard deviation in ABV was 0.8 L. Twenty-seven of these patients had an average intra-patient standard deviation in ABV <0.5 L.ConclusionsWe demonstrate feasibility of ABV-calculation by an automated algorithm after dialysate bolus-administration, based on the BVM-curve. Based on our results from this simple “abridged” calculation approach with routine clinical measurements, we encourage the use of multi-compartment modeling and comparison with reference methods of ABV-determination. Hopes are high that clinicians will be able to use ABV to inform target weight prescription, improving hemodynamic stability.

Estimation of potassium levels in hemodialysis patients by T wave nonlinear dynamics and morphology markers

ObjectiveNoninvasive screening of hypo- and hyperkalemia can prevent fatal arrhythmia in end-stage renal disease (ESRD) patients, but current methods for monitoring of serum potassium (K+) have important limitations. We investigated changes in nonlinear dynamics and morphology of the T wave in the electrocardiogram (ECG) of ESRD patients during hemodialysis (HD), assessing their relationship with K+ and designing a K+ estimator. MethodsECG recordings from twenty-nine ESRD patients undergoing HD were processed. T waves in 2-min windows were extracted at each hour during an HD session as well as at 48 h after HD start. T wave nonlinear dynamics were characterized by two indices related to the maximum Lyapunov exponent (λt, λwt) and a divergence-related index (η). Morphological variability in the T wave was evaluated by three time warping-based indices (dw, reflecting morphological variability in the time domain, and da and daNL, in the amplitude domain). K+was measured from blood samples extracted during and after HD. Stage-specific and patient-specific K+ estimators were built based on the quantified indices and leave-one-out cross-validation was performed separately for each of the estimators. ResultsThe analyzed indices showed high inter-individual variability in their relationship with K+. Nevertheless, all of them had higher values at the HD start and 48 h after it, corresponding to the highest K+. The indices η and dw were the most strongly correlated with K+ (median Pearson correlation coefficient of 0.78 and 0.83, respectively) and were used in univariable and multivariable linear K+ estimators. Agreement between actual and estimated K+ was confirmed, with averaged errors over patients and time points being 0.000 ± 0.875 mM and 0.046 ± 0.690 mM for stage-specific and patient-specific multivariable K+ estimators, respectively. ConclusionECG descriptors of T wave nonlinear dynamics and morphological variability allow noninvasive monitoring of K+ in ESRD patients. SignificanceECG markers have the potential to be used for hypo- and hyperkalemia screening in ESRD patients.

POS-525 INTEREST OF MANNITOL IN INTRACRANIAL HYPERTENSION DURING HEMODIALYSIS IN A PATIENT WITH ACUTE BRAIN INJURY: A CASE REPORT

Hemodialysis (HD) Patients with acute brain injury are at increased risk of dialysis disequilibrium syndrome (DDS). This is due to the added risk of increased intracranial pressure (ICP) during or following dialysis. We present here a case of severe intracranial hypertension due to post traumatic subdural hematoma in a long-term HD patient, improved by continuous mannitol infusions during HD sessions. A 37-year-old Caucasian woman, in HD during five years, had a car accident in january 2021 with initial loss of consciousness, vomiting, severe headache and a Glasgow score of 14/15. Cerebral CT showed frontal hemorrhagic contusions, a right temporal subdural hematoma, subarachnoid hemorrhage, a non-displaced fracture of the sagittal/frontal bones and severe cerebral edema (figure 1). The patient was transferred to the neurosurgical department for medical management and monitoring. No emergency surgery was needed. On day 4, during her first hemodialysis session post brain injury, the patient presented neurological deterioration, severe headache and vomiting. Her blood pressure was of 143/63, heart rate recorded at 76 and oxygen saturation was stable at 100%. On suspicion of cerebral edema, the session was stopped. CT revealed exacerbation of cerebral edema, with no change in lesions or hemorrhage. Similar problems were encountered on the following session. We tried a test dose of Mannitol 20%: 50ml over 5minutes after start of hemodialysis. Neurologic signs disappeared and the patient was stable. Slow Continous mannitol infusion at a dose of 0,2g/kg body weight was undergone during 3-hours HD session with blood pressure and heart rate monitoring. No complications and no clinical significant changes were observed, except a mild elevation of blood pressure(174/95) controlled by mannitol infusion rate reduction. On day 8, the patient received slower dose of Mannitol 20% : 0,2g/kg body weight over 3.5hours of hemodialysis with 50ml infused over 20min and the remaining 60ml over 3 hours. Repeated blood tests showed no hypernatremia. From day 10 and onwards, the patient was able to tolerate hemodialysis with similar settings. On day 20, a further CT scan showed improvement in cerebral edema and temporal hematoma. we began administrating smaller doses of Mannitol ( 0,1g/kg body weight). On day 28, Mannitol was discontinued, as neurological functions were stable and control cerebral CT showed almost total resorption of the hemmorage and a marked edema reduction (figure 2). This case highlights the inherent risks associated with hemodialysis in patients with acute brain injury. The patient in question was likely predisposed to DDS due to cerebral edema after traumatic subdural hemmorage. In high-risk patients, we suggest the infusion of hypertonic solutions such as mannitol during dialysis. It seems to be well tolerated and may allow correction of ICP and optimisation of hemodialysis sessions. However, the risk of hypertensive crisis and hypernatremia should be considered.

The efficacy of hemodialysis on paraquat poisoning mortality: A systematic review and meta-analysis.

Paraquat (PQ) poisoning is a serious public health concern, especially in developing countries, due to its easy access and lack of awareness of potential harms. No effective treatment has been reported yet. Conventional hemodialysis (HD) is still used in many centers for excreting PQ or reducing acute kidney injury, but there is no consensus on its efficacy. Therefore, we aimed to review the HD efficacy in PQ poisoning mortality. We searched Web of Science, PubMed, Excerpta Medical Database, Google Scholar, Scopus, Cochrane, Web of Knowledge, Pro-Quest, ScienceDirect, Springer, Clinical Key, Scientific Information Database, Magiran, and Iran-doc, in publications before January 1, 2020. We compared patients who underwent HD (Group 1) with those who did not (Group 2). The outcome was considered mortality/survival. The data were analyzed by Comprehensive Meta-analysis Software. This systematic review and meta-analysis included five studies with a combined total of 203 patients. The patients in the Group 1 had higher mortality than Group 2 (odds ratio, 2.84; 95% confidence interval: 1.22-6.64; P = 0.02). There was no evidence of publication bias (P value for Egger's test = 0.833). Although HD did not affect the survival of patients, other variables such as the amount of ingested PQ, poisoning severity, the time between PQ ingestion and the start of HD, duration, and times of HD sessions may influence the results regarding mortality.

Cognitive function in children and adolescents with end-stage renal disease on hemodialysis

Background Cognitive impairment is a common problem in patients with end-stage renal disease (ESRD). The aim of this work was to study the effect of ESRD on cognitive function in children and adolescents on regular hemodialysis (HD), and to identify the possible risk factors affecting their cognitive function. The patients selected were those with ESRD on regular HD attending Alexandria University Children's Hospital, between January 2017 and December 2018. Patients and methods Cognitive function was assessed using the Stanford-Binet Intelligence Scale: 4th edition. At initial assessment, total intelligence quotient (IQ) and its four subdivisions (abstract visual reasoning, quantitative reasoning, short-term memory, and verbal reasoning) were measured for each patient. This was repeated for each patient after 1 year. Statistical analysis used Data was collected and analyzed using the SPSS (Statistical Package for the Social Sciences) program for statistical analysis (vs 21). Results In all, 47 and 41 patients were included in the first and second assessments, respectively. There was a statistically significant decrease in total IQ and its four subdivisions between the first and second assessments. Total IQ and its four subdivisions showed a negative correlation with patients’ age, age of onset of ESRD, age at start of HD, duration of ESRD, and duration of HD. Conclusions ESRD has a negative effect on cognitive function in children and adolescents with ESRD, and this continues to progress despite regular HD. Age of onset of ESRD, age upon starting HD, and duration of ESRD and HD are risk factors for decreased cognitive function in patients with ESRD on HD.