Time In Hemodialysis Patients Research Articles

#1588 Modifiable factors associated with fatigue and prolonged recovery time in hemodialysis patients: a French multicenter observational study

Abstract Background and Aims Fatigue and dialysis recovery time (DRT) are two important patient-reported outcomes that highly affect the well-being of patients on hemodialysis. The DOPPS working group showed that prolonged DRT increases mortality. Therefore, this study aims to assess all modifiable dialysis-related factors, associated with DRT and fatigue, that could be addressed in future clinical trials. Method This is a French multicenter observational study that included all patients ≥ 18 years, on chronic hemodialysis for >3 months, who consented to participate during December 2023. Patients with cognitive problems, active cancer and admitted to hospital were excluded. The study got the approval of the local ethics committee. DRT was assessed six times by asking at each session for two non-consecutive weeks: "How long did it take you to recover from your last dialysis session?" Fatigue was assessed by using the French validated SONG-HD fatigue scale that includes three questions: in the last week, "did you feel tired?", "did you lack energy?", "did fatigue limit your usual activities?". Logistic regression analysis assessed the association between DRT>12 hours and fatigue score ≥4 with all demographic and dialysis-related factors. A sub-analysis of DRT-related factors was performed for very elderly ≥ 85 years. Results A total of 536 patients and 2967 sessions were analyzed. Mean age was 68.1 ± 14.3 years with 10.4% above 85 years; 60.9% were males, median dialysis vintage was 41 (22.5, 80) months, 33.2% had diabetes, 46.3% had cardiovascular (CV) disease, 5.2% were on nocturnal hemodialysis, 14.4% had a catheter and 63.3% were on HDF. Median dialysate sodium was 138 (136, 140) with a minimum of 130 to a maximum of 142. Median DRT was 140 (45, 440) minutes with 42.7% of patients recovering in <2 hours, 16.2% in 120-360 minutes, 26.1% in 361-720 minutes and 14.9% >12 hours. The mean SONG-HD fatigue score was 3.1 ± 2.3 with 18% having no fatigue and 37.7% having a score ≥4. DRT and fatigue score were significantly associated (P < 0.001). Factors significantly associated with DRT>12 hours are summarized in Table 1: sex, diabetes, CV disease, BMI, ultrafiltration rate/Kg/hour, duration of session, blood flow, Kt/V, blood pressure, membrane type and all routine blood tests were not associated with DRT whereas intradialytic change in natremia was significantly associated with recovery time (Fig. 1). In multivariable regression analysis, factors associated with a fatigue score ≥4 included females (OR = 1.74; 95% CI: 1.21, 2.51; P = 0.003), and lower hemoglobin (OR = 0.83; 95% CI: 0.71, 0.99; P = 0.003). In the subgroup of patients ≥85 years, HDF was associated with prolonged DRT (OR = 4.2; 95% CI: 1.04, 17.03; P = 0.045) and lower hemoglobin was associated with fatigue (OR = 0.51; 95% CI :0.28, 0.93; P = 0.029). Conclusion DRT and fatigue are significantly associated however modifiable factors associated with prolonged DRT are not exactly similar to those associated with fatigue. A negative intra-dialytic change in natremia and low frequency of dialysis are two major factors associated with longer DRT, with HDF significantly associated with longer recovery in very elderly patients, whereas the modifiable independent factor associated with fatigue is the hemoglobin level.

Farsi Version of the Body Image Concern Inventory in Iranian Hemodialysis Patients: Validity and Reliability

Background and Purpose:Patients on hemodialysis often struggle with their body image. This study was conducted with the aim of investigating the validity and reliability of the Persian version of the body image concern questionnaire for the first time in hemodialysis patients in Iran.Methods:In this cross-sectional study, 400 hemodialysis patients from Iran were assessed using the Body Image Concern Inventory (BICI). By using exploratory factor analysis (EFA; with Maximum Likelihood Factor Analysis and Promax Rotation) and confirmatory factor analysis, the construct validity of BICI was assessed. To check for internal consistency, the average interitem correlation, Cronbach’s alpha, and McDonald’s omega coefficients were used. Stability was assessed with intraclass correlation coefficient (ICC).Results:The participants’ average age was 53.2 (SD= 13.2) years, and more than half of them were women (54.60%). Four factors extracted from exploratory factor analysis (EFA) show that the total cumulative variance explained by these factors was 44.46% of the total variance. Item factor loadings varied between 0.415 and 0.970. Internal consistency coefficients were considered acceptable (>0.7). Also, stability was evaluated as good (ICC = .839).Conclusions:The Farsi version of the BICI scale as a self‐report measure of concerns about dysmorphic appearance has 19 items and shows acceptable reliability and validity. Consequently, the scale can be used by nurses to evaluate body image among Farsi-speaking hemodialysis patients, which can help them to take necessary actions to decrease the level of concerns in these patients.

Association of abdominal aortic calcification with longitudinal changes in left ventricular mass of patients on hemodialysis and its prognostic value.

Vascular calcification (VC) and myocardial hypertrophy are very common in patients on hemodialysis (HD). Previous studies have only assessed the cross-sectional associations of VC with left ventricular mass (LVM) and the predictive value of individual factors. The present study investigated the relationship between abdominal aortic calcification (AAC) and LVM increment over time, and the combined effect of these factors on the outcomes of HD patients. 104 HD patients were enrolled. AAC scores were evaluated on left lateral lumbar spine radiographs. Echocardiography was performed to calculate the LVM changes during a 2-year period. At baseline, 91 patients (87.5%) had varying degrees of AAC (median score 6.0, range 2.0-11.0). After 2 years, the mean LVM change was 7.49g (range -5.03-26.00 g), and 68 patients (65%) had an increased LVM. Patients with higher baseline AAC scores had significantly larger LVM and LVM index increments. Patients with increased LVM had significantly higher baseline AAC scores and hemoglobin, serum phosphate, and hypersensitive C-reactive protein levels. Multiple stepwise linear regression demonstrated that the baseline AAC was the only independent predictor of increased LVM after 2years. 28 patients (26.9%) died in the subsequent 5 years. Patients with lower baseline AAC scores had a significantly higher cumulative survival rate than those with higher AAC scores. However, the LVM change (either alone or in combination with the AAC score) had no significant effect on survival. In conclusion, AAC is an independent predictor of LVM increase over time in HD patients. Prevention and treatment of VC may be a promising intervention target to improve left ventricular remodeling and outcomes in HD patients.

Effect of the arterial needle bevel position on puncture pain and postremoval bleeding time in hemodialysis patients: A self-controlled, single-blind study.

This study aimed to investigate the effect of the bevel orientation (facing upwards or downwards towards the skin) of the needle inserted into the arterial limb of the arteriovenous fistula (AVF) on puncture pain and postremoval bleeding time. This study, using a single-blind crossover design, was conducted on 35 maintenance hemodialysis patients who had been dialyzed for at least 6months and in whom blood access was via an AVF. AVF cannulation was performed with the needle bevel pointing upward in the first six sessions and the needle bevel pointing downwards (towards the skin) in the subsequent six sessions. Needles were always inserted in the direction of blood flow. At each dialysis session, cannulation pain was measured using a visual analog scale (VAS), and the bleeding time at the end of dialysis after needle removal was recorded. The VAS score and postremoval bleeding time were lower when the needle bevel pointed downwards towards the skin during insertion (P<0.05). Insertion of the needle with the bevel pointed downward decreased puncture pain during cannulation and bleeding time postdialysis on needle removal.

Evaluating the effect of intradialytic cycling exercise on quality of life and recovery time in hemodialysis patients: A randomized clinical trial.

The aim of this study was to assess the effect of intradialytic cycling exercise on quality of life (QOL) and recovery time in patients who underwent hemodialysis. Hemodialysis patients were recruited from the referral dialysis centers affiliated with Isfahan University of Medical Sciences, Isfahan, Iran. Patients were randomly assigned into the intervention and the control groups. Patients in the intervention group exercised on a stationary bike for 12 weeks (3 times per week for 30 min); however, patients in the control group received usual hemodialysis. The kidney disease QOL (KDQOL)-short-form version 1.3 was used to assess QOL. Patients were asked to answer the question "How long does it take to recover from a dialysis session?" to assess recovery time. A total of 110 hemodialysis patients, including 60 in the intervention group and 50 in the control group were analyzed. A significant increase was observed in the generic (mean difference ± SE: 1.50 ± 0.44, P = 0.001), kidney disease (mean difference ± SE: 0.84 ± 0.28, P = 0.004), and overall QOL (mean difference ± SE: 1.18 ± 0.33, P = 0.001) scores after 12 weeks of intradialytic cycling exercise in the intervention group. Furthermore, a significant difference was noted between the intervention and the control group regarding the mean difference of all QOL scores after the intervention (P < 0.05). We also found a significant difference in the mean difference of recovery time between the intervention and the control group after the intervention (P < 0.001). KDQOL and recovery time could improve in hemodialysis patients after 12-week intradialytic exercise.

Assessment of cognitive impairment and related risk factors in hemodialysis patients

BackgroundCognitive impairment in hemodialysis patients has been acknowledged over the last years and has been reported in up to 80% of patients. Older age, high prevalence of cardiovascular risk factors, such as stroke and transient ischemic attack, uremia, and multiple metabolic disturbances represent the most common factors for cognitive impairment in hemodialysis patients.MethodsWe conducted a prospective cohort study on 408 patients from 10 hemodialysis centers in the regional government district of Middle Hesse (Germany). Patients underwent a neuropsychological test battery consisting of five tests, in addition to a phonemic fluency test, to assess cognitive profile. The patients were classified as no cognitive impairment or mildly-, moderately- or severely-impaired cognitive function, depending on the degree of impairment and number of domains where the deficit was determined. We analyzed the cognitive profile and the change in performance over time in hemodialysis patients based on their cognitive status at baseline vs. 1-year follow-up.ResultsOf 479 eligible patients, 408 completed all tests at baseline. Only 25% (n = 102) of the patients had no cognitive impairment. Fourteen per cent (n = 57), 36.5% (n = 149), and 24.5% (n = 100) of patients showed mild, moderate, and severe impairment, respectively. In patients with cognitive impairment, all cognitive domains were affected, and impairment was significantly associated with depression and education. The most impaired cognitive performance was immediate memory recall, and the best performance was found in naming ability. No significant change was observed after 1-year follow up in any domain. ConclusionOur study shows that the prevalence of cognitive impairment in hemodialysis patients is high and that it is affected by the presence of depression. Furthermore, education has an effect on cognitive test results. As depression has a significant influence on cognitive impairment, its early identification is essential in order to initiate treatment at an early stage, hoping to positively influence cognitive performance.

A study of Factors Affecting Dialysis Recovery Time in Haemodialysis Patients in India.

Background:Patients on maintenance haemodialysis (MHD) often complain of fatigue and tiredness following haemodialysis sessions leading to poor compliance with the dialysis schedule. There is limited Indian data on dialysis recovery time (DRT). The present study was designed to assess the factors affecting DRT in our haemodialysis population.Methods:We recorded self-reported patient recovery times of 120 patients who satisfied the inclusion criteria, over three consecutive dialysis sessions by asking the question, 'How long does it take to recover from a dialysis session'? Data recorded included patient factors like age, sex, co-morbidities, Charlson comorbidity index score (CCI), dialysis vintage, duration of kidney disease, interdialytic weight gain (IDWG), treatment factors like ultrafiltration rate (UFR), SpKt/V, blood pump speed, dialysate sodium, session length, pre and post HD blood pressure and laboratory parameters. Health-related quality of life (HRQoL) was assessed with the KDQOL-SF v. 1.3 questionnaire. Results from the SF-36 score were summarised into the physical composite score (PCS), mental composite score (MCS) and kidney disease composite score (KDCS).Results:The mean age of the study population was 50.6 ± 12.6 years. Among the 120 patients, 77 (64.2%) were males. Thirty-nine patients (32.5%) were diabetic and 95 (79.1%) patients were hypertensive. The mean dialysis vintage of the study population was 26.1 ± 18.6 months, 41 (34.2%) patients reported DRT <2 h; 48 (40%) reported DRT between 2–6 h and 31 (25.8%) reported DRT >6 h. On multivariate regression analysis, higher IDWG, CCI score and UFR were associated with prolonged DRT. Reported DRT also inversely correlated with PCS (r = - 0.66), MCS (r = - 0.65) and KDCS (r = - 0.59) scores which was statistically significant.Conclusion:The present study showed that higher CCI scores, IDWG and UFR were associated with prolonged DRT in Indian haemodialysis patients and patients with longer recovery time had poor HRQoL. Interventions to reduce DRT need to be assessed in further trials in Indian MHD patients.

Does Pulse Wave Velocity Increase Over Time in Hemodialysis Patients?

Objectives: Arterial stiffness, measured by pulse wave velocity (PWV), is reported to be increased in hemodialysis (HD) patients and increases cardiovascular mortality. Previous studies have reported an association between extracellular water (ECW) and PWV. We wished to review whether PWV increases over time and whether this is associated with ECW. Methods: We reviewed repeat aortic PWV measurements using an oscillograph method along with corresponding ECW measured by multifrequency bioimpedance in HD patients a minimum of 5 years apart. Results: Twenty-four patients (16 [66.7%] male and 11 [45.8%] diabetic, mean age 61.7 ± 15.2 years) had PWV and ECW initially measured after 46 (26–124) months of HD and then after 112 (97–202) months. Overall, there was no change in PWV or ECW (9.4 ± 2.2 vs. 8.1 ± 2.5 cm/s; 14.7 ± 2.5 vs. 15.2 ± 2.9 L, respectively), whereas the ECW/total body water ratio increased (0.399 ± 0.015 vs. 0.408 ± 0.021, p < 0.05). We found no association between changes in PWV and ECW (r = −0.05, p = 0.84), whereas there was an association with the change in peri-dialytic systolic blood pressure (SBP) (r = 0.59, p = 0.007). Conclusion: In our small observational study, there was no overall change in PWV, after 5 years of HD, with PWV increasing in 50% and falling in 50%. Changes in PWV were not associated with changes in ECW but were associated with changes in peri-dialytic SBP. Our study demonstrates that PWV does not increase in all HD patients with time, and interventional studies are required to determine whether targeted blood pressure control reduces PWV in HD patients.

Hydroxychloroquine and azithromycin tolerance in haemodialysis patients during COVID-19 infection.

BackgroundHaemodialysis patients are at risk of developing severe forms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: coronavirus disease 2019 (COVID-19). In March 2020, hydroxychloroquine (HCQ) and azithromycin (AZI) were proposed as potential treatments of COVID-19, but with warnings concerning their possible toxicity. No data are available regarding the toxicity of this treatment in haemodialysis patients.MethodsWe report the use of HCQ and AZI in a cohort of COVID-19 haemodialysis patients with focus on safety concerns.ResultsTwenty-one patients received 200 mg HCQ thrice daily during 10 days, and AZI 500 mg on Day 1, and 250 mg on the four following days. HCQ plasma concentrations were within the recommended range (0.1–1.0 µg/mL) in all patients except one, in which maximum concentration was 1.1 µg/mL. HCQ concentration raised until the third day and remained stable thereafter. No cardiac event occurred in spite of progressive lengthening of corrected QT interval (QTc) during the treatment. One patient experienced a long QTc syndrome (QTc >500 ms) without any arrhythmia episode, although HCQ concentration was in the target range. Five (23.8%) patients experienced hypoglycaemia, a well-known HCQ side-effect. SARS-CoV-2 RNA remained detectable in nasopharyngeal swabs for a long time in haemodialysis patients (mean time 21 days).ConclusionsHCQ and AZI are safe in haemodialysis patients at these doses but can lead to long QTc syndrome and hypoglycaemia. HCQ concentrations were not correlated with side effects. We recommend monitoring of the QTc length throughout treatment, as well as glycaemia. SARS-CoV-2 could persist for longer in haemodialysis patients than in the general population.

P1078IMPACT OF A MEDIUM CUT-OFF DIALYZER ON SKIN AUTOFLUORESCENCE IN HAEMODIALYSIS PATIENTS

Abstract Background and Aims Advanced glycation end-products (AGEs) are middle-sized uraemic toxins that accumulate in haemodialysis (HD) patients due to increased production, impaired excretion and insufficient removal. Previous studies have reported that the use of a medium cut-off (MCO) dialyzer promotes a greater removal of larger middle molecules (such as AGEs) than conventional high-flux HD and haemodiafiltration. However, to our knowledge, there is no published evidence regarding the effect of an MCO dialyzer on skin autofluorescence (SAF), a measure of long-term tissue AGE accumulation and independent risk factor for mortality in the HD population. We aimed to investigate the impact of using an MCO dialyzer on change in SAF over time in HD patients. Method HD patients were enrolled in a prospective observational study. SAF was measured using a validated Autofluorescence Reader at baseline, 12 and 24 months. During the initial 12 months patients dialysed using high-flux polysulphone, polyarylethersulfone or polyvinylpyrrolidone dialyzers. At a variable time after 12 months patients were switched to an MCO dialyzer (Theranova; Baxter®). Forty patients who had been using the MCO dialyzer for at least 3 months were included in this analysis. Results Mean age, baseline SAF levels and time on MCO dialyzer were 63±13 years, 3.5±0.9 arbitrary units (AU) and 124±49 days, respectively. SAF increased significantly from baseline to 12 months (3.5±0.9 vs. 3.9±1.1 AU; p&amp;lt;0.0001) but tended to decrease between 12 and 24 months, after conversion to an MCO dialyzer (3.9±1.1 vs. 3.7±0.7 AU; p=0.06). Additionally, mean ΔSAF from baseline to 12 months was positive (0.41±0.68 AU) whereas ΔSAF from 12 to 24 months was negative (-0.18±0.76 AU; p=0.002 for comparison). Furthermore, SAF at 24 months correlated negatively and significantly with time on MCO dialyzer (r= -0.384; p=0.01) though second year ΔSAF (delta from 12 to 24 months) did not (r= 0.061; p=0.7). Conclusion We found in this observational study that SAF levels decreased/stabilised in HD patients after switching to an MCO dialyzer compared to the time when patients were using conventional high-flux HD and haemodiafiltration, during which SAF levels increased. Future prospective and interventional studies with larger sample sizes and longer follow-up are needed to confirm these findings and to evaluate the impact of using an MCO dialyzer on long-term outcomes, including survival.

P1081DIALYSATE SODIUM ALLIGNMENT AND SODIUM SET-POINT STABILITY IN HEMODIALYSIS PATIENTS: TWO-YEAR OBSERVATION

Abstract Background and Aims The low dialysate sodium (NaD) reduces intradialytic weight gain (IDWG) and blood pressure (BP), which are associated with improved outcomes. However, the intervention probably also increases intradialytic hypotension and reduces serum sodium (NaS), that are associated with increased mortality risk, so NaD should be individualized and brought closer to NaS. Predialysis natraemia in hemodialysis (HD) patients is considered constant (set-point) but some observations contradict this statement. The significance of clinical parameters, dialysis parameters and body water distribution is not clear. Method We undertake the retrospective observation among 45 HD patients for 24 months before large-scale prospective intervention investigation for individualization of NaD. We used two-year routinely monthly fixed data: NaS, NaD, IDWG, frequency of intradialysis hyper- and hypotension and seizures, peri- and intradialysis BP, home BP estimates, clinically and by bioimpedance estimated dry weight, ultrafiltration rate, frequency and duration of HD sessions. Results We included 27 males and 18 females of 60 (34-83) years old, with median HD vintage of 63 (29÷93) months. 1048 NaS measurements revealed mean natraemia of 137.1±2.8 (Q5-Q95 132-141) mmol/l (corrected for glucose). No differences in mean NaS according to gender, age, HD vintage, cardiac or liver dysfunction and residual renal function were found. Intraindividual NaS mean varied from 132 to 141 mmol/l and median of coefficient of variation (CV) was 1.4% (1.2÷1.6) (range 0.9-2.0%) which could be attributed mainly to measurement accuracy. The intraindividual NaS Q10-Q90 did not exceed 6 mmol/l with its median 3.0 (2.7÷3.7). Among whole group we revealed slow decreasing NaD trend (-0.12 mmol/l per year, R?0.45) which was accompanied by more prominent trend in systolic BP (-3.3 mmHg/year, R?0.64) and diastolic BP (-1.6 mmHg/year, R?0.49). In parallel, the frequency of intradialytic hypotension increased by 1.6 episodes/100HD per year (mean 2.3±0.6 after excluding the trend). 33 patients (73%) showed no significant individual trend in NaS (&amp;lt;1 mmol/l per year) for 24 months, 8 (18%) demonstrated decreasing trend (mean -1.5 mmol/l per year) while only 4 (9%) - increasing trend (mean +1.6 mmol/l per year). We observed no trend in prescribed bicarbonate level in dialysate. There were no significant associations between intraindividual deviations from individual mean weight before HD and from mean individual NaS. In whole group, intraindividual variations in NaS had no link with mean NaS. We observed the significant variations in NaS only in patients with large CV of predialysis weight (Q90-Q10&amp;gt;5 kg over 2 years). Overall mean of sodium serum to dialysate gradient (NaG) was slightly positive (+0.15±3.0 mmol/l) while 58% of patients had negative or neutral NaG. The latter had lesser IDWG but no difference in intradialytic hypotension frequency. We evaluated the number of random consecutive monthly predialysis NaS need to get acceptable estimation of real mean two-year predialysis NaS: five values gave 94% hit in range -1÷ +1 mmol/l. Conclusion Serum sodium is stable over time in HD patients with the only exception of patients with large intraindividual predialysis weight variation. Pre-HD serum sodium may be used as a parameter for individualizing dialysate sodium prescription.

Influencia de la sobrecarga de calcio sobre el metabolismo óseo y mineral en 55 centros de hemodiálisis de Lima

BackgroundMineral and bone metabolism disorders are common complications in haemodialysis patients that present significant geographical variability. ObjectivesThe objective of this study was to assess these disorders for the first time in haemodialysis patients from Peru. MethodsThe study included 1551 haemodialysis patients from 55 centres affiliated with the Social Health System of Peru in the city of Lima. Demographic data, comorbidities, treatments and biochemical parameters were collected from each patient. Serum calcium, phosphorus and PTH levels were categorised according to the recommended ranges in the KDOQI and KDIGO guidelines. ResultsThe mean age of the patients was 59.5±15.6 years, with a mean time on haemodialysis of 58.0±54.2 months. All patients were dialysed with a calcium concentration in the dialysis fluid of 3.5 mEq/l and 68.9% of patients were prescribed phosphate-binding agents (98.4% of them calcium carbonate). A high percentage of patients showed serum calcium above, and serum phosphorus below, the recommended ranges in the KDOQI guidelines (32.8% and 37.3%, respectively). More than half of the patients had serum PTH values below the recommended ranges of both the KDOQI and KDIGO guidelines (56.4% and 51.6%, respectively). ConclusionsPatients included in this study were younger than those from other studies and showed both hypophosphataemia and suppressed PTH, probably due to an excessive calcium overload through dialysis fluid and the use of calcium-containing phosphate binding agents.

The Effect of Intradialytic Exercise Training on Cardiac and Arterial Health in Hemodialysis Patients

INTRODUCTION AND AIMS: Patients with kidney failure undergoing chronic hemodialysis (HD) treatment have excessively high rates of cardiovascular (CV) morbidity and mortality. Exercise training as a part of a comprehensive treatment program has been shown to reduce the risk of CV events in patients with established CV disease. However, much less is known about the CV effects of exercise training in HD patients. The aim of this study was to determine the effect of 12 months of intradialytic exercise with concomitant protein supplementation on CV health in HD patients. METHODS: This is a secondary analysis of CV parameters measured from a subset of patients participating in the IHOPE trial (NCT#01234441). This analysis includes data from 98 HD patients (54±12 yrs; 59% male) randomized either to usual care (CON) or intradialytic exercise training + protein supplementation (EX) for 12 months. Patients in the EX group performed supervised moderate intensity exercise (RPE = 12-14) on cycle ergometers for 30-45 minutes with a concomitant oral protein supplement (30g whey) during treatment. Ultrasound exams were performed to measure cardiac systolic function (ejection fraction), diastolic function (early diastolic filling pressure; E, early diastolic tissue velocity; E’) and carotid arterial wall thickness (intima-media thickness, IMT). Outcomes were assessed at baseline, 6, and 12 months. RESULTS: There were no significant changes in any CV parameter between groups at 12-months (Group x Time interaction, p > 0.05 for all measures). However, there was a significant main effect of Time for EE’ in the overall study population, indicating a general worsening of left ventricular filling capacity at 12-months that was larger in CON compared to EX (p< 0.05). There was a similar trend for an increase in carotid IMT at 12-months in CON (p<0.05), that was not evident in EX. CONCLUSION: These data indicates that declines in cardiac diastolic function and increases in carotid IMT that manifest over time in HD patients may be attenuated by intradialytic exercise training. Surprisingly few studies have investigated the effects of exercise on CV structure and function in HD patients, thus, these findings warrant further investigation.

Impact of calcium overload on bone and mineral metabolism at 55 hemodialysis centers in Lima

BackgroundMineral and bone metabolism disorders are common complications in hemodialysis patients that present significant geographical variability. ObjectivesThe objective of this study was to assess these disorders for the first time in hemodialysis patients from Peru. MethodsThe study included 1551 hemodialysis patients from 55 centers affiliated with the Social Health System of Peru in the city of Lima. Demographic data, comorbidities, treatments and biochemical parameters were collected from each patient. Serum calcium, phosphorus and PTH levels were categorized according to the recommended ranges in the KDOQI and KDIGO guidelines. ResultsThe mean age of the patients was 59.5±15.6 years, with a mean time on hemodialysis of 58.0±54.2 months. All patients were dialyzed with a calcium concentration in the dialysis fluid of 3.5mEq/l and 68.9% of patients were prescribed phosphate-binding agents (98.4% of them calcium carbonate). A high percentage of patients showed serum calcium above, and serum phosphorus below, the recommended ranges in the KDOQI guidelines (32.8% and 37.3%, respectively). More than half of the patients had serum PTH values below the recommended ranges of both the KDOQI and KDIGO guidelines (56.4% and 51.6%, respectively). ConclusionsPatients included in this study were younger than those from other studies and showed both hypophosphataemia and suppressed PTH, probably due to an excessive calcium overload through dialysis fluid and the use of calcium-containing phosphate binding agents.

Cognitive impairment in hemodialysis patients: Implementation of cut-off values for the Montreal Cognitive Assessment (MoCA)-test for feasible screening.

ObjectiveReliable identification of cognitive impairment in hemodialysis patients is of utmost importance, as it is associated with poor outcomes including dialysis withdrawal and death. High prevalence of cognitive impairment has been demonstrated in several studies using brief screening instruments or neuropsychological test batteries. However, the relevance of cognitive impairment as well as the accuracy of screening procedures have never been studied in this patient population.Methods151 chronic hemodialysis patients (mean age 65.78 ± 14.88 years, 73,5% male) underwent cognitive testing under standardized conditions by the Montreal Cognitive Assessment (MoCA) and, in a second step, the Clinical Dementia Rating scale (CDR), an international standard to measure the severity of dementia. For calculating MoCA cut-off values on the basis of the CDR global score, receiver operator characteristics (ROC) analysis and c-statistic were applied.Results49.0% of patients were categorized as 0.5 in the CDR global with memory being the predominantly affected domain (47.7% of patients scored ≥ 0.5). Youden’s Index led to a threshold of 23.5 points for the MoCA test for optimal differentiation between cognitively normal (CDR global < 0.5) and impaired patients (CDR global ≥ 0.5) based on a sensitivity of approximately 99% and a specificity of approximately 74%.ConclusionInterference of cognitive impairment with patients’ independence and daily life was shown using the CDR for the first time in hemodialysis patients. A MoCA score of 23.5 points turned out as optimal threshold to differentiate between patients with and without functional impairment in the CDR, thereby paving the way for implementation of the MoCA test as a quick and thus highly feasible screening instrument for periodic testing in clinical routine.

Associations of adiponectin and leptin levels with protein-energy wasting, in end stage renal disease patients

ObjectiveThe aim of the study was to examine the prevalence of protein-energy wasting (PEW) in hemodialysis (HD) and peritoneal dialysis (PD) patients in our center and determine whether adiponectin and leptin are involved in the development of PEW. DesignProspective (18 months). SettingUniversity Hospital of Heraklion, Crete, Greece. SubjectsSeventy-four end-stage-renal-disease patients, 47 on HD and 27 on PD. Main outcome measuresAt three sequential time points (baseline, 6 and 18 months) anthropometric, nutritional and inflammatory status data were collected. Serum adiponectin and leptin were also assessed at each time point. Patients were allocated to 3 strata according to PEW severity (0, 1–2 and ≥3 criteria for PEW). ResultsAdiponectin and leptin levels were greater among PD compared to HD patients (p≤0.035). Adiponectin levels were incrementally greater across increasing strata of PEW (p≤0.002). Leptin showed the opposite trend, with lower levels in malnourished patients and higher levels in patients with zero PEW criteria (p≤0.042). Alterations of adiponectin levels during the observation period were dependent on PEW stratum (p≤0.021) and mode of dialysis (p≤0.002), after adjustment for age, dialysis vintage, gender and fat mass index. Particularly, adiponectin levels increased over time in HD patients with ≥3 criteria for PEW, whereas adiponectin levels decreased in PD patients with ≥3 criteria for PEW throughout the study. Leptin alterations over time were not affected by dialysis mode or PEW stratification. ConclusionsOur study provides evidence that increased adiponectin and decreased leptin levels are independently associated with PEW and thus, poor prognosis.

Evaluation and Treatment of Hypertension in End-Stage Renal Disease Patients on Hemodialysis.

Hypertension is one of the most common cardiovascular comorbidities in end-stage renal disease patients on hemodialysis. Its complex pathophysiology is related to extracellular volume overload, increased vascular resistance stemming from factors related to uremia or abnormal signaling from the failing kidneys, as well as the unique blood pressure changes that take place during and between hemodialysis treatments. Despite the changing nature of blood pressure over time in hemodialysis patients, hypertension diagnosed in or out of the hemodialysis unit is associated with increased cardiovascular morbidity and mortality. This review details the causes of hypertension in hemodialysis patients and provides an updated review of the clinical consequences and management of hypertension.

Associations of adiponectin and leptin levels with protein-energy wasting, in end stage renal disease patients

ObjectiveThe aim of the study was to examine the prevalence of protein-energy wasting (PEW) in hemodialysis (HD) and peritoneal dialysis (PD) patients in our center and determine whether adiponectin and leptin are involved in the development of PEW. DesignProspective (18 months). SettingUniversity Hospital of Heraklion, Crete, Greece. SubjectsSeventy-four end-stage-renal-disease patients, 47 on HD and 27 on PD. Main outcome measuresAt three sequential time points (baseline, 6 and 18 months) anthropometric, nutritional and inflammatory status data were collected. Serum adiponectin and leptin were also assessed at each time point. Patients were allocated to 3 strata according to PEW severity (0, 1–2 and ≥3 criteria for PEW). ResultsAdiponectin and leptin levels were greater among PD compared to HD patients (p≤0.035). Adiponectin levels were incrementally greater across increasing strata of PEW (p≤0.002). Leptin showed the opposite trend, with lower levels in malnourished patients and higher levels in patients with zero PEW criteria (p≤0.042). Alterations of adiponectin levels during the observation period were dependent on PEW stratum (p≤0.021) and mode of dialysis (p≤0.002), after adjustment for age, dialysis vintage, gender and fat mass index. Particularly, adiponectin levels increased over time in HD patients with ≥3 criteria for PEW, whereas adiponectin levels decreased in PD patients with ≥3 criteria for PEW throughout the study. Leptin alterations over time were not affected by dialysis mode or PEW stratification. ConclusionsOur study provides evidence that increased adiponectin and decreased leptin levels are independently associated with PEW and thus, poor prognosis.

Longitudinal trends in serum ferritin levels and associated factors in a national incident hemodialysis cohort.

The rise in serum ferritin levels among US maintenance hemodialysis patients has been attributed to higher intravenous iron administration and other changes in practice. We examined ferritin trends over time in hemodialysis patients and whether iron utilization patterns and other factors [erythropoietin-stimulating agent (ESA) prescribing patterns, inflammatory markers] were associated with ferritin trajectory. In a 5-year (January 2007–December 2011) cohort of 81 864 incident US hemodialysis patients, we examined changes in ferritin averaged over 3-month intervals using linear mixed effects models adjusted for intravenous iron dose, malnutrition and inflammatory markers. We then examined ferritin trends across strata of baseline ferritin level, dialysis initiation year, cumulative iron and ESA use in the first dialysis year and baseline hemoglobin level. In models adjusted for iron dose, malnutrition and inflammation, mean ferritin levels increased over time in the overall cohort and across the three lower baseline ferritin strata. Among patients initiating dialysis in 2007, mean ferritin levels increased sharply in the first versus second year of dialysis and again abruptly increased in the fifth year independent of iron dose, malnutrition and inflammatory markers; similar trends were observed among patients who initiated dialysis in 2008 and 2009. In analyses stratified by cumulative iron use, mean ferritin increased among groups receiving iron, but decreased in the no iron group. In analyses stratified by cumulative ESA dose and baseline hemoglobin, mean ferritin increased over time. While ferritin trends correlated with patterns of iron use, increases in ferritin over time persisted independent of intravenous iron and ESA exposure, malnutrition and inflammation.

Reduction of left ventricular ejection fraction after 12-month follow-up in hemodialysis patients.

Introduction: Cardiovascular disease is the most common cause of morbidity and mortality in hemodialysis patients. Objectives: The aim of this study was to detect echocardiographic abnormality in the beginning and after 12-month follow-up in the hemodialysis patients. Patients and Methods: In a cross-sectional study, 60 hemodialysis patients older than 18 years and the dialysis duration longer than three months were enrolled. At the beginning of the study, echocardiography was done and after 12 months was repeated in all of the patients by the same cardiologist. At the end of the study, data were analyzed using SPSS software (version 19). Results: From the total of cases 37 were male and 23 female. At the beginning of the study, mitral regurgitation, tricuspid regurgitation and aortic insufficiency were found in 54, 47 and 11 patients respectively. After 12 months left ventricular ejection fraction (LVEF) decreased significantly, however there was no significant difference between other echocardiographic findings at the beginning and after 12 months. Conclusion: Decrease in LVEF over time in hemodialysis patients may be due to negative effect of uremia on cardiac function, so it seems that periodical cardiac evaluation of these patients is essential and beneficial.