End-stage Disease Research Articles

Causal role of 731 immune cells in diabetic nephropathy: a bi-directional two-sample Mendelian randomization study.

The primary cause of end-stage renal disease (ESRD) is diabetic nephropathy (DN), and a growing body of research indicates that immunology plays a part in how DN develops into ESRD. Our objective is to identify causal relationships between various immune invading cells and DN to identify possible targets for immunotherapy. This study used a complete Mendelian randomization (MR) analysis with two samples to identify the underlying mechanism linking immune cell characteristics with DN. Using publicly available genetic data, we investigated the causal link between 731 immune cell profiles and DN risk. Included were four different types of immune systems: morphological parameters (MP), absolute cell (AC), relative cell (RC), and median fluorescence intensities (MFI). The results' robustness, heterogeneity, and horizontal pleiotropy were confirmed through extensive sensitivity analysis. Following FDR (False Discovery Rate correction method) correction, no statistically significant differences were observed; however, six immunophenotypes were shown to be significantly associated with DN risk at the 0.25 level. Only CD28+ CD4- CD8- T cells were identified as the protective immunophenotype (OR = 0.588, 95% CI 0.437-0.792, P = 4.71 × 10-4). Moreover, DN had no discernible impact on immunophenotyping after FDR correction. Surprisingly, three unadjusted phenotypes with low P values were discovered to be positively correlated with the risk of DN: CD20 on IgD- CD27- B cells (OR = 1.263, 95% CI 1.076-1.482, P = 4.22 × 10-3), CD8 on naive CD8 + T cells with Effector Memory (OR = 1.107, 95% CI 1.013-1.209, P = 2.40 × 10-2), and CD8 on Effector Memory CD8 + T cells (OR = 1.126, 95% CI 1.024-1.239, P = 1.46 × 10-2). Our findings provide a genetic basis for the association between immune cells and DN and should inform future clinical research.

Cohort review of patients with parathyroid cancer in End Stage Renal Disease (ESRD).

Parathyroid carcinoma (PTTC) is a rare malignant endocrine tumor seen in up to 1-2% of all cases of primary hyperparathyroidism. However, incidence of parathyroid carcinoma in renal hyperparathyroidism is a rare phenomenon. We aimed to evaluate the outcomes of PTTC in renal hyperparathyroidism published in the literature. Cohort review of parathyroid cancer cases reported in Medline (via PubMed), COCHRANE and EMBASE between the period 1985 - 2023 in patients with renal hyperparathyroidism. A total of 48 patients (20M: 28F), with a mean age of 49.8 (± 11.7 SD: range 20-75) years. Dialysis vintage was for a period of 8.9 (± 7.2; range 6months to 40years). The mean preoperative values were as follows: serum corrected calcium-2.87 IQR 2.56-3.01), PTH - 221.8 (IQR 86.6 -257.2pmol/L) and serum phosphate - 2.07 (IQR 1.72-2.28) mmol/L. Preoperative imaging was in the form of ultrasound of the neck in 21 of 48 (44%), MIBI scan in 27/48 (56%), contrast enhanced computerized tomography in 14/48 (29%) and MRI neck in 1/48 (2%). The mean size of the cancer was 2.7 (± 1.35) cm and weight of the gland ranged between 0.9 to 4.98g. 18/48 (37%) patients underwent a total parathyroidectomy and 30/48 (63%) had subtotal parathyroidectomy. En bloc excision of the tumour along with the thyroid along and central compartment lymph nodes was only performed in 12/48 (25%), of whom 9 (19%) had it performed at index surgery, whereas in the rest was done for persistent or recurrent disease. After a mean follow up of 34months, 14 (29%) had local recurrence, 1 (2%) had distant metastasis to the skeletal system, and 12 (25%) to the lungs. Cohort mortality was 6 (13%) due to refractory hypercalcemia. Parathyroid carcinoma in renal hyperparathyroidism is rare but when encountered, en bloc excision with parathyroidectomy provides the best chance of cure. Recurrences can be difficult to treat but may be needed to treat intractable hypercalcaemia.

Construction of frailty and risk prediction models in maintenance hemodialysis patients: a cross-sectional study.

As the prevalence of diabetic nephropathy and hypertensive nephropathy increases with age in mainland China, the number of patients with end-stage renal disease is increasing, leading to an increase in the number of patients receiving maintenance hemodialysis. Considering the harmful effects of frailty on the health of maintenance hemodialysis patients, this study aims to identify hemodialysis patients at risk for frailty at an early stage, in order to prevent or delay the progression of frailty in the early stage, so as to prevent the adverse consequences of frailty. A total of 479 patients admitted to the blood purification centers of two grade tertiary hospitals in Anhui Province, China, using convenient sampling. The Frailty Scale, the SARC-F questionnaire, the Simplified Food Appetite Questionnaire (SNAQ) and the mini nutritional assessment short-form (MNA-SF) were used in the study. Pearson correlation analysis was used to explore the correlation among the frailty influencing factors. The incidence of frailty was 24.0% among 479 Chinese hemodialysis patients. Gender (p < 0.05), Malnutrition (p < 0.001), sarcopenia (p < 0.001), and feel tired after dialysis (p < 0.001) were highly correlated with frailty in Chinese hemodialysis patients. Serum albumin concentration (p < 0.05) was a protective factor of frailty. This survey shows that frailty was highly prevalent among Chinese hemodialysis patients. Medical staff and their families should make early judgments and carry out interventions on the risk of frailty.

Investigating Data Diversity and Model Robustness of AI Applications in Palliative Care and Hospice: Protocol for Scoping Review.

Artificial intelligence (AI) has become a pivotal element in health care, leading to significant advancements across various medical domains, including palliative care and hospice services. These services focus on improving the quality of life for patients with life-limiting illnesses, and AI's ability to process complex datasets can enhance decision-making and personalize care in these sensitive settings. However, incorporating AI into palliative and hospice care requires careful examination to ensure it reflects the multifaceted nature of these settings. This scoping review aims to systematically map the landscape of AI in palliative care and hospice settings, focusing on the data diversity and model robustness. The goal is to understand AI's role, its clinical integration, and the transparency of its development, ultimately providing a foundation for developing AI applications that adhere to established ethical guidelines and principles. Our scoping review involves six stages: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarizing, and reporting the results; and (6) consulting with stakeholders. Searches were conducted across databases including MEDLINE through PubMed, Embase.com, IEEE Xplore, ClinicalTrials.gov, and Web of Science Core Collection, covering studies from the inception of each database up to November 1, 2023. We used a comprehensive set of search terms to capture relevant studies, and non-English records were excluded if their abstracts were not in English. Data extraction will follow a systematic approach, and stakeholder consultations will refine the findings. The electronic database searches conducted in November 2023 resulted in 4614 studies. After removing duplicates, 330 studies were selected for full-text review to determine their eligibility based on predefined criteria. The extracted data will be organized into a table to aid in crafting a narrative summary. The review is expected to be completed by May 2025. This scoping review will advance the understanding of AI in palliative care and hospice, focusing on data diversity and model robustness. It will identify gaps and guide future research, contributing to the development of ethically responsible and effective AI applications in these settings. DERR1-10.2196/56353.

Nanopore-based full-length transcriptome sequencing for understanding the underlying molecular mechanisms of rapid and slow progression of diabetes nephropathy.

Diabetic nephropathy (DN) has been a major factor in the outbreak of end-stage renal disease for decades. As the underlying mechanisms of DN development remains unclear, there is no ideal methods for the diagnosis and therapy. We aimed to explore the key genes and pathways that affect the rate progression of DN. Nanopore-based full-length transcriptome sequencing was performed with serum samples from DN patients with slow progression (DNSP, n = 5) and rapid progression (DNRP, n = 6). Here, transcriptome proclaimed 22,682 novel transcripts and obtained 45,808 simple sequence repeats, 1,815 transcription factors, 5,993 complete open reading frames, and 1,050 novel lncRNA from the novel transcripts. Moreover, a total of 341 differentially expressed transcripts (DETs) and 456 differentially expressed genes (DEGs) between the DNSP and DNRP groups were identified. Functional analyses showed that DETs mainly involved in ferroptosis-related pathways such as oxidative phosphorylation, iron ion binding, and mitophagy. Moreover, Functional analyses revealed that DEGs mainly involved in oxidative phosphorylation, lipid metabolism, ferroptosis, autophagy/mitophagy, apoptosis/necroptosis pathway. Collectively, our study provided a full-length transcriptome data source for the future DN research, and facilitate a deeper understanding of the molecular mechanisms underlying the differences in fast and slow progression of DN.

Sanctified Trees (Ficus religiosa and Ficus benghalensis) in India: A Significance and Analogous Mythology

Sanctified trees are the trees of religious importance and cultural significance. In India, trees particularly Ficus benghalensis and Ficus religiosa are such sacred plants with exceptional therapeutic qualities. Because of their aesthetic and natural characteristics, these plants are valued. Thus, in order to preserve certain plants, our ancestors associated certain Gods and Goddesses with them and designated them as sacred plants. Many people still believe in myths and beliefs associated with sacred trees. These historical notions demonstrate the relationship between people and plants, which is also beneficial in the protection of plant species because of their special features. They possess remarkable medicinal qualities that have assisted in the treatment of numerous life-dangers illnesses. These trees were used in the traditional medical practices of Ayurveda, Siddha, Unani, and homeopathy and often used as a medication for several illnesses. Different plant parts were employed to treat numerous fatal illnesses, including diarrhea, menorrhagia, leucorrhea, dysentery, mental diseases, and tonic and astringent. Therefore, the current review is the initiative to do a thorough literature on its phytochemistry, pharmacognosy, conventional and medicinal purposes along with myths and beliefs attached to it.

Network Analysis of Dysregulated Immune Response to COVID-19 mRNA Vaccination in Hemodialysis Patients

Introduction: End-stage renal disease (ESRD) results in immune dysfunction that is characterized by both systemic inflammation and immune incompetence, leading to impaired responses to vaccination. Methods: To unravel the complex regulatory immune interplay in ESRD, we performed the network-based transcriptomic profiling of ESRD patients on maintenance hemodialysis (HD) and matched healthy controls (HCs) who received the two-dose regimen of the COVID-19 mRNA vaccine BNT162b2. Results: Co-expression networks based on blood transcription modules (BTMs) of genes differentially expressed between the HD and HC groups revealed co-expression patterns that were highly similar between the two groups but weaker in magnitude in the HD compared to HC subjects. These networks also showed weakened coregulation between BTMs within the dendritic cell (DC) family as well as with other BTM families involved with innate immunity. The gene regulatory networks of the most enriched BTMs, likewise, highlighted weakened targeting by transcription factors of key genes implicated in DC, natural killer (NK) cell, and T cell activation and function. The computational deconvolution of immune cell populations further bolstered these findings with discrepant proportions of conventional DC subtypes, NK T cells, and CD8+ T cells in HD subjects relative to HCs. Conclusion: Altogether, our results indicate that constitutive inflammation in ESRD compromises the activation of DCs and NK cells, and, ultimately, their mediation of downstream lymphocytes, leading to a delayed but intact immune response to mRNA vaccination.

Vitamin D deficiency may increase the risk of acute kidney injury in patients with diabetes and predict a poorer outcome in patients with acute kidney injury

BackgoundPeople with diabetes are much more likely to develop acute kidney injury (AKI) than people without diabetes. Low 25-hydroxy-vitamin D [25(OH)D] concentrations increased the risk of AKI in specific populations. Few studies have explored the relationship between the 25(OH)D level and AKI in patients with diabetes. We conducted this study to investigate the relationship between the plasma level of 25(OH)D and the risk of AKI in patients with diabetes, and to evaluate whether the 25(OH)D level could be a good prognostic marker for AKI progression.MethodsA total of 347 patients with diabetes were retrospectively reviewed. The primary endpoint was the first event of AKI. The secondary endpoint is need-of-dialysis. AKI patients were further followed up for 6 months with the composite endpoint of end-stage renal disease (ESRD) or all-cause death. Kaplan–Meier survival analysis and Cox proportional hazards models were used.ResultsDuring a median follow-up of 12 weeks (12.3 ± 6.7), 105 incident AKI were identified. The middle and high tertiles of baseline 25(OH)D levels were associated with a significantly decreased risk of AKI and dialysis compared to the low tertile group (HR = 0.25, 95% CI 0.14–0.46; HR = 0.24, 95% CI 0.13–0.44, respectively, for AKI; HR = 0.15; 95% CI 0.05–0.46; HR = 0.12; 95% CI 0.03–0.42, respectively, for dialysis). Sensitivity analysis revealed similar trends after excluding participants without history of CKD. Furthermore, AKI patients with 25(OH)D deficiency were associated with a higher risk for ESRD or all-cause death (HR, 4.24; 95% CI, 1.80 to 9.97, P < 0.001).ConclusionA low 25 (OH) vitamin D is associated with a higher risk of AKI and dialysis in patients with diabetes. AKI patients with 25(OH)D deficiency were associated with a higher risk for ESRD or all-cause death.

Unmet Spiritual Needs: A Study among Patients with Chronic Illness

Objectives: The conventional healthcare system operates on the ‘physiological man’ and overlooks the ‘spiritual man’. Many studies reported on the unmet spiritual needs of terminally ill patients. Despite spiritual care being a predictor of a positive mindset (meaning making) among patients with terminal illnesses, assessing spiritual needs and providing adequate spiritual care is still a distant phenomenon in the healthcare setting. Materials and Methods: With the help of a spiritual needs questionnaire, we analysed the unmet spiritual needs and preferences of 30 terminally ill patients. Specific attention was given to psychosocial, emotional, existential, religious and acceptance of death. Results: The results show that 72% of terminally ill patients reported a strong desire to have their spiritual needs met. Psychosocial needs scored the highest, while acceptance of dying scored the least. The need to be connected with the family was one of the strongest wishes expressed in the study. Religious needs ranked as the second category of needs. Findings show that the highest needs are intertwined with the patients’ culture. Conclusion: In India, religion and family connections are essential; terminally ill patients expressed the desire that meeting these two aspects makes their lives meaningful even at the end stage. The results warrant a spiritual needs assessment as a deathbed test to make the end–of–life more meaningful.

Spontaneous Wing Tip Edema in Captive Birds of Prey: Review of 41 Cases in the United Kingdom (2004-2022).

There is limited literature regarding wing tip edema (WTE) in raptors, and much of our current understanding of the condition is based on anecdotal reports. The aims of this retrospective study were to describe the clinical features of WTE in birds of prey, to identify prognostic factors for return to flight and patient survival following diagnosis, and to develop and assess the clinical significance of a novel WTE grading system. Between 2004 and 2022, 41 cases of WTE were identified in 39 captive birds. No cases were found in wild birds. Harris's hawks (Parabuteo unicinctus), lanner falcons (Falco biarmicus), and peregrine falcons (Falco peregrinus) had the highest frequencies of WTE, and all cases presented between October and May. Increasing days of air frost per month and colder median monthly temperatures were significant risk factors for the development of WTE. Of the cases where patient outcomes were known, 23/31 (74.2%) cases returned to normal flight and 29/34 (85.3%) cases survived. End-stage disease, represented by primary flight feather loss and metacarpal ischemic (dry) gangrene, and enalapril use were associated with poor patient outcomes. Presentation within 24 hours of disease onset, isoxsuprine use, and physiotherapy were associated with improved patient outcomes. This study showed that WTE is an infrequently encountered but clinically significant condition in captive raptors and is associated with an overall high morbidity and moderate mortality risk.

Co-occurrence of rectal and lung cancers: A case report

Co-occurrence of two types of cancers, especially lung and colorectal cancers is rare. This study investigated patients at Bach Mai Hospital who were diagnosed with two or three cancers. Only a few patients concurrently had two cancers. Positron emission tomography (PET)/computed tomography (CT) was used for the staging of cancer, especially synchronous malignancies. In this report, we have presented the case of a patient diagnosed with rectal and lung cancer based on CT, magnetic resonance imaging, and PET/CT scans as well as immunohistochemistry. Managing terminal synchronous cancers is challenging. The efficacy of the preferred anticancer therapy must be considered to ensure patients&amp;rsquo; quality of life. Although the combination of tyrosine kinase inhibitor-targeted therapy and chemotherapy is promising, its toxicity remains unknown. Our patient received two cycles of mFOLFOX6, afatinib, and bisphosphonate. However, the treatment was discontinued due to grade 3 stomatitis and grade 2 anemia. Despite recovery and partial response in terms of symptom and tumor marker reduction, the patient refused further treatment and chose palliative care.

Acute Kidney Injury after Isolated Coronary Bypass Surgery

AbstractAcute kidney injury (AKI) is among the most serious of the common postoperative complications of cardiac surgeries, which can increase the short- and long-term morbidity and mortality of patients. This study aimed to examine possible risk factors that lead to AKI. We sought to compare our AKI rates to national averages in coronary artery bypass grafting (CABG) reported by the Society of Thoracic Surgeons (STS). We reviewed our institution's data for renal failure in CABG procedures performed between January 1, 2020, and June 30, 2023. From the database, we identified 1,068 CABG patients and reviewed demographics, nonmodifiable conditions, and modifiable risk factors. The STS database uses the Risk, Injury, Failure, Loss, and End-stage renal disease definition for renal failure. Of our patient sample, 14 (1.3%) experienced renal failure. The national rate for AKI after isolated CABG was 1.9% in 2023. Chronic lung disease was a risk factor for AKI development. The mean perfusion, cross-clamp, ventilator times, and hospital stay increased in AKI patients. All patients who suffered from AKI had undergone perioperative blood transfusion. Our single-center experience with renal failure is slightly better than the national average. In our population, chronic lung disease and lower preoperative ejection fractions were associated with increased rates of AKI. Modifiable risk factors in our population included perioperative blood transfusion and increased perfusion/cross-clamp times. Lastly, AKI patients spent longer time on ventilators, increased lengths of stay, and increased postoperative mortality.

SGLT2i and GLP1-RA exert additive cardiorenal protection with a RAS blocker in uninephrectomized db/db mice.

Diabetic Kidney Disease (DKD) is the main cause of end-stage renal disease in the developed world. The current treatment of the DKD with renin-angiotensin system (RAS) blockade does not totally halt the progression to end stage kidney disease. Currently, several drugs have shown to delay DKD progression such as sodium-glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like-1 receptor agonists (GLP-1RA). We hypothesized that by combining several drugs that prevent DKD progression on top of RAS blockade a synergistic effect would be achieved in terms of cardiorenal protection. In the present study, we analysed if the combination of a RAS blocker (ramipril) with a SGLT2i (empagliflozin) and/or GLP-1RA (semaglutide) in a type 2 diabetic mouse model could have add-on effects in kidney and heart protection. Male and female uninephrectomized type 2 diabetic db/db mice were treated with empagliflozin and/or semaglutide on top of ramipril during 8weeks. During the study body weight, water and food intake were weekly monitored, glycaemia biweekly and albuminuria and glomerular filtration rate (GFR) before and after the treatment. At the end of the experiment, kidney and heart were isolated for histological and gene expression studies as well as for intrarenal RAS state assessment. Semaglutide combined with ramipril and/or empagliflozin significantly decreased albuminuria but only when combined with both compounds, semaglutide further decreased blood glucose, glomerular hyperfiltration in male mice and glomerular mesangial matrix expansion. In kidney, only the triple treatment with empagliflozin, semaglutide and ramipril reduced the expression of the proinflammatory and profibrotic genes ccl2 and TGFß1. In addition, the combination of empagliflozin and semaglutide on top of RAS blockade was superior in decreasing cardiomyocyte hypertrophy and heart fibrosis in db/db mice. Our results suggest that the combination of SGLT2i with GLP-1RA is superior in cardiorenal protection in DKD than the drugs administered alone on top of RAS blockade.

Percutaneous Insertion of Peritoneal Dialysis Catheters.

Patients with end-stage renal disease undergoing hemodialysis encounter significant challenges in care coordination and experience higher complication rates. Peritoneal dialysis (PD) is an evidence-based alternative that significantly improves patients' quality of life.Peritoneal dialysis catheter insertion methods include open surgical, laparoscopic, peritoneoscopic, and percutaneous image-guided approaches. Despite comparable success rates and cost-effectiveness, the US healthcare system underutilizes the percutaneous method.This article aims to provide an overview of the essential components of the technique of percutaneous peritoneal dialysis catheter insertion, as well as address patient selection nuances and considerations for urgent-start dialysis. Additionally, it reviews the outcomes and complications associated with image-guided percutaneous PD catheter placement, advocating for its wider adoption.

Incidental renal cell carcinoma post bilateral nephrectomy in autosomal dominant polycystic kidney disease.

Renal cell carcinoma (RCC) is more common in patients with autosomal dominant polycystic kidney disease (ADPKD) than in the general population. Diagnosing RCC in ADPKD is challenging due to the presence of multiple renal cysts, often leading to delays and difficulties in distinguishing RCC from cyst infection or hemorrhage. To analyze the prevalence and characterize the clinical features of RCC in patients with ADPKD undergoing simultaneous bilateral native nephrectomy. Between May 2017 and April 2024, 19 ADPKD patients undergoing hemodialysis and awaiting kidney transplantation due to end-stage renal disease (ESRD) underwent bilateral nephrectomies in a single center. Parameters such as patient characteristics, intraoperative blood loss, blood transfusion volume, length of hospital stay, and postoperative complications were documented. Pathological findings for RCC were reviewed. A total of 38 kidneys were excised from 19 patients, with a mean age of 56.8 years and an average hemodialysis duration of 84.2 months. Eight patients underwent open nephrectomies, and 11 underwent hand-assisted laparoscopic nephrectomies. RCC was detected in 15.8% of kidneys, affecting 21.1% of patients. Two patients had multifocal RCC in both kidneys. All RCC cases were pT1 stage, with the largest lesion averaging 16.5 mm in diameter. The average operative duration was 120 minutes, with intraoperative blood loss averaging 184.2 mL. Five patients required blood transfusions. Postoperative complications occurred in five patients, with a mean hospital stay of 17.1 days. The mean follow-up period was 28.1 months. The prevalence of RCC is higher in patients with ADPKD with ESRD than in those with ESRD alone. Thus, clinicians should be cautious and implement surveillance programs to monitor the development of RCC in patients with ADPKD, particularly those on dialysis.

Assessing Clinical Outcomes and Treatment Efficacy in a Patient with Crescentic Glomerulonephritis (CGN)- A Case Report

Crescentic glomerulonephritis (CGN) is a rapidly progressive renal condition marked by crescent formation in the glomeruli, often resulting in end-stage renal disease (ESRD) if not promptly addressed. This case report examines a 54-year-old female with a sudden onset of generalized edema and reduced urine output, which led to her hospitalization. Laboratory evaluations revealed acute renal failure with markedly elevated serum creatinine levels. Despite a background of Antineutrophil Cytoplasmic Antibodies (ANCA)-associated vasculitis, her management was complicated by inconsistent adherence to immunosuppressive therapy. Notably, severe hypertension exacerbated her renal impairment, necessitating immediate intervention. The clinical progression of CGN highlights the critical importance of early diagnosis, continuous monitoring, and a multidisciplinary approach for effective management. Emphasizing patient education and lifestyle modifications, particularly in dietary habits and blood pressure control, can significantly influence treatment outcomes. This case illustrates the urgency of addressing CGN and the necessity of a collaborative healthcare strategy to improve prognosis and enhance the patient's quality of life.

Comparative study between the halfway technique and the standard technique for exchange of tunneled hemodialysis catheter.

When indicated, tunneled hemodialysis catheters are usually inserted using the standard technique but, this technique has its complications. The halfway method is performed by exchange of an already-inserted dialysis catheter (tunneled or non-tunneled) to a tunneled one over a guidewire mounted via the old catheter. In this study, we aimed at evaluating the feasibility, safety, and durability of halfway method in comparison to the standard technique (de novo puncture). This prospective study was conducted during the period from May 2020 till May 2022 and included 87 patients with end-stage renal disease (ESRD) on regular hemodialysis (HD) in need for insertion new tunneled dialysis catheters instead of temporary or malfunctioning tunneled ones. According to the technique of catheter insertion, these patients were divided into two groups: group A (the halfway technique: catheters were exchanged over guidewires under fluoroscopic control; 48 patients) and group B (the standard technique: via de novo ultrasound-guided vein puncture; 39 patients). Instant, delayed complications and 12-months patency rates were reported and analyzed. The frequency of peri-operative bleeding complications was better in the halfway group with comparable infection rate and late catheter dysfunction results between the two groups. One year patency rates were 87.5% in halfway technique group compared to 79.5% in standard technique group, yet without statistical significance. However, there was a statistically significant shorter operative time in halfway group (15.54 ± 2.6 min vs 26.97 ± 5.6 min, p < 0.001). The halfway technique may be recommended over the standard technique of tunneled catheter insertion due to shorter operative time, lower rate of hematoma formation, with non-inferior 1-year patency rates and comparable technical success and infection rates. The advantage of access sites preservation for future demand makes this technique of great value to this group of ESRD patients.

FISIOTERAPIA PALIATIVA: ANÁLISE DE REVISÃO BIBLIOGRÁFICA INTEGRATIVA

With the arrival of Christianity, there was a transformation in patient care, enabling the creation of shelters and hospitals to offer assistance. This movement allowed the reception of people in vulnerable conditions, previously ignored by the health system at the time (RODRIGUES, 2018). By incorporating physiotherapy into a multidisciplinary or broad view of the association of life, quality of life and palliative care, it is possible to expand access to conservative, integrative and multidisciplinary therapeutic treatment options, less tense, aggressive, stressful and painful for those involved, accepting what the natural cycle of life really is like, where we are born, take care of each other and ourselves, and then die. This article carries out an integrative review on the role of physiotherapy in the context of palliative care with a focus on multidisciplinary and humanized assistance. Based on an analysis of studies published between 2004 and 2023, and data collection, carried out through research among patients and family members in the year 2024, the benefits of physiotherapy in relieving pain, improving quality of life and no emotional support for patients with chronic and terminal illnesses.

Exploring the Influence of the Edmonton Symptom Assessment System Implementation in Palliative Care Patients: A Systematic Review.

One of the most essential elements of providing high-quality palliative care is good symptom control, which is guided through an assessment of the evolution of the patient's level of distress over time. The Edmonton Symptom Assessment System (ESAS) was created to measure diverse symptoms in palliative care patients. It is a user-friendly, validated, and reliable multi-item instrument. Globally, ESAS is extensively used to direct dailyclinical careand foster communication across multidisciplinary teams, ensuring coordinated patient management, facilitating referrals to specialized programs, and evaluating the quality of care. In this systematic review, we aim to evaluate the influence of using ESAS on symptom assessment and control among palliative care patients and settings. We have employed both manual and electronic search strategies among databases to determine relevant studies. This systematic review included original studies published between 2013 and 2023 that implemented theESASas part of palliative care for adult patients with terminal illness or advanced disease. Studies recruiting pediatric patients, case reports with limited sample sizes and no descriptive statistics, and nonhuman or laboratory studies were excluded.The ROBINS-I (Risk Of Bias In Non-randomized Studies-of Interventions) tool was used to assess the quality of the included studies, which assessed the methodological quality and potential risk of bias in non-randomized clinical studies. We included eight studies that recruited a total of 3184 patients. Fatigue followed by pain were the symptoms with the highest score on ESAS among all the studies, while the lowest score was recorded for nausea and dyspnea in most of the studies. ESAS scores showed improvement in the follow-up visits. Two of the included studies reported satisfaction with the utilization of the ESAS tool. As stated in our results, it can improvethe overall quality of life for patients receiving palliative care by assisting healthcare professionals, family members, and caregivers in methodically assessing and treating symptoms over time. By fostering better communication among care teams and involving caregivers in the process, the use of ESAS promotes a morepatient-centered approach to care, ensuring that both the patient's needs and the perspectives of their loved ones are considered.

7378 Glargine Induced Neuroglycopenia in Patients with End-Stage Renal Disease: Importance of Insulin Regimen Optimization in Haemodialysis Patients

Abstract Disclosure: M. Shrivastava: None. L. Kaur: None. B. Armendariz: None. R. Kaur: None. A. Shetty: None. In patients with end stage renal disease (ESRD), hypoglycemia accounts for up to 3.6% of all the admissions with mortality rates of up to 30%. A combination of impaired insulin clearance, changes in glucose metabolism and dialysis process makes the patients with end stage renal disease vulnerable to neuroglycopenia.Case description:53 year old female with past medical history of insulin dependent type 2 diabetes mellitus, ESRD secondary to diabetes, on hemodialysis(HD) thrice weekly since two years, presented to the emergency with altered mental status, respiratory distress, tachycardia. Lab work revealed blood glucose(BG) of 23 mg/dl, HbA1c of 8.4%, eGFR of 6, and arterial blood gas showed hypercapnic respiratory acidosis. Patient received dextrose, with no improvement of symptoms. Eventually she developed acute hypercapnic respiratory failure requiring endotracheal intubation with mechanical ventilation, and was transferred to the ICU. As per family, a night prior to presentation, last recorded BG after dinner was 253 mg/dl, she took her night time glargine, which was recently increased by her primary care for poorly controlled HbA1c levels. Brain MRI and long term EEG monitoring findings were consistent with underlying extensive brain injury secondary to prolonged hypoglycemia. Unfortunately, the patient's condition did not improve despite HD and BG correction, eventually she underwent compassionate extubation. Case Discussion:The insulin requirements in ESRD patients are reduced by approximately 50%, regardless of residual insulin secretion. Malnutrition and acidosis reduce hepatic glycogen stores and availability of gluconeogenic precursor, expected compensatory renal gluconeogenesis is compromised by decreased renal function causing hypoglycemia, which is further worsened by inappropriately high plasma insulin levels caused by reduced renal insulin breakdown. Diabetes mellitus patients with ESRD are frequently managed with basal-bolus insulin regimen, and HD up to thrice weekly, leaving them without HD for up to 3 days especially over the weekend. This can result in accumulation of insulin metabolites causing delayed insulin clearance as seen in our patient. In such cases even long acting insulin, such as glargine, can have compounding effects, which could possibly cause fatal complications such as neuroglycopenia. In such patients continuous glucose monitor use with tapering dose glargine regimen may help eliminate this compounding effect. Conclusion: Neuroglycopenia is a rare manifestation of diabetes mellitus with ESRD. Compromised renal gluconeogenesis and impaired insulin clearance can cause inappropriately high plasma levels of insulin. In such patients continuous glucose monitoring along with tapering dose of long acting insulin should be utilized for proper glycemic control to limit compounded effect of insulin metabolite accumulation. Presentation: 6/3/2024